Mil
A Rp:ference Handbook ^--
THE MEDICAL SCIENCES
EMBRACING THK KNTTKF. RANOE OF
SCIENTIFIC AND PRACTICAL MEDICINE
AND
ALLIED SCIENCE
BY VARIOUS WRITERS
A NEW EDITION, COMPLETELY REVISED AND REWRITTEN
EDITED BY ALBERT H. BUCK, M.IX
New York Citv
VOLUME VI ^^'
ILLUSTRATED BY CHEOMOLITHOGRAPHS AND SIX HUNDRED AND EIGHTY-
EIGHT HALF-TONE AND UOOD ENGRAVINGS
NEW YOKE
WILLIAM WOOD AND COMPANY
MDCCCCIII
COPTRTOHT. \9m.
"B7 WILLIAM WOUL) AND COMPANY
PU8LI8HER8' PRINTING COMPANY
32 AND 34 LAFAVFTTE PLACE. NEW YORK
LIST OF CONTRIBUTORS TO VOLUME VL
BENJAMIN VAUGIIAN ABBOTT, M.A.* Nkw
York City, N. Y. , . , , ■
C'ounsi-llnr and Attorney at-Law ; Author of " Abbott s
Law Dictiouary " aud Various Digests.
SAMUEL AV. ABBOTT, 5LD. .Newton Centre, Mass.
Seeretary, State Board of Health of :Massaehusetts.
EDWARD WILLIAM ARCHIBALD, M.D Mon-
TUE.\L, C.\N.\D.^. .
Demonstrator in Patliology, MeGiU I niversity ; Uim-
eal Assistant in Surgery, Royal A letona Hospital.
(JEORGE E. ARMSTRONG, M.D Montreal,
Canada. ,, _,,,, ,. .
Associate Professor of Clinical Surgery, McGill Uii-
versity Attending Surgeon, :Montvcal General Hos-
pital- Consulting Siu-geon, Western Hospital aud
the Protestant Hospital for the Insane, \ erdun.
JAMES RAE ARNEILL, M.D.. Ann Arbor. Mien
Instructor in Clinical Medicine, Medical Department,
'University of Michigan.
ROBERT H. BABCOCK, M.D Chicago III.
Professor of Clinical Medicine and Diseases of the
Chest, Collene of Physicians and Surgeons, Chi-
cago- Attending Physician, Cook County Hospital
and Cook County Consumption Hospital; Consult-
ing Physician, jfary Thompson, St. Anthony s, and
Slarion Sims Hosiiitals.
PE VRCE BAILEY, M.D New York, NY.
Instructor in Neurology. Columbia University New
Y'ork ■ Consulting Neurologist to St. Luke s, Ortlio-
pa;dic, and Babies' Hospitals, New Y'ork.
FRANK BAKER. M.D AYashtngton. D C
Professor of Anatomy, Georgetown University Schoo
of Medicine; Superintendent, National Zoological
Park, Smithsonian Institution, Washington.
FREDERICK AMOS BALDWIN, M.D. Ann" Aruor.
Mich. ^ ^ t ■
Assistant in Pathology, Medical Department, U niver-
sity of ilichigan.
LEWELLYS F. BARKER, M.D Chicago, III.
Professor and Head of the Department of Anatomy.
University of Chicago and Rush Medical College.
DON\LD McLEAN BARSTOW, M.D..New York,
N. Y.
WATLER ARTHUR BASTEDO, Pn.G. M.D. . New
Y'ork, N. Y. ,, ,- •
Instructor in Materia Medica at Cornell Univcraty
Medical College in Xew York City .lormerly Tor-
rev Lecturer on Botany at the New York College ot
Pharmacy.
HENRY G. BEYER, Ph.D., M.D. .
Surgeon, United States Navy. Lecturer on Hygiene,
Naval War College. Newport, R. I.
ROBERT PAYNE BIGELOW. Pii.D. Boston M.^ss.
Instructor in Biology, Massachusetts Institute of lech-
nology. Boston,
W R. BIRDSALL. M. D.* .■ . .New York N. Y.
Formerly Physician to the Department tor Nervous
Diseases, Manhattan Eye and Ear Hospital New
York.
SETH SCOTT BISHOP, M.D.. LL.D. . Chkaoo, III.
Professor of Diseases of the Nose, Thn.at, and Ear in
the Illinois Medical College; Professor m the Chi-
r:\<'0 Post-Graduate ^Medical School and Hospital;
AUeuding Surgeon, Post-Graduate Hospital, Chi-
cago.
AV P BOLLES, M.D RoxBriiY. M.ass.
Professor of Materia Medica and Botany, Emeritus, at
the Massachusetts College of Pharmacy; Visiting
Surgeon, Boston City Hospital.
B MEADE BOLTON. :M. D St. Loris, Mo.
Professor of Pathology, :Marion Sims-Beaumont Cc)l-
lege of Medicine, S^'t. Louis; formerly, As.sociate in
Bacteriolocy, Johns Hopkins University, and Direc-
tor of the "Laboratory of Hygiene, Board of Health
of Philadelphia.
MVJOR W. C. BORDEN Washington, D. C.
Surgeon, United States Army.
lUCIIARD EWELL BROWN, M.D New York,
Assistant' Attending Physician, Lying-Iu Hospitiil,
New Y'ork.
GLENTWORTH REEVE BUTLER, M.D. .Brooklyn,
N Y
Attending Physician to the Methodist Episcopal Hos-
pital and to the Brooklyn Hospital ; Consulting I hy-
sician to the Bushwick Central Hospital.
ARTHUR T. CABOT. M.D Boston, Mass.
Surgeon to Massachusetts General Hospital, Boston.
HUGH CABOT, M.D ^°?'\'i^: ^^S?
Assistant in Operative Surgery. Harvard Universily
Medical School; Attending Surgeon, the bapli-I
Hospital, Boston.
WILLIAM HENRY CARMALT, M.D.. New Haven.
Conn. . , ,. c
Professor of Surgery, Y'ale University ; Attending Sur
geoii. New Haven Hospital.
EMILE MONNIN CHAMOT, B.S., Ph.D. Itiia.a,
N Y
Assistant 'Professor of Sanitary Chemistry and To.\i-
cology, Cornell University; Lecturer onTo.\icol()gy,
New" Y'ork State Veterinary College, Ithaca, N. \.
RUSSELL H. CHITTENDEN, Ph.D. New Haven,
Conn. ,. , ...
Professor of PhvsiolosicalCliemistry, lale University,
and Director "of the^Shellield Scientific School.
WILLIAM JUDKINS CONKLIN, M.D Dayton,
Consulting Surgeon, St. Elizabeth's Hospital and the
Protestant Deaconess' Home and Hospital.
WILLIAM THOMAS CORLETT, M.D. .Cleveland,
Ohio. , ., , ,., .
Professor of Dermatology and Syphilology, \\ estern
Reserve University; Physician for Skin Diseases,
Lakeside Hospital"; C.insulting Dermatologist Char-
ity, St. Alexis, and the City Hospitals, Clevelaml.
WILLI \M T COUNCILMAN, M.D. ..Boston Mass
Shattuck Professor of Pathological Anatomy, Harvard
University Medical Si-hool.
Ill
LIST OF CONTIUBUTORS TO VOLL'ME VI.
MONTC.OMEKY ADAMS CliOCKKTT. M I> I'.i r-
i-'Ai.o, N. V.
Adjunct PrcifVssoi- of Obslcl.rics uiiil (iyna'i'dliijiy,
Mc'ilicul I)i'|i;u-tiiicnt. I'liivci-sity (if BufTiUii; (Jyiiu'
(•()liii;ist t<i IJiilluld (ioiicnil ;uhI V.r'u- County llos-
jiitais, P.ull'alo.
ALFKKI) C. CUOI'TAN, M.I) Ciik ai^), li.i,.
I'liifcssov of Medicine, I'ost. Ciaduate Medical ('ollen'e
of Cliiciijio.
JAMKS K. CltOOK, AM.. M.D. Xkw Yokk, N. Y.
Adjunct Profe.-isor of Olinieal .Medicine mid I'liysiiid
DiasiKis's. New YoiU I'ost-GfaduMte Jledieal Scliool ;
.\tl('ndiii,i; I'liysician, I'ost-Ciradnnle I lo.spitiU.
EDWAUn (TliTIS, A.M., M.I)...Xi:\v Yokk, N, Y
Emoritu,s Professor of iMateria Jlcdiea and Tlierapeu-
lics, .Medical Depannienl, Coluiuliia Univer,sity,
CHARLES TOWNSIIKNI) DADE, ]\1.D, ,Nk\v Youk,
N. V.
Assistant, Dennatolo.nist, Vanderhilf C^linic. C'oluiuliia.
University; Attending DerniMtolofrist. Kaudall's Isl
and Hospital, New Y'ork.
N. PENDI,ETON BANDRIDGK, M.D. . .Cincinnati.
Ohio.
Lately Dean and Professor of the Practice of Surgery
and of Clinical Surj;-ery, ^Nliaini Medical College; At-
tending Surgeon, Cincinnati and Cliildreu's IIos
liitals.
NATHAN S:\11TH DAVIS. .In.. .M.D. Chicac^o, 111,
Professor of Principles and Practii-c of Medicine anil
Clinical .Medicine, and Dean of llie Faculty, North
western rniversit.y Jledical School; Attending I'liy-
si<'ian, ^lercy Hospital and Wesley Hosjiital, Chicago.
liol'.KKT H. M. DAWliAKX, M.D New Yokk.
N. Y.
Altemling Surgeon, City and Polyclinic Hospitals.
I). BRYSON DELAVAN, JI.D....New Yohk, N. Y.
Professor of Laryngology, New Yoik Polyclinic; Con-
sulting IjaryngologisI, (leneral Menioriid Hospital,
and llu' Hospital for Kuiilured and Chipjilcd,
LYDIA M, DEWITT, JED Ann Aunuit, Mien.
A,ssistant iu Histology, Medical I)e])artmcut, Univer-
sity of Michigan,
FRANKLIN ABBOTT DoRMAN, M.D. New Yokk,
N. Y.
Instructor in obstetrics, Columbia I'niversity ; Assist-
ant Attending J'hysician, Sloaiie Maternity Hospital,
New York.
ISADOKE DVEK, Pit. I!., M.D. ...New Oiii,eans, La.
Professoi- of Diseases of tlie Skin, New Orleans Poly-
clinic; Clinical Instructor in Derniatnlogy, Alcdical
Department of Tulaiie I'niversity, New Orleans;
(.Consulting Dermatologist to the Eye, Ear, No.se,
.and Throat Hospital, New Orleans.
J. HAVEN E.MLKSON, ;\I.I).
. Ni'iw Yohk, N. Y.
BEN.IAMIN Tllo.MAS KAIKCHII.D. Ph.D.... New
Yohk, .N. V.
Pharniaceutic.al Chenusl.
EDWARD .MILTON KtHiTi;, M D.Nku Yoi;k, N. V.
Inslriiclor In .Minor Siirgeiy, Columliia Inivcrsily;
Visiting Surgeon, Ciiy Hospital, .New York.
ROliEKT FOHMAD, .M.D Piih.adei.i'hia, Pa.
Demonstrator of Normal Histology, .Medical Dcp;irl-
ment. University of Pennsylvania.
JOSEPH KKAENKF.L, M.D New York, N. V,
Instructor in Ni'rvous Diseasi's, Cornell rniversiiy
.Medical School in New Yoik City; Physician to tlir
Monteliore Iloine; Neurologist to the ('ity llospii.il
ROWLAND GODFREY FREEMAN, Ml) New
Yohk, N. Y.
Clinical Lecturer on Pediatrics and Chief of Pediatric
Clinic, Iniversity and Bellevue Hospital Medical
Colk'ge; Atleiuli'ng Physician, P^iundling Hosiiit:d
and the Seaside Hospital of St. John's Guild, New
York.
JAMES JIA(;oFFIN FliENCH, M.D. . .CiNciNN.vn,
Ohio.
Lecturer on the Theory and Practice of Medicine,
^ledieal College of (Jhio; Attending Physician, St.
.Marv's Hosjiital; Consulting Physician, St. Francis
Hospital for Incurables.
SIMON HENRY' GAGE, B.S Ithaca, N. Y.
Picifessor of Microscopy. Histology, and Endjryology,
Cornell University.
JASPER JEWETT GARMANY, M.D., F.R.C.S, Enc.
New York. N, Y.
Clinical Professor of Surgery, University and Bellevue
Hospital Medical College, New Y'ork.
FREDERICK R. GREEN, M.D CiiicAdo, Ii.i,.
Head Demonstiator of Anatomy and Instructor in O.s-
le<ilogy. Northwestern University Medical School,
Chicago.
JOHN GREEN, M,n St. Louis, Mo,
Siicrial Professor of Ophthalmology, Medical Depart-
ment of AVashingtou University, St. Louis.
JOHN GREEN, Ju., M.D St. Loiis, JIo.
CHARLES RAVENSCROFT GREEXLEAF.. . Behk-
EI.EV. CaI,.
Colonel, United States Army, Retired.
IIENKY EWING HALE, 5I.D....New Yohk. N Y
Assistant DeiiKmstrator of Auatcimy, Medic.il Deinnl
ment, ('(Juinlii;i. L'nivcr.sit_y. New Y'ork.
MRS, JEANNETTE "WINTER HALL.Behwvn, Ii.i..
Formerly, Student of the University of Lei|isic, Ger-
many, De|iartiiient of Biology.
THOMAS HENRY HALSTED, M.D. .Svhaciise, N. Y.
Professor of Laryngology and Otology, Medical De-
partment, Syracuse University; Lai'yngologist and
Otologist to St. Joseph's Hospital, and the "Women's
and Children's Hospital, Syracuse.
ALICE HAMILTON, M.D Ciikaoo, Ii.i,.
Professor of Pathology, Woman's Jledical College of
Northwestern University, Chicago,
GEORGE C, HARLAN, M,I) Piiii.AiiEi.fiiiA. Pa.
Emeritus Professor of Diseases of the Eye, the Phila-
delphia Poly( linie Hosjiital and College for Gradu-
ates in .Medicine; Attending Surgeon, "Wills Plyc
Hcis|iital.
CHARLES HARRINGTON, M.D Boston, ]\L\ss.
Assistant Profc'ssor of Hygiene, Harvard University
Medical Scdiool.
IIEXKY FAUNTLEKOY HARRIS, M.D. ..Atlanta,
(Ja.
Prcife.ssoi' of P:ilholcigy and Bacteriology, College of
Physiciiins and Sui'geons, Atlanta, Ga.
T. STUART HART, M,n New York, N, Y,
Clinical Assistant in the Deiiartmcutsof General Medi-
cines and Diseases of the Nervous System, Medical
Deparlment of (Columbia Urdversity, New York.
FRANK HAItTLEY, 51.1) New York, N. Y.
Clinie;d Professor of Surgery, College of Ph3'sicians
and Surgeons, Columbia University. New York;
Attending Surgeon. New Y'ork Hosjtilal ; Consulting
Singeon, General Memorial and French Hospitals.
(HSTAVUS P. HEAD, MX) Ciiicaco, III.
Professor of Laryngology and Rhinologj', PostGrad-
uate Medical School, Chicago.
IV
LIST OF CONTRIBUTORS TO VOLUME VI.
C. .lUDSON HEHUICIv, Pii.D Ghanville, Ohio.
Professor of Z<iology. Donison University ; Associate
in Comjiarative Neurology. Pathological Institute of
the New York Stale Hospitals.
GUY HINSDALE, M.D Philadei.phi.x, Pa.
Seci('tary, American Cliniatological Association.
KEID HUNT, Ph.D., JI.D Baltlmoue, Md.
Associate Professor of Pharmacology, Johns Hopkins
University, Baltimore.
JIILLER BANE HUTCHINS, M.n.. . .Atlanta. Ga.
Dermatologist to the Presbyterian Hospital, Atlanta.
E. FLETCHER INGALS, M.D Chicago, Ii.i..
Professor of Diseases of tlie Cliest, Nose, anil Throat,
Rush Medical College; Attending Physician, Cook
County Hospital; Laryngologist, Presbyterian Hos-
pital and St. Jo.seph's Hospital.
FRANK W. JACKSON. M.T) New Yokk, N. Y.
Instructor in Jledical Diagnosis, Columbia University;
Visiting Physician, liellevue Hospital; Junior Phy-
sician, Roosevelt Hospital.
GEORGE THOMAS JACKSON, :M. I). .New Yokk.
N. Y.
Instructor in Dermatologj' and Chief of Clinic, Medi-
cal Department of ("olumbia University: Consulting
Dermatologist, Presbyterian Hospital and tlie New
York Infirmary for Women and Children.
SMITH ELY JELLIFFE, M.D. . . .New Yokk, N. Y.
CARL KOLLER, 31. D New Youk, N. Y.
:MAYNARD LADD, M.D Boston-, JIass.
Assistant in Diseases of Children, Harvard University
3Iedical Selmol : Assistant Physician to the Chil-
dren's Hospital; Assistant Physician to the West
End Nursery and Infants' Hospital, Boston.
FRANK WARREN LANGDON, M.D... .Cincinnati,
Ohio.
Professor of Nervous and ^lenlal Diseases. Jliami
Medical College and the Laura Memorial Woman's
Medical College of Cincinnati: Lecturer on Clinical
Neurology at the Clinical and Pathological School
of the Cincinnati Hospital.
GUSTAV LANGMANN, M.D New Yokk, N. Y.
Consulting Pliysieian, German Hospital. New York;
Fellow (if tlie New York Academy of Sciences.
RALPH CLINTON LARRABEE, MS) '.Boston,
Mass.
Assistant in Histology, Harvard University Jledical
School; Phy.sicianto Oiit-Patients, Boston City Hos-
pital.
EDWARD LEAMING. M.D New Yokk, N. Y.
Instructor in Photography, College of Physicians and
Surgeons, ]\[edical Department of Columbia Uni-
versity.
HENRY LEFFMANN, M.D Piiii.ADKi.pniA, Pa.
Professor of Chemistry and To.xicology. AVoman's
Medical Collegeof Pennsylvania ; Pathological Clicn:-
ist to Jeffer.son Jledlcal College Hospital ; Honorary
Professor of Chemistry, Wagner Free lustitiUc of
Science.
WILLIAJt M. LESZYNSKY. ^ID New Yokk.
N. Y.
Consuliing Neurologist. Manhattan Eye and Ear llos
pital ; Neinologist to the Deniilt Dispensary, the
German Poliklinik, etc.
F. A. L. LOCKHART, M.D Montreal, Canai>\
Lecturer in Gyiuecology, McGill University: formerly
Professor of Gyna'Cology. University of Bishops'
College: Gynsccologist to Montreal General Ilosiii-
tal and Protestant Hospital for the In,saue.
FRANK AVORTHINGTOX LYNCH, JI.D Balti-
more, Md.
Associate in Obstetrics, Johns Hopkins University ;
Resident Obstetrician, Johns Hopkins Hospital.
WILLIAM GEORGE MacCALLUM, M.D Balti
moke. Md.
Associate Professor of Pathology, .lohns Hopkins Uni-
versity: R<'sident Pathologist", Jolms Hopkins Hos-
pital.
CLARENCE ARTHUR McWILLIAMS. M.D... New
York, N. Y.
Attending Surgeon, Trinity Hospital; Assistant Sur-
geon, Presbyterian Hospital; Assistant Demonstra-
tor of Anatomy, Cornell University Medical College
in New York City.
HARRY T. MARSHALL, M.D Baltimoke, Md.
Assistant in Pathology, Johns Hopkins University.
ALBERT P. MATHEWS. M.D Chicaoo, III.
Assistant Professor of Physiological Chemistry, Uni-
versity of Chicago.
LAFAYETTE BENEDICT MENDEL, Ph.D.... New
H.WEN, Conn.
Assistant Professor of Physiological Chemistry, Yale
University.
CHARLES SEDGWICK MINOT. M.D., LL.D.. .Bos-
TON, 31 ASS.
Professor of Histology and Human Embryology, liar
vard University Medical School, Boston.
LOUIS J. MITCHELL. M.D CnicAoo, III.
Secretaiy of the International Association of Railway
Surgeons.
DOUGLASS W. MONTGOMEItV. 31. D... San Fran
Cisco, Cal.
Professor of Diseases of the Skin, University of Cali-
fornia.
BENJA3IIN 3IOORE, 31. A Liverpool, Enolani..
Professor of Biocliemistiy, University College, Liver-
pool, England ; Formerly Professor of Physiology,
Yale University.
H03VARD 3IORROW, 3I.D Sak Francisco. Cal.
Clinician, 3Iedical Department, University of Califor-
nia; Consulting Physician fur Diseases of the Skin,
Southern Pacific Railroad Hospital; Consulting Der-
matologist, Children's Hospital, San Francisco.
WILLIA3I S. 3IORR0W, 3I.D...3roNTREAL, Canada.
Lectuier in Physiol. igy, 3IcGill University; Clinical
Assistant in 3Ieilicine, Royal Victoria Hospitiil.
ROBERT C. MYLES, M.D New York, N. Y.
Attending SiirgeoiL Polyclinic Hospital, Department
of Nose and Throat.
JA3IES E. NEWCOJIB. 31. D New York. N. Y.
Instrtictor in Laryngology. Cornel! University 3Iedical
College in New York City; Laryngologist to Out-
Patient Department, Roosevelt Hospital. New York.
ALBERT GEORGE NICllOLLS. M.D. .. Montreal,
Canada.
Lecturer in Pathology, .Medical Dejiartment, 3I(Gill
University; Assistant Pathologist, Royal Victoria
Hospital, Montreal.
.s.V3H'EL NICKLES, 31.1) CiNdNNATi, Onto.
Emeritus Professor of Materia 3Ie<lica and Tlicra|H u
tics, 3Iedical College of Ohio.
WILLIA3I P. NORTHRUI', 31 1) Xew York. X. Y.
Professor of Pediatrics, the University and liellevue
Ilosiiital 3Iedical College; .\ttcnding Physician,
Presbyterian. Foundling, Willard Parker, and River-
side Hospitals.
LIST OF roxTRirsrTORS to vor-iMio vi.
WTLMAM Ol'lllT.S, M.I) San Fhancisco. Cm..
I'lorcsscir 111' l';iUioli)iry ami Ii,-u-tcrii)l(>L'-y. CodiiiT AIcil
ioal ('ollciic: I'atlnildsrist Id the Laiic Iliispilul ami
llio Gcrmaii ll()S|iilnl, ,Saii Franciscci.
FUGKNR L. OlMK. M.l) ISai.timouk, Mi>.
Associate in I'atliolnny. .li'lins lli)|ikiiis UnivcrsitT.
KnWAIil) O. OTLS. M.I) Boston, Mass.
I'mri'ssiir of I'uliiioiiarv Diseases and Cliinat.oloay.
Tults Colleirc Medical Scliool ; Visiliiij; Pliysician to
tlie Free lloiiie foi- Consumptives. Boston ; I'liysician
to the Pepartnient of Tnlieiculosis of the Luniks.
Boston Dispensai'y.
ItlrllAKn MILLS PEAKCE, M.D. . .l'nii.Ai>i,LiMiiA,
I'A.
Dciiionslfator of Pathology, VniversilA ol' Pennsyl
vania.
W. F. I!. PIIILUPS, :\I.r) WAsiiiNteroN. D. r.
Uuile<l States Weather liurcaii. Washington.
N. J. POXCIO i>i; LEON, M.D IIava.na. ('it.a.
Deputy Ilealth Ollicer of the Poit of Havana, Culia;
F(urnei!y Iiisiructof in Jlcdieine, Post-Gi'adnate
Medical School, New York ; and Assistant Visitini;'
Physician, Dcpai'tnii'iit of Diseases of Children, Dis
]iensai'y of Cornell University Jledical School.
GKOKGE M. PRICE, M.D New Yokk, N. Y.
.Medical Sanitary Inspector, Health Department of
llic VMy of New York.
.lAMES .1. PUTNAM. M.D Poston, Mass.
Professor of Diseases of the Nervous System, Harvard
University ]\Icdieal School.
LEOPOLD PUTZEL, M.D Nkw Youk, N. Y.
CHARLES E. QUIMBY, JI.D Ni^:w Yokk, N. Y.
Formerly Professor of ^ledicine. the University ami
liellevue Hospital Aledical College; Visiting I'hysi
cian. City Hospital.
OTTO GUSTAF RAMSAY, M. D.. Nkw PTavt.;n. Conn.
Piofcssor of Obstetrics and (Tyna?oology, Yale Univer-
sity ; Obstetrician to the New Haven Hospital,
JOSEPH RANSOHOFP, M.D Ci.m t.NXAii. Onto.
Professor of Anatomy and Clinical Surgery, Jledical
Colle,se of Ohio; Surgeon to the Cii^einnati. Good
Samaritan, and Jewish Hos]n'tals, Cincinnati.
CHARLES RICE. Ph.D.* Ni.w Y(.hk. N. Y.
Formerly Clicnust of Department of Public Charities
and C'orrection, New York ('ity; and Chairman of
Comiuitlce of Revision and Pnlilication of the Phar-
macopceia of (he United States of America.
GEORGE L. RICHARDS, M.D. ..Fai.i, Kivicn, Mass.
Otologist and Larvngologist, Fall River Union Hos-
jiitiil.
HUNTINGTON lilCHARDS, :M.D.. .Concohi., X. H,
CHARLES AV. R1CHARDS(.)X. M.D. , .. Wasiunoto.n
D. C.
Professor of Laryngology ami Otology. Colundiian
University. Washington, D. C.
C. EIKiENE RIGGS, JI.D St. Paii., Minn.
Professor of Nervous and i\Iental Diseases. Mcilicid
Dc])artnicnt, Univ(0-sity of Minnesota; XeurologisI
to St, Luke's, St. Joseph's. ('itvan<l Connix- Hospi-
tals, St. Paul.
LOUIS WARXER RKUJS, Pn.D..Ni;w Yokk. X. V.
Instructor in Chemisliy and Physics, (lorm-ll Univer
sity j\Ic<lical College in Xcw York Cily.
WILLIA.M (.'ABELL RIVES, .M.D Washincci-on,
1). C.
Formerly Visitin.g Phy.siciaii to the Xevvport ll<)s[iital,
Nc\v]ioit, R. I.
in XTER ROBB, M.D Ci,evei,and, Ohio.
Professor of (Jy naccjlogy. Western Reserve L'niver-
sitv; (jx'na cologist-in-Chief to the Lakeside Ilosjii-
l.af, Cle'velaml. '
ISABEL HAMPTOX RORB Nottingham. Ohio.
Late SnperintcndenI of .Xurscs and Pfinciiial of Tiain-
ing Schoiil of .lohns Hopkins Hospital, Baltimore,
Md.
J. WEST ROOSEVELT, JI.D.*.... New Y<h!k, N. Y.
Formerlv Visiting Physician. Bellcvue and Roo.scvelt
lIos|ii'l.-ds.
THOJIAS MORGAN ROT(:iI, M.D.. .Boston, Ma.ss.
Professor of the Diseases of ('hildrcn. Harvard Uni-
versity Jledical School; Physician to the Infants"
Hospital, Boston; Physician to the Children's Hos-
|iital, Boston.
HEXRY H. RUSBV. M.D Newahk. N. J.
Professor of Botany, Physiology, and Materia Aledica,
New York College of Pharmacy: Profcssoi- of Ma
teria .Medica, University and Bellcvue Hospital
Medical College.
WILLIAM EDWARD SCIIROEDER, M.D..Ciiic.\(io
Ii.i,.
Professor of Surgery, Northwestern L^niversity Medi-
i-al Seho(J ; Attending Surgeon, Cook Count}', Wes-
ley, and Proviilent Hospitals, (Chicago.
R. J. E. SCOTT, M.D New Yokk, N. Y.
Attending Phy.sician. Bellcvue Hospital, Out-Patient
Department; Gyiuecologist, Deinilt Dispensary, New
York.
FRANCIS J. SHEPHERD. M.D Mt)NTKEAL,
Canada.
Professor of Anatomy and I^ecturer on 0|)erative Sur-
gery. Medir;il Delia it mcu.t. McGill University ; Senior
Suigcon. the Montreal (.tcneral Hospital.
BEAUiMONT SMALL. JI.D Ottawa. Canada.
Attending Physi<-ian, St. Luke's General Hospital,
Ottawa; Consulting Physician, the Children's Hos-
pital; Late Examiner in JIateria Medica, College of
Physicians and Surgeons, Ontario.
ANDREW HEERMANCE SJIITH, JI.D. New Yokk,
N. Y.
lilmeritus Professor of tlu' Practice of Jledicine, New
York Po.st-tiraduatc Jledical School; Attending
Physician, Presbyterian Hospital: Consulting Phy-
sician, St. Luke's Hosiiital. New York.
S. EDAVIN SOLLY. JI.D., JLR.C.S. Enci.. .Coi.okado
Sl'ttlNos. Coi..
E-\-Presideut of the American Climatological Associa-
tion.
i;i;i(;.-GEX. george ji. Sternberg. ..avashino-
ton, d. c.
Surgeon General, United States Army, Retired,
THOJI.VS 1). SWIFT, JI.D.* Ni;w Yokk, N. Y.
Formerlv Visiting Physician, Dcmilt Disiiensary, New
Y,)rk.'
HENRY LING TAYLOR, JI.D. ..New York, N. Y.
Professiu' of Orllio]>eilic Surgery, New York Post
(Graduate Medical School and Hosi)ital ; Assistant
Orthopedic Surgeon. Hospital for Ruptured and
Crippled; Consulting Orthoiiedic Surgeon, New
York State Epileptic Colony, Sonyea, N. Y.
HENRY SWIFT UPSON. JI.D. . .Cleveland. Ohio.
Pr-ofcs.sor of Diseases of the Nervous System, Western
Reserve University; Attending Physician, the Lake-
side Hospital. Cleveland.
VI
LIST OF CONTRIBUTORS TO VOLU.ME VI.
JI.D.
.Alhanv,
ALBERT VANDER VEER, Ph.D.
N. Y.
Professor of Didactic. Abdoniiiuil. ami Clinical Sur-
gery, Albany ;\Icdical CoUcjjc; Atleniling Surgeon,
Albany llcjspital; Considting Surgeon, St. Peter's
Hospital, Albany.
FREDERICK HERMAN VERIIOEFF, M.D.... Bos-
ton, M.\ss.
Pathologist, JIassacliusetts Charitable Eye and Ear In-
firmary ; Assistant iu Pathology, Harvard University
Medical School; Assistant Ophthalmic Surgeon.
Carney Hospital, Boston.
JAMES DITMARS VOORHEES. M.D. ..New Yokk.
N. Y.
Instructor of Obstetrics, College of Physicians and
Surgeons, C'olumbia University ; Assistant Attending
Physician, Sloane ^Jlaternity Hospital. New York.
HENRY BALDWIN WARD, Ph.D.. . Lincolk, Neb.
Dean of the College of jNIedicine and Professor of Zo-
ology, the University of Nebraska.
ALDRED S. WARTHIN, M.D...Ann Ainiou, Mich.
Junior Professor of Pathology, Medical Department,
University of Michigan.
GEORGE A. WATERMAN, M.D Boston, Mass.
Assistant in Neurology. Harvard University Medical
School: Assistant Physician. Neurological Depart-
ment of the Massachusetts General Hospital : Assist-
ant Visiting Neurologist to Long Island Hospital.
Boston Harbor.
GROVER AV. WENDE, Ml) Buffalo. N. Y.
Clinical Professor fif Deruuitology, University of
Buffalo; Physician for Diseases of the Skin at the
Erie County Hospital, the Hospital of the Buffalo
Sisters of Charity, and the German Hospital.
M.D.
.MlNNE-
FRANK FAIRCHILD WESBROOK,
.\poi.is. !Mlnn.
Professor of Pathology and Bacteriology, University
of jNIinnesota ; Director of the i\Iinnesota State Board
of Health Bacteriological Laboratory.
CHARLES James white, M.D.... Boston, M.a.S8.
Instructor in Dermatology, Harvard University Jledi-
cal School ; Assistant Phj'siciau to the Skin Depart-
ment, Massachusetts General Hospital.
JOSEPH H. WHITE, M.D Washington. D. C.
Assistant Surgeon-General, Public Health and Marine
Hospital Service of the United States.
HAROLD WILLIAMS, M.D Boston, Mass.
Professor of Theory and Practice of Jledicine, Tufts
College jMedical School ; Phj-sician to Boston Dis-
pensary.
HERBERT U. WILLIAMS, M.D. . . .Buffalo, N. Y.
Professor of Pathology and Bacteriology, Medical De-
partment, University of ButTalo. N. Y.,
JOHN C. WISE, M. D Washington. D. C.
Medical Director, United States Navy.
RUDOLPH A. WITTHAUS, M.D..New Youk, N. Y.
Professor of Chemistry, Physics, and Toxicology, Cor-
nell University Medical College in New York City.
ALFRED C. WOOD, M.D Puiladelphia, Pa.
Demonstrator of Surgery and Instructor in Clinical
Surgery, University of Peuusylvania; Assistant Sur-
geon, Hospital of the University of Pennsjivania;
Attending Surgeon, the Philadelphia, St. Timothy's,
and St. Agnes's Hospitals, Philadelphia.
FRANCIS CARTER WOOD. M.D. New Youk, N. Y.
Instructor in Clinical Pathology. Columbia University;
Pathologist to St. Luke's Hospital, New York.
PHILIP ZENNER, M.D Cincinnati, Ohio.
Clinical Lecturer on Diseases of the Nervous System,
!!\Iedical College of Ohio.
* Deceased since issue of tirst edition.
VU
A REFERENCE HANDBOOK
THE MEDICAL SCIENCES.
MOSS, CORSICAN.— 3/oi(s»« de Corse, Codex Med.;
Jliliiiintliuciiriiiii, Wijim Moss, etc. The alga properly
kuowu by this uame is Ahidium Heliirinthrjcortun Ag.
(order Floridea), a small, brown, mai'ine plaut, with a
tufted thallus of simple or sparsely forked, pointed,
thread-like branches, from 3 lo -1 cm. long. It is a na-
tive of the ilediterranean Sea, and was formerly col-
lected on the shores of the island of Corsica, from which
it receives its name. The anthelmintic mi.xture, how-
ever, still to be found in European pharmacies under this
name, includes, besides this, several other related algae,
among which species of Ccntmium. Puli/xiphituin, Gif/ar-
tina, etc., are commonl_y met with. There is nothing
unusual in the composition of any of the above to e.\-
plaiu their former reputation as vermicides; they contain
iodine, bromine, soda, etc., in composition, and an abun-
dance of vegetable jelly.
As a medicine Corsican moss is of the past. A decoc-
tion is occasionally given to children as a domestic I'cmedy
for lumbrici, etc. 11'. P. B'lllts.
MOSS, ICELAND.— Cetrai!i.\. "Cetraria Islaudica
(L.) Ach. (Class LirhawK)" (U. S. P.). This is a good-
sized terrestrial lichen, with an upright orascending, king
and narrow, leathery, wavy-margined, olive-green thallus,
several times dichotomously branched or irregularly fan-
shaped, witli linear or cuneiform lobes. Apot/ieciri shield-
shaped on the upper surface of the thallus. This lichen
grows in great abundance on the surface of the ground
in open woods and heaths, and on mountain sides, in the
arctic and the colder temperate regions of both hemi-
spheres.
It is a valuable pasture plaut in the extreme Xorth,
and is also employed as an article of human food in parts
of northern Europe. Its medical em|il<iymeut is one or
two centuries old.
Diicd Cetraria is thus described :
From 5 to 10 cm. long, foliaceous, irregularly branched
into fringed and channelled lobes, brownish aliove, whit-
ish beneath, and marked with small, depressed spots;
brittle and inodorous; when softened in water, cartila-
ginous, and having a slight odor; its taste is mucilagi-
nous and bitter.
It .should be fi'ced from pine leaves, mosses, and other
lichens, which are frequently found mixed with it.
Co.MPOSiTiON. — About two-thirds of it is Lkhenin or
moiot starch (CbHjoOs)^, a starch-like substance, .struct-
ureless, soluble in boiling water, the solution gelatinizing
upon cooling. It is an article of commerce as a gelati-
nous mass or a white powder. The properties of this suli-
slauce are purely demulcent. Cktrann or cetmric ririd
(Ci Jlif.Oo) is the bitter ijrinciple, and gives to the drug
its slight medicinal properties. It occurs in commerce in
white masses of fine needle-shaped crystals, soluble in
boiling alcohol, in alkalies, and very slightly in water.
It is distinctly stomachic, like other bitters, and anti-
emetic. It also has the distinct property of increasing
the red corpuscles of the blood. It is therefore in an ex-
ceptional manner tonic. Isolicheniu is very similar to
Vol. VI.— 1
lichenin, but gives the starch reaction with iodine. It is
apparently not active.
Iceland moss is a very useful demulcent, and has gen-
tle tonic qualities, for which it is indebted to the two
active principles above mentioned. It has no specific
action upon the bronchi or hmgs. and its value in bron-
chitis, etc., for which it is mostly prescribed, must be
due to its combined demulcent and tcmic actions. Dose,
indefinite; a decoction is ofticial.
Cetrarin is given alone for all except the demulcent
properties, in doses of 0.01 to 0.03 gm. (gr.ij.-v.).
Ikary H. Rushy.
MOSS, IRISH.— Choxdrus. Carrageen. " Chmdnis
crisjius Stackhouss, and Gigdrtimt mamiUosa J. Agarch
(class A/ffii')" (U. y. P.). A reddish-brown or purplish
alga, with a flat, nianv-times forked or lobed thallus, of
Fig. 3JT5.— Irish SIo^s. (i.uorssen.)
very variable appearance, sometimes with broad, flat,
wedge-shaped, wavy, and iiiciseil. margined lobes, at
other times with linear, roundish, blunt, or emarginate
ones. It is from .5 lo 'JO cm. high, of a translucent, gelat-
inous consistence. The fructifications (cystocarps) are
embedded in the substance of the thallus. along the
smaller branches, wlicre they can be felt as little, wart-
like indurations brnealb the surface. This alga grows
abundantly along the rocky shores of ^^'ester^ Europe
mucous menibraiK'x.
KEFERENCE HANDBOOK OF THE MEUU'AL SCIENCES.
and Eastern America, tliat is, ou each side of llie North
Atlantic. It lias for a long time served as an iniiiUri-
tious food, and as the basis cjf veiretable jellies for the
table; it is also, in some localities, fed to cattle, and used
as a stutfino- for cheap mattresses. Its emi)loyment in
medicine is of recent date, and entirely unimportant. It
is coUccteil on the coast of Ireland and elsi'where in Eu-
rojie, also upon that of Xew Euflaud and elsewhere in
America. For medical or talile use it is Vilcacheil in the
sun. washed, and dried.
Dilsciuption. — Irish moss sliriuks coiisi<Ierably in diy-
jng, and if exposed to the sun, or reiieatedly wet and
dried, bleaches to a yellow color. It is. when dry. hard,
horny, and Ijrittle, but resiinies its original size and con-
sistence after long soaking iu water. In bniling water it
almost completely dissolves. Taste mawkish, mucilag-
inous, and more or less saline, according to the tlior-
onghness with which it has been cleansed. It will make
a stilT jelly with twenty or thirty times its weight of
water.
Co.MPOSiTiox. — Chondrus cou.sists chiefly of a muci-
lage, common also to many other algtt', swelling and
ne"arly dissolving in water, and drying to a hard, trans-
parent substance. It is precipitated by alcohol, and
holds tenaciously about one-seventh its weight of min-
eral matter. It contains, in common with other marine
algw, minute quantities of iodine au<l bromine com-
pounds.
5Ik1)IC.\i, Employment. — For colds, coughs, and es-
pecially acute pharyngitis, a thin mucilage (decoction)
made of Irish moss is a iiopular liouseliold remedy, and
corresponds exactly with the mucilage of elm and flax-
seed, made in the same w^ay. It may be sweetened and
flavoicd with lemon. Boiled with milk it makes an
agreeable jelly ("l.ilanc-mange"). often u.sed as a sick
diet, whose value depends on the milk.
ir. P. Bolhs.
MOSSES. — (Class Mnsci.) The l rue mo.sses, while very
ornamental, and of great biological and botanical inter-
est, are insignilicant from an economic standpoint, while
t^) the Materia Medica the_v yiehl not one important sub-
stance. Some of them, like Sphagnum and Polytrichnra,
have, upon totally unscienlilie gnumds. been used do-
mestically iu menstrual disorders. Others, like Vniiiirin
hj/gro)neti-irn. Hedw., have some reputation as expecto-
rants, the effect piobably depending chiefly upon the
syrup used as a vehicle. jMauy have been very useful,
iu the absence of more refined agents, as substitutes for
tow, oakum, and lint. The preceding, much used under
the title of Mosses, are not of this class at all,
Ileiiry H. Utishij.
MOUNTAIN SICKNESS. Sn- Allitii(?,.% IT/gh.
MOUNTAIN SPRINGS.— Lancaster County. Pennsyl-
vania.
Post-Offick. — Ephrata. Hotel.
Ac( ESS. — Via Reading Railroad. Trains leave Reading
Terminal, at Twelfth and Market Streets. Philadelphia,
daily, except Sundays, at 10 .\.M. and 4 p.m., arriving at
the "springs at 12:44 and 6:4,5 p.m.
This jileasant resort is located on the western slnpe
of tlie Ephrata Mountain, one of the highest points
of land in Lancaster County. JIany charming features
of climate and scenery are united heiV. The visitor will
find pure air, a comfortable and well-kept hotel, excel-
lent fishing, and delightful surroundings at this summer
resting-place. The water of the Mountain .Springs is
celebrated for its purity and s]iarkle. It has not been
analyzed, but we are credibly informed tliat it contains
iron and carbonic acid gas. The springs discharge about
three thousand g:dlnns per hour. Juinis K. Ci-nok.
MOUNT CLEMENS MINERAL SPRINGS.-Macomb
County, ilicliigan.
Post-Office. — Mount Clemens. Hotels.
Access. — Prom Detroit via Chicago .■uid Grand Trunk
Railroad, twenty miles northeast These waters are very
strong brines, as shown by the following analyses made
by Prof. S. P. Duffield:
OxE U.xiTED St.mes Gallon" Cont.iixs:
Snlids.
Mount
Clemens
Mineral Well.
Grains.
Media Spring.
Grains.
Soolbad
Spring.
Grains.
faleium carbonate
Mai?nesiuni carlHmate —
0.98
10O..i(!
Il,!l(i0.0
9:}4..5
(iiS.tS
.07
6.37
27.6
91.0
■ ' It'.lV '
Trace.
11,741.0
8..5
29.0
28.0
8..T
.07
Trac«.
Trace.
Trace.
44 0
Potassic salts
Sodic salts 1
Calcie salt'^
Trace.
11,181.0
iMairiiesle salts \
Sudiuiii (ill' Hide
Calcium cldorule
.Matriicsiuiu chleride
.MaL'tii'siuiu iodide
Ma!-Micsium ijnnnide
Iron
Trace
.\Uunina
silica
11.21
il3
Trace
Xotal
13.6.>1.3.3
11,921.07
11 ?;iti 26
Gases.
Hydrngen sulphide or di-
liydi-ic sulphide
Carh'ijiic acid
Nitrei^eii
Cubic inches.
411.00
.")..S"")
Present.
Cubic inches. Cubic inchi
40.(KI
SJ.OO
These watei-s reseinlile tho.se f)f Achsel-3Ianustein, iu
Bavariti. It is nec-essary to dilute them both for iuternal
use and for liathing. They have acquired considerable
reputation in the treatment of scrofulous disorders of the
skin, bones, aud joints, ami for the improvement and
even cure of paralysis when the disease depends chiefly
upon innervation without decided lesion of the brain or
spinal cord. Cases of chronic rheumatism with stifteued
joints and obstinate cases of neuralgia may also find re-
lief. The waters are used commercially.
MOUNT DESERT. MAINE. -The island of Mount Des-
ert, the fimi'-t I'lie nil the New England coast, lies off
the coast of JMaine, netirly midway between Portland and
Eastport, about one hundreil aud ten miles east of Port-
land and forty miles southeast of Bangor. It is a very-
popular summer resort and has wide notoriety.
The island has an tirea of about one hundred S(iuare
miles, and is fourteen miles long and eight miles wide
at the widest part. A chain of mountain peaks extends
across it from southeast to uortliwest. these peaks being
separated from one another by deep gorges and ravines^
which at several points descend below the level of the sea.
The average elevation above the sea-level is almost ,500
feet, and Cireen Jlountain, the highest point, is 1,527 feet
in height. The coast line is liold and rocky and much in-
dented. "Somes Sound." a fiord of the .sea seven miles
long, runs up to nearly the centre of the island, cuttins
through the centiv of the mountain range. The various
indentations, or bays, furnish many good liaibors, such
as Bass Harbor, Southwest Harbor, Northeast Harbor,
Seal Harboi-, and Bar Harbor — the finest of all. lying
ujion the broad Frenchman's Bay.
The island is well wooded with pine, balsam, tind
sjiruce, although numerous fires have made sad liavot-
with the forests. Inland, in the valleys and liiirh np
among tlie mountfiins, ai-e many beautiful lakes and
ponds, the most extensive being Eagle Lake at the fool
of Green jNIouutain, Echo Lake. .Jordan's Pond, and Loii"-
Pond.
Lying about ]Mount Desert are numerous smaller islands
which aie attractive and picturesque, the priucijial of
2
REFERENCE HANDBO(_)K OF THE MEDICAL SCIENCES.
mucouK membranes.
wliich are the Porcupines at Bar Harbor, the Cranberry
Islands, near Southwest Harbor, and Bear, Baker's, Duck,
Greening's, and Sutton Islands. "The western sides of
the niduntain range slope graduallj- upward to the sum-
mits, l)ut on the cast the.v confront the ocean with a series
of stupendous cliffs" ("Appleton's General Guide to the
United States and Canada ").
The island is of granite formation, exhibiting evidences
of the great glacial movement ; and the .soil is dry and
porous. On the northern side the mainland is separated
from the island only by a narrow stream, and a bridge
affords conunuuication between the two. The scenery
of the island is most attractive, varied, and grand, af-
fording innumerable delightful e.xcur.sions by land and
by sea. Good roads and footjiaths extend in every direc-
tion, and in the town of Eden alone there are one hun-
dred and twenty miles of excellent road. The reader is
referred to the Various guide books for an enumeration
and description of tlie mauj' excursions and various
points of interest. Mount Desert has become such a popu-
lar resort that every facility is afforded the visitor for
enjoying and exploring its beauties. Local .steamers run
from' one point to another of the island ; hotels and board-
ing-houses of various prices abound ; and tlie island can
be easily and comfortalily reached either by rail or by
boat from Boston and Portland.
Bar Harbor is the most frequented and fashionable re-
sort, and the cottage life has quite supplanted that of
hotels and boarding-houses. Here beautiful and luxuri-
ous cottages abound, and in the season tlie social life re-
sembles that of New York or Philadelphia in winter.
Every kind of outdoor and indoor diversion isaft'orded.
There are many clubs and churches of various denomina-
tions. The Kebo Valley Club offers opportunities for
golf on its attractive grounds, and sometimes during the
summer tlie North Atlantic Squadron pays a visit to Bar
Harbor, and during " Squadron Week " social gayety is at
its height.
The water suppl}- of Bar Harbor is taken from Eagle
Lake, two hundred and foi-ty feet above the village, and
is abundant and pui-e. There is also an extensive and
thorough system of sewerage. There are adequate jirotec-
tion against fire; man}^ shops and good markets: excel-
lent postal, telegraph, and telephone acconunodations;
two banks; a good police force; an intelligent and
efficient board of health, and good medical service. The
streets are lighted by electricity, which is also furnished
to private residences.
Northeast Harbor and Seal Harbor are mucli frequented
by ■■ cottagers. " and at the former is the attractive Episco-
pal Church founded by Bishop Doane of Albany. Soutli-
west Harbor is beautifully situated at the entrance to
. Somes Sound, and is a favorite resoi-t for those desiring
a more quiet and simpler life. Indeed, almost any iior-
tiou of the island has its especial attractions for tlie sum-
mer resident, and one can visit the island year after year
and always find some new portion to explore. "On the
coast of America it (Mount Desert) has no rival, except,
perhaps, at the bay of Rio Janeiro" (Api)leton, loc. cit.).
Through the kindness of William Miller, Esq., of Bar
Harbor, who made the observations, and the chief
weather forecaster at Boston who placed them at my dis-
posal, the following comiiilation lias been made of the
climate of Mount Desert. In general it may be said that
the summer climate is a cool, invigorating one, with ii
fair number of clear days and the average amount of rain
for this latitude. Fogs are not infrequent and they some-
times last for several days or even a week.
There are no recorded observations of the liumidity,
but it cannot be very different from that of Eastpurt on
the same coast, about eighty miles to the northeast. Tliere
the average relative humidity for Jul}' is 78.7 per cent. ;
August, 78.9 per cent., and for the year 76.3 per cent.
The variations in temperature are con.siderable, and the
air is apt to be chilly and damp. Such a climate would
hardly be suitable for the delicate, for those who had a
tendency to or were suffering from pulmonary or bron-
chial troubles, or from neuralgia. For any one who
needs the influences of a bracing, cool, summer climate,
or for a convalescent from any acute disease, who is well
on the road to recovery, it can be recommended. It is
also useful in some cases of neurasthenia and insomnia.
Some patients who are subject to hay fever find im-
munitj' on the island at one or the other harbors, espe-
cially "at Northeast Harbor. Eihcard 0. Otis.
MOUTH, DISEASES OF. See The Appendix.
MUCOID DEGENERATION, ^ea Degenerations, etc.
MUCOUS MEMBRANES: INFLAMMATIONS OF.—
The suliject of iiulaiiiiiiaiioiis of the mucous membranes
is treated in this article in only a very general way.
The specitic inflammations (diphtheria, tuberculosis,
syi)hi!is, rhinoscleroma, gonorrha'a, erysipelas, influenza)
will be discussed under their respective heads; the ob-
ject of this article being to include only the simple non-
specific forms of inflammation of these structures accord-
ing to the definition of inflammation as given by Ziegler
— namely, a tissue lesion accompanied b.y circuhitory
disturbances, an exudate, and tendency toward repair.
Etiolouy. — Although inflammations of different mu-
cous membranes have .S(nuewhat different etiological
factors, all have to a varying degree a comnKm etiology.
The causes of inflammations of the mucous membranes
are direct or indirect. Among the indirect causes are
changes in temperature, gout, rheumatism, bad hygiene,
decayed teelli, diseases of the ciiculalory. digestive, or
respiratory systems, reflex influences, and idios}"ncra.sy.
The direct causes of inflammations are thermal, electri-
cal, chemical, mechanical, neoplastic, and bacterial.
The application of hot or cold liquids and instruments
to the mouth, pharynx, vagina, or urethra may cause a
stomatitis, pharyngitis, colpitis, or uretliritis. Breathing
of hot air ma,v cause a tracheitis or a bronchitis.
Electricity, applied by means of an electrical sound to
the o'sophagus or urethra, may cause an inflammation of
the mucosa.
Certain chemicals, both organic and inorganic, produce
inflammation" when they come in contact with mucous
membranes. The irritating substance may be mineral
acids, alkalies or salts, gases, organic compounds, and
Climate of Mount Desert Island, Maine, Latitude 44.38° N., Longitude 68.36° AV., for the Ye.vrs from
1890 to 1901. Observations of William Miller, Esq., of Bar Hakbou.
Data.
January.
April.
June.
July.
August.
Septeralier.
October.
Year.
Temperature (degrees Fahrenheit)—
21.08°
i!>.;i
30.7
11.4
49.0
- 11.5
5.ti0
N.W.
11.2
8.2
19.4
42.4°
21.7
5:3.6
31.9
72.8
18.«
3.14
E.
15.1
6.:i
21.4
59.48°
22.8
71.1
48.3
86.3
37.8
2.85
S.W.
16.5
7.5
24.0
65.9°
22.2
77.2
.55.0
90.5
45.0
3.86
S.W.
18.3
6.(1
24.:^
61.9°
22.2
76.3
54.1
89.0
43.S
3.28
S.W.
17.6
6.5
24.1
.58.6°
22.0
70.1
48.1
87.6
m.-i
3.77
S. W.
15.3
7.S
2;i.i
48.5=
•z\:a
59.3
;is.o
73.8
24.4
4.62
8. W.
14.3
S.3
■i?..r,
39.4°
Mean I tf colde'^t .
S.W.
Weather-
Average number of partfv clouiiy (lays
Average number of clear and partly cloudy
ITIllcoilH ITlciiibrallcs.
ITIiloous ITleillbl-alles.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
bacterial toxins. Nitric, sulphuric, lu- liydrocliloric
acid, sodium or potassium liydroxidc, and nitrate of silver
will cause a stoniatilis, I'liinitis, or jiliaryiiijilis, and. if
the irritants arc swallowed, an icsopiiai^ilis and gastritis
may follow. Gases (liydrogcn sulphide, am-
monium sulpliide, cldorine) can.se an iiillamma-
tion of the respiratory tract or the jdiaryux.
The organic conijiounds and the to.\ius jiro- ""
duce marked ett'ccls on tlic diiiestivc tract.
Tliese poisons arc taken into the body as such
or the)' result from decomposition (jf food or
are germ excretions. If the irritation pro-
duced by these sulistauces is marked, a gastri-
tis or an enteritis will follow.
The mechanical agents which cause intlam-
mation are foreign bodies. Poorly fitting pes-
saries may cau.se colpitis, au improper ]ilate in
the mouth a stomatitis, or masturbation may
cause a urethritis. Trauma of any sort is a
direct etiological cause of many non-pin-uleut
inflammations of mucous membranes, and is tlie
avenue of entrance of germs, so that it is a pre-
disposing factor of many purulent intlamma-
tory conditions. Of the foreign bodies, dusts
of certain trades (mining, marble cutting, paint-
ing, milling) cause a chronic intiammat ion ( )f t he
respiratory tract. The introduction of foreign
bodies into the vagina, uterus, bladder, or nose
will produce similar conditions unless they are
removed.
Bacteria are the most important etiological
agents of intlammation. The germs may be
sa)irophytic or patliogenic. causing iidlam-
mation by decomposition, or becoming virulent
antl ])alliogenic. The pathogenic bacteria
produce intlammation by- means of their toxins
which act as irritants.
Classific.wions of Infl.vmmatioxs of
Mucous Membr.\nes. — The factors which en-
ter into inflammatory phenomena are the tissue
lesion, circulatory di.sturbanee, the exudate,
and the tendency toward repair. Base<l upon this the
following cla.ssiticatiou of intlammations of mucous mem-
branes is olfered.
Catarrhal.
Muco-purulent.
Purulent.
p^itirino-i)urulent.
I Fil)rinous.
I nem(.irrlia,gic.
[ Gangrenous.
\ Hypertrophic.
/ Atro])hic.
tis. In chronic atrojihic inflammations, on the other
band, the glands and epithelial lining cells undergo
atroijhy such as occurs in chronic atrophic gastritis.
Acute Caiarrhid Injiiuitmation. — Any mucous mem-
w-^^i:':
11
-«/i4^
'^■^?
i^.r.Tr«
".
Intlammations of
JIucous ^Membranes.
Acute.
Chronic.
According to the amoimt of the reaction on the part of
the connective-tissue elements, tlie general division of in-
tlammations into acute and chronic is made. Tlie term
acute isai)]ilied totho.se intlammations in which the fixed
connective-tissue cells have not begun to show a reactive
change other than the sudden defence needed to protect
themselves from the injurious agents. No fibrol.)lasts or
angiobla.sts are seen in sections of such inliaminatory
processes.
According to the lesion and exudate which they show
the acute inflammations of nuicous membranes may be
divided into catarrhal, muco-iuirulent, purulent, tibrino-
jiurulent, fibrinous, hcinorrhagic, and gangrenous.
Sooner or later, if the irritation causing the inflamma-
tion continues, the fixed comiectivc-tissue cells, especially
the cndotlielium, siiow a reactive change, and form a
fibroblastic connective ti.ssue, which later becomes tirra
scar tissue.
(Jhronic inflammations of imicous membranes are di-
vi<leil into hyptrirophif and ulmphir. depending iiixm the
cli.anges in the nuico.sa' themsclvi'S. Chronic hyper-
trophic inflammations tire characterized by hypertrophy
of the e|)itlielial elements of the mucos.a^ such as occurs
in ehiutiic liypertro|iliic rhinitis or in clu-onic ciiiloinetri-
Fii. SBTfi — \cute Catairfial BiomhUis rt, Cihateii cells, n,. deep celt lavers h,
jfiililet lells, (, marl»(dl\ mu(<iij (cits. (,,iim(ciid cells vMth uuKcud luideii.*;
»/, dtJsqii niiated irlim Id < p!N ( di squamiti d t ilutt^ i 1 1 its 1 liMtstfdi j s of
liiuius, f] t ivi r iif strin.j\ mm its md i us t 1 1 us( 1 s </ ■ \ ri I m lit r fa
limcnus pi itid Clled w itli imu lis and < t lis ^f, d( s (u im ut il i [ itbi liiilii ' t ttie ex-
iiiturv dmt. i. nitait epitlii Iiiim of tin i \ui ti>n duct, h, bwollen hvaline
Insemeut membrane, ?, r(tnne< ti\e tissue (»f the mucosa, partly mtlllratetl \\ith
cells; Hi, dilated blood-ve.ssel ; n, mucous ptaud tjlled with mucus: ?),, lobule of
■ mucous pland without mucus: e, miirratin.!^ cells in the epitheUiuu : 7*, cellular
intlltration of the connective tissue of the mucous glands. (Ziegler. )
braue (uKuith, nose, pharynx, larynx, etc.) may be the
seat of a catarrhal inflammation. On macroscopical ex-
amination, the surface of the mucous membrane presents
a shiny, glistening coating due to a thick, stringy, more
or less homogeneous exudate. Sections of these mucous
membranes show that their epithelial cells are swollen
and the cell iirotoplasm is reiilaced by a finely granular or
slightly stringy homogeneous substance (mucin), which
stains deeply with Uelatield's h;tmafoxylin. The nuclei
of these cells are pushed to one side or toward the base of
the cell and stain faintly with nucletir stains. The epi-
thelial cells lining the glands show a similar change. Tlie
subnuicosa is cedemaious and may show an infiltration of
leucocytes and few red blood cells. The a>dema and the
leucocyte exudate may extend into the muscular layers.
Aoitc Muco-Piiriileiit IriJiiniiiiKitidn. — Change of "tem-
lierature, some irritaling dusts or gases will ]H-oduce in
mucous membranes, especially of the respiratory tract,
au inflammation characterized by a light yellow", semi-
translucent, slightly stringy fluid exudate" which is te-
nacious and adheres to the mucous membrane. The
mucosa is swollen and the vessels are injected. Micro-
.scopically the picture presented is the same as that in a
catarrhal intlamniation. with the exception that a more
marked hdicocyfe infiltration exists in all the layers and
the exudate contains more leucoeytes than doe's that of
the eatarrlial form.
Acnle Piindcrit liij!tiinm((tioii. — Bacteria are the most
frequent causes of this form of inflammation of a mucous
membrane, but certain foreign liodies and drugs will pro-
duce identical ))liciioniena. Foreign bodies in the nose,
(esophagus, or bladiler Avill cause a purulent rhinitis,
fcsophagitis, or cystitis. Turpentine or phenol in the
mouth will produce a similar condition, and bacteria will
causea purulent intlammation of any mucous membrane.
Macroscopically. the mucous membranes affected with
acute purulent iiilhinimation are reddened and swollen
REFERENCE HANDBOOK OF THE 3IEUICAL SCIENCES.
Kltioous Jtlenibranes.
Iflupoiis Kleinbranes.
and tln'ii- surfaces are covered with a thick yellowish
or greenish-yellow, semifluid, opaque exudate. Micro-
scopically, the epithelial cells lining the mucosa show a
simple coagulation or liquefaction necrosis. The exudate
is composed of cell debris, desquamated epithelial cells,
and necrosing leucocytes. The connective tissue of the
mucosa and .submucosa, and often of the muscular layer,
shows a marked leucocyte infiltration which may contain
a varying number of red blood cells, and the vessels are
congested and the connective-tissue fibres are swollen,
due to a'dema.
Acute Fibvino-Purnleiit Inftammiition.- — The same
agents which cause a purulent inflammation may cause a
fibriuo-puruleut condition, depending upon tlie lesion pro-
duced. Cystitis which follows sounding of the bladder
or results from an enlarged prostate or from calculi is very
frequently a fibrino-purulent inflammation ; and a foreign
body in the vagina or rectum maj' cause a similar condi-
tion. The mucous membrane is covered by a yellowish-
gray or greenish, tenacious exudate which adheres to the
surface and when it is pulled off leaves a reddened surface.
The mucosa is thickened and reddened, and the submu-
cosa and muscular coats are o;dematous and congested.
Sections of the organ affected with fibrino-purulent in-
flammation show an exudate made up of a varying
amount of stringy, granular, or hyaiine fibrin, whicli
forms a network enclosing desquamated epithelial cells
and collections of necrosed or necrosing leucocytes. The
epithelial cells of the mucosa are desquamated and show
fatty degeneration, cloudy swelling, or necrosis. In the
subcpitlielial connective tissue of the mucosa and in the
submucosa are masses of leucocytes which may be de-
generating and wliich are surrounded by oedematous
connective-tissue fibres.
Acute Fibrinous IiiflnmMatioii. — The ordinary pus
germs in the rectum, vagina, mouth, pharynx, or nose
ma)- produce an acute fibrinous inflammation. Fraenkel's
pneumococcus and Friedliinder's pneumobacillus will
produce on the tonsils and in the pharynx, larynx, and
nose a similar condition ; furthermore, this form of inilam-
mation is the cause of death in cystitis due to enlargement
of the prostate or to calculi, and fibrinous proctitis or
enteritis may follow prolonged rectal feeding in cachectic
individuals." The difference between this form of in-
flammation and fibrino-purulent inflammation is shown
in the character of the membranous exudate. In the
fering from the diphtheritic membrane due to the Klebs-
Loettler bacillus in the fact tliat the latter can be with-
drawn only with great difliculty and leaves a depressed
surface which looks like an ulcer. Microscopically, the
mucous membrane which is the seat of an acute libri-
nous inflammation is covered with an exudate composed
of granular, stringy, or hj'aline fibrin, which forms a
firm network enclosing few leucocytes, red blood cells,
and desciuamated epithelium. The epithelial cells lining
the mucosa show a simple or coagulation necrosis, and
Tr~- it*.. .« *-. . . ^^ _ ;. - - -
'.'J 1
" »/ e
Fig. 3377.— Acute Fibrinous Inflammation of the Uvula, a. Normal
epithelium; )>, conneetive tis.<ue ol the mucous membrane: c,
reticulated fibrin : ci, connective tissue of the mucosa infiltrated with
fibrin and round cells, and partly necrotic : f, blood-vessels ; /,
hemorrhage; (;, masses of microcijcci. (Ziegler.)
former the color of the membrane is pearly white or
light yellow streaked with red, and the metubrane itself
is spongy and adherent to the surface, and when it is
forciblv removed it leaves a reddened svirface, usually dif-
=:-::-;.-^<:
^,
Fig. 3378.— Chronic Atrophic Enteritis, a. Glandular layer reduced
to one-half its height : b, nuiscularis mucosie ; c, submucosa ; d,
muscularis; f, mucous membrane entirely atrophied. (Zieeler.)
the nuclei do not stain ; fine threads of fibrin separate the
epithelial cells and extend deep into the submucosa:
leucocytes and red blood cells are scattered throughout
the mucosa and submucosa and to a slight extent in the
muscular layers, and the connective tissue of all the lay-
ers is markedly a>dematous.
Acute Uemorrhaciic Infainmntion . — The poisons pro-
duced by putrefaction outside of. and taken into, the body,
cause a hemorrhagic gastritis and enteritis. Turpentine
and croton oil in large doses produce a similar condition.
The mucosiB vary in color from dark red to brown and
are greatl)' swollen, and the contents of the stomach and
intestine are streaked with fresh and decomposed blood.
Microscopically, the epithelial cells lining the lumina
show cloudy swelling, fatty degeneration, simple necio-
sis or coagulation necrosis ; the spaces between the epi-
thelial cells are occupied by cedema and red blood cells,
the connective tissue of the mucosa and submucosa
shows a varying number of red blood cells scattered or
collected in small masses, and all the blood-vessels are
greatly congested.
Ac^iie Gangrenous Inflammation. — The bronchi fre-
quently become the seat of Ibis form of inflammation ;
in some of the cases the disea.se having originated by the
penetration of an ulcer from an cesophageal diverticulum
into the bronchi, while in others it represents a situple ex-
tension of a gangi-enous process in the lung. The iires-
ence of foreign bodies in the nose, oesophagus, or vagina,
or the occlusion of the nutritive vessel of any mucous
membrane, or a simple trauma may e'S'entuate in an acute
gangrenous inflammation. The condition is accotiipanied
by foul odors, caused by hydrogen sulphide, ammonium
siilphide, etc. The mucosa in the early stages resembles
that of acute purulent inflammation, with the exception
that the pathological changes are more marked. In the
latei- stages the mucosa may slough away and the necrosis
may bo .so extensive that the deeper layers are involved.
Chronic llypertrophic Inflammiition. — This form of in-
flammation is most often found in the uterus, but hyper-
trophic rhinitis is common. The mucous membrane is
thickened and varies in color from gray to gi-ay-piuk ;
the glands of the alTecled mucous membi-ane become hy-
pertrophic and some become cystic ; and, finally, I hi' con-
nective tissiie of the mucosa becomes increased in bulk.
Chronic Atrophic Inflammation. — The prolonged use
of alcohol will cause tliis condition in the stouiach, and
caries of some part of the botiy framework of the nose
or the mere presence of a foreign body somewhere in the
nasal cavities is competent to'prodtice chronic atrophic
rhinitis. The mucosa' are thin and in the stomach the
outer layers become atrophic; the glands of all surfaces
iniilleln. [sills.
Multiple Hyalosero-
KEFERENCE IIAXPBOOK OF THE MEDICAL SCIENCES.
affected sliow markoil lUropliy smd tlicii' eiiitlielial rells
show mucmis ilcneiicmlinii ; iinil llic roniiedive tissue of
the mucosa and submucosa is greatly increased aud may
cause coustrictiou of the lumina of some glands. lu the
latter event these glands become cysti<', and the muscular
coats undergo marked atrophy.
I-W(k'i-ick A. Baldwin.
MULLEIN. Sec SerophulariacexB.
MULTIPLE PROGRESSIVE HYALOSEROSITIS.—
DEFixmoN. — An inllanimatiuy allerlidii <>f llie serous
membranes, of chronic and progressive development,
characterized b}' a peculiar overgrowth of Hbrous tissue
witli hyaline metamorphosis.
Thisdisease is a very remarkable one, and, judging from
published cases, somewhat rare. E.xamples have been
recorded in Germany and Austria chirtly by JIamboursin.'
Wei.ss,'- Curschmaun,^ Vierordt,'' Kiedel,'' Rumpf," Pick,*
Schupfer,' Siegert."' Schmaltz and AVeber," Rose,'- Stra-
jesko;'^ in England by Hale White*; in America by
Nicholls'* aud Herrick.'" It is only lately that a com-
plete study of this disease has been attempted (NieboUs),
and now that special attention has been called to it we
may exjiecl in the near future to have many more eases
recorded, for the disease is probably not so rare as has
been thought.
The alTection may begin in various ways, so that differ-
ing clinical types are produced. Sometimes the capside
of the liver is chietly affected, and it is to this class of
cases that the terms " diffuse chronic hyperplastic peri-
hepatitis," "chronic deforming perihepatitis," "Zucker-
gussleber," iiave been applied. In other cases it is
the pericardium or the pleura that is lirst involved.
Nevertheless, in whatsoever way the disease maj' begin,
or in whatever part it may attain its greatest intensity,
it is to be noted that the process is everywhere esseutiall}'
the same, since it becomes diffuse and involves one serous
membrane after another in a steady progression. Conse-
quently the ivvm multiple progrci<Kii-e hyaloserositis, denot-
ing as it does an intlammatory process at once chronic
and continuous, aud emphasizing the peculiar hyaline
change which is so striking an element in the anatomical
picture, is perhaps the most suitable term to employ.
Distribution. — The disease appears to be widely dis-
.seminated, being found in all countries and all climes;
sex appears to have but little importance; theea.ses hith-
erto recorded have been chietly in males. With regaril
to age, the young-
est patient affect-
ed was aged four,
the oldest eighty
years ; those be-
low middle age
are probably the
most likely to be
alfected.
iloHIilD An.VT-
OMY.— T%vo types
of the alfection
have been de-
scribed, the sjiora-
dic and the diffuse.
E.xcept for jiectd-
iarities in local-
ization aud ex-
tent, these forms
are, anatomically
speaking, essen-
tially the s;ime.
The characteristic
lesion is the for-
mation of isolated
nodules or contin-
uous sheets upon
the serosie of a pearly white material having a dense,
cartilaginous consistency. Tliis substance "has been
^Oiiiijared to the sugar upon a cake (Ziic/ctiyuss) and to
"-tr^-
Fig. 3379.— Section of I.iver. Sliowins.' well
tbe Glisson's Capsule Thrown into KoMs.
with the Deposit of Hy.iUue Fibrous Tissue
upon the Surface. (.Nieholls.) (Wlnekel
iilijettlve No. 5, without eyepiece.)
jioreelain. When forming a detinite membrane it varies
ill thickness from a few millimetres to from 1 to .5 cm., and
can be readily striiijied off the subjacent organs without
injury to their
substance. On
sect i on the
membrane has
a semiti'anslii-
cent, almost
gristly appear-
ance.
lu the spo-
radic form the
material usii-
;dly forms llat-
tened plaijues.
but may occur
in elevated or
even polypoid
nodules. The
favorite sites of
localization are
the capsules of
the spleen and
liver, the dia-
phragm, and
the pleurai.
When affect-
ing, as the
process usual-
ly does, more
than one ser-
ous sac, no
order of in-
volvement i s
absolute, b u t
combinations
are numerous.
AVith regard
to the diffuse
form, in the
majority of cases the capsules of the liver and spleen, the
pericardium and the lower portions of the pleune are in-
volved. It is the rule ahso for more or less implication of
the general peritoneum to occur. This results in indura-
tion and contraction of the great omentum and the mesen-
tery ; the omentum is f I'eqiu-ntly converted into an ii regu-
lar tumor-like mass or a thick fibrous cord crossing the
abdomen transversel}-. The contraction of the mesentery
leads to dislocation of the intestines so tliat they lie
bunched upaloug the spinal coliunn. Rands of adhesions,
fibroid and velamentous in character, are found connecting
adjacent structures and are likely to be met with between
the liver and spleen and the diaphragm aud between the
coils of intestines. While all or most of tlie serous mem-
branes are involved in the ]irocess. tliey do not all pre-
sent the same grade of affection. Thus, while one mem-
brane presents the tyjiical "icing" appearance, the other
serous sacs maybe obliterated Ijy simple tibroid adhesions
or traversed by bauds, or in other cases may contain a
fibrinous or fibi'ino-purulent exudation.
In the perihe]iatic form, where the brtmt of the disease
falls upon the liver and diaiihragm, the liver is usually
diminished in size aud much altered in shape, becoming
somewhat globular; the edges are rounded and the ante-
rior border is often rolled back upon the upjier surface.
The gall-bladder is usually contracted aud enclo.sed in ai
dense mass of hyperplastic tissue. The surface of the
liver, after the investing crust is removed, which may
readily be done, is smooth or at most slightly uneven.
On section the organ usually shows brown atrophy, fatty
degeneration, with some passive congestion. Cirrhosis
of the organ does not occur as a rule; at most there is a
slight thickening of the septa passing in from the cap-
sule. The sjileen is often enlarged. "generally covered
with the ■■ icing " membi-aue. and deformed. AVith regard
to the pleura', the right is as a rule nioi-e .seriously involved
than the left; the bases of the sacs are the sites of election
Fu;. iJHi. Si'dionof ivrit -n] .Meiiibraiie in
the " Zin-krrL'u.^s " rnn.lirinn. shnwinp Pen-
vascular LfiK-orytosis and Hvaline Degen-
eration of the Superlidal Fibrous Tissue.
(Nicholls.l ( Camera lueida (irawiug ; Reich-
ert objective No. 3.)
REFERENCE HANDBOOK OF THE 3IEDICAL SCIENCES.
.tliillrin. [<>itis.
jnillIi|>lo Hyalo»;i-o-
for the process. The lungs are usually atropliied and
partiall)- collapsed. Chronic adhesive pericarditis, or,
more correctly, mediastino-pericarditis, is frequently
found. More "rarely an acute c.\udative pericarditis is
present, and more rarely still the pericardiinn may lie
normal. Occasionally the ]iericardial sac is only ])ar-
tially obliterated, and then the adhesions are denser on
the right side toward the diaphragmatic surface. Cal-
careous deposits are sometimes met with in the adhe-
sions. Tlie heart is often small and may show the results
of pericardial adhesion, namely, dilatation and insutfi-
ciency of the valves.
Tlie kidneys in most instances show no special abnor-
mality except possibly congestion. In a few cases inter-
stitial" fibrosis has been found. The digestive tract shows
but little disturbance; the stomach and colon may be
found adherent to adjacent parts. A duodenal ulcer was
fouud in one case. Icterus is never present, unless the
case is complicated by cirrhosis of the liver or by obstruc-
tion to the common bile duct. As complicating condi-
tions which hasten the fatal termination, acute pneu-
monia, pericarditis, pleurisy, peritomtis, and osteomalacia
may be mentioned. A striking feature of the diffuse
foiin is ascites, which is usually extreme. The ascitio
fluid is of pale straw color, high specific gravity, con-
taining flakes of fibrin, and has all the appearances of an
inflammatory exudate. Anasarca is usually not marked
until toward the end.
In addition to the form .just described it should be
stated that an increasing number of cases of serositis of
this hj'perplastic type are being reported as due to tubercu-
losis. " It is beginning to be recognized that tuberculosis
is not necessarily destructive, but, on the contrary, may
be constructive ; — instead of extensive caseation and soft-
ening we may have the formation of a hyperplastic hya-
line "membrane with little or no caseation. In many
cases it is only the discovery of the specific bacillus which
will reveal the true nature of the process. It used to be
thouglit that cases of the jicriheiiatic or "Zuckerguss-
leber" type, to which Curschmaim tirst drew attention
in his classical paper, were never due to tuberculosis ; but
this is certainly incorrect. Recently Strajesko (he. cit.)
and James B. Herrick {lee. eit.) have recorded typical
cases undoubtedly of tuberculous origin.
Hyperplastic tuberculosis of the serous membranes is
in my experience not verj' uncommon, but it is certainly
rare 'for it to attack the capsule of the liver, the pericar-
dium, and the right pleura in such a way as to simulate
Cur.schmanu's " icing " liver and atrophic cirrhosis. The
lesions produced are not unlike those of the simple or
non-tuberculous form, the main difference being that the
process is not so liable to be con-
centrated on any special organ,
but is more generalized over the
seross. Again, ascites is usual-
ly less marked and fibroid adhe-
sions are more numerous. The
membrane produced is rarely
smooth and glistening, but is
covered with fibrin and shaggy
adhesions. A hypertrophic
fibro -hyaline membrane may be
produced also in this form, but
in it caseous masses can gener-
ally be made out. disclosing the
etiology of the case; the casea-
tion may, however, be very
trifling.
Microscopically the mem-
brane in the simple form is
composed of parallel laminae
of connective tissue showing marked hyaline thickening
of the fibrilla?. In the deeper portions newly formed
capillaries can be made out with some perivasoilar leuco-
cytosis. and '" Mastzellen " are numerous. Mnannci/piculli/
the membrane has all the appearance of an organizing
deposit upon tlie .serosse. — a deposit in whicli hyaline de-
generation constitutes the most striking feature. In the
tuberculous form tie connective-tissue fibrillar interlace
freely, and there are usually multiple areas of caseation
with numerous giant cells. Hyaline degeneration is also
present, but is rarely so marked as in the simple form.
Tubercle bacilli can visually lie demonstrated readily on
making smears from the deposit.
In the tuberculous form, unlike the first variety, the
liver is usually enlarged and often shows signs of miliary
tuberculosis with slight interstitial fibrosis. Old tuber-
culous foci are usually fotmd in the lungs, pleura;, and
peribronchial glands. " The case often terminates with a
generalized miliary infection.
Etiology .\xd "P.\thoc;exesis. — Two views have been
advanced as to the causation of the disease. The tirst
is that of Pick, who regards the primary condition as
an adhesive pericarditis which leads to portal obstruc-
tion and the so-called "cardiac" cirrhosis of the liver,
eventually resulting in ascites and thickening of the
liver capsule. The objections to Pick's view briefly are,
that cases occur in which pericardial adhesion is absent,
and in most of the recorded cases it has been shown that
portal stasis was not preseut; nor, again, does the devel-
opment of the physical signs accord with what should
occur were Pick's view correct. It must be said that
all those who have carefully studied the ciuestion are
agreed that the overgrowth of fibrous tissue and the as-
cites are due to an inflammatoiy process involving the
various serosa?, ilost cases give a history of some pre-
vious acute inflammatory disease, and the deveiopmeut of
the lesions can usually be traced from one serous mem-
brane to another. Cases have been known to follow
acute rheumatism, typhoid fever, whooping-cough, mea-
sles, malaria, and perityphlitis. The transmission of the
infective agents f nun one serous sac to another takes place
by means of the lymphatics. In the tuberculous form,
which is anatomically strictly comparable to the simple
type, the true nature of the disease is of course obvious.
With regard to the ultimate nature of the process in the
simple form, some little doubt must still exist ; but it is
probable that micro-organisms of low virulence are at
work.
The inflammatory process usually begins in the peri-
toneal cavity in the form of a hepatitis or perihepatitis,
or. more rarely, about the stomach and duodenum: it
extends to the" right pleura and eventually to the peri-
cardium. Next m frequency, the primary lesion is a
chronic pericarditis with adhesion extending to the right
pleura and thence to the peritoneum ; more rarely still,
chronic pleuris_v may extend to the liver capsule. The
process is accompanied by an exudation of sero-fibrinous
fluid into the abdominal cavitv. which fluid tends to be
Fig. 3381.— Tuberculous Perihepatitis. The illustration shows the thicli hyaline and caseous mem-
brane produced in the chronic hyperplastic type. (NichoUs.)
abundant owing to the involvement of the absorptive
surface of the peritoneum bv the dense fibrous deposit,
and also from the fact that the contracting fibrous masses
sometimes lead to pressure iqion the inferior vena cava
and portal vein, thus promoting ascites. The liver
graduallv diminishes in size, and the spleen becomes en-
larged in the later stages when passive congestion be-
ITIiillipIo lij-alosc-i-o-
.TIu III !>.•>. [silis.
liKFKHK.NCK IIAXDIJOOK OF THE MEDICAL SCIENCES,
comes marked. Gout and alcoliolisiii ajipcar to have
little to do with the i)rocess. Sy|)hilis has l)een known
to [iroduee chronic adliesive and mcnil)raMnus |)erilonilis
(Lancereaiix), but as yet no case ol' nndtiple hyalosero-
sitis has been recorded as due to tliis cause.
Ci.ixii'.M, CoritsK. — Tlie sporadic form lieing entirely
of palholoiiical interest and giving ri.se to no cliaracteris-
tic syni])tonis may be dismissed from consideration. In
thedilTu.se variety, tlie most striking clinical symptoms
an: those lo which Cnrschmann lirst drew attention,
namely, sliortness of lirealh, slight general weakness,
and a gradually increasing and refractory ascites. The
resend)lance to atropine cirrhosis of the liver is striking.
Most cases begin insidiously and give a lu'stury of indeti-
nitc disturbance from tlie first, such as anorexia, dysp-
ncra, and cpi.gastric pain. In other cases the disease
begins acutely with fcvcr, rigors, and epigastric pain,
during which time the liver region becomes lender and
swollen. The art'ection ultimately becomes chronic and
periods of latency ald'rnating with exacerbations are the
rule. According to lla^ maimer of onset we can recog-
nize two main types: first, the jKriliiinitic. and .second.
the uicih'ustnio-ptr/'m nliitl.
In the first, after more or less evidence of involvement
of the liver capsule, such as pain and tenderness in the
right hypochondrium, with or witluait fever, ascites de-
velo])s and the liver is found to be enlarged. It is fre-
quently ob.served later that one or both of the pleural
cavities contain tluid, or the mobility of the lungs is im-
paired bj' adhesions. Finally, in most cases, although
exceptions occur, there develop evidences of adhesion of
the pericarilium, and dilatation of the veins of the neck,
chest, and arms may be noted. As the disease liceomes
well established the liver becomes smooth, hard, and
gradually contracts, while the spleen steadily enlarges
and may become palpable. Anasarca appears only in
the later stages.
In the second ty]ie, the earliest signs aic referable to
an indurative mediastino-pericarditis, namely, pain in
the chest, cough, palpitation of the heart, dyspiuea, car-
diac dilatatiim, and possibly the pulsus paradoxus and
systolic ictiaelion of the chest wall. Signs of pleural
elTusion or adhesion appear and the process eventually
spreads to the liver capsule. As befon', the liver is large
and smoolli, but contrary to what occurs in the peri-
hejiatic form, anasarca is an early, though it may be a
transient sign. As time goes on the liver decreases in
size and a ;ciies makes ils ajipearauce.
In all forms, eventually, paracentesis becomes neces-
sary and must be repeated at gradually diminishing in-
tervals. The condition of the liver and spleen can be
made out only after free tapping. Digestive disturbances
when present are trilling, such as anorexia, constipation,
or diarrhcea; jaundice does not occur in uncomplicated
cases. Albuminuria is fcniud occasionally and is attrib-
utable to passive congestion of the kidneys. Fever is
usually absent exccjit during au exacerbation or compli-
cation. The disease is essentially chronic, lasting for from
two to sixteen years. The .sufferers may not be seriously
incaiiacilated forwork for long periods, but theconditiou
inovcs singularly n'fractory to treatment and relapses
are frequent. IJeath occurs usually from some acute
complication, lobar ]Uieumonia, or jieritonitis.
The tuberculous form of the disease, as the cases of
Straiesko and llerrick have shown, may occasionally
jiresent almost exactl_y the clinical picture of the " icing "
liver of Curschmann's description. Little is known of
this form as yet, but, so far as my experience goes, the
only dift'erences between the simiile or non-tuberculous
and the tuberculous forms are, that in the latter the liver
remains enlarged to the end, fever is more constant, and
the disease tends to run a more rapid course, lu fact, most
cases of tuberculous origin run a course very similar to
that of chronic tuberculous peritonitis, with the adiiition
of evidence of the involvement of the other serous mem-
branes. There is little in the physical signs to suggest
a chronic hyperplastic lesion rather than an exudative
one in these cases, unless the liver capsule is chieliy in-
volved. L'niike wliat takes place in the uon-tuberculous
form, ascites is rarely extreme and sacculation of the
abdominal fluid is more likely to occur. Usually, too,
the disease begins with signs of tuberculous involvement
of the lungs, pleura', peribronchial glands, or, in the
female, the tubes and ovaries.
r)i.vGNOSis AND PROGNOSIS. — The diagno.sis lies be-
tween chronic hyperplastic perihepatitis, atrophic cir-
rhosis of the liver, and carcinoma of the peritoneum,
for in all there may be ascites, more or less abdominal
pain, and, in most, induration of the great omentum.
The combination of extreme ascites with relatively little
anasarca, an adhesive jiericarditis, pleural exudation, or
adhesion, particularly if on the right side, should alwaj's
arouse a suspicion of multiple progressive hj-aloserositis,
and especially peril'.epalitis.
Perihe]iatitis is dilTerentiated from atrophic cirrhosis
by the fact that portal congestion does not occur except
T.VBI.E OP DlI'FEREKTIAL DIAGNOSIS
Special features.
"Ziickergussleber."
Atrophic <-irrhi.Lsis of livi.-i-.
Chri.>nic tuberculous
peritonitis.
Carcinoma of peritoneum.
Occurs ahout middle life or
later.
Slitrht predominance iu
favor of males.
flftcTi a history of acute
Jiericarditis or perihepa-
titis.
No intluciice
(.)f truest about middle aj::i'. . .
aiore frequent in males
Mistory of alcoholism, syphi-
lis, or digestive disturbances.
Frequentiv present
Occasionally present
Commonest between ages of
tweniy and forty.
Predominates iu females
Often a chronic con.i^h : (har-
rha?a, oi- peneral' tubercu-
losis.
ITnimportant
Occurs late iu life.
More frequent in females.
In some case.s a history of can-
cer of stomach or ovaries.
Unimportant.
Unimportant.
Unimportant.
Sex
Previous history
Alcoholism
No iuMiience
A rule becomin^^ chronic or
insidious from the Ilrst.
( ases last for years
(Jenerally absent e.xcept
liiiriny exacei-bation or
sonu' cr>mpiication.
liideilnite and tritlini;
TiillinL'' i>i" n')ne
Onset may he acute or in-
sidious.
Proloufjed
Usually slicfht, often absent..
.\pt t.i be tn»ubIesome
Chronicily
Fever
Pain
'May last for years
Mav be afebrile; when pres-
ent issliirht.
Trillinir
('■mstant ; dyspepsia, nausea,
vomitine. jrastnc liemor-
rhaire. niehena.
Constant
HelfUivelv sIiLMit
Fairly rapid course, with
cachexia.
Uarely absent; due to com-
plications.
Variable.
DigesTivf disturbaiU'L'. .
Ascites
Anasarca
Constant and extreme
Constant hut sliarht
Absent in pure cases
Not cirrli'itic; at first en-
laiped, Ilu'ii small: sniodlh
(;ra(hial enlarirenienl
Thickened and contracled.
Never extreme; may be ab-
sent ; may be heniorrhagie.
Trill in"
Moderate srrade ; may be
hemorrhairic or pseudo-
chylous.
Sli"'ht
Jaumlice
Uvcr
Splci-ii
tMiicntiim
Occuix in twenty-seven per
cent, of cases.
(Mrrhi)tic; at llrst enlartred.
thi-n small :ind warlv.
firadual enlarcfemeiit
.May occur I'Xceplionally
Often enlarged
Nothinir special
Common, when liver is in-
volved.
May be enlartjed, with nod-
ules.
Nothinir special.
often matted up.
REFERENCE HANDBOOK OF THE 3IEDICAL SCIENCES.
.tliilifpl
Kill mils,
HyaloMTo-
much later on and is never marked : secoudlv. severe di-
gestive disturbances, such as dyspepsia, vomiting, lia^ma-
temesis. and niekeua, are not present. Jaundice does not
occur except in the rare event of a nii.'ced cirrliosis ac-
comiiauyiiig iierihejiatitis. a case of which has been re-
corded by Hose.'- The liver is never warty ; signs due
to chol-vniia ilo not occur. Further, the great omentum
is nodular and contracted, while in cirrhosis it never is.
In carcinoma of the peritoneum, when the liver is en-
larged, jaundice is often present, the course is fairly
rapid, cachexia and digestive disturbances are marked.
There is usually some evidence of cancer of the stomach
or ovaries.
Having diagnosed the presence of chronic perihepatitis,
it is ne.xt necessary to determine if it be tuberculous or
not. In the tuberculous form ascites is rarely .so extreme ;
abdominal ])ain and tenderness are apt to be more marked
and the liver is enlarged throughout. Carefid examina-
tion of the lungs, lymphatic glands, testes, ovaries, and
Fallopian tubes, as well as of the urine, faeces, and s]iu-
tuni, should bo made. In suitable eases tuberculin in-
jections should be tried. The preceding table ]>reseuts
in a convenient form the main points characterizing the
various infections likel_v to be confused. Diagnosis may,
however, be very ditBcult and often impossible.
The progno.sis should be guarded; the di.sea.se is essen-
tially chronic and may last for years without .seriously
incommoding the patient. The simple form is steadily
progressive and invariablj' fatal. The tuberculous form
is also practically always fatal, but may jiossibly heal
after suitable interference. Tubeicidous cases and those
complicated with adherent pericardium run a more rapid
course than the others. The special risk to life arises from
some inteicurreut complication.
Treatment. — No specific medication has been devi,sed.
The chief point is to meet the symptoms as they arise.
Pain may be relieved bj- hot fomentations and ojiium.
To relieve the ascites, diuretics have Ix'eu recommended,
notabl}' cafEeinein doses of 0.1 to 0.15 gm. six to ten times
daily ; digitalis and diuretiu ma_v be tried. When ascites
is extreme, tajiping must be resorted to. Some cases, es-
pecially the tuberculous forms, may be beuetited by lapa-
rotomy. Needless to say. the patients must be kept under
the best hygienic surroundings.
Albert George yicliolls.
Bibuogeaphic.il Eefeee.vces.
' Hambounsin : Presse med. Beljje. t. xxi., 1869, pp. 14, li, 18.
^ Weiss : Wiener nied. Jahrb.. 1876.
3 Cin-sflintann : I'eutsctie med. Woch., 1884. p. 5tj4.
* Vierordt : Die einf. chi'on. exud. Peritonitis, 1S.S4.
= Hale Wliite: (.■llnic-al Soc. Trans., ISSS, vil. .xxi., p. 219. and Guy's
Hosii. Reports, vol. xlLx., p. 1.
» Rii'del : Miinehener Tried. Woeh.. 1892.
'Rumpf: Ueber die Zuckergussleber. Deutsclies Arcli. f. klin.
Med., 1893, XV., p. 272.
« Pick : Zeitsc-hr. 1. klin. Med., xxix.. 1896.
' Si-liupfpr : Policlinico. vol. Iv., 1697.
"^Siepert: Veber die Zuckergussleber (Cursclimann) ii. die peii-
oaril. Pseudolebercirrhose (Pick). Vircbow's Arch., Bd. 153, S. 2.il,
189S.
" Sclimaltz 11. Weber: Znr Kenntniss d. Perihepatitis chronica
hypi-nilaslica. Deutsche med. Wocb.. xxv.. 12. S. 18'*. 1899.
^- Itose. U. : Ziir KenutDiss der Zuckergussbtldung an serosen
Hauten. Berliner klin. Wocli., No. 38, 1,899.
13 Eisenmen^cr : Wiener klin. Woch., No. xi., 1900.
" Straiesko; .illg. Wiener med. Zeit., February 4th. 19112.
'' Nicholls : On u Somewhat Rare Form o£ Chronic Inflammation of
the Serous Membranes. Studies Iroiu Eoyal Victoria Hospital, Mon-
treal, vol. i., Ko. Ill, 1902.
" Herrick : Trans. Chicago Path. Soc.. April 14th. 1902.
See also Mader : Oesterr. Zeitsch. fur prakt. Heilkunde, Wien. xviii.,
13. 1.S73.
Askanazv : Febpr Zuckergnssleber. Verein f. wiss. Heilk. 1. Ki'miRs-
I'evj. sitzuiiL' (i. 2. 1S99.
SiniMii: Zur Keinuniss d. Zuckergussleber. Diss. Kouigsberg, 1900.
MUMMIFICATION. See iVea-om.
MUMPS. — (S3"uon3-nis: Cynanche parotida;a ; parotitis;
parotiditis; Fr., OniUoii; Gei:, Zieyeiipetcr.)
Mumpn is an acute, infectious disease, self-limited, and
characterized by inflammation of the parotid, and .some-
times of the submaxillary and sublingual glands, with a
tendency to involve the nianima^, testes, and ovaries.
Nature and Etiology. — Mumps prevails widely as
an epidemic, and also occui-s in tlie sporadic form.
It is propagated by a specific virus the nature of which
has thus far eluded the search of bacteriologists. Nu-
merous organisms have been found in the blood, saliva,
and other secretions by Kortlas, Capitan, Charrin, Boiuot.
and others, but the cultures obtained liave failed to stand
the crucial test of reproduction b\- inoculation. The dis-
ease is communicated by contact with the infected, and
by the intermediation of various substances to wliich the
virus adheres. The contagious principle is suppo.sed to
be chiefly transmitted by the breath, and is capable of
reproducing the disease from the beginning of the parotid
swelling up to ten days or two weeks after the fever
has subsided. It is highly contagious. Wlien the dis-
ease breaks out in schools, children's hospitals, or other
institutions where large numbers of ^'oung people are
congregated, few escape, unless protected bj' a previou.s
attack. However, the susceiitibility is not the same in
all individuals.
It is quite rare in infancy and after the middle perird
of life, occurring chiefly in j'outh and early manhood.
Males are more prone to attack than females. Like the
diseases of the class to which it belongs, it rarel}' occurs
more than once in the same individual.
It is more apt to jirevail during the winter and spring,
but epidemics have been observed at all seasons. Bad
hygienic surroundings certainly favor its diffusion.
^Morbid Ax.vtomy. — The opportunity for post-mortem
examination in cases of mtmips, for obvious reasons, is
very limited. On this account pathologists differ as to
the seat of the morbid process; some locating it in the
gland proper, and others in the jieriglandular connec-
tive tissue. Among those wlio maintain the glandular
origin, some hold that it is rather the fibrous stroma
which supports the acini than the acini themselves,
which are primarily involved.
The w-eight of authority is in favor of the initial lesion
Iieing a catarihal inflammation of the gland ducts, but
the local swelling which gives character to the disease is
unquestionably largely due to an infiltration of the sur-
rounding cellular tissue. The swelling disappears by
the ab.sorption of the exudation, and only in very excep-
tional instances does suppuration take place.
Occasionally the glands remain enlarged for a consider-
able time, and, in very rare instances, the enlargement
and hardening are permanent. Atrophy of the parotid
and other affected glands has been observed as a result
of an attack of mumps.
Sy.mpto.ms. — The pei'iod of incubation varies greatly
and is estimated by difl'ereiil authoi's at fi'om seven ta
twenty days. Premonitory syminoms are, in most in-
stances, eitiher absent, or so mild as to at tract little atten-
tion. TThen present they are those commouh- met with
in mild febrile attacks; chilliness, hot flushes, languor,
anorexia, and sometimes vomiting and diarrhoea.
Yer_y exceptionally the initial symptoms assume a
grave character, and the disease is ushered in with high
fever, profound depi'ession, (lersistent vomiting, and, in
children so predisposed, with convulsions.
Pain and tenderness in the regitm of one or both par-
otid glands, if not present from the beginning of the
illness, speedily make their aiijiearance, and are never
delayed longer than twenty-four or thirty-six houi's.
Swelling appears .simultaneously with the pain and
tenderness. It is at first noliceil in the depression be-
tween the mastoid pi-ocess and the ramus of the jaw, and
is confined to the gland. The adjacent cellular ti.ssue is
soon invaded and the tumefaction extends forward on
the face and downward and backward on the neck.
The degree of enlaigement varies greatly, being at
times moderate and confined to the jiarotid region, and
in other cases involving a large portion of the face and
neck. When both jnirolids ai'e involved and the swell-
ing is fully develo|ieil the configuration of the face is
peculiarly altered, the lower half of the lace being enor-
mously widened and the outline of the chin lost in the
a?dem;i of the neck. The swelling is firm, slightly elas-
^
ifliiscariiir.
iTIiisclc.
KKFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
lie, und moderately sensitive to pressure. Tlie head is
ti.xeil witli the faee directed straight forward, or. if but
one parotid is all'eeted. the head will be inclined to the
diseased side. Tlie skin usually preserves its natural
color, but may be nnl and glossy. Slight desquamation
may take place after the inllamiiiation has sulisidcd.
More or less fever is always jiri'Senl. lasting, in cases
of moderate severity, not more than four <ir live days,
but occasionally it is intense, protracted, and atteuded
with delirium and prostration.
Tint (edema generally extends internally, alTecting to a
greater or less degree the mucous membrane of the ton-
sils and iiliarynx. The secretion of saliva may not be
matc'rially altered in quanlity, but dribbles continuously
from the iiidf-open mouth.
Tinnitus aurium and earache are often exjierienced, and
there may be a temporary (jr permanent impairment of
hearing. " The movements of the jaw are. of necessity,
greatly impeded and very jiainful. Speech is difficult,
and the voice is husky or muffled.
Mastication and deglutition are almost entirely sus-
pendeil. the patient enduring the pangs of lumger rather
than unilergo the sulfering required to satisfy his wants.
JIumiis usually affects both parotids, but not simul-
taneously : the left is most frequently the first to become
involved, and in from two to four days afterward, or
even when the swelling has disappeared, the opposite
gland becomes the seat of disease. Not infrequently the
affection is limited to one side.
Very often the submaxillary and sublingual glands are
affected conjointly with the parotids. Dr. Penzoldt, of
Erlangeu, records an epidemic of mumjis which fell un-
der liis observation, in wliicii there were many cases
in which the disease process was almost wholly confined
to the submaxillary glands.
The sweiliug reaches its height in from two to five
days, remains stationary about forty-eight hours, am]
then rapidly subsides, making tlie duration of the attack
from ten to fourteen days.
CoMTi.uATiONs AND Sequel.k. — These relate espe-
cially to affections of the nervous and glandular systems.
The tendency for the iutlanunation to invade by so-called
metiWtases other and remote glands is a singular and
interesting feature of the disease. As was originally
pointed out by Nieineyer, it is probably not a true metas-
tasis. The testes in males and the mamma and ovaries
in females are the organs of special election. This com-
plication is much commoner in males than in females, and
less common in childhood than in adult life. When the
testicle is invaded, it becomes swollen and painful, and
there is often effusion into the tunica vaginalis, with
oedema of tlie scrotiun. Bruising of the testes is said to
invite the disease.
The migration may take place at any jieriod of the
parotid swelling, wliiih then \is\ially subsides, but occa-
sionally the two inflammations run their course together.
Sometimes thi' inflammation of the parotid disappears
suddenly before the advent of the metastatic affection ; in
this event, alarming constitutional symptoms are liable
to sujiervene. There may be high fever, headache, tle-
lirium, or profound collapse, which jironqitly disaiqiear
on the appearance of the local lesion. The new aft'ectiou
runs a cour.se very similar to that of the original disease,
and lasts about the same length of time.
Atrophy of the testicles sometimes results, or their
function may become impaired from o<'cliision of the
spermatic duct.
^Meningitis is in evidence in a very large percentage of
the fatal cases of mumjis. Various diseases of the ner-
vous system have been recorded as comiilications (insan-
ity, neuritis, hemiplegia, facial jiaialysis), but certainly
in many, if not most, instances, they were mere coinci-
dences
Otitis media is not uncommon and occasionally termi-
nates in permanent deafness. In a few cases a complete
loss of hearing in one ear takes place without the slight-
est evidence of the presence of the intlammation in the
corresponding middle ear; thus warranting the belief
that the lesion — whatever may be its nature— must in
these cases be located in the cochlea or in the auditory
nerve at some point in its extra-labyrinthine course.
Albuminuria with convulsions has been noted.
PiioGNOsis. — Slumps is a mild though painful disease,
and almost invariably runs a favorable course. The in-
flammation of the jiiuotid rarely leads to the formation
of an abscess, contrasting, in this respect, strongly with
the non-specific form of parotiditis which occurs in the
course of typhoid fever and other maladies.
Occasionally a hard. ]iainless enlargement of the gland
is left, whichpersists for a variable time and disappears,
but which in veiy exceptional instances may l.)e perma-
ueul.
The Di.AGNosis is rarely attended with difficulty. The
disease can scarcely be mistaken for any affection other
than the non-specific inflammations of the parotid glands,
which occur as complications of various constitutional
diseases.
The comparative mildness of the general symjitoms. tlie
speedy resolution of the sweiliug, and the epidemic char-
acter of mumps, contrast strongly with the preceding
severe illness and the inherent tendency to suppuration
which constitute the clinical features of the non-specific
or symptomatic parotiditis.
TiiEATMENT.^The treatment is purely symptomatic.
The disease is self-limited and runs a deflnite course, un-
influenced by the administration of drugs.
The patient must remain indoors, preferably in bed,
even in mild cases, until convalescence is assured.
On account of the difficulty in swallowing, the diet
should be exclusively fluid. If there should be high
fever, a bath or surface sponging with te])id water will
be of service. Should there be much pain or restless-
ness, an anodyne, preferably Dover's powder or chloral,
may he prescribed ; otherwise refrigerant diaphoretics,
such as a solution of bitartrate or citrate of potash, or the
neutral mixture of the Pharinacopccia (see under Pi>t,is-
shiiii). w'ill meet all of the indications. External fomen-
tations to the neck are both useful and grateful to the
patient. Soap liniment, to which a little deodorized tinc-
ture of opium may be added, warm olive oil, or the
tincture of belladonna and glycerin (3 i.-| 1.), are
eligible preparations for external use.
When metastasis to the testes or other glands takes
place, the new affection shoulil be treated in the same
manner as if it had occurred independently of the parotid
inflammation. The writer has obtained excellent results
in orchitis from the inunction of guaiacol ( 3 i.) and lano-
lin ( 3 iij.-iv.). When it is applied from two to four times
daily the pain and swelling usually promptly' subside.
If the onset of the metastasis is heralded b_v great pros-
tration, or by alarming symptoms of any kind, stimulants
must be freely given and warmth applied to the body,
A course of tonics is advisable should convalescence be
tardy, IK </. Conklin.
MUSCARINE. See Poisonous Plants.
MUSCLE.— Histology op ^Muscular Tissie. — ^Mus-
cular tissue (Lat., I'eln miiscvliiris ; Ital., Tessitto musco-
larc ; Fr.. Tissii mxsciihiife ; Ger., Mtiskelgewebe) is the
tissue in the animal body the physiological characteristic
of which is its power <if contracting in one direction, thus
giving rise to definite movements. It is composed of
.structural elements, the length of which is usually much
greater than the breadth. JIuscular tissue in some form
is present in all the groups of animals, except the Pm-
tozoa*
Anatomically or morphologically, muscular tissue is
of two kinds: {\) Siriiitc! or slr/jiid miiscnhir tissin , that
in which the structural elements or fibres are marked by
distinct transverse, and usually much less distinct, longi-
tudinal striations. The structural elements are uni- or
* Among the Protozoa, tlie striated ectoplasm of some infusoria
and tlie poiitractile stalk of VoiiicrUa are perhaps physloloirically
unisrular tissue, luit they can liardly lie so consitlered anatomically,
since these orsaiiisuis are supposed to be unicellular.
10
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
.lliif^<*nriae*
Muscle.
niultiuucleated (Figs. 3383 to 8405). (B) Siiwoth or tin-
striated mvaeular tissue, that iu whicli tlu' .struftural ele-
FiG. 3382.— Transection of tho Oi-cipitoscapularis Mnsi-lo of tlii- Cat. to show the Components
of an Ordinary Striateil Mnsilo. The whole muscle and the fascicles were outlined with
the camera lucida at a iiiat'iiillcation of about twenty diameters. The muscular abres,
the artery, vein, and nerve uerr not drawn to scale. (Drawn hy Mrs. Gage.) a. .Artery;
cm, endomysium, the conni'ctivc tissue between the individual flbres: cpm, epimysium,
the connective tissue sunonndiiiL' the entire iiuiscle and girtup off iijmi the perimysium,
which combines the flbres into bundles of fascicles of various sizes : m«, muscle spindle ;
71, nerve ; r, vein (c/. Figs. 3395, 3400).
mcnts are apparently hdiiiogeneous, or marked by fine
longitudinal striations only. The elements are mostly
uninucleated (Figs. 3406 to 3409).
Stiuated MuscfL.VK TisscE.— This, in man and many
of the lower animals, is the so-called flesh or lean meat.
It is usually collected into more ur .ess distinct masses,
termed muscles; and in every case, whether the muscle
is in distinct masses or not, it is composed of structural
or histological elements, which, when viewed lengthwise
under a microscope, are characterized by an appearance
of being composed of alternating dark and light segments
(Figs. 3383 to 3404); this gives the elements their trans-
versely striated appearance. Physiologically, striatetl
muscle is characterized by the rapidity and energy of its
contraction.
Distribntion. —Btnated muscular tissue is present in
all vertebrates and in some members, ;tt least, of all the
great groups of invertebrates except the Prot<i-<ui.
Structurally and physiologically, striated muscular tis-
sue iu vertebrates is"of two kinds; (A) The skelet^il, or
the so-called muscle of animal life, which is mostly vol-
untary ; (B) the cardiac, or the muscular tissue of the
heart, and the other pulsating organs of the blood-vascu-
lar system. This is wholly involuntary, and belongs to
the tissues of organic life.
Skthtiilor Voluntary Muscular r2S.'<wf (muscles of ani-
mal life).^In man and the mammals, this tissue forms
from forty to forty-live ]ier cent, of the entire body
weit;lit. 'Its speciti'c gravity is about 1.0,j8. It is usu-
ally^collected into distinct muscles, the ends of which
are in most cases attached to some firm part (bone or car-
tilage) by means of fibrous connective tissue.
Distribution; In man and the mammals generally, this
tissue forms the muscles of the trunk and extremities,
those moving the globe of the ej'e and all those of the
ear, those moving the lips, and those moving the skin
{plalysma myoides in man, the cutaneous muscles over
nearly the entire body iu many mammals). It is also
present in the tongue, "pharynx, larynx, the true sphinc-
ter of the urethra, and theectal sphincter of the anus;
in mammals possessing them, it is found in connection
with Cowper's and the anal glands. In the oesophagus
of man. the horse, and some other animals, stiiated mus-
cle is usually present only in the pharyngeal half; in
ruminants, the dog, cat, rabbit, house mouse, rat, and
many other animals, it extends to, or nearly to. the stom-
ach ;" and in the rat it is even continued upon the stomach
from the cardiac end of the oesophagus. In many of the
lower vertebrates, besides the muscles of the trunk and
limbs, striated muscular tissue is found iu situations
where it is not present in man. In
birds, iu the iris and choroid ; i}i snakes,
around the poison glands; in finhes,
in the wall of the stomach of Co/i/tis
fiMsih's and !>ynynal/ius acus, and in
the intestine of 7'inca chrysitis : iu
iiniia it forms a dotible layer over tlie
surface of the lung-like air bladder,
and is present in the trabecukv-like
cords within it; in lepidostius. it is
veiT abundant in the trabecuke within
the air bladder ; in pulypterus there is
present an enclosing sheet of muscle
for the air bladder as in amia.
Constituents of .striated Muscular
Tissue. — These are; (A) the essential
and characteristic, elongated and trans-
versely striated muscular fibres (Figs,
3383 to 3396); (B) blood- and Ivmpli
vessels (Figs. 3382 and 33961"; (C)
nerves (Fig. 3382); (D) muscle spiudles
(Fig. 3400) (E) a considerable quantity
of adipose and connective tissue (Figs.
3383 to 3385.) The connective tissue
of a muscle has received special names
according to its position in the muscle:
(a) epimysium or perimysium e.rteritum
(Fig. 3382, ep). This is the connective
tissue which forms a kind of envelope or sheath for the
entire muscle, (b) perimymirn (Pig. 3383, p). This is
the connective tissue
which extends into the
mu.scle from the epimy-
sium. It combines the
fibres into bundles (/<(«-
eiculi, fascicles, or lacerti)
of various sizes, and
separates the fascicles
from one another; {c)
endomysium. This is the
minute network of con-
nective tissue extending
from the perimysium
into the fascicles, and
separating the individ-
ual fibres from one an-
other. Finally, connec-
tive tissue, commonly
in dense masses or ten-
dons, serves to connect
the muscles to other
parts, usually bones or
cartilages, which are
moved when the muscle
contracts.
Fascicles {fasciculi or
l(ieerti) and their Rela-
tions ill a Muscle. — In
some muscles, as the
sartorius, the musctdar
fascicles exteud from
end to end of the mus-
cle. In such a case, if
the muscle has a broad
tendon of origin and in-
sertion, the fascicles are
usually nearly parallel
and of nearly the same
length. Where, how-
ever, one or both ends
are fusiform, as in the
biceps braehii and the
gracilis of man, the cen-
tral fascicles are consid-
erably the longer. In
penniform and bipenni-
ifpmv/*f'w
Fig. 3.3.S3.— Diagram to show the Ar-
rangement of the Fascicles in a Bi-
pennifiinn Muscle {Binin' llrailiii
of the Cat), Each fibre represents
a fascicle. (Drawn by Mrs. (Vage.)
in-e. Muscle corpuscles ; f-i, tendon
of insertion; t-o, tendon of origin;
t', tendinous expansion over the
surface of the muscle (it is thickest
near the tendon of origin); f, ex-
tension of tendon through the
middle of the iiuiscle. It thickens
toward the tendon of insertion.
11
Muscle.
Muscle.
REFERE>'C'E HANDBOOK OF THE MEDICAL SCIENCES
'WM
form miisclc'S the fasc-itlcs are placed oblique!}- to tin'
long axis of tlie iiuisele, autl extend for a eonipara-
tivcl}' small l)art. of its entire leni;lli. In ease of the
bipeuuiform muscles — biceps bracliii of tiie e.it iFii;.
y<J8o), rectus femoris of man
— tile tendon of origin and
tlie tendon of insertion ex-
tend along tli<' entire length
of tlie niusele, on tlie surface,
and also ill llie central jjarl.
Tliis arrangcnieiit of the ten-
don in tlic ]icnnirorm and
liilienniform muscles renders
it oliviously ini])cssi))le to cx-
]iose tlie muscular substance
in dissiction so that it shall
sliow to the best advantage.
In most muscles the compo-
nent fascicles are appro.xi-
niately parallel ■with one an-
other, although not necessar-
ily with tlie long axis of the
muscle. In bipenniform mus-
cles the fa.scicles are paralUd
uilli one another on the same
side, but at an angle with
tho.se of the opposite side
(Fig. 3383): theyareliUe-ni.se
olilique to one another in the
fan-shaped nius<-lcs like the
pectorals and the latis.simus.
Fibri'fs ami iluir Arniii;/!-
meiit in <i Fuscirli. — It was
long sup])osed that tlie in-
ilividual libres forming a fas-
cicle were coextensive with
it, and therefore, except witii
the pennifoiui and bipenni-
form mu.scles, with the mus-
cle itself. It was shown,
however, by RoUelt,' Her-
zig, and Biesiadecki,'- that the
lilires may end wMtliiu a fas-
cicle, being attached tea ten-
don at but one extremity,
or at ueither. It is now be-
,.."." '"I!„i;! lievcd that a fibre rarely ex-
ceeds from 40 to 100 mm. in
Fli, l's4 -Dimi ,i]i (if a Stri-
ated MiiM U 111 \\hi(ii the Kas-
eules 111 (oiiiposeiinf l)ijl One
Leiutl) tf tilius uliKli ari^
ot ii( 11 :\ Iijuil I niirth. It
alvo upRstnts 1 iiiiiM if in
will li tlip tUires die pirallel
iinl e\tt lid fioiii tint til end
iif UiH iiilisi le
Ml^ (idjt 1 III I Muscle
I 01 pU.M 1h , t (. tHIlddll of IIISIT-
tloii ; (-11, leiiilon of orit'iii. length, while a muscular fas-
cicle may lie. in some ca.ses,
ten or twenty times that length, or even longer. In
man and some of the larger animals Felix '' has i.solated
fibres from 120 to l:iO iiiiii. in length, although he
found the majority of the tibres much shorter. If the
fascicle is not over 40 mm. long, the tiliies usually ex-
tend parallel with one another "from end to end oi' the
fascicle; and where the fascicle is iiaralle-1 with the long
axis of the muscle, and the muscle itself does not exceed
40 nun., tlie individual libres likewise extend its entire
length (Fig. 3:is-|), us in the oeeipilolrontalis and many
other niuseles of the cat. the stajiedius, iutercostals, and
some other muscles in man. AVIiere, however, the fasci-
cles considerably exceed 40 mm. in length, the tibres
which originate in the tendon of origin or insertion by
blunt ends, terminate bv fusiform eiidsat different levels
within the fascicle (Fig. 33S.S, ,1). Where the fascicles
greatly exceed 40 mm. in lenglli, part of the fibres origi-
nate and terminate as just described, while those wiiicli
fill the intervening s])ace are tapering and slendi'r at both
ends (Fig. 33SS, Jl). In most cases in which the libres
become taiiering an<l end within a fascicle, each tapering
end is applied clo.sely ton tibre of full si/e (see Fig. 33ss,
and below, under Termination of the Fibres).
In small animals, like the comnion mouse and bat, in
which none of the muscli's attains a length of 40 nini-.
one would naturally expect all the tibres to extend the
entire length of the niusele: but from an extended in-
vestigation of the house and lield mouse, of the mole and
bat and English sjiarrow, it was found by Susanna P.
Gage' that while many of the fibres did extend the entire
length of the muscle, many others ended within it either
with simple tapering points or with .several branches,
and even liy anastomoses with other fibres (Fig. 33S9).
Ilerzig and Biesiadecki found in the muscles of the frog
some of the fibres extending the entire length of the fas-
cicle, while others terminated within it. As stated
above, the fibres in a fascicle are approximately parallel,
and the fascicles, composed of but one length of fibres
(Fig. 3384), show the same number of fibres in transec-
tion at any level, and each fibre is of nearly the .same
diameter throughout its entire length, except at the ex-
treme ends (Fig. 3384), In a fascicle conipo.sed of twa
or more lengths of fibres, the number of fibres varies in
transections made at different levels, and the .same fibre
is not of uniform diameter throughout its entire length
(Fig. 3388). Independently, however, of the tapering
ends of the fibres in fascicles com]30sed of two or more
lengths of fibres, the several fibres of a fascicle in all
forms of muscles vary greatly in diameter, and there is
also a great difference in the number of filires in the dif-
ferent fascicles (Figs. 3382, 3411 ), The coarseness or
fineness in texture of a muscle to the nako'd eye, depends
mostly ou the relative abundance of the perimysium and
the II iiiiibcr (I ml t/ie ,ii.ze of the fibres iu the component
fascicles (Figs. 3382, 3410).
Tekmix.vtiun of Stri.\ted MrscuL.W! Fibre.s. — (A)
Tcniiiiiiition in Ti iiilnii. — The most common mode is in a
dense, tisually rounded or flattened mass of connective
tissue called a tendon. This is always less bulky than
the muscle, and consists of a continuation of the connective
tissue of the muscle, and of the special minute tendinous
prolongations of the individual fibres which reach the
tendon (Figs. 3383 to 3385). All muscular tibres ending
in tendon, or apparently directly upon some hard part —
lione or cartilage — terminate as just described, without
Kin. SIK.— To sliow tlie Attaeliiiient of Muscle to Periosteum ("appar-
ent direct attaclinient to bone), also au Oblique Muscular Attacli-
luent. Fi-oin the scapula of a cat. Magnifled TM\ diameters.
(Heitziiiaiiu.l .V, Tciidinous ends of a striated niiisculiir fibre ifour
are shown I ; P. pcrimysiiiin ; this intermingles with the periosteum,
and witli the short tendinous prolonsratlons of ihe individual tibres.
serves as a teiulon: l'\ pel iosteiiiii : tile perimvsiuiu and tendinous
proloni-'ations of the mnsiular nines interminsle wiUi the libres of
the periosteum and liecome Inst in it; .S, saicolemuia : apparently
continued as part rit the tendinous prolongation of the Obre.
regard to the angle of attachment: there is simply a dif-
ference in the lenirth of the tendinous prolonguiions of
the fibres (Fig. 338.5).
Wlieu a muscular fibre reaches a tendon, the sarcous
substance (see below) ends bluntly (Figs. 3383 to 3388).
In some cases the cud is divided into several short finger-
12
IlEFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
lIuNcle*
Kliisicle.
ffl ;
like processes, and in most cases the supply of nuclei in
tbe muscular and tendinous substance is abundant.
Whatever the form of the terminal part of the sarcous
substance, the libre appears to be directl_v continued by a
bundle of tendinous tissue,
which soon loses itself in
the general mass of the ten-
don (Hgs. 3388 to 3388).
This appearance is clearly
seen in the dead muscular
fibres of all the animals ex-
amined, both in sections
and in isolated fibres.
When the muscle is stained
with acid fuchsin and pic-
ric acid, the muscular sub-
stance is yellow and the ten-
dinous substance pink.
The appeai~ance is then
that the tendon tits into all
the crevices at the end of
the terminating fibre as if
the muscle end with its
terminal processes had been
inserted into a plastic ten-
dinous substance. The ten-
dinous substance is also ex-
tended along the sides of
the fibre and merges into the
endomysium (Fig. 338T).
It was long held by most
histologists that this ap-
pearance indicated that at
its termination in a ten-
don the sarcous substance
merges directly into tendin-
ous substance, and with
the sarcolemma (see below),
forms the tendinous inser-
tion of the fibre. At the
presentday, however, many
iiistologists believe that the
sarcolemma of a museidar
fibre is continued around
the end of the fibre, and
that the tendon is simply cemented to it (Fig. 338()).
The sarcolemma has never been separated from the
tendon, so tliat, if this view is correct, the connection
between the sarcolemma and tendon is more intimate than
that between the sarcolemma and sarcous substance.
This interpretation is a natural, and almost necessari'.
outgrowth of the cell doctrine of Schwann'* and his fol-
lowers, which teaches, above all things, the independence
of the individual structural elements. And these writers
consider the sarcolenuna a kind of cell wall; it must,
therefore, necessarily eutirely enclose the fibre, and the
tendon be cemented to it at the end of the fibre. To the
-constantly increasing number of biologists who believe,
not in the independence, but in the interconnection of
tlie structural elements of the body, there seems no inher-
ent improbabilit_y in the \iew that muscle may merge
into tendon, and the sarcolemma become continuous
with, and form part of, the tendon. The appearances
obtainable by treating dead musctdar fibres with varimis
reagents, and by the stud}' of living fibres, give, in the
present state of knowledge, justification to either inter-
pretation.
(B) Termination of Fibres itithiii a Muxdc. — The state-
ments of histologists concerning the termination of fibres
within a muscle and the relations of the terminal ends
are so variotis, or directlj' contlicting. that some of the
more positive statements will be given before stating
wliat seems, according to the writer's observations, to be
the condition. Frey, 1880: "While it was formerly sup-
posed that every transversely striated fibre continued
throughout the entire length of its muscle, more recently
numerous exceptions to this have been observed; that is.
.muscular fibres which terminate in a point, or some other
Tig. 33.H6.— Muscular Fibre from
the Gastrocnemius of tbe Frog,
to sliow the Termination of a
Muscular Fibre in Tendon.
Magnitledl40 diameters. (Ran-
vier.) c. Muscle columns ; m,
a fold in the empty sarcolemma:
p, retracted conical termination
of the sarcous substance : y. sar-
colemma reflected over the end
of the fibre and adhering to the
tendon ; ^ tendon.
form, at a greater or less distance from the tendinous ex-
tremity. Such primitive fa.sciculi have their connection
with the tendon, to a certain extent, in the interstitial
connective tissue." Klein, 1883: "The individiial fibres
have only ... a relatively limited length, so th,-it, fol-
lowing an anatomical fascicle from one point of its inser-
tion to the other, we find some muscle fibres terminating,
others originating. This takes place in the following
way: The contents of a fibre suddenly terminate, while
the sarcolemma, as a tine thread, becomes interwoven
with the fine connective tissue between the muscular
fibres." Landois, 1885 : " AVithin a short muscle, e.>/., sta-
pedius, tensor tympaui (of man), or the sliort muscles of
a frog, the fibres are as long as the muscle itself. "With-
in longer muscles, however, the individual fibres are
pointed, and are united ol)li(|uely by cement substance
with a similar bevelled or pointed end of another fibre
lying in the same direction." Schaefer, 1882: "In a
long fasciculus a fibre does not reach from one tendinous
attachment to the other, but ends witli a rounded ex-
tremity, invested with its sarcolemma, and cohering with
neighboring fibres."
According to the writer's observations on many differ-
ent muscles of cats at all ages, and less extended obser-
vations upon human muscles and on those of the house
mouse, the fibres which terminate within a muscle always
do so w'ith a very tapering end, the extremity becomiiig
thread-like, and losing its striation. The muscle corpus-
cles (see below) are al.so numerous near the end. and in
some cases the fibre seems to terminate as a bi'auched
corpuscle (Fig. 3388, C). Small lateral branches, some
of them striated, were also present in man}- cases (Fig.
3388, C). Where the fibres were apparentlj-undistuiljed
in tlieir relations, the terminal part, for a considerable
distance, was parallel and closel)' connected with a fibre
of full size, the tapering end following accurately the
outline of the fibre to which it was applied, curving out-
ward over a muscle corpuscle (Fig. 3388, m-c), or'when
the large fibre was corrugated, following the curves
accurately. Herzig and
Biesiadecki ' describe long
lateral branches, some of
which even anastomose in
the intramuscular end-
ings of fibres in the horse.
As shown in Fig. 3381),
branched and even anas-
tomosing terminations are
not uncommon in the
smaller animals, as the
house mouse.
The fibres arising from
the same tendon and ter-
minating within a muscle
may be of various lengths ;
in such a case the longer
ones may apply their
tapering ends to fibres of
full size coming from the
opposite tendon (Fiir.
3388. A, 3389), while the
shorter ones may either
ap|)ly themselves to fibres
from the opposite tendon,
or to the longer fibres
from the same tendon. In
tlie latter case the shorter
fibre has always been ob-
served to terminate before
the longer one commenced
to taper. When a fascicle
is three or more fibres in
length, tlie fibres may be
of various lengths, as
stated above, but the fibres not joined to the tendon
of origin or insertion are tapering at both ends. All
the fibres lap sutficieutly to apply their tapering end
to fibres having their ft'iU diameter (Fig. 3388, B). In
-J 1 ijj mm.
Fl<
:Ws7._Tn'o .^djoiniuir Striated
Muscular Fibres from tlie Proxi-
mal or L'pper End of a Hinnan
Sartorius to show their Tendinous
Connections. * Drawn by Mrs.
Gage. ) Magnified about 3.'»'t diam-
eters. The tendon in each case
seems to be a direct continuation
of the muscular fibre, and to e.x-
tend up on tbe side of the fibre
for a short distance Kef. Fig. 3.3S6).
13
IfIU!^<-l
m u M4- 1
REFEREXCE HANDBOOK OF THE MEDICAL SCIENCES.
all the numenms preparatit>ns observed by tlic writer,
the muscular lil)res terminating within a muscle^were
always very slender and tapering at their lerniinatiou
F I G. 33S.S. — i> i a-
gnuns t'> show the
Kt'latiiiTi and tt.T-
itiinminii of Fibrt'S
in Fas('i<ies com-
posed of Two or
more Lengths of
Fibres. (Drawn
by Mrs. Gage.)
A. Fascicle com-
posed of two
npths of fibres.
The fibres termi-
nate by rounded
ends at the tendon
of orijrin Mnd in-
sertion, and in the
y/ midst vf the nins-
Kij cle by tapering
i^ ends which are ap.
nng
e ap-
'd to the other
ilbres. where they
are of full size.
/■ 1. Fibre arising
at the tendon of
origin and tenni-
n a t i n g i n the
midst I'f the mus-
cle : fJ and /3.
flluvs of dilTerent
lengths arising at
the tendon of" in-
ert ion and ter-
iiinating in the
uiidsi of the mus-
, cle: t-i, tendon of
insertion; t-o, ten-
don of origin. B,
A fascicle com-
posed of three
lengths of fibres;
onlv the ends
reaching the ten-
dons are rounded,
the otliei-s are ta-
pering and areap-
plifd to neighbor-
ing fibres, asin^l.
/i. Fibre ailsing
at the tendon of
origin and ter-
minating in the
midst of the mus-
cle; /;^, fibre with
two tapering
ends, both of
which terminate
in the midst of the
muscle: .' 'X fibre
terminating by a
ii'umbd end in
tlie tfudon of in-
sertion, and by a
tapering end in
the midst of the
muscle; ni-c,
muscle corpuscle.
Thi.s "'Ue itrojects
beyond the sur-
fact-nf f'2, and the
taperinuMmdof f 1
curves o\er this
corpuscle. A simi-
lar condition is
shown in / 1, ^4 ;
t-i, tend<.'n of in-
sertion ; t-n, ten-
f#^ "^if ,*^ ^ ^^ \il VA'iiVv'iH The U-rminai' part
*i^' ^\5 \1 lAV>f'iS'.£;M of a fibre ending
^^ within a nmscle.
' Drawn with a camera lucida at a magnification of Ji") diameters.
The details of structure were determined with a i*r homogeneous
immersion objecUve. and added free-hand, m-c, .Muscle corpuscle.
The one to which the line e.Ktends projects markoUv. and is in the
angle formed by a lateral bninch. The lateral bramtirs are numer-
ous, and some of them show distinct iransvei-se >iriaiions. Just
beyond the conuisde to which the line extends the transvei-se stn-
ation ceases on the nine. At the end is an enlargement or cor-
puscle, with a thread-like continuation.
(Fig. 3380) and two tapering ends were never seen to
lap and be eeniented togetlier: but the sh-ndcr ter-
mination of one fibre was almost invarialily ajiplieii to
a libie of full size, and terminated before tiie supporting
fibre eonimeuced to taper. The apparent terminatiun of
a fibre by a rounded end within a muscle is due, in many-
cases at least, to the tearing and retraction of the sarcous
substance, and sometimes also of the sarcolemma. In
the great majority of cases observed, in which a fibre was
in its natural relations lo the other tibres, and seemed to
end by a blunt or rounded extremity within the fascicle,
the empty sarcolemma was traced to the otiier broken end.
When the hollow sarcolemma appears of altout the size
of a muscular fibre {Figs. 3386, 3391). the true relations
of the broken ends of the fibre are readily determined ;
liut in many cases the stretched sarcolemma collapses
and tapers to a point about midway between the seveivd
ends of the sarcous substance, and often both the broken
ends cannot be seen in the same field of the microscope.
(C) Tcnni nation, of Muscular Fibres in the Skin. — The
attachments of the cutaneous muscles to hard parts, and
the terminations of the fibres within a muscle, are as de-
scribed above for the ordinary muscles. At their cuta-
neous termination
the fibres (in the
cat at least) taper
somewhat gradu-
ally, lose their
transverse sti'ia-
tiou, and, finally,
become indistin-
FiG. 3389.— Figures
showing the Rela-
tions of Muscular
Fibres in Small
Animals. ( From
Susanna P. Gage.)
A, An anastomosis
of two fibres in
the conue cling
branches of which
are seen a nundaer
of longitudinal
clefts. The smaller
fibre ends with the
upper branch. The
larger fibre has its
inaximmn size at
the upper e!id. and
from the lower part
was traced 4 mm.
to its tapering,
branched intranms-
cularend,oneof the
branches fomdng
an anastomosis with
another fibre.
(From the biceps
femoris of a house
mouse.) li. Ter-
mination of an in-
tramuscular end by
anastomosis. A nas-
tomosing branches
were given ofT for
a whole millimetre,
that is for the whole
length of the taper-
ing part. (From the
biceps femoris of a
house mouse.) C,
Tendinous ends of
the rectus abdomi-
nis of a house
mouse. The two
tendinous ends are
shown in the upper
fibre, which was 5
mm. long. Oppo-
site the liiwer ten-
dinous end of the
large upper fibre
are four smaller
fibres from the next
segment. D. Acas-
tomosisof one ta|H>r-
ing fibre witli two
others from the oji-
posite tendon, show-
ing in a iypi<-al way
the relations of aii-
astomosing. intra-
muscular ends to
one another. The
part between tl.e breaks was 3 mm. long, while the whole muscle
was 17 mm. long. Tlie intramuscular ends are branched and
two of them, after anastomosing, seemed to end freely. (From,
the biceps femoris of the house mouse.)
u
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Muscle.
I?Ii:scle.
Fig. 3;MI.— Section of the Lip of tbe Rat
tliroiiL'li the Miiseuluc Levalur Lahii
Stti:ifrioris^ to show the Branching of
the Fibres and their Termination in the
Coriuni. (Busk and Huxley.') a,
Epidermis and aperture of a sebaceous
gland ; h, muscular flbres branching
and terminating in tlie coriuiii after
tapering and losing their InnisMTsestri-
ations; c, connective-tissue cmpuscle.
guisliable from the white fibres of the coritim. In some
animals, as the rat. the fibres at their cutaneous termina-
tion, in the lips at least, divide into several branches,
which taper gradually or somewhat suddenly, lose their
.striation. and in some
cases appear to ter-
minate in connective-
tissue corpuscles: in
othei's they become
indistinguishable
from the white fibres
of the corium (Fig.
3390).
(D) Termination of
Mt/sctilar Fibres in
Mi-icosa. — If one end
of the muscle is at-
tached to some hard
part, or if the fibres
terminate within the
muscle, the attach-
ment of the fibres to
the tendon, and the
termination within
the muscle are as de-
scrilied above for the
o r d i n a r y skeletal
muscles. The ends
of the fibres terminat-
ing in the mucosal
coriiun, taper, some-
times branch, always
lose their striatiou, and are lost in the fibrous tissue of
the mucosa.
(E) Termination of Striated Muscular Fibres in Hollow
Vinecra, and in Connection tcith Vnstriated Muscular Fi-
bres.— In the oesophagus, urethra, etc., where the fibres
for the most part have no connection with a definite ten-
don of origin or insertion, they end by tapering extremi-
ties, the tapering part being joined to fibres of full size,
as the ordinary skeletal nuiscles (Fig. 331^8). Where the
striated fibres mingle with, and are gradually replaced
by, unstriated fibres, as at the gastric or lower end of the
oesophagus, the long tapei'iug ends of the striated fibres
are surrounded on all sides by the vmslriated fibres, to
which they seem to be cemented as the unstriated fibres
are cemented to one another (Fig. 34(J6).
In all cases (skin, mucosa, hollow viscera, and In the
interior of muscles where the fibres gradually taper to
thread-like terminations), the sarcolemma. if present on
the tapering ends, is so cln.sely connected with the fibre
that it is exceedingly dilficult or impossible to demon-
strate it; and near Uie end of the fibre the striation is so
gradually lost that it is difficult or impossible to locate
the exact termination of the sai'cous substance and the
beginning of the tendinous substance — if it may be so
called. No one has ever been able to show a relation of
the non-striated termination of the tapering fibres to the
sarcolemma, anything like that shown in Fig. 3386; and
according to Busk and Huxley,^ such tapering fibres
with non-striated endings furnish conclu.sive proof that
the sarcous stibstance mei-ges directly into tendinous sub-
stance. According to Beale. fibrous degeneration of the
sarcous substance points in the same direction.
Bk.\N'CHING ok STRI.iTED, Skei,et.\l, Ml"SCUI..\U Fi-
BKEs. — In the invertebrates striated muscular fibres fre-
quently branch and anastomose, especially in the walls
of the alimentary canal. In vertebrates these fibres rarel}'
divide, except when terminating in mucosa or skin.
KoUiker described tree-like branchings in the mucosal
ends of the muscular fibres of the fi'og's tongue; and
Herzig and Biesiadecki have described and figured mus-
cular fibres fi-om tlie frog's tongue which possess tree-
like branches at both ends. According to Klein, branch-
ing fibres have also been found in the tongue of the
newt, bat, sheep, goat, cat, and man. Salter " could not
demonstrate them in man. Branched terminations in the
tongue of mammals are certainly greatly in the minority,
&
and are nmch more difficult of demonstration, than in the
tongue of the frog. In the skin of the rat 's lip branching
flbres have been described by Busk and Huxley (Fig.
3390). Finally, the oiilinary skeletal nuiscular fibres are
.sometimes dichotomously divided. This is especially
evident in the tapeiing ends of fibres terminating within
a muscle (Fig. 3388, C'). Short finger-like divisions at
the tendinous ends of fibres
are common (Fig. 3387).
Strcctuke of a St1{I-\TED
>IvscuL.\u FniKE (Primitice
Fasciculus or Fascicle). — Tlie
striated muscular fibres are
the structural or anatomical
elements of the skeletal or
voluntary muscular tissue.
They are cylinih'ical or plas-
matic in form, and rarely
extend the entire length of a
muscle, most of them being
considerably shorter. In di-
ameter, the general average
in man is from 30 /i to 65 /',
being somewhat larger in the
male than in the female; in
the cat 25 fi to 90//; in mam-
mals below man 4.5// ; in birds
31 fi; in reptiles and am-
phibia. .56//; in fishes lOU//;
in insects 63//. The varia-
tions in size in the same ani-
mal are very great, e.g., in
man some of the fibres are
125 //, while others are only
10// in diameter.*
Structurally, most of the
fibres are composed of two
very ditfereut parts — an en-
closing membrane, sarcolem-
ma, and the contractile or
sarcous substance, which in-
cludes the muscle corpuscles.
Sarcolemma (Myolcmma,
Primitice Sheath). — It was
shown by Bowman'' and
Schwann,'* independently,
that most striated muscular
fibres are covered by a thin,
elastic, and transparent mem-
brane, comparable if not
identical with, a cell mem-
brane. It has not been de-
monstrated in the striated
muscular fibres of amphioxus
and petromyzon (Balfour),
nor in many of the fibres of
the tongue of man and other
animals (Busk and Huxley^),
nor in flbres of the eyelid and
eyeball, nor in most of those
of the myelo-hyoid of the
green tree frog ( Beale '). Ac-
cording to some writers it is
not present in developing
flbres, except near the end
of development. In its
chemical and physical na-
ture the sarcolemma is quite
similar to elastic tissue, so that when the dead fibres are
dissected with needles, either before or after special
chemical treatment, the sarcous substance (see below)
* It Is not stated by the authors from whom the above figures \yere
taken CKolllkerand Bowman) whether, in obtaining the diameter of
the fibres, the cut ends, as seen in transections, were measured, or
whether Isolated fibres were measured, nor whether care was taken to
avoid tapering ends of flbres terminating witinn a muscle. In the
measurements given for the fibres of the cat by the writer, only Iso-
lated fibres were measured, and care was taken to measure them only
where they were of full size.
■&
■.'■•-■'. I
Fig. 3391.— Parts of Two Mus-
cular Fibres fnim the Adduc-
tor Magnus of a Dog, to show
the Sarcolemma between the
Broken and Retracted Ends
of the Sarcous Substance.
Magnified 270 diameters.
(Ranvier.) b, .\ thin layer ot
sarcous substance adhering to
the sarcolemma. This some-
times adheres all the way
around and gives a striated
appearance to the sarcolem-
ma; 7/i, sarcous or muscular
substance : m-c, muscle cor-
puscle. In the fibre at the
right some muscle corpuscles
have been separated from the
fibre and remain in the empty
sarcolemma; .s .sarcolemma;
s'. opposite a space between
the sarcous substance and the
sarcolemma.
15
ITIU!>»rle,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
is more ol'len torn than the sarcolemnia. which remains in-
tact and connects tlic severed ends of the sarcous substance
(Fig. 3391). The sarcolemma, under favorable circum-
stances of light and preparation, does not appear homo-
geneous, but librilhited
and punctated, and in
some cases there seems to
be a connection between
the sarcolemma and the
endouiysium. Occasion-
ally, when lh(! sarcous
substance is torn and re-
tracted, a thin layer re-
mains adherent to the sar-
colemma around |iart or
the whole of the circum-
ference. In such a case
tlie sarcolemma iipijcars
striated, but much loss
opaijue than the whole
hbre (Fig. 3391). When
the entire sarcous sub-
stance retracts, the sarco-
lennna appears like a hol-
low transparent sac, and
is often folded (Figs. 3386,
3391). If the fibres are
considerably stretched in
preparation, tlie sarco-
lemma joining the
--7n-c broken ends of the
sarcous substance
may become verj' slender
and appear like a teudin-
otis termination. In most
cases, however, the sarco-
lemma may be traced be-
tween the retracted ends
of the sarcous substance,
although both ends may
not be visible in the same
field of the microscope.
Whether the sarcolemma
simply encloses the .sar-
cous substance as the fin-
ger of a glove covers the
linger, or whether it has
a "structural connection
with the sarcous sub-
stance, is not yet deter-
mined. According to the
views of Krause, delicate
partitions arise from the
sarcolemma and pass en-
tirely through the mus-
cular tibre, dividing it
into com]iartmeuts. When
the sarcolemma of insects
is slightly raised from the
surface of the fibre, it is
wavy, and at the part of
the wave nearest the .sar-
cous substance a delicate
process is seen to extend
to the mnscularsubstance.
This apjiearance was
pointe<l out and figured
liy Bowman, and may be
seen with the greatest
clearness in the musndar
lilires of the larva of <-.;/-7/-
i/iifix. The conunon aji-
P'earance in vertebrate
muscle is that shown in
Figs. 3386, 3391, where
the sarcolemma seems to
be simply an enclosing
sac.
U
■''I'M mm
Fig. 3392."Tlie Toriniiiiil P-irt of a
Musci;lar Fibre ending within ii
Muscle, to slKiw tlie End of ttie
Fibre, Isolated Fibrils, and the
Vari(His Discs whicb are .some-
times seen in >raliinialiuu Mnscle.
From the latissimus of a kitten
five weeks old. The tlbro is not
striated Iieyond the swellinir near
the terminal end, and a striated
bi'anch ispresenton the rif^lii side
just lieyond tlie hir^e mnscle
coi'puscle. .\t, the larporend the
discs are displaced so that part of
a dark disc is opposite a lifrht disi'.
The entii-e Iciifctli of tlbre liiTc
shown is n.t)-'> mni. The inter-
mediate part, indicated tiy dotted
lin^^s, Is preatly abbreviated.
Drawn witli a camera liicida at a
mairnillcation of .sim dianietei-s.
All the detJiils of stnicture were
(leteniiined with a i^ homoireiie-
ousimniei"sionobieciive. iDi'awn
by Mrs. (ia^e.) c-/. Connective-
tissue corpuscle [laitly coverinj;
the tlbre; (/-W, dark disc. This is
very distinctly divi<led into two
equal pai-ts by a nari'ow liudit
band {niiddU^ or Heiisen's disc,
compare Fi^. 'Xl%i)', ^^MiiJhtdisc.
This is divided into two eipial
parts by a narrow dai^k band
(membrane of Ki-ause, intermeiii-
ate disc, conipai-e Fiir. '.liU'.h; jii-r-,
mnscle corpuscle. Tlie cell binly,
nucleus, and nucleoli are all very
distinct.
Stnriiii.'< Snlmiitnce (Munetilar or Coiitrartile SiilMnnci). —
The substance iiroper of the striated muscular libres is
divided info two constituents: (1) the more or less homo-
geneous, semiliquid interiuediate substance or sitrrophism,
corresponding to the hyaloplasm of undift'ercutiated cells ;
and (-) tlie jihrih or sarcostyles, corresponding to the
spongioplasm or network of many cells. The fibrils are
arranged longitudiuall}', and are Ijelieved to be composed
of thicker and thinner segments. The space unoccupied
by the fibrils is filled by the sarcoplasm. As the thicker
segments of the fibrils are opposite one another through-
out the entire fibre, there is given the appearance of a
dark segnieiit or disc followed by a light segment wlien
the muscle is studied under the microscope with trans-
mitted liglit. The dark disc corresponds to the thicker
juirt of tlie fibrils, and the light disc to the thinner part
where the sarcoplasm is iu greatest abundance. The
longitudinal arrangement of the fibrils gives also the
appearance of longitudinal striation; but this is usually
less marked than tlie transverse stiiation. AVhile the ap-
peaniiiee of a striated muscular fibre is so evident and
characteristic, the finer structure has proved one of the
most diflicult problems in histolog}'.*
The dilfieulty of the investigation is greatly increased
because it is so hard to distinguish between appearances
which may be purely optical and those which are due to
structural dilTerentiation. The case is well stated by
Bowman (184(1): "The improvements which have taken
]ilace in the construction of microscopes appear, indeed,
to have only afforded grounds for new differences of
opinion"; and by Leydig (1885): ''The complexity of
structure of muscular tissue, and the fineness of its com-
ponent parts give rise to so many doubts that one is
often led to wish that it were possible to go bevoud the
present attainable enlargement and perfection of the
microseo|iic image." The most varied animals are se-
h'cted from which to obtain muscular tissue for this most
diflicult investigation; insects and crustacca are favoiite
objects, from tjie distinctness of the structural details in
'I
I,
V
>-a- >h I)
FIG. 3303.— Diagram to Show a
Muscte Compartirient. a Jliis-
o'h Case, and the Discs into
■\\iiicli a Miisrif ('onipartmcnt
is ilividctl, a(Ti»rdinL.' (o some
Hist<>|on;ists. Mndiiii'd fnim
Kneehiiann. (Drawn by Mrs.
(iay:e.) Muscle coiiifKfrt-
mint: This one of the series
of sej.nnents of which a striata
ed muscular llhre is supposed
to lift CMinposed. It lucUides
one entire dark dis(" iD-D)
and lialf a liy:ht disc at each
end of the dark disc. It there-
fore corresponds iu extent to
a Bowman's disc. For those
who accept the existence of
Krause's meiidirane. it is the
part of a muscular tlbre be-
tween two such successive
membranes. Miisfh: ca^<e :
This, acciirdiiii? t«. Krause. comprehends a sarcous element (muscle
prism), witli a limited amount of intermediate suiislance at the
sides and ends. The wlmli* cijse is enclosed by Krause's membnine
at tlie ends, and a special membrane at the sides. In the Iliiine,
the muscle case is the part of the muscle comi>arliiieiii hi-iuecn
s and a ; X>-7>. thirh-iiisc, composed of two dark Itamls ((-'/) sepa-
rated 1)V a ligliter disc {m-ch, mlcUUe ri/sc of EuudmtDui. or
Hensen's di.sc. 1,-D, Uglit disc. This is composed of two symmet-
rical halves, each half formintr the end of a muscle compartment.
Each half Is coniposed of two liLdit di.scs \ii-'l), and a tjraiuilar disc
(C(c-(/). the so-called t/jvf»H/ffr or <'cc(s^";-i/ ilisi-, and Ilie disc i-d
{iuttrmctliatc .//m-*, the latter fttrmint,^ the boundary between two
successive muscle compartments. Krause's membrane is usually
said to cimsistof the intermediate disc and the two adjacent acces-
.^.IZSL
■ J.'J;.
>L-D
(try
, with tlie light discs between them.
their muscular fibres. Xo matter what animal is chosen,
it is too often assumed that the structure of all striated
muscle is identical with that under consideration — an as-
* In the ei>idermis of htnti'trn^. and perhaps also in some other
(Islies, there are lart'c clavate cells which resemble very stiikinsrly
short pieces of striated muscular fibres. Not only is the afrreemerit
verv marked, both in ordinary and polarized lipht. but the resistance
of these cells to the action of caustic potash is like that of muscular
tissue (Ma.x Schultze, Arch. i. Anat. u. I'bys., ISOl, p. 281).
16
REFERENCE HANDBOOK OF THE JEEDICAL SCIENCES.
^luscle.
Muscle.
suniptiou wMcli often requires the imagination to fill out
details not visible when muscle, other than that taken as
the standard, is examined. From liis own study, the
writer believes that al'
Pig. iCiiU.— Pait of a Muscular
Fihrv frniii thp.\ddiii't(jr Majr-
nus nf a Habliit, to slU'W the
App*'aram-e k) au E,\Lendfd
Mauanalian Muscular fibre..
Majrnilled 70<) diameters.
(Ranvier.) «. Dork disc; b,
Krause's uieuibrane or ii3t*?r-
mediate disc; c, ligbt disc:
K. naiscie curpuscle seen in
prollle.
the appearances described by
original observers may be
demonstrated. if muscles
from a sutticiently great
number of animals are stud-
ied both before and after the
application of a sufficiently
large variety of chemical
agents, and if a microscope
having sutlicicnt range of
magnilication and excellence
of image is employed.
It was shown I.y Bowman,-'
■whose paper in the "Philo-
sophical Tiansactions,'' 1840,
is the most pi'oininent land-
mark for the histology of
striated muscular tissue, that
the filjres have a tendency
to liieak up into fine librils
(priinitii-e fihrillii'). whicli ex-
tend parallel with the long
axis of the mtiscle, and ap-
pear in structural details like
the entire fibre, and that they
may also break up into discs
which are at right angles to
the long axis of the fibre. In breaking into discs {Boir-
m(i'N'n(linr«). the plane of cleavage is through the middle of
the light disc (Figs. 3393, 33930 ^ach disc of Bowman is
therefore composed of an entire dark disc, with half a light
disc at each end. These appearances were considered by
Bowman to indicate, not the existence of fibrils and di.scs
in the living muscle, but of minute rotmded or angular
liarticles(Bi>wmaii's niivoiis t'/cineiits), which form the true
contractile part; of the fibre; and that these are connected
together on all .sides by a more fluid and non-contractile
substance, sarcoplasm — that connecting tlie sarcous ele-
ment end to entl into fibrils — differing somewhat from
that connecting them side by side into discs, as is shown
from the fact that the I'eagents causing the muscle to di-
vide into fibrils do not cause it to break readily into
discs, and those causing the fibre to divide into discs do
not cause it to break readily into tibi-ils. When, how-
ever, tlie cementing materials at both the sides and ends
give way, the sarcous or ultimate elements of the fibre
are, according to Bowman, isolated. Bowman's views
were so simple, and so in accordance with ob.served facts,
that they were almost universally accepted. There is,
however, great difficulty in deciding what should be con-
sidered a primitive fibril composed of a single row of
sarcous elements placed end to end, as it is possible to
separate a fibre into fibrils so small that the structural
characters are difficult of determination. The term sur-
conn ele/iient, to indicate the ultimate structural and con-
tractile part of a muscular fibre, has been retained by
most hisCologists, although the interpretation of what
constitutes a sarcous element varies with almost every
original investigator.
The following are a few of the more important modifi-
cations or enlargements of the views of Bowman upon
the intimate structure of striated muscular tissue:
(A) Action of Poliirizcd Light. — It was shown by
Bruecke (1857) that the sarcous elements of striated mus-
cular tissue are aniitotropic (doubly refractive), and act
like positive uniaxial crystals, w-iiile the intermediate
substance is isotropic (singly refractive). As the sarcous
elements retain their anisotropic character apparently un-
changed during the shorlening and bi'oadening of con-
traction, Bruecke supposed that they were not simide
but compound b«dies, and he aiijdied the term (liMiarUmtx
to what he considered the elementary particles compos-
ing the sarcous elements, thus borrowing the tenniuology
of Bertholin, \vho used this term to designate the hypo-
thetical crystals of calc spar. On the whole, it cannot
Vol. VI.— 2
be said, however, that polarized light has been of mate-
rial aid in comprehending the structure and action of mus-
cular tissue.
(B) Mnxiii- ('otiiptirtinoitx. Additional Discs. — It was
shown by Bowman that, in addition to the broad light
and broad dark discs, there sometimes appeared a nar-
low, dark line in the li.ght disc and a narrow light band
in the dark disc (Fig. 3392). The dark line in "the light
disc was also figured and described by Busk and Hux-
ley, who considered it a disc composed of a row of mi-
nute sarcous elements. It has also been insisted on by
SharjX'y and Martyn, and later by Krause. Krause in-
terpreted it as a continuous membrane (Kmtise's mem-
hroiic. intermediate disc), extending from the sarcolemma
antl dividing the muscular substance into compartments
{iiiusde compartineiits) which apparently correspond ex-
actly in extent to the discs of Bowman "(Fig. 3392). The
view that Krause 's membrane is a real structure, which
extends from the sarcolemma through the fibre, thus
making a complete piutition, is supported by the fact
that when the sarcolemma of insect muscle is paitly torn
front the fibre, delicate processes are often seen to extend
lo or toward the sarcous substance from the sarcolemma
Djiposite the middle of the light disc. This appearance
has not been observed and figured for mammalian mus-
cle. The view of a continuous membrane making a par-
tition in tlie fibre at regular intervals is opposed by the
fact that a worm has been seen to move along within the
sarcous substance from end to end of the fibre. Further-
more, the sarcous substance of the fibre closed up behind
the worm, and the fibre appeared as before and still
showed unmistakable contractions. Also, that in living
and contractile mu.seular fibres of insects, which are ap-
parently uninjured, the discs sometimes become dis-
placed "for a short distance along a sharp line, so that a
dark disc is opposite a light disc. The displacement of
the discs is shown in Fi.u:. 3393, but here it might have
been due to the traction exerted in preparation, and
hence does not bear upon this question as dnt-s the dis-
placement of the discs in the livin.g and uninjured fibre.
Fig. 33S1.5.— Fascicle of Human Striated Muscle to show the Diversity
in Size of Fibres, tbe Muscle Columns, and the Position of tUe Nuclei.
(Diawn by Mrs. tiaj:(^) Matrnifled about 3.50 diainercrs. ('?>i. Eu-
dduiysium or conurciivc lissue between Ihc individual muscular
tlbivs. lu the lower left-baud corner some nf (be Mhrcs are absent,
the eudomysium aloue .shcwiuir. mc. Muscle cnr|iusi-ies. In mus-
cular fibres with much sarcojiiasm and eviiieut muscle columns,
some of the nuclei are in tbe middle of tbe tlbri- instead of at the
siu-face; /», pale rilMi' witli evenly disti1but*'d tlhrils. and little
sarcuplasm. and the nuclei all at the surface ; r. red flbres sliowin;?
abundant sarcuplasm and e\ident muscle cttlumns. Some of the
nui'lei are in tbe uiiddle of tbe red flbres; .s, spaces from whi<'h the
muscle flbres have been removed to show clearly the suirouudinn
eudomysium.
Besides the di.scs just considered, German investigators
have described others which are shown in the diairram
(Fig. 3393).
(C) Mii.sch C'liscs. — Besides the mu.sele comiKirlnients
Krause considers that each sarcous element (nniscle
prism) is entirely enclosed by a membrane (Krause's
niembraue) forming the end, and a special inembnuie
forming the sides (Fig. 3393).
17
Iflll«<'j
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
(D) Colinheim's Areas, Muscle Columns. — Cohnheim, in
18(i;i. sliowcd Umt in transections of frozen musouiar
fibres, tliere uppeared ilarU iiolygonal areas (Cohnlieim's
Fir;. 331W.— Bln(«l-Ve^sels of Striateii Musciihir Tissue. From a cat.
Mairnilleil TiiHi diameters. (.Heitzuiann.) ^l, Artery: P, perimy-
sium; V. M-'iu.
areas), siir}oinnleil liy narrow liuht lines. He snpjiosed
tliat tlie (larlc areas were tlieeiit ends of sarcotis elements,
and tlie light intermediate siilistanee was the lateral ce-
menting material. It was found, however, that a Cohu-
lu'ini's area might be far too large to re]>reseiit a section
of a single sarcotis element, and the area often showed a
punctated appeaianee; hence arose the conce])tion that
in a striated muscular fibre tlie fibrils arc tirrauged in
bundles {mnttfU' colmints, KoUikcr; pn'mitt're iitiisriihir
ei/!iitilerx, Levdig, Fig. 3:^86), sometliing as an entire
nuiscle is made up of fascicles (Fig. 3382), and that
C<ilmheim's areas represent sections of the liundles of
fibrils (muscle columns), so that a transection of an
entire muscular fibre has the same general appearance
as the transection of an entire muscle. This is most
strikiuff in filires with a larL-^e amount of sarcoiilasm
(Fig. 339.-,).
(E) Tlie UftietiliiUil Ai-ranr/i ment nf O'litnicti/c Siib-
stiiiice. — Ileilzmann' (1ST3) introduced a new idea as to
the stnu-lure of striated muscular tissue — viz., that, like
.sim]ile ])roloplasm, the .sarcous substance is made up of
a relieulum of thi' true contractile matter, tlie meshes of
this reticuhim being tilled by a more lluid iiitermeiliate
substance. According to this view, the reticulum is so
arranged that the nodal or crossing points (sarcous ele-
menls) are at ri'gular intervals both transversely and
longitudinally, the transverse row giving the a|iiieaiauce
of a continuous dark disc, and the longitudinal row of a
libril. The light disc is traversed by tlie lilaments of the
reticulum, which ]iass Vietweeii the nodal |ioints. This
hypothesis, with unimportant modiliealioiis, is now'
adoiited by many histologisls, and appears to be most in
harmony with the latest views concerning histological
structure.
(F) Red (iiiil I'dlc Muscle. — It has been known for a
long time that some muscles, independent of their con-
tained blood, are red and others pale. Kanvier" drew
especial attention to this fact and pointed out an easy
object for study in the semitendiuosus of the rabbit for
red mu.scle and the semimembranosus for pale muscle.
Structurally the red muscle is characterized by abundant
sarcoplasm, .so that the fibrils are not very compact : the
nuclei tire not all at the surface, but some of them are
between the well-marked muscle columns. The longi-
tudinal stri;ition is evident. With pale mu.sclethe sareo-
jilasm is relatively small in amount, the nuclei are at the
surface and the longitudinal striation is not well marked.
In man the red and pale fibres are frequentl_y iutermi.xetl
in the same muscle (Fig. 339.5). Muscle "tissue called
upon for almost con.stant contraction, like the dia-
pliragm, has also much sarcoplasm.
V.CscuL.Mi Supply op Stri.vted Muscle.— As in other
tissues, the blootl- and l_ymph vessels of muscular tissue
do not cuter the structural elements or fibres, but are in
the connective ti.ssue surrounding them.
(A) Blodd-tesscls. — The blood-vessels of this tissue are
Very numerous, and are estimated to contain one-fourth
of the blood in the entire body. As a rule, each muscle
reeei\-es two or more arteries, and gives off a corresiiond-
ing numlier of veins. Tlie larger vessels run in the
perimysium, and send small branches into the fa.scicles,
where they break up into a characteri.stie, parallelogram-
mic network of tine capillaries, the longer part (if the
mesh extending parallel with the fibres. The capillaries
arc the smallest in the body, many of them being smaller
than the blood corpuscles of the animal to which they
belong. In man the size varies from 3..5," to 6.-5 /i (Kiii-
liker,'"l86T) (Figs. 338'3. 3390). It was shown by Ranvier
that in red muscle the transverse branches of the cajiillary
network and the smallest veins often possess saccular
dilatations which arc supjiosed to serve as reservoirs of
o.xygenated blood to suiijily the muscles during a long-
continued contraction, or to act as receptacles during a
maximal contraction.
(B) Lynqihutic Vcumis. — The lymphatic vessels of stri-
ated muscular tissue are supposed to be numerous.
The)' lie between the fibres in the perimysium and endo-
niysium. and are said _
by Klein "to have the
shape of continuous
long clefts or chan-
nels. "
yefces (if Striiitiil
Muscle. — The nervous
supply of striated mus-
cle is e X c c e d i n g 1 y
abundant, and consists
of both motor and sen-
sory fibres. The s|ic-
ciai terminations of the
nerves in the tissue
will lie considered un-
der Nerves (q. r. ).
Mvsci.E Spindles,
— Bodies of fusiform
shape discovered bv
Kolliker" (18(i':) in the
breast muscle of frogs.
About the same time
Klihne found similar
bodies in mammalian
muscles. It was dis-
covered also that these
spindle-shaped bodies
contained one or more
striated muscle fibres.
The muscle fibres within the spindle were named by
Kolliker, Wcisinanu's fibres, in honor of their discoverer.
The more common designation, liowever, is iiilriifiisul
fbrcs.
Fir,. 3307.— Cardiac Muscular Tissue
from a Warui-hlooiled Animal, lo
sbow the Form. Brandies, and Rela-
tions itf tlie Cardiac Muscle Cells, (In
the ritrht the limits of the separate
cells with their nuclei are exhibited
somewhat diagrainmalically, Ma^'iii-
flpd. (Schweiger-Seidel.l
18
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Muscle.
Muscle.
Fk;. 3oVI8.— Caiiiiac Muscle Cells of the
Left Ventricle of a Dop, slK^wiiip: the
Form. Branches, Nuclei, and Stiia? of
the Cells. The longitudinal, trans-
versely striated bands in each cell
represent muscle columns. Ma^ni-
I3ed tiCM_) dianielers. (Uanvier.i a.
Intercellular cement at the junction
of the cells: ((.nucleus. The one op-
posite the 71 shows a conical mass of
unstriated protoplasm at each end.
A muscle spindle consists of a thick, fusiform envelope
of laniinated fibrous tissue, somewhat comparable with
the capsule of the Pa-
cinian bodies. lu the
long a.xis of this fusi-
form envelope, and
frequently passing
through its entire ex-
tent, is a bundle of
■ small muscle libi'es.
Entering at one of the
poles and near the
middle two or more
nerve fibres join the
spindle. The sheath
of Henle of the nerve
fuses with tlie wall of
the spindle. Blood-
vessels and Ij'mphatics
are also present (Fii;.
3400).
These muscle spin-
dles are most fre-
quently found near a
nerve aud a blood-ves-
sel (Fig. 3411. B). In
mammals they vary
from 1.5 to 10 mm. in
length, aud from 0.1,^
to 0.4 mm. in diameter.
Sometimes the spindles
are compound, two or
three being placed
siile b}' side, or end to
end.
The muscular fibres
(intrafusal fibres) in a
spindle varj' in num-
ber from one to twenty; but a number varying fiom
three to ten is most eomtnon in manniialian muscle.
In size they are usually much smaller than the ordinary
fibres of the muscle in"which they are situated. This is
more marked in adult than in uew-boru animals. The
size of the intrafusal fibres varies from about '> u to 20 ,«
in diameter. They are characterized by coarser striatiou
aud the nuclei aix' in many
cases iu the middle of the
fibre instead of at the cir-
cumference. Frequently
also iu the middle of the
spindle the nuclei are so
numerous that the striatiou
is lost or obscured (Fig.
3400, A).
The significance of these
bodies has been much dis-
cussed, and various conclu-
sions have been reached.
E-vperiments by Sherring-
ton and others make it al-
most certain that the bodies
are innervated by both mo-
tor and sensory nerves, and
the belief is becoming gen
eral that the}' are iu some
way connected with the
muscular sense (Batten-)
(Huber and DeWitt-").
C.\KD1AC MUSCUL.\K TIS-
SUE.— Distrihntion. — Cardi-
ac muscular tissue is pres-
ent in the heart of all
vertebrates, aud, so far as
has been investigated, in all those parts of the blood-
vascular system e.xhibiting rhythmical pidsations, as
* This figure appeared in Qualn's " Anatomy,*' eighth edition, p. 119,
but the source was not given. On inqiiiry, I)r. Scliaefer informed the
writer that the cells are from the heart of a young rabbit.
Fig. 3399.- Cardiac Muscle Cells,
showing their Form, Branches,
Nuclei, and Stria?. From the
heart of a young i-abbit.* Mag-
nified 425 diameters. (Schaef er.)
a. Line of junction between the
cells (intercellular cement) ;
li, c. branches of the cells.
the C0711IS arteriosus of amphibia and many fishes, and the
great veins next the heart in mammals.*
In the cold-blooded animals, fishes, amphibia, aud rep-
tiles, cardiac muscular tissue is composed of striated cells
which ai-e much longer than broad, and which as a rule
are considerably branched and contain a single nucleus
(Figs. 3401-3404).
In warm-blooded animals — birds and mammals — car-
diac muscular tissue is iu the form of anastomosing seg-
ments or fibres with nuclei at more or less regular inter-
vals along the fibres.
By caustic potasli and other dissociating agents it is
eas3', in the new-liorn aud young, to separate the cardiac
meshwork into segments which are usuallj' branched and
with a single or double nucleus in each segment (Figs.
3399, 3413-341.5). These segments with their branches
liave the appearance of cells, aud are so considered by
t 1 I IJB "•«■
Fig. 3400.— Muscle Spindles. (Draim by Mrs. Gage.) A. Lon0-
tudinal view of a muscle spindle from the striated muscle of the
rabbit (moditled from Ki'Uikeri; (■/». connective-tissue capsule with
nuclei ; if, intrafusal striated nmscidar fibres in the long axis of the
spindle— near the middle they are thickly niicleated ; »i//, motor
nerve distributed to the spindle; .*Ji, sensory nerve entering near
the pole of the spiiiille. The sensory nerve is usually very large.
^'. An ordinary muscular fibre of the rabbit di-awn at the same
scale as the spindle to show the cotuparative siiie and fineness of
striatiou. B, Transection of a compound muscle spindle from the
human sartoriiis magnified 3.50 diameters u-f. Fig. 3410, D)\ if,
iuti'afiisal nuiscular Illires. Two were present in the iippHr and nine
in the lijwer spindle : the diversity in size is well stn)wii in the lower
spindle; C)*, connective-tissue capsule of the spindle, this atipeaiN to
be composed of nucleated lainin:e something as in the Pacinian
bodies. B\ Tw., ordinary striated fibres near the spindle and
drawn at the same scale for comparison. C. Tratisection of a mus-
cle spindle from the sart<Jrius of a child at birth. Magiiified 350
diameters (c/. Fig. 3410, C); ii. intraftisjU fibres; c/j. coiuiective-
tissue envelope or capsule. C, Three ordinary muscular fibres near
the spindle and drawn at the same scale for comparison. They are
no larger than the intrafusal fibres.
most anatomists. In the adult it is much less easy to
separate the heart muscle into these cell-like masses. In
sectious parallel with the so-called fibres, appearances
* According to the investigations of Ranviei', the miiscular tissue of
the rhythmically pulsating (,i/mp(i lu-artsof nmjihihin is in structure
like the ordinary skeletal nmscles, except for a greater tendency to
branch ; also, like the skeletal muscles, its motor nerves are paralyzed
by curare.
19
Irlnsrl<>,
Mustle,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
^/ 100 mm.
like those iu Fig. 3397
are readily obtained if
(ine omits tin; aiiparcnt
division into cells. In
the adult, the heart
seems to be made up
of a sponge-work of
muscle substance. It is
believed by some of the
later investigators (v.
Elmer and Heideuhain)
that iu the course of
development the muscle
>A ^^^^ fl cells form a kind of syn-
b4 ^w^ — ^ \ eytium, and that in "the
^ t?^ V adult at least no true
cell boundaries are pres-
ent.
IntitiKitc Structure. —
Whatever may be the
true interpretation of the
cellular nature of adult
heart muscle, the inti-
mate structure is com-
parable with red rather
than with pale skeletal
muscle, that is. the sar-
is relatively
abundant, and the lon-
gitudinal striation usu-
ally quite evident. The
nuclei are always in the
muscle substance and
uot at the surface (Fig.
340.5).
A snrenlemma like that of skeletal muscle is not pres-
ent, but the large amount of sarcoplasm forms not only a
mass within the lilire but a
kind of mantle over the sur-
face, and this gives the ap-
]iearance of a sarcolemma.
As the so-called Kranse's
meralirane seems to jiiiss
from the surface of this sar-
coplasmic mantle across the
nuiscle substance, the like-
ness is quite striking to in-
sect muscle. The sareo-
A plasmic mantle is often
Fio. iUOl.— t'ardiao. Muscle Cells from
the Ventricle of a Minnow, t^ show
the Fonris tif the Cells with their
Branches. Nuclei, and stri:e in the
Teh-iixtean Fiahrs. A, Cell ap-
pri>xiiiiatelv fusiform in ((inline ; B,
branchi'ii cell, which jippears irranu-
lar rather Ihan regularly strialeil;
C cell with tiepression, in which a
rounded end like the branch of B ooplasm
fits when the ceils are in theirnor-
mal relations iconipare the middle
cell and its relations in Fif?. ;UI.5);
J>, cell appro.ximatinix in shape the
cardiac imiscle cells of warm-
blo'Mled animals ; n. nucleus. In
cells .1, C, the transverse stride dis-
tinctly cross the nucleus.
^
Mmm4
yioa mm
Fig. 3-102.— Cardiac Muscle Cells from the Ventricle of yrelnrm
laliriiliK, to show the Various Forms of Ceils anri iheir striictm-al
Details in a PrrfuitiiiVfinciiitiif An\iihiUit[it. A. l,arL'e-hr;inchcd
cell with twri iniclei whicl! coiilaiii iHutiefrtus nucleoli. .\c:n- the
<md of the l<(ni?est branch the icLruiariransverse striation is irplaccd
by irreLrularly arrauijed i.'nauiies. Larfre cells like this are comiiion
in the heart of JVcc^tirc.s; they are [ilate-like. ils was dctei-nnneil
byaprotUe view: li. ('.cells of apiiro.ximateiy the same tiuikncss
as breadih ; they form the irreai hulk of the lieart, and usualiy ate
branched : n, nucleus with nucleoli.
wavy also, and the Ivrause's or intermediate membrane
seems to be attached to the hollow of the wave.
llliiiiil- and ijiinph TtaxelKof CanJidc iliii^culiir Tissue. —
The vascular sujiply of this tissue is very copious. The
Ciii'diac muscle cells are enclo-sed iu a parallelogrammic
network of capillaries, and the rootlets of its veins are
formed by the union of several capillaries at the same
point. The larger veins possess valves iu man and the
higher inammtils at least. The lymphatics are numerous
;ind consist of passages and spaces in the intermuscular
connective tissue (perimysium) which communicate with
the subpericardial lymph vessels.
JS'erres I'f Cardiac Mu.icular Tissue. — Myelinic and amy-
elinic nerve fibres and small ganglia are very numerous
/ \ A
'/oo mm
Fig. 3403.— Cardiac Muscle Cells from the Ventricle of a Toad (Bufo
Icntiiiuiiisii.'i). to show the Various Forms of Cells and their Struct-
ural Details in an ,) iioiooh.s' Ampliihkin. The striation is rather
tine throuL^hoiit. and townni the ends is, in manv cases, replaced liy
irreoularly ananti'd trninules. .l. D. Broad-lira Dched cells. Cell's
of this kind are phite-like, as was detenuiiied hv causing them to
roll over so that a proille view could be obtained; /(, {'. branched
cells of a|ipro.\imately the same thickness as width. Both these cells
would be nearly fusiform if the lateral branches were removed ; n,
nucleus. In D, two nuclei are present.
in the heart. The fibres extend in every direction be-
tween the nuiscle fibres. The special mode of their ter-
tniuation will be discussed under .Xei-ves (g.v.).
S.MOirril OH rxsTKIATED MuSCULAIl TISSUE. — This is
the ciintriietile tissue iu the animal body, composed of
elongated, mostly uninucleated, fusiform" cells or fibres,
which arc ari-anged in membranes, sheets, ple.xuses, or
scattei'cd bundles, in the various organs.
Distriliiitioii. — This tissue is present in many inverte-
brates and in all the classes of vertebrates. In" mau and
most manimtds it is fmind iu the following situations:
(A) Tln'oiKjIiout Ihciiliiinntarji canal: (1) muscularis mu-
coste; (2) muscular coats of the stomach and intestines,
part of the (esoplitigus, and in the a-sopbageal accessoiy
muscles; (o) as meiulirancs or scattered bundles in the
ducts of the salivary glands, in those of the pancreas and
of the liver, iu the iutestiual villi, aud in the gall-bladder.
20
REFERENCE HANDBOOK OF THE JLEDICAL SCIENCES.
Kluscle.
muscle.
(B) Respiratory organs : in the trachea,bi'ouchi, infundib-
ula. aud, according to some authors, in tlie alveoli nf the
lungs. (C) Urinary organs : in the medullary portion of
the kidney (Jardet '"), in
the calyces and pelvis of
the kidney, in the ureter,
urinar_v bladder, and ure-
thra. (D) 2'lie generative
apparatus : (1) male, in
the dartos of the scrotum,
epididymis, vas deferens,
vesicuiaj seminales and
musculi cjaculatorii, pro-
state, Cowper's glands,
and the corpora caverno-
sa: Ci) female, in the ov-
ary, Fallopian tubes (ovi-
ducts), in the uterus and
all its ligaments, in the
vagina, corpora caverno-
sa; in the nipples, and the
surrounding arcolie. (E)
Vascular system : in the
//,— ™™ endocardium, semilunar
"ifi. 3404. -Cardial' Muscle Cells almost all the blood-ves-
from the Ventncle of a Tounp gpig „„^ larfer Ivmnhat-
Alligator. to show the Various ?'-"' ana lai.u i\ mpuai
Forms of Cardiac Muscle cells and 'CS, in the adventitia 01
their Structural Details In the some arteries aud veins.
Heart of a Replllp. .^. Fusiform „,,,] ;,, conip nf the Ivm-
cell ;«. r, branched cells. These ""?" ?° °"™V " \ '3 ™
make up nearly the entire mass of phatic glands, (t ) In the
the hf;irt. very few being simple capsule, and in manv
spindles like A : it, nucleus in
which the nucleoli are very dis-
tinct.
Figs. 3401 to 3404 are at a uni-
form niagniflcaiion of .50() diame-
ters. The drawings were made
with a camera lucida. and the
finer details of structure were de-
termini'd with a ,', homogeneous
immersion objective, and added
free-hand. (Drawn by Mrs. Gage.)
niaininals also in the tra-
becul;^ of the spleen. (G)
In the skin in connection
with the sweat aud ceru-
minotis glands, and form-
ing the arrector pili. (H)
In the eye and its tieinity,
the rHU-icxdiis orhitalis et
palpehralis of H. Mueller,
in the orbital lissure and forming the ciliary muscle
(tensor choroida; or muscle of accommodation), the
sphincter and dilator of the pupil.
Constituents of Vnstriated Muscular Tissue. — These are:
(A) The contractile or muscular libre cells or fibres form-
ing the essential elements. (B) Connective tissue form-
ing a kind of perimysiuiu which suri'ounds the muscular
tissue aud, penetrating between the tibres. combines them
into bundles. (C) Blood- and lymph vessels an<l nerves.
Relations of the Films. — The fibres forming a bundle or
fascicle are cemented to one another throughout their en-
tire extent, lapping and interlacing so that apparently
solid bundles or membranes withotit fissures aie formed
(Fig. 3406). As a rule, there are no distinct tendons for
uustriated muscular tissue, since in muscular membianes
which entirely surrotmd an organ, tendons would be un-
necessary; and in other cases the close relations of the
^j;^_j^ fibres to the siuTouud-
,.K'rioy%, ing fibrous tissue, and
the commingling of its
perimysium with the
surrounding fibrous
tissue, serves to con-
nect the muscles to
the part to be iicted
upon. In special and
rare cases, tendons ap-
pear to be formed by
the insertion of single
uustriated fibres into
the fork of an elastic
tissue fibre.
Intimate Structure of Smooth or Un.striate/l Muscular
Fibns (muscular or contractile fibre cells, smooth or jtlain
muscular fibres or muscle cells, non-sti-iped or non-stri-
ated muscular fibres, unstriped or unstriated muscidar
fibres or muscle cells, involuntary muscular fibres, fibre
Fiii. 3405.— Transection of Five Cardiac
Muscle Cells, to show the Form aitd
Relations of the Cells in Section, and
the Central Position of the Nucleus in
Three of Them. In the other two the
section w^as not at the level of the
nucleus. The minute dark areas in
the cells represent sections of muscle
columns (Cohnheim's areas). Magni-
fied 55U diameters. (Ranvier.)
cells, or muscle cells). As stated above, smooth or un-
striated muscular tissue is composed of special tibres or
cells which form the essential aud contractile part of the
tissue. They are also its anatomical or structural ele-
ments, and are in general fusiform, sometimes branched,
aud usually contain but a single nucleus (Figs. 3406,
3409). The fibres vary gi-eatly in size, ranging from
30/1 long and 4," wide to 230// long and \o ti wide. In
the gravid uterus they may attain a length of 500/;.
Those of the vascular system are usually smaller than
those in other situations, and thej' are almost invariably
of very irregular outline (Fig. 3408).
JSueleus. — The nucleus is usually oval in outline (rod-
shaped in those of the vascular system), and averages
about 13,u to 20 n long and 4/; to 10// wide. It extends
lengthwise of the cell, and often contains one or more
if-o.
m
Fifi. 3406.— To show the Form and Relations of Smooth Muscular
Fibres in their Length and in Direct ami Ohliiiue Sections. From
the human uterus shortly aftiT delivery. Magnitlcd .lOO diameters.
(Heitzmann.) ('. Capillary 'the cut eiids of two other vessels are
shown in the Jlcfure; f 7-c, cnnnective-tissue corpusile, or plastid in
the perimysium : .1/-/. sriinoth nr unslri;iled mu.scuhir II I ires shown
lengthwise ;ind in their nnnnid retatir.iis I.' one anniher; .V-'^ ends
of smooth uuisrular ilhiesiiit ni)hi|uel> : M-i. ends of smooth iiius-
cular Ilbres i-ut transversely : i^ iterimysium, or interstitial connec-
tive tissue.
nucleoli (Figs. 340(j, 3408, and 3409) A complex intra-
nuclear network has been described by recent authors.
At each end of the nucleus there is in many cases a coni-
cal mass of granular matter: this is siqiiiosed to be
protoplasm not yet dift'erentinted into contractile sub-
stance.
Contractile Suhstaitce of the Sunuith lo- l'u.''triattd Mus-
cular Fibres. — In the fresh condition, and after many
methods of prepai-ation, the smooth muscular fibres ap-
pear homogeneous. exce)it for a few scattered granules,
the nucleus, and the slight amount of granular matter at
21
jfliisclr.
REFERENCE HANDBOOK OF THE IVEEDICAL SCIENCES.
its ends. Uuder I'aVDralilc conditions of preparation and
liglit, tlie l)0(ly <ir the lilue apju-ars no long<-r liomoge-
neousbut di.stiuclly lilirillated, tlic lil)iilse.\ tending jiaral-
lel with the lon.i;
' ^?^«
I'ction of rart of the
eiii'ular Musrul:ir Coat of tlie Huniall
imixlomini. (Prawn by Mrs. tiaffi^;)
This shows Ilu' ciil. etnis of Ihf plaid
liillscular Iliircs ami tlioir roiiiliination
into fa.'iric'lcs. .Ma[.'nill.'(l aliout :!.'ill
iliaiiifti'fs. .1. caiinTa luritia ttiawiiiL^;
(J, i-onriH{'tivo lissllr hi'Iwi'fll tliC lltnt-s,
till* llhfrs havint: falii'li out it is a kiti'I
of fU'loiiiysiinii : ((, micli'tis. AiuK'leiis
appoaiN in only pai't of the cells as only
ji frw ate at the leyel of the section,
t'uinpaiv the lonffitndinal views in Figs.
MH). :il(is, and lUnii. «. F.nlaii.'o.l view
to show the c-onneetive tissii
the cpIIs and that the niuselt-
sln'unkell roiisirlt'|-ahl\'. The
Infl is shown nrjshfunken,
tive tissue liftween the Uhres
fibres, one shrunken and
shnuiken ; *(, nuelen;
shrunken llhre.
Htwi'on
es have
■ at the
m
axis of the tilnc. tmd
being tlierefore of
varying leuglli (Fig.
J409). "Tliey are vei-y
fine and appear like a
sliein of tlJread. lie-
iug in many super-
imposed layers, anil
not in a single layer,
as is shown in Fig.
340!). These fibrils
are supposed to be
the trne contractile
parts of the fibre.
Between them is a
limited amount of
c 1 ear intermediate
substance. Accord-
ing to some authors,
the fibrils are direct-
ly connected with
the intraiuiclear net-
work.
>Sif rC'Iciii im/. — A
thin, homogeneous,
elastic sheath or sar-
f. museie colemma is deseril)ed
21 Z. i^y r'^^ ^i"ti"^?^ .f
euclosmg the mdivid-
ual smooth rauscidar
fibres (Fig. 84()i), B). An equal, or greater, number of
authors deny the presence of a special envelojie or sar-
colemmti, for the smooth muscular fibres of vertebrtites.
Bhioil- II lid ijjiiqih Vtiinilsiif Uiislriiitid Muscular Tixsiie.
— The tilood vessels are less numerous than those of the
striated muscles, but they have the same general aiTange-
ment, the capilliiries forming a network with square or
parallelogrammic meshes. The lymphatic vessels have
been most investigated in the muscular tissue of the
uterus and intestine, whei'e they iire in the form of pas-
sages and lacuna- which anastomose between the fibres.
A'crivs of t<iiii/i)l!i iir Uiititriiitcd Miiwiiliir Tissue. — These
are abundant and consist of myelinic and amyelinic fibres,
wliieharein nnmy situations in the form of a plexus with
ganglia. Thespeciiil distribution to llie individual mus-
cular fibres, anil the
termination of tin'
nerves, will be dis-
cussed under Si n-is
(q.i:).
Histogenesis of
^IrsccL.vK Tissfii. —
Muscular tissue of all
forms in vcrtcbniles is
developed from cells
of the mesoderm or
middle germinal layer.
The ceils are iit first
rounded tuid indi.s-
tiuguishable from oth-
ers of the mesoderiii.
It is only later, whi ti
approximately in the
position of tile futiu'e
museie. that they as-
sume the cinu'aeteristie
form tiinl tippetirtmee
of the structural ele-
ments of the .special kind of musctdiir tissue t
they give rise.
Histiii/i iitsis of Stn'ittid. ,%-th'tiil Miisi'iilnr Tissue. — Tlie
muscles of the trunk are without doubt mtu'nly or entiiciy
derived from sjiecia! masses of mesodermal (rells — luu.'uie
pliites or myotomes {protnrtcbne of older writers). These
Fi(i. ail).H.— SiiKioth or rn.siriated Mus-
cular Fibres of the Vascular Svsiein,
to show their Irrefrular Foiin and the
Hod-shaped Nucleus. Froni the thy-
roid artery of man. Magnitioii :Ud
diameters. (Schaefer.) n, Xui-leiis.
wliirh
aiiiJciir on the dorsal aspect of the embryo, and give it
the first ap])earauce of being composed of a series of seg-
ments. According to some writers, all the skeletal mus-
cles are deriverl from the muscle plates, those of thi^ limbs
being outgrowths or diverticula of the muscle plates:
but working over an exceptionally large collection of
hiuuiui and mtimmalian embiyos of all
ages, Btirdeen and Lewis ' could in no
Ciise demonstrate definite processes of
the myotomes growing into the limb
buds. " They do not deny the possibil-
ity of the entrance of scattered cells
fi'om the myotomes entering the limb
IM'ot.ons, but tlie apyiearance is that tlie
muscles of the limbs arise by a differ-
entitition of a part of the mesenchv-ma,
making iq) so large a part of the de-
veloping limbs.
Velliihir Origin of the Muscular
Fihrcs. — All are agreed that the mus-
cultir fibres are derived from meso-
dermal cells; but there are two views
as to the n'umber of cells entering into
the foi'intition of a single muscular
fibre. These are: (A) That they are
niiilticiiliiliir ill, orii/in. This view
originated with Schwann.'* and is at
]u-esent held by a considerable uum-
l)er of iuvcstigtifors. It tcaclies that
each striated muscular fibre arises by
the fusiim of several cells arranged in
a row, the nuclei of the fused cells re-
nniiuing as the muscle corpuscles.
Tlie entii'e filire is therefore, accord-
ing to this view, a multicellular struct-
ure or cell eomjde.r. (B) That they
tii'e unicellular in origin. This view
origintitcd with Remak,'= and is the
one tidliered to by most later writers.
It holds that each striated muscular
filirc originates from a single cell, the
nucleus of which divides repeatedly
with the growth of the cell. Accord-
ing to this view, the nuLScle corpuscles
are formed by the ilivision of the orig-
inal nucleus, and the entire fibre is
an enormous iiiultiiiiirhur cill.
Whether the muscular fibres are of
multicellular or unicellular origin, the
later course of development is as fol-
lows: The elongated granidar spin-
dles, which are to become muscle
fibres, show first a faint longitudinal
striation at the entire periphery or at
one side, and later a transverse stria-
tion; <n- the two striations appear si-
multaneously. The nuclei and the un-
sti'iated protoplasm occupy the centre
or one side of the fibre "(Fig. 3413).
(irailually the entire protoplasm be-
comes sti'iated, and in birds and mam-
mals most of the nuclei reach the
siirtaee of the fibre; but in the cold-
liloniled vertebrates they are scattered
throughout its entire thickness. Glj*-
cogen is very abundant rluring the
later stages of development.
Siireiili uiiiia. — According to Scbwann,
this is formed by a union of the celi
walls of all the cells originating the
fibiv, the parts of the cell walls which
originally came in contact in the in-
terior having di.sappeared. Others
hold that this is the cell wall of the
single cell originating the fibre; and
still others agree with Busk and Hux-
ley tliitt in tile earlier stages of devel-
opment nothing like a cell wall or
Fir,. 3409.— Smooth,
or Unstriated Mus-
cular Fillies, to
show the Fibril-
la ted Sirneture
and the Intranu-
clear Network.
From the small in-
testine. Highly
macnifled. (Schae-
fer. t ^ 1 , .A n entire
cell or tibre. show-
ihfz the fusiform
shapi', (lie lontriUi-
dinal tllirillation,
the oval nucleus
with its intranu-
c tear network,
and the conical
mass of granular
protoplasm at
each end of the
nucleus. The
flbrilliie appear
coarse and as if
hi a single layer;
in an actual speci-
men they are very
tine and in many
s u p e r i m 11 o s e d
layers. 7} , A
broken fibre, to
show the pi'esence
of a sheath-like
coveiing or saico-
lemma proiectillg
like a hollow sac
from the broken
end.
QO
REPEREKCE HANDBUOK UF THE MEDCIAL !^CIE^'CES.
ITIusole,
Ifluscle.
sarcolemiiia is pvescnt, but tliat it is an after develop-
meut, aud arises b_v a transformation of tlie protoplasm
at the surface of tlie tibre into formed material or a kind
of cuticula. The view of Busk and Huxley seems to be
most in accorilance with the general teachings of histo-
genesis and growth.
Grotclh (Hid Fluctuation in Size of Strittted yiuscular
Fibres. — There are two marked changes in muscular
fibres during their development in the embryo: (1) The
cells pass from the ordinary reticulated condition of pro-
toplasmic cells to the striated condition; (i) tliev increase
in number until about the time of birth, and the sarco-
plasm or uudiflerentiated part of the cell grows propor-
Fig. 3410. -Sections of the Human Sartorius Muscle at Different Afres
to Indicate the chanirt* in Size. (Drawn by Mrs. Gage.) The sec-
tions weiv inadt' itin^uL'ti thf iirnxiniMl fupjitM'! third in each cast*,
and Jilt \\>ri' phntn^rniitli'-'l at exactly th*' saint* scale. The drawings
are frt'iii liaoini,'s diifclly fruni Iht* iihutdtri'aphs. The sertiuns aii*
placed with the correspunding edgfs Ii">kinif in the >ani<- diriTtton.
Magnilled about i.» diameters. .1, SiM-timi irmn a funis '.C nmi.
long: B, section from a foetus 140 mm. long; ('. st'ctinii fmm a
female child at birth; I), section of the sarturius of a wmiaii
sevenly-twii years did; j/i-s, muscle spindles. There are cj^^ht of
these in this cross section. Their position is indicated in solid black
(c/. Fig. 338a aud aiOO).
tionally less, aud the striated part gradually greater in
amount, while the nuclei increase iu number, and iu
mammals aud birds gradually migrate to the surface.
The fibres at about the time of birth are more uniform iu
diameter than iu earlier stages or in the adult (Fit?. 3-411,
A-D).
Lntil receutl}' investigations have not been made to
determine whether the increase in the total size of a
J rk w«'
Fig. 34U.— Sections to show Fascicles of Stiiated Muscle at Different
Statres of Development. (Drawn by Mrs. Gaffe.) Ma ?ni fled about 350
iliameters. .1, Transection "f a fascicle of the sartorius of ahuman
fi I'tiis IG mm. long ; H, fascicle of tbe saitorius of a buiuau foetus
1411 mm. lung ; B', two Ilbres from B iu loniriludinal section to show
the strialion of the fibrils and the central luiclei UO ; C, transection
of a fascicle of the saitoriusinuscle of a female child at t>irth. Here
the nuclei are at tbe surface in most cases, and tbe fibres are more
compact and more uniform in size than in^. If, orD; Z), tran-
section of a fascicle of the sartorius of a woman seventy-two years
old. It will be noted that the fibres show great diversity in size.
The drawing is diagrammatic only in showing some red Ili)res with
abundant sarcoplasm. In the original tbe fibres were all of the pale
variety. c»i, Endomysium surrounding tbe fibres: \\n\ muscle
corpuscles: p. pale fibre with evenly distributed sarcophism and
fibrils: /■, red fibres with abundant sarcoplasm and evident muscle
columns.
muscle from the new-born to tlie adult was due to an in-
crease in the size only of the individual fibres or to an
increase hath in size ond in numher. That the size of the
individual fibres is greatly increased (three to five times)
is very evident to any one who examines new-born and
adult muscle under the microscope (3411, C-D). But
whether or not the fibres aie incix-ased in number as well
as in size with the inci'ease iu bulk fi'om the embryo to
the adult (Fig. 3411), requires a most laborious investi-
gation, and it is necessary in the investigation to keep in
mind the possible ditference in size of a fibre at different
parts of its length, aud to the ftict that man}' fibres end
by pointed or branched terminations wholly within the
muscle, never reaching either tendon of origin or of in-
sertion (Figs. 3388, 3389); also to the possible longitudi-
nal shifting of fibres during the growth of the muscle in
length, Dui'iug the last five years careful investigations
have been undertaken by Jleek '■' and bj- MacCallum ''^
to determine the changes taking place from birth to ma-
turity. The work of Meek was directed to the lower ani-
mals with special reference to the elucidation of the prin-
ciples underlying the most economical and satisfactory
reai'ing of animals for food. He found that during
growth there was an actual lessening, in a given cross
section, of the number of fibres in a muscle, amounting
in many cases to more than one-half.
In the following table the kitten at nine days is taken
as representing the normal number of fibres — one hundred
per cent. It will be noticed that the number of fibres in
a given cross section of a muscle decreases as the age
increases, and that the mother possessed the smallest
23
Kill sell-.
KEFEKE>X'E HANDBOOK OF THE MEDKAL SCIENCES.
number of fibirs. ulUiougli the seetioiuil area of the
muscle was very mucli jrreater tliaii Iliat iu auy of the
kittens. The results nl'itaiued from the vole, rat, and
sheep were equally striking.
T.ini.K in- THK NTMiiKK hfStrhtei) MuscrLAR Fibres ix a Cross
SECTlns OK IME BICEPS BKACIIII OF THE C'AT (FELIS IIOMESTICA)
AT DIFFERENT AlJES. ALL FROM THE SAME FAMILY. (Meek.'^)
.\ge.
9diiVs
2Udavs
240 days
3 years o months.
Sex.
Mall-
Male
Female
I'VinalH (nuiUier
of above I.
An-a of
serlion.
8,4 nmi.
s.l mm.
22.Smm.
41. ,5 mm.
Number
of fibres.
83..514
IH.IOS
.3T.s:*l
3-',03y
Per-
cewtaue
of mires.
4.5
3S
la the investigations of MacCallum on human muscle,
especially the mrtnn'11.1. while a marked decrease in fibres
was not noticed, it was
brought out with great
clearness that the in-
crease in cross section
of the muscle was due
to tlie increase in size
of the individual fibres,
and not to an increase
in numlier. Naturally
an investigation of
this kind is not so sat-
isfactory on human be-
ings as the same rigor-
ous luethods cannot be
adopted as with the
lower animals, where
a whole family may
lie investigated. In-
dividual variation
■within a single litter
is considerable, but
where specimens must
be taken from differ-
ent families, the varia-
tion wcuild naturally
be greater.
In the hiwer animals
it was found that the
decrease in number
was greater witli a
umscle called upon for
great e-\ertion than in
one less actively em-
ployed; and as a nat-
ural sequence, the
muscles of the right
side showed a greater
decrease in fibres than'
the c o r r e s p o n d i n g
muscles of the left
side, although the ac-
tual bulk of the mus-
cles on the right is
usuallv greater than
that oil the left.
The conclusions of
Meek are as follows;
"Up to the time of
birth, in at any rate
the higher mammals,
perhaps in all 1 nt/n i-in.
liyperplasia ehanieler-
i/.es the growth of Iiiiis-
cle; while' alter or
about birlii liyper-
Fai, 3412. — Developine: striated Musen-
lar Fibres, sliowiuL' ItilTMnnit siatres
of DeVHloiaiiflil anil tiiltiMeiit Posi-
tioDs of ihi' fnsinati'it i'roinplasm.
A. Elonirated cell wiUi two liurlei;
tbe lontritiiiliiial striation is iR-iriiniiiii,'
to show Oil the rijrlit siilo. From a
fiPtal shei-p. (Wilson Fox.) /{, He-
velopiiiK miiseuUirllbri'. shovvitiir both
louf^ituililial and transvel'se striations
at the periphery, and a i-enti'al nii-
striated eylinder of prntoplasai i-on-
taiiiin^ several luu'lei. From a
human fonus near the third month,
(llanvier.*) n, Xnoloiis (iliori' is
usually a mass of Klyi'of-n-n nrareai'h
nuelensi; p, ri-ntral unstriatod proto-
plasm; .s, pi-riplu-ral striatod siili-
stance: f, devt'lopini.^ mnseiilar lltiri-.
showing a lateral position of tho iin-
striati'd proio(dasm. Fi-om a thri'H
months' human fietns. (Kanvier. 1 /j.
Nie-liMis; /I, nnsti-iated proto|ilasni at
one side of the llbre: .-■■, striated sar-
coiis sutistanee with Ion|/itiuliiiaI anrl
transverse striatious.
yi'omm
Fir. 3413.— rardiae Musele Tells of the-
Left Ventriele of a Newly Hatehed
Chli-k, to sliow the Form and Strueture
of the Cells, their Centra! .\ppearanee
beintf like that of Adult Colrt-lilooded
Vertebrates. ,4. Branrhed iill ; B, eell
with proixirtions nearly likn those of the
adult: r. two i-ells in thi-ir natural re-
lations, the lower end is fiisiform and
the transverse striation obscure: ?J,
nucleus. In all the cells the striations
extend across the nucleus.
' This fliruri' is almost identical witli the one of developing striated
muscles published by Schwann = in l»3'.i CFl. XIV., Fig. 3i.
plasia ceases, and e.xtra-uterine life brings about a selec-
tion of some of the fibres at the expense of their neigh-
bors. In other ^\■ords, during extra-uterine life muscle,
according to its posi-
tion, sutlers more or
less a reiluetion in the
number of its tilires,
the degree of which
is expressive of its
functional import-
ance. The surviving
elements are at the
same time greatly
hypertrophied, and
the e.\tent to which
this takes place is
also expressive of the
work which the mus-
cle jierforms. or of
which it is ca liable. "
Wliile the above
investigations indi-
cate ciearly that in
passing from birth
to maturity the in-
crease in size of the
individual fibres de-
termines the increase
in size of the muscle
as a whole, the decrease in number of the fibres in a
given cross section may lie due, in part at letrst. to a
nieehanical displacement along the long axis of the mus-
cle as it increases in length. "This mechanical displace-
ment might also account for the fibres with two tapering
ends (Fig. :5388, B). AVhile it is conceivable that the de-
crease in number in a given cross section maj* be due to
a longitudinal displacement, and not to an actual disap-
pe:iranee of tibres, the fact tliat in the more active mus-
cles of the right side the apparent diminution in fibres is
considerably greater than in the corresponding muscles
of the left side, where the length is practically the same,
can be explained only on the hypothesis that there is an
actual decrease in the number of fibres during growth.
An elucidation of the processes involved in the disap-
peartince of fibres during growth, and in the every-day
occurrence of use-
C A hypertrophy and
(^ disuse-atrophy, be-
&3 longs to the domain
^^ of physiologj- and
^g\ still awaits investi-
^^i gat ion, although
teffi M o r p u r g o and
fai Schieff erdecker
psBj' have made a begin-
^J Histor/enexin «/
^' C(irdi<i<^ ilusetilar
W Tissue. — This origi-
j nates, like the other
muscular tissue of
the body, from
mesodermie cells
which are at first
rounded and indis-
tinguishable from
t h e ,surrounding
cells. These pre-
muscle cells in-
crease in size and
elongate and be-
come s ]) i n d 1 e-
shaped. Tliey con-
tain a huge nucleus and reticulated protoiilasm. The
reticulum is tit first irregular, but later it becomes more
regular; and when the cell has assumed a spindle shape,
the appearance is given of clear bodies with rather
definite outlines, arranged in somewhat regular longi-
'mmm.
Fifi. 3J1 1. -I ariliac Muscle Cells from the
Loft Ventricle of a Kitten Three Weeks
old, to show tlie Form of the Cells, their
Slruciiiial Details, and the Commence-
ment ^)f a Close Cnioii betwei-n Two of
them. .1, Larire cell possessing nearly
tile priipoi'tions of those of the adult : B,
two cells in their natural relations ; about
opposite the nucleus of the upper one the
cells are closely united as in the adult
(compare Fit's. :):il)7, ;U03i; C, two cells in
their natural relations, thiMipper one has
two nuclei: u, nucleus. The transverse
striations cross the nucleus iti all the cells.
24
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Muscle,
.^liisfle.
tiidinal rows. These clear bodies are the sarcoplasmic
discs of MacCalhim.'-' As the cells continue to elongate,
the striated tibrils so characteristic of striated muscular
tissue appear iu the cells, ahvays appearing first near
the i>eriphery and graduall}' till ui) the cell, so that
tinidlv the entire mass is jKjrvaded bv theni (Figs.
341.">. S40o).
Th ■ further differentiation, besides the complete fibril-
lalion of the cell body, consists iu great incrca-^e in size,
the production of branchi>s or processes, and the fusion,
apparent or real, of neighboring cells at various poiutsto
produce the anastomosing fibres of adult heart muscle.
It is a very inteivstiiig fact tliat the heart beats rhyth-
mically and vigorously for a considerable time before
Hicre is any sign of the striated fibrils in the cells.
Filirpfi (if Piirkiiijc. — In the heart of many adult ani-
mals (especially ruminants: also iu the heart of the pig,
horse, -dog, cat. hedgehog, marten, and some birds; also,
according to Gcgt>nbaur, sometimes in the human heart)
there appear, in the muscidar substance ne.\t the endo-
cardium, c-liains or groujjs of cells with a granular, nu-
cleated central part and a striated periphery (Fig. 3417).
These cells are supposed to be
cardiac muscle cells in course of
development into those of the
ordinary, elongated, adult form,
with branches and strialion of the
entire contents.
Hixtngenens of Rmooth or Unstri-
ated Mvfculnr Tumie. — The cells
which develop into unstriated
muscular tissue are derived most-
ly from the splanchnic layer of
n--
V
lift®
E- - ^^ -M^i ^^to
Fir,, ntl.i. -rartliao Miisi-li- fells ot the
I.i'fl Vi-iitncie (it a Chilli at Blitli (Full
Teriio. u> shov.' the Form of the CelKs,
tliHir strui'tural Deiails. and their Rela-
tions to One Anolhei-, anil thcii- General
.^trreement with those of < oUl-blouiled
Vt-rt,i'brate,s. A, Larj^e eell with two
nui-lHi : this cell has nearly the propor-
tions of those rif the adult; B, proup ol
cells in their iiatiiral relations ; at the
right of the inidille cell aie twospaees
or llssufes u-onipai-e Fiir. -SlidT). »,
Nucleus. The ti-ansverse siriations cross
the nuclei in all the cells, and each
nucleus pos.sesses several nucleoli.
Tisrs. ;i4l:^ ico^tlaareat a uniform Tuag-
nillcatjon of .'iiMi illatiieters. The draw-
intrs uere niaiie wiih a camera lucida,
and the rluer details of struetiire deter-
mined with a TR honuareneous immer-
sion ohjective, and added free-hand.
(Dravni by Mrs. (iage.)
Fir;. H4lii. — C ar d i a o
Musi-le cells fnim
Kinhrvo Fjirs. (From
.MaiCaiium,'= slightly
iiiodilled.i ,4.. Longi-
tuilinal section of a
iTUdiac muscle cell
fioni an embryo pig Iti
mm. long. In the up-
lier )iart of the flL'in-e
the iiieshwork of the
I'eticulinn is iriv-gulai'
and represents a
somewhat earlier
stage of development.
In the lower half of
the figure the reticu-
lum is regular and the
sarcoplasm is ar-
ranged in rows of
dise-like bodies, a.
Irregular reticiUum ;
Ik regular retictdum ;
V. nucleus; JJ. cross
section of two cai'diac
muscle cells from an
endiryopig of 20 mm.
The upper cell is cut
al)oye or below the
level of the nucleus,
while the lower cell is
cm through the nu-
cleus, f. Sti'iated
fibrils appearingat the
periphery, the sarco-
plasm forms kind of a
mantle or coating for
the tibrils; u. nucleits
of the lower cell.
tlie mesoderm. Tlie cells aj'e at fij'St rounded and granu-
lar; they elongate in two directions, thtis forming the
characteristic fusiform, smooth, or unstriated muscular
fibres. The development of the longitudinal fibrilhition
has not yet been traced. The physiology of muscidar
tissue will form a .separate article (q.r.).
Methods. — Isolation of the strtictural elements for all
forms of muscular tissue is accomplished b_v soaking the
tissue from one to three davsin a mixture of 23 c.c. of
FTft. 8417,— Fibres or Cells of Pnrkinie from the Heart of a Sheep.
Maciiifled about ;ilKi diameters. (Moditled from lianvier."') At
the left the ceils are .shown iu optical section with the peripheral
striated tibiils benveen tlie cells. On the right is a cell viewed from
the surface to show the striated mantle coveting the whole cell. n.
nucleus. Ml 'St of the lells contain tvi'o nuclei; j^ia, striated mantle
at the surface of the cells.
concentrated nitric acid and 77 c.c. of water, and then
foi-aday or more in a half-saturated solution of alum with
five per cent, chloral hydrate. For cardiac muscle, soak-
ing iu a mixture of 41) gm. caustic jadasli and 60 c.c.
water for fifteen to sixty ininvites jiroved more satisfac-
tory forisolation than the acid. Cardiac muscle must be
perfectly fresh in order to obtain satisfactory restdts.
Acid specimens were mounted pennauently in a mixt-
ure of glycerin, 75 c.c; picrocarmine solution, 2.5 c.c.
Permanent preparations of the caustic-potash specimens
were obtaiued by washing away the caustic potash with
a sixty -per-cent. solution of acetate of potash. The cells
may be kept in tliis indefinitely, and mounted in this or
in glycerin or glycei'in jelly. For the fibrillation of the
smootii musculai' fibres, a piece of the perfectly fresh
muscular coat of the small intestine of a cat was kept
from one to three days in 100 c.c. of twenty-tive-ix-r-
cent. alcohol, containing throe- fourths of a gram of picric
acid. Preparations were mounted iu seventy-five-jier-
ceiit. glycerin. Serial sections were made to determine
the relations of the striated muscular fibres to one an-
other throughout the entire length of a muscle, and to
determine the rehitive size and number of the fibres iu a
fascicle at different levels.
(For the general methods of histological investigation,
the reader is referred to the article on llixtiijuiiii-.il 'J'n-h-
niqiie. vol. iv.)
BiBLioGn.\pnv. — The bibliography of mu.scular tissue
is so extensive that it would be out of jdace to give it ;dl
iu a work of reference like the present. For a more
complete discussion of special points, and for the bibli-
ograjilij', reference may be made to the following:
Itumav, Aiiatomy : Allen, Gerrish, Gray, 31<n-iis, (Juain.
JiiKtnlof/y and 'jfi.tfof/i'iii.iin: Bohm - DavidolT - llulier,
Ileitzniann. Klein, KiMliker, Leydig, Piersol, Pnidden,
Kanvier, Schaefer, Strieker. EiKhn/f/or/i/ : Biilfour. llert-
wig, KoUiker, Kollmann, Minot. For inonngraphs one
is refeiTed to special pajiers in the ti';ins;irtions of learned
societies, and in the anatomical and einbryological
periodicals. The bibliography is given in the Anato-
iidscherAiizeiycr, JHIiUnyrnphic Anakiiiiiquc ; " Ergebnisse
35
i?Iusolo.
iTIii»picle«
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
V. MerUcl u. Bonnet": " luilex Ciitalogueof theSurgcdu-
Oi'iii-nil's OtHcc," ••.liiluesbi-riflitc iibcr d. Fortschrilte
<Ier Aiuit.," Jiiiirwd iif ih Ilnii. Micr. Soi-,, Ziit.f. mi/a:
Aunt.
Specific i-cfci'cnce 1ms liccn muilo to the fiillnw ing:
' Barilci'M :iml Lewis: Tin- Wilrh Book and Amei-. .Icmin. Aiiat.,
vol. i.. IHIi::.
'' liimc-n, V. K. : Brain, vol. xx., IrtiT.
» I'.i-ali': Tlans. Roviil Mirr. Sue. ISUl, pp. W-las.
' B.iv.liian : I'llil. trans. U. S., 1.-41), pp. 4.".T-olll.
= Biisk and Ihixley: Tninslalion uf Kijllikei-'s .Manual of Histology,
lS.i:i.
' Kt'li.K, W. : Fi'.stsclii-ifl fill- A. vini KBIliker, ISST.
" Cus.'!'. susainiu 1>. ; The MieiT.scopf, vol. vill., 1888. Froc. Aiuer.
Mifr. Soe.. IMill.
" Heitzinann: Wion. Akad. Sitziinir.sher.. Ixvii., pp. Ul-KJO.
» Herzig niiil Blesiadeckl ; U'ien. Akad. Siizuugsber., xxx., pp.
73-74: xxxiii.. pp. Uii-14'.l.
1" .lai'det : Areli. d. I'liys. Norm, et Path., ISSli, pp. 'Jli-im.
" Koliiker: (iewel)elei]i(', sixth edition, l.ssd.
'= .Mai-Calluin. .1. B. : Anat. Auz., vol. xiii., 1S!I7; Johns Hopkins
Hospital Bulletin. Oetoliel-, l.SHS.
'= Meek. A. : .lourn. Anat. Plivsiol.. vol. xxxiii., ISSW.
" Uanvier: l.i-cons. l.ssil. and 'I'laite T«'huic|ue.
'= ISeiuak : Kroriep's Notiz., lm\ No. 7liS.
1" Kollett : Wien. Akad. SitzunirsUer., .xxi.. pp. 176-18(1.
1" Salter: Toiisrue. Toil.l's (ve. Anat. Phys.
'^Sebwann: I'ntersuelmn^ren, ls:('J.
i» Weismann: Areh. 1. Anat. u. Phys., 18BI, pp. 41-03.
'« Huljer and DeWitt, Jour. Comp. Neiu-ol., vol. vli., 1898.
Siinun llciiry Gaye.
MUSCLE, PATHOLOGY OF.—
I. Striated Vdi.i xtaky Mi'SCLe.
From tlic ])atholos;ical point of view, the important
points to lie considered in tlie structure of striated volun-
taiT muscle are tlie :imount of interstitial connective tis-
sue, the size and shape of the muscle fibres, the strialion.
and the number and position of the nuclei. Normally
the endomysium, or the connective tissue seiiarating the
individual fibres, is small in amount, while that septinit-
ing the fasciculi is considerafily larger in amount, vary-
ing in dilTerent portions of tlie muscle. Tlie distiuctness
of the striation depends somewhat on the methotl of fi.\-
ation and iireparafion of the tissue, but in well-ti.\ed
preparations the fibres show a distinct transverse striti-
tion, due to the difference of refraction of the tibrillarand
intertibrillar sulistances of the fibres, the nltiniiite fibrils
being anisotropic, while the sarcoplasm is isotropic. In
cross sections, the muscle fibres present irregular lighter
and darker areas, due to the ainingenient of the filirils in
columns, known as muscle columns, with a hirger amount
of sarco])lasm between the columns than is found be-
tween tlie indiviilnal fibrils. The muscle fibres are large,
showing normally in ci'oss section a diameter of from
10 u to 100 /i, while they often attain a length of 13 cm.
Their free ends are usually ]iointed. while the end at-
facheil to tendon is rounded. The nuclei of white mns-
<'le libres are situ:ited immediiitely und'-i the sareolcmmii
iind are very uuniennis, a cross seelion of a muscle libie
presenting from one to four or five nuclei. The nuclei of
red muscle iire situated in the sai'coplasni between the
muscle columus. JIarked variations occur in the num-
ber of nuclei, however, as has been pointed out by
^lorpurgo and Biiidi and others. In young muscles, the
nuclei are more abundant and more uniformly distributed
than in adult muscle. In small adult muscles the nuclei
ari^ more abundiint than in the larger libres, while in the
liirge irregular libres the number is very variable and
much smaller than in the smaller tibres or the embryotiic
muscle. Hence growth of iiiusele is not accompanied by
t'orresponding increase of nuclei, the small hlires wilii
high coellicient of growth preserving the juvenile elnir-
aclcr of nucle;u' ;dmndance. These are the libres which
cli;uige most in the ])i-ocess of activity hypertrophy, the
abundance id' nuclei corresponding to a greater reserve of
growth energy.
Under dilTcri'iit iiatliological conditions, any one of
thesi' factors may bi' materially iilfered. The connective
tissiu! may bo increased or diminished in amount. The
muscle libres may be larger or sniidlerthan normal and
may cininge their shape and their relation to each other.
The striation may become indistinct or even be lost alto-
gether, the fibres" assuming a granular or homogeneinis
aiipearance, while the nuclei may be greatly increased iu
number and very irregularly grouped, so that some sec-
tions will contain large numbers of nuclei, while others
contain none. The muscle tibres may .segment into short
discs, or mav break up longitudinally into small .slender
fibrils, which may remain attai'hed;it one extremity, giv-
ing the apiicarance of a branching of the parent fibre.
The pathology of striated muscle has recently been
treated by Pn.ifessor AVtirthin in the American Journul of
I'dtliiihxiii. and with some modifications I have made use
of his classification in the following discussion.
Congenitiil (inoinidka of muscle concern largely the
realm of gross anatomy. Supernumerary muscles may
be found or certain muscles m;i_y lie lacking. Occasion-
ally the origin lU' insertion of a muscle varies from the
uoianal. Such anatomical variations are considered in a
sejiarale article. (See MiikcUk, Anotiutlies of.)
CiKCUL AToiiT DisTUisBANCES. — Voluntary striated
muscle has a very rich blood supply ; numerous arteries
break up into rich, long-meshed plexuses of capillaries,
which surround the muscle fibre, each cell being in con-
tact with several capillaries. The free anastomoses of
these vessels easilj' compensate for any local obstruc-
tions, thromljosis, or embolism, and prevent any delete-
rious results, unless an infective embolus is the cause of
the obstruction, in which case an abscess results. "Iu
cticheetic conditions, fevers, etc., in which the nutrition
of the muscle is lowered, an auannic necrosis may result
from arteriosclerosis, deficient heart action, local com-
]uvssion, inliltratiiais, etc. Such auamiic infarctions are
seen iu senile gangrene, decubitus, etc." (Warthin).
Psoas infarcts, associated with bed-sores, may result from
long continuance of the recumbent posture, in which case
the main arteri&s of the muscle may contain obturating
thi'ombi or may show a proliferjiting endarteritis. In
this condition, the entire muscle may undergo Zenker's
necrosis, a|ipearing white and translucent, but usually
hemorrhages are scattered llirougli the muscle and the
necroseil iirea is surrounded liy tin extensive extravasa-
tion of blood. Scar tissue may replace the necrosed tis-
sue, attempts at regeneration of the muscle fibres being
frequently found ; if the area becomes infected, however,
a psoas abscess may result.
Aiiivmiii of muscle may result from general anaemia or
it may be local iu origin, being caused by obstruction
in the nutrient arteries, compression or aitei'iosclerosis.
The muscle is pale and either soft, as when the alfeetiou
is local, (u- dry, when the ju-ocess is part of a general
ana-mia. The muscle may, liowever, be brown from iu-
crciise of pigment,
Ihiperiemid usually disappears shortly after death, the
]i:issive hyiieraniiii occurring only in the rare eases cd' ex-
treiiie viiscular stasis, while the congestive form is found
in the neighborhood of infhimmatory areas. (Edematous
muscle is softer anil moister than normal muscle, and on
microscopic examination clear vacuoles are .seen in the
protoplasm of the muscle cells, while the connective tis-
sue is much looser than under normal conditions, the
connective-ti.ssue fibres being separated by accumula-
tions of cle:ir fluid. In severe cases, the muscle tibres
may undergo liquefaction.
Jlcmorr/iiii/in in muscle are far from uncommon; they
may result from trauma, from convulsive contractions of
the muscle, from increased blood jiressure, or from de-
gcneriitive cluuigesin the ves.sel walls or in the surround-
ing muscde. Such changes are common in typhoid or
tyiihus fever, in septic conditions, ]iernicious aua'tnia,
etc., while small hemorrhages are frequent in the acute
infections, idiosphorus poisoning, leukamiia, and per-
nicious tintemia. As a I'esult of the hemorrhage, the
muscle libres ;ire jmslied apart and may be desfi'oyed, if
the hemorrhage is large. The muscle iiquefies or under-
goes a coagulation necro.sis. Blood clot becomes organ-
ized and a pigmented scar remains, oidy a few regener-
ated muscle fibres usually replacing a portion of the
connective tissue of the scar. The connective tissue
2G
REFERENCE HANDBOOK OF THE ilEDICAL SCIENCES.
ITIuscle.
Ifluscle.
may, iiowever. develop into cartilage and bone, as in
soine of the eases of traumatic myositis ossiticans.
RktuoghI'^sive Changes. — Changes in size of the vol-
untary muscle fibres are among the commonest changes
met. " Under circumstances of increased nutrition,
whether from the general condition or from .systematic
nuiseular e.\eieise, the muscle fibres increase in size and
we liave a true hypertrupliy of the muscle, while undei'
the opposite conditions of disuse or diminished use of
nuiscle, or when the general nutrition is lowered, the
fibres undergo dtropjiy. the diminution in size varying
with the degree of the unfavorable conditions. The.se
conditions of true hypertrophy and of simple atrophy
are usually transient, the fibre lieing restored to its nor-
mal apjiearance on the restoration of the normal condi-
tions. If, however, the exercise be continued too long
or be carried to an excess, the hypertrophied muscle may
become atrophied, and simple atrophy may lead to de-
generative changes. Simple atrophy, in its simplest
form, occurs in old age, but it is also seen iu cachectic
states, such as tuberculosis, carcinoma, etc., and it may
result from compression of tlie nutrient arteries, Macro-
scopically, atrophic muscles appear paler, dryer, and
firmer than iioriual. A brown pigment, ha-inofuscin,
probably a product of the sarcoplasm of the luuscle fibre,
may develop in tlie fibres, giving them a brown color.
In "some cases, the fibres undergo Jii/divpic Oegeiieration,
serous atrophy, in whicii the muscle appears moist and
soft.
The clinical aspect of tlie muscular atrophies will be
treated under a separate heading. Regarding llie path-
ological aspect of the muscular atrophies, we may say
that atropine degenerations may be neuropathic, de-
jieiuling on lesions iu the spinal cord, or they may be
luimary or myopathic. In the former case, some of the
luost interesting changes are those which occur in the
spinal cord; the cells of the anterior horn are atrophied
and show degenerative changes and the pyramidal tracts
are involved. The degeneration maj' even be traced to
cells in the medulla and nwtor cells of the cerebral cor-
te.x. In the myopathic form of luu.scular atrophy, or the
so-called nuiseular dystrophy, the nervous system shows
no essential changes, although varied and irregular alter-
ations are described by certain authors, such as atrophy
of the posterior root ganglion cells, some cytojilasmic
changes in the ganglion ceils of tlie spinal cord, etc.
None of these changes, however, is found uniformly in
all cases of muscular dystrophy, and the disease is there-
fore believed to originate in the voluntary muscle and
is probably due to some congenital anomaly of develop-
ment. Kollaritz describes atrophy of the motor cells and
of the fibres of the substantia grisea centralis around the
spinal canal, these changes occurring especially in the
cervical and dorsal regions. The peripheral nerves were
intact. He believes that the changes iu the cord and in
the muscle occur together and that both probably depend
on faulty develo]5ment. Atroidiy of the motor cells is
especially characteristic both iu his cases and in those of
Erb, Schultze, Preisz, Frohmeier and others. This may
readily be explained as the result of faulty development,
and the development of muscles might well stop if at a
certain age the motor nerve cells thus atrojihied. while it
is not unreasonable to suppose that the motor nerve cells
might midergo secondary atrophy, as the result of this
degeneration of the muscle fibres. While it was formerly
believed tliat the primary dystrophies could be distin-
guished microscopically from the neuropathic atrophies,
it is now generally conceded that there is no essential
dilfereiice in the pathological jiicture presented by the
two classes of the disease. The idea that the dystrophies
could be ditl'erentiated by the fact that the atrophy was
uniformly jueceded and accompanied by bypertro|iliy of
the muscle fibres has been practically overthrown by the
recognition of the fact that in both the neuropathic and
myopathic atrophies the atrophy uiay be preceded by
hypertrophy, the fibres being enlarged to a variable ex-
tent before the atrophy sets in, and even at the heiglit of
the atrojihic process some enlarged fibres may be found
among the many atrophic cells. In neuropathic atrophy,
however, the localization of the degenerative process
varies according to the localization of the lesion in ''the
cord.
In a case of traumatic transverse myelitis resulting from
an injury to the cord in the lower dorsal region, the psoas
muscles showed the most extreme degree of degenerati\-e
changes, while the lumbar muscles and the leg muscles
contained bundles of extremely atrophic fibres, and the
muscle cellsof other bundles were normal in size, appear-
ing hypertrophied b.y contrast with the alropliied fibres.
In the psoas muscles, most of the cells were very small,
appearing scarcely larger in cross section tlian involun-
tary muscle cells. No transverse striatiou could be
observed in any of the fibres and the cross sections
appeared either homogeneous or finely granular. Some,
however, were vacuolated, some showing very little of
the protoplasmic substance of the fibre, appearing to
consist of nucleus and sarcolenuna, the intervening space
being clear. A few of these fibres in cross section pre-
sented no nuclei : in the majority, Iiowever, one or two
deeply stained, relatively large nuclei were seen near the
end of the oval cell, wl'iile some showed a crescent or
corona of nuclear substance at the periphery. JIany
cells were seen containing numerous nuclei, which were
often hyperchroniatic anil appeared as a dense, fused
mass of deeply stained chromatic substance. These
giant cell forms or sarcolytes were especially numerous
in some fields, while in others very few were found. In
longitudinal sections, longitudinal and transverse cleav-
age could be observed, aud in man}- areas long, narrow,
spindle-shaped cells were seen, which contained long
rows or chains of deeply stained nuclei. There was als#
a marked increase of connective tissue, often accompanied
by a deposition of fat, especially in the increased connec-
tive tissue of the endom.ysium. This picture may be
taken as the tyjiical jucture of muscular atrophy, vary-
ing in degree, but little iu character. The increased
connectiviir tissue, the fibrillar forms mentioned, and the
multinuclear, giant-cell forms have been the subjects of
much discussion. Durante, Kroesing, and others, uphold-
ing the view of embiyological development of muscle
advocated by Hoflfmann, "\Valdeyer and others, that the
striated muscle cell is a syncytium developed by the fu-
sion of numerous spindle-shaped cells of the mesoderm,
describe the lougitudinal cleavage or fibrillation of the
muscle fibre as a return to the embryonic condition.
They state that these fusiform fibres may form new mus-
cle fibres, but usually degenerate and mingle with the
connective tissue, acquiring all its characteristics. To
this tissue Kroesing gives the name myogenous connec-
tive tissue or connective-tissue state of the muscle fibres.
He states thilt the increase of connective tissue in muscu-
lar atrophy is due to the formaticju of this tissue rather
than to an increase of true connective ti.ssue. In prejnir-
ations stained by JIallory's difl'erential stain for connec-
tive tissue, however, it may be plainly seen that tliis
tissue gives the reaction of true connective tissue, so that
we may conclude that, if it be derived from muscular
tissue, "it has acciuired, not only the morphological, but
also the chemical characteristics of connective tissue. It
seems more probable, however, that the muscle degener-
ates on account of the poor nutrition of the tissue, and
that the increase of connective ti.ssue is due to the well-
known tendency of connective tissue to replace lost tis-
sues and to till spaces where it is needed. The fate and
.significance of the multinuclear forms have been cimsid-
cred by manj' authors and have been generalh' regarded
as attempts "at regeneration. Fujinami, however, be-
lieves that in purely degenerative processes, cells mor-
phologically identical with the myoblasts of regenerating
muscle may be found, and that iii these eases they should
not be interpreted as having a regenerative significance,
but rather as degeneratiye forms. AVhile this point
seems to need further investigation, Fujinami's view re-
ceives confirmation from the fact that these multinuclear
forms are quite as numei-oiis in the most extreme degr(-e
of muscular degeneration, where no tendency to rejiair
21
Muscle,
muscle.
KEFERE^X■E HANDBOOK OF THE JIEDKAL SCIENCES.
seems to lie prcsciil iir is to be expecleil, ;is in areas less
severely affected.
Friy'iYmn nixiii-iihir (h/.itrnji/ii^. ill its simple form, pre-
sents a very siinilar iialliolosrie picture to that ilescrilieil
for neiiropatliic atropliy. TJie pseudoliypertrophie form.
liowever, is characterized )iy a marked formation of adi-
pose tissue, foiiiied prolmbly from the proliferated cells
of the endomysium. alllioi'mU Krocsing states that it
arises from a nietapljisia of tiic musctdar ti.s.sue into adi-
pose tissue. This myogen<ius adipose tissue is distin-
guished from true adipose tissue by the presence of
fragments of muscle or by remains of muscle structure
or Arrangement. In this form of atrophy, as in the
others, the muscle tibres are more or less atrophied. A
true hyiicrtixiphy of the muscle may. however, accom-
pany the increase of connective and adipose tissue, as in
the case re]>orted by Durante, in which many of the cells
attaineil a diameter of 180": the nuclei were greatly in-
creased in number, being arranged either iu long lines or
in a circle surrouuding tlie tibiv, Vacuolation and gran-
ular degeneration were also noted in these tibres. Du-
rante believes that the muscular hypertrophy iu this case
was congenital or was developed in early life, while the
degenerations and elephantiasis were probably of much
later growth.
Tlioiiifien's Di.wii.ir, or Miioloniii Cniigemtri. is a special
form of muscular dystrophy, which is hereditary and
congenital and alfecis numerous members of the same
family. It is characterized clinically by the occurrence
of toiiic cramjis. when the jyatient attempts to move.
A case i-ecently descrilied by Koch maybe tivkcn as typi-
cal of the atrd-tion. The patient was twenty-one yeare
<jld and his musrulatiu-e was well developed. The prin-
cipal symptom of the affection was stiffness, slowness.
and ditiiculty <]f molion, esjiecially when lirst beginning
to move, but wearing off later as the effort was con tinned.
This symptom had l«'en noticed since early childhood.
The cramjis are usually painless and may affect the limb
muscles, the eye muscles, and the muscles of mastication,
but the extremities aiv the parts most involved. The
involuntary muscles are sjiared. Cold and nervousness
ma_v cause an increase of the affection, while systematie
muscidar ex<'rcise is beiieticial. The affection is rarely
cured, although it does not endanger the life of the pr-
tient. Erb describes an increase of the interstitial con-
nective tissue, with marked hypertrophy of the muscle
fibres. The finer details of structtire may also be slightly
altered, th<' striations being less distinct than normal, the
fibres appearing more lunnogeneous. lint often vacuo-
Lated. Koch describes a longitudinal cleavage of the
muscle fibres, causing an incn-ased number of tibres. He
states that amitotic division of the muscle nuclei was
observed, resultuig in the formaticm of the Jong, slender
cells containing rows of nuclei, such as are observed in
degenerative and regenerative processes.
Degen'ER.vtioxs. — While th(' various forms of muscu-
lar deseneration have been variously classified, it mav be
Fig. 311S.— Hydropic ItepeiH-riition <if VuluuTar\', Striated Muscle.
(ZieirltT. >
noted that they all tend to occur togctlicr, wherevei- the
muscle is c.xposeil to iuiravcinible conditions. Progres-
sive nniscidiiratniphy. whet her of nervous or of nuiscular
origin, may be aecom|iaiiied livany or ;ill of thi' degener.
ative jii-ocesses, while intlatnniations, injuries of muscle,
and tumors are all. to a greater or less e.xteni, surround<'ii
liy areas of deg(!nerated muscle. One of the most e(]m-
mon and at the same time the most serious degeneration
atfeetiug striated muscle is the yranuliir or pruteid ileyen-
Fitt.
.■Jtlrt. — Zenker's Waxy
(Ziegler.)
Necrosis.
(Tdihin, also known as chmcly sireUinfi. The rilire is usu-
ally enlarged, the striations are less distinct, the cell ap-
pealing distinctly granular. The granules arc not fatty,
since they do not react to osmicacid nor dissolve in ether
or chloroform ; they dissolve in acetic acid. Durante dis-
tinguishes two forms of granular change — one, which we
may regard as physi-
ological, due to ex-
cessive activity of
muscle, and analo-
gous to the gramdar
change iu gland cells
during secretion.
The fibres are en-
largcil and the stria-
tions are indistinct
on accoxmt of the
thickened layer of
granular sareoiilasin
lying between the
siircolcmma and the
fibrils. This condi-
tion is usuall.v trans-
itory, the cell return-
ing to its normal
state as soon as the
conditions which
caused the change
have been altered.
If. however, the
cause persists, the
cell may uu<lergo fatty degeneration or liquefaction or
coagulation necrosis. The second type is a true degen-
eration, leaciing to the death of the cell, and occurs in
cachexias, infectious diseases, myositis, and other mus-
culai' affections.
JI;/(Im])ir- deyciieration of voluntary muscle occurs es-
]iecially iu sujipurative inflammations, chronic oedemas,
etc., and is characterized by the presenc* of clear vacu-
oles in the ]irotoplasm. Fresh muscle thus affected ap-
pears jialc and watery. It may be dLstinguished micro-
scopicall3' from simple a<dema of muscle by the fact that
tJie muscle nuclei stain poorly in case of degeneration.
Fatty def/iiienition occurs in an extreme degree in cases
of phos].)horus poisoning and to a less degree in tuber-
culosis, in fevers, intoxications, etc. The muscle cells
show fat globules in their jirotoplasm, which therefore
appears peculiarly reticular. These may merge into
larger fat dr<i]<lets. These cells stain poorly in eosin, so
that a fibre undergoing fatty degeneration appears hazy
and mottled, while, after treatment with osmicacid, the
droplets show the characteristic black reaction. The
musck' nuclei may also show the characteristic degener-
ative changes.
In cases of inflammations, fevers, intoxications, and
in the neighborhood of malignant tumors may be found
tibres luulergoing simple Jiivvvw/s .• these are larger than
norniiil. show no txansverse stiiations and no nuclei, and
the entire fibre takes an indifferent bluish-red color,
when stained with h;rmatoxylin and eosin. In chronic
(edema, suppurative inflammation, etc., the muscle filircs
may un<lergo iiqutfactimi ■necrosis. The fibres at first
ap)>ear eidarged, vacuolated, or granidar, and finally
dissolve in the fluids in the surrounding tissues. Zenker
has also desei'il)ed a. 'ini.ry or /ii/nlinc tierro.iis of the mus-
cle fibres, occurring in typhoid fever. It may also oc-
cur iu any severe fever, in acute tuberculosis, in sepsis
and variola, and also in wounds, inflammations, and to a
limited degree in all the pathological processes whicli
may result in the degeneration of voluntary muscle. If
the degeneration is of wide extent, the affected muscle is
soft, white and ti-anslucent, resembling fish-fle.sh. The
softening may lead to more or less extensive hemorrhages
in the muscle. The muscles most frequently severely
alTeeted are tlie jisoas. the abdominal muscles, and the
muscles of the tJiigh. The muscle fibres are of irregular
size and form, many of them being swollen. The cross
striatiou is lost, at least in many ai'eas, and a peculiar
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
muscle.
Muscle.
hyaline or waxy mass appears in the protoplasm, the
fibre tiually breaking up into irregular hyaline uiasses,
whieh are afterward absorbed. The hyaliue mass usu-
ally stains poorly with the ordinary stains, Ijut may re-
semlile fibrin in its reaction to Weigert's fibrin stain,
while in the Van Giesou stain it may react like colloid.
The hyaline mass may fill the entire cell or occupy only
certain areas, these peculiar homogeneous areas being
surrounded by gi'imular sarcoplasm, while some areas
may appe:u' striated and quite normal. The nuclei may
entirely degenerate, while iu milder cases they may pro-
liferate and lead to the regeneration of the muscle fibre.
A leucoc}-tic infiltration of the intermuscular coimeetive
tissue may precede or accompany this degeneration. In
senile gangrene, decubitus, infective inflammations,
burns, freezing, and iu lowered nutrition of the skin and
subcutaneous tissues, the voluntary nuiscles may under-
go gangrenous cluuiges, the muscles becoming brownish,
Ijlack, or greenish in color, breaking up into shreds or
liquefying, or, if exposed to the air, undergoing mum-
mification. >[icroacopically, the muscle fibres present
the picture of liquefaction or coagulation necrosis, the
fibres losing their form and striation. A marked leuco-
•cytic infiltration accompanies this process, wliile blood
pigment and crystals of cholesterin and tiiple phosphate
are often found. Iu munuuification, the cells shrink and
lose their form and nuclei and finally appear like horn.
Not unlike a liquefaction gangrene is the degenerative
process described by Hoeu as occurring in tlie striated
muscle fibres of the uvula. This is characterized Ijy a
bleb-like change, a.ssociated with pigment formation and
nuclear proliferation. The sarcolemma is raised by the
vesicles, each of which contains a nucleus, so that the
liquefying process seems to begin in the undifferentiated
sarcoplasm surrounding the nucleus. Cross striation
■can still be seen in places, but the longitudinal striation
is replaced by wavy and undulating lines, due to the
twisting of the fibrilla?. The final stage of tlie degen-
■erative process shows masses of large blebs, contain-
ing small, large, and misshapen nuclei, with pigment,
through the middle of some of whicli runs a shadow sug-
gestive of a muscle fibre. Even in such a mass, some
fibrils may be found wluch still show stri;e.
FiiKjiiientdtiiDi and Fibrillatinn. — In necrosis and in
most of the degenerative and other pathological states of
muscle, fibn'S may be found which are breaking up
either longitudinally into long fusiform fibrils, or trans-
versely into irregular plates or discs of muscle substance.
Often the fibril can be traced to the point where it jcjins
the parent fibre. Tlie process results in the atrophy of
the main fibre, while the fibril which has been split off
may either develop into a new muscle fibre, as in the re-
generation of muscle by the proliferatiim of its nuclei,
or it may still further degenerate, either shrinking into
threads so that the tissue closely resembles fibrous con-
nective tissue, or undergoing fatty degeneration anil
forming a tissue resembling adipose tissue. Warthin
states that ^^ amyloid degeiicintimi of voluntary striated
muscle is rare and occurs especially in the muscles of the
tongue and larynx. The tleposit begins in the capillary
walls of theeudomysiumand may extend around the sar-
colemma, causing an atrophy of tlie fibre. The atrojihic
fibre then appears as if surrounded by a glassy hyaline
substance. Ultimately the fibre disappears and the con-
fluence of the deposit leads to the formation of nodular
masses." The presence of pigment In voluntary muscle
fibres, in the so-called brown atrophy, has already been
menticmed. The pigment, known as hsmofuscin, ap-
pears as brown or yellow granules in the neighborhood
of the nuclei and it indicates a degeneration of the mus-
cle substance. The degenerative processes in voluntary
muscle caused by experimental section of the nerve liav(?
been well described by Ricker and EUenbeck. Chroma-
tin granules appeared in the nucleus on the tweuty-tliinl
day. The nuclei appeared shorter and broader, even
spherical, with loosening of the chromatic network. The
muscle and nuclei showed ojdematous changes. The di-
vision of the nuclei was by direct fragmentation, no
mitotic figures being found. The authors regard this
nuclear fragmentation as a degenerative process, not
leading to the regeneration of the muscle. The muscle
fibres showed atrophy, but very slowly developing,
while the protoplasm showed vacuulation and transverse
cleavage, with diminishing distinctness of striation.
There was at first an increase iu the amount of fat in the
intermuscular connective tissue, followed by diminu-
tion. The muscle was at first liyjieraimic and a'dema-
tous, but later became anaemic. There were also an in-
crease of connective tissue and a narrowing and hyaliue
deposition iu the intermuscular cu]iillaries. The changes
were belie\'ed to be due to disturbances of circulation
rather than to direct influence of nerve section,
Schujeninoff has carefully studied the proces.ses in-
volved in the calcification of striated muscle, both experi-
mentally in animals and by observation of men. He
concludes that the lime siilts are deposited in muscle un-
der certain conditions, as after tlie suture of a wound in
the muscle. The calcification takes place after the fibres
have undergone a colloid degeneration. When the lime
Siilts are absorbed, the calcified fibi'e disajipears. The
calcification of muscle is therefore a local, secondary
process, which stands in relation with the local disturb-
ance of circulation.
Rei;ekei!.\tion op Voluntaky Muscle. — In embiy-
onic life, striated muscle fibres develoii from mesodermic
cells, each fibre being formed by endogenous prolifer-
ation of the nuclei of a single cell. This is the view ad-
vanced by Remak, Schultze, Kolliker, Zenker, and many
others, who contend that the growth both in length and
thickness takes place by this nuclear proliferation, while
the protoplasm changes into the contractile substance of
the muscle fibre. This view is opposed by Hoffmann,
Waldeyer, Kr-oesing. Durante, and many others, who be-
lieve that the muscle increases in length only by en-
dogenous division of the nuclei, while the increase in
thickness is brought about by the apposition and fusion
of numerous fusiforra cells. Experimental degeneration
of muscle has been brought about bj' tenotomy, by neu-
rotom}', and liy sectioning the muscle fibre itself. Nu-
merous experiments have also been undertaken in the
transplantation of portions of muscle taken both from
the Siinie animal and from other animals, even those of
a different sj-iecies. Salvia transplanted muscle from a
rabbit to fill the space made by removing portions of a
dog's muscle. He states that the result was perfectly
satisfactory, as the new muscle replaced the old perfectly
both anatomically and functionally. Others have claimed
equal success in similar experiments, but Capurro, in a
series of experiments recently reported, gained I'esults
which were only partially satisfactory. The result of
transplanting free pieces of muscle was negative. By
using onlj' a porticiu and leaving a pedicle attached dur-
ing file union, he was able to secure sjitisfactory func-
tional results. He observed degenerative changes in the
muscle, such as simple atrophy, Zenker's necrosis, fibril-
lation, increase of connective tissue, leucocytic infiltra-
tion, etc. In these cases, as well as in wounds of mus-
cle, granulation tissue is first formed. The muscle nuclei
proliferate, both by mitotic and by amitotic division, and
buds of sarcoplasm conlainiug the new nuclei grow out
from the ends or boily of the muscle fibre into the granu-
lation tissue. These buds at first show no striation. but
contain many large nuclei and appear like epithelinid
cells. Then in the sarco]ilasm, librils are formed and
thus the filjre becomes striated. Several new fibres may
be formed from one bud or inyolilast. In addition to
these myoblasts, free multinuclear cells are formed,
known as sarcolytes. These are not in connection with
the original fibre, and while some may form new lilin's or
unite either with the old fibre or with new ones, most of
them probably undergo fatty degeneration or necrosis.
The sarcolytes may resemble the myoblasis iu section
and give the appearance of regenerative effort, even
when the conditions are so unfavorable that no atten'pt
at regeneration is to be exiiected. A perfect regeneration
of muscle appears to be possible only when the contrac-
29
miisrlr.
Ifliifeole.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
tile substance is but sliglitly injured and the sarcolemraa
and muscle nuclei are intact, as after freezing, after the
degenerative changes of typhoid fever, sepsis, and trivial
tra'umatic injuries'in AvhiVii but little (if the contractile
sidistance is lost. In more severe injuries tlie regener-
ation is only partial, muscle fibres growing out from the
Fui. 342(1. — Eepi'neriuion of Muscles, Myoblasts, and Sari'olytes.
tZiegler.)
ends of the old tilires into the granulation (issue wliich at
fii'st reijlaces the destroyed muscle ( W'arthin). Volkmann
states that regeneration is functionally important only
after typhoid fever and freezing, while after injuries
the regeneration is so slight that function is not restored
unless the wounds are small. Larger wotmds heal by
the formation of scar tissue, which is muscularized from
both sides and ends, but only for a short distanc<-.
Transplanted pieces of muscle degenerate and are rc-
placeil liy scar tissue, which is in the same way muscu-
larized for a short distance from the sides and ends.
KVunmel, however, reports a case in •wliich he sutured the
ends of muscle which were from 8 to 10 em. apart, and
secured almost perfect restoration of function after six
months. The dift'erences in the reported residts may de-
pend upon dilTereut nutritive or nervous contlitions. but
it woiUd seem from the majority of the reports that, while
vohuitary muscle does regenerate by both mitotic and lo
a limited extent amitotic division, its jiower of prolifera-
tion is extremely limited and does not extend to the com-
plete restoration of large areas of destroyed muscle tibre.
Changes in the MuscrL.\K Nerve Endings. — The
subject of degenerative changes in voluntary muscle can
scarcely be fully treated without some consideration of
the changes occurring in the motor and sensory nerve
ternunations iu this muscle. I am not familiar with any
work rciiortiug llie changes in the motor endings in hu-
man muscle occurring under pathological conditions, but
Hnber has recently rejiorted the residts of some experi-
ments on rabbits, in winch he crushed the posterior tibial
nerves, afterward studying the motor and sensory nerve
endings iu the interossei muscles by means of the intni-
ritaiii methylene blue method. Till the end of the first
day after crushing tlie nerve, the motor endings presented
a normal appearance and the muscle responded to electri-
cal stimulation of the nerve applied below the point of
injury. During the second day, changes began to ap-
pear in the motor endings, ushered in liy relatively large,
usually rounil or oval, deeply staining enlargements, or
varicosities, varying in number, size, and sha]ie, which
were found (m the arborizations of the motor endings.
These changes did not affect all the motor endings at the
same time; but when a majority of all the motoi-'endings
in the muscle showed the nodular enlargements, the mus-
cle failed to respond to electrical stimnlatitjn. At the
same time the nerve fibre showed dei;-eneralive changes
at its distal end. Later, the arborizations disappi'ured or
failed to stain differentially, although the so called sole
plate sometimes stained a faint lilue. The regeneration
of these endings was observed about thirty days after the
experiment, beginning with the formation of fine, vari-
cose fibres ending in a small granule, and ]iassing through
various transition stages to au ending which is in every
respect like the original ending. Not until numerous
regenerated motor endings were fouml, did the muscle
again respond to electrical stimidation. The neuromus-
cular nerve end-organs are the most interesting of the
sensory nerve endings found in voluntary muscle and
have been subjected to the most careful investigation.
Sherrington sectioned the sciatic nerve, causing degener-
ation (if the nerve fibres and complete atrophy of the
muscle fibres, but found the intrafusal mu.scle fibres of
the spindle well preserved and tlie striation retained one
hundred and fifty days after the section. Eichhorst re-
ports the presence of fat globules in the intrafusal mus-
cle fibres of neuromuscular spindles in a case of phos-
phorus poisoning. Griinbaiim found the muscle fibres
atrophied and surrounded Iiy hyaline substance in some
of the spindles in a case of pseudo-hypertrophic paral_ysis,
while Gudden observed atrophy of the intrafusal fibres in
a case of alcoholic neuritis. Batten examined the con-
dition of the neuromuscular spindles in eases of infantile
paralysis, tabes dor.salis, niyopath}', progressive mus-
cular atrophy, and peripheral neuritis, and found the
muscle spindles normal, except in one of the three cases
of tabes examined. After injury of the brachial jilexus,
however, which resulted in complete loss of motion and
sensation, he found changes in the spindles one .year after
the traumatism. The spindles were small, the intrafusal
filires were atrophied and granular with indistinct stria-
tion. w Idle the nerve fibres going to the spindles were
poorly stained. Batten therefore concludes that after in-
jury or section of the nerve the neuromuscular spindles
undergo degenerative changes in time, but much later than
the surrounding muscle fibres. Laslett and Warrington
found the spindles unaltered in a ease of lead paralysis
examined by them. Batten, in a series of experiments
upon animals, sliowed early degenerative changes in the
nerve terminations wit^iin the neuromuscular end-organs,
with later changes in the form, calibre, and arrangement
of the intrafu.sal muscle fibres, but he was unalile to re-
produce the fatty change of the intrafusal muside seen
)iy him in the case of tabes dorsalis. Hulier. in tlie ex-
periments previously described, found that the myelin of
the large seusoi\y nerve fibres going to the neuromuscu-
lar and neurotendinous end-organs showed segmentation,
and that the nerve fibres within the organs were broken
up into irregvilar. deeply staining fragments, which
gradually disappeared. The changes in the sensory nerve
end-organs did not, however, take place until the third
day after the crushing of the nerve. No degenerative
changes in the muscle fibres of the spindle were men-
tioned liy hiiu. Regenerating sensory endings were seen
by him on the forty-first day after the experiment, but
it was not until the end of the second month or the be-
ginning of the third month that the nerve endings in
these organs jiresented an appearance similar to that
found in the normal organs. In the case of transverse
myelitis previously described, the neuromuscular nerve
end-organs showed icdema, the layers of the capsule being
widely separated by clear fluid, and the muscle fibres also
being crowded apart. The muscle fibres of the spindle
did not, however, show any marked pathological changes.
In the neurotendinous nerve end-organs, also, Cattalieo
and others have demonstrated early changes in the nerve
endings,
lNFi..^MM.\'rioNs. — The inflammatory processes in vol-
untary muscle may be acute, suliacute, fir chronic. The
true inflammatory conditions are largely interstitial, in-
volving the connective tissue of the endomysium and
perimysium and the capiillaries, while the muscle fibres
undergo degenerative changes as a result of the changed
nutritive conditions brought about by the presence of the
inflammatory exudate. The inflammations maj' be the
result of the extension of an infianuuation from neighbor-
ing tissues, or germs may be carried into the muscular
tissue through the blood current. Traumatism, disturb-
30
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Muscle.
Muscle.
ami' of nutrition, and vascular elian.ces inaj' also apt as
])(i\verful imlirt'ct etiological factors. Jlyalgia or so-
called rhcinuatic myositis or muscvdar rheumatism often
afTccts the muscles of the back, neck, or the intercostal
muscles. In most cases it is probablj' not a myositis but
a neuralgia, due to slight twisting or lacerati(,)n of some
of the muscle librcs. Its one common symptom is pain
in the muscles. It usually quickly subsides, often sjion-
taneously. If necessar3', auodj'nes or hot applications
will generally give relief.
In (ti-utc piireiifhymatoiismyositis, the muscle fibres show
granular, hj-dropic, and fatty degeneration, Zenker's ne-
crosis, fragmentation, fibrillation, etc. The eudomysiuin
contains large numbers of leucocytes and is axlematous,
while the capillaries and blood-vessels are distended and
filled witli blood cells. If the degenerative changes in
the muscle fibres are not too severe, recovery usually
takes place with complete restoration of structure and
function of the affected muscle. This comparatively
mild form of inflanunation occurs after .slight injuries, in
disturbances of circulation, in typhoid fever, and in the
neigliborliood of new growths. Trichina c_vsts, antlira.'c
pustules and other irritating conditions may produce
similar processes in neighboring muscles. A similar
form of myositis has been called by Froriep monomyod-
tis. It arises on a traumatic or infectious basis and may
lead either to muscular abscess or to an indurative inter-
stitial inflammation which ends either iu repair or in the
formation of a muscle tumor. The coui'se may be acute,
subacute, or chronic. The symptoms consist of extreme
pain in the aflfected muscle, generally iireceded by chill
and slight rise of temperature. There are some swelling
and adema of the skin over the affected part, with swell-
ing and extreme tenderness of the affected muscle, which
soon becomes very hard. Tliere is also contracture of
the'affected muscle, with some diminution of the elec-
trical excitability. A more severe and generally fatal
inflammatoiy affection is known 2t& primary acute p'ly-
rnynxitis. This is infectious in character and is accom-
panied by a'dema and marked swelling of the overlying
connective tissue and hypera'mia and even exanthema
of the overl3-ing .skin. The clinical symptoms are fever,
pain, tenderness, and loss of function in the affected mvis-
cles. These symptoms suggest trichinosis, and Hipp
suggests the name piseudo-trichinosis. The resemblance
indeed is at times so striking that a differentiation can
be made only by removing portions of the affected mus-
cle and subjecting them to microscopical investigation.
This form of myositis is sometimes known as dermato-
myositis, because of thv. simultaneous involvement cjf
the skin and muscles. Polymyositis may also be hemoi'-
rhagic in character, since a marked extravasation of
blood may be found between the muscle bundles. Tliis
usually rnns a clu-onic cour.se, death resulting from in-
volvement of the heart. A case of this kind has been de-
scribed by Bauer: The affection started with severe pains
in the legs, after which swellings gradually developed in
various regions of the body. The general condition was
poor, sleep disturbed, appetite impaired; the jiatient bad
fever, and bis face was reddened but not fcdematous.
The musetdar swellings were jiainful, circumscribed, and
surrounded b3ra doughy, indurated area. These showed
areas of pigmentation surrounded by a violet zone.
Death occurred from a.sthenia. At the autopsy, the nuis-
cli' in places presented a brownish-red appearance, with
punctate and linear pigmentation and in other places a
waxy-yellow appearance. The muscle fibres were partly
normal and partly degenerated with proliferation of the
nticlei. These were separated bya hemorrhagiccxudale,
which in some places showed large numbers of leuco-
cytes, so that a purulo-hemorrhagic effect was produced.
In this case, the staphylococcus was found. In certain
septic cases a diffuse, purulent infiltration of various
muscles may occur, this condition being rarely regarded
as primary and terminating in gangrene of the muscle.
Ziegler describes a case of phlegmonous inflammation of
the subcutaneous and intermuscular connective tissue
near the pectoral muscle, resulting from an infected
wound. Skin phlegmons, erj'sipelas, decubitus, and
purulent artlu-itis may also cau.se similar suppurative
muscular affections. The muscle is swollen and softened
and may be mottled j-ellow, brown, red, and greenish in
color. The pus infiltrates the endomysium and may bur-
row along the sheaths of the muscles for considerable dis-
tances. Small, circumscribed abscesses, either single or
multiple, are found throughout the muscle in various re-
gions in case of hematogenous infection. These small
abscess cavities are filled with pus and tissue debris, and
are surrounded by (edematous and degenerating muscle.
These small abscesses ma\' be absorbed or become encap-
sulated, while larger ones break and discharge their con-
tents, being replaced by scar tissue, which gradually'
contracts and is partly replaced by new-formed muscle
fibres. The scar tissue may undergo calcification, while
the encapsulated forms may become either calcified or
liquefied. On exposure to the air, this greenish-l)lack,
gangrenous muscle evaporates or undergoes mummifi-
cation. Stierlin has described a case of se[3tic total ne-
crosis of muscles resulting from woimd infection with
obstruction of the artery and therefore interference with
the nutrition of the part. The bacteria were gas-form-
ing, putrefactive bacteria. Fragments of the necrotic
muscle filled the abscess cavities. The entire process
was limited to the musculature, the skin being unaf-
fected. The connective tissue and lymph and lilood
capillaries were filled with innumerable cocci, forming
a network around the muscle cells, which appeared in
cross section as homogeneous red discs in which no nu-
clei could be seen. Very few cocci had penetrated the
muscle cells. An aeute interstitial or productive iiiyos-itis
may also be distinguished; it is progressive in char-
acter and generall}' passes into the chronic form. It
■■ ■-^- \ l-i s*V % ..' 'f:'^
f"*,i.:5j..Vv!^::. 'P^ ■-:,■.. A ?-. '^i V-. '
TV
r
}
■ j:
■ ?
\
4
-"W:.
/^■^-■■i'
*'
**^
.^"
"i: • ■'•
' - "..
.- ' -i -V
<■■/
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^,;>
•i -
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v-'-'
^
..^ -."::■..:;"'
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sf
'■"^
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M.
h'
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Fig. 34-1.— Purult'Dt Myositis, witli Necrosis of Muscle. (Stierlin.)
occurs in typhoid fever, chronic irritations, etc. The
primary changes are in the connective tissue, whicli
jiroliferates and causes a secondary degeneration of the
muscle fibres.
Chrunic Mynsitis. — In progressive muscular atrophy,
whether neuropathic or myopatliic, there is a maiked in-
crease of the intermuscular connective tissue, so that the
jllusfle.
Muscle.
UEPEKENCE IIANDIIOOK UF TllH MEDICAL SCIENCES.
small muscle bimdlcs are separated by tliicU liuiids of
coiuieetive tissm-, or the muscle may be eutirely replaced
by comiective tissue. This constitutes the cnuditiou
kijowuas chronic interstitial my>isitis or librous myositis.
It may also occur in the neijjhliorhood ot chronic inllam-
inatory or irritative processes, as ulcers, tumors, para-
.sites. forcigu bodies, etc. It may also attack the uuisc'les
in the iieis;id)orbood of iullamcd joints, as in iidlamuiatory
rheumatism, sout, etc. Acute purulent myo.sitis may
be follow ed by a condition in which the abscesses are
walled in by gramilatiou tissue and ive may speak of it
as a chronic purulent myositis. This occurs most fre-
([Ueutly in the psoas muscle. TVhile the condition may
follow" an ordinary pyogenic infection, it is far more
fommon after specific" infectious, such as tuberculosis,
syphilis, actinomycosis, glanders, gonorrhcea, leprosy,
etc.
Titbereidons Jfi/nnilix may and frequently does occur in
muscles iu the neighborho'od of a tuberculous abscess or
some focus of infection, the process extending directly
into the nmscle from tlie infected area, as iu the muscles
surrounding a psoas abscess or caseaticg lymph gland, or
in the intercostal muscli'S in jiyothora-X "and iu miliary
tuberculosis of the pleura. Primary or luematogeuous
tuberculosis of muscle is, however, rare — a fact which is
explained by the bactericidal action of the muscular Huid,
which, as Tria states, is more ctKcient in its action than
the thiids of any other tissues. Cases of haniatogeuous
tubei-cvUosis of the muscles have, however, been de-
scribed by Habcrmaas, Midler, Delorme, Reverdin, and
Lanz and"Quervaiu, and Steinthal, the latter haviug col-
lected eight cases of primary tuberculosis of the abdomi-
nal muscles. The tuberculous nodules found iu the in-
termuscular coimective tissue present usually a caseateU
necrotic centre surroimded by a zone of lymphocytes and
epithelioid cells with some giant cells, and this is sur-
rounded by a zone of l3'mphocytes and connective tissue.
Blood-vessels are poorly developed in these areas. The
muscle iu the neighborhood of one of these areas may be
normal, but is usually atrophied, while the muscle nuclei
are increased in number and surrounded by a clear zone;
the protoplasm of the muscle diminishes as the nuclei in-
erease in numljer, so that finally the sarcolemma appears
filled with nuclear masses. As the muscle degenerates,
it is replaced by connective tissue into which the tuber-
culous foci extend. Here they consist of lymphocytes
mostly, with a few cinthelioid cells. According to Petit
and Guiuard, the tiUierculous process originates in the
intermuscular connective tissue, the degeneration of the
muscle restdting from the presence of cells called myo-
phages, which send processes between the contractile
fibrils and gmdually destroy them. In none of these
cases were tlie tubertde bacilli demonstrated microscopi-
cally, but the history of the case, the micrcscopic appear-
ance of the tissue, and the po.sitive results gained b^-
injecting the contents into guinea-pigs made the diagno-
sis umiuestiouablc. Tuberculotis myositis must be dif-
ferentiated from syphilitic myositis, interstitial m_vositis,
actinomycosis, eclujiococcus, aud benign and malignant
tumors. A tuberculous abscess may also be found iu
muscle, consisting of iruiscular aud cellular debris sur-
rounded by a thin wall of granulation tissue poor in
blood-vessels.
Siijiliililie MijoxitU may be diffuse or circumscribed.
Iu the former case there is a primary diffuse infiltration
of the comu'ctivc ti.ssue with a secondary degeneration of
the muscle fibres. It occurs especially iu the later stages
of syphilis and attacks by preference tlie muscles of the
extremities. It is characterized liy a iiaiuful, indurated
swelling of the alfected muscle, which is easily dillVren-
tiatcd from other muscular alTections by its promiil re-
sponse to antisyphilitic treatuieut. MuscU.' gumniata,
while not infrequent iu the later stages of sypliilis, liave
not often been described. They may, as in the case re-
ported by Eger, develop many yc ars afl( r the syphilitic'
infection. If no regressive changes have tak( n jilaee,
they are usually indolent in their course, causing no
pain, no disturbance of function, and no alteration in elec-
tric excitability, unless by their excessive growth they
l)ress upon nerves or blood-vessels. They are influenced
more or less readily by the potassium-iodide medication.
The large tumors" may ca.seate, forming deeji ulcers or
abscesses, which heal readily but leave indurated scars,
which mav disturb the function of the muscle. Iu the
earlier stages, the gummas consist of very vascular gran-
ulation tissue which may be mistaken for sarcomatous
tissue, but later the characteristic tkree zones develop,
the outer consisting of vascular granulation tissue, the
inner caseated zone, and the intermediate zone of mature
connective tissue. CMant cells may be present or absent.
The rich blood supply, the ab.sence of tubercle bacilli,
and the response to autis\"pliilitic medication will readily
differentiate these nodules from those of tuberculo.sis.
^•1 Case (if GuiMrrlnml Myositis involving the latLssiraus
dorsi has beeu described by Ware. The microscope re-
vealed a pictiu'e of interstitial inflammation, with cloudy
swelliug of the muscle fibres, though in some places the
striation was still distinct. There was some pn.iliferation
of the muscle nuclei, showing a possible tendency to re-
generation of the muscle fibres. The comrective tissue
was so greatly increased that the muscle fibres were
crowded apart and compiressed. Xo germs were found
except the diplococei. This form of myositis is charac-
terized by the intense sclerotic process, which is so
marketl a feature of gonorrhceal inllammaticin in other
localities. The process generally heals by the formation
of connective tissue, which usually undergoes resolution,
although cases have beeu reported of ossiticatiou of the
affected muscles. If an abscess forms, it is probably due
to a mixed infection. The localization of gimorrhieal
myo.sitis is probably generally due to extension from
neighboring joints and bones, though it may sometimes
result frour metastasis.
Leprous Mi/ositis. — Fujinami describes the changes
which take place in voluntary muscle in cases of leprosy.
The muscle is crossed by white strands cousisting of con-
nective tissue containing many fat cells aud numerous
brown pigment granules arising from degenerated muscle
fibres. The muscle fibres are atrophied, showing either a
very irregular tirrangement of the striatiou or a granular
and pigment degeneration. The nuclei are increased iu
number, enlarged, and very irregularly arranged, while
many of them take the stain iutenseh' and show indistinct
outlines, so that they appear as fused, hyperchroraatic
masses. The changes are similar to those observed iu
muscular atrophy, in the neighborhood of tumors, in in-
flammatory processes, and are jirobably due, not to the
direct action of the bacilli, but to disturbance of the nu-
trition of the muscle, perhaps brought about by chemi-
cal changes iu the lymph caused by the growth of the
bacilli. Colonies of leprosy bacilli are seen between the
atrophic muscle fibres and iu the connective tissvie, and
they are sometimes seen within the connective-tissue cells
or leucocytes.
Actinuiinjcotic Mi/osilis is not at all common, but iu rare
cases a focus infected with the ray fuugus may, either by
direct extension or by metastasis, lead to an iufectiou of
vohmtary muscle. The infection results iu the forma-
tion of nodules of granulation tissue, which may under-
go fatty degeneration or suppurate and form abscesses,
'I'he healiug of these nodules leaves areas of iudui'ation
which arc not ea.sy to distinguish from the .scars of
syphilitic myositis. -\ji inflammatory affection of mus-
cle may also be due to an infection with the [/linulers ba-
cillus. This leads to the formation of many small, gray-
ish abscesses, containing a thin fluid in which the germs
are found. The muscle may become infiltrated with jnis
and chronic ulceration or abscess may result.
AxtMAt, P.vu.\siTiis. — Varieties of clu'onic myositis may
■al-so result from the presence of certain animal parasites,
one of the commonest of which is the Tricliimi spini-
lis. When found in muscle, it is in the encysted stage
of its development, which is known asanieasle. The
poorly cooked measly |)ork is eaten, the capsules dis-
si}lv(' in the gastric juice, the embryos develop iu the in-
testine six or seven days after the ingestion of the meat.
32
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
]Tl||80l<'.
4JTf^|^^^(^'^^^i^^^t-|
Tir
' — Tru hime Fnr^ste i iii \ luntir\ Mus
These pass into tlie muscles, showing a, preference for
tlie diaphragm, tongue, intercostal muscles, neck, larynx,
and thigh nuiscles. The worm penetrates the muscle
libre, which degenerates, the (ibrill;t3 appearing swollen,
gramiUir, and
with '.ndistinct
s t r i a\ The
worm is .soon
surrounded liy
ci clear, homo-
geneous cap-
sule, w h i c h
later becomes
c a 1 c i fi e d ,
, , WW There are at
(/f^ U first evidences
^^ ■ cif acute inter-
stitial inllani-
mation in the
internuiscular
coiuiective tis-
sue, which la-
ter disajipear.
T h e clinical
s y m p t o m s
consist of ir-
regular fever,
gastro -intesti-
ual disturb-
ances, typhoid
s y m p toni s,
(I'deina of an-
kles, paiu and
tenderness in the muscles. Brown notes a marked
leucocytosis in acute cases, the eosinophile cells being
most markedly increased, reaching 68.2 per cent, of all
the white blood cells ]ire.sent. !Muscidar changes take
place similar to those in chronic myositis — increase of
■connective tissue, librillation and segmentation of the
muscle fibres, with granular and hydropic degeneration
■of the muscle fibres, witli proliferation of nuclei and
thickening of the sarcolennna are the most marked
changes noted. Death may result in the acute stage of
trichinosis, or the worms may become encysted within
■calcified capsules and create no further disturbance,
remaining innocuous during tlie life of the individual.
Tlie Ci/sticeiriis ecU nlusa' ma}' sometimes be found en-
cysted in muscle, the cyst being surrounded by a linn
fibrous capsule, the whole being surrounded by a zone
•of inflamed nmsele tissue. The EdiinonieriiH may be
•encysted in muscle, although it is far more prevalent in
the liverand lungs. The capsule is dissolved in the gas-
tric juice, the embryo di'Veloiiing and making its way
through the wall of the stomach or intestine anil either
pas.sing thnnigli the portal circulation to the liver and
thence to the heart and lungs, which are the regions in-
fected in si.xty-tive to seventy-live per cent, of all cases,
or wandering actively to the muscles and other regions.
Gerulanos has recently collected from tlie literature two
hundred and fourteen cases of muscle cehinococcus, one
hundred and ninetv-five of which were single, while
nineteen were nuilti]ile. Most of these were, however,
very limited in number, while the cysts in the case de-
.scribed liy (ierulaiios were very numerous, varying in
size from a ]iinbead lo a man's bead. Some of the largest
had suppurated and contained masses of pus. while others
showed the scolices and hooks, and others contained
nothing except a clear yellowish tluid. The tumors were
white, opa(iue, and either smooth orlobulatedTSurrouii<li cl
by a fibrous cajisule. The cptestion of the origin of tlie
multiple cysts is one of considerable ini])ortance. It is
claimed by some that each cyst develops from a single
embryo, by others that one cyst, containing an eiubryo.
is formed from which (laughter cysts are given olf;
■others believe that the rare cases of multiple cehino-
coccus cysts aredueto ni])ture of a fertilecyst and hence
a reinfection of the surrounding tissues. Gerulanos,
.however, thinks that in his case at least the multiple in-
Voi.. VI.-;'.
fection was due to an active wandering of the embryos,
which follow the ]iaths of the loo.se connective tissue,
surrounding th(^ large vessels, in the neighborhood of
which these colonies were usually found. In the ca.se
reported by Sclioltz, however, the hydatids were found
on the outer side of the thigh, far removed from the great
vessels. In several of the cases rcjiorted, trauma was
described as an etiological factor, but probably, as Geru-
lanos suggests, the trauma has simply called attention of
the patient to a latent tiunor which hasexisted for a long
time. The diagnosis of this condition must lie based on
the presence of an elastic, iluctuating, dense, slightly
sensitive lunior. The sensitiveness will of course depenil
on the exact location of the hydatid. It must be differ-
entiated from neoplasms and cold abscesses. The elas-
ticity and fluctuation indicate tiuid contents, while the
lobulated, multilocular feeling and the history of the
case will generally distinguish the echinococcus cyst
from the cold ab.scess, although the cyst may also some-
times be smooth and spherical. The treatment con.sists
in extir|iation of the tumors.
JIyositis Ossificans. — Jlyositis ossificans, as its name
imidies, is a disease in which an intiammatory affection
of the muscles terminates ir. ossiticatiou. Long regarded
as a pathological curiosity, it is .still a comparatively rare
disea.se, the character and etiology of which are not be-
yond controversy. Ca.ses of pathological ossification nat-
urally divide themselves into two great classes: tlio.se
in which bone is formed in connection with bone, an ab-
normal activity of the cells of the jieriosteum being the
apparent causative factor, and those in which bone is
formed in the softer tissues, having no connection, pri-
marily at least, with the skeletal bones or thdr jierios-
teum. iMj'ositis ossilicans occupies a very prominent
jiosition in this second grouji of cases. Two types of
this disease are sharply diiferentiated-a progressive and
a stationary form. The progressive type, known as
myositis ossificans progressiva, is distinguished from the
Fir,. ;M2;i.— Myositis Ossilicans Prusrcssiva, Sliowiiuj Mullipli' (l.ssnius
Ttinior.s, Foriiilni; an jilniost Continuous I.edgi; alouj; tlie spinal
t'oi'd, FLKatlon of the Head, Mlcrodartylie, etc. (liriuin.soliu.)
localized form by the facts that many series of muscle
groupsare attacked, that it bi'gins in youth ;ii'd ;idviiiices
with occasional jicriods of apparent reposi^ followed liy
exacerbations, wliich may or may not be attributable to
any known exciting cause. This tyjie is much mori!
easily recognized than the second, .so that most of tlu^
cases mentioned in the litenilure belong to it. The ear-
33
muscle.
Muscle.
UEFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Host cases of myositis ossiticans progressiva were reported
in the Pliilosopliical Transactions of 174(1. In llie same
journal in 1741, Copiiing gives tlie following grapliic
ciescription of a case: "Das ganze Iviieligral war ein
zusaninienliangender Knoehen, von deni sieli ein scliarfer
Rand erhob, der wie cine Handhabe aussali, woran man
das Skelet haltcn Isonnte. Es waren ilim jcdes Jahr aus
den Fersen Horner gewachsen, wie die Sporcn bei den
Hahnen und die Ueberwiichse von Knoclien waren in so
grosser ]Menge da, dass es ebeu so sclnvi^r sein wlirde sie
zu zillden als die Stalactitcn in der Grotto der Calj'pso."
In 1869, Mlincbmeyer, giving to the disease the name
suggested Ijy von Dusch, myositis ossificans jirogressiva,
described tlie disease so accurately that little has been
added to his description by later writers.
H(^ declares the disease "to be a constitutional affection
of slow course witli periodical e.\acerliatioiis followed by
periods of ajiparent repose. The first disijirliance of the
muscle ti.ssue begins with a marked intill ration of the
intermu.scular conneelive tissue, so that the name my-
ositis ossificans interstitialis which has been suggested is
not inappropriate; the second stage, that of connective-
tissue induration, consists of an e.vcessive growth of in-
termuscular connective tissue with destruction of the
striated muscle as a result of pressure atrophy or fatty
degeneration. The third stage is that of ossification,
which begins in the centre of the affected muscle in the
connective-ti.ssne groiuid substance. The disea.se begins
in youth with local .swelling and later In.ss of function
and ossification. Sometimes local and radiating pain is
associated vvitli it and also sliglit febrile reaction. The
skin niav be of higher temperature than normal and
the connective ti.ssue may be o?dematous. The swelling
may disajipear after from two to four weeks, leaving the
muscle hard and o^isified, a condition which is sometimes
tem|)orary, but generally spreads to tlie origin and inser-
tion of the nuiscle and remains permanent. "With very
few exceptions, tlie disease makes its appearance in the
muscles of tlie back, especially iu tlio.se of the upper
portion of the back or of the neck. In connection with
the necli nuLscles, the ligamentum nucha' becomes ossified
and the long muscles of the back gi'nerally form one mass
of bone; later, the muscles of the .seapuhe and tlie latis-
simus dorsi are involved ; afterward the anterior muscles
of tile neck are attacked and then the deltoid and the
nuiscles of the axial sjiace. Tlie final result is usually
comjilete fi.\atioii of the head, immobility of the entire
spinal column and ankylosis of the joints of both shoul-
ders in tlie position of adduction, with fixation of the
scapuhc. Still later, the muscles of the arm and fore-
arm may become inflamed and the clliow-joint anky-
losed ; the muscles of the hand, however, possess almost
complete immunity. In the further course of the disease
the muscles of the pelvic girdle, the glutei, and then those
of tlie lower liml.is become involved ; only at the last and
in very severe ca.ses does the disease exfenil to the mus-
cles of the jaw and of the palate, while tlie face muscles
usually remain intact. Ulunchmeyer notes the complete
iminiinity of all muscles which are not attached to bone
at both extremities, hence of heart muscle, of the dia-
phragm and sphincters, the mu.scles of the eye, of the
tongue, the facial muscles, the muscles of the genital
region.s, and the muscles of tlie abdomen. This immu-
nity is not, liowevcr, absolute, since jMi'inchmeyer notes
tlie occurrence of bony tumors in one case on either side of
the chin, the location of wliich coincided with that of the
triangularis nienti. The disease rarely advances steadily ;
it is cpiit.e characteristic that there should lie pauses
which may last for years, the renewal of the jirocess be-
ing either spontaneous or the result of some injurious
influence. Deformities of a more or less severe degree,
involving the position of the head, of the sjiine, and of
the extremities result from the fixation of the joints, from
the degeneration and less of function of the muscles, and
from the increase and subsequent contraction of the con-
nective tissue. jMiinchmeyer closes his detailed descrip-
tion of this rare and terrible disease with the following
vivid picture; "At first deprived of only a few not very
necessary motions, the ]iatii'nt after a time can no longer
carry food to his mouth, the hip and knee on one side be-
come immovalile. and finally walking becomes impossible.
And during this whole long time, there is a constant al-
ternation of hojie, as each tumor disappears and as each
pause occurs, and the sad feeling of bitterest disajipoint-
mcnt as each new symptom appears, until finally all hope
is gone, the mouth can no longer be opened, the food
can be introduced only through an opening artificially
made lietween the teeth ; even swallowing and speaking
become at times extremely ditficult. The mental condi-
tion in a few cases indicates perfect resignation, but gen-
erally deep psychic depression prevails."
Although the disease is a comparatively rare one, a
careful study of the literature has resulted in finding
seventy-eight cases, most of which have followed the
typical course which lias been described. Exhau.stive
study of the literature of this disease has been made by
Jlunchmeyer, Pinter, Pincus. Roth, and others, the re-
sults having been carefully tabulated by Pincus.
Little is known regarding the etiology of the affection.
It occurs very generally in youth, witli very few excep-
tions under fifteen, often in infancy, but Kronccker
reports a case beginning at fifty-four. Males .seem to
exhibit a certain predisposition to tlie di.sease, nine of
Miinehmeyer's twelve cases being males and thirty of
Roth's thirty-nine. Many factors are mentioned as ]ire-
disposing to the disease, such as cold, damj), poor hy-
gienic surroundings, insufficient nutrition, rheumatism,
and other constitutional affections. A congenital jiredis-
position is naturally suggested by the fact that it so uni-
versally occurs in earl_y childhood, that it is so generally
symmetrical in its development, and also by the fact
that it is often accompanied by a curious congenital mal-
formation. This is microdactylie, an ankylosis of the
phalanges of the thumb, and a lack of one ]ilialanx of the
great toe on both sides. This malformation was first
noted by Florsclititz iu 1873, since which time it has been
ob.served in about .seventy-five per cent, of all cases re-
ported. "While this is the most common abnormality
noted iu connection with this affection, otlier anomalies
are mentioned, such as hallux valgus and other malposi-
tions and incomplete development of the testis and other
organs. Lexer has described cpiite minutely the micro-
.scopical a|>pearaneeof .sections taken from several tumors
removed from two cases of myositis ossificans progres-
.siva. Near the periphery of his prejiarations he finds
quite normal muscle fibres. Nearer the centre, the mus-
cle fibres are more or less degenerated, the cross stria-
tions lost, the muscle nuclei increased, so that the fibres
iu many eases resemble giant cells; the fibre is broken
up, while the interiiiuseular connective tissue is in-
creased and infiltrated with leucocytes, especially in the
neighliorliood of the capillaries. The connective tissue
contains many cells of different forms, arising from
division of the connective-tissue cells, which may be
regarded as fibroblasts, while in some places may lie
seen cartilage cells with formation of hyaline cartilage.
Nearer the centre the ground substance becomes denser,
the former connective-tissue cells lie in small angular
sitaces, and the formative cells lie in rather regular rows
on the dense tissue which comprises the osteoid trabecnhe.
Later these become calcified and thus bone is formed.
The fact that these tumors consist of true bone, often
with all the structure of compact bone, is noted l\v many
authors, who have not given so detailed a description (if
their findings as has Lexer. The degeneration of the
muscle fibres, the increase of the connective tissue, und
its infiltration with leucocytes are noted by all who have
examined these tumors microscopically. Kissel, how-
ever, rejiorts a case in which no o.sseous tissue was found,
although the clinical picture was ty])ical of the disease.
The tumors showed only young connective tissue with
remains of altered muscle. In his ca.se some of the
tumors disappeared, leaving no trace, while others broke
down and a puriform liquid was discharged. This case
improved somewhat under treatment and was regarded
by Kissel as an incipient stage of the disease.
34
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Musele,
Muscle.
Tlie prayiiusis in tliis disease is undeniably veiy bad.
Tlie course is, liowever, very slow. interrui)U'd by many
pauses of longer or shorter duration, and death dirertly
assignable to the di.sease is ver_v rare. As a usual tliinjj,
the disease drags its slow course along, the jiatient be-
coming more and more helpless, all vital functions imim-
paired, until some pulmonary complication or some other
intercurrent airection closes the scene.
Treatment seems practically useless ; yet, as in all hope-
less diseases, many remedies arc tried. ]iartly in hope of
relieving the most painful symptoms, and perhaps partl.v
in the hope that the diagnosis may be wrong. Among
the remedies suggested are thyroid extract, phosphoric
acid, sodium salicylate. In a few cases, extirpation of
the tumor was attempted in the earlier stages. Sotmani-
mous is the opinion regarding the bad prognosis in this
disease that we may well be doubtful of the correctness
of the diagnosis in those cases in which cure or permanent
improvement is noted.
Tlie disease has something in common with muscular
rheumatism, with the muscular dystrophies, with poly-
myosites acuta, and with the multiple osteomata, but the
history of the case, the order of advance of the disease
from one series of muscles to another, the symmetrical
nature of the affection, with the characteristic deformities
resulting from the progress of the disease, make the diag-
nosis easy, especially in the later stages.
Cases of myositis ossificans confined to single muscles
or groups of muscles are less frequently noted in the
literature, either because the disease is less easily rec-
ognized or because it seems less striking and worthy
of note. A careful study of the literature lias resulted
in finding thirty -five cases. Some of these cases followed
a single severe injurj', as in the four cases reported b_y
Cahen, in which the growth resulted from the kick of a
horse. Other cases lesidted from repeated injury or
strain, under which heading we may include the ossifi-
cation of the deltoid and arm muscles in soldiers and of
the thigh muscles in riders. This perhaps includes far
the largest number of this'class of cases. Tl;en we have
ossification of muscles occurring in the course of a chronic
inflammatory process, which may be rheumatic, syphi-
litic, or tidierculous.
Cahen describes a case in which, six weeks after a kick
had been received, a bony tumor was found aliout Vi cm.
long on the left thigh, corresponding to the position of
the biceps. After the failure of other modes of treat-
ment, the tumor was excised; after a short time the
tumor returned and was again removed, this time with
the periosteum, to which it had become adherent. The
sections from these two growths present somewhat dif-
ferent appearances. At the perijiliery of the section
of the first tumor and crowded by connective tissue con-
taining many blood-vessels and large spindle cells, he
finds muscle fibres which have undergone many degener-
ative clianges — hyaline degeneration, increase of nuclei
of sarcolennua, loss of striation. etc. Near the centre of
the tumoi', he finds irregularly arranged trabecuhc of
bone, with an epithelium-like lining of osteohlasts, with
many lacuna' and giant cells, and the spaces filled with a
mari-ow extraordinarily rich in blond-vessels and con-
nective-tissue cells. All through the preparation are
scattered bits of muscle, the relation being so intimate
that single muscle fibres arc completely embeihled in
bone. In the secticms from the second tumor, no muscle
fibres are seen. There are three distinct zones: a zone
of greatly increased connective-tissue cells, then a zone
of small-celled hyaline cartilage, which, by ingrowth of
blood-vessels and giant cells, is changed into bone.
There is no distinct boundary between the cartilage and
bone, the cells liecnmiug smaller and losing theircapsules
while the intercellular substance becomes denser, more
opaijue, and stains bluish-red in the haMnatoxylin-eosin
double stain. The development of bone in all cases in-
vestigated stood in direct I'clation with an increase of the
intermuscular connective tissue.
Lehman describes the case of a woman of thirty-six
years, who presented herself with a tumor in the thigli
which had been developing at irregular intervals since
her seventeenth year. The tumor was extirpated and
with it the greater part of the biceps, which was involved
in the tumor mass. Microscopical examination showed
V
/■'.
^m.'
Fit;. 3424. — Microscopio Appearanre ot Muscular and Os.^eous Tissue,
Removed from one of tbe Tumors in a Case of Myositis Ossifli-'ans.
(Cahen.)
a large amount of adipose tissue, permeated by bauds of
altered muscle. The changes in the muscle were as fol-
lows: 1. Indistinctness or entire loss of cross striation;
this condition is called "streifige Pegeneration des jVIus-
kels." 2. Loss of longitudinal .striation — homogeneous
appearance of muscle. No true fatty degeneration was
however noted. 3. Increa.se of mtisch:" nuclei, as is seen
in atrophied muscle. These changes are accompanied by
proliferation of connective-ti.ssue cells. The young con-
nective tissue, in the course of its maturing, luulergoes
manifold changes until from it peculiar fibrous or osse-
ous tissue is developed. The osseous tissue is typical
compact bone except that the lamellar systetus are irreg-
ularly arranged and differ materially in the size and age
of the systems. In soiue portions of the tumor bone was
found, in others mvi.sculo-comiective tissue, and in others
a tissue which forms a transition between lione and con-
nective tissue and might lie <'alled osteoid. sinceHhe struct-
ure of bone is distinct, but ealeifi<-atiou is incomjilete.
This case is interesting on account of the large amount of
fat tissue developed among lhe<legenerated muscle fibres,
so that Lehman has named this a case of myositis ossi-
ficans lipomatosa.
The author has recently reported two cases of luyositis
ossificans limitata, the autopsies on which were iierformed
by Dr. Warthin. (;)neof these cases was that of a young
farmer, aijed twentv-three years, the cause of whose
35
7IH!.<|C.
REFERENCE lIANDlit « iK oF THE ^lEDKAL SCIENCES.
death was pulmonary an<i laniificul tubcrrulnsii?. lie
ilicd April lltli, ISiir. His fliiiic-al liistnry pri'sciils
notliiiiu' of interest, in this eonneelion until iNIaroh 1st,
18SI7. when he eomiilaineil of ]iaiii in Ihe Irl't le.s. On
e.xaniination the left leij ami foul were found swollen,
soft, anil (edematous. 'I'lie tlii!;h was also swollen, al-
thcnmh less than Ihe lej;-. On JIareh '2Sih, lSi)7, examina-
tion showeil the left lej;- only slishlly o'dematous and it
was no longer painful. No tumor was deteeted, liow-
ever, and a marasiuie thromljus was heliev<'d to have
eaii.sed the a'denia. The auto]isy sliowed a very general
tuberculous process. ]5oth lungs were intillraled with
I ubercles and contained large cavilies. Small tubercles
were found in the spleen, liver, adrenals, ami kidneys,
and atuliercnious ulcer in the lower portion of the ileum.
The lironehial glands conlained many areas of caseation,
the mesenteric glands were enlarged, many of them
easealed. and all the lymiih glands of the body were en-
large<l. In the left saphenous vein Avas lound an old ob-
turating thnmibiis, which e\',cnde<l Ihrongh the femoral,
the left external iliac, and into the left common iliac and
the abd<miinal vena cava. Around the wall of the fem-
oral vein there was an urea of hypera'inia and infillra-
tion, originating a|)parently from an enlarged lymjih
gland near by. This gland on section showi'd infiltration
and caseation. Th<' niicroscopieal appearance was as
follows: Both femoral ves.sels were nearly or quite tilled
by thrombi in varicms stages of oiganization. The entire
section showed marked liy]iera'niia, all the .smaller ves-
sels and even Ihe capillaries b"ing distended and packed
full of blood cor|)nscles. The connective tissue sur-
rounding the large blood-vessels, as well a.s that arounil
the smaller ones, was inlill rated with leucocytes, which
were especially numerous in the tissue arounil the capil-
laries. This lencocytie intiltration wasespeeially marked
in the internuiscular connective tissue and around the
cajiillaries of the ondouiysium. Many of the Icucoeyle.s
showi'd degeneration and in some iiorlions of the sections
larger or smaller neerotie, abscess-like areas were found.
Surrounding these neciolic areas, and indeed in many
portions of all thi' sections, attempts at repair were
noticeable. The iiiHammalory tissue had been replaced
by a new granulation tissue, rich in small. Ihin-walled
blood-vessels and in large iilate-like cells with little
fibrous tissue. The most marked changes, however,
were in the muscular tissue. In addition to the altera-
tions in the intermuscular connective tissin- already noted,
various ileseneraliveclian Lies in Ihe inusele w eie olisi'rved.
Fio. ;lt2.'). — Si'rlii.n"TliroiiL'll r.i.tll Tlir"liilinseil Fimmmi-;i1 Vi-s^rls,
Musrli's, Flit, CunniTliM' Tissui'. iiiiil (naaulalinn Tissue ('niinnniiii;
riiltes iif Hone. In. Mlisrle; )., Imrie; i, lillcilliMlinll ; (, Uir"liil>lls,
IM'awn auiler l!ie (ilssrctillLr Iriin-osr.ipe. Wlltl iiiil t.f (Mliii'ia lurlitil,
Miiirnlllcil ahoul eiL'lit times, Ki-iliu-i'il h, .nii'-hiilf siz,' nf ilniu in^',
(DeWitt.)
In some portiiijis of the sretions, especially at a distance
from the centre nf the inllammalory area, the muscle
aiipeared fairly nniiiial, liolh in si/.e and in tlie tiiier
structure. Near I in- cent re of the in lla minatory area, how-
ever, the muscle libres were much sinalli i. of very irregu-
lar contour, and either tapered to a ]inint or divideil into
numerous bundles of linely fibrillar tissue resembling
fibrous connective tissue. The cross striation was lost
anil in some even the longitudinal striation seemed lost
or very indistinct, so that the fibre appeared finely gran-
ular or entirely homogeneous. In some places a nuiscle
nucleus, with a fusiform fragment of sarcoplasm, was
separated olT from the rest of the cell. The nuclei may
be absent from a consideralile jiortion of the fibre and
crowdeil togelher at one end or at one side, and often
a small fr,m'ment of muscle containing many nuclei, or
even a mass nf iniilear substance in which the nuidear
outlines were very indistinct was seen. Small, isolated,
fragments of mu.sele could be seen iu the granulation
tissue and even in and near the infiammatory, necrotic
areas, contaiiung numerous nuclei embedded in homo-
geneous-a|ipeariii!;- iiroloplasm. ]iroilucing Ihe appearance
of giant cells. These may be iiUerpreteil as attemjils at
regeneration of the degenerated muscle fibre, although
)n'obably many of the forms, especially those in the ne-
crotic area.s, were degenerating sarcolytes. In addition
to the ,siniple atrophy, fatty degeneration and Zenker's
waxy necrosis were noted.
In the granulation tissue, which .seemed to have re-
placed the huger inllammatory areas, were irregularly
branching and anastomosing tiabeiadie of osteoid tissue
consisting of a dense matrix, enclosing rather large cells
usually not siirnnmded by a ca]isule. The spaces be-
tween the trabeiadie w ere lilled with very vascular granu-
lation tissue, somewhat resembling bone marrow. Many
of the large cells of these are;is were arranged on the
trabecula>, like the layer of osleolilasts on the trabecnl;i3
of developing bone. .Most of Ihe osteoid tissue had un-
dergone calcification, at least in the central portion. ,so
that, according to Ziegler's definition, it represented a
true ossification process. It may lie added that .some of
the sections were stained by Schiuorrs bone stain, iuiil,
while, as might be expected from the short duration of
the la-oeessand the thinnessof the Irabeculie, nostructure
of compact bone wasto be seen and theeells did not show
the processes so characteristic for adult bone cells, yet in
each case a layer of greater or less width surrounding
the trabecula' gave the ty])ical color reaction given by
bone to that stain. In some of the sections these ]ilates
of bone formed a netuly continuous ring around the large
blofjd-vessels. In others they were scattered throughout
the .section in smaller masses, always found in the granu-
lation tissue, never in the old <'onnective ti.ssiu>, nor in
the intlamniatory tissue which was still undergoing re-
tiograde changes. These ossified masses were found,
not only immediately arouml the femoral vessels, but
also extending out in all directions between the degener-
ating and regeneraling nui.scle fibres, wherever a sulfi-
ciently large area of granulation tissue was found. The
relation of the plates of bone to the other tissues in the
section is represented in Fig. !J42.1. In the marrow
sjiaccs were often seen bits of degenerated muscle, atro-
phied, nun nucleated, and aiipcaring homogeneous.
By I'nna's orcein diU'erential stain and also by Wei-
gert'sstiin for elastic I issue it was shown that a regenera-
tion of the yellow elastic-tissue fibres was taking ]dace
in the granulation tissue. Although the jiatient was tu-
berculous, no tubercle bacilli were found in the eidarged
lymph glands in the neighborhood of this intlanunalory
])roce,ss, nor was the strneliire that of a tubercle, but
rather that of a simple, necrotic abscess. The changes
in Ihe tissue indicate that the in terinuscular in tlam Illation,
the changes in the muscle, and the bone formation ante-
daleil by a considerabh^ period the thrombosis, which
was proliably secondary to the other changes.
In the second case, the clinical history lu-e.sented noth-
ing of interest except Ihe fact that the femur was broken
about five weeks before the death of the patient, but the
fracture was not in the immeiliate neighliorhood of the
point of ossitication of the muscle. The microsco]iical
appearance of the two cases was identical and an obturat-
ing thronibus was found iu the femoral vein in both.
The fact that in these two cases the ossilicatiou was not
discovered until the autopsj' had beeu made and the
3(j
REFERENCE IIAXDBUOK OF THE MEDICAL SCIEX'CES.
.Hum- If.
ITIiiihicle.
tissues examined iiiierosro])ieally is of interest as sii.sgcst-
inj; the possibility fhat ])atliological ossitieationof inusele
after injury or inllaniniation may occur much more fre-
quently than is generally supposed or than can be gath-
ered from the literature, since such an ossifica-
tion, if limited in extent, may not eseite any
sj'niptnms that would lead to tlje diagnosis of
myositis ossilicans. When the diagnosis is ma<le
an'd the disturbance is sufficient to warrant it.
o]K'ralion seems to otTer great hope of recov-
ery. In the cases reported by Calicn. Lehmann.
]\Iunro, and others, entire extirpation of the
tumor, with the periosteum in cases in which
the bone had become adbi-reut to tlie peiiosteum.
resulted in ]ierfect recovery. jMuch difference
of opinion lias arisen as to the true character of
the bone formation. Virehow places the disease
on the border line between infianunation and
new growth and is supported by Lexer, Bollin-
ger, and many others. JIays asserts that it is a
true tumor aiul is supported by Ki'immel, Pin-
ter, Helferich, Pincus, Partsch, Cahen, and
others. Cahen bases liis assumption on the mi-
croscopical ai)pcarance, especially on the fact
that new connective ti.ssue, cartilage, osteoid
tissue, and boue are found in the same section,
thus showing the characteristics of an atypical
growth. They consider the inflanuiiatory phe-
nomena and muscle degeneration to Ije second-
ary to the tumor formation. Pincus, after a
most exhaustive study of tlie literature and of
his own cases, arrives at the conclusion tliat
myositis ossihcans juxigrcssiva is not a di.sease,
hut undoubtedly a tunuu- belonging to the mul-
tiple osteoniata and exo.sto.ses of Vircliow. lie
states that the process begins in the perio.steiim,
the muscle degenerating secondarily, and that
an inborn, not hereditary, ciuistitutioual anomaly lies
at the foundation, the constitutional anomaly consist-
ing of an excessive produetivily of the periosteum and
connective tissue of the locomotor apparatus. The
disease needs for its development an external cause,
which may be trauma or rheumatism. The appar-
ently siiontaueotis cases arising in early life are ically
of traumatic origin and due to intrapartum injuries.
Nicoladoni advances the hypothesis that it is a tro-
phoneurosis, comparable to progressive nuiscular at-
rophy and pseudohypertrophy of muscle. Electrical
tests, however, indicate the absence of any neuro-
pathic factor and the disease is |)robabl3' myopathic,
and citlier primarily inflammatory in character or liav-
ing the primary characteristics of a neoplasm. In
the progressive form of the disease luany of the ttuiiors
are probably neo]ilasms, while others, as would seem to
be indicated by Lexer's description, are developed on an
inflammatory basis. In consequence of the dilVuse inter-
stitial myositis, an indilTercnt granulation tissue arises,
which maj' change cillier into scar tissue or inlci cartilage
and bone. In the myositis ossificans limited to single
muscles or groups of muscles, tlie primar}' condition is
an infiammatory process in the intermuscular connective
tissue resulting in tlie degeneration of the muscle fibres,
either from simple pressure atro])hy or from fatty de-
generation, so that the name myositis inl<'rstitialis ossifi-
cans seems not ina]piU(i|iriate. Processes of repair are
then established, graiudalion tissue rich in librobksts an<l
small bidoil-vessels, in which white librous and ycllow
elastic tibresare S]iaringly developed, isfornied. Instead
of changing to mature connective tissue, liowcver, a
portion of this granulation tissue changes to trabceula:
of osteoid tissue, and the rest into bone marrow which
tills the spaces between the trabecula'. This is not tin-
us\ial since, as is well known, the ililTercnt inetubers of
the connective-tissue group chang<' with great readiness
to other forms of conni'ctive tissue. Cold, luisanitary
stirroundings, trauma, either single or repealed, irrita-
tion, as in the exercise bones, or chronic pathohigical
processes may act as the direct cau.ses of the develop-
ment of the disease. Tliis might be satisfactory cm the
etiology of the affection, were it not that theVxcitini,'
cause is often so slight aiul trivial that we cannot believe
it sufficient to produce thedisease in a normal individual.
Fig. 3121!.— Section Tlirouffli a Few Traliuculic of Piillinli>Rii-:il Bone Formation,
with Marrow ypar^s. Siirroimdiug: (tranutiilioii Ti.^sui'. aiiii, al Itie Periiihery,
Depcnenuiii,? Miis'le Filnes. /». Bone: /;(. iloirpin-iatinL' ninscle: (/, ^rann-
lation tissue; .s, marrow spaces; r, capillaries »iirrouudctl by connective
tissue inHlli-ated with leucocytes, prawn with the aid of the camera lucida.
No. 2 eyepiece; one-sixth incii objective. Reduced t« one-fourth. (DeWitt.J
This is especiidly true of the progressive tyjie, while in
the stationary form of thedisease the irritant cause which
has operated on hundreds of cases has produced ossifica-
tion in very few. The explanation of these f;i< is has
opened a lar,ge tield lor conjecture and speculation.
Virc'how believes that in these individuals there is an
ossifying lux'ilisposition. either hereditary or cougenital,
which iie calls diathesis ossificata sive ossca. IMaunz
suggests as a ju'edisposing causative factor a disturbance
of embryonic development. 1 le says : " In the ' Anlagen '
of musculature, where in later life pathological bone
formations occur, osteoblastic nuclei enter. These nuclei
remain donnanl so long as they ate lielil in check by the
physiological resistanci^ of the neighboring tissues. If.
however, this be weakened, the bone Anla.nen develop
into the pathological bone formation." lie cxplaiii.s
in a similar way the occurrence of exostoses and osteo-
phytes which are so frequently found in conjunction
with the muscular ossification. Those who favor the
view of embryonic disturbance cite the frequent occur-
rence of microdactylie in this disease as an evidence in
favor of their hyi>othesis. Atavistic intluencc. misplaced
periosteal buds and osteoblasls. etc. , have been suggested.
Direct heredity, however, seems from the history of the
cases reported to have very Utile influence. Atavistic
influence seems to be contraindicated by the fact that in
tile band and foot, where splint bones are most eonimon
in the lower animals, these ossecuis gi-owtlis rarely occur.
In the jirogrcssive myositis o.ssilicans, beginning in early
life, it maybe necessary to admit the hy]M)lliesis of a
congenital condition consisting of an abnormal acli\ily
of the osteoblastic, or, if we accept the ^\'cismallll thecjry
of embryonic develoimieni, the ]iersistencc of indilTercnt.
undilTerentiated mesenchymal cells, which, under the
requisite conditions of nutrition, develop abnormally into
nodules of fibrous connective tissue, cartilage and bone.
Siimetimes in connection with the skeletal bones, some-
times in fascia, tendons, ligaments, o\- intermuscular con-
nective tissue. In the locali'.cd form of the di.sease,
however, no such hyiiothesis sei'iiis to l)e necessary. In
these cases granulation tissue is formed, a new conncc-
3T
Iflu!>tele,
REFERENCE HANDBOOK OF THE iMEDICAL SCIENCES.
live tissue, whose cells may therefore revert to the un-
differentiated, indifferent, embryonal cell typo. inescMi-
chyma! cells, which may develop into tibrous tissue,
cartilage, or bone according to the iirevali-nt nutritive
conditions.
WouNos .\ND lN.jrRiESOF Musci.Es. — Injuries of mus-
cle may be of the most varied degree of severity, from a
slight strain or sprain, twisting, or laceration of a few
fibres of the muscle, which results in the so-called my-
algia, to complete severance of all the fibres of th<' muscle.
Mi/alf/ia is a temporary condition of jiain in the muscle,
which is usually neuralgic, and which is caused by a
slight traumatisiii, with possibly an intlamniation of the
muscle, or may arise from an acute infectious disease,
from s3-pliilis. or from some toxic agent, as inercur_y.
alcohol, or lead. The affection is usually but trivial, and
is cured spontaneousl_y. especially if the affected part is
put at rest by the use of splints or strapping. Local
applications of heat and anodj'ne solutions are useful, and
the pain may at times be so severe that hypodernnc
injections of morphine ma}' be ueccssar_v. If the muscle
tilires are weakened by disease or degeneration, or if the
strain upon the muscle is too great, either from an ex-
ternal force or from too violent and sudden contraction,
the muscle may be fractured, either completely or par-
tially. Fractures and lacerations of health}' muscle are
raree.Tcept in cases of sudden, unexpected, or unusual
contractions. Such accidents are more common among
soldiers. Certain diseases, however, such as typhoid
fever, yellow fever, scarlet fever, and other severe fevers
weaken the resistant power of the muscle, which may
undergo various de,generative changes which make it
more brittle. The rectus abdominis, the rectus femoris,
the adductors of the thigh, the calf muscles, the psoas,
and the flexors of the forearm are the muscles most fre-
(juently fractured. The symptoms of fracture of muscle
are quite characteristic, consisting of sudden sharp pain,
with a sensation of giving way and powerlessness of the
muscle. In case of comiilete rupture, a gap is immedi-
ately formed between the broken ends of the muscle
by the contraction of the parts, and this gap, which can
easily Vie jialpated, is a characteristic feature of the affec-
tion. It is soon filled, however, by an extravasation of
blood, which may form a liaunatoma of greater or less
extent and hence a prominence in place of ihe depression.
The skin becomes discolored usually from the extravasa-
tion of bliiod. Wherever nuisele is lacerated, whether
the tear is large or small, blood extravasates into the
tissues, excejil in those cases in which the injury is very
near the tendinous extremity of tlu; muscle, where the
vascular supply is poor. The interference with the func-
tion of the muscle depends upon the extent of the lacera-
tion, the use of thenuiscle being lost incasi's of complete
rupture. If only a few lilires of the muscle are broken,
recovery is usually rapid and complete and the function
of the muscle may be ijiiite well restored even when the
injury is (juite extensive. In these milder cases the oidy
treatment usually necessary is jierfect rest of the affected
part. If. however, the mu.scles are completely torn
iicross, it is usually ni'cessary to suture tlieir ends; and
where there is a consideralde ga]i betwi'en the ends, it
may be well to till in the interval with llie muscle from
Jin animal (muscle grafting), or with sutures of chromi-
fized catgut or kangaroo tendon to act as a tramework
for the reparative material. The interval is at lirst tilled
with granulation tissue, even the engrafted nui.scle un-
dergoing deg<'nerative chang'es; later a sear tissue is
formed, |ienetrateil in jdaces by the regenerated nuiscle
fibres. In spite of the experimental work on muscle
grafting previously mentioned, the consensus of opinion
among surgeons and pathologists seems lo show that,
while Ihe function of Ihe muscle may be fairly well re-
stored, muscle libres are not regenerated in sullicient
numl)ers to till the intervening space. At times the in-
jury icsults in the formation of bone in the granulation
tissue, following the law of the meta])lastie tendencies
(d' Ihe connective tissues. In some cases the musi-le re-
mains inla<t, while the overlving fascia is lorn, generally
as the result of the imjierfect healing of some former
wotuid. In these cases the muscle may protrude through
the opening in the fascia, forming a muscle hernia.
Fere collected tliirty-one cases of muscle hernia in epi-
leptics, fifteen of which were syniinelrical, a finding
wluch would seem to indicate a certain nervous influence
as a possible etiological factor in these cases. The hernia
is distinguished from a neoplasm in the muscle, from an
aneurism, etc., by the fact that it disappears entirely or
diminishes in size when the muscle is at rest, becoming
prominent during the contraction of the muscle. fJen-
erally the opening in the fascia can be felt through the
skin. The condition may often be attended by cimsider-
able inconvenience, ]iain and loss of function of the
affected muscle. Rest and bandaging are usually sutii-
cient to effect a cure in recent cases. In cases of long
standing it may be necessary to freshen the edges of the
rent and unite them by stitches. It is distinguished from
fracture of muscle liy the fact that the symptoms usually
deyelo]j more gradually than those of fracture. It affects
the adductor muscles by preference. Muscle may also
be more or less completely crushed by external violence.
The results of this as well as of other injuries of muscle
depend upon several factors. Apparently identical in-
juries may in one case cause only temporary disturbance
of function, in another ossiticatiou, and in another paraly-
sis. Young tissues tend to heal more readily than old.
The condition of the muscle at the time of the injtiry,
whether at rest or contracted, has a marked infiuence on
the effect of any traumatism. The nerve fibres which
may be cut, injured, (ir compressed may have a vital
bearing on the permanenc}' and .severity of the functional
disturbance. Single or repeated injuries of muscle may
have a real or fancied relation to the development of
malignant tumors, a fact which may be explained by the
a.ssumplion that embryonic tumor-tissue germs are latent
in the muscle, which are either excited to activity by
the irritation produced by the tratuuatism or permitted
to grow liccause the normal resistance of the tissues is
removed or diminished as an effect of the injury.
II. IxVOLrNT.^liY Jlrsci.E.
Involuntary muscle has a wide distribution, occurring
in the walls of the digestive tract, blood-vessels, skin, in
the capsules of luany organs, and making up the greater
part of the struclure of the uterus. Viladder, and other
organs. Its structure is far simpler than that of volun-
tary, striated muscle, and its pathological changes are
therefore le.ss complicated and have received less atten-
tion and research. It consists of mononuclear, fusiform
cells, cemented together to form bundles or membranes,
which are separated by a larger or smaller amount of
connective ti.ssue. The pathological processes in non-
striated, as in striated muscle, consist of infiammations,
degenerations, and ttumu's. Certain abnormalities may
be noted occasionally, such as the presence of striated
muscle fibres among the involuntary muscle fibres of the
uterus. These may be due to the metaplasia of non-
striated into striated muscle or to the misplacement of
embryonal cells.
The pathological jirocesses occurring in involuntary
muscle have not attracted the attention of investigators
as have those of voluntary muscle. This may be ex-
|)laincd, in part at least, by the fact that any disturbance
in the function of voluntary mu.scle causes tuimistakable
symptoms, while in most ca.ses the sym|itoms of change
in involuntary muscle are masked and indefinite and
the iiathological processes in it are often not recognized
until after the death of the pati<-nt. In most cases of
muscular atrophy, whether neuidpalhie or myopathic,
anil in other muscular <legenei'ations the statement is
made <'itber that Ihe involuntary nniscle was normal or
that it was not examined. Certain regressive changes,
analogous to those which' occur in striated muscle, are,
however, observed, having been described especially iit
connection with inflammations and tumcu-s of the myom-
atous type. (Edema of iKm-striped muscle is frequently
38
REFEREXCE HANDBOOK OF THE JIEDICAL SCIENCES.
Klusclc,
noted. Kenntiiiaini described a case of mj-omctritis a>de-
iiiatosa, in which tlie muscle libres of the uterus became
so soft and a-deniatous tliat tlie uterine -n-all was perfo-
rated by a Sound. Microscopical examination of the ni30-
raetrium iu this case showed the muscle bundlcs.separatcd
liy large clear sijaces, equal in size to the muscle bundles
themselves. This condition was especially marked in
the vascular middle layer, in which the blood-vessels
presented thickened walls, the connective tissue of the
intima being especially thickened. The muscle cells ap-
peared cloud_y and in places atrophied. Near the vessels
the muscle libres appeared especially narrowed, even the
nuclei being atrophied. Large areas were found in
which the muscle hail undergone pathological degenera-
tion. No solid strands or bundles were found, and the
single fibres were so small that they gave the impression
of being reduced to fine fibrils, whose single thicker part,
we might almost sa.y whose single dimensional part, con-
sisted of the degenerated and poorly stained nucleus.
The connective tissue was probably somewhat increased,
but not markedly so ; still iu places where the muscle
was most degenerated, some increase of connective tissue
could be observed. Similar degenerative changes are
frequently observed and described in myomata of the
uterus, which have undergone my.xomatous or oedema-
tous degenerative changes.
Atrophy of involuntary muscle occurs under condi-
tions similar to these of atrophy of voluntary muscle.
A neuropathic form of atrophy of involuntary muscle —
although a form which may be considered neuropathic
lias been mentioned in connection with vitiligo and
other skin diseases — has not so far as I have been able
to find, been described. The atrophies are largely due
to circulatory disturbances, as in the case above described,
or to pressure cf a fluid or cellular exudate, as in inflam-
mations. No better picture of atrophy of involuntary
muscle has been given than that by Kenntmann. Similar
atrophy of the involuntaiT muscles of the skin in skin
diseases has been described b}' Unna, PosiJclow-. and
Lelois and Vidal.
Hypertrophy of non-striated muscle frequently occurs
and ma}' be physiological or pathological. The best ex-
ample of the physiological hypertrophy is that found in
the pregnant uterus. Pathological hypertrophy occurs
as a result of stenosis or obstruction of tlie intestinal
canal and other ducts. This is regarded by Herczel as a
true hvpcrtrophy, without increase of the number of cells,
although many authors regard it rather as a hyperplasia
accompanying the hypertrophy. Hypertrophy of the
skin muscles was also described bv Unna in keratosis
suprafollieularis and in pityriasis rubra and other skin
diseases. Iu elephantiasis streptogeues he found the
nou-striated muscles enlarged, but not increased in num-
ber. Calcification of involuntary muscle was noted by
Meslay and Hyeme and others, and Brunings reports a
case of fatty degeneration of a myoma, the process cor-
responding to that in progressive muscular atrophy.
True ossification of uterine myomata has al.so been noted.
Liquefaction necrosis of the dermal muscles was noted
by Unna in abscesses and a collaginous degeneration of
these muscles in erysipelas. Gangrene and other forms
of necrosis have also been observed in myomatous tumors,
as well as cystic degeneration. Nuclear degenerative
changes have also been noted, such as atrophy, vacuola-
tion, granulation, and karyolytic changes. The question
of the rcjiruevidion of involuntary muscle is one which
has been considerably di-scnssed, and upon which authors
are still at variance. Viguolo-Lutati. iu his experimental
study of the pathological conditions in the .skin muscles,
was never able to find karyokinetic division figures, but
frequently, especially after the less severe injuries, he
found appearances which he interpreted as direct nuclear
division. Ziegler states that "there is a new formation
of smooth muscle fibres and also a regeneration after
traumatic, toxic and chemic injuries, as well as in the
hypertrophic new formations of muscle, as in tuiiKirs:
that this process begins with the karyokinetic division of
the nucleus of the muscle cell. However, it is shown bv
experiment as well as by observation of men that there
is very little reproduction of the non-striated muscle
fibres, as in the healing of wounds and areas of degenera-
tion, the regeneration soon ceases and the loss of sub-
stance in the muscular coats of stomach, intestine and
bladder is replaced mostly by connective tissue. The
new muscle tissue is formed j^robably entirely from pre-
existing muscle tissue." IMoleschott and Piso Borne and
Busachi support these conclusions, while Arnold, Aeby,
Frey. Neumann, and Virchow favor the view that it may
originate from connective-tissue cells, and Kolliker and
F5rster believe that ,it devekq.is from embryonal germ
cells or formative cells. Tizzoni also found a zone of
proliferation near tlie diseased area in t_yphoid ulcer of
the small intestine; and Baumgartner iu cases of tuber-
culosis found mitoses in the muscle tissue of the arteries,
veins, and bronchi near the affected area. Herczel and
Baumgartner were unable to find .signs of proliferation
after their experiments, while Vignolo-Lutati found only
direct nuclear division in the skin muscles in his experi-
ments. From all this work we ma_y conclude that regen-
erative changes occur in non-striped muscle as in striated
muscle, both by mitotic and bj- amitotic nuclear division;
but that the result is only a partial replacement of the
destroyed muscle tissue, the main portion being replaced
b)' scar tissue.
Inflammatory processes in smooth muscle are exceed-
ingly common, although generally secondary to similar
processes in the neighboring tissues. Vignolo-Lutati
reports the development of infiammatorj- changes in the
involuntar)' muscle of the skin as the result of the injec-
tion of bacria and also of chemical, thermic, and me-
chanical irritants. With some variations iu degree,
the pathological picture in all these experiments was
essentially the same. The intermuscular connective
tissue was infiltrated with leucocytes, which were either
diffusely scattered through the tissue or formed small
nodes. The blood-vessels Avere distended and filled with
blood, while the whole tissue appeared a?deniatous. The
muscle fibres were swollen, vacuolated and hydropic,
and crowded apart by the exudate. The muscle nuclei
were either granular or vacuolated and karyolytic figures
were noted iu some of the experiments. After the sim-
pler mechanical injuries the nuclei showed direct divi.sion,
which the authors regarded as preliminary to regenera-
tion of the muscle fibres. Purulent inflammation of the
non-striated muscle of the uterus is a very frecpient oc-
currence, while Aristoff notes a case of syphilitic inflam-
mation of the muscle coats of the stomach, extending
from the mucosa. Tuberculous nodes have been noted
in the non-striped muscle of mj-omas of the uterus, as
well as in iuvoluntary muscle in other localities.
Muscle Tumors. — Certain tumors composed largely
of muscle are known as myomas, one class of which
consists of striated muscle and are called rhabdomyoinas,
while the other and more common class of myomas con-
sist of non-striated muscle and are called leiomyomas.
The rhabdomyomas have a stroma of connective tissue
in which cells and fibrcsare found which resemble striated
muscle cells in various stages of development, degenera-
tion, and regeneration. None of the cells ajipear as
uornial, mature striated muscle cells. JIany of the cells
are small, spindle-shaped cells with a single nucleus or
with a few nuclei and with a very faint striation or even
showing no transverse striation at all. Others are larger
and the striation more distinct, but irregularly arranged,
while the nuclei appear at the periphery of the fibre.
Some appear granular, with undiU'erentialed liyperehro-
matic nuclear substance collected in the centre or near
the periphery. Drops of glycogen may lie seen iu the
protoplasm. Sarcomatous, myxomatous, fatty, cartilag-
inous, or osseous tissue may be mixed with the muscle
tissue of these tumors, giving rise to the rhabdomyosar-
comas, rhabdomyomyxonias. rliabdonivochondromas, etc.
The teratomas also consist iu jiart of muscle tissue close-
ly resembling the atypical .striate<l muscle tissue of the
rhabdoniyomas. Th(^ rhabdomyomas may occur in re-
gions in which .striated muscle is nornially present, but
39
niiisiic.
UEFEUEXCK IIAXDISdOK OF TIIIC JIEDICAL SCIENCES.
are far iiicirc I'onunon in tlic kidney, testes, iitenis, and
other organs in which stiiale<l inusele is not normally
found. Tliey occur in cliildhood and even in the new-
born, and il is generally conceded that tlie_v
arise from misplaced embryonic muscle tissue.
Fujinami, however, rejiorts an inti'restinir ease
of a so called cylindroma and rhahdomyonia in
a man of lifty, in the volunlaiy, skeletal nuiscle,
the tumor showing a distinct eiidotlieliomatous
arranijement. There was a hyaline defeneration
of certain t\inior cells, as well as of the vessel
w-alls and comiective-tissue fUires, b\it espe-
cially of the fusiform sarcoma celfs. Fujinami
believes that the cross.s-triped muscle cells arise
from the fusiform .san'oma cells.
Leiomyomas are far more conuui'U iuid occur
visually in adult life and in the organs eon.sist-
ing of non striated mu.scle tissue, as the uterus,
prostate and the nuiscular walls of thestomacli
and intestine. The tumors consist of strands of
fibrous connective tissue, between which are
found bundles of non-striated muscle, running
in dill'erent directions. Altliough often liyper-
lro|)hied, the muscle cells are fairly normal and
yet sharply separated from the surrouialing
muscle tissue, either l)y a connective-tissue cap-
sule or by a dilfereut arrangement of the mus-
cle libres." Blood-vessels run through the tumor
mass, the arrangement of the muscle cells of
the tumor having often a direct n'lation to the
a.vis of the blootl-vessel. These tumors are re-
garded as benign tumors, tlie seriousiu'ss of
which deper>ds upon the size which they may
attain and the organs and tissues upon which
they may jiress. When they occur in the intes-
tine, however, especially in the internal coat,
they cause an obstruction which is often fatal.
They may also cause hemorrhage in the intes-
tine, although this is not often seen in myoma
of the stomach. If situated in the outer coat
of the intestine, they may devehjp for a con-
siderable time before causing any obstruction.
Although the leiomj'omas are generally regarded
as purely benign tumors, Bi'odowski, Ilanse-
manu, and Sehmorl describe niultipU' metastases
in tumors which were regarded as jnu'e myomas.
Such observations are, however, so rare that the question
naturally suggests itself whether some, jiossibly small,
areas of the original muscle t\imor may not have been
sarcomatous. The occurrence of eiiithelial or glandular
tissue within the muscular tissue of the myoma is noted
by Schrcjcder and Huge, lieckliugliauseu, and many
carcinomatous malignant degenerative changes in these
tumors have already been mentioned, Steiner has col-
lected from tlie literature and reported fifty -two cases of
Fig. :i42S.— Muscle Forms Found in tlie Neifililjorhood of >ralii^nant Tuiuors.
(Ku.iinaini.) a. />, c, h. Ampullar degeneration; (/, t, /, y, giaut-eell for-
mation.
mvoma of the stomach and intestine, while those of the
uterus and prostate aie much more uumeious. The
multi])le dermatomyomas form a most interesting class
of cases, in which numei'ous jiainful swellings arise in
the dermis develo|>ed from the non-striated muscle of the
lilood-vessels, from the arrectores pilorum, or even from
the involuntary muscle of the sweat glands. The eti-
ology of the leiomyomas is still in dispute. Although
they usiuilly develop late in life, the theory is advanced bj'
some that tluy are of embryonal origin, the tumor germs
remaining latent, until they are e.\cited to activity by
some irritation. Others claim that they originate by a
metaplasia of the connective tissue. Some claim that
Fig. rW27. — Deixenonition of .Musile t^^hre in), and Penetration of
Filjre l>y Citrciiionia Ci'lls (,/(). (FujltianU.)
othei's. This may give the tumor an adenomatous or even
a cai'cinomatous chai'acter. These adenomatous appear-
ances ai'o found especially in the digestive tract, as in
the case leportcd by Lubarsch, which he regarded as
aberrant jiancivatic tissue, which h;iil e.xcited the sui--
loundiug muscle to new growth. The muscle may im-
dergo also all kinds of degeni'rative changes, such as
calcihcation, gangi'eue, necrosis, cedeuui, inllamniation,
which may be tulierculous or simply |iurulent. It may
also be so richly vascularized as to give it a telangiectatic
or cavernous character. The .sarcomatous and the rarer
Fic. 3429.
-Sliowing Twistinp of Fibrils wilhin the Sanv
(Kujinumi.i
the tumor tissiie arises from the uoustriated muscle of
the blood-vessels and othei's say that the muscle tissue
of the oi'gan in which il develops is responsible for its
gi-owth. While all these theories have strong supporters,
Tt seems reasonable to conclude that the muscle tissue of
40
REFERE^'CE lIANDIiUOK OF THE MEDICAL SCIEXCES.
Muscle,
tlieso tumors visvmlly originates from pre-existing muscle
tissue, eiilicrof blood-vessels or of tlie organ involveii.
or from embryonal germs of such tissue which have re-
FIG
3430.— Shiiwins IrrfgTilar Contour of Muscle Fibres and Irregu-
lar Arrangement of Striation. (Fujinanii.)
mained latent until some cause excited them to gro-wth
or removed the inhibition which was preventing their
development.
Among the less important, because less freijuent tumors
arising in muscle are lipomas, angiomas, tibromas, chon-
dromas, osteomas and myxomas. The structure of these
tumors when found in muscle does not ditfer materially
from their structure in other localities.
Carcinoma in muscle is a result of lymphogenous
metjistasis or of the intiltratiou of the muscle by the car-
cinomatous uodules in the neighborhood. The muscle
fibres take no part in the formation
of the tumor, although they undergo
various degenerative changes, and the
tumor cells may even penetrate the
broken sarcolenuna and fill the muscle
fibre, as shown in Fig. 8427. From
this fact it has been said that the car-
cinoma cells arise from the muscle cells.
but although we recognize the atypi-
cal character of origin and growtli I'f
tumors, yet it seems unnecessary to as-
sume in this case a mode of origin so
remote from the normal type. Inflam-
matory processes may also be seen in
the neighborhood of these tumois.
Sdi-mma is, however, the most common
malignant tumor occurring in non-stri-
ated muscle. These may be very large
and cither consist of round cells or of
spindle-shaped cells. The sarcoma
may be mixed with fat, fibrous tissue,
mucoid tissue, etc., forming the lipo-
sarcoinas, fibro-sjircoinas. and myxo-
sarcomas. As in carcinoma, sarcoma
cells may penetrate the broken sarco-
lemma, giving the impression of being
formed fiom the muscle cells. The
structure of these tumors does not
differ materially from that of analo-
gous tumors in other regions. We are
therefore far more concerned at this
place with the pathological changes pro-
duced in llie muscle by the ingrowtli
of the tumors than with the stnut-
ure of the tumors themselves, which
will be fully treated in another plac-e.
Schaelfer, Fujin;inii, Anzinger, and
others have investigated the changes
which occur in voluntary striated mus-
cle in the neighborhood of malignant
tumors, and liavc found nearly every
possible fonn of degenerative change.
Fujiuami asserts that the alterations in the muscle are
essentially the same in sarcoma as in carcinoma, while
Anzinger believes that degenerative changes are more
marked in the neighborhood of carcinomas, while the
so-called resenerative changes are seen in greater abun-
dance near sarcomas. All agree that the distinctness of
the striation may be greater or less than normal, vary-
ing much in ditfcrent portions of the same preparation.
Atrophy is the most frequent and constant
change," due probabl_v, at least in part, to a dis-
turbance in the nutrition of the muscle, but
partly also to the c.iminished functional activity
of the muscle, and pos.sibly also to nervous and
trophic influences. Pecidiar deinessions. contain-
ing large numbers of muscle nuclei, are often fountl at
the sides and ends of the tibres. giving an irregular
contour to the fibre; this is known as lacunar erosion.
The muscle fibres may also break up, either longitu-
dinally into slender fibrils containing rows of nuclei,
or transversely into segments containing groups of
nuclei. Fujinami also notes a peculiar twisting of
the muscle fibrils within the sarcolemma. Zenker's
necrosis, cloudy swelling, vacuolatiou, proliferation of
nuclei, both liy mitotic a"nd by iunitotic processes, with
marked altcrafions in the nuclear form, are frequentlj-
observed in the neighborhood of tlicse tumors. Fujinami
regards all these changes as essentiall}' degenerative in
character, in spite of the fact that certain multinuclear
forms resembling the myoblasts of regenerating muscle
are frequently seen. Anzinger and others regard these
giant-cell foi'ins as abortive attempts at regeneration.
While more work is needed on this point, there seems
little doubt that at certain stagesof the process degenera-
tive forms occur which closelj' resemble the regenerative
forms of voluntary muscle, although the conditions are
such that no attenipt at regeneration is to be expected.
Fill. 3-t:il.— This Ficim' Shows the Atrophv. Irregular Contour. Faint Striation. and other
Di'L-fneralive ('haiigfs in the Muscle and the InHaniinatory PriK-ess in the Intermus-
cular Connective Tissue in the Neighborhood of a Malignant Tumor. (Anzinger.)
The perimvsium of the vohmtary muscle in the neigh-
borhood of tliese malignant growths is often hyperplastic
and shows leucocvtic infiltration, hemorrhage, a?denia,
fat intilti-ation. Endarteritis and periarteritis are fre-
quent occurrences.
41
^I lisclos.
JIuscIcs.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
'=^:l
\\
J ■*'
Tlie penetration of mast cells and leucocytes auil even
of tumor cells into the muscle cells is one of tlie most in-
teresting points mentioned in tlie study of lliese eases.
Fnjiuami lias tigured a numherof muscle cells contain-
ing a larger or
_. ,_^ ___, smaller number
fl "C •iifX'T'n""!?' ■».*•■'? '"T^T^ "f tumor cells
!!•, .1 V U ,: !' :y: .'.' • '•■'[ ■/.':] and states that
the tumor cells
may be derived
from the degen-
erating muscle
cells. This idea
is refuted by
Schactf e r, al-
though su])|iort-
ed by Schroeder.
Neumann. Bar-
del e b e n. a u d
others. Scbaef-
fer states that
there may be a
great similarity
between the tu-
mor tissue and
the muscle tis-
sue, w h i c h
makes confusion
possible, and
that the tumor
cells may jiene-
trate the muscle
fibres. Tlie ori-
gin and etiology
of these tumors
in mu.scle, as in
other tissues, are
still obscure;
but it seems
more reasonable
to regard the
appeai'ance o f
the tumor cells within the sarcolemma as a result of the
passage of these cells through a broken sarcolemma.
especially as they are accompanied in this position by
leucocytes and mast cells, than to believe that the tu-
mor cells are formed fnnn the contractile substance of
tlie tnuscle fibre by its degeneration.
LydiaiL ZkWitt.
BlBLiOGR.irtlY.
Aiizinj^er; Changes Oe<^urring in the Neighborhood of Malignant
Tumors. Am. Journ. of Med. Si-lences, vol. cxxii.. No. 2.
Batten: Experimental Observations on Early Degenerative (hanges
in the Sensory Endorgans nf Muscles. Brain. 1S98.
Bnks : Beitrag zur Myos. ossif. progi-ess. Berliner klin. Wochensohr.,
1897.
Brennsohn ; Zur Casuistik der Myos. ossif. progress. Bt-rliner khn.
Woohenschr., 189:3, xxix.
Brown : StuiUes on Triehinosis. Joum. of Exper. Med., l.s'.ts.
Cahen: Ueber Myositis OssiCcans. Deut. Zeitschr. f. t'hir., xxxi.,
ISill.
Capnrrn : Ueber den Werth der Plastib mittelst quergestreiften
Muskelgewebes. Arch. f. klin. Chir.. Ixi.. 1901.
Durante: De la degenere.scence dite granuleuse proteique df I;i llbre
musculaire striee. Bull, et Mem. de la Societt? anat. de Paris, sixth
S., 1;h«i.— Regression cellulaiivdi- la llbre musculaire striee. Bull,
ct Mem. de la Soc. Anat. de I'aris, I'.KM).
Eichhorst : Arch. f. path. Anat.. 189.'), cxxxix.
Fu.iinami : Ueber das histologische Verhalten des quergestreiften
.Muskels an der Grenze ln'isarDger (leschwiilste. Arch. f. path.
Anat., Bd. 161. HKlll. - Ueher die liislologischen VeriinileiuTigen des
Muskelgewebes bci der Lepra and eint- liesondere Wiictieruiig und
Hyperchrom:Uose der Muskelkenie. Arch. f. )>ath. Anat.. li;i. 19(10.
Griinhaum : Note on Muscle Spindles in i'seudohypertropliic Paraly-
sis. Brain. 1897.
("irahiim; Beitriige zur Naturgeschiehte der Trichina spiralis. Arch.
f. luik. Anat.. Bd. 1... 1897.
Hackcnbruch : InterstiUal Myo.sitis. Beitriige znr kiln. Cliir.. 189:).
H:d1i-nlinlt : De rossirtcatiou progres. des muscles. Arch, generales
de Med.. 1869. ii.
Ilerczel: Zeitschr. f. klin. Med., Bd. 11.
Ilerzog: Myositis. Deut. med. Woi'henschr.. 1898.
Hoen : A Form of Degeneriiiiun of Striated Muscle met with in the
Uvula. Journ. of Exper. Med.. :i. l.s'.is.
llorseley ; Short Note on Sense urgaus in Muscle and on the Preser-
Fic. :!W2. — Atrophied Muscle with Circura-
scrihed Dilatations and Nuclear Pi'nliferation
in the Neighborhood of the Tumor Mass,
(Fujinami.) o, Carcinoma cells ; /i. atrophic
muscle : c, ampullar portion, beginning of
giant cell formation ; d, giant cells.
vatlou of Muscle Spindles in Conditions of Extreme Muscular
Atrophy, Following Sectieii .if Motor Nerve. Brain, xx., 1897.
Huber : Observations on Degeneration and Regeneration of Motor
and Sensory Nerve Endings in Voluntary Muscle. Am. Journ. of
Physiology, 189<)-1900.
Jamin: Em Fall von multiplen Dermatomyomen. Deut. Archly f.
klin. Med.. Bd. 70, 1901.
Kissel : Sur un cas de myos. ossif. prog. Arch, generales de Med., 1894.
Kocli : Zur Hist<ilogie des mvntoniscii hypertrophischen Muskels der
Thomsen'schen Kr:iukhelt (Myotonia congenita). Arch. f. path.
Anat., Bd. 1613, 1901.
Kollaritz: Beitrag zur Kenntniss der anatomischen Grundlage der
Mnskeldystrophie. Deut. Arch. f. klin. Med., Bd. 70, 1901.
Kroesing : Ueber die Kiickbildung und Entwiekelung der querge-
streiften Muskelfasem. Arch. f. path. Anat.. 12s, 189^".
Lanz u. de Quervain ; Ueber haemat<jgene Muskeltuberciilose. Arch.
f. klin. Chir.. «, 1.89:3.
Lexer : Das Stadium der bindegewebigen Induration bei Myos. ossif.
progress. Arch. f. klin. Chir., Berlin, 50, 189.5.
Mnnchmeyer : U(-ber Mvos. ossif. progress. Zeitschr. f. rat. Med., 1869.
Nicoladoni: Wiener med. Blatter. 1878.
Pincus : Die si'trenannie Mvos. progress, ossif. multipl., eine Folge
von Geburtsliision. Deutsche Zeitschr. t. Chir., Leipzig, 1896, xliv.
Pupovac : Arch, f . klin. Chir., ">1, 1897.
Bicker und Ellenbeck : Beitriige zur Kenntniss der Veranderungen
des Muskels nach der Durchschneidung seiner Nerven. Arch. f.
path. Anat., 1.58.
Both : Ueber Mvos. ossif. progress. MUnchener med. Wochenschr.,
1898.
Schaeffer : Ueber die histologLschen Verandeningen der querge-
streiften Muskelfasern in der Peripherie von Geschwillsten. .-Irch.
f. path. Anat., 1887.
Schnjeninofl ; Zeitschr. f. Heilk., 1897.
Stierlin : Ueber einen Fall von septischer Totalnekrose der Muskeln.
Arch. f. path. Anat.. 128, 1.892.
Strassmann und Lehmann : Zur Path, der Myomerkrankung. Arch.
f. Gvn., 66. 1898.
Vignoio-Lutati : Exper. Beitrage zur Path, der glatten Muskulatur
der Haut. Arch. f. Derm. u. Syph., 57, 1901.
Ware: Gonorrhceal Myositis. .\m. Joum. Med. Sciences, vol. cxxii.,
1901.
Wartbin : Pathology of Voluntary Muscle. Am. Text-book of Path-
ology, 1901.
MUSCLES, ANOMALIES OF.— The musctdar system
of man is siilijeet lo ni:iiiy variations, all of which are in-
tei'esting from a morphological point of view, and many
are important surgically. Not only do mu.scles vary as
to form and attachment, but supernumerary ;ind rudi-
meutary muscles are not infrequent. Again, some may
be absent in a certain number of individuals, i.g., the
pyramidalis, jialmaris longus, etc.
"jMany muscles are meie rudiments of those which exist
in a well-developed condition in the lower animals, and
there is, iu fact, no muscular variiition in man which has
not a corresponding normal condition iu some animal
lower in the scale.
In the present article space forbids the giving of any
extended account of luiiscular vaiiatioiis, for it is a sub-
ject on which volumes have been written. It is intend-
ed to describe only the commoner and more important
anomalies, especially mentioning those whose relation to
arteries renders tliem of surgical interest. The reader
who wishes to obtain a fuller knowledge of the subject
is referred to Wood, Turner, and others, in tlie Juurnal
of Anatdiiqi ami Pliilsidhitiji ; 3. Wood, "Proceedings of
theRoval Societv," lH(J4-'6'9; "Guy's Hospital Reports":
"St. Thomas' Hospital Reports"; Macalister's "Cata-
logue of Muscular Anomalies." iu Trans. Royal Irish
Academy, 187'2; W. Gruber, in the Mnn. of Acad., St.
Petersburg, and Virchow's ^Irr/eN" /. A/in. Med.; Henlc,
"Handbueh, JIuskellehre " ; Hallett, Edin. Med. Jour.,
184-5: Krause, " Ihindljuch." 1880; Testut, " Les Anoma-
lies JIusculaires chez rilommc." Paris, 1S84; also vari-
ous papers in the Jminiid of Annioiinj and J'/ii/xiolor/i/.
Muscles of this Hkad and Neciv. — Oci-itiilo-Fivntalis
varies much as to size and position. The ocripitaUs oc-
casionally ap]iroaclies the median line, and may be di-
vided into several jiortious. Some of its fibres may be
continuous with the posterior auricular muscle.
The FrontdlU may send slips to the nasal and superior
maxillary Ijones. Theile says that it generally sends a
bundle of fibres to the external angular process of the
frontal bone. Its libi-es have been ilescribed as normally
continuous willi the levator labii superiinis aUetjue nasi.
Aurieiiliir MiiKch-''. — Very various as to their develop-
ment. The retiahens is vi^ry often of large size, and its
tendon frequently arises from the neighborliood of the
external occipital protuberance; in such cases its belly is
\-l
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
muscles,
muscles.
ver_v fleshy, and m:iy be divided into two portions. It is
sometimes timueeted witli tlie transversus nuelut. Cm-
veilliier lias described a deep muxcii/us aiiriciiltirisantiruf!,
whicli goes beneatli tlie superior from tlie zygoma to tlie
outer surface of the tragus. The anterior auricular mus-
cle is often very much diminished in size, and its fibres
may be very indistinct.
MiiKch'S <</ t/ie 3V/SC. — Aljscnce of llie pyramidalis lias
been observed. The compressors and dilators are often
so feebly developed as to be seen only with a magnifying
glass.
Tlie Musculun Anonuilus (Albinus) is a slip described as
being freijuently present. Lying beneatli tlie levator
labii superioris ala;que nasi, and arising with it from the
nasal process of the superior maxillary bone, it is inserted
into tlie same bone near the origin of the compressor naris.
Museles of the Fact:. — Zygornaticus Major. Frequently
double. The second head may arise in the neighborhood
of the infra-orbital foramen or from the masseteric fascia
below the zygoma. It is sometimes absent.
Zyijomaticus Minor. Frequently absent. It may be
inserted into the fascia of the cheek. It may Ije fused
with tlie levator labii superioris proprius. zygomaticus
major, or frontalis. It is not infrequeutly double; the
second head may arise in common with the levator labii
.superioris proprius. Sometimes it ari.ses from the orliicu-
laris palpebrarum, and it ma}- be inserted into tlie levator
labii superioris proprius or levator labii superioris aUcque
nasi, or both.
Levator Labii Superioris Prop-itia occasionally sends
a slip to the zygomaticus minor. The writer has twice
.seen this muscle arise by two heads, the extra head aris-
ing from the malar bone. lu both these cases the zygo-
maticus minor was present.
Rinorius (Santorini). Often absent. Santorini de-
scribes it as double, and even triple. It lias lieeu seen
to arise from the z_vgoma, external ear, fascia over the
mastoid process, and the skin over the upjier portion of
the sterno-mastoid.
Depressor Angnli Oris (triangularis menti). Santorini
described a muscle, the transrersiis menti, which is some-
times found arising from the inner border of tlie depres-
.sor. and passing downward and inward acro.ss tlie mesial
line below the chia to the corresponding jiart of the op-
posite side.
Muscles of the Orbit. — Levator Palpebra. Sometimes
absent or fused with the superior rectus. Budge de-
scribes the tensor trochleic, which is a muscular slip given
off from the levator to the trochlea.
The muscles of tlie eyeball are very constant. The
two lieads of tile rectus r.rternus have been seen separate
to their insertion, forming a double muscle. Absence of
the outer head has been noted by Macalister, and Curnow
describes it as giving slips to the outer wall of the orbit
and lower eyelid.
Transversus Orhitm (Bochdalek). This is an arched
slip of muscular fibres passing from tlie orbital plate of
the ethmoid across the upper surface of the ej-eball to
the outer wall of the orbit (Quain). Macalister suggests
that it is a deep, displaced slip of the palpebral fibres of
the firbicularis.
Obliqu us Inferior Acce.'isorius is a slip going from the in-
ferior rectus to the inferior oblique. The writer has seen
a slip going from the inferior oblique to the superior
rectus.
M usclcs of Mastication. — Masseter. Monro has descrilx'd
a bursa as occasionally occurring between the two por-
tions of tills muscle, and Hyrtl has once seen a bursa be-
tween the masseter and the capsule of the inferior maxil-
lary articulation.
Teinjioral. Henke says that sometimes the temporal
muscle, and sometimes the deep jiortion of the masseter,
is attached to the fore and back part of the interarticular
fibro-cartilages of the lower jaw, or from the borders
muscular fibres arise which are inserted into one or other
of the afi>re-inentioned muscles. In many cases tliese
fibres form a well-developed muscul;ir Ijelly. the niu.srulus
temporalis minor, which is in.serted into the bottom of
the sigmoid notch of the lower jaw (Henle). The writer
has occasionally seen a deep slip from the temporal mus-
cle attached to the plerygo-ma.xillary ligament. This
slip is sometimes pierced by the internal maxillary artery.
Pterygiiideus E.vternus. A considerable portion may
be inserted into the capsule of the inferior maxillary
articulation. When the pterygoideus proprius is preseut
the upper head is of small size.
Pteri/rjoiihus Proprius. This is a muscle which is not
infrequentl}' seen arising from the infratemjioral crest
of the sphenoid and part of the great wing itself; it then
passes over the external pterygoid to the lower part of
the external pterygoid plate, or to the tuberosity of the
palate and superior maxillary bones. It sometimes re-
ceives a slip from tlie upi>er head of the external ptery-
goid, and a portion of the upjier head of the muscle may
arise from it. The writer has occasionally seen the ptery-
goideus proprius inserted into the pterygo-maxillary
ligament and alveolar process of the upper jaw" (see Fig.
3433). In one case it sent a slip over the internal ptery-
goid to be inserted into the inferior maxilla near its
angle. Externally this muscle is tendinous, and deep
down, muscular; sometimes it is tendinous along the
inner border only. Wlien the pterygoideus proprius is
present, the upper head of the external pterygoid is gen-
erally much diminished.
Pteri/gosjrinosus (Thane). This name is given to a
muscular slip occasionally seen springing from the spine
of the sphenoid and inserted into the hinder margin of
the outer pterygoid plate, between the external and in-
ternal ptervgoid muscles; the parts are frequently con-
nected b.v fibrous tissue, and sometimes by bone.
Muscles of the Neck. — PUitysma Mi/oides. This
muscle varies considerably in its development. It is
sometimes well developed, thick and red. and at other
times its fibres are pale, thin, ami hardly to be seen. It
has been reported absL-nt by Macalister. Tlie platysma
may reach over the clavicle as far as the fourth rib. It
sometimes fails to reach as far as the clavicle; In such
cases it is reduced in extent at otlier parts as well. It
may have an insertion into the thyroid cartilage or the
sternum. AVlien well developed it has been seen attached
to the lower jaw aliove anil to the clavicle below. The
upper part of the idatysma is occasionally joined by a
slip from the mastoid process, or from the occipital bone.
The two muscles not infrequeutly cross each other iu
Fig. .34.33.— PP, Pterypoiileus proprius; BP. external, ami IP. In-
ternal pter.ViT' ail limsL-Ie. (Shepherd. 1
the median line. The writer has seen the lower fibres
continuous with some fibres of the musculus sternalis.
Fasciculi in connection with this muscle have been traced
to the axilla. The platysma is the jiriuciiKil representa-
tive in man of the skin muscle (panniciilu.^ carnosus) oi
the lower animals. In most mammals willi loose skins
these tegumentary muscles are well developed; e.g., iu
the hedgehog, jioreupine. porpoise, etc.
Occijiifiilis Minor. This is thi' name given to a bundle
of muscular fibres arising from the fascia over the upper
43
iVliiscles.
UEFEHENt'E 1IAX1)I!<»(>R ()F THE MEDICAL SCIENCES.
011(1 nf tlio trapezius mill ondius in llic fascia over llie
upiicr cud of tlic stcniii iiiasliiid. It is pniliably a modi
licalion of tlic slip wliicii occasionally joins llu' ]ilalysnia
from tlio mastoid process or occijiital bone.
Steni(>r/ciiloiiiirstti/diHf:, This nuisclc is usually consiil.
crcd to lie made up of Iwo muscles, llic steiiio iiiasloid
. St.M.
:-R.S.
BM,'
Fig.
;i43t. — Ji..'>i.. Rectus sternalis eiiiuliuuiu.s with (.s*..!/. 1 .steriio-
rna.stnui of the opposite .side. iSheplienl.i
and cleido mastoid. Kiau.se, liowever, regards it as con-
sisting of four muscles, viz.: (1) Sterno-niastoid, (2)
steruo-occipital, (3) clcido-occipital, (4) cleido-mastoid.
Tlic spiiiid accessory nerve jiierces the cleido-mastoid, or
runs between the cleido-occipital and cleido-mastoid.
Krausc suggests the name slirimrli idiiiJiuMoiilciiiirciji-
itiflin, or tlic iiiiifienlu^ qiiinh-iriiiiiiiiiix rapitis. lie says
that the ordinary varielics in man are readily exidiuncd
by the isolation or absence of particular parts, or by the
extension of tlie cleidooccipitalis to the occi])ilal pro-
tuberance. Botli the clei<looccii)italis and sternooecip-
italis may be feebly developed, m- liotli may be absent,
as, indeed, may be the stcriio-mastoid. Again, the
cleido-occi[iital or cliedo-inastoid may be develol)eil as
separate mu.scles. The views of Krause are supported
both by human and comparative anatomy. However,
for ordinary purpo.ses it is sullicient to regard the stcriio-
mastoid as consisting of two muscles. These two ])or-
tions may be completely separate, or ma.v join together
at a much higlier jioiiit than usual. This separation id'
the muscles into two is the normal condition in the greater
number of mammals; c.r/., rumiuants, solijieds. the ma-
jority of caruivora, and many of the anihroiioid a|ies.
The stcrno-niastoid and (deido-mastoid inuscli-s may
be com|iletely fused— a conditinn which is not of great
rarity.
Sternal attachment of the muscle ma.v vary ; the two
sternal tendons may unite on the sternum or cross each
other. The writer has seen the sternal tendon of one
side continuous with a iiiiiseulus sterualis of 1 he o]iposile
side (see Fig. 34341.
The sternal tendon may in rare cases be divided into
two ])ortions, inserted separately into the sternum. The
sternal jiorlion has been noted ab.seiit by jMai'alistcr. .V
sesamoid bone is sometimes seen in the tendon of the
steriio-mastoi{l : this is looked upon as a rudiment of the
cpisternal bone of monotremes and lizards.
The clavicular portion varies considcraldy as to the
extent of its attachment to the clavicle; it not infrc-
((ucntly covers the sjiacc called the subclavian triangle,
and this should be borne in mind wdicn performing the
operation of ligature of the subclavian artery in its third
]iart. The writer once, when operating on the neck,
found the clavicular iiortion absent. In animals without
clavicles the cleido-mastoid foi'uis part of the cephalo-
liumcral muscle, being continuous with the outer jiorlitm
of the pcetoralis major or deltoid.
('Iddii-dcripititl (Ce|)halo-humeral of Flower). This is
a mu.scle described li.v AVood alid others as arising from
the clavicle outside the cleido-mastoid and i-jsertcd into
the superior curved line of the occipital bone clo.se to the
origin of the trapezius. It is usually separated by a dis-
tinct areolar interval from both the sternal and clavicular
(ibres of the sterno-clcido-mastoid (see Fig. 3435).
Tliis muscle corresponds to the cleidooccipitalis of
Krause. It exists asa se|iarate muscle in the guinea-pig,
hedgehog, etc. In apes ;uid monkeys it is always pres-
ent, but is in them continuous with the hinder border of
t he true sterno-clcido-mastoid. In many of the caruivora,
as the dog and cat, it forms part of the cephalo-humcral
muscle. Wood found this muscle thirty-seven times in
one hundred and two subjects.
The sterno-masloid has been ileseiibed as sending sli|is
to the angle of the lower jaw and liyoid bone ((4ruber).
The stcruo-byoid and omohyoid, and in rare cases the
trapezius, may unite with the sterno-mastoid.
A tendinous intersection is sometimes seen near the
lower end of the muscle; the same intersection is seen in
the steruo-hyoid and slerno-thyroid muscles; it is ]irob
ably the remains of one of the transverse septa ui lb •
priinitive ventral muscle ]datc. These inters<'ctions are
seen normally in the rectus abdominis.
Lrratiiv ciinHcuhti arises from the clavicle, and is in-
serted into the {•ervical vertebra-. A fuller description
of this muscle will be given farther on, under Muscles of
the Upper Limb.
Ktiprddiirieiihiri.i is a small mu.scle behind the sterno-
mastoid, which arises by a sleniler tendon from the tirst
]iiece of the sternum, cro.sses above the .sterno-clavieular
articulation, and is in.sertcd into the upper surfticc of the
clavicle. When jiresent on both sides the muscles may
lie continuous in the middle line.
TraiiKrersiin Nnrlin-. This is described b_v many anat-
omists as a normal muscle, wliieli is always represented
■when ab.sent by tendinous fibres. It arises from the ex
terual occipital i)rotuberancc, and is inserted into the
aponeurosis of the sterno-mastoid (see Fig. 343(i),
Sli I'lioltijindcun occasionally arises only from the clav-
icle. In such cases there is a wide interspace at the root
of the neck devoid of muscle. The writer in one case
saw, on both siilcs, the sterno-
thyroid and sternohyoid arise
altogether from the clavicle an
inch outside the slerno clavicu-
lar articulation. On removing
the skin and fasci;i the trachei:
and thyroid gland immediatel.v
came into view.
This muscle is orcasioiial
double. There is .sometimes ai
accessory muscle seen goinij
from the clavi-
cle to the hyoid
bone (cleido hy-
oid). The sic'r
n ci-li V o i d li a s
been described
as occasionally
arising from the
sterno - clavicai-
lar ligament and
llrst co.stal carti-
1 a g e. It is
sometimes fused
with the muscle
of the opjiosite
side, as in tin- horse. The muscular tibres arc not infrc-
([Uently interruiited by a tendinous intersccti<in, which
is generally on a lin<' with the tendon .separating the
two bellies of the omo-hyoid. This intersection is seen
FlU. MK.-r./l., Ceplwili
ra/i.. .splt'liius rapitis
ZillS. (.\ftcr FloWCT,
a Iliistiwoliiali, Jimr.
vol. 1.1
i-limiieral niiiscic; .'s^).
; /), ciclloi.l; 7', trapo-
froiii tlio ilisscition of
o/ Alllll. tllKl I'll!!-':
44
REFERENCE IIANDIKJOK OF THE MKDICAL SCIENCES.
ITIiiM-lefit.
Kliisi'Irs.
r> Tril \el
Aftel H 1 le
niK'hi^.
iKiiiimlly in some uiiiiiKiIs. as the chimpanzee, liorse, etc.
'I'lie miis( Ic has Ix-en Miited as alisent on one side. It
may be united by slips with tlie omo-liyoid, mylo-liyoid,
or sterno-thyroid. All tlie anomalies above mentioned
luive theii' corre-
sponding normal con-
dition in the lower
animals.
Steriiotlijifoulciifi.
Occasionally some of
tlie fibres ot this mus-
cle continue on iip-
waid and arc insert-
ed into hyoid bone
with the omo-hyoiil,
or are continuous
willi the liyo-glossus
muscle. A few
libres may be con-
tinued into the thyrcj-
liyoid or inferior con-
st ri e lor o t t lie
|iliarviix. 1 11 one
case the writer saw-
it, on both sides,
arise, with the sterno-
hyoid, entirely from
the clavicle." 'Wal-
sliam reports a case
("St. Harth. IIosp.
Kep.," 1880) in which
the right sterno-thyroid arose from the left as well as the
right side of tlie sternum and cro.ssetl the trachea. The
left muscle was rudimentary. This muscle would lie a
.source of embarrassment iu performing tracheotomy.
In the gorilla and chiin|ian7.ee some fibres usually ari.se
from the clavicle. The two .sterno-tliyroid muscles are
often united at their origins across the middle line.
Doubling of the muscle, as well as ab.sence, has been
observed. A tendinous intersection is sometimes seen
opposite the tendon of the omohyoid. It may e.\ist in
both the sterno-hyoid and sterno-thyroid in thesame line.
Custdfascialis. Wood describes a slip arising with the
sternothyroid from the hinder part of tlieliisi rili, which
crosses the carotid vessels to be inserted into the cervical
fascia as high as the thyroid cartilage.
Steniofnacialis. This is a slip described by Gruber as
arising from the first jiiece of the sternum behind the
sterno-mastoid and passing upward to be iu.sertcd into
the fascia of the subclavian triangle. It might be called
the tensor fascia? ctilli.
I'/ii/ni/ii/ou/eiif!. This muscle is often fused with the
sterno-thyroid, anil in such cases the sterno-thyroid is
inserted into the liyoid bone. Ab.sence of this muscle
has been reported ; this is generally due to a fusion of
the sternothyroid and thyio-byoid, so that they form
•one muscle, whicli is inserted into the hyoid bone. The
muscle may be divided into two distinct slips.
Crirolii/oid. Walsham first described this muscle as
ari.sing from the lower border of one side of the cricoid
cartilages and inserted into the lower border of the liyoid
bone. Gruber also mentions its occurrence.
JJe/inssor Thyroideir. A small muscle described Iiy
Bradley as arising from the first tracheal ring, passing
over file cricoid cartilage and inserted into the lower
border of the thyroid cartilage.
Oiiitiliyiriihun. This muscle is frei|Uently abnormal.
In 2.50 subjects examined the writer bmnd anoniiilies of
the OHIO hyoid in 39, or about 1 in G. The muscle may
be completely absent, and in rare cases it has been noted
double. Again, one or other of its bellies may- be want-
ing. When the anterior is absent, the posterior belly
(nds in the cervical fascia beneath the sterno-masloiil.
In 2.50 subjects the writer lias seen this arrangement
twice. Sometimes the anterior belly arises from the
clavicle and ascends the neck directly "to its insertion into
the hyoid lione without having any intermediate tendon
or intersection. This has been regarded by some as ab-
sence of the posterior belly. The writer has only in one
subject seen this anomaly; it occurred on both sides.
This muscle has been called the lii'Ulolii/niil. In some
rare cases, however, the posterior belly is altogether ab-
sent, the anterior arising from tlie fascia covering the
subclavian triangle (hjjojiini-iitli.i).
The posterior belly not infre(piently arises from the
clavicle solely. In 120 subjects cNainined, the writer
has seen this arrangement 8 times (1 in 1.5). 'i'lie pos-
terior belly may be double, the supernumerary portion
arising from the clavicle. The writer lias seen this occur
9 times in 120 subjects. In these cases the origin from
the clavicle is generally extensive, and is from the middle
third of the posterior border for a distance of two and
sometimes three inches. In rare cases it may arise from
the sternal end. T\w. posterior belly of the omohyoid
may be so bound down by fascia to the clavicle that the
subclavian triangle is obliterated. In ligaturing the
subclavian, it would be well for surgeons to bear in mind
tills occasional arrangement. This condition is present
more frciiuently when the posterior belly arises from the
clavicle.
The onio hyoid bein.g originally fused with the sterno-
hyoid, it would be natural to see the lower portion oc-
casionally displaced and have its origin from any of the
osseous points between the scapula and sternum, or to
receive supernunicrary heads fiom the varicnis i)oiiits.
The scapular head of theomo-hyoid, besides having an
acces.sion from the clavicle, may receive one from the
coraeoid process, the iicromio-clavicular joint, the acro-
mion process, and even the first rib.
The anterior belly of the omo-hyoid is occasionally
double. The writer has seen this anomaly three times.
In the first case the supernunicrary belly was inserted
into the superior cornu of the thyroid cartilage; in the
second, into the great cornu of the hyoid; and in the
third it blended with the sterno-hyoid.
The anterior belly not infrequently blends witli the
sterno-hyoid so as to form one broad iviuscle, which is
occasionally' bounded below by an arched tendon, as in
the seal. This fusion is due to the non-difl'erentiation
of the primitive brachiocephalic sheet from Avhich these
two muscles are developed.
The writer has twice seen a jKU'tion of the omohyoid
muscle pass over the liyoid bone and go up between the
anterior bellies of the di.ffastrics to be in.serted into the
lower jaw near the symphysis (see Fig. 3437).
The omohyoid may .send slips to muscles in the neigh-
borhood; e.g., sferno-niastoid, sterno-hyoid, and the vari-
ous muscles of the
submaxillary re-
gion. A slip has
been seen going
from the posterior
belly to the trans-
verse process of the
sixth cervical verte-
bra.
The intermediate
tendon of the omo-
hyoid may be ab-
sent or rejiresented
by a tendinous in-
tersection.
Comparative An-
atomy. The omo-
hyoid iseompletely
wanting in many
animals, as the cat.
dog, peccary, mole,
ami also in rodents
without clavicles.
Tlie anterior belly
is absent in the oraug outang. The muscle arises from
the clavicle in the scink and in some of the bats and
the iguana. The intermediate t<'ndon is absent in many
inammals as the echiilna. ornithorhyiichus, the American
black bear, and some of the quadrumana. In the seal
FKi. :M:!7.— slinns tlie iinin-II.voi(t Muscle
('(Ultimiln^ ni" (Iver the Hvnid Hone to lie
Iiis.Tlc.t iiitii llie llifi-rior :M:i.>ii!l;i : iiI.mi,
llw .Muscular I!i-ltv Ki'His; fomi Ihi-'l'cMiinii
(if Itie liiffa.stric- to !»■ InsiTled into the
Itixiv of the ftvoid Bone, ishi-i.lu'ril. i
•io
::iiiiscie8.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
fe^^^:^-r-<L
L.T.
Fir,. 3i3s.—L.T.. Levator tliyroiclea\
gdingfrora HT<iiil Boiu'to Left Latenil
Lobe of TliyroUl Body, (yuain.)
the anterior belly is fused with the sternohyoid and is
bounded below by tin uiched tendon.
Lfi-iitcr GUnid'uhp Thiirfu'ditr. This is a fibrous or
museular band which goes from tlie body of the liyoid
bone tothe isthmus or
one of the lateral lobes
of the thyroid gland.
There may be two or
three slips. The
writer, in one subject,
on both sides, saw this
slip proceed froiu the
obli(iue line of the
thyroid cartilage and
go" to each lateral lobe
of the gland. The
levator thyroidea^ is
looked upon as au
aberrant pcntion of the
muscles between the
sternum and hvoid
bone (see Fig. 343!S). ^
Digiistriciis. The di-
gastric muscle is sub-
ject to many varia-
tions. Occasionally its
tendon fails to pierce
the stylo-hyoid. The
(interior hdly is very
often abnormal ; not
infre([uently the two
aiileriiir licUies unite
in the median line and
completel}' shut out from view the mylo lijoid mus-
cles. The two bellies often decussate, as in tlie Nor-
way rat and ruminants. It is not uncommon to find
the anterior belly divided into two or more parts, one
of which may cross the middle line of the neck and
join the anterior belly of the opposite side. A slip from
the autcriiir belly may jniu the mylo-hyoid, or decussate
in the middle line with a similar slip from the opposite
muscle. These slips may be looked upon as varieties of
the niento-hyoid muscle, described below. In one sidi-
ject the writer saw a well-marked muscular slip given off
from the intermediate tendon and in.serted into the l.iody
of the hyoid bone (see Fig. 3437). Also, in another sub-
ject there was complete absence of the anterior belly on
the left side; the posterior belly ended in the deep cer-
vical fascia attached between the hyoid bone and angle
of the jaw. This might be regarded as a form of the
monogastric muscle, which is vi'ell seen in the lower ani-
mals, as the carnivora. 3Iae Winnie describes a case in
which the nuiscle was monogastric and was inserted into
the middle of the body of the lower jaw. In rare cases
a muscular slip from the angle of the jaw joins tlie an-
terior or posterior belly. The writer once saw ii well-
marked tendiiHjus slip going from the angle of the jaw-
to the posterior belly.
The lu'slcriiir hcUy occasionall.y recei\'es accessory slips
from the styloid process. It has been seen arising en-
tirely from the styloid process. It is sometimes con-
nected by a museular slip Tvith one of the constrictors of
the pharynx. Walsham describes a tendinous intersec-
tion, and in one case a distinct tendon, occurring in the
jiosterior belly. The jiosterior belly has been seen to
pass behind instead of in front of the carotid artery.
Orcijiilii-lnii'iil. Viivrm {Jiiiir. Aiiiit. niiil J'/ii/n.. \iA. v.)
first described this muscle as an additional digastric; he
regarded it as homologous with the stylohyoid of birds.
The muscle is donble-bellie<l ; its posterior belly arises
from fascia covering the occipital bone, and its tmterior
belly is inserted into the hyoid bone beneath the hyo-
glossns. Ilunipliry looks upon it as a superfleial a]i-
pendage to the stylo-hyoid and digastric muscles. There
is a similar muscle in the .seal.
Meiito-liyiiiil (Maealisfer). This is the name given to a
sli]) of muscle of variable size, and sometimes double,
which is not iufrequenlly seen passing, superficial to the
mylohyoid, from the lower jaw near the sj'mpliysis to
the body of the hyoid bone. Occasionally the muscle
does not reach the hyoid bone, but ends in a fascia which
covers the m.ylo-hyoid and is attached to the bone. It is
sometimes triangular in shape. Macalistcr looks upon
the mento-hyoid as a dilferentiated portion of jilatysma;
but it is probably more closely related to the anterior
belly of the digastric and the sterno-hyoid group, which
are "formed from the suiierticial liraehiocephalie stratum
of muscle (see Fig. 3439). The mento-hyoid exists nor-
mall}' in luany animals, as the bat, hippopotamus, etc.
iSti//i//it/iH(h'us. Occasionally absent. Testut suggests
that in cases of siipiposed absence of this muscle it is
fused with the posterior belly of the digastric. A division
of the mu.scle into three has been noticed. It may some-
times pass behind the carotid arterv. It is occasionally
inserted into the tendon of the digastric or lesser cornu
of the hyoid bone. Its fibres may be continuous ■with
the mylo-hyoid, thyro-hyoid, omo-hyoid, or, as in the
ant-eaier, with the muscles of the tongue. It sometimes
arises from the lower jaw and goes to the hyoitl bone
(hyomaxillaris); again, it may not reach the hj'oid Ijone,
but go from the styloid process to the angle of the lower
jaw, as in birds (stylomaxillaris). The writer has seen
this muscle absent in two subjects, once on botli sides.
Stiihiehinidrolnjiniliiis (Douglass); iSlylo/ii/oklcns niter
(Albinus). This is an additional mu.scle which occasion-
ally replaces the normal stylo-hyoid and has the course
of the stylo-hyoid ligament; in other words, it is the
stylo-hyoid ligament become muscular. It is inserted
into the lesser cornu of the hyoid bone and passes behind
the carotid artery. In one case, not<'d by the writer, in
which this muscle existed the normal muscle was repre-
sented by a thin tendinous slip. The normal stylo-hyoid
and this muscle frequently are present together. The
Fig. 34.39.— Showini; Utento-Hyoid Muscle (,V/f) : also, tlie Anterior
Bellie.s of the Digastric Muscles United in the Middle Line by Mus-
cular Fibres (Di. (Shepherd.;
stylohyoideus alter may receive a slip from the lower
jaw. In one hundreiland twenty subjects the writer has
seen this muscle nine times; three times it occurreil on
both sides of the same subject.
i^tyluhyot/iyruideus. This is the name given by the
46
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Ifluscles.
nuscles.
■writer to a muscle seeu by Iiim in a female subject in the
anatomical rooms of JIcGill University during tlie winter
session 1885-86. On both sides of a thin female subject,
in addition to the usual stylo-hyoid, a stylo-chondro-
hyoid was present. On the" left "side this muscle gave
off a slip to the middle constrictor of the pharynx. On
the same side, arising in common with the stylo-chondro-
hyoid, was another muscle of the same size, this had a
w'ell-developed belly, and passed down posterior but
parallel to tlie above-mentioned muscle to a little above
the hvoid bone; here it left its companion and developed
a weil-formed round tendon, which passed under the
middle constrictor and was inserted into the tip of the
superior cornu of the thyroid cartilage. The stylopha-
ryngeus was of normal size and insertion.
" Myhi-hyoid. The median raphe between the two mus-
cles issoi'uetimesabsent. The my lo-hyoid is often closely
united to the anterior belly of the digastric, and may be
partially replaced by it. The sterno-liyoid, omo-hyoid,
or stylo"-hyoid may s"end slips to it. The muscle may be
divided into two portions, an anterior and a posterior, sep-
arated by a considerable interval. This is the arrange-
ment in"some of the rodents. A deficiency of the fore
part is of common occurrence, the origin not reaching
farther than the canine tooth (Quain).
Geniohyoideus. The two muscles may be fused in the
middle line. It occasionally receives a slip from the
great cornu of the hyoid bone. It may be closely united
with the geuiohyoglossus or hyoglossus.
(lehi'ihyorjhmus. This muscle has been found united
with the genio-hyoid. The two muscles may be fused
together, no cellular interval separating them. Slips
have been seen going from the geuiohyoglossus to the
epiglottis, stylo-hyoid ligatueut, and lesser cornu of the
hvoid bone. An accessory muscle has been described by
lienle, Luschka. and Bochdalek, going from the tnental
spine to the hyoid bone between the two geuiohyoglossi
muscles.
Ilyighmiis. Sometimes pierced by the lingual artery.
The niiddle portion of the muscle is occasionally absent,
leaving a larger or smaller interval between the ouleraud
inner portions, and e.xposing the lingual artery (see Fig.
3440). The lingual artery may lie on the muscle instead
of beneath it.
Tridcorilomia (Bochdalek). This is a small muscular
slip which arises from a cartilaginous nodule in the thyro-
hyoid ligament, and passes uinvard and outward to join
the posterior part of the hyoglossus.
0/wiidrofflossus. This h"as been described as a distinct
muscle, occurring normally, separated from the hyo-
glossus by the pharyngeal libres of tlie genioglossus. It
arises from the base oi the lesser cornu and, spreading
out. is inserted into the dorsum of the tongue near the
middle line.
.■<tijloi/hi.iiiiifi. The st3doglossus is occasionally absent.
The'writer once saw it absent on both sides of the same
subject. There is sometimes an additional origin, from
the angle of the lower jaw or the stylo-maxillary liga-
ment. " The whole muscle may arise from these points,
the styloid origin being absent. When it arises from the
augle'of the jaw it is called the myhr/losmis. Gruber has
described a rare origin of this muscle, from the external
auditory meatus {Kti/loaunculiiris). The muscle may be
divided" into two portions; one of which is inserted nor-
mally, the other into the pharynx (Saudifort). JIacalister
lias reported this muscle as double. Henle has descriljcd
a slip going from the styloglossus to the genioglossus
near its origin.
Muscles uf the Pharynx. — Constrictor Superior. The
second portion may be distinct. ^Meckel describes an
accessory slip, arising from the pharyngeal spine and
becoming lost in the middle line of the posterior wall of
the pharynx. The writer once, on both sidesof the same
subject, Siiw this muscle receive a slip from the Eusta-
chian cartilage.
Constrictor Mediiis occasionally receives fibres from the
stylo-hyoid ligament or hyoid bone; al.so from the tongue
and hinder part of the mylo-hyoidcan ridge. It is com-
mon to see a slip from the thyro-hyoid ligament {syndesmo-
plmryngeus, Douglass). The upper fibres of the muscle
may reach the occijutal bone.
Constrictor Inferior. A few fibres of origin maj- come
from the trachea. It is occasionally connected by mus-
cular slips with the crico-thyroid, sterno-hyoid, or sterno-
thyroid muscles.
Stylopharyngeus. Cleavage of this muscle into two or
even three parts has been noted. Gruber has described
a double-headed stylopharyngeus. The accessory head
in his case arose from the mastoid process.
Supernumerary Muscles of the Pharynx are not infre-
quently present, proceeding from the lower part of the
' SK
---fiP
Fig. 5440.— H.Hynglossus muscle deficient in itii central portion: SG,
styloglossus ; SH, stylo-hyoid ; SP, stylopbaryngeus. ( Walsham.)
base of the skull and going to one of the constrictors or
passing between these muscles and the fibrous layer of
the pharynx. They may arise from the petrous portion
of the temporal (pctropharyiiyois), spine of the sphenoid
(sphetiopharyngeus). hamular jiroccss (pterygophoryiigens),
basilar process (octipitojiharynyeus), or from the pharj'U-
geal tubercle of the occipital bone (azygoj)haryiigeus).
PiiEVEKTEBR.\L MrscLES. — Seeilenus Anticus. Ab-
sence of the muscle has been i-eported by !Macalister. In
this case the subclavian vein was in direct contact with
the artery. The attachment to the cervical vertebra? may
vary in extent. The muscle may be divided into several
distinct portions. It is sometimes pierced by the sub-
clavian artery, and in rare cases lies behind the ai'tery,
or, more properly speaking, the artery jiasses in front of
it.
Scalemis Medius and Posticus. These two muscles are
so intimately united that French anatomists regard them
as one muscle. They vary considerably as to the extent
of their attachments to the transverse processes of the
cervical vertebi-ff ; freipiently the slips from the upper
cervical are absent. In rare cases the posterior scalenus
may be attached as far down as the third and even the
fourth rib, as in many of the lower animals. In some
animals, as the bear, it reaches as far as the seventh and
eighth ribs. In man it is not infrequently absent. The
scalenus medius is perforated by branches of the brachial
plexus and frequentlv bv the ]Kjstei-ior seaimlar arteiy.
Sciilenus .1//;(('H((/«"(Albinvis). This is a small slip of
muscle, normal in apes, which is seeu in man occa.sion-
ally. It passes fi'om the transverse processes of tlie lo%yer
cervical vertebra; to the first rib, behind the subclavian
artery, and in front of the brachial plexus.
Tr'ansi-ersalis Cervicis Mediu.s (Toriiblom). Under this
name a muscle has been described as arising from the
transverse processes of the second, third, and fourth
cervical vertebrre, and inserted into the sixth and seventh
cervical transverse processes.
4T
muscles.
REFERENCE HANDBOOK OF THE .MEDICAL SCIENCES.
licctiis Capitis Anticus Mnjor. Varies occasiouiilly in
the extent of its attachment to the eervieal vertebra'. It
is sometimes streni;tlien<'il l)y a faseicuhis from tlie trans-
verse process of tiu; axis, and lias linn noted as liaving
Fl(5. .'Wtl.— .1, .\.\illiiiv hariil. hi'lwi'i'ii llu- liitissimus ilol-si iLt :iiiil
the Kivat pci'loral (i'.i.
no orijrin from tliesixlli cervical. It is fre(inently uinlrd
witli neiglilioring muscles, as the anterior scaliiius. lra)is-
versalis cervicis. el<'.
Rcft'1.1 Ciipitifi Aiitii-ii.t Miner. (Occasionally has a slip
from the axis. Macalister has desciiljed a sii]ii'rnnmeraiy
muscle attacheil to the anterior portion of the atlas (.M.
rectus anterior nu'dins of Crulier).
LoiHjiis Cn/li. The longus colli is siiliji'el to sonii' va-
riation's in the numher of its attachments and in the de-
gree of sejiaration of its constituent parts.
The lower oblii)Ue portion may send a ^.lip 1o the \n-,u\
of the tirst rib. It is also sometimes jirolonged to the
rectus cajiitis anticus major, and has been seen sending
a slip of in.serlion to the basilar porlion of the occiiiital
bone. A supernumerary longus colli (,1/. ti-iiiiKi-irxnli-i
cerriiy'K untiTiar Luschka) may arise by thin, tcndimuis
slips fi-om the anterior tubercles of the transverse proc-
esses of the lower four cervical vertebi'a' atnl be iuserled
by two tendons into the base of the transverse process
of the atlas and the body of the' axis (Ilenle).
MiscLf.s OK Tin-; Uithk Li.mu. — Trnpfzins (Cui-nl-
laris). The attachments of this muscle are sid.iji'ct to
C msiderable v;irialion. The muscle may be much smaller
tlian usual, and have no ocei|iital origin or lie attached to
as few as si.x instead of twelve dorsal spines; it may be
divided into a cervical and a dorsal portion. Again, its
spinal attachincnls may lii' coiilined to the upper three
or four dorsal, or lnwrr Ihnc or four cervical spines, the
other portions being absent. It is sometimes inserted
into more of I lie clavicle than normal, being continuous
with the inserlion of the sterno-masloid. (.)ccasionally
there is a slip passing forward across the subclavian tri-
angle to reai'h the sterno-nuistoiil ; this would be in front
of the third part of the subclavian artery, and interferes
somewhat with the operation of ligature of that artetv.
A,gain, it may be continuous with the deltoid, as is the
case in animals wilhout <davieles. In rare cases the jior-
tion attached to the clavicle isabsent or very small. This
arrangement is seen in .some of I he lower animals, A
slip has been desciilieil going from the anterior border
of the muscle near the clavicle to the steruinii ; this is a
variety of the slerno scapular muscle. Not iiifrequentlv
slips of allacliment unile the Irapc'zius to ihe livator
an.guli sca|iula'.
Tjitisxiiiiiix Ittiivi. The immlier of dorsal vertelna' to
which this muscde is allached may vary considi-ralily. It
may be allai'hed to as many as nine, and as few as four.
The writer hasscen it attached lo all Ihedovsal \ crlelir.-e.
lis attachments to the rilis also vary, the number being
.sometimes increased, sonietinies diminished. It is occa-
sionally attached to the lower anyle of the scapula; Ihe
writer has twice seen it .send slips to the spine of Ihe
scapula.
A.nllfini Band (Achselbogen). This is a muscular
band which crosses the lower part of the a.xilla from the
latissinius dorsi to the ,gieat pectoral muscle near its in-
.sertion (see Fig. ;j44I).
It may, instead of uniting with the great pcctoial, be
inserted'into the coracobrachialis or fascia covering Ihe
biceps. In its course it usually cros.ses the axillary ves-
sels, and hence it is well to bear this in mind in ligaturing
the axillary artery in its third part. It is sometimes of
large size." being "as broad as 6.3 cm., and so may ctiver
a considerable extent of the axillary vessels. More fre-
quently it is a small slip, from 1 to 'A cm. broad. It oc-
curs in about live per cent, of all sub.iects, anil is fre-
iiuenlly on both sides of the same sub,iect. The writer
has seen it in eleven s\ilijects out of two luindred and
tifty noted. This muscular band exists normally in
maiiy animals, as deer, etc., and is the remains of the
continuity which previously existed between the latis-
sinius dorsi and the pectoralis major.
Dijr.ii'i'/iitnir/iliiiris. This is a muscle which is occa-
sionally seen in man in a rudimentary form, but in many
of the lower animals, as apes, lemurs, .seals, bears, etc,
is a wcll-devidoiied muscle, and is the normal arrange-
ment. It is a muscular slip which is given olf from the
lower border of the tendon of the latissimus dorsi, and is
allacheil to various points in the arm. It may end in
the long head of the triceps, some jiortion of the internal
inlermuscular septum, the epitrochlear ]>rocess of the
internal condyle, or the olecranon proc-ess (see Fi,ir. 84-l'2).
In man the muscle is occasionally represented merelv liv
a tibrous band, sometimes bv a small, muscular slip eml-
ing in a librous cord, which is inserted into the internal
condyle, or is continuous with the internal intermuscidar
septum.
li/ii/nihniili IIS ^fin'||■ (iiiil Jfiijiir. Bolh these muscles
arc subject to variatiiui as to extent of ori.gin and inser-
tion. They may lie divided into two fasciculi, as in some
animals.
Ji/ioin/iti-ofriiii/ii/ (occipito-scapuliir of Wood). This
is a slip not iufriiiuently seen in man, and occurs
nornndl,v in manv of the lower animals. <'.,(/., the deer,
cat, ti,gcr, etc., as a well-developed muscle iumiediately
beneath Ihe trapezius, and reaching from the occi|nit to
the base of thespiiieof Ihe scapula. In man it.generally
exists in an inconi|ilete form, and varies con.siderably as
lo its upper and lower attachments. Instead of reach-
ing the scapula it may be connccled with either of the
rhomboid muscles, serratus jiosticus superior, or levator
anguli scapid,-v. Its sujierior attachment may not reach
the occiput, but be connected with the spines of the
ujiper cervical vertebra-. Again, in man,
this muscle may be represented by a sli))
from the aponeurosis covering the splenius
ca|iitis lo the spine of the scapula, or by a
slip from the levator anguli
scapuke to one- of the rhom-
boids. In one case recorded
by the wriler it consisted of a
w(dl-develo]H'd muscular slip
reaching from the transverse
jirocess of the atlas to the
a|ioncuro>is over Ihe
greater rhomboid
{r!iiinili„-,if/oidolL'Sh\c-
alister). The man}-
varieties of this mus-
cle in man have been
earefuUv described
by Prof. J. AVood
(Proceed. Rov. Soc.,
ISTO— see Fig. 8443).
Leriitiir Anr/nli
Si-iiliii!ii: This muscle varies considerably in the exlmt
of its attachmenls to the vertebra' and scapula. It is
often seen atlached lo as manv as .six vertebne and to as
few as two. It has been seen arising from the mastoid
process and occi|iilal bone in addition to its spinal
origin. It may have an attachment to the spine of the
Fii;. ;^43.— r>. Doi'soepitrocl
■\ L, latissimus cloisi.
earis inus-
(I\'ITill.l
48
REFERENCE HANDBOOK OF THE 51EDICAL SCIENCES.
Muscles.
Muscles.
Fig. 3443.— OC, Oooipito-soapular mus-
cle : Z>y levator anguli scapulEe ;
R. rhomboid muscles ; Sp, splenius.
(Wood.)
scajiula, and it sometimes seuds slips of insertion to tlie
first or .second rib. Occasiouall}' it is .seen divided into
two or more slips, the portions connected with tlicdilTer-
c'Ut vertebrie remaining separate. It is ollen connected
with neighboring mu.sclcs
by muscular slijis. The
writer has seeu it thus con-
nected with the serratus
posticus superior, serratus
magnus, deep surface of
the trapezius, coniple.xus,
splenius capitis, rbomboid-
eus minor, and scalenus pos-
ticus. These
slips are re-
g a r d e d b _y
Wood as vari-
eties and inodi-
ficatiousof tlie
oceipilo -sca]i-
tdar inu.sele of
tlie lower ani-
mals. In nian y
of llie lower
animals the levator an-
uuli scapulx is merely
the upper portion of the
.serratus magnus, form-
ins with it a single
mu-scle.
Leva to r Cla riciilcp.
The levator clavicuhie.
which normally exists
in all mammals with the
exception of man, is oc-
casionally seen in him.
It appears as a .separate
mu.scular slip arising from the transverse processes of
one or two upper cervical vertebnc, and inserted into
the outer end of the clavicle. Slips of muscle from the
levatoranguli scapulaN orfromthe upper cervical spines,
to the scalene muscles, serratus magnus, and ribs, are
regarded as modifications of the levator clavicuhe.
Cleidocei-vicdlis (Griiber). This is a form of the above
muscle arising from the transver.se process of (be sixth
cervical and inserted into the outer end of the clavicle.
Gruber looks upon it as a supernumerary scalene muscle
attached to the clavicle.
Pectonilis Major. Many variations of this muscle have
lieen observed. The more common varieties consist of a
greater or less extent of attachment to ribs and sternum,
and the separation of its clavicular from its costal attach-
ment.
M. Testut divides the anomalies of tliis muscle into
eight groups, viz. :
1. Fusion of the clavicular portion with the deltoid.
2. Fusion with the great pectoral of the opposite side.
3. Union with the rectus alidominis.
Union with the biceps brachii (see Fig. 3450).
Separation of the clavicular and sterno-costal por-
tions by an interspace.
G. Division of the costo-sternal portion into two strata
or layers.
7. Anomalies in the mode of insertion into the arm.
8. Complete or partial absence of the muscle.
Testut divides the anomalies of the brachial insertion
into: ('() Insertion into the coracoid process and aponcu-
ro.sis of the coracobrachialis. (h) Insertion into the cap-
sule of the shoulder- joint, (c) Prolongation of the tendon
of insertion into the capsule of the shoulder-joint, (r/)
Supenuimerarv iu.sertion into the humerus, d) Inser-
tion into the brachial aponeurosis, (f) Insertion into
the two lips of the bicipital groove.
Chondrorpitrochlcaris (Dnvernoy). This is the name
given by Duvcrnoy to a nuiscular slip which is sometimes
seen ari.sing from the cartilage of one or two ribs, the
aponeurosis of the external alxlominal oblique, the lower
border of the great pectoral itself, or its tendon; from
Vol. VI.— 4
4.
h.
one of these origins it passes down and out, and is in-
serted in a variable wa.v into the arm. It is often in-
serted into the internal intermuscular septum and occa-
sionally reaches as far as the internal condyle of the
humerus.
Mr. J. B. Vcvnu (Jour. Anat. and Pliys., xcA. v.) has
described under the name of epigastric slips a number
of muscles connected with the lower border of the pec-
toralis major, or arising separately from the sixth or
seventh rib and inserted into
the tendon of the great pecto-
ral, or into the fascia covering
the corac ibracliialis muscle (see
Fig. 3444). They ma}' also be
connected with the latissiinus
dor.si. These muscles are de-
veloped to a high degree in
manj- mammals, and are well
seen in i^igeons and fowls.
Musculus uternalis. Syn. :
Rectus sternalis, sternalis bru-
torum (Albinus), presternal
(Testut). The museulus ster-
nalis is a supernumerary mus-
cle which has alwaA'S excited
a great deal of interest among
anatomists ; even yet its proper
morphological significance is
not fully determined. It is
seen in about three or four per
cent, of ordinary individuals,
but in anencejjhalous monsters is nearly always pres-
ent. Its fibres are generally at right angles, and super-
ficial, to the great pectoral; it is often bilateral, but
more frequently unilateral, and is subject to many
variations. Frequently it nas no attachment to bone
but rests on the great pectoral, at'ached above and
below to fascia (see Fig. 344.5). It is often attached
to the sternum and co.stal cartilages of one side or both,
and is occasionally continuous above with the sternal
origin of the sterno-mastoid, and below, with the ex-
ternal abdominal oblique (.see Fig. 3433).
It usually arises from the first piece of the sternum,
and is inserted into some of the ribs and costal cartilages,
generally the fifiii and sixth. It may be continuous in
Fig. 3444.— E3sample of tlie
Chondroepitrochlearis Mus-
cle (C). (Periln.)
Fig. 344.5. — S, Museulus sternalis, attached uliove aud below to fascia.
(Sheplicrd. i
part with the great pectoral itself and be associated with
deficiency of that muscle. Someiimes it is of small size,
but occasionally it is quite a large muscle, 8 to 10
em. long, and 3 to .5 cm. broad. It has been recognized
under the skin in the living. It derives its nerve
supply from the same source as ti.e jiectoral muscles,
49
muscles,
Muscles.
REFERE>'CE HANDBUUK OF THE :MEDIfAL SCIENCES.
viz,, tlio anterior thoracic. Tlio iiiuscIp is regarded by
Sir William Turner. Dr. Dobsoii, and others as a
reniuaut of a skin muscle. Henle, 'I'hcile. Bourrienne,
and others look upon il as a jirolonualion downward
of the .steruo-niastoid. Ilalbertsnia thoujilit it a muscle
sui (jeneris peculiar to man, and having no animal repre-
sentative. D. J. Cunningham thinks it a new inspira-
tory muscle appearing in man. and is of opinion that
Fig. .^4t».— (f. (7. n, Muscular slips comipfting tlie pi'cloralis minor
<P) Willi the corucubracbialis (C) ami tlie latissuuus dursi \L).
< Sliepberd. )
it occurs more commonly in females, costal inspiration
being more pronounced in them. In dissections of
aneucephalous monsters made by the writer the nerve
supidy was traced, in nearly all the specimens ex-
amined, to the anterior thoracic. These dissections con-
vinced him that this muscle belongs to the pectoral and
not the panuiculus group (see Jour. Anai. and Phyn.,
vol. xix.).
Pectoriilis Mi/iui: The origin of this muscle varies
cousiilerabh'. It may arise from the second, third, and
fourth ribs, instead of the tliiid, fourth, and lifth. Not
infreijuently it arises from four rilis, and the writer lias
occasionally seen it ari.se by five digitations from the live
upper ribs. It has been describi'd as attached to only
two ribs, and Testut, in his work on "Mu.scidar Anoma-
lies," describesa case in which it arose by asingle digita-
tion from the fourth lili; in this case the subclavius
muscle was of large si/.e. Sometimes the pectoralis
minor is divided into a number of slips corresponding
with the ribs from which it arises. It is occasionally
connected with the great pectoral. In one case the
■writer saw it connected by muscular slips with the latis-
sinius dorsi and coracobrachialis, and these two slips
were connected together by a third (see Fig. 844()).
The variations of insertion of the pectoralis minor are
numerous. The luiisele not infrc(iuently jiasses over the
coracoid process and is inserted into the capsule of the
.shoulder-joint and great tuberosity of the humerus. It
Very frequeutl\' is united at its insertion to the coraco-
brachialis. In one case the writer .saw it inserted into
the coracobrachialis by a tendinous exiiansion, o cm.
broad; in this case the coracoid process received no fibres
of insertion. In many of the carnivoraand qiiadrumana
this muscle is normally inserted into the humerus.
In rare cases the pectoralis minor is divided into two
layers which have distinct insertions, and sometimes it is
absent.
Pei-tofi 'is MinimuK. Gruber lias described a slip, to
which he gives the above iiaine, arising from the first
piece of the sternum and cartilage of the first lil); from
this origin it passes outward between the subclavius and
lesser pectoral to lie inserted into the coracoid process.
Some regard it as a variely of the chondro-scapular
muscle of Wood.
Siibdaviiis. The subclavius is not infrequently in-
serted into the coracoid process as well as tlie clavicle;
occasionally it has no clavicular attachment, but is wholly
inserted into the root of the coracoid process. It has
been described as d(nible by some anatomists, but the
supernumerary muscle will be described below as the
sterno-scapular. W'alsham describes a case in which the
subclavius had an insertion into the humerus, as is nor-
mall}' seen in birds. The subclavius is sometimes absent,
its place being taken by the sterno-scapular.
Sterno-dioiuiiv-scajiiiiiir (Wood). Syn. : Scapulocostalis
minor (Macalister), subclavius posticus (Rosenmiiller).
This is a supernumerary muscle of a somewhat cylin-
drical shape, which is attached externally to the root of
the coracoid process or upjier border of the scapula,
passes inward over the subclavian artery and brachial
plexus of nerves, beneath the clavicle and subclavius
muscle, to be attached bj" a round tendon to the costal
cartilage of the first rib, first piece of the sternum, or
both (see Fig. 3447).
Sometimes this muscle passes over the clavicle in place
of beneath it. and occasionally it j:ioes not reach as far
as the coracoid, but may be inserted into the anterior
Fig. 3447.— S5, slerno-seapular niusrle: O, omo-hyoid. (Wooii.)
border of the clavicle (sterno-clavicular anterior). A
variety of the sternoclavicular muscle which the writer
has seen is one which reaches from the sterno-clavicular
articulation to the anterior border of the trapezius. In its
course it passes over the clavicle and across the subclavian
triangle, covering the third portion of the subclavian
artery (see Trapezius). In ligature of the subclavian it is
KEFERENCE HANDBOOK OF THE .MEDICAL SCIENCES.
?lll«4rlON,
ITIiiMrlrH.
PM
wbII to bear this anomaly in mind. When tlie sterno-
scapular muscle exists tliere is sometimes absence of the
subclavius muscle ; the writer has seen this occur once only
out of seven cases; in three cases, how-
ever, the subclavius was much reduced in
size. W. Gruhcr saw absence of the sub-
clavius in seven out of eleven cases of
steruo-scapular muscle.
Comparative anatomy : In the Norway
rat, guinea-pig, wombat, etc., the sterno-
scapular muscle is normally present. In
the horse it is a well-developed muscle. In
animals without clavicles having a sterno-
scaptilar muscle it is regarded as the homo-
logue of the subclavius.
yjh<iiidrii-C'>mcmd is a small muscle de-
scribed by Wood as arising from the first
costal cartilage by a roiuid tendon, and,
passing outward below the subclavius, is
inserted into the coracoid process super-
ficial to the coracobrachialis.
Many other supernumerary clavicular
muscles have been described, such as the
scapuloclavicular, coracoclavicular, su-
praclavicular, infraclavicular, etc.. but
they are so rare that it is only necessary to
mention them and refer readers wishing to
learn more about them to the special works
on muscular anomalies mentioned in the
introduction to this article.
tyerriitiis Mnf/nus. The serratus magnus
may arise from nine ribs instead of eight,
and occasionally it receives a slip from the
tenth. Again, some of the highest or low-
est digitations may be wanting, the mus-
cle thus being attached to only si.x or seven
ribs. Occasionally some of the central digi- Fig- SUi.—SS.
tations are absent, and the muscle is tlien
divided into two portions. Wood has de-
scribed two large muscular bands, distinct from the
serratus. arising from the ninth and tenlh ribs, and in-
serted into theinferior angle of the scapula. He regards
these bands as homologues of the depressor scapula' of
birds. Sometimes there is more or less complete fusion
of the serratus with the levator anguli scapulae. In
many mammals it forms one muscle with the levator.
JIusci.ES OF THE Shoulder. — Deltoid. This muscle is
not subject to many variations. It is sometimes divided
ipto several distinct portions, viz., the clavicular, acro-
mial, and spinal, as in carnivora. The clavicular and
acromial portions are often separated by an interspace ;
not infrequently the clavicular portion is intimately con-
nected with the contiguous part of the great pectoral,
the division between them being determined only by the
cephalic vein. The clavicular jiortion may also, in some
cases, be continuous with the fibres of the trapezius, as
in animals without clavicles.
The insertion of the deltoid varies in posititm and ex-
tent ; in some cases it is inserted mucli lower than usual.
Macalister has describeci a rare anomaly of this muscle,
viz., the prolongation of its tendon as far as the lower
end of the radius: he considers this to be the horaologue
of the extensor plica; alaris of birds.
Testut has described a .slip going from the clavicular
portion of the deltoid to the internal condyle, crossing
in its course the brachial vessels; he calls it the cleido-
cpitrochh'iiris. The deltoid not infrcquenlly receives ac-
cessory slips from the axillary or vertebral borders of the
scapula, and also from the spine and sidjsjiinous aponeu-
rosis.
8iiprait])iii(itu!i. Variations of tliis muscle are ex-
tremely rare. It is very constant both as to its size
and attachments. Occasionally fibres of the great pec-
toralare iu.serted into it. The writer once saw its tendon
pass over the capsvde of the shoulder-joint in a pulley-
like depression, and become continuous with the deep
portion of the insertion of the pectoralis major (see Fig.
3448).
Infraspinatus is occasionally fused with the teres minor.
It may be Connected with the deltoid by a strong fascicu-
lus, and, again, it may be divided into several slips.
Tendon of the suprc'u>pinatu8, conlinnous witli the deep portion of
tbe tendon of tbe pectoralis major {Pil). (Sbeplierd.)
7eres minor is occasionally divided into two portions,
the lower being called the teres minimus.
Teres major may be reduced to the size of the teres
minor. It is sometimes inseparably connected with the
latissimus dorsi. as in some of the lower animals. A fas-
ciculus has been described descending on the fascia of
the arm externally. It is analogous to the tensor fascia;
of the leg.
Siibscapularis. Varies but little. A small accessory
muscle (subscapulocapsularis, subscajiularis minor) lias
been described by W. Gruber, JIacalister, and others,
which goes from the axillary border of the scapula to
the capsule of the shoulder-joint or humerus. Knott de-
scriloes some fibres given off from the lower border of
the subscapularis and inserted into the aponeurosis and
skin of the axilla. These are regarded as remnants of
the panniculus carnosus muscle of the lower animals.
Curnow, Walsham, and others have descrilied a mus-
cle arising from the inner bicii>ital ridge, or the groove
itself, and passing up to be inserted into the capsule of
the shoulder-joint near the insertion of the coracobra-
chialis. Testut describes this muscle under the name of
bracliiocapsularifi.
Coraco-hrachialis. Professor Wood (Jour, of Aiiat.,
vol. i.) considers tliat this muscle con.sists typicallj' of
three portions — superior, middle, and inferior. In man
the middle and part of the inferior portion exist mo.st
constantly, the two jiortions being separated by the
musculo-cutaneous nerve. Both tjie superior and in-
ferior divisions are. however, occasionally seen in addi-
tion to the middle division (coracobrarhialis propriiiK.
The superior {ciirarohnirhialia superior rel hreris). when it
exists in man, arises from the coracoid process, passes
over the subscainilaris muscle, and is inserted lielciw the
lesser tubero.sity. or more rarely into the capsule of the
shoulder-joint (eor(icorap,'<vlaris). This is the normal ar-
rangement in many animals, as the dog, cat, etc.
The inferior division (eoraeobraeJiiolis longiis) is also
occasionally seen. It may be of large size and be in-
51
Muscles.
ITIuscles.
REFERENCE flANDlKioK OF THE MEDICAL SCIENCES.
c —
Fui. :>440.— .1. Corarobrarli ill lis
luiifTus pn^sinfx "viT Mif l>l';it'lnul
vessL'ls (.-l.ci 1(1 ri'iicli llH' inlt'iiuil
coiuivle; r, normal (.-urarohra-
tliialis. (After Wuiiil.)
serted into tlio iutonial condyle or into a supraooudyloid
proooss uiien tliat anomaly exists. It is .sometimes rep-
sentcd at its lower jiortioii by a lihroiis band; this is the
internal braeliial liuanient oT Slrulliel-s. As a nde. the
iuferiiir pcirtiou, when ]ire.sent, ]iasses over the a.\illary
artery, aTid must be kept
in mind when linatdring
that vessel (see Fig.
3-J4!»l.
The eonienbnichialis
occasionally is nut
pierced by the nmsiailo-
cutaneous nerve.
Comparative A n a t-
omy: In animals which
swim or climb, as the
beaver, bear, etc., the
riii-tifii!)r(irhi'ilin lonr/irx is
well developed, la most
of the (|uadiaunana there
is a double insertion of
t h (.' coracobrachialis,
and, in the .guinea-pi.!;,
tlie median variety only
is present, as in man.
In some animals, as the
kan,;;aroo, the muscle is
absent altocrcther. It
has once been found
absent in a human mon-
ster. The coraeocapsu-
laris is present normally
in many animals, i.r/.,
the doi;-,"cat. eti'.
Hii-ijis Bnir/iii. This
muscle is rich in vari-
eties. The most common is the presence of a tliinl head,
which ari.ses near the insertion of the coracobrachialis, and
in close conneetioji with tile brachialis anticus. Thi' pro-
portion of subjects having a third head is, in the writer's
e.xiierience, one in seven; Tlieilc makes it one in nine;
Ilallelt, one in tifteen; Wood and jMacalist.er, one in ten.
In Iwci luuidred and tifty subjects examined the writer
found it live times on l)olh sides of the sarn<' suliject.
The third head generally soon joins the coracoid head
about its middle, but it is occasionally seen quite .sepa-
rate as faras the bicipital fascia, into which it is inserted.
The third head usiadly licsouNide the vessels, but some-
times is seen ccivering tliem. ll may arise from the bi-
<'ipilal gnnive. one of the ridges, or even from the great
tuberosity. The writer lias seen it ari.se from the lower
edge of tlie :;reat iie<-toral near its insertion (see Fig.
34.")(1).
The third head is regarded liy some as an oll'shoot fi'ora
the brachialis anticus. Strut hers lias described a muscu-
dar slip which comes otT fi-om the inner border of the
biceps, passes over the liracl.ial vessels, and is inserted
into the internal intermnsi-ular septum or internal con-
dyle.
The liieips has been seen with as many as four and
even hve heads. The supeinumerary heads, as a rule,
have their origin from the bici)iital groove, body of hu-
merus, coracoid process, cajisule of shoulder joint, or
tendon of the ])eetoralis major. The coracoid and gle-
noid portions of the bicejis muscle may fail to unite,
being coni|iletely separate to their insertion. The long
head is occasionally absent, tlie muscle being uniceiis in-
stead of biceps, as in some animals. The /our/ iw tiliimid
JiiikJ may not iiierce llie capsule, but arisi- from the ca|)-
sule its('lf. the humerus, or the great peeloml tendon.
The tendon cd' the biceps sometimes pierces the tendon
of the jiectoral (see Fig. o4.')((). 'I'hisis a m'Iv rare anom-
aly. It is not uncommon in old joints thai have become
dry from rheumatic disease to lind the long tendon worn
through, and perhafis altachi'd to the groove outside the
capsule, or to the head of the humerus, or absent alto-
geflier. This ])atliologieal condition must not hi.' cou-
fotuided w ith the anomaly above described.
muscle. In
The short or coyacoid head may also in rare cases be ab-
sent.
The biceps may send a slip of insertion to the coronoid
process, capsule of the elbow-joint, or fascia of the fore-
arm. It is sometimes connected with the |ironator teres,
supinator loiigus, brachialis anticus, and palniaris longus,
by muscular slips. In one case, in which the muscular
slip crossed the artery and went to the prouato:- teres,
the bicipital fascia was given olT from it.
The semilunar fascia is often of larger extent than
usual, and may have a high origin. It may be (level
o|ied intd an almost true tendon. It not infreciuenllv
sends olfslioots to neighboring parts.
Jli'itfliiiinididlis (Wood). The writer once saw this
muscle. It arose from the supracoudyloid ridge above
the supinator longus, and between it and the deltoid: it
coursed down the arm between the long .supinator and
biceps, and was inserted into the obliiiue line of the ra-
dius immediately above the in.sertion of the teres. AV'ood
looks upon this muscle as a variety of a fourth liead to
the bicejis.
C'(aniiar,itive Anatomy: A third liead is the normal ar-
ratigemeiit in many animals, e.g., bat, seal, iliinoceros,
etc. The long or glenoid head is absent in many ani-
mals, esiiecially birds. The short or coracoid Injad is
not present in nmny animals, as the .seal, porcupine,
paca, and the carnivora, as the dog, cat, liear, hvena,
etc. The glenoid head in these comprises the whole
the American bear, the coracoid
head is repre-
sented by a
very thin ten-
dinous strand.
Jh'iiehidU s
njjuin/ t ^-~ - T= Antivin. ■^y\\i-
>\ tJlll »!/ I 5^.^ _ -=~^~~=^;;=S 1 (|uenl varia-
tions. It inaj-
be divided in-
to two or three
portions. On
one occasion
tlie writer.saw
a slip iirise in
common with the outer head
of the triceps, and after
ending in a round tendon,
join the brachialis anticus
the coronoid ]U'ocess. The
muscle may be inserted into the
capsule of the elbow-joint, radius,
bRipital fascia, or ftiscia of the
fouirni; it may be connected
with neighboring niu.scles, as tiie
bi( eiLS, deltoid, coracidirachialis,
]iionator teres, or supinator lon-
gus All these varieties have been
s(.cu by the writer. When there
Is I continuity of this muscle
with the supinator longus it sim-
ulitcs a normal condition wdiicli
exists in apes and monkeys, as-
sisting them in twisting their
bodies wdien hanging by their an-
teiioi extremities.
J ueeps E.vten.-iiir Cuhiti. This
is one of the most constant mus-
cles in the body as to its insertion.
One of the most common varieties
is a fourth head arising from the
inner side of the humerus. This
fourth head may come from the
axillaiy border of the scapula.
The scapular head may have a
more extensive origin than usual. The writer "once saw
a strong muscular sli]i, continuous with the deltoid and
separated by a bursa from the teres minor, liave a ten-
dinous insertion into the .scapular head near its i>iigin.
AB~-
Tliinl
aiisiiiLr
FIG. 3450. — .4 R,
liead of lih'*'p>
from the pfcrunili?
jor (/'.V), which is iht-
foralt'il hv the ImiK tcii-
(Inll of the biceps; f 7J,
coracnbrachiiilis. (Shep-
herd.)
52
REFEREXCE HANDBOOK OF THE JIEDICAL SCIENCES.
muscles.
muscIcK.
In some animals, as the American blacli bear, the scap-
ular head is of huge size, and arises from the whole ax-
illary iKirder of the scajnda.
Gruber, ^lacalister, and Testnt each report a case of a
slip .goiiJir from the coraeoid process and capsule of the
shoulder-joiut to the triceps. In one instance the writer
saw a fleshy slip between the triceps and teres major.
Dorsoepiirochleai-is (accessorius tricipitis). Occasion-
ally the muscle to which the above name is given, and
wliich is common in quadrumana and other animals, is
se<'U in man. It lias already been described with the
latissimus dorsi.
KiiitriirlileiKinconeua. Exists frequently in man. Gru-
ber found it in one in three; JIacalister, one in four;
and Wood, one in seventeen. It is triangular in shape,
Ihe apex being attached to the back of the internal con-
dyle and the base to the olecranon process. The ulnar
nerve passes beneath it and supplies it (see Fig. 3451).
This muscle is exceedingly common in mammals. Ac-
cording to Gabon, it is universally i)resent in the edeu-
tata, less frequent among the primates, disappears
among the anthropoid apes, and emerges again occasion-
ally in man as an anomaly. Air. Galtou considers that it,
like the supracondyloid process, is now "an almost func-
tionally useless heirloom, which has descended to us from
r<-mote ancestors." Mr. J. B. Sutton (Jour, nf Anni.and
Plii/s., April, 1885) says that when the epitrochleoan-
eoncus is not represented as a muscle, its place is occu-
(lied by a collection of fibrous tissue having the exact
shape and attachmenis of the muscle, and forming a
bridge under which goes the ulnar nerve.
Subdiicciia'iis. This consists of a few muscular fibres,
which are seen on removing the triceps from the lower
part of the humerus: they extend from the lower end of
the humerus to the capsule of the elbow-joint. It is
homologous with the subcrureus ni\iscle found in the
lower limb beneath the quadriceps extensor. It is looked
upon by many anatomists as a dependent of the triceps.
Ano/neus. Jlay vary as to the closeness of its connec-
tion with the triceps or extensor carpi uluaris.
Pronator Bfidii Teres. Thecoronoid head is sometimes
■wanting, in most animals it does not exist. Occasionally
there is a third licad which arises from the internal inter-
muscular septum, or from a supracondyloid process when
that variation is present; in such cases the direction of
the brachial aitery is often clianged.
Sometimes the third, or supernumerary, head arises
from the tendon of the biceps or brachialis anticus. The
pronator teres may have its insertion lower down the
radius than usual. It may also be divided into two por-
tions, as in birds. The coronoid portion may be sepa-
rated entirely from the condyloid, or there may be a
douliliug of each of these portions.
The pronator teres may be connected with thepalmaris
longus, carpi radialis flexor, or sublimis digitorum in the
forearm and the biceps, brachialis anticus, and coraco-
brachialis in the arm.
Flcror Carpi liadialis. It may receive an additional
slip of origin from the biceps tend<m and fascia, the coro-
noid iirocess, or the ladius. It may have an insertion
partly iiUo the annular ligament, trapezium, scaphoid,
or fourth metacarpal bone.
I'aliiiarin Lnigtis. This is one of the most variable
muscles in the bod}'. It is absent in about ten per cent,
of individuals, and" in rare cases is represented only by a
tendinous band. It does not exist in the soli])eds, rumi-
nant.s, or pachyderms. The form varies considerably.
There may be a central fleshy portion, with a long, slen-
der tendon at each end; the muscular portion may be at
the distal end. It has been seen muscular tliioughout.
and again has been seen to consist of two bellies united
by tendon. The palmaris longus is occasionally double;
when a second muscle exists it gencrallj' arises by tendon,
or is connected with the carpi ulnaris, or sublimis digi-
torum mu.scle. It may arise from the intermuscular sep-
tum between the two last-mentioned nuKscles, by a ten-
dinous origin, and continue as part of the ulnaris as far
as the middle of the forearm, then form a large belly
which ends in a tendon near the wrist. The writer has
seen it furnish the origin of the flexor brevis minimi dig-
iti; a somewhat similar arrangement exists in tiie cebus
and magot. Occasionally it receives an additional .slip
of origin from tlie coronoid process or
radius. It sometimes terminates vari-
ouslj'in the fascia of the forearm, mus-
cles of the little finger, annular liga-
ment, scaphoid, and jiisi-
form bones, and tendon ^'■"'!^_!s^^^'
of the flexor carpi ul-
FiG. 3451. — KA^ Epitrochleoanfoneus covering the ulnar nerve.
(Sulton.)
naris. The writer once saw the tendon of this muscle
near the wrist give off a broad muscular slip, which was
inserted into the base of the lirst phalanx of the little
finger. Most of the anomalies of this muscle correspond
to the normal arrangement in some of the lower animals.
Flexor Carpi L'hiarin. Is fre(.|uentl\' inserted into the
fifth metacarpal bone. It has been seen sending a slip of
insertion to the fourth metacarpal. It sometimes give-s
off a slip to the annular ligament, but this is regarded as
a supernumerary palmaris longus, as are also those cases
in which a separate i^ortion from the epieondyle passes
down to be inserted into the pisiform bone. It is in rare
cases double. I have once seen this muscle absent on the
left side of a female subject.
Flexor Sublimis JJif/itorum. The radial origin of this
muscle is sometimes wanting. The muscle is occasion-
ally subdivided, each of the tendons being connected
with a separate fleshy belly. This is more common with
the index and little fingers, and may be classed among
the anomalies called progressive. The tendon to the lit-
tle finger may be absent, or the superficial flexor may be
connected by slips with the deep flexor and the long flexor
of the thumb. This is the arrangement in most mammals,
and in man. and his order only, is seen the marked differ-
entiation of the flexors. One of the lumbrical muscles
occasionally arises from the sublimis digitorum. This
muscle maj' send a muscular slip to the annular ligament
and palmar fascia ; this is the arrangement in the bear,
and is supposed to represent the p;ijmaris longus.
Flexor Profiuuhis Diijiturnin. In many animals this
muscle is intimately bleiideil with the foregoing, but in
man is generally quite distinct; not infrequently, how-
ever, it is connected with the sublimis digitorum and
also with the flexor pollicis. It occasionally has an addi-
tional origin from the internal cond\le and corcmoid proc-
ess i,X\\e. aectssorius ad jlcxorem. profundum of Gantzer),
which may join anyone of the i)erforating tendons, com-
monly those going to the index and middle fingers (Wood).
This is the normal arrangement in many mammals. The
writer saw this coronoid slip very well developed on both
sides of a negro subject. He also, some years ago, found
a strange variety of the accessoriu.i muscle occurring ou
both sides of the same subject. The muscle arose from
both the internal condyle and inner side of the coronoid
by fleshy fibres, developed into a large muscular belly
which divided into two jiortions, each ending in a ten-
don, the inneriuost going to the terminal phalanx of the
little finger, and the outermost to tlie terminal phalanx
of the index, superficial to Ihe tendon of the sublimis.
On both sides, near the origin of this accessory muscle, a
large slip went to the jirofundus digitorum.
The profundus digitorum may have an origin from the
radius; when this occurs it joins the indicial portion of
the muscle.
Flexor Iialieis. The indicial portion of the profnudu.s
63
Muscles,
muscles.
REFEHENCE HA.N'DBUOK OF THE ItlEDICAL SCIENCES.
may be quite distinct from tlie rest of tlie muscle. In
oue case tlic writer s;nv it coimected with the lic.xor Ion-
gus pollicis liy a Icinliiioiis iiilciscclioii. A flexor indicis
is found in tlic gorilla and cliimiianzce.
Tlie tendon to tlie little and middle lingers n\ay also lie
quite seliar.ite and disliuct from the rest of the profun-
dus. Accessory slips are not
infrequently found going to join
the various tendons of the mus-
cle.
/,iiiiihn'cii/is. Varieties of these
muscles are common: they may
be diminished in number to
three, or in<'reased to live or si.\.
Two may be inserted into one
tinger. or one into two by the
hifurcation of a muscle. Occa-
sionally the iierforating tendons
of the' fourth and liftli fingeis
are furnisheil by lumlirical mus-
cles. The third muscle is more
frecjueutly abnormal than the
others. The writer has seen the
lumbrical muscle of the little
finger arise in the middle of the
fcjrcarm from the siddimis dig-
itorum by a round tendon, this,
after jiassing under the aunidar
ligameiu. developed a large
tieshy belly which was inserteil
into the fifth tinger. This might
he regarded as a case of absence
of the tVnirth lumlirical muscle,
its place br'ing taken by a slip
from the sulilimis.
Flcror Loti;/ii.t l^nUifii:. Has
frequently a sli]) of origin from
the eoronoid process and inter-
nal condyle. This slip has been
seen to pierce the radial nerve.
The muscle may be connected
by a slip with the suiierticial anil
dee]! flexors, and also with the
jironator teres. It is sometimes
fu.siMl with the profundus digi-
FiG. 34.W. — TliH Pr.inator torum so as to form a single mus-
guadratus.Py, consisting ,.i „ ; ,1 ; nporli- .in
of two triangular iior- '"■ "^ ',^ "''^ .C'"'' '"-.ntain ai
lions Willi bases reversed, manimals. It is. sometimes tu.sed
(Fenwick.) with the indicial portion of the
profundus, when that part forms
a distinct flexor indicis, as in tlie gorilla. It has been
observed .sending a slip to the index tinger and also to
the first lumbricalis.
Pronator QiKidratiis. The pronator quadratusis some-
times entirely wanting; it may consist of two, three, and
even four layers crossing each other. The attachment
to the bones of the forearm may be greater than usual.
It occasionally sends a muscular slip from its ulnar or
radial altachuK nt to the carpus. It may ecmsist of two
distinct triangular portions with the bases reversed ; the
anterior arising from the ulna h.v aponeurotic fibres and
inserted into the radius by fleshy fibres, the deeper and
inferior jiortiou inserted into the ulna by tieshy fibres,
and arising by aponeurosis from the radius (Fenwick,
Sappey, and Macalister). (See Fig. 84.i-2.)
The muscle may consist of a single triangle, as in some
animals. e.;i.. the macaque, setil, etc.
Flixor (_\irpi RikUhHs y)n''7'.s' (Wood) (Radio-carpus of
Fano). This is a small muscle occasionally s<'en. It
arises from the anterior surface of the radius below the
oblique line, and is inserted into the annular ligament,
trapezium, os magnum, or other part of the carpus. It
may also be inserted info one of the metacarpal bones.
A variety of this muscle is, in rare cases, seen arising
from the ulna (ubio carpus).
.^iipuiiitiir LiiiHiiix. Tlie varieliesof this muscle .■ire few
in number. It .sometimes has aliigher attachment to the
humerus than usual, and its insertion into the styloid
process ma_y be extended upward along the radius. It
may have no attachment ilirectly to the external condyle
of the humerus, and in such a case it is closely connected
with brachialisanticus. The writer once saw a slip from
the supinator attached to the middle of the outer border
of the shaft of the radius.
The tendon of the supinator may be divided into two
or three sliiis. In cases of absence of the radius this
muscle is wanting.
Occasionally it is double, the accessory portion (/;;Y<c/(jrt-
?vf(^(V(//j) arising with it and being inserted into the radius
in the neighborhood of the oblique line. It not infre-
quently is connected with neighboring muscles, viz., the
deltoid, bracliialis anficiis (as in monkeys), flexor carpi
radialis longior, and the abductor pollicis. The tendon
may lie pierced by the radial nerve.
Kricn.ior Ciir]ii Jiiidialis Loiii/ior ct Brcnor. These
muscles are sometimes coin|detely fused. In many
mammals (horse, pig, etc.) they form a single muscle,
which ends in two tendons. In man the fusion may be
only jiartial. The tendons of one or other of the muscles
may be subdivided. The radmlis longinr may have an
additional insertion into the second or third metacarpal
bone. Wood has described a muscle which he calls the
I'.rtt'imur ciirjii roilidlin ofri minus. It arises from the hu-
merus below the nnjijdix lonr/ior. and is inserted into the
first metacarpal bone, first dor.sal interos.seous muscle,
abductor, or short flexor of the thumb. The writer has
seen a digastric slip given otf from the extensor carpi
radialis longior, which joined tlie abductor pollicis.
Test lit has described an ubiliicteiir Inniienil (fit. punee,
arising from the external condyle, and inserted into the
first phalanx of the thumb. The long extensor is occa-
sionally uniti'd with the supinator longus. Macalister
has recorded absence of the short extensor.
E.ftcnsor Coiiimiiiu'n Ilir/itoriiiit. The varieties of this
mu.scle relate chiefly to the increase or diminution of the
tendons of insertion. The tendon going to the little fin-
ger may be absent, and also that going to the index
tinger. It is more common to have an increase than a
iliiiiinution of tendons. Any one of the tendons may be
suhilivided. and as many as eleven have been observed by
Perrin and Riidinger. due to doubling of some tendons
and tripling of others. Curnow in one case saw twelve
tcndims go to the inner four digits and five to the thumb,
making seventeen in all. Five and six are commonly
seen, the tendons of the little and index fingers being
most often duplicated. The extensor communis occa-
sionally sends a slii) to the thumb.
The indicial portion of the muscle may be completely
separated from the rest, and the extensor minimi digiti
may be inseparably connected with the larger muscle.
KrtciiKor Minimi Diyiti. Sonietinies fused with the
common extensor or carpi ulnaris. It may be double,
the additional tendon being in.serled into the ring finger.
It may have an ulnar attachment, and may be inserted
into the annular ligament. Complete absence of the
muscle has been observed.
Krtntxor Cor/ii I'lmiris. An accessory or .short exten-
sor, going from tlii' lower end of the fiairth and fifth
metacarpal bone, has lieen described. The tendon is not
unfreqiiently prolonged downward to the first phalanx
of the little finger (nhiuris qviiiti). It is also freijuently
connected with the abductor minimi digiti. Sir William
Turner has lately re|iorted a case of absence of this mus-
cle; its ]ilace was taken by a slender band of fibrous tis-
sue. Curnow has also recorded absence of this miLScle.
Supiiiiitor llreris. An accessory su[iinator brevis lias
been obserx'cd going from the external condyle of the
humerus to the radius or ulna. The extent of attach-
ment to the ra<lius may be much greater than usual.
A sesamoid bone is sometimes found in the tendon of the.
muscle. This occurs normally in some animals, and is
also seen in the popliteus, of which the short supinator
is supposed to be the homologue.
F.jtiiiaor <).ixi>, Mi/iinirpi I'ollifix. The tendon of this
muscle is frequently double, and sonietinies is triple.
When double, usually both are inserted into the meta-
54
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Uliisclos.
I^Iuscles.
carpal boue, or one into this bone and the other into the
trapezium, as is the normal arrangement in apes. Tlie
supernumerary tendon ma_v be inserted into one of the
short muscles "of the thumb. The muscle may be double
throui;hout, and Curnow has in one case seen it triple.
Exteitsoi- Priiiii luternodii Pulliri's. Is sometimes ab-
sent, or is not differentiated from tlie extensor ossis meta-
carpi Curnow describes a case of doubling of this mus-
cle. It is found only in man.
Exiensar Secundi Internodii Pollieis. Doubling of the
muscles is not uncommon. Additional muscles are occa-
sionally jiresent, and have been described b)' Curnow
(Jour.'Anat. and P/ii/s,. vol. x., p. 596).
Etteiisov Primi Internodii Pollieis et Indicts. In some
rare cases there is au accessory extensor present, which
arises lietween the extensor indicis and the extensor se-
cundi internodii pollieis; it divides into two tendons, one
of which goes to tlie first phalanx of the thumb, and the
other to tlie index finger. This muscle exists uormallj-
in the dog and manj- otlier carnivora.
E.rtin,vir Indieis. Tile tendon of this muscle is fre-
ciuently divided into two portions, one going to each side
of theinde.x finger; sometimes one of tlie tendons goes
to tlic middle finger. This latter is occasionally seen as
a, distinct muscle {ei-tensorpropriusdigiti medii). It arises
from the lower part of the ulna or posterior ligament of
the wrist-joint, and is inserted into the base of the first
phalanx of the middle finger. It exists normally in
apes.
A sliort e.rtf«w;- !'«rf/ci'« is occasionally seen taking its
origin below the long extensor, from tlie bacic of the wrist
•or a carpal bone; it is inserted with the long extensor
into the index finger. The writer has seen this accessory-
muscle arise from the radius, and pass tlirougli a separate
■compartment in the annular ligament to be inserted into
tlie index finger. The extensor indicis may have a more
.extensive attachment to the radius than usual. Tlie
writer lias seen it connected by a tendinous slip with the
extensor secundi ])ollicis. Curnow describes one case
in which the muscle divided into three tendons — one in-
serted normally, one witli the secundi internodii, and one
with the aponeurosis over the middle finger. A some-
what similar arrangement is seen in the hedgehog, Ican-
garoo, and nianis. It is rarely absent.
E.rteiisor Pnlheis and Indicis (see alio\-e).
Erttnsar Breris Diffitnnini. Very rarely met witli. It
-arises from the back of the wrist, post-annular ligament,
from the carpus itself, or the bases of some of the meta-
carpal bones by fleshy fibres: it sends tendinous slips to
^)ne, two, or three fingers. The writer has seen tliem
going to the ring and index fingers and to the middle
finger. It is probable that tlie extensor brevis indicis and
-extensor medii digiti are varieties of this muscle. (See
Fig. 34.58. )
Tliis muscle is common in reptiles, and survives only
in a few anomalous mammals of the order Edentata
■(Curnow).
Muscles of the H.^xd. — Pnhntiris Breris. Varies
considerably as to its degree of development. It is oc-
casionally altogetlier wanting.
Abductor Pollieis. Some anatomists describe the mus-
cle as normally consisting of two porti(ms— an outer and
inner. It may receive a third belly from the opponens
pollieis, or be connected witli it by a muscular slip. It
may also receive an accessory slip from the extensor car-
pi radialis longior, ossis metaearpi pollieis, palmaris lon-
gus, or from the radius. Not infrequently a thin, mus-
cular slip is seen going from the skin of the ball of the
thumb opposite the tuberosity of the trapezium to the
abductor pollieis. Some regard this latter as a skin-
muscle.
Flexor Brevis Pollieis. The deeper belly of the muscle
is often witli difficulty differentiated from the adductor
pollieis.
Adductor Pollieis. This muscle is frequently blended
witli tlie deep portion of the short flexor of the tliumb.
Abductor Minimi Bif/iti. Sometimes divided into two
•or even three slips. It is often united with tlie flexor
brevis minimi digiti. It may have an accessory slip,
arising from the tendon of the iduar flexor, the annular
ligament, fascia of the forearm, and teiidon of the pal-
tnaris longus. Tlie writer has seen an accessory head
arise from the intermuscular fascia beneath the flexor
radialis and ulnaris. The accessory slip may pass down
and cover the ulnar artery.
Flexor Breris Minimi Digiti. May be absent or re-
placed by a slip from the abductor minimi digiti or op-
ponens. An accessory head may spring from the lower
third of the inner border of the ulna, from the carpi ul-
naris, or fascia of the forearm. A doubling of the mus-
cle has been ob.served.
Opponens Minimi Digiti. Maj' be closely connected
with neigliboring muscles, or receive a second head from
the fascia of the forearm (Henle.)
M. Pisiuneinatus. This is a muscle described liy Ca-
lori, and stretclies between the pisiform bone and unci-
form process of tlie unciform bone.
Interosseous. These muscles do not vary to siny great
extent. They may be double in one or two interosseous
spaces. Henle describes a, pnlnoir interosseous muscle of
the thumb as normal. It arises from the metacarpal
boue of the thumb, and joins the inner head of the
flexor brevis pollieis. Tlie arrangement of the interos-
seous muscles of the hand has been observed, in rare
cases, to be similar to that of the foot.
Accessory Palmar Abductor Iialicis. The writer once
saw a small muscle arising from the third metacarpal
bone, beneath the adductor pollieis and inner head of the
flexor brevis pollieis. After ending in a round tendon,
it was inserted into the base of the first phalanx of the
index finger.
Muscles of the Lower Llmis. — Gluteus Maximus.
The great size of tliis muscle is jieculiar to man, princi-
pally on account of his erect position. In the human
species the muscle always covers tlie ischial tuberositv ;
in apes, this is uncovered. The variations are important.
The muscle may be consideralily reduced in size. Mac-
alister reports a case in which the muscle was attached
above to the last two sacral vertebrre only. The super-
ficial portion of the
muscle is often sep-
arated from the
deep by a layer of
cellular tissue. The
lower edge of the
muscle is some-
times quite distinct,
and represents the
agitator Cauda of
tlie lower animals:
it may be inserted
into the femur or
the femoral apo-
neurosis. The glu-
teus maximus is
occasionally blend-
ed with the tensor
fascifc. as in the
elephant and some
monkeys.
Isch io-feinoral.
The writer has only
once seen this mus-
cle. It arose from
the inner edge of
the great tuberosity
by a round tendon,
whieli soon devel-
oped into a trian-
gular-shaped muscle of considerable size; it was sep-
arated from the gluteus maximus by the great tuber-
osity, and joined it near the femur. It was inserted into
the lower end of the gluteal ridge of tlie femur. The
ischio-femoral muscle exists normally in the gorilla, cer-
tain apes, and other animals.
Gluteus Mcdius. The deeper fibres of this muscle may
-:ebb
FUi. 3453.— EI?Z>, Extensor brevis digilo-
rum. (After Wood.)
55
liEFEP.KNtK lI.VM>l!(»nK OF THE MEDICAL SCIENCES.
ond in a separate tendon, which is attached to tlie upper
bnrihT of the great trochanter. Its upper or lower lior-
der may Ix' separated from tlie rest of the nuisch^, ()<■-
easionaily a bursa is interposed Ijetween the teu(h)n of
the gluteus niedius and tlie |iyriformis. Some of its
tibres may be inserted into tlie pyriformis, or its poste-
rior border may bi' completely fused with that muscle.
(ill/tens Mii'ihii'ix. Ueeasionally divided into anterior
and posterior portions; may sen<l slips to tlie hip-joint,
to tbi' iiyriforinis, g<'melli. <m' vastus e.vternns muscles.
Aii-isxiirji Gliitfii.i Mi'iii/iiiis (fourth gluteal ; seansorius).
The tiln-cs of the anterior liinder are in some cases sepa-
rated from the mu.sclc, and inseited variously into the
anterior liorder of the great trochanter, into the capsule,
or near the lesser troclianter. wlieie it is coimeeted with
the iliacus tendon. It re])rcscnls the seansorius muscle
of apes. Testut looks upon it as representing the extra-
pelvic portion of the iliaeus niusi-lc.
Tiiisiir Viif/iiiir Fininris (tensor fascia'). Varies but
little. May have a supei'nuincrary origin Irnm llic ali-
dominal fascia, iliac crest, and I'lnipart's ligament. It
Flc. 3i.>l. — .17. At. E.Kaniiilt's nf duulilf superlliKil iliiirus imisi'lfs.
is .sometimes fused with tin- gluteus maximus. A dupli-
cation of the muscle has been observe<l by !Maealister and
Testut.
Pyrifrrmis. The most eonunon variation of this uuis-
cle is its division into two portions by the great .sciatic
nerve or its external p<ipliteal lirauch. It is occasionally
fuse<l witli the gluteus medius moif or less comidetely.
It may be connected with the glutens minimus by a few
tibres. Its tendiai is sometimes united with that of the
obturator internus, or receives the gemellus superior. It
may have its origin from as many as live sacral vertebra^,
or as few as one. It frequently has no attachment to
the first .sacral vertebra. It may be inserted into the
capsule of the hiii-joint. Its complete absence has been
nnted by several observers.
Ohtiiriitiir Ititeniiix. Thi^ variations of this muscli' are
unimportant. It may receive supernumerary fasciculi
from various parts in the )ielvis, as the p.soas minor nius-
cle. ischial tnbero.sity, sacro-seiatic ligaments, third sacral
vertebra, |)ubes, etc. A pubic portion is sometimes sepa-
rated by the obtiu'ator nerve.
Ohliinitiir Ej tint UK. "Wood has descril)ed a large fleshy
slip going from the adductor brcvis to join the tendon of
this muscle, and ^lacalistcr lias noted a sc]iaration of a
])ubie fasciculus by the obturator nerve.
(.hiiicUi. Tlie Kiipffiiiy iji iiu'lliis is not infreiiueiitly ab-
sent, or very small in size. The iufi n'or i/i imllint has
also been observed absent, but more rarely. Doubling
of tile stipen'of lias Ik'cu noticed : it has also been seen
fused with the pyriformis and gluteus mininuis. The
gemellus inferior and ipiadratus fcmoris are fre(|Uently
inseparably united to the ubturator internus.
Qiindratus Feiiinris. This muscle may be much re-
duced in size, or absent altogether; in such a case, the
inferior gemellus is larger. It lias been described as
sometimes double. It may be united above with the
gemellus inferior, and below with the adductor magnus.
Biceps Fle.vor Criirix. The two heads may be quite
separate, as in the orang and chimpanzee. The short
head may be divided into several fasciculi, or. in rare
cases, absent altogether. This latter arrangement is tlie
usual one in a large number of mammals. There is
sometimes a third head, which may arise from the femur,
from the ischial tuliercjsily, coccy.x, sacrum, fa.scia lata,
or gluteal fascia. The third head generally joins the
long head, though when it arises from the linea aspera,
or inner condyloid ridge, it joins the short head. The
third head has been looked upon as homologous with the
caudal origin of the biceps in the lower animals. In rare
cases a slip {iKc/iiuralcn/ietis) has been seen going from the
king head to the gastrocnemius, external tuberosity of
the tibia, femoral aponeurosis, and even to the tendo
Aehillis. This arrangement is a moditieation of that .seen
in the iower animals, cs|iecially the bear.
I have seen a musc\ilar slip arising from the biceps
near its insertion and inserted by a tendinous expansion
into the fascia covering the lower third of leg.
.'^ifmitindiiioniisiuul S'namemhrano.-iiiii. Tliese two mus-
cles may be fused into one. The niitiininuhrtiHoxu.'i may
be absent altogether. It has been seen doubli'. (Occasion-
ally, it derives its <irigin for the most part from the great
sacro-seiatic ligament.
The semiieiidiitusiix may have a supernumerary origin
from the coccj'.x, and sometimes gives off a muscular slip
about its middle, which is in.serted into the fascia of the
leg. This arrangement is normal in some of the lower
animals.
Psotts Miigiitit!. Varies somewhat in volume, according
as its origin is more or less extensive It occasionally
forms a muscle qiute distinct from the iliacus. It may
be divided into two portions, between which pas.ses the
anterior crural nerve. This is merely an exaggeration of
the normal condition. An accessory psoas is sometimes
seen ari.sing from the transverse processes of some of the
lumbar vertebra\ The writer, in a male subject, saw
this accessory jisoas of cnnsiderable size; it arose from
the transverse process of the fourth lumbar, and as it de-
scended widened out into a broad muscle, which joined
the magnus in the middle oi the iliac fossa.
Pmiis Pdii-iiK. Frequently absent and occasionally
fused with the magnus. It usually arises from the
bodies of the last dorsal and first lumbar vertcbne, and
soon becomes tendinous; it then ]iasses down to the in-
ner side of the magnus, and ends by being inserted into
the ilio-pectineal line and ])ectineal eminence It has
been noted as having an insertion into the lesser trochan-
ter, as in the seal, guinea-pig, etc.
Although inconstant in man, it is a large, well-devel-
oped, and constant muscle in the lower animals. Gruber
in 450 subjects fcamd absence of thismuscleon both sides
in 188, and on one side in 09; Pcrrin in 113 subjects
found it present in only 32; Theile found it in only 1 out
of 20 subjects examined ; and Testut, 0 out of 82.
It is oeeasioiuilly (hnible
Iliacus. May be divided intosevcral distinct jKirtions.
The deep portion is not infrequently separated from the
superficial by a well-marked cellular interval, and thus
constitutes a separate muscle.
•Superficial Iliacus. Sometimes seim arising from the
crest of the ilium, last lumbar vertebra, or upper border
of the sacrum. In one subject, the writer saw tliis mus-
cle on both sides: on the right side it was a broad, flat
muscle arising from the posterior third of the crest of
the ilium, and on the left a fusiform muscle, which
arose from the body of the last liunbar vertebra and
upper border of the sacrum. Both muscles ended in
strong tendons, which were pierced by the anterior
crural nerve, and joined the iliacus below Poujjart's liga-
ment (Fig. 8454).
Iliocitpsularis rel Iliacus Minor. Arises from the an-
terior inferior spine of the ilium and capsule of tiie hip-
joint; it may lie inserted into the lower jiart of the
56
KEFEREXCE HANDBOOK OP THE MEDICAL SCIENCES.
.lluscles.
anterior intertrochanteric line, lesser trochanter, or ilio-
femoral lij,'aiueut. In one subject the writer saw a
well-marked bursa separating it from the iliacus.
Sajiuriiis. A case of absence of this muscle has been
reported by Meckel. It is occasionally double in its
whole covirse. An accessory portion has been seen hav-
ing an insertion into the femur, patella, or tendon of the
normal muscle.
The .sartorius, in addition to ils tibial attachment, may
have an insertion into the femoral aponeiu'osis, the cap-
side of the knee-joint, or the femur itself in the neigh-
borhood of the internal condyle. All these various in-
sertions are seen normally in mammaliii. A tendinoxis
inscription in rare cases is seen in this muscle. The
•writer has only once met with this anomaly.
Q'iiidricf]:g Exierisor Cruris. Not subject to many va-
riations. Occasionally the acetabular origin of the rectus
is wanting, or it may be reinforced b}' an a<lditional ori-
gin from the anterior superior spine. The riiiti muscles
may be divided into two portions, superficial and deep:
thi.s bihiminar arrangement is the normal one in many
birds. The two vasti muscles are often clo.sely united.
The Siilicrurctis is a muscle which is very variable in
volume. It is often divided into two or more separate
muscular bundles.
ArirKKury J/tud to Quadriceps. The writer once saw,
on the left side of a male subject, a supernumerary mus-
cle which arose by a double tendinous origin from the
anterior portion of the capsule of the hip-joint and the
anterior border of the great trochanter. 'I'he two ten-
dons soon united to form one strong tendon, which
passed down the thigh between the iliacus and tensor
fascia-, lying on the vastus e.xternus; about the middle
of the thigh it developed into a strong muscular belly
three inches long. After passing beneath the rectus it
joined tlie common tendon of the quadriceps.
Grucilis. The variations are unimportant and consist
chiefly of a greater or less extent of origin and insertion.
An accessory head is sometimes seen.
Pcrtiiuus. May be occasionally divided into two por-
tions, as in some of the lower animals, each jiortion sup-
plied by a different nerve — the inner by the obturator,
and the outer by the anterior crural. In one case the
wi iter saw it divided into a superficial and a deep portion ;
the superlieial arose from the pectineal line, two inches
outside the pubic spine, and was inserted into the linea
aspera, with the adductor magnus. The deep portion
was the normal muscle.
The pectineiis is not infrequently tuiited with the ad-
ductor longus: this occurs normally among the Rodentia,
Carnivora, and Quadrumaua. It may be sometimes in-
serted into the capsule of the hip-joint.
Addiictitr Longus. ila.y be divided into two portions
by the passage of blood-vessels. It is often inserted low
down on the femur, and its tendon is inseparable from
the magnus. It is sometimes fused with the pectineus.
Adductor Breris. Occasion.illy divided into two or
three portions — may be continuous with the magnus. It
has been reported as united to the tendon of the obtu-
rator e.xternus.
Adductor Mar/n us. The upper part of this muscle is
so often separated from the nuiin portion that Henle,
M.acalistcr, and other anatomists describe it under the
name adductor minimus or quadratus. Its upper border
is occasionally completely united with the quadratus
femoris. The different parts of the muscle are not infre-
quently separated; the jiortion inserted into the internal
condyle is frcc|uently ipiite distinct (i.ichio-pondjitoid) .
TibioUs Aulicus. This muscle has been seen arising
from the femur, as occurs so generally in the higher
mammals. In the case reported the leg was congenitally
deformed. The tendon is occasionally double, the extra
tendon being inserted into the astragalus or base of the
first metatarsal, as in apes. Tlie tendon has been seen
divided into three portions, and occasionally a sesamoid
bone is formed in it.
I have seen a muscular slip from the tibialis anticus
end in a tendon which was inserted into the pro.ximal
phalanx of the fourth toe. I have also seen this slip in-
serted into the first ))halanx of the great toe.
Til)io/ascialis Anticus. A small nuiscle described by
Wood, Macalister, and Humphry, which arises from the
lower third of the anterior edge of the tibia, over tlie
tiliialis tmticus, and is inserted into tlu' annular ligament
and deep fascia. It is sometimes rejuesented by a ten-
dinous slip from the tibialis anticus, which is inserted
into the fascia of the dorsum of the foot. Gruber de-
scribes a tihio-astrayalus anticus arising from the tibi.a
and interosseous ligament behind the tibialis antitu.s, and
inserted in the neck of the astragalus.
JC.rlensor Proprius Halhicis. Is occasionally united
with the extensor communis digitorum, or short extensor
of the toes. The muscle or its tendons may be double,
and have a supernumerary insertion into the metatarsal
bone or first phalanx of great toe. It is sometimes in-
serted into the second toe. Its tendon may be divided
into three portions {e-ctensor hallucis hmr/us tricaudatu.s).
Extensor Ossis Metatarsi Hallucisis a small muscle aris-
ing from the extensor hallucis, tibialis anticus, extensor
communis digitorum. or as a separate muscle close to the
extensor hallucis, going through the same compartment
in the annular ligament as the hallucis; it is inserted into
the metatarsal bone of the great toe.
E.clensor Priud Internodii Hallucis. In one half the
subjects examined Professor Wood found this muscle ; it
is generally an offshoot from the extensor hallucis, but
sometimes arises separately.
Extensor Longus Digitorum Pedis. Varies considerably
in the mode of origin and the arrangement of ils tendons.
The ntunber of tendons m;iy be increased by the doubling
of any one. It is not uncotniuon for the tendon going to
one toe to give slips to adjacent toes. It may have an
additional insertion into the metatarsus. Occasionalh' a
supermimerary tendon is seen going to the great toe.
The tendons may be united on the dorsum by slips, as in
the hand. It may be united to a greater or less extent
with the extensor proprius hallucis, or extensor brevis
digitorum. Ea<h of the tendons may have a sejiaiate
museidar bell}" in connection with it. AVood rejiorts a
case in which the four tendons had each a separate mus-
cular belly. All these abnormal arrangements have their
corresponding normal conditions in the lower animals.
Peroneus Tertius. Sometimes of large size, and occa-
sionally inserted entirely into the fotuth metatar.sal bone.
Its tendon may luiite with that of the extensor going to
the fourth or fifth toe. or it ma\' unite with the fourth
dorsal interosseous. The muscle may be absent alto-
gether or be double.
Peroneus Longus. Occasionally fused with the brevis.
In one case it has been noted as arising from the femur,
as in many lower animals, e.g, the bear, hyfena, etc. It
may have a suiiernumerary insertion into one of the me-
tatarsal or cuneiform bones, as occurs in some animals.
The tendon sometimes gives origin to the flexor brevis
minimi digiti and outermost plantar interosseous (Wood).
Peroneus Acccssorius. This is a small muscle which
arises from the fibula between the jieroneus longus and
jieroueus brevis, and ends in a tendon which joins the
long peroneal.
Peroneus Breris. The tendon of this muscle is occa-
sionally divided into two portions, the supernumerary
one going to the fourth metatarsal or cuboid bone, or to
the proximal plialanx of the fifth toe, joining the exten-
sor tendon of that toe. It may also be inserted into the
abductor minimi digiti.
Peroneus Quinti Digiti. It arises from the fibula be-
neath the peroneus brevis. and is inserted into the exten-
sor aponeurosis of the little toe. It is seldom seen as a
distinct muscle, being generally united with the jieroneus
brevis. It is seen normally in some animals, as th(! bear
and the cat.
Peroneus Quartus. A muscle which is not infrecpiently
seen arising from the back of the fibula, between the pero-
neus brevil? and lli'xor hallucis. or from the fascia of
the deep muscles of the calf; it is inserted into the ex-
ternal malleolus, peroneal tubercle of the os c^cis, or the
67
iriiisdes.
in 11 solos.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
--A
Fig. o4')5. — .1. Exaniplt'
of 11 third head to the
gastrocnemius. (Wood.)
ridges of the cuboid groove. This is loolied upon by
Tcstiit as ii variety of the ])eroneus quiiiti diffiti.
Ill a male stiliiect tlu- writer saw. on butli sides, tlie
pciiineus longusiilvideil into two portions: theotiterand
larger passed down in tlie usual
eoursc of tlie long muscle, but the
iiuier and smaller portion, which
arose ]iriucipally from the inter-
muscular septum, ended in a ten-
don wliicli passed through the
same compartment in the annular
liiigment as the outer portion, and
immediately before it reached tlie
peroneal tubercle it divided into
two parts, one of which spread
out and was inserted into the
tuljercle; tlie other crossed over
the tendon of the pcroneus brevis
anil was lost in the fascia cover-
ing the dorsum of the foot; be-
tween these two tendons passed
the tendon of the peroneus brovi.s.
This was probaldy a variety of
the peroneus quinti digiti and
peroneus quartus muscles.
Extensor Bnvis Bigitarum. The
number and arrangement of the
tendiins vaiT considerably. Vety
frequently one or more of the
tendons are doubled. A slip not
infrequently goes to the little
toe. The number of tendons may
be reduced to two; occasionally a
single tendon may have two mus-
cular heads in cnnnection with it.
The innermost portion going to
the great toe is often sejjarated
from the rest of the muscles, and
is called the extensor hrevis hiUiicis. Wood descrities
cases in which slips from the tendons of the extensor
brevis joined the dorsal interosseous. There may be a
special slip .going to the second metatarsal bone or long
extensor tendon of the second toe. This
would be the homologue of the extensor
indicis of the hand.
Onutroenemius. The two bellies are
sometimes more or less completely sepa-
rated from each other, as in the mar-
mot, unau, eoati, etc. The most com-
mon anomaly is the existence of a third
head (see Fig. 345.5). This consists of a
band of muscular tibres, which may arise
from either condyloid ridge, the poplit-
eal surface of the femur, or the posterior
ligatnent of the knee-,ioint; passing
down, it most frequently joins on the
united muscle. This third head may
pass between the jiopliteal artery and
vein, or over both vessels and nerves.
It is sometimes divided into two por-
tions.
The writer has seen a third head aris-
ing from the inner side of the tendon of
the biceps femoris. about three inches
above the condyles. It passed down,
and joined the external liead aliout one
inch above its junclinn with the internal
one. This is tlie normal arrangement in
the lion and some other animals.
A slip may be given otT frmu the bi-
ceps, semitcndinosus, or adductor mag-
nus to the ,gastrocnemius. The writer,
in one female subject, saw eom]jlete
absence of the external head. On re-
moving the skin and fat. the tirst structure which came
into view was the pl;intaris muscle (see Fig. o4.')()).
Absence of the wliole musele has been observed.
Occasiotjally a sesamoid Imne is developed in the ten-
Fig. 34.)!'). -.^ i>-
sence of ttie e.\-
ternal head nf
gastrooueiiii us.
(Shepherd. )
don of the external head. A similar arrangement exists
in many animals.
S/leu.i. An accessory .soleus is occasionally seen which
arises from the oblique line of the tibia and joins the in-
ner side of the soleus : it covers the posterior tibial ar-
tery, and is often of large size.
The soleus has been observed of very small size, the
fibular portion alone existing.
It is sometimes inserted into the os calcis separately
from the gastrocnemius, an arrangement which is coni-
nion in many animals. A muscular slip going from the
tibia to the tendinous arch over the popliteal vessels has
been occasionally seen.
Pleintiiris. Tlie plantaris, which is rudimentary in
man and gradually di.sappearing. is of large size iu some
animals, and in them is continuous with the plantar fas-
cia or flexor brevis digitorum. In man it is fre(|uently
alisent. It sometimes arises b.v two heads, the supernu-
merary one coming from the posterior ligament of the
knee-joint or from one of the condyles. The writer has
seen this supernumerary head aiise from the outer head
of the .gastrocnemius and the middle of the outer surface
of the soleus by a tendinous origin.
The plantaris has been seen to arise from the jiopliteal
fascia and fibula. The writer on one occasion saw it
arise solely from the posterior ligament of the knee-joint.
The mode of its insertion
varies, its tendon sonietiiues
joins the tendo Achillis or
internal annular ligament, or
ends in the deep fascia of the
leg. It may send a slip to
the plantar fascia {tensor
fnscice pliintdris). Its tendon
may be enclosed in the lower
part of the tendo Achillis.
Peiplitetis. Asesamoitl bone
is .soinetiines developed in its
teudon of origin. The mus-
cle in rare cases is absent al-
together.
Popliieus Minor. Is a small
muscle, rarelv seen, which
arises from the femur inter-
nal to the plantaris and is in-
serted into the posterior liga-
ment of the knee ■ joint.
Wagstaffe has described an
accessory popliteus which
arose from a sesamoid bone
developed in the external
head of the gastrocnemius, and was in.scrted into tlie ob-
lique line of the tibia superficial to the normal muscle
(see Fig. 34.57).
PeroniotiliaUs. This is a muscle described by Gru-
ber, who met with it in one in seven subjects. It arises
from the inner side of the head of the fibula, and is in-
serted into the upper end of the oblique line of the tibia.
It is placed bene:ith the popliteus. and is looked upon as
the hoincihigue of the jironator teres in the arm. It is
seen in many of the lower animals.
Flexor Lonniis Diyitornm Pedis. This muscle varies
somewhat as to its origin. It frequeutl_y receives extra
slips of origin from the deep fascia and aponeurosis of
the leg, the tibia, fibule, or flexor hallucis. The writer
has several .times seen muscular fibres originating exten-
sively from the deep aponeurosis and flexor hallucis. ami
crossing the tibialis posticus to reach the flexor digitorum.
In some cases the tibialis posticus was completely bidden
from view by muscular tibres. A similar arrangement is
seen iu a great many of the apes. The tendon going to
the .second toe is sometimes absent; in these cases the sec-
ond toe receives a slip from the flexor hallucis.
Fh'.T(ir Areessorins hmgus Dirjitornnt Pedis. This mus-
cle and its varieties have been described under various
names, as tihioaceessorius, oceessoriiis iid neeessuriuni
(Turner): jteriine<»-o!niue'is inlerii'is (Macalister); pronn-
tor pedis (Humphry). It may arise from the tibia or
A.T
Fig. ^57.— AP. Accessory pop-
liteus arising from a sesamoid
bonel/St; P. nonual popliteus.
OVagstaffe.)
58
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
.lliiscles.
iviuscles.
fibula by a fleshy belly and in a well-marked tendon,
which passes through a separate compartment in the an-
nular ligament, either in front of or behind the tlexoi
hallucis, and finally ending by joining the flexor acces-
sorius or the tendon of the long flexor before it divides.
It has been seen to replace the proper aecessorius. In
its course down to the foot, its fleshy fibres generallj'
cover over the posterior tibial vessels and nerves. When
it arises from the fibula and is inserted into the tubercle
of the OS calcis, it is called the penuieocalcaneus inlcrniis,
and is looked upon as the homologue of the pronator
qtiadratus of the forearm. The writer has several times
seen this muscle arising from tlie tibia, and only once
from the fibula. In one case it arose by two fleshy
lieads, one from the flexor hallucis, and the other for two
inches from the inner border of the tibia immediately be-
low the soleus: the two heads united to form a single
belly which, after covering the poisterior tibial vessels,
ended in a tendon. This tendon passed beneath the an-
nular ligament ]iosteiior to the vessels, and in the sole of
the foot joined the tendon of the long flexor; the normal
aecessorius was inserted into this tendon instead of into
that of tlie flexor.
A flf.ror prfiprivs digiti secimdi, arising from the ti-
bia and going to the second toe, has been described by
Bahcsen.
Flexor Aecessorius. The outer head is not infrequently
absent. The muscle is sometimes much reduced in .size
and may even be absent. Its accessory long liead has
already been described under the name flexor aecessorius
longus digitorum pedis.
The numlier of digital tendons to which this muscle
can be traced varies considerably. Offsets may be sent
to the second, third, and fourth toes, and sometimes to
the fifth. In rare cases it can be traced to onl}' two ten-
dons. The muscle has been ob.served going to the flexor
hallucis tendon instead of the digitorum. It sometimes
gives off a slip to the fifth toe (as in monkej's), when the
slip to tliat toe from the brevis digitorum is absent.
Ijioiihricdles. Absence of one or more of these muscles
occasionally occurs. The writer once saw, on both sides
of the .same subject, the two outer ones absent. Two are
sometimes seen going to one toe. The tendons are fre-
quently inserted into the first phalanges of the toes.
Flexor Ilidiuris Lonrjns. Seldom varies. The tendons
of the digitorum longus and hallucis are seldom com-
pletely separated; they are generally united by a slip
from the hallucis to the digitorum, and sometimes by one
from the digitorum to the hallucis. The slip from the
hallucis may generally be traced to the second or thinl
toes, sometimes to all. and sometimes to the second only.
In a subject dissected in 18T9 by the writer, the tendon
of this muscle divided into three tendons, which went to
the great, second, and third toes. The longus digitorum
divided into four tendons as usVial ; but those going to
the .second and third toes were of small size, and joined
the ones from the hallucis. The lumbrical muscles were
in connection with the digitorum tendons. In this case
there was no connection between the tendons of the mus-
cles before division, A slij) may be given off from the
flexor hallucis in the leg, and after passing under the
annvilar ligament, may join the aecessorius. This is a
variety of the muscle described above— ,/?('.)■«;• areessoinus
longus dinitorum pedis. In rare cases the tendons of the
two long flexorsare fused into one, as is seen in the lower
animals. The writer once saw a sesamoid bone developed
in the tendon of this muscle as it passed over the astraga-
lus and OS calcis.
Tihiii/is Posticus. Very seldom varies. Is occasionally
blended more or less intimately with the flexor hallucis.
A sesamoid bone is frequently developed in its tendon.
It has been described as being inserted into the peroneus
longus tendon, second, third, and fourth metatar.sal
bones, and cuboid. Wood has seen it combine with the
flexor brevis liallucis muscles. It has been reported ab-
sent by Budge.
Tihiiilis Seanid'is. This is a mtiscle described Ijy
Bahnseu, Henle, and Linhart. Henle calls it the tensor
.-i^-
Fig. 34.58.— ^4Q, Example of the
abduetnr ossis metatarsi quinti
arising from OS calcis. (Bratlle.v.)
of the capsule of the ankle-joint. It arises from the back
of the tibia below the flexor digitorum longus, and is in-
serted into the posterior part of the capsule of the ankle-
joint or annular ligament. A similar muscle has been
described as being inserted
into the anterior ]iart of the
capsule of the ankle-joint.
Fle.ror Breiis Digitoruin.
The slip going to the fifth
toe, which is usually of
small size, and very often
not perforated by the deep
flexor, is sometimes absent
altogether. Five tendons
have been observed, two
going to the second toe.
The slip to the little toe,
when absent, is occasion-
allj' replaced by a small
muscle arising from the
outer side of the long flex-
or tendon or flexor aeces-
sorius.. This arrangement
is seen in many of the apes.
The tendons of the short
flexor may be united to
those of the long flexor,
and have a common inser-
tion. Some portion of the
short flexor may arise from
the long flexor tendon. The writer, a few years ago,
saw a vep_v good example of this, an arrangenient which
is like that which exists in apes. The muscle consisted
of two portions, superficial and deep; the superficial
arose froiu tlie inner tuberosity of the os calcis, and di-
vided into two tendons whicli w-ent to the second and
third toes; the deep portion, however, arose by a fleshy
origin from the deep flexor tendon before it was joined
by the aecessorius; its tendons were distributed to the
fourth and fifth toes.
AVood mentions a case in which the slip to the fiftli toe
was augmented by another from the long flexor tendon ;
they formed a single tendon, which was not perforated
but blended with the tendon of the long flexor going to
that toe.
Abductor HiiUi/eis. Its tendon is sometimes joined by
a muscular slip which comes from the skin in front of the
inner ankle. AVood describes a muscular slip from the
abductor to the base of the first phalanx of the second
toe.
Ahductor Minimi Digiti. The tendon is sometimes
double.
Ahductor Ossis Aletotnrsi Quinti. A portion of the
above has been described, by AVood and Bradlej", as a
separate muscle arising from the outer tubercle of the os
calcis, and inserted into the base of the fifth metatarsal
bone ; it occurs in about every other subject. Most anat-
omists look upon this as merely an insertion of the abduc-
tor minimi digiti, which fails to exist in about half the
subjectsexamined. Occasionally it exists as quite a sep-
arate muscle (see Fig. 3458), having an extensive origin
from under the surface of the os calcis. The interest at-
taching to this muscle lies in the fact that it is the true
homologue of a muscle always present in the anthropoid
apes.
Fle.Tor Brevis Bidlucis. A slip may be sent to the base
of the first phalanx of the second toe (AA^ood). It some-
times receives fibres of origin from the os calcis or long
jilautar ligament. Occasionally it fails to be attached to
the cuboid.
Adductor HdUuris. Occasionally a slip is seen going
to the base of llie first jihalanx of the second toe; this
may arise from tlie second nielatarsal bone, or sheatli of
the tendon of the peroneus longus. Henle thinks it rep-
resents tlie ii)tcroK.ieux mlnris primus of the hand.
Opponeiis ILiUucis (JIacalister). Given off from the
preceding muscle and inserted into the base of tlie meta-
tarsal bone of the great toe, as in apes.
59
I?I II soles,
IVlusolos.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
AdOuctar Indinn. The writer (inoe saw i. large muscle
arise from the cuboid ami sheath of the peroneus loiigus
teudon. outside the adiluclor hallueis, and ,iro to be in-
serted into the base of tliellrst piialanx of the second toe.
This, iio doubt, is Die hoIn(llo^■ue of the adductor iiidieis
of (juadriuuaua and oilier animals, as the sloth, elephant,
etc.
Tmiuvermis PnU'x. Tin' slip from the fittli toe is often
wanting, and others may tdso lie absent. The whole
muscle is oci'asionally alisent.
Siiperjiciiil Tniiian'riiiin J'n/ix. In 1.ST9 the winter saw.
in the right foot of a male subject, immediately beneath
the skin.a musele which arose from the bases of thelirst
phalanges of the second, third, and fifth toes, and was
inserted into the base of tlie lirst plialan.\ of the great
toe; deeper down the normal Irausversus pedis existed
and was of the usual size.
Flcror Bnrin Miiiinil IJiriiti. A slip of muscle is very
frequently seen given olT from the inner border of this
mu.scle, and inserted separately into the anterior half of
the lateral border of the fifth metatarsal bone. In some
cases it is almost a distinct musele. Hcnie calls it the
opponens vuniiiii diyiti, and looks upon it as the nor-
mal arrangement. It is well developed in the orang-
outang.
Jntermseo'is. Seldom abnormal. 5Iay vary sometimes
in si/e. aceordin.g to the size and use of corresponding
digit (\Vooi.l). A slip is occasionally seen arising from
the base of the second metatar.sal bone and sheath of the
peroneus longus. and inserted into the base of the lirst
phalanx of the second toe. Heiile regards this as the
homologue of the interosseus volaris primus of the
hand.
jMfSCI.T'.S OF THE TlU'NK. — Iiicfiis Ciipilh PdHtiniX
Minor. The writer has once seen this muscle ab.seut
on the right side. The left was of large .size.
Sri'iitns Pik/i'o/.i In f trior. jNIacalister has observed
absence of this niusclc. It may consist of only three
slips, or in rare cases there may be as many as five or
six from the first to the sixth rib. Slijismay be received
from the levator angiili scapula'. I have, in two cases,
seen a well-developed muscular slip arising from the
mastoid process, beneath lliesterno-mastoid, and inserted
into the upper border of the serratus ])osticus superior.
Once I noted a sli|i passing from the fifth cervical trans-
verse process to this muscle.
Sernitu.<< Po.iticH.i Siijurinr. In rare cases the whole
muscle has been absent. Absence of one or more digita-
tions is not infreipient. It is occasionally of larger size
than normal. The writer once saw it. arise from the four
lower dorsiil spines, and two upper lumbar, and go to be
inserted into the five lower ribs.
Spleniiis. The extent of origin of the splenius varies.
It not infreqtiently reaches as high as the middle of the
ligamentuni nucha' ; it may even be attached to theocci])-
ital protuberance (as in the bear). In one subject, on
both sides, the writer saw the splenii attached to the
whole length of the ligament um uuch.'e, the occipital
protuberance, the superior curved line of the occipital
bone, and the mastoid process. The two muscles pre-
sented the appearance of an inverted triangle.
The siilenius colli may hiive a slip of attachment to tlie
third cervical transverse ]u-ocess. The writer has seen it
send slips to the second and third cervical, and in one
case to the cervicalis ascendens. The splenius cajiitis
may be quite distinct from the splenius colli, or these two
portions may be fused together. The colli jiortion has
been reporteil absent.
Rliomho-,i1hii(l (Macalister). Splenitis accessorius, ad-
jutor splenii (Walther). This muscle has already been
descrilied with tlie rhomboid. It is a muscular slip going
from the transverse jirocess of the atlas to the serratus
magnus, rhomboid or serratus jxistieus superior, and is
looked on by Wood as indicating the first degree of dil-
ferentiation in man toward the formation of the occipito-
scapular muscle of the lower animals.
Liffdmenliim Suchm lit plural hji Muscle. The writer, in
one case, saw the upper part of this ligament rejilaced
by strong muscular fibres, w liich were attached to the
external occipital protuberance, the whole length of the
occipital crest, and the posterior tubercle of the atlas and
axis. The external border of this muscle consisted of a
thick, round tendon, continuous below with the liganien-
tutu luichic, which was normal from thes|iineof the third
cervical vertebra.
SiirrdlntDhiilin. Tin- inferior and superior aci'essory
origins of the sacrolumbalis are infrequently absent.
'J'lie rerrirdlis iinctiidtDS may arise as low as the tenth rib,
anil be inserted as high as the third cervical.
SpiiiiiliK Ccrricis. This is described liy Ilenle as a nor-
mal muscle. It is very inconstant, and arises from the
spines of the fifth, sixth, and seventh cervical and upper
two dorsal vertebra?, and is inserted into the spine of the
axis, and sometimes the spines of the third and fourth
cervical verlebnv.
E.rteim>r Uorcygis (sacrocoecygeus posticus). This is
tlie name given to some slender muscularflbres occasion-
ally seen going from the lower end of the sacrum or the
jiosterior inferior iliac spine to the coecj'x. It is the
liiimologue of the great caudal extensor of the lower ani-
mals.
Liiiir/i,\.siii)iis Dorsi. Jlay vary somewhat as to the
number and extent of its attachments. The writer once
saw it receive accessory fibres from the spines of the
third, fourth, fifth, and sixth dorsal vertebra'.
Spiii'itia JJor.'<i. Tlf number of tendons of insertion
ma}' be reduced to three; one spine may receive two ten-
dons.
V<iiiipli:rii.H. The biventer cervieis may be completely
fused with this muscle. It may be fused with the trach-
elo-mastoid or longissimus dorsi. The number of verte-
brae to which it is attached may vary from two to seven.
.'\ supernumei-ary fascia sometimes arises from the trans-
verse process of the second dorsal vertebra, and is insertwl
into the occipital bone beneath the normal muscle. The
biventer frequently receives accessory slips from .some
of the lower cervical or upper dorsal vertebral spines,
or from the ligamentuni nucliae. Slips have been seen
going to join it from the seventh cervical transverse
[irocess.
Miillijidii.i Spiiiic. The origin from the seventli cervi-
cal vertebra uiay fail. Muscular slips may rtiu from the
necks of the first and second ribs to the fifth and sixth
cervical vertelira', as well as between other ribs and ver-
tebra'.
Inter.ipiiudcx. Longer iuterspinous bundles are some-
times found passing over one or two vertebne. In the
neck tlie bundles are broader.
The short /i*<'^(^;cy muscles of the neck may be occa-
sionally doubled.
Kriirniil Jritercostnls. The last ones are sometimes
wanting. Not infrecpieiitly they extend as far as the
sternum between the costal cartilages. The lower inler-
costals occasionally are continuous with the external ab-
dominal obli(|ne.
Interniil Intereosfnh. These freipiently extend to the
vertebral column. The last two are sometimes absent,
orsosmtill that it requires a very careful dissection to
discover them.
.'^iipnirti.stiili.s (Wood); lierttis TJioraci.i (TuTner). This
is a muscle which lies on the upper ribs in the antero-
lateral part of the thorax, and generally extends from the
first to the fourth rib.
It has been looked upon; (1) as the homologue of the
thoracic extension of the rectus abdominis to tlie first rib,
as is .seen so often in mammalia, e.r/., cat, otter, beaver;
("2) as a reproduction in man of the sternocostal muscles
of the lower animals, e.g.. dog, badger, etc.; (3) as be-
longing essentially to the scalene system of muscles, and
corrcsjionding to the condition seen in manj- animals. In
the bear tlie scalene muscles extend back as far as the
.seventh or eighth rilis. The last view is probabl_v the
correct, one.
Triiiiir/ultirif! Stern i. This muscle varies much as to
its extent and jioiiitsof attachment. Absence of one or
both mu.scles has bi-en noticed. Theile reports a case
60
REFERENCE HANDBOOK OF THE 5IEDICAL SCIENCES.
Muscles,
ITlu»»cles«
in which it extended to the clavicle. It is sometimes con-
tinuous -with the tran.svei'salis abdominis, of which it is
supposed to be u remnant or appeudatre.
Diaphva;im. The sternal portion of tlie muscle is not
infrequently wanting (Quaiu). Carruthers {Liinctl, 1M79)
reports a case of absence of the left half of the diaphragm
in a child which lived ten days. In this ease there was
hernia of the small and part of the large intestine into
the thorax. Absence of portions of the diaphragm is
occasionally seen, and in these cases there is nearly
always hernia of some of the contents of the abdomen
into the thorax. At a i)ost-ni(n-tem held at the Jlontreal
General Hospital in If^So on a man aged forty, a portion
of the left half of the diaphragm wasab.sent, and through
the opening the greater portion of the stomach protruded
into the thorax.
A tleshy fasciculus has been seen pa.s.sing from the bor-
der of tl'.e esophageal opening to the (psophagus. Knox
lias described a mimeuhis hepaticocli<ipltra(jma1icus arising
from the left side of the central tendon and passing over
the oesophagus to the right, dividing into two slijis, one
of which went to the under surface of the liver and, be-
coming tendinous, joined the obliterated ductus veuosus
and umbilical vein; the other cro.ssed the right crus and
was lo.st in the peritoneum.
Ilenle and Bourgery describe a muscular slip going
from the costal cartilage of the seventh rib partly to tlie
costal cartilage of the ninth, and partly across the middle
line of the diaphragm to the opposite border of the ster-
nal portion.
Anmnahus Muscle of the Tlinrii.r, Cuniiceled tci'th tlie
Diaphragm (Subcertehral liectiis of Ihuiiphri/ >) In a well-
developed male subject in removing the lung and pleura
the writer found a long, flat, ribbon-shajied muscle I'un-
niug down the left side of the bodies of the dorsal verte-
bra'. It arose from the anterior surface of the head of
the sixth and seventh ribs. Becoming broader as it de-
scended, it ended in two slips, one blending with the left
arcuate ligament, and the other, which remained muscular
with a tendinous intersection, united, by a blending of
the two muscles, with the left crus of" the diaphragm
(Jour, of Anat. and Phi/s., vol. xxx.).
ExteriKil Abdominal (Jhli(pie (obliquus cxternusabdomi-
nis). According to Macalister, the number of attachments
to tlie ribs varies from six to nine, and one or more slips
may be doubled, generally those arising from the eighth
and ninth ribs. It is not imcommon to see absence of the
highest and lowest digitations. The two lowest may be
rudimentary, and an additional fasciculus may come from
the lumbar aponeurosis. This muscle may be connected
with the serratus magnus, as well as with the pectoralis
major, b_y continuous fibres. The mu.sculus sternalis,
when present, may be intimately associated with the ex-
ternal oblique.
A fasciculus has been described going from the ninth
rilj to the skin over that region (Flcsch). This is no
doulit a remnant of the dorso-abdominal skin muscle of
mammals. Poland ("Guy's Hosintal Reports," 1841) re-
ports a case in which the external alidomiual oblique be-
came tendinous at a horizontal line on a level with the
umbilicus. It was inserted as usual into the ilium and
pubis, but had no connection with the linea alba or liuea
semilunaris: the internal edge of the muscle being exter-
nal to the semilunar line, and leaving exjioscd the inter-
nal oblique. In this case the external obliiiue received a
special fleshy fasciculus from the eighth rib, near its car-
tilage.
Interval Abdominal Oblique (obliquus internus abdomi-
nis). This muscle, like the preceding, is subject to va-
riations in the extent of its attacliineuts. Its upper or
lower attachments may be reduced: it may have an ad-
ditional slip of insertion into the ninth co.stal cartilage.
A tendinous inscrijition in the upper ]iart of this muscle
has been described as not uncommon : it generally jiro-
ceeds from the tenth or eleventh rib. Henle describes
once finding in the anterior portion of this inscription a
short, thin cartilage.
Accessory Abdominal Oblique (M. lateralis abdonnnis).
This is a muscle situated between the two oblique mtis-
cles, which arises from the ninth, tenth, or eleventli rib,
and passes down to be inserted into the crest of tlie ilium.
The writer once saw this muscle on both sides of the same
subject: on the right it arose from the tip of the twelfth,
and on the left from the lower border of the eleventh,
rib: this latter muscle was not inserted into the iliac crest
directly, but blended with the aponeurosis of the external
oblique behind and above the anterior superior spine of
the iliinn. Both muscles became broader as they reaclie<l
their iliac attachment.
In .some cases this muscle is attached to Poiijiart's
ligament or to the sheath of the rectus.
Transrersulis Abdominis. The extent of its attach-
ments may vary. Cases are reported in which it was
attached to the whole length of Potipart's ligament. The
spermatic cord may sometimes pieice its lower border.
Fig. .^59. — ^4, .Spliinoter ani continiu-d upward in ttie middle line ami
blending wltli Uie daruw nt tbe scToliiiu ; F, iierinieal fascia; .S,
sphincter ani. (Shepherd.)
especially in those cases in which the attachment to Pou-
part's ligament is more extensive than usual. Fusion of
the muscle with the internal obliciue has been observed,
and total absence has been noticed by Macalister. A
tendinous intersection has also been seen.
Rectus Abdominis. In some cases this muscle has been
seen extending as high as the third, and even the second,
rib. It is not uncommon to see a supernumerary slip
going to the fourth rib. In most animals the rectus ab-
dominis extends higher than it does in man ; in many
it reaches as far as the first rib, c.;].. in the bear, otter,
beaver, cat, porcujiine, etc. The writer once saw a slip
go from the upper part of the rectus to the middle of the
lower bcH'der of the pectoralis major. The number of
tendinous inter.sections may vary; as many as six have
been noticed in the negro.
Pi/rauiidalis. This muscle varies much as to size. It
is very frequently absent, and is occasionally double.
AVhen absent the lower part of the rectus is increased in
size. It is a muscle which is of no use in man,.and is a
mere rudiment of the larger muscle vvhich exists in mar-
supials. It is absent in many of the lower animals, e.;/.,
solipeds, ruminants, and many of the carnivora, as the
dog, cat, bear, etc.
Quadratus Lundiorum. Is sonietimes attached to the
eleventh rib, and to the bodies and transverse processes
of the tenth and eleventh dorsal vertebne. Lange {An-
nals of Surgery,'" vol. ii., p. 289) figures a quadratus
muscle sending a sli|) to the fa.scia covering the pleura
between the twelfth dorsal and first lumbar rib.
Muscles of the Perineum and Pelris. — .^pliineter Ani.
The writer once saw the superficial fibres of this muscle
continued up past the tendinous point ol the ]ierineum,
as a flat muscular slip 6 mm. broad and 5 cm. long.
This slip blended above in the middle line with the
dartos of the scrotum (see Fig. 84,')ti). Oc< n.sionally
fibres of the transvcrsus perinad are inserted into this
muscle.
61
]Tril!«<-lilar All'npliir;
:Ulls4-iil;ii- Alrojiliir*
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Coccygeus. Is sometinies inserted wholly iutu the side
of the sacrum (Quiiiii).
Saffdcof emit III* Antii'im (ciirvator coocygis). This is
the name siven to a few lleshy ami tendinous fibres jiass-
inir from the lower part of the anterior portion of the
s;iernni and eoceyx. It is well developed in animals
with tails.
Trdii.sterKii.i Ptriinil. This muscle is a very variable
one. It is occasionall_v absent, or so small as to be wilh
diltieulty dissected out. It is sometimes inserted either
partly or wholly into the accelerator urina' (bulbocaver-
nosus) muscle or s])liineter ani. This muscle is not in-
frequently fanshaiied. covering the triangular space
formed by the three jierineal muscles. In tliese eases the
ischiocaveruosus forms one edge of the fan. The fibres
are inserted into the accelerator urina'. central tendinous
point, and sphincter ani. The muscle is occasionally
double, the extra sliji joining the accelerator urina' or
levator ani. Ilenle describes a muscular slip sjiriug-
ing from the fascia at the lower border of the gluteus
maximus, and inserted into the lower surface of the
triangular ligament. In one case of absence of this
muscle, the writer found the deep tninsverse muscle of
large size.
yjfc/KV/Wf/'/cwHS (erector penis). Houston has described
a variety of this muscle under the name einii/iressor vena,
(hirsnlis penis. It is a slip arising in front of the ischio-
cavernosus and cr\is penis, which passes upward ar.d for-
ward, and is inserted with its fellow into an aponeurosis
above the dorsal vein. The writer once saw this ex-
tremely well developed. In the dog and some other ani-
mals it is quite a strong muscle.
Bidbiicaternosus (accelerator urina>). This niu,sclc is
occasionally joined by the transversus perinai. Kobclt
describes the tibres which cover the most jirominent part
of the bulb, and which are separated from the others by
a more or less distinct interspace, as the compressor Itetiti-
sphericum bidhi. Frmieis J. S/iepJwrd.
MUSCULAR ATROPHIES, PROGRESSIVE.— The pres-
ence of muscular atropliy at once suggests to the cliu-
iciau one of two possibilities, namely :
1. The atrophy is a si/mptoin. As sucli it may indi-
cate injury, hemorrhage, inflammation, or new growth,
affecting more or less acutel_v the oblongata, the spinal
cord, or a peripheral nerve; or it may be one expression
of joint disease and then due to reflex trophic disturbance
in the cord.
2. The atroph_y is a Jfscasc. In other words, it is
sufficiently regular in its evolution and constant in its as-
sociated symptoms to merit a definite place of its own in
our nosology. The scope of the present article is limited
to this .second group of muscular atrophies, those of the
first group being treated under apiirojiriate headings
elsewhere in this work.
Our knowledge of mu.scular atrophy as a clinical entity
dates from IS.'jO, when Aran ' published the first account
of what we now recognize as progressive spinal muscu-
lar atrophy, although he considered it a disease of the
muscles primarily. The disease was elaborated U]xin by
Duchenne a few years later, whence the name "Aran-
Duchcnue Disease." '»
The muscular atrophies which are clas.sed as distinct
diseases are divisible patholcigically into two types,
namely:
1. Tiie myopathies or progressive muscular dystro-
phies; also known as '■ idiopaihic " nmscular atroidii<'s,
which are characterized by slow pri'mature dissolution
of muscle fibres from inherent vital defect. This is a
long-recognized tissue eondititm for which Gowers has
recently given us the convenient and expressive term
■'abiotrophy'.'' -
Ahiotrophji of Ihc myon would be a concise statement of
the pathologico-anatomic status of this group.
'3. The inyelo]iathies or "spinal muscvdar atrophies,"
characterized jiathologically by the same jnocess (prema-
ture di.ssolution) in the spinal motor nerve elements (an-
terior horn cells or lower motor neurons). Since, how-
ever, these same changes often occur also in the cerebral
motor neurons (pyramidal motor cells) or in other cases
are apparently lindled to the peripheral nerves, a more
comprehensive designation would bo neuronic muscular
atropliy. Abiotrophy of tlie motor neurons, therefore,
would express the pathologico-anatomic nature of this
group.
While this classification serves to define the great ma-
jority of cases, a series of mixed forms or so-called "con-
necting links " between the two main groups is becoming
numerous in the literature as experience in their recog-
nition increa.ses, c.r/., cases which present symptoms of
myopathy and myelopath.v combined. The.se serve to
illustrate the anatomical and physiological fact now well
recognized, that the entire motor tract from the cortex
cerebri to coril and from cord to muscle fibre constitutes
a continuous functionating unit, and cannot sutt'er long
in one part without in some degree impairing others.
There seems no good reason, however, to the writer
for the use of the term "connecting link " for these cases.
The coincident or conseoitive involvement of one more
segment of the motor tract is all that is necessary to the
evolution of these mixed forms, and this may be reason-
ably postulated in any given case.
Accepting the pathological grouping into myopathic
and neuronic, therefore, as the best at present available,
we proceed in the order mentioned to consider the indi-
vidual diseases in each group. The accomjianying dia-
gram shows at a glance tlie anatomical l"cation of the
pathological process in the several clinical tvpes (Fig.
3160).
The myopathies or primary atrophies are divided clin-
ically into several " types," somewhat arbitrarily perhaps,
since there are good reasons for the view held by many
that they are all due to the same pathological processes,
dilTering mainly in location. An exception to this state-
ment, however, must be made in the case of the "p.seudo-
hypertrophy," which is a prominent feature in one
form.
They are all characterized, moreover, by certain clinical
features in common, of which the chief are;
1. Hereditary or familial tendenc_y.
'2. Onset before pulierty.
3. Preponderance in the male sex.
4. Loss of myotatic irritability, and in consequence
loss of " tendon refiexes. "
5. Electrical changes of reaction of qoantitatire charac-
ter (diminished resjiouse to galvanism and faradism), and
absence of typical R. D.
The recognized types of myo]-)athy are:
A. PsEUDo-iiTPEHTROi'iiic Mrscri..\R Atropift. —
Causation. The disease begins in childhood; in two-
thirds of the cases before tlie sixth year (Gowers).
Heredity is traceable in three-fifths of the cases (Dana).
The hereditary inlluence is strongest through the moth-
er's side, though tlie male members of the family are more
frequently affected. Churcli explains the transmission
by the female members of alTected families by the fact
that the disease renders the males impotent.
The disease is frequently preceded by some acute in-
fection— diphtheria for instance, which probably favors
its tmset in those already predisposed.
Sj/mptonis. — Weakness in the legs of gradual onset, ac-
companied by a " waddling " gait and frequent stumbling
without evident cause are the earliest symptoms. These
are usuallj' noticed about the fifth year and are often at-
tributed to carelessness or stupidity on the part of the child.
Later, a noticeable enlargement (pseudo-hypertro]ihy) of
the leg muscles, especially of tlio.se of the calves, appears.
This may extend to the tliighs and gluteal uiu.scles; and
the infraspinati are also frequently enlarged. Tlie en-
largement of mnscles may be slight in some cases, but
even in these an undue firmness with lack of elasticity is
noticeable on pal|iation. The shoulder girdle muscles
are alTeeted later, while those of tin; face, forearms,
hands, and feet escape for a long time, but are probably
alTected eventually in most cases that survive a sulficieut
length of time. Thus in two cases, brothers, aged four-
(!2
EXPLANAT1(,)N OF
PLATE D.
EXPLANATION OF PLATE D.
Serial kinrli.graplis illustraliiiu- llir rliaiaclcrislic iiicllidd nf arising from tlie recumbent posi-
tion in priigrcssivc muscular ilyslrojilix . the jiatient, " climbing up his own legs." (From t'ursch-
mann.)
I'.eginning at th.' b.p of Uft-liand colunui the ligures are to lie read downward ; then begin at
top of right-hand cohumi. The successive utilization of the muscles of the upper extremities to
assist the more atrophied ones of the legs and back is evident.
The weakness of the back muscles is also well indicated by the drooping head, counterbalanced
by the lordosis. The figures represent a case of myopathy with little if any pseudodiypertrojihy.
REFERENCE HANDBOOK
OF THE
MEDICAL SCIENCES
PLATE D
Ik
- .-^
*^lp?**~^
y
<^i^
^ -_ .J^
PROGRESSIVE MUSCULAR DYSTROPHY
(CURSCHMANN)
*i
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Ifluscular Alropliles.
muNCiiIar Atrophies.
myelopathies or
progressive spinal
muscular atro-
phies
teen ami niueteeu, seen recently by the writer, tlirough
the kindness of Dr. W. E. Lewis of Cineinuiiti, one pre-
sented marked weakness of facial muscles, and the occi-
pitofrontalis could not be made to act at all. though the
patient could frown at command. In this same patient
as well as his brothei-, aged nineteen, the hands were
markedly involved, the grasp registering by the dyna-
mometer only nine (right band) and ten (left) in the
younger; and nineteen (right) and fifteen (left) iu
the eider, both showing a reduction in power esti-
mated by me at seventy-five per cent, or more.
Moreover, in the elder of these brothers there was
marked wasting of the thenar group of right hand,
as well as fibrillary tiritchiiiy, though both eases
were typical myopathies in their development and
most other respects.
Peculiarities of posture and gait due to the mus-
cular weakness are developed in time. Loi'dosis is
commonly present when the patient stands. The
gait is waddling and clumsy. Frequent falls result
from the lack of muscular
Ijower and irregular con-
trol of movements, so that
contusions and abrasions
are frequent accompani-
ments of the disease.
Ascending stairs is par-
ticularly difticult, and the
patientarises from the prone or supine po-
sition in a characteristic manner by push-
ing with his hands upon the front of each
tlngh, to steady the legs. Thus he is
said to "climb "up his own legs." (See
Plate D.)
While the statement is commonly made
that the face is unaffected, nevertheless
the facies of most of these patients, ac-
cording to the writer's observation, is
characteristic in some degree of defective
muscular action. A blank, e.xpression-
le.ss countenance is the rule, or again a
marked senile aspect is present after the
disease has progressed for a few years. In one case this
facial involvement notably affected the smile, the mouth
extending horizontally iu a straight line, without the
usual curves, a pathological " ri-mx sdnlvuiciis."
In addition to lordosis, which is common, other forms
of spinal curvature appear late in the disease. Contrac-
tures are also a feature in the extremities, talipes equiuus
often resulting therefrom.
Apparent lengthening of the neck, due to the drooping
of the shoulders consequent upon weakening of the tra-
pezii (Brissaud) is noted.
Fibrillary twitching in the affected muscles is com-
monly absent, but the're are numerous exceptions to this
rule. Notably in the two brothers just cited, the elder
presents marked fibrillatiou in the lower portions of the
pectoralis major, as well as in the thenar muscles of the
right hand.
Sensation is usually unaffected. The writer has noted
one case in which a constant " piickly " sensation was
complained of throughout the trunk and limbs, but most
accentuated on the anterior chest wall.
The tendon reflexes are progressively diminished and
finally lost, as the muscular structure disappears.
The cases without psetido-hypertrophy are separated
from the preceding form by that circumstance and from
each other mainly by differences in distribution of the
atrophy. Two forms appear to require recognition, clin-
icalh' speaking.
B." The Sc.ipri,o-HrMER.\L Form, Erb's "Juvenile
Type" (Fig. 346'2). — This begins as a rule between the
ages of fifteen and thirty-ti ve. though a rauge of from two
to sixty years in ages of patients is recorded (Gowers),
The "shoulder, scapular, and upper-arm muscles are
first affected, though the deltoid often escapes (Gowers).
The pectoralis and latissiinus dorsi commonly wa.ste in
their lower portions. The supinator lougus is commonly
involved. As the disease progresses, the muscles gener-
ally are invaded.
Fibrillary contractions and R. D. are said to be absent.
C. The " F.\cio-sc.\PULO-HuMER\L Form, or L.^n-
douzy-Dejerixe Type. — Also called the "infantile
variety." In this the face is the part first attacked,
but tile ocular muscles and those of mastication es-
cape. The shoulder and upper arm are invaded later.
ftC-
1)H
{af/tiriot- /ifif^P/iS,
glosso - labio - laryn-
g e a 1 paralysis —
chronic bulbar
palsy
amyotrophic lateral
sclerosis or cere-
bro- spinal neu-
ronic muscular
atrophy
peroneal or leg type.
"Xeiiritic" mus-
cular atrophy
myopathies or pro-
gressive muscular
dystrophies
FIG. 3460.— Diagram of Motor Tract from Cortex Cerebri to Muscles,
Showing Sites of Initial Degenerations iu the Progressive Muscular
Atrophies and Dystrophies.
The disease begins earlier as a rule than the two pre-
ceding forms, though marked exceptions to this state-
ment are recorded.
For instance, in two cases reported by Hoppe," one be-
gan at twenty-three, and was alive at fifty-tive. In the
other, a daughter of the first patient, the disease began
at about the twenty-eighth year. These cases are al.so
anomalous in the fact of R. 1). being pi-esent as follows:
In the mother's case, in the thenar and hypothenar
muscles of both hands. In the daughter, iu the opponehs
poll/CIS ami flcror hrcris pn/lin'ri only.
Fibiillation was not jiresent iii either case, and the
mode of on.set and distribution were regular in all re-
spects.
D. Dist.\l Form op ^Myop.vthv.— Gowers' applies
this term to a case recently described by him, which dif-
63
iT9ll!«riil
A fro III
Atropl
II'S,
REFERENCE IIAXDIJOOK OF THE MEDICAL SCIENCES.
Fig.
3401.— Pseiiclo
.Atrophy.
Hvpertropbic Muscular
(c. L. Daua.)
fcrs from the oilier iiiyopHtliie.s chiefly iu the fact of tlie
atrophy Ijegiiining in tlie hands and feet, althoii.uh the
sterno-mastoids and tonjjue were also involved.
The disease liei;an
at ten or twelve, and
at eighteen the pa-
tient still had good
power in the pero-
neal gronps and
calf muscles as well
as in the thighs.
The trunk mus-
cles ap]iarentl_v es-
caped ; of the shoul-
der-girdle muscles
the trapezius only
was aliected, and
that slightly.
Electrical re-
.sponse was dimin-
ished to both cur-
rents.
Another case re-
ferred to at the
same time com-
bined the features
of this type with
those of the scap-
ulo -humeral (form
B).
As that author
remarks, this is
only another link
in the chain of evi-
dence wliich favors
the essential unity of all types cf myopathy.
Piir/ii>/<ii/i/ mill- Jfiir/ji'il Amilijiiii/. — These are i)ractically
the same in all forms of myopathy.
The process is a degenerative atrophy, with irritation
and swelling of muscle fibres and proliferation of nuclei
in the early stages. Later, there is atrophy of the mu.sele
fibres with disapjiearance of their transverse stria>. In-
crease of connective-tissue elements follows the disap-
pearance of nuiscle libres, causing a " myosclerosis " witli,
in the pseudo-liyiiertrophic, forms, a lipomatosis in addi-
tion. Along with the atro]ihy and pseudo-hypertrophy
a nundierof observers have noted anapparent tnii hvper-
trophy in some libres.
The spinal cord and nerves are normal with rare excep-
tions, wldcli are found in the " irregular forms " of the
disease.
Thv (liiir/ni'g/s o{ tlie myopathies in general is simple.
The age of onset (usually under puberty), the slowly
increasing weakness, the waddling, stumbling gait, the
muscular atrophy without U. D." and the absence of
fibrillary twitching sullieieiitly separate the myopathies
from the neuronic or "spinal niuscular atrophies." The
diagnosis of thedilTerent "li/piK"iit myopathy from each
other is mainly a question of the place of beginning and
order of distribution of the muscular atrophy"^ as already
noted. (See Fig. 3404.)
Progii'is/.<i mill Treiitiiiciil. — The di.sease being depen-
dent on inherent defect in tissue vitality, the most
that can be lio|)ed for from treatment is" to retard its
progress and promoter the comfort and general well-
being of the patient. As already seen from .some of
the cases cited, the disease is not always incompatible
with a moderately prolonged life. Froin ten to iwenty-
tive years, however, expresses the usual range of dura-
tion in ordinary cases.
The usual treatment recommended consists of nutri-
tional and tonic measures. Strychnine is spoken highly
of b_v Gowers.
Tlie glycerino-]iliosphales of lime and soda and other
phosidiorous comiiounds would seem indicated in \()iuig
and developing patients.
E.xercise, massage, and electricity have been recom-
mended by most authors. Overuse of these agents may
••■in be snlveil
do harm. Orthopedic measures, such as division of ten-
dons, are useful in the contractural disabilities.
The Spi.nai. Pkoghessive JIuscdl.\r Atuophies fui
Myelopathies,
These are the atrophies of neuronic origin, and imjily
primary degenerative disease of motor neurons of the
cord, or cord and brain combined.
A. PllOGKESSIVE MUSCUL.\U AtIIOPIIY PROPER, OR
Ah.\k-I)i'Chexxe Dise.ase, " \V.\sting P.m.sv." — DeJUii-
lioii. — A chronic progressive disease of the spinal motor
neurons (ventral horn cells), characterized by tibrillarv
contractions, slow atrophy, and gradually "increasing
weakness of voluntary muscles, with I{. D.
Citiiaaiion. — Direct heredity is rare. The neuropathic
diathesis is presumably the chief predisposing factor.
Adult age (twenty-five to forty-five), the male sex, ex-
posure and fatigue, typhoid fever, rheuniatism, gout,
syphilis, and lead poisoning are credited as additional
causes. The actual exciting cause, if such exists, is un-
known. Wh\' Certain "systems" of neurons should die
in some iier.sons and not in others, after the O])eratiou of
file preceding causes, is n iiroblcni whieh
at iireseiit only
by assuming a
"potential in-
sulliciency " iu
tlie nerve ele-
ments, an "abi-
otrophy " (Gow-
ers), only fully
develoiied by
the action of
some jirofound
iuid jiersistent
nutritional
ilrain.
PfitJiohiijii mil?
Mo I'h id A II at-
om I/. — Degener-
ative atrophy of
peripheral mo-
tor neurons(ven-
tral horn cells) is
the essential le-
sion. As a re-
sult of this, sec-
tions of the cord
in alfeited areas
show shrinkage
and disappear-
ance of cell
bodies, with cor-
responding de-
generation and
diminution in
their processes
(dendrites and
a n t e r i o r root
filires). These
changes are nat-
u rally most
markeii in the
cervical enlarge-
ment, since the
disease liegiusiu
the upper ex-
tremity in typi-
cal cases.
The [losterior
horns, together
with tlie col-
umns of GoU
and Burdach, as well as the direct cerebellar tracts are
normal. e\ce))ting in the rari> ca.ses of muscular atrophy
supervening upon tabids dorsalis. of which tlie writer has
.seen two well marked instances. In this case two dis-
UtiH.— Juvenile Type iif ScapMlu.llmiiiTal
Miistular .\tropliy. (c. L. Daua.i
tU
REFERENCE HANDBOOK OF THE jrEDICAL SCIENCES. Muscular Atrophies!
eases are present, according to our present nosology. It
is probable that the first actual flestructive changes occur
in the neuron endings (muscle plates) of the alt'ected
Fig. 3t&3. — Pathological Histology
(Partl.v diagrammatic ; after Erb.
trophy and atrophy ; C, D. atrophy and fatty deposit : r, vacuolization
of dbres; h, hypertrophy of fibres : g. thickened blood-vessel.
muscles (see diagram. Fig. 3460). Following close!}-
upon this impairment of their neurotrophic organs the
muscles degenerate, tibre by fibre, into granular ;ind fatty
material, the transverse stria; disappear, while the adja-
cent connective tissue at first proliferates and later un-
dergoes fibroid changes and contraction. Distention of
blood-vessels is also described.
The pyi'amidal tracts of the cord are
usually affected in some degree. In fact,
so e-xiserienced an observer as Gowers''
remarks that he has not seen a single case
in which they were unaffected.
This, as the same writer aptl}' puts it,
is "the visible e.xpressiou of a tendency
to decay of the whole motor path fiom the
cortex of the brain to the muscles."
Clinical History. — The disease begins
with weakness and wasting of the thenar
and hypothenar muscles of one hand,
usually the right. This may be preceded
by dull aching pains in the corresponding
litnb and cervical region. Otherwise sen-
sory changes are absent. The nutrition
of the bones and skin is not affected. The
wasting advances slowly to other muscle
groups, notably the interossei and lum-
biicales, producing the characteristic
longitudinal furrows betsveen the meta-
carpals, especially noticeable on the back
of the hand. The wrist flexors and ex-
tensors may go next, or the deltoid and
biceps maybe affecteti before the forearm.
In this case, as the writer has seen, the
patient may present the anomaly of a
powerful grasp, with inability to abduct
the arm to a right angle.
The spinal extensors are commonly af-
fected early, producing lordosis and allow-
ing the head to droop forward in extreme
cases.
The upper portion of the trapezius cs-
Voi,. VI. — 5
capes, which may be a diagnostic sign of importance,
as between this disease and the myopathies.
The disease extending downward involves the hips
and thighs, impairing locomotion. Marked
OV weakness of the legs proper also exists,
yjJ^^-g^^ often without atrophy, but with more or
."^SJ^*^^ less spasm and heightened muscle jerks.
" ' ' is the involve-
on for the legs.
In those cases
atrophied, how-
sutlers most,
same process in
be considered
later); and also to the atrophy in mul-
tiple neuritis.
This distribution contrasts with the
myo]5athies, which affect more markedlj'
the calf muscles.
If the disease extends upward, the up-
per cervical segments and the oblongata
may be invaded, giving rise to respiratory
anci bulbar symptoms of grave import,
such as dyspna>a. dysphagia, dysphonia,
dysarthria, irregular licart action, glycosu-
ria, etc. The facial muscles usuallj' es-
cape, but not always.
Fibrillary tremor is a characteristic
symptom and is almost continuous in the
affected muscles so long as any contractile
substance remains. The mechanical irri-
tability of the muscles is increased, light
taps producing marked contractions.
The deep reflexes diminish gradually
and finallj' disappear.
Electrical changes in the affected muscles
are marked and constant. Early a quanti-
tative reduction (diminished response) to both faiadism
and galvanism may be noted. Later, reaction of degenera-
tion in varying degrees from simple sluggish response to
complete polar reversal, i.e., the muscle contracts more
readily (or to a weaker current) with the anodal (posi-
live) closure than with the cathodal (negative) closure.
of Pseudo-Hypertrophic MiiscuJar Dystrophy.
A, H^-pertrophied flbres; B. mixture of byper-
splitttng
neuritic atrophy.
Charcot-Marie-
Tooth, type C.
Fig. 3454.— Clinical Chart of Distribution of Muscular .Atrophies. The shaded portions
Indicate the initial locations of muscular wasting In the diflerent forms. (From
C. L. Dana.)
65
]flii8riilar AfrophioN.
mustard.
liEFERKNCE HANDIJOOK OF THE MEDICAL SCIENCES.
The presence of this R. V>. isMniiii|i(iil:iiil (ii,i;;]i(isliesi,i;u
in excluiiiug the inyo|ialhies (ir " iiliopatliie '' atrojiliics.
Contractions and dcforniilirs due In nneiiual Avasting
of opposing musck'S ai-e cnniiunii. 'I'lie "rlnv-hand " or
"main en griife," lordosis, and lalipcs einiinus are exam-
ples.
The sphincters escape as a rule.
Sexual power is commonly lost.
Eventually the patient presents an extreme degree of
generalized emuciutiou, the " living .skeleton " type.
Pulmonary C(im]diealiiins, liulli:ir |)alsies. Iiedsores, and
septic inf'eclion are of seri<ius jin|ii>rt.
Di(i()i>iisii<. — The myopathies, llie auc (.-uhdl) at time of
onset, the initial allection of the hands. Ihe jiresence of
Fli.. -ihyi. I iiM- ul ,N(.lUill 1'I":ji.-mi.' MumuI.ii .Vl]iil.|l> ■.! 11.." -VI ilil-
Duc-lienne Type. CFroiii tin- Nrurnhi^qL-jil Departiiieut of the t'iii-
ciniKiti Hospital.)
tibrillary tremoraud Ihe \\. 1>, are sufficiently distinctive.
The onset in one hand and the extremely slow progress
separate this from oilier iieurnn diseases, such as multiple
neuritis, lead neuritis, and pciliomyelitis, acute or chronic.
The absence of jiains anil cervical deformity distinguish the
affection from pachymeningilis cervicalis hypertrophica.
Sj'ringomyelia is excluded liy absence of the "dissocia-
tion " sensory sym])toms and of cutaneous trojihic lesions.
Piriijiiiish. — Arrest is said tn he possible in rare cases.
Remissions are more likely to occur. To retard the prog-
ress of the disease and iinjirove the "ei>mpensation " in
the remaining muscle tissue is as much ;is can be reason-
ably exjiected from treatment.
The duration is conunoidy prolonged, varying from
two to thirty years (Dana). The fatal outcome is due to
complications, jnilmonary or laryngeal, resulting from
involvement of the respiratory muscles.
Treiitmeut. — Strychnine nitrate, administered h3'poder-
mically in doses gradually increased from gr. j'j to gr. j'j,
is highly couunended by Cowers, who has seen the dis-
ease apparently arrested by its use.
General hygienic measures, careful diet, avoidance of
fatigue are important. The phosphorus compounds
shoidd be tried.
Electricity, massage, and gymnastics should be used
with caution, and any excess or fatigue should be avoided.
Mercurials and iodides are never indicated anil may do
harm.
B. IIekedit.^ry on Famili.\l Type op Pkoghessive
Sfix-\i. MuscuL.\n Atrophy.— This is a rare form of
neuronic atrophj- described b.y Werding* and Hoffman.''
It is characterized l)y heredity, by early onset (under
two years), beginning in the Inps and back; by rapid
progress to complete helplessness and a fatal termina-
tion at or before the sixth year. R. D. is present, and
wasting of the ventral horn cells has been found. Bee-
vor ' records one case which began in utero.
Diiiynimis. — This is distinguished frtmi the ordinary
spinal atrophies (Aran-Duchenne type) by the hereditarj'
element, early age, rapid progress, and absence of fibril-
lary twitching; from the myopathies, by the absence of
hypertrophy, the presence of R. 1). and the early termi-
nation.
Tmitmirit has not inHuenced these cases appreciabl}'.
C. Amyothopiiic L.\teral Sclerosis. — This is prac-
tically a progressive spinal muscular atrophy (type A)
plus involvement of the ujiper neuron (pyramiilal tracts
of cord) to a marked degree (see Fig. 3400). The clini-
cal dilfereuce consists in the marked spasticity, causing
a stiff legged gait, with toes tending to dig into the
ground. There is also a rather more marked tendency to
I buDiar involvement, and the lower half of the face may
I be affected. The affection does not dift'er materially from
tyjie A as i-egards the prognosis and treatment.
1). Gloss<)-i>.\bio-i..\kyn(:eal Pap.alysis. — C/iiviiie
Prof/rtasim Bulbar Piilni/. — This may occur primarily, or
may indicate an extension upward of ordinary spinal
muscular atrophy (type A). As a jirimary affection the
degenerative jnocess is linnted to the bulbar neurons.
Patients are usually at the degenerative jieriod of life.
In many respects the disease appears to indicate a loca-
lized presenile change.
The chief t:itiiiji/"iiixiirc hoarseness, aphonia, dysarthria,
dysphagia, sialonluea, atrophy, and fibriUation of the
ttingue, glycosuria, cardiac ai'rhythmia, and dj'spncea.
Pseudo-emotional symjitoms, as causeless weeping or
laughter, are frequent accompaniments. The palate re-
Ilex is absent in advanced cases.
The tUiKjiiosis nuist be made from bulbar apoplexy
(small hemorrhage, thrombosis) by the sudden onset of the
latter, witfi .sensory defects of face frequently luvsent;
from cerebral lesions in the btdliar motor path (|).seudo-
bulbar palsy) by the sudden onset of tho latter, with ab-
sence of sensory defects, of atrophy of the tongue, and
also of accompanying hemiplegic symptoms ; from asthe-
nic bulbar palsy (bulbar palsy without anatomical tiud-
ings) by Ihe absence in the laltcrof muscular atropliy and
twitching and by the frequent remissions which occur.
The progress is toward a fatal termination from inani-
tion or respiratory complications in from one to seven
years. Treatment is similar to that of other neuronic
muscular atrophies — viz., rest and attention to hygiene
and nutrition. Electrical treatment may add to the com-
fort of the patient and prolong life.
E. Nei'RITic or Leg Type of Progressive !Mrscu-
i,AR Atrophy, Charcot-^Iarie-Tooth Disease. — This
variet}' of the " neuronic atrojihies " differs from the typi-
cal (spinal) form (type A):
(1) In its hereditary character,
(3) In its onset in the legs and feet (peroneal group of
muscles).
(3) In its slower course.
(4) In the circumstance that the prospects of prolonged
life are better.
It is a rare disease in this couutrv, I'urr^ recording but
G6
KEFEREA'CE HANDBOOK OF THE MEDICAL SCIENCES.
i?IiiKi-iilai'
Kliistard.
-Vlropbles.
five known cases up to 1897, including one reported by
himself.
Pathologically a degenerative neuritis has been found.
The disease therefore affects the distal extremities of the
lower motor neurons.
Treatment is similar to that of the other neuronic
forms. .^'. 11'- LanrjdoH.
EEKERE.S'CES.
1 Aran, F. A.; Recherches sur une malacUe. etc. Arch. Gen. de
Mc?cl.. Paris, li«0, ill., ,5, 173.
= Gowers, Sir William It. : A Lecture on Abiotrophy. Lancet, April
12th. ia02, p. lIKIo.
' Hoppf. H. H. : Zwoi FiiUe von Dystrophia Muscularis Progressiva
mit Eiii:utuiiL'Mi-;i'ti<'n. Centralblatt liir Nervenheilkunde uod Psv-
chiatrie.(i(t.il,,THcft, 1S92.
* Guwei-s anil Taylor : Diseasesof the Nervous System, third edition,
London, 1S99, vol. i., p. .55(1.
^Werding: Arch, tiir Psychiatric, 1891-94, quoted from Gowers'
third edition.
<■ Hoffmann : Deutsch. Ztsch. fur Nervenheilk., 1893-97, quoted from
Gowers' third edition.
' Beevor. 0. E. : A Case of Tonsenital Spinal Muscular Atrophy
(family type), and a Case of Hemonliugt- into the Spinal Cord at Birth,
giving Similar Symptoms. Brain, mnil, p. 8.5.
" Burr, C. W. : A Case of Progressive Neurotic Muscular Atrophy.
Journal Nervous and Jlental Disease, October, 1897.
» Gowers, Sir W. R.: A Lecture on Myopathy and a Distal Form.
Brit. Med. Journal. July 12th, 19(V2, p. 89.
'° Charcot, J. B. : Contribution a I'etude de I'atrophie musculaire
Progressive— Type Duchenne-Aran. Paris, 1S95.
This work coinains a digest of the French literature on the suhjecf.
with especial reference t<.> lite clinical and pathologicitl di>tinetness of
the Duchenne-.\ran form uype A), and the amytrnphic lateral
sclerosis form (type C), whicli Charcot (the younger) considers well
established. The work is beautifully illustrated.
MUSK. — Moscnrs. "The dried secretion from the
preputial follicles of M'm-/niit viim'hifinis h. : Order, liii-
mimihtiii," U. S. P. This little aiiinml, tlie so-called
musk-deer, is a slender-limbed, active, and very timid in-
habitant of the mountain regions of Central and North-
ern Asia. In its general shape It resembles a young deer.
It is 60 or 80 cm. long (from two to three feet), from
40 to 60 cm. in height, witli the rump higher than the
shoulders, of a grayish or blackish-brown color, with
long, slender ears, large dark eyes, and two long, curved
tusks projecting downward from the upper jaw. Tiie
secreting organ containing musk is a large, simple sac,
situated in tlie median line just l>eneatli the skin of the
abdomen, in front of the preputial canal (of tlie male; it
does not e.xist in the female), with which its posterior
wall is connected. It is of a round or oval, plano-convex
shape, 6 or 7 cm. in its longest diameter, and 1 or 2 cm.
or more thick. Internally, it is incompletely divided bv
folds and partial partitions reflected from the wall. Tlie
orifice, often doulile, is situated over the middle portion
of the sac, and is 1 or 'i mm. in diameter. Its position is
easily determined from the outside, because the hairs con-
verge toward it and fairly grow within it. In the liv-
ing animal the secretion contained in the gland is a soft
solid, not much thicker than honey, of a brownish-red
color, and of a most intense, offensive smell. As it dries
it darkens, becomes greasily brittle, and less odorous.
The musk-deer is laboriously bunted in the central and
tforthern provinces of China, in the countries to the north
of India, and in Siberia. — in sliort, over a very extensive
portion of Central Asia, — for its skin and musk glands.
These "pods," as they are called, are cut out as soon as
the animal is killed, and dried, often with the aid of arti-
ficial heat, when they are ready for the market. In this
condition they are flatfish, shrivelled pouclies, covered on
one .side with hairy skin, in the centre of which is the
orifice; the other side lias the black appearance of dried
meat. As now usually marketed, they ai'e jjrepared so
as quite closely to resemble a large fnwl's gizzard. The
contents are dryish, crumbly, breaking as they are turned
out into coarse fragments {called grain.s), of an almost
black color and penetrating odor. The very high cost of
musk has led to numerous ingenious methods of adulter-
ation. Thus, stones and other heavy minerals, hair, diicd
blood. fa;ces, etc., are sometimes introduced through the
natural opening; occasionally, also, the sac is split and
emptied, and then filled and ilextrously sewed up again,
with a mixture containing but little musk, or that of an
inferior iiuality — Siberian musk, for example, inste.id of
that from Tonquiii. (tr tlie musk itself, when sold in
gi'ains, may be tampered with in similar ways. .Sume-
tiines artificial pods are made and filled — the scrotum of
some animal is used, or a bag is made entirely <?<; w>vo
from skin, with a bladder, or some other membrane, for
the back. The geographical source is important in de-
termining the quality of musk; that of China and its
tributaries is the most fragrant and best. Its pods are
roimder, of more uniform shape, and its grains more
odorous and larger. That from the north of India comes
in irregular sacs, and tliat from Siberia in larger and
longer ones. The following are the characters of music
as given by the Pharmacopteia : "In irregular, crimdjly,
somewhat unctuous grains, dark reddish-brown, of a
pectUiar, penetrating, and persistent odor, and bitterish
taste. It is contained in oval or roundish sacs, about one
and a half to two inches (4 to 5 cm.) in diameter, on one
side invested with a sinoothish membrane, on the other
side covered willi stilT, appressed, grayish hairs, concen-
trically arranged around two orifices near the centre.
About ten per cent, of musk is soluble in alcohol, the
tincture being light bi'ownish-yellow, and on the addi-
tion of water becoming .slightlv turl)id. About fifty per
cent, of musk is soluble in water, the solution being deep
brown, faintly acid, and strongly odorous.
" When ignited with free access of air, musk gives off
a peculiar, somewhat urinous odor, and leaves behind not
more than eight per cent, of a grayish ash."
Composition. — Musk is a very complex substance, and
consists chiefly of common animal tissues and secretions.
The following synopsis is from Ilager's "Pharmaceu-
tische Praxis": Fats, cholesterin, jrn.v, biliary matters,
mucus, albumin; besides traces of lactic, butyric, phos-
pliatic, sulphuric, etc., acids ; traces also of ainmonia and
a rolatile oil. Tlie odorous principle lias never been sep-
arated. It is supposed to be formed b\- the gradual de-
composition of .some of the other constituents.
Action axd Use. — This sulistance was for centuries
the leading antispasmodic, and was, during most of this
time, much more highly esteemed in medicine than it is
at present, and it was given for numerous diseases in-
volving disturbance of the nervous or mental faculties —
e.(j., hysteria, epileps}', mania, etc. In a similar manner
several other odorous animal secretions — ci\'et, castor,
etc. — have been emplo^'ed, but of them all musk is b.y
far the least disgusting. Its high cost and imjjressive
odor made it well adapted to hysterical outbreaks, for
the relief of which it undoubtedly has some real value.
As it is, however, it acts in these cases merely as a ]ialli-
ative, and as there are now a dozen or more remedies
which are more certain and far cheaper (a single dose of
musk, wliich might be repeated several times a dav', costs
two dollars or more), musk as a medicine may be consid-
ered as fairly out of use. It can, however, be given, if
desired, in doses of about 1 gm. (gr. xv.) in pill or emul-
sion. A tincture {Tiiictura Masc/ii, U. S. P., strength
one-tenth) is ofticial and may lie used, but is mostly em-
ployed as a basis of perfumery, where the persistent or
" staying " qualities of musk make it of the greatest value.
The odor of music is considerably diminished by fen-
nel, ergot, tannin, sour fruit juices, and some other
things. Mixed with su^ar it keeps verv well.
ir. o. Bolk's.
MUSTARD. — Black Mustard, or Sinapis nigra,
" the seed of Brassica nigra (L.) Koch," and White Mrs-
TARD, or Sinapis alua, "the seed of Brassica alba (L.)
Hooker fil. (fam. 0'/(c//cm)," are thus separately official
in our Pharmacopceia. Since they agree in most re-
s]iects. the_v may be discussed together, and tlieir differ-
ences pointed out in passing. Both are natives of Eu-
rope and Western Asia, cultivated and naturalized in
most countries. Both are slender, tall, and widely
spreading, weedy-looking herbs, witli coarsely pinnatifid
or pinnate leaves, the upper entire, and yellow flowers.
The two tire best distinguishable by the habit of their
pods. In the black mustard these are erect on spreading
67
ITIiiMtard*
Rf:FEKENUE IIANDBOOK OF THE jVLEDICxVL SCIENCES.
pedicels; in the wliite, botli the peflieel uiul the pods are
spreading. While mustard is also a nmirher and smaller
plant. The herbage of both is re]mted antiseorbutic,
and is useil as a salad, also for poultices. The relation-
ship of these plants to some of the forms of turnip, rape,
cabbage, and colza is close and confusing, so that in
India, where mustard is most cultivated, a nnmber of
ill-delined forms e.xist. This condition^partly the re-
sult of natural causes and partly elTected by design-
results in much admi.xture in some lots of seeds. The
following are the descriptions of the Pharmacopceia:
W/iifi .ViiKt((r<!. — "About 3 mm. in diameter, almost
gloliular, with a circular hilum ; testa yellowish, liuely
pitted, hard; embryo oily, with a curved radicle, and
two cotyledons, one folded over the other; free from
starch; inodorous; taste pungent and acrid."
Black Miuitiird. — "About 1 mm. in diameter, almost
globular, with a circular hilum ; testa blackish-brown or
gra\'ish brown, finely pitted, hard; embryo oily, with a
curved radicle, and two cotyledons, one folded over the
other; free from starch; inodorous when dry, hut when
triturated with water, of a ]5uugeut, iienetrating, irritat-
ing odor; taste ptmgent and acrid."
The principal adulterant of whole black mustard is
rape seed, which can readily be distinguished by its
slightly larger size and its peculiar bluish tinge. In the
ground condition, white mustard is often mixed with it.
This addition, if kept within moderate limits, only adds
value to the product, fi>r reasons stated below. Most
other adulterants either contain starch — which may be
determined by the iodine test — or, like curcuma, the most
common of these, they contain resins, which may readily
Vie indicated by the use of suljihuric acid.
Pure ground black mtistard is almost too strong for
safe use upon the table, and curcmna is usually added to
dilute it. Advantage is taken of this to use excessive
quantities of the substance selected i'or admixture.
Hence the importance of the preparation of black mus-
tard for medicinal purposes by purely phafinaceutical
agencies.
Co.MPOsiTioN. — Tlie constituents of the two varieties
of mustard, although presenting close relationsliips. are
not exact ly identical. The_y both agree, however, in con-
taining a considerable amount of a bland, light-colored,
non-drying Ji.ivd nil — a mixture of the glycerin combi-
nations of oleic, stearic, and en/cic iicids ; in white mus-
tard oil In'iiic acid is also found. This oil amounts to
about twenty-two or twenty-three per cent, of the seeds.
The most reinarka';;e constituent of black mustard is the
crystalline, bitter-tasting, inodorous glucoside, iiiyrnnate
of juitiixsiiiiii. or xinii/riii : soluble in water, but not in
alcohol or ether, and in its watery solution decomposing,
in the presence of various ferments, especially of one to
be mentioned below, into glucose, bisulphate of potas-
sitmi, and the horribly acrid, sulphureted, cisciilial oil
of muKtard (isosulphocvanate of allyl, etc.), to which
mustard is indebted in part for its medicinal value, and
which is describeil below. This oil is not present in the
dry seeds or their jiowder, but is produced only when
they are moistened. The develoiiment of the odcr upon
wetting mustard lU>ur is very evident, and distingtiishes
this from that of white mustard. The albuminous fer-
ment which assists in this decomposition is called iiii/ro-
sill, and is common to both kinds of mustard.
The glucoside in white mustard, resembling the sini-
gria of the black, has been correspondingly named simil-
biii, a neutral crystalline substance, soluble in cold water,
and decompo.sed in a .similar way as siuigrin into sugar,
aiilp/iiitc of siiitijtiii, and snljiliiicyiiiaite of ncriiiyl. the
latter corresponding to the essential oil of the black
mustard. It is an acrid and vesicating substance, lint
much milder than the glucoside of the black variety,
and not volatile.
To bring out the full percentage of the black mustard
fill, a certain amount of myrosin, additional to that con-
tained in this drug, is desiralile, and is obtained by judi-
ciously adding a certain quantity of the white mustard.
The tlotir from this mixture is the strongest and best that
can be made. That obtainable in our market is often
the tiour of white mustard only, and is generally more or
less adulterated besides.
An oil exactly resembling that of black mustard has
lieen made synthetically and is in the market.
Action and Use. — Both sorts of mustard seeds possess
the same qualities; they vary onlj- as regards the degree
of pungeuc_y, the black being the stronger. Swallowed
whole they do not disintegrate much, but pass through
the digestive tract. In this way white mustard seed,
particularly, is now and then given, in doses of a tea-
spoonful (S or 4 gm.), for dj'spepsia, constipation, etc.;
like nearly everything else, it has also been employed in
chronic cases of bronchitis, rheumatism, and some skin
diseases, without any rational indication for such em-
ployment. Its rare use at present for these purposes
shows its slight value.
Ground mustard, white, black, or mixed, is an active
local irritant as soon as wet with water so as to jiroduce
the acrid decomposition products of the drug. Applied
to the skin, it is quickly and painfully rubefacient; and
if allowed to remain in contact with it for a hjng time,
it is vesicant — producing a crop of tiue, deep, eczematous
blisters, easily ruptured, very painful, and rather slow
to heal after rupture takes place. Internally, mustard,
in small doses of 3 or 3 dgm., is an aromatic stimulant,
and as such is in every-day use at the table. In larger
quantities. 10 or 15 gm., it is a prompt and valuable
emetic, usually coming up in from two to five minutes
after being swallowed. On this account, and because it
is almost always at hand in the house, it is the most
valuable emergency emetic at our command. For poi-
soning by opium or by other narcotics it is a remedy
almost without an equal.
Ad.mixisthatiox. — The enqjloyment of whole mus-
tard has been noticed sufficieutlj- above. The ground
nuistard in use in this country is that .sold by grocers for
family use, and is seldom, if ever, a plain mi.xture of the
two sorts of seeds and nothing else, which gives the most
])erfect product. It is oftencr ground white mustard
alone, and oi'tener still mustard diluted with a varying
amount (generally considerable) of inert yellow powder.
It is therefore subject to considerable variation in
strength. This is used both internallj- and externally^
internalh', as a stimulant (condiment) and emetic; ex-
ternally, always as a rubefacient. For an emetic, from
a dessert- to a tablespoonful should be given, as a less
amount may fail to produce vomiting but still cause con-
siderable gastric distress. Externally, it is chiefly em-
ployed in foot-baths and sinapisms — for the former, from
one to two tablespoonfuls may be added to a small tubful
or bucketful of warm water; for the latter, the mustard
meal is simply mixed with a little Avater and spread U]ion
a cloth, or it may be diluted with meal or flour to reduce
its strength. In this way mustard is the most wiilely
used local remedy for the sudden and intense pain or dis-
tress of pleurisy, colic, .some neuralgias, etc. It is also
used as a derivatixe in nervous vomiting, cerebral and
spinal inflammations, etc., and in many other couditiorfs
when acute attacks of pain are present. P.oth kinds of
mustard are greatly damaged, or even spoiled, if mixed
with hot water, as this destroys the ferment which brings
out the active decomposition principles. The follow-
ing iireparations are official; Charta Siiiapis, U. S. P..
made by taking ground black mustard, exhausting it of
its fatty oil by percolation Avith benzin, then mixing it
with enough solution of India rubber to make a paste,
and spreading it upon paper. This mustard paper is
almost never made liy the dispensing apothecaries, since
.several manufac'turershere and in France make excellent
substitutes for it that can be easily obtained and carried
everywhere. The activity of the mustard paper is not
developeil until it is moistened in cold or merely warm
water.
Oleum Siiiapis Volatile. U. S. P. The oil of black
mustard is also official. It is obtained by grinding and
macerating black mustard, or a mixture of both kinds,
in water and distilling. It is "a colorless or pale j'ellow
68
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
Mufitard,
Myc-osls Fiingoldes.
li(iuid, having a very puugent ami aci'id odor ami taste,
and a neutral' reaction. Sp. gr., 1.017 to 1. 031. It boils
at 148' C. (idSA" P.). It is freely soluble iu alcolioland
in ether." Its vapor when concentrated is intensely dis-
agreeable, cau.sing lachrymation and severe pain in the
nose. Applied to the skin, it blisters .severely. Diluted
w.ith nine parts of alcohol, or three parts of olive oil, it
causes, when rubbed upon the tcni]_iles or forehead, a
sharp temporary tingling I hat occasionally relieves mild
lieadache. The compound liniment of mustard (Linimin-
tum Siiiapis C'ompositum, U. S. P.) contains:
Volitlile oil of m nstard 3 parts.
Fhnd extract of niezereum 20
Camphor 0 "
Castor oil 15 "
Alcohol q. s. to make 100 "
It is a good stimulating liniment. llcnri/ JI. liudiy.
MYCOSIS FUNGOIDES.— Mycosis fungoides, while
one of the rare diseases of the skin, its real nature being-
still in dispute, has been sidlieienllj' observed since 1.S60
to establish for it a sharply defined clinical evolution.
Alibert first described it in 1811. The symptoms, for
convenience of description, have been grouped in three
stages, which, however, do not always occur in regular
succession. The third or fungoid stage, for example,
appears at times without antecedent lesions, this giving
rise to the erroneous belief that two forms of the disease
exist. There is but one form. The earliest phenomena
vary greatly in the fir.st or so-called premycotic stage,
the only characteristic and constant symptom being in-
tense itclung. Eczema, urticaria, pityriasis rubra, ery-
thema exudativimi, or psoriasis may be sinndaleil in this
stage, the eczematous form being, however, the most
common. Kaposi says that nearly every case of mj'co-
sis fungoides starts with the characteristics of an eczema.
The lesions manifest themselves ujion the trunk, folds
of the articulations, the face, more particularly the foi'e-
head, or, indeed, any part of the body, by more or less
sharply defined erythematous patches, varying from the
size of a silver dollar to that of the palm of the hand and
even larger. Upon these patches the ejiidermis presents
a fine desquamation, and it is but rarely and only in
places here and there that a .slight exudation occurs witli
the formation of thin crusts. The alteration iu the skin
corresponds perfectly to the wtll-known picture of squa-
mous eczema which occurs in'patches of a pale red color
with but slight tendency to become moist. The itching
is intense at this stage, and insomnia is often a trouble-
some feature of the disease. This "eczema " may persist
for several months or for one or two years (French au-
thors denominate this the eczematous stage of mycosis
fungoides), and while certain areas fade out and disap-
pear, others make their appearance. Some of the lesions
persist, extending peripherally over quite large areas of
the body to unite with neighboi'ing lesions. Hence, in
some cases, although rarely, almost a completely general-
ized eczema, witli interspersed areas of normal skin, will
be established. Some of the lesions fade in the centre
while they extend ]ieripherally, giving rise to circinale
lesions. IJesides the desquamation and the slight occa-
sional moisture, no lesions except those secondary to
scratching supervene.
After a more or less extended pei'iod the second stage,
or stage of infiltratiou, .sets in. This is marked liy a
thickening of the skin consequent upon an infiammatiiry
edematous infiltration of the chorion, more particularly
appreciable at the peripliery of the eczematous areas, the
borders of which appear tense, smooth, and shining.
From this time on appear various circinate, sharply de-
fined, more or less elevated plaques and nodules of a
brownish-red or bright jiink color, situated at the centre
or upon the irregtdar borders of the eczematous parts of
the skin. These nodules, plaques, and elevations vary in
.size and may appear upon regions of the skin whicli are
free from eczema, which are locat<'d at the most diverse
points, and which manifest no jtarticular regidarity in
their disposition. A certain number of these lesions dis-
ap]iear completely after an existence of several days or
weeks, leaving no ti'ace other than a slight pigmenti.tion,
while others start up at new points. This S])ontancous
disappearance is quite as characteristic as is that of the
lesions of the first stage. Tlie two periods together may
last many years (fourteen iu one case) before Uie appear-
ance of tumors.
In the so-called third or fungoid stage, whicli in some
instances is the first and only stage, the characteristic
tiunors of the disease aiipear upon dilTereut portions of
the bod.y. They vary in size from a bean to an orange
or even a larger object, and their coloring likewi.se varies
from a pink to a dull red hue. As regards their shape
they are either sessile or peduncidated, well rounded or
lobulated, and distinctly circumscribed. When develop-
ing from the plaques they ma.y be quite flat. The}' may
develop from ]ireviously existing lesions or from the
sound skin. They are usually painful. Like the other
li;sions of this disorder, the tumors may disapjiear spon-
taneously, while at the same time others make their ap-
pearance ; or they may all disappear to return after un-
certain intervals without known catise. As a rule, they
leave no trace behind them of their previous existence,
though they may be followed by pigmentation or slight
atrophy of the skin. Sooner or later some of the tumors
degenerate and lead to superficial uleeiation, usually
followed by papillary excrescences and mushroom-like
growths of varying sizes, from which the disease obtains
its name. At times they may he the seat of much moi'e
destructive ulceration, though with but few exceptions
tills destruction is limited to the new growths: and even
large fungoid and apparently deeply ulcerated tumors
may completely disappear and leave no trace of their
jirevious existence, further than pigmentation and possi-
bly a small atrophic scar.
The general condition of the patient at first seems un-
altered: later, when the tumors ulcerate, exhaustion oc-
curs and the victim usually dies as the result of febrile
processes, of intercurrent disorders, of cachexia, or of
pysemia. Extirpation of the tumors is usuallj' followed
by recurrence, frequently with added malignancy. The
duration of the tumor stage is brief compared with the
others, death frequently occurring within a few months,
though it may be postponed for two or three years.
Although the cause of the disease is not definitely
known, there can be little question to-day as to ifs infec-
tious character. It is probably produced by specific mi-
cro-organisms, but direct evidence of contagion and suc-
cessful culture and inoculation experiments are wanting.
The disease is more frequent iu men than in women, and
usually occurs after the fortieth year, though in a few
recorded instances it began earlier.
Di.^oNOsis. — At the beginning, when apparently sim-
ple eruptions precede the formation of the tumois, the
diagnosis may be veiy difficult, even Hebra having once
diagnosed a case as eczema; and it may also be mistaken
for an exudative erythema, a psoriasis, or a jiityriasis
rubra. The irregularity of distribution, the sharply de-
fined border, and the greater thickening than in any of
tliose diseases might excite suspicion. There is gener-
ally not so much discharge as in eczema with the same
amount of hyperemia; the heaping of silvery scales is
decidedly less than it is in psoriasis; and, finally, there is
too much .scaliness and it persists for too long a time for
exudative erythema. The itching, also, is generally more
.severe than it would be in any skin affection excejit
eczema. Besnier says; "In;dl casesof ambiguous pruri-
tic dermatoses which are i)rolonged and rebellious to
ordinary methods of treatment, llie iiossibility of the af-
fection being the premycotic period of mycosis fungoides
should be borne in mind." When the bright red gives
way to a deeper or more cojipery red, and the infiltra-
tion increases, a suspicion of tubercular lejirosy may be
aroused, but there w-ould be no anasthesia and the scali-
iiess would be much greater than that which leprous in-
filtrations present; moreover, the characteristic liacilli of
that disease would be absent. When the fungal ing tumor
69
m> rosiM Inlesllnali!".
Ulyoloiiia,
liEFEREXCE HANDBOOK OF THE .^lEDICAL SCIENX'ES.
stage is reached there can be no difficulty in mailing
diagnosis. In tlie more localized forms in wliicli there is
no preceding eruption, the disease may be mistaken for
sarcoma or carcinoma cutis. Against this diagnosis,
however, tlieie would be the absence of early implicatii.in
of the lymphatic glands (although tumors in the groin
may simulate them) and the comparative painlessness;
and besides, as a rule, the course would be .slower than in
cancer and the internal organs woiilil never be implicated.
With possibh- two recorded exceptions, the disease
has invariably terminated fatally, the extremes of dura-
tion being nine weeks (a case of Oaillard's) and fifteen
j-ears. The widespread cases, which commence as ap-
parently simple inflammations, are much less malignant
in their" cour.se tljan those wliich begin at once as tumors,
P.\TH0i.ouY. — While the main facts as to the morbid
anatomy of mycosis fungoides are generally agreed upon,
much difference of opinion exists as to the interpretation
to be placed upon these facts. Anatomically, the tumors
consist of rounii cells supported by a scanty, delicate
reticulum, which reiilace tlie normal tissue of the cutis.
Tlie new giowth is somewhat scantily provided with ves-
sels, and as it spreads it destroys the cutaneous capilla-
ries. The l.ioundary betw^een the healthy and diseased tis-
sues is ill defined. " Ranvier and most French observers
have classed it with lymphadenoma, but Sireday thought
it was lymphosarcoma, and until recently all German
authors have con.sidered it to be a sarcoma. There is a
growing tendency among observers at tlie present time
to class the disease with the infectious grauulomata.
Various micro-organisms have been seen in the tissues by
difTerent oliservers and some liave been cultivated, biit
none have as yet lieen demonstrated to have any patho-
genic relation to the disease.
Tre.\tmext, so far as a cure is concerned, seems to
he of little avail. Arsenic has been used hypodermically
with apparent temporary benefit. Large doses of (jui-
nine are recommended. Kesorcin subcutaneously has
failed. The .c-ray has of late been tried, but not with suf-
ficient thoroughness to determine its value. Pyrogallic
acid, aristol, iodoform, ichthyol have been used for the
relief of local symptoms. It should, of course, be the
physician's endeavor to make the patient as comfortable
as po.ssible by treating the various distresshig s^ymptoms
as tljey arise. Vhnrlis T'lirnslieud Dude.
MYCOSIS INTESTINALIS. See Anthrax.
MYDRIATICS AND MYOTICS.— The .i]>po,sing forces
whicli maintain the iris in a state of equilibrium are con-
trolled l)y two sets of nerves: the contracting muscle,
the .^iihiiirter /ni/j/i/ir, and the ciliary muscle being sup-
plied liy the third, while the <lil:iting muscles are under
the influence of the sympathetic nerve. The action of
the third nerve has been very clearly demonstrated, but
that of the sympathetic is not so evident, as the presence
of radiating muscle fibres in the iris is a matter of dis-
pute. Paralysis, or section of the third nerve, is followed
by a relaxation of the sjilnneter muscle and dilatation of
the ptijul, and stimulation of the nerve prodtices contrac-
tion of the musele and niyosis. If the syni|)atlictic nerve
is stimulated there follows a dilatation of thi' pu|)il. and
that the nerve exercises a positive ililating iiitlueuce is
shown by the greater degree of dilatation that takes place
when a mydriatic is placed in an eye in which the third
nerve has been paralyzed. This action of the sympa-
thetic has generally been explained by the direct effect
of the nerve upon tlie dilating muscles; but, since the
]U'esence of these latter has been called in question, a fur-
ther exjilanation is necessary, iiiul it has been suggested
that the dilating nerve acts through the muscular tissue
in the walls of tlu' blood vessels of the iris (see article on
O'Cii/iti).
Alterations in the size of the jnipil may lie due to ordi-
nary physiological action, to some pathological change,
or to the effect of certain drugs. Exposiu'e to a strong
light or to (htrkness. efforts at accommodation, the iiillu-
ence of fear or lit shock, will lu-mluce an eiilai;;cni(ail or
a narrowing of the pupil, according as one or other set of
muscles is reflexly irritated. So also diseases of the cen-
tral nervous system, which interfere with the integrity
of the third nerve. ea\ise dilatation, as is seen in menin-
gitis, h_vdroceiilialus, brain tumors, etc., while an_y pro-
found efteet upon the basal ganglia or depression of tlie
sympathetic will be followed by contraction of the
pupil.
jMydhhtics. — Mydriatic drugs produce their effect
either by paralyzing the motor oculi or by stimulating the
sympathetic nerve. Belladonna and its allies are exam-
ples of the first group, and cocaine belongs to the second.
In the first group are belladonna, hyoscyamus, stra-
monium, and duboisia. the alkaloids of which — atropine,
hyoscj'amine, daturine, and duboisine — are active mydri-
atics and ar<' almost identical chemicall_v. Many other
jilants, not employed therapeutically, are members of the
order Solanace* and possess tlie same iihysiological ac-
tion. Hyoscine and scopolamine are closely allied to
atropine, yet differ from it to some extent and form an-
other group.
Bellddontiii is the best-known mydriatic and lias been
longest employed. Whetlier administered internallj' or
apjilicd directly to the eye, one of its earliest and most
marked symptoms is the dilatation of the pupil. This
persists for several days, the length of time depending
upon the dosage. In some cases of poisoning the pupil
lias remained under the influence of the drug for three or
four weeks. When it is eni]iloyed as a mydriatic, a solu-
tion of the alkaloid is applied directly to the eye in order
to obtain a purely local action. Formerly the extract was
painted around the eye or upon the temple, or an infu-
sion of the leaves was applied as a poultice over the eye.
The pupil is extremely sensitive to the effects of atro-
pine It will be influenced by gr. x7r5'c-.TnT. f"^d a .solution
of the strength of 1 to t<o,tiO() wil'l .iilarge the pupil
within an hour. Accommodation is not affected by solu-
tions below a strength of from one-thirtieth to onc-tentli
per cent. Generally a one-per-cent. solution is selected,
which, instilled into the eye, begins to act in fifteen min-
utes and fully dilates the pupil in half an hour, accom-
modation being lost in one hour. The paralysis lasts for
three or four days and is accompanied by annoying dis-
turbance of vision caused liy the enlarged pupil and loss
of accommodation. ]iIinor disturbances may persist for
several days. For convenience of use gelatin discs are
prepared which contain gr. yjnni' ^"f^ w-hicli are easily
inserted beneath tlie lid. If paralysis of accommodation
is required, discs containing gr. -^^ must be used. A
solution of salicylate of atro|iine is to be preferred to the
sul))liate. as it forms an antiseptic solution which re-
mains free from any fungoid growth such as forms in
solutions of the suliihate.
llcitiiiitriiiniu' is ri'placing atropine when dilatation is
required for the purjiose of examination. The advan-
tage is a more rapid and less prolonged action. The
pupil begins to dilate in the course of a few minutes and
accommodation fails in thirty or forty minutes. Its ef-
fect begins to subside in three or four hours, and the eye-
sight is i|uite recovered witliin twenty-four hours. The
drug is also less irritating to the conjunctiva and is de-
void of constitutional effects when used with firdinary
care. For the purpose of simply dilating the pupil, a
one-per-cent. solution is employed ; wdien accommodation
is to be paralyzed, a two-per-ceut. solution is to be ]ire-
ferred. If mydriasis is required for a ]iro!onged jieriod,
atropine is selected in preference to homatropine
IljlDftriiitiiiiiK and diiliin'ne are rarely or never employed
for their mydriatic action. Their action is the sanu' as
that of atropine, liut they are less to be depended upon
and olfer no advantages.
Ilii'm-iiii exer<'i,ses a much less marked intluenee u]ion
the pupil, and is never used.
Dnhoisiiic. — This alkaloid has iceiaitly been extolled as
possessing a more iiowerful action than atropine and
as producing effects which are of shorter duration. As
it is cheuiically identical with atro|iine. it will iir<ibably
be found to have the same mydriatic action. The sold-
REFERENCE HANDBOOK OF THE MEDICAL SCIEXCEy.
niyt'oKiN Intesllualls.
lYIyeloiiia.
tiou emploj'ed has a strength of one per cent., and pro-
duces dilatation within an honr.
Cucaiiie. — As a luydriatie cocaine differs from atropine
and possesses many advantages. It is mncli less intense
in its action, the pupil is not dilated to so great an ex-
tent, and a certain degree of reaction to light or other
stimulus may be retained. Its effect is accomplished in
half an hour and passes off in a few hours. There is lit-
tle or no influence exerted on the jiower of accommoda-
tion. As before stated, it acts thro\igh the sympathetic
nerves, either by stimulating the dilating muscle of the
iris (if these exist) or by contracting the arteries of the
iris.
When it is combined with atropine a very powerful
mydriatic is obtained, as both a paralysis of the sphincter
and a stimulation of the dilators are obtained. Roller
uses a mixture of equal parts of a one-per-cent. solution
of atrojiiiie sulphate and a five-per-cent. .solution of co-
caine bydrdi'liliirate. This is applied every ten minules
until diiatalion is secured, and if a prolonged action is re-
quired it is maintained by applying the solution three
times a day. In inflammatory conditions much benefit is
also obtained from the anannia and blanching of the parts
which the cocaine produces.
Mydriatics are employed to dilate the pu]iil for the
purpose of an efBcient intraocular examination and to
facilitate cataract operations; also to remove the iris from
the danger of adhesions in many inflanunatnry condi-
tions. The dilatation of the pupil will also lessen the
probaliility of prolapse of tlie iris in wounds of the eye.
For ophthalmic examinations and for simple dihitation
of the pupil, homatropine and cocaine are now employed
ahnost to the exclusion of atropine on account of their
transient action. In examinations in which it is neces-
sary to paralyze accommodation homatropine must be
employed, as the action of cocaine upon the ciliary mus-
cle is insuflicient. In inflammatory states where a pro-
longed cfl'ect is required, atropine, with or witliout co-
caine, is to be ijreferred. It is also indicated in all forms
of iritis and in wounds or injuries accompanied liy in-
flammatory action. When there is much ciliary si)asm,
it lessens the pain and photophobia by paralyzing the
muscle.
The employment of mydriatics is not unacconipanied
by dangers. For example, the alkaloid may be abso?-be(l
to such an extent as to cause severe constitutional dis-
turbances, or some of the solution may pass into the naso-
pharynx and its local action be extended into the throat.
Mydriatics may also, by continued use, prove so irritat-
ing as to produce a conjunctivitis. The most serious
danger is the po.ssibility of aggravating an incipient glau-
coma— a result which h<as freciucntly followed their care-
less em])loyment. This is due to the increased intra-
ocular tension which accompanies the paralysis of the
ciliary muscle, and, although cocaine is thought to have
but little effect in increasing this tension, many cases
are reported in which it has aggravated a glaucoma-
tous condition of the eye. Certain signs of glaucoma,
which readily distinguish it from iritis, are very marked
and should never be overlooked. In iritis the iris is con-
tracted and fixed, while in glaucoma it is dilated and also
fixed; in iritis tlie eye is hypersensitive, in glaucoma it
is almost insensitive. In glaucoma there are also the
early symptoms of vomiting, with inflammation of the
ej'c, and the prodromal disturbances of vision, with liazi-
ness of the cornea, color rings, etc.
Myotics. — The action of myotics is quite the opposite
to that of mydriatics, the contracting muscles being
stimidated and the dilating muscles depressed. With
the contraction of the sphincter pupilla' there is also a
contraction of the ciliary muscle which lessens intraocu-
lar tension. The action of myotic drugs is not well
understood. It is probable that they act upon both sets
of muscles, but even in the case of physostigmine, the
best known of these drugs, many authorities consider
that its action as a stimulant of the motor oculi is the
most important, while others claim that its intlunur i,s
directed chiefly as a depressor of the sympalheiic .My-
otics are of less therapeutic value than are mydriatics,
and were it not for the lessened intraocular tension that
accompanies the nanowiiig of the ]iupil. they woidd
very rarely be employed. They are recommended in
cases of paralysis of the third nerve, but are rarely of
any service, except in the paralysis following diphtheria.
In glaucoma they are of undoubted value. The great
tension is overcome and the eye is relieved, and in many
instances their emploj-mcnt has apparently rendered an
operation unnecessary. In wounds of the surface of the
eye and in corneal ulcers the tendency to rujiture of the
coat is lessened by their use.
Phi/sostigmiiie or Kserine is the drug always selected.
Pilocarpine exerci.ses the same effect, but it is mild and
uncertain. A solution of the sulphate or salicylate of
eseriue is employed, of the strengtli of one-quarter grain
to the ounce. This will begin to act in fifteen minutes,
its full effect will lie reached in an hour and will con-
tinue for two or three hours, and in twenty-four hours
the myosis will have ilisaiipeared. In glaucoma myosis
is more difficult to obtain, and a solution of two per cent,
may be required. The condition of myosis is not so in-
tense as is that of mydriasis, and if atropine has been ap-
plied to the eye eserine will have no effect until the action
of the atropine has begun to pass oft'. On the other hand,
atropine rapidly dilates a pujiil under the influence of
eserine. Biiiiiinoiit Small,
MYDRIN is a ciilorless jiowder composed of epliedrine
hydrochloride, lUD parts, and honiatroiiineliydrochloride,
1 part. It is used in ten-per-eent. solution as an evanes-
cent mydriatic. 11". ^1. Bastedo.
MYELOMA.— Under the greatest variety of names
there have been descrilied in recent years cases of an
affectidu of the bones which have in common certain feat-
ures so distinctive as to justify their un,ion under one
name. Briefly stated, these cases show as a rule evidence
of the presence of nndtiple new growths developing si-
multaneously in the most widely separated bones. Pain
is often felt in these tumor-like masses, and from the de-
structive influence which they exert upon the bony
structure fractures with disldcalion iind deformity soon
appear as the lesult of the most trifling traumatism. A
cachectic condition supervenes in the later stages and is
associated with the occurrence of a pec\iliar urinary con-
dition, — one in which the urine contains albumoses.
Various paroesthesias and pareses may occur, and with
the great increase in the deformities produced by the
tumor masses the patient finally dies of exhaustion or
succumbs to some intercurrent aifectiou.
As early as 18-17 a case of this sort was observed by
Bence Jones' and Maciutyre. Their attention was par-
ticularly attracted to the condition of the urine, in which
a peculiar protcid could be demonstrated. The patient
after a long and very painful illness died, and at the
autop.sy there were found red gelatinous masses replac-
ing in large part the verfebra>, sternmn, ribs, etc. They
designated the condition "osteomalacia fragilis rubra."
Rustizky '^ first gave the name multiple myeloma to
the condition in a paiier published in 18T3. He consid-
ered it a sim]ile hypertrophy of tlie Ixine marrow, be-
I'au.se, although the tumors were multi|)le, they were pres-
ent only in the bones and did not give rise to metastases.
Since then a number of cases have been described un-
der this name, while many others obviously of the same
nature have been designated "osteomalacia," medullary
pseudoleuka'Uiia. sarcomatous osteitis, malignant osteo-
myelitis, lymidiosarconia, etc. Good sununaries of the
literature witli descriptions of cases have recently been
given l.iy Hammer,-' Winkler.-' Wielaiid,^ and Paltauf,*
from which it appears that there is really a well-defined
condition, easily distinguishable from the endotheliomata
and sarcomata of bone, and for which the name myeloma
is most fitting, — a condition which Virchow ]irophcsied,
although at that time no case had been ]iublished.
The di.sease may ]iei'haps lie made eleai- most easily by
the description of a case which oceurrnl recently at the
n
myeloiua.
Myeloma.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Johns Il(i|iUiiis Ilcispiliil anil wliicli lias been reported in
its flinieal and palliiilogieal aspects b_y Dr. Hamburger
and myself. For tlie clinical description I quote from
his paperin the Jolinx llt/pkiiis Hospital Bulletin.{\o\. xii.,
1901, p. 38).
The patient was a colored woman, fifty years of age,
who entered the liospital complaining of "rheumatism"
and a "sprained hip." Her personal and family history
were unimporlant. but for about a year she had had pain
in the region of the right groin and hip. One night
about six months ago, while ])icking up a bucket of coal,
she experienced a remarkable sense of lengthening in the
left arm, and next morning fo\md that ,slie could not rai.se
it to her head Ijceanseof pain and a feeling of weight. A
week later the right arm became affected. She had
pains in the shoulders, neck, and chest. About this time
she noticed a swelling the size of a hen's egg on the back
of her head. Pain and stiffness in the arms continued, .so
that after two monlhs she could not feed herself. Six
days before admission to the hospital, while walking, the
right leg "gave way " without apparent cause. She fell
to the groiuid and since then had not been able to stand or
walk. She suffered great pain in the right hip.
She became nuich <Mnaciated and very weak and an^T-
mic. On admission to the liospital, any movement of the
body was found to produce great pain. Over the occipi-
tal region there was a round, soft, tiuctuatiug mass about
10 cm. in diameter, not adherent to the skin, not movable
on the dee]ier tissues, not tender. A nodule. 3 to 4 cm. in
diameter, was visible on either clavicle over its inner third,
the one on the left being a little larger and evidently
eroding the bone, for manipulation cau.scd pain and crep-
itus. There was another tumor in the left supraspinous
region, about 4 cm. in diameter, connected with the
acromion process of the si-apula. The right leg was ro-
tated outw.'ird and abducted, the upper third of the thigh
being markedly enlarged and deformed by tlie presence
of atumorabmit the size of a chilli's lii'ad. ]iriijeeting
from its pcislero external aspect. It wastirm and tender
on pressure and any attemiit to move the limb caused
inten.se pain.
Physical examination was otherwise negative. There
was no glandular enlargement and examination of the
blood showed only a diminution in the numlier of red
corpuscles with a corresponding duninution in the per-
centage of h;emogloliin. The urine was turbiil, light
yellow, and usually alkaline; from GOO to 800 c.c. were
voided daily, of a specitic gravity varying from 1.013 to
1.030. Heller's reaction was positive. When the urine
was aci<litied anil heated to a teiuperature of .'56' (_!., a
heavy white ]ireeipitate apiieared. It redissolved in part
on boiling and returned on cooling. The nitrie-acid pre-
cipitate disappeared on boiling, to reappear on cooling.
The mixture assuiueil a darker color and particles of tlie
precipitate adhering to the tulie became ]iink. The liiuret
reaction was marked. The proteid content measured
by the Esbach albuminometer varied from 0.3 to 0.6 per
cent.
This case illustrates well the symptoms which have
been s]ioken of as fairly constant, viz. , the emaciation and
ananiia, the siiuullaneous occurrence, over the bones, of
soft, almost tluctuant ma.sses, and the erosion of these
bones with fracture and deformity associated witli great
pain. Particularly well, however, is tlie alliumosuria
illustrated. Acute tnuisitory or .slight albumosuria has
been observed in many acute febrile diseases, and simi-
larly slight pi'iitonuria has been described in tlie greatest
variety of conditions. The work of Ki'ihne and Chitten-
den renders it iirobalile that all of these are instances of
albumosuria, the ]U'oteiil substance found in the urine
being very closely related to, but not exactly identical
with, the products of partial digestion described by those
authors. These cases, however, are without diiliculty
distinguished from those in which the quantity of alliu-
moses is lar.ge and its occurrence persistent throughout a
long time. It has been found (Hamburger) that in the
great majority of cases of detinite albumosuria multi|ile
myelomata have been found at autopsy, although as yet
the evidence is not sutHcient to prove that in all cases of
myeloma albumosuria is found.
The origin and exact nature of this proteid substance
are as yet quite obscure, but when it is present in consid-
erable quantities it is easily recognized by the reaetion.s
described aliove, and especially by its property of redis-
solving at boiling temperature in acidified solution, from
which it was jirecipitated by a temperature of .56" C.
The pathological anatomy of the multiple myeloma
may be made clear by a further reference to the case
above mentioned.' The patient died after a stay of
.some months in the hospital, and at the autopsy multiple
tumor masses were found involving various bones. The
right leg was shorter than the left by about 3 cm., and in
the trochanteric region, where there was a large tumor
mass, there was excessive mobility of the fenuir. The
organs in general showed only the evidences of senile
atrophy and in the lungs a few old tuberculous scars.
On removal of the sternum it was found to contain, at the
points of insertion of the second and third costal carti-
lages, a tumor mass, which, being very soft, allowed free
movement of the two parts of the sternum upon each
other. The left clavicle was much enlarged at its sternal
end, the bone being apparently distended liy the tumor
mass within, for the cortical portion was very thin and
could be compressed by the fingers. On sa^\•ing through
the bone lengthwise the cancellous bone was found to be
much rarefied and the cortical portion very much thinned ;
the marrow was almost entirely replaced by the tumor
ma.ss, which extended quite to the acromial end.
The right clavicle showed evidences of a healed fract-
ure, the portions having united in a somewhat abnor-
mal jiosition, so that a slight angular deformity existed.
The marrow of this bone also showed tumor masses,
which did not, however, cause any extcn.sive erosion of
till' lione.
From the spinous process of the left scapula there
arose a soft tumor ma.ss which on section was found to
have eroded and replaced a considerable portion of the
bony jirocess. None of the cortex or cancellous lione
tissue was to be discovered in this one. The ribs were
not involved. Unfortunatel_y, the vertebral column was
not sawn through, but there were no evident tumor
masses visible from without. The right ilium was com-
pletely eroded through in its median portion by a large
soft mass, wliicli had destroyed the whole thirkness of
the bone and which projected both way.s — inward into
the pelvis under the iliacus muscle, and" outward under
the muscles covering the outer surface of the ilium. The
hipjoint on this side showed no abnormalit}-, but in the
intertrochanteric region a large tumor mass sprang from
the marrow of the femur. At the upper end of the shaft
of the femur there was a fracture, the shaft being dis-
placed upward. On sawing through the bone at this
point the intertrochanteric region was found to be ex-
tensively involved in the new growth, whicli extended
into the adjacent tissues. The cancellous bone was
almost entirely destroyed and the cortex much atrophied
and roughened internally. For a distance of about .5
cm. the cavity of the shaft of the femur was invaded,
llie yellow marrow being pushed ahead and fairly sharply
limited from the dark purple new growth. The bone
marrow was atrophic and axlematous, grayish-pink and
moist in appearance, and sunken below the level of the
'cut surface of the invading tumor. The left femur
showed no evidence of tumor formation.
Removal of the large mass at the vertex of the skid)
revealed a large aperture in the skull, the edges of which
were vci'y ragged, as if gnawed away, with lici-e and
there loose spicules of bone lying in the soft tumor mass
which evidently sjirang from the marrow cavity. This
tumor mass spread itself between the cranium and the
dura for a short distance, and, completely filling the aper-
ture in the skull, projected outward to form the large soft
mass felt under the scalp.
No other tumor nodules were to be found so far as it
was pos.sible ti examine the bones.
These growths presented everywhere the same apjjcar-
72
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
Myeloma*
Ulyeloiua.
ance. Everywhere they evidently sprang from the mar-
row of the bone, from which they were not by any means
sharjily demarcated. Only wlierc the tumor seemed to
invade the yellow marrow of the shaft of the femur was
the outline sharp, but even there the microscopical e.\-
amiuation showed evidences of the presence of tumor ele-
ments far past this outline. Where the red marrow of
the short bones formed the point of origin, the outline
was not nearly so sharp. The well-dctined tumor masses
were perhaps somewhat firmer than such a mass of bone
marrow would be. They varied somewhat in consistency,
however. In general they were soft; some of the larger
ones were almost dittluent, and the}' flattened out when
they were cutand laid out on a pan. Others were less soft,
and in some parts the gelatinous pulpy consistency gave
wa}' to a fair degree of firmness. In color there was also
considerable variation. The greater part of the masses
was of a deep red color, perhaps even darker than that of
the normal red bone marrow, but showing everywhere a
grayi.sh tint. Usually lines and streaks of gray were to
be seen througliout this deep red. and in nearly all the
masses definite nodules of firmer consistency and of gray-
ish-white color were found. At some points there was
a slight j'ellow opacity.
Microscopicalh', the various authors Iiave emphasized
the regularity in form and size of the cells, and Wieland
has adduced this as a distinction from the myelocytes.
Nearly all writers have thought the tumor cells to be
derived from some cell or other of the bone marrow.
Wright alone considers them to be plasma cells or closely
related cells at least, to explain which he states that plas-
ma cells are present in the bone marrow. The results of
attempts to determine the histogenesis of the cells in this
case will appear from the following description of the
microscopical appearances:
The tumor masses present in sections a remarkabl_y
homogeneous aiipearance. There is. as described in prac
tically all of the oliier cases, a delicate stroma with
rather wide meshes in which lie innumerable rather large
round cells. These are not in intimate connection with
one another, but lie singly and loose; sometimes, where
their ninuber is vei'y great, they are somewhat com-
pressed into a polygonal form, but in general they are
quite regularly rounded; they vary slighth' and may be
elongated or pear-shaped or even notched. The nucleus
is large, round, and vesicular, sometimes l.ying eccentri-
cally. The protoplasm presents a rather ragged granu-
lar appearance. Blood-vessels exist throughout the
tumor and are indeed rather numerous. The smaller ones
lie in very intimate contact with the tumor cells, their
walls being merely a single layer of endothelium. Con-
nected with these and the coarser strands of the stroma
are exceedingly tine filaments of connective tissue which
run in between the cells. Everywhere, scattered quite
without order througli the tumor mass and among the
tumor cells, are numerous red blood corpu.scles, wliich are
quite well preserved. These evidently give the dark red
color to the tumor masses, being absent or present in
only very small quantity in the translucent gra3-ish-white
noduJes described above.
More careful examination of the characteristic cells of
the tumor shows them to be distinctly of one type, al-
though certain variations in size occur. They measure
from 13 to 21 ij. in diameter, and thus approach very
closely the myelocytes, while they exceed considerably tlie
plasma cells in size. The nucleus is provided with a defi-
nite nucleolus, which shows especial avidity for certain
aniline dyes. In smears from the tumor the nuclear
structure is shown clearly. Tlie nuclei appear large and
flattened out, and in the general jiale blue stain there ap-
pear irregular spaces which dn not stain or take only the
tint of the cell protoplasm. In this respect they resem-
ble closely the myelocytes as described by H. F. iluUer.
The protopla.sm is rather ragged and granular-looking,
but the granules are not sharply outlined and with spe-
cific stains they take on no different coloration from the
rest of the protoplasm. These are, therefore, not specific
granulations. In sections as well as on smears stained
•with the polychrome methylene blue of Unna or the alka-
line methylene blue, the protoplasm takes on only the
palest greenish-gray coloration ; there is nothing of the
specific staining described by Unna and others for the
plasma cells. With polychrome methylene blue and
eosin the protoplasm stains with eosin.
The relation of these cells to the other normal cells
from which they might possibly arise is therefore about
as follows: In size they greatly exceed the plasma cells,
but agree fairly well with the mj'elocytes and non-gran-
ular cells resembling myelocj-tes found in the l)oiie mar-
row. With polychrome methylene blue, etc., they do
not show the reaction typical of the jjlasma cells; on the
other hand, their protoplasm, although in its raggedness
it does resemble the "granoplasma " described by Unna
for the plasma cells, shows none of tlie specific granula-
tions characteristic of the myelocytes. The presence
of a nucleolus must be admitted for all these various
types of cells, so that it is of no help in determining such
relations. The cells of the myeloma and the myelocytes
and non-granular cells of the bone marrow have in com-
mon, however, the peculiar lacunar structure of the nu-
cleus, as seen in dried smears, which II. F. Miiller* de-
scribes as follows: "With adequate magnification one
sees in the myelocytes a remarkable nuclear structure;
one finds often nuclei in which definite clear fields are
visible. These may be in part nuclear substance, but in
many such nuclei these fields seem to represent tlie cell
substance which stretches itself into pre-existent holes or
pores in the nucleus." And then again: "There is a large
round or oval nucleus limited by a thin chromatin wall
which shows frequentlj' more or less numerous larger
and smaller clear areas, which are often plainl}' seen to
be definite apertures in the nucleus through which the
cell substance extends into the interior of the nuclear
body."
This structure seems so peculiar that its occurrence in
these various cells at least indicates their close relation
to one another. The descriptions and figures of plasma
cells in the papers of Unna,' Jadassohn,'" Marschalko,"
.Justi,'- Krompecher,'^ and Councilman '■* give no hint of
such a structure in the nuclei of these cells.
The myeloma cells are apparenth' separated from the
myelocj'tes by the absence of the char.icteristic neutro-
phile granulations. An examination of a boue-niarrow
smear, and more esjiecially of a smear from actively pro-
liferating bone marrow, will convince one of the great
variations in the abundance of the granules wliich occur
in these cells. In a recent paper on the relation of the
myelocytes to leucocytosis, Rubinstein'' describes the
transitions which take jilaee in the development of mye-
locytes from smaller cells whose protoplasm is cpiite free
from granules. These young myelocytes reach quite
the size of the adult myelocytes before the granules
appear, which thev do gradually a few at a time. The
resemblance then between these non-granular myelo-
cytes, as they may perhaps be called, and the myeloma
cells is mo.st striking, and suggests most strongly the ori-
gin of the myeloma from these characteristic cells of the
bone marrow in one or other stage of their development.
Further evidence of this close relation is given in the
abundant presence of the tumor cells in the marrow ad-
jacent to the tumor masses, where they take on exactly
the arrangement of the myelocytes among the fat cells
and are intermingled with the occasional eosinophile cells.
Indeed, if, in a large section, we pass gradually from the
relatively normal marrow toward the tumor, we fiuil a
gradual and insensible transiticm, the myelocytes being
replaced entirely in time by the tumor cells, which be-
come more and more den.sely arranged, forming finally
ilclinite nodules. Among the trabecuke of the cancel-
lous bone this consolidation of the cells which have the
]iosition and form of myelcjc^'tes into solid strands in
direct continuity with the tumor mass is veiy convincing
evidence of the direct relation between the tunmr and
bone-marrow cells.
Various alterations in the appearance of the tumor
cells, such as fragmentation and i)artial division of the
73
IVlyoiiia.
ITIyonia.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
nucleus, occur. Indeed, one sometimes finds large cells
containing numerous nuclei and a vacuolated proto])lasm
in which irregular or rounded cellular inclusions are
present. These are perhaps best interpreted as evidences
of degeneration.
The- tumor mass as described above contains in the
interstices between the cells very numerous red blood
corpuscles in a very well-jireserved condition. There is
very little evidence of any lireaking down of the red cor-
puscles,— hardly any deposit of hannaloidin in the tis-
sues, which would certainly be present if the presence
of the blood were due to sietual hemorrhage. Red cor-
puscles are found scattei-ed in considerable ninnbers
among the myelocytes and other cells in the normal bone
marrow, however, and it si'ems jiroliable that the condi-
tion here is analogous. The walls of the blood-vessels
in the tumorare nevertheless of extreme thinness and ex-
travasations might readily occur. So also tumor cells
are quite frequently found insiile these blood-vessels l.yiug
among the red corpuscles, although an examination of
the circulating blood a few days before the death of the
woman showed only one or two doubtful myelocyte-like
cells among a great number of leucocytes, the varieties
of which were those of the blood in practically normal
relations.
From this description, then, it is seen that in this con-
dition we have multiple new growths from the bone
marrow, not very shai'ply delimited from the marrow
and showing very gradual transitions into it. The cells
have the form and general characters of the bone-marrow
cells, lacking the specific granules of the myelocytes, but
po.ssessing the iiccidiar nuclear structure found in the
mj-elocytes and tlirir formative antecedents. They differ
in essential particulars from the plasma cells, and in view
of these facts and of the fact that they largely' replace the
myelocytes in the marrow in the neighborhood of the
tumor, there being no sharp boundary between the mye-
loma-like marrow and the myelocyte marrow, we may
consiiler them directly related to these cells and probably
derived from the large non-granular forerunners of the
myelocytes.
The exact relations of this C(mditiou to others with
which we are familiar arc dilhcult to determine. On the
one hand, there are none of the anatomical features of the
ordinary forms of chronic inflammation, while on the
other hand the jirncess differs from that which character-
izes the majority of tumors in its simultaneous origin in
many bones and in its mode of growth, which white de-
structive is not of such a nature as to give rise to metas-
tases. We are quite ignorant of anj' etiological factors,
but on the whole the condition seems most analogous to
those forms of lymphosarcoma which, arising often simul-
taneously from many lymphoid structures, invade and
destroy the adjacent tissues,
WiUiinn O. .WicCK/him.
' Benre Jciiies: Phil. Tnins. liuv. s.ic. 184.S. Part i.. p. o.').
" Deut>fli. Zfits.iir. f. riiir.. I,s7:i Bil. iii.. S. 162.
= Viri-hnu s .\lrliiv, 1S1I4, l'X,\.NVii.. p. itv.
' Vinti..w'.s .Ucliiv. ItiiHi. rl.xi.. p. A'a.
' Priiiiart' uiultipli' Sarc'iiju' ili-r- KriMrliea. Inaug.-Diss.. Ba,sel, 1893.
« F.rf.'i-I)nisse <]cr allinTiiiMTH'Ti PallKildgie u. patholiiirisc-hen .Xna-
tomio. HfraiisKftrt-lu'ii von I.iiliarscli ii. (rsterlasr. 1SS«>. ill., 1. p. OTt'i.
' W. I.. Mai( alluiii: Case of .Multiple Myeloiua. ,)i>uiual of Ex-
ppilllli'Tital Mi'ilic ilii'. vol. vi.. Nil. 1, mill.
'Deiitsihi's .\riliiv f. klin. Mi-il., l.s'.il. xlviil., p. r,~.
» Monat^llHft^■ f. iiiakl. lii-niialoliiLni-, 1891, .\li.. p. 296.
'" KeniniT kliii. Wni'lirnsi hrift, l.s<«, .nx.x., p. 222.
" Arohiv f. iHTiiialiiliiL'ii' u. Syphilis. WJ5. xxx., p. 3.
'= Vin-hiiw's Airhjv. ISHT. il., H. ]'.I7.
" Zii-L'h-r's Ill-ill iiu'i' z. path. Anal., I.sus, xxiv., p. IQ.
'■■ Jiminal •'( Kxiiiriiin iital Mi-ilirim-, IsH.s, iii., p. 4nl.
'^Zeii.si-h. f. ktiii. Mi'il., IIKI), xlii., p. liil.
MYOMA. — Till' myoma is a tiiinor cnmposed chiefly of
mu.scle tissue, theri'fore of mesoblastic origin, and' be-
longing in the connective-tissue gi'ouii. Acconliiiix to
the type of muscle tissue of which myomata are com-
posed, thej- are divided into leiomyoma (Zenker) or mv-
oma hievicellulare (Virchow), containing smooth niiisc'le
fibres, and rhabdomyoma or myoma striocelliilare, eon-
taininii striated muscle libres.
mm^^^^w^
In general, the term mj'oma, without further distinc-
tion, is used for leiomyoma.
Leimnyoma. — Of the two varieties, the tumorcomposed
of smooth muscular fibres is by far the most frequent
and of the most iinjiortance clinically.
Histology. — The pliysiological type of the tissue, the
smooth muscular fibre, is Avidely distributed over the
body, and is best seen in the intestinal canal and in
the uterus. The
smooth muscular
fibres are long, fu-
siform cells, whicli
are connected by
a small amount of
cement substance.
The nucleus is a
long rod - shajied
body .situated in the
middle of the cell.
The tumor is com-
]ioscd for the most
]iart of such muscu-
lar fibre cells, which
are arranged in bun-
dles, closely packed
together, freijuent-
\y interlacing, and
separated from one
another b}' a small
amount of connec-
tive tissue which
carries the blood-
vessels. On sec-
tion of the tumor
these bundles are
cut at various ans^les
Fir. 3466.— Section ol a very Small Myoma
of the Uterus, Hardened in Mtiller's
Fluid and Stained with Hieniatoxylin.
Bands of iiiusi^ular fibres are seen ciit in
various diivctions. (X175.) (After W.
T. Couuciihiau.)
and when the nuclei are brightly
stained the section often appears peculiar. When "a
bundle of fibes is cut exactly across, the section of the
muscular fibres, with the brighth' stained nuclei in the
centre, may be mistaken for round cells with a central
nucleus, or, still more readily, for a section of a nerve.
The nuclei may be mistaken for connective-tissue nu-
clei and the tumor for a fibroma. In the myoma the
nuclei are longer, narroyver, and more refractive than
connective-tissue nuclei, and in the fibroma the arrange-
ment of the fibres in bands is never so characteristic as in
the myoma. In cross-section of the fibres the muscle
substance around the nucleus is seen to be denser, more
homogeneous, and more refractive than the protoplasm
of other cells. AVhen fresh un.stained sections are exam-
ined the tumor may be mistaken for a sarcoma, in which
the cells are often arranged in bundles in the same way,
but a careful study of the nuclei will reveal its true char-
acter. Til separate cells which compose the tumor may
be isolated b_v macerating.small portions in a twenty-per-
cent, nitric-acid .solution or in a tliirty-])er-cent. solution
of caustic potash. This dissolves the cement substance
between th( muscular fibres, and they can then readily
be teased apart. There is often a considerable difference
in size between the tumor cells and the cells of the anal-
ogous physiological ti.ssue. The cells ma_v be very much
larger or very much smaller than these. Sometinies cells
as large as the muscle cells in the rapidly growing preg-
nant uterus are found. There is always with the mus-
cular tissue a variable amount of connective tissne yvliich
is principally fnuiid between the larger muscle bundles.
From this, smaller septa are given off yvhich run between
the smaller liundles of cells. " White (Jahris Ihipkliix Hos-
pital llidhtiii. xi., lU. 1900) has demonstrated that this
connective tissue is of the white fibrous and reticular
types, and that each muscle cell is surrounded by a con-
nective-ti.ssuc ca|isule. He could demonstrate no elastic
fibres. In this cimiiective ti.ssue run the blood-vessels.
In some cases the connective tis.sue is so abundant that it
forms a consideralile part of the tumor, and in others
there is scarcely any present, except around the larger
vessels. The amount seems to vary with the age of the
groyvth, being alwa\s liss in small tumors of ri'ceut for-
74
REFERENCE m\JS^DBOOK OF THE MEDICAL SCIENCES.
Myoma.
Myoma.
mation. "When there is much conuective tissue present the
tumor is generally firm ami fibrous, but in some places it
may have more the cliaracter of loose areolar tissue and
contain numerous lymphoid cells. In some of the very
large myomata of the uterus the development of connec-
tive tissue is so great that the tumor appears to be prin-
cipally composed of this, and it is only after considerable
search that the muscular tissue is found. To this form
the term fihro-myoma is given. In almost every tumor
some places will be found where neither muscular tissue
nor connective tissue can be made out. There are larger
or smaller areas of firm, highly refractive, homogeneous
tissue, in which a few roil-shaped nuclei are scattered.
Such areas are most abundant in the larger tumors, and
represent a hyaline transformation of the tissue. As
a rule the myomas have a \eiy jioor vascular supply,
but cases are "sometimes seen in which the blood supply
is so abundant that tlie tumor almost resembles a cavern-
ous tissue. This variety of tumor will be considered
more fully in speaking of nij-oma of the uterus.
Gross Appearance. — ilacroscopically the myoma resem-
bles most the hard fibroma or one of "the Sitrcomas. It is
always sharply circumscribed, and generally suriounded
by afirm cai^sule of connective tissue. On section of the
tumor it can always be easily separated from the tissue
surrounding it. the cut surface has a whitish or yel-
lowish colour and glistens. It is not homogeneous, but
marked by fissures and lines which represent the spaces
between the muscular bundles, and which often have a
concentricor spiral direction. Whiteranddarkerpatches
are sometimes seen on the surface ; these generally de-
pend on degenerative processes in the tumor.
Orirjin.—The tumor always develops from non-striated
muscular tissue. Unlike the rhabdomyoma, it never de-
velops in any locality where this tissue is not found ; it is
never heterologous. Although its origin from smooth
fibres has long been generally accepted, it is interesting
to note that KoUiker and his" followers believed its origin
to be from the connective tissue. The e.\act histogene-
sis, however, is not always clear. Keifer {LuPresse
meiUcale, ly'J'J, No. 10, p. 49) has demonstrated liy injec-
tion methods small islands of non-vascular tissue in the
uterus, which increase peripherally by the addition of
smooth muscle fibres. In the centres of these masses
was frequently seen an arrangement of cells suggesting
obliterated vessels. From these masses about obliterated
vascular trunks he believes myomata take their origin.
Cohen (Virehow's Arcliir, 1899, clviii., .524). in a study
of the histogenesis of myomata of the uterus and stom-
ach, concludi-s that in many cases it is impossible to de-
termine the origin. Ileexainiued by serial section small
tumors, and in many but not in all he fomid a central
blood-vessel without an adventitia, whose nuiscular coat
could not be differentiated from the newly formed mus-
cular fibres.
In myomata of the skin the origin of the new growth
is supposed to be the muscular coat of the blood-vessels
and the erector muscles of the hair shaft (.Jadassohn).
Mature. — Tlie leiomyoma is a benign tvunor, distinctly
■encapsulated and of slow growth. Although not in it-
self a dangerous tumor, it may, mechanically, cause seii-
ous complications; thus submucous myomata of the
uterus may become eroded and be the soui'ce of a seri-
ous hemorrhage. Pedunculated tumors may be forced
into the cervi.x uteri, causing a spurious labor; or if of
large size they may perhaps produce ]irolapse of the
uterus. Similar tumors beneath the peritoneum may
e.\ert prcss\u'e on the rectum or bladder, oi' liy their
weight bring about displacement of the uterus and other
pelvic organs. They may form adhesions to other or-
gans and thus induce strangulation ; or they may them-
selves, if pedunculated, become strangulated and form
free masses in the peritoneal cavity. JIvomata of tlie
digestive tract may cause occlusion or serio\:s results
may follow the traction superinduced b.v theii' mere
weight.
Etiology. — Little is known in regard to the etiology
•of the myomata. In the uterus the}' are found most fre-
quently after middle life and are much more frequent in
blacks than in whites. On the other hand, the analogous
tumor of the prostate in man is much more common in
the white race than in the black. It cannot be shown
that irritation exerts any influeuce. Some uterine tu-
mors containing glandular acini suggest a congenital ori-
gin, the result of misplaced uterine fragments, thus sup-
porting Cohnheim's theory.
treats. — The more common situations are the uterus,
gastro-intestinal tract, and prostate; the less conmion
are the bladder, skin, nipple, and walls of blood-vessels.
rteni.^. — The most frequent jdace of the formation of
the tumor is the uterus. Every variety of the tumor is
found, and it can be studied best here. The new giowth
may spring from any part of the uterine wall, but usu-
ally from the portion above the cervix ; and it may vary
in size fronr a microscopic nodule to a mass or masses
weighing over a hundred pounds and entirely filling the
abdominlil cavity. The chief mass of these tumors is
composed of muscle fibres, which are generally nmeh
larger than those of the normal uterus. The increase in
size affects principally the width of the cell and the nu-
cleus. Cells are often seen which are wider than the
diameter of a red blood corpuscle. The nniscle fibres
are ari'anged in bundles, which are surrounded b\- wide
capillary vessels. The walls of these vessels consist of
a single" layer of endothelial cells with large nuclei, sup-
portecl by a thin layer of connective tissue. Both be-
tween the muscle bundles, and between these and the
connective tissue of the vessels, are small si.>aces which
contain white corpuscles and are surrounded by a fine
ti.ssne in which here and there nuclei are enclosed. In this
way a cavernous structure is formed, which is not pres-
ent" in the normal uterus. Klebs supposed that these
spaces represent lymphatic cavities, in which the whole
tissue, muscular fibres, and blood-vessels are suspended
by the small bands of connective tissue. Larger blood-
vessels, with thick walls and a wide adventitia, are but
seldom found, and then in the broad partitions between
the larger bundles of muscular fibres.
The tumors ma_y increase in size by the joining togeth-
er of the neighboring growths, but this mode of increase
is rare. Generally it ajipears that the same process of
new formation, in consequence of which the smallest and
most simple myoma was formed, repeats itself. Every
single vessel, with the muscular and ccmnective tissue
belonging to it, proliferates again and forms a second
generation of nodules, which are situated in the original
tumor. These different centres of growlh can, as a rule,
be easily made out, and sometimes the arrangement is
such that the tumor appears to be composed of triangti-
lar masses, the apices of which point to the centre and
the base is along the periphery of the tumors. In other
cases, the formation of secondarj' nodules takes place
only in certain parts of the tumor, and in this way very
irregular, uneven masses arise. This peculiar process of
growth leads to the displacement of the tumor, which
originally is enclosed in the walls of the uterus. If the
' growth takes place most rapidly in the part of the tumor
nearest the mucous or the serous mcmbi'ane, that part
escapes from the muscular tissue and projects into the
uterine cavity or on the surface of tlie organ, and finally
the whole tumor becomes separated from the uterine
walls. In this way the submucous and subserous va-
rieties of the tumors arise, which are either connected
with the uterus by a uari-ow pedicle or have a wider
attachment. This" attachment oflen contains dilated
venous vessels in the loose connective tissue. The tu-
mors which remain within the nniscular coat are termed
interstitial or intramural. When the connective tissue
is much developed the tumor is denser and hartler,
and on section the lines and fissures are not so evi-
dent. The lymph spaces and lilo"d vessels become nar-
rower and partly obliterated. The smooth muscular
fibres remain preserved, Init the single fibre cells can no
longer be recognized, and in ))laee of them small, long,
rod-shaped nuclei are founii embedded in a substance
which appears more or less librillar (tibromyoma). The
76
myoma.
I?lyopia.
REFERE>"CE HANDBOOK OF THE MEDICAL SCIENCES.
b(;st conditions of nutrition are found in the small tumors
of the uterus, ■n-hich sometimes are composed entirely of
muscle fibres and blood-vessels. Such tumors have the
grayish-red. dull appearance which the uterus shows on
section, and microscopically they cannot be distinguished
from the uterine tissue. The small lymph spaces which
were spcikcn of may Ijecome widened to form large C3'sts
filled with a clear fluid aualogoTis to serum and coagulat-
ing spontaneously on cxjiosure toair. Often these do not
seem to have a special lining membrane. Small proc-
esses of connective tissue sometimes grow from the walls
of till se cysts, which penetrate between the adjoining
bands of muscular tissue, and in this way a series of
smaller cysts mav* arise. These cystomyomata of the
uterus may attain a large size, especially when, as often
happens, heterologous formations of a myxomatous or
siuvdinatous character arise in them. Single cysts of
large size, entirely surrounded by muscular tissue, are
sometimes fotmd. Their contents are fluid, generally
more or less colored with blood pigment from nvimerous
hemorrhages which have taken place into them. The
contents of all of these cysts will usually coagulate spon-
taneously. The walls often contain a layer of fibrin of
varial)le thickness, and tlie cysts may be traversed by
bundles of muscle tissue. Dilated blood vessels are often
foiniil in the neighborhood of the tumor, and in the ex-
tramural forms they run in the loose connective tissue
of the attachment. These are the most frequent source of
the hemorrhages which so often accompany this form
of tumor, they being often torn across by the traction of
the tumor. The dilatation of these vessels is nothing but
a passive process, but in some cases there is a ver_y abun-
dant formation of vessels in the tumor itself. Virchow
distinguishes this variety under the name telniir/iccttitic
■mi/'Diiii (jr cKixnioiis mi/oinii. There is little or no develop-
ment of connective tissue, and the vessels are immediately
in contact wit lit he muscular bundles. It is in such tumors
that marked variations in size are seen, the tumorappear-
ing sometimes dcnible its usual size. It is jn'obalile that
this variability in size may be due both to changes in the
amount of blood in the dilated vessels and to different
degrees of contraction of the muscle cells.
There may be mixed forms of myomata. The most
frequent combinations are with myxomatous and sarco-
matous tissue. The myxomatous degeneration occurs
when much fibrous tissue is present. Sarcomatcnis
change is much less frequent. Such tissue develops
around the vessels in the septa between the bundles of
muscles. The myxoinatuus tissue in the tumor can be
recognized as patches of gra.yish, gelatinous material,
while the sarcomatous [lortious are whiter and less re-
fractive than other parts. Combinations with other
forms of tumors do not take place. In the uterus carci-
noma may coexist with myoma, and the carcinoma may
erode and grow into the myoma in the same way that it
grows into the muscle tissue of the uterus itself."
Of the degenerative proce.s.ses the most frequent is cal-
cification, which may affect the Avhole tumor or only
parts of it. When the calcification is complete the whole
tumor may be changed into a hard, stony substance, in
which no tissue or blood-vessels can be made out. Gen-
erally the process is not so complete as this, and a net-
work of calcifieil tissue traverses the tumor, in the meshes
of which small bauds of muscle tissue and vessels are
seen. In some cases a true formation of osseous tissue
has been made out in the tumor, and in one tumor the
writer has oliscrved areas of a<lipose or true fat-bear-
ing connective tissue. Occasionally complete gangrene
may result from inlerference with the blood sujiidy
of large areas. Suppuration is rare but ma\' occur.
After the menopause tliese growths are said to undergo
atrophy.
An interesting lorm which occasionallj- occurs is one
which contains glamlular Structure of the type of the uter-
ine mucosa and iskuownasadenomyonia. It is distinctly
a benign tumor, though its growth may be dill'use. It is
usually situated in the inner layers of the museular wall.
Opinions vary as to the origin of tliisgrov.th. Vmi Reck-
linghausen believes that it develops from remnants of
the Wolffian body, but admits the possibility of its origin
from the uterine mucosa. Cullen (.lohns Hopkins Hos-
pital Reports, vol. vi., 1897), who has studied carefully
two cases, believes the latter to be the only possible ori-
gin.
The presence of a myoma usuall}- produces more or
less hypertrophy of the muscular coat. This is espe-
ciall}' true of the mucous form. Distortion of the uterus
is common. The mucosa is usually atrophied over sub-
mucous myomata, but elsewhere is unaltered (Cullen).
Brand Lirjament. — It is very doubtful if myomata ever
arise in the broad ligament. Tumors found there are in
reality subserous forms which have developed in the lat-
eral wall of the uterus, and have finally become separated
from it.
Front lite. — The myomata of the prostate come next in
importance to those of the uterus, and are most fre-
cjuently found in advanced age. Some of these enlarge-
ments of the prostate depend on an actual hypertrophy,
in which all parts of the gland participate. In others,
the enlargement is principally due to hyperplasia of the
glandular elements, and this form passes most readily
into adenoma. In the third class Virchow has shown
that the enlargement is princi]ially due to a hyperplasia
of the smooth muscle fibres, which make up a large part
of the gland.
This new formation is sometimes diffuse, but more often
is in the form of distinct nodules. The favorite seat for
their formation is on the posterior upper portion of the
gland, and this distinct tumor formation is generally
spoken of as hypertrophy of the third lobe of the pros-
tate. The lateral halves of the gland are the next most
frequent seat of this formation. It is rather rare that
the anterior part of the gland is afl'ected, although
Thompson has described a tumor here as large as a wal-
nut.
DUjesti-ce Tract. — The myomata of the digestive tract
are. next in order, most frequent. Their microscopic
characters do not present any differences from those of
the uterine myomata. Cyst-formation and degenerative
processes are not commonly found. They occur in the
oesophagus, generally near the cardiac end, in the stom-
ach, and in the intestine. Myoma of the appendix has
also been reported. They are comparatively rare in all
these localities, they seldom attain a large size, and usu-
ally do not give rise to symptoms, unless of sufflcientsize
to lu'oduce obstruction or invagination. In the duode-
num such tumors may obstruct the common bile duct
(Dclafield and Prudden). These tumors develop from
the muscular coats of the canal, soon project into the
lumen, are covered only by the mucous membrane, and
may become pedunculated. Less frequently they project
outward beneath the peritoneum.
Skin. — Mj'omata in this location are divided by Besnier
(Hyde) into two groups : simple and dartoic. The former
are rare, less than a dozen cases liaving been reported.
They are generally multiple, occurring chiefly on the
upper extremities and in old people, especially men.
They are supposed to arise from the erector pili muscles.
Tlie dartoic tvpc is more common, generally occurs
singly, and is found nn)st frequently in the skin of the
mammic, scrotum, and labia majora. Thej' may be ses-
sile or pedunculated, and ^■ary from the size of a nut to
that of an orange. Mixed forms may occur, as fibromy-
oma, angiomyoma. and lymphangiomyoma.
/j7(»/rff/-.— ilyoma of tills organ is rare. It was first
described by Virchow, who supposed it to be an out-
growth of the jirostate ; but a myoma of the Ijladder imre
and simple, arising from the muscularis and extending
beneath the peritoneum, has since been described by Bel-
field ( Wien. Idiii. M'och.. 1881, 329), and a somewhat sim-
ilar one bj- Verhoogen (Kelly, " Operative Gynaecology ").
These tumors may be sessile, but are usually peduncu-
lated. They may be submucous or subserous, and vary
greatly in size. In Verhoogen 's case it was the size of
a child's head. They are usually quite vascular.
Urt't/im. — Myoma in this location is rare. BUttucr
REFERE^'CE HANDBOOK OF THE MEDICAL SCIENCES.
rviyonia.
:tl)<>l>ia.
(quoted bj' Kelly) found an ulcerated myoma the size of
a hen's egg in a woman of forty years of age.
Fein*.— Small leiomyomata'h'ave been found in the
saphenous and ulnar veins. A large myosarcoma of the
inferior vena cava has been reported.
Kidnq/. — Minute myomata, usually multiple, are oc-
casionaliy found in the kidney. They are generally
found iuthe cortex, close beneath the capsule, and may
arise either from the capsule or from blood-ve-ssels (Lar-
tigau and Larkin, Journal of Medical Research, N. S.,
vol. 1., No. 1, 1901). They give rise to no symptoms dur-
ing life.
Other locations in which leiomyoma is occasionallj-
found are the spermatic cord (the growth occurring here
sometimes as a myolipoma), the liver (where these
Fig. 3467.— Cells from a Rbalxiomyoma. (From Ribbi-rt and Wolfensberger.) a,h,c. Fibres oj various
sizes with transverse striatiou ; rf, small nucleated fibre without striiP : f . spindle cell with longi-
tudinal strife; /, spindle cell with longitudinal and transverse stria> : g. spindle cells, non-striated,
with elongated processes: /i, i, round cells with concentric and radial striation.
growths are of slight significance), the Fallopian tubes,
ovaries, vagina, and vulva: in all of which locations the
type is generalh' that of a fibromyoma. In mixed tumors
of the mammary gland small masses of both smooth and
striated fibres are occasionally seen.
Rhabdomyoma.— Tins, form of myoma, into whose
structure striated muscle fibres enter, must be consid-
ered one of the rarest of tumors. The first of these
tumors was described by Rokitansky, and since then
not more than thirty or forty cases have been reported.
Von Recklinghausen found in the hearts of newly born
children, in a few instances, small tumor masses which
contained striated muscle fibres. Geuerall.v the tumors
are not pufe forms, but are mixed with sarcoma. The
muscle fibres are, as a rule, not straight and arranged in
masses, but are separated from one another and irregu-
larly distributed in the tumor. The character of the
fibres varies. The well-developed fibres appear as nu-
clear bands of varying width and may have both longi-
tudinal and transverse striations. The poorl}' developed
forms are narrow bands without transverse striations. or
siiindle cells with long processes and imperfect or no
striations; also tliere may be seen irregular round or oval
cells, varying in size, with radial or concentric striation.
Associated with these are numerous cells of indefinite
origin. (See Fig. 3467.) A sarcolemma is not always
demonstrable, but has been described.
The mo.st frequent place of fcu'mation of these tumors
is in the genito-urinar}- system, especially in the kiilne}'
or testicle, and frequently iu the uterus, vagina, bladder,
or ovaries. They occur occasionally-, however, in other
locations, as in the skeletal muscles, "parotid gland (Prud-
den), subcutaneous tissues, mediastinum, and cesophagus.
They are found almost exclusively iu children, and may
reach a very large size; as in the case desciibed by Mar-
chand, in which such a tumor of the left kidney extended
from the diaphragm to the pelvis and weighed 2,770 gm.
Most probably the exijlauation given by Cohnheim of
their origin, which refers Ihem to unused embryonic ma-
terial, is the correct one. Their presence iu such parts
where complications in the embryonic formations take
place, and where there is a mingling of the germinal
la3'ers, speaks in favor of this. Richard Mills Pearce.
MYOPIA — M — {fivuTTia, uvu-iaGi^, also fiVG)7r6^, fjvuip —
from iiiu) and ui/'. signifying winking or contracting the
eyelids — German, Kurzmcttiiijkeit ; French, tue courte ;
English, short- or near-sightedness) — is mentioned by
Aristotle, in the Galenical writings, and by the Byzantine
medical authors — Oribasius. Actius, Paulus ^gineta, and
Actuarius. It is described as a congenital coudition, in
which small near objects
are seen distinctl.v, but dis-
tant objects imperfectly or
not at all; also as the op-
posite condition to that oc-
curring in old persons who
distinguish small near ob-
jects, such as written char-
acters, impci-fectly, but see
well at a distance. It is
further recognized as in-
curable.
These brief statements,
which comprehend practi-
cally the sum of the teach-
ing of the earlier writers on
medicine, and which were
not seriously questioned
until after the middle of .
the last century, include,
nevertheless, two funda-
mental errors: (</) M, al-
though very common in
children, and dependent in
many cases on inherited ten-
dencies or conditions, is
very rarely congenital ; and
(ft) JI is not the opposite condition to presbyopia —
which is a disability resulting from impairment of the
function of accommodation incident to advancing age
— but is really the opposite of hypermetropia — H — (see
Ilypcnnctropia), which is a congenital condition, and
wiiich, like 31, consists essentially in a faulty proportion
between the radii of curvature of the refracting sur-
faces of the eye and the length of the antero-posterior
axis of the e_Teball.
As in II the axis of the eyeball is, as a rule, actually
shorter than in the normally proportioned (emmetropic)
eye, so in M the axis of the eye is. as a rule, longer than
in the emmetropic eye. These two opposite anatomical
conditions constitute, in fact, the essential variations
from the normal in typical II and ]M respectively, name-
ly, axial H and axial M.
Fig. 3468 represents, in section, a myopic eye, the
dotted outline indicating the section of the emmetropic
eye (cf. Fig. ^".'JH, vol. iv., p. 796). It has been exjilaiued
(see Accommodation and Refraction, vol. i., p. 56) that the
■simi of the successive i-efractions at the cornea ami the
two surfaces of the crystalline lens is just sufticient to
focus pencils of parallel rays upon the retina at its nor-
mal position E. and that, through the exerci.se of its ac-
commodation, the emmetropic eye is able to focus, upon
its retina, pencils of divergent rays, such as are received
from near objects (cf. Fig. 2762. vol. iv., p. 797). In the
myopic eye the principal focus — /.(■.. the focus for pen-
cils of parallel rays — is in front of the actual position of
the retina, so that the retinal image of any distant object
is made up of overlapping circles of confusion and is,
therefore, imperfectly defined.
The unaccommodated myopic eye is, however, adapted
for the correct focussing of pencils of divergent rays
emanating from an object at some partictdar short dis-
tance, as shown in Fig. 3469, in which a pencil of rays
11
Iflyopia,
niyopia.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
(livi'i-jfiug from r i.s represented a.s refracted to a focus ou
the retina of tlic myopic eye at M. Tlie distance of this
ftir-jiiiiiit of distinct \-\awn (piincl inn n'mntisxiiiiiiiN — /■),
measured from tlie eye in metres or fractional jnirts of a
nielre. is the reciprocal of the grade of the myo])ia ex-
pressed in dioptrics. Representing this distance hy R,
and the grade of the myopia by .M. we have:
R = ^ metre
[1]
By the e.\crcise of its accommodation the myopic eye
is able to adjust itself for distinct vision at any distance
accommodation (R — P), although extended, by a few
centimetres, in the direction toward the eye, is so greatly
contracted, as a wliole, as practically to annul the part
lilaye(l by the accommodation in seeing at short range;
only in the lower grades of myopia, in which ;■ lies
fartliei- from the eye than the reading distance, is there a
limited field for a partial exercise of the accommodation
to meet the restricted requirements of near vision.
As a consequence of the displacement and contraction
less than R. U]) to a limiting point ;) (Fig. 34T0), which is
called the neKr-pniiit (pnnctuiapni.riiiniiii). The distance
of the iicar-iioint from the eye, represented by P, is the
reciprocal of the grade of the myopia plus the range of
accommodation, both expressed in dioptrics. Represent-
ing the range of accommodaticm liy A. we have:
P = ^^^ metre.... p]
From the form of equaticms |1] and [3], it is evident
that, for increasing values of M, both R and P decrease,
but that R decreases at a greater rate than P. It follows
that for higher gradesof myi>]iia, both rand /< fall nearer
of the region of accommodation in myopia, the interrela-
tion of accommodation and convergence, as it exists in
emmetropia (see Accviumudatwit and liefraction, vol. i.,
pp. 55-58), is materially altered. Thus, in myopia of M
>f myopia, and that
to the ej'e than for lower grade
they also fall nearer together.
Subtracting eciuatiou [2] from e(|uation [1], we have:
R-P = yj-^-j-|--^inefre .... [:i]
The linear measure R — P. which represents the differ-
ence in the distance of the far-i)oint (?•} and the near-
point (p) from the eye, antl which represents, therefore,
the linear distance through which the myopic eye is able
to adjust itself for distinct vision by the full exercise
of its accommodation (A), is
its rt'f/ion of ai'i'onnnitdation. nj
As R is the reeijirocal of M, /'
the region of accommodation,
R — P. is at its maximum (intinity) when M = zero (em-
metropia). Table I. shows the measure of R, of P, and
M=.
-^-
' M -f A ■
K-P =
1 1
M M + A ■
1. I)
1 = l.(»10m.
= asm in.
= 0.:B3 m.
= 0.2.50 m.
= o.200m.
= 0.1(57 m.
7 = O.IW m.
B = 0.125 m.
J = 0.111 m.
it = U.IO" 111.
A = 0.091 111.
■i^. = O.OcS3 111.
-iS = 0.077 m.
A = 0.O71 m.
,V = (i.()()7 m.
t'b = 0.0(3 ni.
i't = o.O.)9 m.
t'o = O.o.5«m.
y', = 0.0.53 m.
I's =0.050 111.
}? = 0.9(J9m.
hi = 0.417 m.
§S = 0.2.5(! m.
Jg - 0 179 m
2. I)
3. I)
4. I)
5.11
6. I) . . . .
i; = o.i:«m.
ijj — 0 104 m
7.1)
8. 1)
VA = 0.0S4 m.
iVi = 0.(K!9 m.
,V't = 0.05.S m.
iVo = 0.0.50 m.
». 1)
10. 1)
of R — P, respectively, for pi'ogressively increasing
grades of myopia, from 1. D to 10. P. in a young person
with an imimpaired range of accommodation of 10. D.
Inspecting Table I,, it will be oli.served that in high
grades of mj'oiiia both the near-point ( p) and the far-
point ((•) are very near to the eye, and that the region of
dioptrics, the farthest point of distinct vision — r — (under
full relaxation of the accommodation) is at a distance of
;rj metre from the eye; but, in oi-der to see an object at
this distance with the two eyes, the axes of the two eyes
must converge to an amount represented by 51 metre-
angles (see vol. i. , p. 583, note). It follows that for perfect
binocidar vision, at or within the distance of the far-
point, a normal exercise of the convergence, correspond-
ing to the distance of the (near) object, must be associated
cither with full relaxation or with less than the normal
exercise (relative relaxation) of the accommodation; in
other words, there is an essential change in the relation
between accommodation and convergence from that
which obtains in emmetropia, in which (normal) condi-
tion an exercise of the cimvergence measured by any
number of metre-angles goes hand-in-hand with the
78
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
:<Iy<ipia.
Myopia.
exercise of au equal number of dioplries of accommo-
dation. ....
As a fact, a notable readjustment of the physiological
bond by which the two functions of accommodation and
convergence are linlied together follows closely upon the
progressive change in the refraction in most cases of
myopia; and this readjustment is often so nearly perfect
as" to admit of the easv and sustained use of tlie two eyes
toax'ther in near work. Thus in most cases of stationary
or%lcnvly progressive myopia, up to a grade of about 3.
D, no difflcult'v is experienced in reading ordinary print,
with the two eves, at approximately the normal reading
distance of about J metre ; also, in notably higher grades
of myopia, very line print may be read, easily and with-
out fatigue, at some shorter distance corresponding to
the distance of the point of intersection of the visual
axes. Hence the very old and widely disseminated be-
lief that myopes, as a class, enjoy a substantial advan-
tage in respect of strong and fine vision in near work, and
that this advantage, together with the further advantage
of partial or complete exemption from the ordinary dis-
abilities incident to presl)yopia, may be held to outweigh
the sinffle recognized disadvantage of imperfect vision
at a distance. That this old belief is, in the main, erro-
neous, and founded in ignorance or imperfect appreciation
of the jiathologv of myopia as tlie visual expression of
distention of the evebiiU from disease, is proved by the
anatomical demonstration of extensive and characteristic
lesions in the fundus and coats of the eye in liigh grades
of myopia; by tlie study of these lesions in the living eye
in their successive stages of development, as revealed by
the ophthalmoscope; by extended statistical researches
on the refractive conditions existing in the eyes of school
chiklreu in the lower and higher classes and grades; and
by clinical experience based on successive examinations
of the eyes of inilivldual myopes, extending often over
manv years. . ^ ,• r
Two fundamental facts, based on exhaustive studies of
myopia during tlie past half-century, are definitively es-
tablislied : . ■, ■ t
(a) Myopia is ordinarily the optical expression of an
elongation of the antero-posterior axis of the eyeball, de-
pentfent on a patliologieal distention of the globe. Fur-
thermore, this distention is in many cases rapidly pro-
gressive, and not infrequently attains to so high a grade
as to become a grave menace to the integrity of the eye
as an organ of vision. _ _
(/)) In many cases of myopia, especially when it is of
hio-h grade or of rapid development, the compensatory
readjustment of the convergence to tlie displaced^ region
of accommodation is in so far incomiilete as to give rise
to a state of persistent conflict between accommodation
and convergence. As alternative issues of this conflict
there may result either an habitual exercise of the accom-
modation in excess of that which is required for perfect
vision at the distance of the point of intersection of fhe
A
an infinite distance. At the same time the near-point (;*)
is removed farther from the eye, to a distance, j, deter-
mined by the magnitude of the range of accommodation
(see Accomminhition and Refraction, vol. i., ii. 57).
The effect of a concave lens added to a myopic eye is,
then, to remove both the far-point (r) and the near-point
(;>) to a greater distance from the eye; Ijut the recession
of r is greater than that of p. The region of accommo-
dation (K — P) is therefore enlarged, attaining its maxi-
mum (infinity) when the (negiitive) power of the lens is
numerically equal, in dioptrics, to the grade of the
mvopia.*
As a result of this re-establishment of a normal region
of accommodation, with the far-point (?•) at infinity, the
requirements for the conjoined exercise of the accommo-
dation and the convergence in binocular vision becorne
identical with those which obtain in emmetropia — the dis-
tance of the near-point, as determined by the exercise of
a certain number of dioptrics of accommodation, now
coinciding with that of the point of intersection of the
visual axes, as determined by au exercise of the converg-
ence measured bv the same number of metre-angles. As
a rule, in uncomplicated myopiiX of low or medium grade,
with unimpaired range of accommodation and normal
acuity of -visual perception, little or no inconvenience is
experienced in utiUzing fully the enlarged region of ac-
commodation and, at "the same time, re-adjusting the
convergence to the changed optical conditions imposed
by the wearing of neutralizing concave glasses. In the
higher grades of myopia, especially if concave glasses
are to be given for the first time, only a partial optical
correction mav be accepted in the beginning, and tlie
full correction" may have to be reached by a later change,
or perhaps through one or more changes, to glasses of
greater power.
With advancing years, as the crystalline lens becomes
progressively harder and less ca"pable of undergoing
changes in forni (see Accommodaiion and Refraction,
vol. T., p. 59), the range of accommodation (A) dimin-
ishes in myopia just as in emmetropia ami in hyperme-
tropia. With decreasing A, approaching zero in old age,
p = . . [ij increases, approaching R =^ . . [1]
M + A i't
as a limit; the region of accommodation (R — P) being
then reduced to zei-o through the recession of -p to r. At
the practically unchanged ^listance of r, the vision of the
myopic eye is still perfect, and whenever r lies within a
convenient reading distance from the eyes, as in myopia
of not less than 3. D or 4. D, convex glasses are not
needed for reading. In myopia of less than 3. D the
need of convex reading glasses is first experienced later
r—
visual axes, or accurate accommodation for the actual
reading distance accompanied by fatigue or insufficiency
of the recti intcrni muscles — muscular asthenopia, or
relative or actual strabismus divergens (see Asthenopia
and Strabismus).
A myopic eye looking through a concave lens of any
(negative) power up to the measure of its myopia is ren-
dered virtually less myopic. AVith a concave lens of N
dioptrics, taking N <"JI, the uncorrected part of the
myo|iia is M — N dioptrics.
If we take N = :M (Fig. 3471), we have M - N = zero.
in which case the myopia is completely corrected (neutral-
ized) by the concave lens, and the eye is rendered vir-
tually emmetropic, i.e., the far-point" (r) is carried off to
Fi... ;mti.
in life than in emmetropia, and relatively weak glasses
then surtice. Similarly, in the higher grades of myopia,
concave glasses weake'r than those which eomiiletcly cor-
rect the eyes for distant vision must be given for reading
at the best distance from the eyes.
» If wp take N > M. ttic effect of the concave lens will be to over,
correct the myopia, and the eye will be rendered virtually hyperme-
tropic (see Hypermetruyia.)
n
ITIyoiiia.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Although the tendency in axial myopia is, as a rule,
in the direction of a prosrressive increase in grade as a re-
sult of progressively increasing distention of the eyeball,
in a notably large proportion of all cases of myopia this
tendency becomes arrested sooner or later, and the length
of the axis of the c.ve may then continue stationarj- for
many years or during the remainder of life. In such
■cases a small decrease in the grade of the myopia,
amounting to a dioptric or two, or perhaps a little more,
may generally be detected in old age, as a result of a
physiological decrease in the refractive power of the
•crystalline lens (see Hypirtnetropia Acrjuisita, vol. Iv. , p.
HOO). On the other han<i, an increase of a few dioptrics
in tiie refractive powerof the crystalline lens is not infre-
quently observed as an incident of beginning senile cata-
ract, and from this cause a true lenticular myopia may
make its appearance in old age, or a pre-existing myojiia
may develop a considerable increase. Thus certain el-
derly persons, who have used convex glasses in reading
for perhajis many years, discover that they can read as
Well or better without glasses (.so-called second sight),
and in certain cases of myopia it is foimd that the con-
cave glasses which have been habitually worn are no
longer perfectly satisfactorj' in distant vision. A re-
Tisiou of the glasses worn bj' myopes, whether for
distance or in reading, is therefore generally indi-
cated in advanced life, changing oftenest to some-
what weaker concave glasses, but occasionally to
stronger, according as the lenticular refraction is found
to have diminished or to have uudergoue a pathological
increase.
The size of the retinal image of any object situated at
or within the di.stance of the far-point of the myopic eye
is greater than in the case of the same object focussed by
an enimelr(>|iie eye through the exercise of its accommo-
dation, in the ratio of the respective distances of the sec-
ond nodal i)oint of the eye (A") from the retina. The size
of the retinal image increases, therefore, for every in-
crease in the length of the eyeball, so that a j'oung per-
son, with uncomplicated myopia of high' grade, may en-
joy, for a time at least, exciuisitely line sight for small
nearobjects. AVith the correctionof the myopia by con-
cave spectacles, the nodal point is moved neaier to the
retina, and, in the case of a neutralizing concave glass
worn at the anterior principal focus of the eye (about 13
mm. in front of the cornea), the distanre of the nodal
point from the retina, consequently the size of the reti-
nal image, becomes the same as in euunetropia. Owing
to this diminution in the apparent size of small near ob-
jects, it not infrequently happens that a myope of high
grade, although aece]5ting neutralizing concave glasses
for distance, is disinclined, or, in the case of subnormal
visual acuity, is unalile to use them in reading. This
may become a source of grave embarrassment to the oph-
thalmic practitioner, who recognizes the dangers attend-
ant upon the habitual use of the uncorrected eyes in fine
near work, but may tind it ditticvdt to persuade a youug
patient to abandon such work as a means to the conser-
vation of his sight.
Origin mid Derelopmeiit nf Mpopin. — In young children
hypermetropia is the typical refractive "condition. Of
100 eyes of infants from one to four weeks old, meas-
ured, under atrojjine, with the ophthalmoscope, by Horst-
maun,' 88 (aggregating 244. D) were h_vpernietropic, 10
were emmetro]iic, and 3 (aggregating 4. D) were myopic.
Of 100 eyes of children between one and two years of
age, similarly examined under atropine, 84 (aggregating
188. D) xyere hj'pennetropic, 10 were emmetropic, and 6
(aggregating 8. D) were myopic. Of 100 eyes of children
between four and five j-ears of age, 74 (aggregating 188.
D) were hypermetroiiic, 13 were emmetropic, and 13 (ag-
gregating 23. I).) were myo]nc.
Of 10,060 pnpilsof public schools in Breslau (including
1.486 children in five village schools) examined subjec
lively by H. Cohn," the percentage of cases of myopia
increased progressively from an average of 6.7 percent,
in twenty elementary schools, loan average of 36.3 per
cent, in two gymnasia (colleges). The grade of myojiia
also increased from an average of 1.8 D, in the elementary
schools, to 3. I) in the gymnasia.
Erismann ^ measured the refraction in 4,338 pnpilsof
schools in St. Petersburg; he found; Of h3-permetropes,
48. .54 per cent. ; of emmetropes, 36.10 per cent. ; of my-
opes, 30.36 per cent. Tabulated iu percentages for suc-
cessive j'cars of school life, Erismann's statistics show,
for seven consecutive school grades, a progressive
decrease in hypermetropia from •5-5.6 per cent, iu the
lowest to 3(i.3 ]H-i cent, in the highest grade, and an in-
crease in myopia from 15.8 per cent, iu tlie lowest grade
to 43.8 per cent, iu the highest. The percentage of em-
metropic is given as 28 per cent, in the lowest grade,
35.1 percent, in the sixth grade, and 21 percent, in the
.seventh (highest) grade; in grades I. to VI. it fluctuates
between 28 per cent, and 35.1 per cent., averaging 26.1
per cent. Studied as a whole, the numbers show {a) a,
progressive increase iu the percentage of cases of m3-o-
pia, (/') a concomitant progressive decrease iu the percen-
tage of cases of hypermetropia, and (r) a nearly constant
percentage of cases of emmetropia. They thus empha-
size the fact, previously suspected, but denied by Don-
ders, that the ranks of myopia are recruited, through
emmetropia as a transient condition, from eyes originally
hypermetropic. It follows that a condition of emmetro-
pic or even of h_yperinetropic refraction may be present
in an eye which has already imdeigoue uotable disten-
tion, and that the beginning of the pathological process
typical of myopia must be dated back, in many cases,
to a period possibly long antecedent to the development
of myopic refraction. In this fact is found an explana-
tion of the cases in which pathological conditions charac-
teristic of myopia of high grade are seen in eyes of rela-
tively low m3-opic refraction, or, more rarely and less
highly developed, in eyes which are optically emmetro-
pic or hypermetropic.
An enormous mass of statistical material gathered by
many observers in manj- lands shows conclusively that
with moderate and easily explicable variations in the
percentages, the conclusions based on the original re-
searches of Cohn and Eiismann are essentially true for
all highly civilized communities.
Distribution of Myopiii. — Myopia is pre-eminently a
disease of the higher ranks of society, and of liighlv cul-
tured peoples. It is widely prevalent in Germany, where
its causes maj- be referred, in part, to the national "stu-
dious habit " ; partly to long hours of school work, sup-
plemented by protracted stud_v hours at home, by arti-
ticial light; partly to the general use of the old German
text, in which the dilfercntiation of certain letters is
especially dillicidt ; and possibly to racial predisposition.
In a relatively small proportion of cases, mj-opia of
high grade and of malignantly progressive type is ob-
served in laborers or other persons who have never been
subjected to the conditions generally recognized as espe-
cially causative of mj'opia; in these cases an inherited
predisposition to myopia may be suspected. Mj-opia
often occurs in certain fanulies, appearing in several
children of a m^vopic ]iarent or parents, an<l sparing
others. Soldiers and sailors are, as a rule, exeiupt ; but
this is mainly a result of selection. Savage races are
largely exempt from myopia; Furnari-' foiuid no cases
among the Kabyles. "Survival of the fittest " and the
absence of exciting causes of myopia afford an obvious
explanation.
Myopia iin Belated to Age. — The statistics of myopia
show that it is essentially an acquired condition ; also
that, in school or college, myopia of high grade occurs
almost exclusively iu the more advanced classes. Every
case of myo]3ia must, therefore, lie regarded as having
passed through a progressive change from a lower to a
higher grade, and, especially in the case of a youug per-
son, as, possibly or probably, still in a stage of contin-
uous or remittent progression. The study^f the refrac-
tion of individual young moypes, examined froiu year
to year, enforces the same conclusion. The age at which
a more rajiid increase is ordinarily first noticed follows
very closely upon that at which considerably increased
80
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
M}0|>la.
niyoiHa.
demands are made upon tlie eyes in study, namely, about
fourteen j'ears. From about tlie fifteenth to about tlic
twenty -tifth year the increase is generally most nipiil.
This corresponds, in a general way, to the years fif ad-
vanced preparatory and collegiate study, with some added
j'carsin the universit}- or in a professional school. It also
includes the ordinary jieriod of apprenticeship to trades
which may demand close and continuous aii]dication.
Furthermore, a somcwliat rapid rate of increase may be
expected to go on, for a time, after the special determin-
ing conditions have been mitigated or have ceased to be
actively operative.
In considering the influence of age in its relation to
the development of myopia, the greater extensibility of
the scleral tissue in children may be assuraetl to play an
important part. Also, in older subjects, the stretched
and tlunned sclera of the highly myopic eye may oppose
inadequate resistance to continuing distending forces to
which it has already yielded. As a fact, myopia is sel-
dom developed, in a previous!}' health}- emmetropic eye,
after the term of youth has been passed; the apparent
exceptions are almost always instances of increase in the
grade of pre-existent, but unrecognized or unacknowl-
edged, short-sightedness.
Myopia of high grade (10. D or more) is occasionally
observed in a child of eight or nine years, and should
then be contemplated with great solicitude in view both
of the disability incident to the high grade to which it
maybe expected to attain and the fear that, later in life,
the integrit_y of the eyes may be endangered.
It lias been erroneously a.ssumed tJiat myopia tends to
diminisii with advancing age. On the contrary, it is al-
ways either progressive or, at the best, stationary. An
apparent exception, based on certain cases in which a
myopia of low grade disappears as a restdt of a decrease
in the refractive power of the crystalline lens in old age,
also the occasional late occurrence of a lenticular typeof
myopia dependent on a pathological increase in the re-
fractive power of the crystalline, have been already men-
tioned.
Clamfication of Myopia. — Donders'' has divided myo-
pia into three categories, basing them on the course and
progress of the disease, namely: (1) stationary M; (2)
temporarily progressive M; (3) permanently progres-
sive M.
(1) The type of the stationary class is represented
mainly by cases of myopia of low grade, Avhich increase
slowly up to a limit not much exceeding 2,5 D to 3. D at
the age of twenty-five years; after the twenty-fifth year
the increase is insignificant. In this category are in
eluded certain cases of myopia of higher grade, which
follow a similar course of slow and limited pro,gressiou.
After the age of about fifty years, distant vision often
improves, owing in part to the smaller pupils, in elderly
people, lessening the diameter of tlie circles of confusion
in the retinal image, and in part to the slight physiologi-
cal decrease in the refractive power of the crystalline lens.
(2) The temporarily progrcs.sive class includes those
cases whicli increase rapidly up to about the twenty-fifth
year, and become stationary, generally before the th'irtieth
year, after having attained a grade averaging about 8. D,
At tills grade the myopia remains practically stationary
during the remainder of life, but with a tendency, in cer-
tain cases, to recrudescence, which may bring the case
under the category of —
(3) Permanently progressive myopia. In this class a
myopia of 6. D or more, at the age of twelve years, de-
velops continuously, but generaUy at a decreasing rate,
up to a limit which may reach or exceed 30. D at the age
of sixty years. "The worst is then to be feared. It is
rare at sixty years of age to find a tolerably useful eye
with myopia of 16. D or even of 13. D " ( Donders).
Ophthtilmoncopie Ap])eam>ices. — The region id' the fun-
dus about the entrance of the optic nerve (optic disc) is
the seat of certain very characteristic changes which, al-
though occasionally seen in eyes of emmetTopic or even
of hypermetropic refraction, are so constant in inyo|iia
that they are ,iustly regarded as typical of this disease.
Vol. VI.— 0
Especially characteristic is an alteration in the choroid
which, from its general configuration, is known as the
"crescent" or "sickle" (Figs. 3472, 3473, and 3474).
Fi ' ■ II Eye.
;i,:;. 1,^ II I '
Fi«s. 3473. 3473, AND 3474,— Represent DitTerent Types ot Crescents
as seen In Ilie erect Image, (Frnm Jaeirer. i
This appears, ordinarily, as a whitish or ,t;rayish-wliite
area, crescentic in outline, the concavity of the crescent
closely hugging the outer margin of the disc, the con-
81
myopia,
myopia.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
vexity cither sharply oiitliiu'd by a more or less ccin-
siiicuonsly |iijniicntp(l border or shaduig jrnuluiiUy into
tlie normal elmroidtil tissue in the general direction of
the fovea. Traversins this area the liuer retinal vessels,
which supply the region al>out the macula, are seen
somewhat straightened in their course, as if stretched
longitudinally. Tlie crescent may vary in uidlli from a
tliiu sickle-shaped band at the disc-margin, from which
it is with dilliculty to be distinguished, to a large area,
apiu'oximately parabolic in outline, which, from its re-
semblance to a conic section, has been named "conus."
In other cases, especially in myopia of high grade, the
appro.ximately regular ctu'vilinear outline is lost, the
altered area taking on irregular and often bizarre shapes.
The myopic crescent is essentially the expression of a
localized" atrophy of the choroid, accompanied in many
cases by a stretching and thinning of the .sclera adjacent
to and mainly at the temporal side of the 0])tic disc. It
thcnljecomcs an area of least resistance whieli may be the
seat of a gradually increasing protuberance or. in ex-
treme cases, of a deforming boss, at the posterior pole of
the eye (xtuphylomn pusticnm).
The pathological processes leading to the development
of the crescent are still imperfectly understood. In gen-
eral, the ophthalmoscopic appearances are such as to sug-
gest a sliding of the choroid on the sclei'a, with attendant
stretching of tlu' choroidal tissue at the tem]ioral side of
the disc. As a result of this stretching, a localized cho-
roidal inflawmatiou of low grade, passing into atrophy,
may be invoked as offering the best explanation of the
origin and subsequent enlargement of the cresceutic area.
The irregular extension of the conus in advanced stages
of the disease is clearly the expression of atrophy follow-
ing choroiditis. Atrophic spots in different parts of the
fundus, indicating areas of previous circumscribed in-
tiammation of the choroid, are of not infrequent occur-
rence in high grades of myopia.
The optic disc in myopic eyes often presents an oval
contour, as if shortened in its horizontal diameter. This
appearance may be simply the effect of foreshortening
due to an oblicpie position of the disc with reference to
the direction fiom which it is viewed. In many cases,
however, there is almost certainly an actual variation
from the ty]iical circular form.
Capillary hypera^mia of the disc is a friMpient condi-
tion, especially in yotuig myopes whose myopia is in the
jirogressive stage: it maybe regarded as the local expres-
■sion of general ocular by pera>mia. At a later ]icriod, after
the congestion has disaiiiieared. the disc often assumes a
]ialli<l tint indicative of ana'mia. and may even present
the appearance of a shallow excavniion.
Liquefaction of the vitreous, witli the preseni'e of finer
or coarser floating specks or shreds, is very connnon in
inyo]iia of higli grade and long standing. Myopic eyes
are also csiieeially subject to detachment of llie retnia,
1>~>-
Fifi. IMT.5.— Lenprituiiinal Section Ttiroutrh the liptie Nerve at its
Entrance into thi' Eye. i From Jaeger. )
a disaster whieli has lieen attrilmled tii a dragging of the
vitreous upon the retina. A bow-shaped rellex concen-
tric with the disc (best seen through a concave lens, a
little weaker than the measure of the myojiia. behind the
hole in the mirror of tlie ophthalmoscope) has been de-
scribed by AVciss ' as a sign of posterior separation of the
vitreous from the retina.
Piilhiilo(jii-(d Aiiiitiiiiii/. — A meridional section through
the fovea and the distal end of the optic nerve (Fig. 24to)
shows, in cases of highly developed conus. a wide sepa-
ration of the inner and outer nerve sheatlis where the
nerve joins the globe. Beyond the limits of the conus
the outer sheath becomes continuous with and reinforces
the sclera, but within the area corresponding to the
conus. where the reinforcing fibres of the outer sheath
are absent, the outer coat of the eye apjicars very much
thinner than in its normal condition or than at the j.ios-
terior region of the globe generally.
A general thinning of the sclera, the decrease in thick-
ness becoming gradually more marked posteriori}-, is
characteristic of the higher grades of myopia.
A typical change in the form of the ciliary body, as
.shown in a meridional section of the anterior segment of
the eyeball, conjoined with an appearance as of an in-
creased development of the radiating fibres and a decrease
in the number of the circular tibresof the ciliary muscle,
as first described liy Iwanotf,' ma\' be regarded as an ex-
pression of the general stretching of the choroid.
Ciiiiscs of JJi/oj)ii(. — The cau.ses leading to the typical
patliological changes in myopia are but imperfectly un-
derstood. Donders ** laid much stress on the hypothesis
of an inherited predisposition, and this opinion is sup-
ported by many clinical facts. Certain families show a
very large proportion of myopes, others comparativeh-
few. The inheritance of a special anatomical condition
of the sclera or optic nerve, implying less than normal
resistance to the operation of distending forces, is not
more improbable than the inheritance of a hypermetropic
configuration of the eyes. Corneal a.symmetry, the ordi-
nary cause of astigmatism, is distinctly transmissible
from parent to olIs])ring. and astigmatic refraction is too
frequently associated with myopia to ailmitof reasonable
doubt that the former stands in a causal relation to the
latter. The general distention of the globe, mainly in
its posterior half and especially aliout the posterior pole,
corresponds to tlie thinner and presumably less resistant
.scleral region jiosterior to the insertions of the recti mus-
cles. The immediate causes of the distention, whether
they are to be souglit in original structural weakness of
the tissues or in increased intraocular pressure, or both,
are matters of dispute. Continuous close application to
fine near woi-k, in which strong accommodation and con-
vergence go hand-in-liand, is a most important etiological
factor. After elongation of the globe lias begun, con-
vergence for the ordinary reading or working distance
tends to evoke aceonimodation for some shorter distance :
but reading or working at this shorter distance implies
an increase in convergence, which in turn incites to iu-
crea.sed exerci.se of the accommodation. As a result of
this inter-action of convergence and accommodation, the
tendency is to a progressive shortening of the reading
distance, and, ])an' putisu. to an increase in the grade of
the myopia.
Wei-ss'lias suggested that a short optic nerve, drag-
,ging on the sclera in inward rotation of the eyes, nm' be
a factor in the development of posterior staphyloma.
Stilling "* has called attention to a particular conforma-
tion of the orbit, giving rise to an alteration in the direc-
tion of the pull of the reflected tendon of the superior
olilicjue mu.scle, as a suppo.sed cause of injurious traction
upon the globe.
Tmi/iiK lit (if Mi/o/iiii. — ''The cure of myopia belongs
to the /'/(/ wtit^' (Donders). Erroneous assumptions re-
garding the causes of short-sightedness have led in the
past to the proposal of a variety of futile or harmful
plans of treatment. Thus attempts have been made to
diminish the convexity of the cornea by the prolonged
application of jiressure. or by corneal paracentesis re-
peated at short intervals. Pi"actice in reading at pro-
gressively increasing distances from the eye lias been
strongly advocated, in the belief that a sujiposed exces-
sive lenticular refraction might thus be gradually less-
ened. Division of one or more of the recti, or of the
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
myopia.
ITIyopla.
oblique, muscles, in order to diDiinish a supposedly in-
jurious muscular iiressureou the globe, has also been ad-
vised anil practised.
Therapeutic measures directed to the removal of con-
ditions of irritation whicii not infrequently appear in
connection with rapidl_v progressive m3-opia, belong to
the realm of rational therapeutics. Rest of the eyes from
near work, protection from exposure to excessive light,
regulation of the general physical condition, and, in
some cases, the local aljstraction of blood from the tem-
ple.s — jjreferably by means of the artificial leech of
Heurteloup — are all of value. The so-called atropine
cure is also employed, with good effect, in certain cases
of rajiidly increasing myopia: tlie eyes are kept imder
the full influence of atropine for about two weeks, in a
moderately darkened room, after which the ]iatient is
permitted to go about with the eyes well protected by
dark glasses; the use of the eyes in near work is forbid-
den for another fortnight.
Use of Cvncai-e GUisses. — The wearing of concave glasses
to improve the distant vision of myopes is lirst mentioned
by writers of the latter half of the sixteenth century ; but
the intelligent prescribing of such glasses, with a view-
to their effect upon myojiia considered as a disease, be-
longs exclusively to modern ophthalmology ; and even
now there is notable divergence of opinion on certain
points. In general, it ma_v be accepted as a well-estab-
lished principle tliat in uncomplicated myopia of low or
medium grade, with normal acuity of visual perception
and unimiiairedrangeof accommodation, concave glasses
shoulil be chosen of such strength as to correct the vision
accurately for distance, and that the same glasses should
be worn for near work. Furthermore, it shotdd be the
aim to raise the vision, as controlled by tests made at a
distance, to the highest point of acuity of wliich the eyes
are capable; and to tliis end even low grades of astig-
matism should be carefully investigated and corrected.
The distance at which the glasses are worn, tlieir proper
ceutration before the two eyes, and the direction of the
plane of the glasses with reference to the line of sight
should all be definitely prescribed and controlled. Inas-
much as the same glasses are worn both for distance and
in reading, thej' should be tilted so that the angle made
by the visual a.xes to the plane of the lenses shall be as
nearly equal as practicable in looking forward at distant
objects and downward on the book (" pantoscopic " posi-
tion). The effect of the tilting of the glasses in increas-
ing their effective refractive power in the vertical merid-
ian, and to a less degree in the horizontal meridian, shoidd,
in every case in which glasses of high power are required,
bo considered and allowed for in deciding upon tlie
formula for the lens. The eyes should, further, be re-
examined, at first at short inteivals and later at intervals
of a few months, in order tliat any change in tlie grade
of the myopia may be jininiptly discovered and corrected.
Explicit instruction slim. Id be given as to the kind and
amount of work which may be permitted; reading or
sewing witlKuit glasses, and especially the use of the
eyes in near work by failing daylight or b}' insutiicient
artificial illumination, should be absolutel_y forbidden.
The glasses (ordinarily sjicctaeles made with elastic sides
curved to fit accurately behind the ears*) should be worn
continuously during the waking hours.
The wearing of neutralizing concave spectacles i.s ordi-
narily attended with great comfort to the patient, and
the progress of the disease is, as a rule, either greatly
retarded or wholly checked. Every renewal or change
of glasses should be rigorously controlled, and it should
be fully explained to the patient or, in the case of a child,
to the ]iarents, that the condition is one that must be kept
under continuous observation for years.
Cases of myopia complicated by low acuity of vision,
whether dependent on impaired perceptive power of the
retina or on irregularity or imperfect transparency of the
cornea or crystalline lens, present especial difficulties
* So iniieli of a concession to fashion may oft^n be made as to permit
the occasional use of a carefully adjusted |)i»cf-N( 2, instead of the
spectacles, in distant vision.
which militate against tlie best results from wearing
glasses. In general, such patients cannot see small ob-
jects unless they are brought very near to the eye, a con-
dition unfavorable to binocular vision. Accordinglv,
they often form the habit of using only one eye in reail-
ing. By this, perhaps unconscious, neglect ofthe retinal
image in one of the eyes, the conditions wliich ordinarily
give rise to a state of conflict between accommodation
and convergence are eliminated, so that reading to a
limited extent witliout glasses may be practicall}' innoc-
uous. Concave glasses maj', however, be accepted in
distant vision, although not in all cases.
Operation, for iheBemornlof the Transpnrent Crystalline
Lens. — The proposal to lower the grade of myopia in
extreme cases, or to render a strong!}- m.yopic eye either
moderately liy permetropic or possibly emmetropic, by the
removal of the transparent crystalline lens, has been fre-
quently discussed, although generally rejected by oph-
thalmic surgeons, to be revived and somewhat exten-
sively practised in recent years." Simple discission of
the lens capsule, discission followed by removal of the
swollen lens through a small corneal incision, and, in
older subjects, extracti<in combined with iridectomy are
the methods which have been recommended and em-
ployed. Apart from the immediate risks incident to the
operation, and the iincertaint}' as regards its possible
effect in arresting or retarding the progressive distention
of the globe, the possibility of later adverse complica-
tions, such as not infi'equently occur in patients upon
whom an ajiparently ideal operation has been [lerformed
for cataract, would seem to forbid resort to an operation
on the transparent lens except in extreme ca.ses, and even
then only after an exhaustive study of the particular case
in all its aspects. In addition to the ordinary chances of
disaster following operations for cataract, it is probable
that tlio removal of the lens increases the tendency to
retinal detachment, which is always to be feared in the
higher grades of myoiiia. On the other hand, the fact
that in the highest grades of myopia the ordinarilv bene-
ficial effect of concave glasses, in sharpening the defini-
tion of the retinal images, is largely neutralized by the
diminution in the size of the images may afford an argu-
ment in favor of the operation. The incidental sacrifice
of the accommodation should not be accorded undue
weight in the exceptional cases in which alone the oper-
ation may be regarded as permissible.
Effect of the nenioml of the Lens on the Refraction of
Ili'jhhj Myopic Eyes. — The average focal length of the
cr\-stalline lens, in situ, is estimated at 43. 707 mm., which
represents a power equal to 23.877 D. But the removal
of the crystalline lens changes the ej-e from a compound
dioptric .system, of three refi-acting surfaces, to one in
whicli the entire refraction is effected at the surface of
the cornea, and in which a single principal point at the
vertex of the cornea and a single nodal jioint at the cen-
tre of curvature of the cornea replace the two principal
points and the two nodal points of tlie complete eye.
In the case of a previously emmetropic e_ye of average
dimensions, the refractive insufficiency caused by the re-
moval of the crystalline lens is exactly corrected by an
addition of 13.428 D at the cornea, which may be repre-
sented by an effectively equivalent meniscus, of negli-
gible thickness, assumed to be worn in contact with the
cornea. But a convex sjiectacle lens, of a thickness such
as is ordinarily required after an operation for cataract,
is necessarily worn at a distance of appi'oximately 15
mm. in front of the cornea, in which position it becomes
a part of a new compound system in wliich a convex:
lens of 11.177 D suflices to correct the aphakial eye for
distant vision.
A myopic eye whose length of axis is equal to the pos-
terior focal length of the cornea (31.692 mm.) has a focal
length (measured from the second principal point. //") of
29,336 mm., and the distance of the concave spectacle
lens which is worn to correct the myopia, measui'ed from
the first principal jioint, h', is about 2 mm. greater than
its distance from the cornea. In the case whicli we have-
assumed, the myopia is measured by a thin concave lena
83
Myopia.
Iflyrrlioliu.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
of —16.326 D, supposed to be placed at tlie position of
the second principal point of the eye, but a stronger con-
cave lens, of no less than —21.334 D, is required for dis-
tinct distant vision when worn \'t mm. in front of the
first principal point, or 13 nun. in fnmt of the cornea.*
It follows that in a case of axial myopia measured by a
spectacle lens of —21.234 D, the eye, after the removal
of its crystalline lens, will be adajited for distinct distant
vision without a glass; and a spectacle lens of -|- 3. D or
+ 4. D will then suffice for reading.
K. Bjerke '■ has collected, from dilTerent sources, 93
reported cases of myopia in whicli emmetroi)ie refraction
is said to have followed the renrnval of the crystalline
lens by operation. In 29 of these ca.ses (31 per cent.)
the pre-existeut myopia, as measured by a concave spec-
tacle lens, is given as 20. D. In 44 cases (47,3 per cent. )
it is given as between 20. D and 26. D, and in 44 cases
(47.3 iier cent.) it is given as between 14. D and 19. D.
The tabulated figures would seem to point to about 19.. 5
D as tlie mean grade of myopia in which emmetropic re-
fraction may be expected to follow the removal of tlie
crystalline lens fmm the eye. The difference of about
— 1.7 1), between the mean of the observed results and
that calculated from the dimensii >ns and corneal curvature
of the schematic (average) eye. may be explained, in part
at least, by errors of observation incident to the employ-
ment of collections of trial lenses of insutficieut range and
with too great intervals between the higher numbers. The
very large number of cases (thirty-one per cent.) given
as of 20. I"), which corresjionds to the strongest concave
lens in the trial eases in ordinary use, points to a probalile
higher grade of myopia than that reported for these es-
pecially typical cases.f If we could assume a slightly
greater radius of corneal curvature in the average highly
myopic eye as compared with the erametro])ic eye, the
discrepancy between the mean observed grade and the
calculated grade of nivopia corresponding to enuitetroiiic
aphakial refraction woiUd practically disa|ipear. The
assumption of an exceptionally shoit radius of corneal
curvature in the higher grades of observed myopia, and
of a curvature of exceptionally' long radius in the lower
grades, as tabulated, would similarly explain the com-
paratively few aberrant eases in which a very wide de-
parture from the mean has been observed. As regards
possible or probable dilferences in the focal length of tlie
crystalline lens or differences in its effective power due
to variations in its ilistance from the cornea, in individ-
ual eyes or as related to ametropia, trustworthy data are
as yet almost wholly wanting.
Precenlion mid Coiitnd of ilyojiiti. — In the evolution of
the race the ej'es have become admirably adapted to the
* The n.ssuniption of a slinrtt-r distancL- frnin the cdriien, in tlie case
of a strontr c'.'Urave as cumpareii witli a strung C(»nve.\ spectacle lens.
Is justillcil liy the fact that a ct>ncavo Icn.s, however strt-inff, is very
thin at its centre. lint a d()iil>lc-cnnVL*.x s[)cct4K'le lens of 11. D has a
thicliness of aliout 4 nini. at its centre ; a ptauo-couvex lens, and still
more a nifiiisciis, is c\en ihicki-c.
As the opti'al tiistatice of a spectacle lens from the eye is measured
to the sei'ond [trincipal ' = nodal) point of tlie lens, which in the case
of a double-eon ve.x lens lies iieaily half the thickness of the lens within
Its snlistance. the optical distance of a dnulile-conye.x lens fi'oin the
eye is {greater, by nearly half its thickness, than its distance, or that
of a double-concave lens, as nieasiired from the snffa<'<' of the cornea
to the back of the lens. In the i-asei't a plano-conve.x lens, worn %yith
Its plane surface toward the eye, the ojitical distance exceeds the
measured distance by itb'.iut the thickness of the lens, and in the
case of a menisi-ns, worn as a iierlscopic lens, the dilterence is still
greater. Conversely, a coni-a\()-cnn\i\x lens, worn with its coiicaye
surface toward the eye. has its priiiripal (= nodal) points outside of,
and liehintl the lens, so that the optical dist^ince of such a lens is less
than its measui'ed disiance. and still less than the measured distance
of any conyex spectacle lens.
In all cases in w hich lenses of high power are worn, and especially
when a thick conyex lens is giyen in aphakia, or a very strong con-
cave lens in myopia of high gi'ade, the form of the lens becomes a
factor ()f too great importance to be neglected.
+ The appearance, in the table, of 11 cases of M — 16. Ii and U
oases of M = 18. 1). with only a single case of M — 17. li and ."i cases
of M = lit D, has lieen explained by lijerke as I'esillting probaljly
from the general omission of the numbei-s — IT. D and — 111. li from
the series of ttlal-leiises in common use. The occurrence of ~0 cases
of M = :.'(l. II, yvith only i cases of M = .-.'l. ll iind .5 cases of M = ii. I),
may he interpret e<l as indicating a similar source of error gruwing out
of the general omission, from the series, of trial-lenses of higher power
than - 20. D.
requirements of binocular vision both at long and at short
range. But the demands upon the eyes. Incident to
higher civilization, have doubtless been always in excess
of the ability of certain eyes to withstand assiduous and
]iroli;inged application to near work. Certain myopes
must alwaj's have had a notable advantage over emme-
tropes in man_y kinils of exceptionally fine work, such as
engraving gems, emliroiderj', writing and illuminating
manuscripts, etc. ; and even now it is said that only my-
opes are successful in the production of the finest needle-
wrought lace. In view of tlie fact that the gravest dis-
abilities of the myope appear somewhat late in life, it is
hardly conceivable tlnit the iiredisposing causes, of m3'o-
pia can ever be appreciably lessened through the oper-
ation of natural or tirtificial selection. It remains to con-
sider some of the more common exciting causes, incident
to the lives of children, with reference to the possible
amelioration of existing harmful conditions.
In civilized communities the school is an all-important
factor in the life of the child, and it is during school life
that mj-ojiia ordinarily develops and attains to a no-
tably high grade. So striking is the observed relation
of myopia to the grade of the pupil in school, that
the designation Scliiilini/opie (school myopia) has been
widely ado]5ted by German writers. As regards ocular
hj'giene, the prevalent methods in teaching and the con-
ditions under which they are carried out are radicalh'
faulty. As a rule, there is an excessive amount of book-
work, required of all pupils alike and relegated in great
part toliours of study at home by uncontrolled and often
badly arranged or insufficient light; many of the best
hours of daylight, during the school sessions, being too
often given up to exercises or occupations tinrelated or
remotely related to the curriculum of studies. School-
rooms, especially in large school-buildings, are often in-
adequately or uneinuill\' lighted, and the desks are not
always so iihiced with reference to the windows as to
afford the best illumination to the greatest number of
pujiils. Preliminiiry investigtition of the vision of chil-
dren entering upon school life, and periodical examina-
tion of the eyes from year to year, with a view to the
early detection of possible visual defects, are scarcely
thought of. Indifference, on the part of teachers, to rec-
ognized symptoms of beginning myopia; inciting chil-
dren with known ocular ilelVcts to perform tasks which
are necesstirily attended with danger to the eyes; and, in
general, sacrificing individiitil pupils to inflexible ar-
rangements of class work are some of the besetting faults
of routine wherever children are brought together in
large classes.
A general recognition, on the part of physicians, that
m_yopia is essentially a progressive and often a danger-
ous disease ; that it may be jirevented in certain cases
and arresteil in its progress in other cases, but never
cured; tliiit prompt attention and careful and continuous
hygienic cimtrol, together \vith the exercise of the high-
est professional skill in the adaptation and renewal of
glasses, are necessary in order to check its progress and
guard against possibly grave pathological changes lat«r
in life; and that the haphazard resort for glasses to ven-
ders who offer advice gratuitouslj', and make their profit
by selling a possibly badly selected priiice-iiez or pair of
spectacles, is an unintelligent evasion of a serious prob-
lem in therajieutics, will go far toward creating and dis-
seminating juster views tlum now ]u-evail.
The not uncommon habit, with children, of reading an
interesting book by failing daylight or by iusutlicient or
bailly arranged artificial illumimition, is especially harm-
ful in the early stages, tis indeed in any stage, of myopia;
fine sewing or embroiilery, as an luiliitutd occupation for
leisure hours, and long-continued apjiliciition to fine work
of whatever kind arc tilso to be deprec.ited.
Imperfect vision at a distance, as demonstr.ated by eas-
ih- available visual tests such its the test-letters of Snel-
len or as revealed by inability to follow blackboard exer-
cises at school, should be promptly reported by the
teacher, and the child excluiled from school until an in-
vestigation of the condition of the eyes has been made by
Si
REFERENCE IIANDliOOK OF THE MEDICAL SCIENCES.
Myopia.
Iflyrrliolln,
aQ ophtlialmic practitioner of recognized competency auci
any necessary treatment, by glasses or otherwise, lias
been prescribed and adopted. In this way astigmatism
will often be detected and corrected, and other abnormal
conditions which militate against the easy and safe use
of the eyes may be ameliorated. Juhn Green.
John Green, Jr.
[List of abbreviations used in this article : M = myopia : tl = hvper-
metropia: A = range of accominodation ; r = far-point 'punhiim
rtiiintif^simum) of distinct vision; p = near-point I/»u/jc((/(« |(ro.ri-
itiiiin) t>f tiisiinrt vision; R = distance of r from tlie Urst principal
point of till- eye; P = distani'cof p from the llrst principal point of the
eye; R — P = region of accommodation: D = diojitrie or dioptrics:
ft = principal point; )i' = llrst principal point; ?i' = .second principal
point ; li — nodal point ; k' = tlrst nodal point ; h' = second nodal
point. 1
> Horstmann : Archives of Ophthalmology, vol. xiv., p. 45, 1885.
- Cohn, H. : I'nters. d. Augen von 10,li60 Schulkindern nebst Vor-
schliigeu znr Verbesserung der den Angen nachtheiligen Schul-
einrichtungen. Eine iitiologische Studie. Leipzig, 1867.
= Erismaun : Ein Beilrag zur Entwickelungs-Geschichte der
Myopie, pesliilzt auf die Untersuchung der Augen von 4,3.58 Schiilem
und Schiilerinnen. Graefe's Arcbiv fiir Ophthalmologie, xvii., i., pp.
l-ra, 1871.
* Fumari : Annates d'oculistique, t. x., p. 145.
5 Donders : On the Anomalies of Accommodation and Refraction of
the Eye. New Sydenham Society, London, 18t>(, pp. :}4fr-;J49.
•^ Weiss : Ueber den an der Innenseite der Papille sichtbaren Re-
tlexbogenstreif und seine Beziehung zur beginnenden Kurzsichtig-
keit. Graefe's Archiv fiir Oplithalmologle. xxxi., pp. 339-:ai, 1.SS5.
' Iwanotr : Beiiriige zur Anatomie des Ciliarmuskels. Graefe's
Archiv fur Ophthalmologie, xv., pp. 284-298, 1869.
« Donders : Op. cit.. pp. 39. 350.
^ Weiss : Zur Anatomie der Eintrittstelle des Sehnerven. Verhandl.
des internat. oplitbalmol. Congresses in Heidellierg, p. 339, 1888.
1" Stilling : Verhandl. des internat. Ophthalmol. Congresses in
Heidelberg, p. 97, 1888.
I'Fukala: Zur Verbessening der Sehschiirfe nach Mvopieopera-
tionen. Graefe's Archiv fiir ophthalmologie, xliii., p. 206, 1897.
■'^ Bjerke, K. : Uebcr die Veriinderung der Refraction und
Sehscharfe nach Entfernung der Linse. Graefe's Archiv fur Ophthal-
mologie, liii.. 3, 19(12.
MYOTICS. See Mydriatics and Myotics.
MYRONIN is a mixture of potash soap, carnauba wax,
and doegling oil (chenoceti), and is employed as a very
stable ointment base, Tt'. A. Bastedo.
MYRRH. — Myrrlm. Gnm Myrrh. "A gum resin ob-
tained hum Vvmmifera Myrrha (Nees) Engler {/j(/?,sy(«((/-
deiidron M. Nees. — fam., Bnrseracea;)." The variety of
myrrh thus detinedis that known in commerce as Somali
or Herabol myrrh. It is official in all pliarmacopa'ias.
though these are mucu at variance as to the species named
as its source. There ap]iears no good reason to believe
that it is derived from any other than the species named
in our detinition, though the inferior varieties (Arabian
and Yemen) and various spurious substances often sold
for it are — some of them certainly, others probalily — (jb-
tained from other species of Com in if (ra. This plant is a
spiny, large slirub or small tree of northeastern Afiica.
The'myrria exudes as a thick milkj- juice from natural
and artificial fissures, and slowly hardens to a red-brown
mass, which is then collected by the Somali natives,
either from the plant or from the ground where it has
fallen. "Dross}' myrrh," containing a large amount of
earthy matter, may result from the accidental entrance
of dirt into these fallen masses or from its intentional
admixture. The substance is chiefly carried to Aden,
whence it is exported to Europe and Ameiica, either di-
rectly or, as was formerly usual, via Bombay. The
"Turkish myrrh," which a generation ago was a favorite
brand, was simply a carefully selected quality exported
via Turkey. Either at Aden or in Bombay the myrrh is
picked and assorted, yet when it leaves those places it
commonlj- contains a considerable percentage of spurious
or inferior fragments.
Desckiption. — In irregular, more or less rounded nod-
ules or tears, from '2.5 to 10 cm. (1 to 4 in.) in diam-
eter, the surface more or less roughened by nodules and
small cavities, as though eroded, red-brown, dull, and
more or less gray from adhering powder; heavy, hard,
and rather tough-splintery in fracture, the freshly frac-
tured surface of a waxy lustre and oily feel, red-brown,
usually variegated by graj- crescent-shaped spots and
intersecting lines; thin fragments translucent, usually
strongly so; strongly and agreeably aromatic, the odor
characteristic; the taste bitter and somewhat acrid, and
produciuga hardening and slight wrinkling of the mucous
membrane of the mouth, though different from the astrin-
geuc_y of tannin ; readily powdered when cold and di'}',
but with difficult}' W'lien warm and damp; the freshly
fractured surface, moistened with alcohol, colored pur-
plish, as is the brownish-vellow alcoholic tincture, by
nitric acid (distinction from bdellium) ; yielding a brown-
ish-yellow emulsion w-ith water; the ten-pcr-cent. ethe-
real extract acqttiring a violet color in the presence of
bromine vapor; if six drops of a seven-per-cent. petro-
leum ether extract be mixed with 3 c.c. of acetic acid,
and 3 c.c. of sulphuric acid be then added, forming a
heavy lower layer, the latter takes only a light rose
color, which does not deepen (distinetion from Bissabul
myrrh): not more than sevent}' jier cent, should be insol-
uble in alcohol, and the ash should not exceed .six per cent.
CoNSTiTUEXTS. — Good myrrh consists of from two to
tive per cent., or occasionall}' more, of the volatile oil
myrrlitiJ. and from twenty-live to fortv per cent., rarely
nearly fifty percent., of resin, the remainder being mostly
gum, with a very small amount of a bitter principle, and
from two to six per cent, of ash. In "' drossy myrrh, " the
earth}' matter increases the ash, frequently to fifteen per
cent, or more. In the poorer grades of myrrh the amount
of glim is larger, at the expense of the resin, ilyrrh
resin is a complex substance, the composition of which is
not fully understood. Myrrh oil, which is sold for use in
perfumery, is yellow or greenish-yellow, thick and vis-
cid, and almost as heavy as, rarely appreciably heavier
than, water.
Action and I'ses. — Myrrh is essentially an aromatic
stimulant, with slightly bitter properties, and a mild dis-
infectant. Its stimulant jiroperties are especially active
on mucous or raw cutaneous surfaces with which it
comes into contact, so that it is a favorite ingredient of
mouth washes, hardening the gtims and acting like a
mild astiingent, and an excellent cleansing and stimulat-
ing application to ill-conditioned sores, for which pur-
pose the tincture is diluted to about one-fourth strength.
Combined with cathai'tics, it enhances their activit}' and
is at the sanrc time somewhat carminative. When ad-
ministered internally it acts as a mild stimulating ex-
pectorant and diuretic, tlirough its res])iratory and renal
excretion. In connection with the latter mode of elimina-
tion, it acts as a stimulating emmenagogue. It has from
ancient times been credited with specific emmenagogue
])roperties, but these effects have proliably been largely
imaginary. In all its internal uses it is almost invari-
ably combined with other drugs, as in the pills and the
tincture of aloes and myrrh, the pills of iron and myrrh,
the com]30tind iron mixture, etc.
The principal ijreparation of myrrh is the official
twenty-per-cent. tincture, the dose of which is 1 to -1 c.c.
(fl. 3 i to i. ). The Tinctura aloes et tuyrrhtt' contains ten
percent, each of aloes, myrrh, and liquorice root, and the
dose is 4 to 8 c.c. (fl. 3 i. to ij.). The Pilulre aloes et
myrrluB each contain 0.13 gm. (gr. ij.) of aloes, about
half as much myrrh, and one-third as much aromatic
powder, the dose being from two to eight pills. The
ilistura ferri compo.sita contains 1,8 per cent, of myrrh,
0.6 percent, of ferrous sulphate. 0.8 per cent, of potas-
sium carbonate, and 6 per cent, of spirit of lavender,
with sugar, etc.
Allied Scbstances. — Bdellium (elsewhere considered)
is very similar in composition and properties to myrrh,
but is very inferior, being less aromatic and one of its
varieties being devoid of bitterness. The myrrh of the
Bible is not our myrrh, but the Baliu of Gilead or Mecca
balsam, from Coiiiniifera (" Biil/tamodtndroii ^') OjiohaUa-
mum (Kunth.) Engler, now rarely seen in commerce.
Henry II. Jlitsby.
MYRRHOLIN— a solution of equal parts of tincture of
myrili and castor oil, is used as a vehicle for creosote in
tuberculosis. Tl'. ,1, Bastedo.
85.
Mjriol.
ITIyxoiiin.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
MYRTOL. — A constituent part of the essential oil, de-
riveil liy distillation, from the leaves of Mjirtiis coiiiinunis
L. It is supposed closely to resemble eucalyptol. It is
a clear licjuid with a powerful but not un].)leasant aro-
matic odor. It is recommended as a disinfectant and
deodorant, but has no bactericidal action. In medicine
it is used to replace the balsams in bronchitis, bleuuorrha-
gia, and vaginitis. In small doses it improves the diges-
tion and stimulates the appetite, but in larger doses it
irritates the stomach. Dr. Solomon Solis Cohen has re-
ported favorably of its u.se in subacute and chrouic affec-
tions of the respiratory tract. It is administered in doses
of from two to five minims, in capsules, rejjeated two or
three times a daj'. Beau moid Small.
MYXCEDEMA. — A chrouic disturbance of nutrition
characterized l)_y accumulation of mucin iu the subcuta-
neous tissue and cau.scd by loss of function of the thvroid
gland. Abundant evidence has proven that myxa'dema
of adults, cretinism, and the cachectic condition follow-
ing removal of the thyroid gland foi' goitre represent the
same morbid process occurring under different circum-
stances. Numerous experiments have demonstrated that
similar conditions can be produced in lower animals by
removal of the thyroid gland.
Rtiiuinil of the Thyroid Gland in Loircr Animals. —
That the thyroid gland is essential to normal metab-
olism and even to life was shown by Schiff as early
as 1859. Its removal is followed either by the acute
symptoms known as tetany or by a chronic disturbance
of nutrition, myxcedema. T^'ithin a few days, often a
few hours, after extirpation o^ the gland iu dogs, the
animal is seized with tetanic contractions of the volun-
tary muscles aceomiiauied by active tremor, awl death
follows, often caused by interference witli res|iiralion.
In .sheep, goats, and monkeys, rarely iu d.jgs, tleath does
not follow these acute s_ymptoms, though .his may oc-
cur, but a chrouic condition superveues; the animal be-
comes dull and apathetic, nutiition suffers, and tlie skin
is dry and the hail' falls out. The subcutaneous tissue
becomes swollen and Ijy chemical exaunuatiou has been
found to contain mucin iu greatly increased quantity.
Ilorsley has iH'rlormed numerous experiments on mou
keys; these animals survive the symptoms of tetany
wliicli fr"ii\iently follows the operation, and within a few
weeks or months develop iu tyi)ical form the chrouic
condition desciibed. 'i'he temperature becomes svibnor-
mal and exposure to cold hastens tlu' progress of the dis-
ease.
Extirpation of the lliyroid gland in young animals has
a remari;a')le elfect. oliserved by vou Ei.selsberg iu shee|)
and goats and by Hofmeister iu rabliits. Develoiiment
is retarded ami the animal remains small and stunted in
ajipearance. The growth of the long bones is liindercd
by interference with the normal transformation of carti-
lage into bone. The luideveloped animal, lilie the adult,
after extirpation of the gland Ijccomes dull and inert and
mucinous material accumulates, particularly iu the sub-
cutaneous tissue.
Extirpation of one half of the thyroid gland does not
cause till' conditions described, but if consideralily more
than half is destroyed nutrition may sutler, though in
some instances little effect has followed when only a
.sixth of the gland was retainetl. After jiartial removal
that part which remains, together with accessory thj-roid
bodies which are not infrequently present, undergoes
hypertrophy and rejdaces the extirpated parenchyma.
Schitf tiisl showed tliat if thynjid ti.ssue were successfully
transplanted into the )ieritoueal cavity of a <log, the thy-
roid gland of the animal might be removed without fa-
tal effect. Numerous experiments have shown that ):ioth
tetany and myxa'dema may be pi-evented by transjilan-
tation of thyroid tissue. Vessale, moreover, demonstrat-
ed that injurious consequences of the ojieration could
be retarded or prevented by the intravenous or subcu-
taneous injection of an extract made from the gland
obtained from other animals, and it was subse<|ueully
fouud that etjually beneficial results could be produced
by feeding animals with the raw gland or with dried ex-
tracts made from it.
licmoval of the Thyroid Gland in. Man: Ojicratire
My.iwdenta. — In 1883 Reverdin described certain changes
winch follow total removal of the thyroid gland for
goitre, and the following year, under the name cachexia
strumipriva, Kocher described a chronic condition fol-
lowing thyroidectomv. The results which follow loss
of thyroid function in man do not differ from those
observed iu lower animals. Symiitoms do uot follow
partial removal of a goitre if a considerable mass of
parenchyma still remains, while iu some instances their
absence is due to the presence of an accessory thyroid
gland which undergoes hypertrophy. In some cases
acute symptoms almost immediately follow the oper-
ation. The muscles, particularly those of the upper
extrenuty, undergo tonic contractions accompanied by
tremor; such attacks may be of mild intensity, l)ut at
times ai'c of great severity, causing opisthotonos and
death by implication of the iliaphragm. More frequent-
ly, however, extirpation ot the gland is followed by
chronic symptoms which sometimes appear shortly after
operation, but may not manifest themselves for mouths.
The patient becomes apathetic and indisposed to exert
himself, mental actions are slow, and voluntary move-
ments are performed languidly. The temperature is
subnormal and the patient feels cold. The sidxntaneous
tissue of the face and extremities becomes swollen and
o?dematous iu appearance, but does not pit on pressure.
The skin is dry, the hair falls out, and the physiognomy
assumes the appearance which, as will be i)ointed out,
is observed in cases of m}'X<ederaa occurring idio])athi-
cally. The symptoms are analogous to those whicli fol-
lo\v thyroidectomy in low-er animals.
Iu a case descriljed by von Brunn a goitrous thyroid
gland had been removed at the age of ten _years, eighteen
years before death. Development had been arrested and
the dwarfed individual, who presented the appearance of
a cretin, had the mental characters of au imbecile. Sim-
ilar cases have been observed.
Myrcedcma of Adults.— In 1873 Sir William Gull, in a
paper "On a Cretinoid State Supervening in .Vdult Life
iu Women," described the symptoms of a disease to
which Ord, several years later, gave the name myxcede-
ma, since its most conspicuous feature is an a-demalike
swelling of the skin caused by^ accumulation of mucin
iu the subcutaneous tissue. The resemblance between
myxcedima, cretinism, and the cacliectic condition fol-
lowing ex;;''pation of the thyroid gland was soon recog-
nized and was fully elaborated in the exhaustive report
upon myxa'dema published in 1888 by the Clinical Soci-
ety of Loudon. Numerous experiments upon animals,
alread}' referred to, lune been undertakeu in order to ex-
plain the pathogenesis of this disea.se, and have been so
successful that an ellicient thei'apy has been established
within thirty years following its recognition.
Myxa'dema of adults may occur at any age, but most
frequently affects individuals between the ages of thirty
and fifty years. The disease is much more common in
women than iu men, the ratio being about five to one.
Ileredit}- plays a part iu its occur 'cuce and se\'eral cases
have been ob.served in the same family. Occa.sionally
myxwdema has followed exoidithalmic goitre, a disease
iu many respects the antithesis of myxa>dema, while in
one instance myxa'dema has been observed iu a woman
whose daughter suffered with exophthalmic goitre.
Pathological investigation has shown the constant oc-
currence of a destructive lesiou of the thyroid gland.
The organ is diminished to one-half or even to one-fourth
of its normal size; the tissue is pale and tough. By mi-
croscopic examination the interstitial tissue is found
increased at the expense of the glandular alveoli, which
are atrophied and in part destroyed ; the gland is the seat
of chrouic interstitial inflammation comparable to cirrho-
sis of the liver or to chrouic interstitial nephritis. Car-
cinoma and actinomycosis affecting the gland have iu rare
instances l)een associated with the disease. The subcu-
taueous tissue is disteuded and spaces occasionally occur
.86
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
niyrtol.
Myxunia.
between the bundles of connective-tissue fibres, while
late iu the disease there is evidence of proliferation of
librous tissue associated witli atrophy of the sebaceous
glands and hair follicles. The amount of nuiciu present
in the subcutaneous tissue varies iu dillerent cases, and
at a late stage of the disease may diminish in amount.
In a case studied by Cranston Charles it exceeded the
normal fiftj' times. Tlie parotid gland and certain other
tissues have been found to contain an increased quantity
of mucin.
The symptoms of myxcedema are characteristic and in
most cases the condition can be readily iliaguosed. Tiie
onset of the disease is usually very gradual, but occasion-
ally within a few weeks it is recognizable. There are at
tirst languor and disinclination to exertion, associated
with slowness in the performance of voluntary move-
ments. The patient feels cold readily and may suffer
much in winter. Myxa'dematous swelling of the subcu-
taneous tissue is observable first in the face, the physiog-
nomy assuming a characteristic appearance which pro-
duces a certain likeness among those affected with the dis-
ease. The features become coarse and broad, the lines of
the face are smoothed out, and the face assumes a stolid
expression. Tlie lower eyelids are puify, the lower lip is
thickened and often everted, the nostrils are broadened.
Subcutaneous swelling occiirs in other parts of the body,
the extremities being at times most markedly affected ;
the hands and feet are broad and clumsy. This a^dema-
like swelling has a solid character, and, unlike ordinary
oedema, does not pit on pressure. The body weight in-
creases in proportion to tlie gradual swelling. The skin
is dry and the nutrition of its a|ipendages suifers; the
hair becomes dry and brittle and falls out and the nails
are stunted.
The subjective sense of coldness is associated with a
subnormal temperature, which not infrequently falls
to 95" F. or even lower. The disease is said to progress
more rajiidly in winter than iu summer, and an important
factor in its treatment is exposure to a warm temperature.
Slowness of mental action is a constant featin-eof myxce-
dema and memory becomes defective. The temper is
usually remarkably placid^ but is occasionally irritable,
and ilemeutia is by no means uncommon. Hemori-hages
from the gums or nose or from the uterus during men-
struation or after pregnancy are not rare. The circula-
tor}', the digestive, and the urinary systems exhibit no
characteristic alterations, though albuminuria often oc-
ciu's. The functions of the sexual organs imdergo no
constant change, and the greater frequency of myxtt'de-
ma in women has not been referable to clianges iu the
female organs of generation. Patients witli myxa>dema
seldom become pregnant, but in exceptional instances
the myxoydematous condition has been found to improve
during pregnane}'.
The progress of the disease is very slow and the patient
may survive ten, occasionally even thirty years. Death
usually occurs with some intercurrent affection, not in-
frequently tuberculosis or nephritis.
Cretinism or Myxadema of Childhood. — No essential
difference exists between the disease myxa>dema and the
condition known as cretinism, save that the latter occur-
ring during the early years of life is associated with arrest
of development. Endemic cretinism occurs in Switzer-
land and iu certain other countries, particularly in the
deep valleys of high mountains where goitre is prevalent.
Sporadic cases occur in the United States and elsewhere.
The disease, affecting females more frequently than
males, usually develops before the fifth year. Lesions
of the thyroid gland which cause destruction of its par-
enchyma and which are analogous to those of myxtt'dema
in adults, occur. In cases of sporadic cretinism the gland
is undeveloped or atrophied. Iu about two-thirds of the
cases of endemic cretinism there is a goitre-like enlarge-
ment, but doubtless the functional ability of the gland is
much diminished; in one-third of the cases the organ has
been found absent or atrophic.
The condition of the affected child is analogous to that
produced iu lower animals and in young children by the
operative removal of the thyroid gland. The stature is
dwarfed and the limbs are short and thick. There is a
corresponding arrest of mental development, so that the
intelligence may not be greater than that of a child three
years of age. while in many instances there is complete
idiocy. The subcutaneous tissue is the seat of solid a-de-
ma, giving the features a coarse, repulsive aspect. Not
infrequently cretins live to adult age or even to middle
life, retaining their dwarfed condition of body and mind.
Treatment. — Experimental pathology and pathological
anatomy, having demonstrated the identity of so-called
idiopathic myxredema and cretinism with the disturb-
ance of nutrition which follows operative removal of the
thyroid gland, have at the same time furnished an efficient
method of treatment. The thyroid gland performs some
function essential to normal metabolism. The effects
which follow removal or destruction of the gland can be
prevented by supplying to the body tliyroid tissue or its
products derived from another individual not necessarily
of the same species. It has been found possible to trans-
plant thyroid tissue, preferably that of the sheep, into
the subcutaneous tissue of patients .sufTering with myx-
cedema, occurring spontaneously or as the result of oper-
ation for goitre, and well-marked improvement lasting
forseveral months has followed. The transplanted tissue
undergoes partial vascularization and functions like the
normal gland, but atrophy occurs and the improvement
is only temporary. Subcutaneous injection of extracts
made from the thyroid gland was introduced by JIurray,
who employed with success a glycerin extract made from
the thyroid gland of the sheep. Products of the gland
administered by mouth have been found equally efficient,
and the effects differ little whether the gland is ingested
raw. partially cooked, diiedand powdered, or in the form
of a glycerin extract. The glycerin extract or the dried
powder prepareii as tablets is most conveniently used,
the dose varying with different ju-eparations. Toxic
symptoms may follow the administration of too large
quantities.
The effects of treatment in cases both of spontaneous
and of operative myxcedema are remarkable. Within
a few weeks subcutaneous swelling disappears, the face
loses its stolid expression, and there is a rapid diminu-
tion of body weight. The mental condition improves
and the temperature becomes normal. The treatment of
cretinism has ])roved almost equally successful. With
administration of thyroid extract the skin soon becomes
normal in appearance and intelligence improves; growth
occurs with surprising activity and the height may in-
crease several inches during the first year. When treat-
ment is begun at an advanced age its effects, as might be
expected, are less satisfactory. In the treatment of all
forms of myxoedema it is necess;iry to continue the ad-
ministration of thyroid products after the disappearance
of all symptoms, since throughout the remainder of life
it is necessary to supply the deficiency caused by the ab-
sence or destruction of the thyroitl gland.
Eugene L. Opie.
MYXOMA. — The name myxoma, or tumor composed of
mucous tissue, was first used by Virchow, who separated
from the other connective-tissue tumors a special class of
formations to which he gave this name. Before this
they had been described under various names, which
generally had reference to the soft and jelly-like charac-
ter of the growth. LaOnnee gave them the name colloid,
because the .soft, trembling, gelatinous character of the
tissue reminded him of partially solidified gelatin.
Those tumors described by Johaimes ^li'iller under the
name gelatinous tumor, or collonenia, belong in this cate-
gory, although the latter name seems also to have been
used for soft tumors of other sorts, as the soft fibromas,
etc. Paget has described them under the name tibrocel-
lular tumors.
Virchow distinguished as a separate variety of the con-
nective tissue, muco'ix tix.itie. which was characterized by
containing in the intercellular substance a quantity of
mucin. This tissue was most develojied in the fffitus.
a
myxoma.
REFERENCE HANDBOOK OF THE 5LEDICAL SCIENCES.
where it formed the jelly of Wharton in the vimbilical
cord, and was also abundant in the subcutaneous tissue.
In the subcutanodus tissue it afterward became converted
into fat, and when it was found elsewhere in the body
Virchow regarded it generally as an antecedent to fat
formation. Its cells ('ather take up fat directly, and so
become changed into fat cells, or they proliferate and the
young cells so formed become fat cells. In tlie adult tis-
sues it occupies but a small tieUl, being found only in the
vitreous body of the eye and in the sulicutaneous tissue
in a few places, here p'rincipally over tlie pubes. Histo-
logically tlic tissue consists of cells eralicdded in a homo-
ge'neous matrix. The cells may be of various shapes,
round, siiindle-, or star-sliaped. "Generally they have the
latter form, and are abundantly provided with processes
which freely anastomose with the processes of neighbor-
ing cells, aiid form a tine meshwork through the tissue.
On section of the tiss\ie abundant Huid escapes, which
has the same propei'tiesas tlmse tluids which contain mu-
cus. Tlu^ mucin in the ordinary secretions of nuicous
surfaces is the result of the action of the einthelial cells,
and is formed in them; but in the mucous ti.ssue it is not
found in the cells, but in the intercellular substance.
The mucin c<intained in the fluid has some of the chemi-
cal properties of albumin, but can be distinguished from
it in various ways. On the addition of alcohol to fluids
containing mucin, there is formed an abundant precipi-
tate, whi<-h can be distinguislied from the allmminous
precipitate, formed in like manner, by the fact that it
swells up and dissolves on the addition of water. Tlie
albuminous jirecipitate is not affected by water. Jlucin
is not dissolved by an excess of the organic acids, but is
readily solulile in an excess of mineral aci<is.
The result of later investigations has been to throw
much doubt on the existence of mucous tissue as a dis-
tinct type of tissue, such as Virchow has described it.
Even in tlie idace where he suppo.sed it to be most typi-
cal, ?'.('., in the umbilical cord, it has been shown that
this is only ordinary connective tissue with an idjundance
of fluid in' its meshes. A tissue almost analogous to mu-
cous ti.ssue is foinid in every suljcutaueous (edema, and
can be produced artiticially by piuicturiug the skin with
a line hypodermic luH'dIo anil injecting salt solution. A
dougliy swelling is sn prochu-ed, and on section the in-
jected'fluid will nut. llow out again, but is held in the
meshes of the tissue and along the fibres. On micro-
scopic examinatiim of sections, made by clipping out a
piece of the swollen tissue with a pair of sharp scissors,
the cells are found separated from one another, often an-
astomosing, and the libres <if the connective tissue do not
appear so prominent. The fact that the supjiosed nui-
cous tissue of Virchow contains mucin cannot be held
as peculiar to it, ami as dislinguisliing it from other
forms of conneelive tissue. JIucin is found in all the
-connective tissues, and the gelatinous a?dematous tissue
does not contain any greater proportion of it than do
other tissues of its class. The fatty tissue which Virchow
supposed to be developed from the mucous tissue does
not stand in any inunediate connection with this, but.
according to Ranvier, takes its origin from cells which
from the beginning are di'Stined to form fat cells.
Following this, R\imler anil Koster have taken the
ground that the myxoma is not to be considered a special
type or class of iuniors, but that it simply represents
conditions which nnght arise in any of the tumors wdiich
contain connective tissue. This myxomatous condition
of the connective tissue consists in its saturation with
serum in consequence of circulatory disturbances in the
tumors, passive congestion, etc. Tliey regard this tis-
sue, wherever found, simply as ordinary connective tis-
sue infiltrated with fluid, or oMicmatous. In every tumor
there can be numerous conditions which might give rise
to this. The veins can easily be compressed by the
growth of certain parts of the tumor, and we cannot sup-
pose that the vessels of a tumor of an}' sort are less prone
to allow of transudation, in ease of passive congestion,
than those of any other tissues. On the contrary, it
seems probable, from the numerous areas of small-cell
infiltration in tumors of every description, and from the
frequency with which red corpuscles are found in the
tissues, that the vessels are easily traversed Ijy the cor-
puscular elements of the blood, and where this is the case
the fluid elements pass through also. The serum would
be most readily taken up in the meshes of the connective
tissue, enlarging these, and tlie connective-tissue fibres
would be forced apart and rendered less distinct. The
fact that we scarcely ever find a pure myxoma, svicli as
Vircliow has described, b\it almost always this so-called
mj'xomatoiis tissue in connection with some variety of the
tumors W'hich contain connective tissue, as fibroma, sar-
coma, carcinoma, etc., speaks much in favor of the cor-
rectness of this view of Koster. Still the term myxoma
or myxomatous tissue, to denote this swollen and o-de-
matous connective tissue, is a convenient one and will be
retained, although the myxoma, in the light of these re-
cent investigations, should occupy no place in the cate-
gory of tumors. The myxoma was first described by
Virchow. and his descriptions of it are in all respects so
full that they have undergone but little modification by
sidisequent writers on the subject. The writer has
thought it best after this preface, which sheds a clearer
light on what has been a complicated subject in onkulogy,
to give, in the main. Virchow's description of the tumor.
The cells in the tumor vary in .shape and in numbers,
this variation depending chiefly on the stage of develop-
ment of the tissue. The younger the tissue is. the more
the cells are inclined to be round and the more numerous
they are. In the older portions the cells are rather star-
or spindle-.shaped. and have numerous processes which
communicate freely with one another, producing a retic-
ular or areolar tissue, in the me.slies of which round cells
are frequently enclosed. When these cellular elements
are fewer in number, the whole tissue has a transparent,
gelatinous appearance, and is similar to the vitreous body
of the e_ye. This forms the A'ariety mi/.tvina hi/aluium.
Virchow has described several otlier varieties, which dc-
jiend on various, for the most jiart minor, ditferences in
the structure of the tumor.
Mil.miiiii 3feiliiUiii-e.- — In this the cells are more abun-
dant, and this gives the tumor a whitish, opaque, med-
ullary appearance.
Mi/jDiiiii- Fihriixii III. ^la this the tumor contains a con-
sidenible amount of fibrous tissue, especially elastic
fibres, which often form dense bands which appear (m
the cut surface.
Mi/.fi)iii(t Jj'jmiiuitiidi's or My.i'd-lijuimii. — In this the tu-
mor contains a considerable amount of fat, either in the
shape of small drops contained in the cells or as fully
formed fat cells. There may be so much fat jireseut that
the tumor has most of the characteristics of lipoma.
Mjl.rniiKi ('iirtHinjliieiiiii or M]i.vo-ehiiiidivmii. — A large
|iro]ioi'tion of till m\'xomata contain islands of cartilage.
This is especially the case in the compound f tnnorsof the
parotid gland and of the testicle.
Mi/.wi/ia Ci/Ktiiidcx. — In some cases the cells of the tu-
mor enclosed in the mucous tissue undergo mucous or
fatty degeneration, and there are formed large cavities
filled with viscid fluid.
Mj/.romit Ti:htn(jii:rtiiiJe.<<. — As is the case with most tu-
mors, the vessels here also maj' be enormously developed,
and I his name has been given to the condition.
Jliiein is found in numerous other tumors, as a result
of the physiological activity or of a degeneration of the
tumor cells. It is found, for instance, in the cystic tu-
mors of the ovary and in most other epithelial cysts.
Virchow excludes these from the myxomata. and has
limited this term to those tumors in which the mucin is
contained in the interstices of the tissue and forms an
integral part of the tumor. Billroth has included with
the myxomata all such tumors, among them goitre. Just
as the most typical formation of miu'ous tissue is foimd
in tlie fu'tus, the mo.st typical examples of myxomata are
found in tissues belonging to the fietus. The myxoma
of the chorion, forming what has been termed mole preg-
nancy, is the most typical example of this myxoma.
Abortion takes place in this case at an early period, and
88
REFERENCE HANDBOOK OF THE irEIHCAL SCIENCES.
myxoma.
Nii'vus.
the cliorion will be found covered with transparent, ge-
latinous vesicles, which are connected with the mem-
brane by a narrow pedicle. Sometimes several of these
vesicles" are connected with the same pedicle, and are
strung along it like rows of beads. The vesicles vary
in size from a pin's head to a nut. On niicro.?copic
examination they are found to be covered with c[iithc-
lium, and composed of a tissue similar to that of the um-
bilical cord, i.e., branched cells lying in a homogeneous
matrix. Other parts of the fcetal appendages may be the
Fig. 3476.— Section of a Myxoma of the Subcutaneous Tissue of the
Thigh. X 3m.
seat of similar formations. Cases have been seen m which
the umbilical cord contained along its course a series of
such vesicles. Also in the jjlacenta itself there may be
an abundant formation of mucous tissue in the form of
circumscribefl tumor masses. Retained portions of the
placeuta may form the starting-point of tumors which
reach a considerable size.
In the adult the subcutaneous cellular tissue is the most
frequent seat of the mj-xomata. Here they are princi-
pally found on the thigh, on the buttocks, on the labia
majora, and on the lower lip. The fat in the orljit may
be a point of origin for the tumor. Such tumors maj'
reach considerable size ; those of the size of a child's head
have repeatedly been seen. These large myxomata
have a distinct! _v lobular structure, and when they break
through the skin they become ulcerated and often very
foul. The}' may have a deejier origin, as from the inter-
muscular tissue. In some localities, where the skin cov-
ering them is not tense, they become distinctly peduncu-
lated.
The long bones are often the seat of tliis tumor. In
this iilace it seems to originate in the bone marrow.
In these tumors various combinations, as with sarcoma
and enchondroma, are seen. The spongy osteoraata,
with soft cellular marrow, may be confounded with
them. The pure myxoma of the bones is a soft, spongy
tumor, which ordinarily originates in the bone marrow,
and in the course of its growth becomes covered with a
thin sliell of bone. At a later stage it breaks through
this and grows as a soft mass. It is always accomimnied
by a new growth of bone, is generallj' lobulated, and
here and tlicre portions of the old bone may be enclosed
in Its substance. The tumor is soft and grayish-white
or yellow. Virchow- compares its tissue to the flesh of
oysters. An abundant formation of blood-vessels may
give a reddish tint to the tumor.
The myxomata often have a heteroplastic origin, and
in these cases the starting-point is most frequently located
in the central nervous system. A considerable propor-
tion of the brain tumors belong in this category, espe-
cially those of the cerebral hemispheres. The dura mater
of tlie brain and cord may also be the place of origin.
When seated on the peripheral nerves the tumor does
not originate in the neurilemma, but in the interstitial
tissue. " Such tumors along the nerves are often mistaken
for neuromata. They give rise to severe neuralgic pains,
and are often multiple." All the nerves of an extremity
may be affected, in some cases several being seated on a
single nerve trunk. In many cases the nerve does not
pass into the substance of the tumor, but over it, and is
generally flattened from [iressure. It is often iiossible to
di.sseet out the nerve from such a tumor and remove the
tumor, leaving the nerve intact. The consistence of
these tumors is so soft that they may bi; easily mistaken
for cysts. They havea tendency to rcturnaftrrrcnioval.
Jlyxomata may also be found in the glandular organs,
where they arise from the interstitial tissue. Such tu-
mors are found in the female breast. The tissue of the
tumor grows into the milk ducts in the form of poly|ioid
masses. The duct becomes dilated into a cyst, which is
filled with the branching growth. The whole tumor
may in this way be enclosed in one large duct, and may
be removed from it, lea\'ing a cavity with smooth walls
On microscopic examination the section often appears to
be composed of small islands of ni^'xomatous tissue sur-
rounded by epithelium. The islands of tissue are the
cross sections of the branching dendrate growth in the
duct. This manner of growth is not peculiar to the myx-
omas of the mamma, but is seen also in fibi-omas and sar-
comas in the same locality. The tumor finds the least
resistance to its growth in the milk ducts, and grows into
and dilates these. Jungst has recently described one of
these timiors in wdiich a great part of the tissue had un-
dergone hyaline degeneration. When the superficial
ducts are the seat of this growth, the tumor may project
as a nodular mass from the breast. This is particularly
apt to take place in the region of the nipple. The skin
covering the tumor becomes thin and finally breaks, and
a soft, fungous, often gangrenous mass appears. This
may have an appearance very similar to that of an ulcer-
ated cancer. If it is closelj' examined, spaces may be
fotuid in which a probe maj' be pushed deeply down
between the single masses of which the tumor is com-
posed.
The mixed forms of the tumor deserve especial atten-
tion, for they are much more common than the pure
forms. They are most apt to be seen with tumors of the
connective-tissue type, as the fibroma and sarcoma, but
may be found with any tiuiiors which contain connective
tissue. In the spindle-cell sarcoma the tissue maj' be
seen to jjass into myxoma. The cells become separated
from one another by an increase in the interstitial tissue
and lose their spindle shape. In carcinoma the most typ-
ical mucous tissue may be found between the masses of
epithelial cells. These mixed fcirms have been given
special names, as carcinoma myxoniatodes, etc. The
fact of the presence of such tissue in a carcinoma or sar-
coma does not influence the growth of the tumor, nor its
prognosis, but may lead to errors in diagnosis. Wher-
ever this tissue is ju-esent the tumor is softer. The mixed
tumors of the parotid gland always contain a consider-
able qtiantity of myxomatous tissue.
In general the tumors described as myxomata are not
malignant. Some, however, are. Those of the central
nervous system are malignant from their position, and
those of the peripheral nerves have a tendeuc\' to multi-
ple formation and to return after extiriiation.
The best and most typical pictures cf this tissue are to
be obtained by examining fresh sections made by the
freezing microtome in salt solutions. After the tumor
has been hardened in almost any of the hardening agents,
the tissue loses its fluid and shrinks very much.
W. 'r. Counnlman.
N/CVUS.' — (Greek, a-'i'Ao^, a-i/.uua ; French, ticeve,
coueiuie. enme, signe, taclie congenitalc, on. piymentaire,
ou de miissance; German, 2Iiil, Muitermal. Muttermuhl,
Mvtterflccken ; Italian, nco [>mitcrno'\, iiero ; Spanish,
iievo, lumar.) (Svnonvms; Mother's mark, birthmark,
etc.)
Definitiox. — A nsevus is a congenital alteration of
the skin, confined to a limited area and characterized by
an increase in the amount of pigment dejjosit, and by a
certain aiuount of hypertrophy of one or more of the
other elements of the skin, especially the vascular and
connective tissues, as well as the hair, fat, nerves, and
89-
Na?vus,
Nspviis,
REFERENCE HANDBOOK OF THE MEDICxVL SCIENCES.
lymphatics. Unua ' aiitl y tlescrilie.s luvvi as: " Circum-
scribed, small malformations of the skin, which liave a
hereditary basis, or have their foimdations laid in em-
Ijryonie life, become evident at different periods of life,
develop very slowly, and are distinguishable by their
Color or the form of their surface."
The following varieties of na-vi may be distinguished:
Ka-ciis Jihf'inKitoKiis ; JV. lipomatniha ; 3'. pir/utentosiis ;
N. jnla.ru ox pilosus ; N. viiiiis Uderis (N. liinurin) ; X.
vasciiliiris ; N. rerrucosus.
JS^a-rns fihro)nntosua \s xasir^md by excessive connective-
tissue development; it varies iu size and involves the
skin in different parts
of tlie liody. As suli-
divisions may be
iiieutioncd: N. foli-
aeeus, in wliicli the
central portions arc
fibi'ous, while the
■circumference is vas-
cular; N. mollusci-
formis, a ]irotuber-
iint pedunculated
form (Fig. 3477) ;
.and N. sarcomatodes,
■nhich at first is a
simple congenital
na'vus, but after-
ward undergoes sar-
•comatous degenera-
tion.
Ha'riis lipiiiiiitlmhs
is a congenital fatty
tumor (lipoma), usu-
ally more or less
fibromatous.
Kafiis pif/menfosu.s,
the commonest form
of uan-us, is char-
acterized by an e.\
Cessive deposit of
pigment in a eircum-
criljed area of the
skin. Tlie discolora-
tion thus jiroduced
vai'ies from ]iale yel-
low to purple (ir <'ven
black. The lesion,
which isusu.-dly level
with the skin, occurs
especial l_v on the face,
liands. neck, arms,
and back. This va-
riety of na'vus is
often vcrrucose, or
elevated ; at times it
is more or less cov-
ered with hair and is
then designated as
A'(ei-iis pilosus or 3'. ^ _ .^-- , ^_^ ^ mi..|,. i ii .i
Niri'iis fitsciiliin's,
K. sitni/iihiriis — "mother's maik." includes a large num-
ber of forms, among w bich are now classed varieties of
angiomata, which einbraee tumors of embryimic ruili-
mentary vessels.
The vascular na-vus may invuhc the ca|iillaries. the
smaller veins, or the terminal arterial branches.
The capillary n;evus is distinctly cutaneous and in size
varies from a pin's head to the (lalin of the baud or even
a larger area; at times it inv<ilves whole regions of the
bod_y. This is the form of na-vus most conunonly met
with. It is usually only slightly elevated, or it may even
be level with the surface of the skin. It is often .seen as
a tiny red spot with lines (dilated capillaries) radiating
from a central point of vascidar liypertrophy. and to it
are applied the terms "spider me vus," or "si)ider cancer."
or na'fiis uraiiciis.
Vascular najvi often begin indistinctly and spread
gradually imtil the}- cover large surfaces. On the other
hand, nani, present at birth, may within a few months
entirely disappear spontaneouslv.
The venous na'Vus is apt to be more elevated than the
capillary. It is smooth, stands at a higher level than the
surrounding surface of the skin, is soft and compressible,
and often is lobulated. The thin-walled veins of which
it is composed couuuuuicate directly with one another
and are bound together by delicate bands of connective
tissue, thus con,stituting a network of intercommunicat-
ing venous sinuses. Such a formation should be called
a na'Vus cavernosus
or an angioma, for
such iu reality it is.
These tumors are
markedly irregular
in form, reddish or
bluish in color, and
at times erectile (iu
women this is espe-
cially noticeable at
the "time of menstru-
ation).
Although there
have been reported
many instances of
congenital u;vvi
which seem to cou-
tirm the belief that
prenatal events,
through the impres-
sions wliich they
make upon the moth-
er, sometimes play a
part in the causation
of these tumors, the
best modein author-
ities are opposed to
this view.
Xamiis Verrucosus.
— A warty nsevus,
often having a hair}-
growlh, and at times
highly vascular and
erectile.
A'tcm.v uiiiiis liiteris
is excluded, by Unna,
from the u;x'vi, but
I inly provisionally.
I am disposed to be-
lieve that this type
(if growth may jirop-
erly be elas.sed among
the uixxi. It em-
braces a number of
types of n«vus, in
which the es.seutial
featiu'e is the ar-
iMi^iii lirMMii'i i-hi.i. 1.1.1 . raiigement ina linear
way following the
distribution of the
superficial nerves. Some attempts have been made to
show the association of this form of na-vus with pre-
vious neurotic influence, injury, shock, etc. The terras
N. neuroticus, N. lim-aris, papilloma ueuropathicum
(neuroticum), etc., have been applied to this type. That
the term iniins hiteris is a misnomer is evident from the
fact that the author has had two ea.ses of bilateral dis-
tribution. To these he has given, by jirefereuce, the
name "linear na'vus."
It is certain tiiat there is a distinct difference in the
arrangement nf the lesions between this variety and the
ordinary ntevi. The arrangement is in sprays and clusters
of lesions, which \'ary in character, some of them having
a pale yellow pigmentation, while others are black.
Then again there are also differences iu structure, some
of the growths being clcarlv vascular na;vi while others
90
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
IVlCVIIS.
Nievus.
Na?vus of the Clieek.
Dyer.)
ilI \ > n iic'j>'.' 1. nil .11
(Case oi Dr. IsaUuie
are mere papillomatovis growtlis. lu some cases tliere is
even ir.vcilvenicnt of the Iviiiiili vessels (lymphangioma)
(see Fia;s. 34T9
and 3480).
T h e Pathol-
ogy of napvi is of
(inly indirect im-
|)ortanec, as the
condition is not
dillicult of diag-
nosis and the
treatment i.s es-
sentially radical.
Uuna {riji. cit.)
1 1 u ite exhaust-
ively reviews the
histological evi-
dence in regard
to the different
types of ua^vus,
and discursively
ai'gues the embry-
onic origin and
course of the sev-
eral varieties
classed by him
under the term
n a; V u s. Soft
nffivi. or the
warty, epithelial types, are recognized as embryonic de-
posits in the upper part of the cutis, while the hard
na'vi are cither of prickle-cell layer origin or else are
found chiefly in the horny layer. The more complicated
na-vi are also considered by him in their complex path-
ology.
Tbe.\tmext. — The necessity for treatment of uan-i
must depend upon the character, the location, and the size
of the lesion or lesions. Simple pigmentary moles are of
little serious importance, and, on accoiuit of their liarmless
character, they need not be removed. In exceptional cases
the melanotic mole calls for early operative interference.
Even the simple moles, when there are several of them,
often cause sufficient distigurement to warrant their re-
moval by surgical interference. Hairy moles are espe-
cially disfiguring. In the case of vas-
cular uEevi, on the other hand, the
danger of accidental hemorrhage must
also be taken into consideration.
There are not a few different ways
in which na^vi may be treated. For tlie
simple pigmentary moles and also for
those of a verriicose character the
employment of escharotics will often
sutHce. Of these we might name car-
bolic acid, chromic acid, glacial acetic
acid, picric acid, acid nitrate of mer-
cury, corrosive sublimate, cantharides
(in collodion or in ether), pyrozoue,
sodium ethylate. nitrate of silver, ni-
tric acid, salicylic acid (alcoholic solu-
tion or in collodion), chrysarobiu, chry-
sophauic acid, pyrogallic acid, liquor
potassie, etc.
In the case of large lesions, or
where the location forbids the use of
caustic applications, the actual cautery
— the Paqueliu or the galvanic— should
be used.
In small pigmentary nsevi electrol-
ysis is preferable. To the negative
pole of a galvanic battery a small needle
(steel, platinum, or gold) is attached.
The positive pole carries the sponge,
which is customarily held in the p;i-
tient's hand. The needle is intioduced beneath the pig-
mented mole and the current is gradually iucreasetl until
the lesion blisters. To accomplish this a current of about
8 or 10 niilliamperes is required, or, if cells with switch-
board are used, there should be as many as from twelve
to twenty cells. Where the moles are hairy, a blunted
broach or needle should be employed. The hairs are
removed first by electrolysis, and then the mole itself is
removed by the orilinary operati\'e procedures. In re-
moving the hairs the needle slioulil be gently introduced
into the hair follicle, the hair shaft serving as a guide
and care being taken not to iiierce the follicle. The cur-
rent is gradually applied until there is frothing at the
pritice of the follicle, when the hair is ready to come
away. If there is resistance on the part of the hair, the
operation is not complete. Not more than from 3 to 5
milliampjres is needed in this operation; in fact, in
some instances a single niilliampcre will be found suffi-
cient. The negative pole of course must be used here.
In the treatment of vascular na-vi, electrolysis is like-
wise of service, but more particularly iu those in which
the area of skin involved is small, and the vessels form-
ing the growth are simply capillaries. The object of
the treatment here is either to cause the absorption and
atrophy of the blood-vessels or to effect their destruction.
Various procedures, all of them more or less inefficient,
have been suggested for the accomplishment of these
objects, but as the space at our command is limited, we
shall describe only those which have stood well the test
of time.
There are two methods for using the ligature. First
of all, it is a good plan iu smaller nKvi to circumscribe
the growth with a single or double silk ligature, draw-
ing tightly and tying on opposite sides of the growth,
when the double ligature is u.sed. Iu the case of the
larger na-vi, the ligature is aii]ilicd at a jioiut a little
remote from the grinvth. An incision is made above the
vein, or small artery, a catgut ligature is applied, and
the wound closed. In either instance tlie growth begins
to pale after several days. In superficial na'vi the whole
patch grows bluish in color. Here and there a .si)ot grows
white where the blood has been absorbed, and finally,
in the successful cases, the wliole patch grows whiter
and whiter. When it is thonght best to resort to excis-
ion, as in the case of dcep-.seaied na'vi, it will often be
found aclvi.sable to ligate a few days or weeks before the
excision. When the cautery is employed, several meth-
ods may be followed. A fine platinum needle may be
Fici. atTli.— Right Side.
Figs. 3479 .\nd .'>t80. — Linear Ntevus: Verrucose,
Diflcri'Ut I'arts of the Surface of the Body.
Fi(i. ytsu.— Left Side.
Deeply Pigmented, and Affecting
(Case of Dr. Isadore Dyer.)
attached to the galvano-cautery, raised to a red heat,
and then introduced into the growth several times in
succession. Linear cauterization may equally well be
carried out by means of the needle or with the small plat-
91
Nartalau.
Nails.
KEFEHENCE HANDBOOK OF THE MEDICAL SCIENCES.
inum knife. Tlie Paquclin ciiutery will serve the same
purpose.
Caustie pastes (BoHgiiril, Feli.x, Marsdeii. etc.) act as
the cautery does, by produeiiig an eschar, and finally a
slough. With caustics, however, the .slough is apt to be
more extensive than when the cautery is used. Hence
the need for caution in using them.
Vaccination lias been used in locations where au irregu-
lar scar is no objection. The slight bleeding need not be
Stopped, except by a temporary compress.
The injection of pure carbolic acid or the tincture of
iodine is followed quite often by gratifying results. Lit-
tle scarring remains, iilugging of the vessels is rapidly
obtained, and the operation is less jiaiuful and of shorter
duration than when other methods are employed. The
injection of a one-per-ccut. solution of chloride of zinc
is used for the same purpose. The percliloride of iron
may be used liy injection, or, as is frecpiently indicateil
in the more elevated growths, silk threads, saturated
with the perchloride solution, should be passed in several
directions through the n;evus, and be allowed to remain
until the}' are absorlied in the contraction, or else slough
out.
Except in the casi- of small n;evi. the treatment is never
highly satisfactory, and the nii'thods employed may have
to be changed several times before the whole of the growth
is removed. It is always well to impress upon the pa-
tient the necessity of perseverance in the matter.
Where the patient will submit, the use of repeated ig-
nipnuctiu'c with the Paquelin canter}' under a general
ana'sthetic will effect good results; otherwise the electric
needle is of most service. A numlier of cures have been
reported after long use of electrolysis. For extensive
n;\,'vi of the capillary variety, multiple needles (as many
as a dozen) attached to the negative pole of the galvanic
current may be employed. Tliis does not answer so well
as the single needle fre(piently introduced. The amount
of current required varies witli tlie jiatient and should be
regulated accordingly, a luihl current being used at the
start.
The teeluiique of this operation is as follows: The jia-
tient should hold the sponge electrode and slioidd turn
on the current when the neeiUe is introduced and turn it
oft' when 11,3 needle is withdrawn ; or, if he does not uund
the greater painfuluess of the proceduri', he shoidd keep
the sponge constantly applied. The needle may be
pushed in to a depth of at least half an inch below the
surface of the skin and parallel with it, and it should be
allowed to remain until a distinct eschar, in the form of
shrivelled skin, shows itself along the line of the needle.
This procedure is to be repeated at each sitting as often
as the patient will permit. As this linear operation al-
most always leaves ridges as the ultimate result, it is
probably better to introduce the needle simply at a right
angle to the surface of the skin, leaving it in position
until a small blister forms. Sever.al such punctures
should be made ateach sitting, and they should be located
as closely together as possible. At each sitting, for a
few succeeding days, a new area should lie selected, and
then each area in tiu'n, beginning with t!ie one tirst se-
lected, should begone overa second or even a third time,
until finally the region so treated ])rescnts the appearance
of a white superficial scar.
For the cavernous variety of na'vus the electrolytic
method is not so well adapteil. In the treatment of this
condition by electricity the positive pole issu)i|ilii-d with
a platinum and the negative pole with a gold needle, or
vice rerm, and b()th are introiluceil at once. dec|ily. The
strength of the current is gradually increased to the limit
of the ]iatient's endurance, and is kept aiiplied as long
as possible.
In both varieties of na'Vus it recpiires months of treat-
ment before any result is obtained, but usually the pa-
tient's endurance is finally rewarded.
Isiidore Dyer.
' Foster : Encyclopedic Medical Dictionnry.
^ I'nna : Histupathology of Diseases of the Skiu, Walker's transla-
tion, p. 1128,
NAFTALAN is a gieenish-black, soft, gelatinous ma-
terial, with a slight cnqiyreumatic odor, and consists of
9() to 97. .5 per cent, of a peculiar Russian naphtha, puri-
fied and mixed with anhydrous soap. It is readily mis-
eilile with oils, fats, ether, and chloroform, and is insolu-
ble in water, alcohol, and glycerin. Kolbl found it of
distinct value in minor skin lesions such as urticaria,
scabies, ii.soriasis, burns, and bee stings. Blocb considers
it almost specific in liurns, but in jisoriasis not so good as
chrysarobin. Several authors report good results from its
u.se in chronic eczema, though it is not recommended in
acute eczema, or when the skin is moist. Skin parasites
are destroyed. It is applied as a thick coat and does
not melt at body temperature (melting point, 70° C. or
158° F. ). ■ W. A. Bastedo.
NAILS, DISEASES OF THE.— Tei{misologt.— As
the study of flie nails demands its own vocabidary, it is
necessary to <lefine clearly the various terms wliich will
be employed in this article.
The root or matrix is that part of the finger imder the
hmula from which the nail substance is formed.
The bed is that portion of the finger lying directly
anterior to the matrix, which forms the floor on which
fb(.' nail rests, but which plays no part in the formation
of the nail.
The plate is what is commonly termed the nail. The
lunula is the white, opaque, rounded part of the plate
which lies over the matri.x and under the eponychium.
Tlie walls of the nail are those parts of the finger which ■
lie along the sides of the ]date.
The eponychium or "quick" is the horny layer which
forms a selvage to the skin over the bed of tlie nail.
Pterygium is a forward growth of the eponychium
over the plate.
Transverse or horizontal will signify the direction
across the plate, while vertical will mean the direction
from eponychium to free or distal border of plate, 2'.«.,
the line in which the nail grown;.
Ax.\'roMY. — The normal sliapi- of the plate is convex
lioth horizontally and vertically. The vertical ridu'es
which appear on many nails in youth and adult life, and
which iucre:ise markedly in old age, are due to the pres-
ence of the papilhe in the underlying bed of the nail.
The color of the nails .should be a delicate pink, due
to the subjacent capillaries which transmit their color
through the normal, translucent ])latesabove. The plate
is com])osed of flat, polygonal, keratinized, nucleated
cells between which are air spaces. Wherever these air
spaces exceed their normal size the plate becomes opaque
and white, a condition which is called leuconychia. The
lunula is white in color because the underlying matrix is
not supplied with vessels. On the thumb the lunula ap-
pears distinctly anterior to the eponychium. but on the
other fingers it does not extend so far forward.
The nail bed is not sharply marked off from the adja-
cent ]>arts of the finger, there is never a clearly defined
bovnulary, and the contiguous jnirts blend into each
other. The lower layer of the bed merges gi-adually
into the periosteum of the last i)lialanx without the in-
terposition of the panniculus adijiosus. The blood-ves-
sels are arranged in an upper ami a lower layer as in
other parts of the skin, and the lymph vessels are well
markcil.
EmiiI!Yoia)Gy. — The nail arises from the ectoderm and
makes its first apiiearauce between the third and fourth
months of fo'tal life.
Genekai> P.\tiioi.ogt.— Disorders of the nail m.ay be
symptomatic of general infections of the skin or of the
body, or may be simply local affections.
Inheritance. — Diabetes, tuberculosis, cretinism, ecze-
ma, psoriasis, or epidermolysis in the iwrents have been
known to cause marked ilisturbances in the nails of the
child, while serious disturbances in the nails and hair
have been a family dyscrasia for .several generations (ride
observations of Nicolle and Halipre in France and of the
present writer in America).
Pitychie disturbances are frequently the cause of nail
92
REFERENCE HANDBOOK OF THE JLEDICAL SCIENCES.
>al'(alan.
Nall«.
derangements. Such txainples have been iveoich'ci
after "apparitions," severe liglitiiing, liysteria, delirium,
mania, overuorlv, or wony.
Disturbances of the nutrition are common causes,
among wliich Heller mentions typhoid, fever, gastric dis-
orders, icterus gravis, infantile atrophy, imeunionia,
ana-mia, jihthisis ])ulmonalis, erysipelas, ei.idiilyniitis,
severe angina, parotitis sujijiurativa, scarlatina, measles,
influenza, gout, rheumatism, accidents, and chililbed.
These conditions are often followed by the appearance
of transverse furrows in the nail plate.
Localized N.^il Affections.
Aiionychiii or absence of nails maj' be congenital or ac-
quired. The former origin is rare, but the latter is not
uncommon, and loss of the nails is frequently observeil
after syphilis, injuries, chemical irritants, burns from
.^-rays, constitutional diseases, eczema, psoriasis, jius un-
der the nail, ringworm, felon, paronychia, shock, Iiydroa
jEstivale, and ichthyosis.
Oiiyi;lintri>i)lii(i almost always results from the .separ-
ation of the plate from tlie bed of the nail, a condition
which usually fallows any hyperkeratosis of the bed it-
-self. Another source of separation is the invasion of
blood after trauma or in connection with certain nerve
diseases — for example, cerebral paralysis, multiple scle-
rosis, or tabes dorsalis.
Oiii/ehm-rhens.- — This term isaiiplied to the condition of
the l)rittleness of the nail wliich follows decreased jnvi-
ductiou of nail substance, and is usually associated with
some trophic disturbance.
Oni/cluiuiis. — An increased growth of nail substance,
and when associated with curving or hooking of the nail
the word onycJiogri/p/ums is usetl. The etiolog}' of this
condition is somewhat obscure, but the deformity has
been observed in connection with wounds, pressure of
shoes, old age, deformities of toes, especially hallux val-
gus, syphilis, tinea tiicoph3'tina, central or peripheral
nerve disorders, old tuberculosis, circulatory disturb-
ances, such as thrombosis and aneurism, leprosy aud
confinement to bed.
The pathology of onA'chogryphosis was carefully stud-
ied by Virchow in 18.5.5, aud his dcscri|)tion which fol-
lows remains the best to-day. There are three gradations
in the formation of a truly gryjihotic nail : First, the flat
or plate shape; second, the conical form; and third, the
perfected claw. At first the bed becomes shortened aud
the pulp of the last jihalanx dimir.islies in size: the sub-
ungual vessels dilate and the stratum spinosum prolifer-
ates with the formation of abnormally high, transverse
ridges, and an accompanying hypertrophy of the stratum
corneum. These changes separate the "jilate from the
bed, especially at the cTislal border, and the plate itself
thickens, becomes _vellow or dark brown in color, and
-shows on its surface ovcrlapjiing transverse ridges.
These ridges, of course, denote an intermittent process.
The second or conical stage results from a continuation
of the previous changes. The lied bccdmes deeper and
forms a distinct transverse ridge, behind which the [ilate
is almost perpendicular, yellow, Iranslucejit, and very
hard; while in front it is opaque. The cells of the jilat'e
are no longer nucleated and apparently lose their b(uuid-
aries. In t)ie deeper portions of the bed the cells soften
and blood finds its way into the intercellular spacesas in
cutaneous horns. The third stage shows a still further
advance from the normal. The <lo\vnward jiressiue of
the plate has caused an almost total disap]iearanceof the
bed. The ridge noted in the second stage lias widened
and the distal portion of the plate has become smaller;
in fact, the last stage is one of atrophy. The resulting
claAv nia_y grow simply downward or downward and
backward, or in rare ca.ses ma}' assume the spiral curves
■of a rani's horn.
Levconydiia (leukopathia unguium, canities unguium).
— The appearance of white areas in the nails "follows
three types, the punctate, the striate, and the total.
Pathologically, we find this normal color due to the
faulty production of nail cells with subsequent imbibition
of air. This abnormality has lieen observed following
wounds, trojiliic distiubauces, relapsing and tyjiboid
fevers, stimulation of nerves by electricity, and. rarely,
congenital examples have been recorded.
K"il(iiii/c/iiii. or spoon-nail, is the concave apjx-arance
wliicli the plate assumes at times. 'I'his condition is
usually the result of an underlying eczema, Init may a|v
pear after other diseases, or without any apparent etio-
logical cause.
Arjnail, or hangnail, is caused bj' the drying up of the
eponychium after insufficient nourisliinent. With the
formation of the hangnail an easy entrance is afforded to
liacteria, and in this wa_v arise many of the sj'pliilitic
chancres and the more numerous cases of paronychia and
of panaritium.
Ihtnunhiirie. — The inva.sion of blood below the nail is
usually traumatic in origin. A squeeze or a blow is fol-
lowed by the btn-sting of a vessel in the bed or in the
matrix ; and when in the latter, the plate is sure to fall.
The blood forms a clot between bed and plate, and if
small, is usuall,v absorbed while a large hemorrhage will
often lift up the plate and produce subsequent atrophy
or jio.ssible loss of the nail. Cases of vicarious subun-
gual luenstruatiou have been reeoided, while other etio-
logical factors in liemorrhage of the nail are scorbutus,
morbus maculosus Werlhofii, tabes dorsalis, or the in-
troduction of foreign bodies below the nail ])latc.
Tnixnnn. — Wounds of the plate mean nothing serious
to the nail, while similar injuries to the matrix always
lead to scars which jiroduce permanent defcuniities.
I'liyiiis inriiniali/s. — Ingrowing of the nail is most
commonly met with in males lietwecn the ages of fifteen
and twenty, and is usually coincident with lack of care
of the feet and the wearing of ill-fitting shoes, but flat-
foot, wounds of the nail walls, and great convexity of
the nail are other possible etiological factors. The first
symptom is pain, followed by swelling and the forma-
tion of pus, and finall,y a granulating sore is produced,
which shows no tendency to heal. Constitutional symp-
toms sometimes make their appearance, and finally the
disease may result in necrosis; but this event is fortu-
nately rare.
linhHiiguiil Tumors. — The presence of new growths un-
der the nail is distinctly uncommon, but, accoiding to
Heller, cases of subungual corns or horns, fibroma, pap-
illoma, leiomyoma, angiosarcoma, angioma, colloid sar-
coma, exostoses, cancer, and enchomlroma have been
recorded,
Sy.mptom.4tic P.\Tiioi,ooir..\T. Involvement of the
Kails.
OiiycJiiimi/fum'.i triri>j>/ii/tina.— Ringworm of the nail is
a rare condition, and is usually caused l)y the inegalo-
sporon. The di.sea.se first appears at the distal end of
the nail and gradually spreads backwaid. The plant
first attacks the l)ed. producing an o]iacity and discolor-
ation of the plate, which usually assumes a whitish-yel-
low tint. As the disease progresses, the color darkens
even to a brown, but never reaches black, as is so often
the case in favus. Coincident with the progressive color
changes the bed becomes more and more Jiyperkeratosic,
the plate is raised more and more from the lied and shows
transverse depressions, transverse elevations, or vertical
ridges, and finally the plate itself is attacked and be-
comes rough on the surface, exfoliates in lamella", atro-
phi<-s or splits, and is finally cast off. The disease is es-
sentially a very chronic one, and even when pro|)crly
treated requires at least two years for its thorough
eradication. If left to itself, the plant has been known
to remain active in the nail substance, even up to thirty
years. The diagnosis is cxtremel.v dilHcult. for even al-
though we have to our satisfai'tion excluded all other
piissibilities. the spores may elude the most diligent mi-
croscopical investigation — in fact, it is only when one
has demonstrated conclusively the gli.steniug, rectangu-
lar spores with rounded corners, five to seven microu'.il-
93
Nails.
Nails,
REPEKENCE IIANDHOOK ()F THE MEDICAL SCIENCES.
limetn'S in diamcU'r. growing in cluiiM formation tliat
one can positively state that tlie disease iiresent is ring-
worm of tlie nail." Un the other hand, if the nail presents
the clinical characteristics above enumerated and ring-
worm is present elsewhere on the patient's body, we
have a certain right to assume that the nail is similarly
infected. The treatment, although tedicuis, always tri-
umphs in the end. It consists in the lii-weekly or tri-
weekly cutting of the nail, and, in case the plate has
been ('ast olT. the curetting of ihe bed and subsequent
painting with Lugol's solution or with acetic or pyrogal-
lic aeid.
On!/r/ii>iiii/rii.ti!! fariim. — Nails are apparently much
more susceptible to tinea favosa than to tinea tricophy-
tiua. The clinical appearances of the diseases are quite
similar. The plant attacks the distal end of the bed ami
produces an opacity and discoloration of the plate. The
hyperkeratosis spri'ails backward and the plate is raised
from its bed, becomes daiker anil darker in color, even
to blackness, and its surface shows transverse depres-
sions or ridges. Often the substance of the plate is at-
tacked and assumes a honeycombed appearance, which
soon leads to crumlding and splitting and final loss of
the nail ; or else the hyperkeratosic granules are extruded
from the bed. leaving, as sometimes occurs in ringworm,
a hollow space underneath the somewhat atrophied and
brittle nail i)late. The disease may be caught from do-
mestic animals or from one's neighbors, and often occurs
in two or more members of the same liouseholil. The
Russian Jews seem to be particularly liable to infection,
and in the writer's four hundred and eighty-five tabu-
lated cases of nail diseases occurring during the last three
years, his eight examples of onychomycosis occurred in
this race. Histologically, one finds a thickened prickle
layer of the bed, elongateil ])apilhr, and an enormously
hypertrophic horny layer in wiiieli the achorion Schon-
leinii appears. The fungus is not so abundant at the
distal end of the plate as farther back, and its m_YCeliuin
grows parallel with the cells of the stratiun cornenm.
The jirocess is much more chronic than in the scalp, and
follows closely the characteristics of ringworm, both in
its life history and in its treatment.
Dis/dftex ('(tiixcil liji Aiihiiiil I'mvigitcs. — This forms a
class about which there is little to state beyond the fact
that in extremely chronic cases the nail jdates show slight
changes. The chief diseases in this group are scabies,
myosis, pule.v iienetrans, and plica polonica.
Irhttitidsi.s (111(1 Xcmdeniiii. — At birth, in .severe cases,
nails have appeared small, soft, and easily detached,
with poorly developed nail walls. In older children and
adults nails may show transverse depressions or vertical
ridges, or may appear dull, v<'ry convex, or even gry-
photic. Hyjierkeratosis of the bed with gray or greenish
discoloration of the plale and final loss are still further
conditions which have been observed.
Elephiintiiisis Antl>ii)n. — Thi^ changes of nails in this
disease are usually liudted to the large toes where in-
crea.sed thickness, yellou- color, and atrojihic changes
have lieen recorded.
HiDii'fkiriitosh itiihiiiiijiiiilis. — Although this is really a
symptom rather than a disease, it slioidd be considered
here in order to gain a better knowledge of this impor-
tant condition,. which is .so frecpiently met with in nail
pathology. This lesion is strictly linnled to the bed of
the nail, and (udy after long continuance does the phde
itself become involved, exceiiting its elevation and in-
crease in convexity. This condition, therefore, illus-
trates well how little the plate depenils fur lis nutrition
upon the Ix'd. The horny mass grows most abundantly
at the distal vnA of the bed and constantly diminishes in
height toward the matrix. Consequently the elevation
of the jilate is greatest near its free border. Unna de-
scribes the histological ideture as follows: One sees ex-
tending into the horny layer papillary-like vascular
processes which contain spindle cells and leucocytes.
The |iriekle layer is thickened and passes without defi-
nite line of demarcation into the horny layer. A perfectly
developed granidar layer does not exist. The horny
cells retain their nuclei and increase in size even up to
the surface, and we note the same medullary processes
Avhich have been described in cutaneous horns. Swarms
of cocci exist in the upper layersof the stratum corneuni
and exert a softening elfect upon the adjacent cells.
Eczema. — The changes obsei-ved in this disease may
occur in the nail walls, matrix, bed, and plate, and are
produced by the same causes that tiring about an eczema
of the skin. The involvement of the nails before the age
of twenty is distinctly imconimon — only six cases in tlie
writer's one hundred and seven occurring before that
age. The disease prevails all through adult life up to
the age of seventy, when it diminishes in freciuency. In
the acute form the nail walls are red and swollen, the
]ilate loses its normal convexity, pain is felt in the bed,
the plate becomes rough, the lustre vanishes, discolor-
ation is present, and soft sjiots appear in the plate which
later form minute punctate depressions. If the cuta-
neous di.sease continues, the nail exhibits one or more of
the following conditions: Transverse depressions or
ridges, vertical ridges, h_v]ierkeratosis of tlie bed with
increase in the convexity of the plate, and subsequent
disappearance of this granular detritus and thinning of
the plate with increased brittleness, exfoliation of surface
cellsof plate, leuconychia, orfinally total loss of the nail.
If the matrix is affected, a deep transverse furrow may
result.
The pathological changes consist in the formation of
eleidiu and horny matter with a'dema and cellular infil-
tration about the vessels of the corium. The prognosis
is decidedly good, and the treatment for the nail disturb-
ances is the same as for the underlying skin disease.
Paroiii/rhiii. — This is a very frei[uent cause of nail de-
formities, and consists in a severe dermatitis of the nail
walls. It is an acute or subacute process, and usually
occurs in women who wash dishes or scrub floors; liut
any individual who subjects his fingers to a constant ir-
ritation may develop this localized condition. The most
common nail changes are discoloration, transverse de-
pression.s, and hyperkerato.sis subungualis with its usual
sequela'. These consist of a lifting of the jilate and sub-
sequent discharge of thekeratosic granules from the bed,
leaving a fiat, horny floor covered by a thin, dome-shaped
roof. All the other alterations of the plate noted under
the heading of eczema may appear in cases of paronj-chia,
but the ones above mentioned are by far the most fre-
quent.
DcniKttiiis rcnciiiit.li. — Under this title will be consid-
ered the acute cases of dermatitis which can be directly
attrilnited to some noxious occujiation or to some chance
|ioisoniug of the skin. Here the commonest symptom is
koilonychia, wdiich appeared in twenty-five of the fifty-
eight cases recorded by the writer. Other frequent
changes in the nail are round punctate depressions, dis-
coloration, transverse depressions, vertical ridges, and
hyperkeratosis subungualis with its usual sequela; of
separation from bed, thinning and brittleness of the
plate.
The prognosis is good in jiaronychia and in dermatitis
venenata of the nails, and the fri-atment consists in the
application of soothing antiseptic washes and oint-
ments.
Trauiiiii and Felon. — These two accidents frequently
affect the nail, and when they are of slight importance
or do not involve the matrix, the results upon the nail
are unimportant. When, however, the matrix is affected,
then we have a permanent change which will reproduce
itself as long as the individual lives. The commonest of
these constant deformities are transverse depressions,
vertical ridges, hyperkeratosis subungualis with its
usual sequela?, and discoloration. The 7nore unusual
changes are round, pvmctate dejiressions, tliinning, ex-
foliation of surface of plate, increased convexity, brittle-
ness, opacity, koiliiuy cilia, grvphosis, leuconychia, trans-
verse ridges, vertical depressions, invasion of air into the
plate with subsequent crnmblingor total loss of the nail.
Under this heading should be considered the results of
persistent biting of the nails, which leads to shortening.
ill
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Nails.
>alls>
tliiuuing, Ijiittlenpss, and koilonyeliia, or to the produc-
tion of transverse ridges or depressions.
Pxoriiixiii. — Tlie involvement of the nails in cases of
cutaneous psoriasis is relatively much commoner lliau is
the r\de iu eczema. The disease can also e.\ist alone in
the nails, but such a diagnosis is in truth a hazanious
one. The condition is most frequently observed in men,
and between the ages of twenty and forty. The simplest
cases consist of round, punctate depressions in the plate,
and Unna and Heller regard this symptom as pathogno-
monic of psoriasis; but the writer cannot agree with this
position, as these lesions appeared in more than one-
fourth of his cases of eczema of the nails. The common-
est lesion iu the writer's experience is a more advanced
condition, and consists in the changes subsequent to
hyjierkeratosis of the bed. namely, a horny floor, partly
covered by a short, thinned, broken, discolored, arched
plate. This change was noted in fifty. seven per cent, of
the cases. Two other common lesions are discoloration,
which varies from yellow to dark brown, and transverse
depressions, both of which occur in about thirty-eight
percent, of the cases. After these four deformities come,
in the order of their frequency, simple hyperkeratosis
subun.gualis, brittleness of the plate, thinning, opacity,
vertical ridges, exfoliation, increased convexity, total
loss of the nail, broken nail, koilonyeliia, disappearance
of lustre, transverse ridges, and vertical depressions.
Pathologicall.v. the psoriasic papules form on the bed.
raising up the plate and allowing the air to be imbibed
by the plate cells. This leads to opacity and discolor-
ation. In the subungual corium there is great dilatation
of vessels instead of the inflammatory oedema observed in
eczema. The progno.sis is almost always good, but there
are severe cases of many years' standing in which the
nails have completely fallen, never to return. The treat-
ment, as in all nail disease, is the same as for the skin,
onl_y one must remember that Roentgen rays have an
atrophic influence on nails and hair, while they exert a
jonic action on undifferentiated epithelium, and for this
reason one cannot expect the marvellous and ra]ud re-
sults which one often experiences after sifljjecting chronic
patches of cutaneous psoriasis to .c-rays.
AVitli the eomiilelion of the descriptions of the last tivc
diseases, the most important part of nail pathology is
finished, for in my experience eczema, paron_ychia, der-
matitis venenata, felon or trauma and psoriasis consti-
tute nearly eighty per cent, of all nail afl'ections, and in-
stead of timling any lesions pathognomonic of any given
disease, we note how constantly the same lesions appear
in the dilTerent processes. This is certainly disappoint-
ing; but as we continue the study of diseased nails, we
shall lie more anil more struck by the freiiuency with
which the same lesions occur over and over again in en-
tirely different processes.
Piti/riiims rubra pilaris. — Here we may tind transverse
depressions, subungual hyperkeratosis with increased
convexity of plate and onychauxis, yellow discoloration,
vertical ridges, and depressions and liypera>sthesia.
Lir/icn ruber. — The nails become atrophied, light yel-
low brown, fissured and brittle at the free end, and un-
even upon the surface.
Fsorusperiiiosiii. — In this rare affection the nails are al-
most always involved, and show one or more of the
following abnormalities: thickening, opacity, vertical
ridges and depressions, fragility at border, hyperkerato-
sis subungualis with elevation of the plate, gryj.ihosis,
eruinbliug away, and final loss.
Aloperiii. — During the last three years I have ob.servcd
five cases of partial or total alo]iecia with bad teeth and
diseased nails. The nails exhibited round inuicfate and
transverse depressions, vertical ridges, or .subungual hy-
perkeratosis with subsequent separation of the jilate from
the bed, discoloration, and brittleness. In mild alojiecia
areata, one occasionally finds vertical ridges and an in-
creased brittleness of the plate, while in the severe cases
of nervous origin the nails have been completely slicd.
PeiujiJiigun. — As a rule the disease is not accompanieil
by nail disorders, but when the exception is present we
find atro])hy and britlleiics.s of the plate. When, how-
ever, a vesicle or bulla form's under the nail, deformities
inevitably result, the commonest of which are hyiierkera-
to.sis of the bed, vertical or horizontal ridges, discolor-
ation, thickening, crumbling, and loss. If a bulla occurs
in the matrix the plate is alwaj's shed.
Epidermoh/sis bullosa hereditaria. — This condition usu-
ally leads to atrophy and exfoliation of the plate, but
examples of gryphosis have also been observed.
Hydroa avtiralc. — 'When a vesicle or a bulla forms
under or near the nail, we must have a resulting deform-
itv. and in one case I noted vertical ridges and loss of the
piate.
Derwalitl.i herpetiformis. — Usually the nail takes no
jiart in this disease, but when the vesicles form near the
nail i.r the process alTccts the whole economy, then we
find round, punctate, or transverse depressions, vertical
riilges, exfoliation on surface of the plate, or invasion of
air.
Scarlatina. — Nail lesions are not common, but trans-
verse depressions and loss of the nails are symptoms
which have been recorded.
DernialiUs e.tfoliatira. — In light cases the nails remain
perfect, but when the general condition becomes severe,
then the most marked distuibanees occur in the nail, in-
cluding round, pimctate, or transverse depressions, hy-
perkeratosis subungualis, discoloration, opacity, grypho-
sis. or breaking of the nail.
Pityriasis rtdira. — Heller mentions as concomitants of
this disease thickness, opacity, fi.ssuriug, crumbling, sep-
arations from the bed, and gryphosis.
Dermatitis calorica. — In mild cases of dermatitis fol-
lowing exposure to heat or cold transverse depressions,
discoloration, separation from bed, and onychauxis have
been recorded, but in severe cases the nails fall.
Dermatitis from Roe ntyen rays. — As in the case of the
skin the involvement of the nails usually occurs in the
operator rather than in the patient. After repeated ex-
posure to the rays, the nails show transverse depressions,
often very deep, increased convexity, vertical ridges,
discoloration, separation from the bed, crumbling of
plate, and finally total loss of all nails which has per-
sisted iu one of the writer's cases for three years.
Scleroderma. — Heller records many accidents upon the
nails as sequelai of this disease. As will be seen by the
sulijoined list, the variations in degree and variety are
unusually large: grypho.sis, local asphyxia of bed, thick-
ening of the skin of the bed, vertical ridges of the [ilate,
transverse furrows and ridges, increased convexity, brit-
tleness, atrophy, erosions of plate, and loss.
Atrophoderina. — In this rare dermatosis the nails oftea
become influenced and exhibit vertical ridges, brittleness,
atrophy, and vertical depressions, while iu seveie cases
the lunula^ disappear altogether.
\'ililif/o may exhibit at times lesions on the nails, and
in my experience 1 have ob.served transverse depressions
and ieuconychia.
Pruritus. — With any of the pruriginous diseases the
nails mav become altered and show t lansverse depres-
sions, vertical ridges, or even koilonyeliia.
Syphilis. — Syphilis of the nails is not common, and
forms only about five per cent, of all nail disturbances in
my observations. Like the general constitutional disease
syphilitic manifestations on the nail may be divided into
those resulting from the |irimarv lesion, from the second-
ar}' eruption, and from the late changes of the disease.
A chancre on the nail wall is followed in a short while
bj" a series of parallel transverse depressions with or with-
out discoloration, or the change may be more intense and
the plate will ulcerate and drop otf in jiart or iit toto.
The secondary stage of the disease shows itself usually
in one of two ways: first, by tlie formation of a papule
on the bed. and second, by a general moist ulciratiou of
the nail. The fnrmation of a papule on the bed is indi-
cated by a red spot in the jilate, which beeomrs yellow
with the subsidence of the lesion. The plate over the
papule becomes thinner and may even be broken, while
the horny layer of the bed thickens, and as a result leu
95
Nails,
Nautui'ket.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
conj'chia may ensue. The secondary ulcerations of the
nail are the most l're(i\ient syphililic manifestations, and
the disease is characterized l)y the large niiraher of the
nails involved. The first signs are redness and swelliug
of the last phalanx aeeonipauied by pain. The nail
walls become affected and the epidermis is raised by tliiid
and tinally ulcerates. Pus appears from the eponyehiuni
and from" under the plate on the sides, ami causes the
plate to look yellow. Blood is imbibed by the plate
cells and the nails become red anil later black. Ulcer-
ations appear alcmir the bed. and as a result the nails fall.
It the matrix is atlected, nails may not be reproduced,
or may grow again gryphotically deformed. The res-
titution of such nails is always a long and tedious
task, and must be brought about by mild local antisepsis
and prolonged general aniisyphilitie tieatment.
The nail lesion associated with late syphilis usually as-
sumes a dry form, and has been termi'il scabrities unguium
syphilitica or ouyxis era(|ucle. At the root of the nail
white, punctate depressions form in vertical series
brought about by parakeratosis and acanthosis of the
bed. These pathological pi'ocesses prevent the foi'ma-
tion of on\'chin, and as a result we Snd liyjicrkeratosis
subungualis with its usual sequeUv. or a thickened. _y(d-
low, crumbling |ilate.
In hereditary syphilis Neumann states that the nails
ma.y assume atrophic forms and a.])pca.r thin and brittle,
or poorly developed.
Lejii-d. — In iiure cases of lepra tuberosa nail changes
are rarely met with, but in mixed types or in |iure ana'S-
thetic forms all degrees of deformities are encouutered,
extending from simple blown sjiots to gry])liosis and
permanent loss.
Viirio'id. — Virehow states that if a i)Ustu!eof smallpox
appears upon the bed, the plate will sliow a yellow,
sunken spot, and may eventually be cast olf; and if
such an accident occurs, the loss will be a ]iermanent
one.
Aihlinoii's DixKifsr. — In tins affection the nail lesions are
practically iiigmentary ones. The nails appear white on
account of the general aiaemia and deposit (d' |iiginenl in
the nail bed or brown streaks or universal daikening of
the nails may appear.
CiitiinciiHS 'J'lihi'iTii/iinis. — The nails show involvement
imly Avhen the tuberculous process exists in the ueigh-
borliood of the nail walls. Transverse depressions and
ridges, vertical ridges, discoloration, hyperki-ratosis sub-
ungualis with its resulting deformities, ('.<'., raising of
plate from bed, increase in convexity of |ilatc, casting
otT of granular debris, thinning and breaking of nail,
and tinal loss, which in this disease ma_y be iiermauent,
are the lesions usually experienced.
JIoiniiD Pkocesses in the Naii, in Connisction with
NoN-CmwNEors Dise.\si-:s.
P/)t7iinif: Piilmiiiiiitii. — Hippocrates was the first to de-
scribe the increased convexity of I he nails in consiim])-
tive ]iatients, and thus the term Hippocratie is used to
denote the high iirching which often exists, both longi-
tudinally and vertically, in this disease. Women are af-
fected in this manner oftener than men, and as a rule the
thuml) nail is the first to show the change. After the
thumb the frecjuency of involvement ext<'uds seriatim to
the little finger. A plausible ex|ilanatiou of this phenom-
enon is given by Pigeaux. who says that the regions
farthest from the heart are subject to (edema, which lifts
U|i the matrix of the nail and causes elevation of the
plate, while imiiiliition of this .same fluid jiroduces a
thickening of the plate itself. Tla- dilatation of the ves-
sel causes the disappearance of the lunula.
Eiiipi/cma. — Hippocratie nails have been ob.servcd in
this (lisease also, but have disappeared with the subsi-
dence of the )inrulent lluiil.
liitrliiti.'t. — Esbach li.is noted a, shorlening of the last
phalanx.
CiirciiiDiiiiilox/H. — In all cachexias nails become softer,
probably on account of the aua'inia of the matrix, bed,
and walls. Observers have recorded also leuconjchia
and onychorrhexis.
Ileiiii DinfiiKf. — Here, as in consumption, circulatory
disturbances are at work, and conseciuently blueness and
Hippocratie nails with "drumstick fingers" appear.
Eiiiliiiliism and Throinhuiiis. — Observations upon these
accidents to the lingers are decidedly rare, but Heller
speaks of blackness, gryphosis, and loss as possibilities.
VlahetiS mdlitiis. — The presence of sugar in the blood
or the subsequent changes in the vessel walls and tissues,
induced by tlie circulating sugar, may produce transverse
furrows, brittleness, exfoliation, or complete loss of the
nail.
Mii/iiriii. — Writers have noted llie iihenomenon that
before the adsent of llie cliill the nail tnrns to a pale
blue <ir slate color.
.^■(Jiiiiitiii!. — In this disease hemorrhage is apt to occur
undia' the nail, producing the variations in color due to
oxidation and lo.ss of the nail involved.
C/ilarofih (tiiil Aineiiiiii. — The lack of nourishment
brings about |ialeness. thinning, and tendency toward
koilcmychia, while in i)eruicious anannia a ditferent class
of disturbances have l)een noted, namely, thiekeniug of
the nail with sulise(pu."nt tissuring and crumbling.
(,'((///. — Here again apparently o]iposite results may be
reached. On the one hand, tlie nails ma}' become thin
and brittle or, on the other band, vertical ridges and de-
pressions may form together with elevation of nail from
bed, with brownish discoloration and subseiiuent gry-
photic changes.
Rlieiitnati.iM. — This affection may attack the nails,
causing transverse depressions, elevations of the plate
with yellow discoloration, brittleness, or gryphosis.
Changes in the Nails in Connection with Dis-
eases OF THE Nervous System.
Peiupiiehal System. — Paralysis or wounds of cuta-
neous vessels produce trophic alterations in the nails.
IIy]iertrophic changes cause thickening, vertical ridges
or gryphosis, while atrophic mollifications aie thinning,
cracking, loss, slowness in growth, di.scoloratiou, vertical
or horizontal ridges, and opacity.
Aciiritis (if Internal Orifjin. — Here changes are less fre-
(pieut than after wounds of nerves, but nevertheless writ-
ers have descrilied loss of gloss, discoloration, transverse
and vertical depressions, brittleness, and bending of the
nail.
Marfan 's lUfnasi' is frequently characterized by disturb-
ances of the nails, such as thickening, blackness, harden-
ing, and gryphosis.
liai/niiiiil'/i Disease. — 5Iild cases of this condition may
exist without changes in the nails, but in the severer ex-
am]des we find vertical ridges and furrows, increase in
convexity and thickening, hypera^sthesia, and possible
loss. Wlien the disease is accompanied by panaritium,
then we find the usual results of .shortening, liending,
vertical ridges, and gryphosis.
Kri/l/irnnirlali/ia is often accompanied by nail changes,
among which have been recorded transverse furrows,
j'ellow discoloration, thickening of the bed at distal end,
bending and thickening of the plate, and loss.
SriNAi, Diseases. — 'J'abes Dormlis. — A very frecjueut
concomitant of this disease is loss of the big toe nail,
which may fall repeatedly. This plienomenon is caused
by trophoneurotic changes and by the inva.sion of blood
between the bed and the plate. Other nail changes are
possible, and examples have fieen recorded of britileuess.
thickening, hardening, and transverse and vertical de-
]U'essi<.ns.
Si/rinr/nnii/ilia. — The almost constant presence of par-
onychia and of panaritium in this rare affection accounts
for the freiiuent and severe involvement of the nails.
Here we find brittleness, lack of lustre, cracks, thinness,
exfoliation, and after panaritium gryiihosis, atrophy,
loss and stumps of nails growing at various angles.
Anterior I'alinini/e/ili.s. — In this di.sease instances of
softening and loss of the nails have been recorded.
96
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
>ails.
Nantucket.
Injured Spine. — After such an accident I )iave noted
transveise depressions and ridges and liyperkeratosis
subuugvialis.
Multiple Sclcnmn. — The nail changes in tliis affection
are very similar to those observed in locomotor ataxia:
uaniel)', brittleness, pain, and invasion of blood between
bed and plate, causing the loss of the nail.
Br.\ln Dise.\ses. — Apoplexy. — Tlie possible deformities
of the uail resulting from sti'okes of paralysis are vertical
ridges, transverse ftirrows, increased arching, thinness
and greater transparency, smallness, brittleness, koilo-
uychia, ecchymosis of bed witli subsequent loss, and gry-
phosis.
Psychoses. — Dementia Pantlytica. — The changes oc-
curring in thisdisea.se are quite similar to those following
apople.xy, and may consist of increased transparency,
vertical and transverse furrows, subimgnal hemorrhage,
transverse riilgcs, 3-ellow or brownish discoloration, and
gryphosis.
Mtlaneholid. — In the course of this disorder different
observers have noted transverse furrows, increased thick-
ness, and slowness of growth.
Fuj;cTiON.\i. NEruosES. — Hysteria. — Nail changes are
seldom met with in this condition, but inslanees of lack
of lustre, vertical and transverse furrows, exfoliation,
thickening and roughness of surface, and final loss have
been recorded.
Epilepsy. — Another disease in which nail disordeis are
rare, but when present they maj' iuclndc thinness, brittle-
ness, deep transverse furrows, roughness of the plate,
and subungual liemorrhage.
JSieuraMhcma. — In thisilisease I have observed discolor-
ation and transverse ridges.
Aercuus Sliocl: — As a result of such accidents patients
have come to my notice with transverse depressions and
ridges, thinning, discoloration, and subungual hyper-
keratosis with its usual results.
TKoriiic Nkukoses. — My.rwdenm. — In my- experience
the only changes in the nails in connection with this dis-
ease have been tho.se of vertical ridges and subungual
hyperkeratosis and its resulting deformities.
Diseases of the Boxes. — Fractn res a*-e of ten followed
by discoloration, wliich varies from yellow to black, by
transverse furrows and by slowness of growth of the
nails.
Acromerjaly. — This interesting process is almost always
accompanied by onychauxis where the nail is enlarged
transversely and vertically and appears fiat, brittle, and
lustreless with vertical ridges upon its surface. In addi-
tion to these symjiloms I have observed discoloration
and subungual hyperkeratosis, but have not observed
the usual .sequeUe of this condition.
Arthritin Dcfdvmans. — In this disease I liave I'ecorded
vertical ridges and depressions, transverse ridges and de-
pressions, discoloration, thinning, and brittleness and
koilonychia.
Acro-arthritis. — In this somewhat allied condition nails
have been shown me bearing round punctate depressions,
vertical and transverse ridges, discoloration and hyper-
keratosis of the bed with subsequent elevation of the
plate.
Nails in Connection- with Youth and Old Age.
The sucking of nails renders them soft and small,
while advancing years produce vertical ridges and a ten-
dency toward increase in size.
Keratosis Kenills. — In conjunction with this disease I
have seen round, punctate, and transverse depressions,
leuconychia, and subungual hyperkeratosis with in-
creased convexity of the bed.
IntoXIC-VTIONS.
Heller records the following changes in connection with
the use of poisons:
Arsenic may cause pain, yellower brown discoloration,
raising of plate from bed with eventual loss. Brooke
Vol. VI.— 7
and Roberts observed in the recent English epidemic of
arsenical poisoning from beer abnormally rapid growth
of the nails with transverse ridges and subungual hyper-
keratosis.
Mercury rarely produces changes, but transverse fur-
rows, blackness, thickening, and loss of the nail have
restdted from the abuse of the drug.
Nitrate of silver ma_v be deposiled in the tissues and
discolor the nail bed blue or gray. I have recently ob-
served a very marked example of this condition.
Lead has been known to destroy the nails
When one has read the facts enumeiated and described
in the preceding paragraphs, I think one must be greatly
impressed b\' the similarity of symptoms resulliiig from
the many diseases which may induce changes in the nails.
This is the effect produced upon the writer, who at the
end of three years' special stud}- of these att'ectious fei4s
more than ever that the [ihysician who states that he can
make a positive diagnosis from the nails alone is making
a rash statement. In closing this article the writer wishes
to acknowledge his great indebtedness to Heller, whose
uuique book, "Die Krankhciten der Nilgel," has been
the model upon which he has based this article.
Vliarks J, White.
NANTUCKET, MARTHA'S VINEYARD, AND CAPE
COD.— The islands of Nantucket and Maiiha s Xim-yanl
and the southern district of Ca]ieCodaieclimatol(igieally
-' , t^NAusHON vje*^..* iV a 71 tucket
*-^ NA6H*1V£N4I. /'
"""""'■ ,i /v.._ ^,-,
£,^>' ■S'^""'"^'''^*'- S o u n d
ICH»PPAOUlDOiCK
Fig. 3181.— Nantucket, Martha's Vineyard, am! Ciipe Cmi, Mas.s.
and structurally so similar, and ;ire grouped in such close
|iroximity to each other that it hits seemed best in the
present description to consider them under one head.
Nantucket, as being situated ftirthest aw:iy from the
mainland, is to be talvcn as the climatoiogic:il ty]M'. its
climate resembling most nearly the elimaie of the ocean
as exiierienced on shi])li(iar(l. of any island on the Atlan-
tic seaboard from Old Point Comfort to the ( !r;iiid Manaii.
The climatic attributes may be briefly suiiuniil up as fol
lows: ((() as being at the ocean level the air contains the
maximum amount of oxygen, a(|ueous vapor, and ozone:
(h) it contains saline particles, i.e., iodine and bromine;
((■) it presents the most regular variiitions of barometric
pressure: and (rf) it presents the minimum diurnal va-
riation of temperature. Other stations included in this
articli' resenil)le it more or less nearly, according to their
jiroximity to tlie sea aiul to modifying local conditions
subsequently to be consideied.
97
IVaiitiK-kot.
Napa Soda Spriu^^i.
liEFEUENTE HANDBOOK OF THE MEDICAL SCIENCES.
The Island of Nantucket (-41° 15' North Lat., 70' W.
Loiij;. ) lies in the All.mtic Ocean twenty-five miles due
south of the niet.acar|)al joint of the lieckoiiini; linger of
Cape Cud. It is of a long-horned crescentic shape, and,
roughl}- speaking, is fourteen miles long and four miles
wide. It comprises in its entire extent about twenty-
nine ihousandacres. It is the mo.st easterly of the group
of islands known as the Elizabeth Islands, in which are
also included Martha's Vineyard, Tuckanuck, Muskeget,
and Naushon. It is almo.st exactly one hundred nulcs
from BciSton.
Striict\irally considered, it is a. vast mound of sand
lightly covered with vegetable mold, gently undulating
in surface, and presenting a .series of high bluffs to the
sea. At difl'erent points its surface is dotted by fresh-
■\vatpr ponds of varying size. The soil is of a light, por-
ous, sanily nature. Rocks are so raie that it weuld be
easil_y jiossiblc to count those worthy of the name upon
the fingers of tlir- hand. There are. practically sixakiug,
no trees. The llora is large and varied. Five hundred
varieties of sjiecies are described as growing without culti-
vation. The botainc range is wide; heather grows upon
the moors: cactus is lo be found freely flowering in the
month of .Tul\-. while in August a visit to a vast field
of hollyhock-iike blossoms of tlii' pink hibiscus is a fa-
vorite excursion. A large variety of birds pause at the
island upon their semi-annual ]iilgrimages: black duck
and ■|Uail live there the entire year, and the neighbor-
ing island of ^luskeget is a breeding place upon which
tliousands of families of sea-gulls are annually reared.
Nantucket, the chief town, is situated upon the north-
ern side of the island, on Nantucket Sound. The resi-
dent population in ls94 was 3.300, though the summer
population is, of course, largely in excess of these figures.
In that year Hi. 300 passengers, not in(duding children.
^vere brought to the island. At the height of its jiros-
perity, 'when the whaling industry fiourisheil. the popu-
lation of the island was 10.000. The town is very old
(the oldest hou.se bearing the date KiSO). Many of the
dwellings and warehouses are built of brick, and the
Dumbi-r of buildings iu general is surprisingly large in
proportion to the present poimlation. A general im-
pression of size and anlii)uit.y is given to the town. The
streets for the most Jiart are paved with sloneand asphalt ;
o\itside the town clay roads extend iu many directions,
and the State road, a fine piece of macadamized road,
eight mill's long, connects the town with Siaseonset. At
a greater distance from the town the roads consist chiefly
of "ruts," and one may ride or tlrive in almost any direc-
tion at will over the moors.
Siaseonset, formerly a small fishing village, eight miles
from the town and connected Avitli it liy a narrow-gau.ge
railroad, is now an exceedingly jiopuhir summer resort.
It is .sifoaied on the ocean and is possessed of several
hotels and boarding houses, a casino, and a fine golf
course. The surf bathing is excellent.
Na.xtcckkt, Mass., Five Years, 1897-1901.
Climatic Data.
Avi-rafft' inaxiinuiii
AveraL'e Ijllllillllllil
Avel'aLre dajlv raiiL'n
Ahsiilult.* ina.xiimim
Ab.solute Ulilliiniilil
Avoratjt' iiiiiiiln'r lit clear <lays
La^ge^t nuinher of clear days
Smallest nuinlier uf clear tiays
Averaf-^e numlR-r cltuidy ami jiarlly
cloudy
Largest number clomly and partly
cloudy
Smallest number cloudy and partlv
cloudy
Averatre number rainy
I.aiuest nund)ei' of rainy days
Smallest niiiufier of rainy ilays
Ayeratre toial rainfall !.
Average relative humiility for four
years
Averaije hourly wind yelocity for
for years
June.
.Inly.
Aueust.
«:.i^F
7:i 9" K
73.9° F
55.7'^
Kli°
(j.l.2»
U/.i'^
in.9»
10.7'>
Tf^"
,SI1°
87*
44^^
."i4°
X"
T.tJ
7.8
10.2
n
10
12.
4
1
.')
23
23
20.8
2G
30
2t)
lil
21
19
S.G
10
9.6
Id
13
11
K
s
7
l.W
2.4.-.
2 22
86..-.
89.3
,8.8.3 1
10
9..->
.8.2 1
Sept.
69° F
lfl.4»
8-,°
46"
11
13
19
21
17
8
11
4
1.7.5
81
10.2
The i)receding table, compiled from statistics prepared
for me by Mr. A. W. Crosby of the weather btu'eau in
Boston, shows climatic data for the five years l.s0~-1901.
From the foregoing table it is seen that the average
number of raitiy da_\s for the four summer months, for
five years, was nine ]ier month. This number represents
the days during which it raineil at some portion of the
day. The number of days in which an invalid could not
exercise out of doors was of course ludch smaller. In
1804. for the months of Jul}'. August, and Septetnber.
there were niru'ty two consecutive pleasant days.
The pievailing direction of the winil is westerly, blow-
ing, as will be seen by the map, over miles of ocean. One
of the most remarkable metetjrological phenomena of the
island is the rarity of electric storms. Thunder storms
ai'e exceedingly rare, passing north or south of the isl-
and. In the iwenty-one summers I have passed at Nan-
tucket I have known the lightning to strike but on three
occasions. Fogsare a more variable feature, their preva-
lence differing in different years. As a rule it is not more
foggy than at other seashore resorts.
The ttveiage temperature of the water for the summer
of 1S04 was 73' F. At the bathing beach it is somewhat
higher. The cause of this high temperature of the water
is a much-discussed <inestion. It is believed by some to
be due to the proximity of the gulf stream, but this
theory is not borne out by fact. Any one interesteil in
the mutter is refei'red to Dr. Peterman's charts.
The water suiijily of the town is derived from a large
fresh-water i.ond. It is between two and three miles
frofu the town, and is in an isolated position so far as
tlwelling-houses ai'e concerned, the house of the engineer
being the only hiunan habitation within the water-shed.
It would be (liflicult to conceive of its ever sustaining
dangerous pollution.
The sewerage of the town has been greatly improved
in recent years by the construction of a sewer to the deep
waters of the outer harbor.
The aveiagc velocity of the wind for the three months
of the summer of 1894 was nine miles.
Fi'om its isolated position Nantucket is particularly
free from contagious diseases. In the ten years 1890-
1900, there have been forty-four deaths frotii tuberculo-
sis, or eleven per ten thou.sand: and fourteen deaths from
diphtheria, or about four pier ten thousand. In 1901 one
case of typhoid fever was rejiorted. It was, however,
an exceedingly doubtful case, and did not give the Widal
reaction. Contagious diseases, when present, are for the
tnost part imported, and are generally so managed as to
reduce to a minimum their further dissemination. This
is the more i'ea<lily accomplished because of the intclli-
gcfit anil energetic co-o])eration of the Boaid of Health.
The anuisements alfoided the summer visitors are
unusuall_y varied. Boating is excellent. Large cat-rig
boals, under the chargeof experienceil skippers, are pro-
vided iu abundance Those iireferring still water maj'
sail in the landlocked watei's of the inner harboi-, eight
miles in extent. More ticcomplished sailors can puisue
their excursions upon the i-ougli watei's of the Sound.
A daily trip by sailboat and by launch is made to Wau-
fiiinet. tibout seven miles up the inner harbor. Still water
for rowing is always found in the inner liarbor, and ex-
cellent light boats may be hired by the hour. It is par-
ticularly safe for women and children because of the
shallowness of the water. The fishing is excellent; blue
fish abound in the season; .sciip and plaice fish (the latter
a large species of fiat fish) are found in great abundance,
as is also the English turbot. Lobsters, clams, ipn.hogs.
and oysters are also abundtint. T'ickerel and fresh-wal^cr
perch are found in the ponds. There is some shooting.
Marsh birds are present throughout the suiiimer, plover
and snipe are fre(|uently killed during their respective
flights, and black duck and rabbits are numerous. Driv-
ing is veiy agreeable ; the fuoors iire for the most part
unfeuced and level, and it is the custom to ride and di'ive
across them in any and every direction. Bicycling is
also excellent. The State road is a perfect piece of mac
adam ; the clav roadsare fair, ai;il there are seveial ag lee-
98
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
>iuiitiM-ket.
Napa iSuda Springs.
able bicycle paths Golf is the principal amusement.
The course is [larticularly tiue, and in man)' respects an
exact counterpart of the Scotch links. It consi.sts of
eighteen holes, is about si.x thousand yards in extent,
and extends over gently undulating ground, in which
neither a tree nor a stone interferes with the pastime.
The turf is excellent, and tine views of the sea are to be
had from many of the trees and greens. Afternoon teas
an<l tournaments are held ever}' week during the season.
From twenty years of summer practice on the island
the writer feels able to recommend the climate as espe-
cially suited for the extremes of life, the very old and the
very young; the smalluess of the diurnal range being a
most important factor. The absence of contagious dis-
eases also renders it a highly desirable locality for chil-
dren. It is well suited to those suffering from functional
nervous affections, neurasthenia, insomnia, and neuralgia;
for valvular diseases of the heart, for convalescence from
diseases of the respiratory organs, for chronic dysentery
and diarrluea, and especially is it specific for the entero-
colitis of children. Cases of tuberculosis and of the
scrofulous diseases of children ai.so do exceedingly well
at Nantucket.
Nantucket possesses an excellent public library ; a muse-
um, containing many objects of interest ; the valuable and
interesting collection of the Historical Society ; an old mill ;
several light-houses and life-saving stations; churches of
nearly every denomination ; gas and electric plants. There
is an excellent hot salt-water bathing establishment.
There are .several hotels, among which may be men-
tioned, The Sea Cliff Inn, owned by a syndicate, and the
largest hotel on the island. The (Jcean House, Point
Breeze, and Springfield House. - Prices vary from $10 to
§35 per week. There are also a large number of excellent
boarding-houses. A. T. Jtowry, real estate agent, solic-
its correspondence upon all matters pertaining to Nan;
tucket, and has a list of available cottages. Rents of the
latter vary from §150 to §1.000, average about §400. An
eminent Boston surgeon and an equall}' well-known
oculist from Philadelphia are among the summer resi-
dents, and can be called on for special service.
M.\RTii.\'s VixET.\KD. —Twenty miles west of Nan-
tucket and ten miles south from AVood's Hole lies the isl-
and of Martha's Vineyard, an Lsland considerably larger
than Nantucket and similar to it in climate, its chief
differences consisting in its nearer approximation to the
mainland and in the fact that it is comparatively thickly
wooded.
At the easterly end of the island Edgartown is situated,
a small and very picturesque town with a resident pojiu-
lation of about eight hundred person.s, and a summer
population much in excess of these figures. Bathing,
fishing, sailing, and driving are excellent, and there are
well-arranged golf links.
Nearer the centre of the island and on the northerly
shore is the town of Cottage City, probably the most
populous summer resort of the cape district. The resi-
dent population is about the same as that of Edgartown,
but the summer population is estimated as being about
twenty thousand.
Vineyard Haven, situated on the north side of the isl-
and, lies about a mile to the west of Cottage Cit}-, and
is an exceedingly popidar summer resort. The resident
population is about one thousand; the summer popula-
tion is largely in excess of these figures.
West Chop is a small summer colony northwest of Vine-
yard Haven. The hotel, casino, and the major portion
of the land are owned by a syndicate of Boston genlle-
men. The bathing and boating are excellent and the
views are particularly attractive.
Similar in climate and in the configuration of land are
the summer resorts situated upon the southern border of
Cape Cod. Among these resorts may be mentioned
Wood's Hole, Falmouth, Cotuitport, Osterville, Hyannis,
Yarmouth, Ilarwichport, and Chatham.
Harold Williams.
* Not inteoded to be a complete list.
NAPA SODA SPRINGS.— Napa County, California.
PosT-OPFicE.^Napa Soda Springs. Hotel and cot-
tages.
Access. — Take Oakland Ferry (from San Francisco) at
8 A.M. for Napa City, forty-six miles distant, arriving at
10;10 A.M. Then take stage to springs, five miles dis-
tant. Spring, summer, and autumn are suitable seasons
for visiting the springs.
The resort is charmingly located on the southwestern
slope of the Coast Range, at an elevation of about 1,000
feet above the level of the sea. From the Rotunda Hotel
many beautiful views are spread before the e3e in all
directions. Looking southward over the beautiful val-
ley of Napa County one sees a landscape seldom sur-
passed for loveliness, and which always remains fresh in
tlie memory. The climate is warm, dr.y. and salubrious,
uniting the advantages of mountain air with breezes
direct from the sea. The mineral springs here are among
the most noted in the State. They number twenty-seven
in all, with an average daily How of about four thousand
gallons. The temperature of the water ranges fr. m 65°
to 68° F. The main sjiring, the Pagoda, from which
most of the commercial Napa soda is obtained, is an
alkaline-chalybeate water, strongly charged with car-
bonic anhydride. It is delightfully clear and sparkling,
and has an agreeably pungent taste. Following is Dr.
Anderson's analysis:
Pagoda Spuing (N.\pa Soda Spring).
One I'.siTED States Gallon Contains:
Solids. Grains.
iSodium chloride 7.14
Sodium bic.^^b^nate 12.9.5
Sodium carbonate 1.10
Sodium sulpliate 1.63
Potassium bicarbonate Tttice.
Magnesium bicaibonale 3.04
Magnesium carbonate 21.76
Calcium bicarbonate 78
Calcium carbonate 9.55
Fei rnus carbonate 7.90
Silica 74
Alumina .57
Organic matter Trace.
Total solids 67.15
Free carbonic acid ga.s, 141.62 cubic inches. Temperature of
water, 67.7° F.
Over this spring is a beautiful pagoda, suppoited by
solid stone pillars, and. resting upim a tessellated marble
floor, a natui'al stone basin has been ai'tistically aiTanged,
through which sparkling soda bubbles in all its freshness.
There are niany other impf)rtant springs at Najia, in-
eluiliug the well-known Iron S])ring and the Lemon
Spring. The former was analyzed by Professor Lanz-
wurt in 18TU. with the following result:
IiiON Spring (Napa Soda Spring).
One United States Gallon Contains:
Solids. Grains.
Sodium clilonde .'i.SlI
Siidiiiiii lili:irl,nnate 13.1:J
Sodium sul|.lrate 1.84
Magiiesium carbonate 26. 12
Calcium carbonate lO.Ri
Ferrous carbonate 7.H4
SiUca 62
Alumina 60
Total solids 66.17
Free carbonic acid gas, undetermined. Temperature. 6.S° F.
The waters of all the springs have the same general
characters — alkaline-chalybeate, clear, and sparkling.
Napa soda water is highly esteemed as a beverage. It is
sold in every city and town of the coast, and is one of
the pleasantest summer drinks to be found. The water
is an efficient aid to digestion, being antacid and tonic.
When taken early in the morning before breakfast its
action is gently aperient. The ferruginous .salts, held in
solution b}- the carbonic-acid gas. are valuable in ana'mia
and chlorotic conditions, nialarial toxa-mia, and many
disorders requiring iron for the constructive metamor
99
1>n|ililiiliii.
Ma»al <Javitiet».
KEFEKENCE lIAM)B<»OK OF THE JIEDK'AL SCIENCES.
pilosis of red corpuscles. Tlie grouails at Napa Soda
Springs cover over a tliousiiud acres of bill and valle_v.
The place is thoroughly iiii|iroved, and the visitor will
find every arrangement provided for his comfort and
recreation" while sojouring there. Among the attractive
features slKJidd be mentioned the e.xeellent bathing facili-
ties, both tub and plunge. There is also a swimming
bath measurini; one hundred and fifty feet in length by
fifty feet in widtli, and with a depth" of water varying
from four to ten feet. Jmi.ixK. Vrouk.
NAPHTALIN.— Under the title y,(jj!i/,ilii,uiii, Naph-
talin, the United States Pharmaeopaua makes official the
hydrocarbon iiajihtlKikiie (CoHs), known also by the
conunon name of " tar camphor." Xaphtaliu (to use the
])liarmacopieial spelling), like benzene, is the fuudamen-
talmemberof a series of aromatic compounds. Naph-
talin is a common constituent of tars, and is obtained
from c(jal larby fractional disi illation. Naphtalin, when
purified, presents itself in large, colorless, crystalline,
rhondjic plates of a pearly lustre and an unctuous feel.
It has a burning taste and a faint peculiar odor. It is
in.solul)le in water, but dissolves in alcohol, ether, ben-
zene, oil of inriientine, glacial acetic acid, and warm
oils, both fixed and volatile. It melts at SO' C. (170 F.)
and boils at 218 t'. (434.4° F.), but yet sublimes at a
much lower teniperat\ire than that of its boiling-point,
and, nii.xed with boiling water, rises in vapor with the
steam. Even at ordina'ry temi)eratures a gradual sub-
limation occurs. It should be kept in well-stoppered
bottles.
Naplitidin is, locally, but slightly irritant, and i-onsti-
tutionally is not ordinarily poisonous — probably becau.se
of incomplete absorption due to its insolubility in aque-
ous thiids. Vet naphtalin is decidedly "antisei>tic " in
the common medical sense of the word. Taken inter-
nally, some absorpti(}n certainly occurs, since naphtalin,
swallowed, reappears in the urine. Naphtalin has been
used in medicine to |irevent decomposition of the urine
in cystitis, by administration, by the mouth, of an aggre-
gate of five grains daily ; but its main use internally lias
been for loctal antiseptic pur|)0.ses in the intestinal canal,
as in diarrhcea and dy.seiitery, and as a vermifuge. It
has lieen vaunted also as an expectorant in bronchitis
and as a constitutional remedy in typhoid fi'Ver. The
ordinary dose ranges fnnu 0.13 to 1 gm. (gr. ij. to xv.),
and, because of the disagreealde taste, the medicine is
best given in capsule. A case of poisoning — an excep-
tional circumstance — has been reported from the taking
of a dose of eight grains; and it is certainly risky to give
much of the drug if there be any kidney disease or weak-
ness. As an anthelmintic for the "seat- worm," naphta-
lin may be given by enema, in sweet oil (1 gm. in two or
three t'ablespoonfuls of the oil). For ordinary internal
uses naphtalin has been largely supplanted by uaphtol.
ExtiriKillji. naphtalin has been used for the making of
antiseptic dressings in surgery. In this application
naphtalin combines the fi'atuics of a fair degree of efli-
cieucy on the one hand, and freedom from irritant or
poisonous elfeets. and from ollen.sive smell, on the other.
The only untoward elTeets charged against naphtalin so
far have been that the sharp jioints of the cry.stals may
wound tender granulations, and that the powder may
cake with lliiid exudates, and so tend to obstruct the free
drainage of discharges. ^lost rejiorters uptm the use of
iia|ilitalin in surgery, however, have failed to ob.serve
eitlirr of these elfeets. Naphtalin may be apiilied in
bulk, in fine powder, to wound surfaces, or by means of
gauze or wool charged with tlu; substanci% by the device
of steeping the dressing in a strong solution of naphta-
lin, and then permitting the solvent to eva|iorate. By
this means a |iorousmateri;il becomes thoroughly impreg-
nated with a fine powder of the hydroearbon. A com-
mon solution for the making of smdi dressings is a
twelve and-a-half-per-cent. solution of ua|ihtalin in a
mixture of alcohol and ether in equal proportion. |See
also Naiihtalin in the article on Anliscptioi in. iSiirgeri/.]
Edward Curtis.
NAPHTO-CRESOL is an alcohol-soluble substitue for
creolin. W. A. Bantedo.
NAPHTOFORMIN is a condensation product of alpha-
anil iHia-naphtol with formaldehyde and ammonia. It
is an insoluble powder, and, being readily split into its
components, is a pow'erful antiseptic for use in snri;ery.
ir. A. JlaKlnh.
NAPHTOL. — By the substitution, in the molecule of
the hydrocarbon Kdjihthilene. of a molecule of hydroxyl
( — oil) for one of the atoms of hydrogen, a deiivate,
CioIIt.OH, is obtained, bearing precisely the same rela-
tion to naphtalin that common phenol ("carbolic acid")
does to benzene. Such derivate is styled napliHiol. and
according to the position in tlie naphtol molecule of the
hydroxyl substitutiim, two distinct naplitolsaie obtaiii-
aiile, known respectively as a-nuplitliol and ji-niiplitlnd.
Of these two bodies ji-napUiliol is the more easily made,
and is the article used in medicine. It is official in the
United States Phannacopceia under the title and siielling
A'ap/itol, Naphtol.
The common naphtol of the markets is an impure arti-
cle, occurring in reddish or deep violet-brown crystalline
ma.sses of a disagreeable, pungent smell. Such a naph-
tol, becau.se of the poisonous nature of some of the im-
purities, needs purification for medicinal use. Frojierly
purified, naphtol presents itself in beautiful silver crys-
talline scales, nearly or entirely odorless, but of a sharp,
burning taste. The crystals are very slightly soluble in
water (in about one thousand parts of cold, and in .sev-
enty-five jjarts of boiling Avateri, but dissolve freely in
alcohol, ether, chloroform, benzol, and oils. Gently
heated, najihtol sublimes, and may be distilled with
steam. It should be kept in dark amber-colored Lotties,
well stoppered. Naphtol is locall.y distinctly irritant,
exciting upon tender surfaces redness, smarting, and
even inflammation, and, upon the healthy skin also, if in
alaiiiiilic solution, acting occasionally with sullieient en-
ergy to develop an eruption resembling nettle rash, So-
luliiais in oils or fats, however, are said to be without
effect upon the sound skin, although acting energetically
upon an eczematous surface (Kaposi). Vovstitutiunidly,
naphtol, ill therapeutic doses, produces but little de-
ran,gement. Some experimental dosings of animals have
been followed by luenioglobiuuria, with convulsions and
death, and, in one instance in the human sub.iect, an ex-
ternal a[iplication of naphtol produced Invmatiiria, is-
churia, unconsciousness, and eclampsia (Kaposi). But
since these effects are exceptional, it is likely that the
samples used in the cases cited were not pure. Ordina-
rily do.ses of from 0.20 to 0.32 gm. (gr. iij. to v.), given
a iiumber of times dail.y, are innocent of harm beyond
some [lossiblc disturbance of the stomach. The medicine
therefore ranks among the r.on-poisonous, and its value
lies in the fact that while it is thus non-poisonous to the
humau system it is yet quite piotent to arrest the devel-
opment of many micro-organisms. It is said to be five
times as powerful in this regard as carbolic acid.
Naphtol is accordingly used as an internal medicine to
disinfect the alimentary canal, as in cases of diarrhtea,
dysentery, intestinal dyspepsia, and especially in typhoid
fever, in which diseasi' its efficacy was first )U'oclainied
by Bouchard. The doses are those already mentioned.
The article is also used as a local application in many
skin diseases, notably xcidiirs, psoriasis, and iczrnid. It
is commonly applied in ointment ranging in strength of
naphtol from one-half to ten per cent., or even fifteen
per cent. The remedy should not be used upon denuded
parts, and weak applications only should be made to
irritated parts such as so cimmioulv present themselves
in eczema.
Foi' iodoniiphtdl, see under the eai)tion Di-iodo-heta-
naplitiil, in Vol. III. Eilirard Curtis.
NAPHTOL ARISTOL. See Di-iodo-Haphtalin.
NAPHTOL BENZOATE is benzonaphtol (-y.c.).
100
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES,
Naphtallii.
Nasal ravlllcs.
NAPHTOl. BISMUTH, orpliol, basin beta-iiaplitol bis-
muth l(t',„ll,U)3 Iii|,+ Bi.Os or (C,oH,0)3 Bi + 3H,(),
is a ucnilral, non-irritatiui;, lisrlit-brown powder of very
slijilit odoraud slightly aromatic taste. lu the intestines
and to some extent in the stomach orphol is split U|.>
into its components, bismuth oxide and betanaplitol, and
so acts as an intestinal sedative and antiseptic in diar-
rluea, dysentery, and intestinal putrefaction. Tlie dose
is 0.5 to 1 gm. (gr. viij. to xv.), usually given iu cap-
sule. Chaumier gave 5 gm. (gr. Ixxv.) a day to young
children without ill effects. In sucli large doses proba-
bly most of the drug passes through unchanged. Or-
pliol is also applied externally as an antiseptic dusting
and drying powder for impetigo, herpes, etc., and lias
been used locally in gonorrhoea and other mucous-mem-
brane inflamniations. W. A. Bastedo.
NAPHTOL CARBONATE, (C,„H,0)=CO. is a di-naph-
thyl ester of carbonic acid prepared b_y acting on beta-
naplitol sodium with phosgene gas. It occurs as shining
colorless scales which are insoluble in water. Recom-
mended as a nou-iriitating intestinal antiseptic iu dose of
0.13 to 1 gm. (gr. ij. to xv.). TF. -i. Bastcdo.
NARCEINE. See Opium.
NARCOTINE (dJI-^sNO:).— Nareotiue is, next to
morphine, the most abundant alkaloid of opium, varyijig
widely iu percentage, both in dillerent varieties and in
different lots of the same variety. The amount has been
reported as low as one per cent, and as high as ten per
cent. It occurs in colorless, shining, acicular or pris-
matic crystals, melting at 176' C. (349' F.), almost insol-
uble in water, solulile in 100 parts of alcohol. 3.5 parts of
ether, 2.7 parts of chloroform. 22 parts of benzene, and
rather freely in hot acetic acid, by which it is usually
extracted. It is only faintly basic and its salts are not
crystalline. It is not bitter, but its salts are .so, and are
at the same time acid. Sulphuric acid turns it, after a
time, to a yellow, changing to orange and red ; the same,
mixed with nitric acid, turns it blood-red. It is decom-
posable into niecouin and cotariiiiie (C,5Hi3N0:,\ tlie lat-
ter far more strongly basic than narcotine itself. Vari-
ous other substances are obtained from it by different
methods of treatment, but they are not of importance
except froin a chemical standpoint.
Crawford and Dohnie (Proc. Anier. Phar. Assn., 1902)
report experiments on warm-blooded animals, showing
that it produces a fall in blood pressure and slowing of
the heart, accelerated but weakened respiration, dimin-
ished .saliva by smalt doses, increased by large doses, an
anodyne effect upon the intestine, prompt and marked
diminution of the urine, and a diminished size of the kid-
ney. Partial elimination through the kidneys and stom-
ach was observed, but none from the bowels, at least not
as narcotine. Similar symjitoins have been observed iu
man, together with profuse diaphoresis. The alkaloid,
if pure, is iu no sense a narcotic, for which reason the
name "auarcotine " has been pro]iosed for it, though it
dfies not seem wise to introiluce this clement of confusion.
Therapeutically, narcotine is an antiperiodic. recog-
nized as of considerable value in five-grain doses. For-
tunately, since it is used in such large doses, its weakly
basic character renders it easily freetl from the associated
active alkaloids, a character to which careful attention
should of cour.se be given. It is a valuable stomachic
and digestive tonic in one- or two-grain doses three times
daily.
Narcotine lias been considerably employed as a secret
remedy for the cure of the alcohol and other narcotic
habits. Ebei't reports many such cases cured or benefited
through its u.se. and his results are confirmed b}' Schulte.
The foiTii of administration in these cases was a grain
hourly. No harm resulted from the use of a gram or
more per day, lieyond the temporary loss of the appetite
for food, followed later by an increase of appetite, and
by weakening, amounting in some cases to semi-prostra-
tion, from the profuse perspiration.
Utnry II. Rnshy.
NASAL CAVITIES: ANATOMICAL RELATIONS AND
RHINOSCOPY.— 1. Anatomy.— The no.se forms the eoni-
niencemeut of the air tract, and is composed of two large
air channels in the centre of the face. The lower jiortion
of this tract is used to convey air; the upper portion has
distributed throughout its mucous membrane the termi-
nal filaments of the olfactory nerve; while the whole
cavity is employed in voice production.
The nose is divided into the external nose and the na-
sal cavities. The nasal cavities are separated from one
another by a thin partition of bone and cartilage, calleil
the septum. Each nasal cavity is surrounded by a set of
accessory cavities, all of which communicate with the
nasal cavity. In considering the anatomy of the no.se,
we find that three divisions may readily be made: (1)
The external nose; (2) the nasal cavities; (3) the acces-
sory cavities of the nose.
1. I'lie E.i-tcrnal Kose. — The external nose forms the
pyramidal projection in the centre of the face, extending
from the brow to tlie upper lip. It is directed down-
ward and forward. It is composed of bone, cartilage, and
muscles which are covered externally with the facial epi-
dermis and internally with the nasal mucous memliraue.
The apex of the pyramid — the root of the nose, the
radix nasi — joins the forehead ; the lateral walls form by
their junction the dorsum nasi, or back of the nose, which
extends from the tip, the apex nasi, to the root of the
nose; the lateral borders slope outward to form two
wing-like leaflets, which are known as the alas nasi or
wings of the nose: the free edges of the al* na.si form
the outer borders of the two nasal orifices, known as the
anterior nares, which are separated by a median pillar,
or columna, the ponticulus nasi. The two anterior
nasal orifices open downward and comniunicate with
the vestibule of the nose, which is comiiosed of that
portion of the nose which is contained within the car-
tilaginous framework and extends from the anterior
nasal orifice to the commencement of the osseous frame-
work.
The walls of the nose proper are composed of the
nasal bones and nasal spine of the frontal bone, the
nasal processes of the superior maxilla, the premaxil-
laiy portion of the upper maxilla, the pars ineisiva, and
the lateral cartilages of the nose. The nasal bone ar-
ticulates above with the frontal bone; its outer border
articulates with the nasal process of the maxilla; while
along their inner border, by their union, the nasal bones
form a crest for articulation with the nasal spine of the
frontal bone, the perpendicular plate of the ethmoid and
the triangular cartilage of the nose. The outer surface
of this bone is .smooth ; its inner surface presents a longi-
tudinal groove for the nasal nerve. Lying external to
the nasal bone is the nasal process of the maxilla, which
articulates along its anterior border with the nasal bone,
above with the frontal, and posteriorly- with the lachry-
mal bone. Its external surface is smooth, while its
inner surface presents two crests for the attachment of
the middle and inferior turbinate bones. The pars pr;ie-
inaxillaris of the superior maxilla unites with its fellow
below to form the lower rounded portion of the aiiertura
pyriformis, the pear-shaped opening of the osseous nasal
cavity. To the apertura pj'riformis is attached the lateral
cartilage of the nose, thus completing the outer portion
of the external nose. The cartilages of the no.se are the
septal cartilage; the triangular, or superior lateral car-
tilages; the alar, or inferior lateral, cartilages; the acces-
sory, or sesamoid, cartilages; and lla; accessory quad-
rale cartilages.
The cartilage of the septum is tlie most anterior struc-
ture of the septum, and is irregularly (|uadrilateral in form.
Its anterior inferior border is unattached, and lies above
and behind the inner plates of the two inferior lateral
cartilages, extending to the anterior nasal spine, which
it embraces. Its anterior superior border is attached to
the crest on the under stirface of the nasal lione, .•mil be-
low the nasal bones the sides of its border are continuous
with the superior lateral cartilages. Its jiosterior su-
perior border is in contact with the perpendicular plate
lOi
Nasal Cavil ioM.
Nasal ravillos.
REFERENCE HANDBOOK OF THE JUDICAL SCIENCES.
of the ethmoid, and the posterior inferior border is re-
ceived within a groove formed in the anterior nasal spine
of the superior maxilla and the vomer for its reception.
Fig. 3482.— Dissection of the External N(ise. Di'iimnstratiiiK the Tar-
tilages and Bones of this Partuf the Nom* iuui ilM'ir lielaiiuiis t" i me
Another, a. Nasal bone; ?j. sesanini.l eartilaires ; c, lll'mns tissue
of ala of nose; d. Inferior lateral eartilatre; c. eartilane "f nasal
septtnn ; A accessory quadrate cartilages; i/, superior latenil
cartilajre.
The cartilaginous septnm is thiuuest in the vestibule of
the nose, and increases gradually in thickness as it ap- |
proaches its attacliment to vomer anil ethmoid.
The superior lateral cartilage is liat and trian-
gular in shape, partially eontiuiious with the an-
terior bonier of the sejital cartilage, of which it
forms fiange-Iike c.xtcnsinns. It is closely attached
along its superior and posterior liorder to the nasal
bone and the nasal process of the superior ma.\il-
lary bone. Its inferior border is attached to. and
partially covered by. the inferior lateral cartilage.
The inferior lateral ctirtilage is bent shiirply around
in front of the anferior nsires so as to form an
inner and outer plate. The outer plate lies in the
plane of the superior cartilage of the nose, and
makes up a part of the outer surface of the nose,
while tlie inner platen lies in contact with the cor-
responding fellow of the oppiisile side and furms
a portion of tlie inner border of the anterior nates.
The lower lateral cartilages unite over the dorsum, but
extend only about half-way back to the maxillie. so that
the intervening siiaee in the ala' nasi not tilled with car-
tilage is made of dense librous tissue.
The accessory cartilages are tour in number in each
lateral wall of the nose. Twii nf these cartilages are
situated in the fibrous tissue which tills in the space be-
tween the [losterior border of the lower lateral cartilage
and the nasal process of the maxilla. Situated imme-
diately above these are two others which are known as
the accessory quadrate cartilages. The nose is supplied
with certain external muscles which are concerned with
the movements of the al;e nasi and with facial expression.
These muscles are the pyramidalis nasi, compressor naris,
102
levator labii superioris aheque nasi and depressor als
nasi. The vessels which sujiply the external nose are
branches of tlie facial and ophthalmic arteries. The
veins empty into the angular vein. The lyiuphatics
empty into" the submaxillary lymphatic glands. The
muscles of the nose are supplied by branches of the
facial, and the general sensation by branches of the first
and second divisions of the fifth nerve.
Tlie Ait.tiil Oii'itiex. — The nasal osseous cavities are
two large quadrangular-shaped cavities in the centre of
the face, and are separated from one another by the sep-
tum nariuni, which extends from the vestibule anteriorly
to the choaniB or jiosterior nasal orifices.
Each nasal cavity has a floor which is almost horizon-
tal ; a roof which is horizontal in its middle portion, but
inclined downward and forward in its anterior portion,
and downward and backward in its posterior portion ; an
inner wall which is vertically directed; and an outward
wall which is directed downward and slightly outward.
The inner wall, or septum, is partly cartilaginous and
partly osseous. The osseous septum is formed by the
crest" at the juncture of the nasal bones, the nasal spine
of the frontal bone, the perpendicular plate of the eth-
moid, the vomer, the crest of the sphenoid bone, and
the crest situated at the juncture of the two palatal
processes of the superior maxilliB and the two horizontal
plates of the palate bones.
The vomer is irregularly (luadrilateral in form, its lower
border articulating" with' the nasal crest of the superior
maxilUe and the palate bones. Its superior border is at-
tached to the rostrum of the sphenoid bone by two wing-
like expansions, or ala. The posterior border is concave
and lies free between the posterior nasal orifices. Its
anterior border is tlie longest, the upper portion of
which articulates with the vertical plate of the ethmoid,
while to the lower portion is attached the cartilage of
the septum. Running downward and forward nearly at
its middle is a shallow groove for the naso-palatine
nerve. The vertical plate of the ethmoid is pentagonal,
and its short anterior border articulates with the nasal
spine of the frontal bone and the crest of the nasal
Fir. IMS). —Vertical Antero-Posterlor Section of the Nasal Cavity,
Demonstrating the i Inter Walt of this Cavity, a. Frontal sinus; h,
superior nirlilnate ; r. middle turbinate ; r(, middle meatus ; f , in-
ferior turbinate: f. spheno-ethmoidal recess; o, right sphenoid
sinus ; h, left sphenoid sinus ; i. superior meatus ; j, inferior meatus.
bones. Its superior border is continuous with the cribri-
form plate of the ethmoid, and its posterior border with
REFERENCE HANDIJooK OF THE MEDICAL SCIENCES.
>asal (avilicH.
>'aMal <'a\ill(>H.
the crest of the siihenoid. Tlie anterior inferior herder
gives attachment to tlie ("irtiliii,'c of the septum, and its
posterior interior border articulates witli the vomer.
Fig. 34S4. ViTliiiil Transvpr-sp Section throiiirh tin- Nasal Fosss.
S(iliii'wli;it IteliiTHi ttiiMr < iMiIrt'. iZurktTkanill.) .1 . Koof of nasal
caviiy: /f. tluui nf nasal caviiy : f, (", aivi'nhir processes: X>, exter-
nal wail of nasal cavity ; (I, *f. (I, three meatuses ; /*, /», tniddle tur-
binated bodies ; c, olfactory slit : d, respiratory region.
The septum is covered with mucous membrane, wliich is
continuous with that which Unes tlie whole of tlie nasal
chambers.
Tlie roof of the nasal cavity is divided into naso-
fi'ontal, ethmoidal, and sphenoidal parts. The na.so-
frontal portion is directed downward and backward, and
is composed of that portion of the roof which is formed
by the nasal bone. The ethmoidal portion is hoiizoii-
tally directed, and is formed by the cribriform plate of
the ethmoid. It is lined with two idws of foramina for
the passages of the median and lateral branehis of the
olfactoi'y nerve. The most anterior foramina give pas-
sage to the nasal nerve. The sphenoidal porti<in looks
downwai'd and forwaid, and is formed by the body of
the sphenoid bone.
The opening of the sphenoidal sinus is to be seen on
the antei-ior vertical surface of the body of the sphe-
noid. The floor of the nose is flattened fiom befoi-e back-
ward, concave fidin side to side, and wider in the miildle
than at either e.xtiemitj-. It has a slight inclination
downward and backward. It is formed in fi'out by the
pars incisivaof the supeiior maxilla and its palatine proc-
ess, and behind by the palatine iirocess (liorizontal
plate) of the palate bone. It presents, ,iust behind the
nasal spine, the upper orifice of the anterior palatine
canal. In the region of the antciii.r jialatine canal, the
mucous membi'ane presents a small diveilieulum, which
is the rudimentaiy Jaeolisou's organ. This oi'gan is moie
highly developed in some of the lower animals, aiid is an
organ of the sense of smell.
Tlie outer wall is the most complicated and interesting
poi'tiou of the nasal cavity. It is formed, in fi-oiit, by
the nasal process of the supei'ior maxilla and the lachry-
mal bone; in the middle, through the lateial mass of the
ethmoid, by the body of the superior maxilla and the in
fcrior turliinaled bone; and iiostcriorly by the pi'rpen
dicular i>lale of the palate bone and the j.terygoiil pmr
ess of the sphenoid. The lateral mass of the ethmoid
bone, which forms a poition of the outer wall of the
nasal cavity, and contains the ethmoid cells, reaches
from the roof of the nasal chamber, where it articulates
with the frontal bone, to tbi' level of the floor of the
orbit, wheie it articulates with the orbital portion of the
superior maxilla and the palate bone. Anterioiiy, it
articulates witli the lachi'vmal boiu' and tlie nasal proc-
ess of the superior maxilla: posteriorly, with the rnugh
surface on the side of the body of tlie sphenoid bone.
These various articulating surfaces serve to complete
the ethmoid cells, and the participating bonesfreqiientlv
contain accessory cells. From the anterior end of the
medial jilateof the lateral mass proceeds a curved prcicoss
known as the processus uncinatus. which serves to cdiu-
])lete the orilice of the maxillary sinus and forms the
lower boundary of the hiatus .semilunaris. This proc-
cess is a narrow bony jilate, which curves downward
and liackward almost parallel witli the lower border of
the middle turbinate bone. It articulates with the supe-
riiir maxillary and inferior turbinate bone, and, through
this union, aids iu closing the orifice of llie maxillary
sinus.
Encroaching upon the lumen of the nasal cavity are
three scroll like sliells of bcnie which arc known as the
turbinate bones. These bones aie scroll-like in form,
each larger than the other from above downward; their
convex surfaces look upward and inward, with a more
or less irregular free border. Tlie superior and middle
turbinate bones are projections from the lateral mass of
the ethmoid : the inferior is an independent bone.
The superior turbinate bone forms a distinct ridge
jiosteriorly, but merges into the middle turbinate ante-
riorly. The middle turbinate is a broad, thin, bony
plate, scroll-like in outline, curling down upon itself,
and has at its anterior inferior surface a slight projection
which is known as the agger nasi. The inferior turbi-
nate articulates anteriorly with the inferior turbinate crest
of the su]ierior maxilla, behind this by the lachrymal
process with the lachiymal bone, and posteriorly it ar-
ticulates with the ethmoid and the lower crest of ihe pal-
ate bone. Tlirough its maxillary ]irocess it aids in clos-
ing the lower jiart of the opening to the antrum. The
body of the inferior turbinate curls downward and out-
ward. These three bones, thi'ough their situation and
outline, necessarily divide the nasal chambers into three
anterior-posterior incomplete canals, which are designat-
ed as the three meatuses of the nasal cavity. The infe-
rior meatus lies between the under surface of the inferior
turbinate and the floor of the nose. Slightly in front of
Ficf. 3485.— Out<»r Wall of the Uiglit Nasal Cavity. Tbe superior and
middle turbinates have been removed, thus deniorisiratiiitr ihe
hiatus semilunaris, the bulla etlimoidalis (c), the frontal i<7), tbe
ethmoidal ih) and the sphenoidal ili) sinuses, the iiitnudtbulum
(c). and the openings of the frontal and anterior etiuiioidal cells
into the nasal cavity (indicated by white arrow heads). The pn>-
cessus uncinatus is shown at((, and thespheno-ethmoldal recess at/.
the centre of that portion which is covei'cd by the iiifcrinr
turbinate bone is the inferior or nasal orifice of the lacliry
mal canal.
The middle meatus presents many jioints "f great in-
terest to the rhinologist. This meatus lies between the
concave under stirtace of the middle turbinate bone and
lu3
>'as;«l Cn vines.
Na!iial Cavities.
REFERENCE HANDBOOK OF Till: .MEDICAL SCIENCEb.
the convex upper surface of the inferior turbinate bone;
and it extends anteriorly from the vesiil)ule of the nose,
into which it opens widVly. through the conuuuniciition
which is known as tlie alrium of the middle meatus, In
the anterior fold of t lie Eustachian tube posteriorly. It
is truncated in fnrin «ilh its widest portion direcled
anteriorly. The outer wall of tlu^ middle meatus jtre-
seuts a deep groove, or semilunar sulcus, kuown as the
liiatus .srmiluuaris. This groove extends from the lower
border of the infundibulum, at the anterior extremity of
the middle turbinate, to just below its centre. Tlie aver-
age length of the hiatus is from 15 to 30 mm. The up-
per boundary of the hiatus semilunaris is created by a
bulbous expansion of ethmoid cells, which is designated
as the bidla ethmoidalis. This groove is crescentic in
shape, and varies from a shallow furrow to almost a com-
plete canal: its direction is from above downward and
backw-ard, with its concavity directed upward and back-
ward. At its upper extrenuty we have the orifice of
the frontal sinvis, wdiile at its posterior shallow^ portion
is the orifice of the maxillary antrum; slightly irregular
in their locations, but usually quite near the orilice of
the frontal sinus, we lind the openings of the anterior
ethmoidal cells. Behind the o|iening to the antrum we
occasionally find a seccuid orifice eommimicating with
the same cavity, known as the ostium maxillare acces-
sorium. The .superior meatus is clo.sed in front and opens
downward and backward. This meatus presents the ori-
fices of the posterior ethmoidal cells and the sphenoiilal
sinus. In reality, tlie orifice of the sphenoidal simis is
near the roof of the nasal fossa, on a level with the suiie-
rior turbinate bone in the recessus spheuo-etlimoidalis,
which is the recess formed by the junction of the ethmoid
with the body of the sphencjiil.
Pi. Tlie Accessor!/ Ciin'tics of the ?iose. — Surrounding
the nasal chamber are a set of pneumatic cavities which
through their location, as well as by their direct com-
munication wilfi the nasal cavity, have an important
anatomical as well as iialliological relatiouship to this
organ. The sinii.'ies are called the frontal, elhmoidal.
siiheiioidal, and antral. The frontal sinus is a small
triangular cavity situated between the plates of the
frontal bmie above the inner angle of the orliit. Tlieie
arc two cavities which are separated, the oni' from tlie
otlier, by a thin septum of bone. The dividing septum
is usually placed in the mesial plane, although it occa-
sionally shows detleclions to one or the otlier side. This
cavity extends fmrn the mesial plate outv,-ard a short
distance beyond the su|ira-orbital foramina. The frontal
.sinuses are very irregular as to their size, shape, and
uniformity of relationship one with the other. The
average vertical measurement is 31.00 mm., the average
horizontal measuretnent 18miu., and the average trans-
verse measurement 25.8 nun. The shai)e is usually tri-
angular, but rarely it may be very irre.gularly jiyramidal
through its projecling upward inordinatelj' lietween the
two plates of the frontal, or outward toward the outer
an.gle of the orbit. The cavities arc tisually of uniform
size and outline, although marked variation in this ri'-
spect is found to exist. There maybe only one ca\ity
filling in the space occuiiied by two, or one largir cav-
ity projecting overtoward a s<'e<ind small cavity ; in fact,
perfectly symiiK^trieal cavities arc rare. This cavity is
rarely irregularly jilaced, and move rarely accessory cavi-
ties are found. Ins|ieetion of the inlerior of the cavity
shows rarely imperfect partitions which form recesses,
giving the interior an irregular ouilinc. It has an ante-
rior wall foinied by tlie outer plate of the frontal bone,
a posterior wall formed by the inner table of this bone,
an inner wall fornieil liy the iiiesially iilaceil se]itum,
and the lloor which is formed by the orbital plate of
the frontal bone. The fronlo-nasal opening, the ostium
frontale, lies in relalion to the septum of the sinus, and
is situated in the lowest jiarl of the lloor. This o]ii'ning
terminates in the nnddle meatus Ihrougli the naso fninlal
canal at the commencement of th(; hiatus scmilunaiis.
The ethmoidal cells fill in the space between the orbital
and lateral walls of the nasal fossa. They vary greatly
in shape and size, and are divided into an anterior and a
posterior group. These sinuses are composed of a num
ber of small cavities separated from one another by thin
partitions of bone. These small cellular cavities vary in
number from one to eight in each mass and usually
open by a common duet. Those cells which comiuuni
eate with the mid<lle meatus of the nose, below the line
of origin of the middle turbinate bone, are the anteriot:
ethmoidal cells. Tlio.se cells which communicate with
the superior meatus above the origin of the middle tur-
binate are the posterior ethmoidal cells. The space oc-
cupied by each collection of cells in the lateral mass is
not uniformly constant, nor is there any regularity in
the number of cells in each collection. The anterior
cells may extend far backward, almost to the sphenoid,
while the posterior group may extend as far forward in
'another specimen. The ])late of bone separating the
two grotips of cells is placed diagonally between the
outer and inner walls of the lateral mass, and does not
normally' present anj- communication of the one group
with the other. The ethmoid cells are bounded externally
by the OS planum, the lamina papyracea, and internally
by the two ethmo-tiiibinates. The superior wall of the
cells is completed by the depressions or fovea> on the
ethnioidal edge of tiio orhital plate of the frontal bone.
Inferiorly they are com|ileted by the ethmoidal edge of
the orbital plate of the superior maxilla. Anteriorly
they are closed in by the nasal process of the superior
maxilla and the Lachrymal bone. Posteriorly they articu-
late with the sphenoidal spongy bone.
The maxillary sinus, or antrum of Ilighmore. is a
pyram;(lal-slia|)cd cavity situated wholly within the
body of the sujierior maxilla. Its roof is a thin plate of
bone which also forms the floor of the orbital cavit}-.
The infra-orbital canal, which serves to convey the
sujierior maxillary nerve and infra-orbital vessels in
their passage to tlie face, lies in the roof of the cavity.
The floor of the sinus is formed by the alveolar border
of the superior maxilla. This wall bears an important
relation to the teelh. The converging of the facial
and nasal walls tit their angle of junction i.s frequently
so acute as lo leave a mere groove to form the floor,
which is then ciilled the sulcus alveolaris. The floor of
the aulrum is usually on a level with the floor of the
nasal cavity. Thii layer of spongy bone between the
floor of the antrum and the root of the teeth varies
greatly. Occasionally this layer is so thin tliat a mere
shell of bono separati-s tlie teeth from the antral cavity.
Ofttimes slight elevations are seen in the floor corre-
s|ionding to the fangs of the teeth. When of average
dimensions, the Uoor has in relation to it the second
bicuspid and the three molar teeth. The posterior wall
is the thin plale of bone which forms the anterior bound-
ary of the zygomatic fossa. The inner or nasal wall of
the antrum, as il, forms 1 lie outer wall of the nasal cham-
ber, is the most interesting aspect of this sinus. That
portion of the inner wall which is situated below the in-
ferior turbinati! hone is continuously os.seous, thinnest
iiumediately below the altaclunent of the turbinate bone,
and forms the outer boundary of the inferior meatus of
the nose. In tlu^ thin portion of this wall, iuimediately
below the attachment of the inferior turbiuale, is the
point of selection for ex ploratoiy puncture. That por-
tion of this wall which is situated above the inferior tur-
binate is partly osseous and partly membranous. The
aperture, the ostium maxillare, by which this cavily com-
nnmicates with the middle meatus, is situated here. As
the ostium maxillare lies just lieneath the level of the
roof of the antral cavity, it permits of only imiierfect
draina.ae. Soiuetinies an additional opening exists in the
memliranous porlion of the nasal wall, designated as the
ostium maxillare accessorium. This accessory opening
is said to exist in about ten per cent, of ca.scs. The
accessory opening cominunicates with the middle meatus
a; a jilaue lower than and posterior to that of the ostium
maxillare, and this accounts for the occasional draining
away of fluids from the antrum posteriorly into the
pharynx. The anterior or facial wall is thin ; at its upper
104
HEFERKNCK HANDBOOK OF THE MEDICAL SCIEXCKS.
>a»>!>l Ciivilirs.
Nasal (avillcs.
margin is tlic infra-orbital foramen. In front tliis sur-
face is murkt'd by the canine ridge, wliicli conesponds to
the soeliet of tlie canine tooth. The facial wall is lim-
ited e.xternall.v bj' the malar ridge. Between these two
prominent ridges, the canine and malar, is a depression,
the canine fossa. The canine fossa varies greatly in
depth. It is at this point that the external or facial
opening is made into the antral cavity. The antial
cavit_y varies also in sliajie and size, and occasionally
septa divide the cavity more or less completely bj' verti-
cal or horizontally placed lamelkf of bone. The average
dimensions are as follows: Vertical height, iJ.ocm. ; the
transverse breadth, 2.5 cm.; and the antero-posterior
depth, 3.2 cm.
The sphenoidal sinns, on account of its intimate rela-
tionship with the cranial, orbital, and nasal cavities,
forms one of the most interesting of the accessory sinu.ses.
They are two in nnmberand occupy the anterior portion
of the body of the splieuoid bone ; a vertical mesial plate
of bone forms the division wall between the two cavities.
Each cavity presents six walls; a roof, Hoor, an anterior.
a posterior, an external, and an internal wall. The roof
is formed by the root of the lesser wings of the sphenoid,
the olivary process, and the sella turcica. This wall is
in intimate contiguity with important cranial structures.
The plate of bone which forms the roof of the sinus is
extremely thin. Attbe junctiou of theexternal wall with
the roof of the sinus, the optic nerve and the ophthalmic
artery pass forward to the orbital cavity. The floor of
the sphenoidal sinus forms the posterior part of the roof
of the nasal chamber. The anterior wall is in the verti-
cal plane, although at its lower border it inclines slightly
downward and backward to ,ioiu the lloor. This wall
is extremely thin, and contains the orifice of communi-
cation with the nasal cavity. This wall ma\' be divided
into an internal portion, which presents the orifice of the
ostium sphenoidale (which opens into the spbeno-ethmoi-
dal recess), and the outer portion which articulates with
the posterior extremity of the lateral mass of the ethmoid,
and tlius coiuplctes the posterior ethmoidal cells. The
posterior wall is formed of the posterior jiortion of the
sphenoidal body. The external lateral wall of the sinus
varies in thickness, and is in important relationship to
neighboiing structures. On its cranial asjiect, it is in
relation to the groove for the internal c;irotid artery and
cavernous sinus. At its anterior aspect it forms the in-
ternal boundary of the sphenoidal fisstire and the inner
wall of the oriiit. The internal wall, or septum, is a
thin vertical plate of bone which is tisually situated in
the mesial plane, separates completely one cavity from
the other, and rarely is defective, 'i'he septum may be
irregularly placed, or wanting, thus giving rise to great
irregnlarity in the shape and size of the sphenoidal cavi-
ties. These vary in size, shape, and relation to each
other. Occasionally accessory cavities are found in the
wings of the splienoid. The average dimensions are as
follows; Vertical height. 20 mm. ; antero-poslerior depth,
SI mm. ; transverse breadth, 18 mm. All of these sinuses
are lined with a mnco-periosteal covering, which is con-
tinuous with the mucous membrane of tjie nasal cavity.
The surface of the mticosa is lined with columnar ciliated
epithelium.
The Jlucotis Jlemlirane of the Xose. — The mucous
membrane lining the nasal cavities is continuous with
that of the pharynx, and extends into the pharyngeal
oritice of the Etistachian tube and the acces.sory sinus.
Anteriorly the integmuent of llje face supplied with
hair and sebaceous glands enters the; nostrils and extends
to tlie inner extremity of the alar cartilage. At the
.iunctionof the superior lateral cartilage and the alar car-
tilage, the limen nasi, there is a nanow zone where the
integument presents tlie characteristics of mucous mem-
brane, and is lined with paVemeut epithelituu and sup-
plied with muciparous glands. From this point the
transition is rapid into the charaGteristic nuicosa of the
nasal chamber. The anterior portion of the inferior tur-
binate, as well as the o|)posite portion of the septal carti-
lage, may have a mucosa lined with pavement epithe-
lium, or with the columnar ciliated variety. The portion
of then:isal tract, known as tlu! olfactor}'" region, is lined
with columnar non-ciliated epithelium. This area (-x-
tends from 1h(! rotd' as low down as the middle tuil)inate
and the iipjier third of the septum. The remaining
portion of the nasal cavities, the respiratory tract, is
supplied with a columnar ciliated epitheliinn. These
cells are long and spindle-shaped, and inteispersed nu-
merously among tl)ese cells are the so-called golilet or
chalice cells. The thickness of the epithelial layer is
from 80 to 70//. The cilia wave toward the post-nasal
orifices. The cilia are slated to move in a thin layer of
fluid. The nasal mucous membrane is inseparable from
the perichondrium, or periosteum. The mucous mem-
brane is very thin in the accessory siiuises. very thick
over the turbiuals, somewhat thinner over the septum,
and Very thin again over the tioor and the under sur-
face of the turbinated bodies.
The muciparous glands are of the tubular and racemose
varietj', and are present in great numbers. These glands
do not differ in any essential particulars from similar
glands located elsewhere in the mucous membrane, being
most abundant at the nu'ddle and posterior portions of
the nasal cavities, and of greatest size at the lower and
poslerior part of the sept um. Beneath the columnar cells
of the mucous membrane, we 0nd a homogeneous base-
ment membrane, and l.ielow this there is "a connective-
tissue layer, which is continuous with the periosteum.
The submucous connective tissue and the epithelial
elements contain evidences of l\'mphoid tissue in the
presence of leucoc.vtes, l_ymphoid collections, and occa-
sional l.ympli follicles.
In the olfactory region, the mucous membrane lias
ijuite a ditTerent histological structure from that in the
respiiatory tract. Here the mucous meiubrane is very
thin, and not so vascular. The eiiithelium is of the
colunutar type, but is devoid of cilia, having a branch-
ing base and a large nucleus. Lyin.g among them
are the olfactory cells of 8chultze, wiiicli are connected
directly with the non-iuednllated filaments of the olfac-
tory nerve. Beneath the epithelial covering, and open-
ing iqion its surface, are mmierons branched tubular
glands, which secrete a serous fluid. These glands are
known as Bowman's.
The gross appearance of the colorization of the mucous
membrane in tlie living subject varies in the different
portions of the nasal chambers. In the upper, or olfac-
tory, region the membrane is of a yellowLshpink in color;
in the respiratory tract it is a light pink; at the posterior
ends of the turbinates it is almost wliitc; while in the
accessory cavities it is of a pale pink.
A most interesling feature of the soft structures of the
na.sal chambers is the arrangement of the submucous tis-
sue over the middle and inferior turbinates and the lower
part of the septum. This important feature is the ag-
gregation of venous sinuses and their large size, form-
ing jjlexuses of blood-vessels over the turbinate bones.
These are designated as the turbinate bodies. This
term^ the turbinate body, is applied to the bone and the
investing soft tissue. The mucous membrane over the
turliinates is divided into two layers, tl.e adenoi<l layer
with iis epithelial covering, anil a deep layer forming
the periosteum of the turbinate bones. Between these
two layers we have a stroma which contains lymph struc-
ttne. AVithiu this lymph structure we have an arum-
dance of venous channels forming plexuses, which, on tic-
count of their r.ipid dilatation and contraction, under
various stimuli, have been designated as erectile tissue,
the .Sclnvellkdrpi'r of the Germans.
This |ieculiar action of the venous plexus in llu^ so-
called tiu'liinal tissue is not so nuicli due to the arrange-
ment of the veins and their relation with arterial iwigs
as to the characteristic walls jiossessed by these vessels
and the arrangement of the muscular tiiires ami elastic
tissue in the surrininding stroma. The muscular layer
of these walls is very thick, .greater than the walls of the
corresponding arteries, and the walls are known to be
thrown into irregular folds. The arrangement of the
105
^asal I'ai'ities*
KEFERE^CE HANDBOOK OP THE MEDICAL SCIENCES.
muscular fibres is irregular, altliousjli the rircular fibres
liredoniinate. This arrangement <if the vessel walls, as
well as tlieeliara<'ter nf surrounding strcnna. a<lapts these
walls lor the rapid emptying and Mllini;' of the venous
plexuses. The venous ple.xuses are more pronoimced
over the inferior turlvinate, especially as to its anterior
and posterior e.xtremities; over the middle turbinate, es-
])ecially along the h.iwer border and posterior extremity ;
and on the septum, in a line with the middle tiu'binate.
corresponding with the anterior e.xtremity of this turbi-
nate— tlie tulierculuni septi.
The vas<-ular su]iply to the na.sal chambers is olitained
from the anterior and ]>osterior ethmoidal arteries,
branches of the ophthahnie; from the splieno-ni;i.xillary
and the alveolar arteries, branches of the inlerual ma.xii-
lary artery; and from the artery of the septum, wliicli is
derived from the facial artery. The spheno-palatinc
artery enters the nasal cliambers Ihrough the splieno-
palatine foramen witli the naso-palatine nerve. Its in-
ternal branch, the naso-palatine. aceomiianies the nerves
of the same name, passing downwani and forward upon
the .septum (which it supplies) toward the anterior pala-
tine foramen.
The external branches supply the outer wall of the
nose, the nasal fossa?, the ethmoid cells, the frontal
.sinus, and the antrum of Highmore. Tlie antral and pos-
t<-rior ethmoid sup]ily the roof, upper jiortion of the sep-
tiun. outer wall of the nasal fossa, the ethmoidal cells,
and the frontal sinuses. The alveolar liranch of the in-
ternal nia.xillary supplies the lining membrane of the
antnun. Tlie artery of the septum is a branch of the
superior conjnarT, a liranch of the facial. The .septal
artery supplies the columnar and the loAver part of the
septum.
The veins of the nasal cavity form idc-xuses beneath
the mucous membrane, and these in turn are drained by
various veins. The veins which iierform this finiction
are the veins Avhich ai'company the spheno palatine ar-
tery antl empty into the pterygoid ple.xus, those which
accompany the ethmoidal artery and empty into the oph-
thalmic vein, and those which empty into the facial vein ;
and still other veins convey the return blood through the
foramen ca'cum and the cribriform |)late to the superior
longitudinal sinns and the intracranial veins.
The lynipliatic vessels of the nasal cavity emi>ty into
the ]>ost-pharyngeal. the internal maxillary, the parotid,
and the upperdeep cervical lymphatic glands. Thiougli
the cribriloiin plate of the etlunoid, the nasiil lytuphatic
ves.sels eomnuuncate with the intracranial lymphatics
and the subdural s|iace.
The nerve distributions for the nasal cavity consist
partly of nerves of olfaction and partly of nerves of
general sensation. The olfactory nerve, the nerve of
the special sense of smell, arises by three roofs: an ex-
ternal root, conmieueing in the deep sid)stance of the
middle lobe of the cerebnuu; a middle root, froiu the ca-
runcula annularis; and an internal root, from the iimer
and back part of the anterior lobe of tlie cerebrum.
The three roots unite and run forward as a fiat band
on the under surface of the brain until it reaches the
cribriform plate of the ethmoid, where it expands into
what is known as the olfactory bulb. From the under
surface of the olfactory bulb are given oil' from fifteen
to eighteen filaments, which, piercing the foramina of
the cribriform plate, are further subdivided and dis-
tributed to the nasal mucous membrane. The_y can be
divided into three grou])s: an inner group which spreads
out over the upper third of the septum, an outer group
sup]dying the superior turbinate and the upper surface
of the middle turbinate, and a middle group which is
distriljuted to the roof of the nasal cavity.
General sensation is supplied to the nasal mucosa
through the nasal branches of the opiithalmic division
<if the trigeminus. This nerve enters the nasal cavity
through a slit beside the crista galli, and then divides
into two branches. Tlie internal of these two branches
supplies the mucous meml)rane of the anterior jiart of
the septum; while the other, the external, descends in a
groove on the inner surface of the nasal bone where, at
the junction of the nasal bone with the lower lateral
cartilage, it pa.sses out of the na.sal cavity. This branch,
in its passage through the na.sal cavity, supplies tlie
mucous membrane of the outer wall as low down as the
inferior turbinate body. Branches of the anteiior dental
nerve are distributed to the mucous membrane of the
inferior meatus and the inferior turbinate body. Branches
from Meckel's ganglion gain access to the nasal cavity
ihrough the sphenopalatine foramen, and. after further
subdivision, supply tlie mucous membrane covering
the superior ami middle turbinate liodies. the ethmoidal
cells, and the iipjier and posterior part of the septum.
The naso palatine, in its jiassage forward across the roof,
distributes filaments in its course, and descends down-
ward and forward along a groove in the septum to the
anterior palatine foramen, where it joins the anterior
jialatine nerve The Vidian nerve supplies the upjier
and posterior part of the sejitum and the superior turbi-
nate Branches of the sympiathetic arc also distributed to
the nasal mucous membrane, being derived princip.;illy
from the sphenopalatine ganglion of the sympathetic.
II. Physiology. — The phj-siological function of ths
nose is of a threefold character; (1) In relation to res-
piration; (2) in connection with olfaction; and (3) ic
]ihonation. The respiratory function of the nose is by
far the most important pliysiological dutj' that this
organ performs. It is during the ]>as.sage'of inspired
air tlirough the nasal chamliers tliat it is warmed, satu-
rated with moisture, and freed from coarse material
therein floating. According to the experiments of Asch-
enbrandt, which have been confirmed by others, a column
of air, in its passage tlirotigh the nasal chambers, on
reaching the pbaryn.x, has had its temperature raised to
86" F., and its degree of humidity raised to the point of
almost complete saturation.
This function takes jilace whatever may be the degree
of temperature or humidity of the external atmosphere,
and is .so com]ilete in its action as to functionate perfectly
during sudden and very marked changes in both of the
enumerated conditions. This function is performed
through the exquisite working of the so-called turbiual
tissue. AVhcn we consider the constant and excessive
changes in its functional activities that are persistently
taking place, one cannot but marvel at the wonderful
nature of this mechanism.
The second important phj'siological function of the
nose is that of olfaction. The sense of smell is depend-
ent upon the impinging of the odorous particles upon
the terminal filaments of the nerve ends in the olfactory
apjiaratus. In order for various substances contained
in the atmosphere to be appreciated as having an odor,
it is necessary that the air should reach the olfactory
region and that the peii]ilieral apjiaralus sliould be nor-
mal. According to Paulsen, the insjiired air passes first
directly upward under the dorsum of the nose, and then
follows the roof, the greater portion of the column pass-
ing through the superior and middle meatus and then
descending downward to the post -nasal orifice. Odorous
piarticles reach the no.se in various forms. Various theo-
ries have been offered to explain the mechanism of olfac
tion, the most ini|.)ortant of which are the mechanical,
the vibratory, and the chemical. (For further informa-
tion in regard to the sense of smell, consult the article
on Olfartoiij Xerre. )
The third iihysiological function of the nose is the
part which it plays in connection with phonation. The
nas;il cavities, in connection with the pharynx and the
buccal cavity, constitute that portion of the" vocal appa-
ratus by which quality and character are given to the
voice. The importance of the nasal organ "in that office
is well demonstrated by the alteration of the character
of the voice when from anj' cause one or both nasal cavi-
ties are obstructed.
III. Riiixoscopv. — In order to obtain a successful in-
siM'Ction of the nasal cavities and neighboring parts, it
is necessiiry to have the best illumination that U. is possi-
ble to obtain, means for projecting this light, and aids
106
REFERENCE IIAXDBOOK OP THE .MEDICAL SCIENCES.
Nasal <'a%'f(les.
Nasal Cavltlps.
tlirough which tliis light can gain ingress into tlic ivnidtc
parts to be examined.
Previous to tlie inspection of the interior of the na.sal
■cavity, it is always well to make a thorongh examina-
lion of tiie external nose. The external coutiguration of
the nose, the aspect
which it presents at
the root, the cvi-
' dences of deviation,
the presence or ab-
sence of marked
movement of the
alic nasi, the pres-
/
(
Fig. 3486.— Posterior Rhinoscopy Mirror in Position Showing Image
ReHHcli-d ThiTfin.
«uce or absence of sound in nasal breathing, the rela-
tion of theaUe to the septum, and the outlines of the
' iinterior nares should all lie thoroughly considered before
the interior of the no.se is inspected. The appearance
of the cutaneous covering of the external no.se, the
presence of excoriation on 'the upper lip, the odor of the
breath, and the character of the voice should all be
thought of in this preliminary examination.
In order that the examination may be successful, it is
necessary to have, first, a good source of light; second,
a concave reflecting mirror for projecting this light;
third, variously devised instruments called speculums
by which the vestibule of the nose is expanded and a
greater volume of light admitted to the interior; and
small plane mirrors for diverting the reflected light and
receiving the image which is thus created.
The Light. On account of the exigencies of circum-
stances, the use of the best light obtainable, sunlight, is
not possible. The light which is sought is one as nearly
white as po.ssible. The three sources of light which are
most frequently used are gaslight, electric liglit, and
lamplight. Any .source of light of .sufficient tutensity
anil penetrating power can be used when circumstances
demand it, and one should adapt him.self to these vary-
ing conditions. In oltice work the source of light can
be controlled, and one shoidd select that which gives
the best ilhimination with the least inconvenience. For
average general utility, gas fed through an Argand
burner serves the best jmrpose. To increase its efHciency
use may be made of the Welsbach manlle, which gives
a whiter light. AVith a moderate degree of care the
mantles last for many months. The light thus obtained
may be ti.xed or movable. It is better to have the
burner attached to a movable bracket which can be
placed at various angles and raised or lowered at jileas-
ure. The apjiaratus is completed by surnumding tlie
light with a cylin<lrical japanned tin or asbestos chimney,
which has a circidar opening of two and a lialf inches
in diameter through its lateral wall at the middle. This
contrivance ,shulsoffall the rays of the light excepting
those coming through the lateral aiierture, A further
part of the ei|ui]iment is the device known as the iVfac-
kenzie condenser. This latter device is not essential,
but renders the examination easier for the examiner.
The electric light may be used in two metlaids,
directly and indirectly. The direct method is the use of
the electric lieadligbt: the indirect method is the use
of the electric light by reflection, as we use gaslight.
The objection to the electric headlight is its weight and
its want of penetration. With the use of the ground-
glass globes we liave a very good .soui-ce of indii-eet
illumination in electricity. The sludi-nt's, or Hochesier
lamp, forms the best form of oil light. This liglit can
be made whiter by the addition of a small piece of cam-
phor to the oil, as suggested by fSajous.
The instrument by which the light is reflected inio the
various cavities to be examined is known as the bead mir-
ror. This min-or is a round, concave mirror, from three
to four and a half inches in diameter, with a focal dis-
tance of from eight to fifteen inches. It should lie suji-
plied with a central orifice. The central oritice is for the
purjiose of more exact observation, as, through its use.
the angles of incidence and reflection are made to coin,
cide, and, therefore, tlie jiiclure is rendered more perfect.
This mirror is more serviceable if it is worn suspended
through a ball-and-socket joint from a head-band which
encircles the forehead. It may a 1. so be suspended from
a rod which is attached to the'lamp which furnishes the
source of light. Steadiness and immobility, when it is
fixed at the projier angle, are the most desirable features
in the i-efleeting mirror. One having a diameter of three
and a half inches has, in my hands, proved the most .ser-
viceable. For the purpose of permitting as much light
to enter the nasal ea\ity as possible, it is necessary gently
to dilate the vestilmle through the means of a specului'n
wliich is inlroduced into the anterior nares. Tlio.se specu-
lums which are constructed on the bivalve system are
the most serviceable. Their numbers are legion. I ]ire
fer the Scbnitzler's. Hartmann's, Ingals',"liotirs, and
others are of this style. A numbcr'of fine, wire-like
speculums, such as the Jarvis, the Boswortb, the Good-
Willie, and the Ives, are made on the bivalve prinei]ile.
Others are made to be self-retaining. The Schnitzler
instrument, as offered for sale in the shops, is too cum-
bersome. I have it in a light frame, which not only
makes a neater but a more useful instrument. The indi-
vidual preference in sjieculums is also a question of
adaptability and use. In making exiimiuation of the
post-nasal space and the nasal cavities from behind, what
is called posterior rhinoscopy, it is necessary to ha\e.
in addition to a good light and the head reflector, small
plane mirrors constructed like those used in examining
the larynx, and a tongue depressor. These small plane
mirrors are fixed at an angle of lOo' to the shaft, and
vary in size from three-eighths to three-quarters of
an inch in diameter. The largest mirror which it is
possible to use in the individual casi- should always In-
employed. This mirror is used to reflect the light behind
the curtain of the palate.
Usually it is necessary to control the tongue, as only a
few patients are able to' hold it relaxed in the tloorof the
mouth during an examination; therefore it becomes nec-
essary to depress it through the aid of a tongue depressoi-.
Numerous forms of depressors are on the market, but
one that especially recommends itself, on account of its
simplicity and of' the ease with wliieli it may be kept
aseptic, is the one invented by Dr. D. Braden Kyle (Fig.
3488).
The nasal probe is indispensable to a thorough exami-
nation and understanding of diseased conditions in the
nasal cavities.
Examination of the nasal <-liamlieis through the ante-
rior nares is called anterior rhinoscopy, while examina-
lOT
Na<<>al <'avilic'6.
Kasal Cavtlleiii.
KEFEHEXfE HANDBOOK OF THE JIEDICAL SCIEXCES.
lidii of the upper pharynx and nasal chambers from be-
hind is known as posterior rhinoscopy.
In tliese examinations of the nasal cavities the rela-
tionship of the patient and physician with rei^'ard to the
source of light is absolutely the same as it is in laryn-
goscopic examinations. The patient sits in a simple
straight-back chair, without bead sup|>ort. The ph_v-
sleian sits
<lin-etly in
front of the
patient, or,
w hat i s
preferable,
directly beside and on the left-hand
side of the patient. The source of
light should l)e to the right of the
patient, just to the side of and on a
level with tlie upjicr border of the
right ear. The patient should sit in
an easy, erect, comfortable position,
when the exannner reflects the light
iu a circle just upon the area to be ex-
amined. Either may tljen move, with-
in a certain latitude, from tliis fixed
position; nevertheless, it will be noted
that when they return to the examin-
ing position the light will fall directly
on the point upon which it originally
fell. Tlie method of exanunation. as
well as the character of furniture u.sed
tor patient and doctor, is a (piestion of
mdividual preference and perfected
method on the jiart of tlie operator.
In anterior rhinoscopy the operator
first makes a mental notation of the
appearance and general contigiu'ation
of the external nose. The light is then
thrown upon the uose. the bead of the
patient is slightly tilted backwarti, and
the general appearance, the patency,
and the outline of the anterior nares are
noted, after which the tip of the uose is slightly tilted
upward and the vestibule is thoroughly inspected. Lit-
tle children fear in.strumenls. and, as their hairs are un-
developed, we can often make a thorough inspection
without the use of speeulnms. Special care should be
made to note fissures, abrasions, or pimples on the inner
surface of th'i nares. which would make the introduction
of the speculum painful.
We are now prepared to introduce the speculum.
This instrunu'nt should be gently insimiated into the ante-
rior nares in a closed state. After the s)>eculum is placed
slightly within the vestiliulc, it is moderately dilated
until slight resistance is felt. So pain should ever be
given. With tlie instrument in jiosition, the two cnira
being controlled by the jiressure of the thunili and index
finger of the left baud and with the little linger of the
same hand hooked under the lower jaw. the patient is
practically under control of the examiner. Slight jiress-
ure is usually all Ihalissuflicienl to make the jialient move
iu a required direction. Witii the patient's bead slightly
tilted foi'wai-d, the lirst object that attracts attention is
the prominent rounded red mass on the outer wall pro-
jecting luarly to the lloor of tlie ui«i\ and which we rec-
ognize as the anterior end of the iiiterinr turbinate body.
Opposite this we recognize the cartilaginous wall of tlie
septum, and below, the (loor of tlie nose and tlie inferior
meatus. A(-conling to the amount of space between the
inferior turliinate and the seijtum. we can see to a greater
or less depth within the nasal cavity toward the pharynx.
In many cases, with a fair amount of space bi'lween
these parts, or when the turbinal tissue is contracted un-
der the use of cocaine, we can well see the ]ios1erior
pharyngeal wall. A tilling of the patient's bead slightly
backward lirings into view the middle turbinate, whicli
is paler and more translucent than the inferior, and just
opposite its anterior extremity on the sejjtal wall is seen
often an aggregation of erectal tissues, whiih is desig-
Fio. .>tss. - Kylc'.s
Tongue Depressor.
nated the tuberculum septi. The whole extent of the
visible upper surface of the inferior turbinate is seen in
this jiosition, as well as the middle meatus. It is oiilj-
when tlie middle turbinate is removed or has undergone
gn^at atrophy that the interesting features contained
within the middle meal us are brought under observation.
Tilting of the patient's bead still fartlier backward brings
into view the upper portion of the middle turbinate and
the roof of the nasal cavity. It is rather unusual to be
able to demonstrate the superior turbinate body. Occa-
sionally the oritice of the sphenoidal sinus can be made
out. The ii.se of the probe is indispensable in making this
examination, and so also is the instillation, after the pre-
liminary examination, of a very mild solution of cocaine,
— a procedure wliicli should be followed by a rc-exam-
iuation of the jiarts after the effects of the drug have
become manifest. Great care should be exercised in ex-
amining the septum; it .should be viewed from both
sides, and t he head should be held carefully in the middle
line.
Posterior rhinoscopy is the most difficult procedure in
the examination of the upper air tract, and therefore re-
quires more tact and skill in its prosecution. The position
of the patient and of the source of light, and the methods
of retlection are the same as in anterior rhinoseop}'. The
only instrumental addition is the rhinoscopic mirror and
the tongue depressor. I have never found it necessary
to make use of the so-called jialate retractors, but see no
objection to the use of such an instrument, for holding
forward the soft jialate. if the examiner .so desire. Tlie
most desirable instrument for retracting the palate is
that invented by Dr. J. A. White. Occasionally the
examination can bo made without the use of a tongue
deju'essor, but this is exceedingly rare. After depressing
the tongue, and noting the space between the soft jial-
ate and the pharyngeal wall, as well as that between the
pendent uvula and the base of the tongue, the largest .size
mirror which it is possible to use is gauged. The mirror
is first heated to a proper temperature and the tongue
carefully depressed. In introducing the tongue depres-
sor care should be exercised in so introducing it that the
tip of the tongue depressor first comes in contact with
the tongue just; posterior to its arch, which is somewhat
anterior to the circumvallate papilhi. The tongue is
then drawn downward and forward into the floor of the
mouth. Backward pressure of the tongue is always to
be avoided, as it is certain to give rise to retching and
gagging.
If the depressor is so placed as to excite distress on the
patient's part, it should lie immediately removed and
replaced. The depressor should be held between the
thumb and index finger of the left hand, while the other
fingers passunch'r the patient's chin. The mirror, which
has been properly warmed, being lightly held between
the tliumb and index finger of the right hand, is now
quickly introduced into the widely ojieii mouth along its
left wall until wv come to the dependent palatine arch.
The imjiortaut feature iu the introduction of the mirror
is so to insert it as not to come in contact with any of
the tissues. As the palatine arch is reached, the mirror is
gently insinuated by slight dejiression and rotation so as
to glide through tlie space between the left pillar and
the base of the tongue without coming in contact with
either.
After the mirror has jiassed behind the palate and has
readied tile jiliaryngeal sjiace, the operator, by slightly
rotating the handle, may bring the retlecting surface
around so as to face him, and liien he should slightly
dejiress the handle so as to carry the mirror upward
until its upper border is slightly hidden behind the soft
Jialate. The mirror now being in position, its handle is
so held toward the left angle of the ]iaticnt's mouth that
there is no interference with the thorough illumination
of the buccal cavity. Finally, the mirror is to be rotated
from right to left, deju'essed and elevated, and given
different degrees of angles while in jiosltion so as to bring
into view in rajiid succession the various surfaces and
jiarts of the ujiper pharynx and back of the nose.
108
K£n:H£.NCE IlA.NJJliotjK OF TllK MEDICAL SCIENCES.
\aNal f'avflies*
Nasal Cat Ities.
The success of the procedure depends upon the depres-
sion of tlie tougue, the careful introduction of the mirror,
jmd the ability of the putieut, not only thoroiighly to
relax the soft palate, but also to hold it immobile in this
relaxed state long enough for the operator to make a
thorough iuspectioB of the parts. The patient is an un-
certain quantity. JIauy can submit to a rhinoscopic
examination without any ditTioulty; others require care-
ful manipulation and several ellorts httve to be made
before a successful view is obtained; and, finally, there
are a few who are so constituted as to present almost in-
surmountable difficulties to the exploration. The great-
est difficulty is the retraction of the soft palate, which in
some individuals takes place immediately upon the intro-
duction of the mirror into the mouth. Careful training
in nasal breathing with the open mouth and with the
sounding of the nasal consonants en and em, will often
overcome this obstacle. Among the other methods which
have been suggested for overcoming these obstacles may
be mentioned the application of a live-per-ceut. solution
of cocaine to the palate and post-pharyngeal wall, and
the employment of the palate liook. The image reflected
in the mirror at an_y given moment represents only a
small section of the whole region. Consequently, in or-
der to .gain a fairly complete view, it is necessary to con-
struct it in one's mind from the separate smaller pictures
obtained by changing from time to time the angle at
which the mirror is ])laced. Usually one observes first
the upper surface of the soft palate and the lower por-
tion of the posterior border of the septum which forms
the inner boundarj- of the post-nasal orifice, the choana'.
Then, b\' giving the mirror a slight upward inclination, it
will bring into view the whole length of the septum,
hroad above and tapering to a narrow edge below, and
the posterior view of the nasal cavities as displayed
through the choana\ On either outer wall, from above
downward, will be noted tlie ridge of the superior turbi-
nate body ; Immetliatel.y below itand sejiarated from it by
a dark line — the superior meatus — will be observed the
middle turbinate body which stands out as a somewhat
elongated fusiform bodj' of a very faint ]iinkisli-white
appearance. Below the middle turhinal body will be
seen the middle meatus, and immediately below this the
upper half of the inferior turbinate body, which oft
times seems to merge into the lloor of the choauw.
The color of the inferior turbinal body is of a grayish-
white, resembling much the color that an ordinary mu-
cous membrane assumes when oedematous. By slightly
inclining the mirror to right or left, tUe corresponding
mouth of the Eustachian tube will be observed, as well
as the depression which sejiarates it from the post-
pharyngeal wall — the fossa of Kosenmiiller. By chang-
ing the angle of the mirror to a more obtuse angle, the
dome-like vault of the ]>har\-nx will be brought into
view, as well as the upper portion of the post-pharyngeal
wall. The vault of the pharynx is usually dome-like
and smooth in its contour. In some individuals it may
show elevations and depressions, or be so filled out as to
appear flat, these alterations depending upon the amount
and degree of enlargement of the pharyngeal tonsil.
Besides the rhinoscopic methods of exploration of the
• nasal chambers and post-nasal cavity we have, as addi-
tional aids to diagnosis, the digital exploration and the
use of electric tran.sillumination. Digital exploration is
especially of value in exploration of the post- nasal cav-
ity in very 3'outhful patients and in adults in whom it is
impossible to make use of posterior rhiuoscop}', or in
whom, for various other reasons, it is desii'able to make
use of this method. This procedure can usually be made
in little ones, without causing alarm, b}' the u.se of .iudi-
cious tact. No instruments are necessary. The hands
should be well washed and the index finger scrubbed
with a nail brush before the examination is made. The
child is seated in the examining chair while the parent
sits in front of the child and holds the little one's hands.
The operator stands to the left side of and facing the
patient, with the right hand firmly grasping the vertex
of the head. I usually find it wise to tell the patient
what I pro|)Ose doing and of its impleasant nature, but
at the same time I assure him that the jirocedure does
not cause pain. The ]iatient is then told to open widely
the mouth, the hands and head are firmly grasped, and
the index finger of the right hand is quickly but dex-
trousl}' introduced into the mouth and behind the soft
palate into the post-nasal place. In this manner the
character and conditiou-of this region may be quickly
determined through the tactile sense.
Another method of making the examination is by plac-
ing the child in the position described by Dr. A. A.
Bliss. By this method the child is placed in the lap of a
nurse or parent, facing forward. The little one's legs
are held tirmly Ijetween the legs of the assistant, while
the arms of the assistant are slipped under the armpit of
the patient and the hands extended upward and held
firmly on either side of the head. The child is thus held
immobile. Transillumination of the accessory caxities
is resorted to as an aid to the diagnosis of the condition of
these pneumatic cavities. The value of this tuethod of
exploration lies in the fact that most of the pneumatic
spaces in the normal state allow the transmission of
rays of light through their thin walls. The light used
for this purpose is electric, furnished through the me-
dium of a small lamp of about six candle-power. The
method of its application will be described in the article
devoted to the diseases of the accessory sinuses.
C/mrles 11". Richarclson.
NASAL CAVITIES. DISEASES OF: ABSCESSES OF
THE NASAL SEPTUM.— Abscess of the .septum may be
either acute or chronic. The former is generality the
result of hamatoma, erysipelas, typhoid fever, or small-
]iox, and is located tipon one or both sides of the car-
tilaginous septum. The chronic abscess is generally
due to sj'philitic infection, but it may be the result of
poisoning by arsenic, copper, or mercury, or it may
possibly be traumatic.
While the acute abscess is commonly found over the
cartilaginous septum, the chronic abscess generally ex-
tends to the bony part, and it is often caused by disin-
tegration of gummatous infiltration of the mucous sur-
faces. The swellings are usually rounded, and they
appear red and inflamed and sensitive to the touch.
When a syphilitic abscess is opened it emits foulsmell-
ing pus, and if a probe be introduced into the abscess
cavity necrosed cartilage or bone may be detected. In
most chronic cases the treatment, after the abscess has
been opened, is the same as that recommended for nasal
syjihilis. A'. Fktclttr Iiif/nh.
NASAL CAVITIES, DISEASES OF: ACTINOMY-
COSIS.— I have been unable to discover any report of
well-marked cases of actinomycosis of the nose, though
it is probable that the disease sometimes affects this
organ. £. F. I.
NASAL CAVITIES. DISEASES OF: ACUTE IN-
FLAMMATIONS.— The man\- varieties (if ui-ute iufiam-
malion nf the nasal mucous membrane that are men-
tioned in medical literature may be eomju'lsed under the
following headings: (1) Acute Catarrhal Rhinitis, (3)
Acute Purulent Rhinitis, (3) Acute Membranous Rhini-
tis, (4) Acute Phlegmonous Rhinitis, and (5) Acute Rhin-
itis due to Occupation or to Trauma.
(1) AcuTic C.-\TARRH.\i, RiiixiTis. — Synonyms: Acute
Coryza, Cold in the Head, Acute Kasal Catarrh, etc.
This disease is an illustration of the simplest form of
exudative inflammation occurring in a mucous mem-
brane and affords us the most accessible illustration of
such a process inasmuch as the changes occur under direct
observation. Any special peculiaiities which it presents
are amply explained by the vascular mechanism of the
nose, which calls for a somewhat extended consideration.
^'||sculnr Meclianiism nf the yotie. — The vascular mech-
anism of the nose (and the glandular as well) is some-
what unique, and a tidl understanding of it is called
1U9
N'awal CaviticK,
Na)«al Cavities.
REFERENCE HANDBOOK OF THE MEDICAL SCIENXES,
for iu order to explain tlie sequence of various pathologi-
cal changes. To the hlooii supply of tJK! turhiuates does
tliis observation a|iply with s|)ecial force. The larger
artciioles are well supplied with muscular coats and lie
iu the deepest layers of the mucosa close to the bone.
They give olT branches which supjily, by a network of
capillaries, the periosteum. glan<ls, and the epithelial
layer. These capillaries are collected into veins which
dilate into venous sinuses, the larger lacunae of wliicli
are the deeper, while with them the superficial lacun;e
(cortical network) commiuiicate. These lacuiuB agaui
empty into the veins accompanying the ]irimary arteri-
oles into the periosteal layer. As a rule the capillaries
do not enter directly into the sinuses but are at tirst
collected into veins. It is a matter of doubt whether
the arterioles empty directly into the sinuses, as is the
case in the erectile tissues of the genital tract. There is
in the nose nothing comparable to the tunica albuginea
of the genitals to e.xert direct compression on the sinus
contents.
These views as to anatomical structure are these of
Ziiekerkandl (as quoted by J. Wright), who also reminds
us that the arteries enter the nose through various
bony foramina along with the veins. If the artery
dilate from any cause, sucli dilatation must compress
the vein against the bony wall. While therefore the in-
flow of blood to the part sujiplied is increased, the out-
flow is diminislied and engorgement results. Arterial
contraction jiroiluces of course the rever.se effect.
Another point deserves mention. Sections of the mu-
cosa taken from infants show veins eompres.sed between
the parallel fibres of the periosteal layer and the elastic
fibres and glands external thereto. It is here also evi-
dent that engorgement of the superficial tissues supplied
by dilated arterial twigs will bring an increased pressure
to bear against the \cin and olislruct the outflow of
blood. As a result of this general arrangement here and
in the radical vessels there may lie serous transudation,
especially in the region of olfaction, without any neces-
sary glandular intervention. It is estimated that under
normal conditions this transudation amounts to one
pint in twenty-four houis. Zuckerkandl has also
described a special network of veins surrounding the
glandular mouths in such a way that the engorgement
of the former woidd necessarily close the latter. Wright
believes that the foregoing facts clearly explain the
lihenomcna of ordinary acute inflammations of tlie nasal
mucosa. The first visible stage of a coiyza is a nasal
ocelusicm following upon vascular engorgement of the
erectile bodies. A preceding vascular constriction is
assumed, but this is ]irobleinatical. Now with the blood-
vessels all full and with the stinuUationof the glands, we
sliouhl expect the seeiefion of mucus to be discharged
almost coincidently with tlic congestion; but this is not
so, for secretion is scanty for the first few hours, and
even for daj's it may be almost watery. Later, when
vascular tension relaxes, it; begins to assume a nnicous
character. Evidentlv this absence of secretion is due to
the occlusion of tlie glandular conduits by the surround-
ing plexus of veins. The primary watery exudate comes
by transudation directly from the blood-vessels through
the areolar tissue and surface e|>itheli\un.
The contraction of the smooth mtiscle fibres and of the
elastic fibres of the stroma contributes to the collapse of
the venous sinu.ses, the floodgates of the radical veins
being opened by the conlra<-tion of the encroaching
arterioles. Expression of glandular contents follows,
the glandular mouths having been opened b^' the sub.si-
dcnee of the su|)erticial venous engorgement.
Oin'iis nf Ariite Ciiliivrliiil Illiiiiitis. — These arc predis-
posing and exciting. The former include the variiuis
diatheses, especially the sy])hilitic, rheinnatic, and gotity.
The existence of the uric acid or litha'inie state strongly
|iredispo.ses to corvza. A patient who eats heartily of
animal food and who does not take sufficient exercise is
far more liable to "take cold " than is one leading an
op|iosite life. Furthermore, the prevalent habits of liv-
ing in overheated houses and of swaddlini.' thebodv with
too heavy clothing, especially the wearing of tippets,
mufflers, etc., powerfully invite the very dangers they
are popularly supposed to avert. The combined effect
of the foregoing modes of life is easy to appreciate.
The system is overloaded with nitrogenous food and
elimination is deficient. As a result there is set up a
sort of autotoxannia leady to be fanned into open out-
break by any one of a large class of excitants. Excesses
in alcohol, tobatco, and veneryalso predispose to coryza.
The exciting cause is generall}' exposure of .some kind,
wet feet, draughts, standing or sitting in a cool place
when the skin is covered with jierspiratiou. Often a
localized exposure, such as a draught through a partiallv
open door or windi;iw, seems to act more powerfully
than a general exposure. The amount of moisture in
the air, as well as its temperature, requires, considera-
tion. A combination of cold and moist air offers the
most favorable conditions for exciting an attack.
Coryza may be a symptomatic lesion in many general
diseases, e.;/., measles, scarlatina, smallpox," scurvy,
whooping-cough, typhoid fever, influenza, diphtlieria.
diabetes, crysijielas, and rheumatism. The atTection
under these circumstances offers no pathological or clini-
cal peculiarities.
I'athologji. — At first the nose is diy, but after a few
hours a serous discharge cimics on, and" in the course of a
day or so liecomes very abundant. As the disease pro-
gresses it becomes mucousand finally muco-purulent. It
may consist of almost jiure yellowish pus. Later, it les-
sens and at last ceases, and the patient is well again.
No special bacteriology attaches to the affection. The
discbarge contains the usual micro-organisms which have
their habitat in the nose. They are relatively, as well
as absolutely, increased in quautit_y. Lennox Browne
refers the yellow color of the later secretion to the staphy-
lococcus pyogenes aureus, whicli he saj'S exists under
these conditions in nearly pure culture.
Siimptiniis. — An attack commences with a sense of nasal
occlusion, burning, tickling, and occasional sneezing.
Later come headache, mild general malaise, fever, pains
in the eyes and over the regions corre.sponding to the
various accessory sinuses. These jiaius may be due to
direct extension of the inflammatory process into the
sintis linings or to their occlusion and consequent im-
jiaired ventilation. This extension of the inflamma-
tion to the sinu.ses explains the large amount of discharge
regularly present, for it is dilficidt to believe that the
quantity of muco-jius voideil in a severe coryza can come
from the lining of the nasal fossa; alone. Iii an ordinary
case the foregoing sequence of changes will extend over
a period of from four to seven days, often longer.
Pror/iiosis. — "While the lesion is a comparatively trivial
one, it must not be forgotten that frequent coryzas lay
the foundation for subsequent hyjieitropliic chatiges and
may possibly intioduee some serious disease ; they should
therefore be promptly cared for,
Treiitinent. — This may be prophylactic, abortive, or
palliative. Most of the patients who consult the physi-
cian for a cold iu the head, commonly regarded as a
trivial affair, do so because they are .sufferer.s"from an in-
termittent or continual seriesof such attacks. Nosoouer
is one ended than another begins. For such patients a
lilain talk on the necessity of changing their mode of
living is the first thing re(iuired. It will afford more
satisfaction to both physician anil patient than will drug
administration. In season and out of season three things
must be insisted on. (1st) Avoidance of too much aiii-
mal food. Meat sliould be eaten only once a day. To
the gouty the time-honored advice may be given of "no
red meat and no vegetables taken from the groiuid";
(•id) jiropcr <laily exercise; (3d) jiroper care of the skin
and the eliminative functions; this includes regulation
of the bowels and daily bathing. Not every'patient
may be led to jump into a tub of cold water on rising,
but every patient should go over the surface of the body
daily with water. At fiTst this may l)e tfpid, but as
tolerance is established the temperature should be low-
ered until the water is distinctlv cool. Actual thcrmo-
110
KEFEKENCK IIA^DUOUK OF THE .MEDICAL bLlE.XCEiS.
Nasal Cavities.
niftric figures are not so good a guide as the patient's
sensations, tor a personal equation is eoiieerned in tlie
.sensation of coolness. In winter tlie Ijntli sliould be
tal\en in a room properly warmed, and in case a tuli-liatli
be taken tlie patient should dry liiinselt not standing in
the water hut on a bath-mat or rug. In this way much
of the immediate chilliness after the bath and sluggish-
ness of reaction can be avoided. Delicate patients may
be advised to sponge one-half of the body on rising and
the other half on Retiring, the unbathed" iiortion being
clothed. Some fortitude may be required to inaugurate
(he process on the part of tliose who have never been
jji-operly trained in this respect, but they should be en-
eouragt'd to persevere until a dail}- bath is taken on rising.
llih is the time of tlie din/ in. irlricli to hiitlie, not at night.
If lor any reason one wislies to take an old-fashioned hot-
water and soap bath at bedtime, it should be followed by
a cool affusion. One soap bath weekly is ordinarily suf-
ficient for those who take daily ablutions. In all cases,
after the bath and the a]iplication of the drying towel,
there should be a vigorousaiiplicationof the Hesli-brush.
or Turkish towel, "Lulfa "sponge, etc., to promote reac-
tion. Brisk, li,ght gymnastic exercises may be employed
by those whose reactive powers are deficient.
"Finally comes the matter of proiier body covering.
Good stout slioes should be worn with felt or cork in-
soles if necessary. Rubbers should he regarded as a de-
vice of the enemy of gooil liealth. Of coiu'se in a heavy
rainstorm they are permissible, but the habit some peo-
jile have of wearing ruljbers whenever the walks are the
least damp is dangerous to health. Being practically
air-tight, the}' prevent evaporation from the feet and
elimination of waste material. With equal vigor a pro-
test is uttered against all chest protectors and pads, also
against the wearing of heavy furs, etc., iniless they lie
immediatel.v removed on coming in fiom the cold. Oiu-
prevalent habit of wearing our heavy wraps when inside
the house is most reprehensible. The old sa_viug that
"sealskin sacks kill more pefiple than does smallpox " is
not far from the truth. The clothing next to the skin
should be woollen, or at least contain a certain propor-
tion of that substance. Some of the meshed garments of
silk and linen are also commendable. There is no sense,
however, in swathing the bod.y in heavy woollen so as to
bathe it almost constantly in perspiration. "Sanitary"
woollens are sanitary only in so far as they conform to
physiological law'S, it matters not in what countrj' the,v
are made or whose name they bear. The so-called " union -
suit, " with vest and drawers made in one piece, is the ideal
garment for both winter and summer, the weight being
changed according to the season. Theoretically the same
weight should be worn next to the skin the year round, the
outer clothing varying to fit the season, but there are not
many who will take the pains to live in this physiological
manner. Some textiles are composed of a woollen hiyer
covered on both sides with a cotton mesh. In this wa.v
the porous qualities of the woollen aie retained without
its irritating effect on the skin. So-called "medicated"'
miderwear belongs to the category' of "medicated " fian-
nel and "medicated '' toilet-paper. Excesses in alcohol,
tobacco, etc., must be sternly interdicted.
If undue space seems to have been devoted to the
foregoing directions, it must find its excuse in the
writer's increasing experience that full directions in
these respects will often render any drugs unnecessary.
In some instances it is possible to abort an ordinary
coryza, but the efficiency of the countless measures de-
vised for this end is conditioned upon their early em-
ployment. The combination of a hot drink with five
grains of quinine and ten of Dover's powder is un-
doulitedly one of the most common. This aims at elimi-
nation by relaxation of the skin, in other words, at
diajihoresis. Tlie plan has the following objectionsi
digestive activity is retarded and the biliary flow dimin-
ished, and with opium in full dosage there is also an
increased reflex excitah!lit,v. Full dosage of quinine
checks oxidation, depresses the circulation, lowers body
tempreature, and lessens perspiration. Under the con-
ditions we are discussing, abstraction of water by heat is
not sufficient to restore the bodily equilibriuiii. It is
preferable to give a full dose of calomel, followed by
small and frequent doses of quinine.
JIaiiy ])hysicians use the familiar rhinitis or cory/.a
tablet triturates. Familiar combinations are the Lincoln
formula: Camphor gr. j^. belladonna extract fi.ni \. ai.il
quinine sulphate gr. \; and the Edwards formula: Atm-
pine sulphate gr. -^-f,. aconitine gr. ^Jn. morphine sid-
phate gr. ^, and calomel gr. -f'^. Either or both of
these may be taken hourly until physiological elTects
are manifest, when they must be continued at longer
intervals.
Recently stress has been laid ujjon the autotoxiemia
presented by many coryza jiatients, especially by those
who are its freqiicut victims. These patients are suf-
ferers from uric-acid excess. Hence the advice is given
to put the |)alient through .some vigorous exercise such
as gymnasium work or a ride on horseback, etc., scour
out the bowel (not merel,v give a light laxative) and
then give full doses of the simple alkalies such as the
hicarbonates of soda or potash until the urine is free-
ly alkaline, the patient meanAvhile goin.g to bed for a
day or .so or at least remaining quiet. In the case of
plethoric individuals this plan of treatment is far more
efficacious than are the older methoils. The.se latter aim
at establishing relaxation and favoring elimination, but
they take no account of the s|)ecial unch'rlyiug diathesis.
In so far, the.v are but jiartially i<leal remedies. L'n-
doubtedly they are of service, but it must be remem-
bered that coryza is not a long disease and will gener-
ally get well of itself. Moreover, they do not ahva,vs
abort an atack.
The Turkish bath has alwa3"S enjoyed a high reputa-
tion for aborting coryza. If it be tried, the patient must
keej^ in-doors for some time, and if practicable should'
remain at the bathing establishment over night.
In some instances the malad.v will yield to frequent
a]))dications, in the form of a spray, of the active prin-
ciples of the suin-arenal bodies (adrenalin), in say 1 to-
2.000 solution. This contracts the ve.ssels by itsaction on
their unstriped muscular tilires. It must he added that
some patients show a decided idio.syncrasy toward this
remedy, and that while its immediate eltect is in the line
of relief there c|uickly comes a secondary relaxation,
sometimes so severe that the patient's last state is worse^
than his first.
Palliative treatment consists in the thorough tiiishing
out of the nares with some warm alkaline solution. It is
dovibtful whether the addition of distinctly antiseptic
preparations is of much advantage. Normal salt solu-
tion or a mixture of salt, borax, and biearl)onate of soda,
one teaspoouful of the mixtuie to the ]iint of lidiewarm.
water, is as good as any. By such remedies the excess
of secretion is removed from the nas;rl passages, and
conditions are set up favoring a restoration to the nor-
mal. The smarting in the narescan lie relieved bj' some
such remed}- as Ferrier's snulf (Moiphine muriategr. ij.,
]iowdered acaciie 3 i.i.. and bismuth subearhonate 3
vi.). A little of this may be ins\iltiated every few hours.
If the patient comes for oliice treatment, the nares ma,y be
clean.sed with some alkaline solution, tlieii sprayed with a
little iri'iik cocaine (not over two per cent.) and adrenalin,
and this followed tqi w-ith some oily preparation such
as menthol in albolene, resorcin with benzoinol, weak
cam|ihor menthol, etc. Frequent sulTerers with coryza
should neur be given cocaine solutions to he used at
their own discretion.
Spiess insists that most of the sneezing in an ordinary
coryza comes from a |)ost-nasal irritation. lie- therefore
advi.ses the insufflation into this region of an an.isthetizing
powder, such as orthoform 2 parts to sozoiodolate of
soda 10 parts.
In the case of very young children a laxative .should be
given with a hot bath, and then they should be put to
bed. Cocaine, if used at all. must be enqilnyrd with
the greatest caution. In infants the ilisease seems to he
conveyed from one jiatient to another in the .same family.
Ill
ISaMal <;avUics.
Nasal i'avltles.
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
and couseciucntly ti'mporary isolation is advisable. Den-
tition and i-arions teeth seem to be pi-edis|iosing eauses.
Difficvilty in nuvsini^ is one of the most important feat-
ures, ^iir local treatment a weak nientliol solution in
albolene may he nsed, the application being made through
a medicine dropper.
(2) AciTK Pi iiri.i-:NT Rhinitis. — Synonyms: Blenuor-
rhagic, Gonorrho'al Rhinitis.
The condition designated purulent rhinitis commonly
occurs in children and r\ins a chronic course. There
are, however, in both adults and cliUdren, cases of acute
intlamniatioM with the free discliarge of almost pure
pus. Tliese are not to be confounded with sinus alTec-
tions in which the nose serves merely as the conduit for
the escape of discharges.
Cdii.si'x. — The disease is essentially the expression of
some form of infection. In very young childreu and
babies a leucorrlKcal ili.scharge in the mother seems to be
the infecting agent; in fact, 'most of the cases occurring
in early life are due to this cause.
Piitholiirju. — A high degree of inflammation of the
mucosa c.\ists with excoriations, and gonococci may be
found in the discharge.
Si/w/iliiifi^. — If the ehiUl is onl\- a few days old it be-
gins to sneeze, while pus Hows "from the nares and ex-
coriates the surronndiug skin. This character of the
discharge is in strong contrast to the earlier appearances
of the discharge in a simple coryza. There is oftcai a
eoniplieating purulent conjunctivitis and the iullamina-
tion may s])read to the nnddle ear.
Tridt'iiH-iit — This consists in tlie thorough cleansing of
tlie nasal passages with antiseptic washes. AVith young
children the jialient must lie held in the upright position
witli the head slightly bent forward; otherwise some if
the fluid may run down into the larynx and setup spasm.
Boric-acid solutions are serviceable in the earlier stages
and may be followed by slightly astringent combinations.
Tlie oleostearate of zinc s<'rves as an efficient vi'hieh' for
medicinal agents. AVith adults, and even with children
in whom the malady runs a longer course, it may bo
advisable to apply cocaine and then luake a single appli-
cation of silver niti'ate, sixty grains to tlie ounce. This
may be followed liy a temiiorary increase in the dis-
charge, but its ultimate elTects are advantageous. Some
of the newer silver sabs find here a suitable field. We may
inenlion jirotargol in ten-per-ceiit. .solution and argonin
in the same stiength. The latter is said to lead to the
early disaiipearance of the gonococcus, subsidence of
discharge, and prompt restoration of tissue integrity.
Of less value are argentamin and largin. With any of
these, insufflations of some antiseptic powder, such as
aristol, dermalol, no.sophen, etc., may advautageousl\'
be combined.
(;i) AciTK .Mkmisk.\N(iis RiiiMTis. — By this design.'i-
tion we refer to that form <d' acute rhinitis in which we
lind a deposit of tibrin.on the septum, on the turbinated
bones, or on both.
(,V"/,w.'i. — A consideration of the causes at once shar])ly
divides tlie cases into ( 1st) those due to the Klebs-Loelller
bacillus (nasal <liphtheria) and (3d) those due to various
other micro-organisms, pus- and fibrin-producing cocci,
especially the staphylococcus, streptococcus, liacilbis
coll, ami pneiimoeoccus. A French ob.server vepoits
several cases due to the bacillus of hog septica'niia.
Solutions of continuify of the intranasal tissues natur-
all.y predispose to and invite infection. The latter is
not so common in the nares as might be at first sup-
posed, for it must be rememben'd that there is a con-
stant serous outpouring whieli cleanses the tissues, that
the passagesare continually Hushed with air, and that the
cilia of tlie epil he] ial cells tend to ward olT all deleterious
jihysical agents.
Pdtliiildiiji. — In membranous rhinitis the whole tliirk-
ness of th(! mucosa becomes congested and swollen.
There are an emigration of leucocytes and exmUUion of
plasma from the vessels. Hence there is formed fibrin
which infiltrates the interstices of the connective-tissue
elements of tlie mucosa, and also arranges itself as a
membrane on its surface. At times there is a super-
ficial coagulation necrosis of the superlieial layers of the
epithelium, rnderthese circumstances the membrane is
formed, mil of true tibrin and pus, but of necrotic epithe-
lium alone. In most ca.ses the combined effect of vascu-
hir congestion and pressureof the exudate is sufficient to
starve out a portion of the mucosa involved, and thus
sloughs are formed, the separation of which gives the
familiar ulcer.
It is thus seen that the process is identical with mem-
brane formation an\-where, and that the ajipearance is
Ihe same no matter what the exact exciting cau.se. Fre-
([uently there is partial organization of the membrane,
in thesense that it becomes lamiualed, jiermeated with
leucocytes and epithelial cells, and lu-esents partial vas-
cularization. The areas most frequently atleeted are
fh(^ faces of the inferior and middle turbinates and the
anterior portion of the septum.
Si/m/itiimn. — In many eases the onset of sympton;s is
not unlike that of an ordinary coryza. There is dryness
of the nosy follow(d liy irritation and sneezin.g. with
headache, fever, and general malaise. Next follow the
group of symptoms referable to obstructed nasal breath-
ing, anosmia, aprosexia, sore mouth from direct impact
of air, paresis of the soft palate, leading to a muHled
voice, etc. In other cases, and especially in y<iung chil-
dren, there is the typical appearance of a drooping child
without any special features suggesting nasal trouble,
unless perchance the stoppageof the naresorthe a|)pear-
ance of a iiurulent tlischarge at the outset calls attention
to that area.
Examination shows the mucosa covered witli a false
membrane of a whitish-gray color. Removal generally
causes bleeding, but gentle manipulation may clear the
membrane without this sequel. The membrane fre-
(|uentl_v exfoliates and re-forms, so that the jirocess is ex-
tended over <lays and even weeks. The general health
does not seem to be depleted so much as might be ex-
pected considering the nature of the le.sion.
Diagnosix. — The question to be decided in the presence
of a given case is. Is it diphtheritic or not? While typi-
cal cases of the two conditions may present sharply de-
Hiicd boundaries, there are many in which the diagno.sis
can be made only by the culture test. There has been
much discussion as to whether there are really two dis-
tinct arfeciions or whether all are not true diphtheria with
a bacillus of diminished virnlency in the milder cases.
Wishart has divided the jiartisans on this matter into
tliree groujis: (Ist) Those Avho consider diphtheria and
membranous rhinitis to be distinct affections; (2d) those
who consider that there is but one disease, but that the
degree of contagiousness so varies that we may safely
neglect to isolate such cases as otter no clinical or bacte-
riological evidence of di]ilitheria; and (iid) those who
would isolate every case. (It may be added that Wishart
does not lielievi" in the duality of the di.sease and advises
isolation under all circumstances.)
Out of ninety -eight cases collected liy this ob.server
from various .sources and reported as membranous rhini-
tis, sixty-nine showed the Klebs-Loetfler bacillus. E.
Mayer notes that the earlier in tlie diseasi^ the test is
made the more likely are the bacilli to be found. In the
light of our present knowledge, then, the ditferenfial
diagnosis in a dmitbful case is to be made by the culture
test. Some cases are found in which no Klebs-Loeffler
bacilli are met, 3'ct there is incontrovertible evidence that
such eases have spread contagion to others and that the
membrane in the secondary cas<'S hii>i .shown the bacilli.
A possible! explanation would be th;it the bacilli were
overlooked in file primary cases; Init this experience has
li;ippened fo some of our most careful bacteriologists. If
culture media are not at hand, we must rely U]ion the
general clinical features of the disease. Fac:tors suggest-
ing the presence of true diphtheria would be a history
of exposure, coexisting deposits iu the throat, swelling
of the cervical glands, distinctly fetid odor from the
nose, a marked constitutional involvement, and an offen-
sive discharge excoriating the surrounding skin. Not
112
REFERENCE IIAN'DBOOK OF THE MEDICAL SCIENCES.
>'asal Cavities,
Nasal Caville«.
iiuich reliance, however, can be placeil on the degree of
severity of cuiistitutional symptoms. Tlie occurrence of
albuminuria and the development of paralysis would
al.so bear in tlie direction of diphtheria. The opposites
of the factors just enumerated would suggest mere coc-
cus rhinitis.
Xasal diphtheria has always been regarded as a most
malignant form of the disease, and this view still holds
in those cases in wliicli the deposit begins in the throat
and spreads to the nose. But we see at the present time
cases of true diphtheria with the deposit confined to the
nasal mucosa and in which the constitutional symptoms
are verj' mild. In this connection reference may be
made to some recent studies by R. O. Neumann concern-
ing the forms under wliich nasal dipjitheria may occur.
He has several times seen cases in which apparent!}' sim-
ple coryza was due to the diphtheria bacillus. In many
instances the general symptoms produced were more
marked than those of a simple cor}/.a, but very much
less marked than in an ordinary case of diphtheria. The
discharge from the nose, was sometimes .sero-purulent,
sometimes markedly purulent. Neumann comes to the
following conclusions from his study: Simple rhinitis,
associated with virulent diphtheria bacilli, is much more
frecjuent than is commonly supposed. The s_ymptonis of
this disease are not always the .same. It comes on very
olten in a very mild form and may even be unobserved
l)y the patient. It is (juite in contrast with the so-called
rhinitis tibrinosa, as there is no formation of membrane.
Both forms e.xisl upon a similar basis, so that one
should net speak of them as two different diseases; the}-
should be divided into nasal diphtheria with membrane
formation, and nasal diplitheria witlioul membrane for-
mation. If the fact be considered tliat not only rhinitis
libriLosa, but also nasal diphtheria, especially the la.st.
may serve as a focus of contagion for the surrounding
neighborhood, it ^vould be wise to investigate bacterio-
logically all doubtfid eases of cor3'7,a.
Prognosis. — This is always good, although after either
form there may be an anaemia, especially in those living
in bad surroundings. Either type of the disease ma.y
attack all cla.sses in society.
Tri'iitnient. — As a matter of precaution every case of
membranous rhinitis should be isolated imtil a culture
test can be made. In other words, it is better to consider
all ca.ses diphtheritic until the contrary is detinitely
shown to be true. If the Klebs-Loeffler bacilli are fomid.
full autito.xin dosage should be administered and the
usual hygienic and quarantine measvu"es instituted. If
the test is negative, we may give calomel in half-grain
doses every four hours tmtil five grains are taken. This
is given with a view of aborting the membranous forma-
tion wliich in 3'oung children is apt to accumulate rapid-
ly and be verj' thick. For the ].iuri)ose of counteracting
h_yperinosis we may give to a chilil of five years, eight
to ten luiuims of the muriated iron tincture in glycerin,
every three hoiirs. For local applications nearly everj'
antiseptic in use has been at some time suggested. The
sj-stematic use of any one is preferable to the desultory
and changing use of several. The nares should be
cleansed with a warm alkaline spray, and if there is
much tenacious secretion it may be loosened up with
equal parts of hydrogen peroxide and lime water. If
the membrane shows the least tendency to exfoliate, this
should be assisted by gentle manipulation and the pas-
sa.ges should be carefully dried with antiseptic cotton.
Then it is well to apply pure iron tinettire by means of a
swab and to follow it b_v the insufflation of some powder,
as iodol, aristol, nosopjien, etc. Iodoform emulsion has
also been suggested.
(-1) Acute PnLisGMONors Rhinitis. — This is a process
attended with the localized formation of pus, generally
in the deeper layers of the mucosa and submucosa cover-
ing the septum, and it generally presents itself tinder the
form of the familiar septal abscess. One or two in-
stances of abscess in the mticosa covering the turbinated
bones are recorded, but in such cases the abscess has
been caused by the burrowing of pus from the maxillary
Vol. VI.— 8
.sinus; so also dentists have foiuid a purulent coUection
on the nasal lloor from some tooth abnormality, butlhese
cases are so rare that they need not he considerc<l here.
Ciiiixes. — Septal abscess is practically always referable
to some trauma, as from a blow or a fall. Other jiossi-
ble causes are some intranasal opciation and infection
in measles, scarlatina, diptheria, erysipelas, and typhoid.
/'«//("%//.— Following the traunia there is an elTusion
of blood into the tissues (hoematoma), and this effusion
may separate the two lamella; of the cartilage. The
initial injury may have licen so .slight as to escape notice
and yet lead eventually to absct-ss. If the elTu.sion is
small it becomes ab.sorbed; if it is large, absorption is
but [lartial and is followed by the brealiing down of the
remains of the clot and formation of pus in the usual
numner.
Symptoms. — These naturall_v follow from the history
of the case. There is the initial jiain of the injury fol-
lowed by swelling of the external parts and nasal occlu-
sion, tmilateral or bilateral. The (niter swelling subsides,
while nasal occlusion persists, and, in case of abscess,
the formation of pus is accompaaied by burning and ir-
ritation with perhaps a slight general febiile movement
and malaise. Examination reveals on one or both sides
a tense, bulging swelling, soft on palpation, and with
evidences of severe local inflammation. .
Diagnosis. — The use of the prolje will differentiate the
swelling from the turbinated bones and from all forms
of tumors projecting down from points of attaehnii'tit
higher up ib the nares. The swelling does not subside
under cocaine. Spontaneous rupture never occurs.
Any unilateral purulent discharge from the nose sug-
gests sinus disease or a foreign bod}'. The history of
the case will generally clear up all doubt as to the
nature of the lesion.
Tnatnii'nt. — Cases of recent tratima in which abscess
seems threatened may be treated with ice compresses
over the nose, while iodine tincture or five-percent, car-
bolic .solution may be applied directly to the septal
mucosa. As .soon as the presence of pus is determined,
the latter .should be evacuated by free incision on both
sides of the septum, as the abscess contents are apt to
form a pocket. The cavity is syringed with hydrogen
peroxide and a warm alkaline solution. A delicate strip
of antiseptic gauze is then eanic'd to the bottom of the
cavity to provide for drauiage. This should be changed
in twenty-four hours. This dressing provides for heal-
ing from the bottom; otherwise the cavity may retill.
AVith a view of maintaining the patency of "the incision,
it has been recommended that the latter should be made
wth the galvano-cautery knife. If the case is one of
any duration, the pus will have a very foul odor. Sub-
sequent cleanliness is all that is riMpiired.
It must be borne in mind t hat tlie initial escape of blood
may be between the perichondrium and the cartilage or
between the two cartilaginous plates which are imifed
by a diploetic structure. The cartilage may fracture,
allowing a eommuiu'cation between the two nares. In
case the contents of the cavity are at all grumous it is
well gently to curette through the incision and remove
all necrotic particles. If the |)crichondrium remains,
the cartilage will be reiiroduced. Perforation may oc-
cur. It is well to be cautious in promising a perfectly
normal contour of the nose after healing is complete, for
some cases show a slight depression just behind the tip.
Another condition ipiite rare but requiring mention in
this connection is that known as acute sennis perielion-
drilis of the nasal septum. While jierichondrial intlam-
mations are, as we have seen, c<immon enough after
trauma, there is a form of iuHammatiou whidi develops
in this locality without known cause. It must be due
to some form of infection, though the time and mode of
entrance of the infecting agent cannot be determined.
The clinical histcry is somewhat as follows:
The first symptom is nasal stoppage. gra<luaily increas-
ing and attended witli the |ihenomena of local iiUiam-
mation. At times there are mild general symptoms.
Examination reveals the .septum swollen on one or both
113
Nasal CavllirN.
Nasal Cavities.
REFERENCE HAXDP.OOK OF THE MEDICAL SCIENCES.
sides and freni'ially Murtiiiitinj;-. Incision niiiy i-v.-iciintc
fills, wliilc probinsi may show u caiimis cdnditiiiii nC the
cartilngc, wliicli may lir paiiially iiciiic. Snniclinics car-
tilaginous sc(|Ui'Slni 111' considcralilc size conii' away
Mn(lcr tins Mianiciivn'. The especial danger of ihe con-
dilion is lliat it may lea<l lo a marked deprcssinn of (he
contour of llie ncpse just at the juiiclioii nf the linnes and
cartilages.
Tlivis far, the condition lias been piaclically that of a
septal ab.scess with a maximum destruction of lissiie,
but then' are cases in which incision evacuates only
clear serum, which is oilorless. and hence a .separate
classilicatiou is given by some authors to the lesion,
which is often called serous cyst of the si^ptiim. Treat-
ment is the same as for absce.ss.
[0) ACCTK liUl.NITIS DIK TO OcCf f \TION OH TuAIM.V.
— Certain occupations lead to acute rhinitis^ this is espe-
cially true of tlio.se which aie alteuiled with the giviu.g
oil' of dust — ('.,'/., milling, weaving, stone-cutting, cement
grindin.g, etc.. or of tbosi' which are associated with the
,giving olT of no.xioiis fumes— occu]ialions. for example,
which reipiire llii' handling of amnmnia. chlorine, ar-
senic, mercury, bichromate of potash, etc. Workers in
pliosjihoriis often have a coryza from tlie constitutional
clVects of the remedy, asdo patients who take the iodides.
Laboratory workers may be thusalTectcd by Ihe fumes
of osmic acid. Burns, scalds, smoke, steam, foreign
bodies, and operations on the nose must also be included
in the list of causes. The arsenic eaters of Styria fre-
(|Uentl_v show .septal |)erforations which have originated
in a similar way.
J'lit/wlryi/. — There are no special b-itiires in the earlier
sta,i;es of an attack. In fact the atfectiou often runs a
suliacute rather than an acute cour.se. The changes are
generally accentuated on the anterior part of the sep-
tum, wliicli ,soon becomes irritated and, in dusty sur-
roundings, covered with a scab of dirt and secretion.
The patient iiibs this olf and takes some of the epithe-
lium along witli it. The deposit reforms, is again re-
moved, and a vicious circle is thereby inaugurated. As
a result there are bemorrhage, ulceration, and often
jierforation. After perforation has taken place the edges
generally heal, and curiouslv enough these patients after-
ward seem quite immune to the ordinary caiLSes of acute
catarrh.
Siiiiiptoiii!'. — These all- the same as iu acute coryza
from any cause. Deformity never ai'ises from the per-
foration.
Trciitiiifiit. — i)hv\m\ii\\ the llrst thing to do is to
remove the (latient from the source of irritation. Work-
ers in bad atmospheres should wear respirators. Thor-
ough local and general cleanliness should be maintained,
with application of stimulating remedies, such as cam-
|ihor-menthol, to ulcerated surfaces. Healing may lie
assisted by astringents, siicli as alumnol and weak zinc
chloride. Tincture of benzoin and boroglyceride ma}'
be used as local sedatives. Juiihs K. JS'i'irrmiih.
NASAL CAVITIES, DISEASES OF: CHRONIC RHI-
NITIS.— (Synonyms, Ithiintis chrouica. Chronic catarrh.
Chronic i-oryza, and llydrorrhiea. ) This alfection con-
sists of a chronic inflammation of the nasal mucous mem-
brane, characterized by exci'ssive secretion (rhinorrlHca)
with discharge from the anterior or posterior nares, or
by dryness of tlie nose with the formation of crusts.
It occurs in all climates and among all classes of peo-
]de, Init is more freipient where the atmosiihere is often
dam|) and chilly, as beside lar,ge bodies of water; bow-
ever, it is also found in the arid regions of the West,
particularly at high allitiides where tlieie is inueb dust,
and it also occurs inlauil, in localities far removed from
bodies of water and free from any unusual amount of
dust. The .symptoms are most common in the winter,
spring, and fall months, and are usually aggravated by
damji chilly weather. Persons who are much out of doors
are less likely to be alTected by it than those whose
occupations contine tliem to the house. .Mthoiigb all
are subject to the disease, it is more loniinon in chil-
dren and young adults, but it is not infrequent even'
among infants and those past middle life. According
lo the various manifestations of the di.sease it may be
convenient to divide it for the sake of description into
biur varieties: ( 1) Simple chronic rhinitis, (2) in tumescent
rhinitis, (3) liy]ieitro]iliie rliinitis, and (4)atroiihic rhinitis.
The first is characterized liy intiammation with eousidera-
hle secretion, but with little or no swelling and obstruc-
tion of the uares. Tlie .second is marked by intermittent
swelling, occurring usually when a person is l.ving down
and especially in the latter part of the night, by much
aggravation of the symptoms on slight exjiosure to cold,
b\- frecpieiit clearing of the throat, often by hoarseness,
and sometimes by excessive discharge. The third va-
riety is characterized b}' more or less constant obstruc-
tion of the nares with hypertrophy of the soft tissues
over the turbinated bones, and sometimes of the bones
themselves, and also by hypertro])hy of the soft tissues
over the septum. The biurtli variety is characterized
by wasting of all of the tissues within the nares and a
corresiiondiug enlargement of the cavity, with the col-
lection of mucous crusts, which decompose and cause a
foul odor from the nose. In the majority of cases all of
these varieties originate in much the same way, though
there are indiviilual instances in which neither variety
can be traced to any previous ;ilfection.
SiMri.i-; CiiiioMC Kiii.MTis.
Simple chronic rhinitis is characterized by catarrhal
congestion and inflammation of the mucous membrane
with but little swelling. It is usually attended liy a
good deal of irritability of the Schneiderian mcmbraue
and excessive discharge of a thin watery fluid which,
under the influence of the frei|Uent e.xacerliations caused
by cold, becomes muco-iiurulent in character.
Etiology — Chronic rhinitis in many cases appears to
result from debility, due to digestive disorders or im-
proper food, or to confinement within doors and lack of
exercise. In some cases it is clearly of nervous origin
and is occasionally one of the manifestations of neuras-
thenia, but most commonly it appears to be caused by
frei.|uent colds, improper clothing, and exposure to dust-
laden or damp and chilly atmosphere. In numerous
cases an inherited predisposition may be detected.
Ax.\ToMi(Ai. .\Ni) P.vrnoijOiiic.^T. Cii.\u.\CTi'.nisTrcs.
— The mucous niendiraiie is usually evenly conge.sti'd
and moderately swollen, but at times the swelling is
limited to the turliinated bodies or upper part of the
,septuin. Ero.sions iiarticularly of the cartilaginous seji-
tnm may be present, but ulceration is not a feature of
the disease unless it has been caused by frequent
removal of crusts by the finger nail. Tlie"ei)ithelium
anil the subepithelial tissues are found infiltrated with
round cells, especially abotit the glands and vessels.
The layers of the epithelial cells become increased and
the upper cells are flattened, with here and tliere pal dies
of uorinal ciliated epithelium remaining. The condi-
tions, it will be seen, are not very different from those of
inflammation of the mucous membranes in other part.s
of the body, the pathology of which is described else-
where, ami therefore need not be coiisi:lered in this
article,
Sv.MPTOMATOi.OGV. — The p:ifient usually gives a his-
tory of often recurring colds in the head, which have
become more frequent and iiersistent until the symptoms
are present the greater part of the time. Itching, burn-
ing, and tickling sensations are experienced in the nose,
and sneezing may occur upon the slightest jirovocation.
as upon ex|)osure to a slight draught or slightly irritat-
ing vapor. Weakness of the eyes with pain and head-
aches is frequent, and often there are partial ana'inia and
defective hearing. Occasionally the sense of taste is also
obtimdcd. Laclirymation is easily excited, andconunonly
there is an excessive watery discharge from the nose
which, with the |)rogre.ss of each recurring inflammatory
attack, becomes muco-purulent and acquires a more dr
less offensive odor. The nose is commonlv obstructed
lU
REFERENCE HAXUBOOK OF THE MEDICAL SCIENCES.
Nasal Cavltlrs.
Nasal Cavities.
for a few days during tlie recurriug colds, but at otlicr
times nasal respiration is free excppting when it is im-
peded by the profuse secretion. The general health is
usually good, but slight derangement of the digestive
organs is common. In some cases cobweb-like shreds of
mucus are seen stretching from one side to the other of
the nasal cavity with Ijut little secretion. In others the
surfaces may be dry, and in still others watery or muco-
purulent secretions may be found in abundance, espe-
cially in the lower part of the nasal cavity. In most cases
the naso-pharyngeal mucous membrane is also congested
and more or less covered with secretion similar to that in
the nose, but generally less watery in character. This
causes frequent hawking and attempts to clear the
throat. The nares are usualh" somewhat obstructed by
swelling of the mucous membrane, especially during the
acute exacerbations, Init in some cases it is ditficult to
draw a distinct line of demarcation between this condi-
tion and tr>ie hypertrophy of the mucous membrane.
Di.\GN0sis. — The diagnosis is usually easily made by
insjicction, and there are no diseases excepting liypents-
thetic rhinitis or autumnal catarrh and diseases of the
accessory sinuses that are apt to be mistaken for simple
chronic rhinitis, [jrovided intumcscent rhinitis be ex-
cluded by a careful study of the histor}'. In simple chronic
ihinitis the prolonged duration with gradually increasing
susceptibility to cold, the nearly normal size of the nares,
the absence of exqui.site tenderness, and the occurrence
of exacerbations independently of the conditions produc-
ing hay fever will generally enable us to exclude the
latter and intumcsceut rhinitis. The occurrence of pro-
fuse secretions upon both sides instead of one, with the
history, will nearly always enable us at once to distin-
guish this from disease of the accessory sinuses. Some-
times, particular!}- in children when there is excessive
pvu'uleut discharge, cleansing of the nares will be neces-
sary before a diagnosis can be made.
Phognosis. — The affection is tedious and apt to extend
over several years, and may terminate in one of the other
forms of rhinitis, particularly the hypertrophic or atro-
phic. In some instances, especially in children, owing
to secondary infection wilh pyogenic germs, a simple
watery discharge that might otherwise have continued
unchanged for months or years becomes purulent and
oftensive in character.
Treatment. — The treatment of this form of rhinitis
must be tentative and symptomatic, and is therefore not
very satisfactory. Attempts to cure it by local measures
alone will nearly always be disappointing. It must be
remembered that in many instances it is kept up by a loss
of tone of the general s^vstem or by various disturbances
of the digestive organs, and until the.se are relieved by
proper hygienic and tonic measures little can be accom-
plished in the treatment of the nose. Whenever practi-
cable, the patient should be removed from the sources of
irritation and his mode of life should be so ordered as to
prevent unnecessary exposures; and by improvement in
the general health, to steel him a.gainst those which are
unavoidable. Two principal olijects are to be kept con-
stantly in view in the treatment of these cases: First, to
relieve irritability of the nasal mucous membrane by sed-
atives and protective applications; and second, to cheek
the secretions or to prcvi.-nt their collection in the nares.
When the secretions are watery and profuse, nothing is
needed for cleansing the nasal cavity ; but wiien they be-
come mucii-purulent detergent washes or sprays may be
necessary to clear the nose before local remedies can have
any effect. Wherever practicable, watery applications
should be avoided, as these tend to increase the swelling
of the parts and appear to have little intluence in check-
ins secretion; furtliermore. the watery an'i!ic;itv.'io 7>'if "-.
frequently find their way through the Eustachian tubes
to the middle ear and cause deafness. Commonly, ex-
cepting in cases in which the secretions dry and form
cr\ists. oily applications are sufficient, aided by the pa-
tient's efforts at blov.ing the nose to cleanse tlie cavity.
It is only in the most exceptional cases that these cause
inconvenience by passing into the Eustachian tubes, and
the protection which they afford the mucous membrane
from irritating substances or from the cold or damp at-
mosphere is a distinct advantage. Non-irritatin;;- dis-
infectant and slightly astringent powders are usuallv
beneticial. For detergent purposes a weak solution .if
potassum permanganate, an alkaline solution containing
about four grains of the bicarbonate and the chloride of
sodium to the ounce; Dobell's solution, or a solution pre-
pared from Rhodes' or Seller's tablets may be employed
in warm water, care being taken that it be not forced into
the Eustachian tubes. These solutions cannot safelj' be
used with the nasal douche, but ordinarily they may be
snuffed from the hand or from a glass without danger.
Freer's irrigating tube, which consists of a straightened
Eustachian catheter [lerforated with three or four tine
openings just back of the closed end, throws verj- tine
streams which may be employed to wash out the nose
and naso-]iharynx without danger to the car. The re-
moval of the drying crusts is aided b\- treating them with
oily substances applied either by the atomizer or by a medi-
cine dropper. The sensitiveness of the mucous membrane
varies greatly in different patients, and therefore it is nec-
essary to begin the treatment with the mildest remedies,
and it should be the invariable rule that the applications
be not strong enough to cause discomfort for more than
five minutes; this applies to those made by the jiatient
three or four times a day; those which areniade by the
physician once or twice a week ought not to cause dis-
comfort for more than half an hour. Commonly it is
better that little or no irritation be caused bj" any "appli-
cation that is made. Oily sprays tend to coat the siu-face
and protect it from irritating particles, and therefore are
most advantageous in hypersensitive conditions of the
mucous membrane. Those most commonly employed
consist of various volatile oils in melted vaselin, or, bet-
ter, in oleum ]ietrolatum album. These should be ap-
plied by the patient four or five times daily by means of
an atomizer which throws a large spray, or tliej' may be
applied by a medicine dropper or even a small oil can.
Various substances may be combined with these bases for
the purpo.se of diminishing the .secretion. One of the
most etiicient of these is terebene in the proportion of
ten or twenty minims to the ounce. Thymol half a grain
to the ounce, menthol from two to five grains to the
ounce, oleum pini sylvestris one-lialf drachm to the
ounce with oleum caryophylli from three to five minims,
or oleum cinnamomi from one to two minims to the
ounce, have proved most satisfactory in my hands; but
other similar applications may be employed with advan-
tage if care be taken that they be not too stimulating or
irritant. A watery solution of adrenalin chloride, 1 part
to .5,000, contidning about eight grains of boric acid to
the ounce, will be found beneficial in some cases, and
weak solutions of silver nitrate, copper sulphate, and
zinc suli>hate or chloride, from one to two grains to the
ounce of distilled water, are sometimes efficient. Sed-
ative powders are frequently more advantageous than
spra)'s, and are commonly employed in addition to the
oily applications already recommeuded. ISoric acid, bis-
muth, iodol, benzoin, and various other substances may
be employed for this purpose, mingled with starch and
sugar of milk. A seilative powder containing ten per
cent, of boric acid, twenty-five per cent, of iodol, two
per cent, of starch, and enough sugar of milk to make
one hundred parts, with occasionally one per cent, of co-
caine, will sometimes give much relief. When there is
an offensive odor, aristol may well be used in jilace of
iodol ; and various combinations mav be made with other
remedies, such as bisnnith. oxide of zinc, and pulverized
gum benzoin. It is well to use these powders after the
oily soray has been a"'ii''"d.
In cases in which there is marked hypcra'sthesia of the
nasal mucous membrane, the greatest g(}od will be ob-
tained by superficial cauterization of the sensitive spot.
The spot should be searched for with a flat probe light!}-
rubbed over the surface; when found, and after it has
been ana-sthetized with cocaine, it should be cauterized
with a flat guai'ded electrode with sutiicient thorough-
115
Masai I'avitit'M.
Nasal CavitieH.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
ness ti) whiten the mucous mcmlinuic over uu iirca about
iii'i-uliinetre iudiuinetcr, but thc<'aut<Mizatioii sliouUl not
111.' cui-ried far fuough to destroy this tissue. 'Pile elTeet
of this treatineut is to destroy tlie terminal fibres of the
liy |>ei'sensitive nerve and thus the eauso of the disagree-
aiile symptoms is removed. The sedative sprays and
powders should he used in the intervals between the eau-
leri/.ations, and the latter slioukl not be repeated oft.ener
than onre in five or ten days.
iNTtMESCKNT RlIINlTIS.
This affection is often spoken of merely as chronic ca-
tarrh, and is sometimes classed as liy])ertro|ihic rhinitis;
but on account of the pathological condition it might
well he called coryza vasomotoria chrouic'U. It is char-
acterized by swelling of the Schnciderian nuicous mem-
brane, especially of the inferior turbinated bodies, hut
also of the middle turbinals and sometimes of the tuber-
culum septi. This swelling causes obstruction to respir-
ation through the occluded naris. It often involves only
one side at a time, though it clianges frequently from side
to side, and both nares may be oljstructed at once. One
of the characteristic features of the disease is the swelling
which occurs upon one side while the patient is lying
uijou that side, and which may be transferred to the
other side within a few moments when the position is
changed. Tliese sudden changes in the seat of swelling
are also uoticeable even when the patient is erect, and
sudden disappearance of swelling upon exercise is a
conuuon symptom.
AN-VTOMICAL .\ND P.VTHOLOGICAL ClI.\K.\CTEliISTl(.'S.
■ — The pathology of intJaramation of mucous membranes
is described elsewhere; but we should note that in this
condition, although congestion is usual, the membrane is
not infrequently paler than normal. The swelling oec\irs
most frequently over the inferior turbinated body, but
nray involve other parts, as already mentiimed; it results
froin a paretic state of the mu3c\ilar elements of these
structures and of the mu.scular walls of their cavernous
vessels. The inflammatorv changes are the same as
those in the variety known as chronic rhinitis and liyper-
trophic rhinitis, though less extensive than in the latter.
Tlie naso-pharyn.x and pharynx are nearly always in-
volved, and not infrequently the inflammation extends to
the larynx and trachea. In conse(|uence of extension of
the inilammation along the Eustachian tubes, partial
deafness is present in many cases, and this is usually ag-
gravated by exposure.
Etiology. — The causes are the same as those of simple
chronic rhinitis.
SvMPTOM.\TOL()GY. — Patlcnts sulTering with this dis-
ease usually give a history of unusual susceptibility to
cokis which are present during the large jiart of the
changeable weather in the spring and fall, though in
some cases they are also ].iresent in the winter and even
in the warmer summer months. The disease gradually
increases until eventually the patient is annoyed much
of the time, esjiecially at night, by obstruction of the
nasal cavities. This occlusion causes mouth breatliing,
and sooner or later in most instances sets u)) intiamma-
tion of the naso-pharynx, the pharynx, and even the
larynx and tra<'lica. In<leed, the great majority of cas<>s
of chronic mild laryugilis are due tointuine.si-ent rhinitis,
the effect of the intermittent swellings apiiearing to be
even more disastrous to the larynx than is the more jier-
sistent obstruction due to hypertrophic rhinitis or nasal
mucous polypi. As a result of disturbed sleep, the iia-
tieiit is apt to awaken unrefreshed and with a headache.
In most of these cases the nasal nuieo\is membrane is
h3'persensitive, and the |)aroxysius of sni'ezing may be
excited by breathing colli -lir or the inhalation of dust,
and in some cases even by stepiiing into a bright light.
Sudden changes of temperature, whether from heat to
cold or the reverse, are very apt to bring on attacks of
sneezing with occlusion of the nares. Sometimes the ob-
struction is brought on ipiickly by exposure to cold ; but
usually the reverse is true, and it is only in the ti-mperate
atmosphere witliin doors that the patient experiences the
greatest annoyance. A patient who may get along com-
fortably with" tlie temperature at T3° F. will frequently
tiiid the nasal Jiassages obstructeil when the mercury rises
three or four degrees higher. Occasionally such patients
are annoyed by attacks of redness and inflammation of
the end "of the nose; and not infreijuently they are
troubled with itching or tickling of the nose, or by simi-
lar sensations in the mouth associated with dryness. A
stuffy sensation in the nares or one of pressure with act-
ual pain is not infreiiuent, and these patients are often
the victims of a temperal or occipital neuralgia or lieiui-
crania due to Ihe piTssure. It should be understooil,
however, that these are notconunou symptoms. Mental
hebetude, loss of memory, and inability to concentrate
the thoughts are due to this disease in rare cases.
Among other nervous phenomena that sometimes result
from intumescent rhinitis may be mentioned paroxysmal
cough, spasm of the larynx, and even spasmodic asthma,
which may occasionally be removed ijy curing the ca-
tarrhal conilition. Excessive lachrymation and photopho-
bia are also si mietimes caused by this form of catarrh. In
a considerable number of these patients the secretions
from the nares are increased, but in the majority the i^a-
tient does not have to use a handkerchief excessively,
and the greatest complaint is of the desire to hawk and
clear the throat, especially in the early morning or after
eating. The secretions are essentially the same as tlio.se
of simple chronic rhinitis, though usually they are not so
abundant. However, the amount of discharge may vary
much from time to time, and exacerbations are frequent
from slight colds in the head. jNIany jiatieuts who pre-
sent the usual symptoms of intumescent rhinitis deny
the existence of obstruction of the nares, even though
upon examination the cavities may be found more than
lialf closed. The reason for tliis is that they have be-
come so accustomed to breathing through the narrow ori-
fice and to existing upon a minimum amount of air that
they have no realization of the comfort of normal respir-
ation. In intumescent rhinitis the tongue is so commonly
coated and the digestive organs are so freciuently dis-
turbed that the suspicion arises that, in some cases at least,
gastric disturfiauce is the jirimary disease. Upon inspec-
tion of the nares the mucous membrane may or may not
be seen to be congested, or it may be even jialer than nor-
mal. Usually it is swollen upon one side or the other,
although frequently at the first examination one must
rely largely upon the history in making the diagnosis,
for both nans may be pi'rfectly free. If the membrane
upon the turbinals or the tuberculum septi be swollen it
may be made to contract speedily b}' the application of
a small (juautity of cocaine, or it may be readily com-
pressed by a probe. Sometimes, indeed, the mere dread
of an examination will cause rapid retraction of a swol-
len membrane. The normal width of the nares in an
adult is about one-eighth of an inch, and the color of the
mucous membrane is a few shades deeper than that of
the gum. Proliably in fo'ur-fiftlis of all cases of intu-
mescent rhinitis the congestion is considerably greater
than this, and the constriction of one or other or both of
the cavities ma\' be from thirty to seventy-five per cent.
The swollen membrane over the tuberculum septi is gen-
erally a few shades darker in color than the normal tis-
sues; but the swollen menibrane at the back part of the
septum, when brightly illuminated either from the front
or by posterior rliinoscop3', is ajit to apjiear of a grayish
color. Tlie posterior cuds of the turliinated bodies may
also, when swollen, appear grayish in color, and may
.somewhat resemble mucous poly[)i; Init these changes
are more a]it to be found in hyi)ertro])liic rhinitis. The
mucous membniue of the naso-pharynx is often congested
and bathed in secretion, and commonly more or less fol-
licular inflammation of the phaiTux is present.
Dt.iGNosis. — Intumescent rhinitisis to be distinguisiied
from sim]ile chronic rhinitis, hypertrophic rhinitis, hay
fever, and nasal mucous polypi. It is distinguished
from simple chronic rhinitis by the absence of swelling
in the latter. If at the first examination the history in-
116
IlEFEKENCE IIANDIJOUK OF TlIK MKURAL SCIKXCES.
^'awal <*a\iile».
Nasal Cavfllis.
dicatcs that the [latient is troubled by frt'iiucnt obstruc-
tion of the uares, altliough tlie cavities ma}- appear free,
he must be sent away aud directed to licep watch of the
symptoms and report specifically at another visit. At a
second visit it is probable that swelling of one side will
be present. Intumescent rhinitis is distinguished from
hypertrophic rhinitis by the history, which indicates in-
termittent swelling, and usually by the presence of swell-
ing in the intumescent form only upon one side at the
examination, by the yielding of the tissues before slight
pressure of the probe aud their retraction under the influ-
ence of cocaine. In hypertrophic rhinitis, although the
tissues refract luider cocaine, they do not to so great an
e.\tent as in the intumescent variety. Hay fever is dis-
tinguished from intumescent rhinitis by the history of
rep^^ated attacks at a certain lime year after year, by the
e.xcessive sneezing, and by the irritation of the eyes and
throat wliich usually attend hay fever. Xasal mucous
polvpi can hardly be confcmnded with intumescent rhi-
nitis excepting by the tyro. Their color a. llLMit grayish,
their position as a rule in the upper part of the nasal fos-
sa, their mobility as indicated liy the probe, and the fact
that a probe may be passed on both sides of them should
be sufficient to establish the diagnosis in any case.
Prognosis. — Left to itself, intumescent rhinitis occa-
sionally subsides spontaneously, but it commonly ex-
tends over a long period of time: and eventuallj- true
tissue hyperplasias occur and hypertrophic rhinitis is the
result. In rare cases, however, this form appears to pass
directly into atrophic rhinitis. The frequent obstruction
of thenares, occurring chiefly at night in this affection,
leads to chronic pharyngitis aud laryngitis, and often the
Eustachian tubes and middle ear become involved and
throat deafness follows. In singers the voice is likely to
be ruined by persistence of this affection. The general
health suffers from imperfect oxygenation ; and. although
to the casual observer the patients may appear robust,
they have little endurance. B_v proper treatment the
obstruction may be entirely removed, aud as a rule the
hyper.sensitiveness of the mucous membrane will disap-
pear with it. 51ost of the other symptoms speedily sub-
side soon after the nasal cavitiesare made free, and a final
cure may be predicted in tiearly all cases. The effects
upon the general health of the cure of the local trouble
are most gratifying. Sleep is no longer disturbed, the
nasal respiration is restored, and the patient becomes
more vigorous mentally and physically. There is some
liability to recurrence; ne\erthelcss it is best to relieve
only the obstruction that is apparent, rather than to
make the nasal cavities abnormally large. The treat-
ment may be resumed at some future time if found nec-
essary, but usually the symptoms do not recur for sev-
eral years at the worst, and in the majority of cases the
patient is completely cuii'd.
Treat.ment. — All sources of irritation should be
shunned, and special care should be taken to avoid cold.
Exposure to draughts, cold, or even undue heat, especial-
ly in badly ventilated rooms, or the inhalation of irritating
dust or vapors is especially liable to cause this variety of
inflammation. Much may be done to guard against rhi-
nitis by care as to clothing. The daily coki bath with
vigorotis friction and regular exercise do much to pre-
vent the nervous exhaustion and the loss of tone of the
vascular system, which are often responsible for this
affection. The condition of the digestive organs should
always be carefully attended to. Local treatment of a
sedative character is important during the early stages.
and will often be sufficient to prevent further develop-
ment of the disease. The various oily preparations men-
tioned in the treatment of chronic rhinitis will be found
beneficial at this stage of the disease, and sedatives aud
mildly astringent powders may do much to lessen tlie
discharge and will sometimes give consideralile relief to
the obstructed respiration. Adrenalin chloride in solu-
tion or in powder, of a .strength of abiml 1 to 4.UU0 or
5.000, may in some cases be used four or five times a day
with gn.'at advantage. Cocaitie gives the greatest relief,
but unfortunately its continued use causes a paretic slate
of the mu.scular coats of the veins of the cavernous tis-
sue of the turbinals; and after a few weeks or months
the patient's condition is much worse than it was in the
beginning. There is reason to believe also that the co-
caine favors hypertrophy. Aside from this, its perni-
cious effects upon the nervous system and the great dan-
ger of the formation of the cocaine habit render it
absolutely unsafe excepting for verj' short periods of
time. The physician should never give a prescription
containing cocaine lest the patient have it repeated and
so form a cocaine habit ; and even while the patient is
under the physician's observation he should not be al-
lowed to use more than from an eighth to a quarter of a
grain daily, and this sliould be discontinued as quickly
as possible. AVhen it is necessary to employ it. a one-
or two-per-cent. solution in a saturated solution of boric
acid in distilled water niay lie employed, or a similar
amount niay be rubbed up with one per cent, each of
sodium bicarbonate aud sodium biborate, two percent,
of the light carbonate of magnesium, and sufficient sugar
of milk to make the required quantity. These sprays
may be applied with any good atoiuizer, but the No. .10
Davidson is the best in my opinion for oily applications.
The powders are most couventiently applied by a simple
insufflator with a glass tube and rubber handball and
tube. For personal use the patient may have a short
glass tube, about four inches in length, to which is at-
tached a rubber tube, about ten inches in length: one
end of the glass tube should be flattened. The powder
is jilaced in the round end, the rubber is slipped over this
end, aud then the fiat end of the tube is placed in the
nostril; the other end of the rubber tube is taken in the
mouth, and the patient gives a ciuick puff which throws
the powder well through the naris. Oily applications
may also be made to the nose with a medicine dropper or
a small oil can when the patient finds this more conven-
ient. 5Iore stimulating applications maj' be made to the
nares once or twice a week.
The applications made bv the physician should never
cause discomfort for more than ten or fifteen minvUes,
and those made by the patient should not cause irritation
or smarting for more than a minute, and should not be
sufficiently strong to give a feeling of stuffiness in the
nares aftei'ward. Of the aqueous solutions recommended
for personal use by the patient three or four times daily,
some of the best are boric acid, eight grains to one ounce,
sodium bicarbonate aud sodium biborate, of each two
grains to one ounce, listerine forty to sixty minims to
one ounce, or distilled extract of hamamelis or of pinus
canandensis thirty to fifty minims to the ounce. The
saturated solution of boric acid in camphor water is also
recommended. For personal use an excellent aiiplication
con.sists of one-third grain of tiiymol with three minims
of the oil of cloves to the ounce of oleum petrolatum
album, or its strength may be increased by the addition
of various substances, combined or singly, which should
seldom exceed the following amounts to each ovmce:
Menthol, gr. ij. : terebene, m xv. ; oil of cas.sia, njij. ;
camphor, gr. i. : ol. pini sylvestris, 3 ss. Scmie prefer
the use of heavier oils, and many employ vaseline, which
is melted each time before the application, the theory
being that it remains longer in contact with the mucous
membrane than would the lighter oil. When the secre-
tions are free, the nose should be cleansed in the same
manner as recommended for simple chronic rhinitis. In-
deed, most of the remedies applicable to that disea.-^c may
be used at times with advantage in this affection.
The foregoing measures, however, can relieve only the
milder cases, and if is not proper for a physici.-m to keep
a patient under treafmeut more than two or three weeks
liefore he adopts more radical nieasiu'es. unless what he
is doing is found to be accomplishing great good. The
radicaltreatment of intumescent rhinitis consists in de-
struction of a portion of the tissues by chi'Uiieal agents
or by the galvano-cautery or by removal of the swollen
masses by the snare, or cutting them away by knife or
scissors.
Cauterhation by jlcj'tfs.— When satisfactory galvano-
117
Nasal <'avillei).
Nasal Cavities.
HEFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Ciuitcrics rcuikl not be obtiiinecl. there was much reason
for the eniploynient of the clieniieal eausties, and tliese
are still preferred b_y some pliysicians. allhousli they
cause mucli greater irritation of tln' parts witli eorre-
ponding discomfort: to tlie patient, and do not, eom-
ni<inly at least, yield such accurate results. Of the
chemical agents u.sed for the purpose chromic acid is per-
haps the best. A few crystals of this may be fused on
the end of a flat aluminum probe by holding it over a
light for a few moments, luid then the parts may be ac-
curately touched without much danger of the chromic
acid extending beyond the jiart to be cautei-ized; bow-
ever, tlie operator slioidd lie ready to spray tbi' parts im-
mediately with an alkaline solution in order to neutralize
any excess of the acid. A very small amount of the
acid, not exceeding in bulk a pellet 3 mm. in diameter,
should be employed, and the area of membrane touched
at any one time should measure not more than an eighth
of an inch in width and from a half to three- fourths of
an inch in length.
The cauterization should not be repeated within less
than from ten to fourteen days. Some ]irefer touching the
surface at several points with the acid, and some use
solutions of various strengths instead of the fused acid,
and repeat the cauterizaticm in four or five days. Tlie
priucijtal objections to thcchromic acid are the ditlicully
of controlling the extent of cauterization and the pain
that is likely to follow tlie cauterization for many hours.
Jlonoehloraeetie and trichloracetic acids are also used for
the same purpose, but in my hands they have not jiroven
satisfactorj'. Some operators have obtained good results
from the employment of electrolysis, commonly using a
bi])olar electrode, the needles of which are 4 or 5 mm.
apart. A cunent of from 2 to 10 milliamperes, lasting
for from three to five minutes, is employed. If the
elfcct of this electrolysis could be confined entirely to the
submucous tissue, it would prove a very attractive ojier-
ation, but many times a slough forms, ami often the
wound thus resulting is larger than that obtained b_v the
usual forms of cauterization.
Galraiincaiileri/. — Cauterization by the galvauocautery
should be done with a wire heated to a cherry-red color
only. If heated less than this the line will not burn suf-
ficiently deep and the heat will radiate more to other
parts; and if a white heal be employeil. the instrument
will cut almost like a knife, and bleeding will result. I
like best for the purpose a knife-like electrode, about 10
cm. in length, tlu' blade of which consists of No. 21 pilat-
inum wire and is about 15 mm. in length. A finer wire
heats much (|uickeraud cools more rapidly so that we
either get a sharp cut with bleeding or fail to biu'u the
tissues decpdy enough. The parts should be first ana'S-
thetized with coe.-iine, the solution of wiiich .should not
ordinarily exceed a strength of four per cent. ; this is
best applied by a thin swab of cotton wound uiion a flat
aluminum probe, with which all <pf tlie part to be touched
is gently rubbed about every minute and a half until from
two to four ap]ilicatious have been made, liy which time
the amesthesia will be completed. This is much better
than to employ a spray or a tampon of cotton, which
spreads the cocaine over a large area and causes absorp
tioD of an unnecessary amount, to tlie detriment of the
patient. A solution which has been found by long ex-
perience to be satisfactory on account of its good I'ifects
upon the parts, and the absence of constitutional symp-
toms excepting in the rarest cases, consists of atropine
gr. yV. strophanthin, gr. 4, oil of cloves "liij , carbolic
acid gr. x., cocaine muriate gr. xx., and enough water
to make an ounce. When the ana'sthesia is complele,
the soft tissues will be thoroughly atTect.eil, and tlien the
electrode should be carried to the posterior end of the
turbinated body where the platinum wire is iiri/ssed
against the tissues, the current is turned on, and with a
slight to and fro movement the electrode is drawn to the
front part of the nasal cavity, burning the .soft tissues
down to the bone throughout the whole line. Usually
two lines extending from the ba<'k to the front part of
the inferior turbinated body will be necessary, one at the
junction of the upper and the other at the junction of the
lower with the middle third. In sensitive persons not
moie than half th(> line can be made at one sitting, and
in no case should more than a single line across the whole
length of the turbinated be made. The electrode should
always he lifted from the tissues before thecuri'ent is cut
oil, otherwise it is apt to tear out tlie eschar and cause
bleeding. After the cauterization the nose should be
sprayed with a solution of about five minims of oil of
cloves ill an ounce of liquid albolene, and this followed
by insutHation of three or four grains of iodol. The nos-
trils should then be closed with a pledget of cotton, and
the patient should be tolil to wear cotton whenever out
of doors, or in any ]>osition w here he is liable to take
cold, for four or five da_vs; then he should be allowed to
change it and put in fresh cotton as often as <lesired, A
ten-per-cent. solution of methylene blue may be employed
to touch the line of cauterization in place of iodol, or "the
(■onipound tincture of benzoin may be used for this pmr-
pose. The latter in some cases bas seemed peculiarly
etlicacious in the prevention of subseipient reaction. A
similar cauterization may be made in the opposite naris
in from ten to twelve days, and these maybe repeated at
similarintervals until the swollen tissues have been suffi-
ciently reduced. Usually two cauterizations upon each
inferior turbinated body are sufficient; sometimes one is
necessary ujion each middle turbinated, and occasionally
two .short lines will have to be drawn thnnigh the tuber-
culuin sejiti. It is well to have the patient return to the
ollice four or five days after the cauterization, and to pass
the probe between the oppo.sing sides of the nares inonler
to prevent avlhesions. The patient is given a small
iiuantity of powder containing three per cent, of cocaine
and twenty-five per cent, of iodol with one and one-half
percent, each of biboiateand bicarbonate of sodium, and
three per cent, of the light carbonate of magnesium, with
sufiicieut sugar of milk to make the whole quantity about
one hundred grains. Tliis the patient is directed to in-
sufflate into the nasal cavity two or three times a day for
the purpo.se of keeping down the swelling. He is" also
given an oily sjiray containing (Uie-third of a grain of
thymol and from three to five minims of the oil of cloves
to the ounce of liquid albolene, which he is directed to
use freely in both nares four or five times daily. The
piowder is continued for four or five da_ys and subse-
quently is used only once a da_y, but the oil is continued
regularly until other treatment is instituted, or for two
or three weeks. The freqiu'ut superficial cauterizations
which are recommended by .some appear to destroy more
tissue, to give the patient more discomfort, and" to be
much less efiicient. I have .seen one death from ulcer-
ative endocarditis evidently caused by the suppuration
set up by this latter method. Usually such cauteriza-
tions cause little or no pain either at the time or subse-
<|Uenlly, and may give the patient no more discomfort
than would be ex]ierieuced from a severe cold in the
head. However, the patient should be warned, in order
to prevent unnecessary anxiety, that there is likely to be
some bloody discharge from the nose for two or three
weeks. The principal di.scoinfort following cauteriza-
tions is from the eil'ects of the cocaine upon the nervous
system; therefore care should be taken to use as little of
tills as is practicable. There are occasionally initients
wdio cannot tolerate a sulhcient quantity of "cocaine to
produce ana'sthesia. in whom eucaine may be advanta-
geously substituted; ten or fifteen grains of the bromide
of potassium or a cup of strong coffee will commonly re-
lieve the immediate poisonous symjitoms caused bv the
cocaine; but it will not always succeed, and in patients
peculiarly sensitive to the drug, none of it should be em-
ployed in the subsequent treat^ment except tojirevent the
pain of actual cauterization. 'When the turbinated bone
it.self is enlarged, or when there is ajuominent defiecriou
or spur from the septum, adhesions are very likely to oc-
cur if cauterization upon the turbinated body is made
upon that side. In these cases, therefore, an "operation
upon the bony tissue should usually first be done. In
spite of all precautious, adhesions sometimes result.
118
ItEFEKE^CE HANDBOOK OF THE MEDU AL SCIEA'C'ES.
\a»»al 4'avilief'.
i\asal Cavltied.
Whon this accident occurs it is best to wait until com-
plete healing takes place, anil then the adhesions should
be cut with scissors. A pledget of wool or bit of rubber
tissue may be placed between the opposing siiifaces to
prevent renewed adhesion, and after four or Hveda.ys the
healing will usually occur without ditticulty . Sometimes
-adhesions ma}' be prevented by touching the raw surface
with nionochloracetic acid, as this forms an eschar that
tends to remain until the healing has taken place under
it. Follicular tonsillitis occasionally follows the cauteri-
zation of the uares. I have .seen it in abinit one-half of
one per cent, of the patients operated upon, though not
more than one-fourth as frequently as this if the individ-
ual cauterizations are consideretl. In rare cases otitis
media is said to have followed the operation, and I have
known of one ea.se in which an inexperienced operator
made an extensive cauterization that was followed by
fatal meningitis. More or less blood is mi.xed with the
■discharges in the majority of cases for two or three
weeks, and occasionally a secondary hemorrhage may
occur at the cud of a week or ten days. I have never
had this experience myself, but have known of two cases
in the practice of experienced operators in which an
alarming hemorrhage recurred time after time until the
patient was in the gravest danger; however, in both the
bleeding was evenUially check<>d and the patients made
-a, good recovery. I recall two or three cases in my own
experience in which ery.sipelatous infianunatiou of the
■skin covering the nose, lips, and cheek invariably fol-
lowed cauterization. It is needless to say the operations
were not repeated when this tendency was discovered.
Occasionally in cases of extreme intumescence the swol-
f len tissues may be grasped with a snare, providing this
is done before cocaine hus been applied ; but excepting in
the rarest instances this operation is reseived for hyper
trophic rhinitis. D. Bradeu Kyle removes a prism-
shaped piece with a knife instead of cauterizing, and
believes that he gets better results in this way. The
pharyngeal and laryngeal symjitoms usually improve
speedily after the nares have been made free, though it
is well to carrv on appropi-iate treatment for these parts
during the treatment of the rhinitis. In professional
singers whose living depends upon the voice, the cure of
intumescent rhinitis is of the very greatest importance
for the prevention of chronic laryngitis, and in nearly all
cases, fortunately, we may contidently predict the happi-
est results from judicious radical treatment.
HYPERTROrmC RlIIN'ITIS.
Hypertrophic rhinitis is a common affection, but it is
not met with so frequeutlv as the intumescent variety.
It is characterized by obstruction of the nares with dis-
charge from the naso-|iharynx and the nostrils, and fre-
quent hawking to clear the throat. It is often associated
with chronic laryngitis. The obstruction in the nares is
permanent, yet it varies considerabl}' from time to time
•on account of the varying degrees of swelling.
AXATOMKAl, AND PaTIKiI.oGICAI, CuAHACTEUISTICS. —
Permanent thickening of the mucous membrane and
sometimes also of the turbinated bones is found in this
disease, and the nasal cavities are usually from one-third
to three-fourths closed by the swelling. The mucous
•surface may be congested or paler than normal. It is
sometiiues smooth as in intumescent rhinitis, but is often
more or less nodulated, and at times presents one or more
tumor-like masses which are sometimes mistaken for
fibrous or fibro-nivicous ])olyiii, Tlie condition affects
both the middle and the inferior turbinated bodies, and
is not infrequently observed on the tubercvdum septi.
In many cases the inferior turbinated body is nearly as
smooth in appearance as in the intumescent form of the
disease, but usually its anterior extremity is more or less
furrowed or nodular. The anterior end of the middle
turbinated not infrequently presents numerous nodules,
more or less translucent, and having something of the
appearance of nasal nuicous or tibro-mucous poly]>i. The
hypertrophy at the upper part of the septum is generallj'
smooth, and at first appears to the observer like thicken-
ing of the bony septum. Hypertrophy of the posterior
ends of the turbinated l.Kidies usually presents a las])-
berry-like appearance, and may vary in color from a
whitish-gray to a dark livid hue; thejiosterior end of tbit
middle turbinated, liowever, is generally lighter in eolor
and less granular upon the surface, and it often appi'ars
much like a mucous polypus. The condition is due to
overgrowth of the connective tissue and bony elements
in varying degrees, l)ut the pathology of the disease will
be consitlered elsewhere.
Symi'TOMATOLOOY. — The symptoms are not unlike
those of intumescent rhinitis excepting that the nasal oli-
struction is more persistent and usually more complete.
The patient generall}' complains much of accunuihilion
of the secretions in thenaso-pharj-nx and often of ci>mpli-
cating laryngitis. Pressure symptoms, such as loss of
the sense of .smell, headache, nasal or supra-orbital neu-
ralgia, and sometimes ocular symptoms, are more often
present in this than in the intutuescent form of the dis-
ease, and when present they are more persistent. Mid
die-ear disea.se with throat deafness is also common, and
unfortunately after the hypertrophic rhinitis has persisted
for some time, its elfects are very likely to remain e\cn
though the disease in the nose mav be cured.
DiAGxosis. — Although the disease is frequently mis-
taken by general practitioners for nasal mucous polypi,
careful inspection of the nares should exclude all affec-
tions excepting intumescent and syphilitic rhinitis. In-
tumescent rhinitis is distinguished from the h3pertro-
phic form by greater variation in the degree of nasal
obstruction, by yielding of the tissues readily before the
probe pressed upon them, and usually by contraction of
the swollen mass to its noriual jirojiortious or even less,
upon the application of a weak solution of cocaine.
Commonly, also, the mucous membrane is more congested
in intumescent rhinitis than in the hypertrophic form.
Syphilitic rhinitis causing uniform swelling of the tur-
binated bodies cannot always l.)e distinguished from sim-
ple hj'pertrophy, but the historj' of the case and I he
effects of treatment, or the occurrence of ulceration of
the Schneiderian membrane with evidences of former
syphilitic involvement of the fauces or other parts of the
body, will usually enable one to make an accurate diag-
nosis. Nasal polypi are coiumonlj' recognizable u|)on
inspection; but if this is not sufficient, the passage of a
probe upon both sides of the pol\-pus and its movability
will generally distinguish it at once from the hj-pertro-
phied turbinated body.
PnoGNOSis. — Left to itself, there is little tendency for
hypertrophic rhinitis to terminate in recovery. On the
contrary, it is liable to increase gradually until the nares
arc three-fourths or four-fifths obstructed and then to re-
main permanent for a long time; in other instanc<'s the
hypertrophy gives way to atro].ihy, and tdtimately well-
marked atrophic rhinitis results. There are also un-
doubtedly some cases in which the h3'pertrophy grad-
ually subsides and the nares are left practically in a
normal condition, but these are extremely rare. Sub-
jected to proper treatment practically all cases of
hypertrophic rhinitis may be cured in a comparatively
short time, though the gentle or puttering treatment
that is often adopted is likely to extend over years with-
out much relief.
TuEATMENT. — The more vigorous treatment recom-
mended for intumescent rhinitis is equally applicable in
the hvpertrophic form of the disease, but the tentative
soothing treatment recommended in the former is almost
useless. The hj'pertroi-ihied tissue must be removt'd in
some way so as to bring the nasal cavities to a normal
calibre. In doing this, however, the physician should
be careful not to render the nares abnormally large, be-
cause if they are left too small they may he made larger;
but once too much tissue is removed, nothing can restore
it. Care should also be taken not to destroy nnicous
membrane when it is possible to avoid ibis, or rather to
leave as large a surface of mucous membrane as should
normally be present. The author is not at all in sym-
ll'J
Nattal <'avi<i<>t>.
Naeal Cavities.
REFEKENCE HANDBOOK OF THE MEDICAL SCIE.NCES.
patliy with Ihc litllc dubs or cuts that keep a patient
(luiiciug constant attendanee for months, but believes in
radical ojierative measures that will usually not avcrag(^
more than one Ireatiuent per \v<;ek for from six lo twelve
weeks, by which time the patient should lie cured.
Among tiie operative measures lo be adopted are those
reconuuended for intunu'scent rliinilis. uamely, cauteri-
zation witli add or preferably tiie galvanocaulery.
These are to be done in tlu' way dc^scribed for that afTc^e-
tion. When it is possible to engage a coirsiderable
))orlion of the liyiiertrophied soft tissues in the loop of a
cold wire snare or of the galvanocautery ecraseur, it
may be removed proviiled that too much nuicous mem-
brane be not .sacrificed. Of these methods the cold wire
snare is jireferable in most, cases, as it leaves less scar tis-
sue. In .some cases cutting away of a V-shaped piece,
as recommended by Kyle, is an excellent operation. Ju
some the spoke shave may be used for removin ; i-edu'i-
dant tissue; in others, jiarlicularly when ther? is a mass
of soft tissues pendent from the lower edge of the infe-
rior turbinated, tlie hypcrtrophied tissue can easil_v b cut
awu}- with nasal scis.sors, but in the milder cases the gal-
vauocauterj' is preferable. In many cases it is important
not to sacrifice the mucous niembrau?; i:i such, liyper-
irophies of the tuberculum septi or of the tm'biuated
boclies may often be sjieedily reduced by the nasal ti'e-
jihine passed beneath the nuu'ous membrane. Wiien the
bony tissue is also increased, removal liy the nasal burr
is ]ierhaps the best oiieration. It is |iassed thiough the
nuicous memliraue and the bony tissue is cut away be-
neath without the danger of bl'jcding that sometimes at-
tends cutting with other instruments. When tb.e byper-
irojihy involves the tissues .iust in front of the i>osterior
edge of the vomer, linear cauterizations have jiroven to
the author most satisfactory, A niunber . f cases have
been seen in which all other obstructions of the uarcs had
been removed and the nasal cavities appeared free, but
yet the patient continued to complain of hawking to
clear the naso-pharyn.x, and this was not relieved until the
submucous iutiltration at the sides of the vomer had been
cured by cauterization. In any of these operations local
anaesthesia and sub.se(iuent treatment are carried out, as
recommended in intumescent rhinitis. Wlieuever cut-
ting operations ar<' perfcu-med. it is safest to pack the
naris with a striji of surgeon's lint, which has been sat-
urated with boric acid and iodoform, to prevent the dan-
ger of lileeding which is a]it to occur two or three hours
after the operation. The packing should lie allowed to
remain for two or three days, after which it shoidd be
gradually removed, or removed all at once if it can he
done without giving the jiatient pain or exciting hemor-
rhage.
ATiiopiiic liinNi'iis.
Atrophic rhinitis is a chronic inflammat ion of the nares
in which not only the membrane but the bony frame-
work undergo atrophy wherebv the nasal cavities be-
come more or less enlarged. It is characterized by col-
lection of the secretions which become diied into scabs
and adhere to the wall until decom|iosilion takes i>lace,
thus causing an e.xtremc'lv offensive odor which is known
as oza>na. It occurs in all countries and among all
classes of people, but is most frequent in young adults,
partietdarly in girls. It is seldom ofjserved before the
tenth or after the thirty -fifth year of age.
AN.\TONric.\rj and Patiiolixuc.m, ('iiaractki;istics.
— In consequence of the atro]iliy of the mucous mem-
branes or of both the nuicous memliranes and the bony
tissues the nasal cavities become enlarged, sometinies to
two or three times their normal dimensions. The atro-
phy may be eontined to the mucous membrane, but usu-
ally the bones also are involved and lliey may be short-
ened in every direction. The turbinated bodies are iiio.st
affected, and not infrequently the turbiiial bones are en-
tirely absorbed. iShortening of the nasal bones causes
.sinking in of the bridge and may ju'oduce a Hat juig, or
saddle-shaped nose. The disease is often a seiiuel of
hypertrophic rhinitis. jVIoritz Schmidt has observed
cases in which jiart of a turbinal was liypertrophied and
other parts were atrophied.
Etiology. — In many cases the causation of the disease
cannot be ascertaine<l, but there is certainly a consider-
able number in which repeated colds lead toliypertrojihy
which terminates in atrophy. Many have sougiit to find
a specific micro-organism, and Abel and Low-enberg have
isolated the iiacillus oza'iur" which has been suppo,sed to
act as an etiological factor. D. Braden Kyle liy rejieated
inoculations from advanced cases of atrophic rhinitis was
unable to discover any specific micro-organism, though
various pathogenic bacteria were commonly found, such
as the pneumococcus of Fraenkel, Klebs-LoetHer bacil-
lus, Koch bacillus, the bacillus fa'tidu.s, and various
streptococci and sta])hylococci. The origin of the dis-
ease not infrequently dates from one of the exanthema-
tous fevers.
iSyMProMATOi.ooY. — Commonlj' the patient's general
health is not imiiaiicd by the disease, an<l headache and
other nervous .symjitoms tliat commonly attend rhinitis
are not often jiresent; but as the affection progresses the
general health may sufl'er and eventually pallor, loss of
strength, and emaciation, strongly suggestive of tuber-
culosis, may occur. Often the patient presents the ap-
pearance of what is commonly known as the strumous
diathesis. The nose is ajjt to be broad, the nostrils and the
lips arc prominent, and the whole phvsioguomy is lacking
considerably in expression. There is usuall\' but little
discharge from the nose, excepting once or twice a week
when 'Jie crusts come away; decomiiosition of the secre-
tions causes r. persistent offensive odor, which, although
the patient does not recognize it himself, makes him an
object of disgust to others. Occasionally this condition
i:. unaccomiianied bv stench, and in almost any case thor-
ough cleansing may prevent this symptom. Usuall}'
there is but little if any difficulty in breathing through
the nose, excepting when it becomes blocked by crusts
of mucus. The eyes are often weak, the sense of smell
is usuall_v lost, and partial deafness commonly exists as
the result of extension of the disease to the middle ear.
When the process invades the accessory sinuses, tlie pa-
tient may suffer from distressing headaches and neu-
ralgia.
Although there is a tendency to formation of dry scabs
anil crusts in the nose, occasionally the secretions consist
only of a semi-fluid adherent pus or soft purulent coagu-
la. This condition is especially ajit to be present during
intercurrent attacks of acute rhinitis.
The mucous surfaces are not usually entirely covered
by the crusts, and where they are exposed the membrane
is commonly pale. Immediately after the scabs have
been cleared awc.yand th( nares have bi^en washed, how-
ever, the mucous membrane is ajit to appear congested,
though not ulcerated. Secretions are found in the nose
in varying (luantity and of viu-ying consistpjice. Those
which have remained the longest have a brownish or
blackish color; others may be of a yellowish or greeni,sh
hue. There may be various jiatchcs of pasty or sticky
pus, or hard yellowish, grayish, brownish, or black scabs
of various size. The odor clings to the crusts after their
removal, but after the nose has been kept thorouirhly
cleansed for a few days it will entirely disappear excejit-
ing in very rare cases in which there is persistence of a
fetid odor in spite of thorough cleansing. Clases of this
sort sometimes result from involvement of the accessory
sinu.ses. In rare instances th<! disease is confined to erne
side, but it is usually bilateral.
When the nasal cavities have been cleaned the tiirbinals
may appear as mere shrunken ridges, or they may have
been entirely absorbed. Not infrequently the naso-
pharynx can easily be seen through the nostrils, and
sometinies the orifices of the Eustachian tubes are in
sight and the motions of the soft palate are plainly visi-
ble. In some cases the atrophy of the bones proceeds
more rapidly than that of the muciuis membrane, and
then folds of more or less congested mucous membrane
will be found hanging, particularly from the upper part
•120
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
>ia»»al C'avitfe§,
Nasal Cavities.
of tile narcs. The process is rarely cnnlnnecl entirely to
the luisal cavities, but also involves the iiaso-|)haryii.\ and
niiildle ear, and in many eases tlie mueous membrane of
the laryn.x and trachea will be found congested and swol-
len or'parlially covered by adiierent pus. Tlie drying
secretions not infrecjuently lodge in the iiaso-pharynx or
even lower upon the pharyngeal wall.
I)i.\(iNosis. — The alVection is to be distinguished from
lupus, syphilis, suppuration of the frontal, ethmoidal,
or maxillary sinuses, and from rhinoliths or foreign
bodies in the nares. The essential factors in the diagno-
sis are the offensive odor, tlie disgusting scabs, the en-
lari,a'ment of the naies with a liLstory of preceding
catarrhal symptoms, and the absence of a syphilitic his-
tory, and of eruptions or scars indicative of this disease.
Luiius nearly always involves the external surface
first, and the ulceration and cicatrization arc quite differ-
ent from the apjiearances found inatrophicrliinilis: there
is very little daiig<'r therefore of confounding the two.
Syi')hililic disease of the nares is attendeil by an ex-
treiiicly olVensive odor, though different from that of
atrophy, the quality being sufficient to establish the
diagnosis with thosewho have seen much of the two dis-
eases. Syphilis usually attacks the septum and causes
destruction of bone, whereas atrophic rliinitis causes
atrophy of the turbinated bodies. In syphilis there is
comiiKinly extensive and marked ulceration, which is not
present iii atrophic rhinitis. The history of the two is
commonly (piite dilferent. In doulitful cases the diag-
nosis may be aided by specific treatment.
SuiJiniVatiou of the accessory sinuses gives rise to an
offensive odor, though somewhat different from that of
ozajua. An inspection of the parts should make it easy
to differentiate sinus disease from simple atroi>liio rhi-
nitis. In suppuration of the accessory cavities there is
usually more or less thickening of the mucous membrane
instead of atrophy. The affection is commonly confined
to one .side, whereas atrophic rhinitis is generally bilat-
eral. In suppuration of the sinu.ses the nasal cavity
may be more or less filled witli liquid pus, Uiougli
usually it does not contain a great quantity, and there is
seldom the tendencj' to the drying of .secretions and the
formation of thick scabs and crusts which is so prominent
in atrophic rhinitis.
Rhinoliths and foreign bodies in the nares give rise to
an offensive discharge, but this is unilateral. When the
secretions have been cleared away, inspection and palpa-
tion with a ]irobe enable one readily to differentiate !)<■-
tweeu these and atrophy.
Prognosis. — The disease usually continues for many
years, but tliere is a tendenc}' to recoveiy about the thirty-
fifth year of age. With appropriate treatment the disa-
greeable symptoms may be promptly removed and the
disease may often be cured in from one to three years,
though sometimes the patient will have to eoiitinne
cleansing the nose two or three times a day until middle
life. Tliere seems to be some relation between atropine
rhinitis and pulmonary tuberculosis, but this may be
only casual ; however, the gradual deterioration of health
due to the persistent disease in the no.se may place the
system in a condition for the development of a general or
localized tuberculosis. It cannot be expected that the
atrophied tissues will be renewed even under Ihi' most
favorable circuiustanees, but occasionally this result will
be obtained. I have even seen hypertrophi<' rhinitis fol-
lowing atrophy.
Tueat.mi-:nt. — Of greatest importance is the frequent
and careful cleansing of the narcs not only for the pur-
po.se of relieving the offensive odor, but also in order that
the remedial agents may be brought in contact with the
mucous membrane. Commonly some alkaline wash is
necessary to remove the dry secretion, and for this ]Mir-
pose a solution of equal parts of the bicarbonate and of
the chloride of sodium, from a half drachm to a drachm
each to the pint of warm water, answers about as well as
anything that can be employed; but various combina-
tions of saliues and anti.septics are recommended by dif-
ferent authors. The patient should lie directed to cleanse
the nares from two to four times daily, using from one to
three pints of water, as occasion may require, so that the
secretions shall all be removed. When this is done regu-
larly, he w ill not be annoyed by the offensive odor. The
wash may be snuffed from the hand or from a nasal cup,
or it may be used with a syringe or nasal douche ; Ijiit
the last two methods arc dangerons because water may
pass into the middle ear and set up infianimation, result-
ing in deafness. As a rule it is best for the patient to
snuff the fluid from the hand or from a nasal cup made
for the purpose. A good instrument fcu' clean.sing the
nasal passages is the Freer nasal irrigating tube men-
tioned in the section on simide chronic rhinitis. A pow-
der containing six drachms each of sodium bicarbonate
and sodium chloride makes an excellent wash when used
in the proportion of one drachm to the pint of tepid
water. Rhodes' or Seller's tablets, from two to four
each to the pint, may be used .similarly. The patient
sliould attend to the washing himself, but he should be
seen by the physician at least once a week during the be-
ginning of the treatment in order that thoroughness may
be secured. After the washing the patient may apply
to the nares various powders or sprays, and occasionally
the physician should make stronger ajiplieations. Pow-
ders are especially useful when the secretion is thin and
free, and the sprays when a tendency to desiccation is
marked. The powders may lie ajiplied by any simple
insufflator. I commonly recommend a glass tube about
four inches long with (Hie-eighth to three-sixteenth inch
calibre: one end of this is flattened, the other end round.
From a quarter to half an inch of powder is inserted into
the roimd end — amounting to from half a grain to a grain
and a half; the end of a rubber tube, about ten inches in
length, is slipped over the same end, the flattened end of
the glass tube is placeil in the nose, the opposite end of
the rubber tube is taken between the lips, and a cjuick
puff is given whereby the powder is blown thoroughly
into the nares. The" powders that I have found most
beneficial, and which may lie vaiiously combined, are
made by rubbing up the active ingredients with sugar of
milk. For this purpose we may employ yellow oxide of
mercury from one-half to three-fourths of one per cent. ;
iodol 25 per cent., boric acid 10 per cent., aristol from 5
to 8 per cent., gum benzoin or myrrh '2~i percent., ber-
berine muriate 10 per cent., and cucaine from 1 to 3 per
cent. The latter must be used guardedly, but when
carefully watched it is sometimes an excellent remedy,
which by causing paresis of the vaso-motor nerves ap-
[lears sometimes to induce regeneration of the tissues.
Kyle also recommends the nitrate of silver, from 1 to 4
jier cent, with stcarate of zinc. The sprays are com-
monly prepared by dissolving various substances in
oleum petrolatum album. The drugs most frequently
used are carbolic acid from one-half to one per cent.,
iodine from one-tenth to one-fifth per cent., oil of cloves
from one-half to one per cent., oil of cinnamon one-half
per cent., thymol one-fifteenth of one per cent., menthol
from one to two per cent. ; five per cent, of ichthyol has
also been highly recommended. It is often desirable after
a thorough cleansing of the nares to apply one of these oily
sprays and to follow it by the ]iowdcr. Gottstehi's wool
tampons sometimes produce excellent results. Moritz
Schmidt, Gautier, and Jouslain have highly recom-
mended copper electrolysis by the bipolar method ; or
the positive pole with a copper needle may be used in
the nose alone and the other pole applied indifferently to
other parts of the body. In the bipolar method a steel
needle is inserted into "the lower turbinal while a toi)per
needle is introduced into the middle turbinal, or the coji-
per needle may be inscrtcil into the lower turliinal and
the steel needle into the se|itum, the vopper needle being
connected with the positive pole. If preferred a plati-
num needle may be used in place of the steel. The nares
having been aniestlietized, the ncedlesare introduced and
currents of from 3 to 1.5 milliampfres are passed for from
live to ten minutes. The treatment may be repeated after
a week ortwo. It is best toreversethe current for about
half a minute just before removing the needle in order to
121
Nasal <'a\ill<'s.
Nasal Cavities.
KEFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
loosen the coagiilum that fastensabout tlic positive pole.
The current siiould. however, lie reduced to zero before
the switch is changed to reverse it. otherwise it will
cause the patient a good deal of jiain. Jleniiigitis has
followed this ojieration and the criliriform plate lias l)een
carelessly perforated. Vei'tigo. syncope, and orliital
neuralgia sometimes follow. E.xcellent results have
been obtained by this treatment in some cases, but in
others it has proven useless. Injections of dijihtheria
antit(i.\in have been tried but without avail. Vibration
massage has also lieen employed with, it is claimed, good
results. " /■'. Fhtrhn- lii'iiih.
NASAL CAVITIES. DISEASES OF: CONGENITAL
AND ACQUIRED DEFORMITIES.— I. Dekm.uoid Cv.sts
.v:.i) FisTi 1..K. — Thesi- cniiditiniis are congenital or are
noticed shortly after birtli. They appear at tlie junction
of the nasal bones with each other and of bolh with the
frontal, as rounded tumors (in case of cysts) of variable
size, not freely movalile liut rather adiierent to the
<leei)er tissues. They are covered with normal skin, and
the centre line is generally on a level with the canthi of
the eyes. A trauma of the mass may lead to a fistula or
the latter may be congenital. The moile of origin of
these conditions is thus explained liy Bland Sutton; The
rudiment of the nose in the embryo is represented by that
process of the primitive skull, known as the fronto-nasal
plate, which is separated finm the lateral portions of the
face by the orbitonasal tl.ssures. Tlie rounded angles of
these i)lates are known as the glulnilar jirocesses. each
one of which forms a portion of the ala of a nostril and
the corresponding pramiaxilla. These processes fuse in
the median line, giving rise to a central piece (philtrum)
of the upper lip. Dermatoids are invariably situated in
the line of the internasal tissure and are in all probability
due to ineoni|ilete fn.sion of the glulml.ir jiroces-ses.
According to Witzel dermatoids in this situation are
not to lie regarded as "sequestration" growths — i.e.,
formed by a sipieezing off of tissue when the lateral
balves of the body coalesce. — but result front the imper-
fect apposition of the two tuberosities which, projecting
from the centre of the face, arising on buth sides of the
median nasal furrow and approaching each other to com-
plete ciialcscenee. ought to form the cartilaginous nose
and septum.
Sirielly speaking, a dermatoiil tumor is comiiosed only
of tissui's found in the skin and mucosa. The cysts va-
riously contain sebaceous material, cellular debris, fat
crystals, and hairs. L'nstriped muscular fibres may ap-
pear in the cyst wall. The fistulie are lined witha filirous
material covered wiih sebaceous matter. The walls are
covered with iy|iical pavement epithelium, while the
subepidermoidal tissue shows scattered aggregations of
round cells. Tin- deeiier layers show connective tissue
of low grade, scattered mucous glands, and giant cells.
Symptoms may be w.-mting. the swelling being noticed
only as something oI.)jec-tionable from a cosmetic point of
view. Fistula' generally give oil' a constant or intermit-
tent discharge of sebaceous or lunco-purulent matter,
which causes an excoriated area on the surrounding skin.
Treatment calls for tlie laying open of tlie cyst or fis-
tula. Willi excision of the entire fistulous tract by means
of a raspatory or sharp spoon. If the fistula branches off
the top and burrows beneath the nasal bdiies. this tract
may be cauterized with the galvanocautery. The whole
is then allowed to heal from the bottom. The fistula
may reopen after it has once healed. Snnietinies a plas-
tic operation may faciliiate recovery.
Cysts are rare. Birkett. writing in 19(11). reported two
instances and colleeti'il six others from varimis snurees.
Since then Krieg has rejiorted two more. Fistuhe, how-
ever, are by no means uncommon. The .f-ray niaj' help
to clear up a doubtful diagnosis.
11. CoNGENiT.\i. Occasion of TirE N.^bes. — Complete
congenital occlusion of the anterior nares is an extremely
rare condition. Jarvis reports two eases, and claims that
they arc the first on record. One of his jiatients was a
boy of eighteen, who jireseuted, instead of the dark out-
lines of the nares. cuji-shaped depressions about 4 mm. in
depth, the barrier being of membranous consistency ; one
side admitted a very fine ]>robe while the other was abso-
lutely impervious. 'I'he other case was that of a girl of
sixteen, in whom the inferior meatus on both sides was
blocked by bony growths of ivoiy hardness. At times
she had been able to e.xpel a little air through the nose.
Krieg has reported a case— probalily of syphilitic origin —
in a boy of three years.
Congenital occlusion of the posterior nares is by no
means uncommon. The barrier may be either membran-
ous or bony (the former being far more common), com-
|ilele or partial. According to C. H. Knight, the condi-
tion may result from (1) exostosis or simple hypertrojihy
of the osseous structure of the middle or inferii>r turbi-
nate; (2) a ridge or exostosis from the vomer; and (8) an
adventitious bony plate springing from the floor of the
nose or from its outer cavity. HoA\ever, in most instances
which belong strictly to this category, the bony plate
spreads like a web over one or both clioana>. being di-
rectlj- continuous with the palate bone, of which it forms
an integral part. Sometimes the obstruction is a de-
flected vomer which enlarges one choana at the ex|)ense
of the other. Luschka believes that the bony plate is a
continuation of the free border of the horizontal plate of
the palate bone; Kundrat. that it is an extension of the
vertical portion; both eomlitions are possible. In some
cases the central portion of the barrier appears membran-
ous, surrounded by an irregular fringe of bony spicules
projecting inward from the periphery; such cases are
naturally attributable tohypernutritive changes. Iiigals
believes that membranous closure in this region is not
congenital, but always the result of syphilitic, diphther-
itic, or other disease processes.
SijinptomK. — These naturally vary according to the de-
gree of obstruction. If the latter is complete at birth,
the chances of survival are very few. Difficulty in nurs-
ing may be the first thing to call attention to the possi-
bility of the existence of the lesion. If the obstruction is
partial, the patients grow up, laboring under all the disad-
vantages of nasal occlusion, both in its local manifesta-
tions and the distal disturbances to which it may give
rise. In unilateral occlusion there is often a partial lack
of development of the corresponding side of the face and
of the vertebral column. 13y animal exiierinientaticm
Zicm has shown that these effects are directly due to
nasal occlusion of the corresponding side. In infants
there is "not only the inability to suckle and the conse-
quent difficulty in obtaining sullicient food, but also the
exposure of the bronchial tubes and delicate air cells of
the lungs to the constant irriUitiou of air insulficiently
moistened, filtered, and warmed." The nose generally
secretes moisture, but the secretion is apt to accumulate
in an annoying manner. From mouth-breathing the nro-
pliarynx is generally dry. The voice lacks its nnniial
resiinance. The sense of smell is in abeyance while that
of taste may persist though imjiaired for its finer ciuali-
ties. The effect on hearing is variable. This function is
often perfect. Toynbee contended that under these con-
ditions the act of swallowing would cause a constant suc-
tion on the I^.uslaehian tulieaiid thus lead to a depression
of the membrana tympani. but such a sei|uel is by no
means constant. In many instances the ease with which
the jiatient will sustain impairment of these three special
senses is quite remarkable, and, as Knight observes, in
notable contrast with the disturbance following a similar
acquired post-nasal obstruction.
Tridtmeiit. — The barrier must be pierced, the opening
enlarged, and the patency thus acquired maintained.
In patients of fortitude this may be done under cocaine.
For membranous occlusions the galvanocautery will suf-
fice; bony barriers require the trephine or chisel and sub-
sequent enlargement with revolving burrs. The open-
ings should be made as large as possible. Much difltculty
may be ex]ierienced in keeping them pervious. For some
time after the operation pledgets of oiled gauze should
be inserted, anci after healing has taken place bougies
and dilators should from time to time be passed.
12-2
KEFEUE^CE HANDBOOK OF THE MEDICAL SCIENCES.
Masai CavllicM.
Masai Cavities.
III, Malformations. — Several eases of congenital
median fissure of tlie nose liave Ijeen reported; also cases
of nasal lierniatropliy. In one instance of the latter the
right half of the organ was normal. The median portion
was covered with skin, but instead of the left half there
was a body 1.5 cm. long by 0.70 cm. wide, and in sha]ie
like an elephant's trunk. This process was extirpated,
leaving a permanent fistula. Tlie patient was a child of
live years. Such cases are among the curiosities of medi-
<-ine,' and each one can be considered onl}' in the light of
the problems whicli it presents.
.MaH'ormutions of tlie ahv may be congenital or they
may result from disease. Various ])lastic operations have
lieen s\iggested. One devi.sed by Koenig merits special
mention, lie takes a flap made uji of the entire .suli-
.slance of the auricle and sutures this in place of the
defect in the ala. As this flap contains cartilage it heals
well.
Outside of the various alar deformities resulting from
tissue destruction, especially from syphilis, there may
be a sim|)le collapse of the alar cartilages, so that insuf-
ficient air reaches the interior of the nose, and the impact
of the inspired air tends still more to close the nasal en-
trance. The condition ajipears at times to be merely an
accentuation of a congenital condition, or it may, result
from lack of development, or from inactivity of the nasal
wings. Tlie whole ala may be atTected, or merely the
plica veslibnii — i.e., the outer border of the inner nasal
o]U'ning, There may be a la.xity of the entire nasal wall
with defective action of the dilator and levator mnscles.
In the congenital cases it will be found that the part
principally at fault is the band of tissue at the junction
of the lower lateral cartilage and the bony margin of the
anterior uares, its position being noted externally by the
depression usually seen immediately above the lower
expanded part of the nose. If the middle turbinate lie-
comes enlarged, the entrance to thenaris is apt to become
smaller.
The main s}-mptom of the condition is nasal obstruc-
tion leading to mouth-breathing.
The condition in old pers<ins may often be relieved by
the wearing of a delicate tubular spring within the nares
to hold the ahe in position, or a flat metallic band may
be inserted. A similar procedure is often of great liene-
flt in the temporary collapse seen in typhoid fever, pneu-
monia, etc.: also in tuberculosis involving the larynx.
The increased air supjily is very grateful to the patient.
In young persons an etl'ort should be made to reston' the
tone of the dilator ahe muscles. Practice in stretching
these will increase their activity. The lubrication of the
interior of tlic nares with some ungvient carried on the
finger will stretch the parts and assist in the recovery of
their normal tension. In other words, we should apply
tlie jirinciple of massage.
IV. FltACTIlUE AND DISLOCATIONS OF THE NaSAL
Bones, — Fractures of the nasal bones constitute about
one per cent, of all fractures. They may be simple,
compound, or comminuted. Both bones are generally
involved. The injury may also alfect the perpendicular
plate of the ethmoid, but the vomer geiieially escapes.
The fracture may also extenil to the nasal processes of
the superior lua.xilhe; the cribriiorm plate of the eth-
moid is, fortunately, rarely involved. It niaj' also in-
volve the zygomatic arch or extend to the frontal sinuses,
thus possibly opening a piortal for .septic infection of tlie
meninges. Occasionally the lachrj-mal bone is involved,
with obstruction of the tear duct. Very often the nasal
bones are not really fractured but simjily separated from
their attachment to the superior maxilhe, or the bones may
become .separated from each other; this separation may
allow the bones to remain in perfect apposition, or they
may be depressed.
The causes of this class of injuries are blows and falls.
It has been said that displacement in the infant may come
from the pressure of burying the nose against the breast
or in tlie pillow.
The exact lesion iiroduced varies according to the di
rectiou of the trauma. If it is from below, the brunt of
impact falls upon the septum, while the nasal bones may
escape. The triangular cartilage is detached from its
bony surrotmdings, including the nasal sjiine of the su-
perior maxilla. Here there i.s merely swelling of the
septum, whicli may run on to ab.scess with not much ex-
ternal deformity. It the trauma is from the side, both
bones may be dislocated laterally, while their internal
borders remain in contact. If it is from in front, the
nose is flattened, the inner boixh'rs of the bones are
driven outward and tilted so as to form a sharp ridge on
either side of the nose. Perhajis the most common form
of injury is a transverse fracture about the middle of the
bones, driving back the lower fragment or possildj- both
bones backward between the nasal processes of the supe-
rior maxilhe, thus leaving a depression instead of the nor-
mal nasal convexitj'. Unless the upper half of the bone
is distinctly driven in, the perpendicular plate of the
ethmoid generally escapes.
The symptoms are cijisfaxis, deformity, and marked
swelling. The latter may extend to the cheeks and eye-
lids. From the direct resultsof the traumaor from forc-
ible blowing of the nose immediately after, there may be
a subcutaneous emphysema with crackling on pressure.
The latter condition on the forehead (when the nose has
not been blown) is an evidence that the frontal bone has
also been fractured. iMore or less ecchj'mosis quickly
forms. The swelling niiiy mask the exact nature of the
injury. The nose ni[iy retain its normal shape or be but
part of a diffused swelling. In the latter .state, bony
crepitus is elicited with dUliculty ; it may possibly be ob-
tained in minor cases.
Diagnosis is made fiom the foregoing conditions and
from careful digital examination. It is to be remembered
that many of the so-called "broken noses" have never
been actually fractured. Rhinoscopy should never be
omitted. In doubtful cases the .r-ray may accurately de-
termine the relative positions of the various bony struct-
ures.
Treatment calls for the restoration of the bony parts to
their normal contour anil for the adoption of such means
as will keep them in their proper ))ositions. The actual
relations must first be tletermined, and for this purpose a
general anaesthetic (a little chloroform) is often necessary.
The under surface of the nasal arch shcuild be carefully
pnibed for irregularities. In many cases the bony parts
are easily replaced and only a cold compress is required.
In more ditlieult ca,ses an instrument, such as a metal
catheter (fiMiiale) or the closed blades of a dressing forceps
should be introduced into the naresand the bones elevated
to their proper level, while their position is regulated by
the fingers on the outside. The object is to restore the
nasal arch. If this can be done and the iiatient is a self-
controlled person who will let his nose ;ilone, the above
measures are all tlj;it isreijuired. Instruments should lie
covered with light rubber tuliing. It is better, as a rule,
to dispense with external splints and plugs in the nares.
The emphy.sema requires no treatment. Epistaxis is
treated in the usual manner. Firm union results in from
two to three weeks.
If the bones should show a tendency to fall in again,
thc}^ may be raised by tlie insertion, within the nose, of
an indiarublier ililator, introduced empty and then
filled with water, or a piece of rubber tubing may be
used. Plugs and splints are generally useless because
they rest on the floor of the nose, while the trouble is
higher up, and thus is not reached by them. If the nasal
bones show a tendency to separate, we may make a plas-
ter splint by having tlie patient lie flat while several lay-
ers of a plaster bandage are moulded over the nose, the
ends being carried out on to the cheeks. The ends carry
tapes which fasten behind the head. Thus the apparatus
is well worn at night. Another ,serviceahle material is
gutta-iiercha, wdiich may be cut to the general shape of
the ]iart, covered with antiseptic gau/.e and then ren-
dereil malleable by insertion in hot water. It is then ac-
curately fitted to the nose and secured by tapes. Block
tin, thin cop])er, and aluminum may be used in the same
way. These splints may be padili'd with cotton to exert
123
Na^nl Cavities.
Nasal Cavities.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
pressure in any direction re(.|iiired fcr nmintainiti.ir liie
(iriiper shape of tlie luise. Anollier devic-e is tlic eniidoy-
mcnt. witliin tlic nose, of the Herniiys sponnc niaterinl.
cut to lit the niiris. Variinis head- hands witli foreliead
plates, to whieli nasal apjiaralus may be t'ast<'ne<l. have
l)een employed. In the worst cases it is justitiable. it'
marked del'onnily lias resulted, to cut down on the frag-
ments, replace them, and close the wound. TIk^ result-
\b'^ scar will be trivial in comparison with the del'orniity
unrelieved by operative intervention.
V. Saiidi.e Nosi';. — This term is applied to that par-
ticular deformity in which tlie usual convexity of the
nasal bones is replaced by a depression which is the more
marked from the fact that the mechanical conditions
causing it also tip the ]ioint of the nose u])ward. The
deformity is generally the residt of some idcej-ative ])roc-
ess, syphilis being resiionsible for the majority of cases.
The nasid bones are supported in I heir anterior third by
the quadrangular cartilag<\ and in their posterior two-
thirds by the perpendicidar plate of the ethmoid. Con-
sequently the entire cartilage may disapjiear without any
change iii the external contour of the nose; but when the
destructive process encroaches upon the ethmoid or sidi-
jacent vomer, the support of the arch begins to crumble
and deformity results. The latter is still further aggra-
vated when the destructive jirocess invades the nasal
processes of the sn|)erior maxilla.
Various operations have been devised for the relief of
this condition. In minor conditi(ais a suiiport may be
introduced thiough a sidicutaneous incision. Marked
deformities requir<i exiernal incision. With such oper-
ations the names of Israel and Koenig ai'c intimately as-
.sociated. A deep incision is made along the ilorsum of
the nose, and a flap from the forehead contaitnng skin,
periosteum, and a .small fragment of bone is diverted to
till the sunken area, the fia]) lieing stitched to the lower
portion of the nose. Thedeuuded space on the forehead
is then closed, while secondary operations are required to
close the lateral gap.
Another type of operation is that of raising the de-
pressed area and maintaining it in pi.isition by a bridge of
some light metal, such as platinum or aluminum : cel-
luloid has also been used for the same purpose. With
such procedures the names of Lerievant and Martin are
a.ssociated. A very convenient form of bridge is that
devised by F. E. Hopkins, in which the rounded convex-
ity of the bridge is supported on each side by an arm
which runs out on to the upper surface of the superior
maxilla and is there secured. For the insertion of such
apparatus it may be advisable first to perform Rouge's
operation, consisting of incision through the gingivo-
labial fold, dissection of the lip and face from the sub-
jacent bone as far as the border of theuares, and the divis-
ion of the sejitum. so as to allow the entire ii<isi> to be
turueil up over the f:iee. thus more or less comiiletelv
exposing the bony o]ienings of the nasal ]iassages. The
great objection to all such a|>paialus is that we cannot
foresi'e that it w'ill be cond'ortably worn, and moreover
there is ^dways danger that the ])ressure of the bridge
will lead to ulceration and destruction of tissue. In se\'.
eral instances the jiain attending the wearing of tlie
bridge and the threatened integiity of the tissue have
compelled the removal of the sup])orl.
A very recent plan of treatment, and one that pronnses
much, is that of parallin injections under the skin .so as
to raise the latter to a normal position and thus restore
the normal contour of the nose. It was di'vised by Ger-
suny. of Vienna, in li)00; and while it is still Kuh jiidici:.
suHicient time has elapsed in several instances to predi-
cate its success and wid(> a|iplicability 'l"he skin is
carefully disinfected ;uid cocainized with a four-percent,
solution, whiidt is also carried into the area to be occu-
pieil Ijy the parallin. The melting-point of the latter
slnudd be about lO.'i' F. The ordinary white parathn is
too luird, while the soft variety, known as white vase-
line, is too soft. A mixture of the two may be niaile of
just the right melting-point. A .syringe, made entirely
of metal, is preferable, with a needle of moderate calibre.
The parallin mixture is first sterilized and then drawn
into the syringe, which is kept in sterilized hot water.
When all is ready for the injection the syringe is allowed
to cool until its contents is.sue, not as a liquid but as a
coherent string. The needle should be inserted at a lit-
tle distance from the depressed area, but carried beyond
the point of greatest defect, and the material slowij- ex-
pelled, the syringe being meanwhile slowly withdrawn.
The parallin remains plastic for about half a minute,
during which time the nasal convexitv thus produced
can be pro])erly moulded. A temporary lymi)liatie a'de-
ma may follow, but it has been found that the paraffin
will retain its shape, and that it produces no deleterious
consequences when onci' lodged under the skin. It grad-
ually becomes encapsulated by connective tissue, a fact
which is still further a<lvant.ageo\is in heljjing to retain
the new shape of the no.se.
Objections have been made to the effect that this new
mode of treatment may cause some danger of lung em-
bolism; also that any rise of body temperature might
cau.se a melting of tlie paraffin. On this account some
have lu'eferred a paraffin with a higher melting-point,
sa_y one of IIU F. As far as is known, no cases of em-
bolism have resulted from supranasal injections.
VI. Syneciii.e. — Adhesions may occur in any part of
the nasal chambers, but the great majority of them are
visible by anterior rhinoscopy. The}' assume various
appearances and are of various shapes.
VdiiKei. — In many of these cases the synechire are the
result of some operation in the nose, especially the over-
zealous or careless use of the galvanocautery ; less fre-
ipiently, they follow the use of cutting instruments.
Some cases are attributable to traumatism, such as a fall
or a blow. Even when operative intervention has been
ftdly justified and skilfully perfonned, neglect of after-
treatment ma}' iead to unfortunate results. Adhesions
may also result from the use of chemical caustics, or of
powerful Inemostatics, as the Li(|Uor ferri chloridi. A
few cimgeuital cases are recorded. The condition also
follows diphtheria, measles, scarlet fever, and occasion-
ally acute and chronic rhinitis. Basing his statements
upon autops}' records, Zuckerkandl found inflammatory
cases far more common than traumatic, bis figures being
in the proiiortion of seventeen to three respectively;
statistics based on cUni<'al experience shovv traumatic
ca.ses to be more common. They are more apt to occur
between the upin-r turbinates and the septum than bi--
tween the latter and the inferior turbinate.
In all ac-quired cases the mode of production is essen-
tially the same. Either from trauma or from some tro-
phic disturl)ance leading to loss of tissue two o]iposing
surfaces become bared, and later approaching eacli other
become fused in the [n-ocess of healing.
Sijiiijitiiiiis. — Symptoms de]H'nd on the degree of nasal
oljstruction. Diagnosis is made hy inspection, and the
extent of the adhesion is determined liy the prolve.
Tredtnicnt. — This consists of the removal of tissue ex-
cess and the prevention of readhesion until both sides
have healed. The question turns upon the proper
metluKl to be adopted in each individual case. In oper-
ating on either the septtim or the turbinates the utmost
care should be exercised not to wcnind the (>p|.)osite sur-
face; if inadvertently the least injury has been inflicted
on the healthy tissue, some form of tampon should be
W(M'n for a few days, A pledget of oiled gauze or cotton,
a thin jdate of celluloid, or some form of tubular .s-jdint
may be used. These should be removed dail.v, cleansed,
and reinserted. So also in treating severe acute injuries
of the septum or ahe nasi, we shtmld bear in mind the
necessity of maintaining the patency of the nostrils dur-
ing healing. In cases in which the adhesion is firm and
hard, it ma_v be cut through with tlie galvanocautery or
.scissors, and the cut edges kejit apart as above indicated.
In narrow nostrils it is extremely dilficult to prevent re-
adhesion. Watsiin has advised persistent friction with a
cotton-wrapped i)robe, stating that he has often seen ab-
,sorptiou of the adhesion follow this man(puvre. Others
have suggested the encircling of the adhesion with a loop-
1l>4
EXl'LANATIOX OF
PLATK XLV.
EXPLANATION OF PLATE XLV.
Figs. 1, 2. ;uui 3.— Pupillary Growths Removed from tbe Xasal Mucous ilembrane by Cleans of the
Wire Suare Heated to a Red Heat. They represent simple hypertrophies of the mucous mem-
brane.
Fig. 4. — Ulcer on the Left Side of the Septum Xarium. the Xasal Mucous ^Membrane Everywhere
Else Being (Juite Healthy. Syphilis many years previously. Specific treatment was tried in
vain. Healing finallj- took place under the combined use of a long series of cauterizations and a
paste containing resorciu.
Fig. 5.— Smooth Hypertrophy of Both Lower Turbinates, in a Man Fifty-three Years of Age. The
most marked pathological changes existed in the pharynx and larynx. The picture gives a faith-
ful representation of a genuine connective-tissue hyperplasia. Xeither pressure with a probe nor
the ai'plication of cocaine caused the mucous membrane to j'ield to a noticeable degree. Both sides
weie aliiiut eciually altected.
Fig. (i. — Polypoid Degeneration of the Middle Turbinates, iu the Case of a Woman, Sixty-live Years
of Age, who had SulTered for Some Time from DacryocystoblennorrhQ?a. Smooth liypcrtrojihies
of the midille turbinates aie often scarcely- distinguishable from true polypoid growths. It is only
after the mass has been extracted that one is able to establish the fact that it represents an altered
state of the mucous membrane covering the concha. After the operatiou the latter will .sometimes
be found denuded of all covering throughout quite an extensive area. (Xote the vascularization of
the tunidi', )
Fit;. T. — Papillary Hypertrophy of Buth Lower Turbitiates in a Woman Forty-two Years of Age.
Excrescences of considerable size are visible iu the i)icture. Those situated in front and above
are veiy vascular and red,
Mhereas those which lie
farther back and below
are cpiitc pale. The right
middle turbinate shows a
condition of smooth hy-
pertr(i|ihy.
Figs, S and 10. — Epistaxis
due to a \'arii'iise Condi-
tion of the Blood-vessels
of the Cartilaginous Sep-
tum. In both of these
pictures the artist, in mak-
ing the diau ing of the right half of the nose, has turned thi
the left as he cnuld, in order to secure as broad a view of the
the left half of 1 he Muse lie has simply reversed the process.
Fig. !t. — lly|iertro]ihy of the Lower Turbinates: of the Smooth Varietv on thi
p.ilypHicl hvper- '
I'lasia I
aiUerinr end nf /
the ri^ht lower -
turbinate 1
spina septi
— sceliolic septum
* anterior end of the
( left lo.ver turbinate
I lar^e-sized, variously
I colored papillary
j hyperplasia? of the
I left lower turbinate.
Key to Kisr. 7 of riate XUII.
patient's head as far round toward
sejitum as possible. In the case of
Riiiht Side, of a
I'apillai'y Xature on the Left and iit the Posterior End of the Turbinate.
Fic;. II — Papillaiy Hypertrophy of the Posterior Ends of the Lower Tui'binates. of such Dimensions,
on the Right Siilc, as Entii-ely to Cover up the ]\Iouth of the Eustachian Tube and Clo.se the Pos-
terior I^nti-ance of the Right X'arial Passage. On the left side the hypertrophy is less pronounced.
Fig. 12.— Polypoiil Hyinrtiophy of the Posterior Ends of the Lower Tuibinates. (Also remains of
])hai'yngeal tonsil.) The patient was a young m:in. eighteen years of age. Altliough these poly-
[loid masses ai'esomewliat hummoeked or knobbed, as they generally are, they should, in the pres-
ent instance, still be classed as smooth hypertrophies.
Fig. 13. — Abscessof the Septum Xai-ium. Pi'obably of Traumatic Origin, iu the Case of a Child Fifteen
ilonths Old. On the left side there is a s)iot where softening has ali-eady taken place and where
a s]iontaneous luiiture is aliout to occur.
Fig. U. — I'erl'oration of the Septum Naiium in the Cartilaginous Portion. Quite Far Forward. The
margins of the opeuing still show irregularities of the surface and are eroded. The nasal mucous
membrane as a whole is i)ale and atrophic. On looking through the opening, either from the
right side or fi-om the? left, one can see the surface of the o])]iosite turbinate as far back as to its
postei-ior end. The i)atient was a woman thirty -four years of age, and the cause of the defect was
probalily lupus.
Fig. 15. — Another Instance of Pcu'loiatioii of the Septum Xarium in a Patient who Manifeste<l X'"o
Other Evidences of Disease The etiology in this case is unknown.
Fig. 10. — Abscess of the Septum, witli Pidtrusion of the Overlying Mucous Membrane only on the
Left Side. (Perforation occurred spontaneously.) The aniei-ior end of the left lower turbinate is
in an inflamed and swollen condition.
REFERENCE HANDBOOK
OF THE
MEDICAL SCIENCES
PLATE XLV
PATHOLOGICAL CONDITIONS OF THE NASAL MUCOUS MEMBRANE
'From the "Atlas der Kranfthviten tier IVase." bif Dr. P. H. Gerbfr.t
KEFEREXCE lIAXUiJOOK UF THE MEDICAL SCIENCES.
\asal i'uvilies.
Masai Cavities.
of. Steel wire, wliieli is worn in the nose anil gradually
tightened from day to day ; the adhesion is thus gradually
cut through, and the purls heal as the section advanecs.
Still others pass a silk thiead loop through the centre of
tlie adhesion, wait until Ihe central opening has liealed,
and then cut from it — that is, they use the fauiiliar
method employed in separating the adhesions between
webbed fingers from burns. Reunion is always pre-
vented by the presence of the narrow strip of cicatricial
tissue at the base of the cut. In the use of the knife to
make the separation, care should be taken not to injure
the tissue at its back. After healing is complete, the
narrow band back of tlie original central perforation may
be severed. In all these cases the systematic after-use of
some form of dilator is for a while advisable.
VII, Peufokations OF THE Skptum, — These may re-
sult from syphilis, typlnis, typhoid, scarlet, and otlier
fevers in wliieh trophic disturbances lead to a local dis-
organization of tissue. Other causes are acute iirimary
chondritis (rare), trauma (either accidental or surgical),
pressure of tubes and splints, etc. A frequent variety
of perforation is that following the lesion known as
"simple perforating ulcer," which occurs in perfectly
healthy persons without any dyscrasia. It is distin-
guislied from tubercle and syphilis by the condition of
its edges which are regularly siuooth and healed, by
the absence of accompanying lesions on the outer Avails
of the nose, and especially from syphilis by the fact
that the latter shows a selective atbnity for the bony
structures, w-hile the simple perforating ulcer is strictl}-
contined to the cartilage, lu the latter, four stages pre-
sent them,selves: (1) injury or long-continued irritation,
as from picking the nose to remove the crusts that fre-
quently form at this site; (3) hemorrhage into the mu-
cosa (the .xanthosis of Zuckerkandl) ; {■'>) erosion of the
capillaries with consequent impairment of nutrition;
and (4) partial atrophy leading to pierf oration or not,
according to the presence or absence of infection. The
exposed site of the ulcer re,gularly leads, however, to
infection. After the perforation has taken place we tind,
as noted, a rounded or oval fenestra in the septum with
smooth edges. It occupies the area known as the " locus
Kiesselbachii. " There is no specific bacteriology of the af-
fection, the ordinary sta|ihy lococci and streptococci being
found. While forming, the ulcer ap|-.cars as a truncati-d
cone with the ba.se supertieial. Theaiea becomes macer-
ated by the nasal .secretions, and there is really a necro-
biosis of the mucosa. The tissue loss is also favored by
the fact that at this ,site the mucosa is unusually thin,
and contains a small congeries of rather large vessels.
Symptoms are wanting after the edges have healed.
Many cases come under observation only on systematic
examination, liaviug given no symptoms whatever, (See
Plate XLV., Figs. 14 and 1.1.) "
'Treatment calls for measures to combat any existing
dyscrasia. If the edges are raw. a tifty-per-cent. solu-
tion of silver nitrate may be applied; later, we may I'se
iodine gr. v., iodide of pVitassium gr. x., in half an ounce
of glycerin,
VIII. Outgrowths FitoNr the Septu.m. — These ni.ay
appear as crests, spurs, ridges, orroundeil masses on any
portion of the se])tum. A favorite area is along the lines
of junction of its various bony and cartilaginous com-
ponents. Some of these excrescences are lit t le more than
thickenings of the mucosa, and if their removal be deemed
neces.sary, it can be effected with the galvanoeautery.
Reaction following the application of this agent to car-
tilage is often severe and it must be u.sed with caution.
If the outgrowths contain cartilage we may em|)loy
knives, .scissors, gouges, draw'-shaves, and electrolysis;
if they contain bone ,salts or true bone, we may use tre-
phines, saws, or chisels.
Previous to all sueli manipulations the nose should be
carefully cleansed with some disinfecting agent and then
cocaine and adrenalin applied. Most of these operations
can be done under local aniesthesia. After-packing is
best omitted. If the wottnd is smooth and respii'ation
can be carried on through the affected side, bleeding will
quickly cease. Packing causes retention of .secretion
with lialiility to infection. So also antisei)tic powders
should not be so friM'ly employed as to form a crust in
the nose. Tlie patient must keep quiet for a time and
wear just inside (lie vestiliule a /.i"i.si: |ilug of cotton to
strain out the dust from the inspired air. He must /v,/;
his jiiHio-.H ijutof/iiii «(Mnand be taught the ])roper method
of blowing the organ when using cleansing washes.
IX. DEVLvrioNS OF THE Septi.m. — The causes of this
condition may be traitnia, the long continuance of turbi-
nal abnormalities, or a faster growth of the cartilaginous
septum than of its bony frame. It is not always easy
to est;iblish the history of trauma, for it iii:iy refer liaek
to any one of the numerous falls of childhood. Many of
llu'Se, regarded at the time as trivial, may be the starting-
point of hyperuutritiou with couse(|ueut deviation. It
is impossible to make any classification of deviations that
is entirely satisfactorj'. They may involve the bone or
cartilage, and may be vertical, horizontal, or both.
They are generally associated with some local out-
growth.
Tlie symptoms are those of nasal obstruction with its
effects upon both neighboring and distant organ.s. !Many
minor degrees of deviation give no symptoms and re-
(|uire no treatment.
The number of o]ierations devised for tlie correction of
deviated se]ita is legion. Only a few of the more useful
ones can here be mentioned,
77/c Asch OiH rittivii. — This is done under general anies-
thesia, Nitrous oxide is an ideal agent. Previous to
the administration of the aiuiesthetic, adrenalin solution
should be applied to both sides of the septum. If any
adhesions exist between the septum and turbinates, they
are broken up by means of the gouges belonging to the
special set of iu.struments devised for this operaticjii.
The blunt blade of the scissors is inserted into tin- ob-
structed nostril and the cutting blade into the other. A
crucial incision is then made, the scis.sors being with-
drawn for tlie change of position in the second cut;
this latter crossing the first as nearly as possible at
right angles at the point of greatest convexity. The
forefinger is then inserted into the obstructed nostril;
the segments made by the incisions are pushed into
the oppo-sito nostril and the jiressure is continued until
they are thoroughly broken at their b.ase and the resili-
ency of the septum is destroyed. On, t/iiK paint dcjicmls
tlie succfss of the operation ; for unless the fracture <f
these ser/iiieiits is mxiired, the resilicitey of the eoriilage will
not be oivreoine and the operation will fail. The septum
is then to be straightened with the flat-bladed forceps.
The little lilood there may be in the nostrils is wiped out
with a cotton pledget and a flattened hard-rubber or
block-tin splint is inserted in each nostril. These act as
suiqioiis for Ihe septum and tend to prevent .secondary
henK)rrliage. The jiatient should be kept in bed for two
or three days, ice cloths being apjjlied over the no.se if
there is swelling or pain. The uares should be sprayed
through the tubes with some auti,septic. Twenty-four
liours after the operation the tube on the previously jiat-
eiit side is removed and not replaced. The nostril is
cleansed and an anti.scptic powder insufflated. It is well
to protect the naris with a loose i>le(lget of cotton when
in the open air. The tube on the previously occluded
side may remain /« ,v//« for another twiMity-four hours,
when it is to be withdrawn, the no,stril cleansed, and the
tidje replaced. It is a sitlint for the septum and may bi-
withdrawn daily for a week, then on alternate days, and
gradually at lengthening iiiterv:ils until healing is eoni-
plete. If the case can be seen daily, the tube can prob-
ably be removed at the end of from two to three weeks.
It must be of such a size that it can be easily reinserted
without pn'ssure. else it will be crowde<l out by the tis-
sues behind and the operation will be at best but partially
successful. It is completely hidden by tlu; ala'. and if
well fitting catises no discomfort to the )ia.tieiit. Sulise-
quently to its permanent removal small liits of granu-
lation tissue may re(|uire cauterization or removal with
foicejis in order that an entirely smooth surface may be
I2i
Na«al <'avlllt<8.
Namal faviticnt.
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES
left. Care sliouUI also l)c laki-ii sci to make tlie incisions
tliat (lie tube will rest (in I be lliMir of tlic nose.
7'/i( WiitnoH Operation. — Tills is espeeially applicable
to those cases in which the deviation is marked and low
down, so that it is impossible to biini;' the lower frajr-
nient into line. Instead of cutting out an elliptical jiiece
aloni>' the horizontal line, as is recommended liy some
aulhiirs, Watson makes a bevelled incision, the ed.ije of
the kint'c being directed ujiwardand toward the opposite
siile, and carried thrnnnh tlir nirtHiKji' Iml )iut tlie mucosa
of I Ik' opposite side. The incisiim is made on the crest
of the deviation. If a vertical deviation exists at the
same time, a triangular-shaped portion with the aju'X
uppciniost may be removed. The upper portion in the
horizontal incision is pressed over toward the other side,
wliere it hooks on to tlie lower and is thus held in place.
Tlie ])rojeeting base can afterward be removed.
The (Ilea no I) Ojieration. — The tlelil of (iperation is co-
cainized and c.\])osed by a si'lf-relaiiiin.g nasal speculum
A thin saw is introduced alon.g the floor of the septum
beneath the deviation. The sawing is continued in a
horizontal direction until the blade has penetrated some-
what <leeply into the tissues, when the direction is rapidly
changed to one nearly vertical. It is of the utmost im-
portance that the bhide be now held exactly parallel to
the septum in order that the cut shall be around and not
througli any part of the deviation. The length of the
vertical crura is then (juickly increased by means of a
small bistoury curved on its flat, and the tlaj) is thrust
through the hole in tlie septum liy means of tile fore-
tin L:er.
While the tinger is siill in the nares, it is carried iqi
along the anterior and posterior crura in order to make
certain that the edge of the flaj) has conipletel_v cleared
them, and the neck of the flap is then sliarply "bent. It
is not necessary to denude the edges that are in contact.
Tlie pressure results in necrosis (at least of the superficial
epithelial layer) of the mucosa, after which the parts
unite. The special claim made for this operation is that
it destroys the resiliency of the llap (a condition of sue
cess in any operation) at its neck. It is at this )ioint,
and ]iractically at this alone, that resiliency is active — i.e.,
at tlie neck of a com|iaratively long, narrow flap — and
hence has a powerful leverage to overcome before it can
thrust the inferior edge of the flap back tlirougli the sep-
tum. The neck should lie bent to nearly a right angle.
T/ie Pill Opcnilioii. — This operation, devised by Rob-
erts, is performed by making an incision through the
most prominent ))oition of the convexity, breaking up
the resilicnej' with a stellate punch, and introducing a
steel pin through the more open nostril, thrusting its
point through the anterior part of the septum, forcing
the curved portion of the latter into proper position, and
then burying the jioiut of the pin in the jiosterior part of
the se|itum on the previously occluded side. The head
of the pin should be covered with some smooth material
to prevent irritation of the columella.
IiKjaW Operaiioii. — In cases in which the cartilage is
bent almost at right angles across the nostrils, Iiigals dis-
sects up the mucosa, removes a triangular jiiece of car-
tilage of sufficient size, incises the latter farther back at
its upper or lower part to destroy its resiliency, and
maintains the septum in jdace by a plug in the occluded
naris.
Hoi's Operation. — Roe has devised an operation apidi-
cable to either bony or cartilaginous deviations. He in
sists upon the necessity, even if the ileviaticm be confined
to the cartilage alone, of fracturing the bone at or adja-
cent to the attachment of the cartilage. The chan.ge in
direction of the latter attachment tends to hold the car-
tila.ge in its new |iosition. Roe's ojieration rec|uircs a
special fenestrated forceps, one blade of which is an ovate
ring wliiic the other — long, narrow, anil rounded — fits
loosely into it, so as not to injure the septum. The
length of the handle prevents compression of the ante-
rior jiortions of the sejitum. The male blade is intro-
duced on the convex, and the female blade on the eon-
cave side of llie deviation. The closure of the blades
crowds the deflected portion of the septum into ami
partly through the opening, indenting and fracturing it
without affecting the surrounding area. The septum is
held in its new position by a plug of metal wrapped with
sterilized cotton or gauze. It is placed on the originally
convex side and fills the naris.
Moure's Ojieni/ion. — lloure. of Bordeaux, has devised
an operation wliicli he icgards as an imiuovement on
that of Asch. Spurs and thickenings are fir.st removed
with a .special instrument consisting of an elongated ring
with cutting edges on its elliptical extremity. These
tilades are concave externally and convex on the opposite
side. Bleeding is checked by the cautery. Luxations of
the antero-infcrior jiart of the sejitum are resected with
a knife, the mucosa being sutured. After full healing
has occurred, the septum is attacked. Under cocaine an
incision. 3 or 8 cm. long, is made close to and iiarallel with
the nasal floor, special scissors resembling those of Asch
being employed for the purpose. A second incision is
then made at an acute angle to the first and near the front
of the nose. There results a movable fragment held in
front by the anterior part of the base of the septum,
which has been left uutouched toward the tip of the nose,
and behind by the perpendicular plate of the ethmoid
and the vomer. The next step consists in the introduc-
tion, on the side of the deviation, of a tubular dilator
formed out of the parallel blades, the outer one being
rigid and the inner one malleable. The inner one is
modelled to the septum by forceps introduced with a di-
lator. The dilator is left /// */7(/ for eight da}'s, the parts
being ke]it meanwhile scrupulimsly ch'au.
All tliese operations have been variously modified by
surgeons according to the requirciuenls of individual
cases. The main points to bear in mind are: (I) To re-
move all excess of tissue before attempting to strai.ghten
the septum; (2) to weaken the support of the latter by
incision, fracture, etc., making sure to destroy the resil-
iency of the parts .so that the septum will remain in its
new position; and (3) to hold it there by some form of
splint until healing has occiu'i'ed in the new position.
Scrupulous jiost-operative care, frequent changing of the
plugs or splints, etc., so as to avoid retention of nasal
■secretions, are very important factors in the attainment
of a successful result. James K. Neieeoiiih.
NASAL CAVITIES, DISEASES OF :
lES. Srr .\ir I'o.s.soi/i.s, ,1,-.
FOREIGN BOD-
NASAL CAVITIES, DISEASES OF: GLANDERS.—
(Synonyms: .Malleus. Farcy. E(|uinia.) Gkmdcrs is a con-
tagious disease contracted from the horse and character-
ized by the foruiation of nodules, which soon become
pustular and ulcerated, with symptoms of septicauuia
and tliick niueo-purulent or sanious offensive di.scharge
from the no.se. It would not deserve space in this ]dace
were it not tlKit from its rarity we are especially in need
of an accurate account of its symptoms and signs, be-
cau,se personal experience is generally wanting. Al-
though the di.seaseis generally C(mtracted from tliehor.se,
it must be understood that it alsoaffects mules, donkeys,
goats, cats, dogs, sheep, and jiigs.
An.\to.mic.\i. .\nii P.\tiiiii,()(4ic-\l Ciheacteiustics. —
In men the disease is characterized by irregular and some-
times very extensive ulcers in the no.se, especially if it has
been of long duration. Astlieulcers expose the cartilage
and bone, these tissues become necrosed, and thus the en-
tire septum and hard palate may be destroyed. Ulcer-
ation sometimes extends to the frontal sinus, pharynx,
larynx, trachea, and bronchi. (Edema of the larynx
may result from the inflammatory changes. Microsco]ii-
cally, the tubercle or iiodide of glanders aitiers from that
of tubereulo.sis, in that it is vascular, has no giant cells,
and breaks down liy suiipuration instead of undergoing
cheesy degeneration. At the autopsy conditions are gen-
erally found which closely reseinlile those of pya'mia.
Etiolooy. — The affection is contRicted from the horse
or other animals and is caused by the bacillus mallei.
Symptom.\toi.ogy. — The disease may beeither acute or
1-2Q
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Nasal Cavities,
IVasal Cavities.
chninic. The chronic affection runs from four to eifjlit
months, but the acute generally terniiiiates within Ihrec
weeks. The stage of incubation is from three to five
(lays. After this jieriod an inflammatory reaction takes
placeat the site of inoculation, which may l)e progressive
and lead to abscess formation or may retrograde. Latei-,
there are symptoms of general infecticjn, malaise, head-
ache, jiains in the joints and muscles, and high fever,
often attended b}' an erysipelatous rash of the nose and
throat, which is soon followed by vesicles that burst and
discharge a thin serous tluid. The disease ma_y afl'ecl
various parts of the body, but its most marked manifes-
tations are in the nose and throat. The discharge from
these parts is always e.xtremel}' offensive and usually
thin and ]irofuse at first, but later thick and glutinous
and sometimes streaked with lilood. The voire com-
monly becomes husky or it may be lost, au<l cough and
dyspniea may develop. The chronic form is ushered in
by a chronic nasal discharge, which may be so scanty
that it mcrel.y forms crusts, or it ma}' be quite profuse
and ])urulent; or as the result of ulceration the dis-
charges may be yellowish, brownish, or bloody. Upon
inspection snndl ulcers are often found situated beneath
the crusts, and sometimes characteristic noihiles of a
whitish color are seen seated upon an inflamed mucosa.
These nodules soon break down in the centre, making
small uliters which may extend and coalesce with others.
In man the nodules are much less conuiion than in the
horse, and indeed they may be cntirel)' wanting. As ul-
ceration progresses, necrosis of bone and cartilage occurs,
and the septum may be perforated. As the disease ex-
tends backward, tdeers and inllammatory infiltration
appear on the ])iisterior pharyngeal wall, in tlie mouth,
and on the tongue. When tfie larynx is reached the
voice becomes hoarse and breathing may be difficult. In
the huigs glanders produces symptoms of bronchitis.
The intestinid canal maj' also be invaded, as indicated bj'
gastric disturbances with diarrlia>a, and the di.sease also
attacks the skin, causing multiple abscesses or ulcers.
Di.\GNOsis. — Glanders is to be distinguished from na-
sal syjihilis and tuberculosis. Nasal tuberculo.sis is usu-
all\' associated with tuberculosis at the apex of one
lung; it is commonly much slower in its progress than
glanders, and it cannot be traced to contact with the
horse. Finding of the pathogenic bacilli in either case
will make the diagnosis certain.
Syphilis frequently resembles glanders, but the con-
stitutional symptoms are much less pronounced. The
history is very different and the bacillus mallei cannot be
detected in this disease. Notwithstanding this, how-
ever, most cases of glanders are ineffectuallj' treated for
sj'pliilis for some time before the real nature of the ail-
ment is discovered. The chronic disease may last for
weeks or months, and whenever an obstinate nasal ca-
tarrh exists in people who are much occupied with
horses, a careful examination for glanders must be made.
If nodules and ulcers appear, together with abscesses and
ulcerations of the skin, in stablemen and others having
much to do with horses, the existence of glanders should
be suspected and the pus carefully searched for the
bacilli. In order to confirm the diagnosis it may be
even necessary to inoculate a male guinea-pig, in wliich
case the characteristic nodes appear in the testicles after
three or four days. The inoc\ilations arc made into the
peritoneal cavity.
PiiotiNosrs. — The chronic disease runs its (-oursc in
from four to eight months and terminates fatally in at
least ninety-five per cent, of the cases. The acute affec-
tion often is superadded to the chronic disease, and when
this occurs death invariabl_v results in from six to eight
days, but |)rimar\- acute disease usually lasts for about
three weeks. As the disease progresses, the patient
passes into a typhoid condition which, in the acute form,
soon terminates in coma and death.
TuE.VTMENT. — Prophylaxis is of the greatest impor-
tance, and those working about horses should be able to
recognize the disease prom]itly, but the insidious course
of chronic glanders in the horse may make the diagnosis
very difficult for a long time. In all such instances the
services of a veterinarian should be <'m])loye(l. Little
can be hoped for from the treatment of the di.sease, but
locally strong solutions of creosote, tincture of iodine,
nitrate of silver, and carbolic acid have been recom-
mended, and it is claimed that recovery has in some cases
followed the use of mercurial ointment. General sup-
|iorting remedies are of cour.se indicated. The .secretions
and discharge coming from the no.se of a patient suffer-
ing from glanders should be carefully disinfected.
E. Fliti-hrr l)i(j,ih.
NASAL CAVITIES, DISEASES OF: HEMORRHAGE.
— The term epistaxisis applied to bleeding ficim the nasal
( avilicsuiid ad.iacent sinuses. Owing to the unusual vas-
cidarity of the nasal region, the delicacy of its construc-
tion, and its liability to accident, no.seble(Ml is of very
common occurrence.
Etiology. — It maj- be due to traumatisms: to local
affections of the nasal cavities, such as hyiicra'iuia, dilata-
tion of superficial blood- ves.sels, superficial erosions of the
mucous membrane, ulceration ; to the presence of foreign
bodies or of pharyngeal adenoids ; to various systemic af-
fections such as amemia. pinpura, and scurvy; to dis-
eased conditions of the brain, heart, liver, or kidneys; to
typhoid and typhus fever, measles, scarlatina, di])htheria,
pneumonia, etc. ; it may be vicarious, occurring in women
at the menstrual period; or, linally, it may arise from a
variety of other causes dependent upon severe excitation
of the circulation or irritation of the siu'face of the nasal
mucous membrane.
It may occur as a result of toxic doses of certain drugs
which are eliminated through the mucous surface of tjie
upper air passages. It is present in fractiues of the
skull, especially at the base, atul is also found with neci-o
sis or caries of the bony skeleton of the nose. It has
been caused in gunners by the severe concussion of hea\y
firing. It occasionally follows coitus. Sudden transi-
tion from a normal into a rarefied atmosphere may cause
it. It is not infrequently the precursor of cerebral apo-
plexy. It is commonly met with in boys at the age of
puberty, and in girls it may piecede the establishment
of the catamenia. It may occur in women during preg-
nancy and at the menopau.se. It is common in childhood,
less so in middle life, and again more apt to occur with
advancing age.
The bleeding may come from one or both nostrils.
Originating from the deeper part of <ine nasal cavity the
blood maybe deflected into the nasal cavity of the op-
posite side, and escape outwardly through that nostril or
into the pharynx. Dangerous nasal liemorrhage may oc-
cur during sleep, the blood being swallowed without at-
tracting the attention of the patient. Serious loss of blood
may tluis result. The presence of bleeding in such a case
would probabl}' be demonstrated by changing the posi-
tion of the patient and causing him to clear his throat.
Bleeding most. fre(piently originates from the anterior
and inferior part of the nasal septum, and when it comes
from tliis lo<ality it is seldom dangerous, although in
some rare cases it may be severe and through frc(|Uent
recurrence it may cause serious ana'iuia.
The bleeding jioint ma_v be located in any part of the
nasal cavity, or there may be a general oozing, widely
diffused over the surface of the memlirane. as in ha'uio-
pliilia, jMirpura, aud the anainia of children. When
coming from the anterior portion of the nares the blood
escapes from the nostrils, but when from the deeper
parts of the nasal cavities it may pass backward and be
swallowed and later vomited, or it may pass into the tra-
chea and be coughed up. The latter accident is not com-
mon. When the bleeding is from the up])er and anteiior
jiart of the nasal cavity the hemorrhage may be serious.
This is explained by the close connection bilween the
anterior ethmoidal vessels and the intracranial circula-
tion.
Plethora, especially when accompanied by delicient
menstruation, i)ortal congestion, aud some forms of
Bright 's disease, may be relieved by epi^faxis.
121
IVa»«al <*avlli<'«,
N<i»al <'a\ili«-s.
liEFEHEXCE HANDBOOK OF THE MEDICAL SCIENCES.
Hiuiuatoiiiatii of the uasal (.■uvilies an' iiKirc i-oiiunoiily
met with on the seiituni. Tlicy arc occasionally seen as
the result (jf traumatisni. Exaiuinalion will ol'lcii dctcr-
niiiic the location of the liK'eiling iioini, which is apt to
be found upon some part of the cartilai;iiions seiitum.
The anterior region of the nose is the most frequent seat
of this trouble.
DiAdNosrs. — In hemorrha.m^ from the anterior nares the
nasal cavity, having been cariMully cleansed, should he
e.\amiiied by anterior ihinoscopy, and an attempt made
to locate lh(' |irecise spot from which tile l)leciling takes
]ilacc. This will generally be fouriil in the region of the
septvun, Episla.xis must be dilVerentiated from luvmop-
tysis, from ha'matemesis, and from bleeding from the
lower and meilian pharyn.x. Tliis may l)e done by care-
ful examination of the uasal cavities,
PitOGNOSis, — The prognosis is generally good. When,
however, the l)lee(ling is dciicudent upon a general diath-
esis or some systemic disease it may be very dangerous,
Tre.^tment. — The treatment of ciiista.xis must depend
upon its origin and upon its cause. It is necessary, tlicre-
fore, to determine as far as possible what these may be.
Vicarious bleedings and
tlicse wliicli occur at the
crises of certain fevers,
may, if they are not ex-
cessive, be allowed to
continin:'. lu conditions
of plethora and iu vica-
[i^^^
Fi(i. 3489. — Plugging ttie Posterior Nares l>y Means
ot IJellorq's Snmni.
T 1 o u s men-
struation it
should not be
unnecessarily
checked. Un-
der oi'dinary
circumstan-
ces simple
means will
usually beef-
f e c t i v c i n
stopjiing the
lUiw. These
consist in ab-
solute rest and in keeping the liead erectand avoiding the
conunon mistake of inclining it forward and downward.
If the bleeding is from the anterior jjart of the nose. iires.s-
ure of the ala against the .septiuu may clicck it. Tlie ap-
plication of cold totheuoseor thcinsutHation of cold water
is often cUective, When the bleeding point can be found,
aiiplications should, if ]iossil)lc. be made directly to it.
This shiiuld be done by lirst drying the place with absorb-
ent cotton and then applying to it nitrate of .silver, chro-
mic acid, or even the galvanocautery. Astringents, such
as alum or tainu'n. may also be applied. The iron picpa-
rations are as a rule wor.se than useless, and should never
be emiiloye<l O! late the use of two remedies lias been
suggested, both of which experience has )niived to be of
great vabie. One of these is aniipyrin, the other is the
cxti-act of suprarenal glands The 'aiiti|iyrin shoidd lie
dissolved iu water, about ten grains to the ounce The
suprarenal extract should also be used in strong so
lution. The bleeding cavity having Ik'cu frcid from
clots l)y means of cold water, about hall an mince of
one of the above solutions shoulil be iiisiiltlalc-d and
retained in the nose as long as possible. This should be
repeated once or twici' unless the lilccding is iimncdiate
ly checked
The careful employment ol this method is very clTcc-
tive. When simpler means fail, the hemorrhage may be
oonlrolled liy jiackiug that part of the nasal cavity fnun
Avhich the bleeding comes. Fortius purpose a sponge
should never be used. Far liel tc r is it to iiiliciduce into
the nasal cavity auarrow strip of surgical gau/c and then
to pack it in carefully against the re(iuired sjiot. If the
bleeding point is in the upiier part of the cavity, the
lower jmrt may be left free to permit of normal resiiira-
tion. The proximal end of the gauze strip should be left
free, so that in the withdrawal of the tam|ion only so
mn<-h need be removed at one time as can be readily de-
tached. Forcible removal is certain to cause a recurrence
of the bleeding. Great care should therefore be exercised
and the ])lug should be saturated with some solvent solu-
tiiiu before any manipulation is applied to it. As a rule
the plug should not be retained for more than one day.
If it occurs posteriorly the bleeding may be checked by
inserting a tampon into the nasopharynx, and, if neces-
sary, at the same time packing the anterior part of the
nasal canal. For packing the naso-pharyngeal region a
flexible catheter or a I5elloC(|'s cannula {11, in Fig. 34Sit),
to the distal end of wdiich a loop of silk has been fastened,
should be passed through the nose and its distal end
brought into the pharynx. To the loo]) a strong ligature
shcuild be fastened and drawn upward and then forward
until the attached end is outside of the nostril. A tam-
pon of lint or cotton (T). saturated with vaseline and
attached to the middle of the ligature Avhich should be
about eighteen inches long, should be in readiness. The
tampon should then be ilrawu carefully into jilace by
li iction \ipou the string, aided by manipulation with
linger in the pharynx. The tampon having been
placed, it is well to make a firm block of ab,sorbent
cotton around which the anterior end of the siring
may be wound and held in the vestibule ni the
nose. The iiharyngeal end of the string should be
brought out of the mouth and looselv attached to
the patient's ear. To remove the tampon, tlie best
plan, as a rule, is first to cleanse the parts as thor-
oughly as practicable and then ajiidy to them a .so-
lution of suprarenal extract in order to secure the
.greatest possible contraction of the blood-vessels.
Lastly, the parts should be covered with liquid
vaseline, and time enough allowed for it to saturate
the surface of the tampon as deeply as it can pene-
trate. Only the gentlest traction should be applied
to the string while the tampon is being removed.
Severe bleeding may re<piire the use of revulsives in-
ttuded to cause reflex contraction of the uastil blood-ves-
sels, the administration of remedies intended to quiet the
action of tlie heart, the application of pressure, externally
and internally, and iu extreme cases transfusion or some
kindred measure. In the most severe and intractable
cases of cpistaxis the nasal cavity may easily become sep-
tic, and thus another serious feature be added to the case.
D. Jlri/m/ii Diliivaii.
NASAL CAVITIES, DISEASES OF: LEPROSY.—
Leprosy of Ihe uosc altcuds soiiiecascs of general lepi"ns\'
or elephantiasis, and is characterized by a formation of
nodular masses and <litluse thickening of the skin of the
bridge of the uosc, which by being thrown into vertical
folds causes the condition known as t'acies leonina. The
nose, especially below the bridge, becomes deformed liy
the growth around it of nodular ma.sses that enter into
the substance of the nasal tip and ahe, cliaugiiig them
into tliree tumor-like masses that lie side by side, sepa-
rated by di'cp lissures. It is also attended by congestion
of the mucous membrane with unifiu'in or nodular swell-
ing and considerable deformity and ulceration,
EnoLcKiV ,\Nn P.\tiioi.oov, — This part of the subject
has been fully disiaissed in the article entitled Leprosi/,
and the reader is therefore referred to it for information
on the subject
Sv.MPToM.\Toi,ooY, — .\nione the early symptoms are
dill'use thickening of the skin over the bridge of the nose.
This is at first bright red, but later of a brownish red
and shiny appearance, in a still later stage it Iiccoiik'S
paler and of a light grayish-brown, or liiially it darkens
to a chocolate color. Deep, iiainful, anil bleeding fissures
occur between the I umor-like projections at the end of
128
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Nasal Cavities.
Nasal Cavities.
the nose, ulcerations develop, and cicatrices are formed
leading to a great variety of deformities. In time tlie
nose tiatteus, broadens, and sinks in. the nostrils often
being narrowed to mere .slits bj' thicUening of the ala;
nasi. The appearance of a nose iu this condition is
likened to that of a hound This change is due mainly
to destruction of the cartilages of tlie e.xternal nose and
the cartilaginous septum, and to cicatricial retraction of
the external nose. Sticker believes that the initial lesion
of lej^rosy is usually an ulcer above the cartilaginous part
of the nasal septum, and it has often beeu found that the
disease attacks some portion of the nasal cavif 3- before there
are any externalmauifestationsinolhcr jiartsof the body.
The primary focus may thus be hidtlcn for a long time
and the disease ma_y easily be mistaken for other affections
of the nose. At tirst there are obstruction to nasal res-
piration and a free watery discharge which later becomes
purulent and extremely offenisive on account of ulceratiou
and neci-osis. Severe epistaxis also frequently (iccurs.
After a period of mouths or years, the discharge gradu-
ally ceases and the uares become dry. About this time
leprous nodules may appear on the face and external
nose. The nasal mucosa, which is at first red, graduallj-
fades and becomes yellowish, grayish, or [lui'e white, due
to the liard leprous infiltration. This infiltration may be
diffuse at first, or it may form tubercles and tumors, from
5 to 15 mm. iu diameter, which spring from the anterior
part of the septum aud the anterior end of the inferior
turbinals. Unless preceded by pharyngeal leprosy the
disease first invades the anterior portion of the nares, but
as it ])rogresses the cartilagiuous or bony septum may be
destroyed by ulceration. In this stage the secretions
often dry aud fill the nares with large hard crusts that
can be removed only Avith consideralilc force, a procedui-e
wdiich is likely to cause free hemorrhage that may be
sufficient to require packing of the cavity. The destruc-
tive process may also affect the turbinated bodies. Fi-
nally ulceration ceases, cicatrization follows, and the
dense scars ma)' obliterate the nasal cavities. As a rule
the ulcers and other leprous lesions display characteristic
anaBsthesia wheu touched with a probe, and the sense of
smell is lost.
Diagnosis. — Tlie diagnosis must depend upon tiie pres-
ence of the peculiar thickened nodular formation, ulcer-
ation, cicatricial contraction, and the odor of the secre-
tions, and the finding in them of the bacilli lepra-, which
are apt to be abundant. It is often difficult to make an
examination of the uares because of the contraction of
the nostrils or of the sensitiveness of the formations at
the end of the nose. The thick dry crusts may also ])re-
vent a satisfactory inspection. Tlie disease can gener-
ally be distinguislied from tuberculosis by the presence,
in the latter, of tuberculous deposits in other parts of the
body and by the occurrence of thickeuing and cicatricial
contraction iu leprosy. Iu a few cases syphilitic iufil-
tration may simulate leprous nodules, but the history and
the effects of antisj'philitic treatment usually clear up the
diagnosis iu a short time. Again, the progress of syphilis
in the nose is much more rapid than that of leprosy.
Pkognosis. — There appears to be no tendency to sj.ion-
taneous recovery, and uufortunately treatment offers
little hope fif cure.
Tre.\tmknt. — Internally the gurjun and the chaul-
moogra oils have been highly recommended, the former
in doses of five to ten miuinis, the latter in doses of two
drachms, but there is much doubt as to whether either
does any good. B3' way of palliative treatment the dry
secretions should be softened by ointments and alkaline
or oily sjirays. The obstruction of the nares may be re-
lieved jiartly l)y severing adhesions or by other surgical
measures, and bougies may sometimes be employed to
keeji the nares free from obstruction. However, care
should be used not to cause much bleeding or to give the
patient much pain. E. Fletcher inr/id.i.
NASAL CAVITIES, DISEASES OF: MUCOUS POL-
YPI.— Niisul iiiiuous ]>oly])i arc liy]ieriilastic. (edema-
tous outgrowths originating cominonlj' from the mucous
Vol. VI.— 9
membrane of the parts of the nasal cavity above the lower
turbinated bodies. They cause obstruc-tion of the nares
and usually free discharge of watery mucus. JIucous
polypi occur oftener in men tlian in women. They are
seldom found before the twelfth year.
An.\T0MIC.\L AXD P.\TII0L0GIC.\L Cn.\R.\CTERISTICS. —
JIucous polypi are generally smooth, glistening, and
translucent, and of a grayish-white color, but they may
also have a pink or yellowish tinge. Occasionally tiiev are
opaque aud bright red. Portions of the growtli that are
exposed to the air in the nasal vestibule are sometimes
covered with thick pavement epithelium that has the
appearance of white paint. These growths may be ses-
sile or pedunculated, and rarely they are found hanging
b}' a mere thread. According to their surroundings they
may be globular, pj'riform, or flattened. Many may clus-
ter together, large, small, aud minute specimens aris-
ing from the same attachment. The number of the
growths varies greatly, but they are generally multiple
and often fill both nasal fossiu from the nostrils to the
posterior nares. Polypi originate most commonly from
the lower border and outer surface of the middle tur-
binated body and from the region of the hiatus semilu-
naris, though they may also grow from the superior
meatus and turbinal. They are very rarely attached to
the septum, and so seldom do they arise from the lower
turbinal and nasal floor that their origiu from these parts
is a pathological curiosity. The pathology of these
growths is considered elsewhere.
Etiology. — The most frequent cause of the disease is
chronic rhinitis with polvpoid hypertrophy of the middle
turbinated body, a condition which precedes the forma-
tion of true polypi. Polypi are occasionally caused by
foreign bodies, and often appear to result from chronic
suppuration ; they are therefore a frequent accompani-
ment of empyema of the accessory sinuses. They occa-
sionalh' precede malignant growths originating in the
deeper parts of the nasal cavity or in the sinuses. Suc-
cessive crops of polypi may thus be removed until the
carcinoma or sarcoma has made enough progress to be-
come visible.
Symptoms. — Polypi often exist for years before the
jiatient is made aware of their presence by obstruction in
the nose. A watery or occasionally purulent discharge
from the nostrils is one of the first mauifestations of the
disease. This sj'mptomis accompanied or soon followed
liy gradually increasing obstruction iu one or both uares.
3Ian_y patients do not seek relief until the nasal passages
become nearly or completely clo.sed. The sensation of a
body moving to and fro iu the air current is sometimes
felt. As the growths increase in size, sensations of ful-
ness and pressure occur in the upper part of the nares, or
there may be actual pain that may radiate to the fore-
head.
Pol3'pi growing from the septum are often vascular
and cause severe no.sebleed, and rarely the growths in
other locations are angiomatous and give rise to the same
svmptom. In most casi'S the sense of smell is lost. The
catarrhal inflammation is liable to extend to the lach.
rymal duct and to cause its stoppage with resulting lach-
rymation, and deafness frequently results from deflation
of the middle ear and catarrhal otitis media. The symp-
toms of polypi are aggravated during damp weather by
swelling, while a dry atmosphere improves the patient's
condition. The usual results of mmith-breathing, such
as injury to the incisor teeth from drying of the enamel,
]iharyugitis, and laryngitis, follow the disease, which
frequently also gives rise to reflex disorders. Prominent
among the latter are fits of sneezing, lachrymation. and
conjunctival irritation. Asthma is frcquentl_v caused by
l^olypi, though not so commonly as rejiorted by some
authors. Other reflex phenomena such as nightmare, mi-
graine, headache, giddiness, hay fever, epilepsy, and gas-
tric disorders are occasionally observed, but they often
remain unchanged after operation. Inspection usually
disclo.ses onlv the foremost of the growths, but the polypi
at the posterior part of the group may often be seen by
posterior rhinoscopy. A large polypus may appear as
129
Nasal t'avilles.
Nasal Cavities.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
a tninslucent spherical tumor resting upon llie soft
palate, while tlie pedicle by which it hangs is usually
iucUien. Smaller growtlis till the space bclwccn the
turliinals and posterior end of the septum, or that be-
tween the lower and middU^ tiirlnnals or between the
middle turhinal and llie ui)])er border of llic ehoana. In
this location the growths are sometimes of almost glassy
transparency and dillicult to sec. In other cases they
appear like muco-piis.
Di.vGNOsis. — Polyjii have so characteristic an appear-
ance that they are not easily mistaken when seen by
anterior or posterior rhinoscopy, and palpated with a
probe. In a case of nasal obstruction the nasopharyn.x
should ahvays be examined, as there may be no polj-pi
in tlie anterior part of the nose wliile the |)ostei'ior nares
maj' be occluded by them. The inexperienced might pos-
sibly confound septal deflection with a polyptis, espe-
cially when the convexity of the deformity presents the
ajipearance of a pink or red tumor in the nasal vestibule.
Tlie concavity of the deflection in the opposite naris, and
the fact that a jirobe can be passed on only one side of
the prominence of the lient .septum, while it may pass on
both sides of a polpyus, should prevent error.
Polypi are distinguished from tliickening of the turbi-
nated bodies by their translucence. ligliter coloi-, lack of
resistance when touched, and their great mobility. AVheu
the turbinals are lirmly jiressed u]ion with the end of a
Ijrobc, a chiiracteristic sens(.' of bony resistance and im-
mobility i't felt. The swelling of the septum, due to
chronic abscess, is of a deeper color than that of a poly-
pus; it is usually much the .same in both nares, anil it is
not |)(issible to pass a prol)e between it and the septum.
Foreign bodies generally cause unilateral offensive jiuru-
leut. discharge, while polypi arc commonly attended by
bilateral, watery, and odorless secretion. The sensation
given to the probe is also quite dilferent. JIalignant
tumors of the nasal cavity or of one of the sinuses may be
hidden from view by polypi created by the irritating ef-
fect of their growth, and tlie_v then cannot be recognized.
Visilile malignant growths have a grayish, pinkish, or
deep red color and often a sloughing and idcerated sur-
face. They commoidy s]iring from the septum, a site
rarely occupied by i)olypi,and they usually bleed easily.
Pain and rapid growtli are characteristics of the malig-
nant neoplasms, and carcinoma generally tdcerates early
and gives rise to stench. The hardness and immobility
of cnchcindrnnia and osteoma make it impossilile to mis-
take these affections for polypi.
Prognosis. — ThisaiTecticaiisnot dangerousto life, and
in the great majority of cases the jiatient need expect no
worse troubles than nasal obstruction- and aimoying dis-
charge. Deformity of the bones of the face, formerly
attributed to mucous polypi, is .seldom if ever caused by
tliem, Imt is a result of the distending effect of libioiil
tumors upon the skeleton of the nasal cavity or is due to
the destructive and distending advance of malignant dis-
ease. In iirerhinoscopic days these growths were often
confounded with pol3'pi, and hence frog face and other
deformities were attrilnited to tlu' latter. In rare cases
vascular polyjii produce dangerousepistaxis. Although
single polypi are sometimes ex|ielled. spontaneous recov-
ery does not occur; and even after careful removal of the
growths there is a notorious tendency to recurrence, so
that many patients suffer from the dread of repeated
operations. Assurance maj' be given that Jiolypi do not
change into malignant tumors, and patients should not
be worried by the statement that they may jiossibly pre-
cede the latter.
Tuii.VT.MiiNT. — Procedures undertaken without the aid
of rhinoscopy, such as evulsion with jiolypus forceps or
curettage after laying open tlie nose externally, inflict
needless injury on the patient and are not to be reeom-
mended. The most .satisfactory method of treatment is
removal of the growths with the steel wire snare or ecra
seur. The one preferred by the author is a modilication
of one devised by Clarence Blake. The snare is armed
with No. .5 steel (liano wire, which in practice has been
found to answer better than the other sizes. The loo|i is
passed in vertically, its under edge turned beneath the
polj'pus, and then with a backward and forward move-
ment it is worked up as near the pedicle as possible.
The loop is now tightened, and, if thought best, the
polypus is cut off at once, but usually better results are
obtained if it is torn from its base by traction. There is
little danger in this way of removing any of the normal
tissues, for it is almost impossible to include within the
snare anything but the polypus. When polj-pi grow
from broad bases, and are attached over the w^hole sur-
face of a turbinated body, the bone may be torn off with
the snare if much traction be made. Under such cir-
cumstances the experienced operator, noticing the in-
creased resistance of tlie normal tissue, instead of con-
tinuing the traction, will tighten the wire loop and cut
the growth as near its base as possible. When polvpi
rejieatedly grow from a large surface of the midille tur-
binal, it is sometimes better to remove the body entirely
to prevent recurrence. The operator should have sit
hand forty or fifty a]iplicators wound with absorbent
cotton for swabbing out the blood while the operation
proceeds, as it is useless to try to catch the tumors when
the nose is tilled with blood. S])rayiug the nasal cavities
before operation with a solution of adrenal extract will
materially lessen the bleeding. Wliatcver operation is
performed, the parts should flrst be thoroughly anii;sthe-
tized with a four- to ten-percent, solution of cocaine,
which is best ajiplied by means of a hypodermic syringe
fitted with a long, blunt, silver nozzle bent at the end,
so that the solution may be thrown up about the base of
the tumors. Sometimes botli cavities may be cleared at
once, but it is usually preferable to remove the growths
that can be easily reached, and to complete the ojieration
at one or two subsequent sittings, as this generally gives
the patient much less discomfort tlian one long sitting.
After the piolypi have been removed, the patient should
cleanse the nose once or twice daily with a wash of so-
dium bicarbonate, a teaspoonful to the pint of lukewarm
water. Antisepsis and healing will be promoted by in-
sufflation two or three times daily of a powder containing
ten jier cent, of boric acid and twenty-flve percent, of
iodol, wit.li sugar of milk sufflcieut to complete the mixt-
ure; together with tlie use of a spray containing about
one minim of oil of wintergreen, two minims of carbolic
acid, and three minims of oil of cloves to an ounce of
Oleum petrolatum album. If the secretion be ]irofuse,
ten minims of terebene may be added with advantage.
The patient should return in about a week, when it will
often be found that polypi which were invisible at the
time of operation have descended and may lie removed.
He shouUl return a.gaiu in from four to si.x weeks, so that if
the poly pi are growing thej' may be thoroughly destroj-ed
with the galvanocautery.
In some ca.scs mucous polyjii do not return after one
thorough removal, but usually recurrence taki-s place
and ojierative procedures must be repeated from time to
time until complete destruction of the growths is effected.
When empyema of one or more accessory sinuses exists,
this must be relieved before the patient can be freed from
relajises; and in those instances in which the tumors
originate from the region of the hiatus semilunaris or
superior meatus it is occasionally necessary to remove
the middle turbinated body in order to reach the site
from which they grow. In order to get at polypi lo-
cated behind a deflection or large spur of the septum,
it may be necessary flrst to correct this deformity. In
the majority of cases operations upon the uasalskele-
ton are unnecessary, and careful treatment will eradi-
cate the disease. Polypi in the posterior nares can in
most instances be reached by )iassing the snare through
the nostril, but the assistance of a finger in the naso-
pharynx to adjust the wire may be needed; and in
cases in which the polypus is very large, the wire loop
may have to be drawn in through the mouth and passed
u]) behind the soft palate by an instrument devised for
that juirpose, as recoiiimended by the iiuthor in the re-
moval of retronasal filirous tumors.
E. Fktelier Inguls.
130
REFEREJ^CE HANDBOOK OF THE AIEDICAL SCIENCES.
INasal Cavities.
Nasal Cavities.
NASAL CAVITIES, DISEASES OF: NEUROSES.—
I. Ni:ri;<iM;s nv Ui.fachcin. — Tlie cilfuclmy iirivc (-(in-
sists of about twenty tibres given oil' from the under sur-
face of tile olfaetory bulb. Tliese tilires pass down
through the cribriform plate, dividing into two groups
as they enter the nose — an inner group distributed over
the upper third of the sejitum, and an outer group dis-
tributed over the superi()r turbinate bone and the upper
half of the middle turbinate bone. In structure it differs
from other nerves in being composed of non-inedullated
fibres. The olfactor_y centre in the corte.x is not definitely-
known, but is generall)' associated with the temporal lobe
(Gray).
The nerve is liable to disorders in connection with both
its point of origin and its distribution.
Parvsmia is a perversion of the sense of smell. While
the sense of smell may or may not be perfect for ordinary
odors, there are in addition certain imaginary odors.
This is comparatively common among the insane, and
is found in epilepsy, hysteria, and syphilis. It has
occurred in connection -with the epidemic disease — the
grippe, cases having been reported in which the patient
■was annoj'ed for days by unpleasant odors and tastes.
The writer has observed this condition in connection
with atrophic rhinitis wlien the ordinary sense of smell
was destro3'ed. Here the condition is one of consider-
able annoyance to the individual. The affection is com-
paratively rare.
llilpervsiidii is an exaggeration or hj'perffisthesia of ol-
faction. In this affection odors whicli are not ordinarily
noticeable to the healthy nose arc present as exagger-
ations, causing great annoyance. The odor of an offend-
ing substance is often retained for several hours after the
removal of the offending material. Like parosmia, it is
comparatively rare. There seems to be some connection
between it and certain disorders of the sympathetic nerve.
Both parosmia and liyperosraia seem to be dependent
more on some general nervous disorder or some neurotic
liredisposition than upon any disorder of the olfactory
nerve within the nose itself.
The treatment of both the foregoing affections should
be directed to the cause so far as it is possible to ascertain
it, as direct treatment of the nerve is not likely to do
much good.
Anosmifi. or Loss of Smell. — This is by far the most
common of the affections of the olfactory nerve, and may
have its po-nt of origin within the cranial cavity or within
the nose.
Anosmia Intracrnnialis. — This may be caused by injur-
ies, tumors, degeneration, as in locomotor ataxia, general
paralysis, senile decay, intracranial syphilis, congenital
absence of the olfactory nerve, hemorrhage, meningitis.
and abscess. Cases illustrating these various forms of
origin have been reported b}' several observers. Com-
pared with the total number of cases of anosmia, those
of central origin must be considered to be rather rare.
Anosmia JVasalis. — This form of anosmia, in which tlie
pathological condition is of nasal origin, is bj' far the
most common. It may be the result of either acute or
chronic processes. For the function of the sense of smell
to be properly performed, air, with odoriferous particles,
mtist freely reach the terminal filaments of the nerve, and
these are stimulated to activity only when in a moist
medium; hence anythingthat interferes with the free ac-
cess of air or with the moisture of the part will cause
partial or complete loss of the sense of smell. Acute
anosmia is usually due to acute processes, like colds in
the head, the grippe, acute ethmoiditis, hay fever, or to
any condition that temporarily blocks the nose. With
the sub.sidence of the acute condition the sense of smell
usually returns.
Owing to the close relationship between the sense of
smell and the sense of taste, anosmia is usually accom-
panied by very pronounced loss of taste, especially of
flavors. If the sense of taste is unchanged, the loss of
the function of olfaction is only partial.
The chronic forms of anosmia occur in connection with
anatomical changes in the nose, such as spurs, pni-
nounced deviation of the septum, or any changes which
close the nostril, especially hypertrophic conditions of
the middle turbinate. Tliey also accompany the degen-
erative conditions of the mucous membrane, such as atro-
phic rhinitis, in which the na.sal cavity is aV'normally
widened, its walls are covered with crusts, and the mu-
cous membrane is dry to such an extent that the sensitive-
ness of the terminal nerve filaments is lost.
The syinptuinaloloyy anil diagnosis offer no particular
ditficult}'. In testing the (question of loss of smell, acrid,
sharp, or pungent substances must not be used, as they
produce irritation of the sensitive nerve filaments rather
than stimulation of tlu.^ olfactory nerve.
In theacute affections the;(/v/(7;««/s is tisually good. In
the chronic forms, when the disease has lasted for any
length of time, degeneration has probablj' taken place,
and the prognosis is not so good. White' reports two
cases which were entirely cured by treatment of the nasal
disease, one after twenty years and another after ten
years of complete anosmia. The author has had .several
cases in which the sense of smell returned after the re-
moval of nasal polypi. In one instance the sense of smell
had been lacking for a period of several years. But cases
like the one just referred to must be regariled as com-
paratively rare, as it is the rule that when the sense of
smell has been deficient for a long period of time, the
possibility of its recovery must generally be considered
doubtful : and the correction of the apparent cause in the
nose is not always followed by as gratifying results as
could be desiied.
The treatment consists in the adoption of measures
which improve the general nervous system and bring
the nose and throat into the best possible condition, so
that all parts of the olfactory nerve distribution will bo
accessible to the air. The area of the distribution of the
nerve should be stimulated by such agents as friction,
the use of iodoglycerin, solutions of the various stimulat-
ing oils, as camphor, menthol, eucalyptol ; and an attempt
should be made to increase the bliKxi supply and the se-
creti(jn of the part. While the improvement secured will
fi-ecjuently be satisfactory, the writer lias many times
been disappointed as to results of treatment, and more
often than otherwise in those cases of anosmia in which
examination of the nose does not show any apparent physi-
cal cause for the condition. Several of these have fol-
lowed attacks of the grippe, and have been only partially
relieved, and occasionally not at all, b_y treatment ; nor
have all the cases resulted satisfactorily even when iutra-
na.sal conditions such as polypi, etc., have been found
which were apparently sufiicient to account for the con-
dition.
II. Reflex Nasal Nkcuoses. — The connection be-
tween some irritation of the no.se and sneezing has been
known and considered from the time of Hippocrates;
while the writings of the early physicians, as Aurelianus,
Avicenna, Pechlinus, Salmuth. and Van Ilelmont, show
that they were familiar with various rellexes of jirobable
nasal origin, such as rose cold, cough, headache, and
difficult breathing. The influence of powerful and dis-
agreeable odors on the organism was noted by many
authors.
In the eighteenth centurj' Guiniirecht advanced the
theory that irritation of the trigeminus in the nose was
transferred to the pneumogastric, producing reflex phe-
nomena in the throat, stomach, heart, and lungs Roga
carried this theory still further, and demonstrated or sug-
gested the relationship between the genital tract and the
upper air tract; while Wejjfer described a large number
of cases in which headache, cough, vomiting, vertigo,
disturbances of vision, and olher nervous symptoms were
de|)endent upon nasal disorders.
One of the first attempts to define this connection be-
tween distant organs as a distinct reflex was made by
Muller, in his physiology of ISi;!. when he wrote that
irritation of any "mucous membrane in the body could
give rise to a respiratory reflex. The credit of first call-
ing attention to the nose as a definite point of origin of
various reflexes, with practical observations as to the
131
Nasal Cavities.
Nasal Cavities.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
treatment and cure of tlie same, probably belongs to
Voltoliui,- who advaiu'cd the proposition tliat nasal
poh'ps cause asthma rc-tlexly, or else by hindering respi-
ration they change the chemistry of breathing and alter
the structure of the lung. His publication in 1«T1 -was
soon followed by a host of observations, contirmatory and
otherwise, b)' different authors. Among these was Ihie-
nisch,-' wlio'observed that asthmatic paro.xysms disap-
jjeared after removal of ])olypi, and reappeared only npon
the return of these growths, and B. Fracnkel,'' who re-
garded llie asthma from polyjii as a reflex cramp of the
iironehi produced by irritation of the sensitive nerve
fibres, and. in agreement with SchaelTer,^ also stated that
this irritation could depend u]ion or be brought aliout by
catarrhal changes in the nasal nuicous meml)rane.
Asthma was the first disease to be irgarded as a reflex
neurosis, Ijut various other affectifins were soon placed
in the same category, especially various colds in the head
— the so-called nervous head colds.
Next came the observations of Hack, who in various
publications in 18S3, 1S83, a?id ISSi," widened very much
the range of reflex nasal neuroses, until there were in-
cluded inigraine. supraorbital and ciliary neuralgias,
nightmare," various coughs, vasomotor dislm'banccs of
the vessels of the .skin, epilepsy, and secretory neuroses.
These were later followed by reports still farther ex-
tending the field of reflex nasal trouble. Among these
were cases of exophthalnuc goitre, diabetes, affections of
the larynx, heart and stomach, chorea, dysnienorrlKea,
enuresis, and so forth, until a larger ]iart n{ tlje pathology
was said to be dependent njion disorders of the nose.
These publications of Hack's, with their accompany-
ing brilliant results, called the attention of the whole
world of medicine to this subject. Considerable opposi-
tion to Iiis views was aroused; and he admitted before
his death that his theories had been carried too far by
many of his followers. In the main, however, they have
received general confirmation; the subject of nasal neu-
roses alread}' has a considerable lileralurc; and these
neuroses an.' frequently sei'U to jilay an important part
in pathology.
In order to produce a reficx, a sensitive or sensory
nerve in connection with a ganglion, and a motor or vaso-
motor nei've fibre are necessary. The chain, of which
the gauti'lion is the centre, being present, the point of
origin of the rcllcx can be at cither extremity. All the
conditions necessary for the production of reflexes are
found in their highest development in the nose; since the
"nerves supplying the Uiisal jnueous memlu-anc are sensi-
tive nerves, originating near the floor of the fmu'th ven-
tricle and having connections with many ganglia, as the
otic, spheno-palatine, Gasserian, ophthalmic, and others,
which in tin-u _onnect with motor and vaso-m<itor fibres
and with many sensitive areas in the I'espiratory tract by
means of the pneumogastric and s]iinal accessory nerves,
t'onneetcd with these is the sensory nei've of tlie nose,
the olfactory, which supplies the upper portion of the
nasal cavity over both the septal and turbinal areas.
Piitholoyij. — The nose through its normal physiology is
particularly liable to reflex influences; as its whole func-
tion of warming, moistening, and filtering tlu^ inspired
air is controlled by a highly complex nervous mechan-
ism, which anatomically adjusls itself under normal con-
ditions to the varying atmospheric changes. Its ]iower
as a protective organ, through the information which it
gives of the presence of various odor.s and i>oisonous
gase.s, and by alarms such as sneezing, cough ;[nd glot-
tis spasm, is also dependent upon a reflex action.
In proportion to the number of cases of nasal trouble,
the number of |)athological nasal refli'xes is probabl)'
comparatively small. Their presence in the individual
case depends lari;ely u|)iiu the nervous make-up of the
individu;d; and they are more ai)t to be ]iresent to a
pathological extent wlienever there is increased sen.sitive-
ness of the general nervous and reflex mechanism of the
entire body.
An attempt hiis been made to find certain so-calird re-
flex points or specially sensitive areas in the nas:d nui-
cous membrane, and such have been described by various
authors. J. N. !Mackeuzie ■ thinks that the posterior
portion of the inferior turbinate is the most sensitive
area, though he does not claim that this is the only one.
That this area is sensitive, and that its irrtation will
frequently bring about a severe paroxysmal cough is
easily determinable in some individuals by passing a
Eustachian catheter without previous cocainization ; in
many persons quite a paroxysm of coughing will be set
up. The author has met with several instances in which
it was impos.sible even under cocaine so to abolish tliis
reflex that the catheter could be used satisfactorily. In
onecase vomiting was in variabh" brought about whenever
the catheter was used. Other authors have regarded the
middle turbinate area as the sensitive one, but Spiess*
thinks that the principal ]ioint of irritation is the tuber-
eulum seiiti. A survev' of the literature, however, will
soon convince one that there is no certain reflex point.
Init that the entire nasal mucous membrane can be the
subject of reflexes in every point of its entire extent, the
septum as well as the turbinate area.
Hack theorized that tiie cfnidition was due to swelling
of the erectile tissue through the nervierigentes, a theory
not accepted In' others, as the presence of nervi erigentes
in the nasal mucou.s membrane has not been proven.
Anatomically, the nasal mucous membrane is supplied
by the first and second branches of the trigeminus as to
ordinarv sensation, and as to special sense by tlie olfac-
tory; and impressions are taken not only directly to the
brain, but also indirectly, by means of the branches of
communication with the various ganglia and the brain,
to the entire nervous system — sensitive, motor, sympa-
thetic, and special si'use. The nasal or ethmoidal nerve
comes frcnn the lirst branch of the trigeminus, and covers
in its distribution the anterior portion of the nose, the
septum, the anterior ethmoidal cells, and the frontal si-
nus. The second branch, the superior maxillary or den-
tal nerve, supplies the flocn'of the nose and the maxillar_v
antrum ; while the posterior jiart of the nose, the septum,
the posterior etlimoidal cells and the sphenoid sinus are
supplied from branches of the spheno-palatine ganglion.
Irritation ca.n be carried to the brain through the mo-
tor, the vaso-niolor, the secretory, or the sensory tracts.
Through the brain the olfactory is brought into contact
with the entire .system, while the trigeminus is in con-
nection with tliesplieiio-]ialatine. otic, and ciliary ganglia,
and the point of origin of the latter in the medulla is in
communication with all of the motor fibres coming there-
from. It is therefore clear that, under favorable condi-
tions, sensory or sensitive irritation of the nasal nervous
elements can be referred to far-removed parts of the body,
and the most various symptoms produceil.
Etidloiiy 1111(1 Ptithdlotjii. — The method of origin of all
of the nasal reflexes is the same. The first act is an irri-
tation of the all'ercnt nerve fibres, sensory or sensitive.
This is followed by the transmission of this irritation to
the ganglion and its ap|)earauce as an action, motor or
otherwise. The exact way in which all this is brought
about is still imperfectly understood. The nerves of the
nose have a close relationship to tlie respiratory centre,
aside from the fact that iullammation beginning in the
nose frequently jiasses by direct continuity to the lower
respiratory renion. Irritation begun in the nose lias ex-
perimentally brought about closure of the glottis, expi-
ratory tetanus, and sto|ipage of respiration. The same
phenomena are causi'd liy irritation of the vagus. The
origin of a number of reflex neuroses of the respiratory
organs can he explained on the theory that nasal irrita-
tions are carried by wa}- of the ganglia to the respiratory
centre, and then pa.ss along fibres of the spinal accessory
and vagus or along the spinal nerves. This is seen in
the I'ase of glottis cramji, jiaroxysnial cough, and bron-
chial asthma.
JIany eye alTections. such as blepharospasm, strabis-
mus, anomalies of accommodation, asthenopia, and jiupil
changes, seem sometimes to be dependent upon nose aft'ec-
tions. The reflex tract is by way of the motor root of
the facial and oculomotor nerves, and irritation aloui; this
132
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
NaNsil Cavities,
Masai Cavities.
tract can cause clonic or tonic action of the muscles. Tlie
tear function is affected directly through the laclH\ymal
nerves, branches of which supply tlie unicous membrane
of the nose. On the other hand, Ziem ' tliinks that tlie
relationship of eye diseases to nose affections is brouglit
about chiefly tbrovigli the blood and lympli tracts, and
only seldom througli tlie nerves.
According to Jurasz, these reflexes can be advanta-
geousl)' divided as to their causative significance into
three groups ;
First, those reflex neuroses in which the sensible irrita-
tion originates iu the nose and the resultant retle.K a]>-
pears iu an organ outside of the nose ; in this class are
asthma, cough, bronchitis, epilepsy, eye and general
nervous and neuralgic disorders.
Second, retle.x neuroses in which the sensible irritation
is in the nose, aud asserts itself as a reflex within the nose
itsi^lf ; under this head are embraced the various forms of
nervous catarrh, vaso-niotor rhinitis, hay fever, hydror-
rhrea, rose colds, and others.
Third, refle.x neuroses that have their sensible irritation
in some other organ and are carried reflexly to the nose,
producing nervous colds, hj-peramia, swelling of the
mucous membrane, nosebleed, erythema, ledenia. and
other anomalies of the outer nose; contained iu this last
group are those dependent upon digestive ilisturliances
and tlie class of affections caused by disorders of the sex-
ual apparatus, to which latter the researches of J. N.
ilackenzie, Grayson and others have called attention.
Pathologically, the theoiy of origin of the first group
is one of irritation of the afferent nerves of the nose,
which pass over through the ganglion to the efferent
vaso-motor nerves; aud the final ett'ect is produced by
changes in the ^-olume of the blood-vessels.
In the second group we have only to do with vaso-mo-
tor and secretory disturbances in the nose itself, the path-
way of communication probably passing through one of
the near-by ganglia. The primary irritation comes from
the trigeminus or olfactory nerve endings, to be trans-
ferred to those nerves which effect clianges in the volume
of the vessels and in the quantity of the secretions. In
these cases the brain and spinal centres are not neces-
sarily concerned, but the circle is made complete with
the iielp of the peripheral ganglia, aud the reflex curve
is often short.
In the third group the theory of origin is not yet .satis-
factory. The phenomena appear as the result of the
sensible irritation of organs far removed, as the skin in
case of colds, the alimentary canal, and the genital ap-
paratus, and consist in changes iu circulation aud secre-
tion iu the nose. The sympathetic system is probably
the principal medium of communication between the
parts involved.
In such a highly complex mechanism as the nervous
apparatus, the localization of the irritation is frequently
difficult, especially so as the irritation can be at either
end of the cliaiu. In the main, those reflexes which
have their point of origin in the nose itself, and which
are the most common, are due to direct irritation of the
parts, which may be produced iu a variety of waj's — by
simple changes in volume, by touching, rubbing, or press-
ing them, by active hyperemia, by the direct effect of
cold, or by the odor of flowers. When there is complete
closure of the nostril, the reflex is less mauifest than when
there is variation of volume, irritation being caused at
one time and not at another.
The severity of the reflex explosion does not necessar-
ily bear much relation to the degree of apparent irrita-
tion, as slight irritants frequently cause considerable
reflex irritation ; in fact, the most marked reflexes seem
to be associated with the least manifest pathological
changes. Slight ulceration in the nose has been known
to cause considerable cough, scraping of the throat, and
inabilit}' to sing, aud has been entirely relieved by cau-
terizing the spot with nitrate of .silver. Such a case has
been reported by M. Schmidt, and somewhat similar ones
by others. These cases are more likel_y to occur in those
of highly nervous make-up The excessive irritability
of any single portion of the reflex tract may be due to a
local disturbance or maj' be a partial manifestation of
some general neurosis, such as neui'asthenia or hysteria.
Heredity does not seem to play any particular part.
These cases are more common among the better classes
than among the poor, and occur in those of highl}- ner-
vous organization.
The arthritic diathesis has been regarded by French
writers as an important factor, and there are man}' who
regard hay fever as dependent upon this diathesis.
^Miile, as regards nasal neuroses in general, the arthritic
diathesis ma_v be a predisposing factor, it is certainly not
the only one.
These neuroses are rare in children, and are most com-
mon between the ages of fifteen and fort}'. Race has
but little influence.
Climate aud the season of the year are important fac-
tors, and one class of nasal neuroses — hay fever, the term
being used here generically — is especially frequeut in the
summer and autumn seasons. The climatic vagaries of
asthma are well known; nearly every asthmatic has his
private climate, one asthmatic doing well in a climate in
which another does badl}', aud rire rei'sa. The writer has
kuown asthmatic members of the same family, one of
whom was relie\ed by removal to a certain jjlace while
another was invariably made worse.
As regards the etiology of asthma, it is probable that
many cases are dependent upon a nasal reflex condition,
but not all. The pathology aud etiology of asthma have
not yet been satisfactorily worked out. "Want of space
will prevent its discussion in any detail here. It seems
e\ ident that both local aud general factors are concerned
in its causation. Asthma is a vaso-motor bronchitis, with
— in many cases — a cause or an exciting factor iu the nose.
Certain it is that the correction of nasal pathological con-
ditions relieves aud not infrequently cures the disease.
The nervous area of the interior of the nose is extremely
sensitive; aud any abnormal nasal condition can setup
reflexes. The most conimou of these pathological causa-
tive conditions are chronic liyiiertrophic catarrh, new
growths, deviations and spurs of the .septum, syuecliia?,
cicatrices, foreign bodies — that is, any condition which
causes increased volume and pressure in some part of the
na.sal mucous membrane; while in atrophic conditions
the nervous sensibility is so far diminished that the re-
flexes themselves are also greatly diminished aud reflex
neuroses are rare.
Operative procedures frequeutly bring about reflex
disturbances, such as sneezing aud cough, and ma}' even
lie followed by vertigo, laryngeal spasm, or more serious
conditions. The use of tlie galvanocaulery snare has
been succeeded by exophthalmos and rapid pulse; such
a case has been reported by Semon. F. R. Packard '»
has reported a case of transient monocular blindness of
the left side following removal of the auterior end of the
left middle turbinate with the cold wire .snare. The
writer has seen acute insanity follow operation on the
nasal septum in a boy of ten. It was evidently due to
the pressure of the retaining plugs, and on their removal
recovery was promjit.
There seems to be some sympathetic relationship be-
tween the erectile portions of the generative tract aud the
other erectile structures of the body. Ungratified sexual
excitement, as well as excesses in coitus or unnatural
sexual habits have brought about coryza of reflex origin.
In tyjie this closely resembles that <pf hav fever, aud in
the absence of a history might be mistaken for it.
Grayson" has reported a case iu which turbiual en-
gorgement in an engaged young woman was due to ex-
cessive demonstration on the part of the young man to
whom she was engaged. This brought about ungrati-
fied sexual excitation, which was the cause of the nasal
eugorgeraent. He cites another case, the patient being
a male, in which excessive sexual indulgence had caused
nasal obstruction accompanied by marked hypersecre-
tion, sneezing, and headache. All kinds of treatment,
local and general, had been tried, the cause not having
been suspected. When this was ascertained and the
133
Nasal Cavities.
Nasal Cavities.
REFERENCE HANDBOOK OF THE MEDIC^VL SCIENCES.
habits corrected, tlie nasal condition promptly got well
without further treatment.
Mackenzie '• gives an account of a some That similar
case, the patient being a woman, and the Ci^use exces-
sive se.xual indulgence on the part of herselt and hus-
band. Here the complaint was of asthmatic bieathing,
with stoppage of the nostrils. Jloderation in their mar-
ital relations soon brought about a cure.
That there is a physiological connection between the
sexual apparatus and the nose is .shown b\- various recip-
rocal relations between engorgement of the turbinate tis-
sues and menstruation, such engorgement occurring in
.some women regularly during menstruation. Occasion-
ally in tliose whose menstruation is irregular there is an
engorgement of the nasal erectile tissue corresponding to
the regular time of the menstrual epoch. Fliess'^ made
investigations, the results of which seemed to show that
painful, profuse, or irregular menstruation may in some
instances depend upon an intranasal cause. He cites a
number of cases to show that the pain of certain forms
of dysmenorrhoea ma)' be temporarily dissipated by the
application of cocaine to the nasal mucous membrane, or
permanently controlled by cauterization. Such a case is
reported in the table of cases appended. Fliess regarded
the inferior turbinate and the tuberculum septi as those
portions of the nose which have a special relation to dys-
menoirhceic pains. Vicarious menstruation sometimes
occurs in the nose. In boys around the age of puberty
nosebleed of apparently sexual origin has not infrequently
occurred.
A case of sneezing following tooth extraction in a tif-
teen -year-old girl has been recorded.
Hypertrophic rhinitis in connection with digestive dis-
turbances is one of the most common of observations;
and many catarrhal cases of this class, even with consid-
eralile hypertropliy, frequently get well on the correction
of the digestive disturbance. It sometimes happens that
complete nasal stenosis will follow a full meal. Whether
these cases dependent upon digestive disturbances are
true reflex neuroses or only parts of a general congestion
which is circulatory in origin, may perhaps be a question ;
since all of the hypertrophic conditions of sudden onset
that are dependent upon digestive disturbances might be
brought about tlirough a passive congestion or through
a loss of the nnrmal vaso-motor tone.
t<i/>np>iiiiii/tiiti,rii/, — Patients usually complain of the
particular condition that troubles them and not of the
disease of the nose which is the cause. Asthma, neural-
gia, migraine, nervous disturbances of the ej-e, voice, and
heart, epilepsy, muscle cramp, goitre, spasmodic cough,
and the like, can appear without any manifest signs of
affection in the nose and yet be of nasal origin. Again,
complaints of the nose, as narrowing, anomalies of secre-
tion, itching, pressure or ]5ain, may lie so mild as hardl_v
to be noticed, or the jtatieut may not complain of the
nose at all. Frequently cases of this sort ai'c not cor-
reetl3' diagno.sed until they have lasted a long time, and
the (liagnosis may then be reached only by the method of
exclusion.
In the first group the rhinoseopic findings are swell-
ing, hypertrojihy, ulceration, new growths, foreign bod-
ies, septal deviations, abnormal adhesions. The.se are also
the ])rineipal objective causative factors in the second
group, as these two classes are dependent upon the same
general reflex mechanism, and differentiate themselves
only through symptoms varying in causation and quaHt_y.
The neuroses of the second group have lieen given an
enormous number of names. They can all be described
uniler one head, to which .Turasz has given the simple
de.signatiou fif "nervous head colds." The general term
"ha.v fever" includes them all.
IJii!/ Fecer. — The symptoms of hay fever come on in
paroxysms, and in persons ajjparently well they last
minutes or hours and then disappear. When the patient
has been under the inlluence of a jiathological condition
for a long time, the attack can last weeks or mouths, with
occasional short breaks. While most frequent in sum-
mer or autumn it may also occur at other seasons of the
year. Here there is a direct irritation affecting the sen-
sory or sensitive nerves of the nose. This irritation may
be due to an emanation from plants, as in pollen hay
cold, hay fever and hay asthma: to the odor of flowers,
such as rases, violets, and others; to the cooking of cer-
tain foods ; to the odor of various aromatic substances ; or
to the emanations from various living animals. It is well
known that now and then attacks of asthma are brought
about by riding behind a horse. These are usually per-
sonal idios\-ncrasies. In 1893 Bishop advanced the the-
ory that the real cause of haj' fever was an excess of uric
acid in the blood, favored by profuse sweating, and com-
mon at the hay-fever period of the j"ear. For the devel-
opment of the disease specially sensitive nerve centres,
h.yperasthesia of the sensitive nerves of the nasal mucous
membrane, and the presence of irritating agents are nec-
essary. His theories have been accepted by many.
The condition begins by irritation or itching in the nose,
followed by sneezing and the discharge of a copious,
clear, serous fluid. These symptoms are of all degrees
from mild to severe, and the sneezing may be terrific.
Bobone has reported a case of unconsciousness and cya-
nosis as a result of cramp-like sneezing. Fink '■* thinks
the large amount of secretion comes from the accessory
cavities, the antrum principallj', and that the secretory
fibres of the trigeminus are the ones affected. The se-
cretion is usually thin, but may be thick ; frequently
large numbers of handkerchiefs are required. On the
oiher hand, sneezing may be present and the condition
be one of hydrorrho?a only; or with occasional attacks of
sneezing the patient may complain of hindered respira-
tion, stopped-up nose, reddened eyes, swollen conjunc-
tiva;, al)un<lant tears, intolerance to light, itching in neck,
cough of an irritating character, pain in head, "migraine,
trigeminal neuralgia.
In additii m to the above there are frequently a laryngitis
and a pharyngitis, with cough and sense of oppression
in the chest, ditlicult respiration, and more or less dis-
tinctive asthmatic S3-mptoms. Fever is rare.
On inspection the nose conditions are frequently found
to be not in accord with the severity of the S3'mptoms.
While marked pathological conditions are sometimes
present, there may be only redness and swelling; on the
other liand, the mucous membrane often appears pale or
even aua'mic.
This group of cases appears most frequently in the
summer and autumn seasons; and the principal exciting
cause seems to be the presence of the pollen of certain
plants, as roses, haj', golden rod, ragweed, and others.
There has to be an individual susceptibility, but the pol-
len is a]iparently the exciting cause. From June to
September is, in the United States, the most susceptible
perio<l, and from the 10th to the 31st of August the worst
time, as the ragweed, the pollen of which is then in
bloom, is the most irritating of all the pollens.
In the third group, originating outside of the nose, the
symptoms are those of a nervous head cold — swelling of
tire mucous membrane, stopped-up nose, sneezing, irrita-
tion, increased mucous secretion. Vicarious menstrua-
tion, abnormal dryness of the mucous membrane of the
nose, anosmia, hallucinations of odor, changes of the skin
of the nose, redness— all these may be of genital origin.
Indigestion may also cause many of the same syniptoins.
Dia;/nnsis is not usuall_v difticult in the group in which
the whole process is in the nose, but is diiflcult when the
origin is in the nose and the a|iparent seat of the symp-
toms is in other organs. Jurasz thinks that inasmuch as
nasal neuroses sometimes follow lirilliant results of nasal
therapy, we have assumed tl\a.t post Iioc. ergo propter hoc.
The teaching of Hack's went so far in its results that,
given any ])athological nose condition, it was stated as
the cause of any affection present, and the diagnosis was
made entirely as a result of the nasal examination. This
belief gained such a foothold that it was said at one time
that the whole pathologv was seen through the nasal
speculum, and everything abnormal that could not be
defined was considered a nasal reflex.
Whenever we have a reflex neurosis which is not clear
134
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Nasal Cavities.
Na^al Cavities.
in its origin, or there is the remotest suspicion of one, the
nose should be carefully examined, since doubtless many
pathological conditions do come from changes in this or-
gan ; hut, on finding some trouble in the nose, one cannot
be exactly certain that the cause of the neurosis is found,
as the nasal condition may be only an accompaniment
and not a cause. Many people have extreme pathologi-
cal changes in the nose "without any accompanying reflex
phenomena. The mere presence of a nose atfection in
the course of a disorder known to be a reflex neurosis
will neither prove nor disprove that the nose is the cause
of the reflex neurosis. An attempt should be made ex-
perimentally to bring about a reflex irritation of the sup-
posed zone of origin. While this is probably accurate as
a diagnostic measure, it is not absoluteh" certain.
Cocaine is one of the most valuable diagnostic reme-
dies, since if under its influence the reflex disappears it
is proliable that it is of nasal origin. Weak solutions of
adrenalin chloride will act iu the same manner.
In doubtful cases treat the nasal condition and await
results. If a cure is effected, the probability of the diag-
nosis being correct is very great.
In neurasthenic patients the moral effect of doing
something in the nose may bring about relief and cure,
even when the real cause is not in the nose at all; hence
it will not do to label every neurosis that improves under
intranasal treatment as a reflex nasal neurosis, tliough of
course this is probable.
In the third group it is ditbcult to make the diagnosis,
since it is not easy to demonstrate with exactness that a
nose affection is the result of a remote pathological proc-
ess. Here therapy has only slight diagnostic value.
The prognosis is good after tlie removal of the cause,
but there are apt to be many relapses. If the affection
has lasted a long time, as in asthma, secondary trouble,
as emphysema, may be the result.
Thenipeidic^. — The treatment of the nose must be di-
rected to the condition present. In the first group of cases,
correct whatever is abnormal iu the nose so far as possi-
ble, but do not promise too much. While the results
are often brilliant, as in cases cited in the table, they
may not be. In cases in which pressure is the cause of the
reflex, leave the nose as roomy as it is possible to make
it. The details of treatment will depend entirely upon
the condition present. The moral effect of intranasal
surgery is often considerable.
The treatment of hay fever must depend somewhat on
the conditions found. Whether the uric-acid theory be
correct or not, it is certain that remedies which favor gen-
eral elimination are of great value, although the writer
has not had any specially brilliant results from treat-
ment based upon this theory. He is in the habit of get-
ting the nasal mucous membrane into as good condition
as possible before the attack ; and during the attack he
cauterizes with chromic acid, allows the patient a spray
of adrenalin chloride (1 to 16,000) to be used as needed
at home, and gives internally a tablet of; Quin. sulph.
gr. ss., amnion, chlorid. gr. ss., camphor, gr. ss., opii
pulv. gr. .jJ^, ext. aeon. gr. ■^, ext. bellad. gr. j'^; one of
these tablets to be taken every two to four hours, with
such remedies for the general elimination as seem de-
manded. While this does not ciu-e, it greatly relieves.
Fiuk {I.e.) thinks the cautery is of no permanent influ-
ence, and says he relieves his patients by insufflating
raistol into the antrum. As the natural opening of the
antrum is very difficult to find eveu b}' tlie experienced
rhinologist. and especially difficult when the tissues are
swollen, this method of treatment can have but limited
application.
Adrenalin chloride, the active principle of suprarenal
gland, isat present amuch-vaunted specific for hay fever.
That it causes the mucous membrane to shrink and ]iro-
duces immediate relief at the time it is used, and that
it is the most powerful devascularizing agent for the
mucous membrane yet discovered, are midoubted facts.
Its effects are more positive and last longer tlian those
of cocaine, which was formerly used for temporary relief
In hay fever.
In the writer's experience with powdered suprarenal
extract he did not find that its effects were lasting. It
produced immediate relief, but there was a stage of re-
action in which the condition was about as rmcomfort-
able as before; indeed, any agent of so powerful a con-
stringing nature would seem of necessity to be followed
by a reactionaiy stage in which dilatation takes place;
tliis has been the experience of several who have used the
adrenalin chloride. On the other hand, it must be ad-
mitted that many practitioners are apparently having
good success iu the treatment of hay fever at the time of
the attack, with a 1 to 5,000 solution of adrenalin chloride
used as a spray two or three times dail_y. AVhether it
has any permanent value it is too soon to state. Inas-
much as it produces temporary relief at the time of the
attack, it is a valuable adjunct to the therapeutics of the
disease. Used in connection with the previous correc-
tion of any nasal difficulty, the sufi'erer from hay fever
may be enabled to go through the attack witli only slight
discomfort.
In regard to the strength of the solution to be given,
it seems to the writer as though the weakest solution
that will produce the desired effect should be u.sed, even
though it is stated that there is no danger of accjuiring
the habit. As stated above, he has found a solution so
weak as 1 to 16,000, to answer veiy well. The diluting
solution may be either decinormal salt solution or some
weak alkaline nasal spray solution. The 1 to 1.000 solu-
tion of adrenalin chloride is used as the base for dilution.
Adrenalin solutions are probably not very stable, and
if used for some time shovdd be frequentl}' renewed.
Whenever the remedy is ordered for the patient's use,
weak solutions sIkjuIJ be given, never stronger than 1
to 10.000, the stronger solutions being administered by
the physician himself in the form of spra_y, or applied
on cotton pledgets directly to the swollen mucous mem-
brane.
In addition to the loCal use of adrenalin iu hay fever, the
extract of the suprarenal gland is administered internally,
in doses of from five to ten grains at frequent intervals,
until the nasal mucous membrane shows that the vaso-
motor paralysis is under control, when the dose is dimin-
ished or the intervals between the doses increased so that
from fifteen to twenty grains are given per da_v. Should
giddiness or palpitation appear, the dose is to be dimin-
ished. Five to ten grains three or four times a day may
also be given for one or two weeks before the expected
time of attack. The internal administration is to be kept
up during the haj'-fever season. The adrenalin chloride,
1 to 1,000 solution, iu doses of five to thirty drops, may
be used instead of the extract of the gland.
Adrenalin has also been administered by instillation
into the eyes, reaching the nose through the tear passage.
It may also be given hypodermaticalh'.
Curtis '^ has proposed to obtain immunization by ad-
ministering the fluid extract of the plant, the pollen of
which acts as the exciting cause, and he has had some
success with ragweed.
In all conditions of nasal neurosis, in addition to the
local measures, treatment should be directed to the gen-
eral system so as to lessen the nervous irritability.
The bibliograpliy of this subject is so extensive that
s]3ace cannot be given to it here. The reader desiring to
study the subject in detail is referred to the extensive
bibliography given in the article by .1. N. JIackenzie on
the .same subject in the previous edition of this Handbook ;
to the article b\' Dr. jMackenzie on the relations between
the nose and sexual apparatus, already referred to; to
the article on nasal neuroses in Burnett's " System of the
Diseases of the Nose and Throat," by Joseph A. White;
and to the very extensive and comprehensive bibliogra-
phy in the article on nasal neuroses in lleyiuann's " Hand-
buch der Laryngologie." bj' .lurasz, to which article the
author desires to express his special obligations in the
preparation of the foregoing.
The following table gives a number of examples of the
various reflexes considered, with the detailed treatment
and the results. These cases are mostly unpublished,
135
Nasal CaTlties.
Nasal Cavities.
REFERENCE HANDBOOK OF THE JVIEDICAL SCIENCES.
Cases Illustrating Vauie
i
M.
43
M.
M.
44
M.
49
F.
40
F.
3(1
F.
46
F.
40
F.
;io
F.
M
M.
.-,7
F.
(iS
F.
23
M.
10
M.
22
M^
U
F.
40
F.
22
F.
45
F.
75
M.
49
M.
65
M.
45
M.
43
Symptoms complained of.
Asthma .
Asthma
Severe asthma ,
Asthma, severe whenever nose ob-
sirurteti; neurotic temperament.
Asthma and cough ,
Three or four years;
bepan as hay fever
twenty years affo,
Nightly for ten
yeai-s.
Three yeai-s
Several months.
Asthma several
years durini? wet
months; couRh
six months.
Asthma Twelve months.
Asthma, nasal obslruriiMn. headache.' Years
Astliuia I Five years ...
I
!
Cough: larynx iintation; occasional^ Several years
hoarseness. I
Severe coughing .
Several months.
Dyspnoea, severe, continuous Three months
Spasmodic breathing at night.
Spasmodic cough Twelve years
Fifteen years .
F,piU'i>sy
Epileptiform attacks every two to Si.\ years.
three weeks.
Epilepsy ,
Nine years
Sneering nnd watery fiischarge from One year .
niise with erythema uf tin- skin of
the external nose.
Paroxysmal sneezing
Three years .
Vaso-motor periodical neurosis (hay Twenty years with-
fever) followed by severe attacks of out rehef.
asthma. I
Hay fever. Attacks
every year.
began June Ist Fifty years .
VcrtiL'O with tendency l<» fidling Three months .
Tic douloureux.
Tic doulnureux .
Conjunctival congestion; photophobia Three to four year
Nasal conditions.
lation of septum to right apex
pressing hard on lower turbinate;
iliviif ti.ft niiilil li- liirlii iinti
Dev
pp
by.
pres:
turl
•essing hard on lower turbinate;
p-pertrnphyof left middle turbinate
■essmL'Hii'M-ptuni and uf U'ft lower
rbinate prfsi^iiig on tloor of nose.
Bilateral ethmoiditis with poljin ,
Polypi ,
Exostosis of left septum ; hypertrophy
of right inferior turl)inate; mucous
membrane very sensitive ; watery
discharge; obstructed nostrils',
woi-se at night.
Right middle turbinate much hyper-
trophied ; septal crest on right side.
Abscess of antrum.
Large rhinolith with hypertrophy of
turbinate tissue.
Hypertrophy of jmsterior ends of in-
ferior turbinates with complete nasal
stenosis.
No complaint of nose, hut spurs in
contact with inferior turbinate of
each side were found.
Hypertrophied inferior turbinates,
and later, stenosis at night.
Septal spur on right side with deflec-
tion of septum to the left and en-
larged infenor turbinates.
Two small polyps at lower edge of
right middle uirbiuute, none else-
whei-e; net nasal obstruction.
Hypertrophied inferior turbinates . . .
Deflection of septum with complete
stenosis.
Complete closure of left nostril due
U) deflected septum and left nasal
bone.
Marked lymphoid hypertrophy
Both middle turbinates hypertrophied
and prt'ssiUL' against septum ; edges
of turlnnati's putTy and red.
General swelling of nasal mucosa;
sensitive to probe; sneezing induced
by contact with flowers and iuten-
sifled when nervous.
Hypertrophied inferior turbinate, left
long lii'uy spur nn septum t)f the
same side pressing on turbinate.
Hypertrophy of both middle turi'i>
nates; complete stenosis at time of
attacks which have occurred in the
winter also.
Hypersensitiveness of mucous mem-
brane; general hypertrophic rhi-
nitis; swollen middle turbinate;
deviated septum. !
Pressure deviation i>f septum on an-
terior end of riL'tiT mid'ile turbinate
which was bypenr-'phied.
Hypertrophy of septum and opposing
middle turbinate of right side.
Deflected septum causing intranasal
pressure.
Relationship between nose and
symptoms complained of, and how
determined.
Wheezing, cyanosii.. and dyspnoea al-
most instantly and completely re-
lieved when the congestion of the
interior of the nose was relieved by
cocaine and contact prevented.
By exclusion and result of operation.
Cocaine gave relief as did partial re-
moval (»f polypi.
Severe asthma only when nose oc-
cluded ; under nervous excitement
mucous mendirane would swell and
asthma come on at once.
Asthma always relieved by cocaine
spray.
Evacuation of pus from antrum fol-
lowed by immediate relief ; recur-
rence of empyeuia caused return of
asthma.
By treatment
No exciting cause except general
nervousness outside of nose;
touching diseased parts with probe
brought on attacks of dyspnoea.
Treatment for cough and larynx did
little good ; cautery of eacli infeiior
turbinate so as to remove contact
with septum, afforded relief.
Diagnosis m doubt for some time ;
involvement of lung and unfavor-
able prognosis given by rnmiictHut
physician; taken to a specialist who
exanuned nose and suggested treat-
ment for nasal conditions.
By result of operation ; no organic
cardiac disease ; some emphysema.
Irritation of polypi with probe
caused spasmodic, almost couviil-
sive breathing.
Hiul been treated for uterine trouble,
vesical tnntlile. rectal trouble, and
nervous trouble with no result;
cocaine to nose caused cessation of
cough.
History t)f trauma followed by attacks
of epilepsy.
Followed a broken nose .
Removal under ether was followed
by cessation of attacks for eighteen
months.
Determined and verifled by treat-
ment.
When away from Dowers sneezlnR
stopped.
other treatment ineffe-nive : opera^
ti<m on nose suggested as offering
some hope.
Ri-lief from coeaine and from local
treatment of the nose.
Treated for liver, kidneys, and ner-
vous system without avail ; spas-
mipdie cough elicited on touching
sensitive area together with sense
of gidditiess.
By area of pain aiid result of treat-
ment.
No treatment except to the nose gives
any relief; cocaine and adrenalin
give temporary relief.
136
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Nasal Cavities.
Nasal Cavities.
TIBS OF Nasal Neuroses.
Treatment.
Result.
If improvement,
has it cx)ntinued V
Reporter.
Where
reported.
Remarks.
Retracture of the septum and replacement
in median line; reduction of swellings and
abolition of contact. Tbis treatment con-
tinued off and on for two years as occa-
sional colds caused renewed thickeoinp,
renderinir cnutcrizaliiai necessary.
ReuHiMil under L'l'iicial anaesthesia of all
.Attacks gradually
diminished in
severity and
complete relief
was finally at-
tained.
Almost complete
relief.
Cure
So far as known ;
relief since 1893,
last report 1899.
Yes
G. A. Leland...
G. B. Rice
Wm. Porter . . .
C. F.Theisen..
W. A. Martin..
Chas. W. Rich-
ardson.
Personal com-
munication.
Personal com-
munication.
Personal com-
munication.
Personal com-
munication.
Personal com-
munication.
Personal com-
munica tion,
also Laninyo-
Persiinal com-
munication.
Niirthwastcrn
Lancet, 1890.
nccr.isi-,1 iiiiiie and pniypoid tissue.
Coniptcte ri-inoval n[ polyjii with cauteriza-
tion at pniiit of ori^'in.
E.xostosis reiii..\vd ; turbinal hypertrophies
reduced; scnsiliM' area cauterized ; tem-
poraiy clianirc i>[ t-llTnale; fxenerai tonic:
tl-eatnient willl rctrulal inn of habits i-f life;
stiululallt^ and tnliaccn sloppt-d.
Right middle turliiiiatc removed February,
1S114. followed by relief from asthma and
cough f(U- one year; recurrence was fol-
lowed by fiirilier operative work, since
which no fuitlier tiiailile.
The iisual treatment for ciu'e of antral em-
Apparently com-
plete cure.
Cure after second
operation.
Yes
So far as known ;
last heard from
in 19til.
Yes . . .
Reporter thinks this case
one of pure rhinitis ner-
vosa.
Reporter regards impacted
or hypertrophied middle
turbinate responsible for
more nasal neuroses than
any other condition.
pyema.
Remoyed rhinolith which weighed Ofteen
grains and had a cherry stone as nucleus.
Yes
M. D. Leder-
man.
J. E. Schadle . .
Yes
Occasional cautery; relieved and declined
any further operative treatment.
Improvement, . . .
Two years t<;)
present.
Author.
Yes, for ten years.
Yes, but still has
sensations of
pressure about
the chest.
Yes
Within knowl-
edge of author
M. D. Leder-
man.
L. B. Graddy,.
This case was a patient of
the author's many years
ago ; the correct diagnosis
was made by Dr. F. I.
Knight, to whom credit for
suggesting treatment is
due.
Removed spurs and corrected deviation of
septum.
Removal of polyps with cold snare
Worse for ten
days then great
improvement.
Complete and im-
mediate relief.
Personal com-
munication.
Personal com-
munication.
Complete and
lasting relief.
yes
J. A. Stucky...
Personal com-
munication.
Reported by author in arti-
cle on *' ReHex Cough."
Medical Record, August
5th, 1899.
Operation on septum
Relief for six months then returned.
T. J. Harris . . .
Name n n -
known.
Urban G.Hitch-
cock.
C. N. Cox
Personal com-
munication.
Personal com-
munication.
N. r. Medical
Journal and
personal com-
munication.
Personal com-
munication.
Operation of straightening septum
Operation as stated and then reoperation
after attacks began agam.
Removal of tips of each middle turbinate . . .
but after secnii
has been no attii
Xo seizures since
four days pre-
vious to opera-
tion.
Apparent cure a
until a blow on
on petit mal aga
1 operation there
■k for two years.
Yes. since .lanu-
ary, ISKB.
ter last operation
the head brought
n.
Petit mal has continued;
operated on for hypertro-
phy of the inferior tiu-bi-
nate in last two years with-
out result.
Tonics, adrenalin 1 to 10,ij0(l
Two or three
slight attacks in
past three years.
C. F. Theisen..
Personal com-
municatiou.
Removal of septal spur; galvano-cautery
applied to turbinate.
Removed anterior end of each middle tur-
Four weeks after
treatment an-
noying symp-
toms disap-
peared.
Great Improve-
ment ; no June
attack ; August
attack less
severe.
Cure
Yes, as far as
known.
Yes
M. D. Leder-
man.
A uthor's case . .
Personal com-
munication.
No attack in year 1902. Pa-
binate.
Removal of right middle turbinate ; cautery
of inferior turbinate.
O.J. Stein
-Larj/ni/osciipc,
Deoem ber,
1898.
tient apparently perma-
nently cured.
Septum placed in proper position ; worse
immediately after, then gradual diminu-
tion of attacks in frequency and severity.
Galvanocautery
Final cure
Good
No return of at-
tack since 1896.
G. A. Leland . .
W. Cheatham. .
G. D. Murray. .
Persoiuil com-
munication.
Personal com-
munication.
Personal com-
munication.
Many cases nasal reflex re-
Removal of piece of septum with saw re-
lieved pressure.
lieved by cautery but
many not ; is not so hopeful
as to results as formerly.
13Y
Nasal Cavilics.
Nasal CavitiefK,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Cases Illustrating Varie
F. 37
24
23
41
10
Symptoms complained of.
Intense supra- and infraorbital neu- Four years.
ralgia, rigbt side of face.
Severe pain in head Two years .
Headache
Sick headache (mijrraine) with com-
plete prostration.
Headaches, chorea, pain in eyes: ina-
bility to fl,x vision.
Following' !iervous excitement had
increased conjunctival congestion,
lachrymation and profuse watery
nasal discharge.
Headache; Inability to n.\ vision;
chorea iu arms and legs ; skin sensa-
tions neurotic tvpe. For years in
saniloriunis. Diagnosis of petit mal
(neurotic family history).
Unable to swallow solid food since
early childhood ; if attemptetl al-
ways vomited.
Indigestion with cough .
IJysiiienorrhoea
Diffuse u.'dema joints, hand and ankle
Tachycardia
Temporary insanity
Two to three years.
Each attack several
days.
Several years
Three til four years.
Several years.
Many years .
Several years .
Several years.
Nasal conditions.
Exostosis of right lower turbinate
pressing on septum.
Intranasal pressure from spur of left
nostril.
Chronic hypertrophied rhinitis
Sharp exostosis buried In posterior
end of inferior turbinate.
Polypus in left nostril; closed eth-
moid cells.
Septum thick ; spur on one side : tur-
binates boggy: polypoid degenera-
tion of left middle turbinate which
was pressing against septinn.
Both middle turbinates solid: no
cells.
Adenoids.
Reported nose perfect but examina-
tion showed spur in each nostril and
hypertrophied tubercles of each
septum.
Hypertrophy of middle turbinate
Polypoid degeneration of mucous
membrane near hiatus semilunaris.
Pedunculated tnyxotlbroma of the
ptisterior end of "middle turbinate.
Followed removal of adenoid and
operation for deflection of septum,
done under ether.
Relationship between nose and
symptoms complained of, and how
determined.
Shrinking under cocaine relieved
pain at once.
Const^int pain more noticeable duiing
cold in head.
Headache worst w'hen hypertrophy is
greatest.
Increased tension in nose from any
cause brings on attack.
Complete relief from treatment of
nose; none from other measures.
By result of treatment
By result of treatment
Suggested as possible cause
By results of examination and treat-
ment.
Results of treatment..
Seemed to be due to effect of plugs
placed in nose to hold septum in
position.
having Iteoii giveu tlie author in tlic fcinii nf ]«'i'soual
communications, ami to tlie writers ot wliich he desires
to express )iis iutlebteduess.
Ga/rf/c L. liifliitrd.1.
References.
* Article Nasal Neuroses, Burnett's System Ills. Nose and Throat.
' Die Anwendung d. ilalvanokaiistik u s. w., Wien, ls71.
= Zin- Act. u. Tlier. d. Asthma bronch. Berl. klin. Wochenschrift,
1874. No, 411,
* Article in Ziemssen's Cyclopaedia, vol. iv.
^ .\sthma, etc. Deutsc-he nied. Wochenschrift, 1879.
^ For conijilete list see Bibliographie nasaler Retlexneurosen, by
Junisz in Hevmanirs Hundbucli d. Laryngologic, \Vien, lHUii.
" Previous edition IttMeiencc Handbook, vol. v., p. 224.
^ Etiolottie einiger nasak'r Keilexneurosen. ,\rchiv fiir Laryn-
gologic. Bd. vii., p. ;il).1: also Zuckerkandl : .\natomietler Nasenhi'ihle,
Bd. 1., p. inl, PI. X., Fig. 4.
" Beziehungen zwischen Augen- n. Nasenkrankheiten. Monatsheft
fiirOhreidieiik., 1.S93.
'" I'liUa. Med. Jouin., July Kith, 1898.
" Trans. Amer. Med. Assn., 1.897, section on Laryngology.
■■-Johns Hopkins Knlleiiii, January, 189:!.
'■' (.luotalion fioui MacUcnzi.'. (. r.
n Ileutsdie uied. Woch.. XoVHiiilier 14th, 19111.
'5 .Medi.'al News. Jiil\ Tlli, 19110.
NASALCAVITIES, DISEASES OF: NEWGROWTHS.
— Perliaiis eonti'ary tn "what is iiniti- ui-iiorally l)c-
lieveii, new giowtlis in tlie nose ale e.xceeiliuuly rare.
Mucous polypi, siuirs, and thicl<euiugs of the bony
and cartihiginous .septum ai'c seen more commonly
than any or than all forms of new growths CDniliineil,
but, being of purely intl;inimatory origin and not tu-
moi's in the Inie sense, are not deseriiied under lliis
lieading.
Motitz Sehinidf, among 33,007 nose and throat pa-
tients seen in ten yeai's, found tliat but iA. or 1 in
every l,oTO, pre.sentetl some form of true neoplasm in
the nose. Of these, 757, or 1 iu every 4:{, liad mucous
polypi: /.('., mucous polypi occurred more tli;in forty
times as often as all forms of tiue new growths com-
bined. Of benign and mtilignant neoplasms, there
would seem to be about ;ui equal ])roportioii ; if any-
thing, malignant growths appeared more often tliaii
benign tuinofs.
1. Bexign Neoplasms.
Anoioma. — This new growth is usually found on the
septum and is composed almost entirely of blood-vessels,
generally large Ciivcruotis veins, surrounded Ijy a slight
network of connective tissue, its epithelial covering being
the same as that of the pai t from which it sprang. Bos-
worth says that it ma_y lie located in any part of the na-
sal cavity; liowever, if seen anywhere but on the sep-
tum, it is proljably but a localized hypertrophy of the
mucous membrane in which the vascular changes are
most maTlced. It occurs at all ages, most freriuently in
early life, when it may be congenital, and very rarely in
old age. It is a .soft, rounded, mulberry-like growth,
varying in color fi'om a bright red to a purple, movalile,
pedtmculated or sessile, bleeding easil_y on toucliing with
a probe, and, as before stated, is almost invarialil}' found
on the ;mterior part of the .seplum. Tlie tumor 'may be
reduced or einidied b_y iiressui-e, iiud, if counected with
an artery, pulsation may be detected. Frequent attacks
of nosebleed, tdwav'S beginning on the same side, consti-
tute the earliest symptom. The epista.xis may be tilarm-
ing and dilHcult to control. Nasal stenosis on the affected
side develops with tlie growth of the tumor, which may
be rapid or slow. 3Iore or less discharge is likely to be
present. Thei'e is no pain.
Treittmeiit consists in the removal of the gi-owth by
the cold wire snare under cocaine an,T?sthesia and adre-
nalin to lessen the hemorrhage. If the growth be pedun-
culated, the application of the snare is simiile; if it be
sessile, a needle transfi.Kes the growth at its base, the loop
of the snai-e being thrown over this: and in either case
one or two hours should be taken in removing the tumor,
RectiiTence does not take place if the removal has been
complete.
Bony Cysts. — Osseous cysts in the nose are not rare.
AVIieu present, they are found invariably at the anterior
end of the middle turbinated lione in persons above
twenty, and much oftener in women than in men. The
etiology is interesting — several theories having been ad-
vanced as to the mode of their iirodtictiou. jMcDonald
thinks the lesion was originally an "osteoiihytic periosti-
ISS
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
TIES OP Nasal Neuroses. — Cmitinued.
Nasal Cavities.
Nasal CaTlties.
Removal of right lower turbinate with saw
and scissors in 1898.
Removal ol spur
Cliromio acid to turbinates
Shrinking turbinate with cocaine, and supra
rt'ual, as patient declines operation fur
permanent relief.
Reiunval of polypi; opening of ethmoid
cells.
Removal of left middle turbinate and the
septal spur.
Opened through middle turbinates and
drilled into left sphenoid sinus : antipyrin
and suprarenal locally; general tonic
treatment.
Removed..
Removal of spurs and hypertrophies of
septum and of diseased tonsils by electro-
cautery dissection.
Ustial surgical measures
Surgical
Surgical ; removal
After removal of plugs was all right in a
few days.
If improvement,
lias it continued ?
Complete cessa-
tion of pain.
Insta n t a n e 0 u si Yes
relief from pain.
Relief Yes, for si.x years.
Temporary relief.
Cure
Complete relief .
Cure .
Swallowed solid
food next day
Entire disappear-
ance of cough
and indigestion.
Cure
Cure
Cure
Cure
Yes.
Y'es.
Yes. has g.ained
thirty pounds.
Yes, six years . . .
Yes. six years . . .
Yes. eight years.
Yes
Yes
Reporter.
P. S. Donellan.
G. D. Murray..
J. C. Thompson
J. A. Keneflck
P. J. Gibbons.
J. F. McCaw .
P. G. Gibbons.
Unable to
credit as re-
porter did not
sign name.
Ed. Pynehon . .
Henry L. Wag-
ner.
Henry L. Wag-
ner.
Henry L. Wag-
ner.
Author's case.
Where
reported.
Personal com-
munication.
Persi )nal com-
munication.
Personal com
munication.
Personal com-
munication.
Personal com-
munication.
Personal com
munication.
Personal com-
munication.
Personal com-
munication.
Personal com-
munication.
Personal com-
munication.
Personal com-
munication.
Personal com-
munication.
Remarks.
Was of suicidal tendency
and when worse iodine was
detected in secretions.
Reporter thinks trouble due
to abnormal reflex causing
spasm of pharyngeal and
oesophageal muscles.
tis," secoiidary to au liypertropliy of tlio mucous mem-
brane of the middle turbinate, cau.sing tlie inferior boi'der
of this to curl outward and upward until it met the body
of the bono above where at length adhesion took place,
finally causing a closed bony cavity lined within and
without with mticous membi'ane. Another explanation
is that the cj'st results from a rarefying osteitis, the in-
flammation beginning in the mucosa, involving later the
periosteum and bone, and tinally resulting in the porous
formation observed in other liyperplastie processes. A
simpler and moreprobableexplanation than either of these
is to be found in the fact that there frequentlj- exists in
the anterior end of the middle tui'binated bone an ethmoid
cell, which communicates with the middle meatus or
with the other cells of the ethmoid labyrinth. Inflam-
mation causes complete fir pai'tial stenosis of the orifice,
the secretion is retained, and the cell gradually becomes
larger as the walls distend, until finally theie is produced
a bony cyst. This is covered externally with mucous
membrane that may either be normal or have undergone
polypoid degeneration with polypi resulting, or. again,
may have atrophied. The mucous membrane lining the
cavity has columnar ciliated epithelium, and, through
pressure of tlie retained secretion, often becomes attenu-
ated, the glandular elements undei'going absorption, the
membrane becoming polypoidal or granulating. The
cyst contains air or may be tilled with a yellow viscid
fluid, muco-pus. or clear pus. On several occasions the
writer, on opening the cyst, found a mucous polyp pres-
ent in the cavity.
The tumor presents itself as a smooth, rounded, an-
terior end of the middle turbinated body, and varies
greatly in size, being often so small as to pass uuoli-
served, while at other times it may be .so lai-ge as to
reach down to the inferior turbiuate or even to the
floor of the nose, and frequently jmshes the septum
over sufficiently to cause stenosis of the opposite naris.
the tiunor occup3'ing the concavity of the septum which
it has iiroduced. The symptoms are those due to ]iress-
ure of retained secretion and to obstruction. Hemi-
crania with exacerbations of acute pain duiing colds in
the head is the most characteristic and distiessiug symp-
tom. The pain is referred to the inner side of the eye,
radiating to the foivhead or across tlie face, causing often
iuteuse trigeminal neuralgia. There is a feeling of press-
ure and throbbing. Actual exophthalmos may occur
from the outward pressure. Attacks of luegrim with
vertigo and partial unconsciousness and vomiting are
often complained of. Nasal obstruction, depending upon
the size of the tumor, is present on the affected side and
may be quite marked in the opposite naris.
Pvo(jnom» is good and recurrence is not to be expected
followiug proper treatment.
Tfealinent is surgical and consists in the removal of
the cyst (under local anaesthesia) by the cold wire snare,
Grunvvald's or other nasal cutting forceps.
FiBi!0.\i.\. — Fibroma is a connective-tissue growth,
somewhat resembling histologically the mucous polyp,
but differing from it in the large amount of connective-
tissue fibres crowded together with but few intervening
interstitial spaces. The epithelial covering is the same
as that of the polyp. It springs from the submucosa or
outer layer of the periosteum, and arises from the poste-
rior third of the middle <n' superior turbinated bodies or
from the roof of the nose, and is said never to spring from
the septum. It may arise in the .sinuses, and often ex-
tendi from the nasopharyn.x into the nasal fossa?. It has
a rather thick, firm pedicle or may liave a verv broad
base. If pedunculated, the growth is downward and
backward into the nasopharynx, where it appears as a
round or pear-shaped grayish-]iiiik tumor, firm and hard
to the finger, bleeding easily on probing, having a lather
smooth surface, ami teniling to fill the postnasal space.
In the nose it is of the same character, but is longer
and more slender, conforming to the shape of the nasal
cavity. Its growth is steady and persistent, inisliir.g
aside adjacent bones, causing ulceration and adhesions,
invading the neiniil.ioring sinuses and orliital cavities,
and producing finally much deformity, such as the char-
acteristic frog face and exophthalmos. Tlie tumor is
very vascular and the walls of the blood-vessels are very
much thinned. This form of growth occurs in early life,
between the ages of fifteen and thirty or forty, and in
males more often than in females. Of six cases of
139
Na»a4 Cavities,
Nasal Cavities.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
fibroma in the nose and uasopliaiynx seen by the writer,
four were in men, two in women. — the youngest in a boy
of .si.xteen, tlie oldest in a. man aiiout forty
Tlie etioloyy is not linown, trauma possibl}- having to do
with the development Early in the disease the patient
has repeated attaclvs of epista.\is, often severe, the blood
coming not only from the tumor, but also from the ulcer-
ated niueovis membrane, and nasal obstruction develops
first on one side, then on the other, as the uasopharyn.x be-
comes lilled with the tumor. A copious watery or muco-
puriUent discharge constantly flows from the nose. The
voice becomes thick and nasal, the mouth drv and open,
the senses of smell and taste become impaired or lost, and
tinnitus and impaired hearing develop. Pain is absent
at tirst, but, as pressure on adjacent parts develops, it be-
comes steady. Deformity arises if the tumor is not soon
removed.
Prijcjiums is good if the tumor lie removed. If it be not
removed, death will ensue from copious hemorrhages or
from extension of the disease to the brain.
Removal can usually l)e accomplished by the cold wire
snare, but it may be dilHcult tn surround tlie growth.
The large loop is passed through the nose into the naso-
pharynx, the index tiuger of the left hand then pushing
the wire about the tumor, when the loop is drawn. The
pedicle may be so liard or the base so broad that the wire
may be repeatedly broken and the galvanocauterj- snare
be required before the tumor can be severed. The pedi-
cle or base may be cut with scissors, and in tmusually
large tumors it may be necessary to expose the nose bj-
an external operation before the tumor can be removed.
Profuse hemorrhage is to be expected in the removal of
fibroma by whatever operation, and death has occurred
during operation from this cause. Electrolysis has been
employed to lessen the size and reduce the vascularity of
the growth before operating.
Osteoma .\nd Cuon"dro.M-\. — The.se true bony and car-
tilaginous tumors are not to be confounded with the ex-
ostoses and ecchondroses so frequently met with on the
septum.
Osteoma originates from the ethmoid, vomer, accessory
sinuses, and other parts of the bony framework. Both
the cancellous and the cburnated varieties are met with.
The tumor grows steadily, though slowly, pushing ev-
erj-thing before it, invading the orbital cavity, displac-
ing the e3-eban, and causing intense pain. The tumor
has a bony connection with its point of origin or a pedi-
cle of mucous nieml)rane and connective tissue. It is
covered with mucous membrane, and is so hard that it
cannot be penetrated by an exploring needle. It is usu-
ally single, smooth or irregidar, and may be of any size,
depending upon the time it has been growing. The
symptoms are pain, early and continuous \\n\\\ the prcss-
lu'e destroys the nerve tilaments, nasal ob.struction with
all its results, impaired sense of smell, rauco-jiurulent
discharge, and freq uent attacks of epistaxis. Exojihthal-
mos. with or without blindness anil epiphora, is pro-
duced sooner or later, as well as other evidences of ex-
ternal deformity. The diagnosis is made by the history
of a slow growth, by the use of the probe or the needle,
and in doubtful cases bj' the microscope.
Prognosis depends upcui the extent of the tumor at the
time of examination, but it is usually goi id. The treat-
ment is entirely surgical and nearly always intranasal.
The tumor may have to be divided into "fragments by
the motor trephine, bone forceps, or saw, and removed
in pieces when it is too large to be extracted through the
nostril. AVhen the tumor is quite large and iuaccessible,
an external operation will have to be made, but much can
be done by modern intranasal surgery without resorting
to the more radical external operation.
Chondruma occurs less often than osteoma. Il s]irings
generally from the anterior part of the seiitum, but may
come from the ethmoid or other accessory sinuses. It
is a smooth, rounded, sessile tumor with a broad base
covered with normal-a]")pearing mucous membrane. It
is found in early life. The symptoms are those of oste-
oma, excepting that there is no tendency to bleed. It is
differentiated from osteoma by its permeability to the
needle and by its sessile base; from malignant tumors by
its slower growth, absence of hemorrhage, and harder
sensation conveyed through the probe.
Prognosis is good if the tumor is entirely extirpated.
Removal is accomplished by the knife, saw, cold or gal-
vauocautery snare.
P-\PiLi.oM.\. — Both hard and soft varieties of papil-
loma are met with in the nose. The hard variety resem-
bles in all resjiects the cutaneous wart, and is conlined to
the vestibule and anterior part of the septum, usually of
one side, and is commonly single, but may be multiple.
Man}- cases of the soft variety have been reported, but
the majority of them are not true papillomata, being
nothing more than papillary hypertrophies. These lat-
ter, sometimes known as '"Ilopman's papilloma." are of
common occurrence in hypertrophic rhinitis, occurring
along the inferior border and posterior ends of tlie infe-
rior turbinated bodies — sites where true papillomata do
not occur. Jonatlian Wright, who has investigated this
neoplasm with perhaps greater thoroughness than any
other rhiuologist, says that only ..bout a dozen cases of
unquestioned papillomata of the nose have been recorded
in literature. True iiapillomaapjiears to be restricted to
the anterior part of the septum, tlie floor of the nose, and
the anterior part of the external wall. It occurs at any
age and iu cither sex, and is usually single, unilateral,
and of small size, lint may grow to be as large as a
hazelnut, obstructing the nasal oritice. It may be ses-
sile, but almo.st always is pedunculated, grayish-pink in
color, with irregular surface and well-marked jiapilla?,
somewhat resembling a raspberry. It is very vascular,
bleeds easily, causing frequent attacks of epistaxis, and
has some tendency to ulceration. Pain is seldom pres-
ent. There is more or less pi'ofuse nasal discharge. Un-
less the growth is completely removed, it is likely to
recur.
Trciitinent. — Removal is best accomplished by the cold
wire snare, and any part remaining should be deslro\'ed
with the galvanoeautery. Vaseline or other emnllient
should be kept applied until healing has occurred, and
irritation by picking the nose is to be avoided. lugals
recommends the application of the tincture of tliuja
occidentalis to prevent recurrence. The possibility of
papilloma degenerating into or later becoming a malig-
nant tumor, especially in persons in middle life or later,
should alwa3's be borne in mind.
3. M.\LIGXANT NeOPLAS.MS.
AnENOM.\, sometimes classified as a benign tumor,
shows sooner or later malignant changes, undergoing
either carcinomatous or sarcomatous degeneration. "This
has been so in nearly, if not quite all, cases which have
lieen ol.iserveil and reported. Pure, unmixed adenoma in
the anterior nares is necessarily extremely rare, because
of the alwence of gland structure in the nose. Hopkins
and Leiand each reported a case of adenoma in the nose
at the meeting of the American Laryngological Associa-
tion in 1897, both cases ultimately taking on carcinoma-
tous change, and Lelaud's showing also a transition in
one part to papilloma. Mayer has recently reported (A>n.
Miiliriiir. August 2d, 1902) a case of adenoma, showing
sarcomatous ilegeneration in parts. Thi' tumor is to be
regarded as malignant. It presents itself as a grayish-
wliite granular polypoid mass, firm in consistency, the
surface .soft and pultaceous, bleeding easily, it devel-
o])s much more slowly than either sarcoma or carcinoma.
S-^RCo.MA is the commonest form of tumor met \\itli iu
the nose, if we exclude mucous polypi and oflier tumors
of purely inflammatory origin. AH varieties found iu
other parts of the body occur in the nose, but the round-
and spindle-celled sarcoiuala are most frequently seen,
and after these in points of freijuency are myxosarcoma,
melanosarcoma, and filirosarcoma, the other forms being
much more rare. Both sexes are equally attacked. The
period most susceptible to sarcoma in the nose is the
flftli decade, between the fortieth and fiftieth years, but
14 U
REFERENCE HANDBOOK OF THE 3IEDICAL SCIENCES.
IVasal i'avilles.
>asal raTillos.
no age is exempt, cases being seen in early infancy and
in extreme old age. Of eiglity-four cases collected and
anal_yzcd as to age l\v HaiTis (Phila. Montldy Med. Jmir.,
June, 1899), thirty-four, or forty percent, of the eases,
were Ijetween thirty and tifty; four were under ten
years of age and five between seventy and eighty.
As to etiology, little is known. Sarcoma is found so
frequently associated with mucous polypi that thei'e
would seem to be some basis for the belief that under
certain unknown conditions mucous polypi do undergo
sarcomatous degeneration. Trauma, accidental or sur-
gical, may be an etiological factor in this transformation
from a benign to a malignant growth, and crude methods
in operating have been suggested as a possible cause : but
facts are wanting to substantiate this, too few cases bear-
ing on this being reported to base any conclusions upon.
Symptomatology. — The earliest S3'mptoms are unilate-
ral nasal obstruction, progressing steadily and rapidl_y,
and repeated attacks of nosebleed. Epistaxis is a prom-
inent symptom throughout tlie course of the disease, and
may become a verj' serious and alarming one. Discharge
from the nose is profuse, at first watery, tlien muco-pui--
ulent and bloody, and later on the odor of necrosis
makes it offensive. Pain is conspicuously ab.sent in the
earh- part of the disease, but, as the growth encroaches
on the accessory sinuses, it becomes constant and steadily
increases in severitj'. With the s])reading of the tumor
into the accessory sinuses and neighboring cavities more
or less deformity of the face occurs, such as exoplithal-
mos and fulness at the side of the nose and of the cheek
with discoloration of the skin over the affected area.
The growtli may protrude forward through the nostril or
backward into the pharynx, as in the case of a two-year-
old child seen by the writer. Vision may become im-
paired from pressure on the optic nerve after involve-
ment of the sphenoidal sinus. Nasal obstructiim
becomes so complete that the patient has great distress
in breathing and in eating, speech becomes thick and
mutfled. the senses of smell and taste are lost or much
impaired, nasal discharge becomes most profuse and
offen.sive, pain is constant, insomnia adds to the distress,
and the patient loses weight and strength, and finally
dies, unless relieved bj' surgical intervention, from ex-
tension of tlie tumor through the cribriform plate of the
ethmoid or roof of the sphenoidal sinus to the brain, or
death may result from sepsis and exhaustion.
The objective appearances of sarcoma are not alto-
gether characteristic. It is usually pedunculated, but
may be sessile, and arises most often from the cartilagi-
nous and bony septum and the middle turbinated body,
but it has been seen originating from any and all parts
of the nose. The color varies from that of a simple mu-
cous polyp to a yellowish-pink or dark red, most often
the latter. It is ordinarily ([uite soft to the touch of the
probe and bleeds easily on examination, as in the round-
celled variety, or it may be (|vnte firm, as in tlie fibrosar-
coma. The surface is smooth, unless ulceration has oc-
curred. The tumor may have originated in any of the
neighboring cavities, invading the nose secondariiy. The
writer, some ten j-ears ago, had rmder his care a physi-
cian in whom a gliosarcoma of the dura mater perforat-
ed the base of the skull at the region of the sella turcica,
invading the sphenoidal sinus, and causing softening
and absorption of the cribriform plate of the ethmoid.
The glands of the neck are not involved, unless it be by
direct extension of the disease to them. Sarcoma is to
be differentiated from simple mucous polyp, angioma,
adenoma, carcinoma, and sj'philis. The iodides should
be administered to exclude syphilis in a doubtful case,
and a microscopical examination of a ])iece of the tumor
removed liy the cold wire snare should always be made.
Prvgiiosh depends ujion the site of the origin of the
tumor, the extent of its invasion, and the variet_v of the
neoplasm. Sarcoma, having its origin in the se|)tum,
especially the cartilaginous part, offers the most favoi'-
able outlook, while one arising from the middle or supe-
rior meatus is most unfavorable. The round-celled sar-
coma, the commonest variety seen in the nose, is also the
most virulent. Jlore than fifty per cent, of all cases are
fatal. Of one iiundred and three cases in Harris' table,
the final termination was slated in but fifty-five, and of
the latter twenty-five ended in death and" thirty in re-
covery. All but one of the thirty were operated upon.
Twenty-two of thefee latter, however, were reported as
cured within a year of operation, and it is probable that
recurrence took place in some or many of them latei'.
Treatment. — .Surgical intervention at present offers
practically the only chance of recovery. The ojieration
must be thorough and the tumor completely eradicated.
Fig. :U'."|. AuiiiMHui ,,( th.- .%,,»,■. « m, m, iin.ni .Nimuiiiiinus Ih-ir.-ii-
eration. i(.'a.se reporieti In' Dr. Kmil .Muver iu Atntrwaii Mttli-
cine, August 2a, 1902.)
If the tumor is pedunculated and arises from the .sejitum,
especially at its anterior part, an intranasal operation
with the .snare may be entirely efficient; but if the growth
comes from the middle or superior meatus or invades or
involves the accessor}' sinuses or is inaccessible in any
way, an external operation must be done. The nose is
released and the jiarts involved are laid l.iare, the tumor is
removed by cutting or the use of the snare, and the base
is thoroughl}' curetted. Should recurrence take place,
this should be lemoved at once. In inoperable cases —
and many are inoperable — Coley's mixed toxins may be
given with some hope of diminishing the size and retard-
ing the development of the tumor, even if not curing it:
such a cour.se being specially indicated in the spindle-
celled variety.
C.\ncixoMA, much more rarel_y seen in the nose than
sarcoma, is always primary and occurs as epithelioma or
cj'linder-celled carcinoma. It originates most freipienth-
from the cartilaginous seiitum and the turbinates, but
more often still it is an extension into the nasal fossa'
from the neighboring accessory sinuses, especially the
maxillary. It is found during or after middle life, differ-
ing in this respect from sarcoma, which occurs at all
ages. Unlike sarcoma, which has its origin in the deeper
structures and fcirms a distinct tumor, epitlielioma be-
gins in the mucous membrane, ulcerating and destroying
as it progresses. Nasal obstruction and ])ain of a neu-
ralgic character are early symptoms. The dischai'ge at
first is acrid and of a sero-sanguinolent charar'ter, but as
ulceration occurs the discharge is more jirofu-se and be-
141
Xasal Cavities.
Nasal Cavities.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
conies putrid and fetid, giving to the patient and his sur-
roundings an odor tliat is persistent and otrensive. Re-
peated attaclvs of epistaxis occur. Tinnitus and impaired
liearing and earache are often comidaiued of. As the
growtli extends into llie accessory sinuses, tlie orbital
and cranial cavities, a new set of syniptians develops.
The elieek becomes full, the eyeball is jjushed out, vision
may become imi)aired, jiain is greatly increased, and
liuiilly signs of meningitis or brain abscess develop.
01)]ectlvely, epithelioma presents itself early in the
disease as au'infiltration of the nuicous membrane, sug-
gesting a papillomato\is liypertroi)hy, but ulceration
soon takes place, leaving the edges of the ulcer hard and
the surface angry and covered with a thick, grayish se-
cretion. Bleeciing follows the slightest limbing. The
tuniorshows marked tendency to invade the deeper parts,
with little inclination to extend outward to the skin.
Sooner or later the submaxillary and cervical glands be-
come involved, though tills is notalways so, and cachexia
develops only after the disease has existed for some time.
The differential diagnosis is to be made usually from
syphilis, lupus, and tulierculosis. Antisyphilit.ii^ treat-
ment will often clear up a suspected epithelioma, and
when an}' doubt exists the iodides should be given, if
but for diagnostic jnirposes. Luims has a very marked
tendency to extend to the skin, which is usually in-
volved. In a case of suspecteil primary tuberculosis,
the bacillus will be found if that disease is present. The
microscope may be re(|-uired to determine the iliagnosis of
epithelioma ; in employing it, however, one must not over-
look the jiossiliillty that the removal of a piece of the tu-
mor may lie followed by renewed activity of the growth.
The pror/nusis is absolutely bad, few if any authentic
cases of recovery having been rejiortcd. The disease
appears to be more raiiitUy fatal in the nose than in most
other ]iarts of the bod}'. Treatment heretofore has been
unavailing ; operation secniingly not only not eradicating
the disctise, but not atfordi'iig even temiKirary relief. The
growth I'ecurs rapidly. While the .r-ray as a curative
or remedial agent in the treatment of cancer is still ex-
perimental, yet the very favorable reports of its use in
other iiarts of the body would make it seem that the pa-
tient sliould be given whatever benelit there may be in
this treatment. Pain may be reliexed somewhat by or-
thoform or other local an,-estlietic, and toward the enil
narcotics should be given to relieve the sufferer, and an-
tiseptic washes used locally throughout the disease.
^Thnnuls II. Ihilstal.
NASAL CAVITIES, DISEASES OF: PARASITES.—
The lucseuce of animal parasites within the nasal cavi-
ties is of relatively infre(iueut occurrence. In the ma-
jority of cases such an event is purely aecideula! ; true
parasitic infection — i.e.. the jircsence of animal forms
which reproduce, or pass one or more stages of their ex-
istence, within the nose — is very rare. As is the case
with the external auditory canal, the nasal oiitices, under
certain conditions, may form favorable avenues of en-
trance for such creeiiing forms of animal life as are fond
of escaping the light by crawling into dark places. The
residence of such animals within the nost; is usually but
temporal}'; during this time they do not draw nourish-
ment from the body tissues. The ell'eets jiroduced ;ire
cliietlytlm.se of local irritaticni or nbstruetidii. To this
condition the term pseudopanisitiou may with j'nipriily
be applied.
PsEUDOP.vRASiTisM. — Among such iiseudojiarasites of
the nasal cavities maybe mentioned earwigs, ceiiti]iedes,
numerous beetles, insects, sjiiders, mites, bedlmgs,
leeches, and worms. Entrance into the nose is usually
obtained during sleep, very often in the open air, during
the daytime. The local syiii[)toms of irritation and ob-
struction maybe very slight or severe. Bloody or nmco-
puruleiit discharges may be produced. In many cases
the chief .symptonis are of a nervous character, due to
fright or worry. The intruder may penetrate intu the
fnmtal siuu.ses. Such cases may be attended by danger-
ous symptonis or even result fatally. It is said that cen-
tipedes are especially likely to reach the frontal sinuses.
Cases are reported of these animals remaining in the
frontal sinus for years, drawing their nourishiiieiit from
the secretions of the cavities.
The occasional entrance of round worms {Aticm-is liiin-
hricnides) mio tlie upper air passages and into the nasal
cavities is of clinical importance. As is well known,
these worms may, during the sleep of the alTiicted indi-
vidual, wander from the intestine, through the stomach
and a>soiihagus, into the mouth and upper air passages.
Ordinarily no especial symptonis are produced, but the
jiassage of the worm into tlie larynx may cause serious
symptoms of suffocation or even result fatally. Imjior-
tant obstructive symptoms may also arise from the pene-
tration of the worm into the Eustachian tube or tear
duct.
The O.vyuris rermkiiliirin may be transferred from the
anus to the nose through uncleanly habits, but does not
remain in the new location.
True P.vr.^sites. — Prittuzou . — Various forms of proto-
zoa (Aiiiahd, Ceroimoiiiis, and Trieliiiinimiis) have lieen rc-
13orted as occurring in the nose, in such conditions as
ozicna, purulent catarrh, whooping-cough, noma, etc.
It is very doubtful if any of the appearances, described
in the majority of such cases, were really jirotozoa; it
is much more likely that they represented degenerating
cells, leucocytes, etc. Jlore careful observations are
needed to settle this point.
Wiinns. — The accidental presence in the nose oi Ascnris
and Oxyiirix has already l.ieen mentioned. I have been
unable to tliid in the literature any well-authenticated
case of Ci/x/irrn-iift of the nasal cavities. Only two or
three cases of nasal Erhinoeocciis have been reported.
In one of these, oliserved by Rogers, the patient, a
woman aged thirt}'-four years, had had a severe nasal
obstruction for two and a half years. During a violent
effort to clear the nose there was an escape of a large
quantity of clear, straw-coloieil lliiid. Two months later
a cyst-like body was removed b\' snare from the middle
turbinate; this was ruptured during removal. The
microscopical examination showed the presence of numer-
ous echinococcus booklets in the walls of the cyst.
Anichnida. — Pcntu.itvma denticiilitti/m, the larval form
of PentiisUiiiiii tiinuides, is found in the nasal, frontal, and
maxillary .sinuses of various animals, particularly in the
dog. Rarely, the parasite may lie foiinil in the human
nose; the infection usually takes jilacej from dogs, or
through the accidental inhalation of the young lai va\ or
by the eating of contaminated food. In the latter case
the parasite later wanders from the alimentary tract into
the nasal cavity. Its presence there causes inliammation,
nosebleed, etc. The diagnosis rests ujion the occurrence
of severe irritation, and the demonstration of the parasite,
Innei'tif. — The must common and ini]iortant nasal para-
site belonging to this chiss is the maggot or larva of cer-
tain flies, both of the biting and the stinging varieties.
The fly lays its eggs upon I'ither the normal or diseased
mucous membrane of the nose: in the latter case proba-
bly attracted by the odor of secretions. Certain varieties
may Uwce. their way into the healthy nose and there de-
posit their eggs. Such an infection occurs, in the great
majority of cases, v>licii the affected individual falls
asleep in the open air during the daytime. The 8arco-
plmrjii Ciinnirlii, SiiruiiJiiiyd, Wv/ilJ'ii/uii/. Miisrn (inthni-
popliari<i, ^Jllxc(l nidarcn'iiii, Mtiscii domestica, Mnsm gtabu-
hiiift, Pidpliilii ciiKii. Liiriliu inaeellaviii, Oi'^truii h'/ri.i. etc.,
ha\'e l.ieen reported as proilucing maggots within the
human nose. In certain tropical countries, Mexico, Cen-
tral America, the tropical portions of South America,
West Indies, Hindustan, etc.. such infections are not un-
common. The condition is known as .l/(//'/w'.s luiritim.
In the great majority of cases tlie affected iiulividuals
have a history of ozKiia or jiuruleiit nasal catarrh. The
LticiUa maeeUaria, however, frequently attacks the
healthy nose.
The symiitoms of myiasis are usually very severe ; it is
said that the sufferings may be so intense as to lead to
suicide. The number of eggs laid upon the nasal mucosa
142
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Nasal ruvEties*
Nasal Cavities.
may be very great, as many as live lumdred eggs of
Lucilia macellaria (Texas screw-worm) liaviug been re-
moved at one time. In other cases several hundred
larviE may be removed or discliarged. The eggs hatcii
rapidly, and nasal obstruction soon results, with intense
pain in forehead, cheeks, etc. A waterv or blood}' dis-
charge, cedema of the neck and face, vertigo, sleepless-
ness," delirium, coma, reflex vomiting, and convulsions
mark the atlection. Fever may or may not be present.
The nasal mucosa may be completely destroyed and the
bones denuded through the efforts of the growing larvre
to obtain nourishment. Within a short time, one to two
weeks, the larva; leave the nose to form their cocoons
outside. The character of the nasal discharges usually
changes after the maggots have left the nose, becoming
more purulent. The inflammation may persist for a long
time, or in other cases the symptoms m,ay abate imme-
diately ujion the removal'of the parasites.
The history of the case, the symptoms of rapid obstruc-
tion with watery or bloody discharge, and the demon-
stration of the presence of the maggot make the diagno-
sis clear. The prognosis is on the whole favorable, but
fatal cases may occur.
The treatment of nasal parasites in general con.sists,
first, in the removal of the parasite; secondly, in the
treatment of the local condition caused by its presence.
In the case of maggots or other parasites which are more
or less lirmly attached to the mucosa, various antiseptics
may be used for the purpose of stupefying or killing the
parasite. Inhalation of chloroform, etiier, turpentine,
bichloride solutions, calomel powder, decoctions of to-
bacco, balsam of Peru, are among the remedies suggested.
The filling of the nasal cavities with warm glymol is
advised, especially in the case of maggots; the oil tilling
up the spiracles of the larvoe kills them, and they are
then easily washed out. In very rare cases it may be
found necessary to explore the frontal sinus.
Aldred Scott Wartldn.
NASAL CAVITIES, DISEASES OF: RHINOSCLERO-
MA. — On account of the wide diffusion of the lesions
it has been suggested to .substitute the name scleroma,
without a local qualification, for this affection. It is a
rare disease wliicli is seldom found excepting in Austria,
Hungary, and Italy. It is characterized by a peculiar
connective-tis.sue growth in the mucous and submucous
tissues of the respiratory tract which forms nodes, tubei--
osities, or slightly raised, smo<ith, flat, and extremely
hard patches. In course < if time these are seen about the
nostrils or upjier lip, and finally they invade any and
every portion of tlie respiratory tract. These new
growths are of a cartilaginous hardness, and owing to
the atrophy of the new tissue, the_v form dense cicatrices
without the intervention of ulceration.
An.-\tomic.\l Ci[.\racteristics and Cot'IiSE OF THE
Disease. — Hard prominences, varying usually in size
from a millet seed to a pea, and diffuse infiltrations char-
acterize the disease. The affection usually begins in the
salpingo-palatal fold or in the clioanx, and gradually
progresses forward until the vestibule of the nose is
reached, where it may terminate, or it may involve the
external integument, occasionally invading the upper lip
and changing it into a hard, snout-like protuberance.
It also extends downward involving the pharynx, larynx,
trachea, and bronchial tubes whicli become constricled
by the contracting cicatrices. The diffuse infiltrations
are firm and very rigid, and in proportion to their size
mechanically obstruct the nares. Later, they luidergo
cicatricial transformation, and further obstruct or eom-
pletel}' obliterate the nasal passages by the contraction
of the resulting sears. When the cartilaginous external
nose is involved in the disease, it becomes deformed by
nodidar protuberances of intense hardness. The integu-
ment of tlie uo.se is at first dense and white; later it red-
dens or acc£uires a livid hue. Occasionally slight vdeer-
ation occurs and fissures sometimes form, especially
between the aire and the cheek. In the nasal vestibule
the disease often forms voluminous folds, which mav
protrude from the nostril. These are of a bluish-red
color and are sometimes a centimetre in thickness.
Etiology. — Among those who have given this affec-
tion the most study it is generallj- believed to result from
the presence of the Frisch bacterium, which is always
Fig. 34t)l.— Rhinoscleroma. (Fri)nil,e Dentu et Delbet's "Traitt^de
Cliirurgie.")
found in con.siderablu numbers in the cells in the lym-
jihatic spaces of the affected part. There is no proof
that it is contagious.
Symptomatology. — In the beginning the disease is
marked by symptoms of simple chronic rhinitis, which
may extend over a period of several years. The secre-
tion, at first watery, graduallj' becomes purulent. After-
ward it dries into scabs or crusts, which as they decom-
pose emit a very off'ensive odor, different from that of
ordinary oz;i?na and apparently peculiar to rhiiioscleroma.
The scleromatous tissue is not usually deposited until the
catarrhal .symptoms have existed for several years. On
account of the painlessness of the disease and its gradual
accession, patients connnonly do not present themselves
for treatment until a number of years after its beginning.
Diagnosis. — Khinoscleronia is to be distinguished from
syphilis, epithelioma, and keloid, though as the latter is
distinctly a disease of the skiu which often a|)pears in old
cicatrices, it is not at all likely to be confounded with
rhinoscleroma. The essential "features iu the diagnosis
are the chronic course of the disease, the cartilaginous
hardness of the infiltration, the formation of cicatrices
without previous ulceration, the invasion — during the lat-
ter portion of the disease — of the larynx, trachea, or plia-
rj'n.x, and the broadening and deformity oi the external
nose by the scleromatous dei)osil.
Syphilis in the tertiary stage also leads to cicatrices
which might be mistaken for those of rhinoscleroma, liut
.syphilitic lesions dilTer from those of the discasi- under
consideration in that their ]irogress is more rajiid and
the hardness of the gummy deposits less marked. The
syphilitic nodule also commonly ulcerates, whereas the
scleromatous one does not. Again, the specific treatment
of syphilis is usually followed by speedy improvement.
14:3
Nasal Cavities.
Na)^al C'avUios.
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
whereas the iodides and nierciuials do not affect tlie prog-
ress of scleroma.
Epithelioma causes induration and some nodular infil-
tration of the .skin, but the nodules are softer than tho.^e
of rhinoscleroina and they soon ulcerate and bleed. The
disease also runs a much more rapid course than the one
under ccmsideration.
Phognosis. — This affection cdmnioiily extends over
many years. There is no tendency to spontaneous re-
covery, and unfortunately treatment is unavailing e.\eepl
in the way of palliation. In conseqvience of the tendenc_v
to cicatricial coutiaction. when the alTection involves tlie
laryn.\, tlic trachea, or broncliial tubes, it may ])rove
fatal by obstruction to respiration, lint it does not usually
shorten life.
TnE.\T.MEXT. — The treatment is entirely operative and
palliative. Obstructive infiltratinns may be removed
and thus relief be obtained for several years, though it is
impossible to prevent recurrence and extension to oilier
parts. Even extensive radical operations in tlie begin-
ning have no intluence in preventing the progress of the
disease. In the operative measures outgrowths in the
nose may often be removed by the snare, but the liarder
tissues must be cut away with a sealiiel or trephine, or
removed with a sharp spoon, and the o]ieration may be
finished with a galvanocautery, <ir hardened nodules may
be reduced by electrolysis. The wounds left by these
operations leadily heal. It is generally thought best not
to interfere withfacitU deformities, as recurrence is prac-
tically certain and excision would only necessitate re-
peated plastic operations to cover the defects resulting.
/•;. Fhirlitr Illffllls.
NASAL CAVITIES, DISEASES OF: SINUS AFFEC-
TIONS.— Till' anirums of Iliglonore are irregularly
shaped cavities situated in the head between the upper
teeth and the orbital cavities. They vary in their di-
mensions, the horizontal and antero-posterior diameters
averaging about 25 mm. There is one normal opening
in each sinus — tlie hiatus semilunaris — which is situated
in the uppermost part of the inner wall. This opening
frequently becomes occluded by intlaminatory processes,
and an art iticial opening is then created b\- the internal
wall rupturing at a point posterior and inferior to the
normal aperture. Occasional!}' the roots of the molar
teeth project upward and form small pyramids on the
floors of the sinuses. Semicircular membranes, bands,
and bony jiartitions, one-fonrlh to one-half inch high, are
frequently found dividing the lower and lateral portions
of the cavities into compartments.
The walls of the canine fossa' and the inner or nasal
walls, beginning at a point about one-third of an inch
above the floor, are very thin, excepting those parts which
give attachment to the middle turbinate bones. The inner
lip of the hiatus semilunaris forms a small canal which
connects with the mouth of the infundibulum or na.so-
frontal canal; a freijuent result of this being that the
fluids fi-oni the frontal sinus and anterior ethmoid cells
flow down into the antrum of Highmore. The principal
physiological function of the- nasal accessory cavities is
to supply fluid secretion and warm air to the nose and
to sitrvc! as resonance chambers within the head. During
inspiration the apertures, including the naso-lachryinal
ducts, have a tendency to open, while during expiration
the_v partially close: at the beginning of inspiration the
partial vacuum jiroduced takes a part of the latent air
from within tlie cells, and the velocity of the inspired
current fvirther draws from them. Toward the end of
the inspiratory act new air enters the cells to fill the par-
tial vacuum, this entrance being aided by the natural
law by which warm air is displaced by cold; on ex-
piration the rix-(i-tci;r/i> jjressure piirtially closes the
cells. These to-and-fro currents of ;iir constantly draw
the tenacious mucus from the cells, overcoming the
adver.se conditions of small openings ;ind the law of
gravity.
There are four groups of sinuses which eoinmunieate
with the nasal cavities, viz., the frontal, the maxillaiy,
the etlimoidal, and the sphenoidal. As the diseases of
the frontal sinuses have already been fully discussed in
Vol. IV^., under the heading Frontal Sinuses, etc., the
present writer will consider onl}- the affections which in-
volve the other three grou]is of sinuses.
I. Diseases op the SIaxillary Sinuses.
ExioLociY. — Much has been done of late to solve the
problems as to the cause of diseased conditions within
the antrum of Highmore. Distinguished writers differ
considerabl}' concerning the relative frequency of differ-
ent morbific agencies as causative factors. Careful ob-
servers are proving that acute infectious diseases are re-
sponsible in many cases that were formerly attributed to
other causes, and this is in accord with my own investi-
gations.
The teeth are responsible for nearly one-half of the
seriously diseased cases that have come under my obser-
vation. A careful examination of the teeth extracted in
a series of cases gave abundant evidence of alveolar peri-
osteitis, caries, and necrosis at the root end. In other
cases the maxillarj- bone was necrotic, carious, and de-
stroyed to a variable extent, ffidema of the nasal mu-
cosa and polypoid changes existed as definite causal
factors in a large proportion of the cases of nasal origin.
More or less pressure upon the middle turbinal by a de-
viated and thickened septum, this in turn pressing upon
the ostium maxillare, approximately closing the hiatus
and cavisiug retention of .secretions more or less laden
with pathogenic bacteria, was a prominent factor in many
cases of chronic muco-purulent discharge from the an-
trum.
I am convinced that the sup]iiuative rhinitis of child-
hood often leaves a local su]iiiuratiou in the antrum which
continues generally througli adult life, unless proper sur-
gical procedures are emplo.ved to relieve it. Syphilis,
tuberculosis, tumors, and foreign bodies occasionally
cause suppuration of the antrum.
Sy.mptoms. — Empyema with complete occlusion gives
rise to extremely painful conditions, and there isafeeling
as though the antrum would rupture from the intense
liressure. These symptoms disappear immediately after
a vent is secured. In those cases in which the acute and
subacute catarrhal processes occur in the nasal cavity
and extend into the antrum by continuity, there are a
slight fulness and a sensation of stuffiness in the region
beneath the eye, associated with a thick muco-purulent
discharge into the middle meatus beneath the bulla eth-
moidalis.
Complete convalescence in these cases takes place with-
in from three to six weeks. Postnasal catarrh is a con-
stant symjitora. In the chronic cases mucus and pus are
discharged tlirougli the anterior nares. Most patients
who have very thin fluid in the antrum complain of it
running down over the upper lip whenever the head is
inclined forward.
Asthma, tubal stenosis, and tinnitus aurium, impair-
ment of hearing, mental lassitude, and iuabilit}- to con-
centrate the attention for any length of time are all com-
mon symptoms. Pain is a most irregular symptom ; it
is absent at times even in the ntost severe cases. It is
often localized in the temporal or the occipital region.
The most constant symptom is more or less discliarge of
muco-pus over the lower posterior part of the lip of the
hiatus semilunaris.
Pathoi.oov.— A classification which I made several
years ago of the pathological conditions practically holds
good to-d.ay. In this there were eight subdivisions, as
follows: I. Acute, catarrhal, suppurative, and infectious
sinusitis witliout complete .stenosis of the normal outlet.
II. Acute catarrhal, snpiiurative, and infectious sinusitis
with complete occlusion of the normal outlet. III. Sub-
acute and chronic catarrhal and suppurative sinusitis with
moderately obstructed opening, with or without decom-
l)0sing pnro-mucoid debris. IV. Polypoid degeneration.
V. Alveolar periostitis and periodontitis attended by sup-
purative caries, necrosis, or other pathological changes
1-i-i
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Nasal raTitles.
Nasal Cavities.
at the root end. VI. Atrophic rhiuitis. VII. Tumors
and foreign bodies. VIII. Sj'philis.
The cases of the first class are very common. Tlie dis-
ease is u.sually self-limited and frequently loaves the mu-
cous membrane much swollen and hyperplastic. Occa-
sionally associated with an acute infectious disease there
is a necrosis of the antral muco.sa as well as of other parts
of the mucous membrane of the respiratory tract. When
there is complete stenosis, and when neither na-
ture nor the surgeon relieves the condition, the
consequent tension causes necrosis of the soft
tissues, and this occasiouallv extends to the bone.
In the subacute and chronic catarrhal suppura-
tive cases, when the opening is moderately ob-
structed, the muco-purulent secretion frequently
becomes partially inspissated, formsan accretion, and acts
as a foreign bod}-, causing the destruction of tissue. These
by-products frequently destroy the surface of the mucosa
and start small ulcerated areas which, if not cured, extend
in time to the periosteum and often to the bone itself.
Polypoid and cedematous changes which involve the
ethmoid often have their origin in the antral mem-
brane. If the}' occur on the lateral or upper walls of the
cavity and remain more or less flat or mammillated, there
is a possiljility that the mucous membrane at these points
will, under favorable circumstances, return to its normal
state. But if these growths once become pedunculated
it seems to be impossible for them to return to the condi-
adrenaliu are carefully applied throughout the middle
and inferior meatuses. After the shrinkage of the mu-
cosa has taken place a soft silver probe is used in the
region of the ostium maxillare. The patient's head is
Fig. 3492.— Cannula Needle for Aspirating: and Irripatin^ the Antrum of Highmore throuirh the
Wall of the Middle Meatus.
tion of a normal mucous membrane. Caries, necrosis,
and periosteitis in the molar or bicuspid roots frequently
extend through the bony floor of the antrum and give
rise to tistuhe, the discharge from which pushes up the
periosteal lining of the cavity, and often leaves it float-
ing in a muco-purulent medium. Ruptures may take
place through this membrane at different points, causing
a discharge of .secretion into the antrum. The antral
membrane becomes very tliick and granidar, and the
mucosa and bony wall of the cavity degenerate. The
atrophic process, which is the consequence of suppura-
tive rhinitis in early childhood, invades the antrum,
frequently destroys the epithelium and the glandular
structures of the mucous membrane, and leaves a scle-
rosed membrane which secretes a semipuru-
lent matter;- this decomposes in the warm
air of the antrum and issues through the
normal opening into the nose, where it is
formed into crusts by the inspired air.
Tumors, especially the syphilitic gumma
and the epithelioma, may form in the an-
trum.
DiAGXosis. — A discharge of pus from one
nasal cavity is by far the most suspicious
individual symptom of empyema of the
maxillary sinus. It is the writer's custom
in all cases of nasal and rliinolarj-ngeal dis-
ease to make a complete investigation of the condition of
the nasal cavities and the rhinopharynx, and then to
account for the condition of the accessory sinuses as far
as modern methods will allow. 'When a disease of one
of the sinuses is associated with a discharge, cocaine and
Vol. VI.— 10
Trocar and Cannula for Penetrating Antrum 'n'aUs.
placed in different positions, the best one being that with
the top of the head on the floor, the patient lying across
a chair. 'W'hen this position is assumed, and especially
when the patient at the same time forcibly blows his
nose, the secretion within the antrum will generally be
forced to flow over the lip of the hiatus beneath the
bulla ethmoidalis.
In making the test by transillumination, I usually em-
ploy a four-candle power electric lamp of moderate bril-
liauc_y, the patient being in a dark room, and the lamp,
attached to a suitable holder, being held within the closed
cavity of the mouth. I do not rel}' entirely, however,
upon" the electric lamp, but use it only as an indicator for
further efforts at determining the condition within the
maxillary cavity. If there isa unilateral umbra, warrant-
ing the suspicion that the an-
trum of that side is diseased, the
investigation must be pushed
in other ways until the con-
dition of the antrum is as-
certained. Frequently after a
curved irrigator has been
passed through the normal
opening, and more or less
forced irrigation employed,
definite evidence of a suppura-
tive process is obtained. If
this jirocedure cannot be ac-
complished, puncture should
be made with a curved trocar
through the antral wall near the
unciform process, at a point
situated posteriorly and inferi-
orly to the hiatus. In other cases it may be necessary to
pass a trocar through the wall of the inferior meatus, when,
under forced irrigation, some of the retained secretion
or debris will be expelled through the natural opening.
In certain cases of cj'stic tumors I have found it neces-
sary to make an exploratory ojiening through the canine
fossa? before the diagnosis could be definitely settled.
Prognosis. — The prognosis of diseases of the maxillary
sinus will depend upon the pathological conditions pres-
ent in each individual case. The ordinary cases of em-
pyema are extremely annoying and affix-t the general
health in many ways; — constant swallowing of the fetid
pus is one of the most objectionable features.
The diseases of these sinuses are not uearlv so fatal as
FIG. ;3494.-Rubber and Metal Att.iohment for Central Cannula.
those of the other sinuses on account of their distance from
the cranial cavity. Even malignant tumors are more
curable here. In empyema cases the jirognosis depends
upon the manner, method, and extent of the surgical pro-
cedure. If sufficient drainage can be secured, either into
145
Nasal Cavities,
Nasal Cavities.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Fui
Antrum Tubes.
Rubber
the mouth or into tlio nose, and if caref\il curettage of
the antrum be employed, the drainage and ventilation
being maintained until' nature's pioeess restores appro.xi-
niately the uuieosa, the prog-
nosis ean be said to be fairly
favoraljic.
In all infectious cases the
prognosis is favorable if com-
jilete irrigation can be carried
out through the uormal oj'eu-
iug.
Tre.\tmext. — In consider-
ing the best treatment for the
individual cases, one must ascertain, through every
kuown method, the exact pathological conditions. It
must be borne in mind, however, that while some of the
apparently worst forms of antral empyema have been
cured by the extraction of a tooth and a few weeks' irri-
gation tlirongli the socket, there are other cases of ap-
parently a much less serious character, which resist all
our therapeutic efforts in the most stubborn manner.
Thus, for example, the writer has seen cases of trivial
discharge (the oidy symptoms being a moderate post-
nasal catarrh), wliich, after a thoroughly radical opera-
tion, have terminated in the most obstinate purulent con-
dition. Since we cannot obliterate the antrum without
objectionable results, we must try to restore its functions
without destroying too much of the lining membrane.
The author believes that he was the first to insist upon
not treating the antrum in full accordance with the pre-
vailing surgical teachings. It is his belief that thorough
curettage fre(|uently induces a worse condition than the
disease for which it is eiujiloyed. It is his rule, in ca.ses of
long history and severe disease manifestations, to make
large openings through the legion of the canine fossa and
malar ridge and counter-openings through the inferior
or middle meatus, and then to carry out a gentle and
careful curettage of the nnicosa an<l a firm and decided
curettage of whatever bare bone may be found. After
these steps have been taken the cavit}' is to be packed
with aristol or iodoform gauze which has been passed
through mercuric-bichloride solution. This packing , is
never allowed to remain longer than a week. At the ex-
piration of this time the mucous niendirane is inspected
occasionally, the exuberant gi'anulatious are removed
with the curette, and the cardinal principles of free drain-
age and free admission of air are utilized as far as the
conditions of the individual case will ijcrmit. As sup-
plementary measures various forms of tubing may be
introduced into the antrum, for drainage purposes, and
the membrane may be re-ineised as it closes <iver the
aperture. I have occasionally bad ]iatieuts who appar-
ently were cured by treatment through
the natural opening, but these evi-
dently were cases in which purulent
semi-decayed collections had formed
and acted as a leaven tn |ieriietuate the
suppurating foci.
AVhen one is called upon to treat a
case of antral disease, thedillieult prol)-
lem of selecting the best operative ju'o-
cedure at once presents itself. If it is
a case in which the evidence jioints to
a diseased tooth as the causal factor,
removal of the tooth is imperative. A
certain proportion of these eases may
be cured b_v tliis ]iroeedure alone, with-
out any further interference. And
even if the dental disetiso has already
involved the antral walls, causing
caries and granulation tissue, in some
of these cases a cure may still be ef-
fected by drilling a hole into the floor
of the shins through the tooth .socket, for the
of securing proper irrigation and ventilation. When
the granulation tissue extends practically throughout
the antral walls and more or less bare bone exists, re-
moval of the nasal wall of the antrum is indicated in
either the inferior or the middle meatus, preferably in tlie
former. During the first few weeks after the establish-
ment of such an opening it is usuall\' best not to use any
tube. A rubber tube is extremely useful in favorable
cases, but if the opening is larger than the head of the
tube, the latter is apt to disappear into the antrum and
cause annoyance.
■\Vith the aid of Dr. Dixon, a dentist of New York City,
I have hail constructed a permanent tube of gold or sil-
ver. A small band is placed around the most available
tooth, a silver or gold wire is welded to the baud, and
then the gold tube is welded to the distal end of the wire.
The patient can insert and remove these tubes at will,
and when proi)erly made and inserted they give little or
no anuo3'ance or discomfort.
The small curette with a malleable handle should be
introduced from time to time toa.scertain the condition of
the mucosa, and if exuberant granulations abound they
should be gently curetted.
Thorough cleanliness is essential, but it has been found
that too frequent irrigations are injurious. A solution
of boric acid or of common table salt is the most accept-
able to the mucous mendirane. Certain fonl-smelling
cases have been relieved in a few days b.y the injection
of a mixture of three grains of iodoform in two drachms
of liquid alboleue; this mixture being left in the cavity
for two or three days.
In cases iu which polypi develop, it will sometimes be
nccessarj' to remove these, at frequent intervals, from
different parts of the cavity of the antrum. In cases of
sarcomatous disease a complete and thorough removal of
all parts of the antrum is necessary: and the same pro-
cedure would be advisable in epithelioma if the disease
could be detected in the early stages; but, unfortunately,
in most cases of epithelioma the disease has already in-
vade<l the ethmoid and involved the l.vraphatics by the
time wdien it is discovered.
II. Diseases op the Ethmoidal Cells.
Tlieethiuoidcellsconsist of a number of cavities, irregu-
lar in size, situated beneath the anterior jiart of the brain,
from which they are separated by a very thin lamella of
bone. They lie to the inner, upper, lower, and posterior
sides of the inner half of the orbital cavity. They are di-
vided into posterior and anterior cells. The anterior cells
communicate with the middle meatus of the nose, and the
posterior cells empty into the superior meatus. The an-
terior cells have several openings. Some open into the iu-
fundibulum and cause confusion in differential diagnosis
between frontal sinus and aiiteiior ethmoidal cell dfsease.
The cell of the bulla ethmoidalis opens high up near
Fig. 34i)ij.— Antero-excisor Forceps for EnlaitJiiig i J|ifiiings in the Accessory Sinus Walls.
[turjiose
the attachment of the middle ttirbinated bone. These
cells are frequently hidden from view by the middle tur-
binal.
Etiology. — One form of disease of the ethmoidal cells
is characterized by an :ibiindance of waterv infiltration,
146
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Nasal Cavities.
Nasal Cavities.
which, if not relieved, usually terminates iu the develop-
ment of a polypoid state. This iufiltration, iu the writ-
er's opiuion, is caused hy intumescent pressure xipou
the venous vessels. The anatomical construction of these
cells favors the retention of bacteria and the continuation
of the so-called polypoid state when once it has been
established. Occasionally the septum or an exostosis or
enchonUroma protruding from it presses upon the middle
turbiual, so as to clo.se the nasal openings, and then de-
generation occurs within the ethmoid cells as a conse-
quence. In a few cases an inflammatory and necrotic
process iu the antrum extends from this cavity to the eth-
moid ; in others the disease extends from the frontal sinus.
Cysts occasionally form in one of the cells and extend
backward and forward through the intercelhdar walls,
finally making their appearance above the inner cauthus
of the eye where the bone is probably thinnest.
Acute catarrhal inflammation of the Schneiderian mem-
brane sometimes obstructs the openings of the cells for a
very thin, and often it feels as if the probe were on ex-
posed bone when as a matter of fact the latter is in a
fairly normal state. This has led many of our best writ-
ers into controversies in regard to diseases of this region.
Treatment. — Whenever there isextensive serious dis-
ease in the ethmoid bones it is the wiser policy to remove
a part of the middle turbiual at once. This rule would
not hold good, however, in all atrophic cases. In the
polypoid cases all visible polypoid tissue should be re-
moved with the snare or excisor forceps; when there are
intracellular pol.ypi the floors of the sinuses should be re-
moved with trephines piovided with speciall)' constructed
guards and by means of lateral and antero-posterior cut-
ting forceps. The curette provided with a malleable
handle has proved most serviceable in removing iutra-
and intercellular diseased tissue and cells. The securing
of free drainage and the free admission of air are just as
important here as they are in the case of the antrum. In
removal of the middle turbiual the lateral cutting forceps
Fig. 3497.— Jackscrew Excisor Forceps for Removinpr Portions of the Floors and Walls of the Ethmoid Cells and Antrum of Highmore.
period of several days. This causes putrefaction of re-
tained secretion, and this in turn destroys the mucous
lining of the cells. The pus thus formed discharges
either through the normal outlet or through an artificial
opening. If the pressure has been sufficient to jiroduce
necrosis and the drainage has not been fi-ee, we have as
a result chronic thickening with pus production or watery
ffidema with polypoid changes.
In cases of syphilis tumors in the ethmoid cells some-
times break down and form the basis for jiolypoid de-
generation. Osteosarcomata in this region are frequently
the cause of pain and of a discharge of broken-down
tissue products.
Symptoms. — Post-nasal discharge is one of the most
common symptoms of ethmoidal cell disease. Dull and
deep-seated pain around tlie orbit, and in the frontal,
temporal, and occipital regions is often experienced. In
cases in which tliere is retention of the secretion under
tension, the paiu varies according to the amount of peri-
osteal disease and the degree of interference with the
drainage. The patients show some nieutal dulness, and
especially complain of a disinclination to mental activity.
Sneezing, an escape of watery fluid, and more or less nasal
stenosis, especially during autuumal weather, are some of
the general symptoms of polypoid ethmoidal disease.
Di.\GNOSis. — Diagnosis of ethmoidal cell disease is usu-
ally made without any special difficulty. In cases of
latent empyema iu the individual cells, however, the
diagnosis is fi'ec|uentl}^ not made until after the patient
has been under observation for some time. The cavity
should be thoroughly cocainized and sprayed with ad-
renalin in 1 to 10,000 solution. The nose should be
cleansed of all secretion, careful note being made of the
examination with a probe around aud within the ostia of
the respective cells. Cotton applicatoi's should be used.
To cleanse thoroughly the region of the su.spected ostium,
time should be allowed for the discharge of more i)us
before a second examination is made with the soft silver
probe to ascertain whence the discharge comes. A small
posterior rhinoscope is most usefid in demonstrating
secretion in the superior meatus. The extent to which
the pathological process has advanced, and the (piestion
whether there is an a>dematous, a polypoid, or a sclerosed
state, are matters which can be determined partly liy the
patient's appearance, and especially by the character of
the ])us and mucus. The probe will convey a good idea of
the state of the mucous membrane, but it frequently mis-
leads us in regard to the condition of the bone. The com-
bined periosteum and mucous membrane of these bones is
should be passed beneath the septum and the outer wall,
engaging the middle turbiual lietwcen its jaws, and then
a section of the bone should be removed. This enables
the wire ecraseur to be easily adjusted around either the
anterior or the posterior end. I liave found the smallest
cannula and the Bosworth snare to be the most feasible
instruments.
The proximity of the ethmoid cells to the orbital cavity
and the brain, and the necessity of operating in a field
covered with blood, should make the boldest operator
cautious. With the aid of cocaine and adrenalin and
with the patient's assistance, the ditfieult operation of
penetration and removal of the floor of the sinus is made
comparatively easy and safe. W^hen the artificially es-
tablished openings in the cells are lai'ge enough they "usu-
ally drain so well that it is necessary to irrigate tliem at
stated intervals only. When the process extends far up
into the little cells above the orl)ital cavity or into some
of the recesses under the cranium the results of treatment
are not so satisfactory. I have found the daily insuffla-
tion of a powder composed of aristol two paits, boric
acid one part, to be tlie most satisfactory after-treatment.
When there is considerable pus a modified spray of Do-
bell's solution or of a solution made with Seller's tablet
is effective. Under this treatment the patient usually
makes marked improvement. Fre(iuently, however, a
small amount of discharge continues from some inacces-
sible cell, and often also the condition is aggravated tem-
])orarily by taking cold.
III. DisE.\SES OF the Spiienoid.m, Cells.
Inflammation of the sphenoidal cells is usually' conse-
quent upon acute rhinitis, especially when due to infec-
tion. Polypoid changes are frei|uently the cause of
chronic disease. Syphilis commonly affecis the cell wall
with a gummatous deposit and the ethmoidal mucocele
occasionally extends through the dividing cell. Tumors
sometimes develop in or e.\tend into the cavities.
Symptoms. — The subjective symptomsofan acute in-
flammation of the sphenoidal sinuses are heatlaehe and a
full, heavy feeling over and behind the eyes. In cases
of chronic suppuration there are deep-seated pains in the
orbital, temporal, and occipital regions, feelings of de-
pression and oppression, discharge of pus or mueo-i3us
over the anterior surface of the sphenoidal cell at the
posterior extremity of the middle turbinal body, aud dis-
turbances of the field of vision. The objective symp-
toms are hyperplastic oedema of the nasal mucosa cover-
147
Nasal CaTlties.
Nassau.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
ing the cell, disc-liarge of pus aud muco-pus, polypi, ami
pharyngitis sicca, due to destruction of the epithelium
bj- tiie pus, which flows constantly over the postphar-
yngeal wall.
Pathology. — -Changes involving the bone substance
and the lowering of its vitality occur in tho.se sphenoidal
cases in which fhe mucosa has undergone polypoid de-
generation. The bone becomes brittle under these cir-
FIG. ;M98.— Guarded Trephine for Reinovins Obstructing Portion of
the Septum near Anterior End of Middle Turbiual.
cumstanees and loses much of its cohesive quality. In
neglectcil syphilitic cases necrosis of the bone or soft tis-
sues always fdllows the gummatous process. The chronic
suppurative cases with more or le.ss stenosis of the normal
opening are usually protracted by the irritating qualities
of the degenerating jiroducts.
Diagnosis. — Diseases of the sphenoidal cells are usu-
ally easily diagnosed. The obstruction in many cases is
at the posterior end of the middle turliiual. and its early
renuival will facilitate matters greatly. Pus imder fa-
vorable conditions can be seen at the normal opening in
the uppermost jiart of the anterinr wall of the s|ihenoidal
cell. An irrigation tube passed througli this opening
will confirm the provisif)ual diagnosis.
Treatment. — 'i'he treatment of sphenoidal disease is
moi-e satisfactory in its results th.an that of the other
sinuses. Complete removal of the jKisterior end of the
midille turliinal will usually demonstrate tlie point from
which tli<' pus makes its exit. The upper anterior wall
should be penetrated with a guarded awl or tre]ihine
and afterward curetted. Extensive removal of the an-
terior wall with a cutting forceps, gentle curettage, irri-
gation, insulliations, and repeated excisions of the raem-
Biane wliicli forms over the opening will often cure the
most olistinale and apjiarently hopelessly diseased condi-
tions of the sjihenoidal sinuses.
I do nut favor tlie pi'ocedures of opening the sphenoidal
cells through either the antrum or the ethmoidal cells, as
I do not think such extensive destruction of tissue is war-
ranted. Iti>hirt ('. Mylcn.
NASAL CAVITIES, DISEASES OF: SYPHILIS.—
Syphilis, eitla-r I'ongeiiital or ac'cjuiicil, may appear in
the nose in :iny of its three stages. The disease is char-
acterized by obstruction of the passages from swelling of
the mucous membrane, or by more or less extensive ul-
ceration with destruction of caililages and bone.
Anatomical and Pathological Ciiakacteuistics. —
The mucous membrane may be found thickened in
patches or ulcerated, or obstruction may arise fi-om gum-
matous thickening of the ])eriihiindrium or periosteum.
In the latter case the cartilage or bone beneath often
suffers necrosis and is finally separated by tlie process of
sujipuration. Necrosis occasionally results from exten-
sion of the nlcciations from the mucous nienilii'ane. and
rarely the parts undergo molecular destruction and are
gradually alisorbed, being replaced b_v gianulalion tissue.
Primaiy sypliilis is occasionally conveyed to the nose by
picking witli the finger nail, but tlie hard chan<a-e is very
seldom seen. On theexternal nose the ])rirnai'v sore usu-
ally ajipears as a Hat induration of moderate size; within
the nose it commonly occurs on the septum as a red. flat,
hard growth covered with purulent .secretions, whicli
bleeds easily, theexternal nose at the same time being
swollen and red. Neuralgic pains and fever may coexist
and the submaxillary andsublingvial glands and those in
front of tho ear are often indurated. In .secondary nasal
syphilis theajipearanees maybe simjily tho.se of an acute
coryza. or mucous iiatchi-s may be found upon the
Schneiderian membrane similar to tliose so commonlv
observed in the throat. In this case coi)]ier-cnloi'ed pap-
ules or macules with fissures at the junction of the nose
and the up|)er lip or in the sulcus alaris ari' ajit to lie
present. Gummatous syphilitic infiltrations may involve
the mucous membrane, the perichondrium, or the peri-
osteum. These soften after a time and deep, sharp-cut
ulcers with undermined borders result, with sooner or
later destruction of cartilage or bone. Often this de-
struction is limited to the septum, especially its bony
portion: but in some cases it involves all of the sur-
rounding parts. When the nasal bones are destroyed
the bridge falls in, but this does not occur from destruc-
tion of the septum alone.
Etiology. —The affection is caused by the specific vi-
rus which ma.v infect the fo-tus in utero or during birth,
01' which may be acquired afterward in various waj's.
Sv.mptomatology. — Primary syphilis of the nose
causes the symptoms of an acute catarrhal rhinitis of a
severe grade. The initial lesion is likely to be compar-
atively large, and various lymph glands may be infected
aud greatl3' swollen. In the secondary stage there are
much congestion of the mucous membrane and abundant
muco-purulent secretion with obstructed respiration.
Mucous patches are likely to be found at the edge of the
nostrils and upon the anterior portion of the nasal mu-
cous membrane. At the same time secondary manifesta-
tions are apt to occur in the throat and upon the skin.
The tertiary symptoms commonly come on between the
first and third years after infection, but sometimes not
until many years later, and they are not infrequently
seen at anj' time between the fifth and the fifteenth years.
When the disease attacks the turbinated bodies it some-
times causes an ap]iearance very like that of simple liy-
pertrophic rhinitis and the parts do not retract readily
under cocaine; but thiscondition is frequently associated
with yellowish ulcers having a clean-cut border and hard
infiltrated base with more or less induration about the
ulcer, and is therefore not apt to be confounded with
hypertrophic rhinitis. When the disease attacks the peri-
osteum or the perichondrium, a smooth elastic swelling
results which is usually apparent upon only one side.
Later, breaking down takes place and ulceration results.
The denuded cartilage or bone dies and is subsjequently
separated by an ulcerative process from the surrounding
tissue. Commonly the patients do not present them-
selves for treatment until ulceration has occurred, and
then the necrosed cartilage m- bone may be found firmly
attached or lying partly loose in the na.sal cavity. Atro-
phy of the turbinals maj' also occur and destruction of
the orbital plate of tbe ethmoid bone and of the hard
jjalate is not uncommon. The dead bone usually jiresents
a blackish, uneven surface, and is the source of an ex-
tremely otfensive odor.
Diagnosis. — The primary lesion in the nose may be
mistaken for a malignant growth. The imist valualile
points in the diagnosis are its hardness and the great
swelling of the lymphatic glands. Frequently the true
nature of the disease is not recognized until the second-
ary symptoms ajipear. The .secondary sta.ge of the dis-
ease in the nose causes the symptoms of chronic catarrhal
rhinitis, but it conu'S on much more speedily than the
latter, and by careful inspection mucous iiatchcs or con-
dylomata may sometimes be detected. The history of
the case should be very carefully scrutinized, andany
external manifestations may aid in the diagnosis. Ter-
tiary syphilis of the nose is not likely to be recognized
when it involves the turbinals alone, as the ap|iearauce
is that of hypertro|)hic rhinitis; but wlieu gummata and
ulceration occur, a careful weighing of the iiistory of the
antecedent synqitomsand signs will generally enable one
to make a correct diagnosis, although often the jiatient
will deny any specific infection. There is generally no
difficulty in <listinguishing tertiary nasal syphilis from
atrophic rhinitis if the na.sal cavities be first thoroughly
cleansed. It should be recollected that simple perfora-
tion of the cartilaginous septum is seldom sj-philitic,
whereas perforation ui the bony septum is nearly al-
ways so.
Lupus is to be distinguished from syphilis, first by the
fact that it usually occurs at an earlier age than .syphilis,
excepting when the latter is hereditary ; "second, that the
U8
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Nasal Cavities.
Nassau.
reddish papules or tubercles of lupus are quite distinct
from many syphilitic manifestations, and that thoy are
often associated with distinct signs of lupus externally.
Lupus also is much more prone to attack the cartilage
than the bone, and it is much slower in its progress than
syphilitic ulceration.
Fhoososis. — The outcome of nasal syphilis is mate-
rially affected by early recognition of the disease and
efficient antisypliilitic treatment. Although in many
cases the destructive process is not extensive, in others
not only the septum but the nasal bones, orbital plates,
and hard palate are involved in widespread necrosis. In
rare eases the disease progresses rapidly in spite of all
treatment, and may terminate fatally within three or
four months. Death has also resulted from fragments
of the necrosed bones falling into tl.t. larynx.
Tre.\tment. — Secondary symjitovis and those of the
tertiary disease, when mild, usually yieid rapidly to ap-
propriate internal and local treatment. In syphilitic af-
fections of the nose, prompt and thorou.gh antisyphilitic
treatment should be inunediately instituted, the nares
should be kept clean by mild alkaline sprays or washes,
condylomat;! or mucous patches should be touched with
nitrate of silver or tincture of iodine, and the latter or
solutions of from ten to twenty grains to the ounce of
sulphate of copper shoidd be used in case of tertiary ul-
ceration. Dead bone should be removed as soon as it be-
comes loosened, and sometimes it is best to cut it away
earlier in order to prevent the jirolonged offensive odor;
but it sliould be recollected that if the bone be cut away
too early, the disease is liable to extend to tissues that
would otherwise have escaped. Antiseptic sprays and
powders, such as are recommended in the article on atro-
phic rhinitis, may also be employed advantageously.
E. Fletcher Jng'tils.
NASAL CAVITIES, DISEASES OF: TUBERCULOSIS.
— Though tuberculosis seldom involves the nasal cavities,
secondary tuberculous lesions are occasionally met with
in this locality and a few cases of the primary disease
have been noted. Miclielson observed nineteen instances
of the primary disease in thirty-eight cases of nasal tuber-
culosis. It should be remembered, however, that the
early symptoms and signs of the pulmonary affection are
not always recognizable, so that they may have been
present in some of the cases believed to be primary nasal
tuberculosis.
Anatomical and Pathological CnARAcxEiiisTics.
— The disease may be observed as a diffuse infiltration,
or as a tuberculous tumor with or without idceratiou. or
in the form of exuberant granulations. Ulcers may fol-
low the infiltratiou or the tuberculous tumors, but they
sometimes appear to be the primary lesion: however,
they are nearly always secondary to pulmonary tubercu-
losis. The disease commonly attacks the anterior part
of the cartilaginous sciitum. but it ma3' involve any por-
tion of the nose or nasojiliarynx. The tumors are gener-
ally small and of a grayish-white color, but may attain
the diameter of 3 or 3 cm. before they finally Ineak
down. Thej' are sometimes pedunculated, at other times
sessile, and they comn.only bleed easily. The tuberculous
inliltration is prone to attack the septum, but may also
invade the turbinals. It causes a firm, resistant swelling
of a pale color having a somewhat granular surface.
Tliis, like the tumors, is ultimately followed by ulcer-
ation. The tuberculous ulcer is generally round' or oval
and at first shallow, but ultimatelj- it becomes much
deeper. The borders are irregular, having a worm-eaten
appearance ; they may be level or may be prominentl_y
raised by tuberculous 'infiltration. Miliary tubercles may
often he seen on the floor of the ulcer and surrounding
it. The floor of the ulcer is of a pale, grayisli-red color
and is sometimes covered with granulations, wliile the mil-
iary tubercles wjiich surround the ulcer ; -e translucent
or of a yellowish or grayish-white color. On breaking
down they cause irregularity of the ed,ge of the ulcer, and
by the extension of the process the cartilage or even the
bone may be destroyed, leading to perforation. Exuber-
ant granulations may spring up and hide the ulcer or
perforation or even a tumor. They are analogous to
fungous granulations found in other parts of the body.
Etiology. — The causation is the same as that of other
forms of tuberculosis.
Symptomatology. — The disease comes on insidiously,
causing the symptoms of an offensive rhinitis witli free
purulent discharge, which tends to collect and form scabs
and crusts that hide the ulcers. Epistaxis is an occa-
sional occurrence. At first the constitutional symptoms
are slight. In the majority of cases this alTection is sec-
ondary, and in nearly all instances it terminates with
laryngeal or inilmonar}- tuberculosis.
Diagnosis. — The disease is to be distinguished from
lupus and syphilis. Lupus resembles the infiltrated
form of nasal tuberculosis, but commonly begins in the
integument and slowly extends, showing a marked ten-
dency to cicatrization, whereas the tuberculous ulcers
spread more rapidly and there is little if any tendency to
healing; indeed, it is impossible to cure oiie of these ul-
cers unless the general condition improve.
Syphilis, especially in tlie late hereditary form, is some-
times very dilticult to distinguish from tidjcrculosis, but
u.sually its more rapid course, the headaches and neural-
gias that are apt to accompany it, and its proneness to
attack the bone instead of the cartilage distinguish it
from tuberculous disease. The antecedent history may
be of great value in the diagnosis, and a microscopical
examination of the secretions or the scrapings from the
ulcers or granulations is liable to reveal the tubercle ba-
cilli, though the latter can seldom be discovered in the
infiltrative form or in the tuberculous tumor. The re-
sults of treatment are also important — a .syphilitic ulcer
usually improves speedilv under specific medication,
whereas the same treatment is likely to aggravate tuber-
culosis.
Prognosis. — The course of the disease is slow unless
the lungs be already involved, and it may possibly ex-
tend over several years; but when the tuliereulosis' also
affects otherorgans it runs a more rapid course to a fatal
termination.
Treatment. — Detergent sprays and washes may be
used to keep the nares clean, and tuberculous tumors
that interfere with respiration ma_y be removed by the
snare or otherwise. The infiltrations are best destroyed
l\y the sharp spoon or by electrolysis; fungous grani'da-
tions ina_y be scraped away with a curette and tlie base
treated with lactic acid; indolent ulcers ma_y be curetted
and then treated with lactic acid. In these cases the
parts should be anicstlietized as thoroughly as jiossible,
and lactic acid of a strength from fifty to one huudrecl
per cent, should be carefully applied. It is well to add
to it from three to five ]ier cent, of carbolic acid in order
to prevent prolonged pain after the effects of the cocaine
have disappeared. In some instances excellent results
have been obtained by carefully touching the surface of
tlie tidierculous ulcer with the galvauoeautery. It is of
prime importance to attend to the general health, because
until this is improved we cannot hope to obtain much
betterment in the nose. Even in primary cases we can
scarcely hope to remove all of th(^ tuberculous tissue by
curettage or by other surgical measures, and therefore
we can .seldom, if ever, completely cure the disease.
E. Fletcher lii;iiils.
NASROL — sodium sulphocaffeate. symphorol sodium —
is a bitter crystalline powder slightly soluble in cold
water. It is a more powerful diuretic than call'eine, and
the caffeine effect on the heart is said to be lessened.
Dose 1 gm. (gr. .\v.) daily. 11". A. Brixtedo.
NASSAU.— The town of Nas.sau, capital of the Baha-
ma Islands, lies on the north shore of the island of New
Providence, at a distance of about two hundred nu'les
due east from the southern point of the Florida ]ienin-
sula, and about thirty miles north of the jiarallel of lati-
tude which passes through Key West. The exact lati-
tude of Nassau is 25° 5' 3(i " N., only two degrees north
1-19
Nassau.
Naiilieiiii.
REFERENCE IIAN'DBUUK OF THE MEDICAL SCIENCES.
of tlie Tropic of Cancer; its lonnituck^ is 77' 21' 15" TV.
It is the largest towu in tlic Baluunas, and lias from
twelve to sixteen thousand inhabitants. Tlie island of
New Providence has an extreme lengtli from east to west
of nineteen and tliree-eightlis miles, an extreme width
from north to south of about seven miles, and an aver-
age width of about five miles. The liigliesi ground in
the island is only 120 feet above sea level, and nowliere
throughout the' whole grou]i of the Baliama Islands,
many of which ari' \-ery much lai'ger than New Provi-
dene'e, does the surbiee attain an" elevation aliove sea
level of more than 23U feet. " The formation of all the
islands is i lie same— calcareous rocks of coral and shell
hardened into limestone, honeyeonibed and perforateil
into innumerable cavities, witliout a trace of primitive
or volcanic rock; the surface is as hard as Hint, liut un-
derneatli it gradually softens and furnishes an admirable
stone for building. . . . The soil, altliough very tliin, is
very fertile. . . . Excejit in tlie island of Andros. no
streams of running water are to be found in the whole
group."
The town of Nassau "extends along the water front
for about three miles and back to the crest of a slope, on
which stand the Government House and many of the fin-
est private residences, at an elevation of ninety feet above
the harbor. The streets are laid out at right angles with
each other, and aie uniformly macadamized, as are also
the numerous excellent drives around the island; and the
houses are generally btiilt of stone, with the surrounding
grounds ornamented with a tropical jirofusiou of flowers
antl trees." As for the general character and appear-
ance of the country back of the hill just mentioned, we
read, in Mr. Charles Ives' work, entitled "The Isles of
Summer." that, "with the excejition of a very few
square miles occupied by Na.ss;iu and its suburbs, there
is little npou the island, except water and wilderness;
the former is brackish and throbbing, and in simie places
appearing and disappearing with the long pulsations of
the sea's diurnal tides, and the latter, to a large extent, a
dense low jungle, with stretches of pine forests rising
from a thick undergrowth of scrub palmettoes."
Turk's Island, and Dunmore Town, on Harbor Island,
are other health stations or winter resorts of the Baha-
mas, but I possess no detailed information respecting
either, and practically it is true, as stated by Mr. Ives,
that "Nassau is New Providence and the Bahamas."
The climate of Nassau is tropical, and far warmer than
that of the Bermudas; but for the fact that the Bahama
Islands lie in the track of the trade winds, and for the
fact that they are islands of small size and of rather
sparse population, the climate could hardly fail to be an
unliealthy one ; as it is, the climate may be regarded as a
healthy one, at least during the colder mouths of the
year. The following figures, derived from one year's
observations, were sent me by the superintendent of the
Canadian Meteorological Service, biang kindly procured
b_v Mr. 11. Beavunont Small, of Ottawa. They show the
mean temperature (degrees Fahr. ) of each iif the twelve
nninths of the year in iiuestion.
January, 09 "; February, Ti" : March, 71^; April, 78 ;
May. 7!t"; June. «3 ; Jiily, 87'; August, ^S ; Septem-
ber", 87'; October, 80'; November, 74'; December, 70'.
Yearly mean, 7i^.7 .
The data of Table A show the " 3Iean of Daily Obser-
vations on week days, for ten _years, from \^r>'> ti> 1864."
This talile is ipioted from Mr. Ives' book, where it is
"copied from the otfieial report of Governor Uawson for
180-i. iiage 14, compiled from the records kept at Nas-
sau's .Military (Observatory." Governor Rawson's con-
clusions, based upon this table and upon others given in
his report, are also qtioted by Mr. Ives, and from them
w'e extract the following stiitements: "The greatest
maximum heat exceeds the average heat by not more
than 12"; the greatest minimum falls short of it 10 . . . ,
From May to October . . . the rain fall amounted to forty-
four inches, and during the remaining six months to nine-
teen inches. . . . Northeasterly and easterly winils are
the most prevalent from September to February, during
Months.
.January...
Feltruary..
March
Aiiril
May
June
July
Auitust . . .
September
Octulier. ..
November.
December.
Averajtre...
Thermometer at
9 A.M. (Degrees
Fahr.)
81
84
88
88
88
86
83
Min.
■Wind at 9 a.m.
Four chief points, in
order of prevalence.
N.E., E., S.E., N.
N.E., E., S.E., S.
E., S.E., N.E., N.
N.E., E., S., S.E.
N.E., S.E., E., S.
S.E.. E., N.E.. S.
E.. S.E., S., N.E.
E., S.E., S.. N.E.
E., N.E., S.E., N.
N.E., E., S.E., N.
N.E., E., E., S.E.
N.E., E., S.E.. N.
Rainfall on
ground in
month.
3.4
2.4
4.5
-'.4
6.9
6.4
6..5
6.7
.5.3
7.4
2.8
2.4
4.6
which months they blow during one-half or two-thirds
of the whole time. Northerly winds seldom blow, ex-
cept during those months, and then only for three days
in a month." As for northwest winds, the bane of the
Atlantic coast of North America during the winter sea-
son, they occur from November to JIarch, about two
daj'S in a month." "The Bahamas," says Mr. Ives, "are
slightly but agreeably refreshed by the coldest winds
that ever reach them from the north and west." The
relative frequency of the winds from the different points
of the compass is given by Jlr. Ives, in a table quoted
from Governor Rawson's report, showing "the percent-
age proportion of days in a year during which they pre-
vailed at 9 A.M.," as follows;
North
Northeast..
East 21.4
Southeast 1S.6
.2 per cent.
South ll.O^per cent.
Southwest 5.0
West 2.3
Northwest 5.3 "
In Table B the reader will find data, derived from offi-
cial reports, and quoted from two tables in Mr. Ives'
book, one of whicli presents data for the year 1878, the
other data for 1879.
TABLE B.
(Two Years' Observations.)
,
3 = = a
^iis
^izi
•5 S £^
~ H £ <
5i = §
ti
n --:
s 'S is-
-5 = Ss
<|t?
l§ii
52
c 1: >.
3 'S
- 1;
S
Degrees.
Degrees.
Degrees.
Inches.
January
77.0
61.0
14.5.0
3.ra
11.0
February
78.0
62.5
148.11
4.17
9.5
March
82.5
6.5.2
153.5
2.60
6.5
April
82.8
70.0
154.0
1.80
6.5
May
8<).5
70.5
156.5
5.56
10.0
S9.S
89.5
88.8
71.0
71.3
77.0
155.0
159.0
157.9
9.66
6.74
9..55
16.5
July
19.n
August
15.5
September
87.5
70.0
1.5:3.5
7..58
22 0
October
85.0
74.5
15:3.0
6.9:3
15.25
November
81.5
66.5
1.57.5
.5.41
8.0
December
78.2
li,").S
1.55.1)
1.49
9.0
The maximum and minimum temperatures, and the
rainfall for each month of the year in the three years,
1880 to 1882, are pulilished in one of tlie English " Blue-
books "for 1884 ("Statistical Abstract for "the Several
Colonial and Other Possessions of the United Kingdom in
Each Year from 1868 to 18S2"). wdiich was kindly sent
me by Mr. II. B. Small. "Without (juoting these in full,
suffice it to say that the absolute minimum temperature
throughout the whole three years of observation was 64°
F., occurring in March, 18S1 ; that the absolute maxi-
mum was 90° F. , occurring in Jtily and in August of the
same j'ear; and that the average monthly rainfall for
each of the six months, November to April, was as fol-
lows; November, l.oinches; December, l.Sinches; Janu-
150
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Naulielm.
ary, 2 inches; Februarj^ 1.8 inches; March, 1.5 inches:
April, 2.1 inches. Mr. Ives' rainfall statistics for 1879
correspond very closely with those just given, and the
higher average figures found in Table B are caused by
the exceptionally heavy rainfall of 1878.
Despite the high figures for minimum temperatures
T\ii;eh have been given in the accompanying tables, I
find a writer in the New York Ti'mcf/. Jlr. William Drys-
dale, referring to the occurrence of a temperature of 55' P.
at Nassau, and speaking of the desirability of securing
at the hotel one of tlie few rooms in which a Are may be
had in cokHveather. He also complains of the strong
wind which prevails at Nassau. The relative humidity
in winter is eighty three per cent, and in spring seventy-
six per cent. (Hinsdale).
Excellent sea-bathing may be enjoyed at Nassau
throughout the year, the temperature of the sea water
being usually in the vicinity of 70' F. throughout tlie
year (Solly). Yachting and' boating are favorite pas-
times, and the facilities for both are excellent.
IIii n t ington Eicha rcU.
[As will be seen from the above, the climate of Nassau
is a moist, warm, marine one, agreeable for a winter resi-
dence of several mouths. After some days of acclimati-
zation it is found to be not uncomfortably warm, though
it is more or less debilitating. It is warmer than the
Azores, Madeira, Teneriffe, or Bermuda (Solly).
There is very little if any rain during the winter, and
there is a continufius succession of tine days. The hu-
midity is high and the nights are damp, so that the in-
validhad best be in doors after 6 p.m., and not venture
out too early in the morning.
The water supply is from rain water kept in cisterns,
and its purity obviously depends upon the care exercised
in keeping the cisterns clean. So far as known to tlie
writer, there is no general sewerage system at Nassau,
but the natural drainage is good, as the town lies at an
elevation of one hundred feet above the level of the sea.
The soft, porous limestone rock absorbs water rapidly, and
wells and cisterns in the vicinity of cesspools and vaults
may easily become contaminated. The Baliama Islands
in general are said to enjoy a reputation for healthful-
ness, the mortality being under eighteen in one thousand
(Hinsdale).
There are two great hotels at Nassau, the " Royal Vic-
toria " and "The Colonial." the latter affording accom-
modations for a thousand guests; there are also good
boarding-houses, and guests can be accommodated in
private families.
Nassau can be reached direct from New York by well-
equipped and comfortable steamers: or one can go by
rail to Miami on the east coast of Florida, and from there
by steamer in about twelve hours.
There are many attractions at Nassau, although after
a while life becomes rather monotonous. The vegeta-
tion is tropical and very varied in fruit and flower. The
roads are very good for driving or cj'cling, both inland
and along the shore. Sailing, fishing, and bathing are
also a feature of the place. A visit to the Sea Gardens
is a delightful excursion in the bay, where, through the
clear blue water, coral growths of varied hues and forms
and sea sponges are seen. There are a good public library,
schools, and churches, and reliable medical service.
There are both still-water and surf liathing. and an excel-
lent sandy licach. "Not a beach from Panama to Para,
where anything like the comfort and benefit can be found
as on this beautiful sweep of sand at Nassau " (Hutchin-
son). Golf and other outdoor sports are also to be had
here.
By chartering a small schooner pleasant excursions for
several days can be made to Eleutlaera Island, Governor's
Harbor, and otlier neighboring islands.
This climate is essentially the same as that of the lower
coast resorts of Florida, and is suital)le for a similar class
of cases. It is not favorable for tuberculosis, as no moist,
warm marine climate is, as has been elsewhere discussed
in this Handbook. Neither is it good for rheumatism
or neuralgia, on account of the dampness, especially at
night. It is, however, favorable for chronic bronchitis
and catarrhal affections of the pharj'nx and larynx. It
is said to be very beneficial for Bright's disease, espe-
ciall}' the early cases. Cases of neurasthenia and those
suffering from the effects of overwork do well here.
Convalescents from various diseases with lowered vital-
ity are favorably influenced by the winter climate here,
where "no rain falls at that season, and each day is a
repetition of the one just passed, balmy breezes and
cloud-flecked skies," and where the usual daily range is
from 70" to 73' F. Edward 0. Otis.]
ItEFERENCF.S.
Tlie Isles of Summer, etc., bv Chas. Ives. M.A.
Under tbe Southern Cross, by Vim. F. Hutchinson, A.M., M.D., 1891.
Notes on Nassau as a Health Resort, by Hamilton Ospood, M.D. Bos-
ton Medical and Surgical Journal, 1884, vol. iii., p. 555.
The Nassau Almanac.
In Sunny Lands, by Wm. Drysdale, New York, 1885.
Medical Climatology, Solly, 189;, p. 434.
History and Guide Book to the Bahama Islands, by J. H. Stark, Bos-
ton, 1891.
Various Guide Books.
NAUHEIM. (BAD-NAUHEIM.)— Of the almost innu-
merable health resorts and watering places that abound
in Germany, none is better known than Bad-Nauheim,
incorrectly spoken of as Nauheim. I say incorrectly,
because not such a great distance away is another town
called Nauheim, which is devoid of all interest to sight-
seers or invalids. The prefix Bad signifies a bath, and
hence designates an_v place to which it is prefixed as a
watering place or spa. This explanation is necessary,
since mistakes are sure to occur if letters intended for
this fainotis resort are addressed merely to Nauheim
without the distinctive prefix Bad, or if the invalid in
quest of health inquire of German railway officials for
Nauheim, and not Bad-Nauheim.
The chief interest attaching to this resort lies in the
natui'e and properties of its springs and the diseases to
whicli their waters are applicable, and yet there is much
of interest in the history of the place. It is situated
about twenty miles north of Frankfort, whence it is
reached in forty minutes by the Jlain-Weser Railway.
The location of the town is both healthful and pictur-
esque, since it lies on the eastern slope of tbe Johannis-
berg, which forms a spur of the range of mountains
known as the Taunus. Tlie slope on which the town
is built descends gradually to the bank of the Usa River,
and thus provides excellent drainage, so that the soil
dries quickly and permits visitors to walk out directly
after a shower, which, judging from the summer I spent
there, is of comparatively frequent occurrence.
Alighting from the train and walking down Bahnhof
Alice (Depot Street), which descends rather sharply tow-
ard the west, one obtains a beautiful view of tbe Johan-
nisberg beyond and of the town with its magnificent park
and cluster of springs and bath-houses in the foreground.
Emerging from this short Depot Street the traveller comes
on to the Ludwig Strasse, which, lined witli attractive
villas along its eastern side, curves in a semicircular di-
rection toward the west, and joining the river helps form
the ovoid space in which are situated tbe bath-houses and
springs that are the pride of the inhabitants and the ob-
ject of the invalid's long journey.
On the further bank of the Usa spreads out the spa-
cious park, which is said to be the finest of its kind in
Germany, and with its shaded walks, covered seats, and
Kur.saal", offers irresistible attraction, and invites to the
out-of-door pleasures of which the Germans are so fi>nd.
The southwestern extremity of Ludwig Strasse leads
into Park Strasse, wliich runs to the west, and is bor-
dered by attractive shops, while the quaint town once
enclosed by a wall, of which the remains may still be
seen at the" south, lies mainly to the south and west of
the park on the slope of the Johannisberg. From this
brief description it is plain that Bad-Nauheim can justly
claim both healthfulncss of site and beauty of scenery,
which must minister to the comfort and pleasure of the
summer visitor.
151
NaiilK-liii,
Naiihvliu.
REFERENCE HANDBOOK OF THE IVIEDICAL SCIENCES.
Thesemi-invalitl or tourist who can enjoy the pleasures
of walks and drives is afforded ample opportunity for
the indulgence in such pleasures. The more seriously ill,
conlined to a chair in the garden or to an apartment, can
feast his eyes on the beauties of the Taunus range in the
distant background, or on the beautiful park with the
throngs of pedestrians, carriages, and wheel chairs mov-
ing restlessly in and out among its trees and on the shores
of its artificial lake.
The hours for recreation are many in Bad-Nauheim, for
baths and the morning drinking of its curative waters
consume but a .small jiortion of the time ; and hence the
visitor must have varied pleasiu'es and pastimes if he is
not to find his sojourn wearisome and suffer from home-
sickness. It was the realization of this fact and of the
powerful aid to heallh derived tlierefrom which led Dr.
Friedrieh Bode, one of Bad-Xauheim's early physicians
and benefactors, to insist on the necessity of suitable
provision for agreeable recreation as well as of desirable
homes and means of treatment. He was a far-sighted
physician who realized that healthfulness of body re-
quires healthfulness of minil. and tliat to the latter con-
tentment and diversion are essential.
Ti)-ilay. therefore. Bad-Nauheim is no longer a meagre
litlle village without an apothecary shop, or even toler-
able Indgings for invalids as in Bodc's time, but is a
beautiful spot where twenty thousand invalids besides
other visitors are comfortably, even lu.xuriously, hou.sed
and fed every year between Jlay 1st and October. Be-
sides fine hotels with modern comforts where the wealthy
may be amply ]irovided with all they can desire, there
are iunumeralile |irivate homes and boarding-houses for
persons of lunnljle means.
Bad-Nauheim is a Mecca for invalids from all over the
world, and hence one there meets delightful jieople whose
aci|uaintance is both a pleasure and a profit.
No lover of music who has passed a summer at this
cliarnung resort can fail to recall the delightful band con-
certs which are given three times a week at the Ivursaal.
anil are enjoyed in the open air after tlie German custom,
with 1 he accom]ianiments of cigars and beer or other li(iuid
and solid refreshments. These concerts are of high order,
and the stirring nuisic is rendered with a spirit and pre-
cision that never fail to arouse the most unim]iression-
able. Of a Simday afternoon the usual weekly pro-
gramme of instrumental music is varied by grand" vocal
performances renilered by well-trained choral societies of
male voices from neighboiing cities. These (-(mcerts are
rare treats and are very largely attended by enthusiastic
and appreciative audiences. The air of the midsummer
afternoon is usually comfortably cool and freed from an-
noying insects, so that to sit in the open ministers to
health as well as to pleasure.
The history of Bad-Naulieini goes back to the days of
the Romans when tho.se stern warriors contended "with
the fierce Teutons for the iio.sses.sion of this part of Ger-
many. Even in that early day it was a higldy prized
possession, not, however, for its baths, but forthe salt
contained in its waters. By the uncivilized Teuton the
salt was procured by sprinkling the water on to a tire
and then obtaining the saline ])recipitate from the ashes.
The Romans, on the contrary, as shown by modern ex-
cavations, evaiiorated the water in lai-ge jians supported
above the tire by foundations of liriek.
Saline s]irings were considered so ])recious by the Ro-
mans that they were regarded iis holy. It was the cus-
tom to cast coins into the siuings as votive olTerings. and
to this day it is stated that pieces of cojiiier money, bear-
ing the imin-ession of Hadrian. Domitian, and Trajan are
often found upon cleaning out the basin of the Schwal-
heimer Brumien. There are to be seen in the vicinity
remains of old Roman villas and of that wonderful wall
of defence whii-li extended through Southwi'st Germany
for a ilistauee of five hmidred and fifty kilometres, and
enclosed that portion of the land which had been con-
fiuered from the native inhabitants. One of the best pre-
served remains, ]irobably of a Roman temple, was ilisen-
tombed near Homburg, another frequented spa, to which
visitors at Bad-Naidieim may drive comfortably in two
hours or less. It is thus seen that the subject of this
sketch lies in a part of the Fatherland which is full of
historic interest.
According to tradition it was Bonifacius who came to
the heathenish inhabitants of this Wetterau district and
converted them to Christianity. He is said to have built
the chapel still stantiing on the Johannisberg, wdiich
mountain had for ages been consecrated to the worship
of Baldur, the god of the stm. For two thousand years
the Germans had annually assembled on the Johannis-
berg and celebrated the feast of the midsummer solstice,
July '.34th. now known as Johannistag or St. John the
Baptist day.
It is also interesting to note that for many years the
holy chapel dedicated to Christ by Bonifacius and the
temple at which worshipped the still unconverted Ger-
mans stood not far apart, and on each 34th day of Jidy
could be heard the sacred music of the two congrega-
tions, the one in praise of our Blessed Redeemer, Uie
other in praise of Baldur the sun god.
The subsequent history of Bad-Nauheim is eventful.
It was twice ravaged by war in the Thirty Years' War.
at the close of which tlie Wetterau country was desolated
and almost depopulated, and again in the succeeding
century during the Seven Years' War.
During all these centuries Bad-Nauheim remained still
only a somce for salt. Baths were not given as a thera-
peutic agenc}-, nor were its waters drunk by invalids as
were those of not far distant Homburg and Wiesbaden.
In the fore part of the last century we read that the offi-
cials of the salt works used the saline water for bathing,
not however therapeutically but merely forthe jiurpose
of cleanliness, since other water was not convenient.
In 1833 Salt Insiiector K. WeLss persuaded Internal
Revenue Commissioner Jleisterlin to tiy a bath in this
salt water, which he found so agreeable and invigorating
that he determined to propo.se to the Kurftirst the ere(>
tion of a bath-house. This establishment was first
opened to the jniblic in July, 183.5. Thus ^vas instituted
this world-renowned resort which, from receiving ninety-
five patients that first year, is said now to accommodate
id)out twenty thousand invalids annually, to whom are
given an average of three hundred thousand baths.
Of all the various springs that have been bored from
titne to time only five are now in use, namely; Kurbnm-
nen and Karlsbrunnen. which are saline purgative wat-
ers: Ludwigquelle, which is alkaline iu consec(uence of
its containing soditnn bicarbonate; the Great Sprude! or
No. 7, in use since 1S3'J, and at that time tlie largest and
strongest of all ; and last but not least the Friedrieh Wil-
helms(iuelle or No. 12, now the spring furni.shing the
greatest how and e.xtremel_v rich in COj. No. 14 (Ernst-
Ludwig) was completed in 1900, having a depth of two
hundred tmd nine metres.
There are six bath-houses of wdiieh No. 4 receives
water, after having been freed from gas and iminirities,
from Spring No. 7. In this house only simple l>rine
baths art! given. Houses Nos. 1 and 6 receive water direct
from the two springs at a temperature of 87"' to 93 F..
and very rich in aci<l and salts so that it can be employed
in the "Sprudelstrombad " or flowing effervescing bath.
The other houses also obtain waters from the two great
springs, but only after they have flowed into their re-
spective basins, .so that the tenqierature of the water is
somewhat lower (8.5" to 90.5" F. ) and not (iuite sn rich in
CO:.
The baths in use may be simple saline or warm saline,
and the flowing saline or Howing effervescing bath, as the
case may require. In addition, of course, douches, hip
baths, etc., found at all watering places, are given. The
analy.ses of th<' various springs will be found appended.
At first the waters of Biid-Nauheim were reeonuneiided
for the treatment of gout, rheumatism, aiKCmia, and dis-
orders of the female pelvic organs, but their seo]ie has
been widened and now embraces diseases of the heart and
nervous system.
For the first-mentioned affection patients are advised to
152
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Maiilieini.
Nauheini.
Analysis of the Nauheim Mineral Waters. The Amounts op Solids ake Given in Gra.ms as Con-
tained IN 1,000 Grams of W.vter.
Constituents.
Chloride of sodium
Ctiloride of liliiiuni
('liloride of potassium
Cliloride of ammonium
Chloride of calcium
Chloride of magnesium
Bromide of magnesium
Sulphate of calcium
Sulphate of strontium
Bicarbonate of cali-ium
Bicarbonate nf inai:rnesium
Bicarbonate of sodium
Bicarbonate of iron
Bicarbonate of manpanese
Bicarbonate of zinc
Silicic acid
Arseniale nf ircm
Phosphate of iron
Oxide of copper, chloride of thallium, oxide of lead, nitric acid, or-
ganic substances
Amount of solid constituents
Absolutely free carbonic acid gas
Semi-free carbonic acid gas contained in the bicarbonates
The active carbonic acid, i.e., the free and semi-free together..
Temperature ]^|lS^^i^H:;.;:;:;;:;::;:;;;;:;;::;;;;:;;;::;:
Springs for the Baths.
No. 7. No. 12.
Grosser
Sprudel.
21.Sai.5
.0493
.4974
.0.550
1.7000
.4403
.0060
.0347
.0390
2.3541
.03S3
.0065
.0104
.0335
.00030
.00046
Traces.
37.0886
2.3764 =
1216.6 c.c.
.7:i43 =
375.7 c.c.
3.1106 =
1593.3 c.c.
31.6°
88.88 "
Friedrich
■\Vilhelms-
guelle.
29.2940
.0536
1.1194
.0712
2.3249
..5255
.0083
.0353
.0499
2.6013
.0484
.0069
.0089
.0313
.0003
.0007
Traces.
36.1695
1.9777 =
1039.9 c.c.
.8123 =
416.2 c.c.
2.7900 =
14.56.1 c.c.
.35.3°
95.54°
Drinking Springs
Kurbrun-
nen.
15.4215
.0367
.5270
.0371
1.0349
.7387
.0063
.0238
.0334
1.1461
.0262
.0080
.0070
.0186
.00016
.00034
19.0549
21.4°
70..55 °
Karls-
bruinien.
9.8600
Traces.
.0731
.0113
1.0578
.3040
.0014
3277
!0087
.9515
.0152
Traces.
Traces.
.0087
Traces.
.0002
Traces.
12.4196
Ludwig-
Quelle.
0.3411
.0012
Traces.
.0388
Traces.
.3692
.1938
.0938
.0098
Traces.
.0131
Traces.
1.0478
18.8°
8.5.84°
drink freely of the water of the Kiirbnmuen, ^vhich is
rich in chlorides of lithium, potassium, and the bicar-
bonate of lime, and, when a more strouglj- alkaline water
is indicated, of that found in the Ludwigbrunuen. These
springs are thought to be of special virtue in the removal
of deposits about the joints. For the stiflfuess and swell-
ing of the articulations occasioned by gout, baths are
ordered which, beginning with thermal brine baths of a
temperature of 93' to 9.')° F., are gradually changed to
more stimulating ones, the effervescing water of Spring
12 being considered especially suitable. Finally, resort is
had to the flowing effervescing bath, which is powerfully
stimulating to the circulation, and is a specialtj' of Bad-
Nauheim owing to the uneipialled richness of Spring 13
in carbonic acid with its temperature of 93' F,
Patients suffering from an;i;mia and chlorosis are said
to be much benefited by bathing in the waters of these
springs on account of "their containing iron as well as
stimulating salts and COi, while at the same time the.v
drink the purgative waters of the Kurbrunneu and Karls-
brunnen.
Disorders of the female pelvic viscera, particularly pel-
vic e-\iidates, are said to be favorably influenced by the
warm brine baths, either with or without the addition
of carbonic acid.
Diseases of the spinal cord, as well as neurasthenia and
other disorders of the nervous system, also receive treat-
ment at Bad-Naulieim, and Medicinalrath J. Groedel. in
his little work, "Bad-Nauheim: Its Springs and Their
Uses." cites cases of the kind which have been remark-
ably helped. Professor Erli, of Heidelberg, sends numer-
ous patients thither and highly praises the virtues of its
waters in this class of cases.
As already stated, the waters of Bad-Nauheim are re-
puted to be of special efficacy in the treatment of both
acute and chronic articular rheumatism, being employed
in the form of baths, as has been the plan of management
at other health resorts for centuries. Cases of compara-
tively recent development are subjected to the influence
of the simple warm saline bath, but in protracted and
chronic forms of the affection the stronger and carbo-
nated waters are employed. The design of the bath is
to promote liealthy circulation in the affected joint, and
it is believed that the comparatively cool (93° to 9.5^ F.),
strongly saline, effervescing, and hence powerfully stim-
ulating baths of this spa accomplisli this result more cer-
tainly than do the hot weaker baths given at other
resorts.
The treatment of cardiac diseases, for which Bad-Nau-
heim has justly attained so great a renown, is an out-
growth of the treatment of articular rheumatism. It
was Dr. Beneke, one of the earlier physicians at this re-
sort, to whom credit is mainl\- due for the development
of this use of Bad-Nauheim waters, although the Schott
brothers. Groedel, Heineman, and others have luought
the treatment to its state of perfection. Beneke contrib-
uted reports wherein he showed that this means of ther-
apy is beneficial in four ways: (1) by preventing col-
lapses of acute rheumatism, which would increase an
e.\istiug valvular defect; (3) by promoting absorption of
endocarditic products in the same way that these waters
favor the absorption of inflammatory deposits in the
joints; (3) by exerting a soothing effect on the heart's
action; (4) by improving compensation in old-standiug
valvular disease. It was this last-mentioned effect which
led Groedel to affirm in a pa|jer contributed to the iV;'-
liner Minisehe mexHcinisclu; Woc?tenschrift in 187b that
these baths improve cardiac energy and are a powerful
heart tonic in other diseases besides valvular.
Carbonated thermal brine baths tend to (piiet and regu-
late the action of the heart, improve its innervation, and
increase its muscular tone. It is this ett'ect which, in llie
experienceof all physicians who have employed tin- treat-
ment, makes it applicable to all forms of circulatory dis-
order, whether depending upon endocardial or myocar-
dial disease, or merely upon nervous derangements. It
is generally taught that severe degrees of arteriosclerosis
and aortic aneurism are injuriously affected by such
baths, but Groedel has show'ii that if they are given in
such a way as not to augment blood pressure, even these
two diseases raav be materially bcm-fitcd.
The methods of employing balneology in the manage-
ment of cardiac di.seases is simple and yet requires an in-
telligent conception of the principles concerned, and of
153
Naval llynlt'iK'.
Naval Hygiene.
KEFEHENC!': IIANDBCX )K OF THE MEDICAL SCIENCES.
the cfffcfs produced by batlis of ditl'cTcnt. strengtlis and
tt'mpenitures. The ivarmer, less strongly saline ones
serve to soothe and relieve the wcali, irrital>le heart,
whereas those that are strong in mineral ingredients and
charged with CO;;, and at the same time of low temper-
atures (86° to 83° F.), stimulate the organ to increased
work. It is clear, therefore, that the.se last are permissible
onl}' after compensation has been re-established, or iu
cases that have never displayed very obvious weakness.
It is not claimed that the balneological treatment of car-
diac disease can be given only in IJad-Nauheim, but that
here the advantagis for this foi-ni of management are es-
peciall.y good. This is particvdarly true of the flowing
efl'ervesceut hath, which, it is said, can nowhere else be
given; and as it is powcrfidly stimulating, this kind of
bath is highly beneficial in suitalde cases.
Very briefly stated, the following is the metluxl of or-
dering tlie treatment. Atfirst, liatlisure prescril)ed which
are weak iu salts (about one per cent, of sodium chloride
and one-tenth ])er cent, of calcium chloride) at a temper-
ature of !).)' to 1C2' F., and for a duration of from five to
eight minutes. Carbonic acid is not added in the begin-
ning of treatment, or at most in a very weak jiercentage
of CO2. As time ]iroceeds and cardiac energy grows,
the strength of the baths is increased until the salts men-
tioned approximate three per cent, of the sodium and one
per cent, of the calciumchloride. Carbonicacid isadded
in the course of time, as determined bj' the judgment of
the physician, and pari pasim the temperature of the
water is reduced and the length of each bath is increased,
until at last the patient remains in the tub about twenty
minutes.
In the fore part of the treatment the hatlis are inter-
rui)ted by an occasional day of rest (one out of every
three or four), but toward the end of the course such in-
terrui'tions come at longer intervals. Patients are also
required to lie down ami rest after each treatment for an
hour or so, in order that the effect of the bath may be
retained and opportunity be given for a nap if inclina-
tion thereto be felt.
In adilitiou to balneology patients are usually in-
structed to take exercise either in the form of massage,
the so-called resistance exercises, or, as the heart becomes
cipial to it. 1)3' walking on the level or up the gentle in-
clines prepared for the carrying out of Oertel's terrain-
kur. The diet and intake of fluids are also supposed to
be carefully regulated.
As has been stated in numerous medical journals, this
balneological treatment can lie very well given at home
by means of artiticial waters, and, as my experience has
abundantly proved, with excellent results. It is not pos-
sible, however, successfully to imitate the current bath,
and in addition it is dillicult to get patients to make
treatment the sole aim of existence as at Bad-Xauheim.
In concluding thisbrief sketch, which by reason of the
limitation of space aflotted is necessarily cursory and in-
complete, I desire to express my sincere thanks to Dr. II.
N. Heineman and to Dr. Groedel for valuable assistance
rendered by them. I am also indebted to muueidus pa-
pers by Dr. Scliott and others. liuhcrt II. Bahawk.
NAVAL HYGIENE.— IxTHom-cTiox.— Naval hygiene
may be Inii-tiy detiued as being that branch of hygiene
which applies the principles of sanitation to the "condi-
tions peculiar to life at sea, and especiall}' as existing in
ships of war. Although, in actual practice. a]ipearing
more or less modified to make them meet the peculiar
conditions prevalent on board sea going ships, the laws
of general hygiene nuist remain essentially and funda-
mentally the same. Adajitation may at times necessitate
and require a modification in the jH-aetice. but can never
be allowed to go so far as to alter the lu'inciples of what
is known as good hygiene, and so recognized by the liest
sanitarians the world over.
The importance of the study of hygiene to tin- naval
surgeon cannot be exaggerated. I'idess he jiossesses a
profound theoretical as well as a practical knowledge of
the essential and fuudameutal principles and purposes of
hygiene, the naval surgeon of to-da_v can hardh- be called
"up-to-date," for without that knowledge he is barely
able to perform but half his duties as sanitary officer on
board a war-vessel. Since these duties must be confined,
in form at least, to recomiuendations, made to his com-
manding otficer. it is hardly to be expected that his recom-
mendations will meet with the approval, required by reg-
ulations, unless the medical officer at the same time is able
to jirove to his captain that he possesses the necessary
and requisite knowledge to entitle him and his recom-
mendations to that attention and consideration which
alone can make them effective.
To the naval architect tlie careful and conscientious
study of hygiene is likewise of very great importance.
At least one of the essential conditions implied in the
construction of a warship is that it shall be so designed as
to affoi'd a given number of men a wholesome shelter
during the performance of their duties; that the condi-
tions on board be such as to preserve the life and health
of the men, aiding them in, instead of interfering with,
their most etfective duties and excluding outside influ-
ences that are detrimental to these ends. The naval con-
.structor owes it to himself, to the naval service, and to
the people of his country that the best possible arrange-
ments be made, that the best methods be ado])ted, and that
the best work be done to advance the interests of hygienic
living on board the ships which he designs and builds, as
as far that may be within the range of his power. The
ventilating system for a ship of modern construction, for
instance, must be considered to be so essential that without
it the ship would be of little value and its use limited.
Since the tyjieand details of a ventilating system must
be adapted to the type of the ship, it shoidd from the be-
ginning form a part in the design and struct\ire of the
ship and not be left to an afterthought. The construc-
tor, realizing the difficulties, may commit them to an
expert ; but even then it is necessary that he have enough
knowledge of the subject and of the results to be aimed
at that he can readily and conscientiously accede to the
demands of tlie expert, instead of regarding them as un-
reasonable; he should, moreover, possess enough knowl-
edge on the subject to enable him to pass a just and
proper estimate upon the value of the services of the
emplo3'ed expert himself. Thus, in giving out con-
tracts, he is usually besieged by competitors. Competi-
tion leads to low bids and these lead to poor work and
material. The result must be prejudicial to the interests
of the naval service and to the constructor as well.
Scientific facts are stubborn things: they will not and
cannot remain long ignored ; mere opinions, whether offi-
cial or unofficial, cannot sidetrack them, and thus the
inevitable conclusion remains that we must bravely face
these facts. In so far as the life of the sailor is influ-
enced by the training which he must and can receive
only on board a warship in commission and at sea, it is
perfecth' evident that that life is either increased or im-
paired in value to the .service in direct proportion to the
improvements in the hygiene of his immediate environ-
ments. These are intimately connected with the im-
proveiuents in the coustruetiou of the ships on which he
has his being.
Fortunately, there is abundant proof of the fact that
within recent vears, at least, a deeper recognition of the
importance and of the profound significance of ships' hy-
giene on the part of all the officers of the naval service
has become manifest. It has become clearly recognized
that the strength, the power, the health, and the endur-
ance of a ship of war, in action or out of it, whether on a
mission of peace or one of war, can be but those of all
its inmates combin<'d, and, consequently, every man indi-
vidually either adds or detracts from the sum total of
the ship's power and endurance in direct proportion to
the standard of liis physical health. But the highest
aims and objects of liygiene are not merely to preserve,
but to raise the average standard of the health of our
men to its maximum capacity. All training is more or
less useless unless done on that basis.
Having once recognized these things, it becomes our
154
REFERENCE nA:SDBUOK OF THE MEDICAL SCIENCES.
!>'aral Hygiene*
Naval Hygiene.
next dvity to examine into the conditions, to consider some
of the facts, upon which the successful solution of so
high a problem depends. The three mainstays of all
living things that people this earth are air, water, and
food. An etlicient ventilation, a good water supply, and
an abundance of good and wholesome food must ever re-
main the principal subjects of our study and claim our
first care and consideration. But before entering upon
a more detailed study of these, we are impelled at least
to call attention to what seems a most necessary pre-
liminary to the successful administration of all hygienic
laws in every organized body of men such as constitutes
the navy, fjy that we mean the instruction of the men
under tVainiuV in the laws of the hygiene of our daily
lives.
It has been found repeatedly and constitutes an almost
daily lesson of the sanitarian that one of the greatest and
ever-present dangers from disease, on the part of the men
in both the army and navy, is the ignorance of the most
simple and elementary laws of health that must gov-
ern the cvery-day conduct of their lives. E.\amples
of this might be cited ad infimtum, but we need go no
further than merely call attention to the lessons that
have been taught us, during our short war with Spain,
by some of our volunteer regiments. Man}- of our brav-
est sons, because untrained and uninstructed in these
things, died within a few weeks of going into their lirst
encampment. Hence the warning linger, fortified and
supported by an expeiience that should never again be
allowed to lapse into forgottenuess, points directly and
unwaveringly to the necessity for instructing the men in
the simple and elementary laws of health. This is clearl}^
and distinctly the dutj- of the medical officers of the navy,
the only officers in the service who, by the very nature
of their training and education, should and can be held
responsible for initiating reforms and improvements in
this direction.
"Nous somnies si z^les partisans de
la ventilatiou que nous n'hesitons pas a
la consid^rer comme le premier facteur
de rhygiene des navires. plus important
a lui seui que tous les autres reunjs." —
ROCHAKD ET BdDET.
I. Ventilation.
To supply a ship's complement of men with a pure,
good, and wholesome atmosphere at all times and under
the most varying conditions of activity, rest, and climate,
is a problem which as yet has not been completely
solved. The ditferent climates through which men-of-
war have to pass within a short space of time, and the
conditions which these impose upon our problem, would
alone be sufficient to demand the
greatest po.ssible elasticity in the
range of adaptability from any ven-
tilating system that is known, while
the large number of small water-
tight compartments into which the
interior of a modern warship has
been systematically reduced would
make it seem almost next to im-
possible to keep the air inside all of
these in a desirable state of purity
and in constant and measured cir-
culation. While, therefore, we agree
with the distinguished French hy-
gienists whom we have quoted above
as regards the very great importance,
to the hygiene of war-vessels, of an
efficient ventilating system, we
must also recognize and acknowl-
edge that in no other department
of naval hygiene do we find our-
selves confronted with as great and
perplexing difficulties as we do in
the ventilation of warships of re-
cent construction. We may accordingly be pardoned for
devoting to this subject more time and space than to any
of the others.
no. 3499.— Rerknaffers
Model Paper Bo.n.
(From Karl Scbmiilr.i
Ventilation means to produce currents in the air.
Currents are produced (1) by rarefying a colunm of air at
some place, through heat or suction, and (2) by condens-
ing at some other place, through either cold or compres-
FiG. 3500.— Illustratiug Distriliution of Pressm-e in Heated Rooms.
(From Rubner.)
sion. An excellent illustration of the effects of heat and
cold upon the creation of aerial currents is furnished,
in nature, by our regular winds. Along the equator
we have a belt of calms, sevei-al degrees in width, over
which the air is rarefied and expanded, rendered spe-
citically lighter under the influence of a vertical sun, and
consequently a constant current ascends into the higher
regions of the atmosphere ; then this current flows north as
well as south from the equator, passing over the cooler
trade-winds which flow in beneath them from either hemi-
sphere. The warm equatorial currents descend toward
the surface of the earth in about the thirtieth degree of
latitude. The same currents cross the winds coming
from the poles and proceed converging toward them as
surface winds, whence they again ascend and, now, pro-
ceeding in a direction toward the equator, they descend
through the calms of Cancer and Capricorn, become sur-
face winds, and form the trade-wimls already alluded to,
thus completing their figure-of-eight form of circulation.
A similar process, though on a much smaller scale, may
be seen daily in the large chimneys of some of our great
manufacturing establishments. Through the fires, the
column of air contained inside of them is heated and
rarefied. The rarefied column of air, consequently, rises
very much as a stick of wood foiTcd lengthwise under
water will rise, and the specifically heavier air, out-
side the chimney, will press inward from below. The
cause of this movement is the difference in temperature
between the in.side and outside coluimis of air. for if this
difference disajipears ecjuilibrium is re-established and
the movement ceases.
In houses and dwellings of all kinds, these sjime physi-
cal forces are constantly at work, tending to bring about
a change of air within them. The porous nature of our
building materials, the winds, and the differenees in tem-
perature between inside and outside air are the efficient
causes of this natural ventilation. In an experiment by
vou Pettenkofer it wasfouml that in a room of 7.5 cubic
metres' capacity one complete change of air was produced
in one hour through a difference in temperature between
inside and outside, of "20 C.
In order to illustrate the working of the jirinciples of
this natural ventilation, Reeknagel made a box of thin
paper (see Fig. 3400) iierfeetly cid)ical in shape, leaving
the bottom s^ide uncovered.' Through this uncovered
lower side he heated the air by means of au alcohol lamp,
155
Naval Ilys;'ieiio.
Naval Hygleue.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Fio. rail. — 11 Ills
trates the Princi-
ple of Natural
V e n t i 1 a 1 1 o u of
Sbips. (Fruiii
Munson.)
thus imitating the conditions under which natural venti-
lation occurs in any heated space iu which iloors and
windows are closed. It was shown by luanometrical
measurements that in the upper portion of such a box
there was overpre.ssiu'e. wliile in the
lower portion of it there was tmder-
Ijressure. In the upper portion the
walls were pressed outward, in the
lower portion they were pressed in-
ward. Aljout the middle part the
pressure was = 0, anil the line of this
zero pressure was called tlie neutral
zone. (See Fij;-. .5800, line JV J\').
It will easily lie perceived that wher-
ever ventilation is effected by suction
or exhaustion there must be nnder-
pressure, produced thi'oughout the
entire enclosure. The neutral zone
will rise up to the ceiling or near the
place where the exhaustion is done.
The region of underpressure will rise
until it prevails throughout the entire
sjiace. Under such conditions air tends
to press into the enclosure from below,
through cracks in the sides, or whei'-
ever underpressure e.xtends. In case
the adjoining rooms are kitchens,
closets, stutTy cellars, galleys, pantries,
engine- and hrerooms, bilge or store-rooius, as would be
the case on board ship, all tlie ettluvia from these would
be bound to jiass into any of tlie living sjiaces that are
ventilated after tliat fasliioii.
These facts would liold good everywhere, although a
ship is vastly diffi'rent iu its material construction from
any building on shore. A ship's bottom and sides, un-
like those of a house or building, must practically be
made both water- and air-tight; hence, whatever fresh
air gets into a vessel must come from the to]i side and
thence find its way. as best it can. to the various parts
below. It represents a Reckuagel's box with its inside
air heated, but with its partly open side on top. instead
of at the bottom. Whatever natural ventilation occurs
in a ship can best be illustrateil by the classical experi-
ment with the un.stoppeied lidttle. If we lower a lighted
wax taper attachnl to the end of a wire down to the bot-
tom of a wide-mouthed bottle, the little tlame will burn
brightly for a short time, then grow gradually dimmer
and climmer and finally die out altogether. If we now
change the conditions of our lirst experiment by inserting
a piece of cardboard into the neck nf the bottle so as to
divide the cylindrical opening iiilo two neaily eiiual
parts vertically, and now again inlioduce our lighted
taper to the bottum, it will burn brightly to the end.
The heated air charged with carbon tlioxide will ascend
through the neck on one side of the cardboard, while a
current of air. pure and cold, will descend on the other
side of it and support the life (if the tlame. As long as
the hot air alone came thi'ough th(^ neck, fresh air was
prevented fi'om entering, and whatever little did lin<i its
way into the bottle was returned liefore it reached the
candle at the luiltom.
The same pvinci|ile is also well illustrated liy Fig.
3-501. Here tlie fresh air enters through the longtube.I,
and the foul air jiasses out through the short lube />.
A single central tube. lieinge((iiivalent toaseptum. will
answer the same purpose. In this arrangement the warm-
air current passes up through the central tube, while the
fresh, cool current will descend outside of the tubular
septum. In ease, however, this central tulie should be
provided on top with a hood which is turned to the
wind, then the c<ild air will pass down it and the warm
air ascend aroimd and outside it. As long as nature has
her choice, the column of hot air will be found to occupy
the centre and the cold-air currents will arrive from the
peripheiT. These simple princiiilesexplain the method of
ventilating ships by .means of wind-sails, of no matter
what construction they may he. through hati lies. The
essential diUVrence iu the methods of ventilating houses
and ships is that, in the former, fresh air can be ad-
mitted, in fact presses in from below, with the greatest
case, while in the latter it must first be drawn from
above downward, which is a matter of .some dillieulty,
therefore also rei:|uiring special means for its accom-
plishment. It uliould never be dr/iirn dtucn at a i^hice
irliire it meets irith tin tiseendiiir/ etirreiit of warm air.
Fresh air having arrived at the lowest compartment of
the ship, its distribution to other parts of the vessel can,
of course, only be effected on the same principles and Ijy
Ihe same means that are employed iu the ventilation of
houses on land.
After the air has left the ventilating pipes and entered
the smaller compartments and living spaces, its further
distribution follows the laws of temperature and pressure
differences, either existing naturally or being produced
artiticiall}'. Whenever a ship happens to run against
the wind, its inside temperature will be found consider-
iilily higher in the after-part of the vessel than in the
forward part; with the wind on her side, the leeward
side will show a higher temperature than the windward
side. These differences are of course greater in the in-
terior of the ship than on the upper declv.
These simple principles of natural ventilation woidd
not have been dwelled on at such length, were it not that
daily experience has abundantly shown that an undue
lack of appreciation of them in putting them into prac-
tice is almost equivalent to entire ignorance of them,
and hence their having been emphasized. The juoblem
of ventilating ships on the best ijrinciples deserves our
most serious stufly and devotion.
yatural-Air Currents in Steamships. — The student of
ships' ventilation will do well to begin with familiar-
izing himself with the movements of natural-air currents
within ships of dilferent types, both under varying
and under average conditions. In doing this, he will at
tirst meet with many rather startling surprises. The
currents move iu quite unexpected directions and seem
difficult to explain. Thus, in sailing vessels, a number
of canvas wind-sails are iu use (see Fig. 3.jO'2); these
wind-sails are usually suspended from some point high
above the upper deck and have their heads turned to the
wind. The air is led down into the deepest portions of
the ship by the wind sail which passes straiglit down
through therlilTercnl hatches whiili are usually superim-
pii.sed. Under these conditions, the foul air rises outside
of the wind-sail to e.scape into the open. When, however,
either bj' accident or design, the ojieu lieads of the wind-
sails are turned away from the wind, these currents will
be found to be exactly reversed, the wind-sail becoming
an uptake for the foul air and the remaining space in the
hatch, outside the wind-sail, becoming a down-take for
fresh air. In sailing vessels the
tempemture and pressure dillVr-
ences are, comparatively speaking,
slight and, conse((uently, a rather
trifling circumstance suffices to
reverse the air curients within
them.
In a steamer of modern cnn-
struction, such as a cruiser or bat-
tleship, with enormous Hre- and
engine-rooms, large steam pipes
and a number of auxiliaiy en-
gines, situated for the most part
in the middle or central compart-
ments of the ship's body and ra-
diating considerable amounts of
heat, air currents from all |iarts
of the vessel would, tuider aver-
age conditions, move in their di-
rection, that is, from the c<ilder
parts toward the v,-armer higher
ments. Local heat-pro<lucing centres and open hatches
will, hmvever. here also lu'oduce interference currents
which are Sdinetimes dillicult to explain, although per-
fectly natui-al when traceil to their cau.se. Tiie nat-
ural ciu'rents in steam vessels are not so easily' diverted
Fii;. Sice.— Shows a Can-
va.<w Wind-sail of the
Ordinary Pattern.
lower and peripheral
and central compart-
15(3
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Naval ■I);£iruo.
as those iu sailing vessels, for reasons that must now
seem obvious.
From the consideration and study of these normal air
currents in ships, we derive one very important lesson
with regard to the subject of the artiticial ventilation of
■vessels iu general, namely: that any air currents estab-
ished by artificial means and intended for purposes of
ventilation must be so directed as to have coticertintj
rather than conflictin;/ action with the normal ship's cur-
rents. It must be clear that the most effectual as well
as the most economical plans for ventilating ships b.v ar-
tificial means, after natural ventilation has been found
insufficient, consist in providing means intended to aid
and increase the ventilating capacity of the natural cur-
rents.
A supply of fresh air. directed in separate air shafts to
the lower and most peripheral compartments of a steam-
ship, would be the first step to be taken and quite in har-
mony with the general principles of ships' ventilation.
Hollow masts, hatches, engine- and fireroom gratings
and chimney casings, owing to the high temperature
existing about these places and the consequent tendency
of a strong upward current, would send the foul air out
of the ship without the aid of any other power directed
to effect this end. By such a sj'stem alone will it be
possible to realize the nearest practicable approach to
that continuous mass movement of air so desirable in
artificial ventilation. The air. fresh and cool, sent into
the extreme peripheral parts of a ship and starting from
these parts on its way through the ship, in a direction
converging toward the various natural outlets, would do
the most efficient ventilating work attainable and with-
out being turned back. Its flow can be so graded that
there will not be the slightest danger from too great a
draiight.
Eciiiiomy in Ventilation. — The best principles of econ-
omy in ventilation are met, when the arrangements are
such that the air-contaminating substances are gotten rid
of without becoming mixed with the incoming fresh air.
The nearest possible approach to such economical mass
movement, in a continuous flow, which can be realized
in the ventilation of a ship, is iu the vertical movement
of air, wlien, for instance, fresh air is admitted below
and foul air passes up through hatches or other natural
vents. This condition clearly demands that the supph"
of fresh air be directed into the lowest and most ]ier-
ipheral compartments of a ship through channels other
than those operating as the natural outlets for foul air.
To cause downward currents of fresh air througli tliese
natural outlets of foul air, by creating various degrees of
underjiressure in the lower compartments of a sliip.
through exhausting the air there, mtist, in view of these
facts, be considered contrary to every good principle in-
volved in ships' ventilation so far considered.
Different ilethnds of Ventilation. — In tlie words of
Woodbridge ('' Lecture Notes ") " ventilation is by the
vacuum or the jileninu luethod according as the greater
motive power is in tlie discharge or in the sujiply part of
the system. That power may" be solely in either one or
the other of the two ]iarts, or it may be shared between
them. Its predominance in the one or the other deter-
mines the vacuum or the plenum character of the venti-
lation."
Vacuum Method. — This method causes a movement of
air into an enclosure l>y creating a partial vacuum witiiin
it. Into such an enclosure the air then flows through
every available channel both provided and accidental.
From whatever points, therefore, the pressure may be
greater than iu tlie enclosure, ventilated by the vacuum
method, from thence it will move toward that enclosui-e.
Each such space, therefore, is more or less at the mercy
of its surroundings and of conditions beyond the control
of its occupants. The vacuum luethod of ventilation on
board ship puts the breather at the ]ioint of discharge of
foul air and sends into the living spaces specimens of air
from every part, near or remote, whether filled with
good or foul air.
Plenum Method. — This method puts each compartment
under a slight pressure ami thus prevents leakage of air
from adjoining compartments. It tends to accelerate the
flow of air through natural outlets and gives the occu-
pants control over the source and velocity of their air
supply. This method puts the breather at the point of
sup])ly and consequently in position to breathe the best
of air. It is recommended as the best by Rubner, Kirch-
ner, Karl Schmidt, Notter, Harrington, and Jhnjson.
As it applies to ships, it is more nearly a method of re-
moval than the other, and this constitutes the highest
degree of efficiency for any ventilating system. We
have seen that it answers to the best principles of econ-
omy. The method is the one best adapted to warm cli-
mates in which men-of-war spend at least ninet_v per
cent, of their time. It will supply a steady current of
fresh air to all the compartments in the ship alike, and. by
tending to produce even contlitions of temperature and
pressure, it will prevent currents and counter-cuiTents
between the different enclosures iu spite of free com-
munication existing between them.
The usual objections made to the plenum system of
ventilation are that it gives rise to sensible draughts and
causes dangerous colds. This is very true for houses iu
a cold northern climate with a temperature difference be-
tween inside and outside air of from 60° to 70' F. and in
which the air coming into the rooms is not sufliciently
warmed. These dangerous draughts of northern climates
can, however, not be taken into account when designing a
ventilating system for a ship of which it is known be-
forehand that it will fpend ninetv per cent, of its time in
the tropics. We heat the air by artificial means in our
northern climates before admitting it into the living
rooms, in order to enable us to take in a larger supply of
it without becoming sensible of it. But, in the tropics,
as luust be evident, we need not resort to such artificial
means of heating the incoming air in order to diminish
existing temperature differences, and, consequently, the
dangers due to sensible draughts. Ventilation" iiere
must, on the contrary, be designed for the double pur-
pose of having a cooling as well as a ventilating effect.
Besides, a dry atmosphere of low temperature^ is here
borne with greater ease and comfort than a moist atmos-
phere with a high temperature, on account of physical
heat regulation being more prominently active in the
warmer climates than in the colder cliinates. It is the
common experience of hygienists and sanitarians that air
currents of a temperattu-e and veli>city pronounced dan-
gerous in northern climates must be considered well
within the range of perfect safety iu ships cruising in
the tropics. An efficient supply of air to the lower
decks of a ship in the tropics rarely, if ever, gives rise to
a dangerous draught or even a noteworthy feeling of
discomfort. The colds are generally caught on deck
while the men are aslee]) in an ex])Osed part of the .ship.
;\Iany people fear draughts, and attribute to this cause
not only all the colds tliey catch but also all their other
ills into the Uirgain. Some are so acutelv sensitive, es-
pecially within doors, that they feel air currents that are
beyond being measured by the most delicate instnunents
of precision. The same people will sit out of doors,
where the air moves at the rate of 10 metres a second,
without either complaint or harm.
Of one thing I am tiaily growing more assured, naiuely :
that the limits to the velocity of air currents, given in
works on ventilation, for houses and buildings, do not
apply to ships. To live on boar<I slii)> is more like living
out of doors than living within a room.
Air currents tliat would be both disiigreeable and dan-
gerous in rooms of houses on land are still borne with
comfort and without danger on board ship; hence, also, a
much larger supply of fresh outside air can be provided
for in the case of ships than in that of houses and Ijuild-
ings on land without overstepiiing the safety limits.
Dilution or Remorul in Ventilation. — The ideal aim of
any ventilating system, in tlieory at least, must be the
getting rid of the foul air in an enclosure and the replac-
ing it with fresh air, without the two becoming luixed.
In practice, however, anil as Hiibuer has long since
157
Naval H yg;ieue.
Naval Hygleuo.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
pointed out, we are obliged to take the air for inspiration
from tlie same reservoir into wliicli we send our expira-
tory air. It would, therefore, seem impossible for any
ventilating system to separate the one from the other, and
all ventilation must, accordingly, proceed after the man-
ner of a process of dilution and be so arranged as to keep
the enclosed air from reaching a comjxisition very much
different from the outside air.
According as to whether we remove tlie fmil air and
replace it with fresh air without the two becoming mi.\ed,
or whether we maintain in the air of an enclosure a com-
position not dangerously far from that found outside by
the constant and continuous introduction of fresh air, we
may be said to ventilate either by the method of nmoi-nl
or by that of diliitinii. The removal method reaches its
maximum applieabilit.y and elticiency in such cases as
the tireplace. the chemical hocid, the kitchen range bon-
net, and the blacksmith's forge. The m-arcst ]u-acticable
approach to this method on shipboard is effected b_y the
eseajie of foul air through an open hatch. Whenever
and wherever air is warmed in transit, as it is in steam-
ships in passing from the cooler iierijiheral compartments
toward the warmer central ones, economical and effectual
escajie of foul air occurs Ijy an vipward movement through
a hatch. The foul air, under such circumstances, makes
a direct escajie into the open and does not ret\mi to mix
with the incoming fresh air, providing, of course, the
proper outlets are free and unobstructed and it meets or
passes no compartment on its way in which und<'riiress-
ure exists. In such ventilation, economy, efiicieuey, and
excellence reach their maxinuun. What tlie chemical
hood is to the laboratory, what the range bonnet is to the
kitchen, that the vertical foul-air shaft or hatch is to the
ventilation of a ship. Providing the lu-oper number of
fresh-air inlets has lieen provided and (listrib\ited in such
a manner as to allow the incoming air to do the most
effectual ventilating work, such would be the natural
air currents on board e%'ery ship of the type represented
iu the above descriptinn.
Would any one with the full knowledge and appre-
ciation of these i>rinciples of natuial ships' ventilation
choose a ventilating system at variance with themV Let
us confess that it would be <lilficult for any one to believe
that such a one exists. Ventilation by natural means
having been found insutlicient, let us without hesitation,
and basing our arguments upon the above grounds, put
the fresh air directly where it is most needed, place our
power on the sup|)ly side of our .system and tlius give it
the plenum character; let us aid rather than antagonize
natural currents, and we shall have the satisfaction of
coming nearer to a perfect method of ventilating a ship
than by any other known means.
Perflation signifies a bhjwing through. When the
wind moves across the deck of a ship that has its ports
open on both sides, as is sometimes the case on the decks
that are above the water line in tine smooth seas with
light winds, such decks may be saiil to be ventilated by
perflation. No method of either natvu'al or artilieial ven-
tilation is comparable to this in tlie volume of air moved
and in the ventilating effect produced. It should, there-
fore, be taken advantage of and used at every fa\'orable
opportunity that offers itself for the purpo.se of directly
al'rating parts of shijis not generally' accessible to such
direct ventilation.
RtliitiiiH. hctirieii Si:c<>f lif/rjns and Tiinnaf/eof S/ii/ig. —
Notwithstanding the great im]Hirlance of tlu; hatches in
their relation to the veutilation of the interior of ships,
there seem to exist no fixed rules for a detinite relation
between the square area of them and the tonnage of ves-
sels which the constructor is bound to follow. Thus,
Rochard and Bodet mention several very striking in-
stances, illustrating this very important ]ioint, as existing
in the French navy: L'Oriita of tlie French navy has
hatches of a total square area of 64"'-, 40 and a displace-
ment of 8,000 tons. The Forbin has only one-fourth of
the displacement of the Ocean, while her hatches have but
one-tenth of the sc(nare area of that vessel. The Ilarhe
disjilaccs nearl}' one-third more than the Ociau Ijut her
spardeck hatches have a square area of only one-half that
of the Ocean. A number of similar instances could be
cited concerning shijjs in the American navy and show-
ing the same lack of jiroper relation between the square
area of the hatches and the tonnage, but the above exam-
ples suliice.
Nor are the number, size, and location of these hatches
and their relation to each other on the different decks of
the same vessel matters of minor importance to the in-
terests of the ventilation of the vessel. Tlius, superim-
posed hatches favor the natural ventilation of the lower
compartments, while alternating hatches favor the circu-
lation of air through the 'tween-deck compartments.
The location of a htitch often determines its function as
an up-take for foid air or a down-take of fresh air. Tur-
rets, railings, and other obstacles in the way toward
hatches and ventilators divert a large quantitj' of air,
preventing it from going into the ship. Jloreover, with
the wind ahead, the forward compartments ai'e the best
ventilated, the hatches in this part becoming inlets,
while the after-ones become outlets. The velocity of a
head wind is increased by the speed of the vessel, so far
as its ventilating effect is concerned. The opposite is
true for a wind going in the same direction as the vessel.
With the wind on either side, the best ventilating work
is done liy perflation.
Wooden gratings with which hatchways and air-shafts
are co^■crcd reduce the area for ventilating jjurposes
three-fourths of their capacity. Perforated iron gratings
are recommended and come into use more and more, be-
cause they have been found superior to wooden ones.
Thus, simple hexagonal openings in iron plates in which
the arms, se|iaiating the openings, are just one-half the
width of the openings themselves, decrease the ventilat-
ing capacity by only one-half instead of three-fourths.
Ventilation is not equally important to all eomjiart-
ments, and from this point of view the\' have been di-
vided into four classes:
1. There are the cells of the double bottoms. Tiiese
are rarel_y ojiened, and whenever opened for inspection
they are never entered without the air enclosed within
them being changed liy means of portable ventilators.
Their influence upon the hygiene of the vessel is practi-
cally nil.
3. There are the various storerooms for cordage and
sails, provisions and clothing, water, ammunition, en-
gineer's stores and otliers. In these it is only necessary
that the air should not absolutely' stagnate.
3. The 'tween-deck eomparlinents that are inhabited
by the crew are, of course, of the greatest importance
and ventilation here must be ample, safe, and constant.
4. The various workshops, engine- and lirerooms in
which men stand watch or are kept at work for stated
periods night and day. The rooms in which are located
the steering, pumping, liydraidic, circulating, and con-
densing engines, and which in protected cruisers and
battleships are foimd below the protective deck, need a
sure and steady air siqiply. Ventilation of these places
has the double purpose of cooling the air as well as re-
newing the oxygen. Inlets in these compartments
should lie distributed all around, in onier to avoid the
dangerous effects that would be produced \iy a single
strong current.
Siinrccti of Cotitayiiinaiion </f t)ie S/iiji's Air. — The com-
position of the air onboard ships of war is influenced:
(1) By human life and activity ; (3) by various nuisances
of an iniiiistrial origin; (3) by the bilge water.
1. Human life and activity change both the physical
and the chemical composition of an atmosiihcre in several
ways, naniel}' : (a) tliej- take from it oxygen and replace
the same with carbon dioxide; (b) they increase its hu-
midity ; ('■) they add to its temperature.
From the physical side, the processes of life have been
likened to the phenomena commonly oViserved aljout a
steam-engine. Neither animal life nor steam-engines can
be kept going without food or fuel; both do a definite
amount of work, the energy for which is derived from
the oxidation or combustion of substances put inside of
158
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
>iai'al lly;
Naval Hy.
:ieuo.
;ieiio.
them, and both produce certain effete end-products that
are similar, namely : carbon dioxide, water, heat, and the
various products of excretion (ashes).
An eflficient ventilation to an overcrowded ship is as
necessary and has the same signiticance as forced draught
for a furnace overloaded with coal. A deficient ventila-
tion is attended b}' the elimination of a series of products
that are not normally present in either expired air or per-
spiration ; to this class of compounds belongs t"he authro-
potoxin of Brown-Sequard. These jioisonous substances,
produced under the influence of a deficient ventilation,
may well be compared to the products of an incomplete
combustion produced in a furnace and cou.sisling of both
invisible poisonous gases and visible smoUe. Since a
state of overcrowding must be looked upon as the nor-
mal condition of life on a warship and as a necessary
accompaniment of all activity there, an etlicient ventila-
tion on board a ship becomes a much more serious prob-
lem than on shore.
If we assume with Rochard and Bodet that, under nor-
mal conditions, a man with his respiration vitiates 1
cubic metre, or about 86 cubic feet, of air in one minute,
he vitiates in one hour 60 cubic metres, in twelve hours
7,200 cubic metres. A group of 500 men, the usual
number on board a battleship, would then vitiate in
twelve hours 360,000 culjjc metres, or about 13,960,000
cubic feet. Such a group of men living iu a space of
2,500 cubic metres capacity would vitiate their available
air quantum 150 times, and, to keep it pure and within
respirable limits, it would need to be renewed 12.5 times
per hour. How overcrowding ini'a-eases, apparently in
geometrical progression, the carbon dioxide, organic
matter, and the numljer of germs iu an atmosphere is
shown by Carnelley, Haldane, and xinderson (Kirchuer)
in the following table:
Living In —
Carljon dioxide.
Per minute.
Organic matter.
Per minute.
Number of
germs.
Per litre.
One room
Two rooms
Tbree rooms
1.13
.09
.77
U.I 11 .'■.7
.1)11)1
.ni)l,5
60
46
9
No wonder that the mortality tables show a corre-
sponding increase. Peojile living in one room show a
mortality of 23.3; those living in two rooms a mortality
of 18.8, and those living iu three rooms 17.2, while tliose
who live in four or more rooms have a mortality of only
12.3 per cent, out of a general moi'tality of 20.7 per cent.
These conditions are directly applicable to life on board
ship.
But human life and activity add also heat and moisture
to the atmosphere. An adult man produces in hisliody
in twenty -four hours 2,300 large calories, an amount of
heat sufficient to increase the temperature of 23 litres of
water from 0° to 100° C. Througli the skin, by evapor-
ation, he loses from 600 to 2,400 c.c. of water in twenty-
four hour.s, the exact amount depending vipon the temper-
ature, relative humidity, and the amount of movement
of the atmosphere surrounding him. This would corre-
spond to a heat loss of from 348,320 to 1,373,280 calories.
The total heat loss is distril)uted as follows:
von Helmlioltz.
Per cent.
Vierordt.
Per cent.
i()!i)
:.'.9
86.9
11.1
Tlirough bowels and liidneys
3.0
2. Industrial nuisances. The modern battleship may
be said to combine within its sides all the varied indus-
tries of a manufacturing town pressed into the smallest
possible space with all its accompanying nuisances in a
concentrated form ; the principal ones among them being
those which come from the engine- and tii'erooms, in the
form of gases, heat, and moisture. The products of in-
complete combustion of coal may find their way into liv-
ing spaces through pi'ocesses of diffusion or the wrong
kind of ventilation such as the vacuum method. Heat
may accumulate owing to faultj' construction or imper-
fect covering of heat-i'adiating .surfaces in certain living
spaces, close to engines and steam pipes. Steam escapes
moi'c or less constantly from imperfect or worn-out
joints. The mean loss of water from escape of steam
through pipes alone in a modern protected cruiser has
been estimated to be about four tons daily. Plumert
mentions a case of poisoning with carbon monoxide which
occurred in one of the compartments of a torpedo boat, and
which .shows how dangerous gases may be diverted and
get into living spaces. A hole was bored through one of
the bulkheads separating the smoke-room from the living
spaces, for the jjurpose of laying electric wires, and
through this small opening, the carbon monoxide had
made its way from the smoke-room to the men. In an
empty ammunition room which had remained closed up
for some time on board the iSnchseii, Gartner found up to
51 parts per 1.000 of carljon dioxide. The men who en-
tered this compartment became suddenly asphyxiated.
3. Tlie bilge is a constant source of air contamination.
This fluid accumulates perpetually near the keel, along
the bottom of the very lowest compaitment of a ship
and corresponds to the ground water, surface water, or
sewage of our buildings ou land. It is sea water mixed
with the off-fall fi'om all sorts of cargo, provisions, wash
water, coal, ashes, gi'ease from machiuei'v, dead rats, the
organic matter from evervthing living in the .sea. iu short
a poitiou of evei'3'thing that finds its way sooner or later
into ships, will gravitate finally into the bilge.
In iron ships the sea water comes in through the shaft
alley alone, while iu wooden ships it may at times press
in through every seam below the water line. The bilge
is therefore less abundant in the foi'iner than in the lat-
ter. Dr. Nocht found from 3,000 to 15,000,000 germs
in 1 c.c. of bilge water, Fermentation is \'ery naturally
the normal condition, and the gases constantly produced
pass either into the ship's atmosphere (jr accumulate
witliin spaces not ordinarily included in the general at-
mospheric circulation. The farther away we pass from
the keel of a ship, the higher we ascend the ship's ladder,
the purer, the drier, and the cooler becomes its atmos
phere.
Besides the above-described sources of eontauiinatioE
there are others which are, however, not remedied, as are
these, by an efiicient ventilation, and hence they were
not included in the above enumeration. These are dirty
personal habits and dirty clothes as well as a diity ship.
Nothing short of water, soap, the brush, and strenuous
woi'k will reach these.
liifliience i/f ViUnted Air on Ilumna Life. — There is.
besiiles sudden death due to asphyxia from the inhala-
tion of air overcharged with carbon dioxide, a process o.*
s/ojo dying, due to living in badly ventilated room.s, which
is not so clearly and so generally recognized nor so direct
ly and clearly traceable to its cause. Non-medical obser-
vers and the victims themselves do not realize the causal
connection between bad ventilation and this condition,
hence also the lack of complaints with regard to poor
ventilation from that source. The usual and immediate
effects of breathing foul air are pallor of the skin, dis-
tui-bances of digestion, impairment of assiniilatinn. loss
of muscular and mental vigor, ami a tendeuey to physical
break-down and disease. The dilTerence in the complex-
ion between the deck-hands and the fire- and engine-room
men on board a man-of-war may well l)e seen at a mus-
ter, when the two classes of men are drawn \\\i in line on
opposite sides of the deck of the ship. On one side you
may see the ruddy and rosy faces of the deck-hands, on
the" other the pale, sallow "features and sunken eyes of
the men w'ho work below.
Anthropoto.i-i Kx in Air. — Determinations of earljou di-
oxide often fail to give information in all I'espects sati.s-
159
Naval Hysieue,
IVaval Hysileiie.
REFERENCE HANDBOOK OF THE IVIEDICAL SCIENCES
factory as regards the degree of atmospheric coutami-
nation, and an air must often be pronounced unfit fur
respiration, especiall_y on board sliip, before either lack
of oxygen or the undue accunudation of carbon dioxide,
and even watery vapor can l)e accused of being the
causes thereof.
What exactly these poisonous substances are and
whence they originate, what their nature and chemical
composition may be. we do not as yet know with cer-
tainty. In their elfects tliey are like poisons. Since
they are known especially to accumulate in jilaces over-
crowded by human beings, an exact knowledge of their
origin and composition would be of great interest to
naval hygiene.
Brown-Sequardand d'Arsonval once believed that tlicv
had discovered in stagnant expired air a toxic alkaloid
which, consequently, they named inithrn/xito.riii, and
which, indeed, when injected un<ler the skin of mice,
killed them within a few hours. R.auer repeated but did
not contirm the experiments of Bro\vn-8equard. The
problem has recently been taken up again by Formanek
(ArchtB f. Jlyf/icne, Bd. xxxviii.. Heft 1), who makes it
appear likely that the problematic substance is an am-
monia compound, not .so nuich the result of the decom-
position of expired air as it is of the decomposition of
urine, fa'ces, and of the buccal contents of the animals
experimented on. He concludes that the distress, the
navisea, and the fainting fits which occur in overcrowded
enclosures imder |)oor ventilation cannot be attributed
to a single and always uniform factor. It seems, there-
fore, that Formanek likewise has failed to contirm the re-
sults of Brown-Se(iuard and d'Arsonval. According to
the experiments of Liibbert and Peters on guinea-pigs,
the poison, if it exists at all, is nut an organic, that is,
not a carbon-containing or coml>ust iljle substance. AVolf-
hiigel insists that it is not contained in normal but always
only in stagnant and decomposed expired air. The pres-
ence of a well-defined, well-characterized chemical poison
in bad air would form one of the most eonveuient means
of determining the degree of its contamination. Stich a
substance is as yet imknown. Nor is it definite!}' known
whither these sulistances do tlieir harm through being
iidialed or whether their presence in the atmosphere sim-
ply iidnbits the further elimination <if them from our
bodies, and thus gives rise to poisoning by the retention
of an exerrtoiv iimduct. Certain it is, according to
Hubner, Seegen, and Nowak,
tluit when animals are kept in
riosed spaces, in which care is
taken to remove the expired
earlion dioxide and to re-siqi-
]ily the used-u]! oxygen, the
aidmals nevertheless succumb
after a time.
Entinidtion of the Qwdilji of
' '.—Since, as we have Just
seen, ehcmislrv has as vet
Fio. 3.")03. -Represents the Lunire-Zpckenriorf Ciulmii-Dioxicle Ap-
paratus. (From KirchniT.)
failed to find a <-()nveinent ehemieal <cim|ioinid in the
air by the determination of wliich we might standarrlize
a normal atmosphere, we uuist resort to less direct meth-
ods. Experience .seems to hold the chenneal determina-
tion of the amount of carlion dioxiile as the most reli-
able method for estimating the quality of a siiecimen of
air. The method for the determination of the amount
of orgainc matter in air with potassium permanganate
h.ns been foimd very inaccurate by Archarow and Em-
merich, and the method proposed by Rietschel, of using
the temperature as an indicator of the degree of contam-
ination of the air. could hardly find application on board
ships which produce heat in such enormous amounts
as do the modern battleships and protected cruisers.
Determination of Carbon Dioxide in Air. — It is known
that barium oxvhydrate combines with COo according to
the formula, Ba(OH)» + COj = BaCOs-f II.O. Petteu-
kofcr jiroct'cds as follows: A bottle containing 5 litres
of the air to be examined receives 50 c.c. of baryta water.
After thorough shaking and allowing t(.i stand for a few
minutes, all the CO2 that was in the air of the bottle is
now supposed to have combined with the barium oxy-
hydrate. The uncombined barium is now converted
into an oxalate according to the formula; CiOiH^-t-Ba-
tOII). = C.O.Ba -J- 2HnO. From this the amount of CO,
in the specimen of air may easily be computed. Altln >ugli
accurac}' is decidedly in favor of Pettenkofer's method
with baryta water, other considerations will sometimes
cause us to sacrifice accuracy and to decide in favor of
another method on account of its convenience. Several
methods of this kind have been published recently.
Thus, " A Rajiiil Method of Determining Carlionic Acid
in Air" has appeared in a recent number of the Journal
of Ilyiiitno (University Press, Cambridge, England) by
John Ilaldane. The apparatus, ueatl}- fixed in a wooden
portable box, represents a siiuple form of llaldane's gas
analysis apparatus ; it is so arranged that the CO2 is ab-
sorbed by a potasli solution. The final readin.g indicates
the parts of CO2 contained in 10, OHO parts of air. The
whole oliservatiou can tie made in five minutes. Lunge
(see Fig. 3508) ("Ziu- Frage der Ventilation," Zurieli,
1877) uses a bottle of 50 c.c. cajiaeity, closed by a double
perforated cork and containing 7 <-.c. of ii 0 to 1,000 bary-
ta solution. Through one of the lioles in the cork a long
glass tube reaching to the bottom of the bottle is intro-
duced ; the outer end of this tube is closed with a piece
of rublier tubing and a clamp. The second hole in the
cork is provided with a short tube, the outer end of whieli
is connected with a bidb. This rubber bulb has a slit
wliich serves the purpose of a valve, permitting the air in
the bulb to be pressed out without going into the bottle,
but not to re-enter the bulb, except with the air that
passes through the baryta water in the bottle b}' way of
the long tube. To this end the clamp, of course, is taken
off. The bulb having a capacity of 25 c.c. the air quan-
tum, sent through the baryta water, can be easily esti-
mated. TVlien the test is made, the air is drawn tlirough
the bottle until a lead-pencil mark on the side of the bot-
tle, opposite the ej'e of the observer, becomes invisible
through its content's. The table below gives the values.
To the number of fillings must be added two volumes
representing the capacity of tlie bottle.
Number of
fillings.
Volumes
per lU.dllO.
Number of
llllinss.
Voliuiies
per 111,1100.
4
.5
B
17!li
14. s
1-'.(1
8
9
10
11
11.0
9.8
s.s
This method has more recently been greatly im|U'Oved
bv Luimc and Zeekendorf (Zi itsclirift f. 'aiirieirandte
Chciiiie. 1S88. Heft 14. and 1889, Heft 1). Instead of
baryta water, a decinornial solution of soda is used.
To 1 litre of the solution there is added 0.1 gm. of
plieuol|ilitlialein Avhich colors the solution dark blue.
Two cubic centimetres of this solution are mixed with
100 c.c. of air-free distilled water. The empt}' bottle
is now filled with thi' air to be examined and 10 c.c. of
the dilute solution are added. The bulb is now worked
once and the liottle shaken for a minute. This proc-
ess is repeated until the color of the fluid has changed
from blue to yellow.
The \'alues may be seen in the next table ;
100
REFERENCE HAJJTDBOOK OF THE MEDICAL SCIENCES.
Naval H}<:;ieiie«
iVaval Hjsriene.
Table IV.
Niniilier of
Voluuies
Number of
Volumes
linings.
per l.tXX).
tllliugs.
per 1,000.
48
0.3
8
1.3
35
.4
7
1.4
27
.0
0
1..5
31
.6
5
l.R
17
7
4
2.1
10
.9
3
2..")
9
1.0
3.0
More recently still a neat aud liaufly iiirlhod similar to
the preceding, and based on practically the same princi-
ples, has been devised by Dr. G. W. Fitz. This nietliod
is carried out by shaking a small quanfity of dilute lime
water, colored pink with phenolphthalcin. with succes-
sive portions of air tmtil tlie solution is decolorized.
The method has of late been made still more practicable
by Woodman aud Richards {Tcchnolagy Qnurtciiy, vol.
xiv. , No. 3, June, 1901). Since I have used this method
quite a little and have found it to answer every purpose
on board ship, being easy of application, also sufficiently
accurate, a detailed descriptiou, given by Woodman and
Ricliards, will here follow :
Dexeription of Method of Using the Shaker for Determin-
ing the Amount of Carbon Divxide in the Air. — "The
method of preparation of the solutions and the manner
of making the tests which have beeu found to give the
best results will be described iu detail, since experience
has shown that the.se directions cannot be too minute.
^^ Preparation if Vie Tent Sidiition. — The solution used
is a dilute sohilion of lime water colored with ]ihenol-
phthalein. To freshly slaked lime add twenty times its
weight of water in a bottle of such size that it is not
more than two-lliirds full. Shake the mixture contin-
uously for twenty minutes, and then allow it to .settle
over night or uutil perfectly clear. The resulting solu-
tion is the stock lime solution, or 'saturated lime water.'
If made in the manner indicated, each cubic centimetre
of it ought to be very nearly equivalent to 1 mgm. of
oavbon dio.xide. If, however, it is desired to know the
strength of it more exactly, it may be determined by
standard acid.
"To prepare the 'test solution,' pour into the 1-litre
bottle of the testing apparatus one measured litre of dis-
tilled water, and add 5c.c. of solution of phenol])hthaleiu
(made by dissolving 0.7 gm. of phenolphthalein iu 50c.c.
of alcohol and adding an equal volume of water). Stand
the bottle on a sheet of white paper and add the ' satu-
rated lime w.ater,' drop by dro]) from a pipette, shaking
the bottle thoroughly after each addition, until a faint
pink color is produced which is (jermanent for one min-
ute. Now add 12.6 c.c. of the 'saturated lime water, '
shake, and immediately connect tlie bottle again to the
apparatus.
Table A.
Standard
test
solution.
CO,
in 10,(K10.
r
"Half
solution."
CO2
in 10,000.
Standard
test
solution.
CO,
iu 10,000.
0
"Half
solution "
CI i„
in lO.rxKl.
22 2
50
15,6
8.9
270
4.1
18.0
70
12.4
5.6
290
3,95
1.5.1
90
10.2
5.4
310
3.8
K.O
110
8.7
5.1
330
3.7
11.3
13(1
7.5
4.8
:v,o
3.6
9.9
1,50
6.6
4.7
370
8.8
170
5.8
4.5
390
8.0
190
5.2
4.4
410
7.3
210
4.8
4.3
450
6.8
230
4.5
4.0
4SI0
6.3
2.50
4.3
3.9
530
"To shorten the time required in testing air which is
low in carbon dio.xide, it may be found advantageous to
use a solution only half as strong as the above. This
'half solution ' is prepared in precisely the same wav,
Vol. VI.— U
Fig. 3504.— T he F 1 1 z
Shaker. Full size.
(From Woodman and
Richards. )
using 2.5 c.c. of the pheuolphthulcnu solution and 6.3
c.c. of the 'saturated lime water.'
■' While this procedure doe.s not give iin e.xnct volume
of solution, it is believed to be t!i(^"best for the jivepara-
lion of this dilute test solution, .since it obviates th(' nec-
essity for pouring llie prejiared .solution from the measur-
ing flask into the bottle in which it is kept; 1'2.6 e.e. of
the stock lime soluti(JU is added
rather than 10 c.c, in order to keep
the values obtained with the re-
sulting solution more nearly com-
parable with the older valu'es cal-
culated on the supposition . that
10 c.c. of 'saturated lime water'
was equivalent to 1'2.6 mgm. of
carbon dio.xide.
•• Method of Makinrj the Tl'S^.— See
that the inner tube of the shaker
slides readil}- iu the outer one,
moistening the rubber collar slight-
ly if necessar}'. Have the inner
tube pressed down to the Iiotlom
of the lai'ger one, and measure into
the apparatus 10 c.c. of the test
solution from the automatic jiipette.
Pull the inner tube uji to the 5 c.c.
mark (the bottom of the inner tube
serving as the index) and close the
end of the tube with the finger.
Hold the apparatus horizontally,
aud shake it vigorously for exactly
thirty seconds.
"The amount of air which is thus
brought in contact with the solu-
tion is equivalent to 30 c.c, as there are 3o c.c. of
air above the liquid when the small tube is forced to
the bottom of the larger. Remove the linger, press
down the small tube again to the bottom of the larger
and draw it up to the "20 c.c. mark. Shake the appa-
ratus again tor thirty seconds. The amount of air
brought in contact with the solution is now 30-|-20 = 50
c.c. Repeat the shaking, using 20 c.c of fresli air eacli
time until the pink color is di.scharged. The amount of
carbon dioxide corresponding to the number of cubic
centimetres of air used will be found in Table A.
"A'oto and I'recaitfions. — Care should be taken that
the finger used to close the end of the tube is perfectly
clean, siuce on a warm day the free acid iu the |)rrsi)ira-
tion might easily vitiate Ihe results.
"If greater accuracy is desired, the shaker should be
tilled with the air to be tested before running in the test
solution. This may be done readily by filling the .shaker
with water and emptying it or by forcing air into the
tube by means of a small rubber biilb.
"The apparatus should be shaken vigorously and con-
tinuousl.v during the thirty seconds in orderto absorb
]iractieaily all of the carljon dioxide in 20 c.c of air.
Tlie number of shakings ought not to be less than one
hundred during this time.
"Care should be taken not to contaminate the air while
the Sitmple is being taken. The breath should be held
momentarily while the air iu the apparatus is being re-
placed, and the sample should be collected as far to one
side of the bod\' as iiossible. It ought not to require
over ten seconds to replace the air, and the entire test,
with air containing, say. b parts of carbon dioxide per
10.000. should not re([uire over si.x minutes,
"If less tliau 90 c.c. of air is rec(uired to discharge the
pink color, the test should be repeated, tisiug 10 c.c. of
air each time after the first 30 c.c.
"It is not necessary to rinse out the shaker after mak-
ing each test, but it should be carefully washed and dried
after iLsing, and the jiarts ke]it separate when not iu use.
"The 'half-solution ' is used in exactly the sanu' man-
ner and amount as the I'egular test solution, reference
heing made to the ajipropriate portion of the talilc"
Air Quantum yenhd. — The ventilating plant to be de-
signed for a place <ir ship must be given a ventilating
161
IVjii'jil Il5ii"ieil<'»
ISavnl llyjiicuc.
REFERENCE HANDBOOK OF THE IHEDICAL SCIENCES.
capacity of power sufliciont to do tlii' work which it. is
iulcndcd to do. The air quiuiluin lu'cded depends vipoii
thi-amouutof atmospheric viiialion lliat may be expected
to occur ill tlie place tol)e ventilated. Tlius. tlie changes
tliat occur ill a given volume of air dininii- a single act of
respiration may be .se( n in the following table:
Tabi.k V.
Contains ix Vui.imf. tku Ce.xt.
Oxygen
Nitrogen
Ciirbon dioxiii*'
'jii.iii;
T:i.e:;
.10
Expired air.
ir,.03
rsi.O:;
4.3S
According to tliis t:ilil(', the iiitrogeu of the air is the
only one of'its coustitncnis that remains tmchauged in
quantity ; oxygen is dcerea.sed about one-fifth and car-
bon dioxide has increased a hundredfold by the respira-
tory act. The following calculation will serve as an
exiimiile of the method that is generally employed to de-
termine the air quantum which the ventilating system
must sujiplv to a place in a given time, before our system
can be iiroiiounced satisfactory : Given an enclosure, her-
meticallv sealed, of 40 culiic metres capacity, filled with
fresh aii-, originally found to contain 0..5 part per 1,0(10
of carl)ou dioxide." Every cubic metre of this air con-
tains, conse(inently, 0..") "litre of carbon dio.xide. An
average i^erson contiued in tliis space would produce
23.6 litres of carliou dioxide within one hour. _ This
quantitv, when added to that normally present iu the
above 40 cubic metres of air, would" bring the tolal
amount of CO; .at the en<l of one hour up to 4'.;.0 litres
or 1.00.) per thousand.
The maximum limit of ('On alhuved by Petteukofcr
for a good quality of air is 0.7 pea- 1,000, and this we see
has been seriou.sly surpassed. Ruth and Lex have
ailopted 0.0 jier l.o'oo for their maximum limit, and Car-
nelly, Haldaue, and Anderson want 1.0 per 1,000 adopted
for (Iwelliugs. If we adopt for the sake of illustration the
limit of I'etrenkofer, and further assume that fresh out-
side air contains, on an average, never more than 0.5 jier
1.000 or every litre 0..") c.e. of CO.j. then every litre of air
may take ni'i 0.2 c.c. of CO.. bid'ore the normal carbon
dioxide maximum limit is exceeded. Consecplently, we
need 113 litres or 113 X 0.2 c.c. = 2'3.6 of CO.^: we need
113 cubic metres (3,991 cubic feeOof fresh air in one
hour and for an average iierson. iu order to keep the air
of a place within respirable limits. Notter quotes Roth
and Lex as estimating the amount of CO™ produced by
an average person iier hour at 2i) litres and the hourly
quantitv of air re()uiicd at 100 cubic metres. If we state
this quantity of air, with Notter, as 3,000 cubic feet per
hour, it is just one cubic foot per second.
It will be seen that we can vary our calculations con-
siderably cither by extending oiir maximum limit of
CO.; or "by starling with an air of a higher standard of
purity to' begin with. If, for instance, we would venti-
late our test enclosure with an air that contained onlj'0.3
of CO-j per 1,000, we would require only .jOo cubic me-
tres to take up the above 22.0 litres of CO.; exhaled by
an average person in one liour.
The needed air quantum is generally calculated ac-
cordinc to the following simple rule-nf-thn'e: (1) n:
k 22 6
l = k:ili-q); (2) n ; ; (3) n = 7:^;— r^ = 113 cubic
1.0
p-q 0.7-0. .5
metres: (-1) n = , 7," ,',' - = •'•^■- fiibie metres (^iliireke and
1.0-0..«
Talile VI. sliows how the
l.O-O..".
Schultze, by Kirchneri.
amounts vary within the limits of purity demanded.
Some of tlie medical officers of the French navy ajqiear
to be keenly aware of the needs of t'leir service- from a
hygienic ]ioint of view. Thus. Rochard and Boilct. in
their excellent wiu'k on "Naval Hygiene '' ip. 143), make a
strong anil timely ajipeal for thi' ii.troiluetion of more
scieuiitic mcthiMis in the invrsligiitinu .if naval sanilary
Table VI.
Air required per Max and per Hour.
allowed per l.aKI.
In cubic metres.
In eulnc feet.
0 fi
231)
n:i
7.">
45
r.tisi
3,991
3,M9
9
1,943
1 0
1,.589
problems, an aiipeal which L"'nited States naval medical
ollicers might take seriously to heart, very much to their
advantage" They say: "Nous demandons iustainment
qu'on mnuisse les medeeins-majors de tons les batiments
de guerre d'un auemometre de Cassella," etc.. and they
dep'lore the departmental penury in not providing na\-al
surgeons with the instruments necessary for better re-
search work.
F(U- the determination of the air quantum they propose
to enqdoy what they have termed the "coelHcicnt of ven-
tilation."' In tills, the hour is taken as the unit of time.
Any air space, no matter what its cubic caiiacity, in
which the air is renewed once in an hour, has a coefticient
of 1. Where the air is renewed twice in an hour, that
enclosure has a ventilating coefficient of 2. Wherever
it t;ikcs two hours, that place has a coefficient of i
]{ .
etc. The
efficient is expressed by the fraction
H
which R represents the number of times the air is re-
newed and H is the time required to do it iu. Accord-
ing to this plan, the facts in ventilation could be intel-
ligently recorded. Thus, for instance, ■) cubic metres
(f70 cubic feet) is the average air space allotted to one
man in the French navy. This space is so smaii that the
air in it would have to be renewed 22.6 times, i.e. , it would
have to receive a cocllicient of ^-^^ iu order to bring the
air quantum up to that re(|uired by our average adult in
the preceding example, which was 113 cubic metres.
But almost every work on ventilation tells ns that the
air in any i-nclosure cannot be renewed more than three
and at most five times, lest there be danger from
draught. If we allow the French sailor to breathe into
his allotted air space of 5 cubic metres for one hour,
assuming that the air originally contained 0.') COo per
1,000. then that air would contain 5 COo per 1,000 at
the end of the first hour. If we allow the air to be re-
neweil three times, or em|doy a coefflcieut of -J, it would
contain 2 parts CO-j per l,o"00; with a coefficient of j.
it would reach only 1.4 CO, per 1,000.
A saika- ou active duty generally turns into his ham-
mock at 9 P..\i. and is called at 5 .\.M., when not called
out fiu- a watch before. He would sleep for eight con-
tinuous iiours iu a space the air of which, at the end of
that time, would scarcely keep a candle burning, even
under a coefficient of J. ' It is dilticnlt to imagine that
he would wake up again, as we all know he does, un-
less actuallv sup])lied with more air than our calculation
allows him". Can any one doubt that, in practice, be
somehow gets much 'more air, draught or no draught,
than our theory allows him to get? There are sliips iu
the United States navy, and training ships at that, in
whidi the average air space per man is only two-thirds
that allowed in tlie French navy, which apparently sliows
much mori' strongly than docs the above instance, that
mori' air //(".■./ get ini'> living spaces than even a coefficient
of f could ]iut there.
The UKU-e the (piestion is studied and the Iietter we are
beccaning ac(iuaiuted with the facts, the more it is found
that the rules that have been winlied out to govern the
ventilation of houses and buildings on land do not and
cannot, be madi' to apidy to ships without consideralile
modificati(ai. We shall iiave to break with fixed stand-
ards as regards the numlicr of times we are allowed to
renew the air in enclosures anil part company with dan-
gers from draughts, when going to sea iu shijis.
The coefficient of Rochard anl Bodet may be said to
1(1
KXPLAXATION OF
TLATE XL VI.
EXPLANATION OF PLATE XLV^L
Plans of till' I'liili/il JSIatrs St<':iiiishi|is Knimiyi' ami luiihn-/,//, illiisl raliMi; llic |ili'iiinii syslciu
iif vi'iitilatioM. installfil liy Naval ("onstriictiir .1. J. Woodwanl. I . S, N,
Kl(. I— riaii .if V\i\nv \)rrk. Slinwiiiu 'I'niiiks and C'n« Is fur I'assayr nf Air.
Kn:. >- — Kcpicsmls a X'crtical l.onnii mlinal Sriticm, Sliowiriu Tnuiks ami Cnwls fm ihr Supply
of Air.
Fiii. :'. — licpicsinls Kdiwanl Knd nl Uciili Deck. Slmw Iiil;- How Frrsli Air Is Distiifiulud from
.Main Dn k lo l,i\ini; Sp.iccs. W .iln Closcls. etc.
Flo. 1. — I'lan al Spliiil.i Dn-k.
l-'io T), — LooUini; Forward from lOnjxiiU' Kooin. Fii;s. -1 and ."isliou, in plan and clrvalion how
frcsL air is supplied Pi ilii' cnuinr rooms.
Flo. (J. — lii'picscnls Plan lliidn;;li Ward-mom. Mess ro.nii, and Stalorooms ((ullioaril of Same,
f^howiiiy Mi-lliod ol l>i-liiliuli)pj Frisli .\irfrom Main \Cnlllalin'4' Hni-ls lo ( Itlircrs' l.i\in,!;
t"liaf(s.
REFERENCE HANDBOOK
OF THE
MEDICAL SCIENCES
PLATE XLVI
>-
^ .
o g
LU z
Q O
Z Q
<o
I-
QJ "J
O ^
DC ^
< P
1 CO <
LU 3
CO
CO 3
CO °-
Z)
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Naval Hygiene*
Naval Hygiene.
be ii simple, convenient, and accurate means of recording
tlie ventilation of an air space. It might witli great ad-
vantage be used in company with the "air cube." The
air cube is expressed by the fraction ^. I stands for
cubic space, M for the number of men in it. Tlius a
spaceof 100 cubic metres capacity with four men in it,
lias an air cube of 25 cubic metres.
Tvating the Sufficiency of a Yentilating System. — This is
done (1) by determining the cubic capacity of the living
spaces with the air quantum siipplietl to each in a given
time, and (i) by examining the air both chemically and
baeteriologically. For tlie measurement of the cubic
capacity of ships' spaces, the three simple rules given
by SlacDonald are still sufficiently accurate and answer
ail the purposes of the sanitarian: (1) Take the largest
measurements of length, breadth, and height that the
space w-ill admit of, for the determination of the main
cubic capacity. (2) Take the cubic capacity of all ir-
regular spaces and recesses in communication with the
principal space, and add their sum to the latter. (3) Take
the measurements of all obstructive bodies and projec-
tions and of ever_vthing that impinges upon the available
air space and subtract the sum from the gross cajjaeity
already obtained. Since it will greatly facilitate calcula-
tion to take down the measurement in feet and tenths of
feet rather than in feet and inches, the following table
may prove useful :
Table VII.
Inches.
1
3
4
.5
6
7 8
9
10
11 12
Decimals ^' a
foot
0.08
o.ir
0.2.5
0.33
0.44
0.5
0.58 0.67
0.75
0.83
0.92 1
A few simple rules will satisfy the requirements of the
sanitarian. For example, the area of the segment of a
circle equals two-thirds of the product of the chord and
height, plus the square of the height divided by twice
the chord (Ch X H x i)+{^X
The area of the triangle equals tlie base multiplied by
one-halt the height. The circumference of a circle e(]uals
D X 3.1416. Toascertain the areaof an ellipse, multiply
the product of tlie two diameters by O.T8.')4. The cubic
capacity of a cylinder equals area of base multiplied by
height.
The total number of cubic feet, with additions and de-
ductions made, must now be divided by the number of
berths or hammock swings in the different crew spaces
and the result is the cubic space per head or air culie.
The total air quantum that passes through a sp;ice c;in
be determined only by means of an anemometer and the
area of the ventilating trunks. The velocity of an air
current in metres per second is ascertained in accordance
with the formula v = a + h— where a and b are constant ;
a refers to internal friction and b to vane inclination; u
is the number of turns and z the duration of the observa-
tion in seconds. The air volume is then calculated by
the formula: L = f. v. 3,600, where f is the area of the
intake in square metres. For example: The hands of
the anemometer stand at the beginning of the observa-
tion at 3,420, and after operating 7. = 130 seconds, the
reading of the hands indicates 3,900. The instrument
had made n = 480 turns. The constants are a =0.18 and
480
b = 0.14, and thus we get v = 0.18 + 0.14— = 0.74.
0.56
The measurements of the inlet area gave 0.26 x 0.38m. or
f = 0.0988, consequently the pipes propelled L = 0.0988,
0.74, 3,600 = 263.2 cubic metres of air per hour.
Pressure differences existing between different com-
partments of a ship are ascertained by differential man-
ometers; these serve chieti)' to indicate inequalities of
ventilating jiower in different compartments with rela-
tion to each other and to determine the direction of the air
currents existing between adjoining compartments from
one with more into the one with less pressure.
An ingenious method for determining the amounts of
air discharge which occurs in an enclosure — a method
which can be applied to ships — was devised by Pettenko-
fer. After closing all openings into a room, he generates
COa by burning stearin candles. The candles furnish a
definite amount of CO-, per hour and the CO2 of the air is
also known. AVheu the power of the ventilating system
is to be ascertained, the blowers are started and tlie air
fmm the centre of the enclosure is examined at intervals
for COj. The rate at which the CO2 disappears gives
testimony of the eflioieney of the ventilating capacity
of tlie system under investigation.
Carbonic-acid examinations by any one of the abovs-
described methods will complete the test of the ventilat-
iag sufficiency. Bacteriological examiuations of tlie air
of shijis have not yet been made to my knowledge. The
difficulties of preserving or making culture fluids are
alime to blame for this serious oinissicjn. Sjieeial re-
search work has, however, shown that the number of
germs in a culiic metre of air decreases at sea in direct
proportion to the distance from laud, until, in midocean,
the air is found absolutely sterile but a few feet above
the upper deck of a ship. Fischer {Zc/'tscJuift f. Hygiene,
Bd. 1. 1886, p. 421), in examining sea air. found one germ
in 44 litres of air ; at a distance of one hundred and twenty
miles from the coast, it was found to be sterile.
Ventilation' of Different Types if Vessels.
1. Bctttleships " iLear-m rye " and ^'Kentucky" (see Plate
XLVI. and description of figures). — Mostexcellent exam-
ples of ventilation on the iileuum principle are furnished
by these two battleships of recent construction. They
are practically sister ships and the ventilating system is
the same in both. The Kearsarge and Kentucky are the
liest ventilated ships in the United States navy (see Plate
XLVL).
The United States Steamship Kcarsaeycm a twin-screw
armored sea-going battleship with a displacement of 11.-
ri'J6 tons; she was built at Newjiort News, Va., and was
fii'st commissioned on February 20th, 1900. She has an
upper deck, main deck, berth deck, splinter deck, protec-
tive deck, holds, and double bottmns. There are in all ten
fifty-inch electrically driven fans, of twelve horse power
each, and giving each a speed of 500 revolutions per
minute Avith an output of 160 \o\\%. Every fan forms an
independent supplj- system for a certain part of the ve.-;sel
and is located as near as practicable to that part of the
vessel which it is intended to sui>i)ly with air. All the
air is drawn from above the spar deck and iiropelled down
below the main deck; from thence it is driven through a
s_ystein of branches into the various compartmmfs into
wdiich these are made to open through numerous small
outlets, provided with adjustable cowls or terminal
trumpets that can be turned in an}' desirerl direction or
closed at will by shutters.
The ten supply systems are distributed about as fol-
lows: (1) Two s_ystems. supplying all the furward com-
partments of the vessel, have the lilowers located .sym-
metrically on each side of the centre line of the vessel in
the blower room, on the splinter deck, and underneath tlie
conning tower. (2) Two systems, supplying the dyna-
mo-rooms and ammunition passages on splinter deck,
with blowers symmetrically located on each side of
centre line of vessel, on berth deck over dynamo-room;
they receive their fresh air through two ventilators, situ-
ated between the smokestacks and outboard of the two
ventilators supplying the berth <leck. (3) Two systems
supplying compartments in niidslii]i portion of splinter
deck, including passages, also u]i]3er and lower dynamo-
rooms; blowers .symmetrically located on each side of
centre line of vessel, in upper dynamo-room; they take
the air through two ventilators situated between the
smokestacks and inboard of the ventilators that supply
163
Naval U3'«;ioue«
Naval Hj'^'lene.
REFEREXCE HANDBOOK OF THE 5IEDKAL SCIENCES.
the dynamo-room. (4) Two systems suppl3'ing the en-
gine-rooms; blowers located in the ensiue-room hatch ou
main deck and taking their fresh-air supply through two
ventilators abaft the after-smokestack, and in the engine-
room hatch. (.■)) Two .systems, supi)lying all the after-
compartments of the vessel; blowers symmetrically lo-
cat<_'d on each side of the centre line and in blower-rooms
on spar deck abaft the main mast.
The fresh air supplied in this manner, after doing its
ventilating work, tiuds its way out of the ship through
the various hatches and the exhaust-leads of the smoke-
stack. There are besides some special exhaust blowers
of three horse power each for the steering engine-room,
officers' water-closets and lavatories, crew's and petty
officers' lavatories and closets. The large vertical ex-
haust-trunks from the lire- and engine-rooms are made to
extend high above tlie upper deck in order to increase
their draught and so as to prevent the escape of hot and
foul air from these compartments into the living spaces.
The eight tirerooms are suiiplied with air for forced-
draught purposes. There are eight steam-fans located
underneath the tirerooms' ventilating tiunks, each fan
supplied with air by means of a separate smaller trunk,
coming from above the upper deck, and titted with a
jjortable cowl. When forced draught is being used in
any flreroom, that lireroom is kept closed and all the air
that is forced in finds its way out through the furnaces
and thus goes up the smokestack. Incidentally, of
course, this forced draught furnishes fresh air to the tire-
men, stokers, engineers and others who ma}' happen to
be in tlie tireroom. AMien the forced draught fans are
not running, the same ducts furnish fresh air, by natural
means, such as temperature differences, to the men in the
lireroom.
No fans or other artificial means are provided for forc-
ing air into the coal bunkers. The free admission of air
into these is effected liy sejjarate inlets: while the outlets
are connected with the exhaust leads of the smokestack
system. With regard to the working efflciencj' of this
system on the U. S. S. Kenrmtn/e, Medical Inspector J. C.
Boyd, in his annual report to the Surgeon-General, 1901,
says: "The total volume of air that is brought into the
ship per minute has never been accurately determined,
but estimating the probable capacitj- of the blowers,
based upon the cubic feet of air per minute that can be
delivered for each horse-power, it will be readily .seen
that the air throughcjut the ship can be changed within
a few minutes. The cubic cajiacity of the ward-room is
5,376 feet, and it has been found tiiat the air is changed
1.5.6 times per hour, or everv 3.8 minutes."
2. Biittle.fhiji '• I/linois. "—The veutilati(jn of the lUiiuih,
like that of \\n^ Kciirsii.nje and A'eyi/'/rA//, has the power
also those of the compartments above this deck which are
located forward of tlie diagonal armor. The four after-
ventilating .shafts sujiply the staterooms above the pro-
tective deck and the storerooms and magazines which are
below this deck. They also suppl}- those compartments
of the ship above the protective deck which are included
between the di;igonal armor and the sides of the after-
part of the ship. All the fans are driven by steam ex-
cept the two that supply the dynamo-rooms: these are
driven by electricity.
The discharge of foul air is effected: (1) through two
large shafts, leading from the engine-rooms highabove
the spar dcclc; (2) through gratings in both the protective
and the splinter decks, and (3) through the military mast
which lias the outlet immediately beneath the tirst gun
platform. The exhaust side of the system has no fans
and does not seem to need any.
The mid-ship section of the lUhioin, which includes
the engine- and tirerooms, is supplied with four large
supply shafts ou each side of the ceuti'e line. The air is
taken from above tlie spar deck and driven by strong
steam fans through tiie fire- and engine-room spaces.
Foul air escapes througli hatches and gratings as well as
through the tires and smokestack.
The steam steering-room is ventilated on the combined
plan, having driving fans on both the supply and ex-
haust sides of the system, while the W.C. 's have the
power on the exhaust side only. To judge by the smell
that hovered about these, they did not seem to lie suffi-
ciently ventilated. Besides the aljove, there are two
separate shafts, also provided with steam fans, which
supply all the cjuarters located above the protective deck
and lietween the diagonal armor and the sides of tlie ship.
The maximum temperature observed in the tireroom
during the entire trip was 110° F. The adjoining table
shows temperature in the engine-room:
Table vixi,— Temperatcres, Decrees Fahrenheit.
Engine-room,
port.
Upper trratinjr,
>iarltit:ir<J.
121 l;?2 V£i
IIH lai lis
llfi 111! 11.5
lU lis 11!)
lu iia 119
lu 110 in;
lis 11!) VX)
1(19 no 111
Aft
liw im HIS
112 11:3 lU
Fig. a50.5.— Shows Uie Plan ot the Upper Deck of the Uiwhe with its Eisrht Hatclies. Marked
bv Treble Lines. Four small ones are in the centre line of the ileek, and the four laree . _
ories (enffiue-roum hatches) are arranwd symmetrically by twos on each side of the the upper deck have an areatin.g surtace
All lenipenitnres were taken al 11. 1~, and 1.
3. T/ie French Biiltleship '' Ilt/rJie." — This ship deserves
special menii(m in connection with the subject, of venti-
lation, because it jiresents a novelty in not sliowing a
single winils;ul above the upper deck.
All the air is taken into the ship
through eight hatchways, extending
from tlie tipper deck down to the pro-
tective deck. The system has the
great advantage of allowing the air
to pass between decks before reaching
the lowest compartments, much to the
advantage of these compartments be-
tween decks during the night. The
eicht large hatchways of the Uuchc ou
centre line of the deck. (From Rochard et Bodet.)
on the supply side of llie system, and is, therefore,
eff'ected on the plenum principle. The following de-
scription is from a few notes taken during her speed trial
and will onlv give thelcailing points: There are, on the
JUinois. eight large square air shafts, serving as inlets
and taking the fresh air from above the ujiper deck.
Four of these inlets are distributed about the forward
side of the forward turret of the ship and four of them
sire distributed similarly about the after-turret of the
ship. Of the four forward ventilating shafts, two sup-
ply the dynamo-rooms and two supply the quarters,
storerooms, and magazines below the protective deck, as
of 42 sqiiare metres (see Fig. 3.505): to
this must be added the openings of the
smoke boxes, and those of the ammunition hoists of the
four turrets, which may in reality be regarded as hatcli-
ways. The access of air down to the protective deck is
assured in sufficient quantity by three large hatchways,
arranged like air pits between the upper and the pro-
tective decks.
There are in all twelve large inlets (see Fig. 3.506),
each section of the sliip having its own ; the last three
sections alone are ventiliited by a common hatchway.
This last one is very large, because the spaces which
it is intended to ventilate are the steering engine-room,
that of the piuuping engine, etc. The various tirerooms
164
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Naval Iff glene.
Naval Hys:I<'ne.
each Oldening being 7 metres
Fig. 3506.— Shows all the Supply Shafts of the UinhR. Especially the Three Great Superimposed
Hatchways Extending from the Upper Clear Down throuRli the Jlain Deck to the Protective
Deck. (From Eochard et Bodet.)
have their own Inlets,
square.
The fortunate position of the exits (see Fig. S.'iOT) for
vitiated air permit.s the inlets in tlie protective deck to
have tlieir full effect. The four-
teen sections into which the ves-
sel is divided are not, however,
eqtially well cared for iu this re-
spect. The tliree forward sec-
tions being for
tlie most part P/Z2.
storerooms, are iil
merely aerated
by one circular
opening, which
serves jiotli as a
supply and an
exhaust at the
same time. The last two sections, which include the
steering engine-room, have likewise but one hatchwa}'.
Everywhere else, a large number of conduits is ar-
ranged so as to take the hot air out from the com-
partineuts below the protective deck and conduct it
above the spar deck. These are (1) the military mast
system, which exhausts the forward turret, the section for
tiie wounded, and the forward pumping engine-room ; ('2)
the chimnev mantle system, which exhausts the four fire-
rooms : (3) the protective casing of the conning tower,
through which escapes a portion of the air from a space
between the engine-room and the fireroom : (4) the great
centi-al shaft, divided into several smaller trunks, lets out
(rt) the hot air from the engines, the exhaustion of which
is effected by a fan through a perforated deck ceiling;
(6) the air of the midship pumping engine-room, steam
pipes, store- and ammunition-rooms: (o) an isolated con-
duit for the after ammunition-room; and (fi) the after
military mast, througli which escajies the air from the
after pumping engine-room and ammunition storeroom.
It is interesting to note that the exhaust pipes are placed
inboard of the su])ply sliafts.
3a. n. .V. SS. ''GIntteii" and " DeiYisiniion."— Accon]-
ing to MacDonald the plenum system of ventilation has
been adopted without exception in Great Britain ever
since the earlier seventies. Examiiles are H. !M. SS.
Ghittea and Derastation. T!ie (JInttcii has a rectangular
supply shaft, five feet six inches b.y six feet four inches,
beginning twelve feet above the upper deck and reach-
ing down to the level of the main deck, .iust abaft the
smokestack. At the liottom of this shaft there are four
fans connected with two transverse trunks, the upper of
which is sixteen by twelve, and the lower sixteen inches
square. The fans, driven by steam, take the fresh air
from the shaft and send it into the trunks, through
which it is propelled b_v means of smaller pipes into
every cabin and compartment of the ship, fore as well
as aft, by goosenecked funicular ends that open a few
inches from the floor of the deck.
There are in tlie Ghitten one hun-
dred and thirty-three of these
outlets. All the fans are pro-
vided with distinct sets of en-
gines which work independent-
ly, but in the
Jbevaxtiilion the
arrangement is
such that, in
case one or two
shafts get acci-
dentally blocked
or otherwise
rendered use-
less, the third
can be made to supplv all the compartments whose ven-
tilation would be thus interfered with.
The following table, IX., shows the relative number of
supply and exhaust fans in some of H. j\I. ships : it clearly
shows how even the combined system is gradually giving
way to the plenum system of ventilation in the royal navy.
4. The Austritin Oxist Befenfe V(S!<fl>i " ilonarch,"
" II7cH," and " Budapest." — All these ships have a very
large number of water-tight compartments, one hundred
and forty -two of which are located beneath the protective
deck and thirteen are above
that deck. Each compartment
is provided with its own two
ventilating pipes, one for the
admission of fresh air, the other
for the discharge
of foul air. The
two pi lies reach
above the main
deck and are
themselves wa-
ter-tight.
As a general
rule, all efforts
at ventilating water-tight compartments do in a meas-
ure endanger the purpose which these compartments
are designed to serve. In all English vessels of this
type the protective deck is left intact, while in French
and iu Austrian ships the bulk-heads are almost never
perforated.
Table IX.— (From Nottek.)
Name of ship.
EXHAUST Fans.
Supply Fans.
Number.
Diameter.
Number.
Diameter.
Devastation
Thumlerer
Trafalgar
«•
4 ft. Bin.
4ft. Bin.
Tn-o 6 ft. -
one 4 in.
4 ft. r, in.
3 ft. 8 in.
3 ft.
3 ft.
3 ft. 3 in.
4 ft.
3 ft. B in.
3 ft.
3 ft.
3 ft.
4
4
4
4
4
6
6
8
3
5
4
4
13
.5
6
4
4
2
2
2
2
1
.5 ft. 0 in.
5 ft. ij in.
4 ft
Nile
4 ft. 6 in.
4 ft. 6 in.
4 ft. 1 in.
4 ft. Ij iu.
4 ft
Imp^rieuse
E«iiubur^ni
Polypbemus
Howe
One 4 ft. —
one M ft.
4 ft
4 ft
Camperdown
Royal Sovereign . .
Roval Artbiir ....
4 ft.
.^> ft. 6 in.
Four 'T ft —
Dreaduau"'ht ....
one 3 ft.
4 ft
4 ft
Collingwood
4 ft.
4 ft
3 ft.
3 ft.
3 ft.
3 ft.
3 ft.
FiS. 3307.— Loneitudinal Section of the Hncltc, Showlug all the Passages for the Evacuation of
Foul Air, also the Independence of tbe Different Compartments from one another. (From
Rochard et Bodet.)
The engine-rooms on all these ships are ventilated on
the plenum principle. The air is taken from above
decks and pressed into horizontally arranged ventilating
trunks, divided into branches
leading the air down the sides
to the floor deck, whence it
passes into the engine-room
space. The escajie of foul air
is effected through one hirge
s h !i f t. lociit<!d
amidships over
the engine-room
and provided
with an electric
exhaust f ti n
with cowl on
top.
The boiler-
rooms are sup-
jilied with air through eight air shafts, four of which
have fans, while the foul air escapes through the chim-
ney, the hatch openings, and several special exliaust
pipes. All the other compartments are ventilated
through a large numlier of electrically diivcn fans which
act on the plenum principle. The coal bunkers are
165
IV aval Hysleiie.
Naval Hygiene.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
merely counectwl with the system of exhaust pipes wliieh
lead into the cliimney casing and tlie military masts.
The varions cells for" the confinement of prisoners are
traversed Ijy fhe ventilatinir pipes intended as supplies
for the ammunition storerooms. Tlie air escapes into the
cells throtisli small apertures in these jiipes and leaves
the cells through openings in the bulk-heads.
The forward station for the wounded has one. the after
station two fresh-air inlets witli cowls, while the foul air
escapes through separate outlets. Jlost of the officers'
cabius are dependent for their air supidy on perflation,
and this must be considered an important flaw in the
whole system. All three of the above-named vessels are
also provided with steam ash ejectors, which contribute
largely toward keeping the .ship's air clear of tiuely di-
vided particles of inorganic matter.
5. f. .9. Trdiiiiiif) fillip " Pntiric." — ATc will conclude
the chapter on ventilation with a descriptiou of the
Pra/r/f'.t .system of ventilation, giving at the same time
the results of some investigations into the working elli-
ciency of the latter. The ]ireseut training-ship P;v/(;-!'( is
the converted steamer El S>1 of the Jif.rgan Line Steam-
ship Company. She hasalength fif 404 feet over all and
a beam of 44 feet; she has a gross tonnage of 6,783 toiB,
and is provided with a single screw, driven by a vertical,
inverted three-cylinder triple-expansion engine of the
ordinary marine" pattern for commercial use, built at
the Cramps' shiiiyard in 1800, and last comtnissioncd at
the Boston navy yard on Noveniber Utli, 1001; sh<- has a
spar deck, a gun deck, and a berth deck with the usual
holds and storerooms below.
Since the berth-deck compartments are the only ones
which have artiticial ventilation, all her other compart-
ments depending upon ventilation liy perflation, tlie
former will be the only ones included in the following
description. The lierlh deck of thi' I'niin'e is divided liy
tlie large engine- and hreroom hatch into a forward and
an after section of nearly equal dimensions, and lietweeu
them there is no comnnmication. the two iron bulkheads
of the hatch reaching clear across from one side of the
ship to the otlier.
Tlic forward section of the lierth deck is again divided
by two cross l>ulklieads into three compartments with
two communicating doors, symmetrically placed on each
side of the two dividing bulkheads. Tlie most forward
of the three com|iartments is used for sick-quarters, the
one next to this comprises the petty oflicers' quarters, and
the third givi's berthing space to a large number of men.
The after-section of the berth deck is likewise divided
into three compartments, the most forward of which ac-
commodates the dynamos, the next gives berthing space
to the marine guard, and the last is for the chief petty
officers.
There are three large square and three small oblong
and rather narrow hatches in her decks, all superimposed
and therefore well intended to send both light and air
directl}' down into the deeper parts of the ship. Tiie
two electric fans of 110 volts each are both tai the gun
deck, just fore and abaft the tire- and engine-room
hatches respectively. Each of the two large ventilating
trunks, after passing tlirough the gun deck, bifurcates,
and the two branch trunks with their inlets run along
the sides of the various com]iartments wliieh they tra-
verse, at a height above the berth-deck flooring of six or
seven feet.
The two tables, showing the results of the anemomet-
rical oliser vat ions, are intended to exhibit at the same
time in a diagrammatic manner the relative position of
the different compartments, their cubic capacity, the
number of inlets, and also tlie relative distance of the in-
lets from the fans or blowers. As may be seen in the
columns of "cubic feet exhausted per hour," the
amounts of air taken up by the different inlets decreixse
very tapidly and directly with their distance from the
bloAvers. Inasmuch as the observations on the inlets and
outlets rarely agree exactly, the largest tigure is always
taken as indicating the true value of the amount of work
done by the fans.
Table X.— axemometrical Observations o.n the Ventii.atio»n
OF THE Berth-Deck Compartment, made on r. S. S. Prairie,
AT Sea, on January .5th Between the Hocrs of 1 and 3 a.m.
Number ok Inlets Twe.ntt-Six, with an Average Square
Area of O.i Feet.
I. Forward of enRine- and firerooms ; average difference in numlier
of turns of anemometer between the inlets Is eiglity-flve per
minute.
.H a.
a
IS y
■- i-^
'S'x K
Bow.
Hi
III
2;-5
Sum.
13
11
i.-).nflO
ir.sso
i9,!eo
21,061)
24,01 !()
2H,iai
28,140
30,120
32.11)11
34.2i;o
3li,:iO(l
:ts,2,sii
4i),:ai
Sick-ijiiarters, cubic air space,
4,7IKI feet, e,xbausted 22 times
per hour: available air per
head and per hour, 5,370
cubic feet.
1,1,900
17,8SO
19,920
21,!W0
24,IHiO
2H,1(K1
2«,U0
1:3
11
10
9
8
7
6
.5
4
3
1
107,400
in
it
,s
Forward bertli deck, cubic
air space, 10.209 feet, e.x-
hiiusted 2:.^ times per hour:
available air per head and
per hoiu-, 2,ij74 cubic feet.
200,520
H
5
4
3
1
Main berth deck, cubic space,
2.'),li04 cubic feet, e.\haust.ed
lf>..5 times per hour ; avail-
able air per head and per
hour, 1,726 cubic feet.
30,120
33.160
34,260
36,300
38,2,10
40.320
423.880
Blower.
Grand
Uital,
730,800
II. Bprth-rtpflv cnmpart.nifnts abaft the engine- and flrerooms;
;tvtriii:t' liilTfrence in uuniiter of turns of anemometer between the
inlrt.s is tliirly-eight per minute ; decreasing in a direction from the
blower.
IE
^1
■sit
Blower.
4
Ill
iP
1^1
Sum.
1
a3,780
33,880
31,9.80
31,0.so
30,120
2i),320
28,320
37,430
26,.520
2."i,.sil(.l
34,900
24,1100
23,100
2:.', 200
Dynamo.
3:3.780
33,880
31.9,S0
::i,iisii
30.130
2',l,330
28,320
37.430
36,;",30
35,.''I10
34,900
24,000
23,100
22,200
1
3
4
5
6
7
8
9
10
11
12
13
14
1.33,320
3
4
5
Marines' quartfi-s. cubic air
spacH. ll.SL'T fei-t. exhaustpd
SOtiniHSii.T hour; available
air for brenihint: purpnsps
per hour and per head, ■t,s:5
cubic feet.
301,440
8
•>
10
11
12
Chief petty officers' quarters,
cubic air space, Kl.^'ii'.t fi-et,
exhausted 25 times j.rr h'Hir;
available air per liead aud
per- hour, ;{,430 cubic feet.
2,57,280
13
Closets. 1 Pantry.
46,200
14
Stores. Stores.
44,400
Stc
rn.
Cirand
total.
782.640
The after berth-deck comiiartments of the Pnn'rie. b}'
reason of their relatively smaller cubic capacity, are much
better ventilated than the forward compartments, lioth
fans doing aliout the stime amount of ventilating work.
The blciwers are run at night only.
The tests for the amount of atmospheric carlion dioxide,
exhibited in Tables XI. aud XII., were made according to
the metliod of Fit/,, as modified by Woodman and Rich-
ards and described in the jireceding jiages. In making
these examinations, it Avas the intention to get, as nearly
as that was possililc under the <'ircumstances. a true and
absolutely fair estimate of the amount of carbon dioxide
present in the atmosjihere of the different jiarts of the
ship. None of the dark places in which the air naturally
stagnates, such as storerooms and holds, and where the
carbon dioxide was found up to 2i to 40 parts in 10,000,
were included in these observations. The tests shown in
166
REFERENCE HANDBOOK OF THE :\[EDICAL SCIENCES.
>ava! Hygioiic.
>a\al ]I>£;'it-ue,
Table XI.— Carbos-Dioxide* Observatioxs. Series I., V. s. s.
Prairi)-. Hampton Roads, Va., December 27th to 2Stii. ship
Heaiiim; X.E. by E. and W.S.w. Respectively. Wixn N.E.,
STKEXCiTII -'. atmospheric TEMPERATURE DCRIXG PERIOD Of
observations Varied from 39° to 45° F. Weather Partly-
Misty and Partly Cloudy*.
Time of day.
, i
■r.3
SB
is
y
Remarks.
c-
8,5
9p.M
Id 0
in.o
12.0
u.n
10. n
Hatches partly covered.
11:30p.M
10.0
B.5
9.0
9.U
9.0
7.5
Blowers started at 12 mid-
night.
1 A.M
8.4
4.3
D.»
«.2
6.0
5.0
Blowers stopped at 5:30
A.M.
6 A.M
an
fi.n
7.2
8.2
5.5
7 '^
Gun-deck ports closed.
lU: 30 A.M ....
8 fi
(i,2
4.1
K.ll
5.5
3.1
Gun-deck ports open.
UiMa.m....
7.5
3.5
3.11
4.11
4.0
3.0
Gun-deck ports open.
1 P.M
5(1
3 2
4.5
4.(1
3.4
3.(1
7 P.M
7.5
4.0
10.0
4.2
4.ti
14.0
Raining ; hatch covers on ;
hammocks.
Averages.
General
Night
Day
Difference .
6.1 6.4
8.3 8.0
3.9 4
4.4 3.3
Difference between night
and day. averages.
• Numhers in columns indicate amount of CO2 contained in lO.iXKI
parts of air.
Table XII.-Cabbon-Dioxide Observations. Series II.. V. S. S.
Prnirir. January 4th to 5th. At Sea Between L-iTiTUDES
16° 13' 30" and 1.5° 08' N. AND LONGITUDES 64° 25' AND 63° 40' W.
Course E. by S. Strength of Wind 4. atmospheric Temper-
ature Varied from 78° to 81° F. Skt Partly Blue, Partly
Cloudy.
■/-
^ .
^
.
Time of day.
BS
«d
6
Remarks.
9 P.M
8.8
8.8
8.8
5.6
5.6
5.6
■Wiud forward, weather
clear.
11 P.M
4.1
4.1
5.0
3.7
3.7
3.6
Wind athwartship: ports
open.
1:30-2:30 A.M.
5.8
6.2
6.3
4.3
4.0
3.9
Blowers running half
speed.
11 A.M
4.3
7.0
8.2 5.0
3.7
3.6
No one occupying sick-
quarters.
1:30-2: 30 P.M.
4.8
4.8
5.5 4.4
c.ti
3.H
All pun-deck ports open.
5 P.M
5.0
5.2
5.8 4.2
4 0
4.6
All gun-deck ports open.
Averages.
General
5.5
6.0
6.6
4.8
4.2
4.2
Influence of open gun-deck
Night
6.2
6.5
6.5
4.4
4.4
4.4
ports shown ; teuds to
Dav
3,7
5.6
6.5
4.4
3.7
3.9
lessen the difference be-
Difference . . .
2.5
.9
.0 0.0
.5
tween the night and day
averages.
the tables represent the compartments that are inchided
in the general circulation of the area ventilated by the
blowers. The results show wlmt the carbon-dioxide con-
tent of the ship's atmosphere available for breathing pur-
poses may be expected to be, when the ship is at sea and
is sailing under the most favonMe conditions of weather
and climate. The influence of hatches, whether open or
closed, of gunports, of the direction of the winds and of
the blowers upon the carbonie-aeid cimtent, may be seen
in the tables and studied in counectiou with the column
of remarks.
As the blowers operate on the vaeuum princi]>lf. it
must, of course, be expected that the air, when it reaches
the breather, is at its woret. The differences between the
night and day averages in series I. were rather large, as
compared with thi5se shown in series II. The colder cli-
mate at Hampton Roads made it neccssar_y for the com-
fort of the men sleeping below to keep the hatches cov-
ered and the ports closed. Under such conditions the
vacuum system of ventilation shows its weak points.
The fans arranged in accordance with the jilenum prin-
ciple would easily remedy these defects and convert a
very faulty system of ventilation into an efficient one.
In concluding the chajiter on ventilation we would
emphasize two leading and important factors intluenciug
a ship's ventilation, namely: (1) The plenum system of
ventilation for ship's purposes is uucnuilitiedly recom-
mended. (2) That the high atmospheric temperatures
and humidities prevailing in warm climates, together
with the prominent part played by physical heat regula-
tion on the part of tlie men, make it possible that the air
in ships may be renewed from fifteen to twenty times
]5er hour, without danger from draughts.
II. Water.
Everj- living organism, every single microscopic cell
of this organism, has its normal amount of water under
which alone it can perform its proper function, and the
slightest departure from this normal percentage amount
of^'ater peculiar to its composition begins to initiate the
series of changes that can have but one ending, namely,
the death of the organism. The human body has in its
composition sixty-live per cent, of water, of which it
loses 2,.500 gm. daily. As it receives from .yOO to 800 gm.
in the food, the remainiug loss must be made good by
drink. In experimental animals death inevitably ensues
whenever tlie loss of water amounts to from twenty to
twenty-five per cent. Those of us who live in temperate
climates, in which water is fotmd everv-where in .sufficient
(juautity to suiiply our daily needs, hardly ever think of
the possibility of "dying of "thirst ; but those who live in
the tropics know well how- pressing and dangerous thirst
can become as compared to hunger. As a means of per-
sonal cleanliness, it has become well recognized that it is
econonn' to be lavish with the water supply, especially
among soldiers and sailors, who must be so trained that
cleanliness of person becomes to them a necessit}- and a
habit.
With regard to the water-supply of ships, the last flftj'
years have brought about great changes. The general
introduction of steam has made not only the voytiges
shorter, but it has been the means of making ships al-
most entirely independent of the shore as regards their
water-sup]ily. In times of wooden ships ancl long pas-
sages across the seas under sail alone, the water question
was one of most serious concern to all seafaring men.
Besides this, the generally prevalent lack of knowledge
at that time of the importance of cleanliness in collect-
ing, storing, and distributing the water on board ship
was the cause of untold misery and long suffering, due to
poor water and to the separation from a base of sup]ily.
The water was carelesslj- collected and then stored in
tanks or barrels down in the dark holds of the ship. Often
neither thewaternor the barrels were examined, and con-
sequently they left much to be desired as regards cleanli-
ness. After a time the water began to emit a disagreeable
odor, the essence of which was sulphureted hydrogen.
This gas was produced by the decomposition of the sul-
phates in the water. In the course of time this gas was
reoxidized and the disagreeable odor disappeared. This
periodical reduction of the sulphates and oxidation of
sulphureted hydrogen recurred several times during a
voyage, and it was a common saying among sailors that
the water had to putrefy three "times before it became
potable.
It certainly was true that the water did cease ferment-
ing after a time, and conscciuently it was often better at
the end of a voyage than at the beginning. We now are
perfectly well acquainted with the causes of this fermen-
tation and make use of this very jjroiierty of water to
purify it before liUration. It istlie septic-tanU method
which has been found so effective in removing a large
percentage amount of germs and fermenUible organic
matter, and which makes subsequent sand nitration so
much more effective in jn'oducing a pure and ]iotable
water than it would be without it.
Although most of the naval vessels are supplied with
distillers for the production of drinking-water from sea-
water, it cannot be said that all ships of the navy are
absolutely independent of water supplies from natural
107
Naval Hygieno.
Naval Ifygieiir.
kefere:xce handbook of the jiedical sciences.
sources on shore. Circumstances arise on every niival
vessel, and arise often, under Aviiieli tlie wuti^r tauli.s are
filled with water coming I'rom shore. Naval sanitarians
can, therefore, not 3'et atford entirely to disregard the lij'-
giene of water supplies as found in nature.
The (lueslion of the water supply to naval vessels
would, aceordingly, resolve it.sell into (1) the supply
from natural sources, and {'.i) the supply through distil-
lation from sta water.
1. Surri.Y FuoM N.\tcuk's Reservoirs. («) Ruin
Watci: — The quantity of water wliieb a cubic kilometre
of air is able to take up, when sat nrafed at a temjierature
of l."i= C. (GO' F.i. is no less than l.),9flO,000 litres. In
the tropies the atmosphere covering a square mile of sur-
face, at a temperature of 3(1 C. (S.'>' F.), takes up two
anil a lialf millions of cubic metres of water. This water
is driven by the wind to the dillerent parts of the world,
and returns to the earth in the form of rain, snow, or hail.
The water, when it evaporates, is pure; but wdieu it re-
turns to the earth in the form of meteoric water it shows
various forms of contamination, having absorbed not
only the gases of the air, but carrying down also more
substantial ini])urities witli it. It is easilj' seen that rain
water nutst dilTer in character with the (luality of the at-
mosphere through which it falls; it must dilTer with the
season of the yeav. and wliether it falls in town or coun-
try. As rain purifies the air b\- taking down dust and
smoke, it must become purer the later it is collected.
Of the water which is thus returned to thi^ earth by
precipitation, a small portion evaporates again immedi-
ately; the greater portion sinks to certain depths from
the surface, becoming whi^t is known as surface water;
■ndiile still another portion runs otf into rivers, brooks,
and lakes, and the rest returns by way of the rivers ami
streams to the great sea whence it came.
In its pa.ssage through the atmosphere, it takes up, in
the hrst jdace, a certain volmne of air. The o.xygen of
the air being more easilj' solulile in water than is nitro-
gen, the air ilissolved in water is richer in o.xygen than
the almosi)lieric air. Beside.s oxygen, rain water ab.sorbs
carbon dioxide, ammonia, and nitric acid. The farther
above the surface of the earth rain water is collected, the
more nitric acid it contains; and the nearer to the earth's
surface it is collected, the more ammonia is found in it.
The reason for this is that the ammonia emanating from
the soil is gradually oxidized into nitric acid as it rises
into tlu' higher regions of the atmosphere. Thus 1 litre
of water contains: Ammonia at 7 metres, 5.04 nigm. ; at
47 metres, 3 mgm. Nitric acid at 7 metres, ^>.GH mgni. ;
at 47 metres, 7.36 mgm. Rain water contains from seven
thinisand to twenty thousand bacteria in 1 c.c, which
expl.dus why it undergoes rajiid feruu'Utation on standing.
Bujwid. who examined a bailstiaie (i em. long and 3 cm.
thici;, fiiund twenty-one thousand bacteria in 1 c.c. of
melted ice. Foulin, at .St. Petersburg, discovered in a
hailstone a coccus that proved pathogenic to mice.
Schraelch, in examining some ice from high mountains,
in high latitudes, where organic life is not abundant,
found b\it two microbes in a evdjic centimetre of ice from
lostedlasbrli in Norway. Rain water is a .soft water and
very good for washing p\irpo.ses; when used for drink-
ing purposes, the first p(.)rtions of it should always be
rejected.
(h) Sm-face Water. — The term surface water is applied
to the water contained in rivers, brooks, and jionds, into
which the earth's surface is drained, es]iecially after
heavy rains. The comiiosition of such water is iutiu-
enced by local conditions, depending partly on the geo-
logical formation of the place, partly upon the character
and amount of sewage wa.sheil into it and furnislied by
the towns in the vicinity. Epidemi<'S of typhoid and
cholera, traceable to infected river water, contiiuic to re-
cur with frequency, and these would be still more fre-
quent than they are, were it not for the self-puriticatiou
of river water and the nitrifying action of a certain class
of saprophytic wafer bacteria, tiiuch wafer, therefore,
needs a thorough chemical and bacteriologieal exandna-
tion before being taken on board, unless it comes from a
place where sand filtration is used, and where all sewage
is thus filtered before it is allowed to pass into the river,
brook, or lake.
(c) Ground Water. — That portion of rain water which
neither evaporates inuneiliately nor Hows fiif into rivers
and brooks, but which gradually drizzles down into tiie
dce])er layers of the soil, until it strikes an impermeable
layer of clay, upon wdiich it accumulates, is known a.s
ground water. As such it may feed a neighboring well
or find its waj- to the surface again in the form of a
spring. Borings often reveal the existence of several
such sub.soil lakes superimposed. The water, while driz-
zling through the permeable layers, gives up suspended
matters, Init takes up soUdile ones instead, and hence its
composition is essentiall}' different fi-oni that of either
rain or surface water. All those particulate impurities
which rain water washes down from the atmosphere it
loses in the nppermost layers of the permeable soil and
before it becomes ground water; the organic matters are
destroyed b_v oxidation, furnishing carbonic and nitric
aciils. Ground water, when obtained at a depth of 20
metres below the surface and well protected, has an
agreeable taste and should possess a temperature repre-
senting the mean annual temperature of the place,
which temperature is accepted as the most favorable
temperature which a good drinking-water should pos-
sess. All the superfluous ground water finally flows off
into subterranean li^'crs and lakes, which in turn are
drained into the all engulfing sea to start on a new round
in its circulaticm. Such water is probably tlie best that
can be obtained from natural sources.
In the royal navy of England and in the navy of the
United States, the rule is that no water is to be taken or
used on board imtil it has been examined and passed by
the surgeon. In home ports, the wafer is either directly
liumjicd on lioard from the city mains or it comes along-
side the ship in a water boat. The latter method is usu-
ally bad and the water is often found contaminated, owing
to leaky bottoms and leaky decks. No wooden wateV
barge should be allowed "to bring drinking-water on
board a ship. In many foreign ports, recourse is had to
fetching the water from shore by clearing the ship's
boats oi^ all removable gear and then filliug them with
water directly from the main; finally towing the boats
back to the ship ami pumping the water on board. All
these methods are objcetinnable, because no boat is abso-
lutely water-tight and sea water is bound to leak into it.
A time may come when it becomes necessary to take
a battalion of men on shore and quarter them in a town
fin- some time. Un<ler such circumstances experience
has shown the following rules to be worthy of adoption:
(l)Let the men t:d<e their water from the same places
from which the inhabitants di'aw theirs; these places
should l)e jilotfed down liy the oflicers arranging for
(piarfers for the men. In case the water supply of the
town is not free from susjiicion, avoid taking water from
wells in slojiiug streets and from those which are located
in the neighborhood of poor dwellings, fiUjtories, dung-
heaps, and avoid likewise, if you can, water flowing
through the town: take it, if possible, from a point
aliove the town. (2) Make provision against the con-
taraintition of the town water by the men themselves,
who should be instructed in how best to avoid dangers
from such a cause. (3) Mark the good wells from "the
bad ones. (4) Wells that have been out of use for some
time mvist first be jiumped <iut before they can be used
ag.ain. (.")) Confandnated wells must beplaced under
guard. (6) The too fn>quent and too copious use of a
well is to be avoided because large draughts would
cause a too ra]iid flow of the neighboring grovnid water
in the direction of the well, through the' subsoil, which
might seriously interfere with the filtering capacity of
such a soil, residfing in drawing impurities in with it.
(7) In the case of wells, small rivers, and brooks, dams
can be bidlt in several places, of which the highest may
be used for drinking purposes for the men, the lower for
the animals and for cleansing pui-poses. (8) In case of
rivers and shallow lakes, small bridges and waterways
168
REPERE^-CE HANDBOOK OF THE JIEDICAL SCIENCES.
Naval Hyi^iene*
Naval Hjgiene.
should be constructed so as to enable the men to get their
water farther away from the shore and prevent them
from stirring up the sediment at the bottom, which may
harbor pathogenic germs. (9) In case the water has been
rendered turbid by heavy rains, small wells may be sunk
near the river and the filtering action of the soil or sand
be taken advantage of ; such wells must be protected and
covered over by boards. (10) If the soil permits, tubu-
lar wells may be bored.
In France, Pasteur tiltei's have been most generally in-
troduced into all barracks. The water runs through
these tilters under a pressure of 10 metres, and, in places
where this pressure cannot be obtained by natural means,
it is produced by artificial means.
The great danger to troops is, as we all know, typhoid
fever. No army seems to escape a certain amount of it.
The typhoid bacillus respects neither race nor climate
and is practically ubiquitous. Extensive experiments
are now under way in England and other parts of Eu-
rope on the subject of the possible chances of vaccinating
soldiers against typhoid, cholera, plague, and other dis-
eases. The m(3rtality from typhoid among the English
troops in South Africa has been so great as to induce
some of the best English bacteiiologists to engage in
serious experimentation in that direction.
For the purpose of sterilizing a suspected water in the
field, in the absence of means for boiling large quantities
of it, the method of Schumburg is the best. He uses
bromine to render the water germ-free and removes the
bromine afterward by the addition of ammonia. The
apparatus comes conveniently packed in a box with the
chemicals ready for u.se, and in qiiatilities weighed out so
as to sterilize any given amount of waterin five minutes.
2. Supply TuROL'on Distillatiox fro.m Se-\ Water.
— If rivers, brooks, and lakes are the drainage basins into
which Uows the surface water of certain small circum-
scribed geographical areas, the great oceans may be said
to receive the combined drainage of all the continents of
the globe. From a chemical viewpoint, perhaps one of
the principal differences between ground water and sea
water is found in the large percentage of salts that are
contained in the latter. These salts perform an impor-
tant function which it is well to keep in mind. They
assist in the penetration of solar heat, which otherwise
would act on the surface only; salts also retard evapor-
ation. Sea water teems with living organisms which,
hut for the preserving action of thebiine, would die, and
the products of their decomposition would render a life
at sea practically unbearable if not altogether impossible.
The salts in sea water also are the efficient causes of some
of its circulating currents. Those, for instance, from the
Jlefliterranean into the Atlantic, according to Maury, owe
their main strength to this agency. The freezing ])oiut
of sea water is put down a.s 37.2' F. The .specific gravi-
ties, according to location, are as follows: (1) North At-
lantic, 1.02676: (2) South Atlantic, 1.02664; (3) North
Pacific, 1.02658; (4) South Pacific, 1.02.J48.
The temperature of the sea water is higher than that
of the ground water of the same region. It varies, of
course, with the latitude and the depth, and is greatly
influenced by the circulation of the vaiious currents
coming from different localities. The Atlantic is the
coldest, the Indian Ocean the warmest.
T.iBI.E XIII.
3 "
Hard-
§
1
§1
s
fl
NKSS.
S
—
z = =
= a
o
tt
X
J3
o
H
<,
S
H
O
H
b.
Hastings, two miles
from sliore 3.955
0.291 o.ia->
I).(1U5
ii.oi:h
(i.i.Ta
'ixm
(WS
Wii
GuIfotParia
.ooa
.027
1,330
380
The composition of sea water has been found to vary
imewhat in different places and at different depths. In
somewl
the vicinity of the poles, the percentage amount of salts
is somewhat less than at the equator, while in certain
parts of the Mediterranean more salt is found than in the
great oceans. The average composition of sea water is
given in the preceding table from Notter, to which has
been added an mcomplete and partial analysis made of
the water in the Gulf of Paria.
According to Hales, it was Jean Antoine Gadesden
who, as early as 1516, proposed ilistiUation as a means of
rendering sea water potable, and in 1560 Sebastien de la
Palliere, of Sicily, proposed to the Duke of Moedina
Coeli, wiiile the latter was besieged by the Turks, in a
fortress in which the cisterns had run dry, to distil sea
water. He succeeded in producing thirtv-five barrels of
potable water in twentj'-four hours. In 1717 Gauthier
made an unsuccessful attempt to introduce distillers
on board ship. After him, Liud proposed to utilize the
steam coining from cooking utensils and condense it by
leading it through cold-water tanks. Three j'ears later,
Poissonier designed a distiller which was similar to that
of Lind, hut which again failed of adoption on account
of its taking up too much room '^n board! Finally Irv-
ing designed a distiller for which he received a pension
of £500 from the English Government. All this shows
how much the necessity for an apparatus of this sort
was felt. A rather long time, however, had yet to pass
before distilling became as general and practicable as it
is now. There is perhaps no seagoing man-of-war at the
present day that is not provided with one or more of
these distillers, of which there are a large number of pat-
terns.
In the French navy the "Cousin," modified by Mou-
raille tt Co., and the "Normandy," which latter has the
evaporator and condenser united into one apparatus, are
generally in use. A special refrigerator bj- Perroy and
a coudensor by Eraser are also in common use. In the
English navy the "Normandy," "Kirkaldy and Caird,"
and ■' Raynor " are employed. In the Austrian navy the
French distillers have been adopted. The United States
Naval Standard Evaporator is made of several sizes, the
largest of which possesses a productive capacity of ten
thousand gallons of distilled water per diem. The gen-
eral design is identical for all sizes. The apparatus con-
sists of two part.s, namely: (1) the evaporator and (2) the
distiller, sometimes called the condenser. The evapor-
ator consists in a hollow cylindrical shell, made of steel
and placed horizontally. The lower half of this cylinder
is partially or loosely occupied by tubes running length-
wise, and fixed in their position at either end to a pair of
plates which permit of the tubes being removed for scaling
in their entirety. The tul«'S are connected with the main
lioilers, from which steam is run into them generally at a
pressure not exceeding forty pounds. The sea water in-
tended for distillation fills that portion of the lower half
of the cylinder which is outside the tubes, but not C{uite
reaching the upper level of the highest tubes. It is in-
deed the intention that the tubes shall not be completely
immersed in the salt water, the upper level of which is,
on the contrary, maintained considerably below the top
of the tubes. The customary pressin-e within the shell
is about ten pounds. By the use of the valves, the dens-
ity of the sea water is generally niiiiutained at ■^. The
tubes of the distiller are made of tinned copper or brass;
the joints are soldered. Thus we see that the evapor-
ation of the sea water is caused by the heat imparted to
it through the steam in the pipes which the sea water
surrounds. The steam it.self does not mix with the sea
water. The distiller or condenser is a cylinder, made of
lirass or iron in various sizes, placed vertically and fitted
with straight tubes for circvilating cooling water, which
is made to enter at the bottom and discharge at the top.
The steam to be condensed passes through the condenser
in the inverse sense.
On vessels which are equipped with very large plants
for distilling water, the apparatus is arranged difl'ereutly
from the above. The work of distilling is divided into
two or three stages and the working efiiciency of the
plant is thereby correspondingly increasetl. Under this
16&
Naval Ify;£leue.
Naval Hygiene.
REFERENCE IIANDBOCJK OF THE 5IED1CAL aClENX'ES.
system, steam from llie lidilers is usud to evii]iorate tlie
water in tlie tiist set of evaporators; this evaporated
steam is used to lieat and evaporate tlie water contained
in tiie second set of <'vaporators, and lliis in turn is made
to evaporate tlie water contained in a third set. This last
steam is finally condensed to water in a distiller of the
above description. This system more than doubles the
actual thermal efticienc.y of the distilling apparatus, but it
is not installed except in very large ships, on account of
the com])lications in mechani-
cal tittiiiffs Avhicli it necessi-
tates.
The luecautions usually ob-
FlG. 3508. — (From Kircliiit'r. I The Transatlantic liners of tlie North German Lloyd are
eqnipiipii with disTillcrs of th'^ " .Arnie " patent. These were preferred on aceount of
th<*ir coiiitiininir Ln-cal i-fll<-ary, siiuill si):nf and ease with which they can be handled
and winked. Tln' mndfiist-r is shown in the adjoining two figures A and B. The
stcani f;rneratfd in an an.xillary lioUor is made to enter, at D. int(7the condenser, which
consists of a vertical cylinder, lie cm. lone: and 30 cm. in diameter. The steam now
passes into a nnmhcr of tubes, made of thin copper r r, outside of which a constant
and rapid stream of cold sea water passes from below upward, enterimr at KZ and
leaving' the cooler at Jv.l. The distilli'd water, at the lower end of tlie i-ondenser,
enters a charcoal niter, F, where it is puriiled, and, at the same time, aeratetl by the air
comiiiir in Ihroiitrli the tnl)c L, with w liicii it is here in ( imiinieation. The water,
liolh llltereil and ai-raled, is llnally colle.ted at TA. The apparatus furriislies IScubic
metres of «:(i.k1 pniable water ill Iweniy-f'iiir hours. The warstiips of the imperial
(Jeriiian navy ale all equipped witli distillers made on the same principle as those of the
" Acme " jtatent.
served arc as follows: (1) The ]ilant is oiierated only
when pure sea water is oliUiinable. (~) For drinking-
water, the phint is not o)ienited to its full cajiacity. in
order to reiluee primiug or carrying salt water directly
over into the distillate. (3) Tests of the complete plant are
made daily to insure tightness of all the joints. (4) The
water level in the evaporators is kept low. (o) When the
shi]) is under way and rolling heavily, the plant is worked
at its lowest capacity. (0) The ]iressure of the cooling
water in the distiller is limited by deparlinental order
to thirty pounds, wbieli is to miuiiiiize the duugernf salt
water leaking into the distillate. (7) Tests of the distil-
late are made every tiftei^n minutes.
The process of distillation, however, always involves
an expense which .sometimes nitiy be consideral.ily grettter
than the price at which good drinking-water can be
bought on shore, and then it becomes the duty of com-
manders of vessels to secure such water when of good
quality and whenever practicable. Besides, the jirocess
of distilling is not always faultless and the product occa-
sionally needs looking into.
Wafer DixtiUrd from ,S<a ll'./^i;'.— Although the water
obtained from sea water by distillation may not be abso-
lutely pure, it has nevertheless stood the test of many
years' jiractical experience, and hence must be consid-
ered to be iiarmless. The mineral salts, contained in sea
water, sodium and magnesium chloride, lime, alkalies,
acids, bromine, iodine, etc., especially magnesium chlor-
ide, in decomposing during the process of distillation,
vitiate the product to a certain degree. In order to ob-
viate these objectionable features, Rnbncr (" Lehrbuch d.
Hygiene") proposes the following preliminary treatment
of Siilt water befoi-e distilling: The salt water is to be
mi.xed witli milk of lime in special tanks and kept, being
constanlly stirred up, for fifteen minutes; it is
then heated up to a temperatui'e of about (iO'
(.'. by steam. All organic matter is thus de-
stroyed and coagulated. Magnesium chloride
is decomposed b}- the lime and the magnesitx is
jireeipitated. After all lias settled the water is
siphoned off and distilled. This preliminary
treatment, if itcould be cariied out practically,
woidd no doubt result in a more uniform pro-
duct of distillation; it would, however, neces-
sitate a reconstruction of all the evaporators
and condensers at present in use.
That sea water under the present system of
distillation does not furnish ;i uniformly pure
product may be seen from Table XIV., which
represents an almost daily though partial an-
alysis of such water, continued for nearly a
month. Free ammonia was determined with
Nessler's reagent; the nitrites were ciualita-
lively determined with the sulphanilic acid
and naphthylaniine test; the nitrates with
brueiiic and sulphuric acid; chlorine with a
volumetric solutinii nf silver nitrate, pntassiiim
chromate as indicator; hardness with standard
soap solution: and the organic matter, repre-
in milligi'ams of oxygen, was deter-
by a standard solution of potassium
permanganate All these solutions
were made on board shi]) and accord-
ing to the mcthials given in Harring-
ton's excellent manual of "Practical
Hygiene." The analyses show that
the water produced in our distillers
always contains quite appreciable
quantities of chlorine, lime, and mag-
nesium salts (represented by hard-
ness), and also organic matter; less
frciiuently ammonia, and still less frc-
(|Ueiitly nitrites and nitrates. All
tliese, in the above Ciuantities, must be
considered harmless. With few ex-
ceptions the water was free from odor
and perfectly colorless.
An important jioint, to which it is
necessary to call attention in connection with the chemi-
cal composition of w.-itcr distilled on board ship, is the
liygienic significance of it. It will be seen at once that
we must judge this from a standard entirely tlitferent
from the one in accordiincc with which we would judge
a surface or a ground water. Ammonia, nitrites, nitrates,
as also chlorides, when found in a iiroperly collected sam-
ple of river or well water, would justly arouse gretit sus-
picion, while the same chemical compounds in the water
distilled from sea water arouse no such suspicion. These
stand simply for a certain timount of nitrogen in dilTerent
stages of oxidation and are otherwise jierfectly harmless
in the quantities in which they appettr. No living or-
ganism, neither an animal nor a vegetable parasite, ca-
pable of producing disease could po.ssibly survive such
a ])rocess of distillation.
The following table is inteiesting from quite another
Jioint of view; it shows that, while a small (luautity of
organic matter is constantly jireseiit in the distillate, !ini-
raonia, nitrates, and nitrites are almost as constantly ab-
sent. This would indicate an almost absolute absence
sented
mined
TA
170
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Naval Yly^ieue.
Naval ISy^;ieue*
(pf all o.xidation during distillation. 'Whon, however, we
consider tliul the salt water, from which our distillate is
obtained, does not come directly from the sea, but has
alreadj- been used as condense w-ater and gone through
the distiller in which it has been heated up to a high
temperature, then this is easily explained. By the time
such water arrives in the evaporator as feed water, all
the air has been driven out.
Table XIV.— T.^bclated Results ok Twenty-Two Analyses of
Water Distilled from Salt Water by the XJnited States
Standard Evaporator.
U. S. S. Prairie.
Gulf of Paria.
January, 1S03.
B
s
1
1
Chlorine.
in milligrams
per litre.
Hardness,
In millit'rams
calcium chloride.
11.1 =
a-5S
3
+
0
+
+ +
+
+ +
+
I)
+
+
+
+
+ +
0
0
0
0
0
0
0
0
0
0
0
(1
1)
n
0
n
0
0
0
0
(1
+ +
0
0
0
+ +
0
0
0
0
0
0
n
0
u
0
0
0
a
(1
0
(1
0
+
0
0
0
0
0
0
0
0
0
220
m
211
10
.50
20
24
130
8
13
20
20
1W1
30
30
20
90
12
20
32
SO
32
10.0
.5.0
4.0
B.O
11. 0
16.0
7.0
13.0
4.0
i.O
5.5
6.0
10. 0
4.5
5.0
5.0
10.0
7.0
8.0
6.0
8.0
5.0
0.0
4
2.0
3.5
6
1.7
3.6
8
2.0
9
3.3
10
6.5
13
2.0
14
3.0
Ifi
3.0
i:
18
30
3.0
4.0
4.5
21
5.0
*>•>
3.0
33
25
26
2.5
2.0
3.0
27
2.0
28
120.0
30
3.0
T/ie Stmrage and Distribution of Water on Board. — If,
notwithstanding the fact that, as we have seen, no rea-
sonable objections can be entertained from a sanitary
point of view against the water distilled on board ship,
complaints, and very pressing ones, are .still often heard
against the drinking-water supplied to otlicers and men,
what are they due to? In almost every instance to un-
clean tanks and faulty pipe connections, as perhaps the
following instance from my own e.xperience will best
serve to illustrate. It was not many days after our
ship had been placed in commission and her officers and
men had begun to live on board, that the presumably
pure and distilled water was found absolutely non-pot-
able and everybody refused to drink of it. Tin' water
was undoubtedly and indescribably bad. A sample of it
was immediatel}' collected from one of the spigots in the
galley, under the usual precautions, and analyzed, with
the following results:
November 36th, 11)01, sample of water supposedly dis-
tilled:
1. Color. — Distinctly yellowish, very turbid, depositing
on standing a brownish tlocculent sediment.
2. Odor. — On being heated in a flask and shaken, a
very perceptible, strong, musty odor is present.
3. licMdue. — On evaporation grayish-white, turning
black on being heated to redness.
4. Free as well as albuminoid ammonia present in large
amounts, forming brownish precipitate.
5. yitrites. — Positive reactions with the starch iodine
test as well as with the sulphanilic acid and uaphthyl-
amine test.
6. Chlorine. — NaCl. 3.5 gm. per litre.
7. Ilardne-'is. — Equal to ninety parts of calcium chlor-
ide in ten thousand parts.
8. ]\Krates. — Positive reaction with brucine.
9. Lead. — Grayish discoloration with hydrogen sul-
phide and acetic acid.
10. Organic Mattir. — In abundance and not determined
quantitatively.
Based upon the results of the above analysis, the prob-
able source of contamination was put down as being dirty
salt water from the harbor in which the ship was lying;
also improperly cleaned tanks and pipes, as was "made
apparent by the water giving reactions for lead. When
the result of this anah'sis and the inevitable conclusions
it led to were communicated to the commanding otticer,
an immediate inspection of the entire water-sujiply sj'S-
tem of the ship was made, and the source of the contami-
nation quickly and decidedly traced to a very faulty
system of ])ipe connection existing between the sweet
and the salt water reservoirs on board. Owing to this
connection, it was impossible to draw either sweet or
salt water from any of the spigots without getting a
mi.xture of both in varying proportions-
The bacteriological examination of a sample of this
water, made at the Bacteriological Laboratory of the
Harvard University College of Medicine, showed the
presence of liqucf_ying bacteria in large numbers, while
that of a sample of water collected from the distiller
proved absolutely sterile.
A more common source of lead in shiji's drinking-
water is found in the pipe joints, especially in newly
made ones, of which several instances have recentlj^
come to our notice. The red lead used for the purpose
of making joints water-tight should be forbidden and
asbestos used instead, in all pijies use<l for water distri-
bution. Early in the history of distilling water on board
ship and the laying of pipes for its convenient distribu-
tion, A. Le Ffevre, of the French navy, discovered lead
in the water; and cjuite recently Dr. Cautellauve (1891-
93), also of the French navy, has again reported .several
cases of lead poisoning from the same cause, during his
cruise in the East on board the Troude.
Time and space do not permit hereto go into a detailed
description of the various methi )ds of modern water analy-
sis. Nor is it necessary to mention the characters that
a good drinking-water should possess. These are mat-
ters of general hygiene and can easily be found in every
work on that subject. There is no doubt that the naval
surgeon, equipped with a practical knowledge of the
laboratory methods used in water analysis, will be well
able to make such a selection of apj^aratus and reagents,
before .going to sea, as will enable him to make a very
satisfactory water analysis, wherever and whenever
called upon to do so. There may be some difficulties as
regards accommodations on board some ships, liut tiiere
are none that cannot be overcome. His difliculties cer-
tainly cannot be greater than are those of the army sur-
geon in the tield.
The water-supply systems and the chemical composi
tion of the water supplied by them, of every one of the
islands near our coast, including all the Antilles, should
be sj'stematically investigated. The composition of
every important well in common use and out of use on
every island should be known, recorded, and plotted on
geographical majjs for immediate reference. With some
encouragement and the necessary means and apparatus,
this work could easily be done by naval medical officers.
III. The Ration.
Foods .\xd Nutritiox in General. — While it cannot
be expected, in the limited space allotted to this paper,
that we enter at all into the special physiology of nutri-
tion or into the chemistry of foods, it is, on the other hand,
absolutely necessary and unavoidable briefly to t<iuch
upon those of the leading principles and methods accord-
ing to which the nutritive values of those of the food
substances in coininou use on board all sea-going vessels
and included in the navy ration, are ordinarily deter-
mined.
Daily experience and observation have sufficiently ac-
quainted us with the fact that the physical ]iart of our
existence consists in a perpetual and constant effort on
the part of the living organism to adapt itself to an ever-
changing series of outside conditions. In this supreme
effort the organism uses up constantly i>art of its own
organized substance, expending it as, or converting it
171
Naval Hygiene.
Naval H ygieue*
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
into, mechanical -u-orlv and heat. If the body weiglit is
to be maintained and the life of the organism is to con-
tinue successful in the struggle, this expenditure in or-
ganized substance must be made good. The jiroducts
of ■\vear and tear incident to the process must also be
promptly removed.
Since tlie .source of the energy tluis expended by a liv-
ing animal organism can be restored only tlirongh the
introduction and tlieas.siiniiation of certain definite quan-
tities of organic and inorganic food substances, their
supply, preservation, jireparatiou, digestion, assimila-
tion, and dissimilation liave been among the principal
subjects of study and investigation on tiie part of physi-
ologists. Since, moreover. lhesupi)ly of these substances
ami their assimilation must vary directly -n-ith the energy
expended by the organism in a given time and under
varying conditions of envii'imnient. a balance between
supply and expenditure must be maintained and the in-
fluence upon it of different conditions be known, as well
as the relative vahioof the food itself. We must be able
to measure the energy expended and to ascertain its food
e(|uivalent, if we are to make no mistalie in our provi-
sions.
Since, finally, it is of coequal importance to the life of
the organism "that the ])roducts of wear and tear should
be as jiromptly and as completely eliminated as new ma-
terial is appropriated, the maximum working efficiency
of the living machine is conditioned not only by a projier
bali'.nce between supply and demand, in accordance with
different environmental and subjective conditions, but
is, moreover, determined by the individual capacity for
maintaining a high balance between assimilative and dis-
similative functions. The latter determine the difference
between two individuals and between ditfercnt races of
mankind. This functional capacity on the part of both
the individual and the race can be developed and in-
creased tlirough systematic training.
Acccirding to Verworn, tissue metamorphosis (Stoff-
wechsel) comprises a long series of comjilicated chemical
processes, beginning with the entry of nutritive sub-
stances into the living cells of the body and ending with
their exit. These processes follow each other like the
links of an unbroken chain, and might not inajitly be rep-
resented l>y a binomial curve. In this curve the ascned-
ing arm would then represent all tliose processes which
lead to the repair of living matter: the top of the curve,
those highly compli<"itcd processes leading to the syn-
thesis of ]>rotoplasm itself ; and the descending arm. the
processes leading to, and finally ending in, tlie decom-
position of living matter into the simplest end-jiroducts
(urea, carbonic acid, water, etc.). With the beginning
and the ending of the highly complicated process and
the materials found at tiiesc two points we are fairly
well acquainted; the rest is as yet wrapiied in darkness.
Fvoih, in tlie phv-siological .sense, are classitied into ni-
trogenous, also calle<l prnteids. and non-nitrogenous, in
which are included the? fats and carhohydiates. While
fats and carbohydrates may, to a certain extent, be sub-
stituted for one another, non-nitrogenous substances can
never be made to take the ]ilac(' of proteids in luitrition.
The latter must be regarded as by far tlie most important
food .substances and as absolutely indispensable jiarts of
a complete and perfect diet.
The prnteids form the cliief components of tlie cells in
the ti.ssues of all pilauts as well as animals, and. accord-
ing to the researches of Voit and Pettenkofer. the absor)!-
tion and o/.ouization of oxygen and its elTect upon all the
chemical processes within the cells, are entirely under the
direct control of the nitrogenous )iart of thrir ti.ssues.
Without the participation of the nitiogrnous tissues,
neither oxidation nor any manifest atimi of energy is
possible. Mechanical motion and heat may be evolved
through the oxidation of both fats and carbohydrates,
but the initiative to the manifestations of the.sc must be
given by the tissues containing nitrogen. Proteids have,
moreovei'. been found to produce fats and possibly also
carbohydrates under certain conditions.
Fnt.H are chemical compounds consisting of a trivalent
alcohol, glycerin, and three molecules of a monobasic
acid, chiefly stearic acid, palmitic acid, and oleic acid in
different proportions. Thev all contain hydrogen and
0X3'gcn as well as carbon, but no nitrogen, their'general
formula being represented b}' C,„n,!.b. The formula
suggests that the fats need oxygen in large quantities for
their complete con\-ersion into water and carbon dioxide.
The cai-inki/drates compuse the sugars and the starches
which are for the most piart of vegetable origin. It has
been shown that the formation of starch granules in the
green plant goes onhand-in-liand with the decomposition
of carbon dioxide by the chlorophyl granules, under the
influence of sunlight. On the hypothesis of von Bae_yer,
the carbon (C) of the carlion dioxide, the moment it is
set free, combines with llie water (ILjO), taken up by the
roots of the plant, and forms one molecule of formalde-
hyde (CH;0). Six of these molecules of formaldehyde
now link together by polymerization and form one mole-
cule of a mono.saccliarid (CoHi.Ob) and through further
polymerization of the monosaccharids thus formed, and
with tlie loss of one molecule of water by eacli, starcli
hnall}' results (Cclli„0i,). This hypothesis has met with
the most general acceptance. In the group of the car-
bohydrates also belong cellulose and pectin. Cellulose
forms the solid skeleton and, when boiled with dilute
sulphuric acid, it gives dextrin f.nd glucose. Pectin is
the vegetable j<'lly found in various ripe fruits.
All living organisms must, moreover, have a certain
amount of o.ri/f/tn, without which life is impo.ssiblc; and,
lastly, initcr and units. Indisjiensable are sodium, potas-
sium, magnesium, calcium, and iron, and their combina-
tions witli phosphoric, sulphuric, carbonic, and hydro-
chloric acids.
Food I'liliif. — The food value of an eatable substance
is generally expressed by the number of calories or heat
units which 1 gm. or any other definite quantity of
it will develop, when completely burned in a calorime-
ter. The amount of heat that is developed during the
combustion fif, for instance. 1 gm. of substance in a calo-
rimeter is exactly the same as that which is produced
when 1 gm. of the same substance is completely oxidized
within the body. In a living organism about thirty per
cent, of this value can be put out in the form of mechani-
cal work, while the remainder passes off in the form of
lieat. We know, thanks to the researches of Voit, that
an average adult laborer, performing his daily work,
puts out in mechanical work and lieat the cqui^•alent of
about three thousand calories. In order, therefore, that
the man shall not lose in weight, his daily diet must be
such as to balance his loss and have a combined caloric
value of at least three thousand units. If we, further-
more, will take into calculaticm that about four hundred
of the units at least must come from proteiils, five hun-
dred from fats, and the remainder from carbohydrates,
we have the most necessary data for the <-alculation of
the man's diet. Thanks to the labors of Voit ami Rub-
ner and their numerous piupils, these determinations have
been greatly sim])lifled in reci.'nt years.
Outside condit'ons, personal and racial habits, climate,
age, and , sex may alter the relative proportions of pro-
teids, fats, and carbohydrates in a certain diet, but the
above jjroiiortions must stand as answering to the aver-
age requirements of an adult workingman in a temper-
ate climate. In calculating the dietary value of a ration,
we must also allow for an una\'oidabie loss in the
preiiaration of the different parts of it. In meats, a loss
of twenty per cent, of the raw material is generally al-
lowed for bones; with salted herrings, thirty -.seven per
cent. ; pickled herring, twenty-nine pt^r cent. ; potiitoes
boiled and then peeled, seven percent.; ]>otatoes peeled
raw, thirty per cent. ; if eggs be used, ten ]ier cent, in
weight is deducted for the shell, etc. Another source of
loss from the gross weight is in the different degrees
of digestibility of foods, for which allowance must also
be made As a general rule, animal foods are much
more completely digested than foods of vegetable origin.
Rubuer has shown that proteids from meat and milk dis-
appear almost entirely, while those from bread and espe-
172
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Naval H jjil*"!!*'.
Naval Hyi;l<*ur,
Table XV.
Name.
Beef, very fat
Beef, inetUuiu fat
Beer, le:m
Mutton, very fat
Mutton, meiJiuui
Mutton, average
Pork, fat
Pork, lean
Pork, grease from ,
Beef tallow
Veal, fat
Veal, lean
Poultry, meaiuin
HoreetleKh
Meat powder
Carnesecca
Carne secca, boiled
Bacon
Bacon, roasted
American canned meat.
Chicago corned beef . . .
Corued Ix^ef
Preserveil ln*ef
Pickled beef
pemmican
Pork, pickled
Ham, smoked
Ham sausii-.'
Be^f satisa.L'.-
C'ervelat sausage
HeiTing, pickled
Sardines
Pike
Carp
Salt cod
Salt mackeri'l
Sui'ikHii haddock
Smoked !ialil)Ut
Smoked linrring
Cannnd salmon
Canned iiia<kere]
Canned lunuy
Eel
Pompano
Salmon
Shad
Shad roe
Smelts
Spanish mackerel
Trout
Caviare
Clams
Clams, litUe neck
Crabs
Lobster
Oysters
Scallops
Shrimps
Peas
Peas, dried and boiled..
Peas, canned
Beans, broad
Beans, kidney
Sago, fresh
Sago, canned
Soja bean
Lentils
P« 'tatties
Potatoes, sweet ,
Beets
Carrots
Oyster plant
Parsnips
Radishes
Turnipa
Asparagus
Cabbage
Cauliflower
Sprouts
Celery
Lettuce
Spinach
Onions
Apples
Pears
Peaches
Apricots
Plums
Prunes, dried
Cherries
Orantres
Grapes
Melons
IN 100 PARTS ARE CONTAINED :
NUTRIENT UNIT IN:
SfM NlTr.IE.NT
UMTS IN :
Proteids.
Fats.
Carbo-
liyOratt^s.
Ash.
Cellul.
Pruteids.
Fats.
Carbo-
hydrates.
100 gm.
1 OUIIIV.
17.0
29.5
1.0
.59.5
2.59.5
;319.0
95.0
31.0
5-5
1.0
73.5
4S.4
122.0
:!7.o
:SO.ri
1.5
1.0
71.7
13.2
85.0
35.0
1(1.5
29.0
1.0
.57.7
2.55.2
313.0
94.0
17.0
6.0
1.0
.59.5
.53.8
112.0
;i4.0
17.0
18.0
1.0
.59.5
1.58.4
218.0
65.0
U..')
37.5
1.0
.50.7
330.0
380.7
114.0
20.5
7.0
1.0
71.7
61.6
133.3
40.0
..5
98.3
1.7
864.2
865.9
260.0
.5
98.3
1.7
8(U.3
8t)5.9
260.0
19.2
7.2
.8
....
67.2
63.4
103.(i
31.0
20.3
6.8
1.1
60.9
59.9
120.8
;!6.4
21.0
2.0
1.0
73.5
17.6
91.1
27.3
21.7
2.6
1.1
76.0
33.9
98.9
29.7
«9..5
5.8
1.1
243.2
51.4
294.6
88.4
51.7
13.4
181.0
117.9
298.9
89.7
■H.a
8.9
131.0
78.3
199.3
.59.8
9..')
76.0
.5.4
:«.3
668.8
702.0
210.6
1.7
94.5
.5.4
6.0
831.6
837.6
2,51.3
29.0
11.5
4.0
101.5
101.3
202.7
00.7
23.3
14.0
4.0
81.5
123.2
204.7
61.4
IW.S
6.4
1.8
135.8
.56.3
192.1
.57.6
29..-)
8.0
103.2
70.4
173.6
53.0
2.5.9
.2
21.0
80.6
2.0
82.6
34.8
35.4
55.3
1.8
123.9
48;).8
609.7
183.9
9.7
75.7
.5.3
:i4.o
66(i.3
7(KI.2
210.0
24.5
36.5
10.5
85.7
:j31.2
40(i.9
122.0
12.87
24.43
10..52
3.3
45.0
215.0
a8.9
298.9
89.7
27.31
19.88
15.1
.5.5
95.6
174.9
.55.9
:(26.4
97.9
17.5
40.0
.5.5
61.3
:K2.0
4l;3.2
124.0
19.0
17.0
16.5
66.5
1.50.0
216.5
64.9
23.0
2.0
24.0
....
811.5
1.8
82.3
24.7
1.'<.43
.53
1.0
(i4.0
4.7
68.7
20.8
21.80
1.0
i.;h
76.5
8.8
85.3
25.6
27.42
.36
22.0
....
96.0
3.2
99.2
39.8
18.88
25.17
10.4
(JO.O
221.5
281.5
.84.4
33.68
.17
2.06
117.9
1.5
119.4
35.8
20.57
15.(6
12.96
72.0
132.3
204.3
61.3
36.44
15.82
11.(56
127.6
139.2
266.8
.80.0
20.06
15.7
l.(W
70.2
las.l
208.3
(.3.5
19.91
8.(«
1.93
(59.7
76.4
140.1
42.0
21.53
4.a5
1.69
75.3
3.5.6
110.9
;j:b.3
18.3
9.1
1.0
(!4.0
80.0
144.0
4:3.2
18.7
7.5
1.0
65.4
66.0
131.4
:!9.4
21.2
12.8
1.4
74.2
112.6
186.8
56.0
18.6
9.5
1.3
65.1
8:!.0
148.1
44.4
20.9
3.8
2.6
1.5
7:i.l
3:3.4
9.6
116.1
34.8
17.3
1.8
1.7
60.5
15.8
76.3
32.9
21.0
9.4
1.5
73.5
82.7
1.56.2
46.9
18.9
2.1
1.2
(ili.l
18.5
84.(5
25.4
30.0
19.7
7.6
4.6
105.0
173.4
28.1
306.5
91.9
S.6
1.0
2.0
2.6
30.1
8.8
7.4
46.:t
13.9
2.1
.4
4.2
2 7
7.3
3.5
15.5
26.3
7.9
16.6
2.0
1.2
3.1
.58.1
17.6
4.4
80.1
24.:3
16.4
1.8
.4
2 2
57.4
15.8
1.5
74.7
22.4
6.2
1.2
3.7
2.0
21.7
16.6
13.7
52.0
15.6
14.8
.1
3.4
1.4
51.8
.8
12.6
(55.2
19.6
25.4
1.0
2.6
88.9
8.8
.6
98.3
29.5
22.85
1.79
.52.36
2..58
5.43
70.8
1.5.7
212.8
299.3
89.8
7.0
.5
16.9
1.0
21.7
4.4
62.5
88.6
2(5.6
3.6
^
9.8
1.1
11.2
1.7
:S6.3
49.3
14.8
24.27
i.i;i
49.01
3.26
7.09
75.2
14.2
207.4
396.8
.S9.0
23.21
2.14
.5:3.67
3.69
3.55
71.9
18.8
211.7
303.4
!I0.4
2.3
.3
7.4
.8
7.1
3.6
27.4
36.1
10.8
1.1
.1
.3.8
1.3
....
3.5
.8
14.0
18.3
.5.5
30.4
17.7
29.1
4.1
94.3
1.55.8
107.7
3.57.7
107.3
25.7
1.89
.53.46
3..57
3.04
79.6
16.6
181.0
"77 '*
8:3.3
2 2
.1
18.4
1.0
6.8
.8
69.7
77.3
3:5.3
1.8
.7
27.4
1.0
.5.6
6.1
105.4
117.1
3.5.1
1.6
.1
9.7
1.1
4.9
.8
39.9
45.6
13.7
1.1
.4
9.3
1.0
3.4
3.3
38.1
44.7
i:i.4
1.11
,-,
17.1
1.0
3.1
4.4
67.0
74.5
:"* :3
1.6
.5
13.5
1.4
5.0
4.4
55.1
64.5
19.3
1.3
.1
5.8
1.0
4.0
.9
2.5.2
30.1
9.0
1.3
2
8.1
.8
4.0
1.7
32.9
38.6
11.6
2.1
3.3
(> .»
.8
6.5
28 2
11.1
4.5.8
13.7
1.6
.3
5.6
1.0
5.0
2.6
31.4
33.0
9.6
1.8
.5
4.7
7
5.6
4.4
30.0
30.0
9.0
4.7
1.1
4.3
1.7
14.6
9.7
23 3
46.5
14.0
1.1
.1
3.3
1.0
3.4
.9
16.0
30.3
6.1
1.2
.3
3.2
2.1
3.7
2.6
30.0
36.3
7.9
2.1
.3
3.2
.9
6.5
2.6
15.1
34.3
7.3
1.6
.3
9.9
.6
5.0
2.6
38.8
46.4
14.0
.36
8.2(5
4.3
.31
1.3
31.7
32.9
9.9
.36
7 22
1..51
.49
1.3
38.5
39.7
8.9
.65
4.48
6.06
.69
3.0
....
19.1
31.1
0.3
.49
4.69
5.27
.82
1.5
20.4
21.9
6.6
.4
3.56
4.34
.66
1.2
1.5.6
16.8
.5.0
2.3
.5
65.0
1,5
1.4
7.1
4.4
24.5.7
257.3
77.3
.67
10.24
6.07
.73
2.1
40.6
43.7
13.7
.8
.2
11.6
.5
2.5
1.8
44.8
49.1
14.7
..59
14.:!6
3.6
..53
1.8
55.2
.57.0
17.1
.92
.18
9.05
1.04
.73
2.8
.9
36.1
39.8
11.9
173
!\av;il ily:;i*'ni'.
Naval Ily<>:ii>ui>.
REFEHKXCE HANDBOOK OF THE MEDICAL SCIENCES.
Taiji.e XV. — Contin ued.
Name.
IX 100 P.IRTS ARE CO.VTAIXED:
NrxKiEXT Unit ix :
Sum Nctriext
Units in :
Proteids.
Fats.
Carbo-
hydrates.
Ash.
cellul.
Proteids.
Fats.
Carbo-
hydrat^is.
100 gm.
1 ounce.
4.0
.13
1.07
.51
1.43
6.6
.9
13.5
3.5
3.1
4.2"J
12.0
13.3
11.35
2.7
3.0
2.S.25
39.64
33.9
18.9
36.93
37.0
31.5
6.0
7.0
10.9
7.1S
ll.o
13.7
9.7
10.0
1.0
.5
'i.3
10.75
13.6
9.0
6.5
3.3
'l.il
12.0
24.5
6.3
16.0
Ifi.l)
20.7
iS
11.7
16.8
12.8
19.5
8.3
15.5
21.3
16.8
16.9
19.0
16.9
33.1
21.5
19.3
16.3
21.1
19!6
* V '
12.0 '
4.0
4^7
8.4
11.0
11.33
36.7
85.0
80.0
23.78
.38.24
33.3
31.0
30.68
38.3
12.0
1.0
L6
9.38
3.0
3.0
3.8
6.7
2.0
5.6
.3
1.0
.5
12'.3
7.1
31.0
30.4
4.8
4.5
93.8
9.3
1.3
8.5
20.5
23.3
17.4
4..S
4.5
9.6
6.4
5.3
12.6
9.0
2.5
16.3
36.3
33.9
4.2
■5.8
.50.0
7.8
6.28
4.44
3..S6
59.6
3.3
.5
4.9
4.8
4.6
.50.8
48.7
13..3;)
3.0 '
9.3
48.0
.53.5
75.0
73.1
71.3
71.0
09.6
64.5
82.0
il6.5
63.0
73.t;
63.75
iW.O
76.8
78.5
65.0
63.0
7.6
42.3
41.7
67.6
'.4 "
1.5
i.V '
2.4 '
'ti.27
3.35
6.97
8.1
1.9
'I'.ij
2!o
2.4
2.0
1.8
1.0
3.0
7.1
3.49
4.4
4.7
4.43
5.0
3.3
1.5
1.0
1.1
..83
.8
3.0
1.3
1.4
'I'.i)'
3.8
;;.,«<
.8
1.0
1.5
1.7
.5
4.0
5.6
1.9
1.0
\.i
1.6
1.3
1.0
.3
.5
4.7
4.0
.4
1.2
1.4
1.0
1.3
1.3
.9
1.7
1.1
1.0
.8
1.0
1.7
1.0
3.0
.15
.81
.48
.4.S
1.6
.4
iVi' ■
1.4 ■
l.ll' ■
1.S.2
11.6
1.4
12.4
.4
3.3
1.6
4.4
30.5
3.8
43.5
12.2
10.8
15.0
42.0
43.0
39.7
9.4
7.0
fts.g
103.7
115.1
66.1
94.3
94.5
110.2
20.0
21.7
:«.8
31.5
34.1
39.4
30.0
31.0
3.1
1.6
3.7
33.3
38.0
37.9
30.1
7.1
3.7
37.3
T5.9
19.3
56.0
56.0
72.4
m.\
40.9
58.8
44.8
68.3
29.0
.54.2
74.5
.5S.8
.59.1
66.5
.59.1
.S0.8
75.2
67.5
57.0
73.8
79.4
68.6
....
'l.76
lti,5.6
a).2
6.1
41.4
73.9
96.8
99.(1
23.49
i48.0
704.0
200.5
:B6.5
284.3
1.S4.8
270.0
349.11
105.6
8.8
4.4
14.0
81.6
17.6
17.6
33.4
.59.0
iV.i)'
49.3
3.6
8,8
4.4
'l.V
1 08.3
63.5
].'>1.8
179.5
43.2
39.6
816.6
81.0
10.1
74.8
1.S0.4
204.3
l.j.3.1
43.3
.39.6
84.5
.56.3
46.6
IIO.S
79.2
32.0
14;i.4
3IS.6
201.5
37.0
51.0
19.6
29.4
36.3
18.3
16.8
336.4
13.3
l.R
18.1
3.6
30.7
31.0
180.3
49.4
ll.V
34.4
177.6
194.2
377.5
270.5
363.4
363.7
357.5
3.38.6
3013.4
357.0
329.4
273.3
333.1
233.1
384.3
390.5
240.5
329.4
17.0
i.5i:.:
1.54.3
»50.1
'1.5
5.5
5.2
S.il'
33.0
29.8
39.5
19.8
31.3
248.7
16.1
1.50.9
65.5
19.5
77.1
146.9
320.0
188.1
244.3
7.55.0
704.0
299.4
440.2
3SB.3
350.9
3W.2
a>4.6
2,50.2
3(16.4
32.5:3
373.6
315.1
319.7
320.9
328.6
306.5
a58.6
229.4
276.0
383.0
320.3
314.7
319.4
253.0
229.4
31.8
301.9
392.7
444.1
3:j5.5
9il.7
117.5
.S24.3
147.1
.51.7
l:i3.6
225.3
27214
1.S2.1
96.4
119.3
14:3.3
115.4
113.1
169.9
160.0
97.3
310.9
375.6
275.3
126.3
119.6
9.6
8.9
8.8
5.9
3.4
74.6
4.8
45.3
19.6
5.8
23.1
44.0
96.0
.56.4
73.3
336.5
211.3
89.8
132.0
119.8
75.3
109.3
106.4
75.0
61.9
66.4
97 6
Bhifk iifrries
RaspiH'i-ries
Zgc without shell
Milk, skimijieil
Alilk, g"oat"s
Milk, oonileiisud
Milk, coudensed, Swistf
Butter, fresh
Butter *;:illt'd
Clip*'-;*', T Hit I'll
Chet-si-. .VuMTicini
Chei-^i'. rjtiiiriiibeit
Chei'se. t lirsllill'
Cheese, earawav
Bread, wheateii
Biscuit, iiavv
102.1
94.5
95.9
96.3
98.6
93.0
107 (i
Floui-. wheateu
Flour, barley
Ciirii. iri'juiis
SUL'ar lalie
iMolass.-s
Honey
Btiekuiieat
6.8.8
82.8
114 9
Macaroni
93 4
nice
95 8
Prunes, dried
liaisins
75.6
6.S.8
6 5
Cnilee, innoasted
90.6
87 8
Chocolate
Beef bt'art.
133.3
70 6
Beef kidney
39 9
Beeflner
a5 3
247 3
Beef toncue
44 1
Beef tiipe
15 5
Beef toninie, pickled
67 6
Beef ton<j:ue, canned
Pork, feet
81.7
546
Pork, kidney
3S9
.35 8
Veal liiMlt
43 0
Veal liver
X3.9
JIutlon kidney
Mutton liver
Broiler chickens
Fowls
.51.0
48.0
30.0
63.3
113 7
Ttirkev
Chicken liver
82.6
37.6
3.5.9
ciiilly vegetables reapjjear in
erable proporticm.
A simple and approximate!
eiilatiiig the uiitritivc value (
pulilislied by 8elium))urg. f-
dilTercnee in tile fooil value
alile proteids, giving the form
ter a value of ii.l per gram.
8.8 and the carbohydrtites on
vtirious constituents of a diet,
and carbohydrates, tlieir weig
]ilied by tiieir respective va
added t'osether would eive ;
total food value of a diet in n
ent units, llemembering th
ailiilt workiiigman must lia
the ftee
V accnra
if a diet
chumbu
jetween
er avail!
The fat
3 of 3.7.
expressc
ht state
lues, the
.sum cot
umbers r
It a suf
ve at le
^s in qui
e met ho
has rect
ig make
animal a
; of 3.5 ai
s have s
Given.
d in prot
1 in grai
several
respond!
f calorie
icient d
ist 3,00(
te consii
J for ca
ntly bee
< a sligl
ml vege
id the Ui
value <
then, til
eids, fath
ns, mult
amottnt
ng to th
-1 or nutr
et for ;i
miti'ien
-
-
n
t
f
e
-
s
e
-
t
unit
drat
500,
of as
inea
TI
SOUl
Plui
port
Unit
colu
prot
give
the
100
Tl
s, and th;
es, and sa
and 35,
certaiuin
le adjoin
ees, nota
nert. Rat
s of tlie
ed States
mns give
eids, fats
tlie num
text two
£rm. and
lere are
It the pr
Its in a c
ve wouli
g and ci
ng Tabic
bly, Koe
lUe. Not
United S
Departn
the perc
earboliy
lier of nu
columns
Dne ouuc
i few foo
iporlion
omplete
I have a
ntrolliuj.
XV. has
nig, Ku
ter, Har
tales Fis
lent of A
entage C(
drates, et
trient un
give the
' respect
d substa
of protei
diet shou
Q easy an
' the diet
been con
bner, Ki
■ington,
h Comm
grictiltui
uupositio
c. ; the n(
its conta
sura of
vel}'.
nces of
Is, fills, (
Id be as
(1 simple
aiy valu
ipiled frr
'clmer, £
Munson,
ission an
e. The
n of eacl
'Xt three
ned in IC
nutrient
vegetable
■arbohv-
L50, 100,.
method
s of any
in many
)Chmidt,
the re-
d of the
first five
food in
columns
0 parts :
units in
origin,
174
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Naval ■■y<;Irne,
INaval Hygiene,
not iiichuled in this list, such as the tomato, cucumber,
squiish, pumpkin, egg plant, and vegetable marrow;
they liave about the same nutritive value as celery and
lettuce. The Jellies and jams are semi-solid glutinous
pri'parations. made by boiling fruit juices with sugar
and allcjwing to cool: jams are similar preparations
which include the pulp of the fruit as well as the juice.
Their nutritive value must be determined by taking their
ingredients separately in each case. Tea, coffee, and
chocolate owe their nutritive value more to the stin-.ulat-
ing effect of the alkaloids which they contain than to any-
thing else; they are condiments rather than nutritious
snlistances.
The caloric values, originally assigned to the several
pro.ximate principles of foods, by Rubner and Stohmann,
were as follows: 1 gm. of proteids, 4.8 calories; 1 gm. of
fats. 9.0 calories; 1 gm. of carbohydrates, 4 calories.
It was soon found, however, that, while the fats and the
carbohydrates were as completely o.\idized withiu the tis-
SHe cells as they were when burned in a calorimeter,
namely, into water and carbon dioxide, the proteids left
an unconsumed remnant. If, for instance, 1 gm. of pro-
teid material is decompo.sed within the organism, it leaves
a remnant of urea, uiic acid, and a few other nitrogenous
substances, excreted by the kidneys and the intestines.
The 4.8 calories, therefore, that were assigned to 1 gm.
of ]iroleids, as their food-value in calories, represent only
a jiart of that value in calories which we would obtain
if 1 gm. of proteids was burned in a calorimeter, where
it would, of course, be completely consumed by oxida-
tion. According to Rubner, the unconsumed renuiant
amounts to 23 to 38 per cent, of the original quantity of
proteiils ingested. In other words, if 1 gm. of protcid
material is decomposed within the body, is converted
into water, carbon dioxide, urea, etc., only so much of
its potential energy is converted into heat as will raise
the teiuperature of 4.8 kgm. of water 1° C, while if 1
gm. of proteid is completely assimilated within tlie
organism, the amount of energy added to the latter is
equal to .").7 calories, or its full caloric value. The atjove
values for proteids, fats, and carbohydrates, in their prac-
tical application to the calculation of the food values
of a certain diet or ration, liave had to be moditied still
further. Allowance had to be made for a certain percen-
tage amount of indigestible matter peculiar to the dilTer-
ent articles of food, as well as for the energy that had to
be expended on their digestion, in order not to overesti-
mate their net value. After making these necessary de-
ductions, Schumburg gives, as the net values, the fol-
lowing numbers in calories: 1 giu. proteids (animal), 3..J
calories; 1 gm. proteids (vegetable), 3.1 calories; 1 gm.
fats, 8.8 calories; 1 gm. carbohydrates, 3.7 calories. It
is on the basis of Schumburg 's figures that the food
values in table XV. have been calculated.
Voit's original standard reiiuiremeuts in proteids, fats,
and carboh3'drates, for a moderately hard-working adult
man, are: 118 gm. of proteids, 56 gm. of fat, and 500 gm.
of carl)ohydrates. These standard requirements have
stood the test of many years of scientific controversy and
have proved themselves practically unassailable.
The following table is intended to show the number of
calories obtained from Voit's standard by using both
Rubner's and Schumburg's figures:
Table XVI.
Name.
Grams.
Multiplied by—
nubner's flgures.
Scliumburg's figures.
Proteids
Fats
Carboliydnitcs. ,.
ll.H
m
500
X 4.8 = .566
X 9.5 = 533
X 4.0 = 3,000
ToUiI, :3,098
X 3.5 = 413
X 8.8 = 493
X 3.7 = 1..H5U
Total, 3,755
(In a paper on the "Hygiene of the Navy Ration,"
published by me in the Proceedings of the United Slates
Naval Institute, vol. xxv.. No. 3, the total caloric value
of the ration was estimated as amounting to 2,696 calo-
ries. This number was obtained after making all due
allowance for indigestible matters as well as taking into
account the losses incurred in cooking and the general
preparation of the food; it agrees so nearly Willi Voit's
standard, multiplied by Schumburg's figures, that this
agreement is considered an additional proof of its cor-
rectness. Unfortunately, the proof of this paper not
having been submitted to the writer, a few errors have
crept in, owing to the wrong position of the decimal
points in the numbers there given; they are, however, so
easily perceived as hardly to need any correction.)
From the point of view of their digestibility, food sub-
stances vary quite considerably, and, since only that i)or-
tion of a food substance which is ab.sorbed is of any good
to the organism, it cannot be immaterial in what lorm
food is taken. The following table XVII. by Rubner is
intended to show the indigestible and, consequently, un-
absorlied remnant in per cent., of some of the more com-
nion articles of food.
Table XVII.
Remained un.absorbed.
Meat, dried
Fisti
Ea-ffs, liard-boiled
Milk
Bread, baker's, wbeaten . . .
Bread, inferior quality
Bread, coarse meal
Bread, peasants' rye
Maearoui, poor in e^g
Rite (Risotto)
Corn ( Palenta)
Peas (dried I
Hi-ans (drl.-d)
Be;ins, icesli
Ptttalues mashed
Pi)tat(jes, mashed, different
preparations
Can'uts
Dry
substance.
Proteids.
Fats.
5.3
3.0
4.3
3.5
5.3
0.0
4.4
8.S
7.1
5.3
4.3
31.8
B.7
34.0
13.3
:io.5
15.0
33.0
4.3
17.1
4.1
3(1.4
(j.7
9 1
1.').5
17 5
18.3
3U.3
15.0
19.5
9.4
.30.5
30. 7
39.0
Carbo-
hydrates.
1.1
2.0
7.4
10.9
1.3
0.9
3.3
3.0
7.4
IS. 3
The table shows that tho.se articles of a diet which have
an animal oiigin and upon which we mostl_y depend for
the necessary proteid part of our diet, such as meat, fish
and eggs, are best digested and absorbed. Of the vege-
taljlcs, rice, corn, antl macaroni seem to bo much more
digestible than the vegetables proi)erly .so-called. The
digestion and absorption of all kinds of fats is generally
favorable.
The different composition of foodstuffs, as regards
proteids, fats, and carbohydrates, in itself makes it nec-
essary that an appropriate mixture of them be taken in
order to maintain a certain necessary equilibrium in the
composition of our own bodies.
For, although Pflliger has kept dogs alive and in a
thriving state of health and activity for long periods at
a time, man cannot live forever on an exclusively animal
diet, much less on one of fats and carbohydrates to the
exclusion of all proteids.
Volume of a Diet. — Regarding, as we must, our diges-
tive organs as muscular as well as secretory organs, we
shall have to admit, that, like other muscles, their strength
in grinding up and propelling food material must have
a maximum limit, beyond which they liecome liable to
fatigue and exhau.stion. This limit' has been reached
whenever we become conscious of a feeling of overful-
ness after taking a meal. AVhile a feelingof satiety is,
up to a certain limit, stimulating to dig('>stion, ovei'-ful-
ness has the very opposite eiVect ami ought to be
avoided. Experience and experimentation have shown
that the volume of an averaL:c diet should not exceed
'3,100 gm. nor fall below 1..500 gm. Tln^ daily volume
is, of course, to be distributed among the several custom-
ary meals.
It has been found a most suitable plan, in a temperate
climate at any rate, to make the following distribution
of the daily ration between the different meals of the
1Y5
Naval HysrloiM-.
Naval nyg'lene.
REFERENCE HANDBOOK OF THE JVIEDICAL SCIENCES.
<iay: For breakfast. 12 per cent.; for midday meal, 47
per cent. ; for supper, ;!1 jier cent.
In warm climates, however, it will be foimd a good
rule, especially on board a .sliip-of-war wbere drilling is
done morning and afternoon, not to overfill tlie stomach
of the men at middaj' but to make the heavy meal the 5
I'.M. meal of the day. The above percentage di.strib>i-
tion would have to be slightly modified in accordance
with tliese requirements.
Tlie Dielary Vuluedf One Week's Ration.' — In order to
obtain an appro.ximately correct estimate of the dietarj-
value of the meals as they are actually .served out on
board a ship in commission, the commissary yeoman of
one of them was requestedto furnish us with a list of
the articles included in one week's allowance and divide
that up into the customary three daily meals. With the
aid of table XV., the food value of each meal in pro-
teids, fats, and carlxihydrates was then calculated and
expressed in terms of nutrient units, obtained after the
manner found described in the preceding pages. In this
estimate no deductions were made for indigestible mat-
ters nor for the work expended on digestion, because
these values, as will lie remembered, had already been
deducted in the various multiples used in the calculation
of the numbers of luilrient units which each article rep-
resents. But a loss of t weuty-li ve per cent. , in round num-
bers, had to be allowed for the usual and unavoidable
waste made in the preparaticm of the raw material for
cooking, as well as for a less necessary but always notable
waste incurred in serving.
The results of this work are exhibited in table XVIII.
A careful study of this labh^ is of some interest. It shows,
for instance, that while the sum of nutrient units for al-
most every single day comes up to and often exceeds
the required number, there is quite a considerable lack
of uniformity in the several coiTesponding meals of the
different days of the week. The number of nutrient
units for one day is almost doubled on another day.
It also shows that our sea ration as well as our port ra-
tion was deficient in carbohydrates, while the proteids
were two per cent, below- the standard in the sea ration
and three per cent, above the standard in the port ration.
In table XIX., wliich has been borrowed from Plu-
mert, the proteid content of the United States navj- ration
is given as 69.3 per cent. This estimate, obtained from
our printed allowance-list, puts its dietary value on top
of all the other naval rations. According to our present
calculation, the dietary value of our port ration is but
twent_y-three per cent, in proteids, or just one-third of that
given by Plimiert. Although we must admit that the two
estimates are not strictly comparable, this exceedingly
large difference between the tv,-o nevertheless shows
that there are instances in which discrepancies occur be-
tween what is found on paper and what the men. in ac-
tual practice, get on their table and inside their stomachs.
Projiijscd A'ew JS'api/ Hat ion. — The Secretary of the
Nav3', recognizing the needs of the service and the im-
portance of a well-appointed ration, on July loth, 1901,
ordered a board of officers to examine the ration and the
system of messing in the navy. This board, to which
the writer was originally ordered a member, but was pre-
vented from attendance by illness, held its sessions in
Newport, R. I., and completed its labors September 4th,
with a report, which lias not yet been luade public. A
very complete abstract, however, appeared in the Army
and ISary Jiiiirnid of January 2.5th, 1902, from which we
T.\BLE xvm.
Days.
Suuday .
Monday .
Tuesday .
■Wednesday .
Thursday .
Friday .
Saturday .
Average values .
Bicalifu.sl.
Dinner
Supper
Breakfast .
Dirnipr —
Supper —
T. .lal .
Breakfast. .
Dinner
Supper
Total..
Brvukfast
Dinnir ...
Supper . . .
I!reakfa.st.
Itinner . . .
SuppiT ...
Total..
Breakfast.
Dinner . . .
Supper
Total ..
Breakfast.
Dinner . ..
Supper ...
Total .
In per cent, (round numbers) daily
average '.
Should lie..
Difference.
At Sea. Nctkiext L'.mts i.v-
li».9
HH,").9
I'.e.O
6S7.8
77.0
213..5
512.5
1.-59.0
Stil.tj
ino.si
X'41.(l
im.i)
■S-Sl.ll
U7.7
ISI.O
41S.5
litt.B
743.1
214.0
:!H'.i.(i
147.11
7ti(1.0
IS.O
20.0
- 2.0
a-)3.9
1,207.4
ll',l.4
l.BSU.T
64.9
445.0
4t«.0
9Ui.9
34.1.0
1,4.-)5J3
247.0
2,045.2
a'vt.O
455.0
■Zii.i)
1,043.9
91.0
3O5.0
;J47.7
743.7
279.0
470.0
909.4
l,«i4.4
27.0
2,452.0
iW.O
!,57S.O
40.0
13.3
f 28.7
Carlio-
hydrates.
720.6
371.4
593.0
1,684.0
477.0
3".I0.0
59U.0
1.457.0
409.0
74«).B
492.0
1.647.6
720.6
390.0
466.0
1,,576.6
4.59.0
823.0
417.0
1,699.0
4M.0
390.0
466.0
1,265.0
579.0
721.6
630.0
1,930.6
42,0
66.7
- 24.7
Sum.
1,1S4.4
l,9i-4.7
904.4
4,053.5
618.9
1,048.5
1,215.0
2,S.S2.4
S91.0
2,5lS.4
■til.O
1.266.4
1,075.5
941.0
3,282.9
711.0
1,609.4
.S82.4
3,2ft;.8
818.0
1.284.5
1,.570.0
3,<>72.5
820.0
3,572.6
876.0
100.0
100.0
In Port. NTtriext Txits ix—
Proteids
1(^.9
398.0
93.0
600.9
189.0
664.0
222.0
1,075.0
196.4
664.0
90.0
190.9
3,87.0
151.0
728.9
148.2
390.0
94.0
6;32.2
1,81.0
3i«1.0
149.0
720.0
1.S9.0
399.0
337.0
925.0
23.0
20.0
-1-3.0
Fats.
35:1.9
248.()
1,S4.9
787.4
577.0
2.80.0
403.0
1,260.0
186.7
2,so.O
247.0
713.7
3.54.9
249.0
53.6
624.0
249.0
27.6
216.0
!M9.0
182.0
677.0
138.9
2,452.0
143.0
2,733.9
31.0
13.3
-I- 17.7
Ca^bf^-
hydrates.
720.6
449.0
822.0
1.991.6
409.0
.390.0
590.0
1,389.0
409.0
390.0
492.0
1.291.0
720.6
490.0
686.0
1,896.6
347.0
490.0
9,54.0
1,791.0
309.0
490.0
675.0
1,474.0
409.0
721.6
49O.0
46.0
G6.7
• 20.7
l.l.st.4
l,(a5.6
1.099.9
3,379.9
1,175.0
1,3:S4.0
1,215.0
3,724.0
792.1
1,3:m.o
829.0
2,955.1
1,21)6.4
1,126.0
890.6
3,283.0
1.119.3
1.129.0
1,075.6
3.:iS.S
736.0
1,129.0
1,006.0
2,871.0
736.9
3,572.6
970.0
5.279.5
lUO.O
100.0
1T6
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Naval Hygiene.
Naval Hy<;icne.
Table XIX.— (From Plumert.)
NaTy.
Austrian, in port
Austrian, at seu
German, in port
(ieriuan. at sea
Italian, in port
Italian, at sea
Frem-li, in port
Frencli, at sea
English, in port.
Eusrlisl), at sea
Russian, in port
Kus^ian. at sea
Sweilish. at sea
Norwejriiin, at sea
TnrK'isli. at sea
riiiied States, in port
Initeii States, at sea
Artrentine Republic, at sea.
Japanese, at sea
SrM NUTRiE.NT Units
OF A.MMAL ORIGIN.
Proteids.
386
a<o
373
320
27B
294
286
261
377
318
2.")7
247
379
456
160
480
.%3
518
260
Fats.
1.56
239
2:J5
412
107
HO
176
219
138
.538
229
390
517
473
127
177
461
294
123
si"M Nutrient Units of
VF.fiETABLE ORIGIN.
3M
421
414
394
315
437
333
341
52:j
383
446
171
3S8
419
495
213
402
344
331
29
26
35
29
25
35
24
18
53
49
47
37
27
49
80
46
31
33
Carbo-
hydrates.
503
543
601
.595
475
.560
470
523
572
593
717
733
558
667
72:i
401
.590
336
62S
Sum Total of Nutrient
Units in
THE Daily Ration.
ProteiUs.
Fats.
Carbo-
hydrates.
667
1S.5
.503
701
2.S.5
343
6S7
.370
601
714
441
.593
591
133
475
731
IS]
560
619
200
470
mi
235
5:::3
900
190
.573
680
rm
.593
703
276
717
718
247
733
763
,54i
.538
S75
.533
667
Cm
1.87
723
893
22=1
401
-,45
492
,590
803
326
.53(1
591
149
638
42.9
40.0
39.7
44.8
46.7
40.3
40.3
4:1.3
41.9
46.8
315.6
34.4
49.5
.52.1
24.4
69.2
46.0
60.0
43.9
take the following. This board recommends legislation
as follows:
" Hereafter the navy ration shall consist of the follow-
ing dailj' allowance of provisions to each person: One
pound and a quarter salt or smoked meat, with three
ounces of dried or si.\ ounces of canned fruit, and three
gills of beans or peas, or twelve ounces of flour: or one
pound of preserved meat, with three ounces of dried or
six ounces of canned fruit and twelve ounces of rice or
eight ounces of canned vegetables, or four ounces of de-
siccated vegetables; together with one pound of biscuit,
two ounces of butter, four ounces of sugar, two ounces
of coffee or cocoa, or one-half ounce of tea aud one ounce
of condensed' milk or evaporated cream; and a weekly
allowance of one-half pound of macaroni, four ounces of
cheese, four ounces of tomatoes, one-halt pint of vinegar,
one-half jiint of pickles, one-half pint of molasses, four
ounces of salt, one quarter ounce of pepper, and one-half
ounce of diy mustard. Five pounds of lard or a suitable
substitute, will be allowed for every hundred pounds of
flour issued as bread, and such quantities of yeast as may
be necessary.
"The following substitution for the components of the
ration may be made when deemed necessaiy by the senior
officer present in command :
"For one and one-quarter pounds of salt or smoked
meat or one pound of preserved mesit, one and three-
quarter pounds of fresh meat; in lieu of the article usu-
ally issued with salt, smoked, or preserved meat, fresh
vegetables of equal value ; for one pound of biscuit, one
and one-quarter pounds of soft bread or eighteen ounces
of flour; for three gills of beans or peas, twelve ounces
of flour or rice, or eight ounces of canned vegetables ;
and for twelve ounces of flour or rice, or eight ounces of
canned vegetables, three gills of beans or peas.
"An extra allowance of coffee or cocoa, two ounces of
sugar, four ounces of hard bread or its equivalent, and
four ounces of preserved meat or its equivalent, will
be allowed to enlisted men of the engineer and dynamo
force when standing night watches under steam."
The Board has also recommended some other changes to
be made in the system of messing and has suggested some
much needed reforms in the organization of the personnel
of the commissary department on board ships, but, the
above changes in the food-supply being the only ones of
iuterest in connection with the study of the .actual food
value of the ration, we cannot here consider them.
The same coinmissaiy yeoman who had previously fur-
nished us with a written weekly allowance list, divided
into the customary three daily meals, made up from the
old ration, was now requested to do the same with this
proposed new ration. Tliis he very kindly did. after
having been thorough!}' advised of the promised addi-
VoL. VI,— fa
tious to the present ration, and the following table XX,
shows the food value for this new ration in nutrient
units, expressed in terms of proteids, fats, and carbohy-
drates, which the new ration would j'ield in /tis hands.
While, in our opinion, the ration is very ample, the
fable shows that both in the port ration and in the sea
ration we have an excess in fats and a detieiency in car-
bohydrates, while the proteids may be regarded as just
about up to the standard. ATe also notice the same Jack
of uniformity as regards the distribution of the quanti-
ties between the diifereut daj'S of the week as well as
between the three meals of the da_v that has been pre-
viously noted. The importance of the personal equation
of the yeoman and its influence upon the whole subject
of rationing on board .ship is well brought out. A veiy
natural suggestion, therefore, would seem to be that
either the commissary yeomen of the navy be given a
great deal more instruction as regards the value in nutri-
ent units of the dilferent classes of food which it is their
duty to distribute, than they now possess, or that this
distribution be supervised on board ship by the class of
men wliose training aud education ought to be a guaran-
tee of the fact that they jiossess the required knowledge
to do so in accordance with the best iirinciples.
The Influence of Climate >/pr/n JS'iitntion. — Any discus-
sion of the navy ration would be incomplete without
some consideration of the influence of the various clima-
tic factors upon nutrition. The problem of what consti-
tutes a pro])er ration for a definite climtite can be solved
only on the basis of an exact knowledge of the physi-
ology of general nutrition, as modified and influenced by
the different climatic conditions. When we shall be in
pos.session of a full and complete knowledge of this, tlien
the proper ration fcu- almost any climate will become a mat-
ter of exact calculation and a mere application of princi-
ples to practical life. W'e must, in the first place, find
out what climate is, and in the second i)laco ascertain its
influence upon nutrition.
Since some very important and fundamental work
has, within recent years, been done in this line of re-
search by German "hygieiiists, which must hereafter be
taken into account whenever the c uestions of climate
and nutrition become subjects for further research or
discussion, it is absolutely necessary in this connection
briefly to call attention to a few of the leading points in
this great work. In doing this, only so much of it will
be reviewed as seems necessary for a better undersrand-
iugof the subject under discussion; for a fuller and more
detailed account the reatler is respectfully referred to a
most excellent monograph by K. E. Hanke.*
* " UeOer die Einwirkung des Tr"i)enkliiua.< ;mf die Krniiliriinp. des
Mensehen auf Grund von Versurhcn iiu iropisclien uud subtropisebeu
Sudamerika," von Dr. Karl Erust Kauke, Miiueheu.
177
Naval Hygiouo,
Naval Hygiene.
REFERENCE HANDBOOK OF THE MEDICAL SC:iENCEy.
Taulk XX. — NrMBERs Represent Nutkient LTntts.
Meals.
Sea Ration.
Port Rations.
Days.
Proteiils.
Fats.
Carho-
liydrates.
Slim.
Proteids.
Fats.
Carbo-
liydrates.
Sum.
SunUav
Hrnikf:ist
310.3
3k;!.7
243.0
363.3
881.4
367.6
724.8
.501.4
655.4
1,197.3
l,6(iB.5
1,165.0
210.3
323.4
243.0
262.3
141.5
267.6
734.8
500.4
6.55.4
1,197.3
965.3
1,165.0
Total
7:16.0
121.5
a38.0
102.6
1,411.3
178.0
738.0
1.53.0
1,881.6
541.4
;190.4
795.8
4,038.8
840.9
1,456.4
1,0.51.3
775.7
109.5
327.3
231.1
671.3
194.0
346.8
191.3
1,880.6
5.53.4
530.4
700.4
3,327.6
8,56.9
Dinner
1,104.5
1,133.7
563.1
147.6
3(16.9
2.57.5
1,058.8
569.7
3,480.5
513.4
1,727.6
476.4
724.8
477.3
3,348.5
1,193.7
3,513.3
1,347.1
667.9
198.0
:J1I6.9
338.7
632.0
977.0
3,480.5
339.4
1,784.3
486.3
724.8
476.4
3.084.1
Tuesday
lireukfast.
1,661.3
3,512.2
Supper
944.5
Total
712.0
210..3
2(3.0
1.51.4
3,.563.(i
363.3
(i(l7.0
4:14.6
1,678.4
734.8
373.4
6;S4.6
.5,9.53.0
1,197.3
1,233.4
1,320.6
743.6
210.3
:i2SI.9
132.5
3,686.9
263.3
348.4
381.0
1,687.5
724.8
530.4
434.4
6,118 0
Wednt'sdLiy
Breakfast
1,197.3
1,108.7
937.9
Total
604.7
247.1
339.0
31.5.5
1,303.8
357.3
461.9
318.4
1,733.8
.502.7
:!.S0.4
:i50.4
3,641.3
1,(KI7.0
1,1.81.3
814.3
662.7
281.7
288.9
311.5
891.6
337.4
883.8
733.4
1,689.6
476.4
,5:i6.8
476.4
3,343.9
985.5
1,708.5
1,411.3
Totiil
8111.6
139.9
1.58.6
323.3
967.5
773.5
231.3
430.5
1,233.5
476.4
695.9
360.4
3.002.6
1,388.8
1,075.8
1,094.1
783.1
260.2
:i80.3
149.3
1,833.6
312.1
78.4
377.6
1,489.6
490.4
776.4
644.0
4,10.5.3
Breakfast
1 063 7
9:i5.1
1,170.9
Total
631.7
268.3
309.9
1156.5
1.414.3
189.6
3.431.9
409.0
1,-523.7
.'1.82.5
7.54.8
890.4
3,.558.7
.840.4
:l.496.6
1,46.5.9
5,,H02.9
100.0
KXl-O
789.8
301.7
:165.9
331.7
768.1
2(8.4
1.2;)5.3
:13R.4
1,610.8
476.4
7.54.8
470.4
3,168.7
Breakfast
881 5
Dinner
2,355.9
1,037.5
Total
744.7
17.0
20.0
-3.0
3,030.5
43.0
l:!.3
+ 30.0
3,037.7
40.0
66.7
- 36.7
789.3
30.0
30.0
0.0
1,778.0
37.0
13.3
+ 2:3.7
1,707.6
43.0
66.7
- 23.7
4,374.9
100.0
100 0
DilTeience
Tlic iiliysidlogir-il iimcfss. known ;is heat roirulatinn
or )i(-'at ccononi}', consists, on tlic oiu' hand, in the ]iro-
flnctiou <if licat within tlie living organism tlirough oxi-
dative olianges; and heat-dissipalioii, throiigli conduc-
tion, radiation, ami water evaponition, on tlieotlier. The
remaining baliUice between tliese two phases of tlie piroe-
ess finds e.xpression in tlie normal temperature of the ani-
mal tinder oliscrvatiim. That thislieat-reg\ilating]irocess
is intiuenced by a great variety of both euviroumeutal
and subjective conditions has long been known, but a
more exact knowledg<' of it has only recentl}' been gained
through the researches of Voit and Uuhner and their nu-
merous CO- w( irkers.
En\ii!i)-Nmi;nt.\l Cokditions. — Climate. — Kauke has
recently detiiK'd climate as being " the total mean thermic
eflfect exerted upon a living organi.sm. at a certain point
on the earth's surface." This comprehensive delinition
of climate covers every point on the earl h's surface, both
at sea and on the continent. The total mean thermic
effect is made up of several factors, namely: atmos-
pheric temperature (direct solar rays, njflected and radi-
ated hi-'tit), humidity, air currents, barometric pressure,
and rainfall.
Against the untoward inliuencc of these combined
agencies the organism possesses certain ])hysiological
defences that are summed up in the term hetit regulation,
and, within a certain number of degrees of atmospheric
temperature, the organism is able to ivcommodale itself
to its environment, without losingconlrol of itsown nor-
mal lempertiture. This number of degrees of temper-
ature has, accordingly, liecn called by Hanke Ihe "tem-
jieratnre range." This range has an upper and ;i lower
limiting point, beyond either of wiiich the regulating in-
178
fluence of our physiological meclianism does not extend,
and where our physiological defences begin to break-
down. When, tlierefore, the limits are surpassed, the
normal temperature of the organism will either be raised
or lowered, according as either the upper or the lower
limiting jioint in the range is exceeded. We leave our
normal grouml and enter the pathological arena.
((/) AliiKixplicyic 'J'oiqwniture. One of the most impor-
tant factors in a climate is its temperature. Complete
and accurate sets of experiments on the intiiieuce of at-
mospheric temperature on the temperature range have,
so far, been made on iiniinals only. A sufticient number
of observations, however, has been made on man to
enable us to summarize the tliH'ereiit reactions thus ob-
served into a connected wIkjIc. Thus Voit. in l.STS,
made the imiiortant discovery that the several factors
concerned in the mechtinism of heat regulation did not
all act alike when followed through the whole of the
temperature range. Proceeding from the lower in the
direction of the upper limit, there soon comes a point on
our scale where, for instance, heat production refuses to
take any further part in lieat economy. This ])oint was
likewise observed liy liubner and noted to occur in all
his experiments on the heat regulation of animals.
Ranke now proposes to designate the point "the critical
point "in heat regulation. By it the whole temperature
range is naturally divided into two great groups. Ac-
cording to the present state of our knowledge, the reac-
tions of the dill'erent factors concerned in heat regula-
tion, within the several groups and subdivisions of the
temperature range, are about as follows: At the lowest
limit of the range, we meet with the highest amount of
hciit production; from here on uj) to the critical ijoiut.
REFERENCE HANDBOOK OF THE JIEDK'AL SCIENCES.
Naval Hygiene.
Naval Hygieue.
heat ])ro(luction is found to be gradually diniinisliinsr.
Heat regulation, then, between the lower limit of the
range and the eritical point, occurs prinei|ialiy through
changes in chemical heat production. Water evapor
ation behaves so indifferent ly here that no regulating
function can be attributed to it. From the critical point
on upward, no further decrease in heat production de-
pending upon temperature occurs. In place of changes in
heat production we now notice changes occurring in heat
elimination. This second great group of the tempera-
ture range is again divided into two subdivisions, dis-
tinctly marked out by important changes in the reactions
of the regulating mechanism. In the lower of these
two divisions we find
conduction and radiation
actively increased. Al-
thougli a slight increase
in heat production is
noticeable within this
section, due to quick-
ened circulation and res-
piration, this is e.\actl_v
counterbalanced by a
simultaneous slight in-
crease in water e\'apo)'a-
tion. This kind of regu-
lation extends, in the
dog, to about 5° C. above
the critical point.
In the upper of the
two subdivisions of
physical heat regulation
we tind that radiation
and conduction cease to
be actively or refiexly
increased and are con-
siderably diminished in-
stead. In place of these
factors, water evapora-
tion suddenly sets in.
Rubner has shown
that, when active perspi-
ration begins in man, the
influence of conduction
and radiation ceases to
be exerted upon heat
economy, but that the
work of the sweat glands
here causes a further slight increase in the amount of
heat production.
These somewhat complicated relations will be made
clear by a glance at the accompanying chart, constructed
from one of Rubner's experiments on the dog and in-
tended graphically to illustrate the essential points in
tlie mechanism of heat regulation luuier the influence of
varying degrees of atmos]ihcric temperature.
The next" table (table XXI.) shows the experiment of
Rubner on the dog which the chart is intended to repre-
sent graphically.
Table XXI.— Rcbner's Esperisie.nt.
(4) Ail' Cuvrcnts. Air in motion has a very important
influence upon heat economy. Rubner sums up its in-
fluence by stating that air currents cause physical heat
regulation to begin at a few degrees higher tempera-
ture than during a calm. Ranke expresses the same
thing by stating that air currents cause the critical point
in the temperature range to move a few degrees up-
ward.
((■) Humidit!/. The tliermic influence of atmospheric
humidity is twofold. It diminishes water evaporation
and improves conduction. By increasing conduction it
causes the lower limit of the temperature range to move
upward, and by retarding water evaporation it moves
UPPER
CELS.
30°
FAHR.
86°
CALORIES.
LIMIT.
4
8
12
16
20
24
28
32
36 40
44
48
52
56
60
64
68
72
76
80
84
I o
h-
_J <
< -1
0 D
55 e)
> ^
1 a:
Q.
So'
D- tn
w.
:.
-C
AND R
TTp. "
25°
75°
/
^
f
/
/
\,
/
\
/
a: 2
UJ o
o >
68°
CRITICAL
POINT.
so-
ls"
59"
\
1
s ^
X o
l-
-J <
< _l
s
\
\
\
\,
\,
\
v^
\
7"
«!6
\
s
\
s
s.
\
1
V
s
\,
\
S
s
S
\
\
\.
w
E.<!
C. AND R.'^
H
P.'
LOWER
CELS.
FAHR.
4
8
12
16
20
21
28
32
36
40
44
48
52
56
60
64 68 72
76
80
84
Ll^
/IIT.
CALORIES.
n
il
is
III
2 a S
3.sl
lii
615
C3
n
fi
|H
Is
1-g
il
7.(1
15.0
20.0
11.8
14.0
16.2
71.7
49.0
37.3
83.5
63.0
53.5
2,5.0
30.0
16.9
26.3
37.3
30.0
56.3
In the chart, the ordinatcs indicate the number of cal-
ories, the abscissa, the degrees of temperature. W.E.
stands for water evaporation ; C. and R. for conduction
and radiation, and II. P. for heat production; all else is
self-evident.
Fig. 3509.— Chart Showing Temperature Range and Heat Regulation.
the upper limit downward, thus narrowing the entire
range. Moist cold is colder than dry cold and moist heat
hotter than drj- heat. It will be seen, then, tliat the or-
ganism possesses no defences against the combined influ-
ence of excessive humidities and temperatures.
II. SriMECTivE Conditions. — (</) Food and Feeding. —
That amount and variet}' of food which an organism is
required to take in order to maintain its present weight
is called its need. If more food is taken than is required
for this purpose, the smaller part of the surplus only be-
comes converted into tissue ; the greater part is decom-
posed and eliminated. Consequently, an increased heat
production always follows the introduction of an amount
of food Ijeyond the needs of an organism to maintain its
weight, and tlie consequence of that is that the entire
range is moved downward. This is well shown in one
of Rubner's experiments (also quoted bj' Ranke). In the
experimental animal of Rubner, when it was in a state of
hunger, tliis sudden water evaporation began at a tem-
perature of 33.5° C. ; wlien 200 gm. of meat were given,
the sudden water evaporation began at 19.1^ C. and
when 320 gm. of meat were given, it began at 13.4° C.
This sliows tlie enormous influence of feeding upon the
temperature range; it moves the entire range a cou.sid-
erable number of degrees downward. Under the influ-
ence of high temperatures, therefore, every increase in
the food allowance beyond the mere need must mate-
rially increase the ditflculty of heat elimination and cause
the eritical point to move a corresponding number of de-
grees downward. The proteid food substances are the
1T9
Naval HyftJoiio,
INavaJ Hyglcuf.
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
most powerful iu this vcspecl . tlie fats tlie least elTective,
and the earbohydrates stand lielwecn the two.
(b) ifuKciilar Work. — Niinuu'oiis e.xpt^i'iments have
shown that the influence of muscular work upon the
temperature raiitje is a mo.«t i)owerful one. Since heat
production is greatly increased by all kinds of muscular
work. it.sinfl\ienee upon tlie tenijierature range is, brietly
stilted, that it moves it downward. Near the upjter
limit of the range we may reach a point wdiere a man
may be al)le to c-xist while at jierfeet rest, but where
every attemiit at work will leail to licat accumulation
and heat stroke and other patliological conditions.
(c) C'foM(X</ influences the temperature range b}' push-
ing it a certain number of degrees downward : it has,
then, \\\nm it an influence similar to that exerted by eating
and muscular work.
Tli(! salient points of our subject have now been brought
forward as thoroughly, we believe, as the scanty allow-
ance of space will permit. AVe will simply add the con-
clusions arrived at by Ranke from a most self-sacriticing
set of experiments which he made r.pon himself and pub-
lished in the mouograiih alreatly i-cferred to. Tliey are:
1. The temperature optimum of the European, in mod-
erate clothing, lies between 1.")' and 18"' C. (.59°-()4.4' F.).
providing that the other climatic factors exercise no vui-
due influence at the time.
3. In a climate with an atmosjiherie temiierature be-
tween the optimum and 32" C. (72^ F.) an increased
water evaporation begins to show itself, but no decided
influence upon nutrition is yet noted.
3. In a climate of a temperature of 25' C. (77° F.) and
on the assumption that other climatic factors are without
great influence, a diminished desire for food begins to be-
come manifest; the amount of food taken sinks to that
of a man doing very light work.
4. The climatic effect still rising, the amount of food
taken sudcs below the need of an adult at rest and in a
state of hunger. The proteids remain constant, and every
further diminution occm-s at the expense of fats and car-
boh3'c1rates.
5. If. against the instinctive diminution in the desire
for nourishment, food is forcibly taken in greater amount
than is desired, pathological changes in the general health,
rises in the temperature, and a decreased resistance to in-
fectit)us diseases will occur.
6. If. on the other hand, the quantities of food taken
are permanently diminished in accoi'dance with the de-
mauds of a tropical climate, as is usually the case, a
deficient nutrition of the organism is the inevitable re-
sult, with all the dangerous con.sequences that follow in
its train.
Prom these conclusions and from the preceding dis-
cussion, the leading principles that must govern the
composition of a ration or the diet of a man who has
transferred his residence from a temperate to a tropical
climate may be easily inferred. The details of it are sub-
jects of special research.
A sea climate is pei-haj^s more nearly a purel.y solar
climate than any land climate can ever be. A solar cli-
mate is defined as a climate which would be characteris-
tic of every degree of latitude, if the earth was a mathe-
matically perfect spheroid ^vithout unevenness, and had
throughout the same composition. This is true at least
for the great oceans. Although the value of the total
mean thermic effect of the climate, which the seaman is
exposed to as long as he confines himself to the limits of
his ship, has not yet been determined with scientific ac-
curacy, it may be safely said that; that value is less than
one found over a corresponding latitude on land. It
would most imdoubtedly lie modified by the ship, espe-
cially one of the modern battlcshi)is. iu wliieli every part
has a climate of its own and which must be regarded
as a heat-produeing body ; nevertheless, the total mean
effect on deck will be; found to bi; considerably less det-
rimental than the corresponding shore climate. AVith
the aid of a few thermometers, iisychroraeters, anemom-
eters and some interest and experience in scientific inves-
tigations, this work should present no difficulty. Until
it shall have been done, any expression of opinion on the
influence of the climate in which the seaman lives, upon
his heat economy, and upon the composition of his ration,
would be premature.
IV. Reckciting.
Recruiting for tin; uavj' signifies the separation by a
medical ollicer of the physically fit from the physicaDy
unfit, of the mentally sound from the mentallj' unsound,
of good timber from bad timber, for a most serious and
important service, the common defence of the land aud
its people against a danger threatening their commerce and
their liberty from the direction of the sea. Every jihysician
in the land .sliould be familiar with the principles aud ]irac-
tice of recruiting, and recent experience has demonstrated
the fact that every medical man in the country is liable
to be called upon to do this duty. "Whatever else theie
may be connected with the process of enlisting a man in
the navy or army, the point of gravity in the duty of re-
cruiting lies in the medico-physical examination of the
recruit; but to perform this duty properly requires some
knowledge as well as jiractice. AVe shall be obliged to
limit ouraelves here to giving a very lirief outline of some
of the more important principles involved.
To begin with, it is a mistaken notion to presume that
any individual with a normal heart and a good jjair of
lungs must necessarily be a tit candidate for the navy.
There are indeed many other points of equal importance
which the examiner must keep constant!}' iu mind while
scrutinizing a candidate. Besides seeing to special parts
in the anatomy of an individual, he must look at the man
as a whole. "Generally speaking, a tine form symmetri-
cally propoi'tioned, good development, regular features,
a good clear eye, a frank and open countenance, convev
an impression that is rarely misleading; the}' form an
index to the inner life of the man, usually favorable. On
the other hand, asymmetiy of face and body, irregular
ilevelopment and features, the stigmata of degeneration,
in at least tifty per cent, of the cases are unfavorable in
this respect. They would indicate an abnormal deviat ii >u
from the average, the juvenile otlender in the j'oiuig,
the hardened criminal and repeater iu tlio adiUt. Tile
nav}- can no longer be considered a reform school for the
juvenile olVeuder nor a prison for the cure of the har-
dened adult criminal. Neither the time nor the training
can be given in the service to such objects, however no-
ble, and there are other institutions, maintained by the
state, the special function of which is to attend to these
duties.
Besides good physique, the man, to be of any real and
permanent value "to the service, must bring with him
right from the start a good will, a high sense of duty
and responsibility capable of further training, all (if
which he must lie prejiared and willing to maintain dur-
ing the entire term of service to his country aud his flag.
This may be aiming high, but many years' exijerience.
both in recruiting aud in surveying the unfit, have
proved to my .satisfaction that the service is uot bene-
tited but injured by anvthiug below such a standard.
The Briiiith Nary. — The only other navy with which
our own can be comp;ued as regards the system of recruit-
ing is the British nav}'. Although the system of conscrip-
tion for the army has — until recently at any rate — alwavs
been considered iu England to be adetestable and insuf-
ferable encroachment on individual liberty, .sailors have
at all times been regarded as bound to serve in the io\-al
navy. If they did not enter the service voluntarily,
they were simply pressed into it by the press-gang, often
veiy ruthlessly aud cruelly. Tliese press-gangs, com-
manded by officers, were sent into the ports to seize all
available seamen. The man, thus forcibly enlisted, had
a small coin (the Queen's shilling) pressed iuto his hand,
and it is from this circumstance that the name press-gaug
is .said to have been derived.
This peculiar method of recruiting the navy, scorning,
as it did, all law and humanity, had nevertheless taken
such firm root in the habits and modes of thought of the
180
REFERENCE HANDBOOK OP THE 3IEDICAL SCIENCES.
iVaval Hysicne,
Waval Hygieue.
people of Eiigland that, eveu during the long period of
peace after Waterloo, when bumauitariaii principles were
taking a strong hold on all civilized communities, no
attempt was made to abolish the press-gang. Down to
the middle of the nineteenth century EngBsh admirals
declared that the press-gang was one of the props of the
greatness of England and absolutely indispensable.
By that time public opinion resolutely and persist-
ently objected to this forcible enlistment, so that in 1852
the Admiralty was forced to adopt new methods for the
recruiting of seamen for the navy — methods which turned
out to be highly beneficial, leading as they did to a thor-
oughl)- beneficial reform in the manning of the navy and
to a ver}' superior personnel at the same time. The royal
navj' of' Great Britain and the navy of the United States
are now both recruited on the voluntary system, while
in the continental naval services the system is by con-
scri])tiou.
The average of volunteers lias invariably been found
superior to that derived from those who were driven into
the service either b\' force or by necessity or who entered
for reasons of convenience. So far as the navy of the
United States is concerned, its personnel has markedly
improved during the last twenty-five years, and the gen-
eral public is beginning to look upon the naval uniform
with both ijride and affection instead of as a mark of de-
gi'adation.
For the details and the nature of the physical examina-
tion required in both services, the reader is referred to
Appendices I. and II., at the end of this article. Every
physician may well be supposed to be familiar with the
technique of the examination.
The Eecruitincnt of Officers.— 'DAs presents several
rather interesting as well as instructive differences in the
two services. lu the English service, considerable stress
is laid upon the circumstance that the J'oung naval can-
didate possesses a good family origin and connections.
Under the more democratic form of government f the
United States, this principle of selecliou does not prevail.
Then, again, the promotion to the higher grades o^ com-
mand rank does not proceed by seniority in England as it
does in the United States, but b\' selection.
There is, then, a certain amount of selection at both
ends of the line in the British service that does not exist
in the United States naval service. Besides, the cadet as
well as midshipman in the British service is obliged to
defray not only all his private personal expenses but also
to pay from fifty to seventy-five pounds a year for his
schooling. Thus there is, in addition to the above, a
monej' qualification. In both services alike there is a
physical and a competitive mental examination, in both
of "which the candidate must be successful before he can
become a cadet.
Granting that a certain amount of this selection which
characterizes the British service as distinct from the
United States service is done from motives of interest
other than the best of the service, we must perhaps d-
mit that the resulting average, thus carefully selected,
may in the end be for a steady and constant improve-
ment of their service after all. "Even the least important
of the qualifications, the money qualification, may not be
altogether without a certain value as a principle of selec-
tion. If we regard, for instance, the po.ssession of a cer-
tain amount of this world's treasure by the lad's father
or other relatives as representing a certain amount of
brain power which must have been expended at some time
in order to accumulate it. the natural conclusion would
be that the boy had inherited a part of this same brain
power, in a facultative state, in the same natural way as
he will some day inherit the accumulated ancestral pos-
sessions, "We may, moreover, further assume that early
training might do much to divert this power into other
channels: in other words, turn the lad into a successful
naval officer as his ancestor hsid proved himself success-
ful in other ways.
In the free and unhampered competition in the civil
life of a repul.ilic like that of the United Stales and in the
general scramble or struggle of the masses for social pre-
ferment, high official posiiion, professional distinction,
or financial betterment, almost any individual will in
the end find his level, in accordance with his natural
and inherited endowments, hisabilitics, acquired through
education, and the use which he makes of them. The
gifted, industrious, physically and mentally fittest will
easily rise to the top. \vhile the physically weak and the
mentally deficient will, as naturally and according to the
same law, gravitate to the bottom of this sea of human
life and of the multitude. The process of natural selec-
tion in the social sphere of human existence has full sway
here.
In naval and military life, in coimtries where all are
suppased to be born equal but are not, and in which se-
lection on the principle of true merit and ability has been
found either inconvenient, imi:)racticable, or impossible,
where artificial barriers are created aiKi placed in the
way of the advancement of organized merit and ability,
the results must very naturally be somewhat different.
While, perhaps, a high and uniform level of efliciency on
the part of the individual members of such a body of
men may not be inconsistent with such methods, an ex-
tremely daugei'ous dearth of leaders must, nevertheless,
remain the inevitable result of such a s^-steni, a dearth
most keenly felt at the most inopportune moihents of
national trials and tribulations.
In view of the above facts and considerations the proc-
ess known as recruiting, being practically Ih only gen-
erally recognized and accepted method of selecting those
who are fit for the service from those who are not. be-
comes of an importance all the greater. From this view-
point the physical examination of the recruit, more es-
peciallj', however that f the cadet, must appear in an
entirely new light and one which, in its far-reaching im-
portance, it would indeed be difficult to exaggerate
The Sigidfii'ance of Belectimi by Means of a Physical Ex-
amination.—^iWi the aid of a physical examination, as
this is understood at the present day, the scientifically
trained and practicallj' experienced examiner is able to
select, trom a given number of candidates, a group not
only superior in physique, but also, and at the same
time, one superior in mental qtialifications to the re-
mainder. He can, moreover, by the same means ex-
clude the criminals, criminaloids, and the degenerates.
It has been shown by a series of observations in differ-
ent parts of The United States and other countries, made
by Porter. Christojilicr, Hastings, Beyer, and others, that
children and youths who have inherited an exceptionally
good physique almost invariably also manifest mental
qualifications that are likewise superior. All these ob-
servations, made by different observers and by means of
different methods, have led to such imiform results that
the porrelatiou must seem unavoidable to any unpreju-
diced observer and the application of the principles in-
volved to the process of recruiting follows as a most nat-
ural corollary.
A necessary preliminary step to the ajiiilicafion of these
principles to recruiting is the preparation of tables ac-
cording to the percentile grade system of Francis Gallon
from as large a number of subjects as possible and from
subjects (men and boj's) of as nearly the same type as
those with whom the candidates \mder consideration are
to be compared. Such tables may include any number
of measurements and tests. W'hile height, weight, and
chest circumference must be regarded as absolutely es-
sential, other dimensions are verv desirable.
The tables published in "The Growth of United States
Naval Cadets." United States Naval Institute No. 74,
include a number of tests and measurements in various
dimensions; they will, therefore, do good service in the
examination of" cadets. The adjoining three tables
(XSII., XXIII., and XXIV) were made from (i.901 sailor-
men and boys, and may, coiisecpiently, lie said to be fairly
representative of the" physic|ue of that class of people
who have at all times a|>|ilie(i for eidistnient in the naval
service. Since, however, the averages imist be prepon-
deratiugly luacie u]) from the descendants of Anglo-
Saxon and Teutonic stock, the examiner will still have
181
Naval Hygieue.
Naval Hygiene.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Table XXII. — Heights in Peucentages.
sj
V.iHK IN INCHES AT THE FOLLOWI.NG PERCENTILE GRADES.
i
Age.
SOS
goe
2
>
5
1(1
20
30
40
.50
(ill
70
80
90
95
<
15
124
.59.35
59.87
60,66
61.60
62.54
60.37
64.13
04.82
65.77
6(5.87
67.92
6:j.8
10
305
60.58
61.23
62.06
62.8H
6:l.4(i
64.01
64.62
(».a3
66.19
07.31
68.09
64.7
17
288
61.27
61.99
63.01
0:i.70
64.31
(14.87
(J5.41
05.96
60.83
67.89
68.77
65.5
18
99
62.22
62.76
6:1.71
64.34
04.83
65.43
66.08
0(j.(i7
67.35
68.;i5
69.2(5
66.0
19
158
62.38
6:3.24
64.09
64.91
(a.51
65.68
Ofi.08
07.26
67.81
68.68
69.52
66.4
20
129
63.19
6:j..55
64.21
64.89
65.38
65.84
06.30
06.76
67.41
68.46
69.22
6(5.5
21
745
62.70
03.42
64.:!0
64.96
65.53
66.10
06.73
67.:36
68.02
68.97
69.91
66.7
22
931
62.54
63.42
64.48
05.26
65.95 ,
66.31
67.08
67.71
68.51
69.59
70.41
(5(5.8
23
662
02.85
6:t.()0
64.49
0.5.18
65.82
66.45
67.07
67.75
68.51
69.48
70.16
06.9
24
531
62.44
6;S.23
64.18
64.8S
05..5O
66.16
06.82
67..58
68.43
69.43
69.95
00.9
25
514
62.56
63.43
64.46
05.28
65.91
66..52
(i7.11
67.65
68.;3U
69.:37
70.47
66.9
26
395
62..37
(3.20
(>4.:b
65.18
05.94
60.22
(56.93
67.59
68.38
69.64
70..56
67.0
37
350
62.25
0:i.26
64.31
65.04
65.06
6t;.30
60.9(1
67.00
68.31
69.:30
70.28
60.8
28
336
02.25
(3.11
64.23
05.22
(»..■«
(i6.47
60.97
67.40
68.41
69..57
70.52
(50.5
29
318
02.14
(J1.35
64.21
64.92
(15.."i6
06.18
06..S(I
07.47
68.23
69.:30
70.2(5
(56.7
30
■zm
62.32
03.28
64.:w
65.03
(ii.TO
(i6.34
(;0.94
67.81
68.56
(59.41
69.98
(36.9
31
166
(U..S)
63.28
64.49
05.4;!
66.15
66.65
07.21
67.88
68.54
69.48
70..52
67.0
32
ITU
62.1)4
i;2.69
(i4.0<l
04..'*:!
65.45
06.0:3
6IJ.60
67.:33
68.37
69.:38
69.84
66.6
33
165
61.21
62.39
64.00
64.73
05..56
60.31
66.92
67.56
68.19
68.79
69.46
06.5
34
136
62.71)
(Ki.ai
04.25
05.22
06.18
60.64
07.23
67.80
6S.59
69.(52
70.37
07.0
35
119
6,901
61.6")
(a,07
63.98
64.69
(0.42
66.14
(i(i.80
67..52
68.2S
69.29
70.61
66.0
Total,
T.U5I.E XXIII. — AVeigiits in Percentages.
VAUE IX POU.NDS AT THE FOLLOWING PERCENTILE GRADES.
Age.
a of
1 = 1
£
g
5
10
20
30
40
.50
00
70
80
SK)
93
■<
15
124
80.,S0
89.70
95.95
102.:i3
105.84
109.00
lll.:35
117.80
123.05
129.44
133.80
1011.5
16
;30a
97.08
101.21
104.89
108.13
lll.,50
114.42
116.73
]22..5(l
127.18
1:34.12
141.76
lll.o
17
a<8
1(B.13
1(17.(59
111.06
11.5.77
119.68
122.60
125..53
129.27
i:S3.34
139..S2
142.72
127.9
IK
99
102.90
lOS.ilO
li:i..so
119.70
12:3..t;3
124.94
i:il.47
l:S4.66
1.39.20
147.10
155.:.'5
131.6
19
1.58
111.95
115.i«l
I20.:i0
124.2:5
120..30
128.45
l:!0.!)0
l:34..53
1:3.8.90
147.20
1.52..55
1:30.6
20
129
Klil.45
116.45
12:3.90
127.:34
130.12
1:53.90
137..57
140.47
143.40
147.70
160..55
1:51.0
21
745
116.47
119.97
VUM
12S..59
1:31.92
l:«.!R1
1:38.81
14:t..59
147.44
1,53.77
lOd.lt'
1:57.5
22
931
118.73
122.67
128.15
1:33.05
135.92
140.08
143.88
147.80
1.54.24
163.:i6
17:3.11
141.5
23
(5(52
121..52
124..S3
l2!i.s:3
135.68
1:37.8;)
140.85
144.22
148.24
1.54.04
16:5.10
170.95
140.0
24
531
117.11
122.34
Kill. 13
134.30
ias.15
14:3.27
145..S(;
149.75
155.23
102.,S2
170.:»5
137.4
25
514
120.62
134.10
131.4.5
1:35.18
i:39.:53
143.(57
147..53
1.51.7.S
1.57.44
166.00
173.:i(l
14.5.6
26
395
118.94
124.10
131 .SO
i:!7.(3
141.08
144 ..SI
US.17
152.92
l.)9.riO
1(5S.I7
170.42
146.U
27
3,50
120.00
121.70
131.20
i:)7.(Ki
l41.o:i
146.27
150.75
1.54.9:i
161.(30
109.,S7
177..50
148.3
28
3.56
116.80
12:3.05
1:30.37
137.:30
141.02
144.32
149.18
15l5.:32
161..36
170.28
179.07
144.9
29
318
119.56
127.27
i:i2.:i;3
1:35.78
140..53
144.0!)
149.01
]:i:i.l5
I."i9.,s5
109.64
180.42
140.0
30
250
120.88
124.56
1:50.73
i:35.k:3
141.4:3
146.20
1.51.71
i."ir.2u
KSl.OO
17:5.00
18:3..50
148.6
31
160
122.46
125..53
i:il.(50
1:37.97
144.28
149.1 HI
153.52
l.'i7.6(l
165.27
175.1:i
184.70
1.51.0
33
170
117..50
12:i.80
l;io.(Mj
i;i5.(xi
139.88
145.67
151..50
1.59.110
1(54..50
171.00
179.50
147.5
33
1(5.5
120.75
124 ..SO
i:i:i.5U
i:3s.,50
143.17
140.70
1.5.5.17
1.59.88
1(56..50
K0.5(l
l.s,s.:i7
1.50.1
34
i:36
117.60
12.'<.:3(l
KCi.OO
i:3s,.so
144.13
149.71
1.51.86
102.55
169..52
184.40
198.40
152.8
35
119
6,901
117..85
12:i.:30
i:k.40
140.90
14.5.40
149.:38
1.55.80
li5:i.:3o
169.24
178.20
192.15
1.50.8
Total,
Table XXIV. — Ciuccmference of Chest in Percent.^ges
Vaue in inches at the Following Percentile Grades.
t
Age.
e°«
2
2^1
5
10
20
30
40
50
60
70
80
90
95
s
■<
15
124
:J7.02
27.48
28.29
28.91
29.50
30.07
30.33
;30.99
531.76
;32.72
33.31
:i0.8
10
305
28.10
28.23
29.12
■£).m
29.92
30.40
;i0.95
:31.36
31.83
32.;36
33.51
31.0
17
2.88
28.76
29.28
:3(i.o2
:3ll.31
30.1)0
31.34
31.60
32.20
32.57
3:i.(i9
34.51
31.9
18
!I9
29.13
29..S4
:ki.42
;3o.s9
;3i.:i5
31.80
:i2.28
32.80
33.33
.3:3..s.5
34.68
:i2.4
19
1.58
2SI..54
:ill.l4
:3(l.72
31.21
:3l.6i
32.00
:32.46
.32.93
33..56
34.:i7
34.94
:32.6
20
129
29..5-
:)ll.30
31.13
31. .5S
:32.02
32.30
32.99
33..>!
:34.11
:34.76
35..52
33.0
21
745
:30.23
:«l.83
31 ..50
:3;i.ii8
:32.62
33.14
33.60
:34.06
34.70
:3.5..57
36.:i8
33.6
22
931
30.73
31.:32
:32.12
32.(50
:3:3.(i!)
33.62
34.17
34.77
35.47
36.42
37.29
34.2
23
662
31.02
31. .57
:32.:39
:32.98
:3:3.5l
34.00
34.55
:!.5.12
;i5.72
.36.61
37.43
34.6
24
.5;!1
30.92
:3I..55
32.:3S
:3:i.o(i
:«.ol
34.17
34.65
;3.5.13
35.81
:56.73
37..57
34.3
•&
514
31.29
:32.09
:32..so
:3:(.:io
:3:i.77
;34.29
.34.88
:i5.4:3
35.98
36.94
37.70
34.8
26
395
:!1.26
:32.08
:3:3.(ii
%UA
34.118
;34.67
35.24
:i.5.77
3<5..51
37.56
38.3:5
35.2
27
350
31.23
;32.0.5
:32.90
:3:3.59
34.:M
.34.80
35.38
;i.5.SHI
36.73
37.77
38.32
35.3
28
350
31.12
531.90
:32.92
:3:i.7:i
:34.:«i
34.73
35 38
:i5.97
36.8:3
37.77
38.77
35.4
29
.318
31.24
32.29
:32.96
:3:i.:!(i
:34.:i9
34.83
35.39
:36.00
36.66
37.72
38.86
35.4
30
250
:il.42
:32.09
;3:3.11
:3:3.8i
34.40
:34.95
35.66
:56.34
37.00
:38.13
38.91
35.6
31
1(5(5
31.43
:32.20
:3:3.29
:54.o7
34.71
;55.27
35.78
:36.:3i)
:30.41
37.14
39..57
35.7
32
170
31.23
:32.oo
:3:3.a5
:34.15
34.65
:!5.17
35.76
:36.2!)
:30.77
37.82
39.;30
35.6
33
165
:!2.09
:32.68
;3:3.48
:34.I2
:34.69
:5.5.27
35.86
;)6..52
;!7.23
;(7.98
38..86
:35.8
34
136
31.09
31.86
:i:i.:52
:34.15
:34.20
:i.5.(IO
35.80
:3().54
;37.:39
38.73
39.65
35.8
35
119
6,901
30.99
:32.39
:3:3.60
:34.2s
34.79
;«.26
35.74
36.66
37.84
39.01
39.67
36.0
Total,
182
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES,
Naval Wyslcne,
Naval Hyslene.
to use bis judgment as regards the type of man before
him in adjudaiug his relation to tlie averages given in
the tables. Such tallies are to the examiner what the
compasses are to the navigator. One or two examples
will perhaps help to make this elear.
Example I. A boy presents himself and his nearest
birthday makes him tifteen years old. The measuring
rod gives his height as 63.4 inches, the scale shows that
he w-eighs 109 pounds nude, and the tape measure around
his chest, taken at the level of the nipples, shows that
his chest circumference is 30 inches. Looking now at
the tables, along the line of averages obtained from boys
of his aire (fifteen) we shall find that all these figures fall
under t"he fifty percentile grade. What does this indi-
cate and what is his physical relation or standing when
thus compared to the rest of the boys of his age? It
means that out of one hundred boys of his age, our can-
didate is taller than forty-nine and not so tall as the re-
maining fifty above him; the same is, of course, true for
weisht and" chest circumference. In other words, our
bov'is an average, or mean, lioy for his age.
Example II. Our second boy is sixteen years old, his
heisrht is recorded as five feet and one inch, his weight as
10.5''pounds, and his chest circvimference as 29..5 inches.
Our tables show him to be ten per cent, in height, twenty
per cent, in weitrbt, and thirty per cent, in chest circum-
ference. These^several percentages added together and
averaged make him a twenty-per-cent. boy: lO + SO-f
30 = ^^ = 20. In this manner a boy's physique in its
relation to that of all the other boys of his age and type
is brought out and the physical examiner gains an idea
.of the probable relation of his candidate to the rest of the
f communitv. Although it is, comparatively speaking, a
rare occurrence that^a recruit is found to have all his
measurements fall under the same percentile grade, it
is nevertheless also a fact that, whenever such is the
case, our candidate shows a perfectly symmetrical de-
velopment.
It has been found over and over again that the curves
.constructed from a number of children and youth, meas-
ured and averaged in this manner, when compared with
the curves from their mental examination marks received
at school, run very nearly parallel. An undovibted cor-
relation between the phv'sique and the mental perform-
ances of children and youths is hereby fully established
and tlie application of the principles involved to the se-
lection of recruits made apparent.
The minimum standards of height, weight, and chest
circumference required from boys intending to enter the
navy, as given in Appendix II., are all of very low per-
centage, when compared with tlie percentile grade tables,
and c'annot, therefore, be said to serve any purpose of
selection. If notwithstanding these low limits we get a
class of men into the service that is better than our re-
quirements would indicate, this would seem to have been
obtained in spite of and not with the aid of our examina-
tions.
There seems to be nothing better established and rec-
ognized bv prominent army surgeons— e.g. . Greenleaf,
WoodhulK Munson. Woodruff, Tripler, and others— than
that the lowering of the physical standard is invariably
followed by a lowering of tlie moral standard.
Notter also believes in the correlation between the
physical and the moral standards. 3Ien of defective de-
velopment are noted for the time which they spend on
the sick list, in confinement; they are also known to
furnish by far the ereatest number of deserters.
The following talile (XXV,), showing, as it does, that
the percentage number of deserters has steadily incre;isi(l
since 189,5, except during the war of 1898. would, if at-
tributable to faulty recruiting alone, indeed be a reve-
lation. But. althoush recruiting undoubtedly has its
share in the production of such a large percentage of de-
serters, a careful and unbiassed inquiry winild no doubt
result in tracing such wholesale desertions to a variety of
causes. Such an inquiry, if it were made without fear
or favor, would throw valuable light on the subject.
>Ir. Arthur H, l^ce {S ineteeiith Century Magazint, 1901),
Table XXV.
Naval Fokce.
Total.
Xuinber
of
desert<'i-s.
Year.
Ameri-
can.
Foreign.
per cent.
1S9.5
5,'f20
6,126
14.8:38
11,446
5,''iai
5,219
4.990
5.386
10,ttXi
11,000
ll.ati
22.828
16.8.32
18,000
888
1,041
1,3.57
1,317
2.453
3,100
8.8
1K(I6
9.5
isiir
12.0
1.k;is
ISIS
lillXI
5.8
14.6
17.2
treating on the "recruiting question," says of the English
army, where the standard had been lowered several years
in succession : " Owing to the poor quality of the recruit
enlisted, it ensues that less than 47 per cent, ever serve
their full term; the remaining 53 percent, are completely
lost to the service and the country after an expensive
training and a few years' inefficient service." "Owing
to the same cause, the annual number of desertions has
risen from 3,3.57 to 6,378." "Owing, moreover, to in-
eflScient recruiting, at least 10,000 men disappear an-
nually from the ranks of the army, for no valid cause
beyond moral and physical unfitness," "The pecuniary
loss t<i the nation from this cause alone is over 100,000
pounds sterling per annum, which, in my opinion, might
be entirely obviated if the proper men were enlisted to
begin with."
Sir. Lee's fundamental contention is, that the physi-
cally and mentally developed man is not only incompar-
ably the better soldier, but is much the cheaper in the end.
Lord Kitchener has several times loudly complained of
the poor and useless quality of recruits sent him to South
Africa, and Kulp, from his recent experience, remarks.
"The undersized, underfed, and underdeveloped boys
one sees invalided from South Africa are not at all rep-
resentative of the sturdy English race."
Thus it would seem "that a lowering of the physical
standards in order to increase the number of enlistments
does not add to the value, the strength, or the efficiency
of an army and is an unnecessary waste of public money.
Since tliere has been at all times a large ]>ercentage of
men of foreign birth in the navy, it is interesting to
note the dift'erence in physique between that class and
the native-l)oru American." The adjoining table (XXVI.),
calculated from— as nearly as that could be done— an
equal number of both irroups and of the same age (twenty-
one) shows that, while the Americans have a slight ad-
vantage in height in almost all the percentile grades, the
foreign-born American seaman has a more decided ad-
vantage in both weight and chest circumference.
Table XXVI. — Averages of 350 American akd 316 Foreign
BORX (ALL TWE.\TT-OXE YEARS OLD) COMPARED.
HEIGHT INCHES.
Vr EIGHT,
POU.NDS.
Chest
CiRCe.MKERE.VCE.
c
2
ID
ii
c
1
|i
u
'S
Ami'ri-
can.
d
62.91
62.61
113.2
11,5.4
29.4
311.3
111
6:3..5I1
6:3.411
116.9
119.5
;!0.2
:31.0
20
61.48
64.30
121.5
124.5
31.0
31,7
;3o
65.27
64.86
12,5.0
128.5
31.5
32,3
40
65.96
6,5.40
128,0
i:il.5
31.9
32.8
.50
66..52
65.93
131.4
1:34.7
32,3
33.3
611
67.06
66.6:5
135.11
l;3S.4
32.7
33.6
Til
67.61
67.34
13<.l.l
142,2
3:3.2
34.3
811
68.21
68.05
14:s.5
147,5
33."
34.9
90
68.94
68.88
149.4
1.5:3.9
34.5
95
69.86
69..52
1.57.2
159.2
35.2
36.7
The Significance of War tothe yationaml tlie Race.— It
is said of physicians that a large portion of their work is
directed tow"ard the prevention of disease rather than to
the cure of it, and medical men have the rare distinction
of being perhaps the only workmen known who make it
183
Naval Hyg-lcnc,
Naval Med. Service.
REFERKXC'i: ]IANDi;o(_)K OF THE JIEDICAL J^CIENCES.
their first duty to stop the so\ircC'S of supply wlienco
they derive tlieirineoiiie. To prevent disease and sufl'er-
ing is, ueverllieless, the highest funeiicm of hygiene and
one of tlie nolilest aspirations of modern niedieine. If we
look ujion wars as pn'Vental}le causes of disease and suf-
fering and of death, it would seem to be one of the func-
tions of naval and military hygiene, not only to modify
if not altogether to exterminate Indicts, as we arc trj-ing
to annihilate germs, moscjuitocs, and other disease-pro-
ducing agencies, but also to try to devise means for the
final abolition of war itself. Tlie gradual reduction in
the calil)re and the cliange in shape of the new small-arm
projeclile seem to be a step in this direction. In the same
sense, arbitration may some day li'l a ehai)1er in a work
on hygiene, and the great peace conference at The Hague,
called into being by the august nder of all the Kussias a
few years since, would then coustitute, liistorically speak-
ing, "the first great inlernational attempt at promoting the
fundamental interests and purposes of naval and military
hygiene. War undoubtedly is the greatest and most
merciless destroyei- of the best there is of human life.
The history of every war-like nation usually ends in the
extinction of the best of that nation. Greece died be-
cause the men wlio hud made Iier glory liad all passed
away: leaving none of their kin, they left none of their
kind. The Greeks of to-day are tlio sons of those of
Avhom she could make no use in her conquest of Asia.
Indeed there is strong ground for the statement that
there was more of the old heroic blood of Hellas in the
Turkish army of Edhem Pacha than in the soldiers of
King George who tied before them five years ago.
The cause of the fall of Jiome has been traced to the
extinction of the best of her race through her numerous
conquests; only cowards remained an<l from their brood
came forward the new generations, and eveu C'a'sar noted
the dire scarcity of real men, and " vir,'' the real man, be-
came "homo," a mere human being.
'■ Send me the best _vou have," sai<l Napoleon ; '' I want
men, not boys. " 8ince the time of the French Hevolution
and the Xajioleonic wars, French skidls may be found
piled up in Italy, Austria, Germany, Russia, Egypt, and
Spain. They-are tlie .skulls of the best men that France
had sent into the field. It was only after these were
gone that the great general began to call for boys, say-
ing, "A boy will sto]) a bidlet us well as a man," and
these died without leaving any otTspring. From that
time onward the men of the hue became the fathers of
the present men of France. JI. Legoyt thinks it will
take long jieriods of jieace and ].denty liefore Fi'ance can
recover the tall statures mowed down in the wars of the
republic and of the first Empire.
^Ir. Arthur Knapp, in his work entitled "Feudal and
Jlodern Japan," says: "It is astonishing to find tlait
after more than si.\ generations, or more than two hun-
dred years of ]ie;ice in which physical courage has not
been demanded, these virile powers in the Japanese
.sliould be found unimpaired." The student of history,
however, finds that this is just what he would expect,
for. in times of pe;ice. there is no slaugliler of the
strong, no sacrifice of the braver and courageous. It is
in accordance with the laws of natural historv and is
proven Iiy all the records of human history that the na-
tion whicii has seen the least f>f war always develops the
strongest liatlalions.
Germany, always systematic and thorough, taking ad-
vantage of the lessons taught by scientific research, and,
guided by the best principles of lla: times. guar<ls her
men and reduces the waste in war to a minimum, liy tlie
strictest iittention to scientific hygiene. She is military
rather tli;in wailike. In modern times, the gri'atest los's
to Germ:iny has occurred through eniigialioii, not
through wars. The tendency of all emigration, whether
from country districts into towns in the same country or
from one country to another, has always been to weaken
those left behind. Amnion has shown, for Germany, by
measurements, that the average of tho.se who emigrate is
superior to the average of those who stay behind. Quete-
let has shown that in some towns of Belgium the average
stature was a little higher than in the country. Dunant
found this to hold gcoil with respect to the inhabitants of
Geneva as compared with the countiy people around.
Villerme, ^lanouvrier, and others have shown tliat the
stature of the Parisian conscript is higher by 8 or E) mm.
tlian that of the men belonging to the rural arrondissc-
ment of the Seine. Germany has long since recognized
this, and hence her struggle for colonics, the possession
of which alone can save her ever-increasing population
to her fiag. It is want of room and lack of opportunity
that drive her sous to foreign shores, not fear of military
service I
Holland has become a nation of old men. Her son&
have died in the fields of Java, and Batavia alone is said
to have one million of Dutch graves. Dutch armies are
to-day recruiteil elsewhere, Holland will not waste any
more of her own blood.
" Spain died of empire .years ago. She has never really
crossed our path, it was only her ghost which walked at
Manila ami Santiago. The warlike nation of to-day is
the dee;ident one of to-morrow " (David Starr Jortkn,
Foriiiii. 19U1).
As long as the physician cannot prevent the occurrence
of disease, he will have to continue trying to do his best
to cure it ; as long as war will continue to recur, a nation
will have to face the foe. Since, however, the most
skilful physician for the care and treatment of disease
will in tlie end jirove the least expensive to the family,
so the best sailor and soldier will invariably prove the
more remunerative to the state. To bring a war to a
speedy and successful termination, a nation must offer
as recruits, and lie willing to sacrifice, the best she breeds.
Henry G. Beyer.
APPExnix I. Re'iuircmenlslnrEnKstmcntin iheBrHtsliifav't.—
The British navy is enlisted U|inii tlie Voluntary System. Theseaiiian
must tiavea irctcui physii|iie, thciifrli heiglit, apait from a good devel-
opment, is ronsidered of iio ailvania-je. While no physical exauiiiia-
tion is required for the meicaiiUle marine. lunie but'promisini,^ lails
are aeeepted tor the trainihtr ships of tlis >Iajestv\s navy, ami persons
of whatever aire or class found to he lahorinir under any of the under-
mentioned physical defects or deformities are. liy .\rtii'le llTit of the
Admiralty Instruetions, l.s9!). <-oiisidered unlit for the service ;
(ri) A weak constitution, imjierf.rt devi-lopmeut. or imporiant mal-
fonnation oi- physical weakness, eith"r iiereihtary or acquired.
(/*) Skin disease, temjiorary or trivial ; e.\teusive marlis of cupping,
leeching, blisterintr, or of issues.
(c) Malformations of the head, deformity from fracture or depres-
.sion of the bones of the skull, impaire<l iutelJect. epilepsy or paralysis
or impediment of the speech.
id) Blindness or defective vision, imperfect perception of colors, or
any chronic disea.se of the eyes or eyelids.
(c) Impaired hearin.t?, discharge from or disease of one or hotli
ears.
1/ ) Disea.se of nasal bones or cartilasre and nasal polypus.
(o) Disease of throat, palate, tonsils t>r nn.aiih ; ei<-at rices of neck,
whether from scrofula or frcau suicidal wounds; tnisound teeth or
seven teeth missing or defective in persons under seventeen veal's of
a,';e ; ten defective or dellcieut teeth in persons ahove the age c^f
seventeen.
I/O Functional oronianic disease of the heart or biood-vessels, de-
formity of chest, phthisis, bronclntis, h:eniopt\sis, asthma, dyspnn>a,
chronic cough, or any evidence of lung disease or tendency thereto.
{/) t'ndue swelling or disteniion of the abdomen; disease of liver,
spleen or kidneys, hernia or tendency thereto, incontinence of urine,
syphilis or gonorrhoea.
(.ii Non-descent of either or both testicles, hydrocele. varic'»cele. or
any other serious defect or mahorinalion of the genital organs.
ih) Fistula of anus, hemorrhoids, or auy disease of stomach and
bowels.
(H Paralysis, weakness or impaired motion, or deformity of either
extremity. iiK-Iuding varicosity of veins, especially of the leg, and
distortion or maIformatli>n of bands, feet, lingers or toes,
{mi l^islortion of spine, of the bones of pelvis, no matter whether
from injury or disease, or from constitutional defect,
.^PPK.vnix TI. licqiiimncnlsfnr Eiiliatinoit in the Vnited fitatcs
A'ii('!(.— Brieily stated, the pbysical requirements for enlistment in
the United states navy are as follows: The candidate nuist be of
good physical proportions, and, if accepted, is required to take oath
before eiilislment that he is not sub,iect to llts and has no concealed
diseases. Any of the following conditicais are sutHcient to cause the
rejection of an applicant: tireally retarded development ; feeble
constitution, inherited or a<'quirerl ; permanently impaired gem-tal
liealth; depraved coniiilion of general niitrilion ;*liability to any dis-
ease: chronic diseases or results of injuries sutlicient permanently to
impair eflli-ieticy- such as weak or disordered intellect: epilepsy or
other convulsions within live years: impaiied vision or chronic dis-
ease of the ears: chi-onic or oiTensive nasal catarrh: tiimoi-s of the
nasal passages or great enlarsrement of the tonsils: marked impedi-
ment of speech ; tiecided indications of liability to pulmonary dis-
.ease; chronic heart affections; rupture: non-appearance of testicles ;
dropsy of testicle or cord ; stricture, Dstula or hemorrhoids ; large
184
REFERENCE HANDBOOK OF THE MEDCIAL SCIENCES.
>aval ilysirne.
Naval :^Icd. Service.
varioose veins of lower limbs, scrotum or cord ; cbrouic ulcers ; cu-
taneous and communic:ili]H diseases; unnatural curvature of the
spine; wryneck or other defunnity; liprnianent disability of either
of the extremities or nrticiitatKin from any cause; defective teeth;
the loss or extensive caries of four molar teeth.
In addition to the above, candidates for enlistment as apprentice
must at least fulfil the requirements of the following table of uiini-
mum measurements:
Age in years.
Minimum heipht.
Minimum
weight.
Minimum chest
circumference.
10
4 feet ii inches. 7U pounds.
4 feet 11 inches. 8(1 pounds.
5 feet 1 Inches. 90 pounds.
2ii inches.
2T inches.
28 inches.
NAVAL MEDICAL SERVICE.— I. Naval MEDrcAL
Depaiitment. — Ilistt/iiail JVoticc. — "Tlip Mitriue Com-
mittee " of the Continental Congress made provision at
an eai-lr date for a medical department of tbe navy, and
declared "the care of the sick and wounded to be objects
of great solicitude." In the "Rides for the Regulation
of tlie Navy of the United Colonies." adopted November
28th, ITT.J, this service was defined. After the comple-
tion of the revohitionary struggle slow progress was
made, until 1794, when the entire naval service was aug-
mented; yet at this time the medical departments of tbe
army and navy were one, under an officer who l)ore the
title of physician-general. Not until 1828 were the me<li-
cal deiiartments of the army and navj- divided. In 1843
the bureau of medicine and surgery of the navy depart-
ment was created, and W. P. C. Barton was nominated
its chief. Bj' the act of 1871 the entire service was reor-
ganized, the grades of medical director, and medical in-
spector created, and tlie title of surgeon-general, with the
relative rank of commodore, couferred'on the chief of
bureau. In March, 1898, this officer was given the rank
and title of rear-admiral.
Tbe organization of the medical corps of the navy is
essentiallv tliat created by tlic act of 1871, and amended
by the acts of 1898 and 1900.
Tlie gi~ades, ranks, and titles in the medical corps of
the navj', compared with that of the line of the army and
navy, is shown in tbe table prepared by Medical Dii^cctor
Gihon, as modified by existing law.
U. S. ARMY.
U. S. Navy.
All Officers.
Line.
Medical omcers.
Adniiral.
Rear-Admiral
Captaiu
Comniander
Lieut.-Commander.
Lieutenaut
Lieutenant (Junior
Grade)
Lieut. -(ieni'ial.
Maior-Geueral ...
Brif?adier.
Colonel
Lieut.-Colonel
Major
Captaiu
1st Lieutemmt
Surgeon-Genera!.
Medical Director.
Medi'-al Inspei-ior.
SurfT'^ons (Senior).
j Sura-enns (Junior).
( Passed Asst. Surgeon (Sr.j.
3 Passed Asst. Surpeou (Jr.).
1 Assistant Surireon.
By the act of 1808 positive rank was cimferi-ed on all
officers of the medical corps of the navy, and in 39(1(1 as-
sistant surgeons were given the raidc of lieutenaut(junior
grade), corresponding to first lieutenant in the arniy.
The titles, grades, and numbers hi the medical "corps
of the navy are as follows, viz. : 1.5 medical directors, !•")
medical inspectors, 5.5 surgeons, and 105 in the combined
grades of passed and assistant surgeons.
The nundjcr of officers in tlie gi-iide of passed assistant
surgeon is nut limited, the law providing for promotion
of assistants after three years' service.
The surgeon-general does not constitute an e.xtra num-
ber, but is chosen from the grade of director or inspcctcir
for a term of four years, being eligible to reappointment.
All officers of the navy retire on reaching the ag(! of
sixty-two years.
Examination and Appointment. — A candidate for en-
trance into the medical corps of the navy must be between
the ages twenty-one (21) and thirty years (30). He ap-
pears before a board, which is under oath to rejiort on
his physical, mental, moral, and professional (lualifica-
tions.
Appointments are made in the order of merit reported
by the board.
Tlio examination is: (1st) physical: (2d) mental, con-
sisting of ((/) written, (i) oral, (c) clinical, ((/) practical,
and embraces about six days.
The board of medical examiners sits permanently at
the Naval Hospital, New York. Prior to 1897 no exami-
nation was required from the grade of passed assistant
to that of surgeon, but under present law examinations
occur with each promotion. The examination for the
grade of surgeon relates largely to an officer's experience
attained in the lower grades. It comprises the following
subjects: (a) Naval regulations, in so far as they pertain
to the medical department : (h) thesis on general and na-
val hygiene; {e) thesis on cliuictil medicine; {d) practical
liacteriology and chemistry: (c) microscopv and microbi-
ology; (/) military surgery.
The flow of promotion is dependent upon resignations,
dismissals, retirements, and death.s.
Officers reaching the grade of surgeon at this time
(1900) have been in the service about ten years. The
disposition of officers entering the corps depends upon
tlie exigencies of the service T it these permit, tliey are
ordered to receiving ships, and gain some preliminary
knowledge of the duties and life at sea. Tlie percentage
of those given permission to appear before ihe board of
examiners, who pa-ss, is small. Thus, of the twenty-two
candidates who presented themselves during the "fiscal
year ending in 1890, four were rejected "phvsically,
twelve were rejected jirofessionally, and six were found
qualified for tbe position of assistaijt surgeon. It cannot
be concluded from this statement that the examination
is unduly rigorous, but rather it is indicative of insuffi-
cient academic study and a lack of thoroughness in the
professional equipment, which we fear is far too common
a condition among the graduates of a large number of
medical scliools in the United States.
The compensation of oflicers of the medical corps is
that of their corresponding rank in the line, and is .shown
as follows :
Pat T.IBI.P-.
Assistant Surgeons : Rank of Lieutenant
(.lunior Crade)
P:i.ssed Assistant surfrerms:
Rank xi I.ieuieii:uit (Junior Grade)...
After live years in the service
Hank of Lieutenant
.\fter live years in the service
After ten years in the sei'vice
Surgeons :
Rank of Lieutenant : After ten years in
the service
A iter nfteen years in 1 he service
linnk of Lieuten.ant-Commiiuder: Af-
ter ten years in the service
A iter tlfh^en years in the service
Medical Inspectors, rank of Coinmander :
After fifteen yeai-s in the service
Medical Directnrs, rank of Captain :
.\lter fifteen years in the service
Surgeou-General, rank of Rear-Admiral.
Sl.lJriO.flO
l,().i0.00
i.snti.iHi
l.asn.eii
3.1(i(1.0()
a,;i4o.(K)
a,f)ai,oo
a2.in.no
:j.-)«o.oo
4,(KX1.00
4..">(;n.on
.i.'.tW.OO
Sl,4(B..')0
1.402.50
l.WD.Od
l.liKi.lK)
l,s:!(i.(H)
i.ysy.dii
i.nsit.no
2,142.UU
2.7Ci2.on
2,it7.").«l
3,4(Xl.no
3,82-i.(KI
5,51«UKI
S2,ss.no
2S8.no
2.ss.(in
4;i2.(Ki
4:a.(«i
•I 32.00
432.00
432.00
.irn.oo
376.IX)
oTn.oo
720.00
720.00
The hospital corps of the navy was authorized by an
act of Congress, .lune. 1897, thus'securing for llie service
skilled men for the care of the sick and w-ounded.
The hospital corjis consists of the following grades
and rates: (<«) Pliarmacists, warrant officers: (li) hospital
stewards, chief petty officers; (c) hospital apprentice,
first class; {d) hospital apprentice, second class.
* Only when quarters are not furnished by the Government.
Eight cents a mile is the allowance when tnivelliug under orders.
185
"Naval ITIedical
SersU'e.
KEFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
An examination, physical and professional, before a
board of medical officers, is ix-quired for enlistment and
for promotion in each of the above grades.
The naval medical department nVaintaius hospitals at
the following places: Widow's Island, 3Ie. ; Portsmouth,
N. H. ; Boston. JIass. : Newport. R. I. ; Brooklyn. N. Y. ;
Philailelphia, Pa.; Washington. D. C. ; Annapolis. Md. ;
Norfolk. Va. ; Pensacola. Fla. ; Man- Island, Cal. : Yoko-
hama, Jaiian; C'avite, P. I. Tlie hospitals provided by
tlie oriffiual act of Congress were those at Boston. New-
York. Philadelphia, and Norfolk. That at Philadelphia
has been converted into the Naval Asylum, and a fine
modern structure has taken its place.
The naval hospitals of the United States and other
powers have been fullv described bv Surgeon J. D. Gate-
wood, U. S. N.*
At a comparatively recent date most of these hospitals
have been modernized in construction, and their equip-
ment has been raised to present requirements.
Although the hospital ship Maine has done efficient
service in" South Africa, the floating hospital of the fu-
ture will be the Ambiihinre S/iip. such as was the fiolace
during the late w-ir with Spain. The object of such a
ship is to collect the sick and wounded in a tleet after an
engagement, render inunediate succor, and transfer the
wounded to abase hospital. While the presence of such
a ship amiil hostile fleets had been previously proposed,
the desiraliility of such a step w-as formally advanced,
and earnestly advocated by the present chief of bureau.
Surgeon-General W. K. Van Reyiieu, in a pa)icr read
before the Twelfth International jledical Congress, held
at Moscow in 1S9T. and in less than a year it was this
officer's privilege to commission the S'/aa . a .ship such
as he had described, which rendered such excellent ser-
vice in the war with Spain.
The Suhire hail a displacement of thirt)'-six hundred
tons, was three hundred and seventj- feet over all, with
an average speed of fourteen knots; she carried steam
launches and barges for the transfer of the sick and
wounded. Hoisting and lowering were accomplished by
steam winches. A complete aseptic outlit, form:ddehyde
generators, disinfecting chambers, lavanlry, and drying
room were provided. The jS'/Zf^rf accommodated three hun-
dred and fifty patients. Ventilation was accomplished by
means of powerful blowers and electric fans. The .ship
flew the Red Cross, and was under the protection of the
Geneva Convention. Indeed everything whicli could be
suggested to make tliis floating, travelling hospital a
success was done. The excellent resulls accomplished
justified all expectations, and established a decided ad-
vance in the humanitarian aspect of modern war.
Hospital ships ma}' still serve a useful purpose as be-
fore stated, when the base of a fleet is too remote to per-
mit of the transfer of the disabled. When conditions
obtain, such as those at Santiago, or such as prevail at
present (IStOO) in ilanila and China, the Ambulanee Ship
will be of inestimable value so long as Japan can be used
iis a base.
Service iit Sen. — Thejirogress made in the past tweuty-
five years in the betterment of conditions making for
Iiealth on shipboard are only equalled b_y the advance in
the sciences of medicine and surgery themselves: yet
the former condition is not largely due to the latter, but
rather to the improvement of naval construction and a
higher appreciation of sanitarj- ]iriuci])les, wliich have
been so persistently inculcated. Medical l)ire(tor Gihon
lias drawn a graphic picture of this change; and since
this officer's active service closed, the improvement has
continued, the modern man-of-war presenting the most
striking object-lessons, showing how an observance of
the prime principles, involving a supjily of fresh air,
good lighting, and scrupulous cleanliness, has so far suc-
ceeded as to render a most unnatural life and environ-
ment a comparatively healthy one. In this connection,
it miist be borne in mind what a radical change has been
* " Naval Hospitals. Medical Schools and Tnuninj? School for Nurses."
Press of the Friedenwald Co., Baltlniore, WJ'J.
wrought in the life of a man-of-war's crew by the change
from sail to steam jiower; and to overcome the delete-
rious efl'eet thus bi'ought about has been the most impor-
tant problem which the naval medical officer has been
called upon to consider; and the splendid results obtained
in our service iluring the late war are most creditalile
alike to commanding and to medical officers. We have
eveiy reasonable hope that the lessons of the past are
now heeded, and that the inutility of a ship, however
powerful, .with a crew living in imhealtln- conditions, has
been am]5h' demonstrated. Suc'a was Admiral Vernon's
expedition against Carthageua, in which tlie crew were
crowded into dark, ill-ventilated sleeping quarters, and
were fed upon salt and often decomposing food with bad
water. Surgeon-General Tryou has jiointed out that
when iron and wood supplanted steel as the material for
the construction of ships, a destructible organic substance
was substituted b_y an indestructible, inorganic substance,
and this change worked the most important reform in
naval hygiene. The .sequels of this change were broad
inlets for the admission of air. and light, systematic ven-
tilation, the distillation of water, its preservation in iron
tanks, and the improvement of the rations by the art of
preserving foods. Thus ',vere accomplished the condi-
tions which have made prolonged life at sea not only
possible, but one closely approaching the natural. A
discussion of such questions belongs to the domain of
naval hygiene; they have been alluded to here, and give
the reader an idea of the broader lines of duty which will
engage the attention of a medical officer at sea. The de-
tails and daily rounds ai'e soon mastered, and are imiior-
tant or unimportant, much more in the way in which the
sanitarian of the ship conceives of his duty than in any
other. The naval medical officer will soon learn that it
is in the broad realm of preventive medicine that he will
find his sphere of greatest utilit}'; that to ameliorate the
effects of environment and to reduce the potency of
pathological factors should be his chiefest aim.
The daily duties are defined by regulation ; and besides
attention to and report upon the condition of the sick, they
embrace an inquiry into that of the living spaces, cells,
closets, pantries, and an examination of food and water
issued or coming on board. A duty peculiar to army
and naval medical service is that of determining whether
in a given ease of disease or injury it is the result of
causes incident to service; on this decision rights to pen-
si<in are based, and in it also are involved the rights of
the individual and the Government alike, both of which
are to be respected.
The facilities of the medical department on shipboard
have in late years been greatlj- improved, involving a
comfortable hospital, or sick-bay, usually supplied with
bath and closet. When we consider that the primal ob-
ject of a battleship is the destruction of life, we must ad-
mit that the humanitarian side of the cpiestion has had as
a rule fair treatment. Medical officers at times comiilain
of an insufficiency of accommodation, yet a generous con-
sideration is accorded, and any agencies seriously affect-
ing the interest of the deiiartment are, if possible, reme-
died. The medical supjilics, including hospital stores,
furnished by the naval laboratorj' located at New York,
are usually of good quality ; and this held good during
the stress of the Spanish-American war. The supply
table is varied and the allowance liberal. Complete
antiseptic outfits are supplied, and the instrument
cases are now so complete that when hospitals ai'e in-
accessible, major operations can be performed with con-
fidence.
Inasmuch as the naval inedical officer vLsits all cli-
mates, he should be an authority on climatic diseases,
and consequently the reports of the bureau of medicine
and surgerj- contain frequent descriptions of such mala-
dies. Indeed, since the late acquisition of territory by
the United States, the great need of more exact knowl-
edge of diseases foreign to our own nomenclature has
been greatly emphasized.
The accompanying table exhibits the amoimt of disease
in the naval service for the years 1893-94.
186
REFERENCE HANDBOOK OF THE ]\IEDICAL SCIENCES.
Naval .lledifal
Service,
Mean strenKtU
Daily average number of sick
Avefafre number ot days ot each case
lindcr tn-atinent
A<itiiis.si<)ris. ptT l.(MIU
lnv;Uliic-.l, |iiT l.iKio
DeatlJs, per l.UOU
1893.
10.193
161.35
G.IO
821.24
80.93
3.S2
1894.
10,4.83
172.50
7.31
821.31
97..W
4.57
Recruitiiis for the naval service is a matter of the
greatest importance, as vrii have here au opi)ortiiuity to
sliiit out predisposing and he-
reditary tendencies as well as ex-
isting disease. This work for the
navy is nsually tlone on shipboard
(receiving ships) and for the ma-
rine corps at a rendezvous located
in our large cities. As far as pos-
sible examination for entering the
naval service should be discouraged
on shipboard.
It is to-daj' incumbent on the naval
medical officer to be familiar with thf
duties involved with bluejackets and
marines landed to co-operate with the
army. This service is becoming more
than occasional, especially in the opera
tions in tlie Orient.
Tlie number of medical ofBcers de-
tailed for a ship of war depends princi-
pally upon her size, thin! and fourth rates
caiTying one, second and first rates two,
the flag-ship as a ride carrying but three
oflicers, the senior being the fleet-surgeon,
who is on the stafl" of the commander-in-
chief, and is by the regulations entrusted
with duties largely supervisory in character.
The disposition of the medical department
on a ship in action is provided for only in a
general way by the regulations. The type of
the ships varies
to such an extent
that the matter is
wisely left to the
discretion of the
commanding and
medical officers.
The care of the
wounded in action
will be considered in
the next section.
Service on. Shore. —
Medical officers of the
navy serving on shore
are detailed, according to
their rank, as members of
boards, in charge of hos-
pitals, at navy yards, re-
cruiting rendezvous, on
receiving ships, or on
some form of special
duty. The length of a
shore detail is fi'om one to
three years (usually the
latter), according to the
requirements of the ser-
vice. Recent law makes
retired officers eligible for
duty on shore and at sea.
Not since the Civil War
has the lowest grade of
the naval medical corps
had the full number al-
lowed b.y law. This con-
dition has been atti-ilnited
to various causes, such as
FiQ. 3510.— Lowmoor Jacket. the fact that au assistant
surgeon, upon entering the service, is ranked as a steer-
age officer and is not admitted into the ward-room, and
the further fact that he has eutereil a grade lower than in
the ami}'. Doubtless these facts maj' have exerted an in-
fluence in some cases, but the}' cannot, in the opinion of
the writer, have operated to anj- considerable extent. The
standard of the examining board has been a strong factor,
as is evidenced by the percentage of rejections. The first
two objections have been removed by recent law.
The life of a naval medical officer at .sea is one of prac-
tical isolation; and, despite the literatuie so liberally sup-
plied, he inevitably gets out of touch with the great mass
of the profession. In discbarge of the duties required
of him by the regulations he may have been fully oc-
cupied, but this fortunate!}' does not occur in so
fii as strictly medical or surgical work is con-
■rned. The greatest need of the medical service
t the navy is au opportunity to avail of post-
graduate instruction, and it is much better, with
the present numbers of tlie army and navy, that
such instruction be followed in a civil school.
It may be that in the future the importance of
the interests involved will justify au army and
navy medical school, such as that at Netley in
England ; but until then the medical officers
of the two services must look to the great met-
ropolitan hospitals for advance in the more
strictly professional aspects of their duty, and
some plan by which this can be more syste-
maticall)' accomplislied will greatly enhance
le efficiency of tlie naval medical service.
II. Transport ATiii.N' of the Dis-
U5LED ON Shipboard. — It is proposed to
consider this question as it relates to ships
of the navy, and more especiallv in time
of war; for in the merchant service and in
the navy in time of peacj the difficulties
which are encountered do not call for
anjf special consideration in this place.
Just what the fate of the wounded
will be in a maintained naval action,
ith its inevitabl: high rate of casu-
lities, no one can foretell.
Mr. Archibald Forbes has gone so
Ear as to say that since the introduc-
tion of modern firearms and smoke-
less powder th3 wounded will not,
cannot, be eared for until after the
action (this statement was made
in reference to engagements on
laud), or on the succeeding day ;
but the war in South Africa and
the Pliilippines has totally dis-
proved this position, as never
before has tlie medical depart-
ment been so much exposed
or tlie wounded more scrupu-
lously cared for.
In the old style man-of-war
we had, in all" ships, to deal
with the same general t\-pe,
— we had broad hatches, wide
ladders, easily' removed, and
flush decks. To-day the
decks are cut up and subdi-
vided indefinitely. There is such a demand for siiace that
great ingenuity is necessary to get the requisite equip-
ment and all the quarters within the hull. This state of
affairs is greatl}- accentuated in the battleship. The tur-
rets, tops, and fire-rooms are practically isolated.
For the care and transport of the wounded on a ship
like the Bmeiklyn, an armored cruiser, or the Orcjon, a
battleship, there are from two to three medical oflicers,
an apothecary or hospital steward, and two or three hos-
pital apprentices — an average of five persons. From
each gun-crew two men are detailed as aids, numbering
from eight to twelve ordinarily. With this force the
wounded in a crew of six himdred must be relieved.
Fig. 3511.-
Stretcher for Use
with Slide.
(Wise.)
18T
Naval .llrtlicsil
N*'Ok. [Service.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
A most cmiservative cstimalc of tlie numbei' of
woiiiuiod in naval actions of tlic future is tliirty-three
per cent ; in tlie action bet ween tlic Hi/niir-Jhjiniuc likhiird
and the Sen/pin it i-caclu'd lifly per cent, on each side.
abl}- reported upon b}' a board of officers for use iu the na-
val service (Fig. 3511). Tbis stretcher consists of two
poles seven feet eight inches in length, and a piece of can-
vas si-K feet two inches Ions, into the sleeves of which the
Fir.. 3.")13.— Maban's Streli'lier.
Long before thirty-three per cent, of a crew are placed
hoi-iTdc c<itii1i<it, n()'ai<i will be available from the guns.
The careful medical oltieer, before an action, will have
studied this iiuesliou as ajiplying to his own sliip. He
will have established the stations for the wounded and the
base of supplies. He will have indicated points of tem-
porary shelter about the d<'cks and will have distributed
lirst-aid packages. In all probability there will be no sys-
tematic transDOTt of the woundeil during an action at sea.
In the turrets, tops, and fire-rooms the wounded will be
given emergent aid, and will be allowed to remain where
they fall, or tlii-y will be juished aside into temporary
shelter.
For the dark, narrow, acute-angled passages hand por-
tage is alone available ; and this
method will prevail in those
heated contests in which time
cannot be taken or aid secured
to send all the wounded below.
During the late war with Sjiain
the navy gained little e.viierience in
this respect, for the uund}er of casual-
ties on the American ships was insig-
nificant, while on llie vessels of the
enemy the destruction of life was so
great and the conditions weri' so
friglitful that no systematic relief
could be attempted.
For the removal of the sick or in-
jured from thehold or fire-room, or for
sending them down from tlie tops, we
can conceive of no better device tlian
the Lowmoor jacket (Fig. yolO). which
may lie brielly described as follows:
This jacket is T -.shaped, and
adapts itself to men of dilTercnt sizes.
*rhearnis of the T surround the body,
and extend from the axilhe to the
waist, fastening in front by three
leather buckles and straps; the leg
of the T, passing tlown behind the
body and over the perineum, comes
up and fastens in front liy two straps
and buckles. Two leatliiT sttaiis are
stitched t<i the back of (lie jacket for
its whole length, and their free ends
arc then brought high up above the
shoulders (in the form of loops) anil
carried down to jioints where they
can be fastened b}' buckles to the
front of the jacket. The ends which
extend beyond these lirst buckles arc
to be passed through two other buc-
kles which are fastened to the ends of the
straps (cut olt at a, a, in Fig. o.")l(().
Tlie trans]iortation of the disiibled along the deck, or
between decks, fromabove below, can be accomplished by
by several ditTerent stretchers. The writer devised a
stretcher and slide for this purpose, which has been favor-
188
:i."ji:!.— Giliiin's Stretcher.
two ]ierineal
]ioles run. Two steel stretcher-bars, three-quarters of an
inch in diameter, join the poles (at points where the can-
vas terminates), anil passing through them are secured by
nut and screw. Two canvas bands are fastened to the
frame on either side so as to cross the chest of the occupant
at the a.xilla; and fasten in front with hooks and lacing.
When the iiatient is put upon the stretcher, his insteps
take upon the lower bar, preventing his slipping down-
ward. The slide to be used with this stretcher is made of
ordinary boards, batteneil together, and may be placed in
a hatchway, extending from the coaming to the deck
below, over the ladder, or it can be u.sed without the
ladder. Upon this slide the stretcher is sent below.
The advantage of this stretcher is, that it does not in-
volve suspension of the body;
and it is immaterial whether or
not a ladder is in place in a hatch-
way.
When not iu use the bars are
removed at one end, laid parallel
with the poles, and the whole
is neatly I'oUed. This form of
stretcher is available for land-
ing parties. Lieutenant - Com-
mander Mahan has de-
vised a stretcher which
is described by Medical
Director Gravatt, U. S.
K., as follows (Fig.
3512): " This stretcher is
made of light pine boards, si.x feet
live inches long, fourteen inches
broad, and one and one-half inches
thick, with a wooden batten several
inches in height and tliickucss, firndy
fastened across each end and a little
below the middle. Three canvtis
bands, four inches broad, are made so
as to buckle just across the chest at
the armpits, over the abdomen, and
across the leg. The middle batten
takes under the buttock, ' and gives
surprising support.' A man so
strapix'd can be put in any jiosition,
u-one, upright, oratany angle. Near
each end of the board, rope handles
arc made, by which it can easil.y be
carried through narrow doors and
up and down ladders. By means of
a loop across the head-end it can be
lowered through hatches or over the
side."
The suspension of sick or woimdi'd
men on shipboard is a very unusual occurrence, and it
will probably never be attempted in action. For bearers
to carry a man down a ladder in a stretcher is a very
awkward procedure: and a device like 3Iahan's. when
sending below, will be most serviceable when used with
a slide.
REPEREi^CE HANDBOOK OF THE MEDICAL SCIENCES.
Sfaval Itlodlcal
Xtck. [Sei-vico.
Objections urged against tliis stretcher are, that it
■would l)e injurious in case of thigli fracture, and that it
cannot be availed of for lauding parties. Medical In-
spector Gravatt, U. S. N., reports that he has used Ma-
han's device in cases of thigh fracture without detri-
ment.
There are many other forms of stretcher available for
the purpose under consideration. Wells' ambulance cot
is in use in the United Stales naval service, but, as is true
of other devices of this kind, men cannot be sent below
upon it convenieutly without the slide. This is an ex-
cellent form of stretcher for land-
ing parties. "The improved
cot" of Gorgas, or the "ambu-
lance lift" of McDonald are
seldom used. Gihon's "naval
ambulance cot" is a Secine and
excellent device (Fig. 3.513) and
adapted to any ordiuarj- need of
transportation. ilost of the
stretchers devised for the old
type of ship contemplate the
suspension of the wounded, with
hoisting or lowering; but, as
hitherto remarked, this is a rare
procedure. During an actiou at
sea, if a hatchway is cleared, it
will, as a rule, be used for mili-
tant purposes, and it is only
where the ladder is taken away
that suspension can be practised.
If the ladder remain, one of the
forms of stretcher ahead}' de-
scribed, and with a slide, will be
found the simplest and best
procedure when
is
hand - portage
not desirable.
For an impro-
vised stretcher
Lieutenant Ma-
son, L'. S. N., sug-
gested the use of
a ship's hammock,
which is stretched
and laced to a
wooden frame,
made of poles and
cross-bars.
Jolin C. Wise.
Fig. 3.5U.— Superior Vena Cava and It.s AtDiients. (From Testut.) 1, Superior vena cava; 2,
truoti formed l).v the union of ttie tjracliial and oeplialic veins on the rigtit side ; 2', theeorre-
sponding venous trunli on the left side ; 3, 3. subclavian veins ; 4, internal jugular vein ; .">.
external .iugular vein ; 6, anterior jugular vein ; 7, facial vein ; 8, thyroid veins ; 9, internal
mammary vein.
NECK. SURGI-
CAL ANATOMY
OF THE.— By tlie
neck we usually
mean the space be-
tween the occipi-
tal bone and lower
jaw, above, and the upper aperture of the thorax, below.
For convenience of description it is advisable to divide
the neck, into regions, viz., two lateral, an anterior me-
dian, and a posterior.
The lateral region represents a quadrilateral which is
divided diagonally by the great sterno-mastoid muscle
into two triangles, the anterior (carotid) and the posterior.
Each of these is again subdivided into two by the omo-
hyoid muscle. The anterior triangle is subdivided into
a superior and an inferior carotid triangle, and the pos-
terior into an occipital and a .subclavian triangle.
The anterior imdian. rciimn is divided into two spaces
by the hyoid bone, the upper being called the supra-
hyoid or submaxillary, and the lower the infrahyoid or
hj'osternal region.
The submaxillary region is bounded posteriorly by the
posterior belly of the digastric and stylohyoid "muscles,
and contains the submaxillary gland.
The posterior region includes the portion commonly
known a.s the nape of the neck.
ScKPACE Ajvatomy. — The outline of the neck varies
much in different people; in stout individuals it is round
and full, and the various landmarks are not easily
distinguished; in thin people, on the other hand, eveiy
landmark stands out prominently, and can be made
out by even the most inexperienced. The neck is, as
a rule, fuller and rounder in women and children,
and the pomum Adumi is less marked. In muscular
males the prominences are well seen ; in old ]>eople
who are thin the sterno-mastoid muscles and super-
licial veins stand out well, as does also the internal
bolder of the platysma my-
oides.
Bony Points. — The most im-
portant bony point, and one of
those most easilj' felt, is the
hyoid bone, which is in the
niedian line, a finger's breadth
above the thyroid cartilage. It
is opposite the fourth cervical
vertebra. The cricoid cartilage
is opposite the sixth cervical.
Below and in front of the mas-
toid process, and behind and
above the angle of the lower
jaw, the transverse process of
the atlas can be felt. In the
posterior region in the middle
line is a depression formed by
the complexus and ti'apezius
muscles of each side ; here can be
indistinctly made out the thiixl,
fourth, tit'th, and sixth cer-
vical spines, while the seventh
can be easily felt, and also the
spmes of the first two dorsal
vertebra;. These
become m o !■ e
prominent when
the head is bent
forward; occa-
sionally, when the
spine of the sixth
cervical verteljra
is well developed,
it is quite as
prominent as the
seventh. The
transverse process
of the sixth cervi-
cal vertebra can
be felt on deep
pressure opposite
the cricoid carti-
lage, in the course
of the carotid ves-
sels. This is called
the "carotid tu-
bercle," and here the carotid may be easily compressed
against it.
Anterior or Median Her/ion. — In the receding angle
below the chin is the hj-oid bone, which can l.)e easily
felt in the fattest necks, it divitles the anterior luirt
of the neck into the suprahyoid and infrahyoid regions.
In the median line of the suprahyoid region the anterior
bellies and the digastric muscles cause a slight convex-
ity; on the outer side of each anterior belly of the digas-
tric muscle is felt the submuxillaiy gland lying on the
mylohyoid muscle, which helps to form the lloor of the
mouth. This region is commonl_y cut into in selt-in-
liicted wounds of the throat. About half an inch below
the hyoid bone is the ])rominent thyroid cartilugi- (po-
mum Adami). This cartilage is prominent in dec])-
voiced men and people with thin necks, but in women
and children it is not so distinctly seen; the iiotcli at its
upper border can be easily felt, and is commonly situ-
ated to one side of the median line. The supeiior cornua.
of the thyroid cartilage can be traced with the finger.
189
Ne«k,
Neik.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
The space between the thyroid cartilage and the hyoid
bone is called the thyrohjoid space, a membrane con-
necting these two structures ; this membrane is covered
1)_V the muscles going to tlie hyoid bone from l)elow, and
is ])ierced by the superior hiryngeal nerve and artery of
each side. A cut made through tlie tliyrohyoidean space
would sever the lower part of the epiglottis. The rima
glottidis is opposite the middle of the thyroid cartilage.
Below tins cartilage the finger sinks into a slight depres-
sion, the cricothyroid space; this is tlie sjiace in which
the operation of laryngotomy is performed, the opening
liere being well below the vocal cords. Across this space
ramify two small vessels, the cricotliymid branches of
tlie su])erior thyroid arteries. The ne.xt laiidmarl'; of in-
terest is the cricoid cartilage; it is a guide to many oper-
ations on the neck and air passages, and can be distin-
guished in the youngest and fattest neck. The cricoid
cartilage is opposite the sixth cervical vertebra, and tlie
narrowest part of the gullet is behind it ; at this point
foreign bodic_'s are most likclj' to be arrested. The omo-
hyoid muscle crosses the carotid vessels on a line with
tlie cricoid cartilage, immediately above which line is the
point usually selected for tying the common carotid ar-
tery. The middle cervical ganglion of tlie sy mpatlutic is
also on a line with this cartilage, and a little Ijelow and
outside of it is the point wliere the vertebral artery en-
ters tlie transverse process of the si.xtli cervical vertebra.
Below the cricoid cartilage the finger passes on to the
tracliea, the sejiaratc rings of which cannot be easily
felt, because they are covered by the isthmus of the thy-
roid gland aljove, and below the trachea recedes from tiie
.surface. At the upper border of the sternum the trachea
is one inch and a half from tlie surface. The isthmus of
the thyroid crosses tlic second and third rings of tlie tra-
chea.
In front of the trachea, below the isthmus, lie the in-
ferior thyroid veins, whicli give so much trouble in tra-
cheotomy. Occasioii.-illy an .-irtiMv is I'ouiid lying upon
,j
Fig. 3)1.'). -Dis.seotiiiu of the .N"eck, sliowiiifr tlip Triangles and their
CouK^nts, iTiedenjann.)
the trachea, on its way to the thyroid gland ; it is called
the thj'roidca ima and generally arises from tlie innomi-
nate. The epistcrnal notch is felt at the top of tlie ster-
num, and is oppo.site the second dorsal vertebra.
LiiteridRe'jwn. — The sternomastoid muscle is t he promi-
nent landmark in this region; in thin subjects, especially,
it is well .seen, and stands out distinctly when the face
is turned to the opposite shoulder. The inner border,
which covers the carotid arterv, is more strongly marked
than the posterior, which is tliin, only the lower portion
Fig. .3.516.— Vertical Median Seotitm of the Head anti Neck. 1, LI(fa-
mentum michae ; 2, i-ricoid cartilage; 'i. trachea ; 4, hyoid bone; 5,
Diusculus aiTtenoideiis ; H, \entricle of larvux ; 7, thvroid carti-
lage; 8, cricoid cartilage; y, thyroid body; 10, sternuui. Hfter
Braune.)
showing through the skin. Tlie sternal tendons arc well
seen in nearly everybody, the depression between them
being named the suprasternal fossa. In some necks this
fo.ssa is absent, owing to the space being filled with fat.
The space between the sternal and clavicular portions of
the sternomastoid can usually be made out; in thin necks
it is well marked. The internal jugular vein and carotid
artery lie behind this sjiace; deeper down still, we have
the ape.x of the lung, which sometimes rises an inch and
a half above the clavicle.
The sternoclavicular articulation is an important land-
mark; immediately behind it, on the left side, is the com-
mon carotid artery and the division of the innominate ;
on the right, it is opposite the point wliere the interuiil
jugular joins the subclavian vein to form the innomi-
nate. The division of the innominate artery in children
is higher up than the articulation; in some cases it di-
vides in front of the trachea (sec Artcriex, Anoma!/cs of).
The depression above the clavicle, between the trape-
zius and the clavicular origin of the sternomastoid, is
called the supraclavicular fo.ssa. In this fossa the external
jugular vein terminates in the subclavian, after piercing
the deep cervical fascia. Here also may be felt, in thin
persons, the brachial plexus of nerves and the omohyoid
muscle, and in the angle formed by the sleruomastoid
and clavicle the third ]iart of tlie subclavian artery may
be felt pulsating. At this point it can be compressed
against the first rib. The central point of the greatest
convexity of the clavicle is opposite the third portion of
IftO
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Neck^
Neck.
tlio subclaxian artery. This is a more certain landmark
than the muscle, the extent of attachment of which to
the clavicle varies considerably.
The posterior border of the stcrnomastoid corresponds
pretty closely to the outer border of the scalenus auticus
muscle: this" point should be borne in mind in tying the
subclavian artery.
Behind the stcrnomastoid the chain of lymphatic
glands, when cularired. can be easily felt.
The posterior belly of the digastric muscle corresponds
to a line drawn froiii the mastoid process to the body of
the hyoid bone. When the chin is e.xtendeda prominent
fold of cervical fascia can be felt going from the angle of
the lower jaw. downward and outward.
The position of the tonsil corresponds externally to the
angle of the jaw.
Veins (St"RF.\CE JI.\rkixg op). — The nifist important
of these is the extenud jugular, which can always be seen.
Its course is marked out by a line drawn from the angle
of the jaw to the middle of the clavicle, at which point
it pierces the deep cervical fascia to join the subclavian
vein. It is occasionally joined by
a vein which runs over the clavi-
cle (see Veins, Anomalies af). By
pressing above the clavicle, the
vein is distended, and its course is
easih- traced.
The anterior jugular vein lies on
the sternohj'oid muscle and in
front of the inner border of the
sternomastoid. AVlien the exter-
nal jugular is small this vein at-
tains considerable size.
The surface marking of the in-
ternal jugular corresponds to a
line drawn immediately external
to the line of the artery. Ihe fa-
ded vein runs from the anterior
border of the masseter muscle
downward and backward, and
joins the internal jugular oppo-
site the upper border of the thy-
roid cartilage.
The middle thyroid rein crosses
the carotid artery opposite the
cricoid cartilage.
Arteries (Surface jSIarkixg
OF). —The carotid artery corre-
sponds to a line drawn from the
sternoclavicular articulation to a
point midway between the mas-
toid process and the angle of the
jaw. The common carotid reaches
as high as the upper border of the
thyroid cartilage. It can be com-
pressed against the sixth cervical
transverse process ("carotid tu-
bercle "), which is opposite the
cricoid cartilage. The stijierior
tlii/roid arterj' comes off from the
external carotid a little above the
upper border of the thyroid carti-
lage. The lingual arterj- runs
forward from the external carotid
to the upper border of the great
cornu of the hj-oid Ijone, to which
it is parallel. The hypoglossal
nerve lies above the artery. The
course of the J'acitd artery in the
neck corresponds to a line drawn
from the tip of the great cornu of
the hyoid bone to the outer border
of the masseter muscle.
The occipital arteries can be felt
pulsating immediatel}' below and a
tip of the mastoid ]iroeess.
Nerves (Siiik.vce ^Iarkixg of).-
nerve passes beneath the anterior
mastoid muscle an inch below the tip of the mastoid
process, and emerges from the posterior border at a point
on a level with the upper border of the thyroid cartilage;
it then crosses the posterior triangle obliquely and enters
the trapezius muscle on a level with the sixth or seventh
cervical spines.
The phrenic nerve commences in the neck about the
level of the hyoid bone, and runs obliquely downward
over the .scalenus anticus to its inner edge. In the neck
the phrenic nerve is covered by the sternomastoid.
The superficial cerrie<d nerves all emerge at a point cor-
responding to the middle of the posterior border of the
sternomastoid. The great auricular crosses the sterno-
mastoid on its way up to the ear; the lesser occipital runs
along the posterior border of the sternomastoid ; the sn-
perfieial cercical crosses the sternomastoid at right angles
and reaches the middle of the neck, and lines drawn
from the point of emergence to the sternum, middle of
the clavicle, and the acromion would mark the course
of the suprasternal, supaclavicular, and supra-acromial
nerves.
545
e d
FIG. 3517.— Deep Cervical Plexus of Nerves. (From Testut.) T. II. . . . VIII, Anterior branches of
theeigbt cervical nenes.-l. trigeminal nerve, with its three branches: 2. glossupharyngeal: 3,
pneumogastric. with. 3'. its lu-anch. the superior laryngeal : 4. spinal accessory, with its two
branches-4', that which supplies the sterno-cleido-iiiastoi.l muscle, and, 4". that which goes to the
trapezius: •'>. facial iiervc; li. tlie mam trunk of tlie hv pi .glossal, with its two branches— 6', the
descenflins ramus, and. li . that which supplies tlie thyiMiiyoiil muscle; T. the great sympathetic,
with. 7'. its supeti.T cervical ganglion ; S, the larger luastoiil branch of the cervical plexus ; 8',
the little mastoid In-anch; tf, the auricular branch: in. the tmiisvfrse cervical bnm.li : 11. the
subclavian and subacromial branches: 12. point of anasi sis with the great syiupatlietic;
13. nerve of the large anterior rectus muscle ; 14, trapezian branch of the cervical ple.xus ; lo,
nene of the levator aiig. .si'ap. : IH. ner%e of the rhomboideus: 17. internal desi-endiiig branch:
lb, bend ot the hypoglossal, with its efferent branches that supply the sulphyoidean muscles:
1!), phrenic nerve. With, IS', its anastomosis with the great sympathetic, and, 19', its anastomo-
sis with the nerve that supplies the subclavius muscle ; 20, the nerve of the subclavius muscle ;
21, great occipital nerve. . ,^.1*1,
a. Internal jugular vein ; 7i, the common carotid artery ; c, the internal carotid : a, the
middle meningeal ; f, the subclavian artery.
little in front of the
—The spinal accessor//
border of the sterno-
Tlie cutaneous branches of the cervical plexus are
widely distributed, supplying the ear. back of scalp,
cheek", parotid gland, side 'and front of neck, and upper
part of chest and shoulder.
191
I\<'<-k,
HEFERENC'E HANDBOOK OF THE MEDICAL SCIENCES.
Tlie facial iirrvc semis u liiaiuh tci the neck, wliieh
supplies the )ilatysni;i inyoiiles iiuisele.
TorooRAi'iiicAi, Anai'omy. — Tlu' sl<iii dver the ante-
I'joraiiil latefal rei^ioas of the ueek is tliin and lax, anil in
It
'^.■
't.'S^'i
■/■^v
'/n\i
V
,'a
Fu;. TilR.— Superllciiil Dissection ef Ilie Neck, .showing the DistrilJU-
lionof ttie BnuK'bes uf tlje Superllc-ial Cervical I'lexus of Nerves.
I Ueatli.)
plastic nperatidiis is of great value in making flaps. Tlie
jilatysma is closely connected witli the skin of tliis part
of tile neck. There is frequently some transverse wrin-
kling of the skin aliove I lie hyoid bone, and in this region
in fat people tlieic is much fat, gi\iug rise to wliut is
called a doiilile chin; liere also the sebaceous follicles are
vei'v abundant, luadult males this part is covered with
b.ard.
'I'he skin of the posterior region is very tliick and ad-
lu-res closely to the ileciier structures: tliis is due to tlie
large number of sliort librous connections between the
skin and fascia. Carbuncles and boils frequently occur
hei'c and cause great jiain, owing to the density of the
parts and their free nerve supply.
The iKtpe of the neck is often the seat of pustular and
vesicular erujitions, which are due almost invariably,
when localized in this part, to the presence of pediculi,
tlicse parasites finding a safe habitat in the thick hair
under the prominent portion of tlu^ occijiital lione. Tlio
glands in this region are frequently enlarged in sym-
pathy with eruptions of the liairy scalp. The napi; of
the neck was the favorite site, in ohlen times, for the ap-
jilication of sctons and issues.
Fatty tumors are often seen at the lower part of this
region.
C'KitVic.vi. Fascia. — It is the custom to divide the deep
fascia of the neck into avpcrjin'itl and deep processes.
The superficial fascia invests all the inuselcs, with the
exception of the jilatysma; and some of the veins, as the
external iugular, are also superlieitd to it. It is attached
posteriorly to the sjiinous processes of the cervical vcrte-
i)r;c and ligamentum nuclia'; passing forward it splits to
enclose the trapezius and then crosses tlie jiostcrior tri-
angle; at the posterior border of tlie steruomastoid the
fascia divides into two layers wdiicli enclo.se that muscle,
these- layers unite at the anterior border of the muscle,
and the fascia passes on to the middle line of the neck,
where it is continuous with tliat of the op]iosite side. It
<'overs tlie atilerior triangle, being altaclied above to the
lower jaw. In the posterior triangle the fascia is at-
tached below to tiie clavicle and aliovct b> the mastoid
])rocess and tlu^ sui>erior curved line of the occipital
bone; in this triangle it is jiicrced by the externa! jugu-
lar vein and some of tlie suiierticial cervical nerves. In
tlie anterior triangle the fascia is .-iltached above to the
body of the lower jaw, and continues backward and up-
ward over the parotid gland to lie attached to the zygo-
ma. It scuds a process (the styloma.xillary ligament) be-
t ween the parotid and the submaxillary glands. In front
the fascia i.s attached to the iiyoid bone and covers the
thyroid gland, below which it splits into two layers; the
deeper covers tlie sternohyoid and stcrnolliyroid muscles,
and is attached below to the posterior edge of the first
])iece of the sternum, behind the steruoclavienlar joint;
the superficial and thinner layer passes down o\er the
sternoniastoid muscles, and is attached to the anterior
edge of the manubrium and interclavicular ligament.
The space between these two layers is tilled with cellular
tissue and fat, and sometimes a small gland is found liere.
In this comptirtment are also found the sternal head of the
steruomastoid and the anterior jugular vein. In te-
notomy of the sternoniastoid this space must be opened,
and the vein is avoideil by keeping the knife close to the
tendon of the muscle.
This space is also cut through in performing the oper-
ation of tracheotomy, and air is sometimes drixeii at
every inspiration into the cellular tissue beneath the deep
layer, an occurrence which complicates the opei-ation ex-
ceedingly. The process of fascia covering the jxisterior
belly of the omohyoid and binding it down to the clavi-
cle tiud first rib, is continuous with the fascia covering
the depressors of the hyoid bone.
The deeper processes of cervical fascia are important ;
one comes off fi'om the anterior border of tlie sternonias-
toid and forms a sheath which encloses the carotid artery,
jugular vein, and pncuuiogastric nerve. The vein is
sciKirated from the artery by a thin se]3tum of fascia.
A process of fascia also invests the thyroid body, passes
behind the di'prcssoi-s of the hyoid bone, and lies in front
of the trachea and dec]) vessels of the neck ; below, this
layer is continuous with the libr<nis pericardium.
The prercrtehral fascia is a layer which descends on
the prevertebral muscles, separating them from the phar-
ynx and trsophagus; laterally it joins the carotid sheath
and then proceeds outward covering the scalene muscles,
brachial jdexus of ner\-es, ami subclavian vessels, beconi-
iug continuous with the axillary sheath. It is also con-
nected with the costocoracoid membrane.
Although the cervical fascia intlueuccs to a certain ex-
tent the growth of tumors and collections of matter, this
influence has lieeu much exaggerated, and tumors grow
and matter collects and distributes itself often quite irre-
spective of this fascia.
Pus iu front of the trachea would tend to gravitate
into the anterior media.stinum and on the side of the neck
Fic ;r)19.— Transverse Section of Ilie Necl; thronsfh tlie Fiftli t'civical
Vertebra, showing Cervical Fascia. (Braiine.;
might perfoi'ate the apex of the jdeural sac. An abscess
ill front of the vertebra' woiihl lie beneath the ])reverle-
bral fascia, aiulif itdid not burst into tlie gullet, mightex-
tend laterally and present itself outside the sternoniastoid,
or descend to the jiosterior mediastinum. In some cases
these collections of pus have been known, after reaching
192
REFERENCE HANDBOOK OP THE AffiDICAL SCIENCES.
Neck,
Neck.
the posterior triauglo of the neck, to follow the course of
the brachial plexus and present themselves in the axilla.
Pus pent up between the layers of the cervical fascia has
destroyed portions of not <inly the jugular vein, but also
the carotid artery, and when the abscess cavity was opened
the patient has died of hemorrhage from these vessels.
Dr. S. W. Gross (Amei-iruii Jour, of the Medical Scienctv.
April, 18T1) has collected twelve cases of ulcerationof the
jugidar veins, with hemorrhage into the sacs of chised
abscesses, or into abscesses several da3'S after their con-
tents ha\e been evacuated, or into acute or chi'onic
ulcers. The majority of ca.ses were in children who had
<;ellulitisof the neck following scarlet fever — all the cases
proved fatal.
Dr. Erichsen {St. Petersburg, meet. Woeh., Deeendier,
1877) reports a case of suppurative angina which broke
of itself, and several tlays afterward a profuse and fatal
hemorrhage occurred. The autopsy revealed ulceration
of the internal carotid artery. In such cases the lesson to
be learned is to prevent the destructive effects of diffuse
cellulitis by early and free Incision, and, if hemorrhage
does occur, not to rely exclusively on packing, but to
ligature the affected vessel.
In opening abscesses in the neck, there is some danger
of wounding some of the great vessels if a too free incis-
ion be made with the knife, the vessels being pushed out
of their normal position by the abscess; their exact
course is dillicult to determine. In such cases at first the
skin only should be incised; after this the knife should
be laid aside and a director should be pushed through
the fascia; and when pus runs along the groove of tiie
director, a pair of dressing forceps should be introduced,
opened in the abscess cavity, and withdrawn o]ieu. This
method has the advantage of being perfectly safe, and is
especially adapted for opening deep-seated abscesses. It
is known as Hilton's method.
Arteries ok the Neck. — The two large arterial
trunks which are seen in the neck are the carotid, which
lies in the anterior triangle, and the suhclarian, which
lies in the lower part of the posterior triangle (subclavian
triangle).
The carotid is included in a sheath of deep cervical
fascia with the internal jugular vein and pneumogastrie
nerve. The vein lies to its outer side, and in the living
subject overlaps the artery at the lower end and espe-
cially on the left side. To the inner side of the artery lie
the trachea and njsophagus, larynx, and pharynx, and
low down the recurrent laryngeal nerve. The th_yroid
gland also lies to its inner side. The vagus nerve lies to
the outer side and posteriorly above, and rather more in
front below.
Lying on or in the sheath of the vessels is the ile-
scendens noni nerve. The great sternoniastoid muscle
covers not only the common, but also the internal anil
external carotid arteries. In the undissectcd subject it
is impossible to puncture the common carotid fi'om the
side of the neck without piercing the sternoniastoid mus-
cle (Richet). This fact is not sufficiently dwelt on in
anatomical works, the descriptions given being appli-
cable to di.ssected subjects only. The omohyoid muscle
crosses the artery and vein obliquely and on a line willi
the cricoid cartilage. The most important structures In
hind the artery are the sympathetic trunk, the inferior
thyroid artery, and the recurrent laryngeal nerve. The
common carotid normally gives off no branches in its
course. It divides into external and internal carotid op-
po.site the upper border of the thyroid cartilage. The
right and left common carotid arteries are so similar in
their course in the neck that one description will answer
for both. The left, however, it is well to bear in minil,
arises from the arch of the aorta, and is somewhat longer
than the right, which arises from the innominate o|ipci-
site tlie riglit sternoclavicular articulation. The right
common carotid is generally larger and not so deejily
placed in the neck as the left ; it is also farther away
from the trachea.
As the vessels ascend the neck they become more super-
ficial, and, having a direction somewhat backward, get
Vol. VI.— 13
farther apart as they reach their termination. The sur-
face-marking of the carotid has already^ been described.
The artery may be easily compressed against the trans-
verse process of the sixth cervical vertebra.
Liffotiire of the Conunon Carotid. — A ligature may be
apjilied to any part of the artery, except near its origin
or termination. The usual point of ligature is either im-
FiG. :r)20.— View ot the Common Carotid and Subclavian Arteries,
with tbe Origin of their Branches and their Relations. (R. Qualn.)
mediately above or below the omohyoid muscle. It is
usually ligatured above the omohyoid, as here the artery
is more superficial, and the operation is. in consequence,
easier. An incision should be made along the inner bor-
der of the sternomastoid nuiscle, and the parts carefully
divided until the sheath of the vessels is reached. The
operation is much facilitated by drawing the sternomas-
toid outward and (if the superior operation be chosen)
pidling inward the omohyoid. Should any veins or
small branches of the superior thyroid artery come in the
way, they should be divided betweeu two ligatures.
The sheath of the vessels should be opened on its inner
side, so as to avoid the jugular vein, and the dcscendens
noni nerve should be held aside to avoid injury. The
aneurism needle with the ligature shovild be passed frora
without inward; in this way the vein and vagus nerve
are most easily avoided.
The lower operation is the more difficult one, for, to
expose the sheath of the vessels it isoflen necessary to
divide some fibres of the muscles covering it. Again,
the vein, if large, overlaps the artery; this readers the
passing of the aneurism needle a proceeding of some dif-
ficult}'. On the left side the internal jugular vein is
much closer to the artery than on the right, and so the
difficulty of pa.ssing a ligature around the artery is much
increased. Ligature of the carotid is performed for
wounds of the vessel or some of its branches, also for
aneurism. It has been ligatured for pulsating orbital
tumor. Mr. W. Rivington (iJ/vVM MedicalJournal, Oc-
tober, 1885) records an interesting case of a lioy, aged
nine years, who swallowed a fish bone; this was followed
193
Neck.
Neck.
REFERE-NCK HANDBOOK OF THE MEDK'AL SCIENCES.
by pyrexia, stiff neck, salivation, and a tender lump on
the left side of the neck oppi)site the cricoid cartilage.
Three days later, the boy iiacl two severe attacks of licm-
orrhagc from the mouth. \Vound of the carotid was
diagnosed, and the artery cut down upon and ligatured.
The fish bone was foiuid iu the centre of a clot, and it
had uh'eratcd into tliearlcry. The patient died of ab-
scess of the brain ten d;iys after the ojieralion. A com-
mon site of carotid aneurism is tit the bifurcation of the
common carotid, and the ti-eatmeut is ligature of the ves-
sel below. In aneurism at the root of the neck the car-
otid has been ligatured with success above the tumor.
Ligature at the distal side of an aneurism was first pro-
posed by Brasdor, and piactised by Warddrop. The
treatment of aneurism of thearch of the aorta or innomi-
nate artery by simultaneous ligature of the carotid and
subclavian arteries has been attended in a few cases with
benefit.
Aneurism at the root of the neck fre<iueully gives rise
to " pressure symptoms." When the .great veuoustruuks
are compressed there is cedema and lividity, not only of
the side of the face and neck, but also of the upper ex-
tremity of the same side. Not infrequently cough is
produced by pressure on tlie recurrent laryngetil nerve,
and if the pressiu'c be great, then ptiralysis of the voctil
cords of that side will ensue and cause a marked alter-
ation of the voice. Dilatation of the i)ti|)il maj' also oc-
cur from pressure on the sympathetic trunk.
When the conunon carotid reaches the upper part of
the laryn.x, it divides into two trunks, one of which, the
Fig. 3531.— Relations of tin' Two carotids to tlji- styloid .ind Dip.islrio
Muscles. (From Testiit.) 1, Ma.stoid inoces.s ; 1'. orilln' of tiie ex-
ternal auditory canal; li, styloid procp.ss ; ;i, condyle of the inferior
maxilla; 4, h.void bone: .3, subniaxillary inland ;'(;. ti'. the anterior
and i>osterior bellies of the diijastric miKscle; 7. stylohyoid muscle :
8, myliihyoid muscle; U, hyofilossus iTjuscle: 111, (■oTinuon cai-otid ;
11, internal carotid ; 13, external carntid ; Ki, .superior thyiolii ar-
tery; 14, lingual artery; l."i, l.i', faciaf artery; f(j. occipital artery;
17, posterior auricular artery; IS. iransyci'se arteiv of the face;
19, superllcial temporal iLrtciy ; ;;o, internal maxillary artery; 21,
internal ju^oiiar veui : ^'■J, facial vein ; 2,1, great hypoglossal nerve,
with, 23', its descending liranch.
external, gives off a number of branches, and is distrib-
uted to the superficial piirts of the head and face and the
tongue; the other, the internnj, furnishes blood to tlie
brain and eye. Asa rule, the interna! ciiiolid lias the
194
deeper course, and lies behind the external, but not in-
fref|uently the two arteries lie side by side for some
distance, the internal lying more posteriorly, and being
recognized by tiie accompanying pueumogastric nerve.
The two vessels are separated by the styloid process and
stylohyoid li.gament. also the styloglossus and stylo])liar-
yngeus muscles and glossopharyngeal nerve. The ex-
ternal trunk has two muscles and a nerve in relation to
it anteriorly, viz., the digastric and stylohyoid muscles,
and the hypoglossal nerve which hooks round one of its
britnches, the occipital. After passing behind the angle ■
of tlie lower jitw the external carotid becomes embedded
iu the parotid gland.
lA;i<itiire of the external carotid is not a very easy
operation owing to the number of branches given oil
from it, and the large venous trunks wliich lie over the
lower portion may much increase the dilliculties. The
iirtery is reached by an incision iu the line of the vessel,
having its midpoint about the level of the hyoid bone.
It is usually ligatureil immediately below the" digastric.
It occasionally reiiuires ligature in the course of oper-
ations for the removal of tumors about the angle of the
jaw and neck.
Biiiiiclivfi nf E.rlcriHil Carotid. — The most important
branches in the neck are the superior thyroid, lingual,
and the cervical portion of the occipital and facial.
The superior t/ii/niid arises near the origin of the main
vessel and curves downward, forward, and inward, be-
neath the depressors of the hyoid bone. It is distributed
to the upper part of the thyroid gl.-ind, and can be readily
exposed by an incision between the omohyoid ami ster-
no-mastoid muscU'S. It sends a branch along the crico-
thyroid membrane which is sometimes wounded in the
operation of laryngotomy. The superior thyroiil artery
has lately been tied with success for the purpose of ar-
resting the growth of an enlar.ging thyroiil body.
The liiif/ii)-(l, artery arises from the external carotid
nearly opposite the great cornu of the hyoid bone (it may
however, arise in common with the superior thyroid and
cross the hyoid bone). It runs above and parallel to the
great cornu and beneath the hyoglossus muscle. It is
freqnentlj' necessary to ligature the lingual previous to
extirpation of the tongue.
In ligaturing this ves.sel the one guide which the oper-
ator must rely on is the great cornu of the hyoid bone —
it can always lie felt and its relation to the arteiy is
nearly always constant. The best place to expose the
artery is immediately above the great cornu. Some au-
thorities advise ligature of the artery near its origin from
tlie carotid; but here, owing to the large veins which
cover it, the operation is more dilflcult, and besides we
have no absolute guide as to the exact point of origin of
the artery, which frequently varies. On the other hand,
the relation of the vessel to the gieat cornu of the hyoid
bone is nearly always constant. The incision sliould be
a curved one, and should extend from near the symiihy-
.sis menti to near the angle of the lower jaw. The con-
vexity of the curve should be downward, and its lowest
point ought to reach the hyoid bone. After dividing the
skin, jjlatysma, and deep fascia, the tendon of the digas-
tric muscle should be seari'hed for, and in the angle Ayhich
the lendon forms with the hyoiil bone the artery will be
found running bene;ith the hyoglossus muscle; theliypo-
glossal nerve is seen running over this muscle. If the
submaxillaiy .gland cover the parts, it should be held
aside with liooks. After carefully dividing the hyoglos-
sus muscle the artery xvill be felt pul.satingat the bottom
of the wiumd. If theincision be carried too f;ir liack the
facial vein may be wounded.
When it is necessary to remove the submaxillary gland
the facial :irtery must be ligatui-ed. The operatioii pre-
sents no dilliculties and requires no special descripticui.
The siibdiiDian arterii is, surgically, a very important
vessel. The left siibclaviau lies deeper than the riglit
and arises directly from the arch of the aorta, while the
right is one of the tenninid branches of the innominate
and commences opposite the riglit sternoclavicular ar-
ticulation. Each artery curves upward into the neck
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
Neck.
IV'ock,
under the anterior scalenus muscle, and then descends
into the subclavian triangle under the clavicle and over
the first rili The subclavian vein lii-s in front and some-
what below tile arter\', from ■\vliicli it is separated by
the anterior scalenus
The artery is divided into three portions by the scale-
nus amicus nuiscle, viz.. first, portion internal to the
IMS
Fig. 3523.— Inferior Thyroid and Vertebral Arteries. (From Testuf.)
1. Common carotid artery ; 2, internal carotid artery ; 3. external
carotid artery and its branches: 4. superior thyroid artery : o. lin-
gual artery ; 6, facial artery ; 7, occijfilal artery ; .S, inferior pharyn-
geal artery ; 9, posterior auricular artery ; H). subcla\ian artery and
its branches; 11, thyroid axis; 12. vertebral artery ; 12', posterior
cerebral artery ; i:^, deep cervical artery ; U, subscapular artery ;
15, superior intercostal artery ; 16, internal mammary artery.
muscle; sccoud, portion beneath the muscle; and, third,
portion external to the muscle reaching to the lower bor-
der of the first rib. Sui'gically, the third jiortion is most
important. The external jugular vein crosses the arfer_y,
and the sternomastoid and the deep fascia which binds
down the omohyoid muscle to the clavicle are in front of
it; the brachial plexus of nerves lies above and to the
outside of the third portion of the artery. Posteriorly
the arter_v lies on the pleura and on the scalenus medius.
and finally it rests on the first rib. The third poition of
the artery can be felt pulsating above the clavicle, in the
supraclavicular fossa, and here it may be leailiiy com-
pressed against the fiist rib with the thumb or the handle
of an old-fashioned door-Uey wrapped in lint. The direc-
tion of the pressure should be vertical to the axis of the
body ; before attempting compression the shoulder should
be lowered as much as possible. In compressing this ves-
sel pain is sometimes caused by pressing on the lowest
cord of the brachial plexus, which usually lies behind the
artery; this maybe easily avoided by rolling the nerve
away from the artery, and then the proceeding is quite
painless.
Some individuals (the writer among them) can arrest
the pulse at the wrist by forcibly carrying tlie shoulder
downward and backward. In this ca.se the artery is
compressed against the first rib by the subclavius muscle
and clavicle.
Ligature of the subclavian is, as a rule, confined to the
third portion, or that part lying in the supraclavicular
space between the sternomastoid and trapeziur muscles;
the other portions are so deeply placed, so thickly
studded with branches, and so closely connected with
such important structures as the phrenic and vagus
nerves, the junction of the internal jugular and sulula-
vian veins, and, on the left side, with the thoracic duct,
that ligature is rarely attempted. On tlie right side it
is possible to ligature the vessel between the common
carotid and the internal jugular vein.
The third portion of the vessel is comparatively super-
ficial, being covered above the clavicle by no other soft
parts than the skin, fascia, and fat. In at least fifty per
cent, of subjects it is branchless, and when a branch is
given off from the third portion it is almost invariably
the ])ostcrior scapular.
To reach the artery an incision is made between the
sternomastoid and the trapezius. The skin should be
drawn down and the first incision should be made upon the
clavicle to avoid wounding the external jugular, which
pierces the deep fascia immediately above the clavicle.
The vein should be held aside, or, better still, divided
between two ligatiires, and the deep fascia attached to
the clavicle cut through ; the finger should then be intro-
duced and the scalene tubercle of the first rib searched
for; this tubercle is usually fouud by following down
the scalenus anticus muscle, which runs in tlie direction
of the posterior edge of the sternomastoid. Having made
out the scalene tubercle, the surgeon will feel the artery
pulsating beneath the finger immediately outside the
scalenus anticus muscle. The aneurism needle should
be introduced from below upward to avoid the vein : it
must hug the artery closely so that the lowest cord of the
brachial plexus may not be included.
The operation is performed for aneurism of the axillary
artery, and also of the innominate; also before amputat-
ing the whole upper extremity. In the latter case the
common carotid is also tied. In axillary aneurism the
operatiim is much complicated by the great distention of
the veins and the great elevation of the clavicle.
BraiiclKs of Uie t^iilidacimi. — The subclavian is rich in
branches which are distriliuted in three different direc-
tions, viz., the vertebral and inferior th\"i'oid, upward;
the transversus colli and transversus humeri, outward;
and the internal mammary and superior intercostal,
dowuward. Most of the branches arise internal to the
scalenus anticus: three of them, the transverstis colli,
transversus humeri, and inferior thyroid ari.se from a sin-
gle trunk, the thyroid axis. The posterior scapular is
frequently given off' from the third part of the artery in
place of from the transversus colli. The branches of the
subclavian artery are subject to innumerable variations
both as to their number and origin (see Arteries, Anoma-
lies of). When the subclavian is ligatured, there being
free anastomosis between its branches and those of the
axillary artery, the nutrition of the arm is not interfered
with.
The vertebral artery, which is the largest branch of the
subclavian, arises from the upper ami posterior part of
Fig. :).">23.— sliowintr Line of Incision and Parts Exposed in Ligature of
the Third Part of the Subclavian Artery. (Moditled from lUeer.)
the first portion, and ascends to enter the transverse
process of the sixth cervical vertebra: after piercing the
transverse process of the axis it' makes a remarkable
195
Neck.
ISerk.
KEFERE^X•E HANDBOOK OF THE MEDICAL SCIENCES.
curve ^Fig. 3524, 5) outward and upward to reach the
foramen in the transvere process of tlie atlas, and bend-
ing backward, runs in tlie deep groove on the upper sur-
face of the atlas.
Immediately above the clavicle this vessel lies ver_y
deeply between the scalenus anticus and longus colli
muscles. It has frequently been ligatured here for the
relief of epilepsy ; the operation is a difficult one, owing
to the man}' important structures in close relation with
the vessel. An incision is made along the posterior bor-
der of the sternomastoid muscle immediately above the
clavicle, the transverse process of the sixth cervical ver-
tebra (carotid tubercle) is now searcl]ed for, and the ar-
tery is found lying between the scalene and longus colli
muscles.
Drs. Bright and Ramskill state that disease of the ver-
tebral arter}-, immediately before it enters the skull, may
lead to pain at the back "of the head. The fact that tlie
artery is here in close relation with the suboccipital
nerve, which communicates with the great occipital
nerve, may explain this symptom. (Treves.)
The vertebral artery is sometimes wounded by stabs in
the neck : not a few cases are reported in which the artery
was injured by stabs below the mastoid process. Dr.
King (Lancet, November, 1885) records a case of injury
of this artery in a young' man, aged twenty-five, due to
a deep wound below the left mastoid process ; there was
severe bleeding, so tiie wound was enlarged and the
transverse process of a cervical vertebra was found
broken; the linger pl.aced liet ween two transverse proc-
esses stopped the hemon-hage; the wound was plugged
with strips of oiled lint, and in four weeks the patient
had perfectly recovered. The plug was removed on the
fourth day.
Hemorrhage from wounds of the vertebral artery be-
tween two transverse processes is difficult to arrest;
wooden plugs have sometimes succeeded; occasionally
the artery has been successfullv tied by snipping away
Fio. 3524.— Deep Dissection of the Neck, showing the Course and
Origin ot the Vertebral Artery (.5). (Tiedemann.)
the transverse process and applying a ligature. If this
cannot be done the bleeding vessel may be secured by
artery forceps, which should be left in the wound.
Traumatic aneurisms of the vertebral artery may occur
after a stab in the neck ; the writer on one occasion saw
this follow a wound of the vessel between the second and
third cervical transverse processes. These aneurisms are
commonly mistaken for aneurism of one of the branches
of the carotid — as, for instance, the occipital — and the
common carotid has been tied on this supposition, with-
out avail, of course. The mistake has arisen from the
surgeon tin<ling that pulsation in the aneurism ceased on
compressing the carotid in the neck. Of course, if it is
compressed below the "carotid tubercle," the circulation
in the vertebral is arrested as well as in the carotid ; and
even if pressure is applied at this point, the vertebral
may Vie compressed, for it frequently fails to enter the
foramen in the transverse process of the sixth cervical
vertelira.
The ligature placed on the carotid should be first tight-
ened, and, if this arrests the pulsations in the aneurism,
the ligation may be completed; but if pul.sation is not
arrested, then it is probable that the vertebral is the ar-
tei-y affected, and ligature of the carotid is a useless pro-
ceeding.
The treatment of such aneurisms is very unsatisfac-
tory ; cases of cure are reported from continuous com-
pression with shot-liag, but if this fail operative meas-
ures are of little avail; it is useless to ligature the artery
low down, as the anastomosis above is so free; and if the
aneurism is cut down upon, ligature at the seat of the
aneurism is rarely satisfactorily completed. The writer
once saw the carotid tied for vertebral aneurism due to a
stab with a knife below the mastoid, and afterward the
sac of the aneurism cut down upon; but the hemorrhage
could not be arrested by plugging, or otherwise, and the
patient died. In this case pressure on the carotid against
the sixth cervical transverse process arrested pulsations
in the aneurism, and it was supposed that the atfection
was connected with the occijiital artery.
The inferior thyroid artery is sometimes ligatured at the
same time as the superior thyroid for enlarged thyroid
in exoplithalmic goitre (Graves' disease). Any of the
arteries may lie tempoi-arily ligatured during an oper-
ation by tying the ligature over a piece of rubber tubing
placed on the vessel. The writer has done this with
both the carotid and the suliclavian arteries with success.
Veins OP the Neck. — The nnUrior juyular vein has
already been mentioned as lying along the inner border
of the sternomastoid. It varies somewhat as to its
course, and is sometimes double. Occasionally, the
veins of the two sides are connected by a large trans-
verse branch, whicli is a source of trouble in the oper-
ation of tracheotomy. The anterior jugular, if large
and placed nearer the median line than usual, is liable to
he. wounded in tiuclieotomy. It might also be wounded
in tenotomy of the sternomastoid for wry -neck. The
two anterior jugulars may be reiilaced by a single
trunk.*
In front of the trachea and thyroid gland is a large
vein, the I'lifin'or tlitjroid (vena thyroidea ima), which,
when large, complicates operations on the trachea.
The cxternnl jugular vein corresponds to a line drawn
from the angle of the jaw to the middle of the clavicle;
it runs beneath the skin and platysma and over the sterno-
mastoid muscle, and ends hy piercing the deep fascia
above the clavicle to join the subclavian vein. In the
operation of tying the subclavian in its third part, it
(the vein) must be held aside or ligatured.
The ihteruul jugular Xfin lies to the outer side of the
conimon carotid artery, and when distended partially
overlaps it. In operations for the removal of tumors or
enlarged glands of the neck, this vessel may be wounded ;
ligature in such accidents is the proper procedui'e, and is
not attended by any evil after-effects. The writer has
on three occasions ligatured the internal jugular with
the most hapjiy results.
The subrlatian rein is a continuation of the axillary,
and is in close relation with the clavicle ; it lies in front
of and below the subclavian artery, from which it is
* The anat<imy ot this refiun ha.s been ably described liy Dr. Pileher
in the Annals of Anatomy and Surgery, vol. iii., ISSl.
196
REFERENCE HANDBOOK OF THE IVIEDICAL SCIENCES.
Neck.
Neck.
separated by t.lie anterior scalenus muscle. On the left
side the tUonicic duct empties into it. The point of
junction of the subclavian and internal jugular veins is
opposite the sternoclavicular articulation. The wall of
Fig. 3525.— .'^uperDcial Veins of tUe Fare. Head, and Upper Part of the
Neck. (From Testut.) 1. Frontal veins: 3, parietal veins; 3, occip-
ital veins ; 4, superflclal temporal vi'in ; 5, internal ma.xillary vein :
6, mastoid vein ; 7, anjiular vein ; m. fni-ial \ein ; 'K fxii-inal jiiL^ular
vein; 10, point where the latter iinastonmses with the laeial veni ;
11, lingual vein; 12, superior thyroid vein; 13, anterior jugular
vein ; U, carotid artery; 15, internal juf^iilar vein ; 11), pneumogas-
tric nerve.
the subclavian vein adheres closely to the fascial sheath
by which it is invested; this sheath is connected ante-
riorly with the costocoracoid inenilnane and the elaviele,
and when the shoulder is cari-ied forward the vessel be-
comes expanded. (Quain.) In operations at the root of
the neck great care should be taken to avoid wounding
the large veins, for air is very apt to be sucked in during
inspiration. These veins are so firmly united to the
bones ;ind mus<des. that when wounded they do not col-
lapse, but, on tljc ci)iit]-ary, gape. It should be remem-
bered that the risk of air entering is increased by move-
ments of the upper limb, which still further
open the wounded vein.
Thyroid Body. — This is a highly vascular
organ consisting of two latei'al lobes, one on
each side of the laryn.x and trachea, connected
b.y an isthmus which crosses the second anil
third rings of the trachea. The lobes are
pear-shaped, iind reach fi'om the hftli and
sixth rings of the trachea to the upper border
of the thyroid cartilage; the latend lobes are
covered in front by "the depressions of the
hyoid bone, and posterioi-ly are in contact
with the sheath of the grciit vessels of the
neck. Each lateral lolie measures about two
inches in length, one and one-fom-tli inch in
breadth, and from tliree-fnurths to one inch in
thickness. The weight of the tliyi'oid bcdy is from one
to two oimces, and is greater in" females than in luales.
The isthmus is occasionally absent, the lateral lobes
being connected by librous "tissue only, as is the case in
some animals, viz., the horse, donkey" etc.
Owing to the fact that the thyroid body lies over the
great vessels of the neck, when enlarged it derives from
them a visible pulsation, and a distinct tlirill may be felt.
Such pulsating tumors have been mistaken for a"neiirismi
but as the thyroitl body is closely connected with the
larynx and traeheti, it rises and falls in deglutition, and
so is easily diagnosed from aneurismal or other tiimors,
which are not disturbed by deglutition. When hyper-
trophied the tumor resulting from an enlarged thyroid
is ctdled a " bronchucele " or goiti-e. When a goiti'e g'rjws
rapidly respiration is often interfered with, and oper-
ation has to be undertaken for its relief. It is not neces-
sary to remove the whole gland to relieve the obstructed
respiration, for divisicm and removal of the isthmus only
often gives very good results. Mr. Sidney Jones (Lan-
cet, vol. ii., 1883) reports cases in which excision of the
isthmus not only relieved the dyspnoea, but amonth after
the operation the lateral lobes iuid almost disappeared.
Since the advent of antiseptic sui-gery the extirpation
of large brouchoceles by the knife has become most com-
mon, but the operation, owing to the very important
structures in relation to it, is always a most formidable
one. It is very important in this operation first to ligate
the vessels supplying the gland, viz., the superior thy-
roid above, and the inferior thyroid below, and if pres-
ent, the middle thyroid. In ligating the infei'ior thyroid
artery, care must be taken not to injure the inferior
laryngeal nerve, which winds among the branches of
that artery. Simple cysts may be removed by enucle-
ation. Owing to the conditions which follow complete
removal of the thyroid, viz., myxo'dema, and cachexia
strumipriva, partial removal is the more common oper-
ation except in cases of malignant disease or when the
growth becomes dangerous from pressure.
The CEsoPH.^GUs commences opposite the cricoid car-
tilage ; it lies between the trachea and the vertebral col-
umn. At the lower end of the neck it inclines a little to
the left, and for this reason cesophagotomy is performed
on the left side. Strictures most commonly occur at its
upper part, and foreign bodies are most apt to be arrested
behind the larynx. Foreign bodies, such as fish bones,
mutton or beef bones, have occasionally ulcerated
through the a^sophagus and perforated some of the large
vessels with which it is in contact.
In performing ()siiph<i;iotoiny for the removal of an
arrested foreign body, the incision is made between the
sternomastoid and trachea, the middle point being op-
posite the cricoid cartilage. The inferior thyroid artery
and recurrent laryngeal nerve must be carefully avoided.
The carotid artery is in no danger of being wounded if
proper care be taken.
In a'sophagostvmi/. when a stricture exists high up, thein-
FlG. a52(;.-Tn
lusverse Section of Neck, Opposite Fourth Cervical Vertehra, .showing
Thyroid Body ail. tft.).
cision into the oesophagus is made for the jmrpose of feed
ing the patient by a tube, and so avoiding gastrostomy.
The fact that the operation is performed low down makes it
much more dangerous than a'sophagotomy . and nearly all
the reported cases have ended in death williin a short time
of the operation from diffuse inflammation of the neck.
197
Neck.
Neck.
KEFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
IIyoid Bone. — Tliisis oiif of the most important land-
marks in the neck, and one wliiclj can ahviiys lie felt iu
the stoutest neck. It is the best ,i;uide tor ligal nre of tlie
lingual. In old age the dilTerent portions of the bone
become ossified into one piece, and iu consequence it is
more easily broken by direct violence due to blows or
throttling. Cases are rejiorted of fracture of the hj oid
from yawning and sudden extension liackwani of the
head. The sjniptoms of fracture are pain, dilficulty iu
speaking, iu movements of the tongue, :ind in swallow-
ing.
L.\RyNX .\ND TRAcnE.\. — The luri/n.r is connected
above with tlie hyoid bone by meaus of the thyrohyoid
membrane, and is continuous below with the trachea.
Posteriorly it helps to form the wall of the pharynx. It
consists of several parts, which are closely connected to-
gether by ligamentous structures, nuiscles, and mucous
membrane: these jiarts are the thyroid cartilage, ejiiglot-
lis, cricoid, and arytenoid cartilages. On the upper mar-
gin of the thyroid cartilage is a bursa which prevents
friction as the larynx ascends beuealh tlic liyoid bone in
deglutition. This bursa is sometimes enlarged, and has
to be incised. Tlie larynx is occasionally wounded in
cases of attempted suicide by cutting the throat. Be-
tween the lower border of tlie thyroid and cricoid car-
tilages is the cricothyroid membrane, where the o)5er-
ation of laryngotomy is performed. A small lymphatic
gland is occasionally found here, which may become
enlarged. (For description of interior of larynx see
Lai'!/ii.:\)
Fdrcign Dnd/'cs. — Children not infrequently swallow
articles which are sucked into the larynx during inspir-
ation; these may be arrested by the cords at the rima, or
may lodge in one of the ventricles. If they pass the
rima they usually lodge in the right bronchus. These
bodies can frcijuently be seen wiili a laryngoscope and
extracted with forceps, but very often the operation of
tracheotomy is necessary to remove them.
The TR.\rnE.\ extends from opposite U,s sixth cervical
vertebra to its bifurcation opposite the third dorsal, wliere
it is crossed b}' the arch of the aorta. It measures from
four to live inelies iu length, and from three-fourths to
one inch in breadth. It is covered by the depressors of
the hyoid bone, and has on each side at its upper cud the
(C-^2)
Fig. 3."i2T.— Dissection of tlie Spare in tliM Nec-k vvlii're the iipcration
of Tractieot^tiiiy is Perfoniied. Tile trarliea is e.xpo.st^il, liaving on
eaili siile of it tlie .sleriiolivoifl iiuisele, antl lyins; on it lielow the
inferior tliyroid veins, tltoser.)
thyroid body. It is crossed by the isthmus of the tliy
roid gland opposite its second and third riiiLjs. and has
also in front tiie inferior tliymid veins, and sometimes a
trausverse branch couuecting the two anterior jugulars.
When the middle thyroid artery is jiresent it also lies
upon the trachcit in its eotuse up to the isthuuis of the
thyroid. In children the thymus gland covers its lower
portion. Laterally the trachea is in relation with the
carotid artery and recurrent laryngeal nerve; posteriorly
it is iu contact with the O'sophagus. The innominate
artery crosses the loyver end of the trachea ; this occurs
higher up in children than in adults.
The operation of tnic/uokini;/ is performed above or be-
low the isthmus. It is required for the extraction of for-
eign bodies and for any obstruction to respiration having
its seat in the larynx, as from di|)litheritic nrembrane,
new growths, etc. It is also performed as a preliminary
to certain operations in the neck and mouth.
The distance between the cricoid cartilage and the up-
per border of the sternum, iu ordinary individuals, is
about one inch aud a half (4 cm.); when the head is
thrown back three-fourths of an inch more is gained ; so m
jierforming tracheotomy the neck should be extended as
much as possilile by placing a hard round pillow under
it, aud the iucisiou should be exactly in the middle line,
so as to come between the two sternohyoid muscles aud
anterior jugular veins. In operating there is a choice as
to where the trachea is to be opened, either above or be-
low the isthmus. Above, the parts are more superficial
and blood-vessels fewer, but the space is limited and the
cricoid cartilage hasoften to be cut; below, although the
trachea is deeper and the veins are more plentiful, still
there is more room lor incision, aud we get farther away
from the disease, which is an importaut point in diph-
theria. With our ]iresent means of arresting hemorrhage
the low operation is to be preferred.
LtiryngotDiiiiiis performed in cases iu which it is neces-
sary rapidly to relieve sulTocation, and in adults who
have chronic allectious of the larynx. It is perfcirined
by cutting the cricothyroid membi'ane transversely.
(For a more complete description of these operations
see Tnicheotointj.)
Ly.mpu-VTIC Glands of the Neck. — These are large
and numerous. They frequently enlarge and become iu-
Hamed. and if not excised break down and suppurate, leav-
ing unsightly scars. In scrofulous subjects the glands of
the neck are the ones most frequently enlarged. The
enlargement is always the r.'siilt of some irritation, either
iif the nuicnus iiieiulirane of the throat, nose, ear, etc., or
of the skiu of the scal]i, fare, or neck. The glands are
more liable to enlarge in persons of a scrofulous diathe-
sis, and in them the uniount of involvement of the glands
is out of all jiroportion to the irritating cause; this may
be an eczema of the scalp or a simple sore throat. In
uon-scrofulous individuals the glands are freciuently en-
larged from some special irritating cause, as a diseased
tooth, tonsillitis, malignant disease of the tongue, lip,
etc., but iu these individuals the affection of the glands
is not so wides]iread, nor is the enlargement so great, aud
the glands do not tend to suppurate.
In syphilitics the glandnlif concdtenatir \a the posterior
triangle of the neck are frequently enlarged aud iudii-
rated, but they do not tend to suiipurate. In tonsillitis
an enlarged gland is always felt beneath the angle of the
lower jaw; this is erroneously suppo.seil by m;iny to be
the enlarged tonsil which cannot be felt from tiie outside.
In eczema of the .scalp the glands of the neck are fre-
ciuently enlarged, especially if the eczema be of the pus-
tular variety. Iu delicate children peiliculi not only
often cause an eczema of the nape of the neck, but the
irritation frequently causes enlargement of the glands iu
the suboccipital and mastoid regions.
Occasionally a single .uland becomes enlarged over the
carotid artery, and this has been mistaken for aneurism
on account of the strong pulsation communicated to the
tumor by the artei'y ; these tumors, however, cannot be
emiitied by lateral pressure, and when lifted away from
the artery all pulsation, of cour.se, ceases.
When one or several glands of the neck have become
enlarged and show no tendency to diminish, it is much
Iietter to remove them with the knife. This can be eas-
ily done before the gland breaks down aud suppurates,
and so forms inflammatory adhesions to the surrounding
parts. In cases of " scrofulous necks/' iu which nearly all
198
UEFEKENCE HANDBOOK OF THE 5IEDICAL SCIENX'ES.
Neck,
Neck.
the glands are enlarged, their removal is advisable, for if
left to themselves thej' break down and sup]iiirate, and
after months and perhaps j'ears of discomfort, heal, leav-
ing unsiglitly scars. An argument in favor of early ex-
ci.sion is tliat foci of infection are removed, and the pa-
tient 's chance of good health is mucli greater. Frequently
thirty or forty glands have been removed at one oper-
ation", and the result is almost invariably good, the pa-
tient recovers rapidly, and the amount of scarring is very
trilling. In dissecting out the glands in close relation to
the large vessels, great care should be taken.
Wlien the glands have suppurated and sinuses are left
which will not heal, scraping the sinus and removal of
the remains of the gland wilh a .sharp spoon give very
good results. Mr. Treves recommends puncture of soft-
ened caseous glands with a cautery; he also advises
opening gland abscesses by the cautery highly heated.
The lymphatics of the neck are enlarged, with those of
other parts of the body, in leukaemia and Hodgkin's dis-
ease, and care should be taken not to confound scrofu-
lous glands with enlarged glands in these diseases. Re-
moval of enlarged glands in Hodgkin's disease is, except
for diagnostic purposes, of course, perfectly useless.
The lymphatic glands of the neck are arranged in the
follow-ing groups: Subma^iUari/ {ten to twelve in num-
ber), situated beneath the base of the inferior maxilla ;
these also include the S'ipraliyoid, which are situated be-
tween the two anterior bellies of the digastric muscle in
the ndddle line of the neck. Siiperfcial cerrical (four to
six) situated along the external jugular vein beneath the
platysma and deep fascia. Dfnp ceiricdl (twenty to
thirty). These are subdivided into s'ljicrinr and inferior.
The 'superior are situated about the bifurcation of the
common carotid, and reach to the base of the skull, lying
along the internal jugular vein. The inferior are grouped
around the lower part of the internal jugular vein, and
extend outward into the supraclavicular fo.ssa, becoming
continuous below with the axillary and mediastinal
glands.
The following table, from Sir F. Treves' book on
"Scrofula and Its Gland Diseases." .showing the relation
certain glands bear to the peripheiy, will be found use-
ful:
Scalp : Posterior part = suboccipital and mastoid
glands; frontal and parietal portions = parotid glands;
vessels from the scalp also enter the superficial cervical
set of glands.
Skill of Face and Xeck = Submaxillary, parotid, and
superficial cervical glands.
External Ear = Superficial cervical glands.
I/rirer Lip = Submaxillar}' and suprah3-oid glands.
Buccal Camly = Submaxillary and deep superior cervi-
cal glands.
Oiims of Loicer Jaw = Submaxillary glands.
Tongne : Anterior portion = suprahyoid and submaxil-
lary glands ; posterior portion = deep cervical glands
{superior).
Tonnils and Palate = Deep cervical glands (superior).
Pharynx: Upper part = parotid and retropharyngeal
glands ; lower part = deep cervical glands (superior).
haryiLr, Orbit, and Roof of Mouth = deep cervical
glands (superior set).
Nasal Fossa = Retropharj'ngeal glands and deep cervi-
cal (superior). Some lymphatics from the posterior part
of the fossa enter the i)arotid gland.
P.\itoTiD Gi..\ND. — This gland lies on the face in front
of tlie ear, and extends dee]ily into the space hehind the
lower jaw ; its inferior portion is situated partly in the
neck behind the angle of the jaw, lying on the digastric
muscles in the siibmaxillary region. It is conneeteii with
very important structures, being pierced by the external
carotid artery and facial nerve. This gland not infre-
quently becomes inflamed and suppurates after fevers (as
typhoid) and f>perations on the abdominal viscera. Cases
are reported in which it has become inflameii after ovaii-
otomy, and the writer has twice seen abscess of the |)arot-
id follow .severe blows on the abdomen. These abscesses
are very painful, owing to the tension caused by the in-
vesting fibrous capsule. In opening abscesses here Ihs
incision should l)e transverse, to avoid cutting the facial
nerve, and .should be in front of the line of the carotid
artery. Abscesses of the parotid gland frequently burst
Fir. .3.">2.S.— Dissection of the Neck, sliowing tbe Triangles and tlieir
Contents. (Tiedemann.)
into the external auditory meatus. There are a number
of lymphatic glands in relation with the parotid, which
receive vessels from the scalp, pharynx, etc. Tumors
ai-e not infrequently found in this region, the extirpation
of which gives rise to very severe hemoiThage. The
facial nerve is frequently unavoidablj- injured in the re-
moval of these tumois, and the external carotid artery
sometimes requires ligatui'e.
ScnM.\xiLL.\RY Gl.\nd. — The submaxillary gland is
situated in the submaxillary region, between the anterior
and posterior bellies of the digastric muscle. It lies
partly on the mylohyoid and partly beneath it. The fa-
cial artery grooves the back part and upper border of the
gland. The gland is sometimes involved in malignant
diseases affecting the mouth and tongue. It is separated
from the parotid gland by a fold of deep cervical fascia,
the stylomaxillary ligament.
Nape OP the Neck. — The superficial anatomy of this
region has already been described. The most superficial
muscle is the trapezius, which is covered by a layer of
thick and tough fascia and is jiierced by the great oc-
cipital nerve. To the outer side of the trapezius, and
separated from it as it descends, is the steruomastoid
muscle; crossing obliquely the interval between them are
the splenius capitis and colli inu.scles. On removing the
trapezius, which in this region is usually very thin, the
complexus muscle comes into view, also jiierced h}' the
great occipital nerve; deeper down still are seen the
muscles bounding the suboccipital triangle (I'ectus capi-
tis anticus luajor, supei'ior and inferior oblique), where
are seen the suboceiiiital nerve and vertebral artery.
In the central line is the ligamentum nucha?. It ex-
tends from the .seventh cervical spine to the external
occipital protuberance. In .some animals this ligament
is a very powerful elastic band which suspends the head ;
to it are attached muscles and fascia. The occipital ar-
teiT becomes superficial midway between the mastoid
process and external occipital pi'otuberance. It runs
along the outer border of the sujierior oblique, and is
199
Necrosis.
REFERENCE HANDBOOK OF THE ilEDICAL SCIENCES.
Fig. 3o2n.— Tlie Skin and Fascia have been I!e-
mnved, ami Itif Superflcial Mii.scles PLxpo.sed.
]. steT-nomasU'id ; ~, spleiiius (.-apilis : a, Ira-
pe^^ius ; 4. suiall occipital nerve ; ,5. threat oc-
<-i(iital nerve; 1>. occipital artery. (After
Rosei-. t
rifri)iii|ianicil ]>y the great occipital nerve. The lesser
otcipital luTve winds round the posterior border of the
steruoinastoid. and supplies the lateral region of the oc-
ciput; the suboccipital, being a purely motor nerve,
rarely reaches the skin.
Spinal Cord and Vertebral Column. — Tlie accompany-
ing figure (3.530) shows well the situation of the sjiiual
cord in the neck vertebra. It is not so well jirotected
against injury as in
other parts, for in
the space between
the several arches,
any sharp instru-
iiieiit piercing the
muscular tissue
could easily wound
the cord. The ver-
tebral artery, as has
already been men-
tioned, is also lia-
ble to injury on its
way from one ver-
tebra to another.
From the great mo-
bility of this part
of the spine dis-
location occasion-
ally occurs and
death i.s caused
by pressure on
tile cord. In
caries of the uji-
per cervical ver-
tebrtp, sudden
death has taken
place from the
destruction of the ligaments between the atlas and axis.
When lliis occurs — the head with the atlas inclining for-
ward and leaving the axis in its jiroper position — the
medulla oblongata is crushed against the odontoid proc-
ess, anil so instant death is the residt. (Hilton.)
Caries of the spine in the cervical region is not uncom-
mon. In its early stages the symptoms are somewhat
obscure, the chief complaint being <if pain in the course
of the great occipital nerve, due to its implication in in-
flanunatory exudation. The iieculiar stiff way in whicli
the patient carries his head, and the presence of a sliglit
prdminence which is excessively tender, enables the sur-
geiin to recognize the disease, Thc'se cases occasionally
result in a post-pliaryng<'al abscess, which has to be
opened. This may easily and .safely be done by :iu incis-
ion along the i)osteri(jr border of the steruomastoi<l.
Some advise tapping it with a Irocarthrougli the mouth.
Br.\nci[Ial FisTi'L.E AND Cysts. — III the mammalian
embryo, at the fourth week, there are on each side of the
head, behind the oral cavity, four tissures which com-
municate with the anterior part of the alimentary canal.
These are Ihe homologues of tlie clefts found in iiranclii-
ate vertebrates. Tlie third and fouith tissures in the
human embryo disajipear about the sixth week, and only
the first remains at the en<l of the ninth week. This per
sists as the Eustachian tubr', tynip;inic cavity, and exter-
nal auditory meatus. The structures developed in the
folds between the clefis (l)rancliial arches)are as follows:
First Arch (Mandihuhir): ileckel's cartilage, the an-
terior portion of whicli is developid into the lower jaw.
and the mandibular arch is tMnnpleted by the iiuiileiis
bone of the car.
Second Arch (l/i/oiil): Incus, stajies (Parker), styloid
process, .stylohyoid ligament, and lesser cornu of the
hyoid bone.
Third Arch : Great cornu and Imdy of the hyoid bone.
Fourth Arch : No permanent remains.
Sometimes the clefts lietweeii these arches rein;nn more
or less open, and this fact ex]ilains iheoccurrenci' of con-
genital tistuhe of the neck, as well as that of cysts and
diverticula from tlie lesopliaiius and larvnx.
Paget savs (Proe. lioval Med. Sih-./ISII): "Cervical
branchial fistulas occur as two or three minute orifices on
one or both sides of the lower part of the neck, and they
lead upward to the a'sophagus and pharynx; the lower-
most being near the sternal end of the clavicle in front of
the sternomastoid muscle, the next opposite the thyroid
cartilage, and the highest between the thyroid cartilage
and hyoid bone." When two in number, they are often
symmetrical; they vary in length from one-half to one
and a half inches, and liarely admit a probe. They have
a smooth lining membrane, whiili secretes a clear mu-
cous tiuid. These tistuhe can be cured by cauterizing
them with thegalvanocautery. It is probable that many
cysts and so-calleil h_vdroceles of the neck are due to im-
perfectly closed embryonal Assures.
Sanguineous cysts of the neck are probable originally
branchial cysts, which have communicated with the in-
ternal jugular vieu. Ca.ses are (Ui record in which, be-
fore removal of the cyst, the vein had to be ligatured
(Gllick: Deutsche nied. 'Woch.. No. 5, 1886).
Br.vncihal Dermoids. — These are occasionally seen
in the neck, the most common situation being between
the geniohyoglossi muscles, where the swelling projects
into the submaxillary space and also into the mouth.
They can usually be enucleated. A dermoid sometimes
is seen under the dee]i fascia close to the carotid arteries.
TiiVRoi.iXfa-Ai, FisTri..E and Cysts. — These are met
with on the tongue, at the hyoid bone, and lower down
over the th3Toid cartilage, cricoid, and upper rings of
the trachea. They grow slowly with the growth of the
individual, and are very difficult to eradicate. The cyst
wall is thin and lined with columnar epithelium, per-
haps ciliated. Their contents are mucoid. They some-
times burst, leaving fistulous openings which are difficult
to close. Unless the c_yst be entirel}' removed, it will re-
cur, for if any part of the epithelial lining be left it will
secrete and cause a persistence of the trouble. Tliyro-
liugual c.ysts and fistuliie are the remains of the thyro-
Hngual cluct, which passes up the neck to the tongue
Fir,. a")3fl.— The SnperDcial Tissues have been Removed to show the
Verlebral Arterv Passing Through the Transverse Processes ot the
Vertebra", and also the Relation of the Cord to the .Spinal Canal.
(Koser.)
behind the hyoid bone. The lower part becomes the
isthnnis of the thyroid gland, while the upper part per-
sists as the foramen ca'Ciim of the tongue.
Ti'.MORS OF THK Nkck.— The neck is a favorite site for
tumors, fibrous, sarcomatous, anil others. Sarcomatous
tumors in the early staires can be removed, but they
nearly alwtiys recur. Tumors of the neck, which are
200
KEFEKEN-CE HANDBOOK OF THE IMEDICAL SCIENCES.
Neck.
Necrosis.
apparently so freely movable that their extirpation
would seem to be an easy matter, are found, when cut
down upon, to be intimately connected with the deep
vessels and nerves. In these eases the tumor is freely
movable laterally, the vessels going with them, but there
is no freedom of movement in the vertical direction. It
is remarkable with what impunitj' large tumors may
be removed from the neck, especially if they are benign.
It is not unconunon in these cases to ligature both the
internal jugular vein and the carotid artery, and to cut
through the sternomastoid muscle, and 3'et have the pa-
tient make a rapid recovery from the operation; the
tumor, as mentioned above, if sarcomatous, almost in-
variably returns, for it is impossible in the neck in such
cases to remove sufficient of the surrounding healthy
structures.
Aneurismal tumors at the root of the neck are compar-
atively common, and although in many cases these tu-
mors may have the ajipearauce of lieiug connected with
the subclavian or innominate arteries, yet they almost
invariably proceed from the aoitic arch, and push theii'
way upward under the clavicle into the neck. Fusiform
aneurisms of the aorta frequentl.y simulate aneurism of
one of the great branches.
Tumors inomneetion with the th3'roid gland have been
alluded to in the description of that bod_v.
Francis J. Sliejiherd.
NECROBIOSIS.— The gradual death of tissue due to
slowly acting injurious agents is known as necrobiosis or
indirect necrosis, in opposition to flirect necrosis or imme-
diate death. In necrobiosis the death of the cell is pre-
ceded by some other retrograde change, such as atrophy,
cloudy swelling, mucous, hydropic or fatty degener-
ation, or by one of the pathological infiltrations. In the
case of direct necrosis death of the tissue takes place
rapidly without the occurrence of preceding abnormal
changes in cellular structure. The preceding retrograde
change in necrobiotic processes is by some writers re-
garded as constituting the necrobiosis; but a distinction
should be made between the preceding atrophy, degener-
ation or infiltration, and the molecular disintegration
which constitutes the essential feature of necrobiosis.
The retrogressive changes preceding this disintegration
usually occur so gradually, and in themselves present
such definite characteristics, as to be classed by them-
selves. The use of the term necrobiosis is more theoret-
ical than ]iractical, inasnuich as a practical distinction
between direct necrosis and necrobiosis is at times very
dilRcult or impossible. Necrobiosis is, therefore, best
conceived of as a slowly progressive or incomplete necro-
sis. The gross appearances of necrobiotic tissues vary
according to the nature of the preceding retrograde
change and the degree of necrosis present. Microscopi-
cally, in addition to the characteristic changes presented
by the accompanying retrograde change, the nuclei of
the affected tissue show karyorrhe.xis and a greater or
less degree of karyolysis. The ultimate picture of necro-
biosis is that of necrosis; if the necrobiotic process has
been cliaracterized by cloudy swelling, simple necrosis
follows; if by fatty degeneiatiou, soft caseation (fatty
necrobiosi-s) occurs; if by hydroijic degeneration, lique-
faction necrosis results. The sequels of necrobiosis are
essentiallj' those of necro,sis: regeneration, repair, cica-
trization, calcification, and cj'st formation. Likewise
the causes producing necrobiosis are the same as those
leading to direct necrosis: mechanical, thermal, chemi-
cal, infectious, and nutritional. The injurious agents
may act separately or coincidi'ntly. As a general rule it
may l)e stated that harmful agents of slight power but of
long-continued action are more likely to produce necro-
biosis than direct necrosis. Disturbances of blood sup-
ply, deficient nutrition and oxygenation, as in the ca.se
of chronic anaania, are among the most important factors
leading to necrobiotic processes. Chronic intoxications
and infections also ]iluy a leading role in the production
of necrobiosis. Clinically a neuropathic necrobiosis may
be distinguished. " Aldred Scutt Warthin.
NECROSIS, PATHOLOGY OF.— The condition of
local diuth, tlie death i\i individual cells or groups of
cells within the living body, is known as necrosis. If
such local death occurs immediately or very quickly
after the action of some injuiious agent, it is termed di-
rect necrosis; if, on the other hand, the death of tissue
is of a slowly progressive nature preceded by other retro-
grade changes, the process is designated necrobiosis or
indirect necrosis. The use of the word necrosis without
modifying designation is usually taken as referring to
direct necrosis.
Inasmuch as we have no definite knowleflgc, either
chemical or histological, of the condition of cell life, the
essential nature of cell death or necrosis is also unknown
to us. The cellular change which marks the e.xact mo-
ment of the passage of life from the cell is at present
beyond our knowledge: the slight histological changes
taking place in cells at this moment do not permit us to
determine with certainty the definite boundary between
the .states of cell life and cell death. Our conception of
necrosis is, therefore, based upon the changes which f(jl-
low necrosis rather than upon those taking place at the
moment of cessation of life. The development of mod-
ern microscopical technique has, however, so perfected
methods of tissue fixatiou that it is now possible to fix
and preserve definitely the histological characteristics of
the cells as they exist at the moment the tissue is placed
in the fixing fluid. Our knowledge of the structure of
normal living cells has been obtained from the study
of cells hilled and fixed by such means: and likewise our
conceptions of pathological conditions are based upon the
relative appearances of cells so treated.
As a result of such study certain pathological criteria
have been created. Of these the condition of necmsis is
tliat .state of the cell which is characterized microscopi-
cally by the disappearance of the nucleus and certain
molecular changes in the cytoplasm. The disappearance
of the nucleus or its failure to respond to nuclear stains
is to be taken as the most striking feature of necrosis, in-
asmuch as the nucleus is to be regarded as the most essen-
tial vital element of the cell. Cells may be dead and yet
retain their nuclei, but necrosis becomes evident to us
microscopically only when certain changes in cell struct-
ture have occurred to distinguish tlie dead cell from liv-
ing ones. The loss of the nucleus may occur at the mo-
ment of death or subsequently ; in either case it becomes
the criterion of necrosis. To the disappearance of the
nucleus an,d its loss of staining power the terms kari/oli/-
sis and chromatoli/sis have been applied. These changes
arc very frequently preceded by fragmentation of the
nuclear chromatin. This change is known as knri/or-
rlie.ri.<! ; it has been shown to consist of regular and defi-
nite movements on the part fif the chromatin elements.
Small masses and granules of chromatin may leave the
nucleus and pass into the cell body. ATith the disap-
pearance of the cell membrane fine chromatin granules
may be scattered throughout the cell detritus of the ne-
crotic area. As a result of such diffusion of the chroma-
tin areas of necrosis in the early stage may stain ditl'usely
blue. In other cases the nucleus before its disapjiearance
contracts and becomes smaller, at the same time staining
more deeply than normal {pykiiosis.) Very frequently
the nucleus retains its normal form and size, but gradu-
ally loses its staining power and fades away, both nu-
cleus and protoplasm being converted into a homogene-
ous hyaline mass.
Sooner or later, changes take place in the protojilasm
of dead or dying cells The normal granulation of tlie
cytoplasm may disiijipear and the cell imdergo a hyaline
change. The cell membrane ultimately disappears and
the outline of the cell becomes irregular or lost alto-
gether. Often the cell protoplasm becomes coarsely
granular, the cell ultimately breaking up into a graiuilar
debris. Vacnolation may take place and the cell become
enlarged and swollen trom the imbibition of fluid. As
the result of such swelling, breaks in the continuity of
the protoplasm may occur. C)n the other hand, the diwl
cells may under certain conditions become iuspissatc.l.
201
Necrosis.
Nocrosis,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Extrusion and constriction of portions of the protoplasm
may occur during tlu; process of dying. Ama'boid cells
usually assume a gloljular form. The disintegration of
the iirotoplasm is termed plitsiimsr/i/xix. The ultimate
resuli of tlie ueerotie process is llie conversion of both
nueieusand cytoplasm into a granular debris; when such
appearances are I'ound niicroscopically, tiie condition is
to l)e regarded as one of com]ilcte necrosis.
('iiii.iei< of Xeeronin. — The causes which may lead to local
deatii of lissue may be classed as follows: nutritional,
mechanical. Ihi'miai, cliemieal, toxic, iid'ectious, andneu-
iipatliic.
Disturbances of uutiitiou through interru]:ition of the
circuhiliou arc among the most treciuent causes of necro-
sis. Local ana-mia due to arterial occlusion as a result
(ji Ihrombo.sis, embolism, compression, ligature, or ar-
teriosclerosis maybe the direct cause of local tissue death
(an:emic and licmorrhagic infarction). Likewise stasis
due to mechanical, thermal, chemical, or trojihic changes
in the vessel walls or to weakcueil heart's action may be
a ])rimarv or secondary factor of necrosis. Local as-
phyxia from any cause may result in cell death.
Traumatic violence may through crushing or tearing
cause direct death of cells, or through damage to the
blood-vessels it may cause necrosis Ihrough disturbed
nutrition. Cells sejiarated from their normal environ-
ment as a rule soon die.
Elevation of temperaturi' fmm 54" to 68' C. for a short
period of time causes the deatli of tissue; excessive cold
produces the .same rcs\dl.
The i)rolouged action of ./-rays may lead to necrotic
changes. This has been explained as due to the destruc-
tion of nerves, but this point has not been definitely set-
tled.
Chemic;d and toxic substances of various kinds may
act directly upon cells and cause their death. The
poison may destroy the cells directly or. through chemi-
cal union with the cell protoplasm or intercellular sub-
stance, render life impossible, or by producing changes
in the blood-vessels give rise to necrosis secondarily.
IMost im|iortaut of all as agents of necrosis are the
bacterial toxins, jiarticularly those of tuberculosis, ty-
phoid, cholera, sta])hylococcus, aiul stre|itococcus in-
fection.s. Chemical substances, origiuatiug within the
body, may also give rise to necrosis under certain con-
ditinus.
The bile acids, uric acid, mctabulic products in dia-
betes, pancreatic ferments, etc., may under certain path-
ologii'al conditions give rise to necrotic processes. Fat
necrosis is a .striking example of necrosis arising from the
action of a normal body iirodtud under abnormal condi-
tions. 'I'he pancreatic juicesare absorbed into the lymph
and lilood streams, the fat-splitting ferineiit, stcapsin,
causing necrosis of fal cells in llie neighboring fat tissue,
or even in such di^taut legions as the ]iericardiuin and
fatty marrow.
The direct action of bacteria or other forms of vege-
table and aidmal parasites may also juoduce necrosis of
cell.s.
Primary lesions of the central nervous system and the
peripheral nerves are considered by many writers to give
rise to a trophic or neuro]iathi<; necrosis. The chaiiges
following such lesions are much nmre to be regarded as
dependent upon circulatory disturbances than as trophic
manifestations. As a result of lowered nutrition the nor-
mal resistatice of the affected parts may I"' dimiuished
and bacterial infection favored.
The causes mentioned above may a<-t se|iaralcly or
coincideiuly. The degree of necrosis depends not "only
upon the n;dnre and severity of the exciting cause, but
also upon the condition of the tissue at tlie liuieof in-
jury. Tissues of lowered vitality, in comlitious of gen-
eral ana'inia, marasmus, an<l cachexia, die more easily
than normal tissue; hence long-continued pressure of
slight degree, which tmder normal conditions would pro-
duce no effect, may in such conditions as typhoid fever,
chronic valvular disease, etc., bring about uecro.sis (rfc-
cubitus, iiMnwnic nccrusu). Necrosis occurs also in the
tissues of the aged as a result of slight injuries (senile
iit'crosis).
Varieties op Necrosis. — Though the loss of the nu-
cleus and a greater or less disorganization of the cyto-
plasm form the essential featiires of necrosis, these
changes may be more or less modified, or so associated
with other ]jrocesses as to give rise to difl'erent varieties
of necrosis, recognizable either by gross or by microscopi-
cal appearances. The kind of necrosis depends upon the
location and nature of the affected cells, the character
and severity of the destructive agent, and the nature of
the surroimding tissue, particularly with reference to the
absence or presence of liuids. If the dead cells are on a
surface exposed to evaporation, inspissation may take
place; ou the other hand, if tliere is an abundant supply
of fluid, the cells may become hydropic and ultimately
liquefy; if the factors necessary for the formation of
fibrin are present, coagulation may occur either in the
cells or between them. The character of the necrosis
maybe further modified by infection with putrefactive
bacteria. It becomes therefore possible to distinguish
the following varieties of necrosis, each form presenting
distinct macroscopical and mieroscojiical characteristics
when occurring alone. Between these different varieties
there is, however, no distinct lionudary line. They are
very frequently ccnnbined or may follow each other in
certain cases, so that the practical diagnosis as to the
original form may be difficult.
fl.
Simple.
^, , ,. ( Intercellular.
Coagulation. -, i„t,acellular.
Li({uefaction.
.Mummification.
Moist gangrene.
Caseation.
Simple Kecmsis. — This form of necrosis is characterized
microscopically by the disappearance of the nucleus and
a hyaline or granular change in the cytoplasm, the origi-
nal outlines of the ti.ssue being preserved to a greater or
less extent. Usually the dead cells are somewhat larger
than normal, the protoplasm being more granular and
staining lieavily witli cosin. Less frequently the cells are
hyaline and homogeneous. By .some writers this variety
of necrosis is regarded as a form of coagulation necrosis,
but it seems better to restrict the latter class to those forms
^-^^vr^
^-i«
.^m"T,25i^^i^
Fig. SiSl — Sii i Ic N i s f tli ri tti hum f ttii I niiiferims
Tubes in a i :i.si-.if l.-iirusiinivis. (fYnni Zietrler.) o. Normal I'on-
voliiteci tulililc; /i. a.-scendillK loop tiilmte : c. convotutefl tulnlle
mth necrotif epltlieliiim ; ri. convoluted tuljule witli only a pari of
its epithelium necrot.ln; c, stroma and lilood-vessels as yet unal-
tered. (Prepiiralinn liardened in Miitler's Fluid, and stained witli
!;i.'ntian vioti-f. i MaL'nilleil :!l»i diainelel-s.
of necrosis in which librin or fibrinoid substances are
formed. Simple necrosis usually follows cloudy swell-
ing; indeed, it may be regai-ded"as a late .stage" of this
degeneration advanced to such a degree that the nucleus
has entirely disajipeared Early stages of simple necro-
sis may often be recognized by the presence of diffuse
clirumatin. The gross appearances of simple neci-osis
'202
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Nt'frosis,
Necrosis,
are ^yellowish or grayish discoloration and lessened con-
sistency. Simple necrosis is one of the most common
forms of necrosis; it occurs very frequent]}' in the epi-
tlielium of tlie Ividuevsaud liver as the result of intoxica-
C2iQ- 'z^^^'-'^ ^ ^^ —^^^^^^r^^r&s
Fig. 3532.— Coaguhilioii Necrosis. ( iiuiimn- mcinbnme from the
trachea. (From Zic<rler.l n, TransM.iM' .v ni.iu of the membrane;
b, uppermost I:iyer of the nmrons membrane with pus cells, t7,
scattered tbrouiriiout its substance; c, fibrin threads and granules;
c?, pus cells, ilaguitleil 'SA) ihameters.
tions and infections, but may be found in any of the tis-
sues. It is the most common form of neci'osis founil in
anaimic and hemorrhagic infarcts, and in focal necroses
due to variotis forms of intoxication and infection (ty-
phoid, tuberculosis, diphtheria, scarlatina, etc.). A fur-
ther change in tissues showing simple necrosis, so that
all tissue outlines are lost ami mily a tincly granular mass
is left, results in the condition kmiwn as caseation.
Coar/uliition Necmsis. — This form of neci'osis is charac-
terized by the production, in the necrosed tissue, of fibrin
or substances allied to fibrin, the so-called "fibrinoid de-
gene nttion." The variety of necrosis described above as
simple necrosis is by some -writers regarded as a coagu-
lation necrosis, but there is no positive evidence that it
represents a coagulation process, and tlie resulting suli-
stance is not allied to filirin. Coagulation necrosis oc-
curs only ill tissues rich in proteids and under conditions
favoralile for the ))roduction of tlie factors necessary for
the formation of filn-in. Two forms are distinguished —
intevceUtdar and intracellular. In the intercellular form
fibrin is formed between the drying or dead cells, the
granular debris of the latter finally lying in a more or
le.ss dense network of fibrin threads. By the use of the
Weigert's fibrin methoil this network of fibrin maybe
easily demonstrated. The fibrin may exist also in the
granular, fibro-granular, or hyaline form. The chief
source of the fibrin is most probably an exudate from the
blood-vessels, but some of the factors necessary for the
formation of fibrin may be supplied by the disintegration
of tissue cells or leucocytes. The ells may become hya-
line or granular, and ultimatel.y com]detely disintegrate.
This form of necrosis is most frequently seen in the fibrin-
ous inflammations of nnicous and sernus membranes, and
is hence also called di/t/il/ierilie, croii}u>i/.i, or inenibranciis
necrosis. The diplitheritic membrane may be taken as
the typical example of this variety of necrosis. In .'ill
so-called diphtheritic infiammations there is more or less
■extensive necrosis of the mucosa with the formation of
granular or fibro-granular fibrin between the granules of
cell detritus. IntercelUilar co;igulation necrosis lutiy
also occur in dei'pcr tissues, as in the follicles of lln-
spleen or lymph ghinds, in the liver, kidney, etc. It is
of very commim occurrence in the focal necroses of
toxic and bacterial- origin, and is almost constantly pres-
ent to sotue degree in tubercles. It occurs mueli less fre-
quently in an;emic and hemorrhagic infarction. JIany
chemicals jause coagulation by direct action. The toxa'-
mia of superficial burns is associated with a form of co-
agulation necrosis in the splenic follicles and lymph
glands similar to that seen in infectious processes. The
coagulation of the blood and the process of thrombosis
may be regarded as a form of coagulation necrosis. Tis-
sues showing coagulation necrosis are firmer and paler
than normal, more opaque, and show slight elevations
above the cut surface. The source of the fibrin in the
different instances of coagulation necrosis mentioned
above is not entirely clear. A portion may result from
the coagulation of vascular exudates and "from escapt'd
blood cells. In other cases it has been assumed that
fibrinogenetic substances are derived from the neercsing
cells or from bacteritil products. The small quantity of
librinogen found in the lymph may give rise to a portion
of the fibrin produced during the necrotic process.
The intracellular form of coagulation necrosis is char-
acterized b_y the coagulation of the cell protoplasm into
;i solid or senii-.solid albuminous body more or less resem-
bling fibrin. ,Tbe most common example of this process
is the so-called waxy or hyaline necrosis of striped mus-
cle, commonh' known as Zenker's neerosi.i. In this
change the muscle loses its striations and becomes con-
verted into a hyaline homogeneous substance which
j sometimes stains like fibrin, but often does not. To the
naked eye such muscle appears pearly wliite or grayish,
semitranslucent, resembling fish fiesh. The condition oc-
curs most commonly in cases of long-continued fevers as
typhoid, and is found also in anannic, tberm;il, and toxic
necrosis of muscle. In the fevers the abdominal recti and
the adductors of the femurs are most often alTected. The
exact chemical nature of the coagulated protoplasm is
unknown. The .simple necrosis which occurs in ana'mic
infarcts is regarded by some writers as being a similar form
of intracellular necrosis (hyaline coagulation), but the
process is of a very ditTerent nature from the change seen
in striped muscle; and, as stated above, there is no defi-
nite proof that it is of the nature of a coagulation. Other
writers look upon it as an inspissation process. In some
instances intracellular coagulation may result fiom the
imbibition of fibrinogen-coiitaining fluids and their sub-
sequent coagulation.
Liejtiefaction JHecrosis. — In this variety of necrosis the
dead cells undergo liquefaction ; the dissolution may fol-
low a hydropic degeneration or the necrotic cells may be
dissolved in the tissue fluiils. As a rule liquefactioii ne-
crosis occurs primarily in tissues freely bathed in lymph,
but containing little (if tlie fibrin-forming .substances, as
in the brain, cord, and skin. Burns of the second degree
(blisters) are very common examples of this form ofne-
crosis. Ansemic'infareticm of the bi-ain, tis
tions, simple soft-
ue suppura-
C
ening of thrombi,
atheromatous sofi-
ening in blood-ves-
sel walls, and the
digestion of uecro-
tic areas of stomach
and duodenum bj'
the gastric juice are
all processes char-
acterized by soften-
ing and liquefac-
tion. Liquefaction
is also of frequent
occurrence iu cer-
I ai n tumors. In
other cases li(|Ue-
faction is a second-
niy process folio w-
i u g simple or
eiitigulation necro-
sis. The fibrinous
exudates of inflam-
matory processes
become liquefied
during the later
stages of the infiaiu-
mation or during
the process of heal-
ing, as in the case
of the resolution of croupous pneumonia. Areas of
caseation necrosis and moist gangrene may undergo a
secondary liquefaction. On the other hand, coagulation
may follow liquefaction, the fibrin-forming substances
being produced frinn leucocytes. In the lilebs which
a>
Fio. 3.533. — Zenker's Necrosis of Striped
Muscle Fibres, from ti t'a.se <if Typhoid
Fever, i From Ziegler.) n.Nonnal mus-
cle Ilbre; h. d, degenerated (Hires,
which have broken down into separate
masses; c, c, cells lying inside of the
stircolemnia; (/, connective tissue infil-
trated with cells. Magnified SO diame-
ters.
203
Necrosis.
Neiiiatoda.
REFERENCE HAXnBOOK OF THE MEDICAL SCIENCES.
appear in gangrcuous skin there may occur a coagulation
of the fluid, aud the coagula may later be dissolved.
JIacroseopically, licjuefaction necrosis is characterized
by the formation of blebs on free surfaces, or by cavities
tilled with softened tissue debris, varying in appearance
from a thin watery fluid, as iu the case of brain cysts, to
thick creamy Huid in abscess cavities. The earlier stages
are shown "by .softening and increase in the amount of
tissue juices. Microscopii-Uly. tlie presence of fluid is
shown by clear spaces or vacuoles, stringy disintegra-
~:f
Fig. aSM.— Luiuefacticin Necrosis. Section tLTouirli t:i ■ ejiidennal ami papillarv por-
tions or a I'afs paw, a short lime afler it had iieen livirneil with fluid sealins-wa.x
(ali-oliol : cariiiinf'). (f. Horny lavnr of tho opuh*rniis ; /*, ictc MalpiL'iiii ; c. nor-
mal papilla of the skin ; i/, swollen fpiihi-iial cells, the nuclei ..f which are still
visible at a few points, while at others they haye entin-ly liisappcart-tl ; c. epithe-
lial cells lyintr between the papilla?, the upper ones beiiii: sw.ijlen and elciuL'ated,
while the lower still retuain in a normal cou<lition : /, niiriuous ix'rwi.rk com-
posed of epithelial celts iliroken down so as to be no longer reciit-'nizaoif as such)
and exuilate ; r/, an interitapillary ma.ss of cells which have become swollen and
ba\e Inst tlieir nuclei; h, a part I'f a similar mass in which the cells have been
entuelv deviroyed; ». a papdia that has bef-n llattened by pressure and that is in-
filtrated with cells; A, solidilled subepithelial e-xudate. Magnillctl l.')0 diam-
eters. (Ziejrler.)
tion, etc. Both gross and microscopical appearances
may be altered bj- the presence of blood or blood pig-
ments.
Mummification INecro.ns. — Necrotic tissues exposed to
the air lose their fluids quickly through evaporation, and
become leathery, dry, liard, shrivelled. Iirowuish, or black,
resembling mummy tissue. The condition is also known
as diy gangrene; the amount of decomposition which
takes place is, however, vci-y sliglit, the dryness rendering
the growth of sajirophytic bacteria imiiossible. In the
very earlv stages before the fluids are entirely removed
there is some jmli'efaction usually present, asshown by
the fact that, there is almost always some odor about
mummified tissue. The ]irocess may be regiiixletl as a
moist gangrene in which the processes of decomposition
are cut short by the evaiiorafiou of Huid. Senile diabetic
gangrene, gangrene of the extremities following fivezing
are examples of this form of necrosis. ]\Iicioscoi)ically,
dry gangrene is characterized by the disa]ipearauee of
the nuclei, the cells lieinu- llattened or coutrac-fedinto hy-
aline masses. Cornificatinn may be taken as a physio-
logical example of this form of necrosis.
Miiist Oaiir/reiK. — If necrotic tissues conlainiug fluids
become infected witli sapi'ophytic organisms with result-
ing decomposition, the condition is known its moist gan-
grene {spfiaceliis, giinr/fwria linniiiln, r/ni/f/mna piitrithi).
The formation of gas bubbles due to ithe presence of
gas-forming bacteria gives rise to emphysematfuis gan-
grene {rjaiifirana etii]ihjisimiif<isi:i). The dillerent forms of
moist gangrene, though distinguished by vaiious names,
are in their es.sence identical, since bacteria devejoji only
in moist tissues. As mentioned above, moist gangi'ene
ma}' be changed to the di'y form through evaporation.
Gangrenous tissues are black, greenish, or biownish in
204
color, according to the amount of blood pigment present.
If there was much blood in the tissue before death the
gangrene may be blaek ; if the tissues were antemic the
condition is sometimes designated trJiite gauc/rene. Such
forms are also distinguished clinically by the terms !iat
or cold fjiingrerie. In hot gangrene the heat may come
from an abundant blood supply in the neighboring tis-
sues. The odor of putrefaction is alwa.vs present in
moist gangrene, and \arious gases may be formed. Pto-
mai'ns and other poisonous substances are formed in the
gangrenous area, and the absorption of these
may lead to sapiwmia. Softening and
liquefaction are always present to a greater
or less degree. Microscopically, moist gan-
grene, in addition to the essential features
of necrosis, is characterized by the pres-
ence of products of decomposition iu the
form of fatty iicid crystals, tj-rosin, leucin,
triple phosphate, blood pigment, etc. The
general picture may be that of a simple
coagulation or liquefaction necrosis, or a
combimition of these forms may be pi'esent.
Liquefaction is always present in a greater
or less degiee according to the stage of the
process; all elements of the tissues, even
bone and fascia, ultimately becoming dis-
solved. Jloist gaugieue may be caused by
extei'nal injuries, chemical action, freezing,
burns, .r-ra_ys, pressure, disturbances of cir-
cuUUion with impaired nutrition, intoxica-
tions, and infections. Lesions of the cen-
tral nervous system and peripheral nerves
ai'e also regarded as direct or indirect ctiuses
of gangrene (neiirnpathic gangrene). The
tissues usually affected are those most likely
to be infected with sajirophytic organisms,
viz., the extremities, skin, lungs, external
genitals, uterus, and intestines. (See also
Gangrene.)
Vdnealion Kecreisis. — The term caseous is
used as a gross descriptive designation for
necrotic processes iu which the dead areas
bear more or less resemblance to cheese in
color and consistency. Two forms may be
distinguished, the hard or firm and soft caseation. Either
simple or coagulation necrosis or moist gangrene may be
followed by caseation; the latter condition is to be re-
garded as a postnecrotic chtuige re|n'csenting a more ad-
vanced stage of cellular disiuti'gration. If coagulation
necrosis is present, the caseation is usually of the firm
variety; if there is much Huid in the part or it the ne-
crosis had been preceded by fatty degenei'ation, .soft case-
ation will result. Caseous areas are yellowish oi' gray-
ish-white, more or less firm, dry, or viscid, and on section
resemble cheese in consistency. Jlici'oscopically. the
outlines of tissue elements are entirely lost, nuclei are
absent, and the cells bi'oken into tine granules. Fibrin
threads may be shown by proper staining: fat droplets
and vacuoles may be present. Early stages of caseation
may stain diffusely blue from ditfu.sed chromatin; old
caseation stains red with eosin, but shows no trace of
chromatin. The chemical naftu'e of caseous material is
unknown; it probabl_v includes many different sub-
stiinces derived from the bi'eaking down of proteids.
Caseation is a constant ch;inge in tubercles aud gvim-
niata, and is of frequent occurrence in old infarcts, focal
necroses, rapidly growing tumors, etc. Caseous ai'eas
not infreciuently become liquefied. It is jirobable that
diffusion pi-ocesses take place between the area of casea-
tion and file surrounding tissue; in this way the foiiner
may become inflltratcd with fluid.
According to clinical or macroscopical characteristics
the vai'ious forms of neci'osis are also described as focal,
diffo.te, spreading, central, circumscrihed. etc. Of these
varieties focal necrosis deserves special mention. The
term is applied to small necrotic foci, occurring very fre-
(piently in the course of variovis intoxications and infec-
tions, such as typhoid, diphfi'-ria, scarlatina, smallpox,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Necrosis.
Neuiatoda*
puerperal eclanipsia, tuberculosis, toxa'mia of burns,
etc. The foci are found chiefly in the li%'er, spleen,
lymph glanils, and Uidueys. The form of the necrosis
is usually simple, but tilirin is often present in the necro-
tic material. The later stages present the appearance of
caseation. Focal necroses may not be visible to the
naked eye, or they may resemble miliary tubercles or ab-
scesses, for which they ma3'be mistaken. At other times
they may appear as small pale yellow or grayish spots
barely distinguishable from the surrounding normal tis-
sue. Microscopically, small islands of simple coagula-
tion or caseation necrosis are found. When the necrosis
has been recent, diffuse or fragmented chromatin may be
present and the areas may stain deep blue. About" the
necrotic areas there is often a leucoc_vte infiltration.
Many of the leucocytes become involved in the necrotic
process; their chromatin becomes diffu.se, giving rise to a
deeply staining periphery. In the liver focal necroses are
often limited to the central zone of the lobule about the
central vein; hence the designation central iieerosix. The
same term is also applied to central necroses of bone. Fo-
cal necroses are due to the direct action of bacilli or to
poisons acting directly upon the cells or to local asphyxia.
The changes in the small capillaries of the affected tissue
play a very important paiL Fibrin may be first formed
in the capillaries and lymph vessels, and "thus .shutting off
the supply of nutrition cause cell death. In otlier cases
changes in the capillary walls may be first produced by
the injurious agent; capillar^' thrombosis follows, and to
this the cellular necrosis may be secondary. Transuda-
tion of serum through the injured capillary walls may
also lead to necrosis'of the surrounding ceils. The se-
queUx' of focal necrosis are the same as those of necrosis
in general.
Fat JS'i'crosis. — The necrosis of the fat-containing cells
of adipose tissue forms a condition so striking in its clini-
cal and pathological aspects as to warrant special men-
tion. The condition occurs most frequently in the ab-
dominal fat in connection with pancreatitis. The necrotic
areas appear in the fat as grayish or yellowish, or in some
cases black, opaque areas, soft or gritty, slightly elevated
and usually circular in outline. "The appearance some-
times is such as to suggest that tlie fat had been seared
by a hot iron. Microscopically, the fat cells are enlarged,
the nuclei absent, the contents granular or presenting
the appearance of fine needles radiating from the centre
of the cell. Osmicacid has no effect upon the altered fat
cells. With ordinary stains the necrotic fat cells react in
a variety of ways. 'The granular detritus in tlie fat cells
consists of a combination of lime salts and fatty acids.
If the process is old, the amount of lime salts may be
great. It has been definitely shown that fat necrosis is
due to the fat-splitting ferment of the pancreas, whicli
under certain inflammatory conditions of that organ gains
access to the tissues throiigh the blood or lymph. E.\-
perimentally, fat necrosis nVay I)e produced bj" injection of
pancreatic extract, by ligatiire of the pancreatic vessels,
by introduction of |)ieces of pancreas into adipose tissue
or into the peritoneal cavity, and by the direct action of
steapsin in fat tissue. Not only may the abdominal fat
be affected in cases of pancreatitis "associated with fat
necrosis, but also the fat of the pericardium, liver cells,
retroperitoneal region, and bone marrow. In the major
ity of cases the condition is fatal, but recovery has been
noted, the dead fat cells becoming calcified.
Ucemolyns, the destruction of the red blood cells, and
leticolysis, the disintegration of leucocytes, are discusseil
by some writers under the head of ne'crosis. The exact
nature of these processes is not at present definitely de-
termined. Bacterial products, various poisons, the blood
sera of animals of different species, or of the same species
under certain conditions, are the chief factors in the pro-
duction of these conditions. Normal haMuolysis occurs
in the spleen, lympli glands, ha'm(p|ymph glands, and
bone marrow. In pernicious aua-mia, sepsis, and many
of the acute infectious and intoxications hiemolysis oc-
curs in these organs to a greatly increased extent. " Patho-
logical destruction of the red cells in the circulating blood
occurs also in a variety of infections and intoxications.
The term hietaocytolysi's is more properly applied to this
condition, but has been largely superseded by the word
ha'molysis.
S,)/iii'hp qf M'tmsis. — The course of the necrotic process
d( peiuls upon the anatomical nature and location of the
affected tissue, the course and manner of the injurious
influence causing the necrosis, the condition and envi-
ronment of the affected ])art, tlie amount of blood and
lymph, the nature of preceding changes, the opportunity
for the access of air and putrefactive agents to the part,
etc. About the necrotic area there is always a more or
less marked inflammatory reaction in the surrounding
living tissue. As a result of such inflammation the ne-
crotic area becomes isolated and sequestered. The proc-
ess is called sequmtnitifin, and the area of necrotic tissue
so shut off a is,f/'i,s/riim. The ultimate sequeke will be:
(1) liegeneratiiin following the absorption or casting off
of the dead tissue, new tissue resembling the normal
being formed ; (2) cicatrization ; (3) caicificntion ; (4)
cyst formation, the dead tissue being liquefied and encap-
sulated ; (5) chronic abscess or ulcer.
Aldred Scott Warthin.
NECROSIS OF BONE. See Bone, Pathology of .
NEMATODA.*— The class of the Nematoda or round
worms constitutes a large, rather uniform, and clearly
demarcated group, which by many recent authors ha's
been regarded as of the rank even of a phylum, in which
ca.se the name Nemathelminthes has been applied. The
group is characterized by a cylindiical body, often fili-
form even in its attenuation, and by the heavy cuticular
investment which carries in soiue cases small bristles,
hooks, or spines, but which is consistently without ap-
pendages and manifests at most surface striation, but
never true segmentation. The body cavity is extensive,
but unprovided with a peritoneal epithelium, and the
sexual and excretory systems do not stand in any con-
nection with it. Another striking feature is the entire
absence of cilia in all stages of development.
An alimentary canal is present, at least in some stage
of the life history of all forms. It is with rare exceptions
a permanent structure in the members of the sub-class of
true round worms, or Eunematoda; but in the .sub-class
of the hairsnakes or Gordiaci'u, tlie alimentary canal is
greatly reduced in the adult, in that the mouth is closed
and a delicate solid string of tissue is the only vestige of
the anterior portion of the canal. The posterior region
still retains its cavity and functions in connection with
the reproductive organs of b<ith .sexes, which have with
it a common outlet. In the Eunematoda, on the other
hand, the male organs join the alimentary canal to form
a common cloaca, but the female system is entirely un-
connected with the alimentary sy'stem, and the vulva
occupies a variable position in "the'midventral line. The
sexes are separate, though in rare instances partheno-
genesis or hermaphroditi.sm modifies the usual balance.
By far the largest number of forms belongs to the Eu-
nematoda, which will be considered first, while the Gor-
diacea and, as an appendix, the Acanthocephala will be
discussed sub,se(iuently. Among the Eunematoda the
better known forms are parasitic, though some are fi-ee
living and an occasional species is capable of making use
of both types of environment. The free living sp'ecies
are uniformly insignificant, but atuong parasitic forms
one finds the microscopic blood parasites and the meter
long guinea worm. In respect to location also there ob-
tains great variety ; and one finds these parasites in all
regions of the alimentary, respiratory, circulatory, excre-
tory, and muscular systems, and in connective tissue and
serous cavities.
The greatly elongated cylindrical form tapers as a rule
more or less toward both ends, though generally speak-
* A general discu,ssion of parasitism and its effects will In- found
under ilie heading Parasites.
205
Nemato«ia.
Neiiialofla,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
I-
mi%
ing tlio head is truncated and tliotail acute. Tlic cliitin-
ous cutirula invests the entire Vxidy, and is intnivcrted a
sliort distance at
f* B all oritices. It
bears rarely un-
jointed spines
and bristles and
is marked often
by delicate sur-
face striations.
In cross section
(Fis. 3537) the
body a p jicars
ci rcu lar, and
shows beneath
the cuticula a
ihin hypoder-
nia layer, wliieh
is prominently
thickened at
four points. Of
these the lateral
hnes, fields, or
areas, as they
arc called, are
largest, and are
visible in sur-
face view as del-
icate longitudi-
nal stripes (r,
Fig. 3535). The
dor.sal and ven-
tral median lines
are much less
prominent and
are distinguish-
able ordinarily
only in sectional
views.
Directly be-
low the hypo-
dermis is the
muscular layer
which is inter-
rupted by the
lines already
noted, and hence
liVi MKl^S^^ appears as four
" " "' inuscvdar fields.
The nuiscle cells
(in. Fig. 3536)
are of a peculiar
type iu that a
p ro toplasmic
body is distinct
from tlie con-
tractile fibrillar
portion. The
main tnuiks of
the nervous sys-
tem occupy the
dorsal and ven-
tral areas, ■while
the lateral areas
eoutain each a
delicate canal, which has been interpreted as ]iart of the
otherwise unexplained excretory system ; with the latter
are associated, however, certain stellate cells of peculiar
character, which project from the lateral liclds into the
body cavity and are known as phagncytic organs.
The alimentary cantil ((', Fig. 3535) is a straight simple
tube extending from the mouth, which is always terminal,
to the anus, which varies in location from llie posterior
end to a po.sition on the ventral surface, some little dis-
tance removed from it. Various fealureseoiuieeted with
the canal are of great systematic imjiortance. About tlie
mouth arc found a luimber of li]>s ;uul papilla' character-
istic of the genus or family. Tile buccal or jiharyngeal
de-
FlG. 3535.— Internal Anatomy of Ascnrix litm-
ftricoifi&s, opened alons dorsal line. A . Malt' ;
B, female: c. lateral line; (/»■, ductus ejar'ula-
torius: do, uterus ; i, intestine ; a', a'soj)l]a-
ffus ; <n\ coiled ovary ; r(/. vagina ; r.s, semi-
nal vesicle. (After Delafond.J
cavity, an enlargement at the outset, the muscular cesoph-
agus with a triangular hinien (Fig. 3537) and a ter
minal enlai'gement wliicli may be indis-
tinctly luarked, or may partake of the
form of a distinct Indb, or even two
such, with a valvular aiiparatus, the in-
testine proper followed by the rectum
and cloaca iu tlie male — these constitute
the distinct parts of the alimentary
system.
The sexual organs have the form of a
long coiled tulie, iu the attenuated distal
end of which the sexual cells aie ju-o-
duced, while the proximal portions af-
foi'd storage for the perfected germ cells
before they are discharged from the
body. In the femtile the svsteni is reg-
ularly bifid, although one horn of the
uterus may bc^ undeveloped to ii greater
or less extent, while in the male only
a single tube is present. The varied
debouchment of the system in the two
sexes has already been noted. About
the vulva chitinouslips often of notable
thickness are developed, and on the ex-
ternal surface near the male orifice nu-
merous papilla; characteristic of the
genus or species, and at times a sucker
also arc to be found; these function as
accessory copulatory apparatus, while
in the same category are included ex-
lianding folds of the body wall known as the Iiursa and
awl-shaped chitinous structures called spicules. The
liursa varies from a pair of simple folds lateral to the
cloaca to a cup or bell surrounding it and the posterior
end of the body. The spicules, cither one or two in
nuntbcr, with an accessory guiding piece in some in-
stances, are developed in a dorsal cvagination from the
cloacal wall and provided with special musculature for
extrusion and retraction. Their form varies greatly iu
different species, and with the bursa and circuinaual pa-
pillae ctmstitutes the means for determination of the spe-
cies.
The Eunematoda are oviparous, but in some cases the
eggs are retained long enough in the uterus to contain
when laid a partly or fully developed embryo; and in a
FIG. 3336.— Sec-
tion of BodT
Wall. Higlily
magnified. /(.
Nucleus and p,
prot o p 1 a s m 1 c
body of muscle
cell, m.
Fig. 3.Vi".— Transsection of A^raris Uinihricnitlcfi at \evel of <espha-
ffus. c. Cuticula ; /j, hypoderm ; i. intestine; hi, muscle layer ; d,
dorsal, s, lateral, i\ ventral lines : u\ exci'etory canal. (After
HeriKig.)
few species the embryo deserts the shell before it is ex-
ti-uded from the body". All stages in tlie development of
this ovoviviparous haliit may be observed.
Ordinarily the eggs whicli undergo development exter-
'200
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Nciiiatoda.
Neiiiatoda.
Fig. 3Si38. — AnguilMa aeeti. A. Tail of
male: ac, accessory piece; sp, spicules:
B, spicules partially protruded from anus.
MagniHed. i After Stiles. )
nal to the body of the liost are provided with a heavy
shell to resist the aetion of an tinfavorable environment.
In case the eggs tnulergo development while still in tlie
uterus, the shell is thin. Some speeies develop direelly,
i.e., without a change of host, though a certain stage in
the life histor_v at least is
passed in the outer world : in
other cases the immature worm
lives in another animal, known
as the intermediate host, than
that which hai'-
bors the adult,
or rarelj'iu a dif-
ferent part of
the body of the
one ho.st. In a
few species a pa-
rasitic generation
alternates with a
free living gener-
ation of such dif-
ferent fornr as to
have been regard-
ed as another
species; and the
alternating gen-
erations diif er rad-
ically in method of reproduction. In one case at least
{Trichinellfi) the entire life history is passed within tlie
host and transportation to a new host depends upon the
carnivorous habit. In other cases also (blood tilaria') the
life history is jiassed within two hosts and no part takes
place externally ; but in most instances there is a free
living stage and infection is brought about primarily
through the drinking-water. Some prominent exceptions
to this general statement are noted later.
The family of the Anguillulida', which is difficult to
characterize, contains mostly free nematodes of small
size, transparent, filiform, and tapering to both ends.
The cpsophagus is inflated or has one or two bulbs at the
posterior end. The female possesses double symmetrical
uteri and short refie.xed tubular ovaries, with vulva at or
behind the centre of the body, with few, large ova, and
with development rapid, often ovoviviparous. Tlie male
has two equal chitinous spicules, with or without one or
more accessory pieces. The type genus is
Anguillitla Ehrenberg 1836. • — Buccal cavity very
minute; oesophagus cylindrical w-ith two bulbs, the pos-
terior liaving a valve ajiparatus; vulva behind centre of
body; male without bursa; accessory piece single, faii-
sliaped. The best-known species is the vinegar eel, which
has rccenth' been found as a parasite of man.
Aiif/uiUiila nccti MuUer (Fig. 3.538). — Cutictila iin-
striated, body tapering .sliglitly anteriad; tail greatly
attenuated. Male 1.35 to 1.45 mm. long by 24-28 /i wi<le.
Spicules 38m long, similar, twisted; accessory piece
slightly caudad; no bursa; papillas at least two preanal
and one postanal. Female, 1 to 2.4 mm. long, by 40-72/'
in diaiTieter, contains embryos 0.22 mm. long by Vi n in
diameter.
This worm, which is everj'where common in vinegar,
has been rccentlj' studied by Stiles and Fi-ankland in t lie
role of a human para.site. The specimens were taken in
great numbers from the urine of a female patient, and
were present during a period of thirty-three d.a3-s. The
urine was always very acid and once had a marked odor
of vinegar. In this sample the worms lived tw'o months,
and individuals tlieu removed to vinegar became vigor-
ous and bred ra]iidly.
Patholog\'. — The patient had chronic parenchymatous
nephritis of a degenerative type, and the uriue frequently
contained albumin, but not while the parasites were pres-
ent. No symptoms traceable to them w'ere observed, and
their presence in the bladder remained unexplained. The
suspected use of vaginal douches acidulated with vinegar
was denied by the patient, and no grounds existed for
questioning the truth of the statement. Evidently this
parasite might be present in the vagina if such a practice
were followed. Billings and Miller have reported two
other cases from the United States in which, however,
the source of the parasite was not demonstrated beyond .
question.
Leptodera A. Schneider 1800. — CEsophagus with two
bulbs, the posterior with or without valves. Male with
or without bursa, often six to ten jiapilla; on the bursa or
on the median line ; two short spicules and a single ac-
cessory piece. Some species aie hermaphroditic. A. some-
what indistinct genus, dillicult to separate from that last
described, and perliaps identical witli it.
Leptodera jS'uUi/i K. Blanchard 1885. — (Syn. : Anguil-
l nla leptodera me\\y\ RhalnHtis Nicllyi Ti. Bl. 1888.)
This species is known only in the larval form, in which
it measures 333« in length and 13/i in breadth. The ali-
mentary canal was the only internal organ described; it
displayed two enlargements in the jjharynx, the second
pharyngeal bulb having a dentate armature.
The worms were discovered by Nielly in 1883 in a
young mau, fourteen years of agi\ who was born near
Brest, and had never been out of that region. A dermal
eruption, much like craw-craw, of about five or six weeks'
standing, affected chiefly the patient's limbs. In the
fluid of each papule were found several worms, and the
blood showed on microscopical examination at the outset
of the malady many small nematoda, which, however,
could not be found later; at no
time were they found in fseces or
uriue.
The method of the introduction
of the parasite was unknown; but
it was remarked that the lad had
been in tlie habit of drinking from
brooks. It is easily surmised that
the eggs of the worm were swal-
lowed in drinking, and that
Ov the embryos, hatching out in
the alimentary canal, bored
their way into the
circulation and
thus reached the
skin. Their pres-
ence both in the
blood aud in the
papules is thus
easily explained.
They may have
been, however,
larvse of some
imported fllaria,
though dermato-
sis caused by lar-
val nematoda has been observed in
dog. fox aud horse in Europe by
mauy investigators.
In this connection it is important
to note the similarity of this case to
craw-craw, a contagious vesicular
eruption of the skin, observed in
Africa and iu South America, in
which various investigators have
reported the presence of larval ne-
matoda. Mausou regards craw-
craw as a dermatosis characteristic
of the "sleeping siekuess," endemic
on the west coast of Africa. Mo-
niez has suggested that the para-
sites to which this case is due may
have been imiiorted by soiric sailnr
from Africa, and associates with it
the ca.se of elephantiasis, also ob-
served iu Brittany.
Leptodera pellio (A. Schneidei-
ISliO).— (Syn. : Rhabditis peUio K. Schneider 1860; ]i.
pellio Buts'chli 1873; i?. genitalis Seheiher 1880.)
Male: Length, 0.8-1.5 mm.; bursa with seven to ten
ribs on each side; spicules 27-33/; in length, nearly alike.
Female: Length, 0.9-1.3 mm., posterior extremity long
Fig. 3539.— St roJi 01/-
/ 0 ides steranaUs
from Human Intes-
tine. X m. (After
Braun.)
'ill 7
Nenialoda.
Neiualuda,
KEFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Fic. ■t'lW.- SI roll (i!h
I i)i d e s stercontUs,
A, U halidi tif omi
larva from fresh
ta?(<HS. X 145 : B. flla-
rif4)riu lai-va from cul-
ture; <!t(/, genital cell.
xi;i.'). ( After Braun.)
and pointed, vulva a little in front of the middle; ovary
not i^iiired ; eggs oval, 60 by 3o ti.
Scheiber found this species at Stuhlwei.sseuburg, Hun-
gary, in the urine of a native woman suffering ti-om py-
elonephritis, pneumonia, and acute
intestinal cataiTh. During the en-
tire illness the worms were found
in the vagina in all stages of de-
velopment. Several other authors
have found what is closely related,
if not tlie same form, in the urine
in cases of hainaturia; but the par-
asitism is pniliably accidental, since
Oerle\' has shown that li. genita/if:
Scheiber must be referred to li.
pel/i'o, a common free living form
found in moist earth and putrefy-
ing substances, and also that worms
of this species will multiply in tlje
vagina of white rats. Tliere is fur-
ther to be noted lioth the haliit of
Hungarian peasants in employing
moist earth for poultices and the
record of Scheiber, that patient and
clothing were earth-stained, ren-
dering it altogether likely that
such a poultice had been applied
near the vulva, and that from it the
free living worms had .successfully
colonized the vagina.
LepliiiJrra tcnirola ( D u j a r d i n
1845.)— (Syn.: RhaMttis ieni,y,ht
Duj. 1845; PiUxhra teirs Sclmeider
1866: P. seliricni Bastian 1879; It.
CoriiicidUCohhaU 1879.)
Mouth witli six lips, anterior bulb
of plnnyn.x fusiform, posterior
si^herieal. Jlale: Length, 1.3 mm, ;
tail attenuated, slightly longer than the bursa. Fe-
male: 2 mm. in length and over; posterior extremity
sometimes regidarly attenuated, sometimes sharply
rounded and provided with a very fine tail; vulva
about the middle of tiie bodv; ovo viviparous; eggs GO
liy40//.
This tyi)ica! free living species should be li.sted as a
pseudo-parasite of man by virtue of its occurrence in ca-
davers, and, in one case at least, its confusion with tri-
cliina. Tlie facts in this celebrated ease are asfoUoAvs:
The Englisli selioolsltip Corinmll was visited in 1879 by
an epidemic winch affected many cadets and killed one.
The syinjitoms of the disease were not incompatilile with
trichinosis, .and microscopical examination of the ex-
humed cadaver, imilertaken two months later, demon-
strated in the nmscles of the abdomen many nematoda.
which, with the exeejition of the first one examined,
were dead, but not on(^ was encysted. The ejiidemic
was pronounced therewith trichinosis, and attracted
enough attention to be brought before Parliament.
Cobbold and Bastian easily showed that the worms in
(|Uestion had nothing to do with Tn'r/iinclln, and Oerley
estalilished thi'ir identity with L. ti'i-r/r<i,'ii, which had
uudoiibledly penetrat<'d tlie body after inhumation.
The family of the Aiigiostomiihe inchides small rhab-
ditislike nematoda which manifest in development the
alternation of two types of sexual generations of which
the tir.st is dia>eious, free and very similar to Leptodera.
while the second is parasitic, hermaphroditic, and of a
dilTerent structure.
t^trohi/i/lniilis Grassi 1879. — Parasitic generation with
simple mouth in which no armature is present; cylindri-
cal jiliarynx very long. Free generation with small oral
cavity; pharynx with two bulbs, the anterior fusiform,
the posterior spherical and armed; uiale with two small
spicules similar.
Strinu/i/loidcustercoffilis Stiles and Hassall 19(10. — (Syn. :
Atir/ii/.Uiila intestiiialis and .4. uteirnriiliK Bavay l^i77;
Leptodera inte.ttinnlis and L. sterroralix Cobbold 1879;
Psemlurhabditis stercoralis Perroucito 1881 ; li/iabd/ineinii
strongyloides Leuckart 1883; Stronyyhides intestinalis
Grassi 1883; li. iiitedimik Blanchard 1885.)
Free generation (Bavay 's ^1. slerconilu) both sexes oc-
cur ; body slender, tapering toward the ends ; mouth with
three or four imlistinct papilla;; a'.sophagus 0.16 mm.
long, with well-developed buccal cavity and two bulbs,
tlie posterior of which is armed with three chitiuous teeth ;
anus with protruding lips on right side of body. Male
(Fig. 3541, B): 0.7.5-1 mm. long, 35 to 66 /; thick, with
short recurved tail and two curved, conical spicules, 38 /i
long. Female (Fig. 3541, A): 1-1.4 mm. long, .50-75 /i
biciad, with long slender pointed tail; vulva a little be-
hind the middle of the body and on the right side; uterus
double; eggs ellipsoidal, thin-shelled, 70 by 45f, seg-
mentation advanced, embryo often hatched within body
of mother; embryos at first with tapering tail, bulbous
tesopliagus, and chitinous teeth, soon changing to filari-
form stage.
Parasitic generation (Bavay's ^4. intestinalu) (Fig.
3539). Female only, hermaphroditic or partbenoge-
netic; length 3. 1-2.2" mm., breadth 30-39/;, body slightly
tapering anteriorly, but terminated posteriorly by a
short bluntly conical tail, with rounded and slightly di-
lated tip, mouth with three poorly developed lips (or
none? Strong); cesophagus cylindrical, with no swell-
ings, one-fourth the length of the body or more, distin-
ginshable readily only in color from the intestine; vulva
transverse in posterior third of the body; uterus with
live to six (nine to twenty V) ellipsoidal eggs, 50-!59, or
0.5-70 yu by 30-34, or 39/;, and often joined in strings of
two or three. The eggs are segmenting when laid,
they devek}p rapidly and hatch before being ejected
with the excrement. Embryos rhabditifcn-m, 0.3-0.6
mm. long by 10-32// wide; first molt within twenty
hours if in incubator.
Dr. Normaud discovered tlie species in 1S76, when ex-
amining microscopically the stools of soldiers returned
from Cochin China, who were suffering from acute dys-
entery. Somewhat later he found at the necropsy of a
soldier who had died from Cochin China diarrhoea, the
other form of the species. Both of these forms were origi-
nally St udied and tlescribed liy Bavay. It was in 1883, be-
fore the connection of the two was established l)y Leu-
ckart, who showed them to be phases in the life history
of the same species. In life man harbors in the canal the
one* form {A. ■inte.^tinnlis Bavay) and its young which,
reaching the exterior with the f;eces, maybe transformecl
then into the other adult (.1. siermrali.'! Bavay); the lat-
ter transformation may also take place in the intestine
after death, as in cultures made in confirming these dis-
coveries. Later authors have added many details, which
may be simimarized as follows:
The parasitic generation, which recalls a strongjdid or
a filaria in general appearance, produces eggs so abun-
dantly that from an ordinary infection more than a million
embryos may be evacuated in a single stool. Tlie em-
bryos (Fig. 3.540, A) measure at hatching 0.2-0.24 mm.
long by 13/j broad, but develop so rapidly that those in the
stools have attained a length of 0.30-0.60 mm. by a width
of 16-23/'. The embryos are characterized by a rhabdi-
tiform oesophagus, and under normal temperature they
soon moult ; and then, [irotected asif by acyst in the larval
skin, await more favor.able conditions for further devel-
opment. If keiit, however, at a temperature of 25-35°
C. they develop to sexual maturity in fifteen to eighteen
hours; they copulate in thirty hours, and the females
begin to lay at fifty to fifty-five hours.
After the first moult the structure of the embiyos be-
comes more distinct, and one can see three or four oral
papilla; and a buccal cavity, together with an anterior
enlarged and median constricteti region of the a;sopha-
gus, which is terminated by the n»sophageal bulb, con-
taining an apparatus for trituration composed of three
cliitinous teeth. The intestine which follows ends in a
slightly protruding anus located on the right side. Also
* It is disputed whether the other form may very rarely be found
under the sauie circumstauces.
20S
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Nematoda.
Neinatoda.
on the right, about one-third tlie distiince from the Inilb
to the tail, is the whitish lenticular proton of the sexual
system.
In most cases studied in temperate regions after a few
days in culture, these embryos die or change form, be-
coming elongate and with more tapering tails, theo'sopli-
agus loses its teeth and enlargements and becomes a uni-
form cylinder; the embryos resemble young tilarite and
have taken on the strongyloid form (Fig. 3540, B).
Only thirty to forty eggs are deposited by each female
of the" free generation (Bava}''s A. stercoralis), which de-
velop so rapidly as to ajiproach the ovoviviparous condi-
tion : they hateli out young worms about 0,23 mm. loug,
in winch the oesophagus manifests a distinct rhab<litiform
character. After the first moult, wbicli occurs when they
are about 0.35 mm. long, they acqiure in from thirty to
thirty-six hours the strongyloid appearance, in that the
mouth shows four lips, the oesophagus is cylindrical and
has lost its dental armature, the tail is shortened, and
bears near its end two small lateral wings. At tlie end
of eight days the free form can no longer be found in the
cultures, and all the young have become strongyloid
larvje. If introduced into the intestine, these larvaj de-
velop into the parasitic female, with which tl^e cycle be-
gins anew.
A remarkable modification of this, the normal life cycle
of the species, was discovered by Grassi, who found that
the development might be abridged since the rhabditi-
form embryos may transform directly into the strongy-
loid larv* without the intervention of any free sexual
generation. This direct development has been confirmed
by Leichtenstern, who has observed it ior weeks in suc-
cession, while at other times alternation with the free
rhabditiform generation comes in. The causes of this
transformation are unknown as 3'et: it must, however,
be regarded as an important etiological factor, since the
infection of man may be due to the accidental introduc-
tion of either sort of larva', or of the adult parasitic
form. Stiles has sug-
gested that this ab-
breviation is a step
toward perfect par-
asitism.
The method of in-
troduction can only
be inferred to be im-
pure water or vege-
tables, salads, etc. ,
which have liecu con-
taminated by human
excrement. A 1-
though Normaud ac-
quired the disease in
Cochin China, while
having refrained ali-
solutelj' from drink-
ing anj- but imported
water, and was ac-
,. , , , . , , cordingly inclined to
c.n./i.s. ,t, F.'iiiak- of tree q 'tstion tue pait
Ki'iiciation ill advam-cd stage played by water m
l,i|.iiient; B. male its dispersal, yet in
'ces; xp. jjig ;ji3gp„c(. of -
til
{■iiltiiri.' of faeces: .sp,
Wagnined. (After
fur
Ziriii.) ~ thcr evidence general
considerations nuist
jioint to this as the most probable source of in-
fection. Differences in manner of development
are present in embryos from a single original
infection and external conditions .seem to be in-
determinate; it is possible that the age of the
parent animal is of influence. Embryos with
direct development are at least moi-e resistant,
and alone survive under unfavorable environment.
It has Ijeen claimed after culture exjierinieius by Wilms
that there are not two varieties of the jiarasite, one de-
veloping by the direct, the other by the indirect method,
but that embryos fi'om the same lot of eggs may develo]i
in either fashion. Though the number of cases observed
Vol. VI.— 14
is probably too small for definite conclusions, it is strik-
ing that cases infected with the tropical strongyloids
develop usually with the interpolation of the free sexual
generation, while cases infected in temjierate regions,
both of Europe and America, manifest almost exclu-
sively direct develci]iment. It shnuld not be forgotten
that "there may be concerned here mure than one species
of closely related and heretofore confused forms, which
would account for some of the ajiparently confiicting
statements. Certain it is that the figures of the larvfe,
given by various authors, do not agree in the form and
proportions of the different regions in the O'sophagus,
which for individuals in the same moidt are ordinarily re-
garded as constant, and an examination of the adult para-
sites, as figured by two must recent observers, Strong and
Braun, shows numerous differences in detail, which can
hardh' be eriors in observation.
The observations of Grassi, that tiie alternation of gen-
erations descrilied above is not a necessary featui'e in the
life cycle of this species, is still further of importance as
explaining the enormous number of worms found in the
intestine in some cases. Leuckart records an instance in
which prodigious quantities of the worms were evacu-
ated even a year and a half after leaving the locality of
infection. Such evidence leaves little reasonable doubt
of the multiplication of the parasite in the human ali-
mentary canal, as in fact related species do so reproduce
in other animals and as Anf/iiillulaaceti multiplies in the
human blailder as noted above.
Distribution. — Strniifii/liiUJrs ntdrnnilU occurs very
widel\'. The entire trn]iical and subtropical zone of
Africa, Asia, the Philippines, and the East Indies form
apparentlj' its original home, within which its occurrence
is all but universal. It has also been recorded from Mar-
tinique, Brazil, Hawaii, and in Europe from Sicily. Italy,
and Mount St. Gothard timnel. Sjiain, Russia, and among
brickworkers along the Rhine and in East Prussia. First
reported in the United States by Strong, it has been ob-
served and studied since then twice in Baltimore by
Thayer, who showed its proliable endemic character.
For further data on its occurrence as well as for bibliog-
raphy and discussion of previous cases consult the
splendid paper by the latter author. Stiles has 5 further
cases to be published soon.
Pathology. — At first the wurin was regarded as the
cause of the dysentery in wliieh it was originally discov-
ered and with which it is usuallj' associated; more recent
investigations have thrown some doubts upon this view.
The rarity of the worm in the intestine at the outset of
the disease, its abundance in stools fif convalescents, its
absence in cases which have freely bilious diarrhcea. and
often in severe attacks of Cochin China diarrhcea. and
finally its frequent presence in individuals enjoying nor-
mal health, all militate against the s>i|qioscd pathogenic
role of the species; and both Grassi and Leichtenstern go
so far as to proclaim the sjiecies entirel}' innocuous, "in-
nocent commensals of man."
On the other hand, its luesence is not regarded by all
authors as harmless, even though they do not regard it
as the cause of the disease. Sonsino has found that in
Italy excessive multiplication of the species may give
rise to acute enteritis followed by dangerous an.Tmia.
Golgi and others have oliserved epithelial lesions wliich
they have attributed probably witli justice to the action
of this parasite. Its extraordinary nuiltiiilication in the
human alimentary canal must contribute to the irritation
of the mucosa and to the develo]iment of the lesions pro-
duced by the so-called Cochin China dysentery. Recent
observations of Askauazy serve to demonstrate the path-
ological character of these worms, which he finds to be
actual parasites of the intestinal wall in the duodenum
and jejunum. Here they penetrate chietly the mucosa,
being often found in the eiiithelium of Lieberkilhn's
glaniis. They may penetrat<' to the muscular layer or
rarely deeper than this. These migrations are in .search
of food, as the chyle-filled body of the worm shows; but
no evidence was "found to show that they ever suck the
blood of their host.
209
Nciiiutoda.
Ncinaloda.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
The female deposits eggs in the galleries of the mu-
cosa, which give rise to embryos that wander out into the
lumen of the intestine. In Teissier's ease it was claimed
that these embryos liad taUen a dilferent route and kad
entered the circulation, perhaps by way of the chyle
tubes; their presence here was accompanied by high
temperature, which abated with their disappearance
three days later. More probal)ly tliis case represents a
double infection of Fihiiin with Stroiir/i/li'ii/rK. The
limited uumbei' of Siri>ii(i)ilnides eggs found in the faeces is
to be explained perliapson their deposition deep in the tis-
sue. More recently Strong lias confirmed tlie presence of
adults, eggs and embryos in the epithelium and in the
cavity of the crypts of Lieberliubn. in which cases the
epithelium is often atrophied and less frequently entirely
gone. lutiUrations of small roiuid cells were observed
in some cases, Init no marked inMainmatory changes.
This author believes tliat the parasite is not harmless,
though unt particularly dangerous: and be tinds it capa-
ble of producing an intermittent diarrluea with intestinal
disturbances. It certainly causes some
mechanical injury from its rapid move-
ments.
Prevention. — Tlie use of filtered or
boiled water and abstinence from eat-
ing uneiioked vegetables of any soit,
as well as the destruction of .stools from
patients afflicted witli the parasite, are
evident measures suggested by the life
history. Special mention lias been
made by various observers of the gen-
eral immunity of natives in Cuchin
China tnward both the parasites and
the endemic dysentery, and it has been
explained on the basis of their univer-
sal use of water boiled en- treated with
alum s\dficient to ])recii)itate the or-
ganic matter.
The hydrotactic tendency of the em-
bryos is useful in diagnosis in cases in
which flii'V are present in small num-
bers, sime in the centre of a fecal layi r
s|iread on a culture plate a small cav
ity can be made and tilled with water;
here the embryos collect and are easily
fcinnd. In pure water the embrj'os of
the free generation are apt to perish,
perha))S tiu'ough lack of food materi-
als. Leichtenstern has also jiointed
out that a differential diagno.sis be-
tween this species and Vneinniia is
not diflienlt, .since in fresh fa'ces the
latter form appears only as eggs, the
former only as embryos. The Uncinaria embryo is also
easily distinguished i'nmi tliat of Stroiuiylouhs. since the
latter has a short thin-walled oral cavity, hardly chitin-
ized at all, and a larne spindle-shaped se.vual rudiment,
33" long, while the former possesses a long, heavily
chitini/.ed oral cavity and a minute circular se.xual rudi
ment, only 3/j long. If eggs are taken from the canal
at a necrop.sy, those of Uncinaria are distinguishable
from those of Straiifjyloides by the smaller size and
thicker shell.
Treatment. — Turpentine and male fern have no appar-
ent efl'ect. In mild cases thymol with general tonic treat-
ment is successful generally. Init in severe infections
nothing yet reported is of any apparent value.
A genus which offers evident allinities to both Stron-
gylidtc and Filarida>, but wliicli is usually included in
a separate family, the Gnathostomidre, is represented
among human parasites by a single rare species:
Onat/iostoma niamenw (Levinseu 1889.) — (.Syn. : Clidr-
acanthtis siamensis Lev. 1889.)
The genus is easily recognizable by the numerous
spines which cover tlie entire body, or at least the ante-
rior region. Several species occur in the Feliihe. and in
swine and cattle. This form is known only by a single
female specimen, length 9 mm., bre;idth 1 mm.: about
Fic. Xt^S.—Filaria
tnc<l>ni>t.si.'<, Itdll-
ed on Split Stick.
(A 1 1 (■ r K e d t -
schenlid.)
the head eight circles of spines. The anterior third of
the body alone is covered w'ith spines, the antei'ior of
which are three-pointed, and the posterior simple. The
vulva lies behind the centre of the body.
The specimen was collected in Siam and came from a
small tumor; wlieu this disappeared there were found on
the skin nodules the size of a pea, from one of which this
worm emerged. The same sj'mptoms were observed in
two other cases, and in one of tliese five or si.\ worms
were expelled, but were not pi'cserved.
Family of the Filarida;. — Body greatly elongated, tili-
form ; mouth variable, often papillate, sometimes with
lips and even with a buccal capsule; ojsophagus slender
and without a bulb ; male, with somewhat coiled tail and
a single sjiicule or two unequal ones. Female, with
double ovaiT and vulva near the anterior end of the
body. Many species ai'e ovoviviparous.
Filaria O. F. Muller 1787. — Very slender worms of
ni'arlj- equal calibre throughdut. Males notably smaller
than the females, with coiled posterior end, which pos-
sesses in some ea.ses alar appendages. Spicules ordinarily
ver^f dilferent in size and form. Four preaual papillie
iire idmost constant ; the number of postanal papilla is,
however, variable. Vulva always near the antei'ior end.
Tliese forms are parasites of the serous cavities and
subdermal connective tissue; in general the develop-
ment, though not well known, appears to be indirect
with an intermediate host from Crustacea or lusecta.
Uaillet justly remarks that for the phj-sician this genus
is a sort of "catchall " into which be throws all round
worms, old or new, of which the structure is poorly
known.
Filaria. iiiedineihiin (Linnaeus 1758) — (Syn.: Gardius
niolirieiisis Linn. 17.58; /•'. medinensis Gmelin 1789; F.
drai-iinculus Bfemser 1819; F. irt/iiap/ra Valenciennes
185(): Draciniriibis iiiediHensi!t Cobbold 1S04.)
Female: 30-100 cm. long (ordinarily 50-80), 0..")-3 mm.
broad: body nuiform in diameter, white or yellowisli-
lirown: the anterior end smooth, rounded, with cephalic
shield, and small mouth surrouniled by six papilUr; ali-
mentary caniil atrophied in adult and with all other in-
tern;d organs replaced liy enormously di'vehqied uterus;
vagina has disaiipeared. Uterus tilled with larval tila-
ria', O..V0.7.') mm. long and \h-2~ift wide.
Male doufitfully observed, said to be much smaller
than female, only 4-10 cm. long, found fixed to the fe-
male by its posterior extremity, about 14 cm. from the
anteri<.)r end of the hitter. If the observation is substan-
tiated, the male follows the female into the tissues and
perishes soou after copulation tliere. The vagina atro-
phies subsequently to this.
The so-called " guinea- worm " is the subject of the
oldest records dealing with an}' parasite. Donlitless the
fiery serpents which phigued the children of Israel in the
wilderness were this species. The writings of the Egj'p-
tiaiis and those of early classical times, as well as later
authorities, make definite references to it. The Arabian
physicians knew it well, and Rufus, of Ephesus, not (uily
gives a good description of the disease and its cause,
which he designates as a little snake, but recounts the
commonly accepted opinion that "the Arabians suffer
from it, and many strangers acquire the disease if theif
drink the irnter, for that is the chief cause."
Life History. — The adult female is met with in the con-
nective tissue, particularly of the legs and feet. It ap-
jiearshere in eighty-five per cent, of all cases, and pierces
the derma: a blister forms in the epidermis over this ori-
fice, and on rujituring shows a small ulcer at the centre
of which is a minute o]-)ening. If cold water is dashed
on the surface here, a drop of a milky fluid exudes or a
small tube (the uterus?) is protrudi'd and bursts, setting
free the opaque fluid. Tliis fluid contains multitudes of
embryos 0..')-0.7.T mm. long and ]."i-'3.5// wide: they are
flattened, terniin;ite in a long pointed tail, and have a
striated cuticula and a complete alimentary canal. The}'
swim actively but intermittently, and live six days in
pure water, but from two to three weeks in muddy water
or moist earth.
210
REFERE^X•E HANDBOOK OF THE SEEDICAJ-, SCIENCES.
\<'iiisitoda«
Neiiiatoda.
As uiiiy be followed experimentally Ihey enter the
body cavity of small aquatic animnlsC'^cfc'/w, Fig. 3543)
through ^he joinrs in the e.xoskelctoti, aud them with two
or three moults, occupying live or six «-e.ek», they meta-
morphose into a more cylindrical
form with a tripartite posterior end.
The further life iiistory is uui<uowu.
Fedtscheuko tried to infect cats and
dogs with these infested CVyc/o/w.
but without result. Mansou and
Blanchard have successfully re-
jieated these experiments. Some
further changes may easily be nec-
essar}' before the parasite is fitted
for its final host, rthicli may be
cattle, horse, dog, wildcat, or jackal as well as
man.
The life history, as given above, affords a rea-
sonable explanation of some biological features.
Both the preferential location of the worm iu
legs and feet which are most likely to come iu
contact with standing water aud the expulsion
of the embryos on such contact are admirably
adjusted to secure for the young conditions for
further development. It is a widely current be-
lief among natives in different parts of Africa
and Arabia, both in ancient times aud to-day,
that drinking-water is the source of infection.
In the majority of infected districts drinking-
water is obtained from surface pools which,
according to the observations of naturalists, are
swarming with Ci/dups, and hence afford every
opportunity for the spread of the disease.
Distribution. — Tlie guinea-worm is rather
■widely distributed in tropical and subtropical
countries. Most abundant in Deccan (India) and
on the ^wst coast of Africa, where in some sea-
sous from one half to nearly the entire popula-
tion is affected, it is found more or less from India west-
ward through Southern Asia and tropical Africa, and in
a limited area of Brazil, where its introduction may
proljably be attributed to the slave trade. In Curacoa
aud Surinam, where it was formerly endemic, and where
it was no doubt introduced with negroes, it has now
entirely disappeared. Records of its occurrence in Eu-
rope and North America are from natives of the infected
area or visitors to it, and tliougli frequently introduced
it has never gained a footing in either place. Records
of its occurrence in x\.frica and Aiabia are found iu his
torical and medical works of all agrs. It is also known
to occur in Persia. Turkestan, and Hindustan.
Pathology. — The seat of the adult females is the sub-
cutaneous connective tissue, and they occur most com
Fig. .'iW). -Em-
bryos of Filana
mcdhinisis In
body cavity of
Cyclops. (.Uter
Fedtschenlio. )
Fig. 35i4. — FiTrtria loa. A^ Hpad of male; B. mid body of male
with cuMcMilar bosses ; C, head of female with bosses : D, posterior
end of female wuh two bosses. Magnified. (Aft^^r Blanohard.)
monl}- iu tlie lower extremities, especially in the foot
and ankle, but have been found in the arm. tongue, eye-
lid, scrotum, perineum, anil trunk. As many as live or
six in a single host is not uncommon. The presence of
the worm is not detected ordinarily until it approaches
the skin, where it produces a swelling, at first painle-ss
but later painful, aud ultimately a running .soi-e. Of it-
self the worm may be considered comparatively harm-
less, but the complications incident
to a tropical climate often bring
about excessive suppuration and
gangrene, such as to necessitate
amputation of the part infected, or
even to be followed by death. The
worm is sometimes expelled spon-
taneously, but in the majority of
cases it is extracted by what is
known as the Soudanese method.
The end of the worm is seized firm-
ly between two splints, on which it is gradually
rolled up (Fig. 3.542), gi'eat care being exercised
to avoid breaking the slender body. The man-
ner in which the worm is coiled up In the ab-
scess renders the operation very slow, and while
recovery is rapid when the entire worm is re-
moved, in those cases in which it has been
broken and a part left behind, the result has been
excessive pain and often fatal gangrene. Tlie
physician finds it more satisfactory to remove
the entire worm at once by a simple operation.
In some cases complete cure follows a single
operation ; in others subsequent growths, which
include fibrous tissue with numbers of em-
brvos, call for further operative interference.
Prevention. — Apparently the satisfactory
regulation of the supply of drinking-water will
prove the means of stamping out the disease.
Surface water is particularly suspicious on ac-
count of the large number of Ci/clops likelj- to
be present.
Filariti loa Guyot 1778. — (Svn. : F. oeuH Gerv.
et v. Ben. 1859 (nee. v. Nordm. 1852); Dra-
cuiinihis octiU Diesing 186U: Dr. loa Cobbold 1864.)
Female 30-40 (rarely 70) mm. long, by 0.5 mm. broad,
of cylindrical form (Fig. 3544) with anterior end blunt,
posterior, straight, pointed; cuticula, transparent, yel-
lowish, not striated but marked with minute, chitinous
bosses irregulai'ly distributed; uterus bifid, coiled; eggs
30-35 bv 20-25 /; ; when deposited containing embryos
210-2.50/; in length.
Jl.ale: 20-30 mm. long, 0.3-0.45 broad; cuticula not
striated, but with small papilte except on first and last
fifth; mouth without papilUc; tail (Fig. 3545) slightly in-
curved, with lateral wings and five ventral papilloe on
each side, three being preanal and the first the largest;
spicules two, short, tmeiiual.
It was first observed in 1770. though a print of 1597
seems to show- an operation for its removal. Nearly
thirty cases are now on record ; most of these are only
notes, but recent descriptions of Ludwig aud Blanchard
have made its appearance and
structure known. The earlier
authors were inclined to regard
it as identical with F. mrdiiiensis,
but its specific distinctness main-
tained by others is now clearly
demonstrated. Even if the im-
maturity of specimens eliminates
the difference in size, the smooth
striated cuticula of the guinea-
worm will serve to separate it
at once on careful examination
from F. liiti with its non-striated,
embossed surface. The embryos
differ also.
In distribution F. hut is lim-
ited to an area on the west coast
of Africa (Guinea. Gold Coast.
Gaboon), where it is not uncommon, and cases reported
from other regions, which are largely among slaves of
earlier days, have been those of persons who Iiad come
more or less recently from that region. Such are on rec-
Fig. ast.5. — Tail of Male
Filaria loa with Spicules
and Papilhi?. (.Author's
specimen.)
211
IVeniatoda.
Neiiiatoda.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
ord from Bi-azil. Trinidad, St. Domiugo, France, Eng-
land, and tlic United States.
Naturally the majority of records affect negroes, but
physicians in Africa maintain that the parasite attacks
blacks and -uiiitcs alike, and the nunilier of cases reported
among niis.sionaries supports this view. One of the lat-
ter lias recently been re])(irteil in the United States by
Ward and Jlilroy.
Life History. — From the scattered facts on record
Blanchard has outlined the cour.sc of development as fol-
lows; Introduced into man in the larval form with drink-
ing-water, the form becomes adult in the alimentary ca-
nal. Either before or after copulation it penetrates the
tissues where its development is slow, as shown by a resi-
dence of from four to ten years or more in the body. It
ajipears beneath the conjunctiva of the eye or the skin at
the last iihase of its existence, but it may reach the sur-
face of the body without having acquired its full devel-
opment. That unlike F. mi(Ji>uiixis it does not deposit
eggs in dermal abscesses is chvir from the entire absence
of pus formation and of eruiition in cases of its occur-
rence. It is a prisoner in the body, and the embryos
must escape independeutlj- of the mother. They prob-
ably penetrate the blood, and are drawn from it by some
blood-sucking parasite, from which in some viuknown
TKny they reach ruuning water and in it a new host, or are
inoculated directly when the intermediate host is feeding.
Manson has conjectured that the well known F. (liiinui
is the larva of F. hm. with which it agrees in geographi-
cal distribution. The opinion is .generally accepted
among inhabitants of the affected region that the .source
of infection is to be found in drinking-water.
Pathology. — The parasite is an active migrant through
the connective tissue, hut comes often into the region of
the orbit. Its appearance in the tissue of the lid or be-
neath the conjunctiva is made known ordinarily by itch-
ing or even by slight pain which may disappear with the
withdrawal of the worm, only to recur with its subse-
fjuent return at irregular intervals of days, weeks, or
even months. An individual has been seen to pass
ra]iidly from the one eye to the other over the bridge of
the nose. In one ease only has an immature specimen
been foimd actually within the eye. In addition to
itching, transient ledematous swellings accompanj- its
appearance in various parts of the body. Fugitive tume-
factions, known as Calabar swellings, are not uncom-
mon in lower Nigeria. They are half the size of a goose
egg, painless, sudden in appearance, disappearance, and
recurrence, and may be found in any part of the body.
They are thought to be produced by rubliing when a /•'.
loa ap]iroaches the surface.
Treatmenl. — The negroes drivi' it frmn the eyi' by
dropping a grain of salt into the conjunctival sac or by
extracting the worm with a thorn. Deftness in operat-
ing is necessary, and if after cocainizing the eye the
■worm bo grasped with a pair of forceps, a cut in con-
junctiva or lid gives an opening through which it nsu-
all.v starts to escape, or may be withdrawn by a second
forceps.
Fllitri'i ml I'll! US Leuckart IsOn. — Body tajiering imi-
formly, head roinided. Male 3(1-0.5 cm. long, 40-140 /j
in diameter, tail iuciu'vcd: one postanal, two adanal, one
preanal papilla on each side, two s|iicules U.U8 and
0.177 mm. long. Female 40-70 cm. in length. En>
br_yos iMn long, 5-(i /' wide, resembling F. nocturna
and F. (livrnti. bvit shorter and thicker and without
sheath, head rounded, tail i-ery sharj), clear spot in an-
terior fourth of body.
I,cuckart received two dermal tumors from Gold Coast
negroes containing seveial worms eciiled in a ball and
sunounded by a fluid containingc'inbryos. A sonu-what
similar tumor excised from the arm of a Fr<'neh soldier,
who had been in Daliomey, showed that the worm occu-
pied a lymjih vessel and was surrormded liy a in:iss of
connective tissue. Its identification as the same siiecies
has been questioned. Prout has recently descrilied two
other cases from Sierra Leone. Like /•'. hui, it is vivip-
arous and found in suhdcrmal tissue; but \mlike that
species it is sedentary and produces a circumscribed sub-
cutaneous tumor.
F. conjunctim Addario 1885.— (Syu. : F. palpebraHs
Pace 1867, nee Wilson 1844; F. peritonei hmniiiis Ba-
besiu 1880; Filaria incniiis Grassi 1887.)
Female: Length 10-16 cm., width 0..5 mm.; cTiticula
.striated not embossed or papillate; mouth terminal, un-
armed, vulva near anteriorend; uterusdouble, with eggs
and endjryos measuring 350 b}' 5.5/;. Male unknown.
Dubini first found this species in Sicily in a tumor of
the conjunctiva, and it has been recorded as a human
parasite also in Italy and Hungary. The species is, ac-
cording to Grassi, a normal parasite of the horse and ass,
and is only occasional in man.
Filaria lentis Diesing 1851. — (Syn. : Filaria oeiili hu-
maiii von Nordmann 1832.)
With the case of von Nordmann, in which immature
nematode worms were found in the lens, have been asso-
ciated various poorly known ami often doidjtful cases of
later observers, in several of which it isprobable that the
object was a vestige of a vessel or filament and not a fila-
ria. In three cases the parasite was in the lens, in three
also in the vitreous humor, and in two in the aqueous
humor. The most recent, by Drake and Brockman, at
Madras, has been assigned by Blanchard to Filaria equi-
na, which is abundant in India. The character oif other
species is likely to remain permanently doubtful. Some
of them are very likely young forms of the preceding
species, F. inermis.
Filaria restij'urtnis Leidy 18S0. Length 66 cm., width
at head 0.37.5 mm., at centre 1.5 mm.; anterior end
pointed, posterior blunt; mouth without papilhe; cesoph-
agus 1.125 mm. long.
Passed in West Virginia from the bladder of a man,
fift}' years of age. The patient had been suffering some
days from luematuria. liailliet regards it as evidently a
pseudoparasite. While it was not extracted by the "at-
tending jihysician, he maintained that no doubt existed
as to the correctness of the patient's statements that the
worm had actual l,y been passed.
Filaria laiminis oris Leidy 1850. — Length 14 cm.,
width at head 0.1 mm., at centre 0.38 mm. Mouth ter-
minal. ]iosterior end provided with an epidermal spine,
0.05 mm. long.
Leidy finuul the single specimen in the collection of
the Pliiladel]ihia Academj" laljelled, "Obtained from the
muuth of a chilli," and (pieried if it might be the young
or the male of F. inedine/mis. Leuckart shared the opin-
ion whii h has, however, been questioned by some later
investigators.
F. laliialin Pane 1864.— Length 30 mm. ; pointed an-
teriorly; mouth with four iiapilUe, jiosterior end slightly
infiated ; vulva in jiosterior tenth; uterusdouble, but in
posterior branch rudimentary.
A single specimen only from a pustule ou the upper
lip of a man in Naples, Italy. Not reported since 1864.
F. Ij/niphatiea Treutler 1793. — (Syn.: Hannilaria
hjntpli. Treutler 1703; Filaria linminis.brorichialis Rnd.
1819; 7''. hiiiiiiiiis Dies. 1851 ; F. li/niph. Moq.-Tandon
1860; Stronmiliis hronchialis Cobbold 1870.)
Length about 26 mm.; brownish spotted with white;
transparent anil pointed anteriorly; thickened and blunt
posteriorly ; two short spicules.
First found in 1790 in the hypertrophied bronchial
ganglia of a man of twenty-eight years of age; it has
been reported since then by Brera and by Ziiru, who dis-
covered another specimen at Geneva in 1879, under con-
ditions like those of the first case. The view of Diesing
and Weinland, that it was ]irobabl}' iStri>nfii/lii.i Imif/era-
ginatus (= i^. apri) is improbable according to Railliet,
who views it as a male of F. inermis. The view of
Braun that it is F. equina, a common parasite of horse
and ass in Europe, seems more proliable.
Filaria inimitis Leidy 1850. — jMouth with six papilhe.
Male: 12-18 cm. long, 0.7-0.9 nun. wide; posterior end
with low lateral wings and eight preanal as well as nine
to ten postanal papilla'; posterior end rolled in several
turns like a corkscrew, spicules unlike. Female: 25-30
1\-2
REFERENCE HANDBOOK OF THE liIEDICAL SCIENCES.
IVeiiiatoda.
Neniatoda.
cm. long, 1-1.3 mm. wide, posterior end shortly blunt;
vulva in posterior fourth; ovoviviparous embrj-os 0.28-
0.30 nun. lonjf ami o/i wide, with a greatly attenuated
posterior extremity.
Originall}' found by Leidy in the heart of a dog, it is
now known to inhabit the entire venous system. The
Fig. 3546.— Fitorin Bancrofti. A. Adult male X 7.5. B, Embryo
Irom hydrocele fluid X 300. (Alter Lothrop and Pratt.)
embryos are to be found in the peripheral circulation d\u'-
ing the period of rest. With growth they retire to the
larger vessels and escape from the kidneys or in excre-
ment. Their normal method of exit is unknown. The
parasite is most conunon in dogs living in the open.
The parasite isconmion in the United States, especially
in the South and in South America. It seems to be very
abundant in China and Japan, and is reported also from
Italy, France, Germany, and Denmai'k.
As Jloniez has shown. Braun was apparently in error
in citing Bowlby as authority for the occurrence of this
species in man; and Brauu's own case is too uncertain
in determination to be accepted as evidence in absence of
other instances. If F. immiiis is even occasionally a
human parasite, it should be found as such in the United
States, where it occurs commonly. No case has been
found on record.
Filaria Bancrofti Cobbold 1877. — (S.yn. : TricJiina ci/x-
tica Salisbury 1868, non Filaria cystica Rud. 1819; F.
sanguinis /wi/iims hev/is ISIZ; F. sang.-hoin. ce(jy}it. Son-
sino 1874; F. derma t/iemiea Da Silva Araujo;
F. Wueliereri da Silva Lima 1877; F. sanguinis
hominis noctitrna Manson 1891 ; F. nocturna.
Manson 1891.)
Bodjf elongated, white, opaque, very deli-
cate, showing tendency to coil; cuticvda with-
out transverse striatiou, anterior end slightly
thickened, without liiis or papillix-, posterior
end rounded. j\lale 3.5-40 mm. long; 0.1-0.13
nun. broad, head 51 //, neck 48/;, in diameter;
Hs(i])hagus 0.13 mm, long; tail (Fig. 3547)
slightly bent, 1 mm. long: papilhe
und<'scribed; spicula 0.3 anrl 0.6
mm. long. Female 75-95 mm. long.
0.31-0.28 nun. broad, head 68 «. neek
51 ft in diameter, vulva 0.73-1.27
nun. from head, anus 0.383 from
tail. Eggs 25-28 /( or 35 (Lothrop
and Pratt) by 15//. Embryos 0.137-
0.3 mm. (or" 0.2-0.33 mm!) long by
8-10 (7-11) fi broad, with uustri-
ated cuticula, but euvelojied in a
delicate sheath (Fig. 3546, B).
Although tirst reported as early as 1863 by Demarquay ,
this form has been very generally confused with other
species of the group, especially F. Magalhutn, and even
now only a little can be given beyond the data contained
in the general characteristics which are taken from Mait-
land and Hanson's account, and from that of Lothrop
and Pratt. The discrepant measurements given by dif-
ferent authors are due, in ])art at least, to the fact that
different species were under consideration.
The male (Fig. 3546, A) is much shorter than the female,
and the posterior end exhibits a strong tendency to twist
Fig. 3,W7.— Tail of Male
Filaria Bancrofti.
Magnifled. (After
von Llnsto\\.)
like a tendril. Both sexes manifest a proclivity to curl
into a knot, and various observers note the difticulty of dis-
entangling the individual worms from such a mass. In
the female, which alone has been examined, the anterior
end is traversed by four deep grooves, giving the trans-
sccti(m much the form of a maltese cross. The thick-
walled vagina extends posteriorly a short distance from its
external orifice, and splits into two thin-walled uterine
tubes, which occupy the entire cavity of the body, forc-
ing the intestine against the nuiscular wall at one side.
These tubes are filled with ova and embryos in all stages
of development. The smaller embryos are coiled within
a thin structureless chorion. Preserved specimens maj'
assume a brownish tint, owing to a change in the color
of the uterine walls.
The embryonic tilarife in freshly drawn blood or in
liydrocele fluid are rounded at the anterior end and
pointed at the posterior. Though in constant motion,
twisting and coiling, they never (?) exhibit a true pro-
gressive movement. In freshly drawn blood they are
covered by a delicate sheath, which is indistinguishable
normally except as a flagellum following the tail at some
distance, 0.3-0.4 mm. (Fig. 3.548) ; rarely, when the move-
ment of the body is reversed, this disappears from the
tail and becomes evident at the head (Fig. 3.548, A). It is
evidently the collapsed sheath, which Jlanson regards as
a vitelline membrane, and in such specimens as have un-
dergone endosmotic changes it appears like a distended
sac enveloping the entire worm; such an appearance,
though frequently figured, is entirely unnatural. The
embryos of other species, i\g., F. irnrnitis, are without
this .sheath. These embryos may be kept alive five or
more days in a cover-glass culture of blood, and after
forty-eight hours many empty sheaths may l)e observed.
Attached to the til) of the head is a miuute spine, which
at times is pro-
truded in rapid
succession with a
peculiar " pout-
ing " movement.
Life Histoiy. —
The female is vi-
\'iparous, and the
cnibr3'os, which
are produced in
enormous num-
bers, are evacu-
ated into the
lymph stream and
ultimately pass
from it into the
lilood current,
w here they are
often founil in ex-
traordinary abun-
dance. T li e v
measure 0.2-0.33
mm. by 7-11 /<
(Lothrop and
Pratt, 0,26-0.3
mm. by 0-8 /;).
Twelve hours af-
ter being taken
into the stomach
of a mosquito one
tlnds side by side
free embryos and
empty sheaths.
By the next day
the embrj'os have
traversed the wall
of the stomach
and are in the tho-
racic muscle. At
the end of eleven daj'S they are 20-25/; broad and
more than 580 /; long. At seventeen to eighteen days
they begin to leave the muscles and migrate into connec-
tive tissue in front of the prothorax. Such larvte are
Fir,. 3.M8.— Metamorphosis of Filaria Ban-
crofti in Thorax of Mosquit^i. ^,.lust in-
gested : A', posterior end ; B. five days old ;
r, ten davs old ; D, sixteen days oltl. (After
T. L. Bancroft, except A' after Manson. I
213
Nematoda,
iNeiuatoda.
REFERENCE HiVNDBOOK OF THE MEDICAL SCIENCES.
more slender than before, 18-20 /i iii diameter. These
larvsE show an alimentary canal with a'sophagus well
(lifl'erentiated and rudiments of the reproductive appa-
ratus. While some remain in muscles even up to the fif-
FiG. 3541).— Lari'LB of FHarid Baiirmfti Passing
from Thorax to Proboscis of Mosquito, e. Larv£e;
I, labium ; p, palpus. (Modillccl after Manson.)
tieth day, the most are gone. By even
the twentieth dtiy larvje have penetrated
the heail and proboscis in sections of
which they apjjear crowded into the cav-
ity headed toward the i)oiiit (Fig. 3549).
Like the malarial organism they are inocu-
lated directly. The last stage of development occurs in
the skin; they become adult and copulate there; thus the
variable position of lesions of elephantiasis are explained.
In Aiuipluh's James finds that the transformation re-
quires only from twelve to fourteen dajs, and the activ-
ity of the embryos does not cease. Aectn'ding to the same
author the broad inactive form measures 71-.53 fi long
and tlie slender active form 151-133 /; long and 2.6/'
broad; in this latter stage the o'sophagtis is two-fifths
and the tail one-third of the entire length.
Bancroft and Manson suggested almost simultaneously
that the mosquito miglit serve as a carrier of the embry-
onic filari;e in the blnod. Manson, however, first ob-
served the changes which these emijryos undergo in the
mosquito. He allowed mosquitDCs to suck the blood of
tilarial subject, and found at first that the embryos are
within a delicate sheath or membrane, ap])arently almost
structureless; later, there becomes evident a marked
1rausver.se striation, and the sheath is rui>tured by the
worm forcing its cei)halie end against it. Once free
from the shsatb. the emliryo bores through tlie stoinach
wall of the insect and wanders into the thoracic muscles.
The embryos which emigrtite to the thoracic cavity do so
as soon as they are withdrawn from the human host;
those found some hours later in tin; mosquito's stoinach
are such as by immaturity or injury are not destined to
metamorphose, and changes in such are retrogressive.
According to one view the worm escapes by boring its
way out at the time the mosquito is depositing Iter eggs
on the water, or by breaking out from dying mosquitoes
which fall into a pool, and that the infection of the hu-
man host is brought about by drinking such water as
contains well-developed embryos. It is further sup-
posed that these young worms then bore their way
through the hiunan intestinal wall and attain maturity
at some suitable point. Cojiulation here is followed by
the production of swarms of embryos. In olijection it
may be urged that Bancroft has shown water to be fatal
to the embryos in the course of three or foiu' hours, and
that hence it cannot be the medium by which tliey reach
the human subject. He also says the embryos never es-
cape naturally from the mosquito's body even if in water.
The other hypothesis as to later develo|imrnt is that the
infection takes place when the mosquito containing the
fully developed embryos is sucking blood, and Bancroft
lias |irovcd the migration of such embryos from the
thoracic muscles into the labium, from which he believes
they escape at a definite point at the tip to ])enetrate the
body of the new host. Grassi believes that the larvae es-
cape from the bent labium in the act of biting by rupture
of the cuticula. This part of the life history has not been
cleared up as yet.
In the transmission of embryos certain species of mos-
quito only are culpable; among such are Ctile-v fatifftiiDi
in Australia. AiiujiJieks liossii in India, probably also
Amiphdes iiumvus ; this genus James regards as the proper
intermediate host, since in it the development is more
rapid. In case the embryos are taken up by any unsuit-
able species of mosquito they arc digested in the stomach ;
or if a few individuals succeed in wandering out, they
are absorbed in the muscles.
Distribution. — Tropical Asia, Africa, America, and
Australia are all infected. In Samoa and some other
South Pacific Islands this parasite is particularly abun-
dant, as much as fifty per cent, of the population being
infected.
The first mention of this parasite in the United
States was made by Salisbury in 1868, who found
the ova in the urine. Some years later (1886) Guite-
ras called attention to the presence of the embryos in
the South, reporting four cases from Key West and
one from Charleston, S. C. Only a little later De Saus-
surc luiblished a clinical history of twenty-two cases,
also from Charleston. Since then many cases have
been reported in the Gulf and South Atlantic States,
many of which have been undoubtedly imported, but
indigenous cases are not wanting, and one concerns a
woman who liad always lived in Pennsylvania. The
last account by Lothrop and Pratt gives a most exten-
sive and valuable stuily of two cases in Boston imported
from the Barbadoes, and includes important new data on
the characteristics of the adult worms.
Pathology. — The adult worm was first found in 187G,
by the elder Bancroft, in a lymphatic alwcess of the arm
and subsequently in a hydrocele. The two sexes are
found coiled together, and jirobably live for some time.
Since then this discovery has been abundantly confirmed.
Jlansou has shown that the species normally occurs in
the lymphatic vessels, and that the embryos, as well as
the adults, rarely also gain the circulation by way of the
thoracic duct. The embryonic blood fllarite were first
observed by Demarquay, of Paris, in a man from Ha-
vana, who was suffering from chylocele. The name
P. siinf/tiiiiiii Iiumiiiis. first used for these embryos by
Lewis in India, has been apiilied to several different em-
bryos, which JIanson has distinguislied by approjiriate
names. Whether they lielong to dilferent species or are
stages of development in one or two forms is still unset-
tled, thougli I am inclined to accept their specific iude-
])endeuce. Such embryos have been reported from urine,
tears ( ?), and secretion of the Meibomian glands as well as
from the blood in cases of chybu'ia and elephantiasis, and
also in apparently healthy individuals. In the Barbadoes
nearly thirteen per cent, of the persons examined were
infected, and yet two-thirds of the infected cases mani-
fested no external sign of the disease,
Manson was also the first to establish the periodicity of
the embryos, as those of this species appear in the blood
toward evening, increase in numbers during the night,
and disappear in the morning. Manson views the "filar
ial periodicity as an ailaptation of the habits of the filaria
to those of the mosipiito, the intermediary host indispens-
able to the future life of the parasite." But since it has
been .shown that by reversing the period of sleep the
haliits of the endiryo filarial may be reversed also, the
explanati(m of von Linstnw appears more probable,
namely, that the tonus of the capillaries is reduced dur-
ing sleep; and thus the embryos, which are too large to
enter them during the day, find entrance po.ssible owing
to the increased size of the vessels. JIanson founil the
embryos massed in large arteries and irregularly scattered
through the capillaries in the da,v time.
The presence of embryos in the blood is evidence of
the parasitism of the adult in some part of the lymph
systetn. The duration of life of both adtdt and larva' is
entirely unknown ; for the former, however, it is certainly
several 3'ears. So far as known the embryos do not bring
about pathological changes, though leucocytosis with an
increase of eosinophiles is noted in early stages, to disap-
pear later. The adults occlude large lymphatics and
produce lymph stasis with resulting dilatation ofthelym-
214
REFERENCE HANDBOOK OF THE .AFEDICAL SCIENCES.
Neiiiutoda.
Nciiialoda.
phatics. The clinical manifestations depend upon lym-
phatic obstructions and give rise to both general sj-niji-
toms and local, which latter vary widelj' according to
the part involved and to possible modification by infec-
tive processes.
An estimate has been made of from forty to fifty millions
of embryos in the blood of a single man. and yet the in-
dividual sufiercd no apparent effect. It must be said,
however, that the results of the parasite are brought
about gradually'; they are primaiily a varicose condition
of the lymphatics, giving rise to various conditions, such
as chyl'uria, varicose inguinal glands, lymph scrotum,
chylocele. lymphangitis, elephantiasis ('/. ■('.). In tiie
latter it is probable that the obstruction to the flow of
the lymph produces mechanically the distention and ex-
cessive growth of such parts as arm, leg, scrotum, which
is characteristic of the disease.
For examination JIauson recommends a thick film of
blood drawn at 8 to 9 p.m., when the embryos are most
numerous. Fixing is unnecessary and the stain (fuchsin.
gentian violet) is made by adding a few drops of an al-
coholic solution of the dye to a watch glass ot water.
Overstaining is reducible by dilute acetic acid.
Prevention. — The protection of drinking-water from
contamination by mosquitoes is strongly to be advised,
and the case of the Friendly Islands is cited as evidence of
the value of this measure. There forty per cent, of the
males are affected by filaria-, all the people drinking
from open pools; but the chiefs who have closed-water
tanks rarely acquire the disease. It may, howe%'er, be
urged in favor of mosquito inoculation that tlie chiefs
are also least subject to mosquito bites. la any event,
the protection of drinking-water and the di.^struction of
useless pools will certainly reduce the nuniber of mos-
quitoes, and consequently the extent of the disease,
whether transmitted through drinking-watf ror by direct
inoculatiuu of a mosciuito.
It must be noted that the presence of an infected indi-
vidual is a distinct menace to the health of a community,
since the widespread distribution of mosquitoes capable
of acting as the intermediate host insures tlie possibility,
and under some circumstances the certainty, of wider
transmission of the disease. There is little doulit that
the cases recorded from the Southern United States are
priinaiil3' traceable to such introduction from the West
Indies. Thesame explanation lies near at hand for those
occasional cases which have been recorded in various lo-
■calities, both here and abroad.
Filarla Mngallmeu R. Blanchard 1895.— (Syn. : F. Ban-
crofti Magalh'aes 1892 nee Cobbold 1877.)
Bod}' slender, elastic, resistant; cutieula heavy, cross
striated. Female, 1.").5 mm. long, 0.33 mm. broad at
head. 0.28.5 mm. at neck, 0.7 mm. in maximum; vidva
2..56 nun. from cephalic extremity. 3Iale, 83 mm. long.
0.407 mm. broad; tail with double spiral, on each side
four preanal autl four large jjostanal, papillaj of mul-
berry form (Fig. 3.5.50) ; smaller ( ?) spicule 0. 23 mm. long,
longer unknown. EggsSSby 14jk; embryos0.3-0.3.5mni.
long and .5/; broad with transversely striated cutieula.
Of this form JIagalhaes discovered in Rio Janeiro two
adults in the left cardiac ventricle of a man in whose
blood embryonic filaria; were also present. It was at
first wrongly assigned to F. Bancrnfti, from which it is
easily distinguished b\- the above characteristics. Like
all Nematoda living in the heart the cutieula is tough to
resist the powerful blood pressure, the bod}' being like
catgut, whereas F. Banerofti is delicate and easily torn.
The proportions of embryos and adults also differ ma-
terially.
The life history is unknown.
F. per^dits ]Mansou 1891. — (Syn. : F. sanguinis hominis
minor Manson.)
The embryos, which have been known for some time.
are found in the blood at all hours. They have no
sheath, and measure only 0.18-0.23 mm. long by 4. .5"
broad, being thus much smaller than those previously
described. Their continued presence in the capillaries
may be due to this fact. The head is armed with a mi-
nute, exceedingly delicate filiform spine set on a papilla;
this structure may lie protruded and retracted rapidly.
The embryo not only wriggles actively, but also travels
about very rapidly. It is not numerous, but may be
I'omid in company with F. nocturna and F. diiirnn.
The adult was found by Daniels in a native of British
Guiana, in whose blood both blunt- and sharp-tailed (F.
Ozznrdi) embr3'0s were present. A male and a female lay
in subperitoneal connective tissue. Manson also found
an adult in one case of "sleeping sickness," Aiuong the
negroes on the west coast of Africa from one-third to
one-half are infected, and most such show the earlier
symptoms of this disease in nearly all case;- of which F.
perstiuis is present. Yet this parasite is found in appar-
ently healthy individuals, so that its etiological relation
to the disease mentioned is still a matter of doubt.
F. Ozz<(rdi JIanson 1897.' — Jhde. 4.5 mm. long, 0.06 mm.
broad; female, 70-80 mm. long by 0.12 mm. broad. Em-
bryos in blood, without sheath, sharp-tailed, 0.173-0.240
mm. long by 4-.5/< broad.
The embr3'os were originally reported from the blood
of Carib Indians from BritLsh Guiana, and were present
in about fifty per cent, of the cases examined. At first
both sharp- and blunt-tailed embr_yos were found together
and were regarded as developmental stages of one species.
Daniels found adults, chiefly females, in the mesentery,
and in fat at various points in the peritoneal cavity; and
in a later case two sets of adults, the one which is re-
garded here as belonging to this species, and the other,
which was viewed bj' ilanson as F. ptrntans, to which
the blunt-tailed embiyos are also assigned. The relation
of the adults to these embryos is still a matter of consid-
erable doubt.
In addition to the foregoing there are also several spe-
cies of FHaria. known only b_y theembrj'oiiic form which
inhabits the blood. AYhile von Linstow regards them all
a.j deveiomnental phases of one species, I cannot concur
in a conclusion so widely at variance with their differ-
eii"es in structure, habits, and distribution. They may
be briefly noted as follows:
Filfiria diurna Manson 1891. — Only free embryos of
this species have been observed. They were found in
the blood of negroes from the west coast of Africa. They
appear in the peripheral circulation about 8 a.m., in-
crease in niunbers until noon, and decrease later, to dis-
appear by 9 r.M. The periodicity was maintained for
some weeks. As adidts of F. Iwi were foiuid in one of
the cases. Manson regards it as likely that F. diurna is
the larval form of that species.
Filaria Demarfjuayi Manson 1891. — The embryos of
this species were found in the blood of apparently healthy
natives of St. Vincent, and later also of St. Lucia, West
Indies, and of New Guinea. They have also been re-
ported very recently from other local-
ities in the ATest Indies. They re-
semble the embr\-os of F. Bancroft i in
general appearance; they are, how-
ever, only half so large (in dry smears)
and they are without a sheath. Their
presence in the superficial capillaries is
constant day and night.
For convenient reference the char-
acteristics of the blood filaria> luaj' be
given here in tabular form (p. 216) so
far as they have been determined.
Filaria rommuyrum-nrientalis Sarcani
1888 is a species observed in the blood
of a Roumanian woman. The parasite
measured 1 mm. long by 0.03 nmi.
broad, and had an aiiiuentary canal
and well developed sexual organs.
Family of the Trichocephalida'.
Body extreiuely elongated wiih two
distinct regions, the longer anterior
very slender and the shorter posterior more or less en-
larged. Oesophagus very long, anus terminal. JIales
sometimes without a spicule, more often with a single
simple one which possesses a sheath. Female with sim-
Fio. a'i:>(i.— Tail of
Miile FiUtria Ma~
palhaesi. Magni-
fied. (Aft^r voa
Linstow.)
215
Neniatoda.
Nomatoda.
REFERENCE HANDBOOK OF THE
arEDICAL SCIENCES.
Characteristics of Blood Fil.vri^.
Species
F. diurna
F. nncturna
F. perstmis
F. vohmlu.i
F. Demarquajit
F. Ozzardi
Lenpth
0.300 mm
T..') (I
Present
0 300 mra . . .
0.230 mm
0.350 mm
5fi
0.2O5-0.310 mm ... .
0.17-0.34 mm.
4-5 )x.
Absent.
Sharp.
7.5,^
4."> iii
Six lipped arnijiture
One-flfUi taper
(sharp?).
Indistinct central
granular mass.
Papillated
Retractile spine . . .
Tall
Sharp, one- fifth
taper.
Central granular
mass.
Body
Central granular
mass.
No central granu-
lar mass.
Present. 0.a')3 mm.
pie ovary: vulva at junction of the two regions of tlie
body; eggs witli peculiar translucent plug in the shell
at each pole. ])evelcipnient diicct ami without ecdy.sis.
a
Fin. SIVil.—TrichnceplioUix ti-icliUmis. a. Egg; 7>, female; c, male
witli anterior end emljedaed in mncosa; sp, spicnles. (After
Claus.)
Of the half-dozen gen<'ia only two are important here,
but they include two of the commonest and the most
feared of human parasites.
I'richoctiihaliis Goeze 1782. — Anterior region very long
and filiform; posterior region, which contains the intes-
tine and reproductive organs, short, sharply set ott' from
anterior and markedly inflated. In the male it is rolled
into a s]iiral; onespiculum with iufundibuliform sheath.
In the female the posterior regions are lightly bent, but
not in a spiral. Parasitic in the large intestine and ca'cum
of mammals.
Trichnceplwhis trichiiinis (L. 1771). — (Syn.: Axrnris
trichiurit' L. 1771; Trichoeeplutlns Qoev.i: 17,S'2; T. homi-
TOsSchi-ank 1788; T. iUsikii- RwA. 18U1 ; M,isli;i„,l,-!i Ii<iiiii-
msZeder, 1803.)
Male, 40-4o mm. long, with strongly attenuati-d ante-
rior region comprising thi'ee-Hfths of the total length.
Spicule single, 2.5 mm. long, located in a, s|)iuous pro-
tractile sheath; posterior region in a flattened spiral.
Female, 45-.50 mm. long, with atteiiuatcil anterior
region two-thirds of total lenath. Eggs, ,'jl-.'j:.!// long by
21-28u wide, brownish, thick-shelled, with polar knobs,
anil deposited before cleavage begins (Fig. S.wl).
The striking appearance of this genus, a single sjiecies
alone of which is parasitic in man, is due largely to the
regions of the body. The filiform region contains only
the (esophagus, leaving the remainder of the alimentary
canal and all the reproductive organs for the greatly en-
larged posterior region in which the transparency of the
body wall permits one to recognize the various sti'uctures
even in the living worm. The orifice of the vagina lies
near the level of the transition from O'sophagus to mid-
gut.
Life History. — The eggs are produced in large num-
bers, four hundred thousand annually by a single feuuile
(Leuckart), and undergo no development until they have
passed out of the human body. Cleavage takes place in
water, but only at the end of some months or even more
than a year. The eggs are well protected by the heavy
shell from adverse circumstances, so that Davaine has
kept embryos living within them for five years. The
inti'oduction of these embryos still within the shell is or-
dinarily brought about through drinking-water, though
Blanchard suggests the evident possibility of their intro-
duction on salads
and uncooked vege-
tables. In the hu-
man stomach the
shell is dissolvei:
and the embryos are
set at 1 ibert y to
reach se.xual matu-
rity at the end of a
few weeks, as has
been definitely es-
tablished by the ex-
perimentsof Grassi.
Distribution. —
This is one of the
commonest para-
sites of man, being
distributed over practi-
cally the entire earth,
though more abundant in
the warmer regions. Lo-
cal variations in its fre-
qiieucy are noteworthy.
Braun cites, as records of
autopsies, its presence at
Di'csdcn as
.0 per
at Erlangen 11.1 per
cent., at "Kiel 31.8 per
cent., at Munich 9.3 pe
cent., at St. Petersbui'g
0.18 per cent., at GiJttin-
gen 46.1 per cent., at
Basel 23.7 per cent., at
Greenwich 68 per cent.,
at Dublin 89 per cent., at
Paris 50 per cent., and in
Southern Italy near luo
per cent. This species is
growing rarer in Paris ac-
cording to statistics avail-
able, and probably else-
where also, owing to the
disuse of surface water for
drinking.
Pathology. — Trirhnci-
phalns trichiiinis inhab-
its the human ca>cumoi-
dinarily, but rarely also
the vermiform process and
colon, and may be founi"
in pei'sons of all ages, even
occun-ing in infants of a
year old.
Usually only a few in-
dividuals are present in a
as many as one thousand parasites have been found at
Fic. 3,'k)3.— Intestinal Trirhiua. A.
Female with embryos; B, male,
■, SO. (After Heller.)
single host, but in some cases
216
REFERENCE H^\JS^DBOOK OF THE MEDICAL SCIENCES.
Neiuatoda.
Noiaatoda.
once. Normallj^ they occur with the filiform anterior
region embedded in the mucosa, and recent investiga-
tion tends til (.lemonstrate tliut such as are tiiund free in
the canal have been driven out by post-mortem changes.
This species has been regarded earlier as playing a
pathogenic role in typhoid, chol-
era, and beri-beri, and more re-
cently all pathogenic significance
has been denied it. Thcmgh the
presence of a few does not occa-
sion pathogenic symptoms, yet
since Askanazy has shown the oc-
currence of Inemoglobiu in the
alimentary canal of these worms,
the fact that they nourish them-
selves on the blood of the host
cannot be doubted. In occasional
severe cases noteworthy depres-
sion, suppression of the urine, with
fever, cardiac weakness, and often
nervous symptoms, have been
noted.
Treatment is said to beditfieult.
and naphthalin, thymol, and pel-
letierine have been used with onl)'
moderate success. A later writer
commends santonin as rapid and
effective.
Prophylaxis. — Care in obtaining drinking-water and
in selecting and cleansing uncooked vegetables will evi-
dently limit the spread of the parasite.
Tr'iddnelUt Railliet 1896. — (Svn. : Trichina Owen
1835.)
Very small, slender, witljout marked distinction of re-
gions "in body. Male without spicule, but with lateral
appendages at posterior end, as if a poorly developed
bursa were jiresent. Female ovoviviparous; vulva at
anterior fifth of body. Only a single species.
TrichineUa spiralis Raill. 1896. — (Svn. ; Trichina sjii-
ra?is Owen 1835.)
Male (Fig. 3.5.53,.S), 1.4-1. 6mm. long by 0.04mm. broad,
without spicules, but with a short conical appendage on
either side of the cloaca, behind which are two pairs of
papilkie. Female (Fig. 35.52, .1), 3-4 nun. long, 0.06 mm.
broad; vulva ventral near anterior fifth of body; anus
terminal, viviparous. Fully developed larva, 0.8-1 mm.
long by 0.04 mm. broad ; cyst measures 0.4 by 0.25 mm.
The se.xually mature ])arasite, sometimes called the in-
testinal trichina, inhabits the small intestine of man and
various other mammals. The larval form, known as the
muscle trichina, is found encj'sted in muscular tissue.
Easily infected are man, pig, rat,
mouse, guinea-pig, rabbit; less eas-
ily sheep, calf, horse; with difli-
culty cat, dog, badger. The intes-
tinal form will develop also in
birds, but the embryos are expelled
with fa'ces and do not reach the
muscles.
History. — Encysted trichina were
first noted by Peacock in London
as early as 1828, but it was 1835
before their character as encapsu-
lated entozoa was recognized by
Paget and the parasite described by
Richard Owen. The presence of
encysted trichinaj in man was con-
firmed by a multitude of observa-
tions fxnn various countries, and
Joseph Leidy added a most impor-
tant fact in the discovery of sim-
ilar worms in pork. Feeding ex-
periments by Leuckart, Virchow,
and Klichenmeister, together with
the observations of Zenker on a maid that had died of ap-
parent typhoid, led to the elucidation of the life history
and to proper estimation of the pathogenic character of
the parasite which had heretofore been regarded as harm-
Fig. .3.5.'>!.— Fully Developed Muscle Trichina with Ali-
mentary Canal and Genital Priinoriliuin, Removed
Irom Cyst. Maguifled. (After Leuckart.)
Fig. a5.>t.— f> n c a p s u -
lated trichina. (After
Leuckart.)
less or as the immature form of a Trichorfphahis or
Stronr/yJus. Rapid accumulation of isolated eases and
of epidemics of trichinijsis, almost all from North
German}-, placed beyond question the etiological sig-
nificance and importance of the trichina.
Life History. — If a portion of
flesh containing the larval worms
is eaten by a suitable host, the
larviB are set free in the stomach
and pass into the small intestine.
They attain sexual maturity in
about two and one-half days, c<ip-
ulate, and the male soon dies.
Two opposed views as to the dis-
persal of tlie young have long been
held. According to one the mi-
gration of the embryos is an ac-
tive one in that they bore their
own way out of the canal and
through the connective tissues to
their ultimate seat. The other
view, however, of passive trans-
port by the blood and lymph
streams may be regarded as de-
monstrated by recent work, par-
ticularly that of Graham, whose
account is followed in the main
here. The gravid female bores
into the intestinal wall as far as the lymph vessel.
There the young are produced, being set free by the
female into the lymph stream, which carries them ul-
timately into striated muscle tissue. At birth they
measure 0.09-0.11 mm. in length by 5-6/; in width, and
at the close of this migration but little more, being then
0.12-0.16 nun. long. In eight days these embryos are in
the intramuscular connective tissue and only a few days
later in the muscle fibres themselves (Fig. 3555). The
fibres lose their transverse striation and undergo granular
and fatty degeneration. The embryo increases rapidly
in size, and rolls into a loose spiral in an expansion of the
completely degenerated fibre. By the action of the sur-
rounding connective tissue, in which connective-tissue
corpuscles and Icueocj'tes are contained, a cyst of char-
acteristic fiirm is produced (Fig. 8.554). It is thickened
at the poles and measures about 0.4
mm. by 0.25 mm. in diameter. This
process occupies several weeks, dur-
ing which later broods of embryos
are produced, since each female lives
five to seven weeks and gives birth to
from eight thousand to ten thousand
young. Thus in the early stages of
an infection one finds in the muscle
embiyos in various stages of develop-
ment and encystment, side by side.
Once encysted the larvoe remain
ciuiescent; it may be for long peri-
ods. Thus encysted trichinae have
been found living in human muscle,
twenty-five and even thirty-one
_years after the presumed infection.
Not infrequently, though perhaps
not always, one finds evidences of
further change in the formation of a
delicate calcareous laj'cr about the
cyst (Fig. 3556). In some cases this
encroaches upon the larva so as to
produce ultimately a calcareous nod-
ule in which a remnant alone of the
worm is contaiiud It is held by
some that calcification does not ensue
until after the death of the larva from
unknown causes. Fatty degenerat ion
of the encysted trichinre can also be
observed, and is likewise held to be a pathogenic process.
Such larv.t as rarely occur in connective tissue are with-
out the characteristic cyst, but apj^ear to be smothered
in a mass of proliferating connective tissue.
Fig. 3.5.5.5. — Muscle
Trichina Fifteen
Days .\ftfr Infec-
tion. ;■ Kii. (After
Leuckart.)
217
Neiualoda.
Neiuatoda.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
While it Las been determined experimcutaliy lliat a
considerable mimljer of liosts furnish conditions favor-
able for the development of the trichinse, the normal host
is no doubt the rat, and evidence has been adduced to
prove the introdiiclicn of this parasite into Europe from
Fig. 3556.— Muscle witb EncvstPd Tric-liinaJ in Process of CalciQcation.
( AftiT lirauu.)
the East with the brown (U- Norway rat. The method of
transmission in this siiecies is clear wlien one recalls that
rats are cannibals and universally make way with agetl
or infirm members of the tribe. The well-known avid-
ity with which pigs calch and eat rats explains the in-
fection of swine, and it is from this source that man is
infected.
Nearly all of the epidemics of trichinosis on record are
confined to North Germany. In Saxony from ISOO-TS
there were 3!) epidenncs aifecting 1,2(57 persons, of whom
19 died; at Hedersleben (1865), a town of about 2,00(1 in-
habitants only, a total of 'S.i7 were sick and 1(11 dicil ; at
Emmersleben (1883) fully one-third died among those
who ate the infected meat. Stiles has given a statistical
review of tricliinosis in Germany during recent years,
from which is taken tlie following: 1800-1880—8,491
cases, 513 deaths, (i per cent, mortality; 1881-1898—
6,329 cases, 318 deaths, 5 per cent, mortality.
From the table of .sejiaratc years it appears tliat there
has beeu a general decrease in trichinosis in Ccrmany
during recent years, due jirobably to general education
of the public on the dangers of eating raw pork as well
as to meat inspection. The latter, which removes from
consumption 1,500 to 2,000 trichiuous bo.ss annually, is
carried out in a most scientific manner by an army of
some 30,000 inspectors and microscopists, at an annual
cost (estimated) for tlie German Empire of .'?3,00O,(JO0,
while for the city of Berlin alone the cost is .':i80,000. In
spite of this system and expenditure security from trichi-
nosis has not been attained fnti. for tin' meat exKmined, as
the foUowin.g table shows, according to which more than
half the cases of this disease are traceable to inspected
meats.
During double the period given there have beeu re-
corded in the United States aiiproximately 900 cases.
Of the 18 cases ami 3 deaths alleged to have been due
to American pork during 1881-83. neither Virchow nor
other; have accepted the evidence as tenable, and the
careful examination made by Stiles renders it clear that
the attacks upon Aiuerican pork found in the German
press are not supported by German health statistics.
While the inspection doubtless diminishes chances of in-
fection, it certainly gives rise to a false feeling of security.
Summary for the German Empire 1881-98 Inclusive.
Cases.
Deaths.
3,043
143
1,304
112
13
7
3,388
63
874
1,968
18
18
132
0
84
Data obscure or wanting
Said to be due to American meats
98
3
1
6,339
318
For the years 1860-95 Stiles has collected records of
about 900 cases from the United States. Undoubtedly
during this time cases have been diagnosed as atypical
typhoid or rheumatism which were in reality attacks of
trichinosis, but in the ojiiuion of various authors there
were also unrecorded cases in Germany. Nevertheless it
is clear that there is a much less prevalence of the disease
here, and it is interesting to note the nationality of these
cases so far as recorded.
Table or Two Hundred and Seventy-Four American Cases.
Cases.
Per
cent.
Cases.
Per
cent.
German
" Foreign "
2118
37
10
4
4
76.0
VM
■A.n
1.5
1.5
American
French Canadian —
" French descent"-..
4
3
1
1
1
1.5
1.0
.4
.4
.4
Statistics as to the prevalence of trichinosis are given
by numerous European authorities from examinations
niade at autopsies. The results vary from nothing in
France, according to Blanchard, to about two per cent,
in Germany, according to various authors. Tliese fig-
ures are based upon macroscopic examinations in large
part at least, and Leuckart with others has remarked
that greater success would follow more rigid search. In
tlie United States Williams has subjected five hundred
and five cadavers to a careful microscopical study, with
the result that twenty-seven cases were found to be in-
fected, or five and a third percent. One-third of them
were classed as severe, and only two were evident on ex-
amination with the naked eye. The nationality of the
cases is given in the following table, which is sugges-
tive, though the number is too small to warrant the clraw-
ing of final conclusions:
Posi-
tive.
Nega-
tive.
Total.
Per cent, of
positive
cases
in each
nationality.
6
5
5
1
201
65
.57
10
43
10
37
65
207
70
63
13
49
l;<
27
66
3.89
United States, rolored
British and Irish
CanacUau
7.14
8.06
16.66
12.24
16.66
Other nationalities
0.00
1.51
478
505
5.34
The infection of rats varies so widely in different locali-
ties that little dependence can be placed on figures here-
tofore given from the examination of small numbers of
individuals. The examination of pigs shows in Boston
4-5.7 percent, infected (Billings), in United States army
2.1 per cent, (Ml'iller), in various German districts from
1.5 per cent, to 0.1 jier cent. The records of Mark show
distinctly that reasonable hygienic conditions reduce the
liercentage of infection among pigs enormously, even in
a few vears.
218
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Nciiiatoda,
Neiiiaio4la.
The tricliiiKB are fouud most abundantly in the muscles
of the diaphragm, tonjcuc, and neeU. and are present at
times in incredible uuniliers, estimated by Leuekart at
from thirty to forty millions for a single host (man).
Diagnosis of tlie disease may be positively conlirmed by
the diseovery of embryos in bits of muscle removed from
the patient by scalpel or special harpoon.
The occurrence of otlier nematodes of somewhat simi-
lar size and appearance, the so-called false trichina;, in
the muscles and other organs of hare, rat, mouse, bird,
fish, and even man (ef. case of Cobbold above, under
Leptodera lerricola) make it imperative that tlie determi-
nation be made with care in suspected eases of trichino-
sis. Of dcliuite diagnostic value is the so-called "cell
body " of the ajsophagus, which is prominent in the an-
terior pointed region of the worm and which, though
varying in length, is easily recognizable in all stages of
growtli and in both sexes (Fig. 355o).
Prophylaxis. — Man acipiires the disease by the con-
sumption of pork, in which are found living trichin.t.
The chance of infection from all other animals is utterly
inconsiderable, though a receut German author calls
attention to the necessity of submitting dog meat to in-
spection on account of its rapidly increasing use as food.
It has also been proved that .salting, smoking, and other
methods of curing ham do not afford a guarantee for the
death of trichinte which may be present. Two preven-
tive methods have been suggested. Tlie first is fdllowed
by Germany in her system of meat inspection ; as already
noted the system is expensive and does not afford ab-
solute protection. Furthermore, unless the number of
trichinae present is enormous so that pathological changes
have been induced in the flesh, the destruction of the
meat constitutes an unnecessary loss of valuable food
material. The second method of preventing the disease
is the thorough cooking or curing of the meat so as to
destroy the trichinae. A temperature of 70° C. is sufli-
cient to kill the encysted parasites, but in order that the
centre of a piece of meat may reach this temperature
cooking must be prolonged. One may determine the
sulBcicncy of the cooking by tlie uniform clear gray
color of a cut surface and the absence of red juice under
pressure of the knife. This individual prophylaxis is
both most reasonable and most elfective; for the con-
sumption of well-cooked pork is free from danger.
The old-fashioned slaughterhouse, at which the refuse
was thrown to pigs and fell in part also to the rats infest-
ing the place, was a serious menace to the health of the
community, and offered the most admirable conditions
for the rapid multiplication of parasites, especially the.se.
On the otiier hand, the great modern packing establish-
ments, in which all scraps are utilized under methods
that destroy the life of any parasites present, are impor-
tant agents in the linn'tation of this disease and in the
general improvement of public health. Proper methods
of slaughtering, curing, and preparing pork, and the
abandonment of the unsanitary custom of eating the tlesh
of the pig uncooked are the true methods for the sup-
pression of the disease.
Family of the Strongylid«. — Body elongated, cylindri-
cal, rarely filiform; alimentary canal coiuplete; mouth
provided with six papilhe, sometimes in the axis of the
body, sometimes turned toward the dorsal or ventral sur-
face, and frequently armed by chitinous teeth ; esophagus
more or less enlarged at the posterior end, but not pro-
vided with a distinct bulb; sexes separate; male with
caudal sac or bur.sa in shape like a saucer, or, if deeper,
a bell encircling the end of the body. One or two spic-
ules project from it, and the ribs or rays which mark its
surface have characteristic arrangements in ditTerent spe-
cies. The margin of this sac may be notched or deepl.v
cut, so that it appears to consist of two separate parts ; near
the male orifice a small number of papilla; are often
found. Female with one or two ovaries; female sexual
opening very variable in position. The eggs when laid
have undergone at least ]iart of their development.
Stronriylvs npri (Gmelin 1789). — (Syn. : GonUiiif pul-
monalis apn Ebel 1777; Asearis ojn-i Gmelin 1789; IStr.
siiis Rud. 1809; .S'f)-. paradoxus Mehlis 18;il : Str. elon-
!/atus Duj. 1845; Str. longeraginatus Dies. 1851; Meia-
strongyliis paradoxus Molin 18G0.)
Male, 12-35 mm. long, bursa bilobed, five ribs in each
lobe, spicules very long and slender, measuring 2.5-4
mm. in length. Female, 20-50 mm. long, with short
fish-hook tail at the base of which lies the anus and just
in front of it the vulva on a rounded eminence. Eggs
ellipsoid, 0.0(5-0.1 mm. long by 0.04-0.07 mm. broad;
when laid they contain well-developed embryos.
The parasite inhabits commonly the bronchi and bron-
chioles of pig, sheep, and occa.sionally also man. Dies-
ing reported it first from a six-year-old boy in Klausen-
burg; Chatin found some individuals, probably by
accident, in the alimentary canal of a patient in France.
The observation of Raiuey and Bristowe on nematode
embryos from the larynx, which they called Filaria tra-
c/ieah'x, points to this species even if an exact determina-
tion is impossible. Its abundant occiirrence in the pig
in Europe, and its extreme rarity in man point to some
feature in the unknown life history, which renders hu-
man infection improbable.
Strongjjlus suhtilis Looss 1895. — Body very slender and
delicate, cuticula finely striated, oral papilUe inconspic-
uous; buccal cavity infundibuliform; a'sophagus nearly
one-sixth as long as the body. Male with inconspicuous
ahe at anterior end, 4-5 mm. long, 90 (U in diameter at an-
terior end, 70 /< near bursa; two spicules, 0.15 mm. long,
with accessory piece 0.05 mm. long (Fig. 3557). Bur.sa
bilobed, with asymmetrical ribs. Female, 5.6-7 mm.
long, 0.01 mm. in diameter at head, and 0.09 mm. in
posterior third of body. Tail sharply pointed, anus near
tip; vulva about one-fifth length from posterior end;
uterus bilobed, with a few (three to six, or even eight
or nine) eggs in each lobe; eggs oval, 63-70 by 41-36/u,
thin shelled, unsegmented, or partially segmented in
uterus; develop-
ment unknown.
Infection by
drinking -water.
This parasite
was described
by Looss from
sjiecimens found
at post-mortems
in Egypt. It
occurred in the
stomach and du-
odenum of man
and the camel.
The infection
was regularly
light, and Looss
doubtedits path-
ogenic character
on account of
this as well as its
small size and
unarmed buccal
cavity. Latei-
Ijima reported a
record made by
Ogata of the dis-
covery of as
many as two
I n in d red small
nematodes in
fiuid taken from
t he stomach of
a woman who
died in Japan
during the "Mi-
ura plague " of 1889. These parasites were identical
with Looss' species, and while they were not regarded as
the cause of the epidemic, it is clear that the presence of
so large a number of parasites creates a presumption
against their supposed harmlessness.
In view of its occurrence in such widely separated re-
Fir,. 3.5.57.— .S(7tm(7//I«s suhtilis. A. Tail of
female; o, anus ; (//j, Keuital pore ; i, intes-
tine ; rs, seminal receptacle: ». ut«rus; U,
tail of male; ^. bursa; s. spicules : rs, senii-
Dal vesicle ; C, spicules and accessory piece.
Highly magnified. (After Looss.J
219
NonialfKla.
Neniatoda.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
gions, its discovery in interinedial territory is iirobable,
aud its introduction into the United States by travellers
from tlie Orient or b_v returning American troops is an
evident possibility under present circ\imstances.
Dioctophyiiw i-rniilc (Goeze 1T8'2.) — (Syn. : Ancaris
Cfinis et murtin Sclirank 1788; ,4. rif:cii-ir'lis et renalh
Gmelin 178'J; Sli-onr/i/liis (/igns Rud. 1803; Eiist>-iJiii/i/lu.i
gi!;as Dksiug 1851; Sfronrji/lim rcihdis yhn[.-Taiu\. 1860;
F!u. vinccralh Raill. 188.5.)' '
Generally blood red, sliglitly tapering at both ends, es-
j.eciall_> the anterior; mouth triangular, bordered by six
small papilla;. Male, 13-40 cm. long. 4-G mm. broad.
Caudal extremity obtuse, encircled by mcmbranovis
pouch witliout rib lines, but
with papilla' on margin. One
slender spicule, 5-G mra. long.
Female. 20 cm. to 1 meter long;
5-12 mm. broad ; tail obtu.se and
slighth' curved ; anus terminal;
female sexual opening, .")0-70
mm. from anterior end; eggs
ovoid, thick-shelled, brown, 64-
6.Sh by 40-43//.
This is the giant of all the ne-
matoda, and is a kidney para-
site encountered in man, dog,
cattle, horse, wolf, and many
tish eating animals. It is ex-
tremely rare.
Life History. — The develop-
ment begins in the female worm,
but is completed only after the
egg has been expelled from the
host. Five or six mouths in
winter aud a shorter time in
summer are necessary for the re-
mainder of the development of
the embr_yo. It lives a long time
in water or moist earth, but can-
not endure drying. The em-
bryos will not develop if trans-
ferred directly to the dog, so that
an intermediate host seems nec-
essary. This has been conjec-
tured to be a tish.
Pathology. — Of the numerous
cases reported of the occurrence
of this parasite
in man, the ma-
jority are as-
.signable to other
liarasites. Not
more than ten
are authentic.
Trumbull's case
(N e w York
Medical Heron/,
1897) has been explained bj' Stiles as probably a Fibain.
Unciniiriu Frohlich 17s!). — Anterior end curved dor-
sad; mouth opening obliquely from chitinous buccal
capsule surrfiunded by transpareut border; dorsal por-
tion of capsule shorter than ventral, supported by coni-
cal structure sometimes projecting into cavity; at base
of capsule two ventral teetli; near inner free border ven-
tral wall bears on each side of the median line chitinous
structures or teeth, often recurved like hooks (uncinate);
inner dorsal wall also with teeth at times. Oviparous,
eggs with thin transparent shell.
(3f the species of this genus, which contains dangerous
blood sucking intestinal parasites of the higher mannnals.
two occur in man. one an (Jld-W'orld species long known
and the other recently discovered on this continent. In
medical writings the worm is more ordinarily called .1 hc/ii/-
lostoma. and the disease which it produc<'S is spoken of as
anchylostomiasis. As the recent important contribution
of Stiles, to whom I am also indebted for valualile per-
sonal communications, shows clearly, the name of one at
least of the species in question here is that given above.
Fig.
]ly > 'srr
355S.-Male of Vyicinarin ihwdftlalis.
MagnillHd. (.After Seliulthes,s.,l
and the term uncinariasis or uncinariosis should be
adopted as the correct designation of the disease which
is known also as brickmakers' and miners' ana;mia,
Fig. .'i.i.59.— Oral Capsule of I'nciiiaria durtOenaJis in (.-1) Dorsal
and (B) Lateral Aspect, a, Inner ; h, outer ventral tooth ; c. dorsal
tuoih; r/, stylet: c, dorsal rib; ;/i, buccal cavity; oc, cesophagus.
(After Hertwig.)
Egyptian chlorosis, tunnel disease, etc. Its chief symp-
toms are aua?mia with the circulatory disturbances ac-
companying the pernicious type, colickj- pains in the
abdomen, great weakness, alternating constipation and
diarrho'a with brownish or bloody stools, nausea, and
o'dema. Positive diagnosis is made by the discovery of
the jiarasites and eggs in the fa'Ces. In such cases care
should be exercised not to confuse this with other species.
As the effects due to the two species are not distin-
guisliable, a general discussion may be given for both
together. By means of the powerful armature of the
buccal capsule they pierce the intestinal mucosa and
with the musctdar a>sophagus pump out blood. The in-
testinal ejiithelituu is lost from the area taken into the
capsule, and in aildition to this tlie parasites move from
spot to spot so that the host loses not only the blood
tidien by the parasite directly, but that lost through
many minute hemorrhages at previous points of attack.
The functional vitality of the intestinal wall is evidently
reduced, and some are inclined to believe that the para-
site also produces a poison which acts upon the host un-
favorably.
Thymol and male fern are most frequently used for
driving out these parasites, and Stiles quotes the follow-
ing directions for thymol treatment;
Two grams of thymol at 8 a.m., repeated at 10 .a.m.,
and ca.stor oil or niiignesia at noon. Diet of milk and
soup. As some cases are obstinate, a re-examination of
the fa'ces in a week is necessary, and the repetition of the
treatment if eggs are still to be found. It should be
noted that on the whole experiments are very unfavor-
able to the use of alcohol during the thymol treatment.
Rational prophylaxis must be base<l on better knowl-
edge of the extent of the disease. "When it is suspected
microscopical examination of the fieces and treatment of
all infected individuals are necessary preliminaries to its
eradication. The construction of water-tight latrines in
tunnels. brickyards,
and other corpora-
tion p r o p e r t i e s
where the disease
is prevalent, to-
gether with the
periodic di.sinfec-
tion of their con-
tents by (luicklime
or by cremation,
will largely prevent
the spread of the
disease. If, in ad-
dition, defecation in
other places is forbidden and the regulation enforced,
while on the other hand fresh ]3ure drinking water is
sup]ilied and workmen are impressed with the necessity
of jjcrsonal cleanliness as a preventive for the disease,
Fig. S-Kd. — Bursa of Male Uncinaria
dwicknalis. Magnified, (After Ilailliet.)
220
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Nematoda.
Nematoda.
NDr
the difficulty will be reduced to a minimum. It must
be kept iu mind that Louss has demonstrated tlie proli-
ability of infection from water with larvae coming on
to the skin, so tliat the presence of such larvae in stand-
ing water is a real menace, even it none of it ever reaches
tlie mouth.
Tlie Old-World species has been known for .some time,
and its eiTeets are clearly tracealjle back of the historic
study of Perroncito, which showed it to be the cause of
the severe miners' ana-raia, which was associated with
the construction of
the Saint Gothard
tunnel. It is onlyy^_
wilhiutheyearl9(i2'
that Stiles has
called attention to
the tremendous economic and hy-
gienic importance of the New-
World species iu our Southern
States, although the records of
the presence of some species,
probably this one, extend back
for many years. In Central
America uncinariasis has been
for centuries the most important
and dangerous general disease,
involving twenty-three percent.
of the population; it appears in
the old Indian traditions, and
with the disease is associated
"dirt-eating." The species has
not been precisely determined.
In Africa tlie infected negro does
not seem to be subject to any
resulting ana-mia.
Unciiiariii duodenalis (Dub.
1843) Railliet 1885. — (Syn. :
Ayehyhmliimd dnndfiia/fi Dub.
1843; iStrongylus qiiadridentatus
V. Sieb. 1851; Anrhylostoma
driod. Dub. 1850; Dochiniiis un-
cliyliMoiiiiiia Molin 1860; t<di'ro-
stoina diiiidenale L'obbold 1864;
Str. duodeixdis Schn. 1866;
Dock m ins duodenalis L e u c k.
18T6; Ankylostij/uii eMd Ankyhis-
ttiiinnn diiod. auct.)
Body cylindrical; buccal cav-
ity with two pairs of uncinate
ventral teeth, and one pair of
■dorsal teeth, directed forward; dorsal rib not projecting
into capsule. Female, 10-18 mm. long by 0.5-0.6 mm.
wide; vulva at or near posterior third of body; eggs 53
by 32 fi, segmenting when deposited with direct develop-
ment. Male (Fig. 3558), 8-11 mm. long by 0.4-0.5 mm.
wide; caudal bursa (Fig. 3560) with dorso-medial lobe,
•dividing at two-thirds the distance from base, each
branch being tridigitate, and with prominent lateral
lobes united by a ventral lobe; spicules long, slender.
This species occurs iu theupper region of the small in-
testine of man, and has been reported from Europe, Afri
ca, Asia, the Philippines, and recently also from North
America and the West Indies, where some regard it as of
very recent introduction. A number of cases, including
one fatal one, are on record in the United States within
two years.
Structure. — One point in the structure deserves special
attention — the so-called pharyu.x or buccal capsule (Fig.
355fl). This is very nearly spherical, and is armed with
four strong curved chitinous teeth. At the bottom of
the capsule are two triangular lance-like organs, the
function of which is the penetration of the tissue of the
host. The body is curved dorsad at the anterior end on
accoimt of the shortness of the dorsal wall of the buccal
capsule, so that the orifice actually points dorsad.
Life History. — The eggsaredejiosited in thealinientary
canal of the host and must pass out of the licidy in order
to undergo development, which will not take place in
Fig. SaBl.— Young UnHyi-
nrifi ilnDilcrutUs Four
Day.s .^ftcr Infpc-tidn. .1.
villus ; (Jn, ^eliit:il cell .
i\T'r, aisupliaireal glands ;
MH. oral cavity. ,■ I'JO
(After Looss.)
water, but proceeds rapidly in foeces or in slime, so that
the rhabditiform embryo is hatched in twenty-four hours
at 27" C. As 1" C. kills the eggs in from twenty-four to
forty-eight hours, the climate of a large part of this coun-
try is an evident barrier to the spread of the parasite.
At hatching the embryo measures 0.3 mm. in length, but
grows rapidly, and after moulting once it enters upon a
resting stage within the cast-olf skin of the second moult.
In this, the infecting stage of the parasite, the worms
may live for a month or more in water without fond, but
if subjected to desiccation they perish. This naturally
points to water as the probable means of infection, al-
though the presence of such larvte on moist salads and
other vegetables, eaten uncooked, may w-ell be a sub-
sidiary means.
Recently Looss has brought forward the idea that these
larvae may enter the human bodj- by way of the skin,
which stands in perfect agreement with his earlier obser-
vations, that the larva; which were fed to various animals
in water did not settle down but were discharged per
anum unchanged; yet part of them bored into the mu-
cosa of the larynx and wsophagus and were active and.
growing two weeks later. When taken into the human
body the worms undergo radical changes in structure.
(Jne may distinguish with Looss a third stage without buc-
cal capsule (Fig. 3.561), a fourth with provisional buccal
capsule (Fig. 3562), and a fifth in which this organ corre-
ponds to the adult form. From four t<j six weeks from the
time of infection are required for the para.sitesto mature.
The view of Looss. that infection may take place
through the skin, has been contirmed bj^ a number of ob-
servations and experiments. Most striking was the in-
fection of a limb about to be amputated and the subse-
([uent discovery of many larva', which had forced a way
in between hair and follicle and ajijieared in sections to
have penetrated as far as tlie subdermal tissue. This
method of infection, which Looss
believes to be the most exten.sive,
explains the su.sceptibility of
Egyptian field laborers, and" also
epidemics among brickmakers as
well as all cases in which the
workmen arc wont to work iu
moist earth with bare feet and
hands. It explains the infection
of children walking ou damp
ground, and gives, according to
Bentley, the key to the "ground
itch," or Pani-ghao, an affection
of the skin of the lower extremi-
ties, endemic in Assam and in the
West Indies. Its appearance is
coincident with the advent of the
rainy season, and is associated by
this author witli the presence of
the larva- of Uitcinnria duodenalis
in the soil of the infected areas.
The typical lesion consists in a
]irimary erythema followed by a
vesicular eruption, which fic-
(luentl}' becomes pustular, and
in .severe cases may result in ob-
stinate ulceration or even iu gan-
grene.
Uncinaria americema Stiles
1902. — Ventral recurved uncinate
teeth absent from mouth, one
pair prominent dorsal semihmar
plates, and an inconspicuous ven-
tral pair being present ; dorsal
median conical tooth projecting
prominently into buccal capstde
(Fig. 3565). Female, 9-11 mm.
long by 0.31-0.35 mm. wide; vulva near middle of body
but'' in front of it; eggs (Fig. 3564)64-72/; by 36-40/;,
s(';;menting or with well-developed embryos when de-
posited. Male, 7-9 mm. long by 0.29-0,31 mm. wide;
(lor.sal rav of caudal bursa "divided to the base, each
Fig. 3562.— Clio i ii <i r la
duoilendlis in Slairell.
of Develoiunt'iit. \ 105
(After Looss.)
221
Noiiialoda.
Kfiiiuitxia.
REFERENCE HANDBOOK OF THE jVLEDICAL SCIENCES.
Fh;. IJ.Vi:*.— Bursa of t'lirinm-i'' amn
ing Ribs (f/r. /r, etc.). (f, Aims;
MagniDod. (After Stik-s.)
'rnna, Show-
."^j', spicules.
branch bipartite to tip (Fig. 3563). Species otherwise
similar t(i f. ihiotlrnnlis.
Tliis form lias imly just been differcnliated b^- Stiles
from the long known European {.''. dtntrkiiuHs, from
which in fact it liilfers radically.
It has been obtaincil from cases
of vincinariosis in man in Te.xas,
Virginia, Florida. Porto Rico,
and Cuba, and its wide occurrence
goes to show that the para-
not recognized
hitherto, is
endemic in
the Southern
States, where
it causes the
niostcommon
disease on
the farms and
a m o II g t li e
poor whites.
The life
history of the
parasite is
u n k n o w n,
though the early stages correspond to those of U. diiode-
iinli.s. The cases of the disease have been collected and
abstracted by Stiles, who holds with evident right that it
is not a recently imiiorted disease, but has existed un-
recognized for years. It has been traced from Virginia
to Florida, and is most abundant in sandy areas. Guite-
ras lias ;ilso an unpubli.shed cti.se from Brazil.
I'/ii/mi/opfiTd cmiri/xini von Linstow 1902. — Cuticula
hriivy, non striated, fonning a ])rojertiiig ring about the
head, within which a ]>air of eijuilateral lips bear four
papilla' in the suhmediiui line and two conical teeth near
the mouth opening. (Esopliagus one-fifth the entire
length; lateral lines strongly developed. Male. 14.23
mm. long by 0.71 mm. broad; bursa broad, rounded,
tapering posteriad, with central longitudinal rows of
small conical jiapilla'; siiicules two
unlike; lateral to the rio.ical orilice
two pairs of long stiillied papilhe,
ill front one pair, behind two pairs,
on the tail three pairs more. Fe-
male, 27 mm. long, 1.14 mm. broad,
vulva at one-si.\tli the length from
the anterior end ; eggs heavy shelled,
.'17 by -S!> //.
The single account of this species
by O. von Linstow is based cm speci-
mens, two males and nine females,
in the collection of the museum at
St. Petersburg, Russia. They are
said to have been taken from the
alimentary canal of man in the
C:uicasiis. Further details are not
given.
Family of the Ascarida'. — Body
relatively thick; mouth surrounded
by three lips, one of which is dorsal, the others ventro-
lateral; tt'sophagus long, muscular, intlated at the end
and often accompanied by an a\sopliageal bulb; male
with one or two spicules ; female with doulile ovary, ovip-
arous; development direct. All are intestinal parasites.
Afieiiris L. 17.")8. — Polymyaria, with very prominent
lips; males with two equal spicules .and many jueaiial
and postanal iiapii'a;; vulva in iulvance of centre of
body. More than two hundred species are reeoi-ded ;
three have been reported from man.
Ascnris luiiibricoidcs L. 1758. — Body reddish or gray-
ish-yellow when living; spindle-shaped; lijis (Fig. 3.560)
almost similar, appro.ximately semicircular, with tine
teeth on the edges, the dorsal po.ssesses two pa]iiU:e, and
each of the ventral ones only a single papilla. .Male, 15-
17 or even 25 cm. long and 3 mm. thick, with the |ioste-
rior end curved toward the ventral face'; spicules two.
short, 2 mm. long; papilhe lifty-tivc to si.\ty pnanal tiiid
Fig. ai64.— Eggs of Un-
ci7iaria americana
from Faeces. X 235.
(After Stiles.)
seven pairs postanal. The female, 20-25 or even 40 cm.
lon.g and 5-.5.5 mm. thick, with straight conical posterior
end. The female se.xual opening at the limit of the anterior
third of the body, and situated in a ring-shaped depres-
sion. Fertilized eggs (Fig. 3567) elliptical, shell with
transparent mammillated covering, 50-75 /i long by 40-
58 /i wide, laid before cleava.ge begins. Unfertilized
eggs, irregular, with scanty albumin covering, coarser
granules, and thinner shell, mciisuring 81 by 45//.
This, the common round fliirm of children, is one of
the most abundant and widely distributed of human
parasites. It is distributed over the entire world, and
though more abundant in the warmer regions, is recorded
from Finland and Greenland. It is also more common
in the country than in cities, which may be due to the
presence of the same species in the pig and sheep. This
parasite was well known to the ancients, both the Greeks
and the Romans, altliough the acKapic of Greek authors
is the form now known as Oxyuris.
Life History. — The development of the eggs does not
begin until long after they have been expelled from the
human intestine, and is dependent upon both moisture
and warmth. Under mean
temperature the embryo is
completed in from thirty to
forty days, and then lies in
a spiral wilhin a thin shell,
which it does not seem to
leave so long as the egg re-
mains free, though it under-
goes a moult here. The em-
bryo may live long within
the shell, even up to five
years. The further develop-
ment was believed by Leuck-
ait to rec|uire the interven-
tion of another host in which
a larval stage is passed, but
Davaine was successful in
hatching the embiyos in the
intestine of the rat, and be-
lieves that the intervention of a second host is unneces-
sary. Subse(|iient experiments by various authors have
strongly confirmed this view by raising experimentally
adults in the human alimentary canal two months after
the ingestion of eggs containing embryos. Accordingly
the eggs are probably introduced into the human system
with the embryo within by accident or by means of the
drinking-water. The embryo is then set at liberty in
the alimentary canal, and further development is merely
growth. Of course the infection may be brought about
by the means of contaminated vegetables, especially
salads, which have been imperfectly cleaned.
Pathology. — It has already been mentioned that the
worms are most frequently found in children of medium
growth, but this is due to the ease of infection rather
than to conditions for development, since the worm has
been obtained from persons of all ages. Onlinarily one
Fig. XiSt. — Lateral View of
Head of Uiicinarin amrri-
caiia. c. Oral capsule ; c
oesophagus, i, stylet; /'.pa-
pilla; t, doi-sal median tootti.
(After Stiles.)
Fig. 3.V>ti.— Anterior End of A-^ray^is himhricoidfs. -4. Apical and
Ji, Iiorsal Aspect.
finds only a few specimens at once, hut in some cases
from five hundred to one thousand havi' been obtained
from a single individual. It is noteworthy that ha-mo-
globin has been deteeti'cl in the alimenttUT canal of the
90->
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Neiiiatoda,
Ncmatoda,
parasite, showing tliat its food consists in part of human
blood Their normal location is the small intestine, but
specimens not infrequently wander into the stomach and
are vomited. Rarely they have been known to make
A. B.
Fig. 3567. — Ejrff of Ai^caris himhrwoides from Fjpces. A^ In sur-
face view and Bin optical section. (After Stiles.)
their way into the pharyn.x and choante, with the result
of causing fatal suffocation both in children and in adults :
also into the Eustachian tube or ductus choledochus. and
they have even been found in abscesses of the liver.
Recently a number of unimpeachable cases have been
brought forward in which the worm has bored its waj'
through the uninjured wall of the intestine and has been
found in the peritoneal cavit}-. Their presence here after
having pierced abscesses of the wall is also known, and
in some cases even, in which adhesion of the intestinal to
the abdominal wall was present, the worm emerged from
the body through an abscess at tliis point. In fevers the
Asearida; will spontaneously desert the intestine.
It is evident that these wanderings are associated with
great danger to the host. The presence also even of a
few individuals in the intestine gives rise at times to
marked nervous distui'bances, hysteria, epileptic attacks,
congestion of the brain, aphonia, etc., which are most
easily exjilained on the basis of a poison exci-eted by the
worms. In fact, recent investigators have been able to
obtain such a toxic substance from the body of this spe-
cies, and students in the laboratory
handling specimens of A. megalorc-
phaht from the horse have been dis-
tinctly affected by poisonous emana-
tions. The symptoms disappear with
the removal of the worms. Moniez.
however, is inclined to attribute the
troubles in large part to the use of
santonin for the expulsion of the
woims, as this substance has an un-
favorable effect upon the human or-
ganism. Guiart has called attention
to the important fact that the para-
sites b}' their movements produce le-
sions of the wall so as to afford a
point of attack for intestinal fevers,
and thus become a source of great
danger for the host. Knotted masses
of this parasite have also been the
cause of fatal intestinal obstruction.
Treatment.— In general opinion santonin is the specitic
against A^caris, and no one of the many other substances
tried has achieved the same results. Mouiez advises tiie
use of centigrams equal to the number of years in a
child's age, and for an adult 20-25 cgm. The"drug kills
the parasites, and the admiuisti-ation at the same time of
a purgative is advantageous in bringing about their ini-
rnediaie expulsion. Careful watch should be kept for I hi'
violent symptoms which sometimes accompany the use of
santonin and means taken at once to counteract them.
Asairix o:/.is Blanchard. — (Syn. ; Lumbricus cam's
Werner 1782; A. teres Goeze 17S2, .4. cali and caniculcE
Schrank 1788; A. emu's and fills Gmelin 1789; A. tri-
cmjiidata axuX felis Bruguidre 1791: A. Werneri Rud.
1793; Fxisaria iiiystnx Zeder 1800; ,1. mnrfri'iidta and A.
mystax'Rnd. 1802; ,1. a/atti Bellingham 1839.)
Fifi. aTfiS. — Ascaris
ca n is. A. Male.
(Natural size.) B,
Head showing pa-
pillte and win^s.
Magnified. (Origi-
nal.)
Anterior end oi-dinarily curved and provided with
two wing-like membranes which extend one alons each
side (Fig. 3568). lipsalmost cimal. three to six cornered.
Male, 40-90 mm. long, 1 mm. broad, with twenty-one
preanal and five postanal papilla'. Female, 120-200' mm,
long, vulva in theanterior fourth of the body . eggs almost
spherical with thin shell, 0.008-0.072 miu. "in diameter.
An abundant parasite in the sn)all intestine of cats and
dogs and also reported fi'om various allied wild species,
it has been found several times in man in England. Ger-
many, Denmark, and the United States. Grassi doubts
the accuracy of these determinations since experimental
infection was not successful.
The development is dii-ect and in general like that of
the preceding species The thin shell is highly imper-
vious so that development continues in alcohol." turpen-
tine, etc. It is probable that the embryo does not desert
the shell until taken into the stomach of the host.
Ascaris maritima Leuckart 1876. — Known only from
a single immature female, which was vomited by "a child
in North Greenland in 1805, The specimen was 43 mm
long and 1 mm. broad, and is regar(Ied by some authors
not as a nonnal parasite, but as one accidentally ingested
with the viscera of some food animal. Accordmg to
Leuckart it is very near .1. trinisfiiyn of the bears.
Oiyuris Rudolphi 1803. — Three lips poorly developed
or wanting; oesophagus long and provided with a dis-
tinct bulb. Male with only
one spicule and with two „ q
pairs of preanal papilhe. Fe-
male with greatly elongated,
pointed posterior end, two
ovaries and vulva in anterior
part of the body.
O.ryiiris termie.u laris
Bremser 1819. — (Syn. : As-
caris verniicnlaris L. 1767;
Fusaria termicvlaris Zeder
1803. (Esophagus long and
followed by a distinct liulb
with teeth ; body white, cuti-
cula striated, foi-ming wing
like projections from the
dorsal and ventral surfaces
near the head and also a low
crest along the lateral lines
of the body; three sntall re-
tractile labial papilla'. Male.
3-5 miu. long, with spii'ally
rolled tail ; a single spicule
and six pairs of papilUe.
Female. 9-12 mm. long, 1
mm. broad, tail awl-shaped;
vulva a little in fiont of the
limit of the anterior foui-th
of the body, eggs elliptical,
thin-shelled, 50-54// hmg by
20-27 .« wide, containing an
embrj'o when deposited (Fig.
3569)
This species, known from
remote antiquity, is a cos-
mopolitan parasite of the
human intestine It has not
been definitely recognized as
a parasite of other animals,
but Leidey's 0. c/mipar from
the cat is very likely the
.siuue form. It is more abun
dant in cities than in the
country, and occurs equally
in cold and warm regions.
These parasites are most
.-ihundant in infants, a fact which accords with the ease
(•f auto-infection as shown by the devclopiueut.
Life History. — The embryo develops within the egg
shell while still contained in the \iterus, and it was long
thought that the further development could take place
Fig. S.56S.—( ).!■)/» j'i.s vcrmicu-
laris. «. Female; ^. niale; r.
posterior end of latfcr ; d,
egg with embryo: i. vulva;
.*;.», spicule. Magnified ( Af-
ter Leucliart.)
Nematoda.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
in the canal. In fact, however, the female at the time of
oviposititiu lives in the lower part of the rectum and even
attains the vieinily of the anus, althoufih the earlier por-
tion of the adult life history is passed in the small intes-
tine, where the worms acquire sexual maturity and copu-
late. Evacuated from tile body, the en)bryo undergoes
transformation to the second embryonic stage while still
within the egg shell, and now awaits ingestion by a new
host. The primary infection is by drinking-water or con-
taminated fruit or vegetables, which are eaten uncooked ;
but self-infection and transference to other individuals
are broiiglu about by scratching and rubbing with the
lingers [o allay the intense itcliing caused by the daily
migration of the females out from the anus on to the peri-
neum and the surrounding iiarts. Perhaps in the distri-
bution of Ori/inis eggsthe flies jilay a part such as Grassi
has demonstrated for Tnc/n/i-ejihiiluK and eggs of Tirniii.
The direct develo]imenl is very rapi<l, as Leuckart ob-
tained <'Xiierinientally O.ri/iin'dts (i-T mm. long within
fourteen days aflei' ingestion of the eggs: Grassi and
others have confirmed this by further experiments.
Pathology. — The females are far more numerous than
the males.iind by their migrations determine unbearable
pruritus, which recurs periodically on retiring. In a
number of cases among young girls the worms have mi-
grated into the vagina and have produced onanism, and
even thi' inception of nymphomania. In many cases
large numbers in the rectum have excited no untoward
sj-mptoms, but in others they have jiroduccd reflex ner-
vous activities of all grades up to epileptic attacks, such
as have been noted under Ancan'x. Recent investigations
in Egyjit have demonstrated the respousiliility of this
parasite for nodules on the rectal wall, previously attrib-
uted to f<c/ri.itosomii. which contain eggs of O-ri/nrix ixr-
miciiliiris in a calculus. O.ri/iiris has alsi been recorded
in tuberculous nodules in the cavum Douglasiiof afemah',
and Vuillemin has recently discovered them in a tumor
near the anus of a boy. The latter case shows definitely
the wandering of the worms through 3 cm. or more of
solid tissue. This habit exhibits a new and evidently dan-
genius featvire in the parasitism of this species through
the disturliance of the tissues and the introduction into
them of bacteria from the rectum.
Treatment. — It is dillicult to remove these worms en-
tirely. Vermifuges and purgatives with encmata, etc.,
are successful to a degree; but the ease of auto-infection
is an obstacle to a coni]ilelc cure. Local application of
mercurial ointment will alleviate tlie pruritus, and man-
ual extraction, if prolonged, will reduce their numbers
rajjidly. But in any event treatment is jirolonged.
The .sub-class of the Gordiacea includes forms familiarly
known as "hair snakes" or "hair worms." They are
greatly elongated, slender worms, somewhat lilaria-like
in external appearance, but of radically different internal
structure. Lateral lielils are wanting, and the body mus-
culation isof adilTerent histological type from that of the
Eunematoda. The
nioulh is occluded
and the alimentary
canal ]iersists in the
.adult only as a tunc-
tionless vest i gi al
strand. I n bo t h
si'Ncs the reju'cduc-
live oigans ojien to
I lie exterior with the
alimentary canal at a
terminal nr subternii-
nal cloaca. The re-
pniduclive system is
ciiiisl ruel'd un a dif-
rerenl pliui. and the
lateral canal .system
is wanting." The
male has no spicules, but the posterior end of the bmly
is forked and functiims as grasping organ.
The adult lives free in ponds, swamjis, and other bodies
of water, and the eggs are de|iosited on the stems of
Fig, 3.570. — Giga n toi'h an rli u.< ii i na ^
Male at riglit. female at left. Half
natural size. (Original.)
water plants. The larvK possess a jiroboscis armed with
hooks and boi-e into the body cavity of aquicolous insect
larv.e, or rarely niollusks, where they encyst. Accord-
ing to Villot the second stage is passed in the intestine
and body cavity of tishes. More commonly apparently
the worms develop to maturity in the
body cavity of insects, from which
they emerge into the water for tlie
adult free existence.
Several species have been rejiorted
from the human alimentary canal.
They are jjseudoparasites, having
been swallowed, according to one
view, in the adult condition with
drinking-water; but their occurrence
in fruit, especially apples, makes this
even a more likely source of int'ec-
tion. Lockwood noted in 1876 the
frequent presence, in fruit, of Mi rmis,
another genus of Eunematoda, and
suggested the probable occuri-euce of
this form as a psetidoparasite of man
under conditions; this has not been
actually recorded so far as I find.
But of Gordius as a p.s<'nili 'parasite
Parona has recently listed eleven
cases, the first as early as 1 Gll.s ; of
these Kirtland's(01iio)is the only one
from the United States. Two other
unp\iblislied ca.ses have recently been
communicated to me from i\Iichigan
and Marylaml. It will be of no par-
ticular value to enter here upon a
detailed ilcscripiion of the species
found.
The (iordiaeea are. however, em-
phasized by t'obbold ;is important
for the medical practitioner, .since
they have been passed olf as the
guinea-worm and as ha\iiiu been
evacuated with fecal maltei- by neiii-
asthenic ])ersons under tri'atment.
The Acanthocephala may best be
discussed as an ajqiendix to the class
Nematoda, although they are regar<l-
ed by many as a cognate class and b.y
others are separated even more wide-
ly. The forms included liere, though pjara.sites of the
most complete tyjie, are not common in man. The group
may be characterized as follows: Elongated, cylindrical
bod_y, often deeply corrugated, bearing at ant<'rior end
a retractile proboscis provided with many minute hooks
in rows. No trace of alimeiitaiy canal. Ueproductive
organs open at posterior end: .sexes .separate. Male
with canqiannlate bursa about the oririce. Mostly small
forms, parasitic as adults in vertebrates only. The
structure is uniform, ami can be learned from the brief
account which follows of the largest and commonest
species.
(lifiiiiitorhjjncluis f/innn Ham.ann 1802. — (Syn. : Tmiia
liiniiUiKircn Pallas ITNl ; Kfhhuivlnjiteliva ifUias Goeze
1782.)
Body milk white, sometimes slightly tinte<l. with
transverse iiTcgnlar ridges. Posterior end somewhat
smaller; proboscis spherical, armed with five or six rows
of hooks. The proboscis can be retracted into a neck-like
I'egion. which is much slimmer than the following portion
of the body. ^lale, (i()-!)0 mm. long by H-.'J mm. bi-oad,
with bell-sliaped caudal pouch. Female. 2:!0-:l.')0 mm.
long by 4-0 nun. broad: tail lilunt; eggs almost cylin-
driciil. (1.087-0,1 mm. loiigwilh tliiee embryonic envel-
opes.
The adult worm is found in the small intestine of tlie
pig, ordinarily fixed to the wall by the proboscis, and is
widely distiiliiited.
Structure. — Till' elongated body (Fig. :i17(b is largest
near the heail and tapers gmdually towai'd the posterior
end. Al I lie :interi<ir eiiil a shar|i constriction separates
Fii;. -ViTl.— Giflanfo-
rltiim-liHS tjigas
Opened to Show In-
ternal Anatomy,
?, Lemniscus : si',
seminal vesicle; (,
testis; vO, vas de-
ferens. Modified.
(Original.)
224
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Biematodaa
Neri-es.
tlie body from tlie short neck portion, which is not more
than one fourtli or one-tifth the diameter of tlie body
close to it. F'rom the a]3e.\ of this region may be pro-
jected the proboscis which is contained within it, like
tlie reversed tiuger of a iilove. As tlie jiroboscis rolls
out the hooks also turn outward, and when the probos-
cis is completely extruded the shape of the organ is
nearly that of a sphere on which are from five to si.x ir-
regular rows of hooks. Behind these the proboscis is
slightly smaller.
If tlie internal structure be examined, it will be seen
that the proboscis is provided with retractor muscles, by
means of which it ma\- be withdrawn into the body. At
the base of the proboscis is the small mass of nervous
matter which represents the brain.
There is no trace of an alimentary canal, hence these
forms, like the tapeworm, take nourishment by absorp-
tion. Two elongated sac-like organs haugdown into the
body cavity along the sides of the proboscis. These are
the lemnisci (I, Fig. 3.571); their function is uncertain.
The mass of the body is made up of the organs of the
reproductive system. All these worms are dioecious.
The male organs (Fig. 35T1) consist of two large testes,
together with the ducts and accessory glands connected
with them. The tail of the male has a hemispherical ex-
pansion, something like the caudal bursa of other Nema-
toda; the male sexual opening in the centre of this sac
at the tip of the body is provided witli a small copula-
tory orgau. The internal sexual organs of the female
are much similar in general appearance; the ovaries lie
toward the front of the body cavity, which is largely-
tilled with eggs in various stages of development. These
are discharged by the oviduct, which opens at the poste-
rior end of the body.
Life History. — The eggs of Gignntorijnchus are dis-
charged from the alimentary canal of the host and dis-
tributed with fa'ccs. When eaten by some insect they
are hatched in its intestine. The cnibrvo, which has a
conical form armed at one end with four hooks like tape-
worm hooks, and a number of smaller ones, penetrates
into the abdominal cavity of the insect and encysts there.
In this condition the embryos may even live through the
metamorphoses of the insect until the host is eaten by
some pig. In the alimentary canal of the pig the embryo
is set free, attaches itself and acquires maturity. There
is some dispute as to what insect is the intermediate host ;
the white worm-like larva of the May bug and the larva
of the common rose chafer have been found to contain
these worms in Europe, and Stiles has experimentally in-
fected the larva; pf the June bug in this country. It is
also maintained that various species of snail may func-
tion as the larval host. In all probabilitj- the larva is
not conlined to a single host, but ma}' develop in many.
Leuckart accejits some reports of the occurrence of this
species in man as trustworthy, and Lindeinann says that
it is not rare as a human parasite in Southern Russia.
Schneider notes the consumption, as food, of the larviE
and adults of MekdoiMa, the May beetle, which acts as
the intermediate host, so that infection is evidently pos-
sible.
Gigantorhynclms moniliformis (Bremser 1819). — Bod.y
attenuated anteriorly. Proboscis, 0.425-0.450 mm. long,
0.175-0. liJ mm. broad, with hooks in fifteen transverse
and twelve longitudinal rows. Male, 4-4.5 cm. long.
Female, 7-8 cm. long, or even up to 27 cm., according to
We.strumb. Eggs ellipsoidal, 85 /i long, 45 /i broad.
The normal hosts of this species are field mice, rats,
etc., and the intermediate host in Ital}' has been deter-
mined as BhipK mncronaUi. Calandruccioin experiment-
ing on the life history succeeded in infecting himself with
the adult. The severe symptoms which manifested them-
selves were dispelled by the evacuation of the worms.
In other cases of the occurrence of this species as a hu-
man parasite its identity was less definitely established.
Ecfiinorhynclots ftominis Lambl 1859. — Length, 5.6
mm. ; width, 0.6 mm. ; proboscis almost spherical with
twelve transverse rows of eight hooks each. Large
hooks, 103 /i long, small hooks, 77 u.
Vol. VI.— 15
An uncertain species of which Lanibl found a single
specimen at Prague in the small intestine of a boy who
had died of leukamia.
Eehinorhynchiis sp. Welch 1872.— In 1872 Welch de-
scribed as ErhinorhijnchiiH a body which he found en-
cysted in the mucosa of the jejunum of a soldier. Ac-
cording to Railliet it was evidently a Linguatulid (see
Araclinida).
EchitJorhyncliKS ^t. Moniez 1896. — ^Kunstler and Pitres
found certain peculiar bodies in the pleural cavity of a
patient who had sulTered two years from pleuris}', but
without fever. They interpreted these structures as
coccidia, but Moniez holds with greater probability to
their likeness to eggs of Echiiwr/iyiifhus. The case is
entirely isolated under either explanation.
Henri/ B. Ward.
Principal articles Consulted.
Bancroft, T. L. : Metamorphosis of Filaria Bancroft!. Proc. R. Soc.
N. S. Wales, x.xxiii.. 4S.
Blanobard, R. : Nouveau cas de Filaria Ina. Arch. Parasitol., ii., .tM.
Braun, M. : Die thierlsohen Parasiten des Menschen. Wiirzburff, 1902.
Graham. J. Y. : Naturgesehichte der Tricliitia .spiralis. Arch. mikr.
Anat., 1.. 219.
Huher, J. C. : Bibliographie der klin. Helminthologle, Jena, 1893-98.
Leuckart, R. : Die Parasiten de.< Menschen, vol. ii., Leipzig. 1876.
Linsl^^w, O. von : Arten der Blutfllarien des Menschen. Zool. Anz.,
xxiii., 76.
Looss, A. : Stroti(7.i/'"s 'tubtili.% n. sp., Centralb. f. Bakt. und Par.,
xvlii., 161; Lebensgeschichtedes^4iifc.i;/os(oma dumlenaU, ibid., xxl.
Lothrop and Pratt, J. H. : Two Cases of Filariasis, Am, Jour. Med.
8ci.. cxx., 525.
Manson, P. ; Tropical Diseases, London, 1898.
Moniez. R. : Traite de Parasitolope, Paris, 1896.
.Nuitall. G. H. F. : (In the Kole of Insects, Aracbnids and M.vriapodsa3
Carriers in the Spread of Bacterial and Parasitic Diseases of Man
and Animals. Johns Hopkins Hospital Reports, viii., L
Parona, C. : Pseudo-parassitismo di Gordio nell'uomo. Clinica Med.,
1901, No. 10.
Railliet, A. : Traits de Zoologie m^dlcale et agrieole, second edition.
Pails, 189:^-95.
Thayer, W. S. : Occurrence of StrnnmiMdes intcstinalis in the
United States. Jour. Exp. Med., vi., 75.
Stiles. C. W. : Trichinosis in fiermany. Bull. 30, Bureau Animal In-
dustry, 1901 ; SigniBcance of Recent American Cases of Lincinaria-
sis in Man. Eighteenth Annual Report, Bureau Animal Industry,
United States Dept. Agr., 19(>2.
Ward, H. B.: Parasitic Worms of Man and the Domestic Animals.
Xebr. Agl. Rept., 1895.
Williams, H. F. : Frequency of Trichinosis in the United States. Jour.
Med. Research, vi. 61, liKil.
Also nLimenms slit.rter papers by the same authors, Askanazy. Col>-
bold, Grassi. Hassall. Kiiclienmeister, Lcichtenstern, Leidy, Ludwig,
Magulhae^, Mark. st«issich. Strong, and others.
NEOPLASMS. See T<n,mrs.
NEPHRECTOMY; NEPHROTOMY. Sec Kidneys, etc.
NERVES. GENERAL PHYSIOLOGY OF.— Histologi-
cal AND Gexekal. — Nerves cmisist essentially of the
long, slender processes of nerve cells. The\' are hence
composed of protoplasm, and they possess the general
chemical and physical properties of this substance; but
they diflfer physiologically from other forms of proto-
plasm, in that they possess to a high degree the proper-
ties of conductivity and excitability, while the proper-
ties of growth, metabolism, respiration, and contractility
are feebly developed or altogether absent. There is in
these respects a marked jihysiological difference even be-
tween the nerve and the cell body from which it arises.
Many of the reactions of the cells to external conditions
are the opposite to the reactions of the nerve. The cell
generates nerve impulses; it possesses sjiontaueity or
automatism, absent in the fibre; it is closely dependent
on a supply of oxygen, while the nerve is almost inde-
pendent ; it has an active metabolism, which the nerve
lacks almost entirely; it respires, while the nerve re-
spires little or not at all; it or some of its dendritic proc-
esses may be contractile, the nerve has lost this property
altogether. The physiology of the nervous tissue, which
includes nerve cells, differs therefore in many respects
from that of the nerves proper, which we shall ctuisider
here. In short, the nerve cells possess pre-eminently
the property of automatism or spontaneity; the nerve
libre, the property of conduction.
225
Nerves.
Neires.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
This physiological differentiation of the conducting
protoplasm of the nerve is arconiimuied, as might be ex-
pected, by an histological (lillcrentiatiou. The proto-
plasm of the nerve fibre, eallcil the axis cylinder, or
axon, dillVrs in iihysieal appearance from that of the rest
of tliccell body from which it is derived, in that the; fibre
is striated longitudinally as if composed of distinct
fibrils, and is "surrounded by a fatty sheath. These
librils can be more easily seen in invertebrate than in
vertebrate nerves, and particularly in the leeches, where
they have been traced by Apathy' from one nerve cell
into and even through other nerve cells. Some obser-
vers even go so far as to maintain t hat these fibrils are the
true conducting portions of the fibre, but of this there is
no physiological evidence. Besides this peculiar iibrillar
structure of the axis cylinder, nerves are as <a rule easily
differentiated from other tissues even by the naked eye
by their white, glistening, fatty sheatlis. Nearly all
nerve fibres which take their origin in the brain and
spinal cord, and many having origin elsewhere, are sur-
rounded bj' such a sheath, which is called the medulla,
and such nerves are called medullated nerves. The
nerves of invertebrates and those of the sympathetic sys-
tem of vertebrates, on the other hand, often lack these
sheaths, and are called non-medullated nerves. The
function of this medullated sheath is not definitely ascer-
tained, but it has been suggested that it prevents the
spreading of the impulse from one libre to another. It
appears to intluence the iihysiologieal bihavior of the
nerve, for medullate<l nerves are generally more easily
excited than non-medullated, and they react differently
to an exposure to a constant electrical current. A mo-
mentary exposure of a non-medullated nerve to a con-
stant electrical current may block conduction in the
region of the anode or positive electrode for several
minutes or hours; whereas medullated nerves after such
tieatmeiit recover their conductivity very quickly. •"*
Waller- suggested that thcmi'dulla was reserve material
which was used up by the mel.iliolism of the nerve dur-
ing conduction, and he explained in this way the inde-
fatigability which medullated nerves po.ssess: but Mi.ss
Sowton " has recently shown that the non-medullated
olfactory nerve of fishes is almost or quite as inexhausti-
ble as are medullated nerves, if we may judge from the
imdiminished size of the electri<-al resjionse attending
conduction after long stimulation. Nerve fibres ditVer
from other protoplasm also in the quickiuss with which
they stain blue when exposed to a solution of inethjdenc
blue. It is thus possible to stain them before the other
tissues are colored, and an important method for tracing
the course and <listribution of nerves has been founded
on this peculiarity.
The chemical composition of the axis-cylinch'r ]irocess
is not delinili'ly known. Other portions of gray nervous
matter which it resembles consist largely of colloidal sub-
stances of proteid nature, and dilfer from most tissues in
the unusually large amovmts of lecithin and cholesterin
present. Nothing can be .said positively regarding the
inorganic salts present in the axis-cj'linder process
Rankc* believed its reaction to be slightly acid, but most
observers have found the cut surface of the nei-ve alka-
line to litmus; it is possibU^ that like other protoplasm
it is neutral to phenolphthaleiu. The medulla cimsists
chiefly of cerebrin, lecithin, cephalin, eholeslerin, and
neurokeratin. The latter substanci' forms a horny sup-
porting framework. Lecithin is a trimethyl eh<i'liu-di-
stearyl phosphoric acid glycerin ester. Other fatly acids
may be present in place of the stearic acid, and the leci-
thins from ditferent am'mals viuy in this rcs)icet. The
ke|ilialin or ce|)halin, accoriiing to Koch and Thudieum,
is [irobably monomethyl choliri Icciihin. Tlic constitu-
tion of cerebrin is uid<nown, Imt in t he brain <if the sheep
it contains the sugar galactose, two or four molecules of
stearic or oleic acid contaiiung lutrogen, |)ossibly united
to a hexatomic alcohol or to glycerin. The cerebrins ob-
tained from the brains of dilVi'rcnt aiumals dillVr chemi-
cally. The high eont<'nt. of all nerve tissues in lecithin
and cholesterin is piciliably of physiological importance.
as will be shown farther on, and possibly determines
their susceptibility to the anajsthetics.
As the conducting part of a nerve fibre consists of
protoplasm, it cannot continue to exist for any length
of time if cut off from the rest of the cell, but soon de-
generates and disintegrates. Experiments on plant cells
and infus<iria have shown that portions of the cell cut
away from the nucleus die and no longer grow, although
they may continue movement and some other functions
for some days.' The nerve fibre shows the same rela-
tionship, demonstrating that its maintenance in a. normal
conditiim depends on its connection with a nucleated
part of the cell body. If a mammalian nerve is .severed,
the peripheral portion, whether sensory or motor, loses
its power of conduction and excitability in from four to
six days.' In frogs conduction may persist for from
five to eight days, and, in nerves kept cool, even longer.
These facts indicate that the nerve fibre, however close
its connection with the peripheral cell which it innervates,
is not nourished from it and does not enter into organic
connection with it; and, further, that it is not nourished
by the nuclei of the medullary sheath. No iunnediate
functional reunion of the peripheral and the central ends
of a severed nerve can be brouglit about by suturing, for
whether sutured or not degeneration of the perii)heral
part always occurs. This is accompanied by tlie division
of the nuclei of the medulla and the fragmentation and
fatty degeneration of the axis cylinder and medullary
sheath. Degeneration does not extend gradually down-
ward from the cut cud of the libre, but takes place with
the same rapidity in the whole of the cut-off portion.
The restoral of functicm in the cut nerve is brought
about by the growth downward of the central ends of
the cut fibres — of those fibres, in other words, still in
connection with the nerve cells.* These push down in
the paths of the degenerating fibres and ultimately be-
come medullated and re-establish union with the periph-
eral organs, although this may be jirevented if the fibres
meet in their course any obstacle which tiu-ns them aside.
There appears to be no choice of termination on the part
of the fibre — for example, of a motor fibie for a muscle
cell or of a sensory fibre for a sensory end-organ — for if
the central end of a sensory nerve is sutured to the pe-
ripheral end of a cut motor nerve, the sensory fibies will
innervate the nniscle fibres formerly supjilied by the mo-
tor nerve, and vice ver.sa.' Also if the vagus and sym-
pathetic be cut and the central end of the vagus cross-
sutured with the upper end of the sym]xithetic in the
neck, the vagus fibres growing tipward in the paths of
the degenerating sympatheticinnervate the submaxillary
gland and cause .secretion on stimulation, and thus take
on a secretory function.* Similar facts have been estab-
lished by Langley for the fibres iimervating the pupil
and those erecting the hairs on the cat 's neck, and by
Cunningham and other observers in other nerves. The
time required for the restoration of the function of the
nerve will depend in part on the distance the nerve has
to grow to re-establish union, and in jiart on the nerve
which is regenerating. The longer the distance which
the regenerating fibre has to grow before reaching its
destination, the longer will be the time required for re-
generation. On the other hand, nerves differ somewhat
in their speed of regeneration or growth, and no doubt
constitutional differences of this sort exist among differ-
ent individuals. The time required is as a rule from two
weeks to four or more months. For some reason the
nerve fibres within the cord appear in mammals to have
little power of regeneration if the cord is severed. The
reason ffir this pieculiar reaction is not yet satisfactorily
cxplaine<l. The subject is liaiUy in need of carefid in-
vestigation, since even the iio.ssibility of regeneraticm in
mammals is not definitely disjiroved. '"
Excitability. — Nerves are excitable — that is, they
will respond to stimulation, at any point in the course of
the fibre. No variation in excitability at ditferent points
of the nerv<' has been dt^tected in any one nerve as long
as it remains uninjured iti the liody." but if the nerve is
injuicii by cutting it or it- bi'Mncbcs. an increase of ex
226
REFERENCE HANDBOOK OF THE 3VLEDICAL SCIENCES.
Nerves,
Nerve**,
citability is brought about iu the immediate neighbor
hood of the injury,'" This increase in irritability is
probably due to the electrical disturbance set up in the
nerve by the injury and called the current of rest. This
appaseut variation in excitability, really brought about
by injury following the cutting of branches of the nerve,
has been described by Griltzner and others, and was at
first interpreted as showing variations iu irritability in
the normal nerve. It is easily demonstrated in the frog's
sciatic in the neighborhood of the branches given off to
the thigh muscles. The region of increased excitability
extends about .5-7 mm, along the nerve from the point of
injury.''^ While there is no variation in excitability in
the same nerve, there is a considerable variation between
the different motor nerves of the same animals, those
nerves most frequently used appearing as a rule to be
the most easily excited. Thus the sciatic nerve of the
frog is far more irritable than the brachial nerve to all
kinds of stimuli,'^ and sympathetic fibres appear less ex-
citable than motor.
The change in the nerve which gives rise to the nerve
impulse, i.e., the excitatory change, may be caused iu
any one of tlie following ways: (1) B)' mechanical
shock; (2) by heat of 38' C. or above; (3) by lowering
the temperature of the nerve to + 3° or — 2 ' C, ; (4) by
taking water from the nerve; (•")) by the action of specitic
chemical substances; (6) by electrical currents; and (7)
by ether vibrations,
Mechanical Stiinvlation. — Mcchanicjjl stimulation, first
discovered b)' Swamniertlani '^ about 16.50, may be
brought about either by suddenly stretching the nerve.
bj' shaking it, or by a sharp blow. Pressure gradually
increased does not excite the nerve, though it at first in-
creases its excitability," Mechanical stimulation is sel-
dom used in experimentation, as the nerve is generally
crushed or injured by repeated shocks; but special ap-
pliances have been developed to avoid this so far as pos-
sible. Among these are the tetanomotor of Heidenhain ' "
and the apparatus of Uexkiill," the former instrument
delivering a scries of sharp blows; the latter shaking the
nerve. The excitability of nerves to mechanical stinui-
lation varies gri'atly, and may be artificially increased or
diminished. Thus the extraction of water from the nerve
may render the latter so sensitive to mechanical stimula-
tion that the slightest jar, or the lightest touch of the
nerve with a glass rod will causethe discljarge of a scries
of nerve impulses, causing tetanus of the attached mus-
cle. The time relations of the stimulus and the resulting
contraction are the same with mechanical and electrical
stimulation. After a few blows a nerve may become
non-irritable to further stimulation, but if left undis-
turbed it slowl}- recovere. "
Heat Sdmulativii. — A moderate degree of warmth {10'
-3.5° C) diminishes nerve excitability. To cause the gen-
eration of a nerve impulse by heat the nerve must be
heated suddenly to a temperature of 38° C. or higher.
Heating a nerve quiclvly from 3° C. to 20° C, does not
generate a nerve impulse. These facts show that it is
not a sudden increase in heat or change in temperature
of the nerve which stimulates, but the exposure of the
nerve to a certain critical temperature; and this suggests
that probably heat stimulates by coagulating some of the
proteids of the nerve. This conclusion is supported by
the fact that if the nerve is kept at 40' C, for a sliort time
it loses its irritability permanently, although if it is ex-
posed for a few moments only, an impulse may be gener-
ated and excitability restored if it is again cooled ; and by
the further fact that the temperature at which a nerve
is stimulated by heat is about the temperature of coagu-
lation of a proteid isolated by Halliburton from brain
tissues, i.e., 35 '-40° C, The restoral of irritability on
recooling sometimes observed after a short exposure to
40°-45" C,, is ai)parently opposed to the hypothesis that
heat stimulation is due to coagulation; but this restoral
may be owing to the coagulation having been but partial.
Cold Stiinalation. — If the sciatic nerve of the fro.g is
exposed to a temperature of 3° C. or lower, tetanus of
the attached gastrocnemius muscle sciierallv follows. '*
Cooling the nerve from 20' to 3 C, increases the excita-
bility of the nerve to all stimuli, but does not as a rule
generate nerve impulses sutficiently strong to produce
muscular contraction. The cooling tetanus resembles
that produced by drying the nerve, and there is thus'a
similarity between the physiological effects produced by
cooling and those produced by the extraction of water,
resembling that emphasized by Greeley in connection
with the production of spores in infusoria. Below 0° C.
or —2° C. the frog's nerve loses its irritabilitj', but ma}' be
restored by very cautious warming. Mannnalian nerves,,
according to Howell and others, lose their conductivity
at 5° C, or even at a higher temperature, without pre-
liminary stimulation." It has been suggested that the
tetanus produced by cold is due to mechanical stimulation
by the ice crystals formed ; but this is not probable, since
the nerve may be stimulated at a temperature above the
freezing point of the nerve, and the gradual rise in excit
ability as temperature is lowered shows that the final
stimulation is but a culmination of a process going on as
temperature falls. The increase in excitability produced
by cold is true also for maminaliau nerves (Biedermann).
Conductivity, on the other hand, is reduced by cold.
Not only docs cooling increase the excitability of the
nerve fibre, but the whole central nervous system may
in the frog be brought by this means into a condition of
increased rcfiex excitaliility resemliling that caused by
strychnine,^' The increase of excitability produced by
cooling culminating in stimulation may be compared to
the precipitation of moisture from the atmosphere, and,
as will be discussed on page 232, n\ay be brought into
relation with the change in state of the colloids in the
nerve.
Drying Stimtilation. — If nerves are allowed to dry iu
the air they gradually iucrease in excitability, and finally
nerve impul.ses are generated sufficient, in the case of
motor nerves, to cause a prolonged tetanus or series of
twitches of the attached muscle. The dried nerve, like
the cooled nerve, becomes totally non-irritable and very
stiff, but its excitiibilily may be completelj' restored by
placing it iu water or physiological salt solution, A
similar drying tetanus is produced by placing the nerve
in solutions of sugar, urea, glycerin, or other non-elec-
trolytes having an osmotic pressure of thirteen atmos-
pheres or over, that is, iu solutions containing something
more than a half-gram molecule of the substance to the
litre, or by placing it in solutions of neutral salts of the-
stime osmotic strength. Even neutral salts which by
their own action annihilate nerve irritability will stimu-
late if strong enough to extract water rapidly. The
stimulating action <if solutions of nearly all non-electro-
lytes and many electrolytes except sodium salts and a
few other compounds to be discussed later, is to be ex-
plained by the indirect osmotic extraction of water. If
the water is extracted very gradually the nerve may b<j
dried without generating impulses strong enough to cause
muscle contractions. It has been suggested (Griltzner)
that this stimulation is realh' mechanical, due to shock
or compression of the nerve substance \>\ the shrinking
ti.ssue, but this is probably not the case, A probable ex-
planation of this stimulation will be found on page 232
and may be confidently ascribed to a change in the nerve
similar to that produced by cold.
Clicmical Stimnlulion. — The excitation of the nerve by
chemicals was first observed by Swanunerdam iu the sev-
enteenth century. It has been studied by von Humboldt,
Eckhard, KoUiker, Kiilme, Griltzner'-'" and many others.
The earlier work established the general fact that the
application of solutions of many non-electrolytes and
electrolytes would stimulate motor aiid sensory nerves.
The strong solutions which were used led to the conclu-
sion that most chemicals stiiuulated indinclly by the
withdrawal of water, a conclusiou which was undoubt-
edly correct. The first careful work comiwring solu-
tions containing the same niuuber of molecules in the
litre was done by Grlitzner. who sliowed that some other
factor entered into the stimulation besides the withdrawal
of water. He was unable to discover what this was. but
227
Nerves.
Nerves,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
referred it to ii specitio stimulatiiiy: actiou of tlip salts.
Tliiis sodium fluoride uiid other sodium salts and some
alkalies stimulated in solutions too weak to draw water
from the nerve. Grlitzuer found that with certain ex-
ceptions a relation existed between molecular weight
and stinuilatiiig or poisonous action. In salts of the
same .series tliose of greater molecular weight stimulated
more and i)oisoned more rapidly. Thus sodiiuu iodide
was stronger than the biomide, and this than the chlor-
ide. Barium <'hloride was more baneful than strontium
chloride. (Jriitzner believed that sen.sory nerves were
more readily stinudated Iiy potassium salts than by so-
ilium. while motor nerves were not stimulated by |)otas-
sium salts, l)ut were by sodium. This conclusion is not
correct. Theautlmr'sdbservations-' on a large number of
salts, acids, and alUalies gave the following results: The
frog's sciatic is stimulated by immersion iu solutions of
any salt, if this be sutliciently concentrated. This stimu-
lation, as already stated, is brought about osmotically.
If the solutions have an osmotic pressure no greater than
that of the nerve — /.(., approximately six atmospheres
— only .solutions of electrolytes will stimulate; the non-
electrolytes are ineffective. Of these electrolytes all so-
dium .salts of monovalent or bivalent acids, with one
or two possible exceptions, will stimulate in i.sotonic
solutions. The similar salts <if otlu'i' metals, such as
l)otassium. lithium, calcium, strontiiun, magnesium,
zinc, .silver, mercin-y, aluminum, iron, and ainTuonium,
will not stimulate, but ,i;radua,lly annihilate irritaliility.
Of the sodium salts the monovalent salts, such as the
chloride, bromide, iodide, nitrate, and acetate, are least
powerful; the bivalent salts, such as the sulphate, oxal-
ate, tartrate, and borate, are from two to three times as
powerful as the monovalent; while the trivalent salts,
such as the citrate, fei'ro- and ferricyanides. and the phos-
phate, are about six times as ]iow<'rful as the monovalent
salts. This shows that the stimiil-ition is due to the aninn
and not to Ihecathions, and further, tliat it isde|)enilent in
part upon the nundier of electrical cluirges on tlie anion.
in other words, clieniical stimulation is really due to the
negative electrical charges of the salt, and chemical stim-
ulation is an electrical stimulatiou. The positive ions
hav<^ an effect opposite to that of the anions, and tend to
prevent stinuilation and lower irritability, and this is due
to the positive electrical char.ges whicli they bear. Thus
|)otassium. lithium, ammonium, and hydrogen not only
will not stimulate the nerve except in strong solutions or
when united to still more powerful trivalent aiuons, but
they annihilate nerve irritability very rajiidly. All ac-ids
destroy nerve irritaliility ra|3idly unless ap|ilied in very
dilute .solutions. In .some acid .salts, however, such as
copper sulphate, a nerv<^ may remain highly irritaltlc for
several hours. In solutions ba\ing a strength of one-tlfth
normal or higher, acids will ul'ten stininlale (dsniosis V),
but below thisstrength they aimiliilatc iiiitability. Of the
alkalies, .sodium, potassium, and barium liydrates stimu-
late in dilutions not greater tlian one-twentieth uoimal;
jimmonium hydrate will n<it stinndate the motor nerve,
but destroys its irritability. Tills is in harmony with the
small dissociation of the compound. Of the oxidizing
salts the permanganates will stiiinilate both in the case of
potassium and in that of sudium, in one twelfth <ir oiii'-
fourteenth molecular sulutions. Of the moiKivalent so-
dium .salts the tiuoride, iodide, bromide, and chloride
stimulate iu the order named, the tiuoride beiti.i; the
strongest. Something besides the number of charges is
tints seen to be of importance. Tlie author has suggested
that this is the movement of the charges about the atom,
but this is as yet liy)iothetical. The general result of this
work is that positive and negative iinis act as a rule in
an op|iosite manin'r, ami tliatchemical stinndation proper,
as a|iait from stinndation by osmosis, is in reality an elec-
trical stimulation and jirodnccs the same kind of a change
in file nerve as does electrical stimulation.
Klerincal StimnldUnn. — Nerves may be stimulated
electrically in several ways, but the end result is a dis-
turbance of the electric ei|uilibrium, if we may so term
it. within the nerve and a restdting chance in the nerve
itself which causes the nerve impulse. One waj', as has
just beeu shown, is to introduce the electrical charges
into the nerve iu the form of inns iu solution, but the
more usiuxl method of stinndation is to change the dis-
tribution of charged jiartieles already in the nerve and
thus upset electrical equilibrium. The nerve may be
stimulated by induction liy bringing near the nerve a
highly charged Leyden jar and suddenly discharging the
jar, or, as in unipolar stinndation, by connecting the
nerve with one pole of an induction coil, when on mak-
ing and Ijreaking the primary circuit stimulatiou may
ensue, ■■■ In lioth these cases, at the moment of making
or breaking the current, there is a sudili'U e(jualization of
the char.ges which have been accumulated in the nerve
by induction. In other words, the electrical equilibrium
is iipset by induction. Herz waves may stimulate a nerve
which is near the induction machine, but the nerve
quickly loses its irritability and conductivity under their
intlueuce.'-'' The exact manner of action of the Herz
waves has not been clearly detennined. Induced cur-
rents from the imluctorium and constant currents from
the battery are the forms <d' ektctrical stinnilation most
generally used. Bnth these currents stinnilate in the
saiue way, the differences between them being due only
to ditfereuces in intensity and duration of the current.
The most probable explanation of their action, speaking
in general terms, is that they alter the distribution of
ions in the nerve, the negativity of the nerve being in-
creased in the neighborhood of the cathode owing to the
predominauce here of negative ions and the positivity iu
the neighborhood of the anode. Iu this wa.y a disturb-
ance of electrical equililirium within the nerve is pro-
duced. It a])pears tliat to bring about this disturbance
of equilibrium with sutHcicnt sitddcnness to cause a
nerve impulse, polarization must take place in the nerve.
This polarization is due to the fact that the membranes
surrounding the axis-cylinder process do not permit free
osmosis of the .salt particles in the nerve thidugli them.
It tlnis happens that when a cathode is brought against
a nerve, the negative ions which are repelled from it or
are diffusing into the nerve from it accumulate against
the outside of the mcndjrane lining the axis-cylinder
process. This accumulation of negative particles on the
outside of the membrane holds bound to it on the inside
tlie jio.sitively charged sodium particles or other positive
ions in the nerve in that region. This disturbs the elec-
trical cciuililnium of that pait of the nerve, as it leaves a
surplus of unbound negative cliargesin the nerve at that
point. It is this sudden surjilus of negative charges
which sets up in the nerve that change which causes the
nerve impulse. AVhat the nature of that change is we
shall shortly discuss, but it may be .said here that it con-
sists possilily ill a change in the nature of a precipitation
taking place hi the colloids of the nerve, st rielly analo-
gous to the changes ]iro<luced by cold or by the extraction
of water.
A study of the phenomenaof electrical stinndation has
led to the general law that that form of electrical stimu-
lation is the most effective in which the intensity of cur-
rent is greatest and reached iu the shortest time.'- In
other words, stimulating power is a function of the in-
tensity and of the reciprocal of the time. For this rea-
son sharp sliocks of gri'at intensity, such as induction
shocks, are more cliicient than tlu^ .galvanic current, and
the break-induction shock is more jjowerful than the
make, as iu the latter the rise is more gradual owing to
self-induction in the primary coil. Too rapidly repeated
sliocks will not stimulate, and at 1.5" C. a duration of
0.(.1()1.5 to l),03 second is necessary. Shocks more rapid
than three thousand per see(md generally cau.se but a sin-
gle initial iu;:sele twitch.
It has lieen shown that the nerve impulse does not arise
throughout that portion of the nerve which is traversed by
the current, but only at its point of exit and entry. The
point of entry of the current into the fibre is called the
]diysiologic;d anode, and that of exit is called the idiysio-
logical cathode. The impulse is formed at the cathode
on making the current and at the auod<' on bri'akiug it.
228
REFEREXCE HANDBOOK OF THE MEDICAL SCIENCES.
Serves,
Nerves,
This may be easily demonstrated by ligaturing the nerve
between tlie electrodes so as to interrupt the conduction
of a nerve impulse at this point, when it will be found
that the miiscle will contract only at the making of the
current when the cathode is ou tlie muscle side of the
ligature and at the break of the current when the anode
is on tlie nuiscle side of the ligature. It is a curious fact
that if either electrode is placed on a portion of the nerve
which has been rendered non -irritable b\' ether or in an}'
other way, the impulse which normally is produced by
that electrode no longer appears. It looks as if the pas-
sage of tlie current from a non-irritable to au irritable
portion of the nerve will not stimulate. The reason for
this fact of polar failure is still obscure. Electrical
stimulation taking place at the cathode at the make of
the current is thus shown to correspond to chemical
stimulation. It is always an increase in the number or
efficiency of the negative ions or a diminutiou in the
number or efficiency of positive ions which stimulates.
The positive electrode, as we shall see, diminishes ex-
citability like the positive ions, it makes no difference
whether the charges are applied to the nerve ou atoms
in the form of ions, or from a battery, tlie effect on the
nerve is the same. Electrical stimulation quickly ex-
hausts the excitability of the nerve at the point stimu-
lated, unless the current is frequently reversed. This
exhaustion is frequently attributed to electrolysis; but as
it occurs also with non-polarizable electrodes, it is due
not to electrolysis out to changes brought about in the
condition of the nerve, or, more properly speaking, its
colloidal particles, by the changed distribution of ions in
the nerve. In using the induction shocks where reversal
of the current occurs with every make and break shock,
exhaustion is far less apt to happen than when a con-
stant current is used.
The action of electrical currents on the nerve does not
end with the initial stimulation but cnutinues during
their pas.sage, and will be discu.ssed later under the head-
ing of electrotouus. Suffice it to say here that under
ordinaiT circumstances, and unless the excitabilitj' of the
nerve has been artificially increased by local cooling in
the neighborhood of one electrode, or by drying, or by the
chemical action of sodium chloi'ide or other substances,
the current .generates a nerve impulse large enough to
cau.se muscle contraction only at the moment of openim;
and closing the circuit. If, however, the local excitabil-
ity of the nerve is increased in the neighborhood of one
of the electrodes in any of the above wavs, a series of
nerve impulses causing tetanus may be produced, lasting
throughout the passage of the current or occurring after
its close.
Modifii'atitiii (if ExcitahiUti/. — The excitability of a nerve
at any ]ioint may Ije artiticially increased or diminished.
The local a|i]ilication of cold increases excitability down
to about -f-~ <-'. for the frog's nerve and somi-wliat
higher for the mammalian. Below this point excitability
rapidly falls. Local warming diminishes excitability
until a temperature of about 3-')" C. is reached, when ex-
citability again increases. The excitabilitv of the nerve
is increased \>y local injury such as section, or mechani-
cal pressure, or heat action. For about 5 mm. from the
cut end of a nerve this increase in excitability is well
marked. This increase mav be due to the electrical dis
turbancc or current of injury in the neighborhood of the
injured part, a condition of catelectrotonus prevailing at
this point. In all electrical stimulation thi; disturbing
influence of this nerve current has to be considered. The
local application of alcohol, ether, carbon dioxide, or
chloroform is said to increase excitability at first (Wal-
ler) before anaesthetization takes place. VValler observed
an increase in the size of the negative variation when
these agents were used. It is not impo.ssible, however,
that it is the conductivity which is altered, the general
analogy between the effects of these agencies and moder-
ate warmth elsewhere strengthening this supposition.
Excitability is enormously increa.sed by drying the nerve,
or by taking water from it by osmosis. It is increased
further, temporarily at least, by allowing the nerve to
lie in one-seventh normal sodium-chloride solution, or by
a brief exposure to the sulphate, citrnte, or otlur slimulat-
ing sodium salts, and itns diminished by hydrogen, po-
tassium, lithium, ammonium, calcium, and other positive
ions. Distilled water at first increases excitability and
then diminishes it. Excitability is also powerfully in-
fluenced by the passage of a constant current through
the nerve, being greatly reduced in the region of the
anode and increased in the neighborhood of the cathode
while a current of moderate intensity flows through the
nerve. Excitability increases in the neighborhood of the
anode on breaking the current. The changes in excita-
bility thus produced will be discussed under the heading
of Electrotouus.
SuMM.\KV. — ExcitaUlity. — The facts concerning excita-
bility just stated are most readily interpreted by assum-
ing that all the agencies which stimulate or increase ex-
citability do so by producing the same sort of a change
in the nerve protoplasm. What that change is we are
not yet in a position to state definitely : but the many
striking resemblances of the process to the reactions
shown by colloidal solutions strongly indicate something
more than a passing similarity between the two proc-
esses. The facts may be convenienth' interpreted if we
assume the nerve to consist of electropositive colloidal
particles and stimulation to consist in the coalescence or
gelation of these particles. The action of cold, of me-
chanical shock, of negative ions, and of the negative elec-
trode; in stimulating may on this hypothesis be easily rec-
onciled, all of these ageucies acting in the way specified
to produce gelation. This matter will be considered at
the end of the article more in detail. The various agen-
cies which diminish excitability diminish the tendency
of the particles to coalesce.
Coniliiflieiti/.- — The principal function of a nerve is the
conduction of a nerve impulse. Conductivity is not
something peculiar to the nerve, but is found in all pro-
toplasm. In the sensitive plants, for example, in the
absence of nerves an impulse is jiropagated from place
to place through the cells at a fairly rapid speed. This
observation allows us to disregard at once such elements
as the medullary sheath or longitudinal tibrilla; of the
nerve as unessential in the matter of conduction. As
protoplasm without these structures still conducts, it is
clear that whatever role they may play in determining
other factors of conduction, for example speed, they are
not essential to conduction itself. Conduction takes
place in any nerve in either direction with the same ease.
Thus if a nerve is stimulated in the middle the impulse
|)asses both downward and u])ward and may be detected
by the negative variation or electrical disturbance which
the nerve undergoes. The eft'ect of this impulse passing
downward in a motor nerve is ajiparent in the muscle
<rintraelion: what effect the impulse jiassing upward to
the motor cell may have is not yet determined. The rate
of conduction varies in different nerves. It is highest
in mammalian nerves and in the frog's sciatic, i.e., 25-
to 40 metres [ler second. In the lobster it travels 6 metres-
per second ; in the mollusc, Anodon, only 1 cm, per sec-
ond; in the mantel of Eledone 1 mm, ; and in theelectrie
nerves of the Torpedo at 5' C. 9 metres per second. At
a higher temperature Schonlein found a rate of from 13
to 27 metres per second. -■' In the plant Diona', conduc-
tion, according to Burdon Sanderson, occurs at the rate
of about 2t)0 mm, per second at 30-33' ('. No optical
changes have been observed in the nerve accompanying
the passage of the impulse, but in the insectivorous plant
Droseraand in other jilants Darwin observed that the pas-
sage of the impulse was accompanied by the appearance
of a cloudy preciiiitate in the cell jiroti.iilasni, this pre-
cipitate shortly dissolving. This iirecipitation he called
aggregation and compared it to the nerve impulse.
Influen.re of Temperiiltnr. — The sjieed and character of
the nerve impulse are influenced by temperature. Bern-
stein observed an increase in the height of the muscle
contraction if the impulse passed through a warmed
area. Howell and Binlgett secured similar results in the
vasoconstrictor mauimalian nerves. AValler found that
22!)
Nerves.
Nerves,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
a temperature of 40' C. abolished thy uegative variation
and conduction. In tlie frog's sciatic a U'ni]ierature of
0° C. docs not l)hick iIk^ action cuncnt and tlic impulse,
but at — 2" to —7" C. both are blocked. lirtueen 8 ' and
30' C. little cITect of changes in Icmpcratuic can be seen.
Herrick '•■■'* found that between 10' aii<l 3.") C. there was no
change in the negative variation, but lulcjw 10' C. the
negative variation diminishes. In gcnerala low tcmper-
titure slows and prolongs the negative variation, and a
high tem|)crature causes an increase in height and a
■diminution in duration. In mammals a temperature of
•i' or 6° C. blocks conductivity, but conduction returns
on warming. The tibivs going to the abductors of the
larynx are blocked by cold before the adductors.
T/ie Elect n'ciil PIiiiiiiiikihi nf yirr(S. — Tlie elei-lrical
phenomena of nerves were. lirst studird accurately by Du
Bois-Keymond in 1843-45. Like all protoplasm a nerve
shows a difference of potential between the uninjured
and the injured portions. This diilereuce is of such a
character that the inji'rcd part appears negative to the
uninjured. Thus Du Bois-Rcymond found that if two
electrodes connected with a galvanometer be placed one
on the cut end of a nerve, the other at some point on its
surface, a current Hows in the circuit from the uninjured
surface toward the cut cud and may be detected by the
detiection of the galvanometer. Tliis current is called
the current of rest, or of injury, or the demarcation cur-
rent of the nerve, and it may amount to 0.0035 to 0.03
volt. The amount of this current is about the .same in
warm- aial cold-blooded animals. Besides this current,
which is at its maximum between the equator and the
cut end of the ]iiece cd' nerve, there is a dilTereiice of po-
tential between the two ends of a ucrvc. so that if the
two cut surfaces of a motor nerve or a sensory nerve be
connected with an electrometer there is a small axial cur-
rent. In a motor nerve this axial current Hows in the
nerve fnnu the peripheral to the central end. and in the
sensory roots in an opposite direction.'-" The amount of
Ibis a.\ial <-urrent is not great, but the cuneiit is con-
stantly present, and is greater in the posterior than in
the anterior roots. In the anterior it amounts tn aliout
O.OOOCi of a Dainel, in the posterior roots to 0.0015 of a
Dainel. The electromotive force of the nerve current of
injury is .said to be greater in a nerve used constantly,
like the iineumogastric, than in other motor ucrv'cs. In
non-medullaled nerves the current is greater than in
medullated. This current of rest or of injury persists
for some time, becoming constantly weaker, Iiut may be
still detected several days after section when the excita-
bility is entirely lost. Although the direction of the
nerve current is ordinarily in the sense already men-
tioned, it may be reversed by high temperature and by
desiccation. By approjjriate means a ucrve inav be pre-
pared which shows no current of injury. Thus if a
frog's sciatic is removed from the body and iilaced in
frog's blood containing a little calcium, the eerve after
several hotns is .said to show no iiijiiiy em rmt what-
ever."
It is probable that th<' current of injury may be in-
creased or diunnislicd in many different ways, but tljis
subject hasnot yet been sulliciently investigated to allow
lis to classify the facts in any general group. Ether di-
miinshes the current as do acids; alkalies increase the
current.
The cause of the current of injury is, as its name im-
jdies. probably to be attributed to <'licuiiial ox iihysieal
changes taking placid in the nerve at the |ioint of injury
more rapidly than elsewhere. There! are sev<'ral e\))la-
nations of this change. Du Bois-Rey monil. who sup|)osed
the nerve to be made up of bipolar electric particles, of
which the two ends were negative and the middle pos-
itive, believed it to ))e due to th<' exposure of the nega-
tive ends of the jiarticlcs by tlic section. Hermann-"'
refers it, as do most atitliors, to the alterations in the
stale or composition of the jirotoplasm at the injured
point. The author has suggested that this change con-
sists in the increase in si/.eor the coairulation of the )iosi-
tively charged coUoifial jiartieles of tie- iii'ive lirousht
about by the injury, thus causing a change of their sur-
face of separation from the tiuid leading to the liberation
of formerly bound negative charges. It is impossible,
howitver, at the present tinu^ to state positively what the
real explanation is.
JVcf/iitife Vfirintion. — Du Bois-Reymond'- discovered
about 1S43 that if one electrode from a galvanometer be
jdaced on the cut end of a nerve and the other on its
longitudinal surface, on stimulation of the nerve the
needle of the galvanometer, which had been deflected by
the current of injury, receded momentarily toward zero.
This electrical disturbance he called the negative vari-
ation or curnait of action. It has since been shown that
this electrical disturbance generally or invariably accoin-
lianies the nerve impulse and is a convenient way of de-
tecting the jia.ssing of such an imjudsc. The variation
follows mechanical, heat, or chemical stimulation as well
as electrical. It occurs in plantsand muscles and secret-
ing epithclia as well as in nerves. The variation is of
such a nature that the first electrode reached by the Im-
pulse becomes negiitivc to the other. The negative va-
riation is bipliasic, that is, a positive phase follows the
negative. The negative variation travels at the same
rate as the nerve impulse, and shows other parallelisms
wliich clearly indicate its close connection with the phe-
nomenon of conducti(ni. Thus exposure of the nerve to
carbon tlioxide, ether, or ehloroforiu is said to cause a
])reliminary rise in excitability and an increase in height
of the negative variation, both conduction and the nega-
tive variation being later abolished ;" a ligature abolishes
both the variation and the conduction: cold lengthens
the duration of the negative variation, but diminishes its
height, and warmth increases the height and shortens the
duration. These facts so clearly establish the parallel-
ism between the negative variation or action current and
the nerve impulse that by most physiologists the electri-
cal disturbance is n'garded as an invariable concomitant
of the nerve imimlse. Others hold a different opinion,
however. Cases arc on record in Avhicli the cooled muscle
of a frog has contracted, following a stimulusnot accom-
]ianieil liy a negative variation; and in other instances
the negative variation may be detected without muscle
contraction. Stciuach found in warmed frogs tetanus
produced with the secondary coil -43 cm. from the pri-
mary, while the negative variation tirst appeared when
the secondary coil was at a distance of 3i) cm. Boruttau
believes that iu the one case the mu.scleisa little more sen-
sitive than the electrometer, and in the other the latter is
more sensitive'than tliemuscle. The sizeof the negative
variation is proportional, as a rule, to that of the current
of injury, and up to ;i certain [loint a larger stimulus
causes a larger neg.-itive variation and a larger muscle
contraction. The negative variation is increased by
catelectrotonus and diuunished by anclcctrotonus. A
negative variation occurs also iu the telanns due to nat-
ural stimulation of the nerves of stiychnine frogs. The
cause of the negalivc variation and its relation to con-
duction will bo discussed on jKige 23'2.
Kkrtrotmiiis. — If two eh'Ctrodcs from a battery are
placed ui)on a nerve, a nerve impulse is generated at the
cathode or negative electrode when the current is made,
and at the anode or positive electrode when the current
is broken, providcil the current hi' faiily strong. While
the current tlows through the nerve no impidses arc^ as a
rule generated, l)ut nevertheless a change in irritabihty
is brought about in the nerve. This change of irritabil-
ity iiial conductivity in the ri'giou of the electrodes has
been carefidly investigated by PHiiger and is called olec-
trotonns.™ 'The irritability of the nerve is increased in
tlie neighborhood of the cathode during the passjige of
the current and diminished in the neighborhood of the
anode; after the current is broken the anodic region un-
dergoes a rise in irritability and the cathodic region a
fall. These cliaiigcs may be demonstrated by stimulat-
ing the nerve in the region of the cathode or anode with
stimuli just strong enough in the normal nerve to cause
muscle contraction, when if applied to the cathodic re-
gion an increased muscle contraction is obtained; if ap-
-M)
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Nerves.
Nerves.
plied to tlie auodic region no response follows. If the
current is strong and continued for some time the cutho-
dic region also becomes less irritable. The strength of
current necessary to produce electrotonie effects is very
small, O.OOUl-U.UOOOl niilliampere may suffice. Sensory
nerves show the Siime phenomena of electrotonus as mo-
tor, although Zirlielle thought that both theanodeand tlie
cathode dhninislicd excitability in the former. E.xcep-
tions to the general statement that iiritability is increased
by the ealhiide and diminished by the anode have been
noted by .several observers, i.i.. Budge, Schiff, Valen-
tine, and others. Irritability may increase (though ver^'
rarely) in anelectrotonus, and Nasse has observed several
cases of the total reversal of tlie law. The cause of these
rare e.veeptions is not j'ct clear.
Although the constant current only changes excitabil-
ity but does not ordinarily excite during the passage of
the current, yet in some cases a tetanus of the muscle is
observed during the passage of the current, or after it is
broken.^' This tetanus, called Ritter's tetanus, arises
from the cathode if it occurs during the pas.sage of the
current, and from the anode if it occurs after the current
is broken. This tetanus may be arliticially juoduced at
will if the excitability of the nerve is increased by cool-
ing, by drying, or by tlie osmotic extraction of water.
This tetanus demonstrates the fact that the changes go-
ing on in the nerve during the passing of the current are
of the same nature as those which produce the impulse.
The current really stimulates throughout its passing, only
the changes produced after the current is once applied
are too gradual to cause a mtisele contraction. If, how-
ever, the excitability of the nerve is already arliticially
raised (that is, if the instability of the nerve substance is
artiticially increased), the change is sufficiently abrupt to
generate nerve impulses so tliat a number of muscle con-
tractions take place during the passage of thecunenl.
It is necessary to bear these facts in mind, since the law
of electrical excitation is ordinarily stated in the way
mentioned — (".c, that excitation occurs only at the make
and break of the current.
The explanation of these electrotonie changes of irrita-
bility is not dillicult on the colloidal hypothesis already
sketched. The primary eifect of tlie current is to cause
a disturbance in the even distribution of the ions in the
nerve. Positive ions predominate in numliers near the
anode, negative ions near the cathode. Tlieseions biiiig
about a change in the state of the colloids. Near the
anode the positive ions increase the stabililty of the pro-
toplasmic hydrosol, the colloidal particles are here increas-
ing in numbers and increasing their total surface; near
the cathode, on the other hand, tlie colloidal particles,
owing to the presence of negative ions, are diminishing
in numbers, increasing in size, and diminishing the sin-
face of contact. The stability of the hydrosol is being
reduced near the cathode, and, in accordance with the
general law stated farther on, excitability varies inversely
with the stability of the protoplasmic liydrosol. If this
change is abrupt, so great a contraction of surface of the
particles takes place that an impulse is generated strong
enough toreach the muscleaud causemuscle contraction.
If the change is gradual, as it is after the first apjilica-
tion, the change is not strong enough at any moment to
cause an impulse large enough to reach the muscle.
Stimulation takes place at the anode on o])ening, and ex-
citability is increased here owing to the fact that on
breaking the current the positive ions accumulated here
in excess dilTuse into the region formerly occupied by
the cathode, and the negative ions from the cathodic re-
gion by dilTusion reach the anode. There is thus jiro-
duced in the neighborhood of the anode a diminished
positivity or an increased negativity. The equilibrium
of the solution is at once upset, the positive colloidal
particles suddenly diminish in numbers and surface ami
increase in size owing to this diminution of positive ions,
and this generates, as always, a nerve impulse which
may continue, causing tetanus. Thus the rise in irrita-
bility near the anode is explained. Similarly in the re-
gion of the cathode, on breaking the current there is a
sudden diminution of the negativity of this region and
an increase in positivity due to the diffusion into this
region of the positive ions from the anode. The result
is that a sudden increase in number and surface of the
particles results and conductivity and irritability are ac-
cordingly reduced. In otherwords, a process of solution
is occurring near the anode and of gelation near the cath-
ode during the passing of the current ; after breaking
the current the reverse of these processes occurs. It may
be stated that "these changes, although not visible in
ner^'es, may be readilj- seen in infusoria and other
forms of protoplasm, and the change in state of the pro-
toplasm is of an ojiposite character at the two poles,
liquefaction generally occurring on the anodic side.
Besides the changes in irritability of the nerve pro-
duced b}- the current, there are changes in its electrical
behavior at the same time. Polarization takes place, so
that on breaking the ctn-rent a reverse current in the op-
posite direction may bi^ observed. This polarizing cur-
rent often reverses itself, running first in one direction
and then in the other. This reverstil is less pronounced
in nerve than in muscle and is absent in dead muscle.
These facts show that the polarization current is due not
only to a physical pularization taking place at the limit-
ing membranes of the nerve, but also to a change in state
of the protoplasm. The polarization current may take
place in the same direction as the original current, par-
ticularly after heavy currents of very brief duration.
AVhile a constant current passes through a nerve elec-
trical disttu-bances may be seen on both sides of the elec-
trodes. If electrodes connected with a galvanometer are
applied on the anodic side, it will be found that each
point nearer the electrode is positive to that farther
away, and if on the cathodic side negative to that farther
away. We thus get physical erectrotonic currents.
The.se currents are due in large part, if not altogether, to
the polaiization taking jilace at the boundary of the axis-
cyhnder process, causing a spread of the current along
the nerve.^' They are, however, not altogether expli-
cable on this hypothesis, for they disappear in dead and
disintegrating nerves; they are greatly reduced by ether-
izing the nerve; and they are suppressed if the nerve be
ligatured between the polarization current and the gal-
vanometer electrodes. The currents are more jiowerful
near the electrodes and their intensity is greater on the
side of the anode than on that of the "cathode. The an-
elretrotonic current may have an electromotive force ol
0..') of a Danicll, while the catalectrotonie current has
but 0.05 Danicll. These currents are sufficiently strong
t o stimulate other nerves in contact with thos(^ stitnulatecT.
They exist in non-medulated as well as medullated nerves.
They may be reproduced on artificial nerve models called
core-conductors, consisting <if a wire surrounded by a
solution of an electrolyte. Thesupiiressionof tlie current
by ether may be due to a diminution of jiolarization ow-
ing to an alteration of iiermcabilitv of the axis-cylinder
wall.
Indefatirjahilitji of J\>r«. — Nerves are not supposed to
b(' fatigued by the act of conduction. Bowditch^- cu-
rarized frogs, thus lilocking the nerve impul.se and pro-
tecting the muscle from fatigue. The nerve was then
stimulated by induction shocks continuously for six
lionrs; at the end of that time the curare was excreted
and the muscles began to contract. A similar experi-
ment was tried by JIaschek, who blocked the impulse by
ether, and by Bernstein, '^ who blocked the impulse by
the anode and with the same results. These facts indi-
cate that nerve conduction is not accompanied by meta-
bolic changes.
Metabolism of Xeri-r. — The only evidenei-s of iiu'tabol-
ism in nerve are the changes produced in it by cutting it
oil from its nerve-cell connection and Waller's observa-
tions on carbon-dioxide formation. No heat is produced
by nerve conduction. Electrotliermic contacts sensitive
to 0.001° C. show no indication of heat jiroduetion.'*
Similarly all attem])ts to show that carbon dioxide or
acid are produced liay<' bi'cti fruitless. Waller says that
after exjiosuri's fin a liiii f iiiurval lo (arlionic anhydride
oat
Nerves.
Nerve Tissue.
REFERENCE HANDBOOK OF TILE 3IEDICAL SCIENCES.
nerve irritability is increased and tlie size of uegative va-
riatiou is increased. The same result is obtained if the
nerve is tetanized; so Waller concludes that carbonic an-
liytiride is pi'oduced duriuj.'- tetanizatiou. As many other
factors affect the negative variation in the same way, we
cannot concluile from tliis oljservation tliat the conduc-
tion of the nerve impulse is aecoiM]ianied by a metabolic
change, leading to carbunic-uuhydride formation.
21ie Action of Anmtheticx. — The ana'sthetics, chloro-
form, ether, carbon dioxide, and aleohorall temporarily
annihilate nerx'e conduction, although some observers
state that a preliminary rise in excitability is their first
effect. If not exjiosedtoo long to theaction of the anaes-
thetic the nerve will recover; but if too large an amount
is used, or if the exposure is too long, irritability and
conductivity appear to be permanently lost. Chloro-
form is much more active than ether and the nerve re-
covers from it with much greater slowness. This may
be due to its being less volatile than ether and hence es-
caping less readily from the nerve or to its having a more
powerful action. " The most probable explanation of the
action of the ana>sthetics is tliat they dissolve thelecitho-
proteidsor colloidsof the nerve. Mayer-'= and Overton^"
have pointed out the parallelism of the antesthetic action
to the fat-ilissolving powers of the ana'sthetics. The
nerve is particularly rich in lecithin compounds, and it is
not improbable that theanjestheticsact upon them. The
dis.solving action of these substances may be easily seen in
blood corpuscles, the eggs of many marine forms and other
organisms, so that it is probalile that they act on nerve
protoplasm in the same maimer. There is, hence, nothing
peculiar about the action of the anaesthetics. Tliej- pro-
duce the same kind of a change in protoplasm as do pos-
itive ions, the positive electrode, or warmth. They put
the nerve in a condition of anelectrotonus. They arc par-
ticularly valuable because th.>y are so soluble in proto-
plasm, so volatile, and effective in sucli small amounts.
Oeiifriil Siiiiiiiinrti. — We are now in a position to see
how far the foregoing facts enable us to understand the
processes in the nerve which are represented in the nerve
impul.se. There have been several hypotheses thus far
proposed to explain these phenomena. One of the ear-
liest was that of Du Bois-Reymond. In this theory the
uerve substance is supposed to be composed of bipolar
electi-ieal particles negative at each end and positive in
the middle. The current of rest is obtaini'il by connect-
ing the middle or |)ositive surface with the cut end or
negative surface. As each iiorlion of a magnet shows
the polarity of the whole magnet, so each portion of a
nerve shows the poIarit_y of the whole nerve. The
nerve impulse is simply a turning of these particles on
their axes, so that the negative ends turn toward the
surface. This will explain the action current.
Hermann believed that these particles did not jire-ex-
ist, but that '.h; f.-urrent of injury was due to <-ataliolic
changes laUing place at the cut svirfaee. This became
negative to th:j rest in consequence of these chemical
changes. A similar change occurred during eondviction,
and this change in each part of the nerve caused the part
just 1 lUowing it to be put in a position of catelectrotouus.
On this theory the negative variation stimulated each
part of the nerve in turn and was itself regenerated by
the change which it brought about.
Becquerel .nippo.sed that there were numerous electro-
capillary couples in the nerve which gave rise to electri<-
currents, cell couple, consisting of two dilTerent liqviids,
being separated by a capillary opening or by an organic
m?mbrane. D'Arsonval. who hasdeveloped this theory,
supposed the electrical phenomena to be due to modifica-
tion of the surface of seiiaration of the two liqiuds .simi-
lar to the electrical phenomena shown by the capillary
electrometer.
Loeb has suggested that conducti(m is due to a change
in state of tlie colloids, but has furnished no evidence in
support of this view. The author believes that the facts
indicate 'he truth of thishypolhesisaud suggests the fol-
lowing more specific theory:
The protoplasm of the nerve is es.sentially a colloidal
solution. The colloidal particles are proteid in nature
and in all likelihood are lecithin proteids resembling the
.sheaths of the red blood corpu.scles, as is indicated by the
especial richness of the nerves in lecithin. These parti
cles are of different sizes and are electropositive. They
continually change their state of aggregation, being eas-
ily l)recipilatcd or lirought into solution and easily coa-
lescing with their neighbors or breaking up into a" large
number of smaller particles. Through these changes
the surface separating each particle from the surrounding
fluid augments or diminishes. AVhen two particles cf)a-
le.sce the total surface is reduced; when one particle sep-
arates into two the total surface of separation is in-
creased. Around each particle there are induced in the
water electrical changes of an opposite sign. It will be
seen that any change in the surface of separation must
necessarily produce an electrical disturbance exactly in
the same manner as do the movements of the caiu'llary
electrometer, and in this respect nn' suggestion harun)-
uizes entirel_v with that of D'Arsonval.
Stimulation, whatever its character, whether mechani-
cal, chemical, thermal, or electrical, brings about a change
in the state of division of these colloidal particles. It
produces either one of two effects, i.e., a coalescence of
the particles (gelation), or an increase in number of the
particles (solution). According as a stimulus produces
one or the other of these effects we say that it excites the
nerve or anaesthetizes it. It may fairly be questioned
which effi'Ct is the excitation and which the amcsthetiza-
tion. This question may be answeri'd, I believe, by the
exciting acticm of drying the nerve and of applying cold.
Both of these processes excite or generate nerve impulses.
Since tliey can hardly be suppo.sed to increase the solu-
bility of the colloids, we may confidently assume that
they ctmgeal or precipitate the colloids, and hence that
excitation is due to a diminution in the number of col-
loidal particles and a reduction in their total surfaces;
and conversely, an;esthetization or inhibition is due to the
reverse procesg. All the exciting agencies may be inter-
preted in this way. Thus mechanical shock which dis-
turbs the hydrosol brings about such a condition of tem-
jiorary coagulation or rigidity of the nerve protoplasm
throwing the particles together. This interpretation is
strengthened by Mrs. Andrews' observations on the effect
of shock on the choano-fiagcllates, where the rigidity of
the previously fluid ])rotoplasm can be easily demon-
strated, and by my own observations on other forms of
protoplasm, notalily eggs. Cold, as will be seen, di-
minishes the staliility of the jirotoplasmie solution or
hydrosol, while warmth increases it ; negative ions pre-
cipitate po.sitive colloidal solutions and they excite the
nerve; excitation takes place at the cathode or negative
electrode, where positive colloidal particles will be pre-
ci]iitated ; the extraction of water acts in the same man-
ner as cold. In fact all the phenomena of excitation are
readilj' understood on this hypothesis. Similarly the
action of all amesthetizing agents becomes clear. Posi-
tive colloidal solutions are rendered more permanent by
positive ions, and these amuhilate nerve excitability:
warmth of moderate amount increases the stability "of
nearly all solutions, and this diminishes excitability;
ether and the ana'sthetics dissolve the protoplasm of
eggs and other cells and desfrov irritability : the anoile.
which holds positive colloids in solution, aliolisbes excit-
ability. We may sum up o\u' conclusions in the general
hiw that uerve excitability varies inversely with the sta-
bility of the protoplasmic hydrosol. The less stable the
hydrosol, the more irritable the nerve. Irritiability will
be lost when the uerve is stable, either in the condition
of solution or in that of total gelation. The rise in irri-
tability at the anode on opening the current is due to the
fact that, as already exjilained, by the action of the cur-
rent the particles are greatly divided: and after the cur-
rent is broken the d illusion cnitward of the jiositive ions
reduces the stability of the hydrosol here and it returns
back toward the normal. The electrotonic effects arc due
to the solution being made more stable near the anode
and less stable near the cathode.
232
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Norvcfs.
Nerve Tissue.
As readily as the facts of excitation are understood on
tliis hypothesis, so many of the facts of the electrical
phenomena of nerves may be explained. The electrical
disturbances are the result of tlie alterations in the sur-
face of separation of particles and liquid. Whenever
these particles coalesce, a portion of the negative
charges, formerlj- induced about each particle, are set
free. The portion of the nerve where this is occurring
becomes temporarily electronegative to the rest of the
nerve. Thus the current of injury is due to the coales-
cence of particles at the injured end. This is always
negative to the uninjured part.
If this is true, the exposure of the end of tlie nerve to
acids or ana'sthetics should diminish the current of in-
jury, whereas alkalies should increase it. Such I have
found to be the case. The current of action is the result
of the progressive precipitation of the colloids and a pro-
gressive setting free of negative charges. It is, how-
ever, impossible within the limits of this article to dis-
cuss tlie bearing of this hypothesis on all the numerous
electrical pheuoraena of nerves. It niaj- be stated, how-
ever, that a warmed or etherized portion of a nerve is
electropositive; a cooled portion electronegative to the
normal nerve.
The conduction of the nerve Impulse may be under-
stood on this hypothesis as follows: Each precipitation
of colloidal particles sets free by the accompanying re-
duction in surface negative charges formerlj' induced in
the water about each ])article; these charges at once pre-
cipitate the next layer of particles, and so on. Thus the
negative variation successively stimulates each following
segment of the nerve, as Hermann suppo.sed, and it is
regenerated i)y the change which it itself has produced.
The sheath and peculiar structure of the nerve probably,
as Boruttau supposes, plays an important part in the
electrical phenomena of polarization and stimulation, and
possibly in determining the speed of transmission, but
the cliange in the protoplasm itself is the most important
factor in conduction. Finally, it slioulil in all fairness
be stated that among the difficulties or excrplions to this
hypothesis are the statements that the ana'sthetics bring
aijout a preliminary rise in imtability, and that conduc-
tivity and excitability may vary somewhat independently
of each other. Whether these facts can be harmonized
with the explanation already offered remains for the
present unknown. Albert P. Mathcwi'.
^ Apathy : Millht'ilunffcn a. il. zool. station zur Xeapel. Leipzitr,
1897, xll.
= Waller: .\ninuil Elc.-triiitv. p. TO, IS'.IT.
'Sowton: Prini'il. H"V. s.x-., \<i\. l.wi., p. 379.
^ Ranke: Lehenstie'linLniimHii Uit Xt*rv(-n. 1868, Leipzig, p. 175.
5 Verworn : Text-Book of (ieiieial Physiology, Macmillan.
' Stroebe : Beitr. z. path. Anat. u. z. allg. Path., Jena, 1893, xiii..
p. I(i0.
' Cunningham : American Journal of Physiology, vol. i., 1S9S,
p. 239.
^ Langley : Journal of Physiology, 1899, vol. xxiv.
^ Arloing; Arch, de phy.siol. norm, et path.. Paris, 189t>, p. 7.^.
10 Eichhorst und Naunyn : Archiv f. oxper. Path. u. Phannakot..
Leipzig. 1K74, Bd. ii.— FUrstner u. Knohlauoh. Archiv f. Psychiat.,
Berlin, 1893, xxiii., p. 132.
1 1 Tigerstedt : Studien iiber mechanische Nen'enreizung, 1880.
'^ Gotch : Jounia! of Physiology, vol. xxviii., 19<)2. p. 33.
"Griitzner: Archiv f. d. ges. Physiol., liii.. 189;j, ]i. 103.
n Swammerdam : Bibel der Natur, Leyden, 1737.
'^Tigpi-stedt: Liic.cU.
" Uexkfill : Zeitschrift f. Biologic, 189.5, xxxi. and xxxU.
1' Heidenhain : Untersuch. z. Natnr d. Mensch. u. d. Thiere.
1&58, iv.
'» Boycott: Jour, of Physiology, xxvii., 1902, p. 488.
'" Howell, Budgett, and Leonard ; Journal of Physiology, xvi., 1894.
p. 29.S.
=« (irutziicr: Arch. f. d. ges. Physiol., liii., p. 113, 18a3.
-' Matlicws : Science. N. S., xv., p. 492.
-" E. l)u Bois-Kcviiiond: Untersuch u. thierische Electricitiit. 1.84.5.
-^ i)".\rsnnval : (Vnnpt. rend. Soc. de Biol.. Paris, 1893; ihhi., t.
cx\ i.. p t^ki.
-^ t^cxkiill : Zeitschrift f. Biol., xxx.
" Herrick : Amer. Journal of Physiology, vol. iv.. liKKl, p. 3(11.
^^ Mendelssohn : Dictioiuialr'- dc Phvsioi.,gie. Richct, vol. iy.. p. 31i'i.
" Goteh : .lournal of Physi,.|,.gy. v.. I. xxviii.. 19d2, p. :i2.
'" Hermann: Handbuch d. Physiologic, 1.873, ii., p. Ili2.
2» Waller: Brain, vol. xix., p. «.
'" Pfliiger: Untersuch. fiber Electrotonus, Berlin, 18.59. p. 140.
^'Hering: Sitzungsber, d. k. akad. d. Wissenscli., Wien, 1884,
Abth. 3. Bd. Ixxxi,\.— Boruttau : Archiv f. d. ges. Physiol., Iviii..
1894, p. 1 ; ihUK. l.siW; ihUl, Bd. xc, 1903, p. 233.-Bemstein : Untcr-
suchungen a. d. physiol. IiLst. d. Univ. Halle, 1888, p. 7.5.— Biedermann :
Elektrophysiologie, p. t)94.
^' Bowditch : Journal of Physiology, vol. vi., 18.8.5, p. i:i;f.
'3 Bernstein : Arch. f. d. ges. Physiol., Bonn, 1,877, Bd. xv., p. 289.
=' Rolleston : Journal of Physiology, 1890, xi., p. 308.
" Meyer: Archiv f. exp. Path. ii. Pharm, 1901.
=' Overton : Studien uber die .N'arkosc, Jena, 1901.
=' Biedermann : Archiv f. d. ges. Physiol.. Ixxx., 1900.— Frensberg :
Archly f. cxii. Path. u. PItann., vol. vi., p. 49, 1877.
=" Brodic and llallllnmcin : Journal of Physiology, xxviii., 1902.
3» v. Frey : Archiv f. I'hysiologie, 1883, p. 50.
^" D'Arsonval : Archives de Pbysiolotrie norm, et path., fifth ser.,
1. 1., p. 460.
NERVES, PATHOLOGICAL CHANGES IN. See JV>«-
roiu, til'.
NERVE TISSUE, HISTOLOGY OF.— According to
the fundamental conception of neurology the entire ner-
vous system, central as well as tieripheral, has been re-
garded as composed of morjihological units, the neu-
rones, held together by the supporting tissues, the
neuroglia. The term netirone was suggested by Wal-
deyer in 1891, and was accorded almost universally an
international acceptance b}' anatomists, physiologists,
pathologists, and clinicians. The term neuni. pro|)ose<l
by Rauber, and neurodendron by Kolliker, to designate
the same unit, have not met with similar favor. More
recent investigations, however (Apathy, Betha), have
thrown some doubt upon tlie neurone doctrine as for-
merly held. The neurone consists of a cell body, dendritic
processes, and an axis-cylinder process (axone with its
terminal ramitieatioiis). As the neurone does not consist
only of the cell body, but al.so has proces.ses, some of
which are of extreme length, it is impossible to see the
entire neurone in the majority of cases. As a matter of
convenience, therefore, the description of the neurone
may fall under two headings — the nerve cells or nerve-
cell bodies, and the nerve fibres.
The Nerve Cei.i.. — The essential part of a neurone
originating the nerve impulse is the cell body. Nerve
cells or g:inglion cells, as they are generally called, occur
in groups known as ganglia in the cerebrospinal system,
the sympathetic system, and in the organs of spi'cial
sense. While variable in size, the}' are among the larg-
est cells in the body, often, as in some of the ganglion
cells in the anterior horns of the spinal cord, reaching a
size of from 90 to IS.") /', the cells of Betz in the paracen-
tral lobule being especially large. Many nerve cells,
however, are much smaller in size, the cells of the gran-
ular layer of the cerebellum being only from 4 to 8,u in
diameter.
Study of the morphology of the neurones requires the
consideration of their external peculiarities as well as of
their internal architecture. The ffirmer are best revealed
by the methods of Golgi and Ehrlich, and the latter by
the methods of Nissl iind Held.
Morphology of tlie Sum Cells. — Nerve cells vary greatly
in shape. Starting originally as spherical cells, some may
retain this shape as in the spinal, Gasserian, or other gan-
glia; others may become ellipsoidal, as in the spinal
cord, pyriform as the cells of Purkinje in the cerebel-
lum, pyramidal as the cells in the gray matter of the
cerebrum, or stellated as the multipolar ganglion cells of
the spinal cord. The luost conspicuous peculiarity of
the nerve cells is the branching. Tliis may take place
only on one side leading to a prolongation of the proto-
plasm into a single pole, such cells being known as uni-
polar nerve cells; when the protoplasm is prolonged into
two, usually opposite, poles, the cells are appropriately
designated as bipolar; when the protoplasm extends
in several directions multipolar cells are formed. Each
polar prolongation is continued to form a nerve-cell proc-
ess. Of such processes two kinds are recognized, the
branched protoplnsinlc pnu-eiises and the uxls-eylinder
proimn.
The branched proloplasniic iirocesses, now usually
called ihid dendrites, form prolongations of the [irotoplasm
from the cell body, hence the old name of iirotoplasmic
process. They are always broader and thicker at their
origin, becoming gradually narrower as they divide,
233
Nerve Tlj>!»Uf.
Nerve Tissue.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
splitting up and stibrlividin? in an antlcr-liiie fashion
until a rich Iwig-worli or ai'borization results. Tlie
group of tprniiiial cnd-hrunchcs of llie (k'nilritcs is
linown as tlie telcHleiidnim. The fharactcr of tlie den-
drites, whicli result from the hraneliing of the proto-
plasmic processes, varies much in dilferent ])artsof the
central nervous sy.stem. In 'some cells the branching
commences a slinrt distance from the origin of the proc
ess, while in <itlier cells the jirocess continues for some
distance from the cell body before undergoing division,
and then suddenly breaks up into a large number of den-
dritic branches.
The cerelieljar colls of Purkinje are instances of the
former type, the apical dendrites of the jiyramidal cells
Fro. 3.'J73.— Schcimitic Ri-prt'seiitatiou cif a Lower Mntiir Neurone from
the Ventral Horn of ilir spmal Cord, tojrellier vviih all its prottip'a.s-
niic prort'sses ami tlicir ilivi.sions. The a.xi.s-cyliinlcr pnn-css with
it,s divisions, side tUtrils. or collalerals, and Hit- end raniiltrations
(telodendrions or motor end-plates) in ttio tnnsrio. ic|)icscni jtarts
of a sincrle cell or neuroni'. it.h., ;\.\ono hillork ilovoid )>f Nissl
bodies, and stiowins: a IiMalmcv lo tlhrillaiiori ; n.x., a.vis cylinder
or a.xone, also indistinctly lllndlat<-d. This pro'-css, itt a short dis-
tanee from Hie eel I body, boiotiies sMiTon tided liy a myelin sheiitli.
m, ;ind ;i eelhilar sheath, the netirileiniria, the latter tint heiiifr tin
inte^^al iiartof the neurone; r, (■yto))lasm stiowini,' HiedarK-eolored
Nissl liodies. septirat^'ii fnpiii one tinolher hy Hie litrhler ^Toiitai suh-
stiince; d, protoplasmic processes (dendrites) i-ontainitit.' Ni.ssI bod-
ies; ?;, nucleus: n', nucleolus; ?t./^, nodes of itaiuier: .s.t'., side
llbril: u. of n, nucleu.s of nenrilemma: Ul., motor etid-ptateoi- telo-
dendrion ; »i', striped muscle iHire ; .s. L., setriiieiitiUion of Sclimidi-
Lanterniann. (From "Tin' .\er\ousS\stein and n.sconstitiieni Neti-
loties," by Lewellys K. Darker. I), .\ppleton \ Co.. New York. l.sll'J.)
of the cerebral cortex of the latter. Tlie extent and
complexity of arborization is also variable, being com-
paratively simple anil with little branchinain some cells,
Fig. 3.573.— MulUpolar Gansilion Cell from the Anterior Horns of the
Spinal Cord, Isolated by Maceration and Teasintr. showint: that the
nunieroiis iiranched protopasmic processes ai-e sninewhal displaced
and distorted, owing to UKltlipulatlon. o, ,\.\is-eyliiiiler proci-ss ;
. cytoplasm j^ranular; nucleus laixe, distinct ; nucier.ius darker than
nucleus. (Piersol.)
while in others a complete arliorization exists, forming a
dense forest which extends over a Avide territory. Be-
sides the degree of complexity of arborization the rela-
tion of the dendrites to the surface of the cells is of in-
terest, since this branching may arise from only one or
two dendritic processes as in the cells of the hippocam-
pus, or it may originate from all sides of the cell like
Fig. 3574.— Cell of I'urkinjB from the Cerehellum of Man. Showing
pyriform cell bmly, lar^^e tirborescent protoplasmic jirocess with
gemniiiles forming the tvpictil telodendrla of the dendrilc-. n. Axis-
cylinder process ; /v, collateral tlbrils. (KoUiker.)
a radiation as in tlie ventrtd horns of the spinal cord.
Rarelj' neurones tire cli;iracterizcil by entire absence of
dendrites: such itdnnhHic elements have been observed
in the nervous system of invertebrates and also in the
234
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Nerve TltuKue.
Nerve Tissue.
sijinal ganglia of man. The contours of many lateral
dendrites exhibit the presence of small buds known un-
der the name of r/emmnle^s. The axis-cyUndei' process, neu-
FIG. ;357.').— Golffi's Cell of llii- First Type from tlip Torpus Genicula-
tum of a Cat. Showiiii,^ nurin'rous richlv brauched dendrites, and
the very fine axone witli u.s collaterui branches. (KBllilier.)
rite or axone, unlike the dendrite, is thin, slender, incon-
spicuous, straighter in its course and smooth in outline.
It was formerly described as an unbranchiug single
process, and was supposed to be always the continuation
of tlie axis cylinder of a nerve fibre. Golgi's investiga-
FIG. a'lTli.— Golgi's Cell of tlie Second Type from the Cerebrum of a
Cat. Siiowing x, the eoai^e protoplasmic processes easily dlstin-
giii.shalile from the more delicate a.\is-cyllnder process n. forming
the rich telodendrion of the asone. (Koiliker.)
tions have sliown, on tlie conti-ary, tlie existence of nerve
cells in which tlie axone is branched and does not become
the axis cylinder of a nerve fibre. Hence nerve cells are
arranged into two types — cells of the.^"ra< type, in which
the single uou-branchiiig axone becomes the axis cylinder
of a medullated nerve fibre, and those of the second type
in which the axone does not become the axis-cylinder
process of a nerve fibre but undergoes branching', form-
ing a telodendrion of the axone to which the name of
Fig. a")77.— Sfotor Nerye Cell from Ventral Horn of Gray Matter of
Spinal Cord of Kabbit. nf the three Icpwer pi esses, the middle
one represents the a.xone : all the other processes are tlendrites.
The margin o( the cells and of the masses of slainable substance
appear tno sharp in the reproduction. At the angle of diyision of
the ho ge dendrite at the left superior angle of the cell is shown one
of the wedges of division. The spindle-shaped NissI bodies are well
shown, especially in the dendrites. (From "The Nervous System
and Its Constituent Neurones," by Levvellys F. Barker. 13. Ap-
pleton ,Ss Co., New York, 189(1.1
deridrnxone or netu-opodion (KOlliker) is applied. The
termination of the dendraxone usually takes place by
exhaustion of repeated division. Veiy rarely and only
in exceptional cases the terminal branches are interwoven
to form a basket-like meshw'ork surrounding the cell
body of a second neurone. Axones vary greatly in
length, being very sliort, often only a few millimetres
long; in nerve cells of the second type the dendraxone
never leaves the gi'ay substance. In nerve cells of the
first ty])e, on the contrary, the monaxone may be exceed-
ingly long, some extending, as spinal nervefibres, fully
half the length of the body. Mouaxones are frequently
provided with collatertil branches or paraxones. These
collateral branches should
not be mistaken cither for
the arborization which lakes
place in the dendraxone or
for the true division of the
axone into two branches,
forming a right or an ob-
tuse angle resulting in the
T- or Y-shaped branches de-
sciilied by Hanvier.
In addition to the monax-
one neurones, din.rnne as wiOl
as jMlyaxone neurones
have been observed.
Ramfin y Cajal describes also
iinaxone neurones in the ret
ilia.
The mode of origin of tin-
axone also claims attenlimi.
The axone may arise fnuii
I he cell body directly or else
from the dendrite;" in this
ease the origin is usuallv
near the cell body, while
more rarely it is situated at
some distance from the cell
liody. At its origin the ax-
one is wedge -shajieil and
hence is called the implanta-
fion cone. It possesses cer-
tain characteristics in its in-
ternal structure and will be referred to later. The ax-
one may have protecting coverings or a sliealh. When
-Nerve Cell from the
Horn of the Spinal
an ().\. Showing
iiiiioto[)iiile tlakes,
nucleus ((/). imcieolus, and
the implantation cone or
a.xone hillock (M, devoid of
chroinatoiihilc granules.
(BiJhm-Davidoir.)
235
Nerve Tissut*.
Nerve Tissue.
REFERENCE IIANDBOcnC OF THE MEDICAL SCIENCES.
no envelope is present it is eustoniarv to speali of naked
axonea. Tlie coverings are the iieiiriirmiiiu. or tlie slieath
of >Sc/iW(tiiii, imd tlie mtdiiUiirii siibulaiice
* B ov {\\c irliUeanhiitiiiicedf t<ch>tann. One
iir botli may invest the axone for a
jiortion or its entire length. In the
ease of a nerve cell of the second t_vi:ie,
where the deudra.xone is limited to the
gray siihslanee, no sheath is present,
in irerve eells of the seiond type there
are stretches in whicii the a.xone is
naked, those in whicli it is enveloped
(inly by the nenrileninia, and linally
tracts in which both neurilemma and
mcdidlary substance are present. In
tlie latter case the medullary substance
is the inner sheath, while tlie neurilem-
ma is the (inter one. At times ill-de-
tiiicd liliriiiis tissue, called llenle's
slic.ath, is ]ireseiit outside of the ueuri-
lemma.
Structure eif the JVerre Cell. — Nerve
eells like all other cells consist of pro-
toidasm, to which tlie name of tie'im-
/Jiimii has been apjilied by Kolliker.
They cdiitain an attractidii sphere,
within wlijeh one or more ceiitrosomes
arc situated: a nucleus, which is
larger than in nmst other eells of the
body : usually a single uuclenlus, more
rarely .several nucleoli ; an implanta-
tion cone; several nuclear ca^s, and
sometimes several spindles. A vari-
able amount of pigment granules i.s
also present, depeiidiug upon the age
of the cell. Not every nerve cell, how-
ever, contains the above-enumerated
parts. In fresh preparations, without
tlie use of reagents, the protoplasm ap-
pears more or less homogeneous. With
the use of reagents and different meth-
ods of ti.xation the protoplasm varies in
appearance, being tilirillar, granular,
or vacuolated.
The latter two
conditions at
least may be re-
garded as ])rob-
ably artefacts,
oppiisite the' mid- produced by ic-
ru!.:ir>7it.- I'drtiiins
ofTwoMeilullatwl
Nerve Filires
Stained witli (Js-
iiiic Acid. ( Fi-om
a young ralibit. 1
X 4^.5 diameters.
R, R. Nodes of
Ranviei'. with
axis cylinder pas.s-
ing ttirou^h ; fi,
primitive slieaih
of the nerve or
neui'ilemnia ;
die of tlie .segment,
indicates tlie
nucleus and proto-
plasm lying lie-
tween the neuri-
lemma and the
medullary sub-
stance. In ,1 the
nodes are wider
and the interseg-
mented substance
is more appar-
ent than in B.
(Quain.)
a g e n t s. T h e
granules have a
sjiecial atliiiity
for certain ani-
line s t a i u s.
They apjicar
Very distinctly
when stained by
theNissl method
and are gener-
ally known as
jV i X .« ( bod i e x,
cliriiiiKitophile or lir/roi'd granules
(Pig. 3.577). The granules are
variable in size, regular or ir-
regular in shajie. and are arranged
in gr(m]is, rows, or irregularly;
sometimes simulating rods of
variable thickness and constitut-
ing the so-called " s/<ii/i<d)le aiih-
staiice " of Nissl. That portion of
the protoplasm which has no affin-
ity for stains is known as the
" unstiiinnhle toihxteinee^' of Nissl.
The granules are more concentrated in the inner portion
(or the entvplaxiii) of tiiecell. while in the outer portion (or
the ectopleism) they are more rod-shaped. The i-(id-sha|)ed
elements are present in the deudiite, but are not found
Kio. :!."iS|).— While or Med-
itllated Nerve Fibres
(shortly after deiuhi,
showing the sinuous
outlines and double
contours. (Quain.)
in the axone. Nissl suggested an elaborate classification
of nerve cells, depending upon the amount, the arrange-
ment, and the prop( rtion of the granular substance to
that of the cytoplasm and the relation of the granules
to the nucleus. This classification is, however, not gen-
erally adopted by neurologists.
The spindles, as their name indicates, are spindle-
shaped aggi-egations of chr(iniato])hile granules in the
stainable substance of the nerve cells.
The " viisl'iiiKihle xulixtiitiec" of the cell body consti-
tutes the ground substance, regarded by Nissl as homo-
geneous; but the investigations of Held (by a different
staining method) have not only shown this substance to
become stained of a
deep red color in con-
trast to the blue color
of the stainable sub-
stance, but also the
presence of longitudi-
nal threads not de-
monstrable by the Nissl
metliod. Within the
axone these threads
or fibres appear to
form a honeycomb
net work (the (i.roxpuitr/i-
)iiii). in the meshes of
which granules of va-
riable size (the tieiiro-
soiiiex) are present (Fig
3578).
The iijiiiliiiitiiiion
cone or a.voite hiUnd,- is
free from chroniato
phile granules, and
stands out in markid
contrast to the rest ot
the protoplasm of the
cell bodv on account of
the mottled appear-
ance of the latter.
The iiiich'iis is rel-
atively large, round,
usually centrally situated, surrounded by a delicate nu-
clear membrane, is single in adult man, and contains
numerous granules which have little alllnity for stain,
whereas the neucleolns, situated in the interior of the
nucleus, takes the staining deeplj". Lenhossek has de-
scribed the presence of several nucleoli. The nucli'ar
caps are dense aggregations of chromatophile granules
situated outside of the nucleus, but in close contact
with it.
Nkuve Fibres. — It is evident from tlie foregoing con-
sideration that the nerve fibres are the axones of the neu-
rones. The nerve fibres form the chief constituents of
all nerve trunks and enter largely into the composition
of the cerebrospinal axis, forming not only the whole of
tlie white substance, but constituting also a considerable
portion of the gray matter. Depending u|i(in the char-
acter of the coverings or sheath surrounding the fibres,
the latter are divided info two varieties, the medtiUated
and the non-nuduthtled fibres. Although this distinction,
for purposes of description, is convenient, it must be re-
membered that the same fibre may be medullated in one
part of its course, and later, in a dilfercnt part, lose its
medullary substance before reaching its final lermiiiatiou.
Mednlliiied Xerrc Fihren. — A typical medullated nerve
fibre consi.sfs of the (i.rh ei/liiiiler, the inner or axial por-
tion of the fibre, the mediitlnrii xiilistetiice, or the white
substance of Schwann, surrounding the axis cylinder,
the neiinle'iniiii, or s/icfith of Sekiranii, the outer covering
surrounding the medullary substance, and the nerve cor-
puscles or nuclei. The axis cylinder is the most impor-
tant ])art of the nerve fibre, conveying as it does the
nerve impulse and constituting the onlv part which is
never absent in the nerve fibre. The axis cylinder origi
nates in the cell body of the neurone as its axone and
terminates in the tissue to be controlled by tliat element.
Fig. .SiiSl. — Medulliited Nerve Fibres
from the tJoot of a siiinal Nerve near
its Termination, sliowiug the varicose
appearance of the llbres. n^uain.i
236
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Norve Tissue*
»rvc Tissue.
It appears as a thread, running through the centre of the
fibre, but consists of a bundle of very delicate nerve
Fig. 3583. — Small Branoh of a Miisriilar Nerve of the Frog. Near its
Termination. Showing the well-marked nodes of Ranvier, the
axis cylinder, and the division of the fibres at the nodes. (Kolliker.)
fibrilla?, called the ultimate nerve fibrilhe. lieUl together
by a homogeneous cement substance and surrounded b_y
a delicate and closely adherent membrane, the arihnima.
Surrounding the axilemma is the medullary substance,
much thicker than the axilemma, of soft fatty con.sist-
ency, and acting as a protecting medium to the delicate
axis cylinder. In the fresh state the med-
ullary substance does not lie in actual
contact with the axilemma, but is sepa-
i-atcd from it l)y a lymphatic space. The
medullary substance itself is not liomo-
geneous. but consists of a network of neu-
rokeratin, in the meshes Of which the soft
semitluid substance, the myelin, is held.
The myelin is of au albiunino-fattj' com-
position, containing protagou, and capa-
ble of powerfully refracting light. At
regular intervals, along the course of the
fibre, symmetrical constrictions of the
medullary substance occur, known as the
nodes of Ranmer. These notles are con-
strictions of the neurilemma and com-
plete interruptions of the continuity of
the medullary substance, but not affect-
ing the axis cyliiuler, which at these
points is in contact with the neurilemma.
That portion of the nerve tiln-e which is
situated between two adjacent nodes is
known as the intemode. In tine nerve
fibres the internodes are shorter than in
those of greater diameter, and in filiri'S of
the .same thickness they are shorler in
warm-blooded than in cold-bloo('cd ani-
mals. Near the termination of the fibre
the internodes are also shorter. At the
constrictions the axis cylinder is accessible
to various reagents which cannot reach it
at other points, as they cannot penetrate
Ihe medullary substance. Actual breaks
in the medullary substance are artificial
markings — the SchmidtLantermann seg-
ments as they are called. — resulting from
the use of reagents. These interruptions
may be distinguished from tlie true nodes by their ir-
regular character, their asymmetry, and by the fact that
no constrictions of the neurilemma
take place in these locations. Nerve
fibres are not uniform in diameter,
but vary greath' ; according to Kol-
liker, the finest fibres measure from
3 to 4 //, those of medium size from 4
to 9 H, while the largest possess a di-
ameter from 9 to 20/;. T/ie neuri-
hiinna or sheath of Schwann, is the
outermost covering of the nerve
fibre, and consists of a structureless
or hyaline membrane, surrouniling
the raedullarv substance. Oval nene
nuclei, or nerve cori)uscles, lie just
beneath the neurilemma in depres-
sions on the outer surface of the
medullary substance. Only one
such corpuscle is present in each in-
temode and is usually placed in the
middle of the internode. The med-
ullated nerve fibres in the central
nervous system have no neurilemma,
nodes of Ranvier, or corpuscles. In
the fresh state the medullated nerve
fibre has a glistening, homogeneous
appearance. After tieath the fibre
appears to have a double contour, but
later becomes mottled, as the result
of rapid disintegration. Osiuic acid
.stains the medullary substance black.
Non-Medullated S'ercc Fibres. — The
no7i-meduUated nerve fibres or the
fibres of Re mak are nothing more than
axones or axis-cylinder processes of
neurones devoid of medullary sub-
stance and neurilenmia. The latter,
however, is replaced by a delicate
sheath, beneath v.-hich the small nerve nuclei are located.
The nuclei are more numerous in these than they are in
Fig. a583.— Portion of
the Network of the
Fibres of Remak
from the Pneumo-
gastric of a Dog.
Showing (I, nucleus;
p, protoplasm sur-
rounding it and the
faint striation
caused by the fibrils.
(Quain.)
ml
Ml
tissue of the nene is onl> fclightlj stumed.
n e f M 1 T 1
al I 1 I r
r the f'ei ral
7 el let 1
re 1 I fat
t t er 1
t e 1 f 1 n 1
II tlef 1
ire dtrklj stained tut tl
lyuain.)
after
een
hof
left-
H f.
the
1 ated
ndo-
m ective
237
NerTOU8 System.
Nervous System.
REFERENCE HANDBOOK OP THE IIEDICAL SCIENCES.
Fig. 358.5. — A Simple Funiculu.-^
More Highly MaKnUJed. The ap-
parent small nucleated cells
are sections of the nerve flbres
and their axis cylinders, a.
Axis cylinder; u\ white sub-
stance of Schwann or medullary
substance; 7i, neurilemma; /',
endoneurium : /». perineurium ;
h, connective-tissue cells of the
same. ^Piersol.)
the medullated nerve fibres. Nmi-medulUitetl nerves
often appear varicose and exhibit a inurlied tendency to
l)raneh and t'oi-ni plexuses.
Tlieir ultimate libiilke are
more widely sepai-ated than
arc those of the niedullated
tibi-cs, protoplasm in the
former taking the place of
the cement substance in the
latter. As independent
fibres they occur principally
in the sympathetic system,
but not infi-equently they
are associated with medul-
lated fibres in nerve trunks,
as in the vagus.
Ni'i'te Tniiiks. — The nerve
fibres are usually collected
in bundles or funiculi, sev-
eral of which constitute the
nerve trunk. The individ-
ual fibres are liekl together
b_v a delicate eonuective
tissue, the endoncnriuni. A
certain number of the fibres
are grouped to form a funic-
ulus, the latter being surrounded by a more dense con-
nective-tis.sue envelope, the pcriiwvriiim. The funiculi
in turn ai'e grouped together to form a nerve trinik, and
are surrounded by a larger amount of loosely arranged
connective tissue, the I'puu'un'iim. This ti.ssue suppoi'ts
the blood-vessels and the lymphatics, which invariably
are present in the interior of tlie nerve trunk, as well as
the adipose tissue often present in the larger nerve
trunks.
The Neiiroylia. — The supp<irting substance in the
white matter of the brain and cord, as well as a consid-
erable portion of the matrix of the gray substance, is
made U]5 tif a netwoi'k of exceedingly ilelicate fibres, the
■ncuni;/Ua flbres.
and the neuroglia
cells, two vari-
eties of which are
distinguished —
the sjiiilcr cells and
the iiiossi/ ci'lh.
The cell body of
the spider cell is
s in a 1 1 e r, while
their processes are
long, thin, rigid,
with very little
branching. They
occur chiefly in
the white sub-
stance of the brain
and cord. The
mossy cells have
a larger cell body,
short, richly
branched proc-
esses, and are
principally found in the gray substance, where they are
often in intimate relation with the walls of blootl- vessels.
Hubert Fornutd.
NERVOUS SYSTEM, TRAUMATIC AFFECTIONS OF.
■ — It is not purposed here to aUeiiii)t a detailed ilrserip-
tion of all the alVections of the nervous system which are
caused by trauma. Within the limits of the present arti-
cle nothing further can be attem]iti(l than a brief analysis
of the cau.sal relations in which trauma stands to nervous
diseases, with especial consideralion of the place which
nervous diseases, when caused in this manner. oeru])y at
law. What is to be said, therefore, will be chiefly inter-
esting to the medical man who is brought in coiilact with
injuries to the nervous system and their legal com])lica-
tions. Personal-injury claims form a very iinporlant
Fig. 3f)86.— a Group of Spider Cells from the
White SubstJince of the Brain of Man,
stained by tJoIgi's method. Drawn as seen
under high magnifying power. (Kolliker.)
feature of modern life. Not only trausportation com-
panies, but private individuals as well, fully expect to
]iay for injuries which are received through actionable
negligence for which they are responsible. Similarly,
few receive injuries traceable to the negligence of others
without promptly dc'inandiug compensation. In our
mechanical times the frequency of accidents is enormous.
Consequently, the evaluation of injuries received and the
compensation to which the injured person is entitled are
matters of prime importance. Greater interests are in-
volved than iu any other medico-legal question. This
becomes plain as soon as we reflect upon the large sums
which are annually paid out in such cases. From the re-
port of the Brooklyn Rapid Transit Company for the year
1901 it appears that in that year more than one million
dollars was paid fiu' personal injuries and expenses in-
cident thereto. This sum represented nearly ten per cent,
of the gross receiiJts of the company for the year named.
Indivitlual verdicts are also often very high. As much
as thirty-five thousand dollars has been paid for a per-
sonal injury, and for a death claim resulting from the
Tunnel accident of the New York Central and Hudson
River Railroad of February 8th, 1902. a verdict of SOO,-
000 was returned by the jiny. Verdicts varying from
§10,000 to §20,000 are not at all unusual, and anything
under §1,000 is considered virtually a victory for ihe de-
fendant. Court calendars are overcrowded with these
cases, which form the bulk of jury trials to-day. But
the calendar is not a complete index of the degree of
activity in this branch of law, as for every case tliat
comes "to trial it is safe to estimate that ten are settled
by mutual agreement out of court. If the magnitude of
the interests at stake are taken into consideration, it is
not surprising that trial lawyers should be on the alert,
or that there should be great competition for plaintiff's
cases. As a result, "runners" or "ambulance chasers,"
representing legal firms which specialize in accident cases,
are constantly stalioned aboutcentres of traftic ; they rush
to the scene of accident, and make their apjjearance at
the hospital door almost simultaneously with the injured
person. Thenceforth the claim is prosecuted on the con-
tingent fee plan. The system hits doubtless been much
abused, and has been made the object of much attack and
ridicule. It is made possible solely through the poverty
of the plaintiff, who is generally unable himself to carry
on the great expense of trial at law, and who consequently
is forced to accept professional services which are to be
paid for, on a percentage basis, out of the damages
awarded. It has many very objectionable features. By
such a system the lawyer is made more than an advo-
cate, and the expert medical witness more than a mouth-
piece of science. But no practical and better substitute
has yet been suggested. The question will probably
resolve itself eventiutlly by fewer claims being litigated,
and more being settled by mutual agreement. Mr. Her-
bert W. Page, whose book, "Injuries of the Spine,"
published in ls!82, marked a distinct epoch iu the history
of this subject, told me a year or two ago that litigation
of personal-injury claims in England was becoming more
and more infrequent. Erichsen's book, which appeared
in 1866, and which furnished the original descripliou of
the peculiar symptoms resulting from railway and allied
injuries, gave the first effective impetus to litigation
of this character. For years afterward personal-injury
claims were prominent iu the English courts. But now,
according to the statement of Jlr. Page, they are so infre-
quent that, in his position as consulting surgeon to the
London and Northwestern Railway, he is called upon to
gotocourt only three or four times a year. Ithas seemed
to me that the willingness for compromise is growing in
this country also. Among the litigated cases those hard-
est to compromise are the ones in which injury to the ner-
vous system isalle.ged. In purely surgical injuries, such
as the loss of a limb or of an eye, the cause is definite,
and the question quickly resolves itself into one of liabil-
ity and the appraisal of the value, as far as such an ap-
praisal is possible, of the injured or missing member. But
in nervous affections, and especially iu the functional af-
238
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Nervous System,
Nervous System,
fections, wilh tlieir obscure causatiou, their iudetinite atitl
often bizarre symptomatology, agreement is miicli more
difficult. The contending parties are often at variance
in regard to every iiarticular. Neither is inclined to
give in, and the case, if it is a case, goes to the jurj'.
Nervous diseases are divided into two great classes,
organic and functional. A functional, as opposed to an
organic disease, is one in wljicli the anatomical integrity
of nervous structure remains unimpaired. Fimctional
diseases doubtless have a material pathology. But such
a pathology remains inaccessible by any methods of in-
vestigation at present at our disposal, and we are there-
fore obliged to retain this classification, artificial as wo
know it to be. Of the organic nervous affections caused
by trauma, the vast majority are delinite siu'gical in-
juries to the central or peripheral nervous system. Thus,
injuriesof all kinds to the bead, with injury of the brain ;
to the back, with injury to the spinal cord: or to the
peripheral nerves, are causes. When, in addition to the
cause, wecan demonstrate certain cardinal abrogations of
function of these organs, which we have learnetl to rely
upon as indications of structural alterations in them, the
diagnosis of organic injury is justifi.able. Thus, after
head injuries, paralj-sis of one or more cranial nerves, or
of the e.xtremilies, together with other general symji-
toms, speaks for injury to the brain; paralysis, with an-
esthesia in characteristic areas, anil loss of control of the
sphincters, speaks for iujury to the spinal cord ; paraly.sis,
with degenerative electrical reactions, speaks for injury
to a peripheral nerve. Injuries of this character are or-
dinarily easy to recognize, and the prognosis in regard to
tliem can usually be formulated with considerable pre-
cision. Consequently, in common with other surgical
injuries, when they are seen in court, which they rarely
are, tlie questions for the jury to decide concern the legal
aspects of the accident rather thau its surgical results.
There is a group of chronic organic diseases, with un-
certain and indelinite causation, which are not infre-
quently the subjects of litigation. The most important
of these are locomotor ataxia and general paralysis of the
insane, or general paresis. Others of this class are ataxic
paraplegia, progressive muscular atrophy, paralysis agi-
tans, syringomyelia, multiple sclerosis, etc. These latter
are, however, nuich rarer diseases than the two first
mentioned, and conse(iuentl3' of much less importance.
Both locomotor ataxia and general paresis are compara-
tively common (the latter chielly in cities). As has been
said, their causes are obscure and undetermined. It is
possible, and indeed probable, that injury can act as a
contributing cause in their development. Ijut the weight
of scientific evidence is against their ever occurring solely
as the result of trauma. Both diseases are often latent for
a long time, and both may undergo a sudden outbreak of
symptoms as the result of disease or injury. Both dis-
eases, by their symptoms, expose the victims of them to
accidents. It is consequently not surprising that both
are frequently made the subjects of personal-injtiry
claims. Juries often award verdicts in such cases, in
view of the fact that sworn experts, who frequently' <lo
not at all understand the condition about which they
testify, atfirm that the injury was the sole cause of the
trouble'.
Epilepsy isanotberdisease, which in this connection can
be considered organic, and about whicli legal interest fre-
quently centres. That typical epileptic convulsions fol-
low bead injuries, even when there is no discoverable in-
jury to the brain, is an incontestable fact. In order to
establish a reasonable support for such a contention in
any given case, it is necessary to prove that the patient
had not had epilepsy before the accident, and that the
accident, in character and severity, was of a nature to
produce such a result.
While the three diseases named above not infrequently
figure in litigated cases, the chief interest, both legal and
scientific, in traumatic affections of the nervous system,
centres aliout the functional disorders known, since the
appearance in 1889 of Oppeuheim's monograph, as the
traumatic neuroses. In the earlier treatises, and espe-
cially in Erichsen's, these neuroses were totally misunder-
stood and were classified with organic injuries. Progress
throughout the whole field of neurology has now made
it possible, in most cases at least, to distinguish these
two great classes. As originally described by Oppen-
heim, the traumatic neuroses present chiefly the symp-
toms of neurasthenia and hysteria, but also some which
indicate structural lesions. The term was a taking one,
and has attained a rather different meaning from that
which Oppenheim intended. To-day, by a traumatic
neurosis is understood a simple neurosis, without known
organic basis, plus such characteristics as its traumatic
origin has added to it. Thus considered, the traumatic
neuroses are composed of symptom groups wiiich can,
in nearly all cases, be brought under the rubric of
neurasthenia or hysteria. In causation, they have many
points in counnon. They have both attained their promi-
nence through railway accidents. This is partly due to
railway accidents so often being due to actionable negli-
gence, and partly to the fact that in such accidents phys-
ical injury and mental shock are conspicuously com-
bined. Both mental and physical elements are present
in nearly all accidents. In most ca.ses of neurasthenia
the bruising and shaking up have been considerable, al-
though severe surgical injuries are usually absent. Hys-
teria, on the other hand, is a fright neurosis above all
else, and the history of iujury in its causation is often
very inconspicuous. It is well to observe iu this connec-
tion that in the State of New York there can be no re-
covery of damages unless there has been a definite phys-
ical injury. Injuries resulting from fright alone do not
constitute a cause of action.
Much has been written and much said about litigation
as a cause of functional nervous diseases following
trauma. If one were to be guided by the fluent gener-
alizations of .some railway claiih agents, one would have
to believe that any real injury to the nervous system
could uot occur on a railway : that all persons who al-
lege such injuries either deceive themselves or wish to
defraud the company. Certain experts, on the other
hand, who are especially prominent in plaintiff's cases,
are not inclined to accord much importance to the finan-
cial side of the question. Leaving aside actual simula-
tors and imjjostors, ■who are very lare, I may say that
roy experience has taught me that the question of dam-
ages has a great influence on both neurasthenia and hys-
teria, and that in neither disease is restoration of health
probable while litigation is pending. This baneful effect
is due to the difficulty of carrying out proper treatment
so long as legal questions are pending. Were the treat-
ment for such cases simply medicinal, such a statement
would naturally appear aljsurd. Medicines, however,
play a very insignificant role in the treatment. They
are of some indirect service, but far more important is
the psychological direction of the patient. The diver-
sion of the patient's thoughts away from morbid chan-
nels, the arousiug of his interest in matters not connected
with himself or his troubles, the exclusion from his con-
sciousness of suggestions wliich may magnify or create
symptoms, — these are the keys to the successful Ireatment
of the traumatic neuroses. They are rendered powerless
by the damage claim. The frequent examinations by ex-
perts (in some cases as many as five or six doctors exam-
ine a plaintiff), the law's delays, the legal inadvisability
of the patient's returning to work, and the thousand and
one annoyances inevitable to litigation, render futile any
attempt to control the patient psychologically. These
factors, in my opinion, are tnuch more responsible for the
continuance of symptoms than is any desire which the
patient may possess to profit by his misfortune. This is
especially true for traiunatic hysteria, iu which disease,
aside from its being an agent iu suggestion, the money
question has little or no influence. The q uest.ion of litiga-
tion as a cause of the tr,auraatie neuroses must be kept sep-
arate from the question of voluntary exaggeration of
symptoms actually present, and of simulation or fraud
pure and simple. As far as actual simulation is concerned,
it is very rare, and should not pass undetected by a phy-
239
Nervous Sjstoiii.
Nervous System.
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
siciau who is skilful aud reasonahly resourceful iu his
methods of cxaminatiou. Voluntary exaggeration of
symptoms actually present is more difficult to detect. It
is not often encountered in hysteria. But in neuras-
thenia, the making the most of symptoms is an integral
part of the disease aud inseparable from it. It is, there-
fore, not an easy matter to determine when it reaches tlie
point where the patient exaggerates in spite of himself
and involuntarily, or when it is intentional, voluntary,
and purposeful. There is no rule to guide us in deter-
mining how this question may be satisfactorily answered
in any given case. Some help may be derived from in-
formation obtained from outside sources. But as a gen-
eral rule the physician's concbision must be based on liis
own examination, and the soundness of it is usually
directly proportional to his experience and acumen, both
professional and worldly.
In what has now been saiil. it has been plainly hinted
that the traumatic neuroses arc the results of mental im-
pressions, rather than of physical injuries. The different
ways iu which tliese impressi(jns act and in which their
effects are elaborated constitute the two main symptom
groups of neurastlienia and hysteria. Eacli gioup has
some characteristiis in common with the otlier. But each
has also its own individuality, which stamps it as a deti-
nite clinical entity. Neurasthenia represents irritability,
fatigue, and exhaustion. Such perversion of mental
function as exists is in the line of exaggeration of ten-
dencies common to all mankind. Hysteria, on the other
hand, is ab.solnte delusion. The premises of the neuras-
thenic's reasoning may bi^ sound, but the deductions
which he draws from them are too general. The hysteric,
on the other hand, is wrong in his premises, and the de-
ductions which he draws arc insane delusions. The
former is within the boundary line of mental alienation,
the latter way beyond it. • The characteristics of a case
of traumatic neurasthenia are usually somewhat as fol-
lows:
A man, whose previous life has, according to the evi-
<lcnce, been healthy, is iu an accident in which he is
considerablj' shaken up and badlj- frightened. He is
astonished to find that he has escaped without severe
physical injury. He is able to walk, and in general
accidents lie can oft(>n render assistance to those more
severely injured than he. That night he does not sleep
well. He is disturbed by dreams; or thoughts recalling
the catastrophe thrust thenrselves into his consciousness.
From then on he linds himself becoming more nervous,
more easily fatigued, and more irritable than formerlv.
His sleep is regularly disturbed, and tritles upset him.
He has lost his nerve. In short, he develops the ordinary
symptoms of neurasthenia {7. v.), with which every prac-
titioner is only too fannliar. He dift'ers iu some respects
from the ordinaiy neurasthenic. Pain in the back, only
occasionally complained of in non-traumatic neuras-
thenia, is very luduiineiu iu the traumatic varictv. It
may exist as a dull {■onstant pain, or lie in the form of
lumbago, increased by all movement. The mental state
also is dominated by the recurring thoughts of the acci-
dent, and by a dreail of its repetition. With s\ich slight
variations the picture is the same as in ordinary neuras-
thenia. The mental state varies from tliat of the irrita-
ble, [pierulous, self-centred, intros|iective semi-invalid,
to that of the lU'onounced hypochondriac. Dejtrcssiou is
a dominant feature, and may entirely do awaj' with work-
ing capacity.
Neurasthenic complaints, in addition to tho.se of
fatigue, fear, depression, etc, ma_y refer to neaily all
parts of the liody. Some of them have olijective" sub-
stantiation. There is no true paralysis, but the muscles
are quiek!_v fatigued as has been shown by the ergograph.
There is often tremor of the face, and with it tliere is gen-
erally associated a tine tremor of the ling(ns. In addition
to subjective pain iu the back, there are usuall}' ime or
more vertebral sjiines which are extremely sensitive to
touch. These spots are often shifting, they are not al-
ways in the same places. Headache is another common
sj-mptom. It is referred, most frequently, to "the base
of the brain." Feelings of numbness and tingling are
regularly complained of, but there is never any objective
aua;sthesia. The vascular disturbances are particularly
important. All neurasthenics have imstable sympathetic
nervous systems. Thisconditiou is shown b\' the sudden
changes in color of the face, by the cold hands and feet,
and by the fact that sensations of heat and cold jiass over
the whole body. The heart is also irritable and often
constantly over-active. Attacks of palijitation are com-
mon, aud are iiuluced by trivial causes. There is also a
more or less persistent tachycardia.
Digestive disturbances are almost constant. They,
in common with the mental state, are responsible for the
poor nutrition of many of these patients. Complaints
regarding the genital apparatus are frequent. Women
notice disturbances of menstrual function. lumen these
complaints are chiefl.y in regard to seminal losses, to
jirostatorrhffia, etc, Iu a certain jiroportion of cases
there is loss of sexual desire. The patients worry and
reason about this, and fear that they are becoming im-
potent. Asa result they approach the sexual act with
timidity and often with great excitement. As a result
of their fears tliere may fail to be au erection, or the ex-
citement tmder which they labor maj' cause ejaculation.
These failures become nifire pronounced with succeeding
attempts, until finally, in despair, the patient is convinced
that his virility is gone permanently. In some litigated
cases impotency is the chief item in the complaint. In a
recent case a j'oung Swede, a sui)erb specimen pliy.si-
cally, brought suit for i?3.5,O0O for such a cause. He had
fallen with some wooden structure into a river, and in ris-
ing to the surface had been struck across the thighs by
a wooden beam. He was bruised, but the testicles were
not directly injured. Active sexually before, he alleged
that after the accident he experienced great loss in sexual
power. Experts in his behalf testified that he was sterile
and inciu'ablc. The jury, however, apparently adopted
the view of neurasthenia, for they awarded a verdict of
only §2,000, which sum the judge |)romptly cut in two.
In hysteria, the mental state often has many neuras-
thenic features, but in its salient characteristics it is
totally different. The striking s^'mptoms of hysteria —
namely the palsies, the blindness, and the anicsthesias —
although tbe_v constitute physical manifestations, are of
purely psychic origin, dependent upon delusional beliefs
or on fixed ideas. That they do not result from struct-
ural alterations is |iroved by their inconstancy and sud-
den lluctuations. Their occurrence iu all peoples and in
all times, and their conformity to definite aud consistent
s_ymptomatic behavior in all classes of people, render
absurd the jjosition of those who contend that hysteria
is voluntary simulation and not a disease. It seems to
me very important that it be more generally recognized
that hj'steria is a distinct affection of the mind, and that
its symptoms, while varied, are none the less character-
istic and distinct. Contrary to the popular imjiression,
and to the etymology of the name, it is not rare in men.
Traumatic hj'steria, in mj- personal experience, lias been
more frequent in men than iu women. Present conceji-
tions regarding mental diseases lead us to assume that
they occur chietly if not exclusively in persons who are
hereditarilv predisposed. In most of tlie cases which I
have seen it has been impossible to prove the existence
of an hereditary predisposition. I slioidd add, liowever,
that most of these cases were litigated; consequently too
great scientific value should not to be given them.
The sym]itoms of traumatic hysteria are striking and
varied. They may appear immediately after theacci-
dent, or they may be (ielayed until the morning after,
or even for several days. This interval has been called
bj' Charcot the "period of meditation." During it the
patient is reflecting on the accident, is reasoning about it,
subconsciously, and then he finally develops the symp-
toms. These may be referred to every organ and every
system of the body. The)' may very closely resemble
symptoms due to organic disease. But iu the imitation
there is always a flaw. The reproduction is never per-
fect. Thus, in hysterical paralysis, there are not the
240
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Nervous System.
Nervous System.
degenerative electrical reactions which arc characteristic
of peripheral palsies, or the changes of reflexes, rigidity,
etc., which are characteristic of cerebral paralysis. In
hysterical anaesthesia, also, the loss of sensibility is too
transitorj-, or its association with other s)'niptoms too
contradictory, or its distribution too irregular, to war-
rant the belief that it rests upon an organic basis. It
would be impossible, within the limits of the present arti-
cle, to go into the symptoms of traumatic hysteria in de-
tail. The reader is referred to the article lli/sten'a in
The H.^xdbook, or to the chapter on Traumatic Hysteria
in my work on "Accident and Injur_v in their Relations
to Diseases of the Nervous System. " The following brief
summary of the more important .symptoms may be useful
here. Paralysis is usually in the form of hemiplegia,
without involvement of the face. In an overwlielming
majority of cases it alTects the left side. Monoplegia
usually affects the arm and is generally the sequence of
some slight injury to that member. Paraplegia is rare
in traumatic cases. It is not accompanied by involve-
ment of the sphincters. Polyplegia is most unusual.
The paralysis of hysteria is of a flaccid type, and usu-
ally affects the limb in its entirety. It gets better and
worse, according to changes in environment. It is not
accompanied by electrical degenerative reactions nor by
changes in tlie deep reflexes. Anaesthesia varies in dis-
tribution with the paralysis. Sometimes it affects the
whole body. In hemiplegia, there is hemiauasthesia
on the paralyzed side; in monoplegia, the sensory loss
may affect the whole side, or only the paralyzed mem-
ber. In paraplegia the genitals retain their sensibility.
The ana;sthesia of hysteria is profound and affects all
forms of cutaneous sensibility. It ma_y change its situa-
tion and extent asaresultof mental impressions. Sight,
hearing, taste, and smell are also commonly affected. The
visual disturbances consist in concentric limitations in the
visual fields, changes in the color fields, or amblyopia.
Spasm of the orbicularis sometimes prevents the patient
from opening the eyes. Hysterical deafness is a common
.symptom. If there is paralysis, at the same time, the
deafness is unilateral and on the side of the paralysis.
Deaf-mutism is rare; it occurred in one case in my ex-
perience. The deafness, which was comjilicated by
hemiplegia, led to mutism, and at last report, one year
and a half after tlie litigation had ceased, this condition
still persisteti. The hysterical attack is very important
in litigated hysteria, as the patient is almost certain to
have an attack in court. At a recent trial the plaintiff
was in convul.sions for two hours and a half in the court-
room. Such demonstrations ajipeal very strongly to tiie
sympathies of the jury, though in the case referred lo
the jury disagreed on the lirst trial, and returned a ver-
dict for the defendant on the second. These attacks arc
commonly called h\stero-epilepsj' — clearly a misnomer,
as they are not in any way allied to epilepsy. They dif-
fer from epileptic attacks in the character of the aura, the
quality and duration of the convulsive plienomena, and
the absence of biting of the tongue arid of the invohm-
tary passage of urine. Epileptic attacks are not precip-
itated by excitements and crowds. Hysterical attacks
havea predilection for dramatic surroundings. The lack
of conformity to organic types makes the distinction of
hysteria from the diseases which it simulates nearly al-
ways possible. Juries, however, fail to recognize Ibis
fact and consequently the medico - legal relations of
traumatic hysteria are very peculiar. Under existing
conditions it is almost impossible fora jury, composed of
laymen, to decide justly with regard to traumatic hys-
teria. The plaintiff is generally brought before them.
and he is almost sure to present the acme of all the symp-
toms which he has had. If some of these symptoms had
previously disappeared, they are quite sure to retniii
during the progress of the trial. The psychosis is nour-
ished upon suggestion and introspection, facilities for
which are so profu.sely furnished by the excitement and
observation attendant upon court proceedings. It is en-
. tirely consistent with the nature of this malady that exist-
ing symptoms should become worse or vanished ones
Vol.. VI. — 10
return on such occasions. It is not necessary to assume,
in explanation, any voluntary exaggeration or simulation
on the part of the patient. The efl'ect of this clinical
idiosyncrasy on a jury, however, is disastrous to the
cause of the defendant. The twelve jurors have heard
from the medical experts of the two sides testimony too
often directly conflicting. On the one side the opinion
has been expressed that the patient's condition is due
simply to nervousness aggravated, if not caused by the
suit, and that the symptoms will soon subside when
the legal proceedings are at an end : on the other side, the
belief has been sworn to that the injury is of organic and
irreparable character, or. if perchance its funcrional na-
ture is admitted, that the nervous system has sustained
a shock from which it can never recover.
The jurors may be convinced of the honesty of all the
views which they have heard expressed, and yet they
are unable to determine, from the character of the testi-
mony, which of the opposing opinions is the more likely
to be correct. They are, therefore, obliged to rely upon
the impression made upon them by the injured person
himself. They see before them an individual in an even
worse condition, perhaps, than his doctors had depicted.
They see an alleged paralyzed limb absolutely motion-
less; they become witnesses of an emotional outburst
more harrowing tlian any related in the evidence. And
they see these things one or two years after the accident
has occurred. Their natural inference is that the in-
juries are permanent. They find it hard to believe that
the outlook for a malady wliich has so long defied the
resources of medical skill is anything but hopeless. They
are unwilling, if not unable, to believe in the unreality
of physical symptoms. They cainiot comprehend a part
being the seat of paral_ysis or insi-nsibility, unless there is
some grave physical defect behind it; they do not know
that a limb which is immobile to-day may be in wonted
activity to-morrow. Thrown on tlieir own resources by
the contradiction in medical testimony, they render a
verdict in accordance with their own impressions as to
the plaintiff's injury. These impressions indicate a per-
son severely and probably incurably injured; and the
verdict, rendered accordingly, is generally in excess of
anything to which the plaintiff is entitled.
The two types, h_vsteria and neurasthenia, as above
sketched out, are in most cases distinct and unmistak-
able. In some cases the type of mental state is neuras-
thenic, with enough of the hysterical added to cause a
heraianiesthesia or other permanent stigma of hysteria.
To this type has been given the name of hystero-neuras-
ilienia. In other cases, coupled with the symptoms of
functional disease, are certain signs indicative of mate-
rial destruction in the nervous system. These latter
cases are difficult to classify. It is not to be denied that
some of them are the direct outcome of severe traumatic
physical injuries. Most of them, however, can better
be exphiined on the assumption that some pre-existing
organic disease, such as genci'al arteriosclerosis, syphilis,
or alcoholism, has been made wor.>;e. or has first been
called into prominence, by traumatic agencies.
The prognosis of hysteria and neurasthenia provoked
by traimia is a subject on which verj- diverse views are
held. Reliable statistics bearing on the question are few.
Certain facts, however, are in our possession. Neither
disease is fatal. Some writers maintain that the vas-
cular disturbances of neurasthenia lead to serious degener-
ation in the heart and arteries anil .so to premature death.
Some few instances also are on record in which death dur-
ing the convulsive phenomena of hysteria has occurred.
Such cases are. however, so rare and so poorly sub-
stantiated by reliable evidence that we are safe in assert-
ing that these diseases do not kill. It is not to be denied,
however, that some patients have the same symptoms
for years and years, and, as far as is known, never get
well. On the other band, there is nothing about either
disease which makes recovery impossible. Organic dis-
eases, such as locomotor ataxia or progressive muscular
atrophy, are manifestly incurable. But in the neuroses
j a cure, in the widest sense of that term, is possible.
241
Neuralgia.
Neuralgia.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
The vital i|iicstion <-i)iircTns working capacity: What
are the chaMCfs for a return of workiiij; capacity, pro-
vided lliat liad been lost'/ To this qtiostion the answer
is, that under reasonably favorable eonilitious these
chances are very sood. They are the best in patients
who try to return to work as soon as is feasilile after the
accident, who are young, previously healthy, and of
good family liistory.
The prognosis which can be given in a ease of neuras-
thenia is not always permissible for a case of hysteria.
A person suffering from traumatic neurasthenia can often
be brought to a condition in which he can safely return
to work soon after tlie accident. The subjective disturb-
ances, however, of which he complains may persist for
months or years afterward. Indeed, it is very dillieult to
tell when they stop, and tlic patient may never himself
admit that he is the same as he was before the accident.
In hysteria, on the other hand, recovery may be longer
delayed, Init wlien il comes it is generally morecomidete.
Few if any hysleriivd jiersons can tutdertake any work
before the question of litigation is settled. Rut when
that is once out of the way, a period of a few months
generally, tliough not always, is sufficient for a fairly
complete return of working capacity
Pcarce l>i:/ilri/.
NEURALGIA. — Definition and Nature. — The term
neuralgia in its strict sense signifies pain along the course
of a nerve. Tlie word has been used, however, to inili-
cate conditions in which such pain exists ptn'ely as a
neurosis, to distinguish it from the cases in which inflam-
matory anil degenerative changes are present in the
nerve, to which class the name "neuritis" is applied.
Probably the majority of the neuralgias are dui' in
part only to any primary or essential neuro.sal disorder
of the nervous centres, and indicate, in addition, some
irritation of the sensory nerves from without.
This isemineutly true of most of the typical neuralgias
of the superficial nerves, and as our kiiowle<lge of the
course and pathology of these diseases advances, many
of the conditions formerly classed under the neuralgias
are shown to be cases of neuritis. For instance, tbegrad
ual onset and decline of certain fiu'ms of sciatica and
brachial neuralgia, tlieir protracted course, the limitation
of the pain to the tract and distribution of single nerves,
and the fact that the pain is apt to be remittent rather
than internuttent, together with the presence of tender-
ness along the nerve trunk, persistent alterations in the
sen.sibility of the skin, and even nnisetdar atrophy and
trophic changes in the skin, all tend to point to the neu-
ralgia being .secondary to a neinitis, w hile examination
of the nerve shows characteristic changes of inflamma-
tion and degeneration.
Then tliere are cases, such as some of the facial neural-
gias, in which the character of the pain isthat if neuralgia,
persistent, interniitteid, and freijuently in neurotic indi-
viduals; and liere examination of the nerve, after the
affection has existed some time, often shows degenerative
changes. The (]uestion then arises. Arc these changes
primary or secondary — i.e., is the case a slow progressive
neuritis from the start, or are these changes in the nerve
secondary to the long persistent disorder of function
which underlies the pain? Tlic recent ion theory of Loeb.
that the transmission of nerve stimuli is due to chemical
change in the nerve sidistance, might well accotmt for a
permanent change resulting from constant severe pain
persisting in the nerve.
Finally, there is the class of netiralgias in wliieh the
character, situation, severity, and duration of tin- pain are
wholly determined by ]n'oce,sses acting on bealt by .sensory
nerves, and may be called reflex or symptomatic neural-
gias. These irritative causes, however, if long con-
tinued, may induce a permanent neuralgic, habit of the
nervous centres.
The group of habit pains might also be classed as
neuralgias, and both these and othi'r forms may often be
relieved lij' miaital influences.
It is uncertain whether there are special uirvrsand
nerve centres intended for the conveyance and perception
of painfid impressions, but the results of experimenta-
tion and the dilTerence in tlie behavior in disease of this
fimction — if so it may bi- calle<l — from the other sensory
^unctions. lead to the belief that such may be the ease.
Again, it may be that the nerves of pain are the .same
with the nerves for the general feelings ((7eiiu-iii;iefuhle)
of satisfaction or discomfort, which accompany, and yet
are distinct from, the special .sen.sations of relation, such
as touch, temperature, and the like.
If there are special nerves anil nerve centres for pain,
it is probable that they are the seat of the disease in neu-
ralgia.
It is common to hear the neuralgias of the superficial
nerves spoken of as the only alfections really deserving
the name, and as belonging in a different category from
the visceralgias and the periodical headaches, as well as
from the pains of intermittent recurrence, but of ill-
detined seat, to which children and feebly nourished per-
sons, and especially neurotic persons, are liable.
In so far, however, as these painful disorders occur
under sinular conditions with tj'pical neuralgias of the
superficial nerves, and are themselves of unknown ori-
gin, there is much gained in treating of them both as
kindred affections, and contrasting them with each other.
GkniiI!.\l Etiology and Patuolooy. — An inherited
neiireipiitliie teixh-ney is the most important cause of neu-
ralgia, and it is often impossible, in a given case, to meas-
ure the degree to wliich its intluence is felt. Il is, how-
ever, a far more important element in the migraines and
the visceralgias than in the superficial neuralgias, and
among tlie latter its effect is most strongly felt in the
neuralgias of the fifth pair, and of tlie intercostal nerves.
The exact pathological state of the nervous centres in
neuralgia is not known, any more than it is in the case
of the other neuroses. Some of the conditions that give
rise to it are, however, better tmderstood.
Chief among these are: Aiuvmin. which acts both by
impoverishment of the blood, and by overcharging the
blood with carbonic acid; the presence of abnormal S'lii-
slanecsin theliliiail, as in gout, diabetes, malaria, chronic
nephritis, and metallic poisoning: dhsorptinn of the prod ■
iictn (if imperfect dii/estioii or iiietahoUum ; the im/iairment
(f the cdneiiliir toiiicity, as in fatigue: peripherid irrit,r.
tioiis, such as disease of the teeth, eves, resjiirntory and
digestive tracts, uterus, and ovaries; chronic iidlamma-
tion of the nerve sheath ; lociilized anivmin or cuiir/mtion of
nerces or nerve ceotrea.
Anmniii and states of nrrvoiis debility or chronic fitirpir
are common underlying causes of neiu-algia. even though
not the whole cause, and it is almost always best to sus-
pect them and to fortify the jiatient against them by
ainple nourishment and tonic treatinent. Although
anaemic and debilitated patients are more prone than
healthy jiersons to neuralgias of every sort, this is espe-
cially true with regard to the superficial neuralgias, the
.sufferers from migraine and the visceralgias being often
in good, even robust, health so far as any ana'udc ten-
dency is concerned.
Anannic neuralgias are. as a rule, protracted, like their
cause, but may in the end pass away rapidly under ap-
pro|iriate treatment.
Diabetes sometimes causes intractable and often sym-
metrical neuralgias, especially sciatica, even though the
symptoms of the underlying disease are not marked.
Oont and ki)idr(il rf/w/r/iv'.'i (litha'inia) may cause neu
ralgia. partly b}- alteration of the blood, or by direct irri-
tation of the nervous centres, and partly by inducing
neuritis. These neuralgias are sometimes bilateral and
fugitive, sometimes lasting, according to tlieir origin.
Visceralgias are also common in the gouty, but it is an
open question whether this may not be, in part, because
of the neuropathic tendency which is intimately con-
nected with gout.
Oliroiiic neplirilis. and the vascular and nutritive dis-
orders associated with il. may cause various neuralgias,
both superficial and visceral.
Si//ihilix likewise causes neuralgias both in its earlyand
'242
REFERENCE IIANDIJOOK OF THE IVIEDICAL SCIENCES.
Nt'uraltfiii,
Neuralgia.
in its late stages, acd liere also tlie manner of its action
may be eitlier direct or indirect. It is also worthy o( re-
flection, in a given case of this kind, whether the cause
of the neuralgia may not be the antisyphilitic treatment
which has been used, and not tlie disease itself.
The neuralgias due to mineral poisoiiin;/ ave npi Ui ha
bilateral, or to attack different parts successively. The
arthralgias and visceralgias of lead poisoning belong in
this categor}', but will be treated of with the other symp-
toms of tlie same origin.
Peripheral irritations cause neuralgia which is some-
times confined to the region irritated, sometimes located
in distant parts, and are always to be carefully sought
for and eliminated, since, even when they constitute oidy
partial causes, they may be practically responsible for
the seizures. Cai'ious teeth may excite neviralgiain otlier
branches of the tifth jiair besides that directly irritated.
Injuries, such as severe jars, as in raih-oad accidents, or
blows, even when they do not apparently injuie any par-
ticular nerve, may e.\cite severe neuralgias, and the same
is true of eniotiouril exeitement or incntal orerstrain, acute
or chronir.
The pains due to tlie pressure of caiirerniis f/rairths, or
other tinnom, and aneurisms, though often classed as non-
neuralgic, are really not always to be distinguislieil from
neuralgia by any intrinsic characteiistic. The diagnosis
is often established by other indications of tlie presence
of morbid growths, and, so far as the nervous sv'stem is
concerned, is rendered probable bv nimsual persistence
and severity of the pain, the occurrence of signs of neu-
ritis, such as marked atrophy, contracture, anesthesia,
etc. A bilateral distribution of the pain is also sugges-
tive of such a cause, jiniuting either to pressure upon
synimetrieal nerve trunks at tlnir e.xit from the s|iiniil
canal, or, in the case of the brachial nerves, to a sym-
nietrical enlargement of lynipjiatie glands. Neuralgia of
the fifth pair lias occasionally been tiaeed to aneurism of
the internal carotid.
Cold and damp weather and the atmosplieric' changes
preceding and accompanying storms are fruitful causes
of neuralgic attacks, acting no doubt in part by dejiress-
ing the general nervous tone, and in jxirt l)y causing
congestion or anaemia of the sensitive cutaneous nerve
fibres, and even increasing any neuritis that may be
present.
It is proper to speak here of the relation to neuralgia
of such general intlueuces as ai/e and se.r.
C/»'W/eW is usually considered nearly free from nru-
ralgia, but this is only true of the typical, peripheral
neuralgias of protracted course. The .so-called "grow-
ing pains" of childhood may fairly be called neuralgic,
and children sutler from visceral neuralgias, and some-
times from tj'pieal migraine or periodical lieadaclic.
Puberti/ brings an increased tendency to migraine and
headache, which then usually lasts until the age of forty-
five or fifty. The neuralgias of acute anaemia and chloro-
sis occur also largely at this period, thougli ana'mia is
probably also a cause of some of tlie pains of childliood,
All neuralgias are most common in middle life, mainly
because it is then that the nervous strains incident upon
increased cares and exposures of all kinds make llii'in
selves most strongly felt, and act liotli directly and indi-
rectly by increasing neuropathic tendencies.
Neuralgias rarely bef/in in old age, and when they do
they are very intractable, perhaps because they depend
upon tissue degenerations in the nervous and vascular
systems. It is, however, a noticeable fact to which tlie
writers can liear testimony that, in sjiite of their severity
and persistency, the neuralgias of old age sometimes un
expectedly disappear for longer or shorter periods, or even
permanently.
The female sex shows a relatively great liability to the
neuralgias of neuropathic origin ; the inalc sex to neural-
gias of peripheral origin.
Genku.vl SY.MPTOM.\TOLOf4T. — All neuralgias have in
common a greater or less tendency to j/i rindie and aji-
pareiitly snontancous rerurrrnr, . liiit tlie degree to which
this periodicity is seen varies gicatl_\ .
The mcst regular and sjiontaneons periodicity is met
with in the malarial neuialgias and in those of' mainly
neurosal origin, especially migraine and the periodic
headaches. The visceralgias recur less regularly, but
their outbreaks also are frequently, to all appearance,
spontaneous, that is, due to cj'clic changes within the
nervous centres themselves, and not to irritation from
without. In both cases this tendency to cyclic outbreaks
may be interrupted, and attacks prc<ipitated, by various
causes.
Besides these neuialgias of regular recurrence, persons
of neuropathic constitution are often liable in some de-
gree to spontaneous attacks of pain, of I'clatively short
duration ; but the tj'pical superficial neuralgias of pro-
tracted course, as a rule, show but little of this tendency
to periodical and spontaneous recurrence, so characteris-
tic of the more distinctlj' neurosal neuralgias. They
may recur, it is true, but this is either from a recurrence
of their underlying cause, or because tlie neuritis, which
is usually present as an important com])lication, if not a
cause, does not entirely ixiss away ami excites the neu-
ralgia to fresh outbreak.
Almost all neuralgias have in comniim a tendency to
excite raso-iuotor and tj'o/i/iir clianijrs. Tlie raso-motOT
phenomena are most marked in cases of the migraines,
which are often characterized b^' a marked pallor or red-
ness, or both in turn, of one side of (he head. These vas-
cular changes have, in fact, been widely believed to be
the essential feature of migraine, and to be directly re-
sponsible for the pain: but this is, in the writers' judg-
ment, a mistaken opinion. Similar symptoms are seen in
the other neuralgias, especially those of the neighborhood
of the eye, and probably attend, if they do not cause, the
changes in the glandular secretions (tears, urine, mucus,
gastro-intestinal fluids), which are also very common near
the seat of anj' .severe neuralgia, and even at a distance
from it. The writers have seen a sharp attack of intercos-
tal neuralgia, for instance, of short duration and due to
acute fatigue and exposure, pass entirely away with a
copious discharge of limpid urine, such as often attends
the close of a niigraiuoid attack. Finally, migraine is
often unattended by any noticeable vascular changes.
The tropliic ]ilienomena are most markeil in the case of
the superficial neuralgias, and range from such changes
as are obviously due to neuritis (lierpes zoster and other
cutaneous eruptions, muscular atrophy, and the like), to
the more temporary alterations which are partly of vaso-
motor origin, or due to irritation of trophic or glandular
nerves, and partly of unknown origin (oedema of the
skin, changes of color and increased brittleness of the
hair, temporary muscular eufeeblement, impairment of
the eyesight, possibly even glaucoma, etc.). The cases
associated with herpes are occasionally accompanied by
palsy of the muscles innervated hy tlie affected or related
nerves. The trophic changes in migraine are but slight.
It is often included in the definition of neuralgia, that
the pain is confined to the reijion oj' distribution, of one or
more rierre branelies, but this apjilies only to the neural-
gi.is of the superficial nerves.
It is common to most neuralgic attacksthal the jiain is
iuli'rnriftent orrenrittent in severity. When a continuous
dull aching is present, it may be sus]iected that the neu-
ralgia is complicated by a material degree of neuritis.
For furtherexaminafion of their symptomatology, neu-
ralgias may be divided into:
1. Superficial neuralgias.
3. jMigraine and the perioili< al headaches.
3. Visi-eralgias.
4. Unclassified neuralgias of incgul.ir distribution.
1. The supejfeial neuralr/ias nvL- limited to the course
and areas of distribution of one or more nerves or parts
of nerves supplying the skin and adjacent structures.
The principal varieties are: (1) The neuralgia of the
fifth nerve, of which there are several subdivisions; (3)
tlie neuralgia of the occipital nerve; (3) the neuralgia of
the cervico-brachial nerves: (4) the neuralgia of the ab-
dominal nerves; (.")) the neuralgia of the anterior crural
nerves; ((i) tlu^ ni'uialgia of the sciatic nerves.
243
Neuralgia.
Neuralgia.
REFERENCE HANDBOOK OF THE :MEDICAL SCIENCES.
All those neuralgias have the following peculiarities in
'Common: The attacks are sometimes brief, often of rela-
tively long duration.
The brief attnehx generally occur in persons of neural-
gic habit, and under these circumstances are more likely
to attack the facial, intercostal, or abdominal nerves than
the brachial or the sciatic. They may occur spontane-
ously, or from some special cause, as fatigue, excitement,
or exposure, and may pass away after a night's sleep,
like an attack of migraine, the disappearance being some-
times .-ittendeil with a copious secretion of urine. Gouty
persons are also subject to brief neuralgic attacks; and
there arc other obscure di.sorders of the nutrition (so-
called lithremia, and the like), of which the same is true,
though it is by no means easy to say whether the neu-
ralgia is reall.y secondary to 'the nutiitive disorder, or
both arc symiitoms of an underlying nervous alTectiou.
Vaso-motor ciianges are conunon in acute attacks of brief
duration, leading to pallor or redness of the skin. Such
attacks are often attended also by increase, pieceded at
times by diminution, in the secretion of neighboring
glandular organs, and occasionally by cedema of the
skin. Theseplienomena are perhaps of vaso-motor ori-
gin. Ilypera'Sthesia of the skin is often present.
The ii'tUii-kn (if nhitin/i/ hmy (hiration usually come on
gradually and are recovered from gradually. The pain
is not felt over the whole area of distriluition of the
nerve, but has its points of election, and from these
points the pain spreads or darts farther. Sometimes, and
especially in the case of sciatica, the course of the nerve
itself is the painful region, and it is believed that it is
the sensitive nervi nervorum ramifying in the main nerve
trunk that are mainly or even alone concerned in the
neuralgic process in such cases. General tenderness
along the uervi' points to neuritis, but the localized ten-
derness which has just been referred to, and which is con-
fined to certain definite s])ots {points (loiili»ircv.v of Val-
leix), probably do not necessarily have this significance.
These spots of tenderness are apt to coincide with the foci
of pain, V)ut do not always do .so. They are usually
found where the nerve emerges from a bony or fibrous
canal, or where it begins to ramify in the skin. The
pain is often accompaiued by subjective and objective
disorihrs if the sensibility. The former consist in sensa-
tions of prickling and numbness, or of heat or coldness.
These sens;itions often jirecede or follow as well as
attend an attack. When they overlast the attack a long
time, and especially if they are sliarply localized, they
usually iudieale that the nerve has been tlie .seat of the
inflammation. The '/;;'( (V/cc disorders are of the nature
-either of hypenvsthesia or of anjesthesia. The former is
usually seen at the beginning or at the height of an at-
tack, and the latter usually later. A persistent impair-
ment of sensibilily points to destruction of some of the
sensitive nerve fibres from neuritis.
Tmp/tie c7iaii;/es ia the skin and its appendages, or in
the muscles, are common and usually point to neuritis.
The mu.scles near an acutely painful region are some-
times temporarily jiaralyzed without api>arent cause.
The hair of the eyelirow and seal]) has been known to
"become blanched iluring a neural,gie attack of the fifth
nerve, recovering its color later. This change of color
is proliably due to the penetration of air into the hair
shafts.
TnH.\T-MENT Of SiPEiiFici.vij Ni:i'i;.\nu.\s (c/i/c also
sections on Neuralgia of the Fifth Pair, Sciatica, etc.). —
Oiiisid 'J'reiitmeiit. — The importance of removing the
causes of the neiu'algia is evident to every one, but it is
not equally recognized that it is necessary to remove
partial causes, no matter how many there may be. Such
causes are princiiially . (1) Exposure to alterations of
temperature and weather, to be met by suitable clothing,
change of occupation, temporary removal to a drier, or,
it may be, to a more relaxing climate; (i) periphend irri-
tations, either near or reunite from the scat of p.-nn ; (3)
neuritis, jirimary or induced ((•/(/<' below under Klectric-
ity and Surgical (Operations); (4) dyscrasias, such as
gout, syphilis, diabetes; (o) fatigue, ausemia, lack of
proper nourishment. It should be remembered in this
connection that a state of health sutficient for ordinary
purposes may not be suUicient as counteractive of neu-
ralgia. What would seem excessive nourishment (see
under Neurasthenia), combined, if necessary, with mas-
sage and rest and cod-liver oil, ar.senic, and large doses
of iron, if well borne, is useful in a large number of
cases.
Si/mptornatic Treatment.— This comprises the means
used to relieve pain and to counteract the neuralgic con-
dition and the irritability of the nervous centres. The
imiiortant lemedies of this class are: Quinine, acouitine,
ieide under Neuralgias of the F'ifth Pair), salicylate of
.sodium, opium, the coal-tar products, croton chloral, elec-
tricity, hydriatic treatment, counter-irritation, vibration,
and local manipulation in the affected region, and surgi-
cal operations. The method of use of these remedies is
too familiar to need comment, except that of the last
tive.
Electricity is mainly useful in the form of galvanism,
which is usually applied with one pole of the battery
near the nerve centres, and the other near the nerve
trunks of the affected part. Its special indications are
for the temporary relief of pain and in the treatment of
neuritis. It is proliabl_v indilferent which pole is used
in the painful area, but, on the other hand, it is of great
importance, in acute neuralgias, that the current should
flow without interruptions and that the strength should
not be .suddenly increased or diminished. The electrodes
should be large and well nourished with warm water.
The strength of the current shouhl not be so great as to
irritate the skin, and thereby excite, instead of soothe,
the patient. Moderate variationsof the current strength,
as made by sliding the electrodes slowly over the skin,
sometimes increase the effect. In chronic cases strong
currents are sometimes useful, and it is not necessary to
observe the .same caution as to interruptions of the cir-
cuit.
Static electricity is of value in some cases of neuralgia
given either in the form of sparks or in the unipolar
method of charging and discharging described by Dr.
.Morton.
Jlydriiitic (or Thermic) Apjiliciitions (so far as they can
be used outside of special iustitutions) consist in the use
of the local and prolonged wet-pack {ride under Sciatica) ;
local bathing and showering, or, in chronic cases, the
filiform douche; prolonged general warm baths (useful
as a general sedative); prolonged application of ice (ride
tmder Sciatica) ; or the application of dry warmth in the
form of hot sand or salt bags.
(Jountcr-irritiitiiinmixy be applied in the form of stimu-
lating liniments and ointments, mustard, blisters, the ac-
tual cautery, or spray of ether, or of chloride of methyl.
The liest liniments are those containing aconite and lau-
danum combined with alcohol and chloroform, or strong
.solutions of menthol ( 3 i. to fl. 3 i.). A strong aconitine
ointment (one part to eight) is said to be useful, but
must be employed with great caution. These agents act
not only by the irritation wliich they set up, but prob-
ably by lessening the sensitiveness of the skin as well.
In the same way cocaine, instilled into theeye, will some-
times relieve pain in the globe aii<l in the supra-orbital
region.
Prolonged and iliythmical vibration or manipulation
over an alVected nerve, best done Ity an instrument de-
signed for that purpose (Granville's hammer), is said to
be of service, and similarly some forms of headache can
often be relieved by prolonged manipulation or vibra-
tions with, the linger tips.
Siirgiciil Operntidiis comprise deep injections of irri-
tants, such as water or chloroform ; removal of a portion
of the nerve (ueiu'ectomy); stretching of the nerve; and
extirpation of the nerve roots or of the Gasserian gan-
glion.
Injections of chloroform have been followed by alarm-
ing results, probably by its introduction into a vein,
though this is a rare event. The best way to avoid it is
first to introduce the needle alone imtil its point comes
244
REFERENCE HANDBOOK OF" THE MEDICAL SCIENCES.
Neuralgia,
IVoiirjilgia,
near the nerve, and not to inject the chloroform it any
blood appears. Tlie dose is from ten to twenty minims.
Nerre-stretchituj is iiiipro|)riate for mi.xcd nerves, and
has been applied to almost all the superficial nerves of
the body, including the intercostals. Us effect is partly
to diminish the conducting power of the sensitive libres,
and thereby diminish the irritations reacliing the nerve
centres, partly to alter the condition of nutrition in the
nerve trunks, and partly, no doubt, to e.\ert a so-called
inhibitory action witli regard to the neuralgic condition
of the nerve centres. The operation is not often followed
by serious results if done under proper antiseptic precau-
tions, but when large nerves are treated in this way mor-
bid changes are occasionally set up in llie spinal cord.
This operation has found its greatest sphere of usefulness
in sciatica, to which heading (p. 247) the reader is referred.
Nenirctomy and extirpation of ganglia are considered
under facial neuralgia (j). 246).
SPECi.iL Forms of Superficial Neuralgia,
Trifacial Neuralgia. — The fifth pair is more frequently
affected in neuralgia than any other nerves. Conrad's
statistics of seven hundred and seventeen cases of neural-
gia showed thirty-three per cent, to be trigeminal. This
frequency is due, in part, to the exposed position and ex-
tensive distribution, many attacks being induced by dis-
ease of parts supplied by its different branches, as the
teeth, nose, eyes. etc.
The forms" of trigeminal neuralgia may be clinically
divided into three types:
1. Supraorbital neuralgia.
2. Reflex neuralgia.
3. Tic douloureux.
Tiiis division may not in away be absolute, since many
attacks of supra-orbital neuralgia, though implying a neu-
ropathic constitution as a sine qua non, may be brought
on by peripheral irritations, and thus in a way be re-
flex. "
Furthermore, supra-orbital neuralgia maj' exist as a
type by itself, or the nerve may be involved in either of
the other two forms.
1. fjiipra-orhitnl Neuralgia may be divided into: A.
Those manifested by constant pain. B. Tliose in which
the attacks are intermittent. C. The periodic attacks.
A. The pain in supra-orbital neuralgia may be constant
and persist for several weeks or more. In this case its
character is generally described by the sufferer as twisting
or boring, and radiates from above the eve to the vertex.
During the attack there is generally tenderness over the
supra-orbital foramen. Such attacks are frequently
found with diseases of the eye, especially iritis and glau-
coma, and may be tienetited bv treatment of these condi-
tions. The supra-orbilal neuralgias associated with herpes
are apt to be very persistent.
B. The intermittent type is generally characterized by
making its appearance in the earlj' morning and continu-
ing with great severity till two or three o'clock in tlie
afternoon, when the paiu subsides, only to recur on the
following day. This type, from its intermittent charac-
ter, was once thought to be ahvays due to malaria; and
the fact that large doses of quinine, given three or four
hours before the paroxysm is due, has generally proved
beneficial seemed to corroborate this view.
In this locality, at least, it is usually a sequel of a co-
ryza which extends upward, causing a catarrhal inflam-
mation of the frontal sinuses, to which the ophthalmic
division sends sensory fibres, and free drainage of these
sinuses is essential to recovery. This intermittent type,
however, may persist as a neurosis or habit neuralgia
long after its original cause has gone.
C. The supra-orbital neuralgias which come jKriodicallg
at more or less regular intervals form a group by tliem-
selves, the attacks often being foreshadowed by marked
gloom and depression of spirits.
These attacks may be accoinp'iinied by eye symptoms
and vomiting, and after lasting a definite period of time
disappear. This migrainoid type derives its name not
only from the character and periodicity of the attacks,
but from the fact that it sometimes alternates in the same
jiatient with typical attacks of migraine. Moreover,
there are patients who suffer from migraine from child-
hood till adult life, when the character of the attacks
changes and the migrainoid neuralgia takes the place of
the old headache.
2. Refiex Neuralgias. — The characteristic of the reflex
neuralgias is that they stay until the cause is removed.
The most common form is that due to diseases of the-
teeth, especially where cavities have led to exposure or
disease of the pulp. They may also be due to changes
in the alveolar processes, or to swelling and thickening
of the periosteum of the bony canals through which the-
nerve passes. Alore rarely they are caused by aural dis-
ease.
The pain in this group of neuralgias is usually constant
or jumping, though it maj' be parox_vsmal. simulating
tie doidoureux. It is possible that in some cases true
"tic douloureux" begins as a reflex (tooth) neuralgia.
Against this, however, is the fact that the teeth have so •
often been drawn without benefit. Moreover, these re-
flex neuralgias often occur before the middle period of
life.
3. The third tyi")eof trifacial neuralgia. Tic Dolnurevx,
is to be sharp!}' distinguished from the other forms. It
begins in middle or advanced life and runs a characteris
tic course. The pain is located in tlie area of distribution
of the second, orthe secondand third divisions of the liflh-
nerve, more rarely involving the first or all three branches-
It generally starts in the upper lip or at the side of the
nose, and is described at times as flashing upward along
the nerve, at times as radiating outward like a ])inwheel.
It is paroxysmal in character, the attack being lightning-
like in onset, of extreme severity, and lasts about a minute, .
disappearing as abruptly as it came. During the attack
there is flushing of the affected .side of the face, with
twitchiug of the muscles, and often there are laclirymation
or salivation and a serous discharge from the nose. The
lightest touch ordraught of air will precipitate an attack,
while the patient dare not speak and refuses to eat solid
food, so great is his dread of the pain.
These paroxysms come from several to many times a
da_y, for periods of a few weeks or months, after which
the patient ma_y be free from them for an interval of sev-
eral mouths. It is oftentimes a striking feature in these
attacks that the pains occur with great frequency during
the day, while the sufferer may go to bed at night and
sleep unmolested.
The rule is for these alternations between periods of
pain and periods of relief to persist over long intervals
of time. It is uot uncommon to see patients who have
suffered for fifteen or twenty years.
I'atliologg. — Tic douloureux has been considered dufc'
to degenerative changes in the Gasserian ganglion, as i':--
scribed by many investigators. Coenen. however, man-
tains in a recent article that these changes are secondary
to peripheral operations [ireviously done for relief of 'ae
pain.
Degenerative changes of varying intensity have beea
shown to exist in the nerves by many investigators.
Whether these are the original cause of the pain, or
whether they result from the continued severe par-
oxysms cannot be decided with certainty.
Some investigations have demonstrated an endarteritis
in the vessels supplying the affected nerves, at times re-
sulting in marked diminution in the lumen of the vessel.
This may be a factor in many cases by giving rise to nu-
tritional disturbance.
The treatment of tic douloureux is medical and surgical,
and the former should be given a thorough trial before
the latter is undertaken. If the medical treatment is
successful, the immediate attack is prematurely termi-
nated, but permanent cure is rarely experienced. This,
however, is often all that is accomplished through the
peripheral operations, though the results of the latter are
more constant.
Besides the so-called "overfeedina:,'' and the observa
245
>j<*ural$!:ia.
Nciiral;:;ia.
REFERENCE HANDBOOEC OP THE MEDICAL SCIENCES.
tion of general hygienic rules, tlie following drugs, out
of the large uumljer rcoommeudi'il, give the best results:
Acouitiue (the crystallized alkaloid) is best given at first
in doses of gr. ^^ij to gr. -^Ijj every two to three liours,
in pill fcuni or solution ; then if no unusual susceptibiiitj-
shows itself, in doses of gr. j^ to gr. yj^ or even more,
though this amount is rarely passed without the patienfs
complaining of severe tingling and numbness of the ex-
tremities and sometimes of a sense of cohlness and faint-
ness. A moderate degree of thesis symptoms does not
contraindieate the continuance of the treatment for some
days, or even weeks, if the patient is otherwise in good
health and is con.stantly under observation. Tincture of
aconite root can be substituted ii neces.sary, but is less
certain in its aetii.m.
GelsiMnium niav be given in any reliable preparaticni
until tlie signs of physiological acti<in aii|>ear, tlie most
characliMistic being a drooping of tlie eyelids.
Castor oil rerlainly does good in .some cases, if given
every morning on rising, in half-ounce doses, increased
to one ounce as 'lie patient becomes accustomed to the
drug. Purgative effects often fail to appear after the
first few doses, , hough the remeilial action persists.
Iodide of potassium has many advocates and certainly
does seem to do good in some cases, especially if given
in moderately large doses.
Strychnine in massive doses is recommended bj' Dana,
in cases of not over four or five years' standing. He
keeps the])atient quiet in bed anil administers the str3'ch-
nine subeulaneouly, starting with gr. J^ once a day, and
gradually increa.sing initil gr. |- ir gr. J is reached. This
should be given for four or five days, and then the dose
gradually diminished. This should be followed, he says,
by an ioilide-of-potassium treatmenl.
Opium given in gradually increasing iloses till the pain
is controlled is advocated b_y l>a Tourette, who claims
very .satisraelory results from it.
Siirfiieiil trtfi/iiHiit consists in the /icn'ji/icni! operations,
which may be regarded as palliative, ami the extirpa-
tion of the Ga-sserian ganglion, which gives permanent
relief in most cases.
The perijjheral operations generally consist in cutting
downon the olTeiulingiU'rve — the<■u^^lolnary points being
at the. dental <'anal, iidia- or supra-orbital foramen, or
sphenoma.xiUary fossa — and in twisting and pulling out
as mu<'h of the nerve as possible. This procedure usu-
ally gives freedom from pain lasting from a few months
to two years. Occasionally a patient v\ ill be relieved for
three or four years, and some cases of cure have been re-
ported. The average relief from forty -three such oper-
ations, recently collected liy the w. iters, was ten months.
Three or four peripheral ojierations had often been per-
formed on the same patient. The Giiss( riiiii-f/oiii/Iioii.
opirolion, first done by Uose. ten years ago, is regarded
as the only means of alTordIng pi^rmauent relief, though
it is attended with considerable danger, owing to the lo-
cation of the ganglion and the liability to hemorrhage.
Ilorsley has performed this dithcult o])eratiou twenty-
one times, with only two deaths. The reports of two
hundred and one operations, collected by Tiirk, show
that in seventeen per cent, of the cases the patients died
as a direct result of the operation ; ninety-three per cent,
of tho.se who recovered were considered to have been
permanently cured. This percentage of ernes is, however,
open to some criticism, lor sufficient time had not ehqi.sed
after some of the operations to make it sure that a cure
had been clTected. On the other hand, the reoirrenee of
pain after some of the earlier operations may have been
due to the incompleteness of the operation.
Spider and Fra/.ier have recently brought forward the
question of division of the sen.sory root of the ganglion
as a ra<lical operation. This was tried twelve years ago
by Horsley and resulted fatally. It has never been at-
tempted .since then until last year, when it was recom-
mended as being a simjiler operation, and as attended
with less danger of hemorrhage than the extirpation
operations It is an important recommendation of tins
procedure that it leaves the motor root intact. TIk> only
uncertainty is that regeneration of the sensory root may
later take place with return of the pain. IIow great this
danger is can be shown only by time.
Occipital nfomUjiii is generally an affection of the oc-
cipitalis major ami minor and the great auricular nerves.
It approaches the neuralgias of the fifth nerve in .se-
verity and in its tendency to assume the epileptiform
type, and often superadds itself to them, especially to
the supra-orbital variety, by extension. In its typical
form it is commonly unilateral, and this, together with
its histoiy and the character of the pain, tisually serves
to distinguish it frcpui the <iccipital headache met with
in neurasthenia, chronic nephritis, intracranial tumor,
and eye strain.
In the treittment a diligent search should be made for
organic disease of the vertebrte and surroimding tissues.
This failing, salic3'lates or coal-tar products or the above-
named autineuralgic remedies ma.y be employed for re-
lief of the jiain. Galvanism often acts favorabl_v in this
form of ni'iu'algia. It, however, the pain proves intract-
able and relief cannot be obtained from medicine, surgi-
cal interference may be resorted to and resection of the
nerve may be done. Intradural resection of the posterior
root has n.'cently been performed with successful results.
Bnicliiiil (iiid Ccrrico-hracltiiil NenraUjiah^s the distri-
bution which its name implies, and the characteristics of
a typical superficial neuralgia. Like the rest, it is often
due to injury or neuritis, the latter sometimes being sec-
midary to affections of the shoulder-joint, but it may oc-
cur simidy as a sign of del)ility or a neuropathic diathe-
sis, or from concussion accidents and the like.
The pain usually centres in foci, such as the point of
the shouliler blade, the insertions of the deltoid, the
neighborliood of the supinator longus muscle, the wrist,
and more rarely the fingers, and radiates upward or down
ward from these points. The baud and even the whole
arm are often the seat of sensations of numbness and tin-
gling dm' perhaps to congestion of the nerve, or to dis-
orders of the circulation of vasomotor origin, or to
neuritis, and these sensations sometimes substitute them-
selves for the neuralgic pain.
The pat/iologicol diitgnoxiH should take into account the
possible presence of cancerous cervical glands, pachy-
nu'ningitis cervicalis, spondylitis deformans, and Pott's
(lisea.se (bilateral pain, muscular atrophy, rigidity of the
neck), or of angina pectoris.
Occupations and professions requiring constant use of
certain groups of muscles of the arm often give rise to
extremely obstinate and troublesome pain, which, how-
ever, does not follow the course of any particidar nerves,
liut is generally increased by motions involving the nuicli-
nsed muscles. It is not a muscular affection, but prob-
ably comes best under Oppenheim's head of psychalgia
brachii.
The chief point in treatment of this form is rest of the
affected member, but recovery is accelerated 113' general
tonics and static electricit3'. The treatment of brachial
neuralgias in general is that of the other superficial neu-
ralgias. Surgical treatment by nerve-stretching is pos-
sible at any point, even as high as the cervical plexus.
Intercostal A'ciiralgia is one of the commonest neuralgias
of debilitated subjects, especially women, and of persons
of nervous temperament. The intercostal nerves are sur-
rounded at their origin b\' large venous plexuses, and are
thus liable to suffer from an\' sluggishness of venous cir-
culation. Neuralgia from this cause is more frequent on
the left side, since there is greater obstacle to the empty-
ing of these vessels. It is afso met with in connection
with brachial neuralgia, or with neuralgia of the thoracic
or abdominal viscera. It is often associated with herpes
("shingles"), and then the jiain mav occur two or three
days before the appearance of the rash. It mav pass off
with the healing of the vesicles or may persist for weeks
or months. In many cases of intercostal neuralgia there
are tender points at the seat of the pain, which isusmilly
greatest over the side of the chest at the exit of the lat-
eral nerve branches. Often a tender point is also felt at
the exit of the dorsal or anterior branches. The path-
246
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
Neuralgia,
Neuralgia.
ological diagnosis sliould consider intratlKiracic cancer.
Pott's disease, aneurism (all of which would be likely,
but not certain, to cause bilateral pain), and jilcnrodynia.
In all cases the heart, pleura, stomach, and gall l)ladder
should be carefully examined for disorders. Tlie treat-
ment should be at first directed toward improving the
debilitated and ana'mic condition so often present. Blis
ters are often useful in cases not associated with herpes.
Iodide of potassium, salicylates, or quinine in large doses
may be given with benefit.
Ilio-lumbar Xeurnlgia needs no separate notice except
to remark that it is often found iu connection with affec-
tions of the uterus and ovaries.
Anterior Crural Neuralgia is not verv common and
needs no separate notice. The patholnnical diasrnosis
should consider the possibilities of hip disease, osteo-ar-
thritis of the spine, and pelvic tumor.
Meralijia Parcesthetica. — The symptoms of this condi-
tion, as the name implies, consist of partiesthesia and
pain, and these are located over the area supplied by the
external cutaneous nerve of the thigh. The surface in-
volved usually extends from the crest of the ilium to the
knee, on the outer aspect of the thigh, though onlj' part
of this may be alTected. There is frequrntly a tender
pressure ])oint just below the anterior sujierior spine of
the ilium. This disease may result from trauma, but is
commonly seen in people with a rheumatic or litha'nac
tendency. The treatment consists in hydrotherapeutic
measures, massage, and remedies directed against the
constitutional tendencies. The disease is not a very seri-
ous one, but often resists treatment almost indefinitely.
Sci-\TiCA is one of the commonest and severest varieties
of superficial neuralgia, both on account of the exposed
position of the nerve, which renders it liable to injury
both within and without the pelvis, and also from causes
which are more subtle and less well understood.
The causes of sciatica are : local injuries ; primary neu-
ritis, as in herpes zoster; exposure to sudden alterations
of heat and cold; intrapelvic diseases, even when they
do not directly involve the nerve itself, as uterine disease
for example; gout, diabetes, and the various constitu-
tional affections which impair the quality of the blood or
the general nutrition. Cancerous disease within the pel-
vis may, by ]iressure, give rise to pain which is hardly
to be distinguished at first from sciatica, and this cause
should be suspected if the symptoms are bilateral, un-
usually persistent, or attended with marked signs of neu-
ritis, such as ancesthesia. localized numbness, and prick-
ing, muscular wasting, and especially if other nerves are
involved at the same time. Chronic inflammation of the
tissues around the hip ma}- also give rise to pains which
could be readily mistaken for .sciatica. It is very impor-
tant, and usually perfectly easy to distinguish the pains
of locomotor ataxia from those of sciatica. The former
are bilateral, not confined to the distribution of the sci-
atic nerve, momentary in duration, and usually affect, by
preference, small spots in the fleshy parts of the limb, the
knee, or the heel, or dart down the leg and disappear
again.
Osteo-arthritis of the spine is commonly mistaken for
sciatica, the pain in this affection being caused liy in-
volvement of the nerve roots in the inflammatory exuda-
tion along the vertebra?. This gives rise to pain wliicli
is often (listributed iu patches, along the areas of distri-
bution of these roots, over the front andsideof thethiL'lis
and legs. Many of the curvatures described as sciatic
scoliosis by many authors are really signs of osteo-arthii-
tis, and are due to muscular spasm on the unaft'ected sidi'
of the si)iue, in attem]5ts to relieve the involved nerve
roots from pressure. This condition is recognized by the
marked muscular rigidity on the tuiaffected .side of the
spine. The motion of the vertebral joints is quite free
when the patient bends toward that side, while the lum-
bar spine remains perfectly rigid on any attempt to bend
forward or toward the affecteii side.
Symptoms. — The distribution of the pain in sciatica
may be coextensive with the distribution of the whole
nerve, but oftencr it centres in certain I'egions which
may vary as the attack goes on. Such are the sacral re-
gion, the neighborhood of the sciatic notch, the back of
the thigh, the popliteal space, the calf, the outer side of
the leg, or the outer side and dorsum of the foot. Some-
times the course of the nerve itself is marked out by
darts of pain. "Teniler points" are found at the sacro-
iliac synchondrosis, the sciatic notch, the popliteal space
behind the head of the fibula, behind the outer malleolus,
and often at other places as well. Some cases of sciatica
are of short duration and seem to be of purely functional
origin, while in others neuritis plays a large part in the
production of the symptoms, causing persistent pain,
loss of sensibility, cutaneous eruptions, coldness, and
wasting, and increased pain on motion, voluutar}' or pas-
sive. Even where tliese symptoms are absent, and
where the pain is fully iuterniittent, the absence of
neuritis cannot be confidently asserted in ca.ses of long
standing.
The 'progiiofiis of sciatica depends upon its cause. Ex-
cept when it is dependent upon some temporary irrita-
tion, however, it lasts usually for weeks or months, or
even longer, and is liable to relapses and recurrences.
The .sciatica of diabetes is said to be peculiarlj- obstinate,
even if the usual symptoms of the disease are not severe.
The treat iiu III of sciatica varies with its cau.s;aiou and
its stage (ride also under General Treatment). The re-
moval of diathetic taints, absolute rest, superficial blis-
tering, counter-irritation by a sjiray. of ether or of chlor-
ide of methj'l, the local wet-|iaek followed by vigorous
rubbing with cold water and by warm applications. If
access is obtainable to a hydrotherapeutic iustitution, the
Scotch douche may be used with benefit. Galvanism
Avith long-continued mild currents, cutaneous faradiza-
tion, are alwaj's in place, and turpentine, ijuinine, iodide
of potassium, or salicylate of sodium in full doses, may be
given in fresh cases for limited periods with some liope
of relief. .
In chronic cases the remedies may be jiroportionately
vigorous. The galvanic applications may be as strong
as the patient can bear, and special pains taken to local-
ize the current on the nerve, at the sciatic notch, and in
the popliteal space, by pres.sing the electrode inward, and
seeking to excite referred sensations at the periphery.
It probably makes no ditference whether the anode or the
cathode is emjiloyed over the nerve, or wliether the cur-
rent is occasionally interrupted. Indeed, a series of sud-
den reversirls of tlie current are often of service. Static
el<-ctricity in the forms jireviously mentioned (ride Gen-
eral Treatment) is of value in these cases. Deep massage
along the nerve, even if painful at the time, may be ol
great value, probably b}- removing inflanunatory "cxuda
tions. Ice-bags may be applied continuously along the
course of the nerve, and deep injections (ride under Gen-
eral Treatment) are serviceable, though not without dan-
ger. When othin- means fail, " nerve-stretching " may be
used, and, indeed, under proper antiseptic precautions,
it is not a dangerous operation in itself. It has, how-
ever, been shown that the effects of the traction are felt
in the spinal canal, and myelitis has in a few instances
been excited. A substittite operation is the so-called
" bloodless stretching." in which, the patient being under
ether, the thigh is forcibly flexed on the pelvis and the
leg extended at the knee, and this position maintained
for some minutes. That the nerve can l)e stretched in
this way is beyond question; but it may be doubted
whether the method is really safer as regards its second-
ary effects than that of the exposure of the nerve by a
single incision, and the use of a measured amount of di-
rect traction, upward and downward in turn.
Cocryijiidijnia. — This is a severe neuralgic pain iii the
region of the coccyx, occurring almost exchusively in
women. The pain is marked on sitting or during defe-
cation and micturition, and the end of the coccyx is ex-
quisitely tender to moderate pressure. The condition
occurs almost always iu neurotic individuals, but in:iy be
brought on by trauma or difficult labor. It frequently
runs an obstinate course and is best treated by tonics,
counter-irritatiim. hydrnthera)iv. or 'jiilvani^iui, Kxeis-
24T
/Vonralgia.
Neiirastlicnla*
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
ion of the coccyx maj' be performed, but often fails to
give relief.
It might be ■nell to speak here of the importance of ex-
amining tlie feet iu all cases of vague and obscure pains
in the legs, knees, thighs, aii<l hips, for the greatest va-
riety of sensations, from constant dull aching or buriu'ng
to sharp neuralgic twinges, may have their origin in weak
or broken-down arches, and immediate relief may be ob-
tained from pro|ii-r treatment. Jlelatarsalgia is but one
instance of this sequence.
Migraine — vide the article on Headache.
Viscer.Mj NEtruALGiAS. — The visceral neuralgias are
of great importance, both on account of the sulVering
which they cause, and because of their constitutional
significance. They occur, like the other neuralgias,
partly from general ncrvotis causes, such as fatigue,
go>it,"and otlier eoiistitutiiiiial diseases of the nutritinn,
and especially llie neuropathic tendency, and partly as a
result of fimctioiuil and organic disorders of the viscera.
To what extent actual neuritis occurs as a cause is not
yet known, but it is certain that chronic inflammation of
the nerves is often set up by organic affections of the or-
gans, such as the heart, to the neighborhood of which the
pain is referred.
The pain of the visceral neuralgias is usually deep-
seated, vaguely locateil, and dull, but at the same time
intense and prostrating, and sometimes attended with
faintness, nausea, sweating, and often disorders of the
circulation and secretions. Though not sharply local-
ized visceral neuralgias take their name from the organ
in the neighborliood of which they seem to lie situated,
as the pharynx, the a>,so|iliagus, tlie heart, stomach, liver,
bowels, ovaries, uterus, ri'ctum, testis, etc.
Anrjina Pectoris (-ice Vol. I., p. 22T), thotigh a true vis-
ceral neuralgia, is so often a symptom of heart disease
that it is usually described in that connection. It may,
however, be mentioned here that it occurs not infre-
quently, though hardly in its severest forms, entirely
independently of organic di.sea.se. In a case known to
the writers, for instance, it occurred during a consider,
able period on the slightest exertion, such as rapid walk-
ing, in a lady suffering from temporary deliilily fniin
overwork, and was each time attended with lireathless-
ness, and with pain and numbness in the left arm. yet
eventually passed entirely awaj'. Various other such
cases arc on record.
Dull pain felt dm-ing the intervals of tlie attacks is
looked upon as perliaps indicating neuritis of the (ardiac
nerves, but in such cases cardiac disease probably exists
as well.
It is an interesting question whether nitrite of amyl,
which acts so well in angina pectoris of organic origin,
would be beneficial also in the functional cases.
The treatment shiiidd be, in the first instance, tonic,
and in the attacks itself diffusible stimulants and anal-
gesics would be in place. Besides the outspoken disea.ses
of the heart, increased 'vascular tension sliould be sought
for, and signs of Briglil's disease, as well as functional
irritability of the nerv<i\is cardiac apjiaratiis, such as re-
sult from ])hysical overstrain and from abuse of tobacco
and other cardiac stimulants. Under these circumstances
digitalis or other heart tonics might be indicated.
When the attacksareof frequent ocemTence elerlricitv.
either by the superlieial u.se of the wire brush and fa-
radic current or in the form of galvanism, is said to he of
service, as is also counter irritation over the chest.
Onstrnlgia (gastrodyni.i, cardialgia, gasti ic colic) is per-
haps the most common lorm of visceral neuralgia, and in
its widest sense covers a variety of sensory symiitoms,
ranging from sensitiveness and jiain accompanying the
act of digestion, and perhaiis accompanied with signs of
delayed or imperl'e< t digestion, yet not due to gastritis
or ulcer, to severe paroxysms of pain entirely uncon-
nected with the digestive process.
The cliohigy is similar to that of the other visceral neu-
ralgias, but it is met with in young children oftener than
the rest. It is esp<'cially connnon in gouty subjects and
in persons of nervtnis, mobile temperament, ami the
writers have several times seen slight symptoms of this
general character at the time of the menopause.
The pain in gastralgia is felt jmniarily at the epigas-
trium, and radiates thence upward in the direction of
the oesophagus, and through toward the back, besides
laterally through the abdomen. Allbutt ("Visceral Neu-
roses") says that it may be associated with anginiform
attacks, and it may be attended likewise with superficial
neuralgia of the abdominal walls and other parts of the
body, as the face.
The relation of gastralgia. as well as of the other sen-
sory visceralgias, to the functional affections of the vis-
cera is very imijorfant and calls for further study.
There is no question that many digestive disorders
w'hich attend gastritis, or even cancer, may als,y occur as
pure ueuro,ses, and it is likewise evident that there is a
whole range of nervous disorders, sensory and motor, of
which these purely painful affections form only one di-
vision.
Treatment (ride also under General Treatment). — The
vices of nutrition and assimilation should be corrected,
such as are seen in gout, aitd evinced also by a variety
of nervous symptoms often described under the head of
lithaunia, and sometimes attended with the presence of
free uric acid or oxalate of lime iu the urine. Constipa-
tion should be corrected and the diet regulated, but not
necesarily reduced to a very small amount, even if diges-
tion is attended with pain. Sometimes it will be found
that one kind of food will agree better than another
without apparent reason, and, when the gastralgia is as-
sociated with serious disordiTS of the digestion, it ma)' be
that a patient who does very badly at home will get on
very well it removed from home and placed under the
care of a nurse. Indeed, the most significant fact to bear
in mind is that, as a rule, it is a general nervous con-
dition which needs treatment, rather than the special
symptoms.
Belladonna and the antispasmodics, such as asafoetida
and valerian, besides the gastric stimulants, are of more
.service in gastralgia and the other visceral neuralgias
than their ana'Sthetizing influence would suggest. Mor-
]ihiue must be resorted to if necessary. Deep pressure
sometimes gives temporary relief.
It is not necessary to review in detail the neuralgias of
the other abdominal viscera and of the genital organs.
Attention has already been called to the fact that affec-
tions of the uterus and orarics may give rise to neural-
giform afTections in distant jiarts of the body, or in the
distribution of the lumbo-abdomiual nerves; but besides
this the uterine and ovarian nerves themselves are some-
times the .seat of neuralgia, not to speak of the pain of
dysi..enorrha'a, which is, doubtless, in part, of that char-
acter.
yriiratffia, (if t/ie lirer is said to be sometimes attended
by swelling of the liver and by jaundice; but here, as
frequently in the ca.si' of the abilominal neuralgias, it is
diflicnlt to guard carefully enough against mistaking an
organic disease for one of the concomitants of a neuralgic
attack.
Neuralgia of the amis and rectum is a well-marked and
painful affection, and the tendency to it ma)- be heredi-
tary. The seizures may come on spontaneously, esjie-
ciaily after fatigue, or may be excited by slight iriita-
tions, such as the passage of hardened fa'ccs, or may
follow sexual intercourse or seminal emissions. The
pain may be accompanied by clonic spasms of the peri-
neal muscles. The rapid injection of hot water into the
rectum, or hard and deep jiressure with some smooth ob-
ject will often stop the attack, wliich otherwise is liable
to last for one or two hours.
Besides the more or less typical neuralgias there are a
number of other painful affections, of spontaneous origin
or provoked by trifling irritatitnis, and of unknown path-
ology, which occur usually in persons of neuralgic or
neuropathic tendency, and are therefore fairly to be
classed as neuralgic, although they do not follow the dis-
tribution of a special nerve. Such are pains referred to
the skin, the muscles, or the joints, not attended by signs
248
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Nciiral<!:ia.
Neiira»ttlienia.
of local inflammation or by any appearance of local con-
gestion or ana-raia, ami capable of coming and going
with greater or less rapidity. The "growing pains" of
anaemic children are of this order, together with a similar
affection sometimes met with in adulls; also the "gen-
eral neuralgia " of ansemic patients, and those dermatal-
gias which are not due to the organic irritation of sensi-
tive nerve fibres, such as occur in locomotor ataxia and
neuritis. The arthralgic pains of false (hysterical) joint
disease might perliaps be included.
The therapeutic indications are, primarily-, to improve
the constitutional and nutritive condition, and to relieve
the pain by local or general baths or liniments, or by
anodj'nes. James J. Putnam.
Qearge A. Waterman.
NEURASTHENIA. — The term neurasthenia (^ nervous-
ne.iii." or iiirrm/s ircaknfss or pivstration) has come into
general use to indicate certain states of the nervous S3-s-
temof which the anatomical hasis is unknown, but which
are characterized, on the one hand, by a lack of vigor,
efficiency, and enduran , affecting usually a large num-
ber of the nervous functions, and, on tlie other hand, by
signs of active derangement, which in part seem to occur
as positive symptoms, and in part are due to a failure of
the mutual support and control which the different parts
of the nervous system .ff rd each other in health.
In its widest sense the term neurasthenia is used as
covering the groups of symptoms usually indicated by
such names as nervous prostration, spinal irritalion, neu-
ropathic or neurotic diathesis. Even abnormal mental
states, such as mild degrees of melancholia and "morbid
fears," are often classed as neurasthenia, but their rela-
tion to a more serious malady should not be forgotten.
Sometimes neurasthenic symptoms are secondary to
localized pathological affections in one or another part of
the body, and this fact has led some observers to recog-
nize in neurasthenia onl}- a symptom of errors of refrac-
tion, litha'Uiia, uterine disease, organic disease of the
brain or cord, and the like. It would, however, be easy
to ]iush this attempt too far, and the writers certainly be-
lieve tliat neurasthenia is a useful term to indicate states
of nervous weakness which are often primary, and which
even when secondary usually imply a pre-existing basis
of functional disease.
Since a sense of fatigue is generally one of the chief
symptoms in the neurasthenic individual, it is possible
that an actual pathological change in the nervous sj'slera
is the cause of this condition. Hodge has shown that
fatigued animals show degenerative changes in the pro-
toplasm and nuclei of their ganglion cells, and some such
process may bo the underlying cause of certain types of
neurasthenia. On the other hand, the tired feeling may
be a purely psychological symptom or the result of an
inharmonious working of a brain of which the several
parts ma_y be structurally nonnal.
It has been said with some truth that hj'sterical and
hypochondriacal persons are always neurasthenic, but
that neurasthenic per.'^ons are not always hysterical or
hypochondriacal; and hysteria has also been spoken of
as "nervousness" crystallized into the form of a detinite
disease. Although typical cases of neurasthenia and of
hysteria differ widely, yet the two affections run into
each other, and the saiue patient may, at the same mo-
ment or at dilTerent periods, show symptoms of both dis-
eases.
While it is true that neurasthenia should be looked
Mpon — relatively to hysteria and insanity — less as a dis-
tinct disease than as a departure from health, and as an
expression of the mode in which degeneration of the
nervous powers first shows itself, still it must not be
forgotten that neurasthenics present certain symptoms
which are almost as characteristic as those of any other
of the neuroses.
Symptom.\toi,ogt. — The sj'mptoms called neurasthenic
are convenientl_v divided into those which arise as a sign
that tlie patient is unequal to the ordinary tasks of a
fairly healthy person, and those which are manifestations
of a morbid action on the part of the nervous system
over and above the indications of simple inefficiency.
These can be called, for convenience' sake, neyalire and
positive symptoms, respectively. Thus, the neuntive
symptoms are those of fatigueor pain arising without
sufficient cause, but .still due to effort, and, within cer-
tain limits, proportionate to the effort made; while the
positive symptoms are nervous outbreaks or signs of ex-
cessive weakness of special kinds, occurring almost inde-
pendently of effort, and at least out of proportion to it.
The negative and positive symptoms may run into each
other, as, for example, when, in the place" of an oversen-
siliveness or self-distrust, we find an ever-present sense
of anxiety or " morbid fear " ; or, when a simple incapac-
ity of the eyes to bear a prolonged strain passes into a
high degree of photophobia or asthenopia; or when in-
stead of a simple feebleness of the digestion we have an
active nervous dyspepsia, and so on "through the whole
range of nervous functions. Usually the symptoms of
special nervous derangement appear "on a l)ackground of
general nervous weakness. It sometimes happens, how-
ever, that some one symptom is so prominent that it
seems to stand almost alone. In like manner some cases
present almost exclusively mental symptoms, and cannot
bear a slight emotional strain without great suffering
and yet may show more than ordinary pln-sical strength
and endurance; while with others by tar the most promi-
nent symptoms affect the muscular "and vegetative func-
tions.
The late Dr. George Tsi. Beard, to whom we owe many
valuable observations on this subject, attempted to base
tipon this fact a division of n-nirasthenic symptoms into
cerebral and spinal, but this is premature and is not
based upon sufficiently well-grounded reasoning.
Individual cases of neurasthenia vary so greatly in the
grouping of their symptoms that it will' be better t"o study
the symptoms themselves cue by one rather than to at-
tempt to describe different type's of the disease. It is,
however, worth while to bear in mind that the term "ir-
ritable weakness" aptly indicates the character of many
of the conditions met with.
Special Symptom at olorry. — The temperament of neuras-
thenics is essentially mobile. They are usually quick,
versatile, and sensitive, and may be talented aiid intel-
lectual, though they rarely have the robustness and
endurance necessary for great success. Often a sense of
nervous weakness and effort is present, which gives rise
to self-consciousness and self-di.strust, and finally to a
suspiciousness toward others, and to a vague feeling of
isolation and dread.
A healthy organism should respond to calls upon it
with an elasticity like that with which the cushion of a
billiard-table responds to the blow of the ball.
With neurasthenic patients this is usually not the case.
A trifling impression arouses an exaggerated inirard re-
action in the form of egotistic or self-distrustful ideas,
while the outirard reaction is correspondingly feeble or
unduly delayed. Slight obstacles seem mountains, and
some patients can hardly persuade themselves into a de-
cision or an exertion, although under the influence of
some slight excitement they may act with energy and
intelligence. A similar undue inward reaction is .shown
in other departments of nervous energy besides the
strictly mental. Thus, even with patients who seem
well-balanced and of good self-control, trifling causes
may excite or maintain neuralgia or dyspepsia, disorders
of the sleep, collapse of strength and the like, with pro-
voking and inexplicable readiness.
Instead of the vague sense of anxiety and dread, spe-
cial "morbid fears" are often present. The variety of
these fears is endless. Among the most common is the
fear of large open sjiaces, fear of crowds, of walking
alone, or riding in railway trains, fear of conl.-imiuation
fiom touch, fear of taking food and the like, fear of be-
coming insane.
In many cases, of course, these symptoms mean .some-
thing more serious than neurasthenia; but often, on the
other hand, they represent the natural or " reasonable "
249
Neiirasllioiiln,
>lcurasllioiiia.
HEFEKENCE HANDBOOK OF THE JH^DICAL SCIENCES.
fears of liealtliy persons acting uijoii a iiiorbkily sensi-
tive tenipcraiiieut. Such persons begin by being vaguely
timorous and distrustful and end bj' having special
■' fears. "
Soinetinies the neurasthenic teuii)erarnent approaches
the hyst(;rical temperameut, in exhibiting gross selfi.sh-
ness and fondness for exaggeration and for attracting at-
tention; but, as a rule, ncurastlienic (latients are docile,
patient, self-sacrificing, and intelligent, or if they are
.selfish, it is because of a life of senii-invalidisni, or of
haliits of painful intros|ieetion, and is not due to a lack
of moral sense, whicli is rather characteristic of tlie hys-
terical temperament.
On the other hand, it is not uuconunon to see neuras-
thenic patients e.vhibiting some of tlie special disorders
which are usually eonsideied as peculiar to hysteria,
such as hemiplegia disorders of sensation or motion, al-
teration of the deep redexes, pliotojihobia. etc.
The (h'f/estii'e dinnrdirs of neurasthenia may vary from
sim]ile feebleness of the digestion, or digeslion perhai'S
sulliciently well performed but attended Willi pain, to
disturbances almost or (|uite iiidistinguisliable from true
catarrhal alTecticins. Such patients are also very subject
to visceral neuralgias, which, when they alVeel the nerves
of the digestive tract, are often attended with marked
signs of functional di.sorder of the corresi)onding' organ.s.
C)ther symiitoms are likewise met with, wliich are
hardly to be called digeslivi\ though afieetiiig the diges-
tive organs. Such are attacks of nausea, not due to the
taking" of food; attacks of diarrha-a, or, more strictly,
dis<harges of watery fluid, coming on suddenly as a re-
sult of slight nervous fatigue or excitement, and passing
away as quickly, cr jierliaps permanently yielding to an
improvement in the patit'Ut's general condition; or dis-
charges of large ipiantities of mucus, in masses or strips,
with or without faeces.
Tlies<' nervous disorders of the digestion are of so much
practical im|iortance and interest that they have of late
years attracted much attention.
Often the only conclusive diagnostic sign to distin-
guish them from organic afl'ections is the fact that they
do not improve under the usual treatment of gastro-
intestinal catarrh, chninie ulcer, etc., which they sinndate,
while they are greatly iiitluenced by improvement in the
patient's general comlition and surroundings. Thus, a
removal of the patient from home, or his sidijection to
the "rest cure" (see luider Treatment), may elfect what
the mo.st careful dietetic am! me<liciual treatment had
failed in years to aeconi]ilish.
Finally, it is not to be forgotten that in any given case
the symptoms may be in part of organic, in )iart only of
functional origin.
In some cases the iK'iirotic dyspepsias are so severe
that, wh;it with the nausea and vomiting and geniaal
distress and pain, the patient's strength is greatly re-
ducecl. and his life may even be threatened. In two
cases under the eaie <if one of tis the.se symptoms were
attended with symptoms of insanity of the melanchnlie
type, iuid witli suiciilal tendeucy.
Sciisvri/ Difiinhrs. — 'i"he most important type and in-
.stance of the disorders (jf special seii.se is simple ((Mienn-
pi'ti, which is often so severe thai .some patients, wim
may have otherwise no more serious trouble than a cer-
tain delicacy of health, are, for years together, almost
totally unable to use their eyes for any fine work. This
ma_y be due in jnirt, or wholly, to weakness of the mus-
cles of convergence and accommodation, and is some-
times remarkably relieved by a systematic method of
exercise, ecjinbined, if necessary, with suitable glasses.
Other patients are iiiucli annoyed by sparksof light lloat-
iiig in I lie field of vision, or by glimmering sensations
similar to those which often precede si<'k headache.
Tinnitus aurium is .sometimes found, but this is less
likely to be a pronunent symptom in simiile neurasthe-
nia than to occur as a sign of irritation of the nervous
centres, such as may imply toxic conditions of some
sorts-
Neurasthenic patients are subject to >ifiu,i/i/i<i, or to
neuralgiform attacks, both superficial and visceral, and
usually shifting and fugitive in character (see under
Neuralgia), and to periodical headaches.
BackacJie. sometimes with excessive sensitiveness to
light pressure over the spine, is very coniniou, and may
be associated with some slight uterine disorder, though
it may also occur alone. It is usually increased by exer-
cise, and especially by using the arms above the height
of the shoulders, and by anything which causes general
fatigue.
The pain of the neurasthenic backache may be along
the Vertebral column, or farther outward, especially
about the sacral and iliac attachment of the large mus-
cles of the back. It is often provokingly obstinate un-
der local treatment, and tlisajipears the soonest under
such treatment as best a.grees with the patient's general
condition. Sometimes, in the class of cases to which the
name of "spinal irritation " was formerly given, the sen-
sitiveness of the back to slight pressure, comliiuc.'d with
the local pain, is the most prominent symptom present.
In such cases, besides the local sensitiveness, the pressure
gives rise to special peripheral sensations, thoracic, pul-
monary, abdominal, etc., according to the level at which
it is made.
P(tiii in tlie miinrleJi and juiiils is not unconiiiion, with-
out it being possible to discover any sign of typical rheu-
matism, gout, or neuralgia, and this symptom, like so
many others, is capable of attaining a prominence out of
proportion to the rest. Thus, in the case of a gentleman
of whom one of us has had the care, intense muscular
pain in the legs, beginning after an interval of quiescence
of half an hour and rising steadily in severity, is bnmght
on so easily by tlie least exertion that the patient has
been obliged for many years to give up walking almost
altogether.
Another very common variety of pain, not precis(dy
neuralgic, is a distressing snixv of presxnre at the rerte.r or
inripiit, often combined with tenderness and stiffness of
the muscles of the neck. This is usually a sign of some
special fatigue or strain, but some patients suffer from it
idmost coulinuously, and find in it a source of serious
distress.
Para'sthc/tio (" jiricklinganil numbness") in the extremi-
ties, or assuming the hemi|ilei;ic distiiliufion, is likewise
often complained of, but it is to be remembered that the
same symptom is met with in debilitated women who are
not especially neurasthenic, in cases of chronic lead poi-
soning, and in other conditions.
Palpitation and earijiae in-riiutarit;i are not uncommon,
and we have seen one or two ])atients with peculiar dimr-
ilers of the respiratory rlnitlnn. One of these was cured
by systematic exercises of the respiratory muscles.
The wiileis have noticed that rardio-renpirotori/ nn/r-
loiirx ocriiv with great fre(iuency in young male neuras-
thenics of the thin, poorly nourished type. Sometimes
this murinui' is very transitciry.
Xerroiis conyh is sometimes a markeil and obstinate
symptom, and may last for mouths, without any (local)
cau.se whatever, and then pass quickly away. These
coughs, like many other of the neurasthenic symptoins,
are associated at times with slight irritation in the nose,
or pharynx, or ears, (u- in the genital tract. Sometimes,
instead of the cough, we find a verit.ible asthmatic seiz-
ure, and in this connection the seniineurotic origin of
hay-cold is to be remembered.
It is not uncommon to see in patients who cannot be
called other than neurasthenic an almost periodteal reetir-
renec if st/inptmns, such as migrainoid headaches, attacks
of exhaustion, sleeplessness, and the like. Usually some
slight overexertion or fatigue seems to act as the imme-
diate cau.se of these outbreaks, but the cause and the effect
are out of proportion to each other.
Neurasthenic iiatients are, as a rule, very easily affected
hy .itiinidaiits of every kind, anil at the same time they
often feel rather a desire for them. In sjute of this, they
are by no means always inclined to be immoderate in in-
dulgenci', and need not necessarily be ail vised to abstain
altogether from their use.
250
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
IVoiirastlieiiia.
NeiiraNtheiiia.
Insomnia, in one or another form, is almost always
present at one time or another, and forms one of the
most important symptoms of neurastlu'iiia, on aeeoinit of
its indirect etfects as well as for the sulTerinj: that it oc-
casions. The early morning period of wakefulness is a
time when the depression of spirits, from which neuras-
thenics often sillier, makes itself most prominently felt.
It is also true, however, that such patients usually
sleep more than they themselves believe, and that they
do not suffer from an amount of real fatigue at all in
proportion to tlicir sensations in the morning after a
night of restlessness and tuipleasant dreams. E.\cessive
i/rr>ir,tim:<Kis a less common sxniptom than insomnia, and,
though annoying, less serious in its results.
Vaso-motor Symptoms. — Besides the fact that nervous
patients are prone to blush easilj', a fact w Inch usually
indicates only a general emotional excitability, they often
show symptoms wliich are fairl}- attributable to a morbid
action of the vaso-motor nervous .svstem. Such are the
vascular spasms of dir/ifi inortni, chilliness, and urtica-
ria, and the vascular dilatation which causes erythema-
tous patches, burning, and swelling of the hands and
feet, and even chilblains.
The general sensation of heat, which leads certain pa-
tients to go about with light clothing in the coldest
weather, is probablj' not really of vaso-motor origin, nor
have we a right to attribute to this cause the attacks of
profuse sweating on the slightest e.\ertion from which
neurasthenics occasionally suffer, or the watery dis-
charges from the bowels already alliKled to. It is more
probable that these are neuroses of the glandular nerves
themselves.
The "hot flashes," which are often sucli a serious an-
noyance, are .sometimes attended with visible Hushing of
the face, hands, etc., and with distres.sing sensations of
fulness and pulsation in the head — .symptoms which are
probably vaso-motor in cli:iracter; but sometimes they
are unattended by any such phenomena, and, so far as we
know, are neuroses of sensittion only, and analogous to
the many other morbid feelings with which such patients
are liable to be attacked.
The sexufil functions a.re. apt to be disordered in various
ways. Impotence, [iremature ejaculation, sense of pros-
tration after se.xual intercourse, and similar symptoms,
are much ofteuer met with amcmg neurasthenic than
among healthy persons; and it is with persons of this
cla.ss, both male and female, that irritations in the geni-
tal tract produce, indirectly, their most serious results.
The sexual instincts in ueurastlienics are usually active
and practically normal, the grave perversion of desire
belonging rather to the category of insanity.
The generiil nutiitin: conilition of neurasthenic palienls
may be good and their muscular strength quite up to
the normal. Thej' are, liowever, tisiudly spare in flesh,
and if, as often happens, their appetite, digestion, and
power of assimilation are disturbed, they may become
greatly reduced in health. On the other hand, many of
these patients, and some of the wor.st cases, are over-fat.
and often at the same time ana-mic.
The metabolic functions are apt to be at fault, and in-
deed, strictly .speaking, it is often im|iossil)le to say
whether the nervous or the nutritive disorder conies tirsl.
Free uric acid, urates, or oxalate of lime are often found
in the urine; the phosphates are liable to be increased,
and the quantity of the urine may be increased or dimin-
ished, or both in turn.
Where such conditions as these are traceable to func-
tional diseases of the liver, or to a gouty inheritance, or
to the absorption of products of imperfect digestion, the
nervous symptoms which occur may fairly lie considin d
to be secondary.
On the other hand, there is little or no doubt tliat tlie
nervous weakness may be the primary atTection, and,
even in man_v cases of gouty parentage, it is probable
that the impaired nervous system is often a direct inheri-
tance.
The pupils arc apt to be unusually large in moderate
light, and very mobile.
The voice sometimes shows signs of the universal ten-
dency to irritability and weakness, and lacks the normal
firm, .sonorous quality.
The /luii; tict/i. and skin of neurasthenics are said by
Beard to suffer from premature denutrition; but this is
ditficult to prove with certainty, though it may be ad-
mitted as possibh' that a lack of nervous vigor should
show itself in this direction as well as in so many others.
The following .sketch by Dr. Clifford Allbutt may be
quoted as giving an excellent picture of one variety of
neurasthenic patients.
After speaking of the contrast between the neurotic
and the hysteric types, and the absence in the former of
the exag,gerated selfishness and feebleness of purpose,
which are characteristics of the latter, he sa.ys: "He en-
ters your room with a brisk step and a quick, observant
eye. You see a slightly built, meagre man, of sallow-
complexion, or, if colored, with the color painted liigh
tipon the cheek-bone. The cheeks and temples are hol-
low, and the temporal arteries are vi.sibie under the lean
skin, which often shows tanned markings, deepened dur-
ing attacks of pain; the hair is straight, fine, and sparse
upon the scalp; the features are sharp, often prominent;
the lips thin, and the skin dry: and some remnants of
eczema may be seen about the chin or ears. The bodily
frame is lightly and often finely built, the bonj- fingers
and wrists and the visible sinews and radials betray-
ing the absence of fat. Here and there, in later life, a
knotty knuckle may tell of goutj- parentage. The pulse,
when most tranquil, usually ranges between 70 and 80,
and accelerates on the least excitement. The clavicles
and ribs in like manner are prominent, and the heart's
apex may be seen to beat sharply before the eye; its
systole to the ear is likewise short and sharp, and the
second sound very audible over a wide area. The limbs
are small, but often very sinewy; such persons are as
active as birds, and the absence of fat in their muscles
often gives to these, in states of health, the quality of
hardness under the hand. Their conversation, again, is
lively and voluble, often keen and brilliant, but impres-
sionable rather than imaginative; you may generally
notice in them, too. some little blinking, twitching, or
tattooing trick which quickens as thoughts and cords
come faster. His companions will tell you that he is
subject to great fluctuations of the animal spirits; gay,
even fascinating, in society ; bi'Isk, orderly, and thorough
in business; but at home dejected or fretful. He is a
small eater, a light sleeper, and a worn worker. These
persons are the heirs of every true neurosis, from ius;in-
ity to toothache; and, on the whole, when we consider
the infinite perturbations of intermarriage, it is surprising
how true they run. or how clearly you may detect the
neurotic strain in mixed descendants. Of their visceral
neuroses I shall have to speak hereafter, and would only
say now that in both sexes of them nilgraine, stomach-
ache, and wind}' colic are frequent and eminent, and re-
ceive the name of dyspepsia; and in the women are added
to these uterine and ovarian neuralgias and hypera'sthe-
sias. To call these suffering women of the neurotic type
hj'sterieal is to confuse all duo acceptance of names, and.
what is worse still, is to confuse the real relations of
things. The neurotic woman is sensitive, zealous, man-
aging, self-forgetful, wearing herself forolhers; the hys-
teric, whether languid or impusive, is purjioseless, intro-
spective, and selfish. In the one is the defect of endur-
ance, but in the other defect of the higher gifts and
dominion of mind."
Besides this, which might be called the intellectual
type of neurasthenia, there is another, in which the ele-
ment of feebleness, mental and physical, is the preilomi-
nating characteristie. Many of the "fat ana niies "' be-
long ifo this class, and in them, in lieu of excitability and
misdirected force, tlie nervous symptoms suggest those
of hysteria, of a mild type, in their exaggerated response
to slight irritations.
IxFLUEN'CE OF Aoic .\xi> Sicx. — Xeuraslhenia. tmlike
hysteria, is almost as common anmng men as among
u'onien. In its full development it is a disease of -pu-
251
Neiira»«llioiiia.
NeurastUcnla.
HEFEKENCE HANDBOOK OP THE MEDICAL SCIENCES.
berty and middle life, but signs of the neurasthenic ten-
dency are to be found in early youth, consisting in a
general mobility of tcmiierament. oversensitiveuess, and
precociousness. and the occurrence of special nervous
symptoms, such as insomnia, somnambulism, chorea,
night-terrors, etc.
Still later, especially in young women from sixteen to
twenty years of age, various other signs of nervous
weakness ma_v make their apjiearance, such as headache,
backache, e.xtreme and causeless lassitude; and these
years constitute in fact a critical period, during which
many persons are nervous invalids, who may later re-
acqiiire good health. Very often these pei'iods of prostra-
tion are "attributed to special causes, such as falls, over-
exertion, and the like, Init these events are rarely more
than e.vciting causes, and are not necessary to the result.
Such attack's are often diagnosticated as aua'mia, or
chlorosis, or as "spinal concussion," but their failure to
respond to ordinaiy tonic or local treatment, and the fact
that they are nften relieved Ijy means addressed to the
general nervous condition, point to their true origin. Of
course, true ana'raia may complicate tliis condition of
nervous prostration, or even act as its cause, and may re-
quire its own sjiecial ti'eatment ; but the important point
is that the nervous element in the case is not to be over-
looked.
Course and Prognosis. — Neurasthenia is not likely
to shorten life to any marked degree, unless it causes
severe disorders of the nutrition. It does, however, oc-
casionally happen that a patient dies from no other ap-
parent cause than a prostration of the nervous functions.
On the other hand, neurasthenia is not, as a rule, an
acquired disease, but an inherited weakness of the ner-
vous system, and in this sense is not, strictly speaking,
curable. It is, however, often possible to remove the
patient from the circumstances which call out the mani-
festations of this weakness and thus practically to effect
a cure. Sometimes even with the best of treatment par-
tial improvement and frequent relapses are the rule.
Constant watchfulness and good judgment rarely fail to
bring some amelioration. Acquired neurasthenia may
pass away with the cessation of its cause, or may over-
last this for many years, as in some cases of railway ac-
cidents, or similar injuries, and in the case of neurasthe-
nia of the menopause.
Neurasthenic symptoms sometimes constitute the first
stage of outspoken mental disease, but. on the other
hand, patients may be severely neurasthenic all their
lives long without suffering from more serious mental
trouljle.
The relation of neurasthenia to organic disease is ob-
scure, but very important.
The fact that neurasthenia is so often associated with
disordered metabolism, and with impaired nutritive vi-
tality fif many tissues of the body, and that its course is
often marked by the frequent occurrence of functional
disturbance of the heart and vaso-motor system, makes
the inference natural that the nervous ciisorder must
sometimes pave the way, or, more strictly ])erhaps, mark
the commencement of more or less serious organic affec-
tions.
Our opinion in the matter, as regards chronic neuras-
thenia, is at present limited to this inference. AVe do,
however, know that dcuie mental strain ma}' be the
starting-point of such affections as chronic nephritLs,
diabetes, and probably many other disorders.
Di.\iiNOSis. — This has been sulticiently covered by the
foregoing sections. It cannot, however, be amiss to re-
call again that the presence of neurasthenic symptoms
only shows that the efficiency of the ni'rvous system has
received a blow of some kind, and leaves still before us
the task of seeking the real source of mischief. It is es-
pecially important to recognize that some organic dis-
eases, such as disseminated sclerosis or cerebral tumor,
may cause neurasthenic or hysterical symptoms, and
perhaps for a time no others.
Ktioi.oov. — Neurasthenia must be distinctly counted
as bvlonging to the great family of neuro.ses, and is in-
heritable from parents suffering from anj' one of this
group of affections. It stands also in a similar relation-
ship to various constitutional diseases, such as gout,
phthisis, ana'uiia, and other less well-marked disorders
of the nutrition (litha'inia), as well as to all of the many
influences which impair the vigor of the nervous system,
including even organic disease of the nervous centres.
Chief among the causes that tend to develop and main-
tain the neurasthenic tendency may be mentioned an
irregular, unhealthy, and overstimulating life, especially
at the time of childhood and pubertj', when the emo-
tional nature is so active; and, at a later time, exposure
to responsibility and worry greater than the patient is
fitted to bear.
Some patients are, in fact, neurasthenic only in relation
to their surroundings, and appear healthy when tmder
conditions more suited to their powers and character.
One-sided, or unsystematic education in youth, or in
earlj' professional life, which makes success in later years
possible only at the cost of undue strain, is a fruitful
source of mischief.
It has been said that neurasthenia is more common in
America than elsewhere, and that the cause of this con-
sists partly in the peculiarities of the climate, partly in
the fact that we have been brought rather rapidly under
the influence of an overstimulating state of civilization.
These statements and arguments are suggestive, but
cannot be asserted positively without further proof.
Among the special causes of neurasthenia may be men-
tioned disease of the uterus and ovaries in women, and
of the prostate gland in men; also concussion accidents,
fright, grief, or mental strain. A condition of nervous
exhaustion, which may be called acute neurasthenia,
may be due to excessive overwork, as has been already
alluded to.
Some of the more local neurasthenic symptoms may
also be excited by irritations in the sensitive mucous
tract, especially of the nose, and by errors of refraction
in the e_ve.
Treatment. — The first indication for treatment is. of
course, to remove special causes of the neurasthenic state,
such as disorders of metabolism, anannia, errors of re-
fraction, disease of the uterus and prostate, chronic fa-
tigue, etc. It is often found, however, that this attempt
is less successful than bad been anticipated, because the
true relation between the symptoms and their causes had
not Ijeen made out.
It is also noticeable that the neurasthenic condition can
be largely relieved by appropriate general treatment,
even while the irritation that caused or maintains it still
persists.
The treatment of uterine dlseyrclers especially may, on
this ground, often be jjostponed to advantage until the
general health has been partially restored by other
means, or at least until the confidence of the patient has
been fully gained ; for, except under these conditions,
the local treatment may do more harm than good.
It is certain that benefit often follows gyniT>cological
operations on neurasthenic subjects, but it is often diffi-
cult to say why this happens, and equally difficult to ob-
tain relial)le statistics for estimating the relative number
of good and of poor results.
One jwwerful factor with some patients is the sense
that now, at last, the real cause of tlie long illness has
been found. This cause can be counted on the most in
cases in which many other treatments have been tried in
vain.
It would, however, be unreasonable to deny that ])el-
vie disorders, even when painless, may act as foci of
morbid excitation, so that where operations are not likely
to do harm they may be advised. The fact should never
1)6 forgotten, however, that no surgeon should operate
in this class of cases without the advice of a judicious
physician or without having made a careful study of
neurasthenia.
It should be noted that the statement made above as
to the effect of operations as the starting-jioint of new
encouragement, or hope, applies equally to operations
252
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Neurasllicnia.
NeuraBllienta.
on other organs, as tlie nose, or ej'es, or to the overcom-
iug of morbitl mental habits and analogous influences.
It is a dangerous practice, however, to undertake oper-
ations with encouragement as the sole excuse.
The ue.\t indication is to secure that perfection of nu-
trition for the nervous system which will enable it to
work at its best; and to place the patient in surround-
ings suited to his individual powers and needs. AVhere
this is distinctly impossible, the aim should be to enable
him to bear the strain imposed upon him with as little
cost as possible.
As has been said, many persons are neurasthenic only
in relation to their surroundings, and enjoy good health
when leading a simple life, or while in the country,
though they cannot stand the excitements and responsi-
bilities of the town. Many persons break down under
the strain of emulation and competition, who can do
good and active work if freed from these influences.
Tliej- must learn to estimate their endurance justly, and
not to be misled by their excitable temperament into at-
tempting too much.
When the needed change cannot be secured, the time
of labor should be shortened by an hour of recreation and
rest in the middle of the day, or by early bed hours. Pa-
tients who do not sleep well should not work later than
the early evening hours.
If exercise can be taken freely, this furnishes an im-
mense resource, where rightly used, and even when vig-
orous exercise is not well borne, as is very often the
case, especially if the patient is at thes;xme time exposed
to other sources of fatigue, neurasthenics almost always
gain by being a great deal in the open air. The subject
of exercise is so important that it must be worked out in
detail for each case. Where horseback-riding, rowing,
tennis, etc., are to be had, the problem is relatively sim-
ple; but for ladies, and in winter, recourse must be had
to such amusements as battledore, some thorough system
of calisthenics, frequent short walks, and the like, and to
rubbing with a wire or hair flesh-brush, either dry or
moistened with w'ater, or salt and water.
Neurasthenic patients are, from the want of confidence
in their strength, apt to fall into unsystematic habits of
life, or to be without a regular occupation, and both
these wants should be carefully met. Frequent short
intervals of recreation, and frequent change of scene
are useful, unless incompatible with proper regularity
of life. Almost any change is apt to work well at
first.
The strict observance of regular hours of work, rest,
and exercise often saves much wear and tear, and makes
the difference between an efficient and a useless person.
Even a very feeble person can have some real interest,
and take some real part in the work of life.
Patients w-ith feeble nervous systems are usually better
when taking as much food as their digestions allow, and
that is commonly more than their appetites would sug-
gest.
In spite of "delicate stomachs, "if the nervous strength
is withdrawn from other directions and turned to tlie
service of the digestion, such persons can usually greatly
increase their food without much difficulty. As a rule.
the most suitable kind of food is that which agrees best
with the digestion, but in certain cases great benefit is
obtained from special diets. (See article on Gatit.) In
some cases of sick headache I have found a distinct ad-
vantage in alternating between the albuminous and the
vegetable diets.
Thoroughly cooked and strained oatmeal, or 3Iellin's
food, with warm milk, can be taken as a matter of rou-
tine, in the forenoon and afternoon (not always well
borne at this latter time) and at bedtime, or one or two
eggs, boiled or raw, or scraped meat mixed with bread-
crumbs and .slightly broiled, may be substituted.
The medicinal treatment of neurasthenia is mainly use-
ful in correcting the disorders of nutrition with which
the nervoussyinptoms are associated. Of the drugs that
are thought to improve, directly or indirectly, the vigor
of the nervous system, only arsenic, cod-liver oil, nux
vomica, and perhaps the glycerophosphates, are of much
value.
The temptation is strong to exaggerate the anaemic ele-
ment in neurasthenia and to give iron largel}', but this
is not advisable, unless distinctly indicated.
Neurasthenia may be the indirect result of conditions
which are susceptible of benefit through the so-called
organotherapy, and the range of this mode of treatment
is still subjudice. Here, too, in many cases, the physi-
cian who believes in the specific treatment cures through
the encouragement which his conviction carries.
Electricity, in the form of galvanization of the head,
general faradization, the static breeze, and electric baths
are sometimes of distinct service. The simplest method
of using electricity is to pass the faradic current from the
neck to the feet and hands alternately, for fifteen minutes
or half an hour, daily.
For the more complicated methods, the special text-
books must be consulted.
A judicious hydrutherape.utic treatment is after all the
very best method of exciting the vaso-motor activity of
the nervous system and thus setting better nutritive
proces.ses on foot. Its success depends upon the choice
of methods by which a good "reaction" will be brought
on and maintained. Usually some warm application
(blankets, hot cabinet, hot bath) is used to warm the skin
and then the stimulus of cooler water follows. At this
stage friction, or some other form of mechanical stimula-
tion, is very useful.
A " powerful reaction " is a good thing, but it is a very
eas\' matter to fatigue a very delicate patient, and so one
must often be content with a moderate reaction. A good
system of graduated baths might embrace;
1. The blanket pack followed by hard friction with
cool or cold water.
2. Hot baths followed by quick, strong affusions.
8. The dripping sheet, preceded or not by the wet
pack.
For some cases of neurasthenia, where the patient is
able to go about and take part in active duties, the above
treatment is sutiicient ; for others, further means are
needed to meet special symi)t(ims. or to overcome an
amount of prostration such as confines the patient to the
bed or house, or totally unfits him for any active em-
ployment.
In order to treat successfully the mental symptoms of
neurasthenia, the physician must thoroughly win the
confidence of his patient by attention, kindness, and by
showing self-confidence and authoritj-, and must provide
suitable employment for his thoughts, as a basis for spe-
cial advice.
The nervous indigestion is in most cases best treated by
a careful attention to the general condition, including, if
necessary, removal from home, etc.
The food should be simjjle and digestible, but it is
striking how little these cases, in spite of the violence of
the symptoms, are benefited by attention to the digestive
functions, such as is required in true cat;irrhal gastritis.
A similar statement may be made with regard to the
other special symptoms of neurasthenia. They may all
be helped somewhat by such symjitomatic treatment as
would naturally suggest itself, but as a rule they are to
be taken as a sign of general nervous weakness, and re-
quire general treatment.
It has been said, with truth, that neurasthenic patients
are cured, not by physic, but liy the physician.
Nervous indigestion is often benefited by electricity
(faradic or galvanic current, or both combined in one cir-
cuit) used as a general tonic, or applied directly to the
epigastrium, with one pole at the back of the neck.
Such patients should also abstain from active exercise
after eating.
The cases of pronounced invalidism require a special
consideration. Although they need to be treated on the
lines which have been already laid down, it is for them
that the so-called "rest-cure," elaborated and practically
invented by Dr. S. Weir Jlitchcll, is so pre-eminently
useful. For patients who are so reduced in strength,
263
Neiiriuo,
Neuritis.
REFERENCE IIANDBOOK OF THE MEDICAL SCIENCES.
and nervous vigor and self-confidcnct' that tlicy become
more deeply implicated the more they struggle to free
themselves, the rejuvenation often secured Ihrougli this
meaus is remarkable. For some of them, it is the moral
element in the "cure" wliich is the most important, for
others the opportunity for nutritive im]irovemeiit.
The "rest-cure" consists of several parts — seclusion,
generally with removal from home and complete rest in
bed, during si.\ or eight weeks: forced feeding, massage,
and electricity. This system may be modilied or simpli-
fied to .suit special needs, but in severe cases there is no
part of it that can be safely omitted. The complete re-
moval from resi)onsiliilily and care, from uidiealthy and
fanu'liar surroundings, I lie an.\iety of friends, and most
of all, from a vague sense of responsibility as regards
themselves, whicli the enforced rest involves, gives a feel-
ing of mental repose, like that alforded by a long sea
voyage to a (jerson sim]il_y fatigued by overw-ork.
The foml consists at Hrst of skimmi'd milk.* given in
small quantities every two hours, and rapidly increased
until the iiatieiit takes two ([uarts daily. Solid meals are
then gradually added, so that soon the Jiatient is taking
a very large (piantily of noiuishment. and in the absence
of all other calls upon his nervous strength, digests it
perfectly well.
ilasaage] is given once, or even twice, daily, taking the
place of voluntary exerci.se. The latter is absolutely for-
bidden, even to the e.xteut of feeding one's self, with the
result that the iiatieni, having no excuse for feeling tired,
soon loses even the ai)prebension of fatigue. After a
time muscular exercises are added to the niassagi', and
eventually sul)stituted for it, and the patient is gradually
allowed to walk.
As the )iatient is obliged to lie constantly in bed. it is
imiiortaut that her lime shouhl lie sulliciently occupied,
and this is not dilbcult, especially if she has a private
nurse of the proper temperament and experience.
The following was the daily seliedvile of a liatient of
the writer's, and may lie taken as a typical specimen; 7
-\..M., small cup of black colfee ; patient allowed to brush
her teeth. 7;4;') — Hands and face washed, tire made b_y
nurse. S — Breakfast, which at thistitne consisted mainly
of a iiiiit of gruel (taken slowly, and kept warm when
(lesire<l. by table-lamp). 8:30 — Sjionge liatli; bed made.
!l:;!il — Windowsopen for half an hour (the weather being
cold the p:itient waswarndy covered e\ce|it fur the face.
10~Brcatlniig .•xereises; f('>od. KhiiO— Hands and feet
exercise, following by reading aloud for tifteen minutes,
11:31) — Temperatin-e of bodv taken, and patient tolled
in blankets. 12— Fooil. 13:30— Bath given. 1 p.m.—
Massage and rest. 3 — Hair brushed, reading aloud. 4 —
Food; breathing exercisi'S. 7 — Hands and feet exer-
cise; liatient arranged fcir the iiii;ht. 8 — Food. 10 —
Food.
In .sonif cases we have given p:itients breathing exer-
cises to carry out every hour or two : and, as a conunence-
ment of more vigorous exertion, have had them roll over
from one side of the lied to the other a certain number of
times. These bints from personal experience are offered,
not as constituting material moditieations of the trcat-
mentas laid down by Dr. .Mitchell, but as likely to prove
useful where tin' full trriitmciit cannot be carried out.
which so often lKip]iens.
The cases which are the most beni'tited by the rest-cure
are those- in which the nervous symptoms are caused or
maintained mainly by simple ana'uiia or impaired luitii-
tion. Even in the purely "nervous" eases, however, an
occasional treatment of tliis kind often gives a chan<'e to
stjart fresh once more, which is invaluable.
Some cases are not helped at all in tbis way. This
may often be suspected lieforcliand, but someliiiKs a
fortnight's trial must be given them (Playfair), and if
• Miltc mixed Willi luilf iis i,ulk of uaiiiieul jflly ;ui>Wfi-s au aiiinir-
able inirpose.
+ The writer lias fnuuil the appli«-alion of the wet [lai-k or blanket-
pack f<ir an hour or less, as reeomnieiKh'il by Dr. Mary T'litnian-.facolii
(" Ma.ssaee and the Wet Pack in the Treatment of Aua'inia " ), a useful
a(i.)imc'l to tlie luassage.
this is ex])lained to them in advance, they are usually
stimulated to do their best.
Perhaps the most indispensable condition for success is
that the physician should gain and keep the fullest con-
fidence of his patient. How he will best accom|ilish this
must di'pend, in the end, upon his own character and
temperament. If he never allows himself to be dLseour-
aged, and insists on the systematic brushing aside of
morbid thoughts on the pari of his patients, heTwill often
be agreeably surprised at the results which he initiates.
Jiimes J. Putnmn.
Oeorgc A. Waternuin.
NEURINE. — Neurine is a ptoma'in which is fre(|ncntly
found in meat anil other ailicles of food which have un-
dergone a certain amount of decomposition. Chemically,
it is a derivative of ammonium hydroxide: is, in fact,
trimethyl- vinyl-ammonium hydroxide, N(CH;,)3CHCH.;-
OH. It is often confuseil with choline: tlie lattei-, how-
ever, is trimethyl - oxyethji- ammonium hydroxide,
N(CIl3);,Cjn4<->H<->H. Neiiri'ne was lirst preiiarcd syn-
thetically in 18."i8 by Holfuiiinn by treating triinethyla-
mine and ethylene bromide with silver oxide or potassium
hydroxide. The name neurine is lUte to Licbreich,' ".vho
is usually credited with having obtained the substance
by boiling iirotagon for twenty-four hours with concen-
trated barium hydroxide. According to later investiga-
tors, however, it seems very probable that Liebreic-h was
dealing not with the vinyl base (neurine) but with an
impure preparation of the oxyethyl base (choline).- More
recently neurine has been obtained by Brieger^ from pu-
trefying hoise, beef, and human Hesh. Brieger also ob-
tained it from human brains by boiling with barium
hydroxide: it apjiears probable, however, that neurine
occurs in the brain only as a result of juitrefactive
changes, for Gtilewitsch could find no trace of it in per-
fectly fresh ox briiins.-" It has also been obtained from
decomposing mushi'ooms; such mushrooms are very poi-
sonous.
The genesis of neurine in the above cases is very ob-
scure; it may he that it is formed from the cholin whicli
is a part of the lecithin and jirotagou molecule (see arti-
cles on dholin and Lieithiii). Bayer showed that choline
chloride could be transformed into neurine by chemical
proces.ses; this was done by heating the choline chloride
with concentrated hydriodic acid and red phosphorus and
then treating the iodine compound so formed with silver
oxide. On the other hand, neurine may be convcited into
choline by tirst making the iodine compound and then
heating this with silver nitrate.* Schmidt and Weiss,"
moreover, found that choline and its salts could be con-
verted into neurine by the a<'tion of micro-organisms.
It is a signilicant fact that neurine is almost always ac-
companied by <-boline: hence it is probable that the
latter is. as a rule, derived from the former by the loss
of a molecule of water.'
Neurine is a colorless syrup .soluble in water and alco-
hol; it has a strongly alkaline reaction and forms easily
soluble .salts. 'When heated, either dry or in conceutrabii
solution, it decomposes with the formation of trimethyl-
amine (N[CH3]:,). With platinum chloride neurine
forms a double eonipound (Cr.MijNCl).., PtCl,, which is
insoluble in alcoliol; this compound is soluble with diffi-
culty in hot water, from which it crystallizes in small
octahedra. These ciwstals melt, with decomposition, at
19o..Vlil8' C. and contain 33.0 per cent, platinum. A
similar double salt is formed with gold chloride. A sub-
stance isomeric with muscarine may be obtained by treat-
ing neurine with hypochlorous acid and then decompos-
ing the I'esulting coiuiiound with silver oxide.
Neurine may be isolated from organic lii|iiiils contain-
ing it by the method of Brieger. The method is essen-
tially as follows: To an alcoliolic extract of the m:iterial
is added a saturated solution of mercuric chloride in alco-
hol. The precipitate (wdiich contains most of the neurine)
is washed with iilcohol and water and then decomposed
by liydrogen sulphide; the mercury sulphide is filtered
oil: and the filtrate concentrated and taken u]) in alcohol.
254
REFERENCE HANDBOOK OF THE JDiDICAL SCIENCES.
Neuriue.
Neuritis.
The ucuriiK' is precipitated by an alcoliolic solution of
platinum chloride; the precipitate is washed iin the filter
with a little cold water (which dissolves the choline salt
of platinum chloride) and the neurine salt is recryst»il-
lized several times from hot water.
Neurine is a very poisonous substance: 40 ragm. (in-
jected subcutaueously) per kilogram body weight is
fatal to rabbits. The symptoms are very similar to those
caused b\' muscarine. A few milligrams of the hydro-
chloride injected into a frog causes within a short time
complete paralysis of the extremities with, a little later,
a diminution of reflex excitability. The heart is greatly
slowed and linally stops iu diastole, as in muscarine poi-
soning; atropine will cause the heart to begin beating
again. As small a quantity as two inilligiams is fatal
for most frogs. After the administration of neurine to
mammals there are profuse salivation, dysjinrea, diar-
rhoea (due to increased peristalsis), great slowing of the
heart and a fall of blood presstu-c, and finally convulsions
and death from failure of the respiration. Before the
depression of the heart and respiration there is often a
brief period of stimulation, due probably to the sensation
of nausea. Cats seem to be much more sensitive to
neurine than are rabbits or guinea-pigs ; when a cat is
poisoned with this substance there is, in addition to the
symptoms noted above, a marked secretion of alkaline
sweat from the ball of the foot. Many of the symjitoms
of neurine poisoning are antagonized by atropine. Init
even after the administration of this drug theie remains
a condition of general paralj'sis. The fatal dose for
animals is ten times as great wlien the poison is given
by the mouth as when injected subcutaneoush'.
Under the name of "neurine" a weak .solution of
choline was formerly occasionally used as a solvent for
diphtheritic membranes. Reid Hunt.
Referexces.
' Liebreiob : Annal. d. Chem., 134, p. 29, 1865. Ber. d. d. chem.
Gesell., 2, p. 12, lsi)9.
"Gulewitscb : Zeit. f. physiol. Chemie. 27, p. 79, 1899.
3 Briefer : Ueber Ptomaine, Berlin, 18tt.i>-lfS87.
' Gulewitsch : Lie. cit.
' Bode : Annal. d. Chem., 267, p. 268, 1891.
« Schmidt und Weiss : Chem. Centralbl., 1887, p. 1345.
* See Shorey : Juum. Amer. Chem. Soc., 20, p. 113.
NEURITIS. — Neuritis is infiammafion of a nerve trunk
or its branches. As a localized affection involving a sin-
gle nerve it generally attacks certain nerves, such as the
branches of the brachial plexus in the upper extremities,
or of the lumbar or sacral plexus in the lower extremities.
The cranial nerves may also be attacked by neuritis.
When only one nerve trunk is affected, the condition is
usually spoken of as "isolated," "localized," or "mono-
neuritis." When many of the peripheral nerves are in-
volved at the same time, it is characterized as multiple
neuritis, or polyneuritis, a condition meriting special de-
scription, and which will be discussed later. Neuritis
may be either acute or chronic, or the symptoms of acute
neuritis may persist for a long time and tlien become
chronic.
The causes of neuritis are numerous. It may be due
to traumatism such as direct wounding or contusion of
the nerve, or to compre.ssion of the nerve by sudden and
forcible muscular contraction ; to dislocation of joints ; to
injury to the nerve from fragments of bone resulting
from fracture; to compression of the nerve from the for-
mation of callus;- to pressure of growths; or, linally. to
pressure upon the nerve trunks iu the axilla during the
use of CKiitches. Neuritis may also be caused by chem-
ical agents such as ether, osniic acid, or alcohol, "coming
in direct contact with the nerve through subcutaneous in-
jection. It may also develop from refrigeration through
exposure to cold, and as a complication or sequel of vari-
ous infectious diseases. It may also arise by extension
from adjacent inflammation.
Patients who are addicted to the excessive use of alco-
hol, or those suffering from chronic toxic disorders such
as gout, rlunnuatisni. diabetes, chronic nephritis, or syph-
ilis, are more predisposed tcj the development of local-
ized neuritis after slight traumatism or exposure to cold.
Arteritis obliterans and arteriosclerosis may also be con-
sidered to be predisposing causes.
Pathologically, there are various types and degrees of
neuritis. We thus have; 1. Perineuritis, in whicli the
inflammation originates iu the perineurium to which it
may be limited. 2. Interstitial neuritis, in which the
inflammatory process is located principally in the inter-
stitial structure of the nerve. 3. Parenchj-matous neu-
ritis, in which the uerve fibres undergo inflammation and
degeneration. The first two forms represent a true in-
flammatory process. In the third form, the same changes
often occur which usually arise as a consequence of cx<m-
plete division of the nerve. As these different processes
vary in degree and are frequently found in combination,
their clinical differentiation cannot always be accom-
plished.
Isolated neuritis is generally a perineuritis or interstitial
neuritis. There are redness and swelling of the connec-
tive tissue enveloping the nerve, the blood-vessels of the
nerve sheath are distended with blood, and there may
be minute hemorrhages. Sero-fibrinous exudation and
migration of leucocytes follow the hypera>mia. These
changes may be limited to the sheath (perineuritis), or
may extend into the substance of the nerve (interstitial
neuritis). When the process is severe or of long stand-
ing, the nerve fibres may also become Involved. In the
parenchymatous form the inflammation begins in the
nerve fibres, resulting in their degeneration and atrophy.
Symjitiiti.s. — Pain in the cour.se and distribution of the
nerve is the principal symptom. Its degree varies with
the extent and intensity of the inflammatory process.
The nerve trunk is sometimes swollen and extremely sen-
sitive to pressure, thejiain often radiating to the ultimate
distribution of tljc nerve. The ]iain sometimes affects
the entire extiemity, which may become extremely hy-
pera^sthctic. It is variously described bj- patients as
darting, boring, burning, and occasionally shooting
through the cour.se of the nerve. It is increased by
movement and is usually worse at night. Numbness
and tingling may also be pi-esent. This may be attended
by some constitutional disturbance as increased pulse rate
and rise of temperature. Should the nerve fibres become
involved, objective sensory disturbances may arise, such
as varying degrees of antesthesia in the area of the dis-
tribution of the affected nerve, with weakness or muscu-
lar paralysis. Herpetic eruption or glossy skin may also
be present. In severe cases anaesthesia, paralysis, and
atrophy usually take place. The faradic irritability of
the nerve and muscles is at fir.st increased, but gradually
it diminishes, and is finally lost when the nerve fibres
undergo de,generation.
The neuritis ma}' ascend a nerve (" ascending neuritis "),
reaching the plexus from which the nerve arises, and
thus extend to several or all of the nerves of the limb.
The inflammation has also been known in rare instances
to extend to the spinal cord, causing suljacute or chronic
m_velitis.
Pnigimus. — Acute neuritis may disajipear in a few
weeks if the cause can be successfully removed. The
most favorable cases are those due to slight traumatism.
More commonly the affection persists in a chronic stage
for many weeks or even months. The most protracted
forms ari.se in patients with gout or rheumatism, or in
such toxic cases in which the toxin cannot be removed at
once. When the axis-cylinder processes are involved, as
in degenerative neuritis, the condition may last for manj"
months, paralysis and atrophy becoming permanent if
the nerve fibres do not undergo regeneration. An opin-
ion as to the prognosis oflen depends upon tlie changes
in the electrical irritability of I Ik- nerves and muscles.
Tnnimeni. — When a nerve is divided by a woimd, the
.separated edges should at once be approximated and su-
tured. In compression or injuries of nerves from lux-
ation, fracture, callus, tumors, inflammation of soft
parts, abscesses, etc., it is the first duty of the physician
to insist upon immediate surgical measures to free the
iiijuied nerve if possible.
255
\eurltl8.
Neuritis.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
A cure is not always acooniitlislied by this mctlioii
aloue, iuasmuch as any accompanying muscular paraly-
sis calls for subsequent treatment. Under such circum-
stances surgical intervention must be tlietirst step, other-
wise all other treatment will prove futile. The general
constitutional condition of the patient must not be over-
looked. In acute cases absolute rest of the affected limb
IS essential, either by keeping the patient in bed. or by
immobilization of the limb by a suitable supporting
bandage. The relief of pain is an important feature.
In acute traumatic •'ases a Chapman's ice bag applied
along the course of the nerve, or cold compres.ses often
prove valuable. The application of hot-water cloths
amehorates the pain in many cases. When amesthetic
areas are present, extreme care should be observed when
hot- water cloths are apjilied, in order to avoid burning the
skin. Blistering or supertieial linear cauterization over
the affected nerve trunk often effectually relieves the pain.
At times it is necessary to administer some of the coal-
tar derivatives .such as phenacelin, acetanilid, or salipy-
rin. When the pain is persistent and severe, anil is not
relieved by other means, we must resort to the use of
opium, morphine, or codeine. Local injection of a solu-
tion of cocaineat the-seat of the greatest pain often gives
relief. The continuous galvanic current is also of great
value in diminishing the pain. The anode should be
placed over the atfected nerve, the current strength
being from si.\ to eight milliamperes, the application
lasting live or si.x minutes daily. For the ])aralysis ac-
companying degenerative neuritis after the acute sj'mp-
toms have subsided, the application of the labile or inter-
rupted galvanic current to the affected muscles seems to
hasten the recovery of mntility by improving the nutri-
tion of the nuiscles and accelerating the regeneration of
the nerve. Massage is generally contraindicafed during
the early period of the intlanunation, but it can be favor-
ably utilized later. Small doses of mercury have been
rc<'onnnended by Cowers for flu- purpose i.f influencing
the neuiitie process.
MiiLTifi.E Nkcuitis ok Poi,vneuritis. — This is a dis-
ease in which many nerves are inflamed simultaneously
or in rapid succession. It usually affects symmetrically
the nerve trunks in the extremities, partieularlj' in their
]ieriplieral distribution. In this form of neuritis the
pathological luocess originates in the nerve fibres, the
adventitial structures generally being involved second-
arily. In mononeuritis the nerve sheaths and the con-
nective tissue, as a rule, are ]u-imarily affected. As early
a.s 1828 Graves described the condition as "a form of
generalized paralysis probably dejiending ujion disease
of the pin-i[)licral nerves." The first authentic case with
po.st-mortem verilicatiou was published by Dumesnil, of
Rouen, in lH(i4. but it was not until further oliservations
were repoited liy I.aneereaux in ISTl. Eichhoist in 187."),
.Joffroy in 18T',I. Leyden in 18S0, and Grainger Stewart in
1881 tliat tlie doctrine of nudtiple neuritis was placed
upon a .sound pat hological basis. During the last twenty
yearsmany observations and monograplis relating to this
subject have been i)ublished, the literature now being
quite abiuulant.
Elioloriy. — Multiple neuritis is invariably t he result of
some toxic sulistanee eirenlating in the blooil. A verv
large numl)ir of dilTerent causes arc active in its produc-
tion.
{n) Polt<ottonNiiuhKtiinris i itirothfCtd into f/w ."ft/yfiin^ihe^L'
being mentioned in tlie order of their importance): Alco-
hol, lead, arsenic, cojiper, silver, phosphoius, mercury,
carbonic-oxide gas, bisulphide of carbon, and nitr'o-
benzol.
(b) PinmnxoriijiiHttiii'j iritldn Ihilnnlii (autotoxic): Dys-
crasic conditions such as gfiut. diabetes, tuberculosis,
carcinomatosis, .syphilis.
(c) As a sequel or compUcalioHdf rtirinux iiijeiliniis dis-
eases: Diphtheria, influenza, typhoid fever, smallpox,
scarlet fever, measles, pneumonia, whooping-cough,
epidemic cerebrospinal meningit is, erysipidas, gouorrlaea,
malarial toxaemia, acute articular rheumatism, leprosy,
and all fortns of scptica'mia.
The majority of cases of multiple neuritis are traceable
to alcoholic excesses. It is hardly necessary to mention
that the vulnerability of the peripheral nerves to the
effect of alcohol varies in different individuals. One
person may indidge in large cjuantities daily for years
without developing neuritis, while man3- others" who
probably possess less resistance in the peripheial neurons
are attacked by the disease after the continued daily use
of a comparatively small amoiuit of alcohol. The writer
has seen several cases resulting from the daily u.se of
about two ounces of whiskey continued for three or four
months. 5Iultiple neuritis as a sequel of acute alcoholic
intoxication is almost unknown.
According to the preponderance of one set of symp-
toms over another, nudtiple neuritis has been classified
into various clinical types, such as:
1. A muivr or puni/i/tie ti/jie (alcohol, arsenic, diph-
theria, Landry's paralysis).
2. ^1 sensori/ ti/pe, an ataxic foi'm which is often de-
scribed as "pseudotabes'' or "ueurotabes jieripherica,"
and is most commonly due to ar,senic or alcohol.
3. A riiso-molor type (erythromelalgia, Raynaud's dis-
ease).
4. An endemic form (beri-beri or kakki, particularly
prevalent in Japan and the Dutch East Indies).
Multiple neuritis occurs most frequently, however, in
transitional forms, and may then be characterized as a
common or mixed type in which motor, sensory, and
va.so-motor phenomena arise in various combinations.
Polyneuritis usually occurs between the ages of twenty-
five and fifty years. Aside from the form due to diph-
theria, it is rare in chililren, although it has lieen occa-
sionally observed between two and si.x years of age. A
number of ca.ses of multiple neuritis in children as a re-
sult of alcoholic poisoning ai'c now on record. In one of
the writer's cases the child, who was five years old, had
been given whiskey and beer daily for several months by
its ignorant mother, for the purpose of strengthening it
after an attack of diarrhcea. The disease rarely occurs
after the sixtieth year.
Stiiiiptoms. — It is now well established that in nudtiiile
neiu'itis no set of synqitoms is exclusively related to a
single cause. A description of the symptomatology of
tlu^ alcoholic form will convey a knowledge of the gen-
eral features of the affection.
JIultiple neuritis may be either acuteor subacute in its
on.set, and may follow or accompany an attack of delirimu
tremens. The temperature may be slightly elevated in
the beginning, and some fever may continue throughout
the acute period of the disease. Normal tcm|)erature is
not uiuisual. At first there is often tingling, or a sen-
sation of " pins and needles" or nundmess in tlie extremi-
ties, with vague sharp pains or aches, which gradually
become more acute. The iiarasthesia> and pain arc soon
followed by nuiscular weakness, or paral_vsis, or inco-or-
dination. Either the upper or lower limlis or both may
be involved, lirst and chiefly the hands or the feet. The
feet are affected more fre((uently than the hands; motor
symptoms may exist in the legs, and only sensory .symp-
toms in the hands. This is accompanied by tcndei-ncss
along the nerve trimks and in the nuiscles. the muscular
tendernc.ss usually increasing to an extreme degree. The
CO (irdinatin.g jiower may be affected at the .same lime.
Tremor is often conspicuous. Most freciuently the knee
jerks are absent, this di']iending directly on the involve-
ment of the anterior cr\iral nerves. The knee jerk is
present or even exag.gerated in some cases of slight de-
gree, and this invariably indicates that the anterior crural
nerves are intact.
In the lower extremities the nerves most commonly af-
fected are the iieronei and the posterior tibial and their
branches. Occasionally the anterior crural nerves are
also involved. Thus, the paralysis usually affects sym-
metrically the corresjionding tibial group of muscles
producing " foot-drop." In severe cases nearly all of the
nerves of the extremities may gradually become involved,
and a more or less complete paraplegia develops.
The upper extremities may escape entirely, or the
ir>k\
REFERENCE HANDBOOK OF THE :MEniCAL SCIENCES.
»uritl8,
Neuritis.
paralj-sis is aln\03t always of lesser degree and extent
than in the lower extremities. The musculospiral nerve
and its branches are most commonly affected, thus pro-
ducing paralysis of the extensors of the wrist and hand
and "wrist-drop." It often happens that otlicr nerves
are also involved. A peculiar feature in these cases is
the implication of the nerves in their peripheral distribu-
tion, the paralysis usually being more pronounced in the
distal portions of the extremity. This is also indicated
bv the fact that at times when the supinators and the
long abductor of the thundj in the upper extremity and
the tibialis anticus in the lower extremity remain intact,
there maybe paralysis of the other muscles which receive
their supply through the same nerve trunks. Sometimes
the muscles above the knees and elbowsare also affected.
In tlie more severe cases the diaphragm and tlie muscles
of the abdomen akso become involved. In rare instances
several of the cranial nerves may be implicated, the facial
muscles, those of the tongue, or the ocular muscles thus
becoming atlected. The paretic or paralyzed muscles
soon become llaccid and undergo atrophy and present
the reaction of degeneration. Sensory disturbances are
often associated with the loss of motor power. They
may be altogether absent or exist alone. In aildition to
thesubjective sensations already mentioned, extreme hy-
pera^sthesia may exist over the affected parts, or tac-
tile, pain, or muscular senses ma}- be affected in various
degrees. In the ataxic form inco-ordination is the chief
symptom. It is usually accompanied by muscular ten-
derness, and exists with or without the affection of cu-
taneous sensibility just described. The inco-ordination
in these cases resembles closely that of tabes, hence the
form in which this symptom is predominant has been
called "pseudo-tabes." Its most frequent cause is alco-
hol, but it has also resulted from arsenical poisoning and
from infectious processes.
Tropliic changes occur in prolonged cases in the nails,
skin, and hairs, and are similar to those of ordinary- neu-
ritis. In uncomplicated cases the sphincters of the blad-
der and rectum are not involved.
In some severe cases in which the neuritis is widely
distributed, the pneumogastric nerve or some of its
branches may become affected, causing interference with
the action of the heart, the muscles of respiration, and
the vocal cords.
All of the s.ymptoms vary according to the acuteness
and intensity of the disease, and they also differ accord-
ing to the cause. In lead poisoning the paralysis is usu-
ally confined to the upper extremities. In alcoholism all
four extremities are often affected, the arms escaping
more often than the legs.
Mental Symptoms. — A somewhat characteristic disturb-
ance of memory often takes place. In general, it may
be described as a peculiar form of forgetfuluess with de-
lusions of recollection. The memoiy for recent events
is generally confused but not always eutirel}" lost. Oc-
currences of some days, weeks, or months previously
are misinterpreted by the patient as of quite recent oc-
currence, or as having just taken place. Although he
may be confined to bed and unable to move, he maj- as-
sert that he has just returned from a long journey, or
has been out for a ride, or has just visited friends, etc.
In some cases there are insomnia, delirium, talkativeness,
or incoherence, or other more pronounced manifestations
of acute alcoholic insanity or confusional insanitj*. All
of these mental symptoms are essentially due totoxiBmia,
and bear no direct relation to the degree or form of the
neuritis. Although more commonly observed in alco-
holic subjects, they are known to occur in the course of
multiple neuritis due to other poisons and also from in-
fection.
Diagnosis. — In acute cases, when all of the characteris-
tic symptoms are present, and the patient is unable to
move from tl-.e bed, the diagnosis is very simple. It is
the subacute forms that often present some ditliculty in
their diagnosis. On account of the presence of inco-or-
dination, pains in the legs, and loss of knee jerks, and
.some objective disturbances of sensibility, it has some-
Vol. VI.— it
times been mistaken for tabes. It is easily dilierentiated
from tabes, however, on account of the presence (in mul-
tiple neuritis) of tenderness of the muscles and nerves,
the neural character of the pains, the symmetrical dimi-
nution or loss of muscular power, the absence of bladder
symptoms, and the presence of the inipillary light retlcx.
Multiple neuritis has also at times been confounded
with atypical cases of poliomyelitis, but poliomyelitis is
most frequent in children ; its onset is abrupt, the paraly-
sis is rarely symmetrical in its distiibution. and tlierc is
generally an absence of all sensory symptoms.
The history of some form of toxa-mia known to cause
polyneuritis is a potent element in the differential diag-
nosis.
T/ie Diagnosis of (he Toxic Cause., and the Differenti-
ation of the Various Types. — It is not always easy to de-
termine from the clinical symptoms alone whether a
certain case of multiple neuritis is caused by alcohol, ar-
senic, lead, or some infectious process. However, there
are certain elements in the history, a peculiarity in the
distribution of the paralysis, and well-defined indications
associated with some special forms of toxa-mia or infec-
tion, which often conclusively piove the cause of the
neuritis.
For instance, the somatic and ps3'chical symptoms
may present a classical picture of chronic alcoholism.
Thus, in a<ldition to the polyneuritis, there may be tre-
mor in the lips, tongue, and hands, toxic amblyopia,
chronic morning vomiting, cirrhotic liver, albuminuria,
delirium tremens, or alcoholic dementia. Arscnieal nen-
riti.s is often accompanied by vomiting, a general brown
pigmentation of the skin, and the presence of ar.senic in
the urine. In some cases the ataxia is more pronounced
than are the motor .symptoms. The arsenic has usually
entered the s_vstem as a result of acute poisoning after an
ineffectual attempt at suicide. Occasionally the neuritis
is produced b_v the prolonged administration of medicinal
doses of Fowler's solution as used in the treatment of
chorea in children, or from the inhalation of arsenical
dust given olf from wall ])aper and other articles contain-
ing arsenic. Recentl_y a large number of cases of arseni-
cal poh-neuritis occurred in England from the use of
beer in which arsenical glucose had been used in its
manufacture.*
Multiple neuritis from lead poisoning is most fre-
quently found among those whose occupation requires
frequent or continuous contact with lead. The acciden-
tal causes are numerous, such as the contamination of
drinking-water by leaden pipes, the cooking of food in
vessels containing lead in their manufacture, the use of
various cosmetics, hair dyes, etc. It has also been traced
to snuff, which was found to contain lead. As a rule,
the lead enters the system through the alimentary canal
as a result of tmcleanliness, and the pollution of food by
hands that have been in contact with lead. It may akso
enter the system through inhalation, and by ab.sorption
through the skin. As in other forms of toxa'inia indi-
vidual susceptibility to the effects of lead has much to
do with the development of neuritis. People in general
ill health, and lho.se addicted to alcoholics, are more
predisposed to the toxic action of lead. The upper ex-
tremities are more commonly affected, a blue line is often
seen on the gums, and lead may be found in the urine
(.see article on Lead Palsy).
Polyneuritis from diphtheria may be attended with
wasting and anoesthesia; but the weakness in the limbs
usually succeeds paralysis of the palate and ciliary mus-
cle, which are never seen in other iorins of polyneuritis.
Course and Prognosis. — Multiple neuritis usually takes
an acute or .subacute course and reaches its height in a
few weeks or a few months. It then remains stationary
for about the same period, and gradually recovery takes
place. Some cases are very severe and are accompanied
by high fever, and may terminate fatally in a week or
two from paialysis of the heart or diaphragm, or from
* Glucose is made by the iiction of sulpburic acid on various kinds o{
starch. The origin of the arsenic was found in the sulphuric add
which is commonly made from arsenical pyrites.
257
Neiirodiu.
>euri»iio.
KEFERENCE HANDBOOK OF THE 3IEDIGAL SCIENCES.
pulmouary (pdema. It sometimes assumes a eourse simi-
lar to that of LamliTS paralysis. The eoiiditiou is al-
ways serious when the patient's general health is poor in
consequence of a recent infectious disease, or iu severe
types of chronic alcoholism, etc. Wlieu the vagus or
phrenic nerves become involved, the life of the patient
may be in constant danger, although recovery has oc-
curred even under such circumstances. When the paral-
y.sis is confined to the distal portions of the extremities,
the prognosis is more favorable. In exceptional instances
the course may become chronic and progressive. In the
majority of ca.ses, however, in tlu' absence of complica-
tions the disease terminates in complete recovery. Even
in favorable cases tlie alTection may last from several
months to two years or more, di'peuding upon the under-
lying cause, the extent and intensity of the nerve degen-
eration, and the recuperat ive ]iowcrs of the patient. The
prognosis is always materially iullueueed by the course
and" virulence of the toxamiia. When the sphincter of
the bladder is involved, it is usually indicative of exten-
sion of the inllanunatory process to the spinal cord, thus
rendering the prognosis as to recover_v more doubtful.
Treat inent. — The treatment of polyneuritis is essentially
symptomatic. Aside from the cause of the toxtemia the
various forms receive practically the same treatment. It
is essential to discover, if ]iossihle, the cause of the neu-
ritis, and to remove it or discontinue its further action.
This should be the first consideration, jiarticularly iu
cases due to alcohol. The sudileu withdrawal of the cus-
tomary stimulant is not always advisable, particularly
when cardiac wealiuess is present. This can usually be
successfully accomplished, however, by the administra-
tion of siutable heart tonics. Rest in bed. with general
supporting treatment, is desirable or absolutely necessary
in the ma.iority of cases. A local or general warm wet
pack for the purpose of producing diaphoresis, if tlie pa-
tients strength admits, is often followed by excellent re-
sults in the early stage, or, if the patient is strong enougli
to bear the necessary procedures, a warm bath for fifteen
or twenty minutes daily often proves beneficial. General
constitutional treatment applicable to the special condi-
tion constituting the toxannic process should never be
forg(jtteu. In order to prevent deformities, faulty posi-
tions of the extremities should be corrected by giving
the necessary support to paralyzed muscles. Thus when
there is " foot-droj) " the feet should be kept at right
angles with the leg by means of sand-bags, jiillows, etc.
For the purjioseof relieving the ])aiu anodynes shoidd be
administered when necessary in the same manner as men-
tioned in tile description of the treatment of mononeuri-
tis. When tlie dia|)liragm becomes paretic or paralyzed,
artificial re?|iiration and the li_vpodermatic injection of
strychuiue must be resorted to. Indicationsof lieart fail-
ure are to be met by absolute rest and the administration
of cardiac stimulants. AVlien deglutition is interfered
with, the patient should be fed through the (I'sophageal
tube in order to prevent the entrance of food into the
larj-nx or bronchi.
Fortunately such emergencies arise only in exception-
ally severe cases. After all of the acute symptoms have
subsided, massage and electricity will prove useful.
WiUiam, M. Lt'szi/ii!'/,'!/.
NEURODIN, acetvl-p-oxv-phenyl-urethane, C.H,.-
OCO(ll„.MI.COOC2H,-„ is prepared by acetylation of
the compound formed by the interaction of chlorocar-
bonic ether and amidophenol. It is a colorless, odorless,
crystalline substance, soluble in 1,400 parts of cold water
and readilv in boiling water. It is antipyretic and anti-
neuralgic in dose of 0..5-1..5 gm. (gr. viij.-xxiv. ).
ir. .1. Rixtedo.
NEUROEPITHELIOMA. -The name of neuroepitheli-
oma was lir.st given by Simon Flexncr in IS'.tl to a pecul-
iar tumor of the retina in which were found collections
of cells resembling the rods and cones of the external
nuclear layer. Flexner believes this tumor to have had
its origin "not in the supporting cells, but iu the neuro-
epithelial cells of the external nuclear layer, and to be
therefore not a glioma but a neuroepithelioma. In this.
ti.ssue he found the tubular oralveolar arrangement of the
cells, so common iu glioma of the retina: and among the
cells of the tubules he found tiny rosettes composed of
loug cylindrical cells, the pointed extremities of which
were turned toward the lumen of the rosette and formed
there a membranous ring. These cells he considered
rudimentary rods and cones. He answers the objection
of IwanoCf to the formation of tumors from any cells ex-
cept supporting cells by quoting Klebs' opinion that all
the elements of the nervous system are capable of pro-
liferation.
Three years later. Wintersteiuer reported a case of so-
called neuroepithelioma of the retina in which rosettes
similar to those described by Flexner were found. Win-
tersteiuer meutions Flexner's work, but claims to have
made his discovery quite indepeudentlj- of the latter, and
does not give him credit for the name "neuroepitheli-
oma.'' Ue found transitions between the rods and cones
and the tumor cells, and considers the membrane formed
by the jjrocesses of the cells to be analogous to the mem-
braua limitans externa. In a later mouogra])h Winter-
steiuer iliscusses eleven tumors with ejiithelial rosettes
which he found among thirty -two gliomata, and in two
cases of microphthalmos. He regards these tiuiiors as
originating in misplaced cells of the rod-and-cone layer.
Several other authors have reported similar tumors, but
without giving them the same interpretation. Thus
IJecker describes rosettes of cylindrical cells in a tumor
with a marked alveolar structure which he called "tubu-
lar angiosarcoma." Bochert, Eisenlohr, Jung, Thieme,
and Van Duyse probably were also dealing with the same
kind of tumor under the name of glioma or gliosarcoma,
or angiosarcoma. Two observers, Greef and Hertel,
working with the Golgi method, were able to demon-
strate the presence of true ganglion cells among the
ordinary spider cells which formed the mass of the tu-
mor iu both cases. They did not, however, apply the
term neuroepithelioma to these tumors, but preferred to
use the name neuroglioma ganglionare, after similar tu-
mors in the central nervous system.
The best criticism of the views of Flexner and Winter-
steiuer is given by Ginsberg, who examined two tumors
from a case of microphthalmos, and found iu them the
same rosettes of epithidial cells described by the two
former. Ginsberg, however, regards these as cylindri-
cal cells from the pars ciliaris retimie, not rods and cones.
These cylindrical cells are undifferentiated cells of the
original Anlage of the retina, formed before the neuro-
blasts and spongioblasts. As these primitive cells are of
epithelial origin he suggests the name "carcinoma reti-
na-,''instead of neuroepithelioma. He bases his theory
not only on the appearance of the cells composing the
rosettes, but also on the fact that these primitive, undif-
ferentiated cells are capable of proliferation, while iu the
case of highly specialized cells, such as the rods and
cones, there is great doubt as to the possibility of their
proliferation. The tumors which Wintersteiuer has
called neuroepithelioma Ginsberg regards as probably
formed from primitive epithelial elements, and not from
the highly specialized neural epithelium.
Alice Hamilton.
NEUROFIBROMA. Sve Filjivma.
NEUROMA. See Fibroma.
NEUROMA OF THE SKIN, PAINFUL.— This is an
exceedingly rare atlection, Imt two cases in which the
skin was luimarily affectcil being on record. Dulir-
ing's "Case of Painful Neuroma of the Skin." American
Journal of the Medical Sciencts, October, 1IST3, was the
first noted and was followed by Kosinski's case in the
Centralblatt fiir Vhirurgie, No. 16, 1ST4. Both cases
occurred in men, aged seventy and thirty years re-
spectively. In Duhriug's case the tumors had been
developing for ten years and in Kosinski's for fourteen.
258
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
IVeurodln.
Neurone.
The tumors, varying in size from a pinhead to a filbert,
toiitluent and disseminated, were tliiclily studded over
tlie areas affected. lu the lirst case the)' extended from
the left scapula over the shoulder down the arm to the
elbow, occupying principally the area of distribution of
the circumfle.x nerve, and in the second case over the but-
tocUs and upper part of the thigh, corresponding to the
area supplied by the small sciatic and external cutaneous
nerves. The lesions were arranged irregularly, not cor-
responding exactly to the course of the nerves mentioned,
and formed firm, flat, or oval, elastic nodules, tixed in
and extending below the skin, and movable only with it.
The integument between the nodules was normal, they
being purplish or pink in color. In Duhring's case the
skin over the nodule was slightly scaly. At the outset
pain was variable, but later it became excruciating and
occurred in violent paroxysms, lasting an hour or more.
Since they are never malignant these neuromata are
best not interfered with unless great distress is caused by
the pain. In both the above cases resort was had to a
removal of portions of the nerve supply with resulting
quick relief from pain and gradual and almost complete
subsidence of the nodules.
The new growth is composed of firm connective tissue
and nou-niedullated nerve fibres.
Charles Towns/tend Dade.
NEUROMIMESIS. Sec Joints, Chronic Diseases of.
NEURONE, GENERAL PATHOLOGY OF THE.— Ix-
TRODicTio.N. — Nolwitlislanding the liberal ninnber of
papers which have been published in recent years upon
the pathology of nerve cells, we have still, in an essay
to construct a general pathology of the neurone, only
fragmentary data at our disposal. The neuropathologist,
like all other special pathologists, meets with insuperable
difficulties, due to the fact that a well-developed path-
ology of the cell in general is still lacking. Investiga-
tors are coming more and more to the opinion that in
order to build up a satisfactory pathology of the cell,
research ought not to be limited to the cells met with in
the special tissues of highly differentiated animals, but
should be extended to unicellular forms, in which the
conditions of life are simpler and with which the possi-
bilities of experiment are more manifold, and the experi-
ments themselvesare more easily subject to control. In-
deed, at the present time, part of the pathology of each
of the special types of cells of the vertebrate animal is
based directly upon inferences drawn from work done
upon one-celled species. Thanks to the very extraordi-
nary distribution of the protoplasm of the nerve cell in
space, however, it has been possible, in nerve cells or
neurones, better than in any other specialized type, to
study the results of injury to a part of the cell : indeed,
this kind of injiu-y can perhaps be better studied in them
than in any of the simplest organisms. It is owing to
this circumstance, doubtless, that such a goodly portion
of that pathology of the neurone which has thus far been
evolved has to deal with degenerative and regenerative
processes following upon damage to some one of its
parts, partieularl}' its axcme.
In view of the variety of liypotheses still advanced
concerning the ultimate structure of the protoplasm of
the normal nerve cell (see this H.vndhooii, Vol. 11. . arti-
cle. Brain, Histology of), it is by no means surprising
that there is lack of unanimity of opinion regarding the
fundamental nature of the changes which are met with
in the neurone when it is di.seased.
The studies of the botanist Fischer, of Leipsic, have
shaken microscopical histologj' at its foimdations. Now
that we know the varying results which can be obtained,
not only by the use of fixing reagents of different chem-
ical constitution, but by the empio_yment of the same re-
agent in different degrees of concentration, we must needs
be chary of the conclusions we arrive at from the examina-
tion of fixation pictures in nerve cells, not only in health,
but also and perhaps more particularly in disease.
The scepticism excited by these recent observations
has, in some quarters, probably become excessive. Real-
iziflgthat the stainable substance of Nissl can be precipi-
tated in granules of different size by alcoholic solutions
of varying strengths, that b\' treating nerve cells by one
series of vigorous reagents, the so-called ueurofibi'ils of
Apathj' or of Bethe may be demonstrated, while by treat-
ing the same nerve cells b_Y a different series of powerfully
modifying solutions the honeycomb structure of Butschli
or the neurosome rows of Held may be put in evidence;
and bearing in mind, further, that microscopic ajipear-
ances similar to karyokinetic figures, centrosomes, and
cytojilasmic radiations ma_Y be jM'oduced b)' the action of
fixing reagents upon albuminous solutions injected into
the empt3' cellular spaces of cork, there are tliose who
woiUd go so far as to say that the microscope and micro-
scopical histological methods liave been and can be of very
little help to us in unravelling the structure and deciding
upon the functions of cells. Such pessimists, however,
forget the wonderful advances in neurological knowledge,
anatomical and pathological, which are directly attribu-
table to the use of the microscope. It would be as illogi-
cal for the student of the nervous sy.stem to give up the
study of fixation jiictures as it would be for the chemist
to abandon the method of precipitation as a means of ac-
quiring knowledge concerning the compusition of solu-
tions. It may be that the protoplasm of the nerve cell,
as well as protoplasm in general, consists cluefl_y of
colloidal particles held in suspension b_y virtue of the
electric charges which they possess; if so, we may expect
that some day new and desirable information will be de-
rived from a study of artificially prepared colloidal solu-
tions. Such a line of investigation, attractive and prom-
ising as it is, will unquestionably be that along which
many can profitably work; but it is to be hoped that
there will be others who will continue and extend those
studies by histological methods which have done so much
for us in the |)ast, and which, many of us are convinced,
are capable of supplying us with still more valuable in-
formation in the future.
In the brief sketch of the general pathological mor-
phology of the nerve cell to be made here, the changes
due to "functional activity will first be referred to; next
a description of the processes of necrosis and necrobiosis
as they affect the neurone will be given, followed by a
brief discussion. (1) of the various degenerations which
involve the whole neurone or parts of it ; (2) of regenera-
tive phenomena; and (3) of the changes couseciueut upon
various forms of intoxication.
Refere.\ces Bearing tpox the Ge.veral Scbject.
Barbacoi, O. : Die Nervenzelle in ihren aiiatomisclieii. piiysiologischen,
and patboIot?ischen Be;{iehungen naeli den neuesteu Tutersu-
chunKen. Centralbl. I. allg. Path. u. paili. Anat., .lena. Bd. x.. 1899,
pp. ")~. S6.5. [A collective review witli 418 references to articles on
the subject.]
Barker. L. F. : The Nervous System and Its ConsUtuent Neurones,
New Yorli, 1899, chapters xix.-.\xv., pp. 31.T-312.
Ewing, J. : Studies on Ganglion fells. Arch. Neurol, and Psycho-
path.. New York, vol. i., lKy.H, pp. 26.3-440.
Golilsclicidfr, A., u. Flatau. E. : Normaie und pathologiscbe Anatomie
der Ncnenzellen, Jena, 1898.
Van Gehuchten. A. : Anatomie du sysT^me nerveux de rhornnie,
Louvain, third edition, t. i., 1900, cap." 14 and \T\ pp. :5i;i-:i:39.
Lukjanow. S. M. : Grundziige einer allgemeinen Pathologie der
Zelle, Leipzig, 1891.
Schmaus, H., u. Albrecht, E. ; Pathologie der Zelle. Ergebn. d. allg.
Pathol, u. pathol. Anat., Wiesb.. .Jahr^g. Ui. (1896). l.HiiT, ss. 470-541.
Albrecht, E.: Pathologie der Zelle. Ibid., Jahrg. vi. (1899), 1901, SS.
900-951.
Spiller, W. : Pathological Changes in the Neurone in Nen'ous Dis-
eases. J. Nerv. and Ment. Dis., New Y'ork. ISXXI, pp. 487-505.
Mott, F. : On Degeneration of the Neurone. Brit. 51. J., Lond., 1900,
I., pp. 1.582-1590; II., 82-90.
Changes due to Functional Actiyitv in the
Neurone.
In this connection the studies of Hodge upon the his-
tology of fatigue are by far the most important hitherto
undertaken. His researches were made U]ion the nerve
cells of various animals, including sjiarrows. swallows,
pigeons, and honeybees. A comiiarison of the cells of
such animals captured in the morning with cells of ani-
mals of the same species killed after a long day's exercise
259
Neuroue.
Neuroue,
REFERENCE ILVNDISOOK OF THE MEDICAL SCIENX'ES.
showed alterations both ia the protoplasm and in the nu-
clei of the fatigued cells. The nuclei were smaller than
normal in the tired cells, had irregular margins, and
staiueil with unusual intensity. An examination of the
protoiilasni re\'ealeil a shrunken apijearance. and it
stained more feebl.y than normal. The changes in the
cells of tlie occipital cortex in the iiigeon, as ilepicted l>y
Ilodge, are verj- convincing. Ilodge'searlier imports di<i
not contain satisfactory data with regard to the behavior
of the stainable substance of Nissl, as he used osniic acid
fixation for some of the cells anil sublimate fixation with
Gaule's stains for others.
Later on JIanii, working with other methods, compared
the pyramidal cells of the cerebral cortex auvl the motor
cells of the ventral horn of the spinal cord of a dog at rest
with tlio.se of another dog after a long period of muscu-
lar activity. In a further series of experiments he ban-
daged one eye of dogs leaving the other exposed, killed
the animals after twelve hours, and compared the retinal
neurones, those of the corpora quadrigeniina. of the lat-
eral geniculate body, and of the occipital cortex of the
one side with those of the other. He concludes that the
stainable substance of Nissl increases in amount in nerve
cells which are resting; it diminishes during functional
activity, owing to direct utilization by the cell proto-
plasm. In addition. Maun describes an increase iu the
size of the cell bodies and of the nucleus and of the nu-
cleolus iu the early stages of functional activity; if tlie
activities be prolonged to fatigue, there are shrinking of
the protoplasm and contraction of the nucleus, the bor-
ders of the latter becoming irregular. Sin;ilar investiga-
tions have been made by De Jloor and Pergens.
The studies just described refer to tlie changes which
occur iu nerve cells as the result of that normal excitation
of cells which accompanies nuiscular activity or normal
retinal illumination. Opportunities for studying other
forms of normal functional activity might well be taken
advantage of. It is desirable, too, that methods should
be devised for testing tlie etTect of alterations of temper-
ature, light, moisture, and non-poisonous chemical stim-
uli upon different groups of neurones.
The effects of electrical stimulation have been investi-
gated to a certain extent. For cxam]ile, Hodge stimu-
lated the peripheral sensory nerves of cats and afterward
made sections of the spinal ganglia. In the ganglion
cells on the side of excitation he found a decrease in the
size of the nucleus and a change in its shape. The cell
body, also, gradually diminislied in size. Vas, on the
other hand, stimulating tlie sympatlietic for fifteen min-
utes, found r, distinct increase in the size of the cell body,
and a disapiiearance of the stainable substance of Xissl
in the region of the perikaryon immediately adjacent to
the nucleus. The nucleus itself, Vas states, becomes
swollen and tends to be disjilaced toward the periiihery,
sometimes even causing a bulging at the periphery of
the cell. The somewhat conflicting statements of Hodge
and Vas have been reconciled liy the experiments of Lu-
garo, who demonstnited during the early period of exci-
tation a state of turge.sceuce in the protoidasm of the cell
body, while later on, when the stimulation had been con-
tinued long enough to cause fatigue in the cell, progres-
sive diminuticm in the size of the cell body was met
with. According to Lugaro tlie tigroid sulistance slowly
increases in amount during the earlier period of stimula-
tion; after Die cell has become fatigued, it is deen-ased
in amount and tends to be more diffusely distributed
throughout the cell body.
References Bearing upon Changes die to Functional
Activity.
Hodge, C. F. : Some Effects of StImulatiiiK Ganpllon Cells. Am.
Jour. Psyctiol., Baltimore, vol. 1. (1SR7,-8.S), pp. 47tMsi).— gome Ef-
fects of Electrically Stimiilatinir (ianirlii'n Cells. Am. J. Psvrliol..
vol. ii. (1.S8S-.S9I, ■ pp. :J76-IIL'.-A MiiToscci|)ical Study of the
Nerve Cell during Electrical STiimilati'in. Jour. MorphoL. Boston,
vol. i.x. (1S94), pp. -UiM+iS.— A Microscopical StiKly nf Chan^'es due
to Functional .\ctivity in Nerve Cells. J. Morphol., Bust., vol. vii.
(1893-y3). pp. ftVliiS. ■
Vas. F. : Studien uber den Ban des Chromatins in der synmathischen
Ganglienzelle. Arch. t. mlltr. Anat., Bonn, Bd. xl. (ISW), SS. 375-
3S0.
Mann, (i.: Histological Changes Induced in Sympathethic, Motor,
and Sensory Nerve Cells by Functional Activity. J. Anat. and Phy-
siol., Loud., vol. xxix. (1S9,5), p. ItlO.
Lugaro, E. ; Sur les modlBcalions des cellules neryeuses dans les
divers et;its fnnctlonnels. Arch. ital. de biol., Turin, t. xxiv. I.1S95-
fltji. pp. ;.'.')S :.'si. Also Sperimentale, Sez. biol., Firenze, An. xlix.
(l.s'Xo. pp. l.VJ-193.
Pergens, E. : ,\ction de la lumit-re sur la refine. Ann. Soc. roy. d.
sc. med. et nat de Brux., t. v. i ISHtli, pp. ;i.s(j-421.
De Moor : La plasticite morpholnirique lies neurones cerebraux. Arch,
de biiil.. (iand, law, pp. 723-7oa.
For other references see Barbacci, Barker, and van Geluichten, cited
above.
Neckosis AND Necrobiosis op the Neueone.
By the term necrosis of the neurone is meant that con-
dition or set of conditions in which tlie cell is rehitively
suddenly killed ; by necrobiosis of the neurone is indi-
cated the process which leads, through a series of path-
ological clianges, gradually to the death of the cell.
Necrosis of nerve cells is met with in trauma, in infec-
tious processes directly involving the nerve tissues, iu
sudden cutting off of the oxygen supply {(inamic n-ecro-
Kts) and possibly under other conditions.
The classification of direct necrosis introduced by
Klebs is ]ierhaps the most satisfactory one we po.ssess.
If the noxious agent which kills tlie cell affects it equally
in all its parts, one gets a microscopic picture not unlike
that met with in the artificial killing brought about when
we fix the nerve tissues in the fixing reagents of I he lab-
oratory ; the structure of the protoplasm and nucleus is
relatively well preserved. The nucleus is. however, in
some cases, first attacked by the nnxa, in which event it
may either be dissolved (/iitri/nli/sin) or become fragmented
{/cfiryorr/ie.tt's) ; iu such instances the alterations in the cell
body may at first be slight, consisting perhaps merely of
cloudy swelling. In forms of cell death, on the other
hand, in which the protoplasm appears to be first at-
tacked, a primary vacuolar degeneration of the cell body
{pldsmiin'/ie.rin) ma}' be encountered.
A cell is doomed to death if its nucleus be destroyed or
injuied beyond a certain degree. The studies of Coiido-
relli upon the effect of mechanical injury to cells have
shown us that rupture of the nucleus not infrequently
occurs as a result of trauma. Schmaus has suggested that
we may here have an explanation of the direct necroses
of ganglion cells which may be assumed to take place in
commotio ceiebralis and commotio spinalis. Tissues un-
der these conditions should be studied in the early stages
and with the aid of modern methods. A beginning has
been made in this direction ((/. Barbacci. lee. cit., p. 819).
We know but little of the effect of powerful electric
currents acting directly upon the neurones. A few cases
of electrocution have been examined post mortem with-
out, it must be confessed, adding much to our knowl-
edge. There is here room for fruitful experimentation
in the light of the results which were obtained by Eschle
upon artificial necrosis due to electrical influences (see
also work of Corrado. cited by Barliacci).
In disi'ases associated with periiiheral neuritis (diph-
theria, lead poisoning, etc.) we have exquisite examples
of partial nerve-cell necroses, the jioison killing the ax-
ones of the neurones through a distance of from a frac-
tion of 1 mm. to several millimetres. The effect on the
whole neurone is the same as that which follows upon
artilicial section of the axone (ride infra).
Careful studies of karyolysisand karyorrhexis in nerve
Cells have still to be made. There are only fragmentary
remarks upon the subject in the bibliography. The dif-
ficulty of the study is aggravated by the unusual distri-
liution of the chromatin in the normal nuclei of nerve
cells.
The so-called condition of pyknosis in which there is a
condensation of the nucleus and cell body is worthy of
mention. 8chmatis assumes that the so-called "'sclerosis"
described by Friedmann in acute myelitis is closely allied
with pyknosis. This author found in cells otherwise
nearly intact glistening masses which stained intensely
with nuclear dyes; such masses appeared at first in the
periphery or in the interior of the cells, as though they
had resulted from fusion of the spindles and granules of
260
REFERENCE HANDBOOK OP THE JIEDICAL SCIENCES.
NeiiroiK",
Neuroue.
the stainable substance of Nissl. Later, the cells dimin-
ished iu size, though the glistening staining increased.
The nucleus was often well preserved for a long time.
It may be that some of the "'cln-omophile " cells of Xissl
belong iu this category, though in most instances it
would seem that they are to be regarded as artefacts due
to the fixing reagent.
A series of uecrobiotic changes have been described by
Pandl in nicoline, bromide, and cocaine poisoning. In
chronic poisoning with nicotine, the nucleus of the cell
becomes shrunken, the cell body is diminished iu size,
and the paraplasm aud the nucleus stain of a dark color.
In cocaine and bromide poisoning the nuclei show en-
larged nucleoli; tlie chromatic threads in the iiroto])lasm
lie closely pressed together, sometimes becoming merged
witli the deeply stained ground substance of the nerve-
cell body.
The e.xperimental work of Klemm upon plant cells has
shown the way for a series of e.vperiments upon nerve
cells, which, it is hoped, some one in the near future
may be induced to undertake. According to Klemm,
when a cell is suddenly killed there is never any contrac-
tion of ii, nor any considerable alteration in couligura-
tion. These are the signs of a much slower dying proc-
ess. The visible alterations in the proto|ilasm of plant
cells on sudden killing are, according to Klemm, of three
kinds: (1) Precipitates: usually granular structures giv-
ing an iucreased granular appearance to the cell. Such
granules may be united in the form of chains, networks,
and dendritic structures. Instead of granular preripitatcs
a fibrillary appearance may be produced. (2) Pheuome-
na of solution : vacuole formation, foam formation, and
the like. (8) A mixture of granulation (coagulation) in
the plasma with formations of fewer aud smaller vacu-
oles.
Where death is not so sudden and yet very inteuse
effects are suildenly pi-oduced, the most marked alter-
ations in cnntiguralion are met with. In the still slower
"physiological" death the terminal jihenomeuon is usu-
ally coagulation of the protoplasm, and there is a ten-
dency to various forms of degeneration — granular degen-
eration, vacuolar degeneration, etc. Dying protoplasm
has the tendency to break up into .small clump-like
masses which assume a more or less spherical shape.
REFKREXCKS BEAKINIi 0.\ NECROSIS AND XKCROBIOSIS.
Schmaus. tt. : Nckmse and .Xt'krnbi.jse. Erirhn. d. allg. pathol. Mor-
pbol. u. I'livsii.l . Wii-sli., is'.i;-,, Hd. 1.. ss. i:ir-149.
Klebs, E. : Dit- allu'i-imMne Patlic.|,<i,>, ji., l,s,s(i. s. 10.
CondorelH ; lslio|iaiol(it:i:t dt-I iuh-Ihu nelle conlusioni. Catania. lSt*l.
Eschle; Bi.^ina^^f zuiii studiuin di-r Wirkiinff elektrischer Stronie auf
die tliierisiiirn (li-webe. Arcli. f. path. Anat. [etc.], Berl., Bd.
cxxxviii., islu, S. 371.
Friedmanii. M. : Ueber die def^enerativen Veranderungen der Gan-
glienzellen bei akuter Myelitis. Neurtil. Ceiitralbl.. Leipz., x.. 1891,
1-U.— Ueber profrressive Veranderungen der Ganglienzellen bei
Entziindnngen, nebsteinem .\nbang iiberacMve Veranderungen der
Axencvlinder. Arch. f. Psvchiat.. etc., Berl., Bd. six. (18S7), SS.
■ 244-268.
Pdndi, K. : ITeber die Veranderungen des Tentralnervensystems naeii
chroniscber Verpiftuug niit Broni, Knkain, Nikotin und Antipvrin.
Ungar. Areb. f. Med., Wiesh., Bd. ii. 0893-94), SS. 2.57-284.
Soukbanofl. S. : Sur I'bistologie patbologique de la polyn^vrite dans
ses rapports avee les lesions de la cellule nerveuse, N. ieonog. dt-
la Salpetriere, Par., t. x. (1897), pp. .347-:).>4.
Eleiuiri, P. ; Desorganisallonserscbeinungen der Zelle. Jahrb. f. wis-
senscb. Bot., Bd. xxviii., 1895, S. 027.
Atrophy of Neurones.
Hod.ge, of Claik University, has made us familiar with
some of the changes which take jilace in neurones in se-
nile atroph)-. In a man ninety-two years old, dead of
marasmus, the ganglion cells as a rule looked fiiirly noi--
mal, though he describes a diminution in tlie number of
the Purkinje cells in the cei'ebellum and slight shiinking
of those wliich weie pivsent. His study of the S|iinal
ganglion {'ells denionsti'ated I hat the nucleus nearly al-
ways had an irregvdar contour, was more or less
shi'unken. and often devoid of nucleolus. The cell pio-
toplasm was rich in fat and pigment, which were absent
in the firtns. Hodge's description of fat and pigment in
a forty -seven-year-old man is accompanied bj- the sugges
tion that the man suffered from premature senescence due
to alcoholism. I am of the opinion that the pigment
which he describes is visible iu the nerve cells of nearly
all human beings and jji'obablj' at all ages, except in the
fo'tus and in early childhood. I have been struck with
the comparatively lai'ge number of times the so-called
lipochrome of normal nerve cells has been described as a
pathological product. Some of those who have studied
the Gasserian ganglion iu tic, dauloureux have fallen into
this error.
Hodge studied the changes due to age in bees, as well
as in human beings, and described shrinking of the nu-
clei, vacuole formation in thepi'otoplasm, as well asdimi-
nutiou of the total nunilier of cells.
Studies of a similar natuie have been undertaken by
Vas. This investigator made use of the method of Nissl
in examining the nerve cells of old people. He describes
various alterations in the stainable substance of Nissl,
and states that in the last stage the cell body is trans-
formed into a strongly staining, formless mass, which
may be bi'oken up into clumps. It does not seem impos-
sible that Vas may have had to deal with artefacts, per-
haps the " chromophile " cells of Nissl. They can be ob-
tained occasionally in nerve tissues from individuals of any
age. I have pictured one in a former publication (see
Fig. 73, "The Nervous System," p. 124).
According to Babes, the processes in the anterior horn
cells of the spinal cord are reduced in number iu old age.
In a group of intact nerve cells one sometimes finds in
old people shrunken, colloid, or very pale elements with-
out nucleus or nucleolus, or witli a strikingly pale nu-
cleus. The tigi'oid masses are ]iale and few in number,
or they inaj' be entirely absent iu the periphery of some
of the cells. In other old people the nerve cells appear
to be nearly normal, which proves. Babes thinks, that the
capacity for resistance varies greatly in different indi-
viduals.
The pigment (lipochrome) is certainly more abundant
in (.)l(ler people, a fact repeatedly confirmed bj' Marines-
co. Rosin, myself, and others.
The more one studies the descriptions of atropiiy of the
nerve cells in old age, the less he feels satisfied with the
studies which liave thus far been made. The subject
should be taken up again now that we have better meth-
ods and are more familiar than formerly with changes in
the neurones due to causes other than senility.
One of the later studies is that of JIarinesco, according
to whom the senescence of the nerve cells is due to a
defect of mettibolism. The anatomical changes include
a deci'ease in the size and number of the tigroid masses;
sometimes the Nissl bodies are transformed into grannies
of variable size (senile chromatolysis), especially around
the nucleus, but often throughout the whole cell. Mari-
nesco believes that the "pigment" really represents a
pi'oduct of the involution of the cell, and that when it is
increased in amount it reduces the nutritive and respira-
toi'v capacity of the cell. The number of dendrites
diminishes and their bi'anches di-sappear. Finally the
volume of the perikaryon itself decreases. He denies
neui'onophagocytosis due to senility. Instead of an in-
crease in the glia cells, these cells disappear pun' passu,
with the vauishing of the nerve cells.
Of the atrophy which may take place iu a neurone
\\ hen its axone is injured, or when iinpidscs which nor-
mally come to it are cut off, mention will be made in
connection with secondary and tertiary degenerations of
the neurone.
References Bearing upon Atrophy of the Necronk.
Hodge, r. F. : Die Nervenzelle bei der (iebiirt und beiiu Tode an
Alterechwartie. Anat. Anz., Jena. Bd. ix. (18941, SS. 7Wl-riO.—
Cbanires in Ganglion Cells from Blrtb to Senile Deatb : < ibservations
.m Man and Honev-Bee. J. Pbvsiol.. vol. xvii. 1 1894). pp. 12!l-i;i4.
Juliu.sliiirger, II.. u. E. Mever: Beilrage zur Patbologie der Ganglien-
zelle. Monatscbr. f. Psvcbiat. a. Neurol.. Berl.. Bd. iii.. p. 3bi.
liohertson, W. F., and D. Orr; The Normal Histology ami Pathology
of the Cortical Nerve Cells. J. Ment. Sc. Lond., vol. xllv., 1898, p.
729.
Babes, v.: Teber den Einfluss der verscbiedenen Infectionen auf die
Nervenzellen des Riickenmarks. Berl. klin. Wchnschr.. 1898, Nos.
1, 2. and 3.
261
Neurone.
Neurone.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Redlk-li, E. : Senile Gebirnatrophie. -Moiiatsdir. f. Psydiol. u. Neurol.,
Berl., Bd. v., H. a S. 2is.
Sander. M.: Untersiiehunfren iiherdle AltersveraiKlenmeen itTiRurk-
enmark. Deutsche Ztscbr. f. Nerveuli., Leipz., lid. xvii., SS.
.369-^96.
Pugnat, C. A. : De la destruction des cellules nerveuses par les leuco-
cytes Chez les animau.x ages. Coiupt. rend. Soc.de blol.. Par., vol.
Iv. (1898), 2i-'.
Degenbr.\tion8 of the Neurone.
Under tliis lieadina: will be considered ('/) Primary De-
generations (it the Neurone, iiieliidini; (1) cloudy swell-
ing. (3) fattv degeneration, (3) vacuolar degeneration,
(4) pigmentary degeneration, (5) allnimiiious degener-
ation ;"and (A) "Secondary Degenerations of the Neurone.
(a) Pri.mauy Degenekatio.ns of the Neurone.— (1)
(Jloudy Sirellinr/.— In view of the fact that ijarcuchyma-
tous degeneration or cloudy swelling has been described
in connection with the aeu'ti' iidVclions and intoxications
in most of the organs of the body, it is ratlier sin-prisiug
tliat we find so few references in the bililiography to this
form of degeneration in the nerve cells. The changes
which accompany infection and intoxication are so char-
acteristic and con.slant in the various secreting cells that
it seems probable that a similar degeneration has been
frequentlv met witli in tlie nervous system, but has been
described" tind<'r a dilTerent name. Doubtless the ]ires-
cnce of the peculiar tigroid masses in tlie pi'otoplasm of
nerve cells has been responsible for the dilficulty in
studying this change. If one reads Beiiario's careful re-
view ofthe whole stdjject of cloudy swelling and then
examines the articles liyEwing, Mariue.sco, and others on
the pathological changes in the nerve cells in acute in-
fections, lie cannot but feel that the preliminary swelling
of the nucleusand proto])hismaud swelling of the tigroid
masses followed by their breaking up into tine granides,
described liy tliese writers, corresjioud more or less closely
to the cloud_v swelling which affects gland cells. Tin;
alterations described "by Fianca in the nerve cells in
pl.igue, and by Camia in the nerve cells in influenza, are
very suggestive in this connection.
References Beari.ng on CmrpY sweeli.ng.
Benario : Die l.ehre von der tiiilien Scliwellung in ihrer Entwlckelung
uud Bedeutunu. WiiTZbiu'g, l.SHl.
Ewiuit, J.: studies on Ganirlion Cells. Ai'cb. Neurol, and I'syclio-
Pathol,, New York. vol. i.. pp. 2ti,'!-44t>.
Marinesco, (j.: Recherclies sur rjuelques It^slons peu connues des
cellules nerveuses corticales. Roumanie med., Bucarest, vol. vii„
181W, p. Ilia.
Fraiii-a ; Contriimtiou a IVtude des alterations des centres nerveux
dans la peste liubimicpie humaine. I,e Nevra.Ke, Louvain, 19(XI.
Camia, M. : Due casi di psicosi conseculiva ad influenza, con auiopsia,
Rlv. d. patul. niTV. e luciu., Firenze, vol. v., 1900, p. ItlU.
(2) Fiitli/ Jliyiiicmtion. — Fat droplets of smaller or
hirgcr si/c are frequently met with in nerve cells in the
most dilfciriu |iathological processes, Ijnt especially in
infections and intoxications. These are usually met
with in the ijrotojjlasin of the perikaryon and are visible
as yellow, glistening droplets in frozen sections, or as
black spherules in Marelii preparations. I have often
seen black droplets in the nuclei of nerve cells in Marchi
specimens: in some instances they ayipear to lie coinci-
dent with the nucleolus.
(3) Vdriiiihir Deiji iierdtlii)!. — The sttidy of vai uoUir de-
generation of the nerve cell lias had an interesting history.
In the older )iublications. wliere tlie studies wei'e nearly
all made upon Mi'illcr's fluid preparations, nothing was
more common than to read of extensive vacuolar degen-
t-ralions in tlie cells of the brain and spinal cord. We
know now that the majority at least of these were noth-
ing more nor less than artefacts due to the action of the
liaiilening reagent (work of Kreyssig and of Trczebin-
ski). In some of the more recent studies, however, true
vacuolization of both protoplasm and nucleus of the
nerve c.:lls has been described. Nerlich has investigated
tlie origin of vacuoles in a case of cerebral tetanus in
which the nucleus nervi liypoglo.ssi, tlie nuelmis nervi
facialis, and the nucleus motorius nervi Irigemini con-
tained vacuolated ganglion cells. He found occasionally
as manv as iwentv vacuoles in a single cell. The cell
body was swollen, though often surrounded by a large
pericellular space. The nuclei were not altered, though
they were sometimes displaced from the normal position
b_y the vacuoles.
Besides in tetanus, vacuolization of the nerve cells has
been described in various infectious diseases, in acute
poisoning with mineral acids (ganglion cells of the heart),
and in fasting. Sometimes the nucleus, as well as the
cell jirotoplasm. is vacuolar (Kazowsky).
The study of vacuole formation in cells generally has
been ap])roached recently from the experimental side.
Two kinds of vacuoles may be distinguished according
to their origin: (1) .solution vacuoles, which increase in
size with the diffusion and endosmosis of the agent jiro-
duciug them: (2) expulsion vacuoles which are formed
suddenlj' as a result of coagulation and do not usually
increase in size.
References Bearing upon Vacuolar DEfiENERATiox of the
Nerve Cell.
Schmaus, H., u. E. Albrecht : Vakuoliire-fettige Degenerationen.
Ergebn. d. allg. path. M.upbol. n. Physiol., Wlesb.. 189.5, SS. 1.51-161.
Nerlleh : Ein BeltraL' zur I.ehre voiii Kopttetanus. Arch. f. Psychlat.,
etc., Berl., Bd. -\,\iii. ' lsii:.'i, 8. liT:;.
Popoff. N. M. : Patli<il"gis<-h-anutnniische Veriinderuugen des Cen-
tralnervensy.steiiis bei der a^latischeu Cholera. Arch. f. path.
Anat. [etc.]', Berl.. liil. c.x.Nxvi. ils94i, S. «.
Kazowsky, A. D. ; Uelier die Veriinderung in den Herzganglien bel
akuteu Mineralsiiurevergiftuugen. Centralbl. t. allg. Path. u.
path. Anat., Jena, Bd. v. IlS94), S. 11120.
SUitkewltsch : I'eber Verilnderungen des Muskel- imd Driisen-
gewebes, sowie der Herziranglien beini Hungern. Arch, f. exper.
Path. u. Pharmakol., Leipz., Bd. xxxiii. (Is94i, SS. 41.5.
Strobe, H. : Experinientelle Untersuchiingeu iiber die degenerativen
und reparationischen Vorgiinge l)ei der Heilimg von Verletzungen
des Riickenmarks, etc. Beitr. z. path. Anat. u. Physiol., Jena, Bd.
XV. (1S94). s. ;KJ.
For a list of diseases in which vacuolar degeneration has been de-
scribed, see Barliacci : loc. cit., p. 805.
(4) rir/mentury Dfr/eiin-iition. — In frozen sections and
in Nissl preparations of adult nerve cells in various
parts, a yellowish pigment can be made out. This is
said to be entirely absent in the newl3'born. According
to Pilcz, Cibersteiner, and others it appears at different
periods of life in different nerve cells, at the sixth year in
the spinal ganglia; at the eighth year in the anterior horn
cells. The amount of pigment increases as age advances
{rif/e supra. Atrophy).
This pigment is not identical with that of the locus ca^-
ruleus, substantia nigra, or substantia ferruginea. It
may be improijcr to speak of it as pigment at all. It
stains black with osmic acid, and thus is easily visible in
JIarchi preparations. It seems to be related to the fats
( Ri isin). Ramon y Cajal regards it as a metabolic jirciduct
of the cell, which "the lat ter cannot rid itself of. Whether
it arises from the stainable or from the unstainable sub-
stance of Nissl is not known. Obreja and Tatuses be-
lieve tluit this )iiginent is of a fatty or myelinic nature,
probably related to lecithin. They therefore look upon it
as a store of nutrient substance in the cell; according to
their findings it is tliminishetl in amount in the anterior
liorn cells in strychnine poisoning and in tetanus, while
after prolonged rest it is increased. Against this view
van Gehuchten urges that the substance is absent from
the nerve cells in early life, and further that in a case of
tetanus which lie examined there was no diminution in
the amount of jiigmeut. The whole matter required
further investigation,
Refere.xces Bearing upon So-callep Pigmentary
degeneration.
Eosin. H,: Ein Beltrag zur Lehre vom Bau der Ganglienzellen.
Deutsche med. W<-hnschr., Leipz. u. Berl., Bd. xxii., 1890, SS.
39.V397.
Ram6n v Cajal, S. : Texlura del sistema neryioso del hombre y de los
vertebrados, Madrid, 1899. t. i.. pp. l:»i-130.
Obreja et Tatuses ; Le iiigment des cellules nerveuses. Compt. rend.
Soc. Sc. Mi^d., Bucarest, November, 1898 (c.'. Rev. Neurol., Par.,
1899, p. 326) .
Barker, L. F. : The Nei-vous System and Its Constituent Neurones,
New York, ISKi, pp. 1117-108.
(,■)) Alhtiwi/iDii.i Diyi'iu riitiiiiix. — Accepting the defini-
tion of Klebs, by albuminous degenerations are to be uu-
2*i2
HEFEREXCE HANDBOOK OF THE MEDICAL SCIENCES.
Neurone*
Neurone,
derstood those disturbances of nutrition in which insolu-
ble albuminous bodies are deposited in the tissues. In
the nervous system we have to deal with two such albu-
minous deposits: (a) the so-called Russell's fuchsin b<jd-
ies, and (i) the corpora amylacea.
Ad (a). Russell's fuchsin bodies described in cancer, in
1890, have since been proven non-specitic as far as these
tumors are concerned. They occur under normal condi-
tions in various tissues of the body, including the nervous
system, but are greatly increased in numbers under patho-
logical conditions. 'They are usually extracellular in
situation but may occur also inside of cells. As a rule,
several of them exist together. They are small, round,
homogeneous bodies, varying from 0..5 to 20/; in diam-
eter. Under the microscope they appear as glistening
ma.sses looking not inilike fat droplets, when exam-
ined in water. They stain intensely by Gram's method
and in acid fuchsin. In Ehrlich's triacid stain the_v are
tinged sometimes with the acid fuchsin, sometimes with
the orange. In Heidenhaiu's iron lurmatoxylin they
stain black. Lubarsch found them in large numbers in
atrophic conditions of the brain. The probabilitj- is that
they are products of the cell protoplasm, rather than of
the nucleus. Some of them may be swollen and altered
cell granules. It is not impossible that line granules in
the cell protoplasm undergo chemical change and fuse to
form the fuchsin bodies. xVgain it has been suggested
that they may have their origin from lecithin. Lubarsch
found that pure lecithin yields the same staining reac-
tions as do the fuchsin bodies; on the other hand, pure
lecithin is easily soluble in alcohol, while the fuchsin
bodies are not.
Ad (b). Corpora amylacea have long been known in
the central nervous system. Their origin and siguifl-
cance have been much disputed, but there can lie no
doul)t that they are very numerous in atrojjlnc and de-
generated portions of the brain and spinal cord. L'nder
normal conditions they appear in the third decade of
life and are never absent in people over forty. In the
ccrelirum they are found in the lining of the ventricles
and in the traetus olfuctorius; they are less frequently
fomid»in the cerebellum. Kedlich supposed that they
had Iheirorigin in the nuclei of neurogliacells. Accord-
ing to a widespread opinion they arise from the coagula-
tion of myelin. It is not unlikely that some of them at
least have their origin through the union with normal
tissue juices of altered cell protojilasm exuded from the
cell. Spiller believes that at least a portion of the cor-
pora amylacea have been derived from altered blood-ves-
sels. The colloid bodies described by Bevan Lewis and
also by Spiller would seem to be closely related either to
Russell's fuchsin bodies or to the corpora amylacea.
Recent studies make it seem certain that greater differ-
entiation among these structures than that ordinarily
made is necessary. Thus Siegert has divided them into
corpora versicolorata (including the "corpora amylacea"
of th central nervous system) and corpora fiava (includ-
ing the "corpora arenacea " of the central nervous sys-
tem). The corpora versieoloi-ata, so-called because they
taJ<e a variegated tint in iodine or bromine, yield the
"amyloid reaction" with aniline dyes, and are further
characterized b_y their brittleness and their morphology.
They may be, {(i) spherical, ovate, or polygonal with
rounded angles; (b) concentrically lamellated, and (c)
sometimes radially striated. They never arise through
direct transformation of cells, nor do they become calci-
fied. The corpora fiava, on the other baud, behave dif-
ferently in solutions of the halogens (chlorine, bromine,
iodine), staining of a yellow color oulj' in Lugol's
solution; Ihey do not j'ield the amyloid reaction with
the aniline dyes. They are waxy rather than brittle;
they vary greatly in their morphology, being sometimes
smoothly spherical, s<jmetimes very irregularly shaped.
Concentric lamellation may not be visible in them and
they are never radially striated. I'nlike the corpora
versicolorata the corpora fiava are said to arise directly
from the transformation of cells and to show a decided
tendencv to become calcitied.
Refere.vces Bearing cpcn .\LBrMiNocs Degeneratioxs.
Kletis, E. : Handbuch der alleemelijen Patliolofrie. Bd. ii., S. 100.
liedlich. E. : Die .tmyloidkOrperchen de.s Nervensystt-m. Jalirb. f
Psychlat., Bd. x. {WVi). \-m.
Siceert : Untersuchunpen iilirr dip ('on^ora amvlarea .sive amyloidea.
.\rcb. f. path. Anat., vh\. lii-il., nd. i x.\i.\.. .s.' .ii;i.
Lubarsch, O. : Bie albiiaiinnspn DeiriTienitionen. Ergrf)n. d. allg.
path. Morphol. u. Physiol., Wiesb., l.^ifi, .SS. Wl-a»l.
Spiller, W. G. : On Amyloid, Colloid. Hyaloid, and Granular Bodies in
the Central Nervous S.ystem. N. York M. J., 1S98, August i:Jth.
(h) Secoxdaet Degexer.\tion, and Modifications
IX THE Neurone following upon Injudt to the Ax-
one. — The nutritive centre of a neurone is in the peri-
karj'on. The trophic infiuence emanates from the nu-
cleus. If any part of a neurone be severed from its
connections with the nticleus. the separated part dies.
In case it is a medullated axone, which suffers solution
of continuity, not only does the whole axone, distal from
the lesion, undei-go disintegration, but the myelin sheath
degenerates in the same area and the nucleated sheath of
Schwann or neurilemma undergoes imjiortant modifica-
tions. These phenomena taken in their totality are usu-
ally designated as secondai'v or AVallerian degeneration.
In the early part of the last century it was known that
interruptions of the connection of peripheral nerves "with
the central system could lead to their degenei'ation
(Nasse, Yalantin, Stannius). The first careful study of
the subject, 'n-jth establishment of a law, vvas that un-
dertaken by ATaller, and from him tiie process has de-
rived its name. He described it in detail — the coagiUa-
tive breaking up of the mj'elin sheath and the dissolution
of the axis cylinder. If a motor nerve is cut. all the
fibres in the peripheral end degenerate completely as far
as the muscles which they supply, the central end either
remaining entirely intact or perhaps, as a result of the
trauma, degenerating as far as the first node of Ranvier.
If a sensory nerve be cut distal ward frcmi the spinal gan-
glion, all the sensory fibres of that nerve degenerate to
the very peripher}-, though the portion of the nerve still
in connection with the ganglion, as well as the central
intramedullary continuation of the nerve, remain unde-
geneiated. On the other hand, if a dorsal root of a spi-
nal nerve is severed between the ganglion and the sjiinal
coi'd, the portion of the nerve attached to the ganglion
does not undergo degeneration, but that connected with
the cord degenerates typically, not only in the portion
outside the cord, but also throughout its -whole intra-
medullary extent. This is the proof wliich has been
brought for the view that the cell bodies in the spinal
ganglia are the trophic centres for the peripheral sensor}'
neurones. Following upon Waller's investigations came
the observations of Tilrck. which demonstrated that the
same law liolds within the confines of the central nervous
system — for example, for the pyramidal tract. Since
Tlirck's studies a host of observations have established
the general validity of the law for all groups of neu-
rones. When an axone degenerates, the retrogressive
process involves not only the main axone btit also its ter-
minals, together with the coUatei-als belonging to it with
their terminals.
The study of .secondary degenerations has been much
facilitated by the introduction of AVeigert's myelin
sheath stain and the osmic-bichioniate method of Marchi
and Alghieri.
The finer histology of secondary degeneration has been
studied by Homen, Howell and Huber, Tooth, von Nott-
haft, Ceni, and others. Von Notthaft sidxiivides the
changes which occur in the nerve after section into two
stages, the first including the alterations which take
I'lace during the first three days (fi-agmentation of mye-
lin and of axone for a distance of one or two intei'iiodes
on each side of lesion), probably due to trauma. The
second stage, beginning on the second or thii'il day and
confining itself to that part of the fibre cellulifugal from
the lesion, represents the true Wallerian secondaiy degen-
ei-ation; it is not the direct result of the trauma, but is
due to the severance of that jiart of the neuidnc fiotn the
iT'ophic influence of the nucleus. In this second stage
I he axone swells up and undergoes fragmentation, and
263
Neiirtm**.
NeiiiMfue,
liEFERE^e'K 1IA.\I)I5()()K OF THE MEDICAL SCIENCES.
tlieiiiycliu disintegrates into droplets cellulifugally from
tlie lesion, as fur as the peripheral termination. By the
fourth day a niuitipliealion of fhi' nuclei of the neuri-
lemma can be made out. Liquefaction of ihv myelin be-
gins by the si.xth or seventh day and continues until the
si.xtieth or eightieth day. when all of il is dissolved and
most of it has been absorbed. The absorption is com-
plete by the end of three or four months. If the degen-
eration affect medullated nerve fibres inside the central
nervous system, neuroglia cells can be seen undergoing
proliferation after some forty-five or tifty days (Ceni).
This proliferation ceases at the- end of three months and
sclerosis follows.
Marchi's method demonstrates the existence of degen-
erating fibres as early ascight or ten days after the lesion,
and will ccjntinuc ti) demonstrate their presence until all
the myelin of the degenerating fibres has been absorbed,
that is, until some three niojifhs have elapsed after the
injury. At a later jieriod we have to resort to 'Weigert's
method; the areas which have degenerated show, of
course, an absence of black tibres. Marchi's method is
far more delicate than Weigert"s; the former will reveal
single degenerated tibres: the latter can be relied upon
only when there is a considerable area of lightening in
the region otherwise uniforudy filled with black fibres.
Anatomists liave applied these methods niost extensively
in experimental work for the determination of the cour.se
followed by the medullated axoues of the various groups
of neurones of which the nervous system is made up.
Pathologists utilize Ihem to study the secondary degener-
ations which accompany various diseases of the nervous
.system in human beings.
For many years it was believed that the cellidifugal
alteration, deserilied by Waller, was the only one which
occurre<l alter axone lesion, hut the introductiou of in<ire
<ielicate methods still has rcvealetl the fact that surpris-
ing changes occur in the neurones cellulipeta! from the
lesion, and particularly in the cell body or perikaiyon
itself. Xissl by tin- apidication of his methylene-blue-
and-soap method has demonstrated definite alterations in
the cell body as early as a few hours after axone lesion.
The changes are most marked, however, when animals
are killed from eight to fifteen days after the operation
in which the axones have been cut. Nissl refers to this
method of study as "the method of primary irritation."
His results have been confirmed by Flatau. 3Iarinesco,
Lugaro, Van Gehuchfen, Eiianger and myself, and many
others.
The change which takes place in the cell bodies of the
nucleus nervi facialis, foi- exam))le. after section of the
nerve trunk near the pes anserina, consist chiefly in alter-
ations in the tigroid masses, in a moderate swelling of
the jierikaryon, and in a displacement of the nucleus
tow'ard the axone hillock. The change seems to affect
the tigroid masses first. The siiindles lose their typical
stichochronie arrangement, break uii into minute jiarti-
cles. become scattci'ed diffusely throughniit the cell, and
finally undergo solution, the sulvcnt pnucss iiffecling the
tigroid masses in tin- interior of the cell lirst, and extend-
ing gradually toward till' ]HTi|ihery. This disintegration
and solution of the ligrciid has been variously designated.
Marineseo calls it rlirniihitiJiixi-i : van (iehuchten, chro-
iHi/liisis ; Ketterer. (■/in)iii"p/ii/i/>.i.i ; Kohnstamm gives it
the name tigivli/^is, and the l,iit( r term is the iine w hich
I prefer.
Marine.scohas described twodislinct stages of the proc-
ess: (1) A stage of riiictiii/i. in which the tigroid under-
goes the changes above described; and CJ) a ]ihase of
repaii-. during which the tigroid elements are restoreil to
a more or less normal api>earance. The first stage begins
soon after section, aial reaches its maximum in from fifteen
to twenty days. The second stage l;isfs longer. It is
essentially a phase of regeneration, and as in many ca.scs of
regeneiation thcelcnieiils regenerated are ]iroduced in I'X-
cess; the individual tigmid masses are larger and more
numerousthan in the normal cell. During the lirst stage
(that of reaction) the cell is swollen; durini; thi'secimd
(that of repair) it gr;idu:illy nturns tn its normal size.
The nucleus, markedly displaced toward the axone hil-
lock during the first stage, slowly reassumes its former
position in the centre of the cell (hiring the stage of re-
pair. A few cells in motor nuclei, after section, fail to
undergo this repair, and van Gehuchfen assumes that in
them the furgcscence of the cell has taken place so sud-
denly during the Hrst stage and the propulsion of the
nucleus has been so violent that the latter has been com-
pletely expelled from the cell body. Such cells, de-
jirived of their nuclei, necessarily undergo total degener-
ation. It was thought by Marineseo that the stage of
repair was condition;il upon regeneration of the distal
end of the axone. but .Nissl, van Gehuchten, and Foa
have shown that this is an error, and that the altered
cells return to their normal state entirely independently
of the phenomena of regeneration at the point of section.
At least this seems true of ex]ieriments upon animals,
though there are some observations upon the spinal cord
of human beings follow ing upon amiiutafion. which in-
dicate that cells still tigrolytic may be observed in the
cord for from three to seven months after the operation.
There would appear to be an intimate relation between
the degree of injury to the axone and the changes which
take phice in the perikaryon, for when nerves are torn
out, the etfects are very diiferi'Ut from those which follow
simple section of a nerve. Thus Ballet and Marineseo
showed that if a nerve be torn out, a large mimber of the
cells undergo complete destruction and are absorbed.
This may explain the cellulipetal .secondary degener-
ations obtained by von Gudden's method (ride infrn).
One of the more recent developments of the study by
Nissl's method indicates that tigrolysis occurs constantly
after section of a cerebral nerve, but may or may not oc-
cur after section of a spinal nerve, though if inevitably
follows the tearing out of the same spinal nerve (Van
Geluiehten and de Ke<'ff). Tlie inference has been
drawn that the lower motor neurones in the spinal cord
of the rabbit and dog possess a greater resistance to ex-
perimental injury than do the lower motor neurones of
the medulla, pons, and midbrain.
The method introduced by Nissl is of very great im-
jiortance to anatomy, since by means of it the exact cell
bodies which give off the motor axoues to individual
muscles can be easily localized in the central system.
It is now nuich easier to understand the early investi-
gations bearing upon atrophy of the motor roots and
gray matter of the spinal cord after amputation. The
younger the individual at the time of aminifation. and
the longer the time elapsing between the operation and
death, the more marked are the alterations. It would
appear that if an ampulati<in be done early in life, many
of the neurones concerned in innervating the amputated
limb undergo complete degeneration and disap|iear 'o-
tally, that is to s;iv, in addition to the Wallerian cellulit'u-
gal degi'neration, which of course occurs in the ampu-
tated stiunp, there takes place in young individuals a
slow atrophy or slow cclluli|)etal .secondary degi-neiation
of the whole neurone, not withstanding the fact that the
perikaryon with its nucleus is left in the mutilated neu-
rone. This vulnerability of neurones in young animals
is especially well illustrated by the long series of ex])eii-
ments which were made by von Gml(len. The dislin-
g\iished Bavarian investigator showed that after remoral
of an eye in a yoimg rabbit, in the course of some months
not only did a total degeneration of the optic nerve of the
same side and partial degeneration of the optic fiact of
the iiflicr side fake jilace, but also extensive degeneration
occurred in the suiierior colliculus of the corpora ([uadri-
gemina and hiteral geniculate body of the opposite side.
This general observation showed immediately what re-
gions of the gray matter arc intimately related with the
optic nerve. The sttuiy of the microscopic changes in
these primary ojitie centres jirovcd that this method per-
nuts one to draw also imjiortant conclusions concerning
the finer histological connections of the axones of the
optic nerve with flu'ir centres of origin and of termi-
nation. Thus while in the superior colliculus after the
opi'ration above mentioned entire rows of nerve cells had
26-i
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Neurone,
^'t'liroiie.
disappeared from tlie superficial layer of gray matter, in
the lateral geniculate body tlie ganglion cells were but
very little altered: but between them, and especiall}' in
the gelatinous sul)stance lying in the lateral part of this
nufleus. there had been a very great loss by absorption
of tine nerve tibres. the terminals of the ojitic nerve. It
was easy to interjiret these observations. Where as a
result of the lesion there had occurred cellulifugal degcn
eration of the ground substance in direct continuation
with cellulifugal degeneration of nerve fibres in the optic
tract anil optic nerve, we have to deal with tlic nucleus
of lerniinalion of tlie a.\oues of neurones, the cell bndies
of whicli are situated in the retina. On the other hand,
in the part of the coUiculus superior where there had
been a celhdipetal disa]ipearance of ganglion cells, as a
result of the removal ot the eye, it was e\ident that we
have to deal with a nucleus of origin of centrifugal ax-
ones which run out through the optic tract and optic
nerve to the eye. That tliis conclusion is correct, the
application of the methods of Golgi and of Flechsig to
the jirobleni have left no doubt.
Von Gudden and his pupils utilized this cellulipetal
secondary degeneration in young animals in extending
widely our knowledge of the anatomy of the brain. By
it the nuclear origin of the various cerebral nerves were
very exactly defined, and later, the connections of the
lemniscus, the brachium coujimctivum, the cerebrocorti-
cal pontai paths, and various other tracts were deter-
mined and their centres of origin and of termination ac-
curately established.
.\ study of a large series of pathological cases in hu-
man beings following upon hemorrhage, softening, or
pressure from various causes in the brain has proven
that in hninau beings also the cellulipetal degeneration
(corresponding to the experiments of von Gudden) oc-
curs as well as the tyjiical cellulifugal secondary degen-
eration of Waller. What is more, a study of hiunan
cases reveals the fact that if a neurone of a high oider
fails to receive its normal impidses from a set of neu-
rones of the next lower order, owing to degeneration of
the latter, the former imdergoes a slow diminution in
size throughout its whole extent (diminution in size of
lemniscus accompanying sclerosis of posterior funiculi
of cord). Again, if a set of neurones in a neurone chain
is tniable, through degeneration of the next higher grouj)
of neurones in the cliaiii. to pass (.m its iiupul.-ies to the
latter.it undergoes a slow atropliy, all the neurones of
the set gradually diminishing in size. This is well
shown when, for example, the soma'Sthetic area of the
cortex is destroyed and secondary degeneration of the
thalamocortical neurone system residts; the lesion is fol-
lowed in the course of years by marked diininution in the
volimie of the lenmisinis medialis, of the stratum inter-
olivare lemnisci. and of the nucleus fuinculi gracilis and
nucleus funiculi cuneati of the opjiosite side, the cell
bodies of which give rise to the axones of the lemniscus.
Bethe also studied the degenerative changes in the axis
cylinder after section of the nerve. lie states that the
first change is the disappearance from the fibrillar of a
substance which is primarily colored by basic dyes, and
that with the disapjiearance of the jirimary colorability
of tlie nerve there disappears its excitaliility. There fol-
lows a breaking up of the primitive fibriihe into large
and later into fine granules; at the same time a breaking
up of the medullary sheath with ellipsoid formation.
Degeneration is always apparent in the primitive fibiillic
before such is seen in the medullary slieath. This de-
generation does not occur in the whole nerve at the same
time, but is first apparent near the seat of the lesion from
■which it can be traced at later periods toward the per-
iphery. Corresponding changes are found in the central
stump, though here the degeneration is limited in extent,
though certain fibres may be seen degenerating far tow-
ard the cord. He denies that in the central stump de-
generation ends at the first nerve of Ranvier nearest to
the point of lesion (traumatic degeneration). From his
investigations he confirms the opinion that sensory filires
degenerate more quickly than motor, and he further
states tliat thicker fibres, both motor and sensory, earlier
show signs of degeneration than finer fibres.
ref'erences beakl.ng upon secondary decexekatioxs of the
Neurone and Modifications Foli.owino iton Injcky to the
AXONE.
Waller. A.: Experiments on tbe SectioB of the rilnssophatx iiiteal and
H.vpoglossal .Nerves of the Frog, and Observations of ilie Alterations
Produeeii Thereliv in the Structure of their Primitive FiOie.s. Pliil.
Tr., Loud., 1S50, p. 42!.
Tiirck, L. : Ueber seeundare Erlirankung einzelner liiirkeiiniarli-
striinge und ihrer Fortsetzungen zum (Jehirne. Ztselir. d. k.-k.
Gesellsch. d. Aerzle zii Wien (1S.W), ii.. 311 : IS-B, ii., 289.
Honi^n, E. A.: E.xpeiliiientelier Beitrag zur Pathologle und patho-
loglsohen Anatoiiiie des litiekenmarks (speeiell mit Hinsicht auf die
secundlire Pegenei'ation). Foi-tschr. d. Med., Bert. Bd. ii. (IS,s51,
SS. ~tiT-:.'TH. I'onlribiition experiinentale ;\ la pathohigie et ^ Tana-
tx:)niie patlii'li.gique de la moelle ^piniere. Helsingfors (18S5), pp.
112, T pi., bvo.
Tooth, H. H. : The Gulstonian Lectures on Secondary Degenerations
of the Spinal Cord. London. .1. and A. Churchill (lsg9), pp. 1-77;
also in Brit. )I. ,1.. London (ISSSt), i., 7.5:3, 825. 873.
Notthaft, A. V. : Neue Untersuchungen uber den Verlaut der Degenera-
tion- und Regeuerationsprocesse an verletzten peripheren Nerven.
Ztschr. f. wissensch. Zool., Bd. Iv. (189:j). SS. 1:M-1S».
Cent, C. : Sur les fines ait*^rations histologiques de la moelle i^piniere
dans les degenerescences secondaires ascendantes el descendantes.
(Ahstr.) Arch. ital. de biol., Turin, t. xxvi. (18!W-I)7,). pp. 97-111;
also in Arch, per le sc. med.. Torino, xx. (Is9f'>), pp. i:il-194.
NissI, F. : Ueber eine neue Unt^rsucbungsmethode des Cenlralorgans
speeiell zur Feststellung der Localisation der Nervenzellen. Cen-
tralbl. t. Nervenh. u. Psychiat., Coblenz u. Leipz. (1894), Bd. xrii.,
S. 337.
Marinesco, G. : Des poiynevrites en rapport avec les lesions primitives
des cellules nerveuses. Rev. neurol.. Par., 1896, pp. 129^141.
van (iehuchten. A.: Anatuniie du systeme nerveux de Fhomme,
2d ed., Louvain, 1897, pp. 321-3:3(1.
Barker, L. F. : The Nervous System and Its Constituent Neurones,
New York, 1899, pp. 22:3-247.
von Gudden. B. : (iesamnielte und hinterlassene Abhandlungen.
Herausgegeben von H. (.rastiev, Wievhaden, 1889.
Monakow, C, von : Gehirnpatli'tlogie, Wien, 1897.
Monckel)ei-g, (;., u. .\. Betlie; Die Degeneration der niarkhaltigen
Nervenfasern der Wirti'-ithiere unter hauptsiichlicher Beriioksichti-
gung des Verbalinis dir ITimitivflbrillen. Arch. f. aiikr. Anal.,
Bonn, Bd. liv., l.'^'JU. SS. lo,J-183.
Reoeneration of the Neurones.
The topic includes regeneration of the nervous system
in whole or in ptirt during embryonic periods, the regen-
eration of whole ueuiones in the adult condition, and tlie
regeneration of portions of a neurone aft<'r injury.
In connection with regeneration of the nervous system
in the embryo much work has been done. Recent studies
have revealed a wholly unexpected capacity for regener-
ation in young phases of the embryo. The doubling of
the whole nervous s}-stcm, or of one end of it. is by no
means unconunon. In later embryonic phases the capac-
ity for regeneration becomes less: but until quite a late
period, especially in low forms, very considerable regen-
eration is possible. Interesting as regards the regener-
ation f)f the nervous system are the researches of Harri-
son, who ex])eriniented iqinn the tails of tadpoles. After
cutting off the tail, ils peiipberal nervous system was re-
generated from the spinal cord. There first arose a sin-
gle pair of nerves from cells lying within the cord. A
part of these cells wandered into the nerve root and gave
rise to a large spinal ganglion. Subsef|Uently groups of
cells wandered fartherinto the periphery along the newly
formed nerves and gave rise to from one to three small
ganglia to take the ]ilacc of those ganglia which had been
lost through the operation. The total number of ganglia,
however, was nev(;r completely replaced.
As to the regeneratiiui of whole neurones in adult ver-
tebrates much doubt has been expressed. The prevail-
ing opinion is that if an adult neurone be once entirely
destroyed, it can never be regenerated from neighboring
neurones. That karyokinetic figures can occur in nerve
cells adjacent to an injury has been shown by Tedcschi
:ind Vitzou. The exait histological details of karyoki-
nesis in neurones have lieeii studied in the cereliral cortex
of guinea-pigs after introduction of ;i hot needle by Levi
{rf. Bdrfmivi's Rnietn, loc. cit.. p. 78")).
Most interesting are the various studies which have
been made to exjilain the well-known fact that regener-
ation of peripheral nerves after lesion occurs. There has
been much dispute as to whether the regeneration of
nerve tibres is due to an outgrowth of the axone from
L>t55
Neurone.
Neurone.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
the central stump entirely or to ii fusion of the axone of
the eeutrul stump witli a new jixoiie developeil in tlie
periphery as a result of the activity of the neurilemma
cells. Ill favor of the former view," the investigations of
Waller, Kanvier, Vanlair, Barfurlh, von Notthaft,
Strobe, and Koister are important; while in favor of tlie
latter view the studies of Beueke. Neuniaun, von Bi'ing-
ner, Wieting, and Ballauee and Stewart may be men-
tioned.
According to the Waller-Ran vier- Vanlair view there is
a continuous regeneralioii of tbe nerve fibres in connec-
tion with the iiart of the old a.\one ijreserved in the cen-
tral stump. These authors observed in the distal part of
the nerve the proliferation of the cells of Schwann's
sheath and the formation of bands of spindle cells there-
from, but they maintain tliiit the new a.xoiie is regenerated
independently thereof. After tbe lesion tbe end of the
central part of thea.xone beeoines swollen and sulidivides
into .several fine librils. These filirils grow out from the
central axones and ultimalely reach the periphery; as
they grow out they gradually become surrounded with
myelin sheaths. The delicate young fibrils penetrate tlie
intermediate tissue at the site of the lesion and reach the
peripheral segment of the nerve, the tnlires of whieh have
undergone complete degeneration followed liy jirolifer-
ation of the neurilemma cells. These investigators as-
sert, however, that the altered libres of this peripheral
segment lake no active part in the formation of new
fibres, but simply act as easy paths along which the new
axones from the central stump can grow. If the ci'ntral
and di.stal stumps of the divided nerve are too far apart,
the regenerating axones of the central stump may lie un-
able to bridge tbe gap, in wdiieh event there will be no
return of function; hence the imiiortaiice of the imme-
di.ite coapt.ation of tlie two cut surfaces of a divided
nerve. Even when the coaptation has been carefully
made by a surgeon, many of the newly forming libres
fail to grow out to the pt'iiiibery.
According to the opposite view there is a (Jiwo/itiHi/ous
regeneration of the nerve libres taking place indeiiendeut-
ly of any connection with theeentnd stump, the new libres
becoming eonnected with the latter only secondarily.
The majority of those who su]i]ioit the view attribute
the discontinuous regeneration of the libres of the distal
stump to the development of single segments from elon-
gating cells; these single segments then fuse to form a
coutinuoustibre, which later becomes attached to the end
of an old nerve tibrein tbe central stump. There is thus
a series of fusijiis of single cells to make the new nerve
fibre and sulisequentlv' a fusion of the new fibre with the
end of the old one. The same investigators lielieve that
the Cells which are coneerneil in building the new nerve
fibres are derived by karyokinesis from the cells of
Schwann's sheath (ueiirilemina); a few observers in the
group, however, deny this, maintaining that the new
fibre is derived from the coiineetive-tissue cells of the
endoneuriiim or even from leucocytes.
Neumann's ideas coneeniing regeneration resemble
closely those just described, tliough they ditTer some-
what in details. He states that tbe myelin sheath and
axone of the old fibre do not undergo complete degener-
ation and absorption, but. contemporaneously with the
proliferation of the neurilemma nuclei, mix with one an-
other, becoming transformed to a common protoplasmic
mass, which possesses tln^ eliemical properties of both
axone and myelin sheath. This mass, filling up the old
nerve tulie, gradually gives rise to the new fibre by again
beeoming dilVcrciitiated into myelin sheath and axone.
This dilferentiation is not. however, a ediiliiiiioux process
but takes place iu segments, and its origin and progress
are, he thought, dependent upon and under the C(MitroI of
the axis cylinder of the nerve of the central .stump, for the
.segmental differentiation begins at tbe lesion in contact
with the old nerve tibre and gradually extends toward
the periphery. The segment first ditTerentiated fuses
with the extremity of an old fibre of the central stump,
and gradually the more peripherally situated segments
fu.se to form finally a continuous fibre.
Von Biingner undertook the study in 1891 with new
methods. He decided that the peripheral portion of the
nerve undergoes complete degeneration after section, and
that therefore " healing by the first intention," jiostulated
by some surgeons, does not occur. From the third da.y on,
the neurilemma cells proliferate, the nuclei dividing by
karyokinesis, and the protoplasm of these cells rapidly in-
(•reases in amount. These cells till u]) the interspaces
between the balls of degenerating myelin and ]irobably
participate actively in the destruction and absorption of
the old myelin sheath and disintegrated axone, since leu-
cocytes are not present. No better illustrations of de-
generating nerve fibres are to be found anywhere than
those which accompany von Bimgner's article. The
neurilemma cells next line up in one, two, or more longi-
tudinal rows and soon a slight bbrillation appears near
the elongated nuclei until finally the nuclei of the row
apjiear to be connected by bands of fibrils. Herein von
Biingner .saw the earliest indications of the newly form-
ing axone. Through fusion of the row's of proliferated
neurilemma cells and fusion of the segmental bands of
librils, continuous fibril bands are formed, at the sides of
which the nuclei, leaving their former central position,
now arrange themselves, so that the fibres go past them
in a slight curve. The process is alwaj'S most advanced
near the side of the lesion, the regeneration being slow-
est at the iieri]ilieral extremity of the nerve. Von Biing-
ner believes that the neurilemma cells, and t hey alone, give
rise to the new fibres; he does not hesitate to designate
them "neuroblasts," and believes that they are truly
"nervous" in nature and origin.
Frcun the beginning of the third week on, new myelin
sheaths begin to appear about the newly formed fibres,
and a little later the new neurilemma and the new sheath
of Heiile appear, being derived, von Biingner believes,
from the connective-tissue cells of the endoneurium.
The nodes of Ranvier can be seen as early as the fourth
week.
As to the mode of union of the axone of the central
stump with the newly formed fibres in the periplieral
nerve, vor. Biingner asserts that traumatic degeneration
occurs in the central end up to the first or second node of
Ranvier. Here the end of the old axone undergoes bul-
bous enlargement and fuses w itli new segraentally regen-
erated fibres derived fnmi neurilemma cells of the central
stump; the latter fuse with new segments in the space
between the two ends of the divided nerve, and the}'
with the newly formed fibre of the peripheral portion of
the nerve. He drnies anything like an outgrowth of the
old axone to the periphery, and even an outgrowth across
tbe space between the two cut ends of the nerve.
Neumann, more recently, states his position as follows:
"At present no one doubts that a very important factor
iu the re-establishment of conduction in an interrupted
nerve lies in the outgrowth of j'oung fibres from its cen-
tral stump; the only dispute possible concerns the extent
to whieh this jiroeess takes place. While those who hold
the Waller-Uaiivier doctrine assume that the young fibres
grow out into the peripheral degenerated part as far as
its termination, according to the view which I have
founded and which has later liceu supported by von
Biingner and Wieting, the outgrowth from the central
stump is limited, occurring only in sullieient degree to
bridge over the gap in the nerve, whereupon new fibres
are formed autoelithonously out of the protoplasmic ma-
terial su|iplied by tbe degeneration process."
Wieting agrees with von Biingner in ascribing the re-
generative process in the first stages entirely to the nu-
clei of the neurilemma cells. He lielieves that the neu-
rilemma cells give rise to a large amount of protoplasm
throughout the whole extent of the degenerating nerve,
and that it is through further differentiation of this pro-
toplasm that the new structures are formed. As early as
the fourth day extremely fine fibrils apjiear in the proto-
plasmic contents of the old neurilemma sheath. These
fibrils are alw.ays continuous with tlii^ central axone.
About the fifth day, advancing from the central stump
toward tbe periphery, there is a sharper arrangement of
2G6
KEFEKENCE IIAXDIJOOK OF THE MEDICAL SCIENCES.
Neurone.
Neurone.
tlip prntiiplasmic masses and fibrils witli formation of fine
tibrillury strips, stained of a pale rose eolor and ollierwise
Jioniogeneous. Later, tlie cell boundaries disapjiear, the
protoplasm is drawn out lengthwise, and is deposited as
.a finely granidar eovering upon the strips. The strips
represent young axones. The gray covering is the be-
ginning of the new myelin sheath, and is also to be
looked upon as an e.xcretory product of the cell, the ex-
cretion taking place first from the central stump and ad-
vancing toward the periphery. AVIiile Wieting empha-
sizes that the fibril formation takes place in direct
connection with the old axones, and that the process ad-
vances evenlj- toward the periphery, he maintains that
we do not have to deal with the simple outgrowth of the
old fibre for which the neurilenuna cells merely point the
^\•ay, but have in reality to ilo with a fibrillary transfor-
mation of the protoplasm yielded by the nuclei of
iSchwann's sheatl] or with a libril formation in tlie proto-
[ilasra in connection with the fibrils of the old axone.
A somewhat intermediate position is taken by Howell
and Huber, though they incline to the view that the
yoiuig axone grows out of the old one in the central
stump; it grows into the young "embryonic fibre" born
from the proliferating cells of Schwann's .sheath. Thej-
think that when the new axone grows into the young
"embryonic fibre" the formation of the myelin sheath
has aliea<ly begvui in th(' latter. Their paper is readily
accessible "to readers of English, and need not, therefore,
be further reviewed here. Their work was done inde-
pendently of von Bilugner's, and it is interesting to note
the nearness of von Btiugner's description of his fibril
bands to that of Howell and Huber of their "embryonic
fibre."
The whole subject was taken up again liy von Nott-
haft in 1S92, his research winning the prize otfered by
the medical faculty of Wlirzliurg. His studies of degen-
eration of the nerve, the proliferation of the neurilemma
cells, and the formation of fibrils in the protoplasm inside
tlie old sheath ccmflrm very closely the observations of
Von Biingner; but he dill'ers entirely when he comes to
describe further stages of the process of regeuei-ation.
He asserts that the neurilemma cells do not build the
young nerve fibres at all. Instead, the young nerve
"fibres all grow out from the axones of the central stum)),
and all pass, without exception, into the interior of old
sheaths of Schwann. The young filires pass by nucleus
after nucleus of the proliferated neurilenuna cells, but
any such thing as discontinuous regeneration of nerve
fibres from the sjiiudle cells is, he maintains, impossible.
The microscopic pictures do not even yield a remote sug-
gestion of such a probability. Von Not.thaft cannot con-
ceive how von Biingner came to the iilea tliat the fibril-
lary construction of the protojilasm of the proliferated
neurilenuna cells could be the Anlaye of the new axones.
He seems, however, to have neglected a careful study
and description of the finer histological relations occur-
ring in the spaces intermediate between the two cut ends
of the nerve.
Even more convincing than von Notthaft's confirma-
tion of the Waller-Ranvier theory is that whicli we owe
to the still later researches of Strobe. Instead of being
sa.isfied with the indirect proof of the view which is em-
boilied in this theory, he determined to make a wholly
charseries of observations (so controlled that they should
b(' free from objection) of the phenomena which occiu' dur-
iug the earliest period of formation of the new fibres and
theirconuection with the old. Ileadmits thatbe wasinfiu-
■enced by the pronuilgalion of t!ie neurone doctrine, which
has emphasized the importance of tlie nerve fibi'e as a
piocessof the ganglion cell, but did not permit this to
mi-vent him from studying the actual process in detail.
He was helped very much in his investigations by the
invention of a special staining method for the axis cylin-
ders. Preparations hardened in Jliiller's fiuid were
stained in concentrated aqueous solution of aniline blue
(OJruebler), after which they were differentiated in a
slightly alkaline alccjhol. TJiis gives a deep blue stain
to even the finest young axones, while the cell proto-
plasm in general stains of a very pale blue tint, or by
coiuiterstaining in safranin it stains liglit red in contrast
to the deep red stain taken by the nuclei. After study-
ing all stages of the degeneration itself, and confirming
again the fact that it is complete for both myelin sheath
and axone to the very periphery, he took up the study
of the changes of a progressive nature, finding, as had
pi'evious investigators, tliat the degenerative and the re-
generative ]irocesses in the injured nerve accompany one
another in time and place. He separates sharply the
progressive phenomena which concern the celhdar ele-
ments of the old nerve fibre, that is, the cells of Schwann's
sheath, and the progressive phenomena of true nervous
origin, namelj-, the new formation of the axone and the
myelin sheath. The latter alone have the significance of
the true regeneration of the nerves. The jihagocytic
activities of proliferated neurilemma cells were carefully
studied. Strobe also describes how these cells become
transformed into loiig spindle-shaped elements with lon-
gitudinal oval nuclei tilling up the old sheath of Schwann.
These unite to form spindle-cell rows as the degeneration
products disappear; portions of nerve fibres filled up by
such rows of spindle cells may alternate with other por-
tions of the same fibre consisting of entirely empty and
collapsed Schwann's sheaths. An especial study at the
site of lesion showed that the proliferating cells of
Schwann's sheath enter into this region from both ends
of the divided nerve; but here, instead of forming rows,
the cells are jjrone to be irregularly mixed up and inter-
woven with proliferating connective-tissue cellr, of the
endo-, peri-, and epineurium. This proved that the neu-
rilemma cells possess no inlierent tendency to the forma-
tion of longitudinal rows, but do so in the peripheral
portion of the divided nerve simply on accoimt of the
adaptation of the cells to the special relations of the old
nerve tube in which they avise.
True regeneration, according to Strobe, has nothing to
do with this proliferation of the neurilemma cells and the
bands of spindle cells resulting therefrom, but dejiends
entirely upon the outgrowth and splitting up of tlic old
fibrillaiy axis cylinders directed peripheral ward from
the central nerve stump. These young fibres, by the
method of staining employed, appear as .sharp micro-
scopic pictures; so sharp, indeed, that there can be no
excuse longer for confusing them with the fibril-like
structures in the protoplasmic bauds described by von
Biingner. The impression is never obtained of a new axis
cylinder becoming differentiated out of the protoplasm of
the rows of neurilemma cells. From the very beginning
the young axones are continuous with the old axone, and
show on their first appearance a very delicate but dis-
tinctly developed c<mtimH)Us myelin sheath. The illus-
trations which accompany Striibe's article are veiy con-
vincing. The new fibres gradually lengthen and grow
out farther and farther distalward. The foi'uiation is
continuous, not discontinuous. Passing from the central
nervestump into the tissue intermediate between the two
ends of the divided nerve, the new axones pass between
the rows of spindle cells, when such exist, and between
the fibroblasts which have not been arrangeil into rows
of spindle cells. Having passed through the site <if le-
,sion, the new fibres enter the old peripherrd nerve, some-
times entering into the interior of old nerve tubes still
open: at other times passing between the bands of spin-
dle cells formed from the degenerated nerve fibres. The
course is toi'tuous and the fibres frequently cross one an-
other. The young fibres frequently possess a knoi)lied
terminal swelling.
The young nerve fibres, delicate at first, gradually in-
crease in thickness, the degeneration products of the old
fibres gradually diminish in amount through absorption,
and the normal condition is slowly restored. The cells
of Schwann's sheath are not nervous elements at all, and
the dcsi.gnation of "neuroblast" is wrongly apjilied to
them. They are secondary connective-tissue ensheathiug
cells, corresiionding to t heir me.soblastic origin in the em-
bryo. Slri'ilies work is in complete accord with the neu-
rone doctrine, and furthermore is compatible with what
267
Neiiroiii'.
Neurouc,
REFERENCE HANDBOOK OF THE .MEDICAL tSCIE.XCES.
we know must be tlio origin ot'tlic myelin slieatli. Tliose
liistiilogisis wlio assnnie tliat the myelin sheath is a pi'od
uct ofthe metalKilie aetivity of the neiirilenima cells
seem always to forget that iu the central nervous system
we have innumerable myelin sheaths with entire absence
of the neurilemma covering. That the axone builds the
myelin sheath there can scarcely longer be doubt.
IJailanee and Stewart have recently made au extensive
]iublication altempling to revive the old doctrine of the
discoiuinuous formation through fusion of rcAvsof single
cells. I cannot help but feerthal they are falling into
the error of a now large group of ])redecessors.
The bibliography of the subject must be read with
great caution" JIany of the stat<'ments are obvious mis-
interpretations Such a linding as that of Korolow, who
sees genuine ganglion cells in the central cut end, and
that of Garres. wiio describes regeneralion of branches of
the trigeminus after extirpation of the Gasserian gan
glion, are liasc'd upon mistakes. What Korolow s mis-
take was, it is dillieult to .say. Garres doubtless had to
deal with partial instead of complete extirpation of the
ganglion,
Regeneralion of nerve- libres which h:i\c undergone
solution of continuity inside till' central nervous system
is so imperfect that many have cjuestioned whether it
takes place at all. The physiological studies of Baer,
Dawson, and Marshall, and the i)athological researches
of Worcester, make it seem probable that at least some
regeneration takes place. The evidence in general has
been sifted by Strobe (/w. cit.).
RKFEUK.NCKS I'.K.VRIMi t I'll.V TniC ItEliKNEIt.lTION OF THE NECRONE.
nmfinih. 1).: Artielescm Ili'K-eniT.ition ami Involution. Erpetm. d.
,\nat. u. Entvveklugsgescli.. VVinsl>., lid. viii., ix. and x., Isit9, I'JIHI,
;!ii.l innl.
T5:irhnn-i. i). : Die KervenzHlli-ii in i!irt*n anaioniisolicn, pli.vsio-
l.t!_ns( liPM and palliulofjisrht-r! P.fzii'tiunL'fn naeh d)*n neticstt-n
t'litfisurliunsjrHn. ceutranil. f. all^. I'atli. u. patti. .Vnai.. Jena, lid.
,v.. I.ssll, pp. T.57, StH.
Ton tiiincrner: Uelter die Degenerations- and Hegenerationsvorgiinire
au Nrrven nai li Verleizungen. lleitr. z. path. Anat. u. Plivsiol.,
.Ii-na, lid. X.. ISlll, S. :iai.
von Notthaft. .\. : Neue Unlersuchungen idier dt-n Verlauf der Dege-
utMaUons- uud RegeneralionsprueHsse an veT-ielzten periplieren
Nerven. Inaiiir. Diss.. \Yiirzburg, IStJ^, und Zl.setu'. f. wissenscli.
Zool., Bd. Iv., LSI);:, SS. 131 I3.S.
Stnibe, H.: liii' allgtMneine Hislolo.gie der degenerativen und regen-
eraiiven Pnicesse ini c-pntralen and peripheren Nervensysl^nt nacli
d4ni neiieslen Foi-si-hunL''t'n. 7aisanMnenf:issen*U's Rt-ferat. ( eii-
Irallil. r. allg. Path. u. palli. .^nal., Ji'iia. lid. vi. ilsa,"ii, SS. S4!l-%li.
Howell, w. 11., and (i. I'. HnliHi-: A Plivsiologi,-ai, Histolotrii'al, and
Clinu'al study of tli-' DHgener-ation and Rt'L't'ucraiion ui Prriphci-al
Nerve Fibres after Sf\(>ranet' of (heir connei-Iions with the Nerve
Centres. J. Physiol., vol. xiii. tisti*.;), pp. o:i.j-4oi), and vol. xiv.
IlKU'ii, p. 1.
Baer, W. s., Dawson, P. M., and H. T. Marshall: Regeneration of
the Dorsal Root Fibres of the Second Cervieal Nerve within the
Spinal Cord. J. Exper. M., N. Y., vol. iv. i ls9iii, p]). 3iM.'i.
Worcester. W. . Kfgencrarion of Nerves Fil>res in the Central Nervous
!>ystem. .t. Exper. M., N. V.. vol. ill. (isiisi, N<)veuit)er, pp. 579-583.
IXTO\IC.\TloNS ol' ■rilK NEriiONE.
The best review of tlie literalure of lu'rve-cell intoxica-
tion up to 18'.l9 is lliiit given by liarbacci. lie has col-
lected with gi-eat iissidiiity almost the entire' literature of
the subject and ari-anged the resulls systematically. He
distinguishes shaiply between ihe toxic influences which
are the result of Ihe introdu<tion of stibstani'cs into the
normal organism from thi' outside world — intoxication in
the narrower sense — and those inloxitations which are
the effect of ])oisons develo|ied in the organism itself
through a disi urbanice of metabolism — auto iiituxications.
The formei', in turn, can be further subdivided accoi'd
ing to the ciiemical iiatui'e of the poi.sons, whether they
be mineral or organic; and in Ihe latter case, whether we
are concerned with a so-called organic poison proper or a
vegetable alkaloid or a |)oison of animal origin. Finally
the effects of intoxication ai'c considered by themselves,
according to tlie sjiecial nature of the iiitoxii'ation to
which the alterations met with in the nerve elements aie
to be referi'cd.
In his review of Ihegeneial palliology of the nervi' cell
Barbaeci refei's to a series of s]>ecial moditiealioiis which
the nerve cell protoplasm undergoes in various intoxica-
tions and infections. Most of these have been dealt with
above under the caption, " Degenerations of the Neurone."
A few additional ones, however, deserve especial men-
tion.
Golgi's method has been utilized by a number of inves-
tigators for the study of pathological alterations in nerve
ceils, though it has been, of course, of far greater service
in revealing the normal anatomical relations inside llu;
central nervous system. One is always more or less in
doubt in studying pathological tissues with Golgi's
method as to how many of the appearances met with are
artefacts. One of the commonest findings in pathologi-
cal tissues is tlieso-calli'd nirieose atrophy of the dendrites.
Instead of the normal dendrite, one sees a process studded
by rows of round or oval swellings connected by thinner
or thicker threads, reminding one of a chain of beads.
This change is jireceded, ;is a iiile, by a falling of the
"gemmules" or lateral thorns from the dendrites. The
alteration affects the finest branches of the dendrites first
and extends to the thicker trunks, until, finally, all of
the protoplasmic process of the cell may be iuvolve<l.
Occasionally, liowever, the change is limited to a single
denilritc or even to a single branch. The changes in the
larger protoplasmic trunks of the dendrites, however, arc
not, as a rule, so typically beadlike. Instead, one sees
an irregularity of contour, nodules, indentations, erosions,
roughenings, wrinkles, etc., in the Golgi pictui-es. Any
of the appearances describeil may be met with in normal
tissues, but the change may be regardeil as pathological
when it is exteiisively distributed. For a list of condi-
tions in which these changes have been noted, Barbacci's
article may bi' consulted (/«■, cil.. S. 798).
.\ somewhat similar atrophy att'ects the axones as seen
in Golgi prrpaiiLlions, under cerluin conditions. AVhat
appears t<i be the .same or a similar comiition has been
described liy Golgi as nirimnc /i//pciirnj)/i//.
Of the changes met with in intoxications in tissues
studied by Nissl's method, that of cliroiiiatdlyxis or ti'r/ro-
/i/Ki's has already been referred to {i-idcs)ijirii). The proc-
ess has bi'cn carefully described by Ewing, Marinesco,
and others. It begins, as a rule, with a swelling of the
tigroid masses, though this is not always demonstrable.
Once begun, the pi'ocess involves a gradual vanishing of
the tigroid fromtlie cell protoplasm. The tigroid masses
may <li,sa]ipear in vaiious ways. In the lirsf place, it is
uot\uncoiiimon to .see an irregularity of arrangement ap-
pear. In the cells of the anterior horn, for example, in-
stead of the fy|iiciil stii'hochrome arrangement, one may
meet with gi( at irregularity and disorder Again, in-
stead of sharply isolated tigioid units, these elements
may lose thcii' in<lividuality and be connected with
others in the cell protoplasm in the form of a nctwoik.
Instead of shar|), clean-cut pictures of the individual ti
groid mass, one fictiucntly sees ragged edges and indcti-
niteness of outline,
Ewing has desciibed a tiiic subdivision of the tigroid
masses occuning when tin- tigrolytic process goes on
slowly. In other cases, in w hich the process is more rapid,
the tigroid elements are broken up (|uiekly into very tine
granules and lieeome evenly ilistrilmted throughout the
cytoplasm, giving it a very characteristic " dust-like '' ap-
peai'ance. This is the change designated by Ewing a.s
"f/irinii/ur siiMirisidii." and by the Germans as "statibi-
ger Zerfall." In the tinal stages all the sttrinable sub-
stance of Nissl has disappeared from the cell (stage of
iif}trn)iiiftosis, describeil by .Alarineseo).
The tigi'olysis jnay be total, or it may be limited to
smaller oi' largei' portions of the cell, in which case we
spciik of piiHiid t/r/roli/nis. If it involves the region im-
mediately adjacent to the nucleus, the condition is spoken
of as ri iitni/ or pfriiiiidenr tif/ir/li/sis ; when, on the other
hand, it is the iieriphery of the cell which is affected, the
central iiortion i-cmaining almost intact, it is spoken of
as pir/'ji/ienil or iiiiinjiniil iii/roli/si.i{Fig. 3o8T). l$y iiitir-
jiiediiili- or ruiiceiitrii- t/gri>li/sis is understood the involve-
ment of Ihe middle zone between the nucleus and the
periphery — a very rai-e condition. Finally the tigrolytic
process may involve some particular segment of tt<:
2<;.s
REFERENCE HANDBOOK OF THE IVIEDICAL SCIENCES.
Neurone,
NcEiroiie,
cytoplasm, in which event it is spoken of as xegmental or
drc u tnscribed tigrolysis.
The tigrolysis which follows section of the axone has
been referred to as degeneratiti ii.t-nniilis (Fig. 3588) ; it is
of the central variety as a rule It was supposed by
many that, on the other hand, when a toxic agent acted
upon the cell from without, the
change nearly always consisted
in peripheral or marginal tigro-
lysis. A review of the exten-
sive bibliography, however,
teaches that no hard-and-fast
rule can be laid down.
The changes demonstrable by
Fig. 3.58".— a Nerve Cell from a Part of the Spinal Cord Deprived of
Blood for Six Hours Through Ligature of the Abdumiual Aorta.
(After G. Marinesco, Pre'^e m/v7.. Par.. 1897, pi. v., p. 45). The
peripheral p<jrtion of the cytoplasm contains only a few tigroid
masses, although the latter are still numerous near the nucleus.
Typical perii>heral tigrolnsis.
Nissl's method in the nucleus in various intoxications
include (1) swelling of the nucleus, (2) diminution in
the size of the nucleus, (3) alterations in the form of the
nucleus, and (4) alterations in the contents of the nucleus.
Swelling of the nucleus may vary in degree. In ex-
treme cases actual dropsy of the nucleus has been met
with. Such swelling has been described in a whole
series of conditions, including faradic excitation of the
cell, commotio, ur;emia, cholaemia, tetanus, rabies, and
acute delirium.
A diminution in the size of the nucleus may or may
not be accompanied by alterations in its nucleolus. Asa
rule the form of the nucleus is also somewhat altered.
The contour is irregular, the nucleus looking as though
shrunken. When the contents arc altered, they may be
homogeneous and stain dilfusely and evenly. Some-
times this homogeneity is associated with shrinking —
so-called "'acute liomogenization with atrophy" (Sarbo).
Sometimes the consents of the nucleus stain cvenl}', but
take a different tint from other constituents of the cell,
especially a shade diflereut from that tiiken by the nucle
olus and the tigroid mass. This "metachromatic '' stain
ing has been met with liv Barbacci in various pathological
conditions, but especially in experimental choUvmia. He
points out. liowever. that metacliromatic staining fre-
quently occui's in tissues which have undeigoue post
mortem change, and that therefore great care should be
exercised in reporting instances of the alteration.
Vacuolization of the nucleus has been referred to above
in connection with vacuolar degenerations in general.
Eccentricity of the nucleus or peripheral disposition of
that structure is one of the typical changes in the nerve-
cell bod}' following upon lesion to its axone. That it
may occur under still other conditions has been mani-
foldly stated. Thus it has been described after ligature
of the aorta, in embolism, and in various intoxications.
In some of these instances, however, the eccentricity may
depend not upon the direct action of the harmful agent
upon the cell body and nucleus, but rather upon a simul-
taneous injury to the nerve fibre, in wliich event the
change in the nerve cell would correspond to the ordi
nary axonal degeneration.
Various alterations in the nucleolus, under pathological
conditions, have been described. All degrees of pallor
of the nucleus have been observed in stained pii-para-
tions, the pallor occurring most frequently when the
volume of the nucleolus is increased. Swelling of the
nucleolus is met with under many couditicms, but par-
ticularly after tetanus or stiychniue poisoning. Occa-
sionall)' tlie nucleolus is diminished in size (Ewing).
Uneven staining of the nucleolus with actual vacuole
formation has been emphasized by Lugaro as a common
a|ipearaucc after arsenic poisoning Similar phenomena
have been described by Ewing in hydrophobia.
The shape of the nucleolus is often altered, instead of
being ixiund with regular margin, it ma}' become polyg-
onal. In exti'eme cases it may be fi'agmented, a condi-
tion not to be confounded with the existence of the so-
called secondary nucleoli.
When one approaches the subject of special intoxica-
tions he is almost overwhelmed with the immense number
of researches which have been undertaken in connection
with them. The great vulnerability of the Nissl bodies
and the observations of marked alterations in them in va-
rious intoxications led Nissl and others to hope that we
might find in the study of the stainable substance safe
criteria for the histological diagnosis of the action of
specific poisons. Much disappointment has, however,
been met with as the investigations have proceeded.
The lesions in the majority of instances are not pathog-
nomonic for the special poisons. If specific alterations
are some day to be found, they will probably be in the
ground substance of the nerve cell or unstainable sub
stance of Ni-ssl rather than in the tigroid masses. That
specific poisons have specific ellects is indubitable from
tlie physiological and pathological results of tlieir action.
That specific physical and chemical alterations take place
in certain groups of nerve cells umlcrsuch cii'cumstances
we cannot doubt, but we are far from having found any-
thing like histological changes corresponding to these
specific effects. In all probability we must wait until
our techniciue has become much more refined before we
can hope for histological demonstration. It may be that
the altei'ations concern poi'tions of the nerve-cell proto-
plasm measuring less than the wave length of light, in
wliich event microscopic demonstration would be impos-
sible.
Of the mineral poisons, the effects of which have been
studied, may be mentioned arsenic, lead, antimony, mer-
cury, phosphorus, silver, and aluminum. Of the organic
poisons proper the effects of alcohol, chloroform, anlipy-
rin. trional, acetone, and malonnitril have been studieil.
The effects of powerful alkaloids liave formed the basis
for a large .series of histological investigations. Strych-
nine, morphine, quinine, eigotine, atropine, muscarine,
nicotine, cocaine, and veratrine are among those which
Fig. .3.588.— Spinal Ganglion Cell Showing Marked Alterations Follow-
ing Section of the Sciatic Nerve. Sublimate flxatlon; thionlne
stitining. (After Lugaro. i T.vpical cintml fii/mfi/.-i-" with eccen-
tric i>osition of nucleus : dcgoirratio axonalis.
have been used. Of the poi.sons of animal origin blood
serum of animals of the same and of other species, urine,
thyreoiodine. neunne, and snake poison may be mentioned
as those wIkjsc effects have been particularly investi-
gated. Special interest has attaclii'd to tlie examination
of the changes in tbe nerve cells which occur in the so
called auto-intoxications. Thus in the bibliography
269
Neurone,
Neuroses.
KEl-EREiSICE HANDBOOK OP THE MEDICAL SCIENCES.
there are multiple references to studies of tlie nervous
system iu uneuiia. clioliemia, roproslasis, adrenal ea-
ehexia, thyreoid cachexia, experimental glycosuria, in-
somnia, and the autointoxications following burns.
Finally, the alterations in the iieurones, occurring in a
whole series of infectious diseases, have been examined
and studied; tetanus, diphtheria, hydrophobia, bid)onic
plague, yellow fever, botidismus, se])tica'mia due to va-
rious micro-organisms, anthrax, infectious ]ieritonitis are
among tlie lunuber. It woiUd be beyond the scope (d'
this article to di.scuss tlu'se in detail, and besides Barbacci
has given an excellent ejntome of tlie whole subject in
his collective review, to which in this section reference
has so fre(juently been made. Perhaps notliing better
can be done, under the circumstances, than to quote Bar-
bacci's suuuning up of the wdiolc matter. It is his opin-
ion tliat thealtcrations pcrcci>tiblcin tlie nerve cellunder
variouscondiliousarebcst understood asfoUows: " ^\ hen
a harmful inllueiu-e affects the nerve cell, two series of
processes ere piossiblc: either the harmful intluence is so
intense that it quickly kills the cell, in whicli event the
microscopic picture shows only the typical signs of cell
necrosis; tigrolysis has neither time nor reason for ap-
pearance. The alterations of the protoplasmic masses,
anil especially those of the nucleus, are those which be-
tray the elfect of the morbid causative agent. If, on the
other hand, the iulensily is less, the cell reacts power-
fully at first against the abnormal stimulus and uses up,
in tlie exertion of the reaction, its reserve supply of nu-
triment more or less cjuickly. Herein we see the signili-
cance of tigrolysis; it is the expression, simply of a jihe-
nomenon of reaction. If during this first phase the total
activity of the pathological stimulus becomes exhausted,
tile alterations in the cell progress no farther and the
normal condition is quickly regained, the reserve sujiply
of tigroid substance being quickly restored. In tills
phase of the reaction, the neurones retain theirfunetional
capacity unaltered — a fact w liich explains very well the
striking contradictions between the anatomical findings
and the clinical symiitoms in many affections. During
the develoimient of a disease the nervous system may be-
tray no symptoms which would indicate alterations tak-
iu,g place in it, and yet its elements, on microscopic ex-
amination, show that extensive tigrolytic processes have
already occurred. This is seen especially frequently in
infections and intoxications, and particularly in those
which follow an acute course. But when the inlluence
of the noxa continues to act upon the neurone after the
latter has exhausted all its reactive powers, it becomes
affected in its most vital parts and degeneration follows
upon the reaction. The cell is irretrievably condemned
to dcatli, and the microscopic specimens shew most often
onl}' the signs of a cell cadaver."
It would .seem not unlikely that our knowledge of the
general jiathology of the neurone will be materially in-
creased through the exti-nsion of experimental pharma-
cology, and of those modern researches which are at-
tenqiting to explain t.Iie phenomena of immunity. A
start has already been made in the investigations whicli
bear upon the relations of the chemical constitution of
bodies to their distribution in the organism and their
pharmacological effects. Since Stahlsehmidt, in 1859,
proved that; strychnine could be robbed of its tetanizing
effect through the introduction into it of one methyl
group, and so be transformed into a paralyzant, not un-
like curare, interest in such problems has raiiidly grown.
It was soon shown by other investigators that other am-
monium bases, ilcrivable from various alkaloids, possess
properties not unlike those of curare — a fact of the
highest interest, since Bijlim has since demoustrated that
cm'arine itself is an ammonium base.
The work which has been done upon artiticial antipy-
retics has furthered the ideas under consideration. The
synthetic preparation of antipyrin and iihenac^'tin may
be mentioned as an illustration. It has been shown that
(he antii\vretic effect of aniline deriviitivcs and amido-
Iihenol derivatives like |)henacelin. is pro]Kirtjoiial, with-
in ccrtjiiu limits, to the amount of para-amido-phenol
which is split off in the organism, and it has been
demonstrated that the introduction of acid saltforming
residues (like SOJI and CO-Jl) iirevcnts flie anlijiyrctic
power of su<-h substances. Again the studies U|)on co-
caine and allied bodies support the same principle. It
lias been shown that it is the benzoyl residue which in co-
caine gives it its aua'sthetic power. It was a knowledge
of this fact which led to the synthetic manufacture of
new ana'sthetics which contain the ana?sthesiophore
benzoyl group as their active agents; tlius eucaine, or-
thoform, and nirvauin have been made available. The
somniferous effect of the introduction of ethyl groups
into molecules has been adduced as further" evidence
along these lines. Sulfonal, amylenc hydrate, alcohol,
and dniciu all owe thidr specific properties largely to the
eth3d groups contained in their molecules.
Ehrlicli's studies upon the staining of the living nerve
tissues by a certain small number of basic aniline dyes
(methylene blue, Bismarck brown, chrysoidin, neutral
reil, etc.) is calculated to throw some light upon the sub-
.iect. He has .shown that these neurotropic dyes entirely
lose this power if a suliiho-acid group be introduced into
their molecules. The introduction of the acid group al-
ters the distribution in the organism and completely de-
stroys the neurotropic properties. Ehiiich has pointed
out as specially significant the fact that the majority of
basic dyes which stain the living brain substance liave
also an artinity for adipose tissue. In other words, neu-
rotropy and lipotropy are intimately connected with one
another. It is obvious, therefore, tliat when substances
are ditropic or polytropic their distribution in the organ-
ism, and with it tlieir pharmacological etTect, will vary
more or less with the quantitative relations of the tissues
for which they have attinity. Thus the poisons which
have at the same time neurotropic and lipotropic effects,
if administered in equal amounts per kilogram of body
weight, will have a much more marked influence upon the
nervous sj'stem in an emaciated animal than in one which
is very fat; for, according to the lai de partake, much
more poison will be taken up by the brain.
One of the most important questions whicli we meet
with is that which deals with the reason why certain tis-
sues are selected b_v Certain chemical substances. That
the reasons are chemical in nature seems very jirobable.
It is well known, however, that certain indifferent sub-
stances possess neither basic nor acid characters; and
when introduced into the organism, though they have
no marked chemical affinities, they nevertheless often ex-
ercise extremely toxic effects. This is true, for example,
of ether, alcohol, and various narcotics. In such cases it
is thought that direct chemical allinilies on the part of
the organism are not concerned, but that we have to deal
with a .sort of contact eff'ect, due to the intluence of unal-
tered and ehemieallv unbound molecules present among
the constituents of the tis.sue. But if this is true, what
is it that determines the typical localization of these com-
pounds iu certain ti.ssnes, such as those of the central ner-
vous system? Ehrlich has compared this kind of locali-
zation with the principle of the Stas-Otto extraction
lirocedure. AVriting in ISST lie .said: "The principle of
the mode of extracting poisons introduced b_y Stas-Otto
is based on the fact that in general basic bodies, like the
alkaloids, enter into firm chemical combination in acid
solutions, and hence can only with ditliculty be extracted,
while they can easily be shaken out of alkaline solutio-js.
Acid compounds show, of course, the opposite behavior,
since they are held firmly iu alkaline media, but are easily
given up by acid media. If we transfer these princi|iles
to the questions in which we are here interested we can
easily understand why basic dyes, particularly those
which are not retained in the blood by chemical affinities,
are iireferably taken up by the brain, while the acid dyes
and snipho-acids which are firmlj- held b}' the alkalies of
the blood in the form of salt, a^d, as it were, are anchored
there, show exactly the opposite behavior." Ehrlicli's
observations that adipose tissue takes up many sub-
stances which ••uc also taken up by the brain is signifi-
cant when added to the finding of Pohl in 1891, that the
270
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
No II roue,
>'t'iiroj»os»
receptivity of tlie red blood corpuscles for chloroform
depends ujion the presence in tlio corpuscles of choles-
teriii aud lecithin, and to his conclusion that the relation
of the chloroform to the nerve tissues of the brain is de-
pendent upon the existence of substances of a fatty nature
in the brain. These studies afforded the basis for more
accurate examinations of the cerebral effects of those sub-
stances which are easily soluble in fats and fat-like com-
pounds. That these examinations have Iven fruitful will
be clearly seen from the work of Tlans Meyer on alcohol
narcosis, and tliat of H. Overton on tlie causal relations
existing between solubility in fat and narcotic effects.
But this loose contact effect of poison upon the brain
and spinal cord will not explain another series of intoxi-
cations due to bodies like the antipyretics, various sub-
stances of a basic nature (alkaloids and jilienols) which
are not chemically imliffereut, but, on the contrary, ma}-
be cajiable of entering into actual synthetic relatioiis with
the tissue cells. Loew suggested some years ago the ex-
istence in protoplasm of definite atomic groups endowed
with powerful allinities; to these atomic complexes he
ascribes an important role in the phenomena of intoxica-
tion. It was liis 0]iinion that atomic groups, on the one
hand, perhaps, of the nature of aldeliyde groups, on the
other hand, the labile amido groups, were active in the
protoplasm pro]ier in catcliing lioUl of clu-iuical sub-
stances circidating near them, and for ^^•llich they had an
aflinity. Any compound, he thought, which could com-
bine with either of these atomic groups could act as a
protoplasmic poison; aud the greater its aflinity for
these groups the stronger its toxic effect. But Ehrlich's
experiments with aniline dyes speak against such a sub-
stitutive action of poisons, at lea.st of poisons like the al-
kaloids; for most of tliem can be extracted from the tis-
sues by indifferent solvents, and this would scarcely be
the case if chemical combination with the protoplasm
took place. Ehrlich assumes, on the other hand, that
only two modes of explanation are possible, and that in
one case one may be true, in another case the other.
The one explanation is based upon Kneciit's theory of
the action of dyes depending u])on the formation of in-
soluble salt-like compounds. Pfeffer, in studying the
vital staining of plant cells, has convinced himself that
the staining is due to the precipitation of granules of the
difflcultlj- sobdih^ tannate of metliylene blue. In animal
cells theafhnity of the tissue for an alkaloid might be due
to the formation of a salt witli nucleinic acid, or with va-
rious products of secretion present in the cell ; that is to
say, with substances in the protoplasm rather than with
the protoplasm proper. The second possibility which
Ehrlich sees lies in the probability of the formation under
certain circumstances of so-called " solid solutions " (fedr
Losuvfjen of van't Hoff), a view which Witt has advanced
in dj'e chemistry. Possibly, as he suggests, the distri-
bution of an alkaloid in the organism sometimes depends
upon both causes, the selection being due to a combina-
tion of " salt formation " and of " solid solution."
There is a class of poisons, however, quite different
from all these thus far mentioned, poisons which like food-
stuffs may actually enter into the molecules of the proto-
plasm proper and hujixtd in the protoplasm and become
non-extractable by indifferent solvents; for such poisons
a view like that advanced by Lcew would be more appli-
cable. Sugar residues, for example, cannot be witli-
dr.awn from the cells by simple solvents; they must first
be split off by acids in order that they may be obtained
in a free condition. For such chemical anchorage, as in
all syntheses, two combining groups of maximal chemi-
cal affinity must l)e assumed to exist, one in the cells des-
ignated by Ehrlich as a "side chain " or "receptor." the
other in the food-stuff molecule and called by him a
"haptophore" group. Ehrlich assumes that living pro-
toplasnr is supplied with a large series of such "side
chains " (Seitenketten), which by virtue of their chemi-
cal constitution have the power to anchor the various
kinds of food-stuff's; in other worils, the activities of
such side chains underlie tlie phenomena of cellular me-
tabolism. It is this "side-chain theory" also which
forms the basis of Ehrlich'sdoctrine regarding the action
of bacterial toxins and the production of antibodies. He
believes that the toxins, like tlie food-stuffs, possess deli-
nite haptophore groups which, uniting with correspond-
ing receptors in the protoplasm- molecules of the cells,
permit the toxic effect. As a result of the tlirowing out of
function of these receptors the cells "regenerate" new
receptors of the same kind in excess, many of them being
thrown off into the blood to form "antitoxiu.s. " Only
such poisons as possess haptophore groups can give rise
to the formation of antibodies; against alkaloids, gluco-
sides, or the antipyretic substances, no true immunity
can be produced.
In tetanus, to take a concrete example, the symptoms
all point to an intoxication of the central nervous system.
According to Ehrlich's side-chain theoiy, the poison acts
on the nerve cells because its haptophore grouj} combines
with corresponding receptors in the nerve cells. Tetanus
antitoxin consists of such receptors regenerated in excess
aud thrown off info the circulating blood. When tetanus
poi.son enters the blood of an innnunized animal it is bound
by these receptors and the side chains in the nerve cells
themselves are protected. Wassermann has shown that
the normal tissue of the central nervous system of most
animals that are su.sceptible to tetanus is "capable of en-
tering ill ritro info firm combination with tetanus poison,
and that a mixture of normal nerve tissue and tetanus
poison is harmless when introduced into animals, Ijccause
the haptophore groups of the poison are .saturated with
receptors, and so cannot combine with the living nerve
tissues of the animal under experiment. Other organs
of the body do not combine with the tetanus poison in
Titro.
Interesting, too. in connection with the pathology of
the neurone is another series of facts — those bearins: upon
specific cytotoxins. It is now known that the injection
of the red blood corpuscles of a species a into a species
h leads to the development in the blood serum of species
b of specific products of reaction which are highly toxic
to the corpuscles of s]5ecies a. These toxic substances
are the so-called specific hwmolysins. Delzenne and
JIadame Metchuikoff, by treating animals with the cen-
tral nerve tissues of other species, have been able to pre-
pare a specific highly neurotoxic .serum. Small amounts
of this serum injected into the cerebrum of species a
cau.sed paralysis aud epileptiform convulsions. Experi-
ments made with other cells give similar results; thus
specific leucotoxins (for the white blood corpuscles) and
specific spermotoxins (for spermatozoa) have been pro-
duced. The fact that anti-h;i?molysins and anti-leuco-
toxinscan be made experimentally is very hopeful for the-
future of therapy.
Along the pathways just indicated the hope of the ex-
perimental pathologist and therapeutist would seem to
lie. But an immense amount of work must yet be done
before extensive practical application of these ideas in
clinical neurology may be expected.
LeweUys F. Barker.
References Bearing upon Intoxications of the Neurone.
Barliaoci, O. : Die Nervenzellen in ihren anatomlschen, physio-
loffischen unci patholoRlsclien Bi'/ieliuupen nach den neiiestcn
UntersHchunsen. Centralbl. t. allg. Patli. u. patu. .-Vnat., Jena, Bd.
X.. l.Hlli), pp. T?ir. Rffi.
Ewiufr, J. : sill. lies. in Canglion Cells. Arcli. Neurol, and Psycbopatli.,
veil, i., 189S, pp. 211:1 -HO (Utioa, 1899).
Ehrlich, P. : L'elier ilie Beziehuntren von etiemischer Constitnlion,
Vertlieilung und pharmakoliiqischer Wirkung. Internal. lieltr. z.
iiineren Med. (vou Levden's Festschrift), Berlin, 191)-'. Bd. 1., pB.
U-(,")-7T9.
NEUROSES, PROFESSIONAL. See Ihmds and Fin-
rjiTK, etc.
NEUROSES, TRAUMATIC. See AVrao»s St/stem.
TrmDiiatic Affections of.
NEUROSES, TROPHIC. — Definition. — Derange-
meiils of nutrition dclriiiiini'd l)y variations in the sup-
ply of nervous energy, without observable change in the
nerve tissues.
271
Neuroses.
Neuroses,
REFERENCE HANDBOOK OF THE JLEDICAL SCIENCES.
Tlie study of tht diseases usually iucluded under tins
bead is in large part a matter of the last few years. Sev-
eral members have been added to 1 he i;iim]>, and those
known for a louder time have been more elo.sely seruti-
nized and tlieir ]ihen(pmena described. In s|)ite of this
fact considerable doulit exists as to what particular dis-
eases belong in this category. Authorities differ a good
deal in regard to the nature of some of the diseases and
their ultimate causes. In order to olitaiu an adequate
coueeption of the general features of trophic disorders it
is necessiiry to consider with them some a{ the vaso-motor
diseases. "Nourishment and decay an^ closely and neces-
sarily linked with the blood supply ; this latter is varied,
at least in quantity, by a special nervous mechanism con-
stituting the cardio-vaso-motor system, so that the action
of the n\-rvous system on nutrition must be divided into
its direct action] and the one exerted through the vaso-
motors.
It is obviously impracticable to include in the group
all neuroses associated with tro|)hic change. Nutrition
is profoundly atl'eeted in many, SdUiewhat affected in
most of the ueuro.ses, including such widely varying dis-
eases as chorea, epilepsy, and various neuralgias. Over-
growth or decay should" be the predominant and essential
feature of the pi'ocess, and should affect specific struct-
ures. The results of ordinary vasomotor action and
mere connective-tissue hyperplasias should not be classed
as trophic disorders.
It is tirst to bo noted that a neurosis is properl}- a ner-
vous disea.se without observalile organic basis in the
nerve tissues. It will not be here used in its broader
.sense of nervous disease, whether organic or functional,
as the trophoneuroses would then of necessity include
diseases (syringomyelia, poliomyelitis, neuritis, and many
others) which, although aceomjianied by trophic changes
in various tissues, are evidently not conteinplated in the
present classification.
Granted that the changes in these diseases may occiu-
under the immediate influence of the nervous system,
whether by so-called trophic nerves or otherwise, there
still remains the (juestion whether the nerve changes are
determined by the action of poisons or take place as a
residt of inherited or acquired tendenc\' or from other
causes. Nutritional and degenerative abnormalities are
usually the result of poisons taken into the body from
without, or formed in the body by bacterial or glandular
action. The idea that there are purely functional disor-
ders without organic change is being much modified, and
is giving jdace to the conception of function as varied by
changes of structure or of environment, and especially
by variations of the blood supjily and blood content.
Especially in the i^roup of dise;uses known as the tropho-
neuroses the symptoms from which the patient suffers
are almost exclusively those of olnious organic chaugi* in
the most various tissues. To suppose a fiuietional basis
for such changes is a theory to be adopted, if at all, after
a careful scrutiny of the facts.
The idea of trophoneuroses is suggested bv analogy
from the muscular atr<i|ihy that supervenes oi'i destruc-
tion of the fibres of motor nerves or of motor ganglion
cells in the cord. While tropliie changes in such" dis-
eases as tabes and syringomyelia suggest the possibility
of tissue death from deticient innervation alone, facts are
rapidlj' accumulating which tend to show that some
trojjbic diseases formerly classed as neiuoses are in reality
vaso-motor and trophic disorders determined by lack or
superabundance of secretion of some of the "ductless
glands. The discovery of the importance of the secre-
ti(in of the thyniid gland in myxttHlema. cretinism, and
possibly scleroderma, and the close relationship of the
latter in its varied forms with the atrophies and livper-
trophies. facial hemiatrophy, acromegaly, and other dis-
eases has thrown much light on nutritional variations.
With these facts in view it will be well critically to ex-
amine the diseases sometimes classed as trophoneuroses,
so as to find out which, if any, of them are entitli-d to a
place in this category.
Acropara?sthesia affects mainly women who are much
exposed to cold, and especially those who have their
hands much in cold water. The symptoms are numb-
ness and tingling of the extremities, especially of the
hands, sometimes increasing to buruing or tearing pains.
There may be either hypera'sthesia or anitsthesia, and
analgesia, usually of moderate degree. The symptoms
do not follow the distribution of any nerve or nerves.
The sensory sj'mptoms con.stitute the essential elements
of the disease. Vaso-motor phenomena are sometimes
added, and consist of either redness or blanching of the
hands. Nutritional clianges are slight and unessential.
The fact that vaso-motor symptoms are variable and
sometimes absent indicates that the disease is an affection
of the sensory nerves, possibly a hyperiemia or low grade
of inflammation. The efficiency of ergot in controlling
the symptoms makes this view probable. The disease
usually runs a long but mild course.
Angioneurotic o'dema is the name given toccdematous
swellings which occur suddenly in various parts of the
body, sometimes without apparent cause, sometimes on
exposure to cold. The swellings do not pit on pressure;
they ma_y be white or pink in color; they disappear com-
pletely. The neurotic nature of the disease is sufficiently
indicated by the skipping of the a^dematous spots from
one place to another, sometimes with a rapidity ijuite re-
markable. It is not in any sense trophic, but" is purely
vaso-motor; sometimes, possibly always, on atoxic basis.
In many people of low vitality one or more fingers be-
come wliite. Cold, and corpse like on plunging them into
cold water in the morning, especially in wint*;r. These
are the so-called " dead fingers. " The blanching in severe
cases may involve the hands and exteml to the elbows,
or even to the shoulilers. Numbness and tingling are
present but moderate. The phenomena soon jjass off
when the hands are warmed by the fire. The disease is
not dangerous, nor even threatening except in some cases
in whicii vascular sijasm may be so great as to induce
faiutness. The condition is related on the one side to
acropara-sthesia ; on the other to Raynaud's disease, the
first stage of which it may simulate. Trophic features
are absent. A more profoimd affection of the vaso-
niotorsis seen in Raynaud's disease, one essentially of vas-
cular sjiasm of extreme degree. The stages of blanch-
ing, of local asphyxia with blackish discoloration and of
gangrene, are those of tissue death rather than of retro-
gressive metamorphosis. These jihenomena are vaso-
motor. There are, to be sure, trophic symptoms in many
cases, amounting to marked scleroderma. The fact that
scleroderma may exist without perceptible vaso-motor
change, that in Raynaud's disease blanching and local
asphyxia may go on indefinitely without atrophy, and
the lack of jn'oof tliat there is anj' necessary connection
between the two sets of phenomena, show the non-iden-
tity of the two diseases in spite of the existence of mixed
forms. Vascular spasm of known origin is nsuall_y toxic.
An extreme instance of this kind is seen in the gangrene
of ergot jioisoning. Organic lesion of the vaso-motor
centres is also capahle of setting up vascular spasm and
gangrene. No poisons have been found to account for
Raynaud's disease, and organic nerve lesions have not
lieen discovered.
It is hardly necessary to discuss the question whether
the foregoing diseases are essentiallj' trophic. The
symptoms are those of derangement of the vaso-motor
system; variations of nutrition are not prominent and
are absent in many cases. The ultimate cause of these
diseases is an interesting problem, but is not germane to
the ])resent inquiry.
The general diseases connected with abnormalities of
the thyroid gland are interesting instances along the
boundary between the vaso-motor and the trophic. They
have so lately been assigned to their proper place that
they still often figure as trophic neuroses, and they are
so closely related with the other diseases imder discussion
that they deserve a brief mention.
Exophthalmic goitre is characterized by vaso-motor
phenomena with some secondary nervous manifestations.
The rapid heart action, vascular enlargement of the thy-
272
REFEKEKfE HAXDISOOK OF THE MEDICAL SCIENCES.
Neuroses.
Neuroses.
roid gland, and bulging of the eyeballs point to an in-
volvement of the sympathetic system, and tremor, ner-
vousness, and vomiting make uji tlie usual picture of tlie
disease. There seems little doubt tliat the symptoms are
caused by increased functional activity of the tliyroid
gland. The cause of tliis increase is not known, but
there is no ground for thinking it a pure neurosis; and
exophthalmic goitre ncnv finds its place among the
glandular affections. Changes of nutrition of the body
tissues are great but not specific.
It is otherwise with niy.xa'dcnia. a disease now known
to lie due to lowered function of the thyroid gland. The
dejiosit of nuiciuous material in the skin, giving the char-
acteristic (edematous appeaiance, is not a condition of
overgrowth, and tlic changes in tlie kidneys, blood-ves-
sels,"aud nerve tissues are degenerative, not tropliic.
The disease makes good its title to a place among trophic
dtsorders chieHy by arrest of development in patients in
whom the disease begins in childhood. To this condition
the name of cretinoid idioe\' is given. Its dependence on
lack of secretion of a ductless gland (the thyroid), its
Improvement by ailmir.istr.ition of thyroid extract, and
its close relationship witli niy.\ie<lema are pregnant with
suggestions in regard to trophic variations and many so-
called troj^hic diseases. Meanwhile, in spite of the fact
that trophic conditions arc so largely present in cretin-
ism, and are so closely sinndated in my.xa^dema, neither
of tliem is a neurosis, and neither of them is properh' a
trophic disease.
So far we have considered diseases tliat vary by more
or less perceptible degrees from sensory into vaso-motoi'.
and from vaso-motor into trophic phenomena. In few of
them is tropliic cluinge entirely absent; and while sen-
sory symptoms do not increase in proportion with the
severity of the remaining .symptoms, tliey ai-e still pres-
ent throughout the entire .scries. We now come to a
disease in which sensory and vaso-motor symptoms iilay
an entirely minor juirt, and in winch changes mysterious
in origin are apparently essentially tropliic.
Scleroderma is a disease nut, as its name implies, of
the skin alone, but in its well-developed form is a wast-
ing of the tissues in general, including skin, bones, mus-
cles, mucous membranes. Clinically the present ten-
dency of authorities is toinclude intlie same category all
cases, whether of atrophy limited to a small portion of
the skin or of wasting nf almost all of the tissues of the
body, as in the terrible but happily rare instances of dif-
fuse scleroderma. These cases have the one symptom of
skin wasting in common, but it is improbable that they
depend upcm the same cause. In fact the partial cases,
the so-called morplifea, have in some instances been shown
to be due to organic changes in the nerve tissues, which
is not the case with general scleroderma. The striking-
features of this disease are tlie atro]ihy witlunit sensory
disturbance, Avhetlier an.-esthesia, hypera'Stliesia. iir jiaiiis
other than the discoinfnrt due lo the .shrinking tissues;
and the absence of vaso-motor changes as an essential
pai'L of the phenomena. The latter is limited to a hyper-
emia of moderate degree, shown in the lilac border about
the patches of morpluea. Pathologically the tissues show
a change into connective tissue and a disappearance of
the normal elements.
That so profound and widespread changes as occur in
well-marked sclrrodi-rma slmuld be brought about by
changes in the structure or fiuictions of the nerve tis
sues without direct involvement of their more familiar
functions, those connected with motion and sensation, is
suft'ciently improbable. AVe may leave out of account
organic change in the nerve tissues. If such were pres-
ent and could be shown with a fair degree of probability
to be in causal relation to the symptoms, the disease
would be assigned to the organic nerve diseases. Let ns
examine in brief the reasons usually urged for consider-
ing any disease neurotic in origin.
Symmetry of the lesitms or of the .symptoms is often
supposed to indicate their nervous origin. It issulficient
to observe on this head that although the nervous system
is S3'mmetric, so are the other organs of the body. In
Vol.. VI.— IS
especial the blood-vessels are in tlie main symmetrically
dis|io.sed. Accordingly vascular disturbances, whether
ciinditioned liy blood supply or b\' blood content, are usu-
ally symmetric, except when deterniin<'d by local causes,
as heat, cold, violence, pressure. It is to be noted that
of the two wavs in which tliese agencies have their ef-
fect, one is by mechanical change, and the other is change
of tissue through the action of tlie vaso-motois, so that
asymmetry itself is in many cases the result of nerve ac-
tiim. While vascular action is usually symmetiic, nerve
action is not usually so. Walking is alternate, not s_ym-
metric action; the hands are sometimes moved together,
usually separately; the finer motor acts, as of .speech
and writing are functions of one side of the brain ; the
possession of special sense organs in pairs is an instance
of redundance for safety in case of accident rather than
a necessary s.vmmetric arrangement.
General sensibility is only symmetric in the sense that
the whole of the skin and the other tissues is supplied;
1 lie very ]ioint and essential feature of the whole mechan-
ism is the distinguishing of one side from the other and
of one spot from another. In some s|iecial instances, as
with contraction of both pupils from the impact of light
on one retina, a bilateral result follows from a unilateral
cause. Dilatation of the pupils, however, from an injec-
tion of atropine is not an instance of the same kind, but
is determined by distribution of theiioison to the sympa-
thetic on both sides; excitation of the symjiathctic in the
neck on one side, by galvanism, and the action of atro-
pine on the nerve filaments of one side, bj' instillation into
the e3'e itself, are followed bv dilatation of the jiupil of the
corresponding eye alone. These and other considerations
of a like kind tend to .show that symmetiy of iktvc ac-
tion is usuall_v the result of causes acting bilaterallj-.
The proposition that most nervous symptoms are not
symmetric, and most symmetric symptoms are not ner-
vous, is susceptible of easy proof, and lends little sup-
port to the inference often made that symmetric lesions
are of nervous origin if not proved otherwise.
Another usual reason for considering a manifestation
of any kind as of nervous origin is its association with
so-called neurotic or hysteric symptoms, such as cause-
less laughing and crying, wandering anscsthesia, clavus,
and the like. Leaving aside the inherent improbability
that grave organic changes depend on vague and so-
called nervous Cdiiditiims. or that they have no better
excuse for being than is implied by the insufficient and
unnecessary word hysteria, we may at any rate leave this
factor out of account in considering scleroderma, sutTer-
ers from wliich disease are singularly unemotional con-
sidering the hideous and destructive changes which they
are undergoing.
Acromegaly is characterized by increase of size of the
extremities, the hands, feet, and head; and this fact
gives the name to the disease. The name, Imwever, is a
misnomer, for the enlargements afe true hypertrophies
atfecting almost ever}"^ organ in the boily. The muscles
are large, and in the earlj' stages of the disease they are
powerfid. The bones are thickened and the subcuta
neons tissues form great pads in ilie ])almsand soles. The
lips pi'iitrude. there is an undershot lower jaw, the nose
is big and bulbous. This is. however, only a su)>erficial
view, for the heart, tlie liver, the kidneys, and the spleen
an- ;ilsii enlarged. Theliraiii is inci'cased in size, the skin
is thick and coarse, anil the voice is heavy from rough-
ening of the vocal cords. When the disease begins in
early life the general increase in size produces true gi-
gantism. Marie's saying that "acromegaly is gigantism
in the adult, gigantism is acromegaly in the adolescent,"
while only partly true, is accurate as regards many cases.
One feature of liie disease, the enlargement of the jiitui-
tary gland. earl_y attracted Marie's alteiition. He consid-
ered this the cause of the disease. Further study brings
to light the following dilliculties in the way of this
theory. First, not all cases show enlargement of the
pituitary gland. In one case the gland was entirely ab-
sent. Second, the changes in the gland are not uniform
but of the greatest po.ssiblo variety. Third, many eases
273
Neiirosost,
Ne\i-Boru.
UEFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
of disease of the {riand are rejiorted in wliicli lu) symp-
toiiis of acromegaly were present. Fourtli, pituitary e.\-
tract administered to jiatients does not control tlie diseas(!
as does thyroid extract in myxo'deina. Last, and ])0.ssi-
bly most important of all, ex])eriniental removal of the
hypophysis does not produce the symptoms of the dis-
ease in animals.
Disregarding for a moment tlie evidences in regard to
the pituitary gland as the cause of the disease, let us
consider the theory that acromegaly is primarily the re-
sult of disordered" nerve action. The only alternative
theory worth considering is that it is due to alterations in
the lilood supply, either quantitative or i|ualitative. In
estimating comparatively tlie tropliie influence on the
tissues of nerve anil Ijlood supply, the balance is largely
in favor of the blooii in regard to the importance of its
action. That nervous influences do affect nutrition is
tuidoubted, especially in the ca.se of the muscles and of
the skin. It is to be observed, however, that even in
these instances the muscles increase in size under stimu-
lation, apparently as a result of the increased action of
the nmscle fibres and their increased vascularity, rather
than as a result of any iidierent tro|)hic activity of tlie
nerves supplying them. The muscle (ibres disappear
aft<T the nerves are cut. not directly as a part of the de-
generation of the nerve fibres, but as an indirect and re-
mote result of their loss of function. Atrophies of the
skin sometimes occur as the a])parent result of nerve
lesion, but usually there is only a limited amount of
cliange, such as is seen in the glossy skin of neuritis and
liemi|ilegia; ulcerative processes are in sucli cases prob
ably tlu^ result of germ action from lowered resisting
power rather than destructive processes the direct result
of nerve lesion. But many of the tissues have a mnch
less rich nerve supply than have the muscles and the
skin. The witlespread hypertrophies of acromegaly
would, if of nervous origin, require for their explanation
a tro])hic intiuence out of all proportion with the com-
paratively scanty facts at our disposal in regard to the
trophic intUiciiee of the nervous system on the organs in
general.
The blood supjily we know, on the other liand. to be
everywhere and always of vital importance in nutritional
processes. To say that nutrition is always carried on by
the lilood su]iply is a platitude, but in this connection it
needs statement. The nervous system, when it affects
uutiilion through the blood-vessels, does .so by cliauging
their ealilire. In acromegaly congestions lilay no part
in the clinical phenomena. We are driven to the con-
clu.sion that, so far as we know, the hypertro])hies in
acromegaly are due to qualitative changes in the blood;
whether these changes consist in an increased or deticient
secretion from the ductless glands, the pituitary or the
thyroid or both, it remains for the future to determine.
Facial licmiLitropliy is characterized by a wasting of all
the tissues of one side of the face. The disease occurs at
all ages. Various causes have been assigned, especially
injury at the time of birth, blows, abscesses, infectious
diseases, and cases have been rejiorted in which it has
followed division fif the fifth nerve. The mechanism of
its production is not ajiparent, as division of the nerve is
usually not followed liy it. On the other hand, although
uniloubted changes have been found in the tifth nerve in
ca.ses of apparently spontaneous development, the nerve
has in these cases seemed to share in the general progress
of the disease rather than to be primarily affected.
Severe neuralgic jiains 7iiay usher in the disease, or it
may begin quite jiainlessly as a small atrophic spot on
the skin of the cheek, much like ascleroilermatous patch.
The atrophy gradually involves more of the skin and the
other tissues, esiiecially the subcutaneous tissue and the
bones. One-half of the tongue and the mucous mem-
branes and other structures of the mouth of the affected
side share in the process. The cranial bones 'are thinned
and wasted, the forehead is furrowed, and the whole side
of the face hollowed and mvu'h smaller than the other
side. The hair and beard are thinner than normal.
The changes in the skin may be accompanied by ana'S-
thesia, especially in cases in which the nerve trunks are
much affected. Sensibility to tactile and painful impres-
sions and the temperature sense may be retained, how-
ever, even when the skin and the other tissues are
markeilly atrophic. The muscles often show less change
than do any of the other tissues. They may retain vol-
untary powei- and electric excitability, or n'lay share in
the general atrophy. Tears, saliva, and perspiration
may be secreted normally on the affected side. The pu-
pil remains normal and there is no change in the fundus
of the eye.
The changes are progressive, but may come to a stand-
still at any time. The disease is not dangerous to life
and the changes do not extend beyond the face, which it
disfigures in a way very distressing to the patient. AH
known methods of treatfuent are quite inefTeeti ve. Elec-
tricity, massage, and cod-liver oil have been tried with-
out much apparent effect. The relation of the nervous
system to the disease is not definitely known.
Ili/jiinixtiisifi criiiiii, otherwise known as Icontiasu imsia,
is an enlargement of the bones of the head. The rest of
the body tissues are not atTected. Tlie fact that the
bones alone are enlarged brings the disease into interest-
ing relation with the so called )u-ogrcssive pulmonary
osteo-arlhropathy. The latter disease consists in an en-
largement of the bones of tlie extremities, so that patients
present a superficial resemblance with those afflicted with
acromegaly. These patients, however, show no involve-
ment of the head and no thickening of the soft parts;
they lack the jiads in the jialms and .soles, the roughen-
ing of the voice, the bulbous nose and thick lips of acro-
megaly, and simply show enlargement of the bones of
the arms and legs, and chronic joint alTeetion with creak-
ing, pains, and resulting disability. While there is not
always lung disease, as was at first thought, there is al-
wa_ys toxa'uiia from some cau.se. tulierculo.sis, syphilis,
gastrectasis among others. The changes in both these
diseases are inflammatory, the osteitis in the one disease
affecting not only the long bones but the joints as well,
in the other the change being curiously limited to the
bones of the head. Such peculiarities of distriliution do
n<it. in the writer's opinion, show that the poisons work
prim.irily on the nervous system. A similar selective
action is exercised by rheumatic poisons on certain joints,
on the pericardium, the endocardium, at times the skin
anil meninges in diffeirnt patients, and in the same pa-
tient at different times. The selective action of poisons
is sometimes on the nervous system, at other times
through the nervous system; but in these diseases there
is nothing to show that the action is not on the affected
tissues direct. The organs most rielily supplied with
nerves are not the ones affected, the nervous sj-stem
shows no special sign of involvement, and osteitis, even
though chronic and iiroliferating, is not a usual accom-
paniment of any known nerve change
Two diseases which may be grouped together are
(irlipusif! (hihirosa and I'l/iiiinetrii'id lipoiniiloisis. Both are
characterized by enormous deposits of fat; the essential
difTerence is that in one the fat deposits are the seat of
severe pains, in the other the nutritional changes are j
painless. The synuiiefry of the lesions, and in adiposis
dolorosa the occurrence of pains, have been supposed to
indicate a neurotic basis for flic overgrowth of tissue.
These diseases are certainly essentially trophic. They
are both, however, to be traced to either syphilis or over-
indulgence in alcohol; that is, in either case to poisons
which are necessarily symmetrically distributed by the
blood stream, ajiart from any intervention of the nervous
system. In the case of a<liposis dolorosa it is still some-
what doubtful whether the symyitoms are the expression
of a separate disease juiicessor are sinqily an extreme ac- j
cumulation of fat and a low grade of neuritis, both coin-
mon results of chronic alcohol poisoning. Symmetrical
lipomatosis is a curious symptom of toxic origin.
Localized liyperfrophies of varied distribution have
been described. Facial hemihy]iertropliy is the analogue
and opposite of facial hemiatrophy. It is much more
laic. It is sometimes acquired, but may be congenital.
274
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Ne\v-Borii«
Hypertrophy of one-half the body has been described,
ami so also have hypertrophies of single limbs. One
linger may beiuvolveil alone. These hypertrophies usu-
ally involve all the tissues. Nothing is known of their
caiisatiou. The affeeted part may be vmduly large at
birth and may continue to gi'ow or increase in size, or
the enlargement may begin in later life. No cause has
l>ccn traced for these strange variations from the normal,
and in the absence of evidence to the contrary they must
be regarded as the i-esult of an innate tendency, possibly
but not sureh' of an atavistic character.
Returning now to the criteria to be applied in distin-
guishing to-xic from functional nervous diseases, we may
observe that functional diseases are properly vicious hali-
its set up in the ner\-ous system hy irritants or (loisons,
and are to be distinguished from symptoms due to their
direct and continuing action. The poisons of most of the
infectious diseases, as well as alcohol and other volatile
poisons taken into tlie body from without, are apparently
capable of leaving their impress on the nervous system,
causing symptoms which long outlive their exciting
cause. The action of toxins on the affected tissues them-
selves, and their action by indirection through the nervous
system, are not always easy to distinguish. The sym-
metry of the lesions, as alread_y pointed out, usuall_y
means simply bilateral diffusion through the blood
stream; in the one case to symmetrically ilisposed nerve
structures, in the other to the affected tissues direct. In
especial when intlanimatory lesions are the result, the
chances are much in favor of direct to.xic action and
against intervening nerve action.
The above considerations warrant the following con-
clusions in regard to the diseases under di.^cussiou, which
permit, however, the elements of a provisional classifica-
tion only.
AcropariEsthesia is a sensory neurosis. Angioneurotic
oedema is a sensori-vaso-motor and Raynaud's disease a
vaso-motor neurosis. Exophthalmic goitre and mj-xo--
dema, including cretinism, aie disea.?es of the tliyroid
gland ; the tirst is characterized mainly by vaso-motor
symptoms, the second with special trophic features when
occurring in adolescence, lli/perostosis craiiii and pro-
gressive osteoarthropathy are inflammatory diseases, the
first piobably, the second undoubtedly on a toxic basis.
Acromegaly and scleroderma are trophic diseases, prob-
ably of toxic origin: the same maybe said of adiposis
dohrosit and symmetrical lipomatosis, but the poison in
these diseases is usually if not always alcohol or the tox-
ins of .syphilis. Facial hemiatrophy and the localized
hypertrophies are tro])liic disea.ses of unknown origin,
possibly neurotic. Ilenri/ S. Ujison.
NEW-BORN, PATHOLOGY OF.— TIjc pathological
conditions which may he iiresciit in tlie new-horn at the
time of birth, or which may devcloji duringtlic tirstdays
of extra-uterine life are very numerous and of the great-
est variet)'. These conditions are of great importance, not
only from a scientific standpoint, but also from the fact
that they may hinder or render im])(i.ssible the normal de-
livery of the child, or cause its death either before, dur-
ing, or following birth; or tinally they may affect its
after-development, either by giving rise to pathological
states persisting throughout life, or bj' the establishment
of sueli changes that death, though deferred to a later
period, ultimately lesults.
The conditions known as congenital, further those
pathological states aequircil from the jwirents, the causes
of still-birth, the disease processes incidental to delivery,
the pathological conditions and diseases peculiar to the
first days of lifi.', are all to be considered in this connec-
tion. For convenience tliese conditions may be divided
into the following groups: liitriimir, inheritable condi-
tions, arising either in the individual sexual cells or
through germ variation: anoiiKilicn if ih eelnpnuht. due to
extrinsic causes affecting the mother, abnormal conditions
of the fnjtal membranes, etc. : iiifertioiiK transmitted from
I the parents, particularly from the mother, acquired either
during intrauterine life, m- during delivery, or after
birth; intoxications, either acquired through the mater-
nal blood, or auto-intoxications developing in intra- or
extra-uterine life; diseases of indimduiil tissues, orr/mis, or
systems, peculiar to the new born, idiopathic, or produced
by infection, intoxication, etc. ; neir-i/roirt/is, developing
in intra-uteriue life or immediately after birth.
The Autopsy op the New-bo'kn. — The methods em-
ployed in the autopsy of the new-born differ in a number
of details from the ordinary autopsy teclmi(iue. These
differences are dependent partly upon different anatomi-
cal conditions, and partly upon certain procedures which
are of great importance in the determination of certain
pathological or medico-legal questions. In other respects
the autopsy methods are the same as those given under
the head of "Autopsy" (Vol. I., page 649). The chief
points of difference are as follows:
1. Section of Spinal Cm'd. — The spinal canal is opened
by cutting through the lamina' with the curved bone
shears.
3. Section of Cranium. — After the removal of the scalp
the skull cap is opened in the median line, in the poste-
rior angle of the great fontanel. By means of the curved
bone scissors the longitudinal sinus is then opened both
anteriorly and posteriorly by cutting through the bone
in the line of the sagittal suture. The sutures between
the frontal and parietal bones and between the parietal
and occipital are then cut through from alxjve, down-
ward to the sides of the cranium, far enough to expose
the brain sufficiently for its safe removal. The duia
being adherent to the inner surface of the skull cap is
cut through and turned back with the bones. The two
halves of the frontal bone, the parietal and occipital, are
pressed back from the brain at the level of greatest cir-
ciunference. If the head is to be restored the bones are
held back by an as.sistant while the brain is removed,
otherwise the bones and dura are cut through at the level
of greatest circumference and removed. The anterior
falx is then cut and the brain removed, as in the adult.
3. Section, of 21iora.r. jSeck. iiiiil Abdomen. — A small
block of wood is placed beneath the lumbar vertebr;e.
The main incision is then made in the median line, down-
ward from the thyroid cartilage, dividing just above the
umbilicus into two diverging cuts, extending on each
side of the umbilicus to tlie pubis. The abdominal cav-
ity is then opened just below the ensiform caitilage, and
the opening extended in the line of the skin incision,
(Kissing to the left of the umbilicus. The right flap of
till- alidominal wall is then lifted and turned over to the
right, while the umbilical vesselsare dissected from their
peritoneal covering and slit open toward the liver and
toward the umbilicus. The skin incision passing to the
right of the umbilicus is now extended downwaid
through the abdominal wall, severing the umbilical
vessels. The flap of abdominal wall between the two
diverging incisions is now turned back over the symphy-
sis and the f'wo diverging umbilical arteries are exposed,
the urachus and bladder lying between them. The ar-
teries are now exposed by careful dissection, cut through
at the umbilicus, and slit open.
The thorax is opened by cutting through the ribs in-
stead of the cartilages in order to obtain more room.
This may be done with the bone shears or a dull knife.
The thymus gland is first examined and then removed.
After tlie opening of the four heart chambers the ductus
Botalli is carefully examined. This is done by extending
the incision through the conus of the pulmonary artery
and through the wall of the artery. 'Tlie ductus Botalli
is then found and probed. When the thoracic organs are
removed with the neck organs, the aorta may be opened
and the ductus Botalli opened by means of a probe passed
from the aorta into the pidmonary artery. The heart is
now removed and examined, the foramen ovale receiving
careful inspection.
In many cases it is better to take out the neck and
thoracic organs together. When the question is raised
as to the child's having breathed after birth, the .section
should be conducted as follows: After the abdominal
cavity is opened the height of the diaphragm is taken.
275
New-Boril.
Neiv-Borii.
KEFEKKNCJ-: llAMUiDUK UF THE MEDlrAL SCIENCES.
Tlip oppiihiEr of tilt' alKlomen must picfcde that of the
neck or tlKirax. Hufdrt' llic tlioia.v is opi-iicd tlic upiK-r
air passaj^fs are tightly lit;atviicil. 'I'lie thoracic cavity
is then opened, and |ierieardiuni an<l lieart arc examined.
Tlie larynx ami trachea arc opened loM;;iludinally above
tlic liiiaturc. Tlie neel< and thoracic (jrnansarc tlieu re-
moved. Tlie tliy mus and lieart are removed. 1 he buoy-
ancy of the huijis is Mien tcsied by placing the orgaus
in a" large vessel'tilled with cold water. 'I'he air passages
below the ligature are then opened. Incisions are then
made into the lissueof both lungs, noting the occurrence
of crackling sounds, bubbles, and the amount and char-
acter of the blood. Cuts are also made into the lungs
beneath the water, in order to see if any bubbles arise
from the cut surface. Finally the lnn,gs are cut into
small pieces, and the buoyancy of the separate pieces is
tested. The ]iresence of air in Ihe gastro-intestinal tract
points in general to extra-nterine moveincnts of "swal-
lowing." From this it may be inferred that the child
was boru alive. The swallowed air collects in tlie stom-
ach and gradually jiasses down tlie iutestiues. lu cases
in which the stomach appears to contain air or gas the
organ should be ligatured at both ends and removed and
opened under water.
The lower epiphysis of the femur is examined with re-
gard to the size o( the centre o{ ossitication. The knee-
joint is o|ieiied by a transverse incision beneath the pa-
tella, the leg Hexed, and the patella removed. Cuts are
then made at right angles into the thin layer of cartilage
until the greatest diameter of the centre id' ossitication is
cut through. In the case of iireniatureliirlh the eye may
be examined witli regard to the ]iresence or absence of
the piipillaiy membrane. The anterior half of the eye-
ball is removed and ti.\cd in .Miillcr's tluid for micro,sco-
pieal examinaliou,
Si'KciAi, Points to iik Notkd in the Ex.\min.\tion
')K lilt: 0.\n.\vi;i! ok tuk Nkw-hohx. — The external ex-
amination of the cadaver of the new-born has for its
chief aim the determination of thosceharaeteristics which
give iuforination as to its age and development The
most important of these points are as follows: The aver
age li'Ugth of a mature new-born child is od-,")! cin.,
maximum length 5S cm,, minimum 4.S cm. Boys are
somewhat lon,gerllian girls. The average weight of a
mature tVetus is for boys. 3,310 .mn, : .girls, ;_l,'.3ii(l gm. ;
maximum wi'iglit. ."l.-iOO gm., minimum, 3..~>()0 gni. Diir
iu.g the last live months of intra uterine life the length
of the fietus in centimetres divided by live will give
the age of the fietus in months. The skin i>t a mature
new-born is not wrinkled but sinoolh, of i.illur light
color, the tine body hair being visible only on the
shoulders. The umbilical cord has an average length of
about .~iO cm., and is inserted about the middle of the
body, being thrown olT about the tifth or sixth day.
The hairs of the scalp measure 2-3 cm. in.k'ngth. The
great fontanel is about 2-'.3."> em. wide. The circumfer-
ence of the cranium is 34..") cm. The pupillary membrane
vanishes in the eight h month. The cartilages of the no.si'
and ears are tirm in healthy mature infants. The tinger
nails all' hard, bi>riiy. and cMeiid beyond the linger tips.
The shoulder breadth measures n-i"2cm.. the distance
between the trochanters is!)- 10 cm. The testicles should
be present in the lirni and wiinklcd scrotum (the descent
of the testicles should bi LLin iluiing (he seventh luoutli).
In girls the outer labia meet, but occasionally the inner
labia are visible. The centre <d' ossitication in the lower
ejiiiihysis of the femur usually measures 2-.") mm. in the
full leriii child, but in very rare eases it may be absent
in fully developed children. It is not present before the
thirty-sevenib week of fivtal life. It a|ipearsin Ihe blue-
while ei)i]iliyseal cartilage as a lenlicular mass of red-
dish or brown color in which minule blood-\ cssels are
distinctly visible. The cranium should be carerully ex-
aniiiied for evidence of injury received al birdi. "caput
snceedaneum," laematoma, depressions, overlapping, cle.
In the judgment of the color, consistence, and moisture
of the brain substance it should be remembered that the
brain of the new-born is normally rosy-red, somewhat
translucent, and soft. In the examination of the umbili-
cal vessels the thickness of the walls, the contents (blood,
pus, thidinbi, etc.), intillrations of the surrouniliug con-
nective ti-ssue, as well as of the tissue of the umbilicus,
should lie noted. The lung should be carefully examined
for areas of atelectasis or pneumonia. In tlie case of the
lieart the foramen ovale and the ductus Botalli (closes on
the fourth or tifth day) should receive particular atten-
tion. The adrenals should be examined for evidences of
bemorrhage; the degree of uric acid infarction of the
kidneys should be noted, and in male infants the sper-
matic, renal, and adrenal vessels should be examined for
thrombi.
f, 1nthinsicP.\thoi.ogic.\i. Conditions of the Xew-
BOKN. — The intrinsic pathological conditions of the new-
l)orn are those which arise in the germ independent of
an\' external influence. They may be inherited, existing
in eitlier one or both of the sexual nuclei, or they may
occur for the first time, in a given family, as a primaiy
germ variation. The inheritance may be either dirn-t. or
eoUiiiii-itl. or (itiirixlir. The conditions which are inher-
ited are the same as those arising as primary germ va-
riations. From this the principle may be formulated
that only those pathological conditions are inherited
which originally occur as primary germ variations. In
explaualion of such variation we are at present limited
to the hypothesis that cither one or both of the sexual
nuclei which combine to form the new individual are ab-
normal, or that from the union of two normal nuclei a
pathological variety may arise, or tinally that the patlio-
logii'al variety may be the result of disturbances in the
process of copulation.
The most important of the intrinsic iiatholonical condi-
tions of the new-born are certain malformations, such as
poUiihwiylixnt, chft-liii ltd, c/tft-fool, inbhul fiiiji'm, as well
imothtr iiiiilforiiiiitiiDis cf liiiiids mid fict, ItiiiTlip, iibiior-
iiKfUi^tirhiCM. elrii]itiiiiiii-sis, ichlJtyosis, iilhlniain. etc. The
majority of the ti/pienl ministers and mill furiiuit ions may
also appear as intrinsic conditions, and are not infre-
quently inherited. Of these may be mentioned the 7nal-
fiinnaliiins of tlic face and rriiniiim, spina hijida, ati'esias
of tlie hodtj orifris, tninsposition. (f tin: risrera, 'nialfnrnia-
tions of the lieart and. blood-ressels. and of the sexiiid orijans,
etc. (see also article on 'I'l ratuhiiiji). Further, certain
tumors, a^fliroinata, multiple neiirofibivninta. anep'oinata,
liinipliamiioniatii, osteoniiita. etc.. often appear in certain
families as inheritable conditions. All of these conditions
may be present at birlli. though they not infrequently
appear in later life.
Ahnornialsize of the new-born may be explained asdue
to intrinsic causes. In some cases the weight of thefull-
terni tVetus may reach as high as 12,000 gm., the length
of the body exceeding that of the normal. An abnormal
si:,e of individual parts of the skeleton or of the soft
structures may also be referred to intrinsic causes. Simi-
larly, abnormal siiiaUness of the new-born, of the body as
a whole or of certain parts, may be of intrinsic origin.
Struma eonffenita is regarded by some writers as of in-
trinsic origin. Vonfjenitnl hivniopliitia may be manifested
in the new-born by hemorrhage from the umbilicus, un-
der the scali>. between the meninges, or from ihe body
passages (mel.-ena neonaloriimi. Urnf-mnti.ini and abnor-
mal conditions if the retina arc also congenital conditions,
manifesling tliemselves in tlie iiew-lioru. It must be
borne in mind, however, that many of the above condi-
tions may also be acquired as the result of extrinsic in-
jurious iiitlucnccs exerted ii|>oii (he fotiis during intra-
uterine life.
2. AcijiiKEi) Anom.m.ies of Di'.vei.opment. — In the
production of moiistcisand maU'ormations extrinsic in-
jurious intlueiices ]irobabIy ])lay the chief rijle. Among
the most important of such intluences may be mentioned
trauma to the mother, jarrings of the iiterus. pressure,
uterine contractions, tumors of uterus or jielvic organs,
dislodgment of the ovum, partial separation of the pla-
centa, hemorrhage into the placent.T, placental disease,
diseased cniiditions of the uterus or of the mollier. dis-
turbance ii. the supply of oxygen and nutrition, iiitoxi-
276
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
>cw-Boru.
Ne«-Boru.
cations, infections, etc. Abnormal conditions of the
amnion are also particularly likely to cause malforma-
tions of the fa?tus. Aljuorma! tightness of the anmion,
particularly of the cephalic or caudal end. adhesions
between amnion and fa'tus, etc., cause a great variety of
malformations, such as intra -uterine nmputdtions. apla-
sias and I(iipoplamag, anencephalia, e.rencephatia, thonicie
and abdDininiil clefts, spina, bifida, phoromelia, ciirratures
of the spine, etc. Deticiency of the anuiiotic fluid (oligo-
hydramnios) may also pniduce vario\is malformations,
stich as spinal curvatures, clubfoot, club-liand, and a great
variety of malf&rmations of the ertremities. Of especial
importance are adhesions between the amnion and the
surface of the foetus; they are found very freiiuently in
association with oligohydramnion. They may occasion
a great variety of maUormaticms, particidarly tlmse char-
acterized by a failure of the body clefts to close. Through
the stretching of such adhesions about the fa?tal extrem-
ities amputations of the latter may be produced. Forci-
ble separation of the adhesions from the fwtal surface
may cause irounds ef tlie fcvial skin. Infra-uterine /ra(•^
nres and dislocations are also caused by amnifitic adhe-
sions. An e.xcess of amniotic fluid (hydramuion) may also
cause malformations and disturbances of development in
the fa>tus. In the case of twins one fi.etus may develoji
at the expense of the other, the latter showing various
malformations due chiefly to abnormal pressure. Such
abnormalities are especially likely to occur, if in one am-
niotic sac there is an excess of fluid anil in the other a
deficiency.
Vonr/enital Fractures. — Not all of the fractures found
in the new-born are the results of ditticidt labor, but a
part at least may be referred to trauma affecting I he
mother. The bones of the fcetal head are more fre-
quently fractured than are the long bones. Abortion or
premature delivery usually results from such trauma, but
occasionally a fo'tus so injured may be carried to full
tenn and be born alive. At birth the fracture may be in
the process of healing or entirelj' healed. Apparent in-
tra-uterine fractures may be caused by deficient ossifica-
tion or bv disease of the fa?tal bones (intra-uterine rachi-
tis).
Congenital dislocations are not rare. The hip-joint is
most frequently affected; more often in girls than in
boys. The causes are partly intrinsic, due to an abnor-
mal smallness and faulty position of the joint, as w-ell as
a primary relaxation of the ligaments. Extrinsic causes,
pressure, poor nutrition, deficient amniotic fl^dd, etc.,
play an important part, however, in the production of
the condition.
Pathological Conditions Produced during Labor ; Caput
Svccedaneum. — During the birth of the child an tede-
matous swelling of the loose connective tissue beneath
the scalp often forms, as the result of the passive conges-
tion of the parts presenting. The condition is more
marked in cases of protracted labor with unusually severe
labor pains. The a>dema is often accompanied by mi-
nute hemorrhages. It must not, however, be mistaken
for the true lutmatoma of the scalp. Caput succeda-
ncum has no pathological significance exceiit in extreme
cases ; ordinarily it disappears within from twenty-four to
forty-eight hours.
Cephcdhrrniiitoma INeormtorum. — Occasionally there oc-
curs during birth an extravasation of blood between the
periosteum and the bone, leading to a detachment of the
former. The extravasation is «sua!l,v accompanied by
caput succedaneum, and becomes more pronnnent as the
nedematous swelling disappears. The condition occurs
I most frequently upon the parietal bones, less frequcntlj-
1 upon the occipital, near the posterior fontanel. The
tumor usually reaches its maximum on the third to
fourth day. It may extend o^erthe entire surface of the
bone involved, but is limited by the sutures. Bilateral
extravasations are rare. Tlie tumor is fluctuating, the
scalp covering it bluish, resembling a bruise. If tlie
amount of extravasation is large, or if absorption is de-
laj'ed, the detached periosteum forms bone around the
edge of the haBmatoma. In this way there may arise
around the extravasation a wall of newly formed bone,
or the latter may become encapsvdated ijy bony plates.
In some cases the extravasate becomes purulent. The
blood maj' be absorbed in from four to six weeks, the
cavity obliterated, and the bony plates iniited, so that ulti-
mately there may remain only a localized thickening of
the cranium at the site of the extravasation. Rarely
there may persist a crater-like depression with a thick-
ened rim.
Hir/notonia of the .sterno-cleido-masioid mtiscle occurs
rarely after prolonged labors, jiarticularly after breech
presentations involving traction upon the neck. The
swelling of the muscle is probably more the result of a
local myositis than of a hemorrhage. Suppuration re-
sults very rarel_v. The condition usually disappears in a
few weeks without giving rise to permanent changes.
Fractures, dislocations, and injuries of internal organs
may result from difiiciilt or instrumental labor. Rupt-
ure of the liver or spleen may occur, or in rare cases of
the intestines. External soft parts, as the ears, may be
damaged by the forceps. Of the greatest importance
are the damages caused to the central nervous system in
delivery by the forceps or through turning. Schultze
and Pfeifter found midtiple hemorrhages in the bulb,
medulla, and cord in suth cases. Degeneration of the
ganglion cells also occurs. Fiom the occurrence of such
anatomical lesions it is easy to imderstand the frequent
development of nervous lesions iu children born in difti-
cult or instrumental labor.
3. IxFECTioxs. — According to the views of the major-
ity of writers micro-organisms are not able to pass from
the maternal blood through a normal intact syncytium
into the facial circulation. It must be borne in mind.
however, that owing to the natural jiroeesses of atrophy
and new formation of chorionic villi, which occur con-
stantly in the placenta from the earliest stages of its
development onward, and Avhich are especially marked
during the later months of ]iregnanc\', there are to be
foun(i in every normal placenta atrophic or necrosing
villi, the syncytial coverijig of which, is either partly
or wholly des(iuamated or is undergoing degenerative
changes. Such senile villi form, therefore, points of
least resistance to the passage of micro-organisms. The
constant presence of such villi in the normal placenta
favors the passage into the fretal blood of micro-organ-
isms which may be i^resent in the maternal circulation :
in otiier words, such a thing as a perfectly intact syncT-
tium throughout the entire chorionic surface does not
exist normally, and in every normal placenta there are
conditions favoring the passage of micro-organisms.
There is. however, good reason for believing that the
fcetal tissues are more immune to many infections than
are the maternal, and bacteria having passed the chorion
may either fail entirely of producing pathological
changes, or remain latent until a later period. The prob-
abilities of the transmission of infection from the mother
totbef<etus are iu direct proportion to the severity of
the maternal infection, dealh of the fa?tus usually result-
ing when the di.sea.se of the mother is very severe.
Si/j)hitis. — The most comnn m and most imjiortant infec-
tion of tlie new-born is sy|)hilis. This may be ac<)uiied
from the mother through the ovum, from the father
through the sperm, or through a later infection from
either parent. The chief jiathological changes shown at
birth are: skin lesions (iu about twenty-four per cent, of
cases), either papular, macular, or lieniorrhagic. bullous
eruptions (pemphigus syphiliticus) affecting chiefly the
palms aiul soles; less frequently macular, papular, or
ulcerative lesions of the mucous membranes; fibroid hy-
perplasia of liver (cirrhosis) and spleen; "white pneu-
monia"; gummatous processes in the lungs, thyroid,
thyiiiu.s, liver, bones, .adrenals, etc. ; swelling of the
mesenteric lymph glands: osteochondritis; obliterative
changes in blood-vessels, particularly in the umbilical
vc ssels. The changes found in the bones are very char-
aelerislic, particularly those so frequently iiresent in the
zone of ossification of the epiphyseal cartilages. The
long bones should be split longitudinally, the change
277
Neiv-Born.
New-Born,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
being foiiud most often in tlie femur. Inimcnis. and ribs.
lu normal cases lliere is .seen in tlie Iilnisli, op:i(|Ue. rest-
ing- cartilage a layer of proliferating cartilage recogni/.eil
by its bluish-gray transluciait a]>pearance. Tliis is
bounded in turn by a narrow white zone of ossitieation,
which separates the cartilage from the bone by a straight
or convex line. In the so-called osteochondritis of con-
genital syphilis the area of ossitieation is increased, and
the boundary line between it and the cartilage is irregu-
lar. The area of proliferating cartilage is also increased
and may contain tnedullary spaces which appear as red
stripes. Between the zone of ossification and the bone
there is a layer of .soft yellowish granulation tissue rich
in cells. TJn-ee stages may be distinguished; in extreme
cases the epiphyses may be completely separated by the
softening of the yellow layer. Many authors assert that
the so-called syphilitic osteochondritis is pathognomonic
of congenital syphilis. According to Mewis it is found
only in sixty-two per cent, of cases. By other writers
the changes in liver and s|ileen are regariled as the most
characteristic and constant signs of this condition.
J'li/iciriilo.iia. — Though nearly seventy cases arc re-
ported in the literature as instances of congenital tuber-
culosis, in only si.x cases (Sabouraud, Lelunann. Ilonl.
Ustenow, Auche and Chambrclente, and Lyle) is the
diagnosis placed beyond any doubt, by both the liistologi-
<'al and bacteriological findings. The other cases must
be regarded as doubtful or probable, the diagnosis either
not contirmed by the demonstration of tlie presence of
tubercle bacilli, or doubtftd because of the age of the
child, non-exclusion of syphilis, etc. There is, liowever,
no dotdit that in acute miliary tuberculosis, advanced
]iulmonary or genito-uriuarj' tuberculosis of the mother,
tubercle bacilli may pass through the jilacenta into the
fietal circulation, either with or without tlie ju'oduction
of tuberculous changes in the chorion or decidua, and
give rise to characteristic tulierculons lesions in tlu^ fce-
fus. There is also reason to believe that thefu'tal tissues
possess a greater resistance to t!ie tubercle bacillus, so
that tubercle bacilli may be present in the fietal blood
without giving rise to tuberculous lesions. At a later
period the disease may become manifest, so that the pos-
sibility of a latent infection must be considered.
Viiriohi. — It has long been known that in cases of va-
riola oc<'urring during pregnancy the fo'tus may have the
eruption during intra-uteriiie life, or present it at birth
or develop it soon after birth. The transmission to the
child does not, however, occur in all cases of variola;
further, in the case of twins with separate placentas, oni'
fcetus may exhibit the disease, tiie other escape it.
These ]iheiiomena have been explained liy thehj'pothesis
that the disease does not jiass an intact |ilaccnta; in the
case of twins one placenta may admit the infection, the
other not. The stages of the disease in mother and child
do not usually coincide, the f(e1us as a rule aciiuiring the
infection in the stage of suppuration (d' tlie maternal
eruption. The occurrence of variola during the earlier
months of pregnancy usually causes death of the fcetus
and abortion; in the later months the child often sur-
vives.
ScdHntinii. — Since adults rarely suiter from this dis-
ease, there are but few recorded observations (eighteen in
all) of its transmission to the fajtus. The child at birth
may present the eruption. In other cases of scarlatina
«f the mother, the child maybe liorn without showing
the disease.
Mnisles. — The recorded observations of the transmission
-of measles to the fa'tus in utero are very few. In mater-
nal measles during pregnancy the f(etus may or may not
b<' alfeeted.
Tiiph'iid Frirr. — The child usually dies in cases of ma-
ternal typhoid during the early months of ])regnancy,
but may survive in cases which occur in the later mouths.
The typhoid bacilli can traverse the normal as well as
the abnormal placenta. Since the typhoid bacilli jiass
directly into the ftetsil circulation, intrauterine typhoid
is of file nature of a general septicaunia. the classical in-
testinal lesions are not present. Infection of the tVetus
does not, liowever, always occur in maternal typhoid.
Blumer has re])orted an apparent undoubted case of con-
gi-intal tyiihoid, which is of very great importance as in-
dicating a latent infection. The child was born four
and a half inontlis after the recovery of the mother from
typhoid. On the ninth day it died, after having pre-
sented symjitoms of hemorrhages fiom gums and vagina,
jietechial eruption of skin, slight fever, and convtdsions.
The autopsy findings were cloudy swelling of organs,
presence of phagocytic endothelial cells in the heart,
lungs, liver, kidnej'S, adrenals, pancreas, and uterus.
Typhoid bacilli were recovered from the lung, spleen,
umbilical cord, bile, anil large intestine. Alimentary
infection was excluded, the child being breast fed, and
the short period between birth and beginning of symp-
toms made extra-uterine infection very imin'obable. The
case is unique as showing a long period of latency.
Tiijihiix Feivr. — Only one case occurs in the literature
of a prolialile case of intra-utcrine infection with typhus.
The tivi'- to six-months old fcetus showed black, irregu-
lar petecliix and small vesicles over the body. The
spleen was enlarged, the mesenteric glands and Peyer's
patches were swollen.
Reoirrent Feeer. — In a small numlier of cases the trans-
mission of the disease from mother to fix'tus has been ob-
served. Albrecht found the spirillum present in the
lilood of two cases. He regarded it as most probafile
that the spores and not the spirillum passed the pla-
centa.
Mdliditi. — This disease is also sometimes transmitted
to the fretus, which may be prematurely born living or
dead, or come to full term. Moncorvo saw four un-
doubted cases of the transmission of the Plasmodium.
The new-born child may have fever and enlarged spleen.
The autopsy lindings are those characteristic of the dis-
ease, pigmentation, acute congestion of the spleen, etc.
(Jliiilcni. — A small number of observations occurs in
the literature, of cases showing the transmission of the
cholera bacillus to the fcetus. The occurrence of a hem-
oirhagic endometritis in this disease favors the passage
of micro-organisms through the placenta. Death of the
fcetus usually results from the clianges in the placenta
and decidua. The fcetus may show li_ypeRi"inia and
hemorrhages of the internal organs, intestinal inflamma-
tion, etc.
Iiij1iien:i(. — According to Tow-nsend an intra-uterine
infection of this disease occurs.
Piieiiinoniii. — In a few cases the transmission of the
pneuniococcus from the mother to the fo'tus has been
observed.
Ml iiinr/itin. — In two cases the meniugococeus has been
shown to have passed from the mother to the fcetus.
En/ftipilii.<<. — In children born of mothers suffering from
erysipc'las there may be present a desciuamation of the
epidermis. The streptococcus is not iufrec]uently trans-
mitted to the fcetus, the infection being manifested in
a condition of general sepsis rather than of erysipelas.
The so-called erysipelas neonatorum is an affection usu-
ally acciuired during the early days of extra-uterine life.
Sepsis-. — The sta|ihylococcus and the streptococcus are
probably freciuently transmitted from the mother to the
fcetus. tliougli the published observations of such intra-
uterine transmission are not numerous. The cases re-
]iorted as congenital empyema, jdeuritis, j^eritonitis, en-
docarditis, pericarditis, meningitis, abscesses of internal
organs, and certain skin conditions show the frec|uency
of such transmission. The occtirrence of puerjieral sep-
sis in the mother, or of intercurrent pyogenic infectious
gives rise to such transmission ; but in certain cases the
infection of the fcvtus ajipears to be cryptogenic, a per-
fectly healthy mother giving birth to a sick child which
dies "soon after birth, the autopsy findings being a strep-
tococcus pleuritis. peritonitis, etc.
Bncilbis Coli Communis. — This organism is also trans-
mitted from the mother to the fa?tus, producing in the
lattc-r a general sepsis, or a localized infection, such as
]ieritonitis, pleuritis, internal ab.scess. etc.
Pciivtitis Epidemica. — According to Mitller this disease
278
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
\<'\v-Borii,
N e\v-Born.
may lie tninsmitted to the foetus. It is possible, Iiow-
ever, that the case described by Milller was oue of pyo-
genic infection.
Anthrax. — The foetus may be infected in utero, or may
escape the disease. In the fovnier case tlie fwtus may be
still-born, or bo born alive and apparently well, dying
from the disease a few days later.
Leprosy. — A congenital infection is claimed for this
ilisease, but it has not yet been proved.
4. IsTOXiCATioxs. — According to Ahlfeld those poi-
sons are capable of Ijeing transmitted from the mother to
the foetus which occur in tlie maternal blood in the form
of gases or in solution, pi'oviding that such changes have
not been producc-d in the maternal blood as to render dif-
fusion impossible. It is to be noted, however, that even
in those ca.ses in which transmission of poisons from
mother to fa-tus occurs, the effect upon the fu>tus is
often very different from that upon the mother. In the
case of man}' jjoisons, particularly the vegetable alka-
loids, the effect upon the ftetus is of a much less intense
degree. In the ca,se of animal experiments, strychnine
and morphine have been found to affect only slightly the
fffitus, the undeveloped fatal nervous system appearing
to possess a certain insusceptibility to poisons which
have an intense action upon the highly developed ner-
vous system of adidts. In the case of certain mineral
poisons the feet us also appears to possess a relative im-
munity. Inasmuch as the germ cells cannot be regarded
as existing in the reproductive organs of the parents
whollj- independent of the bodily conditions of the.se in-
dividuals, since they must assimilate food from the lymph
and discharge their metabolic jjiodncts, it must follow
that diffusible poisons in the body of either parent must
be absorbed by tlie germ cells and so cause pathological
changes in their protoplasm. This is well shown in the
case of children born of fathers .showing lead poisoning
or alcoholism. It may be taken as a general principle
that intoxications affecting the general metabolism of
either parent are very likely to cause deterioration of the
germ cells.
Ciirbon mono.vide and illuminating gas may cause death
of both mother and ftetus. A number of observations
have been reported in which the mother recovered, but
death of the foetus resulted.
Chloroform passes directl\' into the fretal blood, a few
whilfs given to the mother being evident in the blood
from the umbilical vessels. The fcetus is, however, very
insu.sceptible to chloroform, even in cases of deep and
prolonged ana'sthesia of the mother. If in such Cases
asphyxia of the fcetus occurs, it is probably to be re-
ferred to other conditions of the delivery than to the
chloroform.
Alcohol. — The sexual cells may be affected by the in-
toxication of either parent. The new-born of chronic
alcoholists very frequently show malformations, and
later psychical disturbances. This is particularly the
case in maternal alcoholism during pregnancy.
Chloral liydrate in medicinal doses lias practically no
effect upon the fietus; in chronic ])oisoning of the
mother the effects are similar to those of alcohol. J/w-
lihine in ordinary medicinal doses does not affect the
fcetus, even when given to the mother for some time.
Chronic morphinists may bear healthy children, but these
are very likely to show psychical disturbances in later
life, (jcca.sionally the offspring may show siiins of
chronic morphinism. That the drug jiasses through the
placenta is shown by the action upon the fa'tal heart.
Digitaline and atropine are said to produce marked and
lasting effects upon the foetus. As mentioned above, the
effects produced by stryrhnine am slight. Fatal poison-
ing of the mother may cause the death of the faHus or it
may be born alive prematurely.
Ptornai/is and To.rinf. — That many poisons produced
in the maternal liody by micro-organisms pass through
the placenta into the fo'tal blood and produce pathologi-
cal effects cannot be denied. Xumerous clinical obser-
vations support this view, though the actual demonstra-
tion of such passage has not yet been made. Likewise,
the poisons of certain auto-intoxications of the mother,
nephritis, etc., affect the development of the f(etus.
Mineral Poisons.— The passage of mercury into the
fietus has long been known, and advantage has been
taken of this knowledge in the hopi^ of curing ftetal
syphilis. Chronic mercurial poisoning is well borne by
the fa>tus.
Ledil. — In chronic lead poisoning of the mother death
of the foetus and abortion usually result, although in
some cases the child may be born alive. In this case the
child is under-deve!o]jed and very often dies soon after
birth. In chronic lead poisoning of the father the sper-
matozoa are undoiibtedh' afl'ected, inasmuch as children
fiom such fathers show characteristic changes which
Avithout doubt are to be ascribed to the lead poisoning.
The bones of .he cranium undergo changes in form
which ma}' interfere with delivery. A large proportion
of the children of fathers affected with plumbism die
before term; of the children born alive few pass the age
of puberty.
Phosphorus may cause the death of the fcetus with the
occurrence of fatty degeneration of the liver and multi-
ple ecchymoses as in the phosphorus poisoning of adults.
Arsenic, cupper, and silrer also pass the placenta. Copper
and mercury are said to accumulate in the placenta ; lead
on the other hand does not.
5. DlSE.\SES OF Co.M.MOX OccrnEENCE IN THE NeW-
ISORX, IdIOPATIIIO OU ACQflKED, AFFECTING CERTAIN
Tissues, Organs, or Systems. — Asphy.ria yconatorum. —
The fcetus at birth may exhibit a condition of apna?a and
cyanosis. This may be due to acongenital malformation
of the heart or bl(iod-ves.sels, atelectasis, "white pneu-
monia." catarrhal or croupous pneumonia, liydrothorax,
thoracic tumor, congenital struma, or disturbances of the
circulatory and respiratory centres. In normal births the
respiratory centres are stimulated by the increase of car-
bonic acid and decrease of oxygen in the blood, in addi-
tion to certain external stimuli. As a result of such
stimulation respiration is inaugurated. If placental in-
terchange is rendered ditlicult or impossible through the
compression of the umbilical vessels or prolonged uterine
contractions, there may occur intra-uterine respiratory
movemeutsof dyspna'ic character. As aresult the lungs
become tilled >vith amniotic fluid and asphyxia follows.
Asphyxia may also be produced liy the occurrence of
rapidly succeeding uterine contractions. Dyspnceic
movements are not produced, but from the rapidly in-
creasing veno.sity of the blood there results a paralysis
of the respiratory centre. The cessation of placental
circulation through birth of the child is therefore not fol-
lowed by respiratory activity.
Albiiininiiria Seematorurn. — According to Virchow,
Dohrn, Hofmeier, and many other writers the urine of
new-born children almost always contains a varying
amount of albumin, hyaline casts, and epithelium. vSuch
limlings have been associated with the uric acid infarct.
They cannot be regarded as pathological as they are
found in wholly healthy children. The albumin usually
disappears after from eight to ten days. The cause is not
known but is referrecf to the increased metabolism after
birth, imperfect formation of glomeruli, changes in blood
]iressure and in the character of the blood. The pressure
in the renal arteries is increased after birth. This fact
may explain the albuminuria and the clesc|uamation of
ciMthelium. Pathological alboininnria occurs in rare
cases of congenital iie|ihritis. The amount of albumin
is always greater than that found physicilogically.
Anasarca yeonntoram. — This condition may be found
in cases of .still-birth in association with hydatid mole.
The a>dema of the foetus may depend upon a maternal
dropsy, obstruction of the umbilical veins, malformations
or disease of thefcetal heart, absence of the thoracic duct,
fa-tal nephritis, syphilis, adcma of the jilacenta due to
syphilis, leukjomia, etc. Fcetal anasarca is often asso-
ciated with hydraniniiin. In some cases the skin of the
fo'tus shows an elephantiasis-like thickening. In the
majority of cases of fcetal anasarca the child is still-born;
in those cases in which it survives birth the increased
279
Tfow-Borii.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCIES.
size of the fa?tal body may rciidiT delivery more difficult.
(See also ffidema iieonatoruiii, in article on (Jidfiim.)
Fatty Der/eiier/il/i/ii <//' tlic yiir-linni. — Acute fatly de-
generation of the liver, heart, etc., of the new-horn is not
infi'e(|iient. It is explained liy decrea.scd o.\yi;cnati(in
and increased metabolism of alhunnn deiiendins upon
any of the cau.ses leading to asjihy.xia, also infections
and iuto.vications. Fatty infiltration of tlie liver is often
as.sociated with fatty degeneration of this organ. Tlie
condition occurs most frec|uently in cachectic and poorly
nourished new-born suffering from circulatory or respira-
tor}' weakness,
Giiiif/nvna NeoiiKtfiDim. — Symmetrical gangrene may
occur in congenital syiihilis. Further, symmetrical, dif-
fusely spreading, or localized gangrene (noma) occurs in
the new-born as the result of certain infections, dijih-
thcria, measles, etc. A variety of organisms have been
found in these cases.
(Junoi-r/iiva yeniintoruiii. — The new-born is very fre-
quentlv infecteil with the gonococcus during birth. An
intra-ulerine iid'ection may also occur. Usually the con-
junctiva, vulva, vagina, and urethra are involved, liut
there may occur also gonorrlueal jieritonitis, pleuritis,
pericarditis, enilocarditis, meningitis, arthritis, etc. It is
very probable that the majority of the eases of iieritouitis
occurring in the new-born female are of gonorrho-al ori-
gin. The presence of a coincident vulvitis orophthalnua
favors strongly the gouorrhu-al origin of the peritonitis.
(See also Oniinri-liieii.)
Ill iiiiirrhiine uf tlie JScw-bdrn. VmhUlcal Ilcmorrhnric. —
Hemorrhage from the cord may occur at birth, either from
laceration, from disease of tlie ves,scls, or fi'om imperfect
ligation. Fatal hemorrhage may occur from injuries to
the cord before or during bii'th. In other cases of more
rare occurrence there may lake place a constant oozing
from the umbilicus itself or from the properly ligated
stump. Such hemorrhage is most likely to occur be-
tween the fifth and fifteenth days. The children atfected
are usuall.v cachectic or under-developed. Congenital
ha'mophilia, syphilis, abnormal composition of the blood,
imperfect coagulability, failure of the normal retrogres-
sive changes in the undjilical vessels so that these remain
distended and patulous, vascular ectasis, etc., are causes
adduced. In some cases no adequate cause can be dis-
covered. Cachectic conditions of the mother are re-
garded as ]iredisposin,g causes.
IIa'ii)ittiiiii:ii.i mid Mcliviia Neonntnnim. — Hemorrhage
from the gastrointestinal tract occurs occasionally in the
new-born without other appreciable .symptoms, and has
therefore been regarded as an essential pathological con-
dition. IlaMiiophilia, syphilis, congestion of the gastro-
intestinal tract, idceratioiis of stomacli or intestines, in-
fection, elc. are the chief causes adduced. According
to von Preuschen mehena neonatorum is secondary to the
occurrence of cerelual la morrhage resulting from deliv-
ery. It is known tliat under other conditions certain dis-
eases of the brain give rise to secondiuy hi'inorrhages in
the stomach and inli'stiue.
llminrrhiiije af luln nnh is of relatively fre(pient occur-
rence in the new-born. The cause is not clear, but trau-
matism during birth, thrombci.sis of the adrenal vessels,
infection, and marasmus are supposed causes.
lliiaorrharje I'litu the kidiui/ may result from thrombosis
of renal vessels.
Hi/drorep/ialiis jS'cnniifunim. — Congenital hydrocepha-
lus is an accumulation of fluid within the ventricles of the
brain. The cranial bones, not lieing united, yield to the
internal pressure and are separated, the fnmtal, parietal,
and occipital bones become expanded and thiime<l. The
cerebral convolutions become flattened, tlii' lieniispheres
finally being spread in thin lamiuie on either side, the
thieknessof the brain substance decreasing from the base
to the vertex. The memln-anes usually become thickened.
The head becomes greatly enlarged, soft, and fluctuating.
The cause is not clear; the condition by some being re-
garded as an inflammatory process of the arachnoid, by
others as due to stasis, caused by obstruction of the vein's
of Galen or of the sinuses. (See Ilydroceplinliis.)
Jctenis Neonntoriim. — A slight degree of yellowish
color is of such freciuent occurrence in the skin of the
new-born that it nuist be regarded as physiological. In
strict usage the term icterus neonatorum should be ap-
jilied to this condition alone. According to Frerichsthe
icterus is due to a fall of ju'essure in the liver capillaries,
thus favoring the entrance of bile into the blood. By
others the condition is explained as due to the excessive
destruction of red blood cells and an increased production
of bilirubin which is ab.sorbed. The dilatation of the
blood-vessels may c.-iuse obstruction of the bile capilla-
ries. According to IJirch-Hiischlrld the jaundice is due
to compression of the biliary capillaries by the dilated
vessels in Glisson's capsule. As a result of the venovis
congestion the connective tissue of the capsule becomes
O'dematous, this also aiding in the compression of the
vessels. According to Ziegler tlie icterus is caused by
resorption of the bile pigment not only in the liver, but
also from the niecoidum which is bsorlied and carried
back to the liver. The |)liysiological icterus neonatorum
is characterized by a diffuse yellowish jiigmentation of
the tissues and a deposit of bilirubin in various organs
and tissues, especially in the kidnej'S.
Pathological icterus of the new-born may be caused by
sepsis (in the maj<irity of cases), syphilis, malformations
of the biliary passages, new formation of connective tis-
sue about the bile ducts, patency of the ductus venosus,
acute hepatitis, etc.
Mjiotoiiiii JW'niHi torn III. — In the early weeks of life the
child may be aft'ected by per.sistent, painless, muscular
spasms without increased excitability of the muscles or
nerves. In this respect it is distinguished from tetanus,
for which it is often mistaken. It is to be regarded as
an exaggeration of the phj-siological hyiiertcmia of the
new-born (p.seudotetanus). The anatomical basis con-
sists of degenerative changes in the anterior roots and
cells of the anterior horns; the exciting causes are gas-
tro-iutestinal disturbances, congenital syphilis, etc.
Oji/it/irilini'a A'eoiiiit'irym. — Catarrhal or purulent con-
junctivitis is of frequent occurrence in the new-horn.
The great majority of casesare of gonorrhceal origin, but
it must lie borne in mind that other organisms (strepto-
coccus, staphylococcus, etc.) may also cause the disease,
as well as the use of too strong antiseptic solutions. (See
Ci'iijiiiirtirii, Ajfii'tiiiiis of.)
Pciiijdiii/iis Aiiuiiitoniiii. — The condition of the skin
characterized by the formation of blebs or bulUe in the
e]iiilermis occurs in a great variety of forms, and its
pathology has been variously described. The etiology
of the all'ection is not clear. Some of the cases described
under this liead are of sy])hilitic origin, others are due to
an infection \\ ith thestie|itocoecus. The form described
as pi iiiji/iif/iis iiriitiix ciiiifiii/iii.yiix iiconatonnii is prnliably a
distinct disease of bacterial origin. In c<'rtain congenital
eases there ajipeared on the second day a gcaieral pem-
]ihigus eruption over the palms, soles, and mucous mem-
branes, the fluid ofthebulke being at first clear, later be-
coming slightly bloody. Bacteriological examinations
have been negative; s\'iiliilis and all ordinary causes of
liemphigus being excluded, the condition is regarded as
due to an iutra-uterine intoxication. (See Pemph/.r/us.)
Piii'iiniDiiiii. — Catarrhal pneumonia occurs ver_y fre-
quentl}' in the first few days of life. In the case of ju-e-
mature births over forty per cent, of the deaths ai'e ilue
to this condition. In eighty per cent, of cases born at
term the infant is poorly develojicd, with congenital
weakness of the respiratory tract. The so-called " white
pneumonia" is due to congenital syphilis. Pneumococ-
cus ])neine.onia may be acquired during intrauterine life
as well as in the first wei'ks of extra-uterine life.
Uiifhitix. — Congenital rickets is rare. Its etiology is
not clear. The condition is associated with hydramnion
and hydrocephalus. Premature birth usually takes place.
Congenital rickets presents a ]iath<dogieal picture similar
to that of extra-uterine rachitis. Two forms of fre'tal
rickets are described, rm-ln'ti.i iirieroiiuiicii and rachitis aii-
iiiitiui.i. The true rachitic process is to be distinguished
from the disease of the primordial cartilages, the so-called
280
I{EFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Ne«'-Born,
New Jflcxico.
ehondnxlyiitrophiiifi-ctaUs, wliich is assofiatiil wiih c niiii-
isni. (Sec Rachitis.)
Sepsis Seunatorum. — Se])sis of the iicw-boni is one of
tlie most, frequent and important conditions of tliis period
of life. Tlie streptococcus, stapliylococcus, pneuniococ-
cus, bacillus coli communis, typhoid bacillus, j^onococcus,
etc. , are the c-xcitiug causes. The organism may be trans-
mitted from the motlier during intra-utcrinc life, or ac-
quired through injury received during delivery, through
in feel ion of such wounds after birth, or through the stump
of tlic umbilical cord. The latter mode of infection is very
common. Cryptogenic infection may occur. The skin
of the new-born possesses much less resistance to the en-
trance of micro-organisms than the skin of adults; the
primary seat of infection in infants often being a small
localized purulent process in the skin, of relatively slight
importance.
SIniiiKi Cnririenitn. — The condition of congenital en-
largement of tlie thyroid is regarded partl.y as inherited
from mother or father, partly as an idiopathic or endemic
disease. The thyroid may present a simple hyjierplasia
or cyst formati<ni. Deliver}' may be rendered difficult.
The infant may die after birth from the result of com-
pression of the trachea. The condition is of relatively
frequent occurrence in the Tyrol.
Uric-nrid Infarction. — In the kidneys of the new-born
infant there is almost always present an acciunulation of
urates which appears as glistening, golden, or yellowish-
red lines converging toward the papilhe of the pyramids.
The urine in the pelvis of the kidnej'S also contains an
abundance of urates. Microscopically the collecting tu-
bules are found to be filled with dark granular masses
which on the addition of acetic acid dissolve, uric acid
crystallizing out. An albuminous framework is usually
left behind. This condition is termed uric-aiid infarction.
It is most marked after the scconcl or third day, but may
be present up to the seveuty-sixth day. It usually dis-
appears jiromptly, but if persistent may lead to irritation
of the kidney and nephritis. It was formerly Ijclieved
that such infarctions occurred only in children breathing
after birth, but it lias been shown that they are found
also in still-born children. The cause is not known.
Changes in metabolism following birth, defective o.xida-
ti<in, inability of the urine of the new-born to dissolve
the acid, are among the causes adduced in explanation of
the phenomenon.
Tetanus Neonatorum. — Tetanus is one of the earliest
and most fatal diseases of the new-born, occurring with
greater frequency in the first and second weeks of life
than at any other age. The infection occurs through
wounds received during delivery or through the stump
of the cord. The favoring conditions are; uncleanlincss,
atmospheric and climatic conditions, primary pyogenic
infection, etc. In nearly every case evidences of inflam-
mation and suppuration are found in the lunbilical ves-
sels.
Thromhosis. — Thrombosis of the adrenal, renal, or s\tv\-
matic veins may occur in the new-born. Hemorrhage
(so-called hemorrhagic infarction) of the adrenal or kid-
ney may result, and in the male infant gangrene of the
testicle and scrotum. Such thrombosis may Ije the result
of traumatism during delivery or septic infection. In
anaemic and cachectic infants there may occur marantic
thrombosis, affecting most frequently the left renal ar-
tery. Hemorrhage and necrosis of the kidney result.
Sclerema Neonatorum. — See (Edema neonatorum, under
(Edema.
6. New Growths. — The most common forms of new
growths affecting the new-bom are the congenital. /ji/v;-
mata, neurofibromata, angiomata, and h/mpliangiomata.
Birth-marks, vascular, pigmented and hairy na;vi, moles,
warts, etc., belong to this class. Special forms of lym-
phangiomatous tumors occur in the tongue, lips, and
neck (macroglossia, macroclteilia . hygroma colli conge/ii-
tuin). Eh'phantiasis-lihe growths may occur locally or
form diffuse thickenings in certain regions. Lipomula
of the neck, back, and axillary spaces are not rare.
Coiif/enital teratoma, representing either a monoger-
minal or bigerminal inclusion, are relatively fre(|uent.
They may be found in any jnirt of the body, but are es-
pecially common on the liead, in the mediastinum, kid-
neys, ovaries, and testicles. Congenital rhaMumi/oi/utta
of the heart, kiduev, etc., are to be placed in this chiss.
The most frequent malignant tumor of the new-born is
the so-called embryonal adenosarconia of the kidneys {mixed
sarcoma). Such growths are most probablj' derived from
inclusions of the myotome and are to be classed with the
teratomata (malignant tcmtomata). The most common
epithelial tumors occurring in the new-born a.re papillo-
matous growths of the larynx, and cystic tumors of the
kidneys, liver, and ovary. Adenomata of the adrenals
and kidneys have been described. Carcinoma has also
been found in the new-born in a number of cases (carci-
noma of the liver, kidneys, stomach, and intestine).
Cases have been reported by Jacobi, Wedl, Brown,
Priedrich, Ritter, and others. Cystic tumors of the pi-
neal gland, cholesteatomata, dermoid cysts, and terato-
mata of the brain and meninges have been described.
Aldred Scott Warthin.
NEW MEXICO.— New Me.xico has climatically the
same features as Colorado, and in a less degree those of
Arizona. The State runs from the Raton range, which
divides it from Colorado, for 890 miles south, to the
bouudarv line of old Mexico. On the west is the main
range of the Rocky Mountains or backbone of the conti-
nent, separating it fiom the State of Arizona. Its east-
ern boundary ranges with the great State of Texas. New
Mexico is for the most part a high ]ilateau rising to 7.000
feet at Santa Fe and dropjiing to 3,500 feet in the- lower
Pecos valley. The general tendency of this high plateau
is to drop from the northwest corner toward the south-
east. As it is on tlie leeward side of the main range, the
winds from the Pacific Ocean are dried for the most part
before reaching it, so that there is very little winter rain
and only a light snowfall. What rain there is falls, as it
docs in Colorado, principally during the months of July
and August, and New Mexico iloes not have the well-
marked double rainy season of Arizona. The winter
precipitation falls usually between January 1st and April
1st, though in the Pecos valley region this period is
somewhat extended and the rainfall is heavier than the
average for the State. The winter rains or snowstorms
are marked by almost parallel curves of from one to
seven inches of precipitation. These curves are outside
the mountain lines, where, of course, the precipitation is
greater. They are caused by the diffuse or diverting
influence of topography on the aqueous currents borne
to New Mexico from the south Pacific Ocean across
Arizona. "The summer rains," writes Captain Glass-
ford, "are otherwise influenced, and the higher precipita-
tions appear upon the levels west of the Canadian River
and upon the Canon course of the Pecos, which includes
Las Vegas and Fort Union. At this point the fall reaches
seventeen inches. The lowest summer precipitation is
found in sections most favorably influenced by the win-
ter rains. The minimum is found in the southwest."
It is very much to be regretted that, in spite of the
climate being the chief attraction of New Mexico to the
travelling invalid, it is almost impossible to get full and
accurate meteorological data concerning the various re-
sorts, and the observations that are reported are usually
for only a very short period, and the humidit j' and wind
have very seldom been recorded. IMany have written in
general terms of the fine climate, but have failed to give
the facts about the local topography, aspect, and soil of
the towns. LTnfortunately for health jiurposes, on the
lower elevations the towns are usually situated upon an
adobe soil in the river bottoms. However, the literature
being such as it is, we will proceed to discuss the more
important places availaVile for health seekers.
In travelling by railway from Colorado into New
Jlexico, as the descent is made on the southern slope of
the Raton range, one notices that tlx' air is warmer and
the sunshine more brilliant. However, the elevated
towns in the northern portion of New Mexico arc very
281
Ne^v Mexico,
New Mexico.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
similar in climate to those of Colorado, although they
are somewhat higher in elevation. I^as V<'gas (6,.500
feet) and Santa Fe (7,000 feet) closely resemljle Denver
in temperature, while Silver City in tlie soulhuest, stand-
FiG. 35.S11.— View of the Montezuma and Hath-tiouses. Las Vegas Hot Springs, New Mexico.
ing at an elevation of .5.800 feet, has a markedly milder
climate, which is partly accounted for by its admirable
shelter from severe winds.
The annual average precipitation for the State is 13
inches, ranging from .5 inches at Deming to .^3 inches at
Chania, while the average of 13 inches does not include
wliat falls upon the mountain summits, which is probably
(Inulile this amoimt.
Tlie annual mean relative humidity approaches 40
per cent, with an annual temperature of GO per cent. ;
the absolute humidity is 3.3 graius, a little more than
that of Colorado, which the higher temperature accounts
for.
In the elevated northern jjortions of the State the
annual wind movement is about the same as that of Colo-
rado, but it is markedly less iu the southern and lower
portions.
Ve.getation is sparse throughout the State, as irrigation
has been very little carried out. The soil generally is
of the jieculiarclay whicli is known as adobe. This does
not reatlily absorb the moisture, but when baked in the
hot sun gives rise to a very tine dust. The treeless char-
acter of the must part of the plateaux and valle.vs com-
bined with the adolie dust, which is light and volatile in
character, maki's the dust storms in this country jiecul-
iarly disagreeal)le.
Charles F. Lunuuis, iu his delightful book upon New
Mexico, which he calls "The Land of Poco Tiempo,"
summarizes the country in this sentence, " Sun. silence,
and adobe." He laments, as all visitors to New Mexico
must, the absence of large and well-eciuipped cities, and
the general .scarcity of the resources of civilization. All
this, however, is rapidly inipniving each year. Good
soft water, gravel soil, and good and well-cooked food
are scarce, but the climate is superb. Above the thirty-
tiftli parallel of latitude the climate resembles that of
Colorado, but is somewhat milder in the winter and
warmer iu the summer. Below this latitude the winters
are markedly milder. Those for whom the more bracing
climates of "the northern latitudes are not desirable, and
who also ni'cd a somewhat lower elevation, can find in
New ^Mexicciulmcist unrivalled climatestor tlieirpurpose.
The summer heat, however, begins to be felt early in
April, and .seems to gather force well into October.'but
for those who can stand a rough camping life the sum-
mer climate of the mountains is delightful.
On the southern slopes of the Raton range is a fine
282
farming country with a gocd all-the-year-round climate.
The air is dry, i)ut the soil is adobe, and there is consid-
erable irrigation carried on. There are no towns of any
importance, but for those convalescent invalids who can
carry on farming
and cattle raising
it is a good coun-
try. Throughout
this district the
rainfall and hu-
midity are higher,
and the tempera-
ture lower than
the}' are in the
country lying far-
ther soutii.
Raton is a small
town on the main
line of the Santa
Fe just over the
Colorado boi'der.
It stands at an
altitude of 6.600
feet and has 4,000
inhabitants. It
faces south and
east with the Ra-
ton range behind
it. It has an at-
tractive country
arovmd it, and
there are several small hotels and boarding houses where
the rates are from $:2.5 to S30 per month for board and
room.
A few miles farther south and lower down lie Maxwell
City and Springer, both of them small villages where
cheap accounuodations can be found in the town or
among the farmers of the neighborliood.
Las Vegas, elevation 0,384 feet, population 8.000, of
which perhaps half are Mexicans and Indians. It is
somewhat exjiosed to north winds, and lying in the val-
ley with an adobe soil, is hot and dusty in summer. It
is generally warm and pleasant during the winter. The
average mean temperature in winter is 40° : spring .5.5°,
summer 80 \ autumn 00' F. The rainfall averages twenty
inches, of wiiich a large half falls during April and
August. The Atchi.son. Topeka and Santa F6 Railroad
has recently built a very handsomeand comfortable hotel
and eating-house, where the famous Ilarve}' catering can
be enjoyed, but accommodations at a more moderate price
can be obtained in the town, and there is a good sani-
tariinn in charge of the Sisters of Charity.
Las Vegas Hot Springs, elevation 7,000 feet, is reached
by a stub railway running .seven miles from the town of
Las Vegas up into the western hills. Here is an excel-
lent hotel, The jMontezuma, with a few other smaller
buildings and some good bath-houses. The Montezuma
is situated on the edge of the canon facing south, and is
well sheltereil from the winds. Las Vegas Hot Springs
has a delightful winter climate, for the most ]iart warm
and dry. It is reasonably cool in sunmier. Tlie sjirings
are both hot and cold. The hot water has a temperature
of 144° F. Tlie mineralization of the springs is alkaline
and small in amount. Tlu'y are not \'ery jioteut waters,
but the bathing is good, and there are some excellent
mud liatlis whicli have been found valuable for rheuma-
tism ami allied disorders.
Santa Fe is reached in a similar manner from the main
line of the Atchison. Topeka and Santa Fe Railroad.
It is one of the oldest and most interesting of the towns
of New Mexico. It retains the character of a Slexican
town, which is an outgrowth of the old Indian pueblo.
It has many qu,-iiut features and buildings to interest
visitors. The chief hotel is a fairly good wooden struct-
ure, but is usually inditlerently kept ; but there is a
sanatorium well managed by the Sisters of Charity.
"Tlie town lies on a treeless plateau at the base of one
of the spurs of the Rocky Mountains. The general trend
REFERENCE HANDBOOK OF THE l^IEDICAL SCIENCES.
IVcAv Mexico,
Now Iflcxico.
of the site is west-southwest, the mountains affording
protection to tlie north and east. Within thirty miles
are peaks of 12,000 and 13,000 feet elevation. The low-
hills are covered with a growth of pinon trees. The
town has of late improved its water supply, but much is
yet to be desired in the matter of drainage, and there are
"few shade trees. The soil is liglit and sandy. The cli-
mate is not very different from that of Denver. It is
somewhat cooler in summer, not quite so cold in winter,
and a little less windy throughout the year." *
The climate is very similar to that of Las Vegas Hot
Springs, but being less sheltered, is somewhat more
bracing, though also more windy.
Continuing the journey southward on the Atchison,
Topeka and Santa Fe Railroad, the traveller crosses the
lower end of the upper Pecos valley between San Maguel
and Glorieta. This is a beautiful upland valley twenty-
five miles north of the Glorieta >Iountaius through which
are scattered stock ranches and small farms. If is a
well-timbered, park-like district surrounded In' moim-
tains. It has a fine climate and good soft water. There
are capital hunting and lishing, and much of the coun-
try still remains wild, there being a timber reservation
covering 702 square miles.
Albuquerque, elevation 5,000 feet, population 10,000, is
situated in the valley of the Rio Grande, and it is here that
the main line of the Santa Fe Railroad Joins its western
division along which flows the travel to California. The
Atchison, Topeka and Santa Fe Railroad Companj' have
built a handsome and commodious hotel and eating-house
similar to that at Las Vegas, where the best food is served.
The old town, which lies near the river bed, is not very
desirable for residence, but the newer part of the town
on the bench above it is well situated. It is a live, mod-
ern city with fairly good accommodations. It has a good
climate, though it is somewhat too windy in winter and
too hot in summer.
Demiug, elevation 4,300 feet, population 3,500, stands
on a plain, just about fifty miles square, surrounded by
mountains. It has a mild climate, it never freezes during
the day in winter, the mean seasonal temperature being":
winter 44% spring 63% summer 87% autumn 64° F. The
wind record has not been kept, but during the spring
the winds are said to be quite high. The precipitation is
8.8 inches, the greater part of the rain falling in the
summer. Accommodations are good.
Silver City is situated on an elevated plateau in the
Chichuachua val-
ley south of the
Pinos Altos Hills.
The soil is sandy,
the rock forma-
tion con.sisting
chiefly of slate and
limestone. It is
at the end of a
branch line of the
Santa Fe Rail-
road, fort_v-eight
miles from Dem-
ing and about ten
and o n e - Jj a 1 f
hours b_v railway
from El Paso.
Foot-hills several
hundred feet in
height surround it
except toward the
south, while a few
miles farther back
are mountains
several thou.sand
feet in height. In
this waj' it enjoys
excellent shelter from winds. No wind record is obtain-
able, but evidence tends to show that the wind movement
* Solly's "Handbook of Climatology."
is moderate. The mean temperature for January is 37°,
for July 72', and for the year 54° F. In ten yea'rs there
have been only six days in which the temperature fell
below 10% and" onl_v twenty-two days when it rose above
90' F. The average annual precipitation is 14.58 inches,
of which as much as 8. 11 inches must usually be credited
to the months of July, August, and Sepember. The aver-
age number of cloudy daj'S is 37. The average relative
humidity is 46 per cent. The absolute humidity is 1.71
grains ; dew point 29. The water is pure, but rather hard.
Silver City lies in the .same latitude as Savannah, Ga.,
but owing to its elevation is, of course, nuich cooler and
dryer. There are four hotels of moderate excellence, and
there is a good Situatorium kept liy the Sisters of ilercy.
The country around, particularly among the pines, lends
itself to a delightful camping life.
Nine miles to the north, at an altitude of 6.040 feet, is
Fort Bayard. The old army fort has been converted into
a general government hospital for the treatment of pul-
monary tuberculosis. It is now in the third year of its
existence. Major D. M. Appel, M.D., surgeon in com-
mand, writes under date of June, 1901, as follows:
"The selection of Fort Bayard as a site for a sanato-
rium for the treatment of pulmonary tuberculosis has
been amply justitied by our results. Its location in the
arid mountainous region of southern New 3Iexico, at an
altitude of 6.040 feet, alfords a climate permitting com-
fortable outdoor life during the entire year. The mean
maximum and minimum temperatures and the precipi-
tation for the past decade are as follows " :
Month.
January
Eebruary
March
April
May
June
July
.August
September
October
November
December
General average
Mean
maximmn.
Degrees Fahr.
13
.52 -h
«
4.5
91 +
32-1-
97
■■u
29
20
I
69.56°
Mean
minimum.
Degrees Fahr.
2:3.15°
25.83 -1-
3(1.93 +
37.10
45.45 +
.52.68
55.34
56.98
52.09
41.30
31.90
24.66
.39.79°
Precipitation.
Inches.
1891, 19.30
1893, 8.89
1893. 15.47
1894, 9.12
1895, 15.09
1896, 18.85
1897, 18.00
1898, 15.91
1899, 10.43
1900, 12.66
Fig. 3390.— Meadows near Las Cruces, Kew Mexico.
The statistics of the results obtained up to the present
time contirm the general favorable opinion of the ex-
ceptional value of sanatorium treatment at high alti-
tudes.
2S3
UKFEKEXCK UA.NDIJOdK OF THE MEIMCAL ^^IIENCES.
Las Cruces, elevation :i,S73 feet, populaliou 3,500.
This little town is situated on the Old >le.\icaii division
of the Santa Fe Kailroad, forty-tliree niil<'s nortii of El
Paso. It lies in the Mesilla valley, whieh is a portion of
the Rio Granile valley. At this point the valley is wide
and fnulfiil under irrination, tlieie being large fields id'
alfalfa. The water is jiure, but somewhat alkaline.
There are moderately good aeeommodations in the town,
but more suitable ones for the invalids are found in the
ranches arounil, particularly at the Alameda, which is a
mile distanl.
The Organ Mountains are twelve miles cast, rising to
a height of .S,<j4!» feet. The winter climate is delightful
aii<l continues |de;isant until Ainil. when the heat be-
comes too great for thecond'orl of Eastern visitors. The
mean ma.xiinum temperature is, as com|iuted for the three
years, 189(1 to t>S9!): autunm, 78' ; winter, 'yS' ; spring 7(i' ;
summer, 92 F, The mean minimum tem])erature is; an-
tiuim, 4r : winter, 23' ; spring. 41' ; suimuer, 00 F. The
average annual rainfall for the last twenty years was
only eight inches. The nundier <if cloudy daj's for tlie
year is twenty-tive. In the winter the average is foiu'
cloudy days a month. The average wind movement is
believed to be about five and fmedialf nules an hour.
The Alameda can accommodate forty guests. The
rooms .are of good size, and there are plenty of porches.
The rates are from §10 to .S1.5 per week. Fifteen miles
east of Las Crnces Van Patten's resort stands in a vallev
of the Organ Mountains at an altitude of 0,000 feet
Here there is a substantial stone house which can accom-
modate twenty-tive ])crsons, and it. is surrounded liy
tents, and is a cool and jileasant ])laee in which to pass
tlie summer.
Pcfo.i Viilley. — Sejiaraled from the Rio Grande \alley
by high mountains is tlie Pecos valley region lying to
the east; it eomiufses a wide belt of land rumiing
(Southward for a ilistanee of one hundred and .seventy
miles from Roswell to Pecos Cit\'. Here irrigation is
extensively carried on, and it is a good ]ilace for those
who have sulliciently recovered their health to carry on
farming or stock-raising. The acconnnodations in the
hotels and boarding-houses are, however, not very good,
and the valley is rather too hot in snnuncrand too windy,
particularly in the spring, to make it desirable for most
invalids. Roswell, at the northern end id' the valley, is
rallnr better sheltered than the town of Carlsbad. The
elevation of the valley varies from 4.000 to 3.000 feet.
At Carlsbad the mean temperature for a\ituinn is 0:r,
winter 44 , spring 03, sununer 79 F.
.S'. Kdiriii Silllj.
NEW ORLEANS, LOUISIANA.— This great Southern
city and port is situated upon .i double curve of the Mis-
si.ssip]ii River, one hundred and seven miles from its
uiouth, although a much less distance from the coast in
a stiaight line. The city lies chielly upon the left bank
of the river, and actually covers about forty square miles,
although the city limits embrace an area of something
like one hundred and eighty square miles. One of the
peculiarities of this city, and one that is doubtless con-
ducive to its healthfulness, is the great area which it
covers, thus permitting liberal air spaces and grounds
about the buildings in the residential districts. The city
is built upon low land, lower than the surface of the
river at high-water mark, and huge endiankmeids of
earth called " levees " are required to jirevent an overtlow,
and even these are occasionally broken through. The
soil is of an alluvial nature, and by digging from three
to four feet one (isually reaches water; lience the liouses
have no cellars, and the dead have to lie buried in tondis
eli-vated above the ground.
There are a large number nf bodies of sv;iter — lakes,
bayous, swamps, and the like — about the city, and to the
nortli of the city is Lake Poiitchaitrain. forty miles long
and twenty-four nules wide. This lake is connecti-d with
the Gulf of Mexico, and forms with the Jlississippi River
an i.stbmus upon which the city is built. The popida-
tion at the census of 1900 was 387,104, coniposcd of
Creoles, Americans, and negroes. It is obvious, from
the low. level situation of the city, that the problem of
drainage is a ditlicult one; this is partially accomplished
by gutters which run into open canals, and these in turn
emjity with a sluggish cunent into Lake Pontchartrain.
A comprehensive system of sewerage, which will elfect-
ually iIis]iose of the house waste and other sewerage and
cause it to be discharged into the river below the city, is
said to be now under construction. The drinking-water
is generally obtained from the rain, stored in tanks or
cisterns, each bouse being provided with such a recep-
tacle, which is a peculiar feature of the architecture.
For other purposes the water of the Mississippi River is
used, this being taken directly from the river without
tiltratiou.
The city itself and its surroimdiiigs are very attractive,
especially to a Northerner. The vegetation is of a semi-
tropical nature and very luxuriant. The variety of races
ami the cianmon use of the French language, the streets,
markets, cemeteries, parks, and various points of historic
interest, and the extensive wliarves with the vast amount
of inland and foreign shi|q:iing, all alford interest and
diversion. The French market is the great " sight " of
New Orleans, anil is best visited in the early morning.
The accoininodations are good, the principal liotel
being the comparatively new St. Charles, occupying an
entire sfjuare in the heart of the city. A favorite winter
excursion is to New- Orleans at the time of the famous
"Marili Gras," which is ,said to be more brilliant than the
carnival at Nice or Rome.
The mortality of the city is about 27.. 58 per 1,000. The
following meteorological table gives the principal char-
acteristics of the climate of New Orleans;
I'l.iM.iTE OF New Ori.eaxs, Lx. Latitcde, 29° .58' ; LONGiTtJDE,
SO" -t'. PERIOD OF Observation, Thirteen Years.
.tan.
Mar.
June.
Aug.
Nov.
Tear.
Temperature—
Aveniffe mean tempeni-
ture ornormat Ideirree.s
.5t 7°
ti3 1°
61.0°
13.1
69.8°
Averarre ranpe
13.9
15 (1
12.4
12.1
Mean of wanite.st
61.2
71.7
87.2
88.1
67.8
Mean of eolilest
■t7.;i
.50.7
74.8
76
.54.7
Hiyliest or liia.xiniuiM
78
84
97
96.5
82
Lowest or ininiiiiuiii
20
36.5
65
69
31.5
Humiililv-
Avera^e iiiean relative. . .
72. 2S
7(K
72.3«
73j;
71.6!5
n.H
Prei'ipltatioii
Average in inclies
5.52
5.75
6.04
5.99
5.58
64.63
Wintl-
Prevailine (tirertion N.
S. E.
S. E.
S. E.
N.
S. E.
Average hourly velocliy
ID miles ' 7.H
8.6
6
5.5
8
7.4
Weather -
Aveniire numl>er ot elear
days 7.6
1(1.1
8
7.8
9.5
110.5
Averase numliei' of f.-iir,
days 12.:;
10,6
16
18.4
III. 2
150. 4
.\veraffe minitier of fair
and clear days ,19.,s
20.7
24
26.2
19.7
266.9
It will be .seen thai the climate is tropical or semitrop-
iciil in nature, warm and moderately moist. The mean
temperature of the year is 69.8° F. The highest average
summer temperature is94°F., and the lowest average
winter temperature is 27' F. On February 13th, 1899,
an extraordinary and unheard-of event occurred, in the
formation of ice at the mouth of the Mississippi River,
the thermometer indicating a temperature of 10' F. On
the 17th of the same month ice Unwed past New Orleans
into the Gulf of Mexico.*
Snow is a rare phenomenon, but cold waves occasinu-
ally occur, accomjianied by fiost. whieh nips the sugar
cane and cotton )daut.
The annual rainfall varies from 31 to 64 inches, the
spring and sununer being the I'ainiest seasons. The aver-
age mean relative humidity is 71.4 per cent., about the
same as that of New York City.
♦"The Oold Wave ot Felirnary, 1899." Guy Hinsdale, Transactioa'
of the American Climatological Association, 1899.
284
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
l\c\v 4>i'IcaiiN.
ISt'M I>o|-(,
Acoording to Hinsdale (" Climatology, Health Resorts."
vol. iv.. part ii., of "Pliysiologieal Therapeutics'') there
is abovit si.\tv-t\vo per cent, of possilile siiiishiiie. Such
a climate is more or less enervating, hut in itself not un-
healthy. A strict quarantine is exercised against the im-
portation of jx'llow fever, of which several epidemics
liave in former years occurred. The amoimt of water
al)out the city would apijear to be favorable for the
piopagation of the mosquito, and hence malaria must be
frequent.
Thei-e are several resorts on the gulf coast at not a
great distance from New Orleans, which are freciucnteil
bolh in summer and in winter. Indeed, the enlire route
from New Orleans to Jlobile along the Gulf is very
attractive. Pass Christian on this line has a mild win-
ter climate, favorable for persons suil'ering from bron-
chial disease, from malaria, or from Bright 's disease, for
convalescents from some acute disease, jind for those
of feel)le vitality. It possesses a good hotel, eotlages,
and boarding-houses. The sanitary conditions are good ;
there is pure artesian well water; the soil is diT and
porous; and extensive pine forests lie inunediately in the
rear of the town. The average mean winter tenqieia-
ture is given by Solly as 70° F. There are opportunities
for driving, boating, fishing, and himting.
Covington, thirty miles to tlie nortli of New Orleans,
reached by a picturesijue journey across Lake Pontchar-
train and up the Tchefuneta River, situated in the midst
of pine woods, is said to have a very salulirious winter
climate, with a "soft air," and is sheltered from all
"Northers." It is considered by some local physicians
to l)c favorable for pulmonary diseases.
Bay St", Louis is another resort fre(|nenl<'(l by tlie New
Orleans Creoles, and said to be rapidly growing in favor
with winter visitors. Biloxi, Beauvoir. Ocean Springs.
and Long Beach are otlicr resorts on the (Julf coast.
For those .seeking rest and diversion tlie trip down the
Mississippi River can he recommended, and from ))erson:d
experience the writer can testify to its charm and vari-
ety. The portion from Baton Rouge to Ncav Orleans
along the sugar plantations is of especial delight and
interest to the Northern traveller. Below New ( )ileans,
through the "delta country" to the jetties and the Gulf,
the voyage is also one of great interest.
New (Orleans can be reached from the nortli by various
lines of railroads, and .steamers with good accommoda-
tions run directly there from New York, occupying
about five days on the voyage.
New Orleans is a convenient port of departure for
Central America and the West Indies.
Edirttnl 0. (Hi a.
NEWPORT NEWS. See Old Point Comfoit.
NEWPORT, R. I. — Newport, until very recently one
of the capitals of Rhode Island, and in some respects
probably the most celebrated of American health resorts,
occupies the isthmus and much of the rernain<ler of a
peninsula which forms the southwestern termination of
the island of Acpiidneck or Rliode Island. This islan<l,
lying in the nnddle of the lower portion of Narragansett
Bay, is entirely exposed at its southern end to the full
sweep of the Atlantic billows, so that Newport, althougli
partly sheltered by the land, partakes in a measure of
the climate of the neighboring oceanic islands of Block
Island, Martha's Vineyard, and Nantucket. Newjiort
is the seat of die Naval War College, of the United
States Torpedo Station, and of the large militaiy post
of Fort Adams, at the entrance to the harbor. It has a
resident po])ulation of 23,000, increased in sununer by
nine or ten thousand, contains public buildings, many
churches, hanks, schools, shops of all kinds, an o]iera
house, excellent libraries, the Newport Casino, and an ad-
mirably eipiip])ed institution, the Newport Hospital; it
is also the home of numerous societies, clubs, and asso
ciations. It is lighted by gas and electricity and has an
electric street railway, running north ami south willi a
branch line to the beach.
The old town, settled in 1639, and built chiefly on the
western slopes of a broad and elevated ridge rising di-
rectly from the harbor, still retains much of the aspect of
colonial days, and in its narrow streets and ancient build-
ings, of wliich, in spite of the increasing encroachments
of modern civilization, many replete with historic associ-
ations are stiil standing, presents the features of an old
New England seaport town and contrasts vividly with
the newer suburbs by which it is surroiuided. The sum-
mer homes are constantly exleiiding until they have
already taken up a consiilerable ]iart of the jieninsula.
Bellevue Avenue, a modern extension of one of the main
city thoroughfares, Touro Street, has been continued due
south as fiir as the ocean, and forms a wide and s]ilendid
highwaj' two and a half miles in length, on each side of
which are placed the stately houses and beautifully kept
grounds of the wealthier summer residents.
The natural features of Newport and vicinity are very
attractive. Bishop Berkeli'V justly described the island
to his friends as " pleasantly laid out in hills and vales
and rising grounds, and hath ])lenty of excellent springs,
and tine rivulets and many tieligbtful lanilscapesof rocks,
and promontories and adjacent lanils. " On the one side,
the waters of the land-locked harlior and Narragansett
Bay studded with islands offer numerous inducements to
the lovers of sailing, boating, and fishing. On the other,
the ocean is quickly rcr lied at the First or Easton's Beach,
at a point where the coast line of the island turns sliarph'
to the east. This beach, seven-eighths of a mile in length,
lies in a sheltered bay and in the season is crowded with
bathers. Hot salt baths are provided there in siunmer.
Further to the east, beyond Easton's Point, lies the longer.
Second or Sachuset Beach, and still farther, facing the
east passage of Narragansett Bay, is the Third Beach.
Besides these, the principal beaches, the shore near New-
port presents a very varied and irregular outline. One
of the most striking parts is "The ClilTs " which may be
said to extend from the west end of the batliiug beach to
the end of Bellevue Avenue, for nearly three miles. The
public walk along these cliffs through the grounds of
some of the finest places constitutes one of Newport's
greatest attractions. Of the various drives, the "Ocean
drive" from the southern end of liellevue Avenue, west-
ward along the shore, is justly celebiated. The interior
of the island, traversed by two main thoroughfares, the
East and West roads, and numerous cross roads, presents
a pleasing diversity of hill and dale with charming views
of the bay and ocean, and there are many peaceful wood-
land lanes bordered with dense shrubbery, which remain
([uite secluded even in svimmer.
The geological formation underlying N<'wpi)rt and its
vicinity is .somewhat coni|dex. and consists mainly of
various rocks of the carboniferous )ieriod. Newport
Neck, as the extreme southwestern cornerof the island is
called, consists of pre-carboniferous rocks, suiiposed to be
partly of igneous origin. In the middle portion of the
Neck a conspicuous reddish granite (protogine) is to be
observed. On this part of the island the rocks are
largely exposed, and are groujH'd in |)ictures(|ue ma.sses.
The Paradi.se Rocks back of the second beach offer inter-
esting features to geologists by whom they have been
frequently studied. iMany of the rocks about Newport
have undergone metamorphic jirocesses, and have also
been greatly disturbed, and in many cases bent and
folded, besides having been eroded by glacial action.
There are several large ]ionds in the vicinity of the city.
The soil under the city jiroper is a tenacious clay, lie-
neath which frecjuently occurs a stratum of water-bearing
gravel. Most of the wells in the couqiact (|uarter of the
city receive their sujiply from this gr;ivel .-ind are for the
most part dangerous from liability to contamination from
deep cesspools dug throvigh the clay.
The climate of Newport is less tfying and more equable
than that of most other places on the New England coast.
Although snow and ice are far from infreiiuent. .yet the
winters are milder and the daily thermometric range is
less than in New York. Providence, and I5oston. Owing
to the influence of the ocean, the spring is rather more
L>.S5
NeWKom's Sprln;;s.
Mew York.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Climate of Newport, R. I. Latitude, 41° 29'; Longitude, 71° 19'. Condensed euo.m a Climatic Chart
OF Seven Years and Eight Months frojh Observations of the United States Signal Service, in
THE Previous Edition of this Handbook.
Temperature —
Average or nnrnial
Average daily range
Mean of warmest
Mean " if coltlest
HjL'tii'.st or maximum
Lowest or minimum
Humidity
Average relative
rreripilation —
,\verage in inches
Wind—
Prevailing direction
Average Ijourlv velocity in miles. .
Weather—
.\verage number clear days
Average number fair days
Average number clear and fair day
Jan.
3n.3°
l."i.4
;i7.7
32.3
fiI..T
- 7.8
74.8?
4.38
W.
11.1
9.3
i3.a
21.4
31.7°
l."i.(l
3i).(l
24.0
iiti.O
- 3.0
74.0?
4..58
W.
11.1
7.,5
12.^
311.0
3(1.2°
14.1
43.7
3(1.6
(!3.0
8.9
73.7X
U.50
N.W.
II. 1
8.3
11.9
April.
44..5°
9.4
50.3
40.8
22.0
70.6;5
4.81
S. W.
9.9
7.8
11.1
18.9
May.
.54.4°
14.0
62.3
48.3
85.3
33.0
74.3*
s. w.
8.1
13.9
21.1
June.
64.4°
14.5
71.3
56.8
89.0
44.8
76.3s;
3.28
S.W.
7.1
9.5
13.6
33.1
July.
70.4°
8.7
74.7
66.0
93.0
53.5
77.8!l
3.67
S.W.
6.8
8.6
13.8
33.4
August
73.0°
12.6
76.3
63.7
87.0
53.0
79.6;J
3.65
S.W.
6.4
9.0
13.4
31.4
Sept.
66.7°
13.3
70.9
.58.7
88.3
41.0
79.1S
3.10
S.W.
8.4
13.4
30.8
Oct.
58.0°
13.6
62.6
49.0
81.5
30.0
75.7:«
3.83
S. W.
9.5
II.O
10.7
31.7
46.1°
13.8
49.3
.36.5
il)
76.0:5
3.50
W.
11.1
8.3
]".0
18.3
40.6°
14.1
43.3
38.1
60.0
-3.0
w.
11.5
8.0
13.0
31 .0
.\verage
for year.
75.5*
47.91
8. W.
9.3
103.7
146.5
350.3
backward, tlie sumiiicr cooler, and tlie autumn warmer
than in the interior. Cultivated flowers have been ob-
served in bloom at Newport lute in November. The hu-
midity in summer is often excessive, and in consequence
of tliis tliei-e are many days extremely close and relaxing
iiltliou^'-h the temiierature is not remarlcalily lii^ih. seldom
rising- above ^i.5' F. The prevailing winds at Newport
are from the soiithwt'st. The rainfall is about the aver-
age for the New England coast. Fogs are frequent dur-
ing the warmer i)art nf the year, especially in earlvsum-
in?r. Thunderstorms are infre(|uent In Newport itself.
The Newport .season may be said to last from .June 1st to
October or even November. The city is. however, much
fie(|uented by visitors before and after these dates, and
in fact to some extent throughout the year. June, ex-
cept for those who dislike the occasional heavy fogs, is a
veiy pleasant nioutli. when the foliage is at the lieight of
its beauty. The temperatui'c of the water at Newport
in summer is remarkably warm, making balbing very
agreeable, and a large proporticju of the tishcs and marine
flora are soutlicrn forms. AVhetlicr this warmth, as sup-
])nscd liy Lorin ISlodget, Stoi'er,* and others, is due to
curi'ents from the Gulf Stream, which is moic (ban one
huuilrcil miles distant, may be doubted, but there is no
question of the fact, and to the tenipeititui-e of tin- waters
which surround its shoi-es the mild climate of Newport
is in laige measure undoulilcdly <lue. There are de-
cidi'd climatic as well as other differences between the
various parts of Newport. The sil nations in and about
the city, which is two miles from the south end of the isl-
and, and some disUince from the .Vtlantic Ocean, are the
warmest and most relaxing in summer, thcjugh on the
other hand generally preferable and more convenient in
winter. The cottage sites on the cliffs arc cooler and
always in gi'eat demand both on account of the sea
breezes, convenience, and beauty of scenery. The
southwest poini of tlie island. Bi'enton's point", as the
prevailing winds ai'e fiom the smilhwest, is the most
exposed and coolest. Lying along the harbor at the
north end of the city is a tlistriet known as "The Point,"
whicli offei's conveniences for boating and is sheltered
from easterly winds in winter. Another attractive but lim-
ited section is the high ground just south of the harbor.
The accompanying meteorological talile is taken from
the former edition of this Handbook. The government
station at New]iort was discontinued in ^larch. 1S88, so
that no recent records f|-om this source arc dlitainable.
Additional liartial observations until isll.j will lie founil
in the Bulletins and Investigations of tin' New England
Meteorological Society and in the Bulletins an<l Reports
of the United States Weather Bureau.
Tlie death rate of Newport is low ami tin- toniiici-ati'
and ciiunble climate seems to be especially favorable to
* "The Mild Winter Climate of Newport. R. I., as the ElTei-t of the
Gulf Stream," bv 11. R. Storer, M.D., Medical Record, Deceucber 22d,
1883.
longevity, which is further aided by the abundance of air
space and the absence of injurious trades and oceuiia-
tions. New'port is admiiably adapted for children, who
thrive there greatly, with the exception that in early au-
tumn a tendency is noticed to the prevalence of diarrha\il
di.seases. For those suffering from tuberculosis and from
bronchial, renal, and rheumatic alfcctions, Newport
shares too much in the geuei'al characters of the New
England climate to be recommended, but for convales-
cents and delicate persons who reside in more inclement
places and w'ho for any reason are not able to seek an
ideal climate at a distance, it will often be found in win-
ter to be very advantageous. Though well known to
the residents, the mildness of the winter climate is as yet
hardly appreciated.
The very sedative and .soothing effect of the Newport
climate renders it useful in man3' cases of overtaxed brain
and nervous system, and neurasthenia — particularly those
which re(inire a sedative rather than a tonic treatment.
On the other hand, in a limited number of cases, espe-
cially in women, the summer climate exercises such a
weakening and relaxing influence (felt by everj' one in
a slight degi'ee) that its effect is actually harmful. For
gastro-iute.stinal di.sordeis it is, generally speaking, con-
traiudicated. chiefly duiing summer. Asthmatics are
sometimes benefited, but sometimes the reverse is the
ea.se.
The sanitaiy conditions at Newport, though su-scepti-
ble of niucli imiu'ovement in the older pai't of the cilv,
are on the whole good. Newjiort has a .satisfactory
sewerage system, the main outlet pipe of which is car-
ried for some distance beneath the watei's of the harbor
and discharges at the outer side of Goat Island. The
city water taken from Easton's Pond and supplementary
soiu'ccs, though not as yet devoid of organic matter which
supports a growth of vegetable organisms and infu-
soria, is of fair quality and has never been recognized as
the cause of any epidemic. Everything for coinfort and
health is attainable to a degree not met with elsewhere
outside of the hirger cities, though Newport is deflcient
in hotel accommodations. There are. however, many ex-
cellent boarding-houses open at all sea.sons.
Newport is reached from New York by the large and
comfortable night boats on Lonjf Island Sound in ten
hours, or by railway to Wickford in five hours, thence
by steamboat acioss Narragansett Bay in anotbci' hour.
Fi'om Boston and Providi-nce theiv is direct comnuinica-
tiim by rail. The lutlcr city may also be reached by lioat.
The neighlioring pleasant resorts of Jamestown and Nar-
ragansett Pier are readily accessible, and there is also
direct communication in summer with Block Island.
Wil/iam C. Hires.
NEWSOMS ARROYO-GRANDE SPRINGS.— San Luis,
Obisi)u County, Cal.
Post-Office. — Arroyo Grande. Hotel and cottages.
'2S(!
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
>c«VNoiii'8 Sprlugs.
>ew York.
Access. — Bj' rail to Arroj'o Graudf, tlieuce b^- stage
two miles to spriugs.
The ocean beacli road affords one of the finest drives in
that .section of tlie (-imntry. The springs are pleasantly
situated at an altiliide of about four hiuidred feet. They
lie about fourteen niik'S south of San Luis Oliispo. The
climate here is one of almost perpetual sunshine, with
occasional spring and autumn rains. On the place are
three principal sjjrings whose waters range in tempera-
ture from 40 to 100' F., and flow 49.000 gallons hourly.
The following analysis was made by Wiaslow Anderson:
One United States Gallon Contai.ns:
SuUds. Grains.
Sodium chloride 4.10
Sodium carbonate 1.7.5
Sodium sulpbate 3.92
Potassium carbonate 15
Potassium sulpbate 2.90
Ma^iesiuin carbamate ■. 6.41
Magnesium sulpliate 2.47
Calcium carbonate 8.25
Calciutn sulphate 76
Ferrous carbonate 3.98
Alumina 33
Silica 2.03
Organic matter 27
Total solids 37.32
Gases. Cu. In.
Free carbonic-acid gas .^ 14.90
Free sulphureted hydrogen .' 3.-56
Temperature of water analyzed, 100.5" F.
These waters have gained considerable reputation in
the treatment of old cases of chronic rheumatism and
gout, catarrhal affections of the Ijladder and bowels, skin
diseases, etc. For uterine disorders the hot sidphurous
douche has been highly recommended.
James K. Crook.
NEW YORK is situated in 41' north latitude. 74' longi-
tude west ficim Greenwich- Its temperature range is
wide (from — G' F. to OU F. Avith a mean of .52.6° F. in
1899), subject to extremes, especially to extreme heat in
summer, and often to sudden changes. Owing to its
insular and seaboard position, the extreme summer heat
is usually a few degrees less in New York than tlie aver-
age of sister cities. Its climate is moist, the relative
humidity in 1899 averaging 76 per cent, at 8 A.xr. and 73
per cent, at 8 r.M- In the same year the rainfall was 42
inches, but in other j'earsit has often exceeded 52 inches.
The average hourly movement of wind varied from 8-6
miles in .July to 18-9 miles in !Marcli. Tlie prevailing
direction of wind is northwest. In 1899 there were 29
thunder-storms, 128 clear days, 127 partly cloudy days,
110 cloudy days. Both in summer and in winter the
temperature in New York is milder than that of Chicago,
and, compared with that city, its relative immidity is less
(in spite of its seaboard situation) and there is le.ss wind,
but there are fewer clear days and more foggy days.
There is more sunshine in New York than inBoston,
Chicago, St. Paul, or Portland, Ore. ; but less than in
Philadelphia, Baltimore, or Denver. The climate of
New York, though stimulating, being moist, changeable,
and in winter rather coo), is unfavorable for those sub-
ject to biouchial and laryngeal disorders, and for pa-
tients ill with, or convalescing from, pulmonary tub€-r-
culosLs. In spite of this. New Yoik is a healthful city.
Its water supply, from Croton and Kensico lakes, is "of
excellent quality and free from contamination. As to
typhoid fever, a large proportion of cases are infected
outside of the city or from sources imported into it. The
same may be said of malaria in recent years, although
this (lass of affections formerly prevailed in Harlem and
the East Kiver districts; and the extensive digging up of
the city now in progress (1903) for the construction of the
rapid transit tunnel has not altered the morbidity statis-
tics. Contagious diseases, developing at home or in
school-houses, are watched by an active health board;
and tropical (.liseases, such as cholera, tvphus fever, etc.,
are almost unknown in New York. The citj-'s aimual
mortality records for the last three years show an aver-
a.se of 67.503, a death rate of 19.42 per l.OOO jier annum.
Of these, the average annual mortality from pulmonary
and other forms of tuberculosis was 9,491 ; fi'ora pneu-
monia, 9,032. The average mortality from typhoid fever
and from diarrhoeal diseases for 1899" and 1900(1898 being
omitted from this calculation because of the unusual in-
crease in those diseases among soldiers returning from
the war in that year) was, respectively. 632 and" 6,897.
Of the deaths from diarrlKeal diseases a little more than
one-half were among children under five years of age,
who supplied one-third of the deaths from all causes. In
1899 there were reported to the city Board of Health 33,-
486 cases of contagious diseases, of which 1.950 were of
typhoid, 99 of smallpox, and 11.001 of diphtheria. Of
41,709 contagious cases reported in 1900, 2,658 were of
typhoid, 156 of smallpox, and 12.913 of diphtheria.
In 1901 there were al)out 4.000 cases of smallpox in
New York, but by adopting the most vigorous measures
the disease ceased to exist in ilanhattan in August, 1903,
The total number of deaths from all causes in 1902 in
Greater New York was ()8.082. The general death rate
of New York was reduced in 1902 to 18.74 per 1.000.
Up to August 16th it was 17.60 per 1,000 against 21,19
in 1901.
Manhattan's death rate was 17.76: Brfioklyn's 16.87;
that of the Bronx, 16.45; CJueens', 19.97; Uichmond's,
24.34. These figures show that irrespective <if its popu-
lation New York is one of the healthiest cities in the
country, and ranks in comparative mortality reco;ds
with thousands of small towns and villaixes.
Ci.iM.^TE OF New York, N, Y.
L.\TiTVDE, 40° 43' ; Longitude,
Ye-\ks-
"4° 0'. Period of Observation, Thirtekx
Temperature < Degrees Fahrenheit) -
Average or normal
Average range
Mean 6l warmest
Mean of coldest
Highest or maximum
Lowest orminimum
Humidity-
Average relative
Precipitation.
Average in inches
Wind-
Prevailing direction
Average hourly velocity in miles .
Weather —
Average number of clear days
Average number of fair days
Average number of clear and fair days.
C
ir
u
Oi
c
a
f
jj
>-,
S
a
s
g
3
•-a
>
a.
a.
^
<
^
36,8°
.59.0°
73.7°
65.3°
42.1°
47.5°
71.5°
54.3°
31.4°
14.6
16.7
17.4
14.9
13.6
43.9
B,s.5
8:^.7
74.4
50.9
31.3
.51.8
66.3
.59.5
37,3
72
94
99
100,2
74
3
34
57
36
67.6;«
65,0«
70.4*
72.8«
69,6!e
65.8?
70.1*
70,7$
72.:w
4.07
2,74
4.46
3.90
3.34
10.06
12.40
10.36
9.70
N, W.
S, W.
S. W,
S, W,
N, W,
N, W,
S. W.
N. W.
W.
11,3
8,5
7.5
8.8
10
9.8
7,6
9,3
10.2
7.5
9.7
7,5
8.8
8.4
24.8
24.6
27.4
21.S
13.5
13
1.5.5
12.1
11.5
38.9
43.2
36.4
;)4.9
21
™,7
23
20,9
19.9
6.3.7
67.8
63.8
56.7
51,2'
69.7?
42..52
N. W.
98,6
1,53.4
252
287
Nlcp.
Mlric Add.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
The lesspiied mortality of 1902 is attributable in part,
no doubt, to tlie lemarkable ami widesjiread absence of
exfcssive heat during tlie sunnner months. In New
York City tlieve was only one day in this year in which
tlie maximum temperature rose t(i'Jl V. i)uriug tlie so-
ealled "dog days" the temperature <lid not gn above 88°
F.. and the niglits have been lircn-zy and cool. The State
of New Yorlilies in tlie main track of tlie cool waves
which emerge liom the northern Rocky >Iountain region
and drift thence eastward over the Great Lakes where
tlie conditions liave lieen nniisnally moderate during tlie
past season, dominated liy a series of cool auti-cyeloaes
from tlie northwest.
The summer rainfall has been excessive, amounting
throughout half of the State of New York to more than
twelve inches during .luiie and July. This is attributed
to an "exceptional strength and per.sistency in the south-
erly winds bearing the vapinof the tropical ocean to feed
the rain clouds producing the excessive precipitation in
our uorthern States.''
The great concentration of population in New York,
now embracing over three and a lialf millions of i)eople,
complicates all problems of health and municipal hygiene.
There are over forty thousand hotels, apartment and ten-
ement houses in the city. The extremes of society are
more widely separated than in any other American city.
Pliilan1hro|iic measures on a very large and generous
scale liave been carried out for years in New York and
have doi;e much to improve the condition of the poor
and sick tmd outcast. It is impossible to enumerate
them, but tlie_v are rapi<lly extending their work and are
more and more generously supiioited.
New York is now well provided with small i>arksin
which tlie poor have an opportunity for recreation and
tem porarily escajie from their crowded quarters. .Music is
provided on summer eveninss. and ]iublic-scliool proper-
ties which formerly were tightly closed all summer, are
now thrown open as playgrounds for the children. Rec-
reation piers along the river front serve a similar purpose
anil are speeiall_v grateful to tired mothers with sick in-
fants. The floating hospitals of St. John's Guild, the
country week associations, kindergartens, and free ice
funds contribute largely to diminisli misery and promote
he.-dth. Van Cortlaiidt, Bronx, and Riversiilc parks are
largely uneultivateil, but very popular. V^in Cortlandt
has line golf Ihiks and skating facilities: in the Bronx
there are opportuiiilies for picnicking, rowing, and
flower-gathering. Prospect Park. Brooklyn, and Central
Park, ilanbattaii. are the largest cultivated ]>arks in the
city. Facilities for tennis, basc^ball. football, croquet,
and amusements for small children are jirovided. Taken
in connection with its suiierb water front, the bay, the
rivers, and the sound. New York, aside from its commer-
cial supremacy, is one of the most desirable places of
residence in the world. Guy Hinsdale.
NICE. -This city is tlie most popular resort on the
Riviera, as it is the largest, containing 93, 760 inhaliitants.
It is one hundred and forty miles iiorlheast from Mar-
seilles, nineteen and one-ciuarter miles northeast from
Cannes, and nine and onehalf miles wi'st from Jlonaco.
It is situated on I lie Bale des Anges, opening toward the
south, at the mouth of the little river PaiiUm. To the
east is the hill of Villefranche. affording protection from
the east winds, and to the west the iiromontory Cap
d'Antibes. which affords partial protection from the mis-
tral or northwest wind. . To the north are the foothills
of the Maritime Alps, the his^best of which is Jlount
Cliauve. with an elevation of '.i.S'24 feet, and standing
seven miles back from the coast. These foothills, as Dr.
Sparks has observed, are too f.ar distant and too mticli
intersected by valleys to afford very good ]irotection
against winds coming from that direction.
The city of Nice consists of three distinct portions: the
old town, on the left bank of the Paillon; the Port, with
a seafaring population; and the Strangers' Quarter, on
the right bank of the river, which is the portion oeeuiiied
bv the winter visitors. This last section is the fashi(. li-
able part of the city, and contains attractive avenues and
gardens, broad streets with tine buildings, and innumer-
able hotels and pensions.
Along the coast runs the Promenade des Anglais, a
beautiful, broad-terraced walk, two miles in length. It
is shaded by palms and other trees, with a pier and
casino near the beginning, and is bordered with hotels
and villas.
In the season from November to May. Nice is visited
by one hundred thousand people, and it then resembles
a northern capital with all its gayety. During the year
about one million people are said to visit it. Between
the foothills proper and the shore, a distance of four or
live miles, is a sloping area of country consisting of low
ridges and shallow valleys. Immediately adjacent to
the coast is a level tract of ground.
In seeking a health resort along the Riviera it must
not be forgotten that Nice is a large, extensive city, and
consequently po.ssesses the tlisadvautages and (lerturbing
influences of a city, viewed from a health-resort point of
view.
The sanitary condition of Nice is said to be the best im
the Riviera, and the water supply "excellent in quality
and (luantity" (Linn).
Nice, by reason of its situation and size, possesses in-
numerable resources for diversion and pleasure. Here
congregate visitors from almost every civilized country,
and life in this gay winter city is made most attractive for
them. At the heigh't of the season the carnival is cele-
brated with great display. Nice is considered a healthy
cit3', its death rate comparing favoralil_y with that of most
French towns. In 1890 there were 2L63 deaths per 1,000.
The following table from Teysseire's figures give some
of the meteorological data for the season, October to
April inclusive, extending over a series of years:
Temperature (degrees
Fahr.) —
Mean
Alisolute inaxiiiuini..
.\bsc»lute miniuiimi. .
Hnnikiit.v--
Meaii relative
^
= c
CO
z
61.61°
52.80°
SS.IB
74.7
:!6.7
■i\.\
1)2. 6S
62. «
48 2°
36.9
63^
cr?
^^
fa- h
46.72"
48.43°
51.22°
66.6
66
70.5
36.5
38.3
33.1
65.8:«
59. 9«
S5.1%
.54°
82
ST. 2
60.4*
"The mean annual temperature," according to Burney
Yeo, "isCO.S' F. The mean winter temperature 49.1° F.,
and the mean spring temperature 58.1° P. The mini-
mum temperature at night is 26.6° F. The coldest
months are January and February. The relative humid-
ity is small, as is seen by the table. The mean annual
rainfall is 32.43 inches, and 19.45 inches for the six winter
mouths November to April. The mean ]iroportiou of
sunny, cloudy, and rainy days for twenty years is:
sunny 219.2. cloudy TT.3, rainy 67.4, and for the winter
season, from October 1st to May 31st, sunny 135.8, cloudy
55.3, rainy 52.8." March, April, and May are the windi-
est months. Of the stormy winds the east wind is the
most common, says Burney Yeo, and blows forty-tive
days in the year.
"Like Cannes." says Huntington Richards. "Nice is
one of the windiest of the Riviera resorts. The mistral
blows about nine times in the year, chiefly in February
and March, and is accompanied by clouds of dust. The
average number of days of complete calm during the
nine autumn, winter, and spring months, as quoted by
Sparks from Teys.seire. is 18.6. while the average number
of days of gentle wind is 303.8, and that of strong wind
days is 69.4. out of which 29.4 occur during the three
spring months."
" It must beadmitted," says Sir Hermann Weber, " that
the changes of teiiqierature are very great, even in sunny
places, when jiassing from a sheltered position to a spot
e\posed to winds, and likewise on passing from the sun
into the shade. A great jiart of the town is al.so exposed
to the northeast wind, owing to a gap left in the sar-
28S
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Mltrlc Add.
rounding heights by the Paillon torrent, and the mistral
is often very annoying, the protection by some rather
low hills to the northwest being ineffieieut. But the
character of tlie climate is remarkably sunny and invig-
orating, and the bright days considerably exceed in num-
ber tlie dull ami rainy ones " Frost rarely occurs, and
then at night. Fogs are unkm>wn. The teniiierature
of the sea water in winter is between 53 and 61 ' F.. and
in summer between 64° and 75° F.
"Nice enjoys." sa_ys Dr. Wendt, in the previous edi-
tion of this H-VNDiiOOK, "notliing more nor less than a
fair average of Riviera climate. This means that it is
not devoid of drawbacks, and that ideal winters are not
found there. Nice is more sheltered than some places,
but is nevertheless exposed to the mistral, which blows
at Nice just as it blows at most other Riviera spots. It
should be borne in mind by invalids and tourists that
Nice and the Riviera in general really po.ssess two distinct
and dillerent climates, viz., seashore or marine climate
and an inhmd or mountain climate. It is cinite well
known ttuit iimnediate proximity to the sea may induce
sleeplessness and other symptoms, denoting too exciting
an action on the nervous system. The dry, sunny inland
air is tonic and sedative; the air in inmiediate proximity
til the shores of the sea is bracing and exciting. The air
of the city and its suburbs is often a mixture of the two.
It is thus apparent that a number of local climates are
found at Nice, concerning which the resident physicians
will inform invalids."
As a geiunne liealth resort it will be seen from the
jireceding climatic considerations that Nice possesses
grave defects, and is perhaps the least desirable of the
Riviera stations, particularly toward the close of winter
and the beginning of spring. As has been well said, it
is "rather a pleasure resort than a refuge for invalids."
It does, however, offer much to a certain class of pa-
tients or semi-invalids. Those seeking sunshine, a cer-
tain degree of warmth, dry air, and comfortable living,
even luxury, will tind it here, under most attractive sur-
roundings.
Anaemia, chlorosis, scrofula, gout, rheumatism, dys-
pepsia, diabetes, Bright's disease, chronic bronchitis,
asthma, and catarrhal conditions of the upper air pas-
sages are said to be more or less favorably influenced by
the climate of Nice. It is not to be recommended for
pulmonary tubercidosis, although it was formerly much
resorted to by this class of cases. For the feeble, from
old age or other cause, it is of value.
The suburb of Cimiez, two miles from the sea, appears
to possess especial climatic advantages. It is said to be
better sheltered and has a more equable climate, and its
influence is more sedative. The late Queen of England
visited this quarter of Nice several times.
Three and a half miles to the east of Nice is Beaulieu.
.said to be one of the best protected sjwts on the coast.
The high mountains rise directly in the rear, cutting ofl:
the north winds. The situation of this little place is
most attractive, and the groves of olive trees, orchards
of orange and lemon, and the luxuriant vegetation en-
hance the beauty of the scener_y.
The excursions in the vicinity of Nice are many and
most attractive, affording marvellously beautiful views
of this picturesque region. La Turbie, 1,600 feet above
tlie level of the sea, on the Corniche road l)etween Nice
and Monaco, is perhaps one of the most strikingly beau-
tiful spots in all this region of magnificent scenery.
For the true invalid the Riviera may possess man)' dis-
advantages, but for one weary with the ro\itine of life,
to roam along this coast from Genoa to Cannes in the
late spring or earlv summer when the vi.'gi-tation is at its
best, is a source of unending delight, as the writer can
testify from jn-rsonal experience. Ediotird 0. Otis.
NIGHTMARE. See Cunsciousncss, Disorders of.
NIRVANIN — diethyl-glycocoll-p-amido-ortho-oxvben
Zoic acid niethvl "hvdrochloride. HCtC-IUjoNCHj.
CO.HN.CeH.OirCOOCHi— occurs in white neutral pris-
Voi,. VI — l!l
matie crystals, very soluble in water. Elsberg at Mount
Sinai Hospital in New York City, found the toxic dose
in rahbits to be 0.23 gni. per kilogram of body weight,
while that of cocaine is 0.02 gm. per kilogram." Boiling
causes very slow deterioration of anaesthetic power and is
|)raeticaily harmless to the drug for short periods Solu
tions purposely infected soon liecame sterile, and one- to
two-per-cent. solutions were still sterile at the end of six
months. Joanin found 0.5-0.7 gm. per kilogram toxic for
guinea-pigs, while betaeucaine is twice, and cocaine nine
times, as toxic. But M. Didrickson aflirms that the toxic-
ity is greater than these authors report, very small doses
having resulted in excitement, hallucinations, and con-
vulsions.
Clinical evidence seems to favor this new compound
as a stable, sterile, very soluble local ana'sthi'tic. In
0.2-0.5-per-eent. solution it is suitable for inflltration an-
a'Sthesia, and in flve-per-cent. strength for local applica-
tion. It is somewhat irritating, and if u.sed for the eye
should be combined with cocaine. It has but little power
of penetration, a flve-per-cent. solution apjilied to a
mucous membrane scarcely affecting the submucous
tissues. It is said to be of value in ]U'uritus and in
dentistry. ir. A. linstcdo.
NITRIC ^C\D.—A(llll(f^lrtis. Under the title Acidtim
j\'ilriciiJii. Nitric Acid, the United States Pharmacopoeia
makes oflicial a liquid composed of sixty eight jier cent.,
by weight, of absolute nitric acid [HNO;,]." Such grade
of nitric acid is a heavy liquid of about 1.414 specific
gi-avity, colorless when freshly made and perfectly pure,
but, as met with in the shops, apt to be of a distinctly
yellowish shade. The acid fumes upon exposure, is
powerfully corrosi ve and stains animal tissues and woollen
fabrics a bright yellow. It dissolves silver, mercury,
copper, and other metals with evolution of red fumes.
It mixes in all proportions with water and alcohol. It
is a pretty potent oxidizer, yielding up a portion of its
oxygen to oxidizable material, and if has a strong aflinity
for water, by reason of which affinity , in part, it is ]io\v-
erfully caustic to animal tissues. It should be kept in
well-stoppered, dark amlier colored boiftlrs.
The valuable properties of strong nitric acid are the
power of the acid to oxidize on the one hand, and to
cauterize on the other. By its oxidizing virtues nitric
acid is a .serviceable disinfectant in situations when- its
corrosive action will do no injury; and its eautcraut
]ioweis are convenient for surgical application. The
acid burns searchingly and thoroughly, yet not unman-
ageably. When using nitric acid as a caustic, it is Avell
to bound the area intended for cauterization by a ring of
oil or of adhesive |ilaster, to prevent the action from
spreading unduly. The acid is then aiiplied by a glass
rod or bit of stick, care being taken to avoid excess.
Swallowed in anj- considerable f|uantity nitric acid is a
powerful corrosive poison. ]U-oducing eflects substan-
tially similar to those eau.scd by sulphuric acid (see 6';//-
jiliitric Acid). The most sirikiiig difference between the
poisoning by the two agents is. that in sulpbniic-acid
corrosion the .sloughs fend to be brown or blackish, while
in that from nitric acid they are yellow. Inluilation of
the fumes of nitric acid also ni;iy kill.
In jiroper dilution nitric acid operates physiologically
as do all the sour mineral acids (see !<iiljihiirii- Acid), and
shares with hydrochloric acid a sort of selective etbcacy
in ilfsorders of the digestive- apparatus. Vonnting, from
many causes, is often relieved effectually liy nitric acid,
and so is diarrhcea, and so is the functional disorder of
digestion commonly ascribed to sluggish action or even
congestion of the liver. Even a special curative action
over constitutional sy])liilis has been proclaimed of nitric
acid, but is at the present day ([iiite properly discredited.
For internal giving, the following prepanition of the
United States Pliarmacopo'ia is to lie used:
Acidiim ^'itricinii l)ihit>iiii, Diluted Nitric Acid. This
preparation is a simple dilutinn of the oflicial strong
acid with distilled water, in thr lu-oporticm a littler less
than six parts of added watrr lo each one of acid. It
2S&
Nitrites.
Nitrites.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
represents ten per eeut.. by weight, of alisolule nitric
acid; is a colorless and strongly sour liquid, non-corro-
sive but highly irritant. Its specific gravity is 1.057.
The internal dose is from twenty to forty drops, largely
dilutetl with 'ivater, and the mouth to be rinsed well after
the taking of each do,se, Edirard Curtis.
NITRITES. — Physiological experimentation and clini-
cal testing with a number of dilfereul nitrites, both of
metallic and etliereal bases, have now develnpci.1 the fact
that such compounds possess certain sti'ougly marked
properties in connnon. These properties evidently be-
long to the acid radical of these salts, so that the nitrites
are to be regarded as foi-ming a natural group of medi-
cines whose peculiar virtues are due to nitrous acid.
The effects wrought by nitrites upon the animal system
are, broadly, twofold, as follows: (tn the one hand, a
chemical change in the composition of lucmoglobiu, and,
on the other, an influence upon nervous and muscular
structures, showing itself by profoimd and, in sutlicient
dosage, even fatal derangement of function. As regards
the effects upon the blood, it is observed that in an ani-
mal under the influence of a nitrite the arterial and the
venous blood both have acqidred in common a peculiar
chocolate hue, wliicli does not change when the drawn
blood is agitated witli air. E.xamined by the spectro-
scope such blood shows a replacement of the bands of
haemoglobin by those of a new compound (Gamgee) very
probably identical with the tiictluvinoglohin of Hoppe-
Seyler; and, tested chemically, this changed haemoglo-
bin is foimd to have its ozonizing jiower very seriously
compromised. Treatment with ammonia restores nor-
mal color and normal functional power to this nitrite-
poisoned blood. The nervous and muscular derange-
ments produced by nitrites are as follows: In moderate
dosage there are felt a fulness and throlibing of the head
and neck, with almost simultaneous very rapid and dis-
orderly action of the heart, and excited and panting
breathing. The face is deepl_v flushed and feels un-
comfortably hot, but the internal general temperature is
found by tiie thermometer t(.i fall. So, too, though the
heart and carotiilg are felt to throb ilisagreeably hard,
yet arterial tension is jiroved to suffer a very great de-
cline, obviously due to the general capillary dilatation,
of which the flushed face is an evidence. In large do.ses,
as observed in animal exjierimentation, initial great ac-
celeration of the heart's action, and violent and liiu'ried
breathing are followed by slow, irregular, and failing
pulse and respiration, fall of temperature, weakened vol-
untary and relies motor activity, and finally, death b_v
respiratory arrest. As regards the mi.'cbanism of these
derangements, tlie initial circulatory phenomena — accel-
eration of i)ulse, capillary dilatation, and sinking of blood
tension — are mainly the ex|iressions of paralysis, sever-
ally, of cardiac inhibition, of resisting power of the mus-
cular elements of the arterioles, and, to a less degree, of
vasomotor control over the same. The heart failure fol-
lowing large dosage is probalily due to direct poisoning
of the cardiac musculature; tiie agitated and panting
breathing of the earlier stages of the nitrite effect seems
to be secondary to the other derangements, but the final
arrest of respiration in fatal poisoning appears to result
from direct paralysis of the nerve centres concerned in
the function. Similarly, the failure of voluntary and
reflex motor power seems to be mainly from paralysis of
the motor tract of the cord, altliouiib to a certain "extent
the muscular contractility is itself impaired.
Nitrous acid in combination is thus seen to be an agent
that immediatel}' attacks the ozonizing function of the
blood and the vital endowments of nerve and muscle
tissues. Many havi> thought that the paralytic phe-
nomena are probably but conseipiences of the blood
lesion, but various i)hysiological eon.siderations make it
more likely that they result from inunediate and inde-
pendent poisoning of the substance of the nervi- centres.
The principal therapeutic applications of the nitrites
are to relieve spasms, or pains referable to spasm, an<l to
arouse the heart in syncope. Tie most notable instances
of the first application are the use of nitiites in the treat-
ment of angina pectoris, spasmodic asthma, and epi-
lepsy. In the first two of these diseases nitrites often
prove of astonishing temporary power, but in the last
they are, as compared with bromides, second rate in
efflcacy. Still, in some cases of epilepsy, where bro-
mides have ceased to impress or where the supervention
of bromism has forced their discontinuance, nitrites have
shown themselves serviceable alternates (Law). For the
relief of syncope nitrites are theoretically indicated where
the cardiac arrest is presumably referable to excess of
inhibition; and, clinically, the nitrite of amyl has been
reported to have restored heart action in cases of syncope
from emotion, from liemorrhage, and from chloroform
poisoning.
The nitrites recognized by the United States Pharma-
copa'ia are the ethereal nitrites of amyl and of ethyl, re-
spectivel}' — the latter in the single preparation, spirit of
nitrons ethev and the salt .sodium nitrite. Also, though
unolflcial, potassium nitrite has been tried in medicine.
Properly also, nitruylyarin should be included in a sum-
mary of the group of nitrite medicines, since, though not
itself a nitrite, there is little doubt that its medicinal ef-
fects are wiought by a nitrite resulting from decomposi-
tion i.if the nitroglycerin w ithin the bod}'. In this place
the nitrites, respectively, of ethyl, amyl, potassinvi. and
sodium will be discussed, nitroglycerin being treated of
under its own title.
Ethyl Mtrite: C^HsNOj. Ethyl nitrite, formerly
called nitric ether, and now nitrous ether, is a compound
that forms by reaction of nitric acid with alcohol. It is
an ethereal flind of agreeable apple-like flavor and pun-
.gent taste — exeeediuglj- volatile, somewhat soluble in
water, and more freely in aU'ohol. Experimented with
in the pure condition, this body produces promptly and
fully the classical effects of the nitrites as above setforth
(Richardson). It is used in medicine, however, only in
the form of a weak alcoholic solution — the time-honored
and well-known preparatiim formerly called street spirit
of nitre, but now oHicial in the United States Pharmaco-
pa'ia under the title Sjiiritus ^Etheris Sitrosi, Spirit of
Nitrous Ether. This preparation is made by distilling
a mixture of solution, in alcohol and water, of sodium
nitrite, and of sulphuric acid. After purification of the
ethereal product, enough alcohol is added to make a
spirit containing in solution four per cent, of ethyl
nitrite. Spirit of nitrous ether is a clear, mobile liquid,
volatile and infianunable. of a pale straw color, inclining
slightly to green, and a fragrant, ethereal odor. Its taste
is sharp and burning. Specific gravity, about 0.836 to
0.843 at ordinary temix-ratures. It slightly reddens
litmus paper, but should not effervesce when a crystal
of potassium bicarbonate is dropped into it. It should
be kept in small glass-stoppered vials, in a dark place,
remote from lights or fire. Spirit of nitrous ether as
foimd in the shops is apt to be of deficient strength from
the fraudulent addition of water or alcohol.
The effects of this s|)irit are the conjoint effects of its
two constituents, alcohol and ethyl nitrite. In the small
doses commonly ju'escribed foi- medicinal pui]ioses the
peculiar nitrite effects are but faintly .seen, and the med-
icine operates as a grateful .stomachic, which is at the
same time mildly diaphoretic and antispasmodic. The
spirit is accordingly much pri'scribed as an ingredient
of so-called fever draughts or mixtures, its tendency
being to ameliorate the discomforts of the febrile state.
In large dosage with this pre])aration the typical nitrite
effects are clearly seen — giddines.s, headache, and throb-
bing arteries having been reported as following an over-
dose, while in another case death occurred fiom inhaling
the fumes from a broken three-gallon jar of the spirit
accidentally spilled in a room. Spirit of nitrous ether
is prescribed in doses of from 3 to 4 gm. (practically
from Til XXX. to tl. 3i.) several times a day. The dose
may be mixed with wat<'r fen- the taking, or prescribed
as an ingredient of mixtures containing saline solutions.
Such mixttires shoidd not be ordered in quantity beyond
present need, .since dilution with water tends to set on
290
REFERENCE- HANDBOOK OF THE MEDICAL SCIENCES.
Mtrlles.
Nitrites.
foot chemical changes iu the ethereal spirit. Spirit of
nitrous ether is an incrcdient of flie oHicial Campunnd
Mixture of Glycyrrhka ("BrDwu Mixtiiri'") of the United
States Pharmacopoeia.
Aiityl Nitrite : CtHnNO.^. Amyl nitrite is used in
medicine under its own form. Under the title Aitnil
Mtris, Amyl Nitrite, the United States Pharraacopa>ia
recognizes the ordinary article of pharmacy, which is an
ethereal liquid containing about eighty per cent, of amyl
nitrite. The remainder of the percentage is made up of
various associated but uniletermiued ethers. The sub-
stance is a clear, very mobile ether, of a pale yellow
color, having a fruity odor almost exactly resembling
that of ripe bananas, and an aromatic taste. When freely
exposed to the air it decomposes, leaving a large residue
of amyl alcohol. It is insoluble in water, but soluble, in
all proportions, in alcohol, ether, chloroform, benzol,
and benzin. Its specilic gravity is 0.870 to 0.880, and it
boils at about 96° C. (205° F.), giving an orange-colored
vapor. It burns with a fawn-colored flame. It sho\dd
be kept in small, dark glass-stoppered vials, in a cool and
dark place. Amyl nitrite is excessively volatile, and the
utmost care is necessary to preserve a specimen both
from loss of bulk and from spontaneous decomposition
by exposure.
Amyl nitrite is the nitrite commonly used in medicine
for the specilic sake of the nitrite effects proper, and it
Is, perhaps, the most striking of medicines iu the matter
of rapidity and intensity cjf action. From its extreme
volatility and jileasant odor the ether is etTiciently and
conveniently given by inhalation. When the quantity
of from three to live drops, poured upon a handkerchief,
is inhaled, the subject isconscious, witliin so short a time
as from three to ten seconds, of a sensation of heat, ful-
ness, and throbbing of the face and head, inmiediately
followed by an indescribable and most distressing coni-
molion within the chest, the heart beating fast and furi-
ously, and the breathing being panting and hurried.
Giddiness and some muscular languor aeconqiany these
phenomena, and perspiration may break out: but in a
very few minutes the derangements of fiuictii.n beyin to
recede, and rapidly, and upon their complete disappear-
ance the subject is left without after-effects, save, possi-
bly, a little dull headache and la.ssitude, lasting from half
an hour to an hour. As.suming such dosing with the
ether to have been in a case open to the therapeutic
powers of the nitrites, the therapeutic effect will have
been as swift and ])ronounced as the physiological de-
rangement. No medical relief, indeed, so nearly merits
the designation of "as if by magic," as the sudden and
complete abrogation of an anginal or asthmatic seizure
that is so often wrought by the swift and jjrofound
action of amyl nitrite. The drug, however, must not be
expected to be infallible, for many cases of angina pec-
toris, of asthma, and ,syncope — notably profound chloro-
form syncopes — often set the nitrite at defiance.
Amyl nitrite is an important medicine for the condi
tious enumerated above as being peculiarly amenable to
the nitrite influence, and also has proved serviceable in
dysmenorrho^aand other affections, painful or spasmodic.
The remedy is most conveniently given by inhalation,
from three to live drops being poured upon a handker-
chief, and the cloth then held to the nose and mouth.
Those who are subject to angina or asthiua, and who
find relief from amyl nitrite, may carry a small vial of
the ether about with them, and, upon the occasion of a
.seizure themselves dash a tew drops upon a handkerchief.
Or it may be sulficient to sniff strongly at the opened
vial itself until the characteristic .sense of tlu.shing and
arterial throbbing proclaim the absorption of asufllciency
of the vapor. If a vial be so carried and used, it should
be but a small one, not over 3 c.c. (v\ xxx.) capacity,
since by frequent uncorking of the bottle the contained
sample of amyl nitrite gets'"" flat " and loses its eflicacy
through chemical change bro\ight about by the exposures
to air. More convenient than a vial, both because of
better jireservation of the medicine and because of com-
bined rapidity ease, and certainty of dispensing of the
dose, are what are commonly called penrls of amyl
nitrite. These pearls are small, flattened, sealed cham-
bers, blown of very thin glass, and charged with fixed
quantities of the nitrite, generally from to two to five
minim,s. For use a single "pearl" containing the pre-
scribed (lose, is crushed in a handkerchief and the fumes
of the liberated ether are inhaled iu the usual way. The
glass of which the pearl is made is so thin that the broken
fragments do no harm. These pearls are not official, but
are quite universally to be procured. Amyl nitrite can,
if preferred, be given by the mouth, dropped upon sugar^
or dissolved in alcohol, in doses of from two to five drops_
Potassium. Nitrite : KNOo. Potassium nitrite is not
ofiicial in the United States Pharmacopoeia. It is a col-
orless salt, slightly deli(iuescent. soluble in water, ami
occurring in crystals or in fused sticks. Tested upon
man and the lower animals, potassium nitrite is found to
produce all the typical nitrite effects; but, as might be
expected, more slowly, while j'et more enduringly, than-
ainyl nitrite. In the exiieriments of Weir Mitchell and'
Reichert ' full doses made themselves felt by .symptoms,
diu-ing a period of from one and a half to Ave liours, be-
ginning within one or two minutes after swallowing.
The doses ranged from three to ten grains, single or re-
peated, and one individual experimented upon took, iu;
divided doses, within a period of six hours and thirteen'
minutes, thirty-five grains of the salt. But fnmi the be-
haviorof sodium nitriteof ascertained ptuity (see below),
the question cannot but protrude itself. Was the sample
of the potassic salt used in these experiments tested for
purity? In the present condition of knowledge of the
sulijeet, the comparatively large (piantities cited above
should certainly not be prescribed medicinally for an
untried subject.
Potassium nitrite gives rise, during the period of its-
action, to eructations of gas of a very offensive phos-
phureted odor, so disagreeable as even to lead in some
cases to nausea and vomiting (Reichert).
tSudium Nitrite: NaNO... The salt is official iu the
United States Pharmacopa-ia under the title Sodii Nitris.
Sodium Nitrite. It occurs in crystals or fused sticks,
freely soluble iu water. Commercial samples are rarely
pure, being composed of nitrate and nitrite in varying;
proportions. The better grades may contain 98. .5 per
cent, of nitrite, but specimens of a salt sold as sodic
nitrite have been found to contain but the merest trace
of that body — O.OIl per cent, only (McEwcn). The
condition of small crystals, as against that of large trans-
parent crystalline forms or the fused nitrite, is said to be>
the best for purity. Sodium nitrite deteriorates on keep-
ing— a fact doubtless accounting for the poor quality
of the drug so often found.
Sodium nitrite produces the peculiar nitrite effects in .e
manner generally similar to potassium nitrite, and, whem
a good sample is employed, can be fatally poisonous, as
has been proved by experimentation upon animals. la
full dosage with the human subject, extreme distress,
and even an alarming condition, have been reported ; the
jirominent complaint being of excessively violent and
turbulent heart action, with great giddiness and general
weakness. In such ca.ses lividity of the lips and nails
has fjuite commonly been observed.
Therapeutically sodium nitrite has proved etficient in
the usual way of nitrites to control the pain in many
cases of angina pectoris, and in cases of freipiently re-
curring paroxysms has, in single do.se, established free-
dom therefrom for halt a day in subjects to whom amyl!
nitrite gave immunity for but an hour or two (Matthew
Hay). Such immunity, furthermore, was secured by a,
dosage small enough not to produce any piououncedl
throl)bing or giddiness or headache. In eiiilepsy this;
nitrite has also been used with .some abatement of the
fits; but it is, in a general way, inferior to bromides for
this particular therapeusis. From the experience witln
the s;ilt so far acquireil, sodimu nitrite can I)e said to Ik-
available for all the therapeutics of the nitrites, and ti»
have the advantages over tlie ethereal salts of a mora
deep-rooted and lasting influence, and of much greater-
201
N Urolx'Uzr no,
Piltroglycerln.
UEFERENCE HANDBOOK OP^ THE JIEDICAL SCIENCE^..
cheapness. On tlie other hand, as eonijiari'd with amyl
nitrite, the .sodie .salt is slower in <'Stalilishinf;' its elTeets,
so that when urgency of relief is demanded the amylic
salt is preferal)le. Scidinni nitrite sives rise to .some dis-
agreeable eructations of sas, Imt in therapeutic dosage
tiie occurrence is slight. The lA™ of sodium nitrite
should, for a pure sample, not exceed (1.13 ,nm, (gr. ij.),
for the larger doses of tive, ten, and twenty grains that
were at first u.sed by investigators have, with good speci-
mens of tlie salt, produced very distressing and even
alarming elTeets. The eiTects of a two grain dose will
persist a numlier of hours, ("an^ shovdd b<' laUcn in pre-
scril)ing tills medicine that the sample is of good quality
and not too old. Edininl C'lirtu.
' Anii'riciin ,Iciia-niil of the Med. Soicnces. .Tiily, Issil.
NITROBENZENE. POISONING BY.— This substance,
also called nitrobenzol, is made by the action of nitric
acid on benzene (benzol), which is one of the ingredients
of coal tar. The formula of nitrobenzene is ('oIIsNO..;
it is a substitution product of benzene. It is a clear,
straw-yellow li(juid, insoluble in water, and possessing a
strong odor, suflicienlly like that of bitter almonds to
permit of its u.sein ]ierfumery andcimfectionery. It has
become a rather familiar article of commerce under the
name of oil of myrliani'. It appears from several re-
corded cases that small doses of the liquid are poisonous,
and even its vapor is active. The symptoms resemble
somewhat those of prussic acid, but there are no imme-
diate insen.sibility and no convulsions. The skin be-
comes clammy, the lips and fingers purple, the eyes
glassy, and the breathing very slow and infrequent.
In a case that occurred in the practice of Dr. ll. M.
Dean, of JMn.scatine, Iowa (}[ii1iciil ISiilhtin, vol. i., p. 50),
violent elTeets followed the mere tasting the article.
The pulse was not much atreeted, but the respirations
occuiTcd at long intervals. The mind usually remains
clear for some time, but unconsciousness idtimately
c'nsues. The diagnosis will generally be determined by
the powerful and cliaracteristi(' odor of the substance,
which can easily be distiiiguisbed from that of both
prussic acid and oil of biltcr almonds, which it most
nearly resembles.
Nitrobenzene is partly converted in the body int<i ani-
line, but its [loisonous action does not depend on this
conversion.
There is no specific treatment , the sym|>loms must be
combateil as they arise. Free washing out of the stom-
ach with lukewarm water has been found to Ije of great
jnlvantagc in many cases of poisoning, and woidd be
ap|)lieable here. Dr. Dean, in the case above referred
to, used tluiil extract of digitalis, one drop every hour,
and also, every few minutes, a tcaspoonful of a mi.xture
■of one part of alcohol and two of hot water. lie could
make the patient swallow by putting the spoon well back
<m the tongue. Henry LifiiiiniiK.
NITROGEN MONOXIDE.— Nitrogen monoxide (N,0)
is the body conuuoidy called iiiiruiiH ii.tide gtis. and for-
merly po])ularly kninvuna l(iii;//<hi//!/ii>t. It is a colorless
gas. practically without smi'll, and with a very faintly
sweetish ta.ste. It dissolves in a little more than its own
measure of colil water, to a less extent in warm water,
and to a less extent still in a saturated ai|Ueous solution
of sodium chloride. Ky combined exercise of cold and
pressure the g.ascan be condensed to the li(piid condition,
yielding a colorless and very mobile fluid. I'lion release
<if ]iressure this tlui<l inunediately springs again into the
state of gas. Nitrogen monoxiile actively supjiorts the
<-ondjustion of inllammablc bodies, luidcrgoing deconqio-
sition ami yielding up its oxygen to the biniung sub
stance.
Xitrogcn monoxide is. physiologically, absolutely
bland, and being also odculess is perfeellv lespiiable even
when substituted, ))ure, for atmospheric air. When so
respired, the gas, from its free solubility in watery flinds,
is rapidly absorbed into the blood. If inhaled witii ad-
mixture of cno\igh atmospheric air for the ordinary
needs of the system, nitrogen monoxide proves pecnl
iarly exhilarant. A sort of tingling thrill runs through
the nerves down to the very finger ends, and, if enough
of the gas be taken, the experiinentcris irresistibly driven
to the commission of some extravagant and silly act, al-
most always such as betokens an uucontrollablj' joyous
state of mind. Singing, shouting, laughing, dancing,
and capering are thus the com.non expressions of the
exhilaration — manifestations whence comes aptlj' the old
name Imii/lihi;/ f/ns, api)lied to a mixture of nitrogen
monoxide and air. AVhen inhaled pure, in entire subsli-
tution for atmospheric air, there is, first, a very transient
exhilaration, and then raiiidly follow the same phenom-
ena as when pure nitrogen is respired, namely, such as
result from the respiration of an atmosphere devoid of
available oxjgen. The blood returning from the lungs
ceases to accjuire the arterial hue, its free oxygen rapidly
diminishes in quantity, the animal speedily loses con
sciousness, and, if the inhalation be continued, dies by
asphyxia, in the same time that it <lies in an atmosphera
of plain nitrogen, and with a similar reduction of the
jiercentage of free oxygen contained in the blood.
These various facts sufficiently jirove that at the temper-
ature of the animal body nitrogen monoxide resists
decom|iosition, so that the oxygen of its molecule is un-
available for the purposes to which ordinarily respired
oxygen is put.
Nitrogen monoxide inhaled pure is, then, practically
an agent that will, without other derangement, jiroduce
the unconsciousness of coma from asphyxia, wiiile not
interfeiing with the free pla}' of the lungs in the respira-
tory act. The clinical ]iheiiomena of the inhalation arc,
siibjectinli/, a beginning feeling of the ]ieculiar tingling
and sense of exhilaration noted above, which, however,
is soon overwhelmed in swift-rushing unconsciousness.
According to the fulness of the respirations the uncon-
sciousness may supervene in from a few seconds to two
or three minutes. In a carefully observed experiment
the writer of this, practising the fullest possible forced
inspiration and expiration, and beginning the inhaling
after a forced expiration, was noted to have passed into
complete unconsciousness in the nuddle of the third in-
spiration. During the continuance of the unconscious-
ness ana'sthe.sia is absolute; and upon withdrawal of the
gas and sulistitutiim of atmospheric air the senses are
regained as rapidly as they wei'c lost, and in two (U' three
minutes the experimenter is in perfectly normal [ihysio-
logical status again. Ohja'tinlji the phenipuiena are a
swiftly <leveloped lividity of the skin and mucous mem-
branes, staring, anil scunctimes convulsively rolling eye-
balls, a convulsive twitching of the hands, and, when un-
consciousness has supervened, a slow, snoring respiration.
The pulse is little aflected. During the unconsciousness
the muscles, with the exceptions noted above, are cpiite
thoroughly relaxed.
Nitrogen monoxide is used as a medicine proper and
as an ■'ana'Sthetic. " Taken in small (|uantities, so as not
to interfere with normal absorpliou of o.xygen, the sub-
stance often seems to abate symptoms of nervous debility
or exhaustion, and hence to lie of value in the treatment
of many so called functional nervous diseases. Forsucli
]uifposes the gas may be given by inhalation, a few
whilTs being drawn from a bag through the usual moutli-
|iiecc, while at the same time atmospheric air is breathed
through the nostrils, ])urposely li'ft unclosed. Another
method of administration is to give an aqueous solution
of the gas by swallowing. A patenti'd solution of such
character, made under a ]iressure of five atmospheres,
has lieen used un<ler the title of cri/r/cnoiis aerated initer.
Nitrous oxide water has but little odor, and is slightly
sweetish to the taste. But liv far the commonest use of
nitrogen monoxide is the administration of the jnire gas
by inhalation, in order to )U'i>duce the anaesthesia of un-
consciousness. Fortius a<lniinisl ration a bag of a ca]iac-
ity of from four to thiily-two litres (one to eight gallons),
according to the )uoposed diu'aticui of the inhalation, is
charged with a pure article of the gas, undiluted. From
292
REFEREXCE HANDBOOK OF THE .MEDICAL SCIENCES.
N' II ro benzene.
Nitroglycerin.
thf bag the .eas is ilrawu tlirniigli a coiinectinj; lube out
of a nioutlipiece so coiistnicled that by an arrangement
of valves the products of exphatiou pass into tlie air and
not back into the bag. and also that the operator ma}-,
by the turn of a switch, admit air and cut off gas at
]ileasure. The patient's clothing being so adjusted as to
otf'jr no impediment to respiration, the mouthpiece is put
in ])lace. the nostrils are gently compressed by the fingers
of the administrator, the stopcock that controls the deliv-
ery of the gas from the bag is turned, and the patient is
enjoined to breathe as fully as possible. As soon as full
lividity of the face and stertorous breathing proclaim the
development of unconsciousness, the patient is ready for
operation, and if .such operation be one of brief duration,
like the opening of an abscess or the drawing of a tooth,
the administrator at once removes tlie mouthpiece as
soon as unconsciousness is attained, ana-sthesia persisting
for a number of seconds after withdrawal of the gas. If
th? operation be a prolonged one. then, as soon as coma
is complete, the administrator, by turinng the switch in
the mouthpiece, gives a little air, and then again, by a
reverse turn, a little gas, and so, guided by the color of
the blood as seen through the skin, by the snore of tlie
respiration, and by the presence or absence of voluntaiy
musc\dar movements, he .skilfully gives, alternately, air
to keep his patient alive and gas to keep him in practi-
cally cont iuuous unconsciousness. In t his way a practised
administrator can maintain prolonged ana-sthesia with
nitrogen monoxide: but by the very necessities of the
case tlie patient is always just on the verge of awakening
to consciousness of pain on the one hand, and to the un-
desirable sudden movement of a limb on the other. Ob-
viously, therefore, despite its advantages of swiftnessand
pleasantness of action, nitrogen monoxide is more appro-
priate, given in the above manner, as an anaesthetic for
momentary than for prolonged operations. In order to
secure an easy continuance of aua'stliesia. Dr. Paul Bert,
i)f Paris, has proposed the method of administering a
mixture of nitrogen monoxide and oxygen under in-
creased atmospheric pressure. Under such circumstances
the ox3'gen of the mixture prevents asphyxia, yet the
characteristic an;esthetic unconsciousness of nitrogen
monoxide supervenes with the usual quickness and
kindliness, and can be maintained continually without
dangerous or even disagreeable elTect. Bert mixes the
gases in the proportion of S') jiarts of nitrogen mon-
oxide to 15 parts of oxygen, and conducts the admin-
istration in a special chamber of compressed air rep-
resenting a total atmospheric pressure of 93 cm. of
mercur}'. Anitsthesia has thus been maintained safely
and pleasantl}' without break for over an hour, tnit
the large volumes of gas required for such prolonged
application and the trouble of providing the com-
pressed-air chamber will probably always interfere seri-
ously with the extension of the method into practice.
Many surgeons use nitrogen monoxide as a preliminary
to ether, in the administration of the latter as an aua's-
Ihetic.
Nitrogen monoxide is obtained from the salt ammoniuin
nitrate by heating the same in a retort. At an elevated
temperature the salt decomposes, and from its constit-
uents water and nitrogen monoxide form (NH,. NO3 =
2H0O + NjO). The gas is supplied by manufacturers,
condensed to a liquid in strong iron cylinders — a con-
venient method of storage, since in this way a large
volume of gas occupies but a small s])ace. Prom these
cylinders the administration bag is tilled as occasion de-
mands. It is not wise toaltem]it to make the gas, unless
provided with apparatus conslrueted for the purpose,
since, unless the distillation be done in a certain precise
manner, the resulting gas may contain dangerous impur-
ities. A pure article of fused ammonium nitrate is to be
used; the heat is to be gradually applied and never
allowed to exceed 400° F. and the gas, after passing
through a series of wash-bottles, one of which contains a
solution of potassa. is to be collected in a gasometer, over
warm water, orover an aqueous solution of common salt.
Edtcard Curtis.
NITROGLYCERIN.— Nitroglycerin, called also .-"/^rj/jr/iH,
is, ch.Miiirally. a trinitrate of tlie radical glycf/ryl, repre-
senteil liy Uie foriuuia, C3ll5(N03)3, equivalent to the
replacing of the three hydrogen atoms of the hydroxyl
groups in the molecule of ghxerin by the nitro-group
N0.2. Nitroglycerin is made by the action of nitric acid
upon glycerin, and is a transparent, colorless, dense oily
fluid, of about the specitic gravity 1.6; slightly soluble
ill water, but freely soluble in ether or alcohol. It is
slightly volatile, inodorous, and of a sweet, pungent,
aromatic taste. Upon concu.ssion. as is well known, it
explodes with extreme violence. Nitroglycerin itself is
not official as a medicine, but thi^ United States Pharma-
copeia recognizes a oue-per-cent. alcoholic .S'liution of
the substance under the title Spirit/is Glonoini. Spirit of
Glonoin. This spirit presents only the physical charac-
teristics of alcohol, in appearance, taste, and smell, and
is entirely non-explosive. But if some of it be spilled,
so that the alcohol has a chance to evaporate, the nitro-
glycerin will become concentrated, and a dangerous ex-
plosion liecomes jiossible. The spirit should, therefore,
be handled with great care. It should be kept in tin cans
instead of in glass bottles, and these should be well stop-
pered and stored in a safe and cool place, aw-ay from ex-
posure to light or fire.
The cfl'eels of a one-percent, solution of nitroglycerin
upon the animal system are. in kind, exacth' those of the
nitrites (see yitritis), with the additional sj-mptom of a
severe and ob.stinate headache. In rapidity of action,
nitroglycerin occupies a position between amyl nitrite
ou the one hand, and the nitrites of the alkali metals on
the other. The agent is powerful; a single drop of the
one-per-cent. soluticm taken upon the tongue produces
within three or four minutes a transient feeling of cere-
bral fulness and frontal jiain. and a dose of fmir or five
drops quickly determines a full nitrite derangement —
flushed face, throlibing arteries, violent aud disorderl)-
heart action, hurried respiration, and splitting headache.
Over-dosage is extremely dangerous, as shown by a re-
ported case in which, after a dose of two aud a half drops
of a./irc-per-cent. .solution, the typical nitrite elTects were
quickly succeeded by sickness, faintness, and coma with
stertorous breathing. The heart's action became alarm-
ingly weak, but the patient linall_v recovered.
Nitroglycerin produces thus exactly the effects of a
nitrite, and accordingly the inference is that in the
career of the compound in the animal economy' it suffers
change into a nitrite, and as such nitrite exerts its activ-
ity. This subject of a possible chemical conversion of
nitroglycerin within the system was studied by Mattliew
Hax- (Prdctitioker, June, 188;>), who found "that nitro-
glycerin is decomposed by alkalies and alkaline car-
bonates, with the conversion of two-thirds of its nitric
acid into nitrous, which nitrous acid then combines with
the alkali to form a nitrite of the same. This reaction,
furthermore. Hay was able to produce by treating a one-
tenth-per-ccnt. solution of nitroglycerin in water with
freshly drawn detibrinated blood, and digesting the mix-
ture for forty minutes in an oven at a temperature rang-
ing between 104' and 113' F. Such mixture assumed
the peculiar chocolate color of nitrite poisoned lilood. and
by analysis, after an hour's digestion, nearly the whole
of the nitroglycerin present was found to have undergone
decomposition.
Nitroglycerin thus seems to be. for the pharmacologist
and physician, but a nitrite-furnishing com|iouiid. wluise
distinguishing fealure is solely the extraordinary intens-
ity of its action, a feature which ll.-iy accounts for by the
fact that nitroglycerin is. by the ]ieculiarity of its com-
position, exempt from the decomposition by the acid of
vhe gastric juice to which nitrites are liable — a decompo-
sition which always renders inert a ceilain jiroporlion of
each dose of a nitrite swallowed as such.
The therapeutic applications of nitroglycerin are those
of the nitrites. The remedy has been used with benefit
in angina pectoris, asthma, and epilepsy. cs]iecially in
pttit iiiid. and also in theaii.-i'inic fi>rmof migraine (llam-
mond), and in nephritis attended with a hard, corded
293
jVUrohydroclilorlc
iVose, [Acid.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
piilso (Robsou), The dose, iu an untried siiliject, should
lie at first but a singU' (iri)|) of the eustomary oue-per-
■I'cnt. alcoholic solution, to lie repeated every lifteen min-
utes until four or live drops sliall liave been taken or
relief experienced. In habitual u.se, as for epileptics, the
■dose will very liliely re(Hure gradual increase. At the
rate of an additional drop per dose each month so large
.51 dosage as twelve drojis three times a day of the one-
per-cent. .solution lias been taken without the production
iif undue derangement. Kilirnrd Ciirtin.
NITROHYDROCHLORIC ACID. — (Aqua Regia.)
Under llie lille Aeiiliiiii yitriiliii'li-iirliliiriniin, Nitro-
hydrot liloric Aeid, the Uiuted States Pliarniaeo])ceia rec-
ognizes the product of mi.'iiug together 180 measures of
nitric aeid and 8^0 of hydrochloric. On making such
mixture eifcrvesceuce oecursand a golden-yellow, fuming
fluid results, .strongly acid and intensely corrosive — more
so than the original aeids of its composition — and also
possessed of tlie peculiar innjicrlies of smelling of chlorine
and of dissolving readily gold-leaf. This fluid is wholly
volatilizabl(^ by heat. As its smell suggests, nitro-
liydroehloric acid contains free chlorine, and the fresher
Hie sample of the acid the higher the percentage of chlor-
ine, since by kecjiing. especially if exposed to light, the
(■hlorine constantly tends to undergo conversion into by-
droehloric acid, deriving hydrogen by the decom|iosition
of water. Nitrojiydrocliloric aeid should therefore lie
made and kept only in small quantities, and the.se, after
all ell'ervesccnce has subsided, should be put up in glass-
stoppered bottles, half filled only, and stored in a cool
place, protected from the light. The reaction whereby
free chlorine is evolved in a mixture of nitric and hydro-
ihloric aeids is now commonly regarded by chemists as
I he following:
HNO, + 3HC1 = 2H.0 + NOCl + 01,..
As already said, nitrohydrocliloric acid is intensely
'Corrosive to animal tissues. The acid is ])0.ssiblc, there-
fore, as a surgical caustic, but the more manageable
nitric acid is commonly and properly preferred. The
special medicinal value of nitrohydrocliloric acid lies in
the influence of the lueparationover the functions of the
liver, and also over certain obscure derangements of
metabolic judcesses, notably over that leading to consid-
erable appearance of calcium oxalate in the urine — the
condition, in short, clinically dubbed o.niliniii. As re-
gards intluence over tlie livei', nitrobydriichloric acid has
long enjoyed the reiiutatiou of tending to abate conges-
tions of the organ, to oppose the march of cirrhosis, and
even to favor the' limitation of ab.sce.ss. and, in so-called
functional disorders of the liver, to cause reccdence of
the syinjitoms. Experimentally, also, Rutherbird has
shown that the aeid possesses considerable eholagogue
power. Nitrohydrochjniie acid is therefore a slaiidard
remedy for the treatment of oxabiria and the various
above-named diseases of the liviT. The medicine can be
introduc('d into the .system eitliei- liy baths or by swal-
lowing. For a liath the acid should be diluted in the
proportion of 8 gni. of the aeid t(i a litre of water (one
lluidoimee to the gallon), an<l the bath taken iu a iranihii
tub. Such baths should b<' about blood- warm, and should
be administered daily, <ir twice a week, according to in-
dications. The duration of tlie bath will range from ten
to thirty minutes, or until a tingling or pricking sensa-
tion is experienced. After removal from the bath the
skin of the balhcr .should be wipeil very dry. Instead of
u general bath, a foot-bath or a s]ionging with a dilution
• if the acid of the strcnglh already given may be substi-
tuted. Tlicse external applicalicais are undoubtedly efti-
cient, and an occasionally develo]ied salivation proves
beyond ipiestion tlie absoi-]ilion of the aeid when admin-
istered in this way. For internal giving the do.se is a
very few drops — from three to live — diluted, at the time
of taking only, with a wineglassfiil or so of water, and
the draught sucked tlirougli a glass tube, with subse-
quent thorough rinsing of the mouth. For preseri)ition
internally there is also in the United States I'liarinaco-
pii'ia an official preparation entitled Arid inn yUro-
hydrochloricHm Dilutnm, Diluted Nitrohydroehloric
Acid, consisting of freshly inade nitrohj'drochlorie aeid
diluted, after making, with nearly four times its measure
of ilistilled water. The iireiiaration is a colorless or faintly
yellow liquid, odorless, or having a slight odor of chlor-
ine, and a very acid taste and reaction. By heat it is
wholly volatilized. This <lihite acid is, medicinally, ob-
jectionable, because the mere fact of dilution tends to
favor the conversion of the free chlorine of nitrohydro-
cliloric acid into hydrochloric acid. As actually dis-
pensed and used, this preparation is, therefore, much
more likely to be a mere mixture of nitric and hydro-
chloric aeids than the specitic clilorinc-containing com-
pound represented by a freshly made sample of the strong
aeid. The dose of the dilute acid may range as high as
twenty drops, to be taken in the same manner as a dose
of the strong aeiil, Edmird Giirtis.
NOBSCOT IVIOUNTAIN SPRING.— Middlesex County,
Jlassachusel ts.
Pust-Offii.'e. — Framingham.
Access viil Northern Division of Old Colony Railroad
or Southern Division of Boston and jMaine Railroad to
station, one and one-half miles distant from the spring.
The spring is located five miles from Framingham, at
the base of Nobscot Mountain, the highest point in ]\Iid-
dlesex County, and comes tlirough crevices in what ap-
p(.'ars otlierwi.se to be a solid le(lge of rock. The water
has a uniform temperature of 4l F., and an average
flow, summer and winter, of fourteen thousand gallons
per day. The surrounding Avatershed is a heavily
wooded glacial moraine, free from human habitations of
any descrijition. Several sanitary analyses have shown
the water to be thoroughly pure and wholesome. The
following mineral analysis was made in 1801 by Daven-
port and Williams, of Boston:
(INK tiNIlKI) ST.ITKS liALLON COXTALSS:
S'llids. (.Trains.
Oreanie aucl \o!aIile matter 0.64
•Silica 53
Iron oxide and alumina 02
Lime earbonate 75
Magnesium carlionate 23
Sodium ehloride 36
Sodium carbonate 38
Potassium sulpliate 30
Total 3,21
Tliere is no hotel on the spring property. The water
is shipped in glass packages and supplied to the markets
of numerous New England towns and cities. The sales
in 180(5 amounted to slightly more than six hundred
thousand gallons. Jiiiin's K. Crook.
NODOSITAS CRINIUiVI. See Mmiihio I'ilonim Pro-
jiri.t.
NODOSITIES, NON-ERYTHEMATOUS. OF AR-
THRITIC PATIENTS.— Though known for a long time
witlioul any pailiculai- attention being paid them, these
curious lormatioiis have lieen more specially observed
stince Barlow and Warner made a careful study of them
a few yiais back. They were followed by several
French observeis, more particularly Brocq of Paris, who
elaborated them into two varieties — a merely clinical dis-
tinction, both forms being made uji of round and spindle-
shaped cells. Tliey are more common in children than
in adults. They may be considered as affording positive
evidence of ilieumatism, though they do not necessarily
appear during tlie fever but may develop on its decline,
or even altogether inde]iendcntiy of any acute attack.
(Osier.) Often their apiiearauce is coincident with the
devclo]iinent of symptoms of pericarditis, sometimes of
|ileurisy, but especially of severe clironic rheumatic en-
docartitis.
The lirst variety, which I'roeq calls ci'/iciiiirii/ rittunroiis
iioilotiiti'rti, is eonlined entirely to the forehead, oeturring
there as ill-defined |ironiinences in and movable with the
skin, although they are sometimes adherent to tlie peri-
294
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Nilroliydroclilorlc
Nose. [Actd.
osteum. They are entirely painless always, and there is
no change of color in the overlying integument. They
are never very numerous, rarely more than two or three,
sometimes only one, being discovered. They vary in size
from a small shot to a pea, and their ephemeral nature
constitutes their chief characteristic. Appearing toward
the end of the day or during the night (Ferel) without any
subjective symptoms whatever, they last but a day at
most, and disa])pear, leaving no traces, to spring forth
again, without known cause, in a new place on the fore-
head.
The second variety (rhenmatie subcutaneous nodules),
by far the more common and belter known, differs from
the first form in that the tumors are subcutaneous and
are more stationary. The overlying integument, un-
changed in color, moves freely over them and they
strongly resemble syphilitic exo.stoses or gummata. To
the touch they are tirra and clastic, freely movable U]iiin
the underlying structures. At times, however, tliis fact
may be demonstrable onl}' with attention, when, for in-
stance, the tumors occur over bone, as in the scalp, where
they give the impression at first of being exostoses. They
are sometimes tender on pressure, .seldom spontaneously
.painful. In size the)' vary from a pea to a filbert and
are sharply defined. Coming in successive crops without
premonition they increase slowly, sometimes quite rap-
idly, in volume to their niaxinuim, remain stationarj- for
a variable length of time — amounting frequently to weeks
or mouths, — then disappear, leaving no trace of their ex-
istence. Their favorite locations are the periarticular
regions — elbows, knees, wrists, and joints of the fingers.
They occur also superficially along the long bones, over
the spines of the vertebra" and sea]iula\ over the iliac
crests, and frequently over the frontal and occipital hones,
these last two being particularly favorite sites. The
nodules, which as a rule are separate and distinct from
one another, although in rare cases they may be confluent,
occur at times in large numbers: more particularly in
adults.
Thej- are to be distinguished from the swellings of
erythema nodosum l>y the absence of color and "from
other cutaneous and subcutaneous tumors by their own
peculiar evolution.
Treatment should be directed toward the underlying
rheumatic diathesis. Charles Townskend Duih'.
NOMA. See Mouth. DiseaseJ< of, in The Appendix.
NORTH HAVEN POOL.— New Haven County, Con-
necticut. The waters of this pool have had a local repu-
tation for more than one hundred years, and it is said
that Dr. Trumbull, the historian of Connecticut, was in
the habit of accommodating boarders who came to avail
themselves of their medicinal etfects. According to an
analysis by Prof. S. W. Johnson, the following ingredi-
ents are found:
Sodium .sulphate.
Soduiiii .hlnriile.
Piitas^uiiii sulphate.
Calrunii sulphate.
Calcium carbonate.
Magnesium carbonate.
Ferrous carbonate.
Silicic oxide
Alumina J
Ammonia -Traces.
Phosphoric acid )
The iron is present in suflScient quantities to give the
waters useful tonic properties. They are said to be of
decided value in chronic skin atlections. The waters are
bottled and sold in one-, two-, and four-gallon jugs.
James K. Crook.
NOSE. INJURIES OF THE.— Injuriesof the nose may
be caused by firearms or by sharp or bluut instruments.
Falls upon the nose and blows with the fist are by far th(^
commonest causes of traumatism. The various lesions
which may be produced are: damage to the soft parts,
ecchymosis, hemorrhage, emphysema, obstruction to the
tear duct, dislocation and fracture, and a variety of de-
formities resulting therefrom.
The soft parts of the nose, like those of the rest of the
face, are abundantly supplied with blood-vessels, and
therefore heal readily; hence ragged wounds should be
carefully sutured and no tissue cut away even tliough
it is badly lacerated, since its vitality will usually be
preserved. Swelling may be limited.'if the patient is
seen early, by very hot or very cold applications. Later,
mild antiseptic lotions, such as a solution of boracic acid,
if applied upon a thin layer of gauze so as to facihtate
rapid evaporation, will be found most grateful to the pa-
tient. At a later stage the wounds may be covered with a
dry dressing, such as one of cotton and collodion. Sup-
puration, on account of the free blood supply, is usually
superficial and easily controlled. The skin'of the nose
is, however, a favorite starting-point for facial erysipelas,
for the treatment of which see article on Erysipelas.
Deeper suppuration should be ]5romptly treated by free
incision and drainage on account of the risk of its extend-
ing to the cranial cavity.
if the tip of the nose is lost, or the damage to some
other ])ortion of it is so great that disfigurement results,
a plastic operation will have to be undertaken at a later
(late to repair the deformity. (See article on licparative
Surfierij.)
Injuries to the nose, like those to the eye, often give
rise to an ecchj'mosis which is very annoying to the pa-
tient. Hot applications and a firm bandage, if ajiplied
sufficiently early, may prevent the spi'cad of blood sub-
eutaneously. Later, the discolored skin can be painted
so as to be less noticeable. The ecchyiuosis will begin
to fade out in the course of five days or a week.
Hemorrhage from the external parts of the nose is easily
controlled. Tiiat from the anterior or posterior nares,
either with or without accompanying fiacture, may be
UHire alarming. It is sometimes kept up by the position
of the patient, who, for the sake of convenience, may
lean fiirward over a wash bowl so as to permit the blood
to flow out through the anterior nares. Such a position,
by producing congestion of the face, tends to keep up the
flow of blood. Ice applied to the nose or placed on the
back of the neck is sometimes of service in stopping
hemorrhage. If the flow of blood is really serious one
should not trust to such means, but should attempt to
check the blood by pressure directly upon the wounded
ves.sel, or by styptics. Hemorrhage! both that which oc-
cuis spontaneously and which has received the name of
epistaxis, and that which follows an injury to the nose,
usually comes from the septum. If. therefore, the ante-
rior nares be examined by reflected light the bleeding
]ioint will usually be discovered. It m;iy be touched with
t)ie point of the galvanocautery or with some caustic or
astringent preparation, by far the best one being a dilute
solution of suprarenal extract which may be" applied,
after the uosti'il has been cleansed, cither uiion a swab of
cotton or in the form of a nasal douche or a nasal spray.
This remedy is so etficacious that it will rai<'ly be neces-
sary to plug the nostrils with gauze for the "purpose of
stopping the hemorrhage. When gauze is used, it
should be inserted in nari'ow strips under the guidance of
the eye until sullicicnt pressure is obtained. At the end
of fi-om twenty-four to forty -eight hours it should be re-
moved, after thoi-oiigh moistening, in older to detach it.
and the nares shoulil be cleansed by anti.septic iri-igation.
The old habit of stulfiug the nostrils full of sponges or
cotton and leaving them undisturbed for several ilays is
absolutely' indefensible in view of the modci-n methods
of controlling hemorrhage. (See also article on Hemor-
rhage. )
Emphysema is a complication due to the jiatieut' s at-
tempt to cleanse his nostrils by violent blowing. Air is
forced through the ruptuied mucous membrane ami fnic-
tuix'il bony framewoik into the subcutaneous ti.ssue. This
complication distorts the visage, but is in no wise a seri-
ous one, and the emphysema will speedily di.saiijiear of
Itself as .soon as the cause ceases to act. The patient
whose nose has been broken should be cautioned against
blowing his nose, an act which m;iy also set up hemor-
rhage and spread infection, as well as cause empliysema.
Obstruction to the tear duct may follow ii:isal injuries,
being usuallv the result of swelling. It leqiiires no
295
NosopUcn.
NotocUord.
IIEFERENCE IIA^'UBOOK OF THE MEDICAL SCIENCES.
treatmeut ami will disappcai- (if itself wlicn tlie swelling
subsides.
Friictinr and Dixlociitioii.—'V\w si>iiil rnuiiewurk of the
nose may be broken or disloratcd. It is made up of the
vomer and the perpendieuiar plate of the ethmoid, to
which are attached the nasal bones and the quadrilateral
cartihige. These structures may be broken in a variety
of ways which it is unncces.sary to specify, since there
are general principles of treatment which sliould be
followed in the case of every fracture or dislocation
associated with deformity. Many fractur<>s are com-
pound internally ; heuce the necessity for perfect clean-
liness, to be secured by antiseptic irrigation. Gentle
external manipulation w'ill often elicit crepitus and ab-
normal motion, while examination of the anterior nares
will reveal the presence of existing deformity. Such ex-
amination is very important, for the future well-being of
the patient depcnils far more u]iou a free nasal passage
than it does upon the correction of external deformity. In-
ternal deformity usually consists of a deviation of the sep-
tum so decided as partially to obstruct one or both nostrils.
The ipiadrilateral cartilage may be loosened and rotated
upon its articulation with the vomer. A moderate tw-ist
of this sort will greatly obstruct both nasal passages.
Whatever the deformity, it sbouhl be forthwitli over-
come and the bones kept in a correct position for a few
days until they bavc^ begun to luiite. Instruments for
this purpose should be smooth, strong, and not too large.
A small periosteal elevator is a suitable instrument with
which to raise tlie depressed bridge of the nose. The
septum may be straightened by sequestrum forceps
whose blades are protected by short sections of rubber
tubing. There are, of course, special iustrtinients for
the.se ]Hirposes. It is necessary that the displaced frag-
ments be thoroughly n'duced ; indecil, over-reduction is
generally desirable. When this is ac(■oluldi^lled, tliere is
little tendency for a reproduction of the deformity, so
that a retaining apparatus is not usually needed. A
nundjer of internal and e:;ternal splints liave been de-
vised. Gauze packing carefully applied enswers satis-
factorily if oidy one nostril needs to be tilled ; if the de-
formity is such that pressiu'C is rei|uired in both nostrils,
rubber tubes moulded t(jtit tlie nostrils are fiir more com-
fortable. Various splints have been devised to keep ni)
external pressure upon the nose. The most successful
consists of a lirm band or plate strajiped across the fore-
head from wliicli by means of a second liand or rod jiress-
ure can be exerted upon the nose. The direction of the
pressiu-e can be re,gidatei-l by screws or by bending a stiff
wire. In some fractures a ]iin tlirust through the nose
from siile to side will keep the bones in position better
than any splints. Such a pin may lie withdrawn at the
end of four or live days.
Deviation of the septum may also be overcome by two
pins passeil in tlie sagittal jilane of tlie liody and crossing
oneanotlier. This is a method of treatment more often
used to correct old deformities
than fresh ones. (Fig. 3.")91.)
Fractiu-e of thi' nose is not
of itself a serious injury.
When the broken bones are
replaced they will unite with
great rapidity, so that the
cure will be complete in from
two to four weeks. If the
fracture extends U]nvard so
as to involvi' the cribriform
plate the patient is exposed
to the risk of sejitic menin-
gitis. Such an injury is
really a fracture of the base
treated as such from the
de. (See article on Ihad,
W'l'iiids (if.)
Difdriiiitij folhiiri iKj Iiijiini. — If a fraetureoi- dislocation
of the nose is left lui treated, or if the surgeon merely Jiays
attention to external aiqiearances and does not correi't de-
viations of the septum, jiartial obstruction of one or both
Fio. 3.W1.— Metliod
the Niisal Septum.
of the sktdl, and should I
first if the diagnosis can lie
nares may ri'Sidt. In man_v cases it is possible to correct
such a defornnty under a general ana'stlietie by forcibly
loosening or refracturing the deformed bones with "a
strong pair of forceps and moulding the nose into ilie
proper shape. Deviations of the se])tum may require
ineisiou or a punching out of certain jiortions to" facilitate
complete reduction. (Consult also the article on "A((.sr//;
CiiHtics, Diseases of: Coii;/! iiitnl and Aeqnirtd Deformi-
ties.''') If the bridge of tlie nose cannot be lifted, a plati-
num, or, better, a celluloid sujiport may be inserted un-
derneath the skin and allowed to cicatrize there, thus
forming an artilicial nasal bridge ; which, if it is properly
shaped, is not to be told from a natural one. The details
of these operations are given in the article on licjutiiilirc
•Siin/rri/. Edirnfd Milton Foote.
NOSOPHEN — tetra-iodo-phenolphtlialein (ClIJ-j-
OH)...C'> (',,H|CO — is obtained by the action of iodine ou
pheiiolplithalein, and is a fine yellowish, odorless, and
tasteless ]iowder. insoluble in waK'r and acids, and soluble
w itii dithculty in alcohol, ether, and chloroform. It con-
tains 61.7 per cent, of iodine and may be heated to S'-iO"
C. (428' F.) without decomposition. It forms soluble
.salts with alkalies and insoluble salts with the heavy
metals.
Antinosiii, the sodium salt of nosopheu, is a dark blue
amorjihous powder, which is freely soluble in water and
alcohol.
Eiidoxin, the bismuth salt of nosophen, contains 53.9
per cent, of iodine and 14.5 per cent, of bismuth, and is
used internally as a gastric and intestinal antiseptic.
Dose, 0.2-0..T gm. (gr. iij.-viij.), or for an infant 0.06
gm. (gr. i.) or less.
Nosophen is a non -irritant i<idoforra substitute which
does not liberate iodine. It is an inqialpable powder, of
use not only asan antiseptic butalso fordiviiig up wound
secretions. It forms crusts, however, which must be
lifted to allow the escape of the underlying secretions.
Caldwell treats ulcers with nosophen in powder or ten-
jier-cent. ointment, or wdth a tifty-per-cent. solution of
antinosin. Steele uses three-per-cent. nosophen gauze for
the treatment of wounds, aliscesses, ulcer.s, etc., and as
intrauterine packing after curetting. Owing to its free-
dom from odor, it meets with much favor in nasal cases. E.
Klebs uses 0.1-per-cent. solutions of antinosin for niouth
and nares, and administers the same solution internally
as an antiseptic in dose of 12-24 c.c. ( 3ii.j.-vi.). Noso-
phen has been used in capsule as an intestinal antiseptic,
and Jlillener employed it with success in combination with
antinosin in thirty six cases of chronic suppurative otitis
media. The antinosin was instilled into the ear in two-
or three-per-ceut. solution, and IIk^ nosophen dusted into
the canal. .Vnlinosin in two-per-cent, solution is also
used bir bladder irrigation.s. 11". .1. Itustedo.
NOTIFICATION OF INFECTIOUS DISEASES.—
Among the ditlereiit measiui s einplnyed liy sanitary au-
thorities for the prevenlion of the spread of infections
diseases, the notification of the occurrence of such dis-
eases now occupies a prominent place. Municipal au-
thorities especially should have tliere(|uisite power every-
where to require immediate notice to be given them of
every fresh outbreak of diseases dangerous to the public
health in order that such authority may take proper
measures for the protection of the community.
The chief advantages of a .system of notiti'cation lie in
the iKissibility which is thus given to a local board of
health to determine the extent of prevalence of an ejii-
demic or a localized outbreak, and to in()uin' into the
local causes which have operated to produce it. The
lioard can then act intelligently in ajqilying the proper
remedies for preventing its further spread.
Laws enacted with this oliject in view have been in
force in the older States for many years, but not until
within the past ten oi- twenty years have pains been
taken to execute such statutes with such degree of efli-
ciency as to make tlii'in really jirotective. The law re-
(luiring the householder to report each case of dangerous
296
REFERENCE HANDBOOK OF THE IVIEDICAL SCIENCES.
Nomoplicu.
Notocliord.
disease to the loeal aiitliority was enacted in Massaelni-
setts in 1793, and tliat uiiii-li re(|uires tlie same duly im
tlie iiart (if the attending physician was enacted in ISST.
Little attention, however, had been paid to the enforce-
ment of these laws until toward the end of the 19th cent-
ury.
Various attempts have been made in Enghind to enact
a similar statute, but tliese efforts were unsuccessful un-
til 1S89. By the terms of the law theu cnailed the noti-
fication of infectious diseases to the .sanitary authoriiy
was made compvdsory throughout London, while the
principle of local option was applied to all other dis-
tricts.
During the j-ear in which this bill was under consider-
ation by Parliament, intense opposition had b<'en mani-
fested by many of the members of the medical profes.sion
throughout England. Objections were offered not only
by the jicople but also bj' the medical profession, but the.
bill passed and finally became a law.
The fallacy of the objections has been abundantly
proven by the experience of the townsof England where
the Notification Act has been adopted. The notification
of each case is made by a certificate furnished by the at-
tending physician, for wliich a fee of two shillings and
si.xpcnce is paid, except in a case in which the person
giving the certificate is the medical ofHcer of a public
institution, when the fee is one shilling.
The diseases to which this act applies are smallpox,
cholera, diphtheria, luenibrauous crou]), erysipelas, scar-
let fever, typhus, typhoid, and puerperal fever, and anv
other infectious disease which may be added to this list
by the sjuiitary authority of a district.
In 1899 the provisions of the act had been adopted in
cities and towns containing more than twenty-eight mil-
lionsof inhabitantsout of atotal of about thirty millions,
and in that year, by the enactment of a new statute ((i'J
and 63 Victoria, chap, viii.) the law became conipulsorv
throughout the whole kingdom.
There can be no doubt that the law relative to notifica-
tion has been productive of excellent results in the jirc-
vention of disease, especially in the cities and large
towns. It has furnished loeal boards of health with the
necessary information relative to the origin of outbreaks
of infectious disease, and in many instances has enabled
them to take timely steps for preventing its further spread.
In compiling certain data for the Paris Exposition of
1900 the writer collected the statistics of six registration
States and nineteen cities outside of those States, includ-
ing the ten largest citiesof the Union, with the following-
result. The figures arc mainlv for the vears 1894-98:
Diseases.
Reported
cases.
Registered Fatality,
deaths. | per cent.
Smallpox
9.222
(i9.7&S
195,783
127,847
317,7.55
2.385
13,284
44,411
9,211
6,424
25 8
Typhoid fi'ver
19 0
Diphtheria anU cntup
Scarlet fever
3;2.7
7.2
2.8
Measles
Total
619,-&5
75,715
These results agree fairly well with those of the Eng-
lish local government board for the eight years 1890-97.
which showed a fatality for typhoid fever of l.S.O.T ])er
cent., for diphtheria of '23 per cent., and for scarlet fev< r
of 4.9 per cent..
Another advantage of the practice of notification in re
cent years consists in the exact data which it furnisiies
relating to improved methods of treating disease, and I lie
consequent saving of human life. In the thiitv-lhird au
nual report of the State Board of Health of "Mas.sachu-
setts for 1901 it ajipears that the notified cases <if di])li-
theria in the ]ire-antito\in period. 1891-94. in reporting
cities and towns were 13,:332. and the deaths in the same
places and time were 3,71)8. making a fatalitv of 38.3 jier
cent., while in the following scven'years. 1S9,5-1901, afti-i-
the introduction of antitoxin the cases were 50,459 tuid
the deaths 7.410, a fatality of oidy 13.1 per cent. The
fatality of diphthciiti in 1901 was only 10.5 per cent, (see
;dso V//.sK(.sY. Fiitidilij iij's. Saiiiud W. Alihull.
NOTOCHORD.— Tlu' notnf hord (,-//y«7r« rlorm/is. Wir-
hehiUte) is a rod of peculiar tissue, constituting ihe primi-
tive a.\ial skeleton of vertebiates. It begins i'mmediately
behind the pituitary body (liypophysLs) and extends to
Fir;. 3592.— Transverse Section of a Younc Mole's Kmlirvn. (.\fter
Heape.) Ec, Ectoderm; Mil., inedullarv Kroove; ilrf., meso-
derm; Ent., entoderm. Siti' of the notochbrd is the central line of
the entoderm.
the caudal extremity. It occurs as a permanent structure
in the lower types, and as a temporai'y one intlie embryos
of amphibia and anmiota. including "man. Comiiarativc
embryology has shown that it is a'greatly modified epi-
thelial tube, which arises as a furrow in the median dor-
sal line of the entoderm, being, in position and mode of
development, analogous to the ectodermal medullary ca-
nal or primitive tubular nervous system."
Development ix M.\m.m.\i,s.— The notochord appears
very early in the course of development ; its differentiation
from the entoderm begins at the time when the medul-
lary groove is not fully marked out posteriorly, and is
nowhere closed. The notochordal Anhujecim be first de-
tected in the entoderm just at the front of the primitive
streak, as an axial band of cells, which at first in mam-
mals is not well marked off from the mesoderm; as the
medullary groove deepens it ])ushcs down toward the
midgut until it conies into actual contact with the noto-
chordal e];iitlielial band (see Fig. 3592). thus dividing the
mesoderm into two lateral masses; this also leads to the
temporary transverse stretching of the notodinrdal baud,
which thereby loses for a while its sharp demarcation.
It soon re-acquires it. and becomes considerably thicker
(Fig. 3593, ttc/i) than the adjoining entoderm, and forms
a distinct, though shallow gi-oove. Sub.sequeutly the
band separates off, and the entoderm proper closes across
under it so that the notochordal band lies between the en-
toderm and the fioor of Ihe medullaiy groove (or later
canal), as shown in Figs. 3598 and 3004, ni-h. This sepa-
ration does not take place at the anterior extremity of
the chorda until .somewhat later, so that for a consider-
able period its front end remains fused with the walls of
the midgut (Fig. 3598). The separation from the ento-
derm is effected, at least in mammals, by the entoderm
proper, showing iiiiclf under the notochord toward the
Fio. 3.59.3.— Transverse section of an Kiiihrvu MmIc. stiiw II. (.ifi.T
Heape.) am.. Amnion; .Vd.. niedulhiiv ltouvc: .l/i/.. nivotoui.-;
I'ne., ctElom or body cavity ; Kn.. I'liiodcnii ; iivh.. iiotiichi)i-d ; iuk.
aorta; vl.ii., vit«-lline artery; .s'oui., somatic mcsoilcnii ; .s'j'(.,
splanchnic mesoderm.
median line, and when the cells from one side meet those
of the other, they unite with them and form ti continuous
sheet of cntodernr below the notochordal cells.
The chorda is now a narrow band of cells, starting an-
teriorly from the wall of the alimentary tract and rnn-
297
IS'otoi-liord.
Notocliord.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
iiiug l)iu-kwiiril to the blastopDvic canul or its equivalent.
the primitive streal; ; but, at the perioil wlieii tlii' canal is
open, the chorda terminates in the eutodermie epithelinm
lining the canal (Heajie.-' PI. xxi.. Fig. oO; com]iare
lined by epithelium, which is thickened on the dorsal side
to form the Aidaye of the notochord. In transverse sec-
tion the chorda appears accortling to the level of the sec-
tion to constitute ]iart of a furrow or a canal (compare
also Heape,' hie. cit.. p. 441, Figs. 40 and 41),
Lieberkiihn calls this canal mesoblasttc, and
Kolliker follows him: but this opinion seems
tome based ujion misconceptions. It is more
reasonalile to sujipo-se tliat the canal is really
the blastojifiric canal, which is preserved for
an unusually long period. We know that the
blastopore tirst appears well forward, and as
the primitive streak grows by concrescence of
the ccteutal line the blastopore moves back-
ward, its anteiior portion fusing with the gen-
eral entodermic cavity. There is no difficulty
apjiarent in assuming that such fusion occurs
quite late in mammals; this interpretation is
continued by the fact that the canal becomes
later a furrow throughout its entire length iu
Fiii. a594.— Transverse Sei'tlmis of :iu Eiii-
l>r.vo Chick, with Eleven t'aii^ of Myo-
tomes. (.After Waliieyer.) ,•!, Some dis-
tance behind tlie last niyi>tome : li, close
behind the last niyetonie"; Kt-., ectoderni ;
M^s., mesoderm; Ent., entoderm; M<L.
medullary proove: C/*., notochord: 11'.,
commencement of the VVoUllan duct;
3/S., muscular segment t»r myotomes.
also Vol, II.. Fig. t)QT). C). The canal remains open for
a time, and is c:iUed by some writei's on mammalian era-
bryology the chorda "canal (if. infvii). For a certain
]>eriod the chorda continues growing tailward by accre-
tions of cells from the walls of the blasto|ioric iiassage,
Ch. Lt.V
Fig. 3.^96. -Section of a Chicken Embryo of about Thirty-six Hours.
(After Waldeyer.) Kc, Plctoderm ; ^mn., me.soiierm cif the soma-
tupleure; SyiU, mesoderm of siijanchnrjpleure: Ent., entoderm;
II'.. Wolffian dact ; m, mesoderm cells: .1/'/., medullary canal; x\
vein; Coc, cceioni; MS., myotome; <_'/i, notochord ; .4o.. aorta.
front of the lilastoporic canal proper, so that its cavity
fuses with that of the entoderm proper.
After it is once formed as a band of cells the notochord
passes through various changes of form, but ultimately
becomes a cylindrical rod with tapering extremities. It
attains considerable size in the embryos of most
vertebrates, but iu those of placental mammals
is alw;iys small, particularity so in the mole
(Ileape'"). It is probable that in mammals the
notochord, when tirst separated from the ento-
derm, is a brcKid. Hiit band, as if compressed be-
Fiii. ;!,'>(l.'i.—TiaMsuTse .section of a Chick Embryo of the Sec-
ond Day. (.Vfler Waldcyer.i S<uii., 'i'lie somatic mesoderm.
and Spi., Ilie splanclinic mesoderm ; Er., ectoderm ; Ent.,
entodenn; r.C, vein; ]!'., Wolihaii duct ; 3/'/., medullary
canal: .to., aorta ; I'i'.. iiotochoid: MS., myotome.
and after the caital is pertiianenlly oblilerated the
chorda may still continue its lenglheiiiiig by :ie-
(|Uisitioiis, at its caudal end, of additional cells
from the primitive streak; such cells ni:iy, how-
ever, properly be regarded as coming from the
entodermic lining of the blastopore. We can,
then, distinguish tlirec iioitionsof the notochord:
the tirst arising fi'om the entoderm of the midgut ;
the .second from the entodeim of the blastoporii'
("inal ; the thiiil iiresiiiti:ilily from the entoderm of
llie ol)literated blast(i|Mire in the primitive .streak.
Urann and others h;ive songlil to altrilnite es.seii-
tial importance to these dilVereiiees, lint, it seems
to me, imiirojierly. It is more reasonable to saj' that the
chorda iirises in the amniota, as in the lower forms, di-
icctly from the entoderm, but presents certain secondary
modifications in its development.
liiebeikiihn has directeil ;ittentioii to a special pecul-
iarity iti the early develoinnent of the notochord in
mammals. There aiipears at lirst a passage — liiilf canal,
lialf ftirrow— which extends nearly the whole length of
the primitive streak; it may be described its a tulie run-
ning along the mcdiiin line, and having an irregular series
of openiuirs ittto the ciitodeiinie cavity. The canal is
Fig. 3.597.— Section tliroiiirh the Dorsal Reffioii of a Chicken Embryo
of Foity-five Hours. .1, Ectoderm: c. entoderm : 3rc., medullary
canal: jP.c, myotomes; Tr.t7, Wolffian duct ; p.p., pleuro-peritoneal
space or c^elom ; So., somatopleiire : v, v, lilood-vessels ; Sp.,
splanchnopleure ; iqi, inner ed.tre of tlie area opaca . v\ ti\ u\ en-
toderm of tlie area opaca; oo, aorta; cJt. notochord. (After Bal-
foiu- and Sedijwick.)
tween the mediilhirv c:iiial and entoderm (ff. Kolliker,
Inc. cit.. Figs. li)4 "to 197, and loc. cit.. Fig. 94; also
Heape,'" PI XIII., Figs. 36 to 43). The "band then
draws together, diminishing the transverse and iucreas-
298
REFERENCE HANDBOOK OP THE IVIEDICAL SCIENCES.
>otorliord*
Notoolftord.
ing the vertical diameter, uutil it has acquired a rounded
form ; finally its outline becomes circular in cross section.
Fig. 3o98.— I.ongitiKlinal Section of the Head Knd of a JIolc Em-
bryo, Stage H. (After Heape.) Ec.^ Ectoderm; En., entoderm;
pro.rtm., pro-amnion; mb., mid-brain; /&., fore-brain ; E»r.ento-
dennic cavity; ht., heart; Mes., mesoderm; »ic(i., notochord.
This series of changes begins near the anterior end of the
chorda, and progresses botli foruai'il and backward.
The mesoderm early grows in between the entoderm
and the notochord, which, however, for a consideralilc
time remains close to the medullary tube (Fig. 3600).
Later the mesoderm penetrates between the notochord
and medulla. The layer of mesodermic cells immediately
around tiie uotoelionl, which are of the well-known anas-
tomosing type (Fig. 3(i01), forms a special sheath, which
at first comprises only a single layer of cells, at least in
batrachia (Gotte," p. S'u, Fig. IfST). This is the com-
mencement of the so-called outer chorda sheath; it sub-
sequently becomes much thicker. In the lower types it
is an important a.xial structure (Fig. 3602, s); in most
cases it is replaced by cartilage, and in all the amniota
the cartilage is leplaeed by the osseous vertebra, the in-
veitebral ligaments, etc. The formation of the vertebral
column involves the disappearance of the notochord as
described below.
Histogenesis. — After the notochord has been formed
as a rod of cells, its cells undergo a process of histologi-
daj" some of th,.^ cential cells become vacuolated, while
the peripheral cells ai'e still normal; at first, as in the
fi'og, there seems to be only one large vacuole in each
ceir(F'g. 3603, B). Around the vacuole is a peripheral
layer of granular protoplasm, in which the nucleus
lies embedded, while the vacuoles themselves are filled
with a perfectly clear and transparent material, which
is supposed to be fluid in its natural condition. Dur-
ing the fourth day (chick) all tlie cells become vacuo-
lated, with the e.xeeptiou of a single layer of flattened
cells at the periphery. In the anura, it is said, there
is no distinct peripheral layer of protoplasmic cells.
The vacuoles go on enlarging until by the sixth day
they have so much Increased at the expense of the
protoplasm that only a veiy thin layer of the latter is
left at the circum-
r;N'--r J.'."-' ■ ^!y.--:-'j ■ -.'•.'- ■ -'■■V-r."-'-.'-.';"J9
Terence of the
cell ; at one part
of which, where
there is generally
more protoplasm
than elsewhere, the
remains of a nu-
cleus may gener-
ally be detected.
Thus the notochord
b e c o m e s t r a n s-
f o r m e d into a
spong}- reticulum,
the meshesof which
correspond to the
vacuoles of the cells
and the septa to
the remains of their
cell walls (Foster
and Balfour). As
GiHte has pointed
out, the process is
accompanied by an
expansion of the
cells, which is the
main f;ictor in the
widening and lengthening of the notochord, which goes
on ji-iri jKissii with the growth of the surrounding tissue.
Fig. 3.599.— Germinal Area *>f a (iiiinea-pifj
at Thirteen Days and Twenty Hours.
(After Lieberliuhn.) ao.. Area opaca;
op., areapellucida; nch„ A nlage of the
notochord as a canal with several irregu-
lar openings on the entodermic side. X 34
diametei-s.
Fir,. .miO.— Section through the Rump of an F.mbrvo Chick of the Third Day. Ch.. Chorion; vim, amnion: Som.. somat<ipleure ; v.v.v,
blood-vessels; Coc .. cnelom ; .</)(., splanchnopleure ; 7n., intestine; oo.. caudal branch of the aorta ; IFrf., Wolfflan duct; t'car., vena
cardinalis; Chji., chorda dorsalis ; ~3/j/., myotome; M(L, medullary canal.
cal differentiation uniqvie in vertebrates. The cells at
first become greatly compressed in the line of length of
the chorda: and hence appear quite thin in longitudinal
sections (Fig. 3603, A. /ic/i. )— hardly greater in diameter
than their own nuclei. Thus, in the chick, by the third
The histogenetic process is stated to be essentially
similar in niammals (W. Miiller, 337-338). There
is the central layer of vacuolated cells and the
peripheral layer of protoplasmic cells. The latti^r
are, however, ultimatelj' converted into vacuolated
299
Notocliord*
Nova Srotla.
REFERENCE IIANUBUOK OF THE MEDICAL SCIENCES.
cells. The cell
wnlls arc perfor-
iitc. havinjr tine
poie^;. tliat cur
R'spoiid jirobalily
to intercellular
liridses of pro-
top la s m.
Tlie inner %^/i
c h o r tl a ''jx^]
sheath ap-
pears early
and is to be
>v?%
?^--'
.,--SP
Fig. lieni.— Mesoderm of Chick of the Third
Day. from elose to the Otocyst. .-l. Nucleus
with the ehroniatiu loops seen in optic sec-
tion, lieiup in karyokiuesis.
regarded as an anhistic basement
membriine secreted by the uoto-
chordal cells.
Shape and Relations
TO Other Parts. — As
soon as the head bend
(first cprebi'al He.viire) ap-
pears(Fi.i;-. 30(14) the noto-
chord becomes corre-
spondingly bent, and its
anterior extrem-
<:-^::
MSf^ :'-^-
.-Ch,
:im
w.d-
ity lies close to . " '.
Rathkp's pocket . ,#'>■-
(Fig. 3604, ////. )—
the evagination
of the (ii'ai epi- ...... -^-w J
theliiim, which is
destined to form
the iiitnitiiry body or
f/t/pop/it/sin reribri. Tlie W."^
notochord never extends
farther forward than
this, hence the skull and head
may be divided into two iiarts,
the pra?-pituitai'y tind the post-
pituitary regions. The latter
region alone contains the noto-
chord. Komiti finds that in the
chick the end of the notochoiil is
united, tit the end of the fourth
and during tlie fifth day of incu-
bation, witli an irregular solid
cord of cells, which gi-ows out
from theciiithelium of the h\i)o-
physis. The coi-d soon disaj)-
pears. Its significance is quite
unknown. Romiti suggests that
it may produce a sti-ain resulting
in the pulling out of the hypo-
physeal evagination. Tliis notion seems to me unten-
able. The ci-iinial portion of the notochord lias not only
the bend shown in Fig. 3004, but also follows the
other curves of the head ; it takes a sinuous cour.sc
besides within the base of the cranium; finally, in
the region corresponding to the middle third of the
spheno-occipital cartilage, it makes a gieat dip
ventralward. The sheath of the notochord in the
cranial region is converted into the spheno-occipi-
tal cartilage; at the di]> just mentioned, however,
the notochord lies entirely below the caitilage. close
against the wall of the pharynx (Froriep, Romiti).
Wiitei'S befoie Froriep had I'ejii'esentcd the elioicht
as having disappeared at the bottom of the dip.
DisAi'PEAR-VNXE. — The tlisapiiearance of the noto-
chord in man commences with the second month
of fietal life. The first step is an alteration of the
characteristic histological structure. accom]:ianied
by shrinking of the tissues, so that a clear sjiiice
appears around it (see Fig. 360.5). The inner chorda
.tp.
Flo. .Stt(13.— Ti'ansverse Section of an Advanced Emhryo
of a Shark, Sctniiuus Urhia^ through the Abdominal
licirion. (The dots represent nuclei.) ,Sp, Spina] proc-
i-ss of the vertebra; ^-Ir., arachnoid space: Md.^ spinal
cor<l : ii.a., neural arches of the vertebra; ,s., inner
sheath of the notochord; ,«'.. outer sheath of the noto-
chord; <7j.. notochonl ; t.p., transverse proces.s of tlie
veitcbra; I'.cio-., cardinal vein; -:1<>., dorsal aorta ; mcs
mesentery; Geii., genital fold; W.d. WolQlan duet;
TI'., Wollllan liody with tubules; c, young cartilage;
3/,^c, muscles developing.
sheath is lost. The cell walls disappear, the tissue be-
comes granular, and breaks up into multinucleate, irreg-
ularly reticulate masses (Fig. 3000), which are gradually
resorbed (Leboucq). In mammals the resorption pro-
gresses more rapiilly in the cores of the veitebra' than in
the intervertebral spaces, and again more rapidly at the
ends than in the centre of each vertebra; hence the
chorda persists a little longer in the centre of
" '" the vertebra, and considerably longer in the
intervertebral spaces; in these lasl the final
remnants of the chorda may be
detected in niiin even after birth.
The cavity between the vertebral
cartilages is a new structure, and
is not the space left by the noto-
-Md. chord, as has been some-
times asserted. It ap-
.^^iia. pears, ho-never, that the
resorption of the chorda
may leave a small space,
which becomes included
in the intervertebral cav-
ity. A peculiar feature is
the frequent per-
sistence of cal-
cified cartilage
immediately
around the noto-
cliord in ossify-
ing vertebrre.
JIoRPHOLOGY.
— The notochord
was for a long
time supposed to
be exclusively
characteristic of
vertebrtites. It
is now known to
exist in am phi -
oxus, which is not a
true vertebrate, and
in the tiinic;ita. !Mor-
phologists have long
believed that it must have some
hciniologue among the organs of
invertebrates. The development
of the notochord in the lower ver-
tebrates indicates very plainly
what must have been the general
character of such an homologous
invertebrate organ. In ceitain
fishes and amphibia the noto-
chord lias been ascertained to
arise as a furrow along the me-
dian dorsal line of the entoderm;
the furrow deepens and then
closes over to form a canal sepa-
rate from the entodermic canal
proper: but the notochordal canal retains for a time its
anterior ;ind posterior connections with the entoderm.
A B
•i/.car.
_J^a«is^i=
Fig. .3603.— Longitudinal Sections of the Notochord ot lionibiiiator. (After
Gotte.) ^-1. Before the appearance of the vacuoles ; B. after tlie appearance
of the vacuoles ; »c/(.. notochord : Km., entoderm. (The cells, as is usual
in auiphibiau embryos, are c-harged with yolk granules.)
300
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
Notochord*
Nova Scotia.
Ultimately tlip lumen is obliterated, the ends become
detached, and so arises the solid isolated chorda. In the
h i g h e r vertebrates
the course of develop -
ment is similar, al-
tlioujxh several of the
]vriinitive features iu
tile formation of tlie
iliorda are obscured.
Ehlers^ has pointed
out that in various
invertclirates there is
a similar canal, the
"Neliendarm" of
( T e ]■ m a n w r i t e r s,
which is derived
from the entoderm
and connected an-
teriorly and posteri-
orly with the ento-
dermal cavity. It is
a very plausible sug-
gestion, which liom-
ologizes the verte-
brate notochord with
Hubrecht has .sought
with tlie proboscis of
Fro.am.
Fifi. 3H04.— Raljliit Enihryo of 6 nun.; Me-
dian Longitudinal Section of tlie Head.
(After Mltialkovics.) The lonnection
between the nioulh, 3/.. and pharynx.
ent.^ is jiLst established: iicli., noto-
chord: Ml., hind-brain: mh., mid-
brain : .f?>., fore-brain : Pro. am.. pR)-
amnios; ?(i/.. hypophysis cerebri : Hf.,
heart.
the invertebrate "Nebendarm."
to homoloirize the notochord
Fig. 3605.— Human F.nibrvo of about Thirtv-Uve Iiavs: Loncrttudinal .Section ot the
Ninth to the Eleventh Vertebr.v. as numbered IX. to XI. i\", Ner\'ous system,
wall of the spinal marrow : d. meningeal layer; Ch. notochord : ^1", aorta.
best observations on its origin in mammals by Heape.'' '"
For its histology see W. MiiUer: for its histogenesis see
GOtte;' for its anterior anatomical relations see Mihal-
kovvics, Froriep,^ Rabl-HUckhard, and Romiti; for its
atrophy in mammals see Ijcbouccj : for its evolution see
Ehlers.^ V/iarles Sedgwick Mi not.
' Balfour : A Monograph on the Development of Elasmobranch
Fishes. London, 1S7S. (Reprinted Works, i., pp. 2(i;<-.5ai.)
^Balfour: Comparative Embryology, vol. ii.
= Ehlers, E. : Xclx'ndanii uud Chorda dorsalis. Nachr. Ges. Wiss.,
Gottingen, ISS-i. pp. :»ii-4ii4.
^ Frori(*i> : Knpfihril dcr Cliorda dorsalis hei menschlichen Embry-
onen, Fest,s.liiift fiir H-nli-. is'*-', pp. 2ti-4ll. Taf. iii.
^ tiegenliauer. Carl : t'.eber das skeletsewebe der Cyclostomen (Hls-
tologie der Chorda, S. 47-19;. Jena Zeitscbr. Nat. Wiss., v., 18tt9, pp.
43.53, Taf. i.
'GOtte, Alex.: Entwickelungsgeschichte der Unke (especially pp.
349 361). Leipzig, 187.5.
' Hasse, C, and Scliwarck, TT. : Studien zur verglelchenden Ana-
lomie der Wirbelsanle, etc. Basse's Anat. studien, i., p. 21.
* Hatschek, B. : Studien zur Entwickehingsgescbichte des Am-
phioxus. Arbeiten Zool. Inst. Wien. iv.. Heft i., Taf. xiii.
"Heape, Walter: The Development of the Mole iTalpa Europea);
the Formation of the Germinal Layers and Early Development of the
Medullary Groove and Notochord. Q. Jour. Micr. Sci., 1883, pp.
412-4.52. Pis. xxvlii.-xxxi.
'" Heape. W. : The Development of the Mole. Q. Jour. Micr. Sci.,
x.wii.. pp. 123-1()3.
'^ Hensen : Zeit.schrift f. .\nat. u. Entwickelungsges., i., p. 3fi6.
'^His, Wilhelm: Erste Anlage des Wlrbelthierleibs, 4to, Leipzig,
1868.
NOVA SCOTIA. — Nova Scotia is one of the maritime
pidviuces of Canada to the northeast of the
State of Maine, lying in latitude 43' to 46"
N. and longitude 60 to 60 "\V. It is a long,
rather narrow peninsula, ■nith a great extent
of coast line, panillel to the mainland, ex-
tending in a direction from ncn-theast to
soutliwest. It is 350 miles in length, in-
cluding Cape Breton, and varies in breadth
from oO to 100 miles. Its area is 20,550
square miles and it has a populatioir of
4.50,396. The surface is undulating and is
traversed by several ranges of hills. It has a
cool, marine climate, and is a favorite sum-
mer resort for visitors.
Tlie following table, condensed from the
more elaboi'ate ones in tlie article on Nova
Scotia in the previous edition of the Hand-
book, conveys an idea of the summer and
autumn climate of this region, the seasons
when one would visit Nova Scotia as a re-
sort. As will be seen, the mean summer
temperature is about 6r F., similar to that
of the British Isles at this season, the high-
est temperature being about 80° F. and the
lowest between 43' and 46' F.
The relative humidity is high and there is
considerable rain. Fogs are also not infre-
quent. Tlie number of fair days is. more-
over, not large for the summer.
Nematodan worms. There is not a single fact which
seems to me to justify, even remotely, this attempt at
guesswork phylogeny.
LiTER.^TUiiE. — Verv numerous embrvological articles
^r %T^f
Fig. 3(J0tJ.— Degenerating Notochord Tis.sue, from the Central Portion
of the Intervertebral Disc of a Cow's Embryo, (.\fter Leboucq.)
contain references to the chorda; below is given a list of
the principal authorities. The best discussion is given
by Balfour, in his "Comparative Embryology";'-' the
CLi.MATE OF Halifax.— Latitude, 44° 39': Lo.voiTrnK B3° 36'.
Mostly for the Year 1883 O.nlv.
June.
July.
Aug.
Sept.
Oct.
Year.
Temperature 1 degrees Fahr. ) —
57.26°
63.40°
17.18
63.77°
19.78
57..5(i°
18.1)3
47.99°
15.95
42.74°
18.67
Mean of warmest
68.82
70.85
73.26
65.60 t54.2:l
Mean of coldest
.51). 1,5
.5:1.66
.54.48
47.03 !:f8.28
Highest or maximum
811.4
81.7
81.2
76.8
73.4
Lowest or minimum
43.2
46.7
45.6
40.5
29.0
Humidity-
Mean felaUve
85?
86«
fm
83*
m
8tS
Precipitation-
Average in inches
3.:«
3..M
.5.34
3.86
5.81
48.52
Wind-
Prevailing direction
S.E.A
W.
R. E.
S.W.
w..
S. W.
w.
Average hourly velocity in
1
4. .51 J.SS
4.SS
5.78
6.97
6.75
Weather-
Number of fajr days
16
19
16
21
15
172
Number of days on which
rain tell
17
k;
12
14
15
14.5
3U1
Nnclelns.
Nurses,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Suc)i a climate is Jiiauifestl.v uiisiiitpd for an invalid or
delicate person, but affords a gralcfnl change to those
who have become debilitated Ijy the summer heat of a
large city, or for .such as need a change of scene and air.
One is always sure of finding it cool in Nova Scotia, and
it is wise for those intending to visit this region to be
provided with warm clothing.
"Certain sufferers from hay fever." says Huntington
Richards, "enjoy perfect imnuinily from that disease at
Halifax, and probably the same experience may l)e had at
many other points in" Nova Scotia." The natural attrac-
tions of Nova Scotia are many and varied, and its chief
city and port, Halifax, "The Garrison City by the Sea,"
presents many objects of interest to the American travel-
ler. It possesses a superb harbor in whicli. in the sum-
mer, is the headquarters of the British North Atlantic fleet,
and on land a garrison is always quartered here. The pub-
lic gardens are very atti-active, and the drives in Point
Pleasant Park afford delightful views of the water. The
country round about Halifax offers many attractive ex-
cursions; and the roads are fairly good either for driving
or for cycling.
In the interior is ''Evangeline's Land," a lovely, pas-
toral region immortalized by Longfellow. The Annapo-
lis basin and valley, the Bay of Fundy, and the numerous
shore places likewise offer many attractions, both to the
casual traveller and to those interested in the early his-
tory of America. Cajie Breton. Prince Edward's Island,
and Newfoundland are conveniently visited from Hali-
fax.
Good facilities for hunting and tishing are to be had in
various portions of this province. One has a choice of
various routes to Nova Scotia: by boat from Boston di-
rect to Yarmouth or Halifax ; or by boat along the coast
to St. John and then across the Bay of Fundy to Digby ;
by rail to St. John: or all the way by land by the Inter-
colonial Railway from Jlontreal or Quebec. The steam-
ers to Yarmouth and Halifax afford excellent accommo-
dations. Edward 0. Otis.
NUCLEINS are a class of organic bodies of acid reac-
tion, intermediate in composition between proteid and
nucleinic acid, and containing from three to ten per cent,
of phosphorus. They occur in association with proteids
in all animal and vegetable tissues, especially in the nu-
clei, and in miik. They are separated from the proteids
by artificial digestion, the latter being changed to soluble
peptones which are removed, while the nucleins undergo
little if any alteration (Bunge). The nucleins are then
brought into solution by potassium hydroxide. The
commercial article is prepared from yeast or yolk of egg,
and may be either nuclein or nucleinic acid. According
to Chittenden, many of the marketed preparations are
worthless.
Nucleins are insoluble in water, alcohol, ether, or di-
lute mineral acids, but are soluble in alkalies. On boil-
ing with weak acid or alkali, and more slowlv with jjlain
water, they yield phosphoric acid in combination with
organic bases. Some, at least, of them split in the body
into xanthin. hypoxanlliin, guanin, and adenin (Piccard).
It is not known to what extent nucleiusare absorbed, but
probably very little is absorbed, as abundant nuclein was
found in the fa-ces of dogs experimented upon (Bokay ).
The asserted value of nuclein in medicine depends on
its ability to stimulate the antibacterial power of the
animal body, and to cause an increase in tlie luimber of
leucocytes. The solutions have been used in tuberculosis
and septicaemia. (Hare.) Vuughan cured guinea-pigs in-
oculated with tuberculosis. ;md rendered others quite im-
mune to pneumococcus infection. J. Mount Bleyer used
it with good results in diphtheria. Sir R. D. Powell re-
ports recovery in one out of five cases of malignant endo-
carditis. The dose is 2 to 3 gm. (gr. xxx.-xlv.) daily.
(Shoemaker.") 11'. -1. Bastcdo.
NURSES, TRAINING SCHOOLS FOR.— That "the
old order changetli and giveth place to the new " would
seem to describe well the condition of nursing affairs ilur-
ing the past decade and to foreshadow the future. It
must be confessed that during tlie first fifteen years of
their existence, dating from 1878, training schools for
nurses made little if any progress from an educational
standpoint: nevertheless, from the very first their intlu-
ence upon the establishment of hospitals throughout the
country has been enormous. Once the value of systema-
tized methods of caring for the sick was realized, hospi-
tals began to multiply rapidly, and in almost cveiy
instauce a training school for nurses formed part of the
organization, until at the present time there are few towns
in the United States of any size that cannot boast of one
or more hos])itals in which the nursing is at least far su-
perior to that of bygone days.
The liLstory of the organization and development of
training schools for nurses is of so great interest tliat I
venture to introduce here a part of the excellent sketch
which was written in 188!) by Prof. AV. Oilman Thomp-
son, of New York, tor the first edition of tliis H.\ndbook.
"Organized nursing schools are of very recent date,
and their establishment arose from the experience of army
hospitals in Eurojiean wars, especially the Crimean War.
The nurses of religious sisterhoods, midwives, and
monthly nurses were originall)' the women who followed
nursing as an occupation. In France the luirsing is
mainly in the hands of Roman Catholic sisterhoods, and
in the hospitals of Paris alone are over six hundred sisters
who superintend the hired attendants. In Russia the
Sisters of Mercy have done the nursing since the Crimea,
and in Italy a similar arrangement obtains. But in Jan-
uary, 1883," the ' St. Paul's Home for Trained English-
speaking Nurses ' was started in Rome by a few grad-
uates of American and English training schools. This
institution has been very successful. Its object is, how-
ever, merely to afford a home to nurses who have been
trained elsewhere. In Germany, among a great variety
of Protestant and Roman Catholic nursing systems, many
have become famous. Pastor Theodor Fliedner founded
the 'Institute of Deaconesses' at Kaiserswerth in 1836,
where, in after 3-ears, Miss Nightingale completed the
ear]}' training which made her such a successful advocate
of thorough instruction in nursing. There are upward
of three thousand deaconesses at present connected with
this institute and with others in Germany modelled after
it. There are many Sisters of Charity who serve as
nurses, and one of the best secular schools similar to the
training schools is at the ' Kaiserin Augusta Hospital ' in
Berlin.
"The ' International Hospital and Field Service Society
of Surgeons and Nurses ' became famous on foreign bat-
tlefields, and after the experiences of the two last Ger-
man wars the ' Albert Verein ' was organized in Dresden
and Leipsic. The nurses of this society are thoroughly
trained by practical courses and lectiu'es. Rewards and
favors are granted for merit, and. if, after three years of
active service, their health should become impaired, they
are pensioned. They are sent out from the scliool to
nurse private cases.
" In Vienna the ntirsing is done by sisters, and also by
women who work without special organization. In Eng-
land female nurses in hospitals are mentioned as early as
1T60, and in 1791 they were indorsed by the governors of
the London Hospital. In 1801 there were women niu'ses
in the 'Woolwich Artillery Hospital. For the past thirty
years special attention has been directed in England to
nursing systems. At Guy's Hospital nurses were trained
by Mrs. Elizabeth Fry for many vears before a scliool
was formally opened in November. 1879. The Protestant
orders of St. John and of AH Saints for many years per-
formed satisfactorily the nursing for King's College Hos-
pital, Charing Cross Hospital, and the University College
Hospital. The Order of St. .lohn sent nurses with Miss
Niglifiugale to the Crimea. In June, 1860, a training
school was founded at St. Thomas' Hospital, London,
through the generosity of Miss Nightingale. This
school, after being in successful operation for several
years, was made the subject of special study by the New
York State Charities Aid Association, and taken as a
302
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Nurses.
model for the Bellevue Hospital School, as well as for
most of the other American schools. In 1874 a school
was opened at Westminster Hospital, London, and ten
years later a special building was erected with accommo-
dation for tifty nurses. It is desired to establish district
nursing among the poor in connection witli this school.
In 1861 a training school was founded in Liverpool for
district nursing, and a great reform in the quality of nurs-
ing was instituted at the Liverpool Workhouse. In 1866
there were two schools in Dublin, and tliere is now an
excellent school at the Glasgow Royal Infirmary. In
1867 a school was founded at the Sidney lutirniary. New
Soutli Wales. There are also new schools in Russia,
Sweden, and Holland.
"Toward the end of the eighteenth century Dr. Valen-
tine Seaman gave a course of twenty-six lectures to the
nurses of the New Yorlv Hospital upou important topics
in relation to nursing and hygiene. These lectures were
published in 1800, and they are the first recorded effoi-t
for the improved training of nurses in the United States.
In Philadelphia in 1888 the Society of Friends formed a
nurse society by which they raised the standard of nurs-
ing and relieved the Roman Catholic sisterhoods from
doing the work alone. The Philadeljjhia Lying-in Char-
ity has instructed nurses in special branches for fort}--t\vo
years. St. Luke's Hospital in New York has been sup-
plied since IS.'JS (until recently) with nurses of the Prot-
estant Episcopal Order of the Holj' Communion. Sev-
eral Lutheran charital)le societies have trained nurses in
various parts of the country, and some two thousand of
these women served during the War of tlie Rebellion.
During this war women nurses were also sent to the field
and hospitals under tlie auspices of the Sanitary Commis-
sion and of the Amerii'un Society of the Rid Cross. Tlie
latter society, aided by the enthusiasm of Miss Clara Bar-
ton, has done a great deal in recent years to nurse the
sufferers from }-ellow fever and from floods in tlie South
and elsewhere. At Syracuse, N. Y., a Protestant Epis-
copal sisterhood has nursed for the Hospital of the Good
Shepherd for ten years, and the deaconesses are sent out
to nurse in private families, in other institutions, and
among the poor. JIany excellent orders of like nature
have long existed throughout the country for the pur-
pose of training and supporting nurses.
"In 1873 three training schools for nurses were almost
simultaneous!}- establislied in New York, New Haven,
and Boston, and from this year dates the impetus to tlie
improved nursing system whicli has led, in fourteen years,
to the establishment of over tliirty-five scliools in various
cities of tlie L'nited States, with an outlay of many thou-
sand dollars. There have been thus far nearly two thou-
sand nurses graduated."
During the period which has elapsed since Professor
Thompson wrote this account, many new training schools
for nurses liave been established, and on the whole these
organizations— both those of recent date and the older
ones — have accomplished in a fairly satisfactory manner
the purpose for which they were created. Nevertheless.
while the progress which these schools have made affords
much cause for gratitude, there still remain not a few
things to deplore. In the first years of tiie organization
of these schools but little thought and care were given to
the theoretical part of the nurse's work; lier education
was almost entirely of a practical nature, and even in this
she w'as allowed to pursueasomewhat haphazard method,
so that what she did w itli her hands was largely mechani-
cal and but little dominated by the mind. The system
of nursing as first instituted in the leading hospitals re-
qtiired, as a rule, a two years' course of training, and
provided during the first j'car only theoretical instruction
in the form of classes and lectures with examinations, at
the end of the time, in medical and surgical nursing;
these examinations being conducted by two or three phy-
sicians. The didactic course was usuallj' covered in a
dozen or fifteen lectures, and as these w-ere given gratui-
tously by busy practitioners it too frequently liajipened
that the nurses were assembled onlj' to be dispersed again
without the lecture, as the doctor was not able to come.
Furthermore, since these lectures were almost invariably
given at eight o'clock in the evening, a nurse on night
duty was necessarily obliged to miss this part of her theo
retical training for a whole month. Again, since in those
days the pupils were often sent out to care for private cases
during the first year, a nurse who averaged attendance
at half the lectures given during her period of training
was considered as doing well. Added to all this was the
fact, which scarce!}' needs to lie emjiliasized. that a wom-
an who does not reach tliis portion of her theoretical stud-
ies until t!ie end of a long day, after twelve or more busy
lioiirs in tlie wards, is in no mental condition to remember
what she hears. An overpowering sense of fatigue usu.
ally renders her attitude one of painful but not always
successful effort to keep awake. As regards the classes
conducted l)V tlie superintendent or her assistants the
student fared little better, as these were held in the after-
noon and her attendance dei^ended entirely upon whether
the head nurse could spare her from the ward, or not.
Here, again, night duty interfered, as the pupil nurse
could not attend the class work witliout losing a part of
her sleeping hours. Thus, when all these drawbacks are
considered, it will readily be understood that to attend a
consecutive course of class instruction was a rare occur-
rence with a first-year pupil.
The aids to .study, in the way of books especially pre-
pared for teaching the principles of nursing, were meagre
in the extreme; the first manuals on nursing being ex-
ceedingly elementary in their subject matter. So far as
the acquisition of knowledge in anatomy, physiology,
and materia mcdica was concerned the pupil was left
pRictically to her own resources, to obtain it as best she
could, from Gray's "Anatomy" and Wood's "Materia
Jledica" ; and as such books were in most cases unknown
territory to the women before their entrance into hospi-
tals, the knowledge acquired was seldom very deep or
very much to the point. The subject of invalid dietary,
if attempted at all, was covered in a few informal lect-
ures delivered by any one who was willing to give them,
and the nurse was only required to sit and observe the
teacher's methods, being seldom called upon to prepare
food with her own hands. Here again, as was true of
her other classes, the pupil nurse was so frequently ab-
sent that little if any benefit was derived from this
course. The only ethical training was that which was
unconsciously experienced from the admirable discipline
which existed, and from the unquestioning obedience
which was always required from the; junior nurse toward
the medical staff, her superintendent, and the senior
nurses. In making this statement I do not wish to be
understood as minimizing the importance of these fac-
tors, since it was just this discipline which has stood so
many nurses in good stead in after years and which has
helped them to do their part in winning a favorable rec-
ognition of nursing work. In addition to the above,
classes and lectures were held at any and all times during
the year, and vacations were in order continuously, so
that in a school for nurses there was little if any resem-
blance to the usual order that obtains in almost any kind
of institution of learning.
This brief sketch of the educational condition in the
early days of training schools for nurses has been given
in order that the clianges that have come about in recent
years and the efforts that nurses have made, and are still
making, to improve nursing education may be more read-
ily understood and appreciated, and the obstacles tliat
still hinder the highest order of work may be realized.
As training schools increased in number the graduates
from the older schools were selected to become the super-
intendents of the new ones, but unfortunately they were
obliged to enter upon their new fields of work without
any special prejiaration for their arduous and resiionsible
duties, and witli no experience beyond what they had ac-
quired as pupil nurses. Hence it necessarily followed
that much the same methods, or lack of methods, were
introduced wherever a .school opened, and any improve-
ment over the old regime was due entirel} to the super-
intendent's own origmality, powers of imagination, and
30c
Nurses.
>urses.
REFERENCE IIANDKOOK OF THE MEDICAL SCIENCES.
aptitude to impart instrurlion. But among these same
siiperiuteudents tlicre was jjnidually developing a feeling
of dissatisl'aetion with the courses of instruction, as out-
lined in the circulars of information, and the}- were be-
ginning to appreciati' that not enough care was given
to these courses, and that justice was not being done
the women who entered training schools but who re-
ceived nothing beyond a thorough course of training in
nrrsing the sick." At the same time came the many
changes in methods of medical work, the hospital physi-
cians and surgeons requiring at the hands of their nurses
greater thoroughness in the details of the work and a
tineuessof iiuish which had not heretofore been expected,
and which demanded a higlier order of intelligence to
execute. I think that hardly any one at the present day
would venture to deny that the science of bacteriology
and preventive medicine requires both physicians and
nurses to be jteople of intellig<'nce. t)f the nurse it is
now expected that she shall have some knowledge of the
lu'inciples of bacteriology in order to appreciate the value
of surgical cleanliness in the i)revcntion of di.sease, and
t<i be able to do effective work. In order to surround her
patient with intelligent care she must imdcrstand the
principles of ventilation and hygiene; for the projier care
of the body she requires a knowledge of physiologj- ; to
aid it to overcome or resist disease slie must be taught
more than a mere .smattering about foods and the prepa-
ration of invalid dietary. Upon the nurse must devolve
the execution of all such minutia', and to do such work
well it is necessary that she should be endowed with
good common .sense, practical ability, and intelligence,
and then receive a proper education in her profession.
As scicui as the trained nurse became a factor in every-
day life aliuses began to creep in. the salaries ccunmanded
began to attract the purely conuuercial woman with no
aptitude for nursing, and the fact that a better class of
students coulii be obtained by the offer of a degree, and
that cheaper and at the same time better nursing could
he .secured in this way led the owners of sanatoriums and
the trustees of small special hospitals to establish training
schools in which the facilities fcir obtaining a proper pro-
fessional education did not exist. As a consequence
luirses who had devoted some of the best years of their
lives to learning their profession were in tlanger of being
classed with those wlio had obtained a certificate as a
lirice for so many weeks' or months' nursing, but who
possessed little real skill or knowledge. Hence aro.se two
evils — the real graduate nur.se lost standing and the pub-
lie was in danger of being inipos(>il upon.
In the face of these many and serinus ])roblems it is not
to be wondered al that tlic leadeis in tlic nursing world
set to work to find remedies. At first, individual efforts
took the form of trying to improve the educational side
of nursing by grading tlie two years' course of instruc-
tion, making a junior and a senior year, with a .separate
course of classes, lectures, and examinations for each
year. The junior year now included instruction in the
first prineiplesof nursing together with stieh mi-dical and
surgical subjects as were needed to be put into inunediale
practice. Th<' .senior year wasdevoted tomcire advanced
teaching and the study of more diftictdt subjects. This
theoretical course was confined to the eight scholastic
months of each year, lieginning in October and ending
with examinations in June, while vacations were given
only during the sununer months. An clfort was also
made to divide Ihe two years in such a way that each
nur.se might siiend a nearly ei[ual amount of time in the
various branches of the medical and surgical services. In
many schools the practiceof sending the jiupil out to pri-
vate duty during her period of training was ilone away
with, in order that she might follow an uninterrupted
eour.se of instruction. Thus liy degrees the- ciuriculum
in many schools was greatly improved.
But to protect the publieand the educated nurse against
the badly trained woman, to overcome the commercial
spirit, and to establish a uniform standaril of education,
individual superintendents, however earnest and infiui'U-
tial, could at first do little; and imtil unity anmng nin-ses
as a body had been effected and the need for reform and
improvement had liecn generally recognized by each in-
dividual nurse, nothing in the way of permanent progress
cotdd be attained. As this conviction gradually spread
among women who regarded their work seriously, it be-
came evident that for nui'ses. as for other workers, or-
ganization was necessary. For many years anything
like unity of thought or work, or friendship among su-
lierintendents and graduates of training schools in Anu-r-
iea was practically unknown, and there was even no
inpn't lie corps among graduates of the same school. But
amcmg the many congresses held in Chicago during the
World's Fair there was one made up of trained nurses,
working as a subsection of the hospital section of the
Congress of the Associated Charities. This was the first
time in the history of nursing in America that nurses had
come together as members of the same profession. The
most important result of this meeting was the organiza-
tion of the Americiin Society of Superintendents of Train-
ing Schools for Niu'ses, and to the efforts of this society
is chiefly due the jirogress since made in the teaching of
nursing. The avowed objects of this organization were
to lay a solid foundation upon which a good practical
educational standard might be established, and to further
the best interests of the luirsing profession by promoting
fellowship among its members. Recognizing that any
advance must come by the creation of an interest and en-
thusiasm in the wiu'k and in the awakening of an cs/Jn'i
lie ciirps among graduates of the same school, the first
steji was the organization of school alumuM associations.
If these were once well established, the leaders foresaw,
a national association would naturally follow^ AYith
such rapidity were these alumn;e associations formed
that at the end of two years thirty-one were reported,
and the proper time having now arrived, steps were at
once taken to form the national association, which held
its first meeting as the Associated Alumna^ of the United
States and Canada in Ajiril, 1898. Since that time its
member.ship has steadily increased until it now includes
fifty-six aUmma' associations.
With the formation of this association, representing the
nurses, and that of the Society of Superintendents, repre-
senting the teachers and leaders, nurses w-ere prepared to
do effective work. Nor was motive wanting, for almost
simultaneously with the organization of the Associated
AlumUi'P, the Spanish-American war began. Although
too late in its organizafiim to be of service as a liody in
the war, the association soon found an opportunity to
work for a jierituuient reform in army nursing. The les-
sons taught by the lack of an etficient and properly or-
ganized nursing force were so severe that at the close of
the war the nurses' societies took steiis to remedy the
evil; and largely to their work and infiiu'ncewas due the
establishment of the army nursing service with a properly
qualified graduate nurse in charge. The army nur.ses
have ])assed their probationary stage and have so far
overcome the strong prejudice against women in army
hospitals that they may now be regarded as a perma-
nency, and another new field of work is opened up to the
graduate nurse.
The next important event was the establishment of a
nursing journal, controlled and managed by nurses for
the benefit of nvirses. The need for such a publication
had been long felt, and to establish it liad been one of the
objects of the Associated Abnnna'. In October, 1900,
two yeais after the organization of the association, the
Anicrii'iin Joiiniiil nf yiirsiii;/ was started under its aus-
pices, through the exertions of individual mcmliers who
assumed the financial responsibility. The undertaking
is now an assured success.
Both societies liave also been active in luumoting a sys-
tem of hourly nursing, by means of which good care of
the sick at home is sujiiilied at reasonable rates to people
of moderate means and to those who cannot very well go
to hosjiitals. The niu'.se who lives at home and pavs her
own carfare visits her patients once a day. or oftener if
necessary, at a charge of about fifty.cents an hour. By
this plan she is enabled to care for .several patients dur-
304
UEFERENXE HANDBOOK OF THE MEDICAL SCIENCES.
Nurses,
N iirses.
iiig the day, iiudcrtake the most important duties herself
h\ each case, regulate allairs in the sick-room, and then
instruct some member of the family what to do during
lier absence. The method has been tried in several of
llie large cities, and physicians who have employed it
have pronounced in its favor in many cases. There is
nuich to be said for some such form of private nursing,
which, when properly carried out, insures proper care for
many whose circumstances do not entitle them to the ser-
vices of the district nur.se, relieves the family of the con-
stant presence and maintenance of the nurse, and lessens
the expense of the illness; at the same time it enables the
nurse to lead a more systematic life, gives her more rest,
and secvires for her a greater degree of independence
while pursuing her work.
New avenues of work and fresh opportunities are con-
stantly opening up to the graduate nurse by which she
may be enabled to do her full share in bettering social
conditions. Notable among special efforts made by the
nurses themselves is that of the Nurses' Settlement in
New York, situated in the most densely populated east
side portions of the city. It aims, in addition to nursing
the sick poor, to be to "the neighborhood all that the col-
lege settlements stand for. This settlement has steadily
increased in size and usefulness, and now has branches in
other parts of the city. Those who know whereof the.v
speak are ready to bear witness that it has already done
an incalculable amoimt of splendid work.
Outside of merely caring for the sick, the special train-
ing of the graduate nurse is being utilized in many ways.
She is now regarded as a useful member on boards of
hospital managers, on health conmiissions, and on inspec-
tion boards, and in at least one city a trained nurse is a
member of the school board. The project is seriously
being considered of having nurses appointed to visit the
public schools daily under the supervision of a physician,
to repoit to him suspicious cases, to indicate the homes
in which any infectious diseases have developed, to point
out unsanitary conditions e.xi.sting in the schools, and at
the same time to care for the numberless minor ailments
and troubles to be found among large bodies of children.
As the Society of Superintendents stands first and fore-
most for the educational advancement of the nurse, much
thought and attention has been devoted to the subject by
its members, the one chief desire on the part of all being
to supply the public with good, intelligent, practical
nurses. To this end many changes have been made.
The cour.se of training in the majority of schools has
been increased to three years, but luifoitunately in only
a few instances has it as _vet been found possible to lessen
the daily hours of practical work. Even to-day the pu-
l)il nurse spends from nine to ten hours daily at work in
the wards. In a few schools, however, in which a serious
endeavor is being made to jjlaee a true value upon edu-
cation, a three years' course of training, eight hours of
daily practical work, and the non-])ayment system have
been established. According to this arrangement the pu-
pil receives no monetary recompense, her education being
considered an ample ecjuivalent for her time and work,
but text-books and uniform are allowed her in addition
to her board, lodging, and laundry work. Good general
and reference libraries are usually provided in the school.
Nursing literature has been much improved and good
text-books in the subjects taught have been specially pre-
jiared in most cases by superintendents themselves who
have gained by long experience a far better appreciation
of the needs and retjuirements of the pupils than pbj'-
sicians could possiblj' attain to. A graded course of in-
struction is arranged for in mo.st schools, but no uniform
curriculum has so far been adopted. Such a course em-
braces, as a rule, the fundamentals of anatomy, phy.si-
ology, bacteriology, hygiene, and materia medica, and
the principles of nursing in all branches of medicine and
surgery. In the third year a course of lectures and de-
monstrations in massage, ob.stetrics, and nursing in infec-
tious diseases and in diseases of the eye, ear, and skin are
given. More and nifire attention is being paid to instruc-
tion in invalid dietary ; and iu a few schools a teacher is
Vol. VI. —'iO
engaged for this branch alone, and the pupils take a
regular four to six weeks' course of study in food con-
stituents and in the preparation and serving of invalid
diet. During this time tliey are not expected to perfoiin
any ward duties. In the matter of nursing in cases of
infectious disease, in which isolation is necessary, instruc-
tion can be obtained in only a limited number of hospi-
tals. This matter belongs to post-graduate work.
Lastly, superintendents are beginning to realize the im-
portance of giving more detailed and .systematic teaching
in the ethics of nursing, the constant observance of which
is just as important to the graduate as that she should be
an expert in practical work.
Although the instruction given in all these various
branches must of necessity be very eleinentarv in sub-
stance, it has been found that the pupil nurse finds it ex-
ceedingly difficult to prepare her class work, write up
her lecture notes, do any collateral reading, and at the
.same time pursue her long hours of work iu the wards.
Lack of time and bodily fatigue make it practically im-
possible to assimilate the theoretical knowledge imparted
in the courses of instruction. Added to this, the women
of to-day have not as a nde a thorough systematic prac-
tical knowledge of the details of housekeeping, so essen-
tial for any one who expects to become a good nurse and
a good manager in a ward. For these reasons an attempt
has been made in one school in Scotland, one in London,
and one in the United States to give the probationers, be-
fore entering the wards, a so-called preliminary course in
hou.sehold economics, in the theory of their work, and in
the elements of nursing. By this arrangement the pro-
bationer is graduall)' fitted to begin her more arduous
tasks in the ward, with an understanding of what is ex-
jiected of her. Results are much belter for the patients,
and the head nurse is spared having so much crude ma-
terial always on hand to teach : while the superintendent
of nurses can feel sure that the preliminary ground has
been thonmghly covered. The chief drawback to the
general adoption of such a ])laii lies in the extra cost it
entails, an outlay w hieh few hospitals can afford. Under
the aus])icesof the Society of Superintendents a course in
hospital economics was established in 1899. in connection
with the Teachers' College, Columbia L^niversity, New
York, the object of which is to qualify specially selected
graduates for the duties of superintendence in hospitals
and training schools.
Among the more pressing matters calling for reform at
the present time are the following; (1) The establishment
of imiform entrance requirements for proliatioucrs and a
uniform curriculum, as a result of which a graduate's de-
gree ol)tained in anj- part of the country and from any
hospital would practically mean the same thing. (2)
Some arrangement by wiiich the small general hospital
may become a branch of the larger training school, so
that every woman after she has been accepted as a pupil
iu a hospital of good standing — no matter whether it be
large or small — shall be assured a thorough practical and
theoretical education as a mu'se. (3) Some jilan in ac-
cordance with which only properly qualified graduates
shall be employed at reasonable rates to do the uur.sing
in special hospitals, and thus do awa}' with one most ob-
jectionable form of training school. (4) The establish-
ment in certain large centres, in different parts of the
country, of post-graduate courses in general hospitals,
which may be attended b_v graduate niu-ses, who will
then be able to keep themselves U]) to date and become
acquainted with the latest changes in medical and surgi-
cal methods. (5) The establishment of methods by w-hich
the public may be protected from inetlicient and untrained
nurses, while the women who have taken the time and
trouble to perfect themselves iu their profession may be
accorded their proper status.
With the solution of the first four of these problems the
Superintendents' Society is more esjieeially occupying
it.self ; the fifth has been left mainly in the hands of the
Associated AlunH«e, and on this |)oint it may not be out
of place to say a few words. Before a physician is al-
lowed to jiractise his ]iriifc'ssii.u he is obliged to satisfy
305
Nutgall.
Nux Vomica.
HEFEKENCE HANDBOOK OP THE MEDICAL SCIENCES.
tlie Stale l)o;u-d that ho is iimpcrly qualilicd. after wliieli
liis name is duly registered, jlay not scinie form of State
examination and registration equally well linda|)plication
in the case of graduate nurses? Vt'c are not suggesting a
panacea — registration will not cure all defects in nurses,
but it will at least afford some sort of a guaranty, and to
a certain extent put it in the power of the ]iuhlic to learn
for itself the legal status of any woman who offers her-
self as a nur.se for their sick; at tlie same time it will
jCrve as a hall mark, as it were, upon the woman who
has spent time and labor to render herself a good nurse.
and will distinguish her from the nondescript individual
who so often poses as a trained nurse.
In this paper reference has mainly been made to changes
which have occurred in the nursing world on this conti-
nent during the past decade. But even should we be in-
clined to flatter ourselves that America has led the van,
it must not be supposed that other countries have been
far l)ehind in tliese matters. It .should be a matter for
sincere congratulation that there has been established an
entente cord/ale between the members of the nurs-
ing profession in all countries, whereby we have
been brought into closer touch than ever before.
One professional link has been forged between
America and England in the form of the Inter-
national Council of Nur.ses, which has as its ob-
ject "the furtherance of the social and profes-
sional progress of all nurses and the mainten-
ance of a high standard of nursing ethics and
esjirit (le fnrpK." and to which we trust nursing
associations in all countries may become allili-
ated in the course of time.
It is a satisfaction to be able to record that in
no civilized country has the development of the
nursing jjrofession been at a standstill, and every-
where our members have been workin,g out their
own problems according to their several needs.
A more comprehensive account of the work being
done by nurses throughout the world will be
found in the Proceedings of the Third Interna-
tiona! Congress of Nurses held in Buffalo in
September, "l!il«.*
While the greater part of the progress in nurs-
ing has been mainly due to the efforts of nurses them-
selves, they have been fortunate in securing in their un-
dertakings the active sympathy of the medical profession
and of hospital authorities who have a])preciated the fact
that the better the nurse the more are their own eilorts
strengthened. It still remains for tlie well-to-do laity to
realize how ncces.sary and important to them is every
st«p taken for the betU'rmeut of the nurse. After all. the
sole object of all the work and progress is to rendei' the
greatest good to the greatest number when sick and in
sore need of the best, that human skill can all'ord. and
were some portion of the flnancial aid so lavishly jioured
out upon university and other institutions of learning
given to render the profession of nursing still more
worthy of its name, such an outlay woidd assuredly be
returned in good measure pressed down and running over.
Isabel Ihiiiqitdn Rohh.
NUTGALL.— G((W.y, U. 8.; Br., (hdh : GnlUr ; Qalla
haUipensis ; G. Turcica; G. leointicit ; G . tiiicturia ; G.
quercina. Excrescences on Qt/ercns liixitmiinr Lam. (Q.
infeetoria Olivier, fam. Ciiptilifene), caused by the punct-
ures and deposited ova of Ci/iiips U>il'^"f''J'''", Latreille)
Gallw tinctoria-, Olivier (Class Jnsccin. Order llymenop-
tera).
The species of oak here named is very variable and
widely disseminated, growing over the greater part of
Southern Europe, in the Levant, and in Western Asia.
The variety which produces the galls is usually a mere
shrub less than six feet high. The insect named is a
small, wasp-like fly. The female jiunctures certain of
the unexpanded buds, leaving a single egg in each, thus
•This report may be obtained through the American Journal of
Nursing, published at 6H Chcslnut Street, Philadelphia, Pa.
306
causing it to develop into a gall, instead of a leafy
branch. A spherical cavity is formed by the growth of
the gall, its lining being of a different structure from that
of the remainder of the gall. The larva, wiien fully de-
veloped, gnaws its way out, leaving a pinhole perfora-
tion. After this occurrence the gall presents quite a
different appearance, being larger, lighter in color and
weight, and less rich in active constituents, such galls
being distinguished in commerce as White galls, and less
highly esteemed than those collected at an earlier period.
Description. — Nearly sidierical. about 2.5 cm. (1 in.)
or less in diameter, with a short stipe, the surface smooth.
FIO. a;07.— The Nutgall Oal;, Sliowing Leaves. Acorns, and One Nut-
gall. (Baillon.)
except for a number of short, thick tubercles toward the
summit ; externallj' deep greenish- or bluish-gray or black-
ish; heavy and hard, but readily broken with a hammer,
exhibiting a more or less dense giaunlar fracture, .some-
times with a waxy lustre: internally, yellowish or pale
brownish-giay, with a centiul nucleus or a cavity con-
taining the more or less perfectly developed insect. The
granular tissue of the nucleus is mostly tilled with small
starch granules and surrounded by a layer of thick- walled
cells forming a shell, on the outside of which is the cellu-
lar tissue containing the tannin. This tissue has often a
radiated appearance near the shell, and contains toward
the surface small scattered bundles of vascular tissue.
Nutgalls are uearlj- inodorous and have a very astringent
taste. Light, spongj-, and whitish-colored nut-galls should
be rejected,
Nutgalls are distinguished in commerce .according to
their color, the hbic or black r/alls of Syria (Aleppo) being
preferred. Siii!/riia rjalls are usually of a grayish olive
green, more spongy in texture and intermixed with irldte
ffalls.
Many other varieties of galls, especially the Chinese
variety, have a similar composition and uses, though sub-
HEFEHENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Nulgall.
Nux Vomica.
stitution or adulteration of the medicinal arlicle is hardly
to be looked for. C'liiuese galls are large, oeeasioually
three inches in length, oblong-ovoid and somewhat tlat-
tened, coarsely tuberculate. tlie tubeieles very irregular
in size and often prolonged into branches. This gall is
(if a yellowish-gray color, densely and softly tomentose
or velvety, light in weight and hollow, the wall being
thin and crustaeeous.
Nutgalls contain upward of .sixty per cent, of gallotan-
nic aeid. two or three percent, of gallic acid, occurring
as a natural derivative of the former, and small amounts
of resin, sugar, and starch.
Action and Uses. — The properties of nutgall are those
of tannic and gallic acids, in a degree corresponding with
their percentages as stated above, and the reader is re-
ferred to those drugs for an account of its action and
uses.
The official preparations of nutgall are the tincture,
containing twenty per cent, of nutgall with ten per cent,
of glycerin, and the ointment, which consists of twenty
per cent, of the drug rubbed up with <'iglity ])er cent, of
benzoinated lard. Ihnrij II. lluahtj.
NUTMEG.— (il///'-/."?/!-!?. U.S.; Br. Semen. Myristictv;
Ger. jMuskatnuss; Fr. Muscade.) The dried ripe seed of
Mjiri.iticd fnifirnnf; llouttuyn (fam. Myristicacca), de-
prived of its testa.
Nutmeg is the product of a handsome, small, ever-
green, dicecious tree, native of the Molucca Islands, now
widely cultivated in tropical regions, such cultivated
trees, "mostly in the JIalay Archipelago, supplying the
commercial article. The fruit is tiesliy, one-seeded, and
when rijie much resembles the peach. The fleshy peri-
carp is tardily dehiscent and the seed is enclosed, though
only ]mrtially covered, by a fleshy network, consisting of
thearil. This is removed and dried to form mace (which
see), leaving the seed as an oval body faintly grooved,
where the aril has rested ujion it. It is dried by a slow-
and tedious process, requiring about two mouths. When
dry the nutmegs are beaten to break tlie testa, from which
the kernel has now shriudcen away, and the latter then
constitutes the oHicial nutmeg. It is nearly an inch in
lengtli and smnewhat more than half as broad, oval tn
ovoid, ver_y slightly flattened in one direction and not
quite equilateral, of a rich brown color, slightly shining,
more or less furrowed, with a circular scar at the broader
end, from which a slight groove runs to a deeper depres
siou near the smaller end. When cut transversely it ex-
hibits a pale, brownish-yellow surface, of a fattv lustre,
and marked by narrow curved brown lines entering from
the surface and containing folds of the tegmen or inner
coat. The odor is strong and agreeable, the taste similar
andsomewhat bitter. The ordinary nut meg of commerce
differs from this in being grayish-white from a partial
covering of lime, which serves the imr])ose of protecting
it against the attacks of insects, to which it is very liable.
Such nutmegs are distinguished as " limed " or "Dutch,"
the others as " brown " or " Penang. "
The important constituent of nutmeg is its volatile oil,
stated in most books to amount to from two to eight jier
cent., but of which there is very niueli more. The otlier
constituents are the following: aliotit forty jier cent, of
iixed oil. of which about three-fourths is removable by
expression, a small amount of an unstudied bitter prin-
ciple, starch, protein, gum, and other ordinary constitu-
ents. The volatile oil {Oleum Mi/ristieii; U. S., Br., or
Oleum Kticistce ^Hthcreujn) varies considerably in char-
acter, according as a larger or smaller percentage has
been distilled from the nutmeg. When freshly distilled
it is colorless, but grows yellow or even reddish and
thicker with age, at the same time changing its odor to .a
heavy and somewhat disagreeable character. It has a
pleasant flavor, followed by a warming and lilting or
slightly acrid effect. Its specific gravity ranges from
0.87 to" 0.90 at 15= C. (59° P.). It is soluljle in an equal
volume of alcohol, the .solution being neutral, and in the
same amoiuit of glacial acetic aeid; it is freely soluble
in carbon disidphide. It consists chiefly of myristicol
(C,„H,„0?) and myriKtirin (CoHmOs), together with pi-
nene, myristinic acid, and other unimportaut substances.
This oil ])ossesses the properties of nutmeg in an inten-
sified degree. The conuuereial article holds a small
amount of the fixed oil in solution. The fixed oil (Olenut
Myriaiea; E.rprcssum, Oleum Aiiciiita\ Adcpx or Butyrinii
Myriiiticm or Nudstw, Nittmey Butter) is expressed by
the aid of heat. It usually occurs in the form of cakes,
wrapped in palm leaves, is solid and firm at ordinary
temperatures, melting at about 45" C. (113° F.), has "a
mottled, orange-brown and whitish color, a s-])ecific grav-
ity of about 0.995, a pleasant buttery taste, but with a
slight fragrance anj taste of nutmeg, "due to the presence
of a little of the volatile oil in solution. It dissolves in
four parts of boiling alcohol or in two of warm ether. It
consists chiefly of inyristin, C\)ii,(V M^-O.^),, with three or
four per cent, of free myri.stic acid. Tliis oil is very
much stibjeet to adulteration with, or substitution by, the
fixed oils derived from other species of niyiislior. es-
pecially that fnim M.fettiui llouttuyn. This fat has no
special medicinal properties but merely those of other
vegetalile fats.
AVhole nutmegs are at the present day scarcely e\cr
sophisticated, though the long, wild, or male nutmegs
above mentioned as being used to adulterate nutmeg but-
ter, as well as some other species, are occasionally olTered
for them. Artificial nutmegs, pressed from a preiiareil
paste and very inferior in odor and taste, have been fir-
quently reported. Ground nutmeg is usually adulter-
ated, often very heavily so, and the freshly grated article
should be insisted upon.
PitoPEUTiKS \v.D Uses. — Almost the entire use of nut-
meg is for Havoring purposes, although it possesses use-
fid properties as an ordinary aromatic stimulant and car-
minative. JIany cases of mild, and several of rath<'r
severe poisoning by overdoses (from two to five nutmegs)
are reported, the symptoms being those of a narcotic or
severe depressant, in some respects similar to those of
overdoses of camphor. There is no preparation, properly
speaking, of nutmeg, though it enters into the aromatic
jiowder and the compound tincture of lavender. Of the
volatile nil there is an oftieial five-jier-cent. sjiirit, thedose
iif which is 2-4 c.c. (fl. 3 ss.-i. ), the do.se of the oil as a
carminative is rq, i. — iij., and a small amount of it enters
into the aromatic spirit of ammonia.
Henrii 11. liusby.
NUTRITION. See Mct„hoUsm.
NUX VOMICA.— L'. S., Br.. Semen stryehni: P. G., Se-
nn li lutei.s eninic'i' ; PuiKon JS'ut ; Dog Button!*; Qiiaken'
l>utfi>n,H. The dried ripe seed of Strychnon Niix n/inica
L. (fam. Loyanuicnrj.
Nux vomica seeds are produced in the East Indies by
a small tree which bears a fruit similar in appearance
to a small orange. There are from one to four seeds,
usually with a few undeveloped ones, found embedded in
the whitish, jelly-like pulp of tlie fnnt. The smaller the
number of seeds the larger they arc likely to be, and the
richer in active con-
stituents. Although
the ])riueipal con-
stituent of the pulp
of the fruit is the in-
diflerent glucosiile
lii)/anin, yet it alsn
contains strychnine
(about 1.5 per cent,
in the dried pulp)
and brucine (aliout
one i)er cent.) and is
h i g h 1 }' poisonous.
The leaves also con-
tain a considerable percentage of brucine. and probably
some strychnine, and are poisonous to cattle.
Desciuption. — About 1.5-2.5eni. (|-1 in.) broad, lentic-
ctdar, btit irregularly curved, with an elevated central
spot upon one or both sides and upon one side a low ridge
Fm. oiins.-Nii.\ VomicM;
and lojigitudiuul section.
Ion.)
uter surface
(After Bail-
307
Nye L.i(lii;i S|ii-iii^>.
•Obstetric 0|>eratioiiM«
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
(the raphe) niiiniiig thence to the edge; externally graj'^
grcenish-giay or liglit yellowish-gray, silky in lustre and
to Ihe toiiefi. densely clothed willi a coat of closely
ap])n'sscd. shining hairs; internally hard, very tough,
somewhat translucent, consisting of two discs of peri-
sperm which enclose a thin, circular cavity and the
embryo which has small heart-shaped, palmately nerved
cotyledons; inodorous and inlcnscly and persistently
l)itter.
Nux vomica .sec<ls ate so abundant and cheap that there
would appear to be little temptation to adulterate them;
yet not oidy is the ])o\vdere(l drug subject to adulter-
ation, but, vvhat is of more importance, it varies widely
in quality. Hence the great importance of insisting upon
ofticial standards as to the alkaloidid assay of the prep-
arations.
CoNSTiTUKNTs. — Tlic one imiiortant constituent of nux
vomica, from a medicinal point of view, is strychnine.
The activity of the drug is wholly dependent upon that
substance, and the de.iirec of this activity conhunis closely
to tlie amount which it contains, although the latter state-
ment is sul)ject to certain modifications, in accordance
with the following facts. Associated with the strychnine
is a certain (juanlity of the similar alkaloid bruciue, —
a quantity which either may be equal to, or may be
twice as great as, that of the strychinne present. Tiie
action of this alkaloid is almost identical with that of
strychnine, although variously estiinaled at from five to
ten times weaker. This variation in the strength of bru-
<-ine is undoubtedly due to the presence in it of variable
iimouiitsof strychnine, which it is almost impossible com-
pletely to remove. It is to be remembered that the alka-
loids, besides being highly insoluble, exist in nux vomica
intimately associated with an extremely tough, liorny al-
.buminous substance, so that if the |)Owdered drug be
taken, they may be less (piickly ;uid completely absorbed
than wdien strychnine alone is administered. Constitu-
ents which are not im])ortant from a medicinal, though
more or less so from a pharmaceutical, standpoint are the
tannin-like (V/r!A"HC(c or xtryelniic arid with which the alka-
loids are combined, a considerable amount of fixed oil, a
small amount of the glucoside loganin, a little gum. sugar,
etc. The condiiued percentage of .strychnine and bru-
.<;ine ranges from two to five per cent, or even more, of
which the strychnine represents from one-third to one-
half. Strychnine will be fully <liscussed under that title.
./?)•«(■?';<(! (C2sH2eNo04 -I-4H3O) occurs in very fine eolor-
iJess crystals, forming a whitish powder, soluble in alco-
iiol. It is distinguished from strychnine by being red-
dened by nitric acid. It forms salts freely, several being
>i|ion the market; Ihe sul]diate, which is si>luble in water,
lis the one chielly euii]loyeil.
Action .\M) Usks. — Exi'epting as to the preparations
.and dosage, an account of the action and uses of nux
vomica would In; a duplication of that given under
f'trye/iniiii; to which the reader is referred. Brucine is
■somewhat used in a similar way, in doses of gr. J|y to gr.
i, the total daily amoimt not to exceed gr. iij. It is also
sometimes applieil externally to relieve itching.
The tiose of nux vomica, in very tine powder, is 0.00-
■0.24 gm. (gr. i.-iv.). Of nux vomica the following are
the offi<-ial preparations, subject to assay by processes
Xirescribed bv the l'harmaco|)o'ia; The extract, to contain
1.') per cent.' of total alkaloid, dose 0.0(W-O.OG gm. (gr.
^r to gr. i.) ; the fluid extract, to contain 1.5 percent, of total
jilkaloid, do.se it|, i.-iv. ; the tincture, to be made by dis-
solving 20 gm. of the dried ollicial extract in 1,00(1 c.c. of a
juixture of three volumes of alcohol and one volume of
water — this tincture to contain a total of O.'.i per cent, of
the alkaloid, and the dose to be O.iJ-I.S c.c. ( Ul,v.-xxx.).
It will thus be seen that the lluid extnict is five times as
strong as the tincture, and the extract ten times as strong
as the tluid extract. /Inu-i/ If. Rushy.
NYE LITHIA SPRINGS.— Wythe Comi.any, Virginia.
I'ost-Offk'K. — ^Vytllevilll■. Hotel and boarding-
Iiouses.
Accf.ss.— Via Norbilk:uid Western liailroad to Wvthe-
ville, thence two miles over macadamized carriage roads
to springs.
Tliese springs arc located in the southwestern part of
Virginia, in a charming. picturesi|ue loc-dity. ime (piarter
of a mile from the corporate limits of Wytlieville. The
elevation of 2.3()0 feet above the sea level gives assurance
of a cool and delightful summer temiierature. The coun-
try about Wytheville has long been celebrated in the
South as a summer health resort, and the _yearly vLsitors
came frfJin far and near. The average _vearly temper-
al ure of Wy tla'ville is 53' F. Tlie .seasonal temperatures
are as follows; Spring, 52° F. ; summer, 70.0 F. ; autumn.
53° F. ; and winter, 32.3° F. The highest summer tempera-
ture observed during the past three years has been 88° F.
in the shade. The region is quite free from malarial and
miasmatic influences. The springs are surrounded by a
tract of eighteen acres of the jirimeval oak forest, which
furnishes a delightful shade in the summer. The accom-
modations for vi.sitors are as yet somewhat limited, but a
conunodious hotel is incinitemplatiori for the near future.
Two good hotclsand numeiousexeellent boarding-hou.ses
will lie found in Wytheville. The springs are three in
nuud)er, two lithia and one chalybeate. The summer
temperature of the two lithia springs is respectively 53"
and 54 F., and the chalybeate 56" F. The following
analysis of two of the springs is furnished by Dr. George
L. Nye, the resident physician;
Nyk I,itiii.\ SritiNii, No. 1.
(Analyzed by AV. L. Dudley, Vanderbilt University.)
ONK I'MTF.n STATKS (i.VLLON CONTAINS;
Soliils. liralns.
Calcium rarbonate 10.83
Lithium oarhnnate 6.41
Iron aiKi alniiiina oxide 31
Silicic acid 1.19
Total 18.54
Nyk Cii.vLVBE.vTE Seniso.
(Analyzed by J. L. Jarman, of Emory and
Henry College.)
ONK I'NITEll STATf:S (iALI.ON CONTAINS:
Solids. Grains.
Potassium c:irlionale a. 01
Sodiuiu larlii.iiate 81
Lillinnii earl I. male 1 .89
Calcium carlionale 11 .fiO
Mag:nesium carbonaip 2.35
Iron and alumina oxide 1.33
Silicic acid 66
Total .• 18.65
Rating the lithium in these analy.ses as the bicarbonate
it would amount respectively to 11.77 and 3.48 grains
per gallon.
The watei's have huig been highly jirized in the treat-
ment of a variety of disorders. Dr. Nye pi'csents numer-
ous reports of cases fi'om competent ])liysicians illustrat-
ing the benellcial influence of these waters in diabetes
and other urinary di.sordeis. Their action in cases of
dyspepsia and intestinal affections is also very advan-
tageous. The chalybeate water is in high repute amon.g
])hy.sieians for the relief of menstrual and uterine dis-
oi'ders conseciuent uiion ana'iuia, Jiiine.i K. Crook.
NYMPH/EACE/t.- 77/,' }Vnt(,--inii F,i„nlii. This
small laiiiiiy of ;ii|uatic plants conti'ibufes several large,
coarse. s]H>iigy. dark-colored rhizomes which have been
used in medicine. The white water-lilies jiertain to the
genus Ciistiiliii Salisb. , though long miscalled ]\')/>tip//<r<i,
the latter name still being applied to them as drugs. The
species most used are C. iillm (L.) Lyons {Ni/inpha'a a.
L.), the European white water-lily, C. odortda (Dryan-
der) VVoodv. et Wood (Nyinphiva o. Diyander), the Fra-
grant or Sweet scented w'hite water-lily, chielly of East-
ern North America, and the ('. tuhti'o.sn (I'aine) Oreene,
the tubenius whit<' water-lilv, chiefly of Central North
30 s
REFERENCE HANDBOOK OF THE MEDICAL SCIEN'CES.
>'yf L,lllila Springs..
Obstetric Operatloas..
America. The yellow water-lilies or pond-lilies. Spat-
ter-docks, or Flatter docks, pertain to the genus 3ym-
phmi L., though long miscalled yuphar. The specie's of
this genus which has Ix-en most employed, and the nature
of which is best known, is N. liitea L.," the European yel-
low pond-lily. From this rhizome has been extractcd'the
white amorphous alkaloid nupharine. to which its bitter
properties are probably due. The constituents of the
other species named are but little known, though they
contain bitter principles apparently similar to nupharine.
All contain resin, tannin, starch, and gum.
The uses of these drugs are not based upon any scien-
tific knowledge other than that they arc mild astringents
and bitter tonics. In this way they have been used as
astringent gargles, intestinal astringents, and for local ap-
plications in gonorrhea, leucorrhn?a, etc. The dose of the
fluid extraet'is i.-iv. cc. (fl. 3 i-i.). Henry 11. liusby.
NYSTAGMUS is an involuntary rhythmiccontraction of
the ocular muscles producing oscillation of the eyeballs.
It is due to imperfect cortical innervation of the volun-
tary muscles of the eye, and may result from either cen-
tral or peripheral causes, or from both. The movements,
which usually affect both eyes, may be vertical, rotatory!
or lateral, but the most conunon'form is from side to
side. It is most commonly oliserved in eyes that are
defective congenitally. as in albinos, or fronicoloboma of
the choroid, raicrcphthalmos, etc. Various inflammatory
or degenerative diseases of the eyes, chiefly when they
occur in early infancy or childhood, frequently cause nys-
tagmus. This condition must not be confounded with
the slight tremor observed upon voluntary movement of
the eyes in efl'orts at fixation in various directions which
is so often found in a.5Sociation with weakness of the ocu-
lar muscles.
Nystagmus may be acquired, and is often seen in those
employed iu coal mines, and is due to the work being-
done in cramped positions under poor illumination, the
gaze being directed obliquely upward. Fati<:ue is thus
induced in the superior recti and inferior obliques, and
also iu the internal and external recti muscles, finally
causing their spasmodic action. This t_\pe of nystagmus
may also be regarded as a fatigue neurosis.
Nystagmus also occurs iu various diseases of the ner-
vous system, and is often a conspicuous symptom in mul-
tiple sclerosis, cerebellar disease, and Friedreich's hered-
itary ataxia. It occurs in many diseases of the brain,
such as tumor, softening, hemorrhage, meningitis, sinus
thrombosis, etc. As a localizing symptom U is of no
value, but it is an important diagnostic .sign in the cariv
stage of degenerative affections of the central nervous
system.
In multiple sclerosis nystagmus is a frequent svmptom.
Spontaneous movements like those seen in alljiuism or iu
congenita! ocular defects are rare. The nvstagmus is
usually manifested when the eyes are moved" voluntarily
in various directiens, especially on lateral movement.
Iu cerebellar disease nystagmus has been classified as
an irritative .symptom, being^ascribed to pressure on the
pons and corpora quadrigemina.
William M. Leszynsky.
OAK ORCHARD ACID SPRINGS.— Geneseo Countv
New York.
PosT-OFKirr;.— Medina, Orleans County.
Access.— Via New York Central Railroad to Medina,
a station forty miles west of Rochester, thence six miles
south by stage.
The springs are not usctl as a resort, but the waters
have been sold to some extent. The accompanying analy-
ses show the waters to possess exceptional ]iroi)erties.
These springs are remarkable in the amount of ifrce
sulphuric acid which they contain- more, indeed, with
one or two exceptions, than is to he found in any other
waters known. Waters eontaininsr this acid in free state
are exceedingly rare. It is said that none of the kind is
known in Europe, .\mong the few known on this side of
the .Vtlantie are the following: One in the town of Byron,
ONE CVITED STATES GaLLO.N CO.NTAIXS:
SoUds.
Spring No. 1,
(Silliman and
Norton.)
Grains.
Spring No. 2,
(E. Emmons.)
Grains.
Oak Orchard,-
acid water,
(Piof. Porter.)-
Grains.
Sodium sulpliate
Calcium sulphate
Potassium sulpliate
.\iuminum sulphate
Magnesium sulphate
Iron sulphate
6., 34
74.89
.5.. 52
21.69
35.60
2.44
4.59
134! 73
vi.Xx
4^98
39.23
1U.S8
129.06
3.16
13.72
2.48
6.41
8.49
Iron protosulphate
32.22
1.43
3.33
6,65
133.31
Silica
Organic matter
Sulphuric acid
Total
314.42
l'.8.40
211.20
near the Oak Orchard Spring: the Tuscarora Sour Spring
in Canada: the Matchless Mineral Well in Alabama: and
several acid springs iu Texas. California, and Virginia.
According to Prof. J. II. Armsby. of Albanv. the Oak-
Orchard water has been tised with advantage in "ill-
conditioned ulcers, diseases of the skin, passive hemor-
rhages, diarrhceas depending upon an atonic condition of
the mucous membranes, and in depravetl and impover-
ished conditions of the body from specific diseases and-
from intemperance. " The water requires dilution before
drinking. James K. Crook.
OAK. WHITE.— QuEHcrs Alb.\. Onk Bark. "Th&
bark of Quercus alba L. (fain. Ciipuliferm),'' V. 8. P.
This species of oak-tree is one of the commonest and most
abiuKlant of its genus, as well as the largest, in Eastern
and Central North America. It yields one of the most
highly prized of American hard-wood timbers. The
bark is thus officially described : "In nearly flat pieces,
deprived of the corky layer, about a quarter of an inch
(6 mm.) tiiick, pale brown: inner surface with short,
sharp, longitudinal ridges: tough; of a coarse, fibrous
fracture: a faint, tan-like odor, and a strongly astringent
taste. As met with in the shops, it is usually an irregu-
larly coarse, fibrous powder, which does n()l tinge the-
saliva yellow." The last character distinguishes it fronr
the largely employed bark of Quercus tinetoria. In
nearly ail temperate countries some locally occurring oak
is used as an astringent: the British oak, Q. Uohiir L.
iu Europe, the holly oak. Q. Ih.v. in France and else-
where. In our own country, also, other species besides
the white oak are sometimes used and were formerly ofli-
cial (Q. coccineavel tinetoria. Gray, etc.).
White oak bark is simply an astringent. It contains.-
from five to ten per cent, of tannic acid— jirobably iden-
tical with the quercitannic a^id of Q. Jioliur—iuufn little
coloring matter.
It is used in decoction (.5^) for cracked or tender nip-
jiles. indolent granulations, leucorrlio-a, nasal catarrh,
etc., and is occasionally given internallv, in do.ses of i.-^
iv. gm. (gr. xv.-lx.). Finely powdered white oak is often
blf)wn into the narcs to check hemorrhage.
OBESITY. See A(lij,os,t„s
Iknry 11. Rustty.
OBSTETRIC OPERATIONS. -Induction- op AnoR-
TION.— This means the interruption of pregnancy before
the period at which the child is viable. It is aii opera-
tion performed solely in the interests of the mother and,
as Hirst says, should be undertaken as reluctantly as-
justifiable homicide. The indications arc; perniciou.s;
vomiting, pulmonary and cardiac disease, nephritis,
chorea, acute mania, inelancholia, and pernicious ana-mia.
Pregnancy may have a very deleterious effect upon each
of the above disorders, an<l iu allowing gestation to con-
tinue, the physician may sacrifice the lives of both mother
and child ; the induction of abortion should be rcgardeil
only as the last resort and never be undertaken without
consultation. Among the loc:d condilions which may
call lor the termination of the iiregnaiicy must be men-
30»
Obslrlrio
Opcratlous.
REFERENCE HANDBodlv OF THE JIEDICAL SCIENCES.
tioned incarceration of therctrolloxi'd '.itenis. lieniorrliagc
from the normally or abnormally situateil placenta, and
excessive contraction of the pelvic canal. In this last
condition the choice lies between abortion and C'a'sarean
section; the claims of each operation should be presented
to the mother.
Methods of LkIiicijh/ Artifieinl Ahortion. — The uncer-
tain methods of drugs and electricity are to be con-
demned. The induction of arliticial abortion should be
made a surgical o|)eration. and. if i)Ossible. completed at
one sitting. There is but little danger if the procedure
has not been delayed until the patienfs strength is ex-
hausted and if careful asepsis is observed throughout.
The instruments required are; rubber pad, leg-holders,
weighted speculum, volsella forceps, steel-branched
dilators, a large intrauterine curette, ovum forceps,
intra-uterine irrigating tube, and fountain syringe. The
patient, having been aua-sthetized. is placed in the dor-
sal position with knees well drawn up and secured with
the leg-holders; the parts about the vulva are shaved
and cleansed, the vagina is scndihed with soap and irri-
gated with warm sterilized water. By means of the
speculum and volsella the cervix is exposed and secured ;
with the dilators the cervix is gradually stretched u)i to
t wo or two and a half inches. Owing to the softening the
tissues usually yield readily, but this part of the o]iera-
tion must be conducted without haste. The finger is the
best instrument for removing the contents of the uterus,
and in the first two or three months of pregnancy there is
but little trouble in reaching the fundus, especially if
counter-pressure be made upon tlie abdomen with the
other hand so as to crowd the womi) down upon the in-
ternal finger. After the attachments of the ovum have
been freed the membranes are drawn out over the hooked
finger. In case of dilticulty the curette may be used to
loosen the tissueand the pieces removed with the forceps,
but the finger is the guide for all intra-uteriiie mani]nila-
tiou, and touch alone will determine when the operatinn
is completed. Finally, an intra-uterine irrigation of Imt
sterile salt .solution will remove clots and act as an elll-
cient stimulant to the uterine muscle. Chemicals should
not be injected into the uterus; when strong enough to
affect bacteria they become poisonous to the woman.
Some operators advise the introduction of a gauze drain,
but this should be unnecessary. In some cases the cer-
vix may be rigid or the pregnancy too advanced for the
operation to be readily completed at one time. Under
the.se circumstances some authors recommend making use
of tents. l)ut the difficulty in rendering them aseptic
sliould forliid their emiiloyment. The cervix may be
partially dilated with the steel dilators and then the
lower uterine segment and cervix firmly packed with
gauze supported b_y a vaginal tampon. Such treatment
controls hemorrhage and stimidates the uterus so that at
the end of twelve hours the packing can be removed,
when the cervix is found softened and contractionsare es-
tablished. If there is no Ijaste the case may be allowed
to progress naturally or the operation can be completed,
but in all cases the finger must be used before deciding
that the uterus is empty. During the performance of
artificial abortion there may be profuse hemorrhage
which usually ceases as soon as the uterus is emptied and
stimulated with tlie hot saline solution. If oozing con-
tinues the hypodermatic administration of ergot and
even the introduction of the intra-uterine tampon of
gauze are indicated. In bad cases of retrollexed uterus
it may be impossible to reach the cervix ; in such cases
the fundus should not be tapjied through tlie vagina, as
some books recommend, but the proper treatment is ab-
dominal section and manual reposition of the uterus.
Induction of Puematurk L.\boii. — Iriflicntio/is. —
JIany of the' indications for this operation are the same
as those mentioned under the heading of Induction of
Abortion, the pregnancy having been allowed to proceed
in the hope of obtaining a viable child. It is evident
that the later the operation can be delayed the better the
chances for the child, and that the after-care will make
a great difference in the infant mortalitv. Deformed
pelves: Here the operation comes into competition with
symphyseotomy and Ciesarean section. Heymann says
that in cases of disproportion between child and maternal
pelvis the best time for the induction of labor is from
the thirty-third to the thirty-fiftli week. Among chil-
dren so born the mortality is 6-1.3 per cent. In simple
flat pelves an internal conjugate of two and three-fourths
inches is considered the lowest limit; three to three and
three-fourths inches in the generally contracted pelvis.
The success of the treatment of deformed pelves by in-
duction of premature labor depends upon careful meas-
urement of the diameters, accurate estiiuatiou of the size
of the fietal heatl, and correct calculation of the duration
of pregnancy. Each case must be studied by itself, and
for further jiarticulars the reader should refer to the arti-
cle on Pilre!', Dtf"rnuiJ. Placenta praevia; In the major-
ity of cases the first hemorrhage does not occur until after
the period at which the child is viable. Labor should be
induced at once, as further delay does not improve the
chances for the child and threatens the life of the mother.
Eclampsia: most authorities advocate the induction of
labiir not only when the convulsions appear, but when-
ever the pre-eclamptic symptoms refuse to yield to treat-
ment. On the other hand, Stroganoff reported fifty-
eight successful cases without the induction of labor
{Aowriciin Gyn. Journal, May, 1901).
ykthods of Indtiri/tg Prciiniture Labor. — Puncture of
the Jlembranes: This method is uncertain and contrary
to nature. Tampoinng the Vagina: This also is uncer-
tain and not advisable unless there is severe hemorrhage.
Injection of Glycerin: This is dangerous, although many
successful cases have bec/n reported. Insertion of an
Elastic Bougie: This is known as Krause's method, and
is advocated by many. An aseptic bougie is passed up
as far as possible between the membranes and the uterine
wall: the bougie is then supported by a tampon placed
in the vagina. If no contractions set in at the end of
eight hours, a second bougie is introduced. When the
lalior is induced, the bougies are allowed to be expidled
ailing with the fo'tus. This method is frequently unsuc-
cessful, and there is some danger of sepsis, as a bougie
is difficult to disinfect without ruining it. The chief ad-
vantage lies in the fact that the procedure is an easy one
for a person who has very little skill in manipulation.
Dilatation of the Cervix : This is the most desirable meth-
od and may be carried out in vaiious ways. The patient
is anaesthetized, the cervix slightly dilated with the steel
dilators, and then the entire cervical canal and vagina
are packed with iodoform gauze. If contractions are not
evoked at the end of six or eight hours more gauze should
be introiluced. As .socm as the labor is started it may be
allowed to proceed unaid<'d. Instead of gauze the rubber
bags of McLean or Barnes ma.v be used; these are passed
into the cervix and distended with sterile water. Before
introduction their strength should be tested awl the num-
ber of syringefuls of water required should lie noted.
McLean's bags are divided by a compartment through
tlie centre so that each side can be distended .separately.
Charpentier do Ribes' ba,g is made of silk covered with
rubber and, when dilated, forms an inverted cone meas-
uring three and one-fourth inches at the base. This bag
is folded, introduced into the lower segment of the ute-
rus, and filled with water; the stimulation is increased
b_v making traction upon the tube ccmnected with the
apex of the bag. These hydrostatic dilators both open
the cervix and cause uterine contractions. De Ribes'
bag is very useful in placenta praviaas it makes direct
pressure upon the bleeding lower segment. A certain
amount of preliminary dilatation is necessary for the pas-
sage of any of these bags. When haste is essential, as in
placenta prievia. the cervix can be stretched by the fin-
gers, later by the passage of the entire hand; manual
dihitatiou may be independent of, or may supplement,
the other methods. The delivery of the ftetus may be
accomplished by version or by the apiilication of forceps
according to the reipiireiuents of the case.
L.\CEK.\TioN OF TitK Cehvix. — Slight ruptures of the
cervix occur in almost every first labor; they may add
310
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
ObHli'ti-U-
Operallous.
somewhat to the danger of septic infectiou, but are other-
wise unimport;int. Deep tears are tlic result of tlie rapid
passage of the fa'tal head through a rigid or iniperfeetly
dilated cervix. Precipitate labor, tlie applicatiou of liigh
forceps, aud version frequently cause cervical laceration.
Malignant disease and the presence of cicatricial tissue
are predisposing conditions. The tears usually are longi-
tudinal and situated on the left side, but may also be
bilateral or stellate ; in rare instances tlie anterior lip has
been torn away by being caught between the inner sur-
face of the pubis and the presenting part. Evidences
of Cervical Laceration: The lesion may be suspected
v.henever the ])rescuting part takes a sudden jump
through a jjurtially dilated cervi.x, but the chief sign of
serious rupture is hemorrhage. Whenever heraorihage
continues from an empty and well-contracted uterus the
parts should be inspected for lacerations. A speculum
is seldom necessary as the parts are so relaxed; the cer-
vix can be caught witli a volsella forceps aud pulled
down into view. I'ropliyla.ns : Non-interference with
normal labor, care in avoiding premature rupture of the
membranes, and the postponement of operative procedures
until the cervix is dilated or dilatable are the important
points under this head. Treatment : Extensive tears,
especially tho-se giving rise to hemorrhage, require the
introduction of sutures. For this procedure anaesthesia
is rarely needed as the parts are not sensitive, particu-
larly just after labor. B)' means of a speculum and vol-
sella the cervix is exposed and .secured; with a curved
needle in a holder catgut sutures are introduced from
side to side. If the gut be chromicized there is no dan-
ger of its too early absorption, altliougli some operators
use silkworm gut. No special after-treatment is called
for, except the removal of uon-absorbable sutures upon
the tenth day.
Sfcnntldfy Trachelorrhnphji. — Neglected lacerations of
the cervix maj' give rise to symptoms and, under some cir-
cumstances, they seem to predispose to tlie development of
cervical cancer. The laceration allows the cervical canal
to gape open and exposes its interior to friction against
the sides of the vagina; hypertrophy and hyperplasia of
the epithelial tissue ma.y ensue, giving rise to the so-
called " granulations " and being accompanied by profuse
leucorrha;a. In other cases tliere is an extensive deposit
of cicatricial tissue making the cervix club-shaped and
producing reflex disturbances. A tear in the cervix nia,v
cause prolonged congestion of the uterus, thus delating
involution and weakening the supports so that displace-
ments readily occur. Symptums : In chronic cases these
may be leucorrhiea, backache, dragging sensations, men-
orriiagia, and dysmenorrho^a, as well as a wide varietj' of
reflex symptoms. The diagnosis can be I'eadily made
by vaginal touch ; on inspection we may see a club-shaped
cervix or a red, eroded-looking surface covered with ex-
uberant "granulations" and purulent discharge. The
varieties of tears are unilateral, bilateral, and stellate.
TnulielorrhiipJiy. — Lacerations which give rise to
symptoms or show signs of irritation .should be treated
by operation. The instruments needed are: a rubber
pad, leg-holders, weighted speculum, a knife or Emmet's
scissors for denudation, volsella forceps, tenaculum,
h;emostatics, needle-holder, and straiglit cervix needles
with large eyes. The patient is anaesthetized, placed in
the lithotomy ]iosition, and tlie vagina cleansed. After the
introduction of the speculum and exposure of the cervix
the anterior and posterior lips are brouglit together liy
means of tenacula so that the extent of the tear and the
position of the canal may be judged. Each lip is then
denuded, care being taken to remove all the cicatricial
deposit from the angle of the tear. In a bilateral lacera-
tion a stri]i of mucous membrane is left in the centre of
each lip to form the lining of the canal ; stellate lacerations
are denuded in such a way as to make the lesion unilateral
or bilateral; all diseased tissue containing Nabothian
ovules and hypertrophied glands should be removed.
The field of operation is kept clean by means of small
sponges on holders or by continuous irrigation. Chrom-
icized or formalin catgut answers every purpose as suture
material, although many operators use silkworm gut.
The sutures are passed from the outside of one lip just
below the angle of the tear, the needle coming out at the
edge of the undenuded cervical canal, then reintroduced
into the other lip and brought out so as to correspond
with the jioint of entrance. The first or angle suture is
the most diflicult to insert. The sutures are caught in
the grasp of a pair of haemostatic forceps and not tied
until all are introduced. After knotting and cutting the
ends of the stitches iodoform is dusted upon the cervix
and the speculum withdrawn. The patient is kept quiet
for a week or ten days at which time non-absorliable
sutures are removed.
L.\CEKATiONs OF THE PERINEUM. — Schroeder states
that the perineum is torn in thirty-four per cent, of
priniipara; and nine percent, of multipara'. The general
cause of laceration is disproportion between the size of
the foetal head and that of the vulvar opening. Some-
times the child is ,so rapidly expelled that the tissues
have not time to become pliable, or, as is the ca.se with
elderly women, the parts may not be sufficiently elastic.
When the mechanism is fatilty the axis of the presenting
part may be directed too far backward and plougli into
the posterior wall ; this is the case in occiput perma-
nently posterior. The perineum is often lacerated when
the delivery is by means of forceps. Tears are divided
into complete and incomplete, according as they rupture
through the sphincter aniornot; the incomplete tears
may extend as far as the border of the muscle or stop
.short of it. In rare instances there occurs a "central
rupture," the child being born through an opening be-
tween the anus and vulva. The laceration extends for
a variaVile distance uji tlie vagina on one or both sides,
rarely in the median line. It is important to remember
that the function of the levator ani may be impaired bj-
overstretching without there being any evidence of ex-
ternal tear. The prophylaxis of perineal laceration i-i
discussed in the article on Ltibor, yorimil. Briefly, this
consists in carrying out one or more of the following
procedures; 1. Restraining the descent of the head to
allow time for the gradual stretching of tlie ti.ssues. 2.
Diminishing the power of the expulsive efforts by the
administration of chloroform. 3. Keeping the present-
ing part well forward undei- the symphysis" 4. Perform-
ing manual extension or flexion, according to the require-
ments of the mechanism, between the pains by means of
a finger in the rectum. After the second stage is over
every case should be examined to learn the condition of
the pelvic floor.
Treatment. — All lacerations should be repaired imme-
diately if possible; the stitches may often be inserted
before the delivery of the placenta while the parts are
numb or the woman still under the anaesthetic, the su-
tures not being tied until after the third stage is com-
pleted. ^Yhen circumstances make postponement un-
avoidable just as good results in the way of union are
obtained at the end of twenty-four hours. Primary
0]ieration — Incomplete Tear: the instruments needed
are: curved needles, needle-holder, .scissors, thumb for-
ceps, and suture material. The rubber pad is placed be-
neath the buttocks and the le,g-holders are ai)plied ; the
parts are cleansed and bits of ragged tissue trimmed away
with the scissors; a wa<l of sterile cotton or gauze may
be placed in the vagina to prevent blood from olisciu-ing
the field of operation. The closure of the incomplete
tear is a simple matter and requires the application of
none but the ordinary surgical jirinciples. The rent in
the vagina should be closed by a running suture of cat-
gut and the remainder of the "tear brought together by
side-to-side sutures of silkworm gut. If no vaginal
stitches are required the silkworm gut may be introduced
and the ends secured with a haemostatic until the pla-
centa is expressed; but if there is much laceration of the
vaginal wall, it is best to defer all suturing until after
the third stage. Complete Tear: The essential iioint of
this operation is to bring together the ends of the torn
sphincter ani. The first suture should be introduced
well back, about on a level with the posterior margin of
311
Operatlous.
REFERKNCE HANDBOOK OF THE JIEDICAL SCIENCES.
the anus, then buried iu the recto-vaginal septum and
hrou.clit out at a coiTespondinsr point on the other side;
usually two sutures suffice fur the sphincter. The rest
of the operation is the same as that for iiiconiiilete tear.
If the laceration extends up the rectum, the rent in the
bowel should be united by meausof catgut stitches intro-
duced from the rectal side of the lesion. There are no
special features about the aftcr-tri-atment; the parts
should be irrigated after each urination and kept dusted
with iodoform. Even whcu the tear was a com|)lete one
the bowels should be moved on the second and each suc-
ceeding day, the fa'ces being softened by the injection of
a little olive oil.
If lacerations Involving the pelvic floor are not sewed
up at the time of their occurrence there may be unpleas-
ant results. The posterior vaginal wall may begin to
roll out, forming a rectocele: as the anterior wall is sup-
ported by the ]iosterlor a cystiicele may be added, and
these two conditions interfere with the functions of blad-
der and rectum. The prolapse of the vaginal walls drags
upon the uterus uutil its supports yield and displace-
ment occurs. The attempt to innervate the weakened
or ruptured muscles is a severe strain upon the woman's
system, and the general health becoiues Impaired, while
tile altered position of the uterus Interferes with the
functions of the pelvic organs so that nicnorrhagla and
dysmenorrha'a may be present. In cases of complete
tear there Is Incontinence of fieccs. The diagnosis of
old laceration is made by inspection and digital examina-
tion; the tear may be represented by cicatricial tissue;
the vulvar opening may gape; on directing the patient
to "liear down." the lack of support Is manifested by a
protrusion of vaginal tissue. Tlie oidy treatment is by
operation, which must not be performed inside of two
montlis after labor in order to give the uterus time for
involution.
Semndary Ptrin&)rrh<ipliy. — During the week preced-
ing operation it Is well to direct tlie patient to avoid
milk and live upon a diet of animal broths and food
which will produce but little residue; such a course
of preparation will add greatly to the prospects for suc-
cess if the operation is to be for a complete tear. For
several days In advance the patient sho\ild be given daily
laxatives and high bowel washes; a large enema should
be administered on the moniuig of the operation. The
instruments required are: rubber pad, leg-hohlers, long
scissors curved on the flat, scalijel. rat-toothed forceps,
tenacula, ha-mostatics, needle-holder, curved and straight
needles, suture material of catgut and silkworm gut.
After the jiatii-nt is ana'stliellzed she Is placed In the
lithotomy ]iosltl(in, the iierineum is shaved, and the parts
are rendered aseiitlc. If. liy means of tenacula, the two
lower caruncuhe myrtiformes ami a point on the poste-
rior vaginal wall are brought together, a good idea of the
area requiring denudation may be obtained. There are
two typi<-al opi'iatloiis which meet the demands of the
majority of cases, Hegar's and Emmet "s.
Heg.mi's OpiiUATiox. — The three points to be deter-
mined In this operation are the apex of the rectocele and
the two lower carunelrs. With thcscalpel a line is made
at the margin of the skin and mucous membraue connect-
ing the lower caruncles of either side, and from these
points the Hue is carried U]) to the apex of the rectocele
on the posterior vaginal wall. This triangular area with
a curved base is then denu<led with the scissors. Begin-
ning at the point farthest up the vagina catgut sutures
are Introduced, the needle lieing directed in a slanting
course downward on one side until the centre of the
vaginal wall Is reached and then upward to a spot corre-
sponding with thestartiirii-point. In tlils way the upper
part of the triangle Is closed almost down to the carun-
cles. A straight needle Is noAV threaded with silkworm
gut and a suture is pas.sed from side to side, beginning
just above the posterior commissure. The next two
sutures are inserted al)ove the lirst "and jiassed Into the
vagina and out again ou the o]ii>osite side, drawing the
two caruncles and the centre of the vaginal wall Into
their correct relations.
Emmet's Operation. — This operatiou is particularly
well adapted to those cases in which the tear Involves
the lateral aspects of the posterior vaginal wall. The
denudation Is triangular on either .side, leaving a V-shaped
piece of nmcous membrane in the centre. The lateral
areas are closed by catgut sutures ; the edges of the lower
part of the denuded area are brought together with silk-
worm gut. the upper suture being known as the '"crown
suture," as it secures the apex of the V before emerging
on the other side. If the tear has extended into the rec-
tum, great care must be taken to freshen the edges of the
sphincter ani; the insertion of the sutures and the after-
care do not differ from the description given when treat-
lug of the primary operation. Non-absorbable sutures
are removed on the eiglith or tenth day.
Forceps. — Forceps consist of two blades, and are eitlier
of the long or the short variety ; long forceps may be ])ro-
vlded with appliances for axis traction. The curves of a
forceps are two, cephalic and pelvic; the former adapts
the blade to the side of the ftetal head, and tlie latter
coincides with the axis of the pelvic canal. Short for-
ceps have no pelvic curve. To insure a tirm grasp good
forceps should have a moderately long handle, and
should be as stiff as possible without making the con-
struction too clumsy. The cephalic curve should be of
moderate sharpness, viz., about tliat represented b}' the
arc of a circle whose diameter is nine inches; such a curve
will grasp the head securely and yet not be ditlicult to
introduce. The tips of the blades should be about one
inch apart when the handles are closed. Long forceps
should measure not less than nine and one-half inches
fnmi the lock; when the instrument is applied to the
head the pelvic curve has its concavity directed upward
toward the symphysis. The blades of forceps are locked
either by means of a pin and slot, or there are grooves on
the shoulders Into which the shank of the opposite blade
sinks. Slioulders upon the liandles or a loop in the
shank above the lock for the insertion of the forefinger
are desirable features. There are many varieties of ex-
cellent forceps In the market, and choice is only a matter
of in<llvidual taste provided the forceps have the charac-
teristics just enumerated.
Axis-Ti!.\CTioN Forceps. — When the blades are ap-
plied to the head at or above the brim of the pelvis the
traction should be made in the axis
of the superior strait, that is, down-
ward and backward. With the
ordinary long forceps traction in
this direction is very difiicvtlt to
carry out, and the force exerted
acts at a disadvantage. In all
axis-traction forceps rods are ap-
plied to the blades iu such a way
that the traction can be made in
the axis of the blades, that is, in
the axis of that portion of the ca-
nal in which thev He. The handles
are held in apposition by means of
a screw, and there are joints be-
tween the rods and bar as well as
between the rods and blades, so
that the head can move freely
cither in rotation or flexion and ex-
tension. The standard axis-trac-
tion forceps Is that which was de-
vised by Tarnler, but there are
many modifications of the original
instrument, one of the best being
tlie Jewett forceps (Fig. 3611).
Edward Reynolds has <levlsed rods
which hook into the blades of any
pair of long forcejis, and are fairly
satisfactory. Forceps should be
made of metal throughout so as to
insure perfect cleansing and steril
izatlon : for the .same reason all the
parts of axis-traction instruments should be detachable.
AHioii and Vsex of Fnrcfps. — First of all, the forceps is a
Fig. .3609. — Hod b I
Forceps.
312
REFERENCE HANDBOOK OF THE jVEEDICAL SCIENCES.
Obstetric
Operations.
Fig. 36111. -Jenk-
Forcevf^-
tractor; it is also a lever as far as producing flexion and
extension of the head is concerned ; but leverage carried
out by swaying the instrument from side to side is to be
avoided as very dangerous to the soft parts of the mother.
In rare instances the instrument is
used as a rotator, as in turning an
occiput forward ; but this also is
dangerous, and, as a rule, the
blades should be allowed to turn
with the head as it descends. Fi-
nally, the powerful a.\is-traction
forceps are compressors, and great
care must be exercised lest this
[iction of the instrument injure the
I'a-tus.
Indications for Appliralion of For-
ceps.— Most frequently the applica-
tion of forceps is required because
tlie maternal forces are unable to
Cipel the fcctus uu account of sim-
ple uterine or abdominal inertia.
Provided there be no contraindica-
tions, it is a general rule that when
the presenting part has remained
stationary for two hours forceps
should be applied ; of course such a
rule is a very rough one. as each
case should be managed to stut
particular conditions. Forceps may
l)e demanded either in the interest
of the child or in that of the moth-
er, and in many instances these in-
terests are combined. Under the
head of maternal conditions should
be mentioned: imeuinonia, valvu-
lar disease of the heart, and ec-
lampsia; accidents, such as placenta praevia, accidental
hemorrhage and rupture of the uterus ; abonnalities of
the parturient canal, such as contracted pelvis, tumors,
and rigidity of the soft parts. Fcetal indications are
imdue variation in tlie strength and rapidity of the heart
beat, prolapse of the funis, and sudden death of the
mother. There are certain definite contraindications to
the use of forceps which are important to bear in mind.
The forceps never should be ajiplied when the contrac-
tion of the pelvic canal is excessive. As a rule, a con-
jugate of three and one-half inches is the limit in ca.ses
of contracted pelves. Forceps should not be applied to
the hydrocephalic head nor to one that has been perfo
rated or is decomposing. Except in a few cases of
placenta pra-via in which ver.sion is contraindicated the
instruments shoidd not be applied to a bend which is
still movable above the brim. Before performing a
forceps operation the meiubraues must be ruptiu'ed and
the cervix nmst either be dilated or dihitable. The blad-
der and rectum shoidd be enijity and the position of the
head known. It is unjustifial)le to make traction upon
a head which is descending in such a Avay as to develop
an impossible mechanism, as in persistent meuto-pos-
terior and brow cases.
Technique in Appli/inr/ Forceps. — The operation is
known as hirli forceps when the head is at the brim; as
low forceps when on the perineum; and as intermediate
forceps when it is between these points. Only the opera
tions of high and low forceps need to be described.
High i'o/re/M.^The operator should haveat hand what-
ever is necessar}' for the treatment of postpartum hem-
orrhage and the repair of ruptured perineum ; strict
asepsis should be observed throughout. The forceps are
sterilized by boiling, and tlie outer surfaces of the blades
smeared with stei'ile vaseline. The patient is anaesthetized
and placed across the bed, or better, upon a table, the
knees being held by assistants or secured by leg-holders.
After the urine is drawn and the parts are cleansed the
physician should make a thorough examination in order to
determine the exact position of the head. The left blade
is introduced first; this is the one lying in the left hand
of the operator and occupying the left .side of the pelvis
The operator grasps the handle of this blade near the
lock, holding it lightly between the thumb and fingers
of the left hand in a position almost parallel with tlic
right groin of the mother; two fingers of the right luuid
are introduced into the vagina, and the tip of the instru-
ment guided gently along their palmar surfaces until the
blade conies to lie beside the fodal head. During intro-
duction the handle of the forcejis swings toward the me-
dian line of the mother and at the same time downward
so as to cause the pelvic curve to adapt itself to the axis
of the superior strait. The shank of the instrument
presses back the edge of the perineum when the blade
is in place. Giving the handle to be steadied by au as-
sistant, the phj'sician passes the other blade in tlie same
way over the one already inserted, reversing the posi-
tion of his hands to do so. If at any time during the
operation contractions of the uterus are evoked the phy-
sician must suspend ojieration until they have passed.
The next step is locking the forceps. To do this the
handles are gently depressed. If the blades do not read-
ily come together no force must be used, but with a
finger within the vagina they should be carefully rotated
until they come into proper relation. If it is now impos-
sible to lock them, it is because they are improperly ap-
plied, so they should be removed and reinserted. After
they have been locked, the handles are brought together
or a towel can be placed between them if the operator
wishes to avoid the danger of making too mucli com
pression upon the head. Before making traction it is
well to make au examination to assure one's self that
the blades : 'e within the cervix, and that neither the
hair nor any of the soft parts are caught
iu the instrument. At first the trac-
tions are made in a direction down-
ward and as far Viack as possilile; tluy
should imitate the action of the uterus
by being intermittent, and the handles
should be slightly separated during the
interval of rest so as to relieve the heai;
froin compression. In diflicult cases the
traction maybe made with the pains, the
patient being placed in Walcher's posi-
tion, viz., at the edge of the table with
her heels just touching the floor. This
posture increases the anteroposterior di
aineter of the inlet, but diminishes that
of the outlet; so when the head has
passed the brim the woman is returned
to her original position. As the head
descends in the curve of Cams, the di-
rection of the traction changes more and
more to the front until, when the head
is on the perineum, the handles of the
forceps point almost directly upward.
The forcejts should now be grasped in
the right hand with the palmar surfaces
toward the operator; with the left hand
he supports the perineum and
shells out the head by swinging
the handles until they are almost
parallel with the woman's abdo-
men. As flexion or extension of
the head is under perfect control
when the forceps are applied, am
pie time m.ay be takeu
to allow for full dilata
tion. Sometimes it is
wise to remove the foi-
ee|)s just before the
largest diameter of the
head comes through
the vulva. When axis
traction is used, the
liandles are secured by
means of the screw and the force is exerted ti|)on the
cross-bar. As the axis-traction instruments are very
jiowerful, it is most important to relax the handles be-
t ween pulls.
Fici. .■3«ll.— .lewett's Axis-Traction For-
cep.s. Witt] Separate Trartidii Rod ,\i-
tached. (Fora detailed dcsiTipIutii of
this instrument see Ibe linntldt/u
Med. JintruaJ. Januar.v, 18'.t.j.)
313
Obsletrlt-
Operations.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Low Forecps. — In a])pl_ving forceps to the head when
lou" down no regard need be paid to the pelvie curve of
the instrument — in fact, there is uo such curve upon the
sliort forceps. The application of the bhides is easy, and
the extraction of tlie head is performed in tlie same way
as during the last stage of a high-forceps delivery.
Forceps ill Bnech Labors. — The forceps are devised to
tit the child's head, but they are sometimes applied to
the breech when impacted. The blades are applied either
o\i'r the trochanters or over the sacrum and posterior
part of thigh according as rotation lias or has not taken
place. The lirst pulls must be gentle as tlie blades are
apt to slip; axis traction is particularly useful iu these
cases.
Prognosis in Forceps Operations. — Low foj-eeps should
cause no danger either to mother or child, but the high
nperatinii is iiot to be undertaken lightly. The dangers
to the mother are sepsis and injury to the soft parts; to
I lie child the long and severe compression often proves
fatal.
Version. — Version or turning is an operation which
alters the position of the f<etus in utero so that the prc-
.senting part is changed and a different pole of the ftetal
elli])se is made to occupy the lower segment. There are
three varieties of version: (1) Cephalic, when the head
is brought to the internal os; (2) pelvic, in which tlie
breech is made to present itself; ('A) podalic, when one or
both feet are pulled into the vagina. According to the
nature of the maiiipulaticms used in its performance, ver-
.sion is divided into external, internal, and combined.
Cephalic Version. — Theoretically this form of version
should be performed in all cases of breech and transverse
presentation, ])rovided there is no need of immediate de-
livery and narrowing of the jielvis is absent. The ad-
vantage is that there results a normal presentation ; but,
unfortunatelj', the field for its employment is limited.
It can be carried out only when the liquor amnii is pres-
ent or immediately after the rupture of the membranes.
To iierform external cephalic version, the patient is put iu
the lithotomy position with knees and thighs well tiexed.
< >ne li.iud is placed over the head and the other over the
breech; then by a succession of gentle impulses the head
is pushed toward the pelvis and the breech toward the
fundus. During a uterine contraction all elforts at turn-
ing should cease, the operator only attempting to hold
the fwtus stationary. When the head has once entered
the pelvis jiads should be placed on either side of the ab-
domen until engagement has taken place. The conihineil
nittlonl is known as the bipolar method of Braxton Hicks,
and is carried out as follows: The patient is ana'sthetized
and placed in the lithotoni)' position; the bladder and
rectum must be emptied. After the parts have been
rendered asejitic, the disinfected hand is passed into the
vagina and one or two fingers into the cervix. The pre-
senting part is pushed away from the internal os in a direc-
tion toward the breech, while the outside hand forces the
head toward the pelvis. When the fa-tus lies obliquely
the operator uses externally the hand which corresponds
to the position of the head. By the cimjoined action of
the internal and external hand the head is gradually car-
ried into the pelvis.
I'c/cic Version. — This operation is not often performed,
as podalic version has largely taken its place. It is indi-
cated in casesin which there is sliglit jielvic iiarrowiugand
no need of immediate delivery, also in transverse ]ne.sen-
tation when the breech is situated lower than the head.
It is carried out by the external and combined methods
in the .same way as described under Ceplialic Version.
I'odalic Version. — This is the most common form of
version. The indications arc: malpreseiitations and mal-
positions, minor degrees of pelvic narrowing, espcciall}'
of the flat type in which this operation may compete with
symphyseotoiu}'. A conjugate of three and three-fourth
inches is placed as the lowest limit tor the elective oper-
ation; this limit may be reduced to three inches if the
woman lie placed in Walcher's position. Podalic version
is also indicated in emergencies such as prolajise of the
cord anil placenta prievia. The contraindications are
tetanic contraction of the uterus with marked thinning of
the lower segment, rujiture of the uterus, impaction of
the presenting jiart, and extreme contraction of the pelvis.
The difliculty of the operation increases according to the
length of time which has elapsed since the rupture of the
membranes. The chief dangers are rupture of the uterus,
sepsis, and constriction of the child's neck by an imper-
fectly dilated cervix. Podalic version is carried out by
both the combined and the internal methods. The C«h/-
liined or Bipolar Met/iod of Hicks: The first part of the
operation is performed in the same way as that described
in treating of cephalic version, the breech instead of the
head being forced into the pelvis. As soon as a knee or
foot is felt opposite the internal os the membranes are
ruptured, the extremity is seized and brought into the
\agina, and the version is completed by traction upon
the leg thus brought down.
Internal L^oihdic Version. — The bipolar method be-
comes impossilile as soon as the membranes have rup-
tured and the uterus is closed down upon the fo?tus.
The hand is introduced into the uterus, one or both feet
are seized, and the turning is made by traction, while the
external hand makes counter-pressure upon the abdomen.
The important points in the technique are as follows:
Place the woman in the lithotomy position, empty the
liladder and rectum, use an aua'sthetic, and carry out
strict asepsis. JIake sure of the pre.sentati(m and posi-
tion, and ,see that the child is alive and in no immediate
danger. Do the version as early as possible after rujjture
of the membranes. Introduce the hand corresponding to
the position of the feet. If the membranes are unruptured,
do not rupture them until the feet are reached. Grasp
one or both feet, and during the traction keej) them in
line with fhefo'tal ovoid. If the hand or arm is delivered,
jiut a tape around it and keep the extremity alongside
the trunk.
Extraction after Version..- — LTsually the child is immedi-
ately delivered, after internal ])odalic ver.sion, by pulling
successively upon the legs and trunk, the line of traction
being directly downward toward the floor until the scap-
ula appear. The body of the trunk should be covered
with a cloth both for the sake of warmth and to iirevcnt
the operator's hands from slipjiing. The next steji is the
freeing of tlie «/'//(*■ which have dragged behind and be-
come extended alongside the head. The posterior arm
should be freed first iu the following manner: The oper-
ator holds the child's legs near the malleoli and forcibly
swings the trunk upward and outward over the thigh of
the mother, keejiing the back of the child anterior. If
the right fietal arm is posterior, the trunk is swung over
the mother's right thigh and vice ver,sa. The ojierator
jiasses two fingers over the posterior shoulder into the
vagina until he can reach the forearm and swec]) it across
the child's face b.y flexion, finally delivering it by exten-
sion. The trunk is then swiing in the opposite direction,
and the other arm delivered in tla; same way.
Extraction of the Head. — In the delivery of the head firm
]iressure from above by the Iiauils of an a.ssistant is most
importiint. The child should lie maile to straddle the
left arm of the operator, two lingers being inserted into
the mouth to maintain flexion; the Angers of the right
hand are laid across the shoulders. Traction is first
made downward and then the face carried over the peri-
neum bj' swinging the child's body up over the abdomen
of the mother. If the pelvis is of the flat type, the head
should be rotated into the transverse diameter of the
inlet. When necessary AValcher's position may lie em-
ployed. Prague Jfethod : The feet are grasped in one
hand, and the fingers of the other hand -are placed over
the cliild's clavicles; the lect are carried upward while
the fingers on the shoulders act as a fulcrum around
which the head swings. Derenter's Method: No atten-
tion is paid to the arms which are left alongside of the head.
Tractions are made upim the feet and shoidders directly
downward .and then the child is swung under the moth-
er's buttocks. This method is Siiid to be ver_v speedy in
apiirojiriate cases. Forceps may be applied to the child's
head by passing the blades underneath the elevated
31i
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Obslolrlc.
Ui><-ratlona.
■-4
trunk. Extraction, as a rule, should not be attempttd
until the cervix is dilatalilc. liaving been rendererl so
either by nature or b\' tlie manual efforts of the opera-
tor. Forceps is said to be particularly useful wheu there
is constriction at the cei'vix.
After the extraction of tlif anus,
the head must be delivered in
from tliree to live niiiuiles at
the longest if a living child is
to be obtained.
Symphyseotomy. — This is an operation
for cutting through tiie pubic syinph3'sis,
allowing the bones to separate, and thus
increasing all the pelvic diameters. A
separation of two and three fourths inches
increases tlie conjugate about onedialf
inch, the oblique one and one-third, and
the transverse a little over one inch; fur-
thermore, a portion of tlie jireseuting part
may enter the opening between the l)ones.
Iiulieatioiin. — The operation is indicated
whenever a slight increase in tlie diani
eters will permit of the delivery of a liv-
ing child, hence in contracted pelves.
The lowest limit for the ojieration in a
general!}' contracted pelvis is three and
three-fourths incites; in a tlat pelvis three
inches (some authors say two and three-
fourths). Thus under certain conditions
symphyseotomy enters the field against
Cesarean section, craniotomy, and ver-
sion. Other indications are impacted oc-
ciput posterior and chin cases. As tlie
operation is designed solely in the inter-
ests of the child, the final decision must
usually rest with the woman or her repre-
sentative. ViintrainOiciilii'iiis. — Death of
the faHus. the existence of ankylosis of
one or liotli sacroiliac joints. The opera-
tion should not be performed before the
cervix is dilated or dilatable.
Methods of Operating.— TXw open or direct method
should be avoided, as the wound is so situated that
septic infection is wellnigh certain. The instruments re-
quired are tlie Galbiati or IMori.sani sickle-shaped knife,
a blunt-pointed bistoury, scalpel, luemostatic forceps,
needles and needle-holder, silkworm gut, metal cathe-
ter, iodoform gauze. ad]iesiv<' jilaster, dressings, and a
strong binder. Sometimes there is difficulty in cutting
through the symphysis (usually becau.se the operatoi-
misses the joint), so a cliain-saw should be at hand.
The patient should l>e ana'sthetized, abdomen and vulva
cleansed and shaved, the bladder and rectum emptied.
An incision about two inches long is made just above
the upjier border of the symphysis and the attachments
of the recti muscles cut sufbcicntly to permit the intro-
duction of the left forefinger behind the symphysis. The
catheter is inserted into the bladder and the urethra and
bladder are depressed downward and to the right. The
sickle-shaped knife is passed along the left index finger
and hooked under the symphysis; by a sawing motion
the joint is cut through in a direction from lielow up-
ward and from within outward. If a few fibres of the
ligament are missed they can b(' cut with the bistoury.
The wound is now packed with gauze to control tlie
hemorrhage and the catheter is removed. The child is
delivered by means of the axis-traction forceps while two
assistants support the siiles of the pelvis to prevent
excessive separation of the bones. An excellent method
of operating is the suhcatii nevus, as advocated by Dr. E.
A. Ayers, of New York. He makes an incision under tlie
elevated clitoris, inserts a probe-pointed bistoury, and
cuts through the joint from above downward and from
behind forward, the left index linger being in the vagina
and pressed against the iiosterior groove of the joint to
serve as a guide.
After-Treatment. — The placenta is expressed and uterine
contractions are secured as after normal labor. The cat he-
I
Fig. :ii>l;;.— lial-
bi.iti's Knife
for iSymphy.se-
otoiiiy.
ter is reintroduced to hold the bladder and urethra away
while tile pubic bones are pressed together, the abdominal
wound is sutured with silkworm gut and a broad strip of
adhesive plaster pas.sed is about tlu' pelvis. The woman
must be confined to bed for at least three weeks and the
most scrupulous cleanliness ob.served. Unless the sus-
pended bed of Dr. Ayers be used, tlie care of the bowels
and bladder is a very troublesome and dillicult matter.
The patient usually requires catheterization for a certain
length of time. The dangers of tlie operation are .sepsis,
hemorrhages, development of fistula-, and lacerations of
the soft parts, all avoidable with ]iroper care. In a very
few cases undue amount of motility at the symphysis
has remained and tlie sacroiliac joints have been injured
by permitting the separation of the bones beyond three
inches.
Prognosis. — The general mortality is given as from
eight to twelve per cent., but many of these fatal cases
were operated upon after the patient was already ex-
hausted or septic. Ayers has reported thirteen cases
withcuit the death of a mother, and eleven children saved.
As the chief danger is sepsis, there should be no maternal
mortalitv when the o]ieiation is performed under favor-
able conditions, and, for tlie average practitioner, it is an
easier operation than either craniotomy or Ca>sarean sec-
tion. The fa-tal mortality is not the result of the opera-
tion, but of the antecedent conditions.
E.MHKVOTOMY. — This term includes all operations de-
signed to reduce the bulk of the ftetus, namely, craniot-
omy, decapitation, and evisceration.
Crenit'ofomy. — This ojieratiou diminishes the size of the
fu'tal head. The indications are: Death of the fa-tus.
If the fa;tus is already dead, there is no rea.son why the
suffering of the mother should not be shortened and the
case concluded as rapidly as possible, even if the partu-
rient canal is of normal calibre. Contracted pelvis: two
and one half inches in the conjugate is placed as the
lowest limit, and even before this limit is reached the
operation may be more dangerous for the luothcr than
Ciesarean section. Obstruction of the canal by tumors,
monstrosities, large size of tlie fa'tal head, and"im]iacted
malpositions of the f(etal head are other indications.
The sacrifice of a normal child's life is seldom justifiable
when the very favorable results of
Ca'sareau section and symphyseoto-
my are considered. How far the
l>liysician should go in carrying out
the wishes of the patient or her
friends is an individual question of
ethics. Instruments required for the
operation arc: volsella forceps, per-
forator, cranioclast or cephalotribe,
metal catheter, and Davidson syr-
inge. The patient is ana?.sthetized
and prepared as for the application of
forceps; the fVetal head is steadied
by grasjiing the scalp with the vol-
sella forceps, and the skull is per-
forated. For this purpose there are
several instruments, such as Blot's
perforator, Smellie's scissors, and
l>raun's trephine; this latter instru-
ment is very satisfactory when the
head presents, as it removes a but-
ton of bone. When the scissors are
used, they are thrust through a su-
ture or fontanel and tlien opened in
various directions to enlarge the hole.
For the after-coming head the point
of selecti(m is the occijiito-atloid liga-
ment, but it may be necessary to per-
forate through the lambdoid suture,
near the ear, or even beneath the
chin. After the jierforation is com
lileted the brain substance is broken iqi and washed out
by means of the catheter. Extraction of the head is per-
formed in one of two ways, either with the cranioclast
or with the cephalotribe. 'When the cranioclast is used
36l:J. — Smellie's
Scissors.
315
Oooupallou.
Oi'ciipaliou,
rp:ference handbook of the medical sciences.
one blade is inserted into tlie opening in the skull, the
other blade grasping the head over the face or ear; the
handles are brought together by means of a nut and
screw and the head is delivered by traction : as the skull
is empty the head undergoes compression
and is moulded in obedience to the pressure
of the parturient canal. The cephalotribe is
applied like the ordinary forceps, and when
the bandies are screwed together the base
of the skull is crushed. Tarnier's cephalo-
tribe has a perforator combined with it, but the crush-
ing usually is unnecessary. Before the pevformance
of^craniotomy the cervix tnust either be dilated or
dilatable. Apart from the danger of sepsis, the soft
parts of the mother may be severely injured in cases
of extreme contraction of the pelvic canal.
BeeapilKU'oN.— The indications for this operation
are impacted shoulder presentations with thinned
lower uterine segment, interlocked twins, and mon-
stro.sities. The usual instrumeut employed for de-
capitation is Braun's liook, but scissors, tine wire,
or even cord can be employed in an emergency. The
patient is an;esthetized and prepared as usual: while
an assistant pulls down upon an arm, if prolapsed,
the hook, guided liy the internal linger, is passed over
the neck of the fon.us and the tissues are cut through
by a series of twisting motions. The trunk is deliv-
ered by traction u]ion an arm or leg ; the head being
extracted by hooking one finger into the opening
at the base of the skull aided by pressure from above.
In difficult cases the head is seized in the forceps or
cephalotribe.
Eeiscemtion. — This operation consists in removing
the contents of the thoracic and abdominal cavities
and is indicated in some neglected cases of transverse
presentation and in monstrosities. The puncture is
made with the scissors and the viscera are dragged out
with the hand or blunt hook; delivery is by podalic
version. In difficult cases the child's spinal
column is cut and the body doubled up before
extracting. Monigomcry A. Cmckttt.
OCCUPATION. HYGIENE OF.— By "occupa-
tion " we mean the regular use of our physical
functions and mental faculties in business and
employment for remuneration, comfort, and lux-
uries. The functional activity of our organs in
a normal way is a physiological condition of health;
the disuse, more or less prolonged, of any organ being,
as a rule, followed by atrophical changes. While the
normal pursuit of occupation is therefore a condition
of health, as well as a corollary of economic life, there
have always existed, in occupations, certain factors
which are productive of pathological changes.
The medicine of antiquity and of tlu' Medireval Ages
ignored the problem of the injurious influence of certain
trades on health, partly because these trades were pur-
sued by the lower classes and the slaves, whose health
was of no special consideration to the ruling classes,
partly because the most injurious effects of occupation
on health are but a iiroduct of the modern system of in-
dustry.
Apart from the few hints in the works of Hippocrates,
Celsus, and (jthers. and the mention by Pliny of the "dis-
eases of the slave," we find nothing on the subject of the
relations of occupation to health until we come to the
.seventeenth century, in the latter half of which we first
come across a notice of occupational disease in the Trans-
actions of the Royal Society of England, in which we
find many pertinent observations on the effects of lead
and coal mining, manufacturing of mirrors, etc., on the
health of the operatives. To Italy, however, is due the
Ramazzini laid the foundation for all further investiga-
tions on the subject, and it is no detraction from his de-
served reputation that his book partly suffers from the
superstitions and ignorance of his age; indeed we must
feel respect and admiration for the many ex-
cellent and true observations, and the sys-
tematic exposilicm of the injurious effects of
occupations which are foimii, for the first
time in medical literature, in his work.
More than two centuries have passed since
Ramazzini's epoch-making work was published —
centuries not only full of remarkable revolutionary
changes in trades and industries, but also charac-
terized by a no less wonderful, progressive develop-
ment of the sciences, among which the study of
the h_vgiene of occupation has kept ecjual pace with
the other branches of medical research.
The list of monographs, articles, and books on
industrial hygiene fills many pages of the "Index
Catalogue of the Surgeon-General's Library," and I
can make mention here of only the more important
landmarks on the subject in medical literature: —
Tissot's work on "Diseases Incident to literary
and Sedentary Persons," published in 1768 in
French, was the next important book; it was fol-
lowed nearly a half-century later by that of Patis-
sier, who, however, gave but a republication of
Ramazzini's work with additional notes ajid com-
mentaries. After these follow, in succession, the
treatises of C. Turner Th.acrah (" The Effects of tlte
Arts. Trades, and Professions on Health and Lon-
gevity." published in 1S31), and of A. C Halfort
(" Die Kraukheiteu der Kuenstler und Gewerbe-
treibenden," published in 1845). These' were fol-
lowed by the works of Levy, Tardieu, and Layet,
and then finally, in the year 18T1, by that of the
great epocli-making work of Hirt — "Die Krank-
heiten der Arbeiter " — which first placed industrial
hygiene on a true scientific basis. In England.
Farr, Chadwiek. Simon, Ogle, and others worked
on in the same line, giving special attention to the
statistical part of the subject of occupational mor-
tality and morbility. Of the later works on the
subject, we can mention only the more systematic
treatises of Popper, Eulenburg, Merkel, Albrecht,
Arlidge, the volume on "Gewerbehygicne " in
Veyl's "Handbuch der Hygiene," the work by
Thomas Oliver (" Dangerous Trades," published in Lou-
don, iyO'2), and the latest work just published in Ger-
many, O. Damraer's "Handbuch der Arbeiter Wohl-
fahrf."
The immense bibliography and the vast extent of the
subject matter of industrial hygiene render any attempt
to review or even to summarize our knowledge of this
branch of medical science within the limits of a short
article, a very ungrateful lask, it being utterly impos-
sible to do justice to it under such restrictions.
I have decided to aliaudon the alphabetical order of
treatment by "trades," handed down by Ramazzini, and
adopted by the writer on this subject in the former edi-
tion of tliis H.iNDiiooK, and I shall treat the subject mat-
ter under the following heads: Occupational Mortality
Statistics: The Diseases of Occupation: The Worker;
The Workplace : The Conditions of Work; The Processes
of Work; Prophylaxis; and, last. "Offensive Trades."
OCCfPATION.tL MoUTALITV STATISTICS.
Occupation is a potent factor in the determination of
human longevity. If we deduct from man's life the
time of infancy and childhood, and the hours devoted to
sleep, the greatest part of it is spent within tlie periods
great credit of the first attempt at a detailed description of industrial activity, and is necessarily largely influ-
of the evils of certain occupations, the treatise of ]?ernar- [ enced by occupation. The relative number of those
do Ramazzini, " DeMorbis Artifieum Diatriba," published
in Modena in 1700, and soon after translated into many
languages, being the first work accurately and vividly to
describe the siiecial effects of each occupation on health.
who die while in pursuit of their occupations bears an
im|)ortant relation to the healthfulness of the occupa-
tions. Moroever, if the figures revealed by the relative
mortality statistics corroborate the scientific a priori de-
31 (i
REFERENCE HANDBOOK OF THE IMEDICAL SCIENCES.
Oet'tipntion.
Occupationu
ductions from the study of the processes of occupations
and their patliological intlueuces, we then have quite a
valuable criterion of the influence of the ditVerent trades
on the lives of the operatives. Herein lies tlie impor-
tance of mortality statistics, as determined by occupa-
tions. In order, liowever, that these statistics shall have
any scientitic value, they must cover large periods, em-
brace great numbers, include various races and countries,
and be projierly prepared and tested. For it is evident
that there are a number of difliculties greatly invalidat-
ing the conclusions drawn from occupational mortality
statistics. These are as follows:
First, occupation, while playing an important role in
human life, is, nevertheless, only one of tlie many factors
influencing it, there being a great number of others, such
as race, country, climate, heredity, geograpliical, eco-
nomic, political, and other conditions, each of which un-
doubtedly affects the livesof operatives; audit isexceed-
ingly difficult to dilTerentiate the cau.sative influences of
occupation on Imigevity from those of all other factors.
Second, there are under the modern system of subdivis-
ion of labor several thousands of special branches of
trades and industries, only a very few of which, how-
ever, and these tlie most genera!, being, as a rule, men-
tioned or tabulated iu the mortality statistics. Thus
there are about half a hundred occupations in Ogle's
tables, not many more in Bertillon's; and in the last
(twelfth) census of the I'nited States there are 140
groups, TO of which are further subdivided, making the
whole number in tlie last census 303. It is obvious that
each of the general groups of ficeujiations may embrace
a large number of minor trades, each of which will have
a different bearing onheallh and life, thus greatly invali-
dating the deductions from the general tables.
Third, iu our modern industrial production, there are
very few tradrs which are hereditary, as the feudal
guilds were, and in which the operatives remained dur-
ing their wliole lives. The greatest number of iudustries
constantly change their personnel, most individuals pur-
suing several trades succes.sively ; and the occupation in
wliich they happen to die gives little indication of the one
in which fliey may have spent the greatest part of their
lives, and where they perchance had received the injuries
to health to which tiie_v subsequently succumbed.
Fourth, certain trades can be pursued only liy very
strong aud healthy individuals; while others, being com-
paratively light, can be carried on by the physically
weak and feeble. It is, therefore, manifestly incorrect
to base deductions on occupational niortalit.y statistics,
seeing that the primary factors (i.e.. the workers) are not
on an equal basis as to health. All the above consider-
ations make it incumbent ujion us to regard occupational
mortality and morliility statistics with a certain suspicion,
and to apportion them only such value as is warranted by
the scientific deductions of the general and special char-
acteristics of each trade, aud its effect on health.
Ogle's statistics deserve the great credit attributed to
them by hygienists, by reason of their careful elaboration
and intelligent preparation. They have been quoted
widely and are regarded as standards. I shall give
Ogle's table, followed by more recent <lata from the last
United States census, and from J. Tatham's recent mor-
bility figures in Oliver's book.
COMPAKATIVK MORT.4I.lTV OK MKS. TWKNTY-FITE TO SiXTY-FIVE
YKARS of A«K. IX DlFKKKKNT OCCIPATIO.NS. FOR TlIK YKAKS
].s.Hi-,H:i, nv W. (UiLK. AS Repurtki) IX A Paper Read Before
THE SEVE.VTH INTERXATIOXAL CONORESS FOR HYfUEXE. IN 1S91.'
Ocpupalions.
n
K>0
108
114
]2H
129
Occupations.
c if ■
"11
13!)
l-Hi
Carpenters, joiners
148
V>2
Paper- makers
Silk manufacturers . . .
va
* The mortality rate of clerRymen, being tlie lowest, is tatifn at 100.
Ogle's Comparative Mortality Table.— Coiid'Hiicd.
Occupations.
111
Occupations.
m
-a
1.59
160
1U6
171
172
172
173
174
175
179
185
188
186
189
191
196
Medical men
202
Coal miners
Shoemakers
Stone & slate quarriers.
Bookbinders
202
210
But^^hers
211
214
Lead workers
216
239
M;i-.tins itr n'klavers ....
Brewers
245
267
Clerks
Liquor dealers
274
Fileniakers
300
Gunsmiths
Earthenware workers .
Cornish miners
Cost^rmongers, p e d -
dlers
313
Wool workers
331
Tailors
Hatters
338
Inn, hotel service
397
Occcpational Mortality Table Accordixg to the (Twelfth)
United States Census for the Census Year of 1900 (Onlt
IX THE " REGISTRATIOX AREA "—TEN STATES").
Occupations.
Mercantile and mechan-
ics, average
Professional average . . .
Laborers and servants. .
Engineers, surveyors...
School teachers
Lawyers
Medical men
Cierg.vmen
Textile mill workers . . .
Plumbers and gasfltlers.
Shoemakers
Machinists
Iron and steel
(ilass makers
Tailors
Printers, pressmen
Bakers, confectioners . .
S&
13.1
15.01
20.2
8.2
12.2
17.3
19.9
33.5
8.8
9.1
9.4
10.5
10.7
10.8
11.8
12.1
12.3
Occupations.
Leather makers
Tin workers
Marble & stone workers
Engineers, Bremen
Painters
Butchers
Plasterers
Carpenters, joiners
Leather workers
Hat, cap makers
Cabinetmakers a n d '^
Upholsterers i
Blacksmiths
Cigar, tobacco workers.
Brewers, distillers..
Stone masons
Coopers
MiUere. dour, grist .
S~
SO.
12.3
14.5
14.9
B.7
16.3
16.1
17.0
17.2
17.5
17.9
18.0
18.3
18.7
19.7
19.9
33.8
36.6
The United States occupation-mortality statistics being only for ten
States and only for one year do not have the value of Ogle's tables,
which embraced several years and the whole of Kngland and Wales.
Comparative Mortality from Specified Causes ix Certain
Dusty Occupatioxs. (Johx Tatham.")
Occupations.
Agriculturists
Earthenware. -
Cutlers
Filemakers
Glass workers
Copper workers
(iiinsmiths
Iron and steel
Zinc workers
Slnne quarriers
Brass wi.ikers
Cliininev-sweeps
Lead wiirkers
Colli 111 wiirkei-s
riiii|ieraii*l wood turners.
Uiipe makers
Masons anil bricklayers ..
Carpet wi'i'kers
Tin workers
Wnol manufacturers
Locksinltlis
Blacksmiths
Bakers and confectioners.
602
1.702
1,.516
1.810
1.487
1,.381
1,228
1,301
1.198
1.176
1.088
1..311
1.783
1.141
1.088
938
I.IKII
873
994
991
935
914
920
Phthisis and
Respiratory
Diseases.
221
1.001
900
835
740
7011
649
645
587
576
553
551
54.')
5tO
526
486
476
4n
4.51
447
428
392
393
100
4.V3
407
373
:k5
317
aw
393
366
361
350
249
347
344
338
32fl
315
213
204
21 C»
194
177
Mortality
kioure.
lOB
3:W
383
402
29.5
294
325
195
240
269
370
360
148
303
3.50
219
235
336
317
191
333
1.59
185
115
668
518
423
445
406
32.5
450
347
307
373
291
397
338
276
267
351
345
234
2,56
205
233
307
317
Occupation.
Occupation.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
"In Ihis tabk' tlie mortality of tlio sevpial dust-produc-
ing occiipatious is contrasted with that »( auriculmrists,
who have been sliowu to suffer the least from the effects
of dust. The aggregate death rate from tuberculous
phthisis, and diseases of the respiratory- system, is shown
in this table, as are also the figures relating to each affec-
tion separately. Columns 1 and 2 give the combined
mortality from tliese diseases in comparison with that of
agriculturists. In the third column the mortality of the
latter is taken as one luuidred. showing tlie proportional
relation to other workers."-'
Diseases of Occiti'.vtiox.
Disease has been defined as an abnormal condition of
the body, a perturbation in the stati' of the living organ-
ism; while life itself is a struggle of the organism w-ith
its environment. In the study of the pathogenesis of
disease, we come to a complex plienomenon, which on
closer study resolves itself into two main branches:
First, the intrinsic constitution of the organism; and sec-
ond, tlie external world, I'.f.. the environment. Among
the environmental conditions influencing life and health,
one. not the least in importance, is that of occupation.
In the mortality statistics we have seen that occupation
does affect tlie longevity of man ; at least, there is a strong
array of figui-es, corroborating cacli other, from various
races, countries, and localities, wliieh persistently .show
that soiue occupations havea very large comparative uior-
tality, and which therefore warrant tlie deduction that
these occupations jiossess some elements or conditions
capable of causing those disturbances in the organism
which terminate life more ra]iidly than is commonly the
case when the conditions in ([uestion are absent. If
death itself, which is but the culmination of all abnormal
conditions of life, can be, moi-e or less directly, brought
on l)_v occupation, how much more likely is it that occu-
pation will influence the daily life and cause the morbid
states called disi:iit.e?
As a matter of fact, since the time of Rjimazzini, w-e
do regard many morbid states as due to the influence of
occupation, and we call them "industiial diseases," or
"diseases of occupation," by wliicli we mean such dis-
eases as are superinduced directly or indirectly by one
or more elements existing in occupation. Tliere are,
however, two points which we must note in the study
of industrial diseases: individual susceptibility, and the
relative importance of occupation in the causation of
disease. Those w-ho have made a study of the jiatho-
genesis of disease know the remarkable role which is
played in health anil disease liy tlie inherited constitu-
tion, personal vital resistance, and [lower of immunity
of each individual. We frequently oliserve two indi-
viduals working in the same trade, side by ,side, influ-
enced by identical conditions, subject to the same harm-
ful elements, and breathing the same foul, dusty, and
poisonous atmosphere; yet while the one, sooner or
later, succumbs to these dangers of his ti-ade, and be-
comes invalidated by the genei-al or special maladies of
his calling, tlie other continues to cnjo_y life, with appar-
ent immunity from all injurious influences. It is evi-
dent that in industrial, as in other diseases, the jiersonal
element, the individual susceptibility must be taken into
account. So far as the (luestiou of the n-lative impor-
tance of occupation in the causation of disease is con-
cerned, tliei-e are those who totally deny that there are
«».(/ diseases of occupation. They claim tliat we nia_y
just as well classify diseases by habiiatioii, soil, sewer-
age; by races, localities, and countries; by nionarehies,
republics, and constitutional govei-ninents, inasmuch as
each of these external factors undoiilitedly bears some
relation to conditions of health, and may, in some more
or less remote way, cause disease. This position is, how-
ever, untenable; for occupation certainly exerts a greater
comparative influence on health than do many of the
other external factors: and there are some industrial dis-
eases which may be directly traced to certain s|iecilic in-
dustries, while this can hardly be .said of the other factors.
Among the industrial diseases there are some which
can be shown to lie directly due to the toxic elements or
substances generated in each trade; others there are in
which their connection with some particular industrv
is more remote; and still other diseases in which occupa-
tion plays only a predisposing role. It is impossible to
give here the detailed description of all industrial dis-
eases, uor is it necessary, as all of these diseases are at
the same time common to all mankind, and are more fully
treated in other parts of this H.\ndbook. The diseases
to lie briefly alluded to here are only those which bear a
direct etiological relation to occupation.
Discuses of the Bespimfoni tSi/skm. — The organs of the
respiratory system are the greatest sufferers ti-om indus-
trial conditions. The resiiiratory passages have been
very aptly named " the entrance port " of the body w-here
most of the infective agents land on their arrival. All
impurities of air, it iiersistently inhaled for long periods,
are liable to produce inflammatory changes in the respira-
tory passages, and so to \veaken them that they readily
become a pre)' to an_y infective organism. The mos"t
pernicious effects on the respiratory organs are pro-
duced by the inhalation of dust. In the divers industrial
processes, all kinds of materials from animal, vegetable,
mineral, and metal substances are undergoing various
pirocesses of transforinatinn, w-ith the inevitable result
that a great quantify of dust is raised and fills the air
of the places of work, and is constantly being inhaled
by the operatives, A mere temporary inhalation of dust
is followed by increased secretion from the mucous mem-
brane of the respiratory passages, by which these try to
get rid of the foreign matter. When, however, the ac-
tion of the dust is persistent and continuous, the mucous
membrane of the passages gets congested, inflaiued, and
denuded of its pi-otective ciliated epithelia, and, with the
weakening of the defensive forces, the entrance of for-
eign matter or infective materials info the parenchyma of
the lungs is no longer prevented. The statistical tables
of Hirt, Ogle, Tatham, Bertillon, Kummer, and of the
United States census, all agree that the greatest burden
of ills due to occupation falls upon the much-abused re-
spiratory organs.
Biv/ichitis. — Of the diseases of the respiratory system,
the most directly traceable to industrial influences is bron-
chitis. Among the principal causes of bronchitis, Hoff-
man'' mentions: (1) catarrhal congestion, (-.3) inhalation of
dust, (3) inhalation of gases. All these factors are pre-
cmvnently those which are most frequently due to indus-
trial conditions. Excessive muscular exertion, increased
body heat due to hard labor, sudden chilling of body
surface, exjiosure to varied and extreme temperatures,
etc., area few of the causes of catarrhal congestion in
the bronchi, leading to subsequent chronic inflammatory
changes. Inhalation of dust as a cause of bronchitis is
easilj' understood when we remember the irritation w-liich
anv foreign matter produces in the mucous membranes,
and the special irritating qualities of a great many in-
dustrial dusts. Poisonous gases and fumes are direct
irritants, and cause intense congestion of the bronchial
mucous membrane and inflammatory changes which tend
to become chronic if the inlialation of such fumes per-
sists. The statistical data, as to the prevalence of bron-
chitis among workers, ai-e not reliable, for the reason
that the disease in its initial forms is hardly one for
which the worker discontinues work or seeks medical
aid, and certainly not one which would figure in mor-
tality statistics. Hirt ' gives the I'lercentage of workers
suQ'ering from chronic bronchitis as from 11 to C9 per
cent. Some dusts are more irritating than others. Thus
Hirt found, in an investigation which coveied 12,000
workers in a dusty atmosphere, that of those who ex-
perienced harmful effects therefrom in a greater or less
degree, 11 per cent, were workers in mineral dust, 13.6
per cent, in animal dust, 14.8 ])er cent, in metallic dust.
18.4 per cent, in dust of a mixed character, and 19 per
cent, in vegetable dust.
Emjilii/seimi. — Emphysema is a disease of the lungs in
which a part of the tissue loses its normal elasticity and
318
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
0<*<'ii|»all4>ii.
Occupatluii.
remains in a state of abnormal dilatation. Emphyse-
ma is caused by all conditions which interfere witli the
normal expiratory functions of the lungs. Among the
causes of emph3'sema are: (1) Catarrhal conditions of the
passages, leading to accumulation of mucus in the bron-
chi, to obstruction of the bronchioles and to violent fits
of coughing ; (3) the lodgment of f(jreigu matter and dust
in the bronchioles, and the obstruction of these channels
resulting therefrom; (8) constrained attitudes, etc., lead-
ing to interference with respiration. Most of these con-
(liUons are present in many occupations. We have seen
that chronic bronchitis is very prevalent among most
workers, and consequently favors the production of em-
physema among them. Hirf* says that from eight to
ten per cent, of all who sulTer frcmi bronchitis have em-
physema. The tilling up of bninchinles with dust is a
frequent condition in tlie lungs of coal miners and others
who work in clo\ids of dust, and such obstruction will
cause compensatory hy].iertrophy and dilatation of other
alveoli, also dilatation of the right ventricle of the heart.
Work in a constrained attitude, playing on wind instru-
ments, glass blowing, lifting of heavy weights, severe
muscular exertion, and alcoholism are among the other
predispc~sing causes of emphysema among workers. Ac-
<'ording to Kubborn " ?iT jier cent, of miners suffer from
emphysema, and accortling to Si'ltman '■ 50 per cent. Ac-
cording to Fuellcr * breathing foul air, deficient in oxygen
and rich in carbonic acid, predisposes to emphysema; he
quotes Seltman's figures to .show that, among coal miners,
of those who worked in pure air onl}' 7.9 per cent, suf-
fered from this disease, whereas of those who worked
constantly in foul air, as many as G3 per cent, were .so
affected, llirt' gives the following table of the relative
frequency of emphysema among workers in dusty oc-
cupations; Of 100 cases of sickness there w-ere among
mi'tallic workers 3.1 per cent., among those exposed to
anim.'il dust o per cent., to vegetable dust 4.7 per cent.,
to mi.xed dusts 5.1 percent., and 1o mineral dusts, 9 per
cent.
Piifiimoiiiihniiri.iis. — Zenker applied this term to affec-
tions of the lungs due to dejiosits of dust in their paren-
cliynia. Several forms of pueunionokoniosis are distin-
ginslied according to the nature of the dust inhaled and
deposited in the lungs. Dust particles are earned to the
lung ti.ssne by direct inhalation and also by the action of
tlie lymph channels. These latter play an important role
in the dissemination of the dust jiarticle.s, as has been
shown by the di.scovery of .some dusts — for instance coal
— not only within the hmg, but also in the liver, spleen,
and kidney.s. FueUer' quotes the report of a French
chemist who found in several .sanqiles of lung tissue,
weighing respectively 1,S00 gm., 2,(S(iO gm., and 220
gm., the following quantities of coal: 85 gm., 140 gm.,
and 114 gm. According to Merkel' the following fac-
tors are determining in the etiology of pneumonoko-
niosis: (1) Thestateof health and individual susceptibility
of the worker; (2) the vulnerability of the respiratory
organs: (3) the duration and intensity of the exposure to
dust inhalation; and (4) the quality and character of th<'
dust. Quimby (see article on L>nir/s, JJiwuses uf : Pnen-
nwnokonum's in Vol. V. of this H.\ndi300K) gives the fol-
lowing more conunou vocations in which laborers are
exposed for prolonged periods to a dusty atmosphere;
Mining of various minerals, and the hamliing of coal in
transit to its point of consumption; charcoal grinders
and carriers, moidders and those who clean castings,
metal and glass polishers, stone masons and plasterers,
chimnej'-sweeps, laborers who tear down old buildings,
potters antl grinders on various forms of stone, l)akers
and pastry cooks, gilders and gold and tinfoil beaters,
workers in mother-of-pearl and lead, jewellers and glass-
cutters, tile-cntters, millers, tobacco workers, grain shov-
ellers, etc.
We shall refer to various jHieumonokonioses when
we come to the subject of dusty occupations and their
infJuence on health.
Tuheirvlmis. — Pulmonary tuberculosis is a very fre-
quent disease among all kinds of workers, especiall}'
among those who work in a dusty atmosphere. The eti-
ological relation of occupation to pulmonary tuberculosis
is not diflieult to understand, although the connection is
not always directly traceable. Occupation is more of a
predisposing than an exciting cause of tuberculosis. All
conditions of occupations, sex, age, foul air, overcrowd-
ing, variety In temperature, exposiu'e, constrained atti-
tude, inhalations of dusts, gases, fumes, and poisons, all
tend to predispose the organism to fall a prey to the rav-
ages of the tubercle bacilli. The infection may take
phrce outside of the place of work, liut generally hap-
pens within its precincts; for tliere is no better place for
the cultivation, distribution, and dissemination of the
bacteria than tlie foul, ill-ventilated, close, damp, over-
heated, dusty shops, where, if only one tuberculous pa-
tient expectorates, enough material may be s])read to
infect hundreds. The prevalence of pulmonary tubercu-
losis among various workers has been noted in the already
cited table of Tatham on mortalilj' due to this affection.
The last United Statescensus gives the number of deaths
from pidmonary tuberculosis in the census year as 109,-
750. Dusty occupations, as already noted, ]3redispose to
phthisis. All statistical data, from Ilirt to Tatham, con-
lirm the statement that tuberculosis is the most frequent
di.sease among all occupations, and the fre((uency is
directly proportionate to the amount of dust that is
formed in the occupation.
L<ihin- Piu'umunui . — It is difficult directly to connect
lobar pneumonia with occupation, although Hirt claims
that the largest number of cases of this malady occurs
among the laboring cla.ss. Congestion and a catarrhal
condition of the respiratory passages and exposure to bud
weather, etc., are tlie main predisposing causes. Bron-
chitis and emphysema, so frequent among workers, pre-
dispose to infection with the pneutnococcus, by reason of
the fact that the normal pulmonary tissue has lost its
power to resist infection. Exposure leads to chilling of
the surface of the body and congestion of the lungs.
The average frequency of jnieumonia was found b)' Hirt ■'
to be 7.3 per cent, in some workers, while in millers
the percentage was 20.3. According to the figures of
the last United Statescensus the laboring class shows the
greatest percentage of cases of pneumonia. Merkel '
denies that dust has any effect on the eti<:ilogy of pneu-
monia. In one hundred and forty dead, out of ten hun-
dred and thirty-live cases of pneumonia, he failed to find
any trace of dust in the lungs. If dust afl'ects the hiiigs
at all, it may do so by the wounding of the mucous mem-
brane, thus presenting a solution of continuity, favoring
bacterial infection. It was claimed that textile workers
are prone to this di.sease, although this is denied by later
investigators. According to Hirt's table those W'ho are
exposed to vegetable dusts suffer the most from pneu-
monia.
Bifieiises of the Nei-mus Sj/.ilem. — The nervous system is
the most abused part, of the organism of the woiker.
Modern indu.stry, with its complex mechanical develop-
ment, enormous rate of speed, intensity of action, and
the great demands on the nervous and mental forces of
men, tends to overstrain the delicate nervous cells, and
sacrifice them to the much-vaunted strenuousness of life.
Some of the factors, more or less frequently aeeiunpany-
ing all occupations, which lead to nervous disturbances
are the following: Excessive cardiac action, intense mus-
cular strain, overuse of an organ or grouji of muscles,
prolonged mental labor, overwhelming res|ioiisibility,
intense anxiety, mental worry, sudden and contiiiuous
shocks and jarrings, extremes of heat, cold, dampness,
and variations of air pressure, inhalations of certain
gases, and the ingestion of certain poisons.
Among the nervous diseases most frecpient amnng
workers are cerebral and spinal hyperajmia, peri])heral
neuritis, the fatigue neuroses, progressive muscular atro-
]ihy, various toxic paralyses, and insanity. According tn
the last census report, perscais eiigageil in literary anil
professional occiqiations sulfi'r relatively more from ner-
vous diseases than iloall the other classes. Thus medical
men show the largest number of deaths due to nervous
319
Oci'Upalioii,
Occupation.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
diseases. The nervous disturbuuces due tn to.vic in-
lluences will be treated later.
The Fdtir/iie Xeiiroses. — These neuriiscs, also i-alled
■■functional impotences," arc directly' due to various oc-
cupations. They manifest them.selves in loss of motor,
sometimes of sensory, power iu some organs or groujis
of muscles; this loss being due to the continuous, pro-
longed, and excessive use of the same. Causes which
predispose tti the.se neuroses arc weakness of the nervous
system, alcoholism, excessive use of tobacco, mental au.x-
iety, and trouble. According to Oliver ^ the primary
seat of the disorder is situated in the cortex of the brain,
and he adds that "altered nutrition nf the cerebral nerve
centres is in all jirobability lesjionsible for thi' defective
muscular movements; and that the spasm is only the
initial fact in the illness." The most common fatigue
neuroses are ■"writer's cram|>" or ■■scrivenei 's palsy,"
telegrapher's spasm, as well as the spasms which occur
in typesetters, milkers, hammerm;'n. piano jilayers, violin
])layers, etc.
Ei/e BiKeiises. — The eyes frequently suffer from effects
of occupation. Injury to the eyes may come from a too
prolonged close application and straining ; from exposure
to excessive light or heat: from various dusts; from gases
and poisons; from liurns and accidents.
Overuse and close application and overstrain produce
pain, asthenopia, myopia, presbyoiiia, and other changes
iu refraction. Clerks, copyists, engravers, draughts-
men, watchmakers, jiroof-readers. etc., are tln)se who
overstrain their eyes.
Certain occupations which compel very close applica-
tion with accompanying constrained positions cause iiys-
Ingniiis. This disorder of the eyes is cliielly due to the
constrained position which some laljorcrs are compelled
to assume during their work, and is very frequent iu
coal miners, live percent, (according to some authorities,
ten per cent.) of whom are afflicted with it; although
workers in other trades, such as compositors, metal roll-
ers, etc., are sometimes affected. The comparative fre-
quency of nystagmus amcing coal miners is due to the
unnatural positions assumed by them when undercutting
in coal seams, lyin,g on their sides, and straining the
eyes in order to follow the pick.
Exposure to excessive light and heat is frequent among
certain trades, as those of silver linishers, burnisliers.
furnace-workers, glass-blowers, electric welders, etc. In
some of these oc('upatious, notably in electric welding,
the temperature may reach 8.(100 F. and over. Con-
junctivitis, hypera'tnia, liypcrasthesia of the retina are
common among this class of workers. Glass-lilowers arc
.said to be subject to cataract formations. Those who
work in dusty trades very often suffer mechanical in-
juries to their eyes, owing to accidental and frequently
unavoidable entrance of gritty, sharp dust particles into
tiie eyes.
The effects of certain gases, fumes, and poisons on the
eyes are well known, and caimot be g(jne into here. All
strong irritants will affect the eyes and jiroduce various
di.seases in tliem. Certain toxic' substances cause various
amblyopias.
Burns and accidental injuries are very common iu
many industries. Of IS, 644 accidents to 2."), 000 workers,
nearly 1.000 were injttries to the eye."
Dcniiiitf'sis. — Many alfectious of the skin are directly
due to certain conditions iu oceu]iations. Thus, the skin
is liable to .scalds and burns, to the mechanical action of
various dusts, to the action of poisons, of irritating gases.
Constant pressure and friction will also cause abrasions
or callosities. The dermatoses vary in their extent and
severity from a simple erythema, to vesicles, pustules,
and ulcerations. Occupational eczema is frequent.
Scalds and burns are very frequent in .some occupations.
Dust, mixed with perspiration, will form crusts, which
irritate the e|nderniis, causing itching and erytlieina, anil
leading to subsequent infection and more serious lesions.
Flax workers very commonly suffer from severe eczema
of the hands and lingers. Lead, ar.senic, and other poi-
sons produce severe skin affections, (^ertain workiis who
are oliliged to scrape hides with their fingers suffer from
a form of disease of the nails, called "furrier's nails."
The constant friction and pressure on circumscribed
places of skin produce thickenings, callosities, and bur-
SiB. These vary in location according to the special char-
acter of the work and tlie parts of body exposed to the
pressure and friction. The hand and" fingers are the
most frequent places of callosities, the knees and olec-
ranon the most frequent places for bursa\
Cardiiic and eire nlutori/ clisruxes owe their origin among
workers to excessive strain and muscular effort, the lift-
ing of heavy weights, the strain at too arduous tasks,
excessive variations in temperature, etc. Cardiac hyper-
trophy and dilatation are frequent among athletes, pro-
fessional iiugilists, gymnasts, etc. Disorders of the cir-
culation al.so depend on alcoholi.sm.
Diseimcs of the dirjeKtire tnirt, unless caused directly by
absorption of certain poisons, like lead, arsenic, etc,
are mostly due not to the occupation, but to the poor hy-
gienic conditions under which so many of the workers
are compelled to live.
Of the funyiciil diseases, apart from woiuuis, fractures,
and dislocations, occupations may cause' hernias, varicose
veins, aneurisms, etc.
1/ift'clioiis Dhcfiws. — There are a numlier of maladies
which are frequently observed in certain occupations, —
maladies which are due to infection by patliogenic or-
ganisms that happen to cling to the materials of work.
AH forms of microbes can be at times found iu various
substances and materials handled by workers. Thus,
the microbes of scarlet fever or of typhoid fever may
cling to the materials handled by the tailor; gardeners,
who are obliged to handle earth, iirc more liable to con-
tract tetanus; the men who care for horses are almost
the only ones who become infected with glanders; the
tunnel workmen are specially liable to anchylostomiasis,
the wool workers to anthrax, etc. The infection by the
last two has been regarded as closely connected with the
occupation, although they can hardly be regarded as oc-
cupation diseases.
Aiithni.r. — This is a disease of cattle, iuduccd by the
action of the bacillus aiuhracis. As it forms the subject
of an extended article in Vol. I. of this H.\NDnooK, it is
not necessaiy that I should enter into any further details
in this place,
AiicJiyhistoiniitsix (maladie des tunnels). — This is an in-
fective disease from which many workers in tunnels of
Belgium, Switzerland. Australia, and other places have
been found siitt'ering. In one pit in the province of
Lii^'ge from fifty to sixty-nine per cent, of all workers, and
in a Hungarian pit eighty per cent, of all workers, were
affected. This malady, of which a pernicious auitmia is
the most characteristic .sequel, is caused by a minute
]iarasite which fixes itself in the upper jiart of the small
intestine by a number of booklets and sucks the blood.
The disease has been fcuind iu others beside tunnel work-
ers. The infective i>arasite is fotmd in the excreta, from
which the infection recurs. Defective sanitary arrange-
ment in the places of work and the lack of care and hy-
gienic supervision are the causes of the spread of this
disease, which will disajipear whenever better hygienic
conditions are established iu tunnels.
Of the other industrial diseases, it remains to mention
caisson disease iuid several minor affections, such as
"shoddy fever," ■■glass-blower's mouth," "stamp-licker's
tongue," etc.
Vdisitoii JJiacase. — This term is ajjplied to a group of
sj'mptoms the ])athology of which is obscure, and which
are met with in workers in compressed-air chambers in
sinking mines, in excavating for piers for bridges, and in
building foundations in boggy soil for large structures.
The danger to the workers seems to be greater on going
out of the compressed-air chamber into the decompres-
sion room than on entering or working in compressed
air. The usual symptoms of the disease are vertigo,
buzzitig in the ears, vomiting, muscular pain, numbness
iu the legs, unconsciousness, followed, not rarely, by
sudden di'atli. The danger is greater the greater the air
320
REFERENCE HANDBOOK OF THE IIEDICAL SCIENCES.
Ooi'lipalion*
Occiipalion.
pressure and the quicker tbe entrance of the worker from
the compressed air into the decompression cliamljer: also
when tlie workers are compelled to climb stairs and un-
dergo cardiac and muscular strain soon after coming out of
the compressed-air chamber. Oliver^ thinks that caisson
disease is due to increased solution of gases iu the blood
and sudden liberation of them. Others regard the syniji-
toms as due to the increase in carbonic acid. Not all
workers exposed to compressed air suffer equally, and
there are some who entireh' escape harm. In the build-
ing of the St. Louis bridge, where the pressure was some-
times as high as from four to six times the normal, there
were twelve fatal cases. In the building of the Brooklyn
Bridge the fatality was less.
■■ Shodd}- fever " is an influenza-like infection which
is met with in workers in rags and shoddy garments. It
is line probabh' to infection with some bacterial organism.
"Glass-blower's mouth" is a swelling of the parotid
gland extending from the angle of the mouth to below
tlie ears, and is met with in glass-blowers.
■• Stamp-lickers' tongue " is a stomatitis sometimes met
with in those who lick labels and stamps, and is due to
infection.
The Factors of Occupation.
The relative increase in the mortality and the greater
frei|uency of disease in certain occupations are in a great
]iart due to the complex group of phenomena which we
call occupation, and which is composed of a number of
fai'tors, each of which has its own special bearing upon life
and health. The primary factors of occupation are: the
worker, the place of work, the conditions of work, and
the processes of work. These primary factors are com-
posed of several minor factors, each of which may play
an important role in the causation of sickness and ma\'
influence the duration of life. A more or less detailed
analysis of each factor is necessary to the understand-
ing of the modus operandi of industrial influence on
health.
The Wouker. — The primary state of health, the he-
reditary "physiological wealth," the physical normal de-
velopment of all organs of the worker, are fundamental
elements in all subsequent influences of occupations on
health. Some occupations can be followed only by the
very strong and exceptionally robust, while others at-
tract the weakling and tbe feeble only. The susceptibil-
ity of tbe worker to the injurious elements of his trade
and his relative predisposition to succumb to the noxious
elements or processes of occupation will greatly depend
on Ills primary condition of health before entering the
trade which he has chosen as his life profession. The
greater the capital of health the worker takes with him-
self when starting on his vocation, the greater will be his
resistance to the dangerous features of his work; the
weaker the worker, tbe more surely will he be affected
by any and all detrimental elements. A perfect eyesight,
hearing, and other physical faculties are therefore abso-
lutely paramount conditions of normal occupation. But
not less than these are also the habits and the care the
worker takes of his life and health while at work. Care-
lessness in the handling of machinery will result in acci-
dents to limb and life; personal uncleanliness in mine,
factory, and shop will be followed by the relatively
sooner ingress into the system of deleterious dusts, etc.
Sindlarly, the worker will be affected by too great addic-
tion to alcohol. The excessive heat or cokl, the relatively
great dryness or too great humidity of the place of work,
the foul and dusty atmosphere, the difficult tasks, the
arduous labor, the strain and tension of machine work, the
worry and fear of the relentless mechanical powers, and
the thousand and one demands on the muscular and ner-
vous functions of workers all tend to the creation of a spe-
cial need and a craving for some stimulating and bracing
drug, which is furnished by the ever-present and readily
obtainable alcoholic beverages. The use, however, (if
alcohol leads very often to its abuse, and the excessive
drinking of alcoholic liquors is bound, sooner or later.
Vol. VI.— 21
to produce pathological changes, and injuriously to in-
fluence the health of the worker. The state of the blood-
vessels in alcoholics, and their relativel)- greater suscep-
tibility to pneumonia and other acute diseases, as well as
to chronic digestive and liver troubles, are well known.
There are several special trades which are known by
their tendency to favor alcoholism in the workers.
Brewers, bakers, drivers, innkeepers, bartenders, glass-
workers, workers in the iron and steel industry are noto-
riously addicted to alcohol.
Sex and Age. — In many industries child and female
labor is very largely employeil ; and the effect of work
on them is very detrimental to health. The injurious
influences of female labor are due to the following fac-
tors: (1) The comparative physical weakness of the fe-
male organism; (2) the greater predisposition to harmful
and poisonous elements in the trades; (3) the periodical
semi-pathological state of health of women; (4) the
effect of labor on the reproductive organs; and (5) the
effects on the offspring. As the muscular organism of
woman is less developed than that of man. it is evident
that those industrial occupations which require intense,
constant, and prolonged muscular efforts must become
highl}' detrimental to their health. Tliis is shown in the
general debility, ansmia. chlorosis, and lack of tone in
most women who are compelled to work iu factories and
shops for long periods.
The increased susceptibility of women to industrial poi-
sons and to diseases, has been demonstrated by a great
uimiber of observers. The female organism, especially
when 3-oung, offers very little resistance to the inrf)ads
of disease and to the various dangerous elements of
certain trades. Hirt» says, "it must be conceded that
certain trades affect women a great deal more injuriously
than men," and he mentions, among others, the effects
of lead, mercury, phosphorus, and other poisons. Even
where there are no special noxious elements, work may
produce, as already mentioned, harmful effects on the
health of women; but when to the general effects of in-
dustrial occupaticm ate added the dangers of dust, fumes,
and gases, we find that the female organism succumbs
very readily, as compared with that of the male. Sliu-
ler ' found that the frequency of sickness in females, imder
eighteen, as compared with that of men of the same age,
is%is 174 to 100. Miss Mary E. Abrahams ^ found tiiat
out of 138 lead-poisoning cases in Newcastle, where the
number of men and wonicu workers was about the same,
there were 94 cases among the women to 41 among the
men. She also found that out of the 23 deaths "from
jilumbism, in the years 1889-1892, 23 were women and
only 1 was a man. The women were all l)etween .seven-
teen and thirty years of age. These figures are substan-
tiated by Hirt.'Arlidge, C. Paid. Taniieu, and others.
The predispo.sition of women in industrial occupations
to disease in general is greater than it is iu men, as was
proven hy Hirt in his statistics of tidjcrculosis among
workers. The effect of work on the physical develop-
ment of women was found to be very detrimental, espe-
ciall_y when they were young. Arlidge ' says that in those
who from their youth work in high temperatures, the
bones and joints are imperfectly developed, and that they
are liable to female deformities and to narrow pidves.
Herkner' found iuhis studies of Belgian female workers
that girls who are engaged in mines suffered from de-
formed joints, from deformities of the spinal colunm, and
from narrow pelves.
It has been estimated that out of every <inc hundred
days women are in a semi-pathological stale of health for
from fourteen to sixteen days. The natural congestion of
the pelvic organs during menstruation is auginenteil and
favored by work on sewing-machines and other industrial
occupations necessitating the constant vise of the lower
part of the body. Work during these periods tends to
induce chronic congestion of the uterus and appendages,
and dysmenorrho^a and flexion of the uterus are well-
known affections of working girls.
The effect of work on the offspring is known to be in-
jurious iu female workers. Abortion is very frequent
321
Oroupatlou.
Ori'upatlon.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
iimimg female workers, especially wlien they work in
certain dangerous trades. Of one thousand pregnancies
among lead workers, reported by Tiirdieu.' six hundred
and nine ended in abortions. Arlidge also found the
percentage of abortions among female workers in the
pottery trade very large.
As far as the effect of female work on infant mortality
is concerned, it lias been sliown lo be detrimental. The
rate of infantile mortality among mirror workers is, ac-
cording to Hirt. sixty-five' per cent. Tardieii and C. Paul
found, among lead workers, an infant mortality of forty
per cent. According to Greenhow, the "infantile mor-
tality is due to the unwholesome influence to whicli in-
fants are exposed in the manufactviring town by the in-
dustrial emjiloynient of married women."" Traces of
lead, jthospliorus. copper, aniline, etc., have been found
in the amniotic Huid.
What has been said about the influence of industry on
young women can, in .some degree, be applied to child
labor in general. The effects of industrial occupation on
children can besununed up as follows: injury to the weak
organism ; the stunting or arrest of growth and physi-
cal development; the ]iroduction of deformities in bone,
joints, and sjiinal colnnm; a dulling of mental faculties;
the acquirement of a predisposition to moral obliquity ; a
lessening of the normal powers of vital resistance; a gen-
eral deterioration of the eonslitution and a shortening of
life by various diseases. (.'Iiild labor, beyond all doubt, is
the greatest cnrse of modern in<lustry. The influence of
child labor on the general health of the community has
been demonstrated by the figures of Layet ((pioted by
Trac}' '"). which show that out af 10,000 conscripts from
ten agricultural districts 4.0'.3U were rejected, while in se-
lected manufacturing districts the rejections for rachit-
ism and small stature reached 65 percent, of the whole
number of conscripts.
Tn?; Pi..\CE OF Work. — The place where work is done
bears an important I'elation to tlie health of the workers.
Work is performed either indoors or outdoors; the former
being pursued in factories, workshops, ami homes. It
was Dr. Guy who cla.ssitied all (jccupati<ins into two
primary divisions — "indoor"an(l "outdoor," and proved
that the latter were much healthier.
There are, however, some special occujiatious which
can be classed among dangerous trades. I refer to min-
ing and til II ml irnrk, which are dangerous to life, limb,
and health by reason of the nature of the work, and also
on account of the conditions under which they are car-
ried on. The harmful conditions in mining and tunnel
work are the following: absence of natural light, foul
air, great heat, increased air pressure, too great humidity,
dangers of the lifts, of luiulage, and of tlie winding ma-
chinery, etc. ; the use of explosives, the danger of cave-
ins, falls of rocks, etc.; sudden inundations by water;
danger of tires from tlie various gases; the constrained
attitudes, the arduous toil, the tension, danger, and worry.
All these conditions, apart from the processes of mining
and the character of the ground, are potent factors in the
great morbidity and high mortality rate among miners
and tunnel workers. Surgical diseases are very frequent,
owing to the great number of accidents; and among the
general diseases favored by work underground are lum-
bago, rheumatism, diseases of the respirator)', digestive,
and circulatory organs.
Factories are places where work is done by the aid of
mechanical power; a irorkshop is a place where work is
done without any mechanical i)ower. Thus a tailor
shop, where the sewing-machines are run liy steam or
electricity, is a factory ; while one in which only foot and
hand power are used is a workshop. The sanitary feat-
ures of the work place, the lighting, ventilation, cleanli-
ness, and the absence or presence of sanitary conven-
iences all affect the health of the workers. The proper
light of workshops and factories is important to the eye-
sight as well as to the general health of the operatives.
A dingy, dark workshop favors not only eye strain, btit
also general uncleanline.ss and ill healtli. The window
area of the shop is also of consequence, as is also the na-
ture of the illuminant at night. The air in workshops
and factories is usually very foul, owing to the over-
crowding of the places and to the lack of proper ventila-
tion. A person at work needs more fresh air 1 han one at
rest, because he consumes more oxygen and exhales more
carbonic acid and organic impurities. The constant in-
halation of foul air acts detrimentally on health, super-
induces lack of tone, muscular debility, and anaemia, as
well as a predisposition to respiratory diseases and tu-
berculous infection.
According to Roth " the worst workshops are those of
shoemakers and tailors. In an investigation made by
him it was found that many shoemakers' sho]is had 7
cubic m., some even less than 3 cubic m. of air space.
He also reports that von Rozahegi found in printing
shops 4.2 per 1,000 of carbonic acid. In some cotton
factories the percentage of carbonic acid was found to be
0. 15 per cent. The .sanitary care taken of the premises is
important, when we remember the large amounts of dust,
waste material, and noxious elements which are to be
found in workshops. The absence of a proper water sup-
ply, of a sufficient number of plumbing fixtures, wash-
rooms and lunch rooms, and of bath and toilet accommo-
dations i.s also an important factor in rendering the place
of work unhealthy for the oiieratives.
The effects of home irovk, or, as it is termed, "sirmt-
shiip" work, are due partly to the defective sanitary con-
ditions of the homes where the work is done and partly
to other causes. The special dangers of sweatslKqi work
are the following: Increased tendency to child and fe-
male labor, the whole family commonly participating in
the work; the constant breathing of a confined, foul at-
mosphere, without the beneficial changes of travel to and
from outside places of work; living, cooking, and sleep-
ing in the workroom; the tendency to prolonged and ex-
cessive wiprk; the effects of dust, etc., on the children of
the home worker ; and the danger of infection by the ma-
terial of work, as well as that of spreading infection from
the homes of the workers into places to which the arti-
cles manufactured in these homes are sent. The health
of sweatshop worker.s is below the average.
Conditions of Occiip.vtions. — To describe here all the
possible conditions of various industries and occupatitms
and their effect on health is obviously impo.ssible. and I
shall therefore confine myself to a brief consideration of
a few of them, and especially of the effects produced
upon the workers bj' such factors as climate, light, air
pressure, strain, mental worry, etc.
The healthfulness of rural occupations compared to
those carried on in citieK is attested by the lower compar-
ative mortality of agricultural laborers, fishermen, and
other outdoor workers, and is ilue to the abundant clean
air, the active life, and the absence of the evils of over-
crowded cities. Artii'e occupations are healthier than
sedentiiri/, on account of the greater muscular activity,
the more vigorous processes of metabolism, and the un-
constrained positions of the workers. Those who are
compelled to engage in prolonged sedentary work suffer
from digestive disturbances, congestion of the portal
circulation, deficient oxygenation, weakness of the mus-
cular .system, predisposition to respiratory diseases, and
a general low vitality. Amcmg the sedentary workers
showing large mortality and inorbility are clerks, book-
keepers, literary persons, engravers, tailors, shoemakers,
etc.
The evil effects of cxjMsiire to extremes in climate are
attested by the many writers on life and industrial occu-
]iation in the tropics. Insolation, extreme muscular and
nervous debility, predisposition to infectious diseases,
etc., are some of the evils which are encountered in tropi-
cal countries. Soldiers, convict laborers, and olheis who
are compelled to do arduous labor in hot climates are
especially prone to become affected with these diseases.
and their mortality is high. The effects of exposure
to extreme cold and inclement weather, as well as those
of exposure to extremely high temperatures, are well
known. Boatmen, fishermen, drivers, motormen. and
others are compelled to work in all kinds of weather,
322
REFERENCE HANDBOOK OF THE .MEDICAL SCIENCES.
4>e(>iipation«
Ocoiipalion*
and are prone to cougcstions of internal organs, respira-
tory diseases, rlieuniatisni. and eatarrlial affections. Bak-
ers, coolis, blaelvsniitlis, engineers, firemen, stolsers, sugar
refiners, furnace worliers, electric welders, anil others
suffer from tlie effects of too high temperatures, ilus
cular exhaustions, thermic fever, muscular debility, re
spiratory tliseases are some of the elfects of a prolonge<l
exposure to great heat. Andrew * reports the case of a
child who had almost universal paralysis after exposure
to great lieat in tlie railroad cars; and several cases of in-
sanity (firemen's frenzy) have also been reported, due to
the same causes. Blacksmiths are exposed to direct ra-
diant heat, and are predisposed to respiratory diseas<s.
Oliver^ .says that a great many blacksmitlis die fnnii
phthisis. lie quotes Ogle's tables, showing that "niil
of 872 deaths of blacksmiths, 194 dii'd of consumption,
183 of other lung diseases, 108 of diseases of heart and
circulation, and 85 of diseases of the nervous system."
In a number of industries the processes employed expose
the men to extremely high temperatures; tliis is notably
the case in the drying rooms of chemical works, in the
furnace rooms of the glass and iron trades, in certain
deep mines, etc.
Ovcrstroug. radiant, and ghii-inij lujht is met with in
the iron and steel industries, in glass furnaces, in engine
and forge rooms, and in electric welding, and is very in-
jurious to the eyes and to the general health.
The excessive relatire humidity of many places of
work, while not a direct cause of disease, predisposes to
rheumatism, catarrhal conditions, and congestions of the
internal organs, and to diseases of the respiratory appara-
tus. H. Wolpert.'' after an exhaustive investigation of
the effect of various degrees of humidity on the heallli of
workingmen, came to the conclusion that "on the whoji'.
the normal degree of relative humidity in a workroom is
when there is no formation of perspiration,"— a degree
which is hardly obtainable in most industries. The trades
in which the relative humidity is very great are, among
others, mines and tunnels, all luidergroiuid work, textile
factories, where steam is introduced in the "sizing"
rooms, bath-houses, etc.
Variations in the normal p?'«s.'i!nT of the in';' are indis-
pen.sable conditions in several occujiations. Aeronauts
and mountain miners and climbers bi'eathe rarefied air,
and suffer on account of the lack of oxygen and diminu-
tion of air pressure. Divers, tunnel workers, caissmi
workers are exposed to an increased air pressure, and are
liable to suffer from caisson disease, described above.
Those who are subject to violent jarring and concussions
in air, such as boiler-makers, blasters, and workers with
explosives, are subject to deafness.
The position ma.mXa.mtid while at work and the attitude
which the worker is compelled to assume in each trade are
not without effect on health. Salesmen and siileswomen in
stores and shops and operatives in factories are frequently
compelled to be on their feet all the time of work, and as
a result the men sutfer from varico.se veins, and hemor-
rhoids, and the women from congestion in the pelvic or-
gans. The bending and constrained attitude assumed by
shoemakers, copyists, tailors, seam.stresses, etc., cause de-
fective development of the chest, deficient oxygenation
of the blood, and )ire<lisposition to respiratory and other
diseases. The constrained attitudes which coal miners
are compelled to assmne while " kirking " or undercutting
the coal seams result in nystagmus, descrilied above.
The duriitiun of work is a potent f;ietor in the effects
of occupation on health. The normal jihysiological ac-
tivity of the body functions is conducive to health and
longevity; but the overuse and abuse of one or more or-
gans or the whole body are bound to produce general ill
health or special injuries. The standard of normal activ-
ity varies with each individual, as well as with the dilTer-
ent kinds of labor and conditions under which it is cur-
ried on. The most correct stau(iard will be that which
is basefi on the sense of fatigue experienced b}' the
worker; and we may assume that, under normal" con-
ditions, work becomes hannfvd when the worker feels
greatly fatigued, and very injurious if the fatigue is
pushed to the point of exhaustion. When in a state of
great functional activity our organs draw a relatively
large supply of blood and produce, as well as eliminate,
a greater proportion of waste matter, in the form of car-
bonic acid, urea, aqueous vapor, organic matter, etc.
The result of overfatigue is a retention of waste matter
and consequent auto-intoxication. Hence the in jurious
effects of too prolonged work and of a workday of too
great length.
The effects of the duration of work will, in part, de-
pend on the tension and ett'ort with wliieli the work is
done. When the work requires too great effort and is
done under special tension, the worker will sooner reach
tlie state of fatigue than he otherwise would. Carrying
heavy loads and lifting great weights require special
muscular strain, and may produce hernias, and cardiac
dilatation; they also predispo.se to aneurisms, rupture of
tendons and muscles, dislocation,?, etc. The excessive
use of one mu.scle, organ, or group of muscles leads to
their eventual injury. Thus, engravers, watchmakers,
writers, tailors, etc., suffer from eye-strain; athletes,
gymnasts, hammermen, etc., from hypertrophy of mus-
cles and cardiac affections; speakers, preachers, exhort-
ers, etc., from vocal strain.
The juviH-.'t in the workday have a great deal to do
with the fatigue effect of occupation, for the reason that
periodical rest is needed for all organs in a state of activ-
ity. It is a fact, that more work is accomplished with
several pauses in the working day than wlien w^ork is
continued without pauses. After a prolonged rest,
more may be performed in one hour than in several
hours at the end of the working day ; and the work of
the latter part of the day is, as a rule, not so good as that
done during the earlier ])art of the day. Insome coun-
tries, notably in Russia, the workday lasts for from four-
teen to sixteen hours, l)ut there are several pauses and
they are finite prolonged (the dinner pause lasting one
hour and a half); as a result the workingmen feel less
fatigue tlian when the workday covers a period of nine
hours, with only a half-hour's midday pause.
The jiractice of carrying on the work in mills and fac-
tories continuously, by means of a day shift and a night
shift of workers, is harndul, first, by reason of the bad
air that is to be found in a constantly occupied place,
and, secondly, by the bad effects of night work on the
general health. Night watchmen, clerks, and all those
who are compelled habitually to work through the whole
night and sleep during the "day, are not, as a rule, in as
good health as are the day workers.
A number of occupations are huzitrdoiin by exposure
of the workers to the risks of accidents to life and limb.
Roofers, painters engagc<l on the outside of Imildings,
bridge builders, etc., are liable to injury anil death from
falls. Furnace workers, chemical workers, etc., are ex-
posed to the danger of burns. Jliners. workers with ex-
plosives, etc., are liable to injury by the falling of rocks,
by explosions, fires. I'tc. Factory and mill employees,
working near or about machinery, are liable to injury
from the engines, belts, running gear, cogs, shafts, Ctc.
Altogether, many trades are pursued under conditions
which are extremely dangerous to the worker.
There are a number of occupations which are character-
ized by the nientnl irorry and nervous strain to which
those engaged in them are subject. Thus, stock brokers,
gamblers, merchants, superintendents, and heads of large
inilustrial and conunercial interests, etc., work under pro-
longed mental and nervous strain, and often break down
in the midst of their work.
Cijynpensution. — The wages received by the workers for
their labor exercise great infiuence on Iheii- life and
health. On the rate of compensation greatly depend
tlie hygienic surroundings of the worker, his personal
comfort, his habitation, his proper eloihing, and the
(piality of his food. The physical health of tlie worker
largely depends upon these factors, and they in turn de-
pend on the rate of conqjcnsation. Asa rule, working-
men who get better wages live better, enjoy better hy-
gienic surroundings, and are in better health. Contiuen-
323
4>i'<-ii pat ion.
Ocoiipatfoil.
REFERENCE HANUBOOK OF THE MEDICAL SCIENCES.
till workers, who receive onl_v a iialtry wajje. and are
viuable to atTord decent dwelling liousi'S and .<;ulHeient
food, are iu a bad state of health when conijiared with
American workingnien, who receive higher pay.
The Processes Employed in Difeekent Occupa-
tions.— The cliief element of danger in most trades lies
in the processes which they employ, these often evolving
substances or fumes which are more or less dangerous to
health. Ilirt buses hiscl.assilicatinnof the different trades
upon the three principal harmful elements — viz.. dusts,
poisons, and gases. This classilicatiou, while not with-
out its objectious, is still the best for our purposes.
Triules Dangerous to Ilcolth on Arroiint of the Dust Pro-
diiccd. — There are a number of industries in which large
fpiantities of dnst are produced. This dust being inhaled
l)y the operatives becomes a source of dauger to their
health, the resjiiratory organs being the greatest suffer-
ers, although dust may also jiroduce gastro-intestiual dis-
turbances anil c'crtain eye affections as well as dermato-
ses. The various kinds nf dusts act alike, iu a general
way. differing very slightly, according to the form and
([uality of each. The first effects of dust inhalation are
irritation and iuflammatiou in the respiratory passages,
the no.se. throat, and bronchi. an<l if the inhalation is
allowed to go on for a certain length of time the iutlam-
niation is likely to become chronic (chronic bronchitis and
emi>hsyema). " The deposit of dust iu the small bron-
chioles, and frequently in the parenchyma of the lung,
superinduces inflammatory reaction iu the lung ti,ssuc,
followed by councctive-ti,ssue formation and sometimes
by consolidati<m in nodules and distinct areas. The later
stages of the pneumonokonioses are characterized by de-
generative changes in the nodules, and iu the other areas
where the dust is deposited. Indeed, modern patholo-
gists are of the opinion that "coal-miner's phthisis,"
"grinder's asthma," " potter's rot," and the otlier pneu-
mouokonioses are, in tlieir last stages, but tuberculous
infections.
O/iil litdiisirii. — Coal miners wlioeommonly inhale large
<|uanfities of dust are subject to respiratory diseases — to
lirouchitis. em]ihysema, and anthracosis. Coal dust has
been found in the lungsof miners, and the quantities are
sometiiues very great. The initial symptoms are those
of a catarrhal intiammafion of the respiratory passages,
accompanied by cough, black siiufuni, dyspuiea, and in
a large jiercentage of eases by symptoms of empliysema.
A time comes, however, though not iu all cases, when
the symptoms liecome aggravated, and general consti-
tutional disturbances are seen whii h are due to degeuei'-
ative chanues ami |>rocesses in the lung tissue. 3Ierkel.
Ailidge, KindHeiseh, Olge, Oliver, aud others are of tlie
opinion that the later stages of anthracosis are not neces-
sarily fubercidous. although the analogy seems charac-
teristic. Indeed, it is claimed liy them that coal miners
are i)arficularly free from tuberculosis. Coal miners are
subject, during their work, to many insanitary condi-
tions besides dust inhalations. To mention only a few
of the dangers of coal mining would be to repeat all the
conditions of work, the dangers of which have already
been described in .-i jM-evious section <if tliis article.
Burnt coal or soot seems to possess speciall}' irritative
qualities. At least, it is a fact that charcoal burners
and chimney-sweeps are great sufferers from pulmonary
tuberculosis. Chimney sweejis also suffer from cancer
of the .scrotum, "chimney men's cancer," an affection
quite frequent in chimney-sweeps in Euglaiul, although
rarer iu the same workers iu other countries.
Iron and ,'<tecl Indiistnj. — The effects of inhaling ii'ou
dust are not (juite t!ie same as tliose which result from
the iidialation of coal dust. In the first ]ilace. iron dust
undergoes absorption aud oxidation to a greater or less
degree in the hmg tissues. Thus Zenker aud Merkel both
found in the lungs of iron workers large deposits of iron
oxide; in ■Merkel's case 7.1 per cent.'' Tlicn, in the next
jilace, the particles of iron dust often woiuid, with their
sliarj) corners, the delicate bronchial mucous mrmbrane,
and thuso])en the way for infection with pathogenic bac-
teria. The branches of the iron and steel iudustry, espe-
cially harmful on account of dust, are those in which
polishing and grinding are done. Thus cutlery workers,
needle makers, and grinders of steel articles are inhaling
large quantities of metallic dust, and are very much sub-
ject to respiratory diseases, and ])artieularly pulmonary
tuberculosis. Dry grinding is the most injurious process
iu cutler}' work, Lloj'd * (|Uotes Holland, who says " that
the average age of grinders is only twenty-five aud three-
quarter years; and young men of seventeen to twenty
.years of age, strong and lough from the pilough, who en-
gaged iu the work died from its effects, as a rule, before
reaching the age of thirty." The general mortality ratio
of grinders from respinttory diseases is, according to
Tatham, five himdred and fifteen to one hundred aucl fif-
teen among agrictdturists. The mortality figure from
phthisis is very high.
Minerol Indnstrits. — Workers who inhale mineral dust,
as stonecutters, masons, plasterers, brickmakers. dia-
mond grinders and polishers, porcelain makers, pottery
aud china workers, etc., are subject to chalicosis pul-
luouum, a term applied to the pathological condition
which is produced by a deposit of mineral dust in the
limg. The deposit of these dusts has been demonstrated
by chemical analysis. Meinel and Malpert found that
such lungs contained inunense amounts of silica, silicic
iicid, phosphate of lime, and sanil,'" The quantify of
dust in the above-named trades is very large. Thus
Oliver^ quotes Lamaister, who analyzed the air in the
Limoges potteries, and found "that the dust is composed
of earthy particles and fragments of granite, flint, glaze,
.soot, and (f larcoal. The atmosphere which the brushers-
ofl, the finishers, and the porcelain makers generally
work in contained C4(J,000,UU(t of dust particles to the
cubic metre, while in some of the rooms the number
reached CsO.UdO.diJO per cufiic metre." That the breath-
ing of air laden with such quantities of dust is injurious
is self-evident, aud the mortality rate of these workers
from n-sjiiratory diseases is very great. Hirt foimd the
average life of stone grinders to be forty-two and a half
years. The mortality rate of potters is the highest; but
this is due to the fact that potters arc also subject to
plumliism. The number of trades iu which mineral dust
abounds is very large.
Te.rtile Indngtriefi.—Yfovlierri in textile industries are
subject to inhalation of organic dust, animal and vege-
table. Among the textile trades which are unhealthy on
account of dust are those which deal in fla.v. linen, cot-
ton, jute, silk, wool, and hair- working. The dust in each
of these branches of the textile industry differs from that
of any other iiid\istry in some of its features, but retains
its irritating (pialilies iu common with all dusts. Besides
the effect on the respiratory system, these dusts seem to
be very irritating to the skin, producing various derma-
toses. Those who cleau and work at the crude materials
are compelled to inhale m<ire dust than the spinners aud
those who work at the later stages of maiuifaeture.
Greenhow foimd that out of one hundrcii and seven tla.x
spinners .seventy were aff'ceted with resiuratory diseases.
Cotton irorkcrs are said to suffer from " pneiuuoiu'e cot-
foneuse," a form of pulmonarj' tuliercidosis due to the
irritating dust habitually breathed by the o])eratives. As
iu other textile iudustries. those who work at the crude
material suffer the most from dust. Cotton dust is also
said to be very irritating to the skin, producing derma-
toses.
Silk icorke)'s are prone to tuberculous affections, and
to all respiratory diseases. Thus, iu one silk spiunery
in Sagrado the percentage of respiratory disease was
twenty. Netolitzky '-' qviofes Combassedes, who on ex-
amination found 71)1), fiOl), 0(10 of particles of dust per cubic
metre in the work-rooms of the silk mills. He .says that
silk workers suffer from respiratory and digesti\e ilis-
eases, and from ana?iuia. and that they present a very
high death rate.
Wool irorkers are exjiosed to animal dust, and also to
the danger of infection b}- any jtathogenic organisms
which may cling to the animal substances, such as hair,
wool, hides, etc. Anthrax is the priucii)al infectious dis-
324
REFERENCE HANDBOOK OF TUK MEDICAL SCIENCES.
Occupation.
Occupatfou.
ease afflicting woohvorkers. The effect of dust inhala-
tion is seen in tlic large nuinlier of cases of sickness from
bronchitis and otlier rcsjiiralorj- diseases. Furriers very
frequently suffer from what is called "furriers' asthma,"
the symptoms of which, however, are due not so mucli
to the effects of dust inhalation as to the various poison-
ous dyes used in coloiing fur.
The inlialation of irow! (/n.tl is claimed to lie without
any effect, although Jlcrkel .states that workers in pencil
factories, who inhale large quantities of dust formed in
the processes of sawing the wood for the pencils, suffer
very much from phthisis. Carpenters, sawmill workers,
etc., are exposed to wood dust.
Tobacco (liixt, in tobacco, cigar, cigarette, and snuff
manufacturies, acts on the worker mechanically, also
chemically, by reason of the nicotine contained in it.
There is a tendency among writers on the subject to
deny the evil effects of tobacco dust on the operatives.
This is liardly true. There is abundant evidence that
cigar, cigarette, and snuff workers suffer greatly from
respiratory diseases, as well as from ana-mia and diges-
tive disturbances.
Flour dust has always been regarded as peculiarly in-
jurious to those who are compelled to inhale it. Miilers,
bakers, and confectioners, but the first especially, have
been stated as having the highest death rate among workers
in non-poisonous dusts. Of 108 cases of sickness among
millers, Shuler- found 34 cases of respiratory disease, 13
cases of tuberculosis, 19 diseases of the skin, 17 of the di-
gestive organs, 4 eye diseases, and 3 of eii-culatory sys-
tem. In the modern forms of flour milling the greatest
part of dust piroduction is done away with, and the effect
of flour milling is not very harmful to the workers.
Those Avho are exposed to the inhalation of rnixed dust —
for instance, street cleaners, carpet sweepers, carpet
beaters, etc. — are liable to bronchial affections. In Ilirt s
tables mixed dustsshowalarger percentage of all respira-
tory diseases than do most of the other dusts.
Tratlcs Dangerous to Ileallh on Aecouut of Pi/isoiious
Substances. — There are a large number of trades, the chief
element of danger in which consists in the poisonous
nature of the materials and substances made in the proc-
esses of manufacture, etc. As tlie toxicology of most of
these substances is dealt with in other parts of this II.\xii-
BOOK. only a very brief description of their effects upon
the health of the workmen will be given here.
Arsenic. — Arsenic in its various forms is used in medi-
cine and the arts for many juirposes. It is employed for
preparing dyes for textile fabrics and for coloring artificial
flowers ; it is an ingredient in many forms of wall paper,
and is used in carpet manufacturing; it is sold as an
animal and parasitic poison, and is used in many other
ways and in combination with various substances. All
persons manufacturing articles in which arsenic is em-
ployed are subject to arsenical poisoning. Arsenic
affects the skin, gastro-intestinal tract, resjiiration, and
especially the nervous system. On the skin the effects
of arsenic are seen in the eczematous eruptions and
various vesicular and pustular sores. On the respiratory
passages arsenic acts as an irritant, and causes a catarrhal
condition of the nose, throat, and bronchi. In the gastro-
intestinal tract arsenic cau.ses .severe irritation, anorexia,
diarrhoea, colic, gastritis; and among the nervous dis-
orders which it produces may be mentioned a general
diffuse multiple neuritis, jirogrcssive muscular at'rophy,
loss of tendon reflexes, local anesthesia, trophic sore's,
and ataxia. Not all who are exposed to arsenic suffer
equally from its effects. A large number of workers in
arsenic seem to enjoy a peculiar immunity from its toxic
effects. As an example of such immunity I can cite a
patient of mine who for the last eight years has worked in a
paint manufacturing establish nent, "packing Paris green
in boxes, for from ten to sixteen hours a day. and seem-
ingly he has good health all the time ; while new men, who
were engaged to assist him in his work, usually showed
signs of toxic effects of arsenic within a very short period
after exposure to the atmosiiherc full of arsenical dust.
itarf.— Lead is the most widely and largely used metal.
The number of its usi'S can hardly be stated; indeed, the
trailcsand arts in wliich lead is not enijdoyed, in one or an-
other form, are not very many. Hence a very large con-
tingent of workers are exposed to plumbism. The mode
of introduction of lead into the system is through the
lungs, digestive tract, and skin. Lead dust is prevalent
in most places where it is used. Leatl is ingested in the
I'Di-m of dust or through the medium of the particles
which cling to the hands, fingers, and per.son of the
Worker. Its absorption through the skin is slight.
Among the tr.idcs in which the workers aie exposed to
the danger of pbnnbism are the following: Lead miners,
white-lead workers, lead-paint manufacturers, painters,
jiotters, calico printers, compositors, pressmen, stereo-
typers, linotypcrs, printers. plumi)ers, filemakers, platers
r)f iron and makers of hollow ware, solderers, makers of
lead toys, vessels, etc., glazers of caids, paper, etc., and
a very large number of other trades into which lead goes
in some of its forms. The elfect of exjiosure to lead is
not the same on all workers. Women and children are
es]iecially prone to plundji.sm. The effects of lead poi-
soning are seen in the anaemia, cachexia, metallic taste in
the mouth, vomiting, constipation, lead colic, bluish line
along the margin of the gums, retraction and ulceration
of the gums; but the most marked effects are those on
the nervous system. There are a lo.ss of motor power in
the hands and feet, Avrist drop, progressive muscular
liaialysis, multiple neuritis, temporary and sometimes
permanent blindness, convulsions, insanity. The mor-
tality of lead workers is very great. Tatham^ .says it is
ninety per cent, above that of other workers, and three
times greater than that of agriculturists. Of the total
deaths which occurred among lead-workers, one-fourth
were due to ]iuliniinary tuberculosis, one-eighth to lead
poisoning. Plumbism is especially frc(}uent among
those engaged in mainifaeluring white lead, printers, file-
makers, and painters.
Stuhler, of Berlin, taking bis statistics from the reports
of the sick-benefit societies, states that of 3,000 printers in
lieiiin, 313 were aimually sick with lead colic."" The
analysis of the dust in some printing shops gave nearly
to per cent, of lead." File-makers also suffer very
largelj' from idumbism. Ogle gives the follow'ing statis-
tics of the comparative mortality from lead poisoning,
based on the death register for 1879-82, in males over fif-
teen years of age: File-makers. 4(i6 per million living;
painters, plumbers, glaziers, 234; earthenware-makers,
153; gasfitters, 63; printers, 37, and all other males, 4.
According to Tatham, the comparative mortality from
lead poisoning in the several trades is the following;
Males occnpie<l in one manner or another, 1, wool manu-
facturers 3, cutters 3, juinters 3. leadmakeis .5. gas-
fitters, locksmiths 0. coaehmakers 7, copper workers 8,
glassmakcrs 13, potters 17, painters and glaziers 18,'
plumbers 34, filemakers 75, and lea<l worker.s" 311."
Mercury. — The effects of mercury upon workingnien
who labored in cinnabar mines had been imted as far
back as in 1665. when reference to the tremor caused liy
it was made by Dr. Walter Pope in the Pliiloso|ihir:il
Transactions." Detailed accounts of the meicurial poi-
soning of operatives is also fimnil in Ramazzini's work.
The industries in which mercury is used, and in w liich
the workers are exposed to the danger of mercuiialism,
are the following; Cinnabar mining, gold and silver min-
ing, where mercury is employed to form amalgams; the
manufacture of scientific instruments, such as thermome-
ters, liarometers, etc. ; the manufacture of electric meters
and lamps, where mercurial ]iuinps are used to create a
vaciuim; the gilding and silvering of mirrors, etc.; the
manufacture of certain ]iaints; the making of phar-
maceutical preparations; also the making of felt where
the felts are brushed with a solution of the nitrate of
mercury. The mode of introduction of mercury into the
.system is by inhalation of the fumes, or by ingestion of
the salts of mercury through deposits on tlic hands, fin-
gers, clothing, etc. Stomatitis, salivation, gastric dis-
turbances, emaciation, cachexia, are symptomsof chronic
mercurialism. The effects on the nervous system are
Oooiipatiou*
0<-ciipation.
REFERENCE HANDBOOK OF THE .MEDICAL SCIENCES.
marked tiviiinrs, paralysis, and psycliical cliaiises. Tlie
tremors and paralyses are notieeat)le espceially in the
museles of the face, hands, and arms. Melancholy, de-
pression, loss of nieniiiry. and hallui-inations are some of
the psychic forms. Kiissniaul has shown that mercu-
nalisni"acts very unfavorably upon women, predisposing
to abortions and to diseased conditions of the infants.
Phosplidnis. — Tlie danger of phosphorus ptjisoning is
almost entirely restricted to the nianufaclure of matches
fnmi yellow phosphorus. Tlie nudiint; of matches from
red phos])lionis (safety matches) is not aeeompaiued by
any dangers. The iiriiicipal cITect of phosjihorus is its
action on periosteum and bones, the maxillary bones be-
ing the most easily alfecled. A prolonged exposure to
tlie action of pliosphorus is necessary before the specific
effects of it arc noticeable. Some writers claim that
phosphorus has no effect on healthy periosteum and bone
and that only those wlio suiter from caries of the teeth
and other alTeetions exposing the periosteum of bones to
the phosphorus fumes are afl'ected. The disease mani-
fests itself in necrosis and se(iucstratioii of the aiTected
bone or of that jiorlion of it which is diseased. The
number of cases of pho])h(irus poi.soniug iu the United
States is not large. Sweden is the coimtry where most
of the match factories are located, and where phosphorus
poisoning is most frequently met.
Capper ntid liniait. — Copper is a metal which is found
in a pure state, and which is also procured from various
ores. Brass is an alloy of co|)perand zinc. The mining
of copper and the manufacture of copper vessels, etc., are
not considered as dangerous as the manufacture of brass
and brass articles. It has been said that workers in cop-
per have often foun<l that their hair, urine, and skin Hun
green. The .salts of copper are more poisonous than the
metal. Arlidge thought that iidialation of copper dust
produces the "copper colic," wliieh is a form of digestive
disturl)ance characterized by pain, purging, vomiting,
and prostration. This is denied, however, by later in-
vestigators, who assert that the symptoms are due to a
mixture of the carbonate of copper and lead.
Workers in brass-smelting and the manufacture of
l)rass articles are .subject to iidialation of brass dust and
fumes. A general catarrhal condition of the respiratory
passages and gastro-intcstinal ti.ict residts from expo-
sure to brass dust. 'What is known as " brassuicn's ague,"
which is characterized by chills, fever, ce|)halalgia, nau-
sea, depression, prostration, and collapse, is thought to be
due more to the zinc in the brass than to the copjier.
Hnxious Gases and Finiies. — Tiie occupations iu which
perceptible quantities of dust or detinite poi.sonous sub-
stances are produced are few iu comparison with the nu-
merous industries iu the processes of wliicli noxicms
gases anil tiiiues are evolved. The industrial lu'ocesses
in which chemical agents and gases are ]iroduced which,
when alisorbed or inhaled, may liecome dangerous to
health, are so manifold and diverse that it is ab.sohitel_y
imi)o.ssible to give even a brief description of them. Nor
is it always possible to trace the harm done to health in
these chemical industries to any one of the elements or
gases prevalent in the process, for iu most of these indus-
tries various and com|)licated processes are being simul-
taneously carried on. and the workers ma^' be exposed to
a number of agents and gases at the same time or suc-
cessively. If we take, as an example the coal-tar color in-
dustry, there are several dozens of various agents pro-
duced, either together or as by-]iroducts, and each of
them may be more or less injurious to health; and it is
exceedingly difficult sometimes tn determine which of
thein has jiroduced the most harm in the case of any ]iar-
ticnlar individual. So widely do eliemiral manufactures
permeate the uhole range of human induslrics that there
is hardly an article or substance made in wliirh chemical
processes of some kind do not take place.
Some of the principal agents and gases evolved iu
chemical trades are the following: Suljihur and its com-
pounds; carbon and its com|ioumls; sodium, sodium
chloride, clilorine gas; potassium and its salts; ammonia,
ultramarine, carlion bisu!i>hide, dynamite, nilroglyeerin
and other explo.sives; chromium, alum, iron and its ox-
ides: lead and its salts; arsenic, copjier, zinc, illumi-
nating gas. coal tar and its products, nitrobenzol, the
various drugs, india-rubber, turpentine, cyanogen com-
pounds, and many others too numerous to mention.
Most of these agents are used, in one or another form,
singly- or in combination, in most of the human industries
and arts ; and many of them are also toxic to a large de-
gree, and injuriously affect the health of those engaged
iu their ]iroduction and in handling them.
The effects of the work with noxious agents and gases
are cither acute or chronic, and the dangers are from
(1) the toxicity of the sub.stances; (3) tlie danger of ex-
jilosions, burns, and corrosions; and (3) the excessive
temperatures wdiich are necessary in most of the chemi-
cal processes. The mode of introduction of these nox-
ious agents into the .system is .somewhat different from
that of the dusts produced iu other trades; and the ef-
fects ari' also somewhat different. 'Wliile the inhalation
i>{ iliist actsi'liictly tipoii the respiratory system, the gases
and other noxious agents of the chemical industries have
each their own effect, each having siiecitic action, but
mostly of a toxic character. Jloreover, while dusts af-
fect the human system only after long exjiosure and con-
tinuous and iirolonged inhalation, the effects of gases and
chemical agents are luoduced after comiiaratively short
exposures. Again, wliile the effects of dust inhalations
may always be seen on the respiratory system, and at
times patliologically demonstialed by the iiresence of the
dust in the lung tissue, the effects of toxic agents and
gases cannot, in most cases, be demonstrated, and, if at
all, only in the blood, by chemical and spectroscopic ex-
;iniiuations.
Kotli cites Austrian stalislicsof mortality and morbil-
ity among chemical workers, lie found the mortality
to be 7 per 1,(100. The iliseas(-s with wliiih they were
affected were distiibuted as follows: 25.7 per cent, for
burns, contusions, and the like accidents; 17.9 percent,
for affections of the respiratory system; 14.7 per cent,
for disorders of thi' digestive tract; 10.8 percent, for dis-
eases of the skin, and 10.5 per cent, for general constitu-
tional diseases.
PnOPHYt>AXIS.
Having brietly examined the various danger.? of dif-
ferent trades, we now come to the most important phase
of our subject, that of jiropliylaxis; the most impor-
tant, for, after all, the aim and purjiose of hygiene in
general, and industrial hygiene in particular, is the pre-
vention of disease and ]ireservation of life. On a closer
study of industrial conditions we find that many, if not
most, of the dangerous elements in trades are prevent-
able, and that there is no need for the terrible waste
of healtli and vast destruction of life prevailing in mod-
ern industries, as shown in the mortality and morbility
statistics.
In the endeavor to improve industrial conditions, and
prevent unnecessary suffering iu the dangerous trades,
medicine and legislation are allied: the one to study and
expound the rules of health, the other to enforce the
hiws based on scientific hygiene. I'nforlunately. the ig-
norance of the workiugmen and the cupidity and negli-
gence of employers are the two stumbling-blocks to the
general acceptance of the better laws of health.
In discu-ssing the hygiene of occupations we propose
to consider the subject under two heads — General Pi'o-
jihylaxis anil Special I'ro|ihylaxis.
(;Jf-:nek.\i, Pi!i)1"iiyi..\xis. — The first ])ersonal require-
ment for preventing the evil inllucnce of occu])ation on
health is the proper selection of a trade ; this is commonly
done by natural selection, or more frequentlj' by accident;
yet it is very imjiortant that certain trades be followed
only by the best ]iliysically endowed constitutions. Were
there a medical sniiervision and control of the selection
of trade by individuals, persons of a scrofulous diathesis,
with a tuberculous family history, would iiol be ])i'rinitted
to embrace indoor, inactive, sedentary occupations, and
326
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Oocupatiou.
Occupation.
cpitainly not anj' in which large quantities of dust must
hv iiilialed ; uor would nervous, delicate, choleric persons
l)e allowed to enter industries which subject the work-
men to great nervous strain, mental worry, and respousi-
l)ilit y. nor those in which they may be exposed to toxic
ai;c'iits which act specificall.v on the nervous system.
Perhaps the proper medical supervision of the selection
of a trade is as yet a dream of hygienists, but it is bound
to lie realized.
Already there are legislative enactments in all civilized
countries restricting, limiting, and partly prohibiting
r/iiJd hibiir, and the highest aim of hygiene is tliat no
child under eighteen should be allowed, under any cir-
cumstances, to engage in any occupation except that of
developing its phy.sical and mental faculties.
Fdiiale labor is also largely restricted, and even prohib-
ited in some trades; and in manj- States legal provision
is made to limit the industrial activity of women during
pregnancy, after childbirth, and in specially dangerous
trades.
The personal cleanliness of the workers is an important
condition in the general prophylaxis of the effects of oc-
cupations. It isafact that in specially dangerous trades,
such as printing houses, lead works, etc., and in all in-
dustries where ])oisonous substances are manufactured
and manipulated by the employees, those workers who
have the least regard for personal cleanliness, who are
careless in washing themselves, and who eat their food
with hands and clothing full of tlie toxic materials, are
the readiest victims of industrial poisoning; while the
more careful often escape all barm. Workers in dusty
and poisonous trades should have their hair on face and
head cropped short and the}' should be compelled to ob-
serve rigid rules of personal cleanliness, the compulsion
being necessary on account of the ignorance of the work-
ingmen and their contempt for the dangers lurking in
their trade, — a contempt bred by familiarity.
The wearing of proper cluthin;/ is an important prophy-
lactic measure in all trades. It must suit the kind of
trade in wliich the individual is engaged. Those who
are exposed to low temperatures should wear woollen
sweaters or flannel underwear, while workers in high
temperatures should wear light absorbing cloth. All
who work in damp, moist, and wet places should have
their footwear imperraeable to dampness, and their cloth-
ing should be made of a material which will absorb moist-
ure without letting it penetrate the uudercloth. The
wearing of rubber-impregnated cloths is inadvisable as it
interferes with evaporation of perspiration; mackintosh
capes, protecting from moisture and at the same time
allowing evaporation, are recommended by some author-
ities. Persons working in dust}' occupations should wear
fabrics with smooth surfaces only, and, whenever possi-
ble, without any seams, folds, or pockets where dust
may accumidate. But the most important prophylactic
measure in this respect is that no clothes worn while at
work should be taken out of the workplace, but nuist be
exchangeil for other clotlies which are to be worn only
outside the workshop. In some trades the employers are
compelled to furnish the workers with two suits of over-
alls to be worn while at \%ork. In those trades in which
corrosive poisons and gases are likely to burn or injure
clothing, tlie worker should wear leather cloth or other
not easily destructible material; and wherever the hands
come in contact with the same substances leather gloves
should be worn. In dusty trades it is advisable to cover
the head with closely fitting caps. There are some in-
dustries in which the cloth worn is the result of estab-
lislied custom and is usual!}" consistent with hygienic
principles. Thus the chimney-sweep's suit, so often
seen on the Continent, is very appropriate to his calling,
and protects him from contact with the irritating soot.
Dnration of Work shoidd be adjusted to the nature of
the work and the standard of health of tlie operatives.
Economists agree that there has been no loss of ]U'i»luc-
tive capacity since the work da}' was reduced from six-
teen to eighteen hours to the ten-hour-day standard ; and
owners who frantically struggled against every attempt
to reduce the working day, and prophesied the decadence
of industry if it was done, liave at last come to see that a
.shorter workday means actually a greater productive ca-
pacity and a better state of health in the workers. No
universal workday can be established or is applicable to
all trades and persons; the length of work should be
carefully adjusted to the age, .sex. and health of the
worker, to the place of work, to the conditions under
which it is carried on, and to the cliaracter and nature of
the processes of each industry. The more unfavorable
the conditions under which the work must be carried on,
the shorter should be the workday. This is the rule fol-
lowed in specially dangerous trades; thns, caisson work-
ers are allowed to work for onl\- from two to four hours
at a time; furnace workers, or ihose who are exposed to
fumes and gases in lead and other trades, work, as a rule,
only in three- to four-hour shifts. The same rule should
be applicable to all other trades.
The number and length of the work pmisei< bear an im-
portant relation to the health of the employees in each
trade, for every physical or mental activity requires peri-
odical relaxation. It has been proven that more work
can be done in two hours at tlie beginning of the work-
day than in twice that time at the end of the day. In
England forenoon and afternoon pauses are lequired for
child workers, besides the usual midday lunch hour.
This rule should be adopted for adults also, especially in
the dangerous trades. The length of the midday lunch
pause should not be less than one hour in any trade, as a
shorter pause leads to carelessness and haste in cleaning
up, to high speed of food consumption, and to failure of
the worker to go outside of the shop for a short breath
<if fresh air.
Xiciht itork is more tmfavorable to health than work
during the day, and, whenever this is practicable, such
work should be restricted; at any rate, the working
hours should be comparatively shorter and the pauses
longer and more frequent than in day work, and there
should also be periodical changes l)etween the day and
night shifts, so that those who for one period are engaged
during nights should at other times be working by day.
Overwork leads to ill health and to fatigue neuroses, and
should be restricted if not entirely abolished. The pro-
phylaxis of the fatigue neuroses can be accomplished
only by due regard to the working capacity of the mus-
cles and organs employed. The burden of work, when-
ever this can be avoided, should not be put on one group
of muscles or on one ornan. Thus writers, copyists,
clerks, and others who have much handwriting to do
should train themselves to employ both hands, and be-
sides they should use tliem in such easy positions as not
to overfatigue the muscles. The same principles may be
aiiplied to overstrain of other organs.
The proper education of the worker in general hygiene,
and especially in the dangers of his specfic trade, is an
important factor in the prophylaxis of many of the occu-
pational diseases.
The problem presented by the unhealthy condition of
sireatshop work is a difficult one for legislators, but very
simple to hygienists, who arc unanimously of the opinion
that all homework should be entirely prohibited; and
that there should be a complete separation of the factory
from the home. It is therefore merely a question of time
when the economic obstacles to the abolition of the sweat-
shop method will be surmounted.
The construction of workshops, factories, mills, etc..
cannot be gone into here, but there is one requirement
which should not be overlooked in this respect, and that
requirement is that industrial establishments should be
constructed for the specific processes to be carried on
therein, and that the plan of adapting any ramshackle,
out-of-date building, unfit for any other pur])ose. to the
uses of factory or workshop, as is frequently the case,
nuist be absolutely prohibited. The size of the workplace
slnnild. of course, correspond to the nundier of employees,
and to the needs of each establishment. The minimum
of fourhundred cubic feet of space foreach worker, which
is established by legislation in many places, is entirely in-
321
4^C4>ii|>alioii.
Occupation.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
iicU-qiiatc: then- should be at least one thousaml eiibic
feet of spaie for eaeh indiviilual, as a geiu^ral rule, and
this allowance sliould he inereased in sjieeial dusty and
otherwise dangerous trades. The walls, ceilings, floors,
and all surfaces of each estahlishnieiit should be con-
structed with due regard to the process of industry
carried on within them. Thus, in all places where dust
abounds, tlie walls, and espi'cially the floors, sliould be
made without any cracks, nooks, etc., where ilust may
accunudate, and "should be constructed of smooth ma-
terial, glass, tiles, or the like, which may easily be washed
and scrubbed. In all workjilaccs where the humidity is
relatively very great, the walls and other surfaces should
be made'of impervious materials, \yheuever practicable,
the tloor should be made of as|ihall. concrete, or cement,
so as to be impermeable to moisttu'e; it should also be
properly graded and drained so as to be easily washed
off. Tins ]ireeaution is esiieeially to be recommended in
mercury and lead work establislmients where the jioison-
ous substances are likely to collect on lloor surfaces. Of
the cleanliness of industrial estalilisluncnts it is sufticient
to say that it is an indispensalile condition of the hi'althy
workshop.
Liylitinij. — On the lu'oper lighling of workshops de-
pends not only the condition of the eyesight but also the
general good health of the workers. The ideal of woi'k-
shop lighting is the avoidance of anything but dayliglit
as a source of light during work; and, if artitieial
illumination is absohitely ic(iuired, the use of eleclricily
only, whenever possible, as other illuminants produce
many iniiuu'ities and unduly raise the temperature of
the workshop.
Bussing" givesihe fi)llowing rei|uirenienls for thearti-
ficial lighting of factories: ( 1 ) The ipuuitily of light slioidd
corres|)ond to the normal leciuiremcuts of tlie room sjiaee
and the occupants; (2) the light should appro.ximate the
quality of daylight as much as possible, antl be white,
and in this respect the liygienic value of different lights
stands in the following order: electricity, argand burn-
ers, open gas tiauK'S, and petroleum nil; (li) stability of
tlame, all flickering and jum])ing light,, being injurious
to the eyes; (4) Inw |noportion of imi)uritics given olT;
(5) low heating capacity. To these requisites may also
be added proper distance from the persons at work, jiro-
per locatiiui of lights, uniform di,striljution, and shading
of e3'es when light is too glaring,
Yentihttiitii is the corner-stone of industrial hygiene ;
for the greatest part of the dangi-rs which threaten the
workers are due to thi^ impurities in the air of the places
of work, imjiuritii'S which can be done away with only
by etiicient nu'thods of ventilation. The impurities in
industrial establishments are the following:
I. Imj)urities caused by the workeis: (</) decrease in
oxygen; (/;) increase in carbonic acid; (<■) increase in
amount of aqueous vapor; (if) increase in temperature;
(<■) inereas<' in amount of org;uue matter.
II. Impurities ilue to the jilace of work: (■/) detritus
from walls, ceilings, tlonrs, and other surfaces; (A) in-
creased hunudity . due to dampness absorbed and n'tained
in the walls and materials of building; ('■) mcudds, fungi,
and other low organisms.
III. Impurities due to ;ii liliciid lighting ami heating:
(rt) increase in amount of carbonie acid and other gases;
and (h) increased temperatuix-.
IV. Impurities due to presence of machinery, etc. : (ii)
increase in temperature fidin motion and fricli{m of ma-
chinery, etc. ; and (A) detritus and waste from tocjls, etc,
V.' impurities due to industrial ]irocesses: (ii) waste
and detritus from cru<le m.-itcrials being crushed, tm-n,
milled, ground, jiolished, etc. ; (//) dust from lu-ganic and
inorganic substances of manufacture; (<•) imisons, gases,
and fumes; [d) infective aycMits and bacleiia Without
going into the detailed study of each of thi'se impurities
we shall only consider here how they are to lie reiudved
by ventilation. Ventilation is either natural or artitieial.
according to the natural or mechanical means employed
to further it. The natur:d modes of vcntil;itinn arc the
followini;:
1. The porosity of the walls and other parts of the
building.
3. The variotis openings made in rooms, such as win-
dows, transoms, doors.
3. Special openings made in windows, walls, ceilings,
etc,
4. Chimney flues and other ducts connecting rooms
with external air.
."i. Cowls and warming devices, made in chimney flues
and other ducts.
The last three methodsare regarded by some writers as
belonging to artificial ventilation, although it is best to
limit the meaning of this term to modes of ventilation
which areacconipli.shed by mechanical means only. The
methods of artitieial ventilation are two: extraction and
jiropulsion. By "extraction " methods we mean the ven-
tilation by which: (1) impure air of a room is extracted
by means of exhaustors, fans, etc, without special means
licing provided for the substitution of fresh air; and (3)
the extracti(m of the impure air by the same methods and
the provision, at the same time, of special openings or
ducts and inlets for the ingress of piu-c air from the
outside. The propulsion method of ventilation consists
in; (1) blowing in, iiropelling, and forcing in air from
the outside into the mom to be ventilated without making
any other provision for the escape of the inqiure air from
the room; and (3) the same methods, plus the addition
of special means of escape for the impure air, A cimi-
binatiou of the two methods is the best. The motor
jiowcr for the ventilating <levices may be compressed
air, water, steam, or electricity. In the propulsion
method of ventilation special means may be also provided:
((0 for filtering the incoming air from its impurities; (/<)
for warming it to a desired temperature; and (c) f(U' reg-
ulating its relative humidity. In the extraction mi'thod
of ventilation ])rovision may be made for: (a) collecting
the impurities of the extracted air in proper receptacles;
(A) cleaning it by precipitation, filtraticui, conqiression;
and ((■) for absorption of gases, etc, by chemical means.
For further d<'tailssce special bookson ventilation, also
the works referred to at the conclusion of this article.
Provision sliould be made in all industrial establish-
ments for artitieial ventilation, for by natural ventilation
alone it is hardly possible to remove all the impurities to
be found in them. In small workshoiis, with a limited
number of employees, with a luinimum of waste matter
and dust, with no machinery in use, no gases or fumes
liberated, natural ventilatiim may be adequate. But in
all other places, es]iecially in large factories, mills, mines,
and funnels, no reliance whatever can be jilaced on natural
methods of ventilation, mechanical means being ab.so-
lutely indispensable. There is hardly an industry in
which some of the above-mentioned motor powers are
not used, and wherever there is motive power artificial
ventilation need not cost more than the initial expense of
the installation of the ventilating a|iparatus, and should
be insisted upon and properly supervised by competent
authorities.
In mines the air is full of imjiurities, and contains va-
rious deleterious gases, known as "black damp,'' "white
tlamp," "tire damp," and "after dam))," — gases which
are dangerous on account of either their toxic or their
explosive nature. Here artificial ventilation must he
provided for on a laige scale, though even then much
of the danger is diflicult to avoid,
Spk(t.\i. Pi!oriivi,.\xis. Ihint. — The following are the
prophylactic measures to be observed in those occupa-
tions which are characterized by the production of largo
quantities of dust.
1. Separation, from all other jirocesses, of those in
which dust abounds.
3. Substitution of machinery for handwork, whenever
this is possible.
3. Substitution of wet for dry processes of production.
4. Instant and continuous removal of formed dust by
special ventilators.
.'). Isolation of the worker from the dust_y process.
6. Frequent change of air and frequent pauses.
328
REFEREMCE HANDBOOK OF THE MEDICAL SCIENCES.
<><■(' II initioii.
Occupatlou.
7. Special devices for prcveuting dust from entering the
respiratory organs.
1 . Tlie processes in which dust is largely formed should
be confined to special rooms, wliich should lie kept iso-
lated as much as possible from the other rooms of the
establishment.
2. The production of dust may largely be avoided by
substituting for hand woi-k carcfulh' enclosed machines.
Machine production requires cimiparativeh' few opera-
tives, thus kcseuing the number of persons exposed to
dust inhalation. Industries in whfch the dust has an
economic value have already partly accomplished this.
In tlour and cement mills, and in sawmills provision is
made for the collection of the valuable dust and its further
utilization. Flour milling was once considered an un-
healthy trade; but since the introduction of self-regulat-
ing machinery, enclosed in chambers, the formation of
dust, from tlie crushing of the coarse grain to the packing
of the finest tlour, has been reduced to a minimum. What
has been accomplished in a few industries may be re-
peated in others,
3. Dust is jiroduced only when the industrial processes
are jicrformed by dry methods. "Wherever possible, wet
processes slioidd be substit\ited by either wetting the ma-
terial, or tlie im|ilenients, or the place of work, the wet-
ting materially reducing the dust. Wools are .sometimes
oiled for this purpose. The wet methods ai'e especiallj'
imperative in work with poisonous substances, and in
the metal grinding industries. Needle, cutlery, stone,
and other grinding and polishing can very well be done
by wet methods, thus preventing dust formation.
4. The instant and continuous removal of dust can be
done only by artificial ventilation and specially con-
structed devices for each trade. Dust is removed liy
precipitation, filtration, and absorption. Precipitation
of dust isaccomjilished by the action of the specific grav-
ity of the dust, by the action of water, a stream or shower
of which is allowed to fall on the dust thus precijiitat-
ing it, and also by centrifugal action. Filtration is ac-
complished by letting the dust filter through cotton,
wool, or other material which may be kept dry or wet.
The proper ventilating devices for removal of dust con-
sist of the following several parts: {n) An expansion or
hood, properl}' fitting or enclosing the tool, machine, or
stand of each dust-)iroducing process and worker. This
hood must be so adjusted as to cover all surfaces or pro-
jections where dust is formed, (i) The tubes or ducts
with which hoods or expansions are connected; the dust
is drawn into the hoods, and conducted from these
into the tubes. These latter must be tight, and should
be provided with cleaning caps to facilitate periodical
cleaning in case of obstruction, etc. (c) Tlie ictttinr/ ap-
pliances are in the form of jets, rosettes, streams, showers
of water which are applied to the dust in the hood, tubes,
or receptacles, (il) The funs, exhaustors, and other
means for aspirating the dust from tlie hoods and tubes
by the creation of a vacuum within the .same. The asjiir-
ating force must be nicely adjusted to the needs of each
trade and process, otherwise the draughts ma\' be too
strong. ((■) Rereptndes which are connected with the
tubes, etc., and in which the dust collects and settles by
its specific gravity, by the action of water, or by centri-
fugal motion.
'). In those industries in which the dust, for one or an-
other reason, cannot lie removed, and in which there is
great danger that it will imiiinge upon tlie face and get
into the eyes of the operatives, special appliances have
been devised for isolating the worker from his work by
an intercepting window, put between him and the dust ;
or he is separated from it by a complete glass partition.
in which openings are made for his arms to go through
for the necessary manipulations; or, finally, the work
may be done by means of long poles and other tools,
manipulated by the workers from the outside of the
closed chambers.
6. Wherever dust is produced in large quantities the
workers slioulil be given fre(iuent ci|iportunities for in-
spiring pure outside air, by making the pauses as freijueut
as possible, and by compelling the operatives to go out-
side of the shop during the.se pauses.
7. ^yorkel•s in dusty trades very often stutT tlicir nos-
trils and their mouths with Hannel or cloth to keep out
the dust. The appliances called "respirators" are an
extension of the same princiijle. The)' consist of a frame-
work made of vulcanite, wire, or metal, which is so con-
structed as closely to fit the lower part of the face, cov-
ering the mouth alone, or the mouth and nose together.
Within this framework some filtering material is placed
for intercepting and collecting the incoming dust, thus
preventing its inhalatiou. There are a great number of
more or less ingenious respirators on the market. One of
these, devised b}' B. W. Kicliardson '* consists of a mask
in which a breathing tube is fitted, on the inside, with
rolled feathers which are so arranged that during iuspira-
tiim they will rise up and filter, while in expiration they
will lie down, like a valve, against the wall of the tube.
This is an example of the ingenuity spent on the con-
struction of respirators. The respirators have, however,
never been popular with workers; Indeed, they are
seldom, if ever, worn, unless by compulsion. The ob-
jections made by operatives against the wearing of
respirators while at Avork are the following: they are
clumsy, uncomfortable, and unsightly; they interfere
with respiration; if the filtering material is thick and
closely woven, respiration is very dirticult — it not, the
dust gets through; they interfere with talking, spitting,
chewing, and smoking; they get wet by the moisture of
the breath, and in general they are a great inconvenience
to the wearers, who would rather inhale the dust than
wear one of them. In trades where the worker is ex-
posed to violent poisons or speciall\' irritating gases, spe-
cial masks, entirely air-tiglit, are provided, and are fitted
with tubes to bring in air from the outside, and with
complicated valves, etc., to let out the expired air. The
objections against respirators already alluded to ajiply in
greater force to those instruments which are used only
in veiy exceptional cases.
The prophi/ld.ris in industries where p(HSfiis, gasex. <iiiil
fumes are evolved and liberated does not diifer in its es-
sential features from the prophylactic principles laid
down for dusty occupations, except that they must be
more strictly and carefully enforced if they are to lie
effective in jirotecting the health of the workers. In
specially dangerous trades the periodical medical exami-
nation of the eni])loyees goes very far toward remedying
the evils of the trade. Wet methods of production shoidd
be insisted U]ion wherever toxic substances may produce
dust. C'ertain poi-sons should be entirely prohibited from
being used and for them should be substituted other ma-
terials less poisonous. Thus the use of any but re<l phos-
phorus should be prohibited in the match industry: no
arsenic should be used in textile fabrics, on wall papers,
etc. ; the manufacture of lead toj's and utensils should
be prohibited, and so also should the employment of lead
in pottery glaze and other mauufaeturo's. JMirrors may
be backed by silver instead of by mercury; ami in the
jilace of the latter poison glycerin may be substituted in
the manufacture of air pumps. The ideal will Ix' reached
when all toxic substances are replaced by non-toxic,
and with time and vigorous agitation this ideal may be
realized.
Wherever gases and fumes are in such abundance that
toxic effects are feared, the wearing of priqier jirotective
clothing, respirators, and masks should be insisted upon
in spite of the objections of the workers.
Other prophijlaetic measures, apjilicable to each indus-
try, diifer according to the nature of the toxic substance
in" each. No alcoiiolic beverages or acidulated drinks
are allowed to arsenic and lead workers, but may be per-
mitted in moderate doses to mercury workers. Workers
in lead manufacturies are given from ten to fifteen min-
utes for washing their hands. Sapolio and ammonium
tartrate arc recommended for the liands, potassium jier-
manganate for a mouth wash. As food, milk and jiork
enjoy special favor with lead workers, and are furnished
by some employers. A number of so-called "sanitary"
329
Occupation,
Occupatluii.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
driuks liavp boon proposfd for \i-.u] ;xs wt'll as other
workers. The vahie of potassium ioilidc as a pro|ihy-
lactic for iihinibisiii, tlioujili liiuli in the csliinatiou of
some, is doulited liy Blum." wlio uvaiW a special study
of phimbism.
Chromium workers should have their faces and noacs
protected with masks to prevent ulceration.
Those who work in soda manufa<'tories and come in
contact with cldorinc gas are advised to drink a t\vo-i)er-
cent. solution of dilute sulphuric acid.
Phosphorus workers are to l>e e.\aminc>d periodically
by dentists for caries of the teelli. Chalk, milk, saponi-
fied water are ieconum'n(lc(l for those who work in or
are exposed to sulphur and its compounds.
The use of common salt is interdicted to merciu-y work-
ers ou account of the danger of the formation of sub-
limate.
Each industry in which special toxic agents are being
manufactured should be jirovided with s]iecial rules for
the gniilance of the employees, and should also bi^ VU)der
the constant care and suiiervision of proper medical au-
thorities.
The priip!ii/lii.iis nf iufcctii'n from crude materials, or
from manufactiwed articles, is important in the hair, wool,
hide, and fur trades especially, on account of the danger
of anthra.K infection, but it is idso imjiortant in all trades
in which goods are imported from Oriental coimtries,
where certain contagious iliseases are endemic. The
only effective pidpliylaitic measure, under these circuiu-
stances, is pro|icr and thorough disinlVction of all sus-
pected materials.
The sperial priiplii/liielic measures against iirriileiil-i to
the ri/es have already been spoken (jf to some e.\tent in
the section relatin.g to the methods of removing dust and
toxic materials. Where the danger from flying particles,
dust, etc.. is very great, it is recommeniled to wear ]u-o-
tective spectacles. A large number of sjiecial spectacles
have been manufactured for persons whose eyes are thus
exposed, but, as in the ease of respirators, they are strongly
objected to by the workers. The wearing of spectacles is
made obligator}- in some trades. Koenigshocfer " sums
U]) the oljjections against spectacles as follows: tiiev
limit the field of vision, they may impair vision, thc_y
simietimes cause headache and pain in the eyes, they are
apt to get diinnied by condensed moisture, the metal
frame is ajil to get hot, and finally, tliey are uncom-
fortable. All of these objections may Ix; removed b}' a
proper construction of the glasses.
Propliyhi.iis (ir/niii.it Acciilenls by Mdeliinerii. — This is
a science by itself, the study of which re<piires special
technical training. In most countries laws are enacted
to .safeguard machinery and ]irevenl accidents. Motor
engines, flywheels, etc.. must be fenced in and provided
with projier guards and rails. Wheels, shafts, drums,
bejts, and all gearing nuist be provided with special pro-
tective appliances. Circular saws, planes, power looms,
and other machinery and tools are all to be properly
guarded with ai)iuc)vi>d devices. Many machines and
parts of them are at jnesenf juovided with proper safe-
guards by their makers. Workers sluudd be thoroughly
drilled in the art of self ]ii()lection and educated to the
dangers of machinery as well as to all ofluT dangers of
their calling. This remark applii-s with special force to
workers in large electri<'al establishments, where a luan
may lose his life, by coming in contact with a wire carry-
ing a powerful current of electricity.
Offensive Tii.\i)Es.
Thus far the effects of occujiations have been con-
sidered only with reference to the health of those engaged
in them — the workers themselves. There are a number
of occupations, however, which affect not oidy their
workers, but the community at large, or, at least,
that part of it which lives in their inunediate vicinity.
These occupations have been nameil "ofrensiv(' trades,"
also "public nuisances," Excejit in trades wliieli allow
poisonotis substances or noxious gases to escape outside
their |ireciucts. and thus directly injure the health of the
surrounding neighliorhood, the dangers to health of the
so-called "offensive trades" are not direct; at li'ast, it is
(litlieidt to show the existence of any diseases or jiatho-
logieal lesions which owe their origin to those trades.
Most of the harmftd effects of these trades are due to the
smoke, noise, and smell produceil, winch may give rise,
in tho.se predisposed t<i such ailments, to certain dis-
orders such as anorexia, nausea, neurasthenia, an:emia,
and kindred ills. Tlic number of offensive trades is very
large, and a classification of them has lieen attempted
l)y the French Governnicirt, which divided them into
three classes, according to the degree of their offen-
siveuess. Tracy,'' in his article on " Public Nuisances"
in Buck's "Hygiene and Public Health," and S. A.
(Goldsmith in his article in the former edition of this
H.\NiJBOOK, gave full lists of those trades, based on the
French classification, as well as detailed technical descrip-
tions of the various processes of the offensive businesses.
The space here being limited, oidy the lu-ophylactic |>art
will be noted, and all technical details will be omitted.
The following are the annoying factors in nio.st offensive
trades: 3'"/.«(', Snioh', Din^t, .S/y/cH, and Unrious Gitscx and
Fui/itx.
jVoixe. — The number of businesses which are character-
ized by excessive noise is (j\nte large, especially in popu-
lous towns. Surface and elevated railroads, driving of
heavy wagons over rough |)avemeuts, nau'ldne .shops,
forge rooms, blacksmith shops, saw and planing nulls,
street venders, street nuisic, etc., are a few of them.
Excessive noises affect especially nervous, neurasthenic,
and sick persons, causing irritability, sleeplessness,
anorexia, and general disturbances. A New York phy-
sician gave to these symptoms the name of " Ncwyorkitis,"
Imt the malady, if there is such, could better be termed
" urbantis." as it is characteristic of all large cities. The
lU'eveution of excessive noi.se is possif)le in a large degree
by luunicijial action. Thus in New York it is not allowed
to create unnecessary noises, especially at night, and near
residential streets; sfreet-liand music is prohibited in the
boroughs of Maidiaftan and the Bronx, railroad com-
panies are compelled to remove "fiat wheel cars," street
peddling is not allowed at lught, etc, ; with a wider in-
troduction of asphalt pavement a fruitful cause of noises
will also lie largely abolished.
Siii'//,-r. — Among the many nuisances incident to city
life is the black smoke belched forth from the chimneys
of manufacturing establislunenls. The coiuposition of
the smoke as it leaves the chimnej' depends on the char-
acter of fuel burned, as well as on the metfiods of com-
liustion and the care witfi which it is carried on. Black
smoke consists of carbon mechanically sus|)ended. and also
of other gases, such as carboidc acid, carbonic oxide, and
hydrogen sulphide. Wood and bituminous coal give off
vi'ry aiumihint and black smoke, while hard coal gives off
very little on account of its cohesivenessand complete com-
bustion. When furnaces are nf adecjuatc capacity, with
grates having a large area, with the coal spread in a thin
continuous sheet, .and with the requisite amount of air, the
production <d' smoke is greatly dinunished." The other
remedies, outside of iisingauthraeitc coal, are the provid-
ing of fall chimneys, .so that the smoke shall be emitted
above the windows of living liou.ses; and the voluntary
or compulsory introduction of smoke-consundng devices.
There are a very large number of patented smoke con-
sumers, most of them based on the principle of making a
more thorough and complete combustion of all particles of
carjion in the fuel.
Bunt. — There are only a few busines.ses in which large
cjuautities of dust may escape outside of the establish-
ments and become a public ntussmce. These are carpet-
cleaning and lieating works, sandblasting of glass, and
street sweeping. Carpet-cleaidng is now done in large
establishments without jiroducing dust. Proper methods
have been devised for collecting the dust and preventing its
coming outside. Sandblasting of glass is to be relegated
outside of ri'sidential streets, the dust usuall}' not falling
farther than about thri'c hundred feet from the establish-
330
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Omipatlon.
0€cupati«»ii«
ments. Street sweeping may be done witli comparatively
little dust it tlie streets are previously well sprinkled with
water and the cleaners are careful.
Smell. — The trades and businesses which are or maj-
become offensive on account of their smells are very nu-
merous indeeil. They include the greatest bulk of gener-
ally offensive trades, as they are composed of all the nu-
merous industries in which animal or vegetable matter is
manufactured or stored, and which may at certain periods
of tl.e procedure give rise to offensive odors. We shall
hcic allude only to the following: (1) The keeping of live
animals and of animal matter. (2) Killing of animals.
(3) ilanufacture and utilization of animal substances.
(4) JIauufacture of vegetable substances, etc.
Keeping of Liee Anini<ih. — As in all ollensive trades,
the keeping of live animals becomes a nuisance only in
populous towns. The nuisance created by the keeping
of live animals, such as horses, cows, calves, swine.
shee|), goats, birds, poultry, and rare and wikl animals
consists in ; (1) tlie specific odors peculiar to each kind of
animal ; (2) the smell from the urine, excreta, and other
organic matter from the animals; (3) the noises which
are made liy them and which disturb the rest of the
neighborhood; (4) the flies and parasites which they
attract to themselves; and (5) possible infective materials
and germs likely to be transmitted to men.
Most municipalities have laws which are intended to
abate the nuisiinces created by the keeping of animals.
The remedies for the nui.sauce are the following: (1) total
prohibition of the keeping of certain animals within the
city limits, or at least in overcrowded neighborhoods; (2)
restricting the building of new places for animals: (3)
proper veterinary supervision and disinfection, to prevent
disease of animals and infection; (4) proper construction
and maintenance of the places where they are kept; (5)
removal of all animal matter likely to give offensive
odors, or to become jnitrelicd. The rules and regulations
of municipalities embrace all of the above-enumerated pro-
phylactic measures. Thus in New York no cows, horses,
calves, swine, sheep, or goats are allowed to be kept in
tenement houses; no stables are allowed on the Siime lot
with a tenement house; and the keeping of all kinds of
animals, even pigeons and chickens, requires a ])ermit
from the Health Department. In Boston " stables are
prohibited within two hundred feet of a church; in Chi-
cago, in order to build a stable, it is necessary to get the
permission of the owners living within si.v hundred feet
of the proposed stable.
Most of the offence given by the keeping of live ani-
mals is given bj' horse stables, as comparatively few
other animals are kept in cities. Stables should be spe-
cially constructed for the purpose. They shmdd contain
at least twelve hundred cubic feet of space and one hundred
and twenty cubic feet of floor space for each horse; stalls
should be atleast six feet wide and nine feet long, and the
stable should be well ventilated. The floors of stables
should be of some impervious material, such as concrete,
cement, bricks set in cement ; no woodwork that cannot be
easily taken off should be laid on flooring. There should
be provision for an unlimited supjily of water, and tlie
floor should be properly graded and drained, ami the
stalls provided with longitudinal "valley drains," jiro-
vided with adjustable covers easily taken up, and the
drains should all be tightly connected with the sewer by a
properly trapped, extra heavy drain. " No accumulations
of manure are to be allowed; as soon as it is collected, it
should be put into barrels or pres.scd into bales and daily
removed. The removal of manure should be done within
the stable, and the carts should be well covered before
they start out from the stable. The removal hour should
be at night or early in the morning. Thus in Boston ma-
nure can be removed only after 12 (midnight); in Jersey
City between 6 p.m. and 7 a.m. The stables should be
kept scrupulously clean and frequently disinfected with a
solution of one pint of formalin to three gallons of water
or a similar scilution of carbolic acid ; corrosive sublimate
solutiim and ereolin can also be used. There is no rea-
son why. with such precautions, the keeping of hor.ses
should be attended with offence. The keeping of other
animals may be made inoffensive by means of similar
methods.
Tlie Keeping of Animal Mutter. — The storage or keep-
ing of animal matter, manure, offal, bones, hides, horns,
skins, fish, garbage, etc., may be attended with offence,
on account of the tendency to speedy putrefaction and
decomposition, when the decomposing matters may emit
very offensive and sickening odors, unbearable by many,
and causing headache, loss of appetite, and nausea in
others. The prevention of their becoming nuisances can
be summed up in the following measures: Immediate
destruction, by burning all needless matter likely to de-
compose; immediate removal from liabitations; .scrupu-
lous cleanliness ; disinfection ; keeping of matter in tightly
closed vessels.
The Killing of Animah.— The killing of animals is one
of the oldest industries of mankind, and has bi-en always
in need of state supervision and control from the time of
Moses in ancient Eg_vpt until the present. The nuisance
created by slaughtering animals consists mostl_y in the
odors peculiar to the slaughter-houses, although other
things, such as the noise created by the animals, the flies
and parasites attracted by the animal matter, as also the
possibility of infection by animal diseases, all play their
part in the creation of this nuisance. The offensive smell
is due to the animals themselves, the fresh animal guts,
blood and other products, and the decomposing animal
matter within the building.s. The remedies for the nui-
sance are: prohibition of slaughtering in an}' but speci-
fied localities; the construction of special municipal
abattoirs; the proper building and maintenance of the
slaughter-houses, their supervision and inspection; the
immediate removal of all by- and waste products; the
refrigeration of meat; the absolutely clean condition of
the places; the provision of special means for destroying
foul- and ill-smelling matter, and the disinfection of the
premises.
Municipal provisions about slaughter-houses were in-
augurated in the United States as early as 1692 in Boston,'"
and are now found in nearly every community. In New
York City slaughter-houses are located onlv in specified
Incalities. of which there are only four or five. In Bos-
ton the slaughtering of animals is concentrated in the
Bn'ghton abattoir; and in New Orleans in the municipal
abattoir. Cleanliness in the slaughter-hou.ses is provided
for in the various Siiuitary codes, the following being
.from a section of the New York law : " All those who are
responsible for the places should cause such places and
their yards and appurtenances to be thoroughly cleansed
and purified, and all offal, blood, fat. garbage, refuse,
and unwholesome or offensive matter to be removed, at
least once in every twenty-four hours after the use there-
of; and they shall also at all times keep all woodwork,
save floors and counters, thoroughlv painted or white-
washed." An unlinuted supply of water is even more
needed in abattoirs than in stables. Goldsmith quotes
Tardieu as saying that in Paris (where the buildings are
of iron and glass) ninety thousand litres are used daily in
each of the five abattoirs, and adds that in New Y'ork a
slaughter-house in Forty-fifth .Street uses nearly five mil-
lion gallons a day.-' The slaughtering of poultry and
smaller animals should also be controlled by the munici-
palities, and most of the prophylactic measures used in
slaughter-houses of larger animals are applicable to them
also.
Utilimdon and Manvfietiire of Animal Substances. —
Modern industry does not allow anything to go to waste,
and in animal trades there is hardly a substance which is
not utilized in some way. Among the many branches of
these utilization industries to lie discussed here are the
following : The rendering of fat ami lard ; bone and blood-
boiling; gut-cleaning; manufacture of glycerin, soap,
and glue, and the preparing and t;inuing of skins and
hides.
Fat Rendering. Lard Refitiing. — Blost of the rendering
of fat is done by the action of heat, although there are
.several chemical "methods in vogue. Since the trade be-
331
Occu|>ati(»ii. [N|>r";;K.
Ocouee AVliite Siiliili.
UEPEKENCE HANDBOOK OF THE MEDICAL SCIENCES.
came concentrated in large establishments, the old method
of rendering fat in ojien ki'ttles lias beconic happily ob-
solete. Tlu^ chief nuisance of fat rendering consists in
the odors " which are all caused, partly by the storage of
decomposing fat on the premises, but mainly by the dis-
tillation of portions of the fat; which |iroduces certain
ill-smelling substances, such as acrolein and allylic al-
cohol, with sometimes capric, caprylic, and caproic
acids,"'*
The prevention of fat-rendering from liecoming a nui-
sance is accomplislied by the foUowin.g measures: (1)
The use of undecomposed animal matter; (3) the em-
ployment of a low temperature in rendering; (3) the
boiling of fat in tightly closed vessels; (4) the use of con-
densers for the removal and destruction of the gases and
odors. The New York Sanitary Code has the following
section: "That no fat, tallow, or lard shall be melted or
rendered except when fresh from th<' slaughtered animal;
and taken directly from the place of slau.ghter. and in a
condition free from sourness and taint, and all other causes
of offence at the time of rendering; and that all melting
and rendering are to be in steam-tight vessels; the gases
and odors therefrom to be destroyed by combustion or
other means equally effect i ve. " Himes '-' says : " The great
secret in preventing nuisance is the avoidance of burning
the materials, or even raising them to high temperature.
The lower the temperature at which the work can be suc-
cessfully carried on, the less is the risk of producin,g of-
fensive smells. The temperature need not exceed 120" F, "
When steam methods of rendering are used, the need of
condensers is imiierative. " Condensers may be of several
styles and shapes. The water may be introduced at the
top, and broken by means of a plate, a short distance be-
low, the shiiwer may also be made l)y means of a rosette.
Tlie conden.scr itself may be made of injn, copper, or even
wood. It should be made as high as possible, in propor-
tion to the diameter. The gases should Ije introduced at
the bottom, and passing up through the water shower,
connect with the furnace tires by a pipe near the top."
(Goldsmith.--) Of thecbemical methods of fat-reiidering
D'Arcet's method is by separation of the fat from its
membranes by the action of sulphuric acid. Lard refin-
ing differs little from the general rendering of other fats,
and, being done mostly by the low temjierature method,
it is not offensive.
Bone and Bbidd PxhUikj. — In the processes of boiling
these animal substances odors may arise which maj' be
ijuite offensive. The following preventive measures are
recommended by the Philadrlpbia Board of Health:™
"The tlciorsof all lione-boiliiii;- ^^talllishments and deposi-
tories of dead animals shall be (lavrd witli asphalt, or with
brick or stone, well laid in cement, and shall be well
drained. The boiling of bones, etc.. shall be conducted
in steam-tight kettles, boilers, or caiddrons, from which
the foul vapors shall first be conducted through scrub-
bers or condensers, and then into the back part of the
ashpit of the furnace lire, to be consumed. When bones
are being dried after Imiling. they shall be placed in
closed chambers, through which shall be jmssed, by
means of pipes, large volumes of fresh air, the outlet
pipe terminating in the lire-pit."
(jut-Chdniiuj. — The utilization of the small intestines
of animals for sausage skins and the nianufaclure of cat-
gut is necessarily accompanied by a great deal of stench
from the foul-smelling contents of the guts and the de-
ciuuposition of animal matter. " The proces.ses should lie
carried on away from habitations; the guts, etc.. should
not be allowed to come in a foul state, but must be util-
ized inunediately, and pro]ier jirecautions taken to let no
foul matter cling to the floor or surfaces of the establish-
ment. This may be accomplished by tlie use <if plenty
of water. The water in the tank where the intestines
are macerated may be disinfected by a weak solution of
chloralum or chlorinated soda."'- Parent -Duchatelet
(Tardieu) denies that ,gut (deaning is harmful to hralth.
Till Manufacture of Sua p. — Soap is manufai'tured from
fat and alkalies. It may become a nuisance: (I) ( )n ac-
count of the large quantity of fat, tallow, anil fat animal
residue, which are collected from all animal waste matter,
and which are. by the time they reach the soap factory, in
a decomposing stale, ('i) By the processes inherent in fat
rendering. (3) By the odors arising from the huge vats
and tanks wiiere the fat is being boiled with the alkaline
lye. The prevention of thetirst nuisance is accomplished
by insisting that only fat in a fresh state shall be allowed
in the soap factories. The means of preventing fat-melt-
ing and rendering from becoming a nuisance have already
been described. The nuisances caused by the odors aris-
ing from the boiling tanks can be prevented by fitting
these with covers, and conducting the vapors either out-
side through a tall chimney, or, as in fat-rendering,
through proper condensers.
Glycerin. — When the fatty acids of the fats in soap
manufacture combine with the alkalies, the base left is a
residue in the form of glycerin, which, before lieing fitted
for the market, must be refined several times. During
this process sweetish unjileasaiit odors are given otf,
which can be prevented by the same means as those
which are used in treating odors from fat rendering.
Gluc-Mdkinij. — All kinds of animal waste matter, hoofs,
horns, skin scraps, leather scraps, etc, are used for the
extraction of glue. As in the other processes employed
for the utilization of all animal waste matter, the nui-
sance comes from the decomposing material, from the
odors given out during Imiling, etc.. and from the offen-
sive residue or "serutch." TJie remedies are the same as
in other kindred proces.ses.
Treutinfj and Tanning of Skins auil. Hides. — Animal
skins, before they are converted into lasting leather,
must go through a number of complicated processes.
In the scraping, salting, hairing, lirining, liming, puering,
tanning, curing, ami other processes very offensive and
disgusting odors often arise; and in liming some sid-
phureted hydrogen may also be evolved. The process
named " puering " consists in soaking the hides in a liquid
composed of ilog's ilung. Tanning establishments should
not be allowed in residential localities. The various
manipulations nia,y be dime with little offence if the places
are ]ux)]ierly constructed and well kept.
Manufariun; of Other Subxtaia'cs. — Among the other
substances, the manufacture of which may become offen-
sive, are the following: Illuminating gas, petroleiun re-
fining, distilling, brewing, vinegar-making, sugar-refin-
ing, boiling of oil, manufacture of varnish, cooking, etc,
lllnminatinri Ga.i. — The nuisance caused by the pres-
ence of gas works in pupulous localities is due to various
gases and odors given olT, during the man\' stages required,
in the process of distilling gas from bituminous coal. The
process especially ob,jeetionableis the "liming." or jiass-
ing the gas through a closed chamber filled with quick-
lime, which is afterward deoxidized and gives off ammo-
nium sulphide and sulpbureted hydrogen. Oxide of iron
has been substituted for quicklime, with a material
lessening of otl'ensiveness, Notwithstanding all the care
employed and des]iite the modern inventions of con-
densers, scrubbers, and other means for destroying and
absorbing olTen.sive gases during the manufacture of
illuminating gas, this business is still quite a nuisance to
a neighborhood, and the best remedy is to remove it as
far as possible from habitations.
In the processes of refining petroleum, offensive odors
are given off. These are due to the escape of fumes during
its distillation, as well as during the agitation of the refuse
or "sludge" acid with alkaline solutions. Goldsmith
recommends that the wash water from the agitators should
be passed through a series of trouglis furnished with cross
slots, to retain all oily or tarry matter: and the treatment
of the sludge shoidd be carried on at a di.stance from
crowded neighborhoods.
The nuisances caused in the processes of brewing, dis-
tilling, sugar refining, and other industries tnentioned,
consist in the odors given off' at certain stages of manu-
facture and may lie iirevented by the same methods as
those described in the section on Fat Rendering.
Tracy lays down the principles of controlling the nui-
sance caused by the odors and vapors which are given off
••532
REFERENCE HANDBOOK OF THE SEEDICAL SCIENCES.
Oot'iipatlou. [Spr'g»,
Oi-ouec AVblle Sulpb.
tluriug the manufacture of various substances as follows:
(1) Conveying and storing in tight vessels. (2) Substi-
tution of less offensive processes for the more offensive.
(3) Proper construction of the places where nuisances
arise. (4) The use of plenty of water, jiroper cleanli-
ness, and drainage, (o) The destruction of all offensive
odors by passing them through condensers, etc., and
from there into the lire pits where they will be consumed.
Giises and Vapors. — The number of the trades which
may become a nuisance to the community on account of
the vapors, acid fumes, and gases which are evolved in their
processes, and are allowed to escape into the surrounding
air, is very large. Among the more important of these
are all the chemical trades; the manufacture of alkalies,
ammonia, bleaching powder, soda, and glass; assaying,
smelting, and the manufacture of jewelry, lead paint,
certain drugs, etc.
The nuisance created by all of these trades can be
summed up in the following: (1) Odors offensive to the
neighborhood. (2) Deleterious gases. (3) Destruction
of vegetation in the neighborhood.
The remedies advised for the prevention, or at least
mitigation, of the nuisances are: (1) Removal, whenever
possible, from crowded localities. (2) Dilution of the
gases and vapors by air. (3) Condensation of gases by
cooling them with water, by passing tliem once, or sev-
eral times, either through condensers filled with water or
through scrubbers filled with wet coke. (4) Absorption
through discharging all gases into fire-pits, where they
aie destroyed by the action of fire, or by jiassing them
through neutralizing substances, which are of course
different for each of the different gases.
George M. Price.
REFERE>'CES.
' Ode, W. : Mortality in Relation to Occupation. Transactions of
tbe Seventh Intematioiial Cou(r. ot Hyf . and Deni.. vol. x.
2 Twelfth United States Census, vol. iii.. Vital Statistics.
' Oliver. Th. : Dangerous Trades, 13.5, 817, 7ta. eZi. :«K, 304, 730, etc.
^ Hoffmann, F. A. : Die Krankbeiten der Bronchien. Nothuagel's
spec. Pathol., Bd. xlii.. 3 Theil, 1 Ab., 68.
' Hirt, L. : Die Krankbeiten der Arbeiter, 8, 9, 13, 30.
' Fueller: Hygiene der Berg- und Tunuel-Arbeiter. Veyl's Handb.
d. ItyKlene. Bd. viii.. X9.
' Merkel, G. : UUe st:iulMiilialationskrankheiten. Pettenkofer and
Ziemssen's Handb. <i. Hyi:. and (ievverbkr.. U)i>.
* Lloyd: Occupational Diseases. Twentieth Centurv Practice, vol.
ill., 444. 44.').
" Blum. A. : Hygienische Fursorge fiir Arbeiterinnen, etc. Veyl's
Handli. d. Hygiene, vlii.
'» Tracv, }!. S. : The Hygiene of Occupations. Hygiene and Public
Health, Buck.
' ' Roth : Allgemeine Hygiene, Veyl's, viil.
'2 Wolpert, H.: Ueber den Eintluss der Luftfeuchtigkeit auf den
Arbeiter. Archiv der Hygiene, x.xxvi.
'^ Notolitzky : Hygiene der Textile Industrie, Vevl's H. d. H,. viii.
" finessing: Die Fabril;. Handbuch der Arbeiterwohlfahrt. O.
Dammer. 38:^'.
'5 Richardson, B. W. : Preventive Medicine, 697,
" Die Gewerljegifte. Dammer's Handbuch der Arbeiterwohlfart.
" Koenigshoeffer : Noebeling und Jankau's Handbuch der Pro-
phylaxe, 7U4.
'* Tracy, R. S. : Publik Nuisances. Hygiene and Public Health,
Buck. 43.5. 430.
" Price. G. M. : Handbook on Sanitation. 146. 144.
2" chapin : Municipal Sanitation in the United States.
*' Himes : Offensive Business. Stevenson and Murphy's Hygiene,
vol. i.
-= Goldsmith. . S. A.: Article "Offensive Trades." Eeferex'CE
Haxddook of the Medical sciences. Brst edition.
OCCUPATION DISEASES. See Caisson Disease;
IJaiiil.t (11,(1 Ftiiiicrx, </(■.; LkuI Poisoning ; Lungs, Dis-
eases of : Pneumonokoniosis ; Siderosis ; etc.
OCEAN SPRINGS. — Jackson County, Mississippi.
PosT-OincE. — ()i;e;iii .'Springs. Hotels.
This is a station on tlie railroad between New Orleans
and Mobile, eighty-three miles east of the former, and
fiftj'-seven miles west of the latter. It may also be
reached by coast steamers from either city. The name of
the springs is derived from their pro.ximity to the gulf,
the beach being but half a mile distant. "According to
Walton the springs are most resorted to by citizens of
New Orleans and Jlobile. The following analysis was
made by Prof. J. Lawrence Smith ;
O.VE UNITED States Gallon Contains :
Solids. Grains.
Sodium chloride 47. 77
Potassium chloride Trace.
Calcium rlil. iride 3.88
Magnt-yiuiii chloride .• 4.97
Ferrous oxide 4.71
Organic matter Trace.
Ammonia Trace.
Iodine Trace.
Total 61.33
Gases. Cu. in.
Sulphureted hydrogen 1.28
Carbonic acid 9.79
The water is a potent chalybeate, the iron being no
doubt held in solution in the form of a carbonate. The
unusual combination of carbonate of iron, chloride of so-
dium, and sulphureted hy-drogen especially adapts this
water to the treatment of diseases of the skin in persons
of a scrofulous diathesis. James K. Crook.
OCHEE SPRINGS.— Providence County, Rhode Island.
Post-Office. — .Jnhnstou.
The Ochee Springs are not properly a health resort, al-
though there are many visitors in pleasant weather.
There are a number of springs in the neighborhood, but
only one is improved at the present time. The following
analysis was made by Prof. John H. Appleton, of Brown
University :
One Uniticd States Gallon Contains:
Solids. Grains.
Magnesium carbonate 1.13
Calcium carbonate 3.20
Calcium sulphate 44
Potassium sulphate 88
Sodium sulphate 41
Sodium chloride 57
Iron oxide and alumina 75
Insoluble mineral matter .58
organic and volatile matter 87
Undetermined 15
Total 8.98
Tin's water is pure and wholesome, and is said to act as
a mild cathartic and diuretic when used coutiuuouslv. It
has been accorded a considerable reputation as an au.xiliarj'
in the treatment of kidney, liver, and stomach troubles.
The water is used commercially. James K. Crook.
OCHRONOSIS. See Pigment, etc
OCONEE CHALYBEATE SPRING.— Putnam County,
Georgia. Post-Office. — Eatontou.
Lake Eaton branch of Central Railroad to Eatonton,
and from thence by private conveyance to spring. This
spring has had considerable local reputation for a number
of years. The waters contain the following ingredients:
Iron carbonate. I Calcium sulphate.
Calcium carbonate. I Sodium chloilde.
Potassium sulphate. | Silica.
The iron is insufficient in quantity to wanant us in
placing the water in the chalybeate "class. The flow is
small but con.stant. the water issuing from a fissure in a
granite rock. Janus K. Cruak.
OCONEE WHITE SULPHUR SPRINGS. — Hall
County, Georgia. Post-Office. — Bowdi'e. Hotel and
cottages.
Location, six miles from Gainesville iind two miles from
Sulphur Springs Station, on the Soutliern (Richmond and
Danville) Railroad. Hacks meet all trains.
This is one of the most attractive watering-places of
the South. Long before the war Sniitherners of wealth
and fashion gathered there annually. A few years ago
the property was ]iiirchased by 3Ir. Ferdinand Phinizy,
of Athens, and many imiirovements were made. The
old buildings were turn down and a hirge, well-ajfpointed
hotel and handsome cottages were erected. The excellent
and liberal management has kept the place popular, and
333
Odontoma,
ffideiua.
REFERENCE HANDHDDK OF T}IE MEDICAL SCIENCES.
it now nuiiil)ers aiiioni; its giu>sts visitors from far iiiul
near. No uruilysis is fiiniislicd. but the waters are said
to be valuable in rheiuiiatism. dyspepsia, and diseases of
the blood. There are also bathing conveniences, includ-
ing shower and plunge baths and a large swininiiug pool.
•Jaiiiis K. Crook.
ODONTOMA.— This term lias been applied in a gen-
eral sense 1(1 a great variety <if tumors arising in connec-
tion with the teeth— frum "the tontli follicle, tlic dentine,
the cement, the enamel, the tissue about the tooth, or
from the tooth structure as a whole. Ditferent names
liave been applied to these growths by various authors,
and at present tlie classiticatiou of these tumors is in a
confused state. The majority of the observations are
rather old, very little study liaving been made recently
of this subiect. By mo.st writers the term odoiitoiim is
limited to those growths which arise at an early pericid (jf
development of the tooth before the formation of the den-
tine. Those developing during later life from the den-
tine, cement, or enamel of the mature tooth are classed
as odontinoids. These are further divided mUnleiitinokU,
arising from the dentine; emuilloith. arising from the
enamel; deiitdlosteoi/id . arising from the cement. The true
odontomata are rare, and for the greatei' jnirt furm soft
growths corresponding to the stage of development of
the tooth, and presenling such varied appearances as to
justify the diagnosis of myxonui, cy.stoma. sarcoma, or
fibroma. Dentine may develop later in the ttimor, the
growth becoming hard, and after comjilete dentiticatiou
stationary in development. Occasionally tliey may reach
such a size as to cause erosicm of the jaw bone. They
may be single or multiple. They are usually irregular
or "nodular; after dentiticatiou tliey resemble dentine in
structure. The odontinoids are usually very small and
unimportant excrescences of the teeth, which are more
of the nature of inttammatorv hyperplasias than of true
tumors, and are found in pathological conditions of the
teeth, particularly in association with diseased roots. In
caries of the teeth there may arise from the exposed pulp
masses of grainilatiou tissue of a polypoid character, the
so-called piilp-polyjts or piilji-r/nniiilonKifK.
The fi/stic tniivirs found in the jaw are sometimes in-
cluded with the odontomata, but by other writers are
placed in a class by themselves. Three forms of these
cysts occur: follicular and pt'rioxtad ci/xts and the mtilti-
locuUir cyxtoiaa. The follicular ri/sln are found only dur-
ing the period of dentition. They are usually monolocu-
lar, rarely multilocular cysts, having a wall lined bj'
cylindrical epithelium. With the exception of those
arising from the wisilom teeth they develop at an early
age and grow slowly. taUiug several years to reach an
important size. They arise from the cystic degeneration
of a normal tooth follicle, or from supernumerary folli-
cles or Aulage. In the cyst cavities there are occasionally
found imperfectly develo|.)ed teeth. The periosteal cysts
arise chielly as a result of chronic inflammatory processes
affecting the roots; they are termed iwroriiingXy periden-
tal, periodontal, subperiosteal, or j'oot ey.\ti. A poi'tion of
these formations arise from collections of pus beneath the
periosteum; others take their origin from grainilation tis-
sue growing about the roots. The inner side of the gran-
uloma is lined with epitheliinn derived from the remains
of the epithelium of the cement. The granulation tissue
may become converted into a linn fibrous capsule form-
ing the cyst wall, the root of the tooth projecting into
the cavity of the cyst. Proliferation of the epithelium
lining the cyst may lead to appearances similar to those
of dermoid cysts. More frequently the cysts contain a
clear, mucoid, or thick brown fluid. They occur mo,st
frequently in the upper jaw. Carcinoma may take its
rise from the epithelium of the cyst wall. The nuiltilocti-
lar cysloinata o'i the jaw are very rare tvimors, taking their
rise from the follicle; e|)ilhelial proliferations from the
follicle forming alveolar or gland-like strucluns, which
become cystic. The cyst walls are usually very thin.
The growths may reach a large size, and cause great de-
struction of the jaw bone. Though seldom becoming
carcinomatous the cysts cause great enlargement and
atrophy of the bone, the bonj' layer over the cysts being
sometimes as thin as paper, or in other cases the bone
may entirely disappear, leaving the cj'st covered only by
periosteum.
Sutton ("Tumors Innocent and Malignant "') defines the
odontoma as a tumor composed of dental tissues in vary-
ing proportiiuis and difl'ereut stages of development, aris-
ing from teetli germs, or from teeth still in the process
of growth. He classes them, according to the part of the
tooth germ concerned in their formation, as follows: (1)
Epithelieil Odontoma, from the enamel organ; (i) Follicu-
lar Odontoma; (3) Fibrous Odontoma; (4) Cenientoma ;
(5) Compound FoUicular Odontoma, all from the tooth
follicle; (G) Radicular Odtintoma, from tlie papilla: (7)
Composite Odontoma from the whole germ. For a de-
scription of these varieties and for illustrations of cases
the reader is referred to this work.
Aldred ,Scott Wart/ein.
CEDEMA. — (Hydro|is, dropsy.) An increase in tlie
amount of lymph within the tissue spaces or serous cav-
ities is known as odeiua or drojisy. The fluid itself is oft-
en called a iransudute : but at the present time the dis-
tinctions formerly held between O'dema and inflammatory
exudate, and transudate and exudate, are no longer em-
phasized, inasmuch as the essential etiological factors are
connnon to both. Various specific terms are emploj'ed
to denote the portion of the body aft'ected by the condi-
tion of anleina. as, for example, hydrops is usually limited
to the collection of tluid within the body cavities, a'dema
to the collecti(m of fluid within the lymph spaces of the
connective tissue or parench\'matiuis organs, aua.^arca or
/ii/ilrosarca to an (edematous condition of llic skin or sub-
cutaneous tissues, ascites to the collection of fluid within
the peritoneal cavity; while /iyilrot/nira.r, hydrapericar-
dium, hydrocele, hydrophthahnos, hydrocephalus internus,
hydrarthros, hydrops bursa rum, etc., are used to designate
the collection of fluid in the pleural cavity, pericardium,
.scrotum, eye, cerebral ventricles, joints, bursa', etc., re-
spectively. Localizations of (vdema of great importance
clinically are tlesignated as odenai of the lunys, a'llema of
the i/toltis, etc. The a'dcmatous swelling of the present-
ing portion of the fa'tal head is known as caput suceeda-
neum. CEdematous conditions of the conjunctiva are
termed cheuajsis serosa. The term dropsy in strict use
shouUl be confined to the collection of fluid within the
body cavities, but is applied in a loose way to any anle-
ma or collection of fluid of such extent as to be evident
by the ordinary methods of jihysical examination.
Lyneph. — Since (edema is a pathological increase of the
lymph, it follows that the production of the former must
depend upon a disturbance of the normal mode of lymph
production. The clear watery fluid which iiermeates the
intercellular spaces of the tissues and bathes the .serous
surfaces is known as the lymph. Its chief source is the
blood, and its constituents are passed through the walls
of the blood-vessels by processes of ditTusion, filtration,
and specific secretory activity of the cells of the vessel
walls. Under certain conditions the fluid of the cells and
other constituents of the tissues may also pass into the
free fluid of the tissue spaces. According to Ileidenliain
the lymph is composed of fluid derived from the blood,
the lymph of tlie organ under considerati(_)n, and the
water contained in the ti-ssue cells and fibres. The ulti-
mate source is. of course, the blood. Formerly regarded
as a passive tiltratiou from the blood-vessels, the forma-
tion of lymph is now considered liy the majority of in-
vestigators to be of the nature of a .secreti(ju of the cells
forming the caiiillary walls. In support of the view of
the selective action of the blood-vessel walls are the facts
that the composition of the lymjih differs greatl}' from
th;it of the blood )ilasnia, and difl'ers also in its composi-
tion in different parts of the body; further, under cer-
tain conditions it may contain more salts and extractives
(urea and sugar) than the blood. The rapid juissage of
crystalloid substances from the capillaries into the lymph
is also a strong point in favor of the view that the proc-
334:
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
4Kloiili>iiia,
<Edciua,
ess is not one of mere diffusion, but is the result of a force
inherent in the cells of the vessel walls. According to
Heideuhain the specific function of the capillary walls
plays a controlling part in the formation of lymph. Cer-
tain substances injected into the blood-vessels increase
the production of lymph (extracts of leeches, mussels,
crabs, peptone, etc.); and it is also po.ssible that the cap-
illary secretion is directly under nerve influence. It is
very probable that certain oedematous conditions of the
skin (urticaria, herpes zoster, etc.) are partly iuto.xica-
tions and in part due to nervous disturbances. The
function of the lymph is the conveyance of nutrition to
the cells and tlie re!no\al of their waste products. From
the lymph spaces the fluid is gathered into the lymph
vessels passing to the lympli nodes, from whicli it is
passed on to the veins by the larger lymph trunks. Not
all the lymph is returned in this manner; a portion is un-
doubtedly taken up directly into the blood-vessels; or
at least in some of the Ij'mph nodes a portion is taken up
by the capillaries of the lymphoid tissue.
Etioi.ooy of CEdem.\. — It follows that as oedema is
the result of an increase in the amount of lymph, such
an increase may be brought about either by an increase
in the amount of fluid passed out of the capillaries, or by
some obstruction to the outflow of lymph through the
lymphatics. In general, the causes of cedema are the
various pathological conditions which may influence the
process of lymph formation. The increased production
of lymph may be due to an increase of the vascular se-
cretion, or to an increased permeability of the vessel
wall. These conditions may be brought about by in-
crease of blood pressure, by pathological alterations in tlie
vessel walls, or by the direct action of certain substances
either upon the cells of the vessel walls or upon the
nerves governing these, stimulating the capillaries to in-
creased .secretion. Within certain limits an increase in
lymph production is equalized by an increase in lymph
absorption through the lymi)hatics and also through the
blood-vessels. Beyond this limit there arises a more or
less permanent over-satiu-atiouof the tissues with lymph,
and the condition of tt'dema is established.
According to etiology four general classes of oedema
may be distinguished; cedema from stnynation of tlic
blood, that resulting from obstniction to the outfluw of
lymph, that caused by disturbance of ctipilliiry secretion,
and adcina ex t-dcuo. Clinically, a great number of va-
rieties maybe recognized: t<i.Ti'c, thermal, traumatic, in-
flammatory, cachectic, infectious, hydremic, aneemic, neu-
ropathic, etc., but all of these fall within the four
etiological classes above named, the great majority
belonging to the third class, namely, that produced by
disturbance of the capillary secretion through alterations
in the vessel walls.
Etiologk Ai. V.\IUET1ES OF ffiDEM.\. — (Edema of Stag-
nation.— Following an obstruction to the onward flow of
the blood, resulting from ligation or occlusion of the
main venous trunks, or in general venous congestion,
due to insufficiency of the heart, the capillary pressure
rises and an abnormal secretion of lymjih takes place.
That the a'dema is due directly to tlie increased l)lood
pressure within the capillary cannot be said to have been
definitelj' proved. It is probable that as a result of the
increased pressure the cells of the capillary walls are
stimulated to increased secretory activity. It is also
probable that degenerative changes in the endothelium
result from the distention of the vessel, so that as a C(in-
seqneuce of an increased permeability of the wall serous
transudation occurs. The fact that in many cases no
changes in the vessel walls of an oedematous area can
be found favors the theory of increased secretion. In
chronic congestion the occurrence of a'dema is also fa-
vored by the resulting loss of elasticity of the tissues
about the vessels. An increase of arterial pressure does
not give rise to redema so long as the venous return is
unimpeded, but in all cases of passive congestion then'
is an increased formation of l.vmph. Tljis may be com-
pensated for by an increased flow of h'mph, but beyond
a certain limit the fluid collects in the tissues. In cases
of general passive congestion the cedema first shows itself
in the most dependent parts of the body, the iufl\ieuceof
gravity favoring the greatest increa.se of pressure in the
vessels of these parts. As in general passive congestion
there is some obstruction to the discharge of the large
lymph trunks into the veins, the lymph of the tissuesls
not removed so rajiidly as normally. Local passive con-
gestion gives rise to local O'dema; thrombo.sis of the
femoral vein causing (edema of the lower extremity, oc-
clusion of the portal circulation being followed by as'cites,
etc. The fluid in a'dema of stagnation always'contains
but a slight amount of albumin. "With increase of press-
ure the amount rises, and a varying number of red cells
may escape from the vessels into the lymph.
(Edema Caused by Obstruction to the Lymph Circulation.
— It has been shown h\ a number of investigators that
obstruction to the current in the lymph vessels is not as a
rule followed by oedema, on account of the numerous and
universal collateral anastomoses, and also for the reason
that the lymph may be reabsorbed by the blood-vessels.
An actual obstruction to the lymphatic circulation can,
therefore, hardh' occur except in the case of the main
lymphatic trunks. Even in these cases, if the production
of the lymph remains normal, collateral channels may
be developed, suflicient to carry off the lymph without
causing adema. According toBaldaert the total occlu-
sion of all the lymph vessels of a part may give rise to a
pure lymphatic adema, which in the case of increased
formation of lymph may develop into a tissue cedema.
Obstruction of the thoracic duct by tumors, aneurisms,
etc., is usually followed by chylous ascites. Even in this
event a Cdllateral circulation may be set up: but in other
cases the rupture of the receptaculuni chyli gives rise to
a chronic chylorrhaa into the peritonearcavity. In the
case of a'dema caused by stagnation lymphatic obstruc-
tion causes a great increase in the degree of the a'dema
present.
(Edema Caused by Disturbances of Capillary Secretion. —
As the result of chemical changes in the blood, imperfect
o-xygenation, aua?mia, infections, into.xications, long-con-
tinued passive congestion, trauma, effects of low or high
temperatures, etc., certain pathological alterations in the
walls of the vessels may be produced, of such a nature
as to cause an increase in the secretion of the vessel walls
and give rise to oedema. The exact nature of the changes
we are at present unable to state ; in some cases the en-
dothelial cells appear granular, cloudy, and are exfo-
hated ; in other cases no changes in the cells can be dis-
covered. It is also possible that alteration of the cement
substance between the cells favors an increased transuda-
tion of fluid. The forms of adema produced by the
above-named factors are known clinically as toxic, infec-
tious, neuropathic, inflammatory, etc.
(Edema ex Vacuo. — After degeneration or necrosis of
portions of the tissue of brain or spinal cord the necrosed
material is absorlx'd and the defect becomes tilleil with
fluid of a very low specific gravity and containing but a
small amount of albumin. In atrophy of the brain and
cord the subarachnoidal space and the ventricles may be-
come enlarged and filled with a similar fluid. This proc-
ess may be regarded as being of the nature of a compen-
satory attempt to restore the normal tension of flic part.
N.\TURE OF THE Tr.\nsud.\te. — The fluid of (edema is
usually colorless or pale yellow, clear, and of alkaline
reaction. A few leucocytes and red cells are usually
present. In cases with accompanying icterus the fluid
may be yellow or even brownish. An excessive number
of red cells may give it a reddish tinge. The collections
of fluid in the serous cavities are more likely to vary in
color in a noticeable degree, and usually contain flakes of
fibrin. Occasionally they may contain large numbers of
des(iuamated endotheliai cells, leucocytes, or fat drop-
lets. After rupture of chyle vessels the admixture of
chyle with the fluid of an existing ascites may produce a
milky turbidity of the ascitic fluid. In other cases the
milky appearance of transudates may be caused by a
precipitation of albumin. The chemical composition of
transudates is closely related to that of the blood plasma.
335
<E<lenia.
(Edema.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
The amount of pi-olciils. salts, aud extractives is a vary-
iug one, and is usually less than that of the blood. Un-
der certain conditions "the salts and e.xtrai'lives may occur
in greater amounts than in the blood, but the amount of
albumin is always much less. The tibriu forming ele-
ments may be absent or present in small amount. Mu-
cin is occasionally present. The projicirticm of albumin
in pure transudates varies greatly in ditT<Tent parts of
the Ijodv. According to Ueuss, the proportion of albu-
min in pleural transu'dations is 2'i.'> /m- mille, in pericar-
dial 18.3, in peritoneal U.l. in the fluid of subcutaneous
oedema 5.8, in that of cerebral and spinal cavities 1.4.
The following table of the specific gravity and albu-
min content of certain transudates is given by Thoma:
Specific
gravity.
Per cent, of
albumin.
Asc-itic fluid in lu-ptiiltis
Ascitic fluid iu i-oilal nhstriiciion (cirrhosis)
Ascitic fluid in L'i*iH-ral \4'nous congestion...
i.fioe
1.008
1.012
I.ou:
1.013
1.007-1.011
0.56
.97
1.96
Plt-ural effusion in general venous congestion
1.30
O.d.i-l.l
As a rule the siiecitic gravitv of a pure transudate
rarely reaches I.OIU. usually falling below, 1.006-1.008.
In iutlammatory a'dema the specilic gravity may reach
1.016-1.020. In inflammatory cedema the amount of al-
bumin is much greater than in pure transudates. The
presence of abnormal substances iu the blood ]ilasma
(sugar, uric acid, bile pigments, potassium iodide, phe-
uolTetc.) leads to the presence of the same iu the fluids
of the ti.ssues and body cavities.
CENEH.\iy Mdhbid Anato.my. — ffidematous tissues are
usually pale, swollen, aud as the result of the deticient
circulation colder than normal. The degree of change
varies with the part involved and the structure of the
tissue. The skin and subcutaneous tissue may take up
an enormous amount of fluid: the skin may become
greatly stretched, and an extremity may swell to many
times its normal size. As a result of the extreme disten-
tion the skin at flrst becomes greatly thinned, smooth,
and shining, later presents linear lines of rupture from
which spontaneous oozing of fluid may occur: iu chronic
frdema the skin usuall}' becomes thickened, rough, scaly,
and iiigmented, aud may show numerous linea* albicautia'.
The most characteristic physical sign of a»dema is that of
I)ittiug on jiressure, indentations made witli the fingers in
o>(Ieinat(ius tissues persisting for some time, because of
the diminished elasticity of the tissues. The lymph
S|)aces of the skin and sid.)cutaneous tissues may become
so dilateil that incision into these allows the fluid toes-
cape in a constant stream. The appearance of the incised
tissue is that of a partial liiiuefaction, so great may be
the saturation with fluid. (Edema of the skin usually
appears flrst over the ankles aud beneath the eyes. The
loose integument of the penisand scrotum may show the
most extreme degree of sattiratinu.
Collections of flind in the body cavities, when extreme
and long coutinueil, cause dilatatiou of the cavity and
compression of neighboiing organs. The serous surfaces
become grayish and more opaiiue and usually present
more or less desquamation. In o'dema of mucous mem-
branes the mucosa becomes swolleu, pale, grayish, more
or less transluceut, and of boggy consi.steuce. In the
case of the lung the alveolar spaces become filled with
fluid, the presence of the fl4iid causes a loss of elasticity
and a partial atelectasis. On section a more or lessabun-
(l;int frothy fltnd 'escapes from the cut surface. In
marked pulmonary oedema the volume and weight of the
organ may both be greatly increased. Solid organs like
the liver and kidney from the nature of their structure
rarely show a marked condition of (edema. Wlien pres-
ent, the cut surface of the organ is moist and glistening.
The microscopical examination of (edematous tissues
shows enlargement of the tissue spaces, separation of the
connective-tissue fibrilla', vacuolization of cells and nu-
clei, and the presence of fine albumin granules iu the
spaces occupied by the fluid. In the alveolar spaces of
the lungs large numbers of desquamated epithelial cells
are also found. In chronic wdema hydropic degener-
ation of some of the constituents of the tissue may take
]dace. As a result of the lowered resistance of cedema-
tons tissues, aud the mechanical injury caused by stretch-
iug, distention, etc., secondary iutlammatory changes are
of frequent occurrence iu and about a'dematous tissues.
Clinical Vauiktiesof (Edkma. — Inflaiuiuatory CEde-
ma. — The cedema associated with inflammatory processes
is not of the nature of a pure transudate, but is usually
classed under the head of exudates. Its etiology is, how-
ever, to be sought iu alterations of the vessel wall similar
to those which give rise to transudates, though of a more
marked character. It occurs as circiunscribed or diffuse
swelling of tissues, or as effusions into the body cavities.
It differs from transudates iu the character of its fluid,
which contains much more albumin aud greater numbers
of red cells aud leucocytes, and a much greater jiropor-
tion of fibrin-forming elements. It may be caused hj any
of the factors — infectious, toxic, traumatic, theripal, etc.-^
that give rise to inflammation. The cedema often seen iu
the neighborhood of infiammatious is known as collateral
a'deina. Inflammatory' cedema is regarded liy some writ-
ers as representing the transition stage between the vascu-
lar changes that give rise to pure transudates or (3?dema,
aud those which lead to inflammatory exudation.
Tiuic. — Heidenhain found that intravascular injections
of the enzymes of the salivary, pancreatic, and gastric
secretions, peptone, egg albumen, decoctions of the mus-
cles of crabs aud crayfish, etc., produced a marked in-
crea.se in the production of lymph. He explained this
jihenomenou as due to the stimulation by these sub-
stances of the secretory functions of the cells of the ves-
sel walls. According to Hamburger bacterial products
circulatiug in the blood may either increase the perme-
ability of the capillary wall or stimulate the endothelial
cells to an increased or abnormal secretory function. A
changed chemical coudition of the blood may have a
similar action. It has been suggested that anjema may
be caused by a lack of oxygen, the resulting chemical
changes in the blood or tissues causing an increase in
osmotic pressure in favor of the tissues over the blood or
lymph. The a?demas formerly regarded as cachectic or
liyilncmic are most probably caused by the altered fimc-
tional activity of the eudothelium due to changes in the
compositiou of the blood. The cedema of chronic ne-
phritis is ])roljably to be explained in the same way. The
acute (edematous conditions of the skin, such as urtica-
ria, are also due wholly or iu part to intoxication. The
injection of certain protective or curative serums (plague
serum) may be followed by extensive urticaria, or even
by a more generalized oedema.
Ilydrajnie or Cac/iectic OCtleiiiei. — It was formerly lield
that a hydra'inic condition of the blood, due either to a
diminution of the sniids of the blood or to a retention of
water, could be a direct cause of an increased transuda-
tion through the vessel walls. The latter were believed
to behave as dead animal membranes, aud the process of
oedema formation to be one of pure osmosis. It was
shown by Cohuheim that hydniemia was not the direct
cause of (edema. Even when the blood is replaced to the
extent of one-half its volume by dccinormal salt solution,
so that there is produced a marked hypoalbuminosis, no
a'dema is caused. In extreme hy dramic plethora, a'dema
may supervene when the auimmt of water iu the blood
becomes very great ; but it does not develop in the same
regious where cedema ordinarily is found. Further, the
occurrence of one-sided hydrothorax, or of bilateral hy-
drothorax with unequal amounts of fluid in the two
pleural cavities, must be taken as stiong evidence of dif-
ferences in the structure and function of the capillary
walls in the two sacs. In general it may be said that
hydra^mia does not produce cedema, but only favors its
occurrence. The anlemas which occur in chronic ans'inia,
cachexias, chronic nephritis, etc., are, therefore, to be
regarded as due to changes produced in the vessel walls
336
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
(Edema.
<Edenia.
liv tlic altered condition of tlie blood or by poisons circu-
hiliiig in the bl<iod. By Tlionui and other writers it is
believed that cachectic and liydra;mic oedcnias are due to
sclerotic changes in the vessel walls {angiosclerotic wdema).
A loss of elasticity of the tissues may also favor the for-
mation of cedema in these conditions. The fluid of hy-
dra'uiic or cachectic o'denia contains but a small amount
of albumin as compared to inflammatory a'dema.
y,'iimp(it/iir OCdei/ia. Angioneurotic (Edema. — If the
production of lymph is dependent upon a secretory func-
tion of the vessel walls it is very pi'obable that such
function is under nervous control, and that under certain
nervous disturbances an a'dema may arise which may
projierly be designated as neuropathic. This is borne
out bymanj- clinical observations. In hysterical indi-
viduals and in persons who have been hypnotized local-
ized ffdemas may occur that admit of no other expla-
nation. In epilepsy pale or red areas of angioneurotic
o?dema are not infrequently seen, in the shape of wheals,
general urticaria, etc. In Basedow's di.sease urticaria
not infrequently occurs, as well as circumscribed, unilat-
eral a'dema localized in the hands or legs. Erythema
nodosum and herpes zoster are also regarded as partly
toxic and partly neuropathic, ffidema also occurs after
spinal paralysis; and iu hemiplegia the atTected side
shows a more or less well-marked adema. According to
Janowski the severing of the vaso-motor nerves in con-
ditions of ffidema is followed by a great increase iu the
amount of the exudate. Vaso-motor disturbances in
myelitis, tabes, sciatica, etc., are also associated with the
pi"oduction of (cdema. Toxic, thermal, or traumatic irri-
tation of the nerves may also lead directly to adema. It
must l)e borne in mind, however, that many writers hold
that the existence of a purely neuropathic adema has not
yet been proved.
OSdema Fugax. — Transitory adema is designated by
this term. Tlie majority of the so-called neuropathic
adcmas are of this nature. Transitory adema is of not
infrequent occurrence in Basedow's disease, chlorosis,
severe anaemia, hysteria, etc. Such ademas usually ap-
pear during the day and disappear after a night's rest.
Fidse DropKji {JJgdrojisin Sp'irin). — The distentitm of
cavities, chiefly those of glands, following stenosis or ob-
literation of the gland duct. The fluid usuallv results
from the retention of secretions; it may l)e a thin serous
or a thickened raucous fluid. In this class belong hydro-
nephros, hydrosalpinx, liydrops cystidis fellea', hydro-
metra, hydrops processus vermiformis, hydrops sacci
lacrymalis, etc.
(Fdenia Intermittens. — Intermittent cedema has been
described in cases of malaria, and in feliris intermittens
larvata. The whole body surface may lie involved, but
often the adema is contine<l to the extremities, thorax,
etc. Intermittent ascites and intermittent hydrarthros
have also been observed,
Giilema lieonatonim (Scleretna or Scleroma ISeonn-
tori-im). — A condition of the skin of the new-born charac-
terized by an infiltration of serum into the subcutaneous
tissue, hardening of the skin, and lowering of the skin
tcmjierature. Many theories have been adduced in ex-
planation of this condition, but it is probable that scle-
roma represents a symjitom complex and not an independ-
ent disease. The majority of children afEected are those
born prematurely. The affection begins usually on the
second to the fourth day. After the eighth clay it is
very rare. Congenital cases have been observed. In tlie
majority of cases the condition is fatal. The adema has
not been satisfactorily explained, but is probably due
to changes in the blood following cardiac insuflicicncy.
deficient oxygenation, and changed chemical nature of
the blood in some cases due to intestinal intoxication.
D'Agata is of the opinion that the condition is of the na-
ture of a vaso-motor and troiihic vagus neurosis.
Occurrence op ffiDE.M.4. — CEdemaisof most frequent
occurrence in all forms of cardiac insuflicicncy, especially
failure of coin pensat ion in valvular disease, chronic ne-
phritis, cirrhosis of the liver, chronic anaemias, and ca-
chexia, conditions in the lungs favoring venous stasis.
Vol. VI.— -22
thrombosis of large veins, or oljstruction ot these by
tumors. In cases of iKemoiiliilia after reiieated hemor-
rhages adema often occurs. Myelitis with decubitus is
often associated with (edema of the lower extremities.
Mediastinal tumors, or growths arising in the lungs or
bronchial glands, or aneurism may cause adema of one-
half the body through pressiu'e upon the large veins. In
chronic chloral poisoning general adema of the skin oc-
curs, and in chronic morphinism adema of the face has
been observed. In both acute and chronic rheumatism
circtunscribed or difl'use (edema often appears in various
parts of the body; in chronic rheumatism it is not infre-
quently associated with arteriosclerosis, particularly of the
arteries of the foot and of the tibialis posticus. (12dema is
also often associated with arteriosclerosis dependent upon
other causes, vessel walls which show sclerotic changes
being more permeable than normal vessels. In cases of
cancer and ulcer of the stomach cedema maj' occur after
severe hemorrhages. In chronic tuberculosis it is of less
common occurrence. In this disease it is more often
confined to one of the lower extremities, usually the left,
as the result of marantic thrombi iu the crural vein or
soine of its branches. When double-sided the adema is
due to cardiac insulfieiencv or to tlie changed condition
of the blood. The development of amyloid disease or
tuberculous peritonitis usually leads to extensive or gen-
eral I edema.
GMlema of the larynx occurs in laryngitis, nephritis,
malaria, cardiac insuflicicncy, enlargements of the thy-
roid, aortic aneurism, pressure of tumors upon the jugu-
lar veins and their branches, after the use of potassium
iodide, inhalation of hot air, in acute infections, variola,
typhoid, etc., in leukaemia, and in tuberculosis, syphilis,
and carcinoma of the larynx, etc. ffidema of the
jiharynx occurs in the same conditions, but most fre-
queutl_v in scarlet fever and in chronic nephritis. The
(edematous mvicosa is swollen, translucent, and pale,
tliese changes being most marked over the soft palate
and uvula. The latter organ may be greatly increased
iu length and thickness and may cause serious disturb-
ances of respiration. 0*>dema of the lung occurs espe-
cially in cardiac insutflcieucy , chronic nephritis, in connec-
tion with ir^flammatory conditions of the lung, and also
in association with cerebral disease. JIarked (edema of
the penis and scrotum is very conunon in cases of exten-
sive general adema. Local u'dema of these parts occurs
in cases of stricture, traumatic injury of the urethra,
bladder and seminal ducts, in infiltrations of urine, in
syphilis, and after operations upon tlie bladder or rectum
as one of the first signs of a phlebitis in the plexus pro-
staticus. There appears also to be an idio]iatliic form of
adema of the penis. In chronic adema of this organ
there often results a marked ])liimosis and a thickening
of themucousmemlirancof the external meatus, ffidema
of the external female genitalia occurs after difflcult la-
bor, in cases of ovarian or uterine tumors, iu abnormal
position of the uterus, jjrolapse, etc.
In cases of infection with the liacillus of malignant
adema there develops very rapidly a general subcuta-
neous adema, in the fluid of which many bacilli are found.
Only a few cases have been reported in man. .some of
these following the injection of musk in the cour.se of
typhoid fever, others occurring during the puerperium.
and others arising apparently without external injury.
It is very probable that some of the conditions reported
under this liead were not iu reality cases of infection b_v
this bacillus.
PiiOGNosis. — The consequences of o'dema vary with
the etiology, location, and extent of the jirocess. Collec-
tions of fliud in the body cavities may cause compression
of important organs, lungs, brain, etc As a result of
(edema of the nerves, degenerations and lo.ss of function
may take place, ffidema of the glottis may cause sud-
den death from suffocation, ffidema of the lungs is very
frequently the immediate cause of death in cardiac in-
sutflcieucy, chronic nc])hritis, etc. Fatal intracranial
pressure may be caused by acute transudation into the
cerebral ventricles and sulimeningeals|nices. Serious in-
33.
CFdoiiia iVeoiialt»rniii.
<Ksopliail£iiK.
REFERENCE HANDBOOK OF THE :\rEnK'AL SCIENCES.
ttTfereiicc with re.s|)irati(iii and circulatioii may bf pro-
duced bj' pressure upon llie lungs or diaphragm or by
]deural or peritoneal dropsies. Iii general it may be said
that the progno.sis in a'dema is serious because of the
important pathological conditions underlying its appear-
ance.
The.\tment. — In general this is directed to the condi-
tion which gives rise to the (edema. Extreme distention
of a'dematous skin may be relieved by punctvire and con-
tiuuous drainage. Collections of fluid within the body
cavities may also be removed by aspiration (see also As-
citrs). Alilnd S;,lt Wiirthih.
CEDEMA NEONATORUM, or o'dema of the new-born,
was Inng coiifnuiidrd willi "scleroma neonatorum" — a
distinct affection. (Edema may occur in infants prema-
turely born or in those born at "term but of poor vitality;
it differs in these subjects in no respect from a-dema in
older patients, and can hardly be considered more than
a symptom, associated as it is with many ditferent con-
ditions of the body. As wilh ledema in general tlie
parts are soft, waxy white, pit on pn'ssurc, and in the
more dependent areas the swelling is greatest. Bad feed-
ing, defective hygiene, exposure to .severe cold soon after
birth, feeble hea'rt action, and atelectasis of the lungs
are all causes tending toward the iiroduction of the sym])-
toin of tedenia iu new-born infants. The treatment is
that of the general condition and shoulil lie directed tow-
ard the underlying causes. Artificial heat to maintain
the body temperature is an important adjunct.
C'hiirks Tuwnshcnd Dude.
CENANTHE. See Poisoiwus PlmiU.
(ESOPHAGUS, PATHOLOGY OF.— The wall of the
rosophagus consists of a iiiucosa, sulimucosa, inner circu-
lar and outer longitudinal nuiscular coats, and an exter-
nal librous tunic. The muco.sa is covered with stratified
squamous epithelium, and contains sparsely scattered
mucous glands and few lymph follicles. In the upper
portion striped muscle is also present in the wall, in the
lower portion only unstriped. The poor blood supply,
the lack of mucous glands and lymph follicles, and the
thick covering of stratitied squamous epithelium ren-
der the a'sophagus less liable to disease than the closely
associated structures, the pharynx and the stomach.
The inde|iendent part jilayed by the O'sophagus in alfec-
tions of these organs is often strikingly^ shown in the
sharply limited borders of inflammatory processes in the
pharynx, the inflammation cea.sing abruptly at the begin-
ning of the oisophagus. Though a'sophageal disease is
relatively rare, it is nevertheless of very great clinical
importance, not only from the fact that disease of the
ffisopbagus ma\' interfere with the proper passage of
food into the stomach, and thus give rise to general im-
pairment of nutrition, but also because of the proximity
of this organ to such important structures as the trp.cbea,
lungs, and aorta. Further, the examination of the (e.51, ph-
agus is relatively ditlicult, and possible only through
the use of special instruments or apparatus. (For meth-
ods of examination see l^toinKcli, Smr/rri/ uff/ic.)
CoNGENiT.VL M.\LF(M{M.\Ti( iNs. — Though relatively
rare, these conditions are of practical interest, inasmuch
as children so affected may li\e foi' some time after
birth, or even reach adult age. The malformations may
exist alone or iu connection with other defects. The fol-
lowing forms have been described:
1. (JiJsophitriit-lrdfhcal Futiihi. — Abnormal communica-
tions between O'Sophagus and trachea may occur. The
most common form is tliat in which tlie<eso]ihagusat the
upper third ends in a blind tube, while the lower portion
opens at its upper end into tlie trachea or bronclius.
The upper and lower ends of the obliterated lesophagus
may be connected by a muscular band oi' a lirm flbrous
cord. This malformation may be due to primary dis-
turbances of di-'velopment, or may lie accpnred during
intra-uterine life as a result of suppurative jirocesses in
the glands lying bi'twecn the o'sojihagus and thi trachea.
The upper part of the resophagus may be closed in this
way by cicatricial contraction, while the lower part may
be connected with the lumen of the trachea, or the re-
verse condition may occur. Children showing this mal-
formation may be otherwise well develojied; tliey die
shortly after birth from inanition or aspiration imeumo-
nia. In this connection should be mentioned also the
rare occurrence of cysts lined with ciliated columnar epi-
tlielium, lying between the oesophagus and the bifurca-
tion of the trachea. These C3'Sts represent remains of the
communicating canal between (esophagus and trachea.
They may reach such a size as to cause compi-ession of
the lesojihagus and secondary dilatations of the same,
and are tlu'reforc of clinical importance. In other cases
they may be discovered only accidentally, having given
rise to no symptoms.
2. Sttnvnis. — Partial obliterations or naiTowing of the
lumen may occur as congenital malformations of either I he
upper or the lower portion of the a'sophagu.s. The lower
eu(i of the upjier portion may open into the trachea, or
may form a blind sac. In other cases the cesophagus may
be open as far as the level of the bifurcation of the trachea,
at which point complete obliteration of the lumen may
be found. In a few cases a membranous stenosis or ob-
literation has been observed, or the lumen has been closed
by a ring-like fold of muco.sa. Those cases of obliteration
in which the continuity of the (esophagus has been com-
pletely broken liave been explaine(i by the development
of tlie trachea and bronchi at the cost of the (esophagus;
while those cases in which the continuity is not wholly
lost. Init in which the two portions of the (esophagus are
connected by a muscular band, have been explained as
the result of a fu'tal pressure-atrophy. The conditions
are rare; only the partial stenoses have clinical signiti-
cance.
3. Tittnl ahxenre of the a'sophagus is without clinical
significance and is found only in acardiac monsters.
4. .1 ri:iliiiilieiili'iii of the (esophagus (di<}'Sopha<i>ii<) has
also been verj' rarely observed. The reduplication may
be complete or jiartial, and occurs in different degrees of
double monsters. It is likewise without practical signifi-
cance.
5. Ciingeiiitiil TJihttiitioiis. In very rare cases there has
been observed just above the cardiac orifice a peripheral
dilatation of limited extent, tlie so-called " fore-stomach "
or ■' antrum cardiacum." Children presenting this anom-
aly usually show the clinical symptom of rumination.
Cii!ct;i.-\Tonv DisTUUis.vxcEs. — Aiiii-e Injpcriiiiiiin oc-
curs in the early .stages of inflammatory conditions. It
may lie due also to the irritation of certain foods or
drinks. Pussire cuiir/cstiii/i. occurs iu all cases of general
passive congestion, particularly in chronic heart and lung
diseases, cii'rhosis of the liver, etc. In chronic passive
hj'pera'mia the mucosa of the o'sophagus is dark bluish-
red ; the epithelium often shows plaques of thickening
(leukoplakia). Local dilatations of the veins occur, the
.so-called nxaj'/inr/fiil lifiiii'niiiiidn or (v(/vV"c.«(see Fig. Stil.5).
In the upjicr part of the (csoijhagus they are relatively fre-
quent, forming small blue nodules or saccular elevations;
these possess no clinical significance. In the lower por-
tion of the (esophagus they occur even more frequently,
particularly in the region of the cardiac orifice, or a few
ccntimetresabove this. The enlarged veins project above
the level of the mucosa, and may form saccular pajiillo-
matous masses resembling rectal hemorrhoids. The di-
lated tortuous veins maj' he as thick as a lead pencil or
even larger. They represent vicarious enlargements of
the collateral branches connecting the portal circulation
(through the vena coronaria ventriculi) with the vena
azygos. They occur particularly in portal obstruction
(cirrhosis, sy|ihilitic hejialitis, pressure atrophy of the
liver, obstruction or thrombosis of the portal vein), as
well as iu chronic jiassive congestion due to cardiac in-
sufficiency. They are found in the majority of cases in
connection with rectal liemorrhoids. Their presence is
revealed clinically by hemorrhage, which may be fatal.
As an early diagnostic .symptom in cirrhosis of the liver
bleeding from usojihageal hemorrhoids is of great im-
338
REFERE^■CE HANDBOOK OF THE MEDICAL SCIENCES.
CEdrnia Nooitaloriilii.
IFsopliagiiN,
portiince. Preceding the heiiKirrhage tliere may be ob-
served pain in the stomach, swelling of the spleen, and
distention of the abdomen, severe pain radiating from
the stomach region to the shoulders or extremities — these
symptoms are followed by stidden hemorrhage fi'om the
a'sophagus. Similar symjjtoms are often seen preceding
hemorrhages from piles. The cause of the tesophageal
hemorrhage may be due to increase of venous pressure
or to idcerative changes in the mucosa over the va-
rices. Rupture of the vari.x has followed coughing, se-
vere muscular e.xertion. dyspnu-a, etc. In other cases no
direct cau.se for the hemorrhage can be found. Repeated
hemorrhages of small size may lead to severe anu-mia.
The relative frequency of hemorrhage from oesophageal
varices makes the condition a dangerous one.
(Exoph(i(jial hemon-hir/es may be caused also by injury,
ulceration, new growths, etc. The hemorrhages very
often arise from the large vessels in the neighborhood of
the fesophagus, rather than from its own vessels. Bleed-
ing from the latter occurs particularly in cancer of the
mucosa. An aortic aneurism may erode the wall of the
oesophagus and rupture into the lumen; or, on the other
hand, the a?sophagus as a result of ulcerative or carcinom-
atous changes may break into the aorta, carotid, left
auricle, etc. Such an event is most likely to happen in
cases of a>sophageal carcinoma. In whatever way pro-
duced, the entrance of arterial blood into the oesophagus
makes itself known b_v the apjiearance of the blood vom-
ited up, providing the hemorrhage is of sufficient volume
to cause immediate vomiting. There may, however, be a
continuous slight oozing from an eroded arter}- or arte-
rial aneurism, and the blood passing into the stomach may
be so changed that its arterial character is lost before
vomiting takes place. In some cases the blood may be
digested and passed on into the intestines.
Retkogk-\de C'iianoes. — (H^sophcigoiiKilacUi is in the
great majority of cases a post-mortem digestion of the
mucosa of the fesophagus by stomacli fluids which have
passed, after or during death, through the cardia into
the a>sophagus. The epithelium is macerated, desqua-
mated, or liquetied : the musculature may also be licjue-
lied and perforated, the stomach juices pa.ssing into the
pleural cavity. In the lightest grades, which are pres-
ent in the majority of cadavers, the mucosa of the organ
shows longitudinal stripes of des(juamation correspond-
ing to the longitudinal folds of the contracted mucosa.
An intravital lesophagomalacia is of very rare occur-
rence, but has been described as the nmml or peptic ulcii-
of the CESophagus, which corresponds in all particiUars
to the round ulcer of the stomach. An agnnal O'sopba-
gomalacia has been observed in severe cases of cerebral
disease.
Atritjiloi of the ccsophagus wall occurs in cachexia.
Degeiierutifjfis of the (esophagus wall are of very rare oc-
currence and have been studied but little. Xceroxls is
the most important retrograde process found in this or-
gan. The most common cause is pressure, either from
foreign bodies lodged within the lumen or from the
pressure of an aneurism or tumor from without. As a
result of the local anaemia caused by the pressure there
occur necrosis and ulceration. The peptic iilccr has been
mentioned. Ihciibilul vdccrs may be found in advanced
stages of severe cachexias, youm of the ch<-c-k or phar-
ynx, gangrenous tonsillitis, or gangrene of the lung ina^'
be associated with f/aiu/reiie of the a>sophagus. Corro-
sive poisons may cause more or less extensive necrosis
of the oesophageal mucosa associated with inflammatory
changes. Gangrenovis oesophagitis occurs also in severe
infections as a rare complication.
Inflammation. — Aoite cutn rr/ml lesopfiagitisiathe most
common form. It is caused chiefly by irritating foods or
drinks, through extension of inflammation from the |ihar-
ynx or stomach, or as a secondary jjlieuomenon in some
of the acute infections (measles, scarlatina, typhoid fe-
ver, variola). As a residt of the small nuinber of glands
in the mucosa there is often but little secretion. The
epithelium maybe desquamated, and the mucosa beneath
hypera-mic, or cloudy white, or yellowish. Small ulcers
may be formed over the surface of the folds, and these
maj- heal with the formation of small longitudinal scars.
In the case of foreign bodies deeper vilcers may be pro-
duced. The symptoms of acute catarrhal lesophagitis
are, pain in swallowing, regurgitation, thirst, raising of
otil.j.— (.Ksuphaseal \'unces
'.After Kraiis. )
secretion, pain on moving the neck, tenderness on press-
ure in the diep cervical region. Spastic contractions of
the (esophagus may also occur.
Clir'iiiic riitiirrhiil (cto/i/idr/itis occurs chiefly in smokcis
and drinkers, as well as in individuals suffering from
chronic pharyngitis or, more rarely, gastiitis. The con-
dition is often secondary to the chronic passive conges-
tion caused by cardiac or pulmonary disease. It is found
also in the portion of the (esophagusal)ove a stenosis. It
may be associated with diverticida. In cases of chronic
gastritis characterized by frequent eructatiims of irri
fating substances or by frequent vomiting of the same,
tliere may be produced a chronic tesopliagitis, which '
may be of a purulent or ulcerative character This con-
dition is not infreqviently found in old men.
Chronic lesophagitis may not always give ri.se to symp-
toms. In severe cases there may lie pain and discomfort
in swallowing. The pain has usually the cbaracter of
pressure, more rarely it is .stinging or biu'ning , wiien it is
severe, spastic contractions and regurgitation may occur.
Moderate quantities of mucus ma_y be expectorated : this
may occasionally contain sti'caksof blood. The difl'eren-
tial diagnosis from tlie accompanying afl'ections of phar
ynx or stomach is often very diflicult. The symptom of
dysphagia, less marked in tlie case of fluids than in the
swallowing of solid substances, is the most constant and
characteristic s_vmptom. Exuniinatinn witli a'So]ihago
.scope or sound is usuall_v dillicull. but is necessary for
the exact determination of the condition. This is of
great importance, inasmuch as the symptoms of chronic
lesojihagitis and beginning carcinoma of the (esophagus
are the same: and the dillercntial diagnosis can lie made
only by means of the a'Sophagoscope.
?.m
<Esopliag;U8.
^Esophagus.
REFERENCE HANDBOOK OF THE >IEDICAL SCIENCES.
In chronic ifsopbiigitis tlie mucosa is deep rediiisli-
blue in color, and is tliicUeued, often .showing' polyjioid
or papillomatous hyperphisias, or tlattene<l plaque-lil<e
areas of epitlielial' liyperplasia (leu]<ophiUia) (see Fig.
3616). The muscular coats are often hyperlrophic. Over
1*
■ f-'^- ■, <'V*'
h
■-fer#r
Vp
|M: •
i
1 !. ■
M .
'U
W-
Fk;. ;«ilii.--Li'Ukuiil;ikia "( tiM' UOsopliiiKUs. lAfier Kruus.i
the mucosa lies a layer of thin or thick, often very ten-
acious mucus, which at times is muco-purulent in char-
acter. Small or large erosions or tilceralinns may also he
present. The lumen is usually dilated, but may be nar-
rowed either synunetrieally or irregularly.
AlmvK.it's may form in either acute or chronic resopha-
gitis, but are rare. In these cases the local symptoms
are severe, c'nills and fever occur, bloo<l or bloody puru-
lent material may be expectoiated. The course is usu-
ally prolonged; dysphagia may e.vist for many mcjnths.
In very severe cases <leath may occur; but mililer cases
usually end in recovery alter several weeks oi- months.
FoUiciihir irxojihiiriitis occurs when the glands of the
inuco.sa become involved. Tin,' gland ducts are ob-
structed, there is extensive mucus formation, the gland
lumen is dilated, and cysis filled wilh mucus are in this
way produced. These rarely reach the size of a jtea.
About the cystic glands tliere is a sniall-eelled iuHltra-
tion: this may leacl lo suppuration and formation of ul-
cers. Oeasiimally a |>lilegmiincius lesniihagitis may be
associated with ihe follicular form.
I'/ilei/iiH/noiix {v.\i>p/iiir/i/is is of rare occ\irrence. It may
be caused by the presence of foreign bndies or corrosive
]ioisous, but the most frequent cause is an extension
from pericesophageal abscesses (purnleni lyni|iliadenitis,
perichondritis cricoiilea. spinal abscesses) nr ironi phleg-
monous ]iroces.ses in tlie ]iharyn.x, or nioie rarely in llie
stomach. It may ;ilso follow a follicular o'soiihagitis;
through the conlluence of the small follicular abscesses a
<lilfuse purulent jn'ocess maybe ]n-odueed. In advanced
ca.ses of pulmonary tvdrerculosisdilfuse purulent ieso|iha-
gilis or abscess formation in the a'sophagus wall may
occur withdul other evideni cause.
Phlegmonous aiosphagitis begins as a pundent infiltra-
tion of the submucosti, followed by a liiinefaction of the
tissue and the formation of circumscribed or extensive
collections of ]ius. The mucosa may be extensively un-
dermined ; at the same time it may be reddened, and" may
jireseut throughout its reddened surface numerous sieve-
like yellowish apertures through which pus exudes.
Large circumscribed collecti(Mis of pus may cause bulg-
ings of the muccjsa into the lumen. The ti.ssues about
the (esophagus may be involved (peri<Tsophagitis phleg-
mono.sa), and the abscesses may rupture into the larynx
and trachea, or more rarely into the mediastinum and
pleura.
The symptoms of phlegmonous oesophagitis are usully
obsciue and oiler few characteristics sutHciently striking
lo make the diagnosis from other conditions certain.
Fever, chills, and dysphagia are the most constant symp-
toms. Pain may be felt behind the sternum or larj'nx ;
pressure upon the epigastrium ma}' occasionally give rise
to violent pain. Dyspno-a may be caused by pressure of
an abscess upon the trachea or U]ion the bronchi. The
ilys]iliagia may increase to such an extent that fluids can
no longer be swallowed. If the rupture of a large ab-
.scess into tlie (esophagus be followed by expectoration
or regurgitation of pus, the diagnosis of phlegmonous
(csopliagitis is reudeied more probable; but even in the
event of such regurgitation the pus may come from an
abscess in the neighlKUlioodof the (vsojihagus, which has
ruptured into its lumen. Only when foreign bodies are
known, to be lodged in the O'sophagus can the diagnosis
of ])hlegin(ini>uso'soiihagitis l)e made with certainty. In
the event of tistuhiuscomnumicatinn between theccsoph-
agus and respiratory tract purulent pneumonia or
gangrene of the lung usually results quickly. The
prognosis is doubtful. Recovery may take place, the
formation of cicatricial tissue in the stdjniucosa and mu-
cosa may give rise to stenosis, or in other cases iutra-
parietal diverticula may be formed, the abscess cavities
beneath the nuicdsa healing at the base but remaining
open and conununicatiug with the lumen of the (esopha-
gus by wide ojienings in the mucosa having sharply cut
vmdermined edges.
In c(jnnection with phlegmonous resophagitis may be
considered also the pirintsiqilhinenl (ibuccsfi. This has its
origin most frequently in tubereidous lymph glands
situated in the neighborhood of the O'Sophagus or in tu-
berculous caries of the vertebial culumn, or it arises in the
course of a pya'Uiia. Further, purulent processes of the
parotid or submaxillary may extend to the connective
tissue about the(esoiiliagus. Involvement of the O'.soph-
agus wall or rupture into the lumen of this organ may
set up a phlegmonous (csophagitis. Rujiture into the
respiratory triict, ]iericardium. or pletira may occur.
The peri(esoi)hageal abscess may reach a very large size,
though often it is small. It is usually fotuid between
the fourth and seventh cervical vertebra'. The abscess
arising in tuberculous lymph glands or ndierculous ver-
lebne is found most often in children, and its location is
ordinaril}' between the vertebra' named. The symptoms
are those of phlegmonous a'sophagitis: fever, chills, dys-
phagia, pain on turning the neck, dyspno?a, etc. Chil-
dren fre(juently become comatose; convidsions maj' oc-
cur; and finally the diagnosis m;iy be made clear by the
apiiearance of a swelling in the neck. In the case of tu-
berculous caries of the vertebra' the abscess may develop
very slowly wilh few or no symptoms. The sound may
be passed into the stomacli withovit difficulty, but usu-
ally with more or less pain.
(Ksopjiiir/i/ix jjiixtii/iisii is th(^ designation given to the
changes in the (esoiiliageal mucosa which occur in .small-
l>ox. Papides develop throughout the mucosa, these
iiecome cloudy and ]iurulenl, the epithelium over them
is cloud}', thickened, and linally undergoes desquama-
tion, leaving small ulcers.
ifi'inhni mills (Kxuplinf/itui (G-^sop7nigitifi Fihri iiona or
])!j)/illii'r/t/>ii). — True (iiphtheria of the (esophagus is
rare; only in cxce|)tional cases is there an extension from
the pharynx into the (esophagus. Cases have been ob-
34 n
REFERE^■CE HANDBOOK OF THE :MED1CAL SCIENCES.
<E6op]iagiis»
<F6oplKagiis.
served in whirh the <i>sopliagvis remained free when both
pharynx and stomach were attacked ; the oesoi)liagus maj",
therefore, be said to possess a certain immimity in respect
to diphtlieria. A membranous or tibriuous ccsopbagitis
accompanied bj' diphtheritic necrosis is of relatively fre-
quent occurrence as a secondary condition in severe cases
of smallpox, scarlet fever, measles, pyemia, cholera,
typhus fever, typhoid, chronic Bright's disease, pneu-
monia, tuberculosis, and in cliildren as a frequent com-
plication in intestinal catarrh. The process is rarely
diffuse, but is circumscribed, and usually localized on the
highest parts of the folds of the mucosa. Small ulcers
may be formed at these places. Usually the symptoms
of diphtheritic a>sophagitis cannot be separated from the
accompanying disease, but in certain cases the disease
may manifest itself through hemorrhage or discbarge of
pseudomembraues from the oesophagus. The prognosis
is very grave. When recovery takes jilace cicatrization
of the diphtheritic ulcers may lead to stenosis of the
lumen.
CEsop/nigitis eorrosiva is produced by the action of cor-
rosive agents, acids, or the caustic alkalies, most com-
monly by concentrated lye, which have been swallowed
either purposely or accidentally. (See Fig. 8617.) The
change produced by the corrosive agent is of the nature of
a necrotic inflammation ; its severity depends upon the
strength or concentration of the poison. In mild cases the
superficial epithelium is necrosed, and is desquamated in
grayish shreds resembling a croupous membrane. Alka-
liesniay cause the cells to swell and form a soai)-like mass.
A more severe action of a corrosive agent may convert the
entire mucosa into a dirty gray or black eschar ; the ves-
sels are injected; the submucosa contains numerous ec-
chymoses, and there is a line of demar-
cation separating the dead ti.ssue from
the inflamed tissues of the subnnicos;t.
Active suppuration occurs and the ne-
crotic mucosa is desquamated. If heal-
ing results, the lumen maj' become
greatly narrowed or graduall}' com-
pletelj- occluded. In the most severe
cases the deeper layers of the oesopha-
gus may be affected. The symptoms
are severe burning pain beneath the
sternnm, dysphagia, intense thirst,
hemorrhage, and collapse. Portions of
the eschar, or masses of bloody mucus
may be expectorated. In the mild
cases the pain ceases after tweuty-
fotir hours, the dysphagia becomes less
from day to day, until the S3'mptoms
finallj' disappear altogether. If much
scar tissue is formed, difficulty in swal-
lowing may be experienced again af-
ter several weeks. Severe cases may be
immediately fatal from shock or from
hemorrhage, or from perforation : in rare
cases the covrse is prolonged, abscess
formation, mediastinitis, pj'opneu-
mothorax, etc., occurring as compli-
cations. Patients recovering from se-
vere corrfisive poisoning are sure to
suffer from cicatricial contraction of
the lumen.
The diagnosis in the majority of in-
stances is revealed by the history of the
case and the evidences of corrosive ac-
tion in the mouth and pharynx. It is
of importiiiice to discover the nature
of the poison in tliose cases which are
seen shortly after tiie poisoning has oc-
curred. Litmus paper may be apjilied
to the mucosa of the mouth or pharynx
as a rough method of diagnosis as to whether acid or alkali
had been used, in case the facts cannot otherwise be as-
certained. The majority of such cases are caused by
concentrated lye or sulphuric acid. According to von
Hacker one-fourtli of the cases of jioisoning with concen-
trated lye are fatal as the direct result of llie poisoning;
in the case of sulphuric ac'd, about one-half. Of tliose
living after poisoning with concentrated lye about one-
half acquire severe stricture of the u'sophagus; of tlio.se
living after sulphuric-acid poisoning about a third show
contraction of the lumen.
(Esophagitis ganriraiujsa is of lare occurrence. It may
follow the action of corrosive poisons, pressure of foreiga
bodies within the oesophagus or of tumors.aortic aneurism,
etc., from without, or it may occur as an extension from,
gangrenous tonsillitis, pulmonary gangrene, etc. Decu-
bital ulcers may occur in the tipper part of the o^sophagua
or in the lowest portion of the pharynx. (See Fig. 3618.)
Two small ulcers, one on the anterior wall, the other on
the posterior wall, corresponding in position, shape, and
size to each other, occur coinciilently, so that one ulcer
appears as the impress of the other. The condition
occurs only in extremely cachectic individuals who have
been confined to bed for a longtime; it is due to the press-
ure of the larynx upon the (esophagus. The ulcers appear
shortly before the death of the att'ected individual and
cause difficulty in swallowing, in this way hastening the
end.
(Esophngitis e.tfoHativa (ffisophagitis Desiccans Super-
ficiali.s). — A number of cases of acute inflammation of the
oesophagus, characterized by a rapid desquamation of
the entire mucosa, have been described. The desqua-
mated epithelium luay form a hollow tube. lo-25 cm.
long. The desquamation may be caused b_y subepithe-
lial inflammation, action of chemicals, etc., but the exact
nature of the disease is unknown. The majority of the
patients were neurotic or hysterical.
Acute imuphiyids of young children occurs in nurslings
Fig. :)017.— (Esophatritif
muc<rsa : h. ha<ii'ii;i
honintrf'Ili'ntl.s (I'M'ply
f, lieppt-r p'lrEitiii
Weicliselbauiii.)
Corrosiva (after swallowiiiij coiH-emraieii iyc). ''. TIih ricrrotlc
I'tiilu'ddetl in a: r, upper purlinu of suliinurnsu. intlllrattMl with
siaiiiinj.' masses (librinV); (7, ltloo(i-vcssel with in'crotk' wail;
f suliiuucosa inditrated Willi ilbriuous nt-iwork ami ieiu-ocytes. (.\fter
as a result of a poor quality of mother's milk, soreness
of the nipple, etc. It may be associated with gastro-iii-
testinal irritation. Attempts at nursing are interrupted
after a few seconds, flu- child cries, is restless, and regur-
^'itates the greater part of t he milk taken. Pressure u pou
3-il
CEsopliagus.
REFEREIs'CE IIAXUBOOK OF THE MEDICAL SCIENCES.
tlie lower part of the sternum is uppurently painful, the
child often crying out. The disease i.s important iu that
it may pass over into an idcerativeor gangrenous inflam-
mation.
I'lcris Pepticiim (Esophagi. — Ulcei's in all respects simi-
lar to the round ulcer of the stomach may ocetu- in the
lower portion of the o'sophagus. and are i-egarded as due
to the same causes: viz., a digestion by the gastric juice.
In cases in which the resistance of the tesophageal mucosa
is lowered, the repeated entrance of the stomach fluids
into the cesophagus may be followed by the development
of one or more round or oval ulcers. The.se vary in size
and depth, their edgesare smooth ; and the bottom of the
ulcer is covered with stringy brownish-black masses.
Occasionally the ulcers are very large and circular, ex-
teniling ring-like about the lumen. They all show a
marked tendency to cicatrization, and lead to strictures,
stenosis, or the formation of diverticula. Ulcers extend-
ing deeply into the resophagus wall may perforate, and,
following this, pyopneumothorax, mediastinitis, ]iulnio-
nary gangrene, pericarditis, erosion of the aorta or other
largevessels, liver abscess, etc.. may result. Carcinoma
may develop in the scar, as is frequently the ease iu the
stoinach. Not infrequently the round ulcer of the stom-
ach and that of the a>so])hagus are coincident.
The symptoms caused by roimd ulcer of the a>sopha-
gus are chiefly burning pain and a sensation of pressure
behind the lower part of the sternum during the act of
swallowing. As a rule, the pain is more sevei'e wlien
solid food is taken than when fluid <Uet is given. At
other times severe canlialgia maybe present; also nau-
sea, acid regurgitations, vomiting, and iiemorrliage,
bloody stools, etc. These synijUoms cannot be separated
from those of round ulcer of the stomach, which is fre-
(piently coincident. The absolute diagnosis may be
made only by means of the tesophagoseope. Ulcers of
.slight extent may heal without complication; after cica-
trization new sym|>tiinis may appear as the result of the
narrowing of tlie lumen. Severe rases are very danger-
Fui. :J<;1S.— Dffu^ilal ricei-s in (He Uiipt-r P:irt nf the UCsniihugus
(lower part of pharyii.\i. < After Kraus.)
ous because of the important complications which may
follow, and on account of the accompanying rapid ema-
ci.-ition and ana-inia.
Specific Infectious Dise.\ses. — Tnhrmildnis occurs as
a secondary process iu severe tuberculosis of other or-
gans, particularly of the larynx and lungs and the neigh-
boring lymph glands. Primary crsophageal tuberculosis
has not yet been reported. The infection of the oesopha-
gus may take place by direct extension from neighboring
organs, most frequently fiom the rupture, into its lumen,
of caseatiug lynipli glands; or from the swallowing of
sputum iu cases of pulmonary tuberculosis, and very
rarely from the metastasis of tubercle bacilli in acute
miliary tuberculosis. It has lieen noted that infection
does not occur in case of rupture of vertebra! abscess
into tlie oesophagus. Infection is made more likely by
preceding affections of the cesophageal muco.sa, ulcer-
ations, etc. The tuberculous ulcers are usually super-
ficial, but may lead to perforation. The edges are cov-
ered b}- hyperplastic epithelium, scattered through which
small yellowish or gray nodules are seen; the bottom of
the ulcer is either smooth or papillomatous. Tuberculo-
sis of the cesophagus may exist without any symptoms;
when symptoms referable to the a-sophagus occur, they
consist in dj'sphagia and pain behind the sternum during
the act of deglutition. Thrush ma.y exist coiueidcntly
with tuberculosis of the a'sophagus, but it is to be re-
membered that in cases of pulmonary tuberculosis thrush
or carcinoma may Ije fcmnil in the (esophagus as an inde-
pendent alfcetion. The use of the oesophagoscope is nec-
essary for the absolute diagnosis.
SmiJiilix. — Ulcerations of the mucosa of the oesophagus
ma}' be piesent during either tlie secondary or the tertiary
.stage, but on the whole they are rarely oliserved. They
have been seen also in ca.ses of congenital syphilis. The
most frequent syphilitic le.sion of the a'sophagus is the
,gumnia. This may lead to ulceration, perforation, cica-
tricial stenosis, liypertrophy of the oesophagus wall, etc.
Dirtieulty in swallowing is the chief symptom. The
differential diagnosis rests chiefly upon the anamnesis,
evidences of syphilis elsewhere, therapeutic test, etc.
ActininnyciiKiK. — A number of cases of primary actino-
mycosis of the tt'sophagus have been reported. Inas-
much as the entrance of infection in this disease is
usuallv through the air passages, the oesophagus may be
involved by extension fri:)m the peribronchial lymph
glandsorfrom thelungs,mouth, pharynx, etc. Inagiven
case it may be diflicult to decide whether the oesophageal
condition is primary or secondary ; but in the majority of
cases it is likely that the primary seat is in the mouth.
It is also probable that, for the infection of the muco.sa
of the oesophagus, some other lesion (erosion, ulcer, etc.)
must be present as a factor favoring the entrance of the
organism. The diagnosis of (esophageal actinomycosis
rests entirely upon the finding of the parasite in the ma-
terial expectorated or removed by means of the sound or
CESophagosco]"ie.
TJini.iIi. — This is tlie most common and important para-
sitic disease of thea'so]iliagiis. It maj' be primary or may
extend from the mouth and pharynx. It is most com-
monly foun<l in poorly nourished children, and in adults
suffering from continued fevers, particularly typhoid and
sepsis, from eluimic cachexias, and from chronic tubercu-
losis, nephritis, and ditibetes, in their last stages. (See Fig.
3619.) Healthy children and adults may be occasionally
affected ; but the disease is liy far most common in cachec-
tic children sutTering from chronic digestive disturbances.
Asa rule, the jiharynx and mouth are affected at the same
time. The appearance of the parasite upon the mucosa
of the mouth, tongue, or pliarynx is very characteristic
and the diagnosis is easily made. The parasite develops
in the ujqier layer of the mucosa, its tilameuts forming a
dense feltwork among the epithelial cells. Slightly ele-
vated whitish or grayish patches, which can be easily
serajied off, leaving a bleeding or tileerated surface, are
seen over the miu-o.'^a. In the O'Sophagus small white,
flattened, or nodular iiatehes may be scattered over the
mucosa, or the patches may be arranged longitudinally,
corresponding to the f(jlds of the mucosa. In other cases
a more diffuse growth may be seen, the oesophageal lu-
men to a large extent or throughout being lined by the
growth. In very severe eases the growth may be so ex-
tensive as to form thick-walled casts of the lumen or even
342
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
(EsopliagnN.
O-^opliagus.
solid cylinders. The growth may penetrate into the
suhmucosa or even reach the muscle coats. Penetration
into the blood-vessels may occur and metastasis of the
parasite result. The reactive intlammation of the ccso-
the oesophagus occurs above a stenosis of a portion of
the lumen or of the cardiac opening. In the latter case
the lumen throughout its entire length may be greatly
dilated.
TiTMORS. — New growths of the asophagus are on the
whole not frequent. Metastatic growths are of rare oc-
currence. Of the primary tumors carcinoma is by far
the most common. Benign tumors causing symptoms
during life are very rare. The great majoritj- of benign
growths are small and clinically luiimportant. Of these
the most common are smuW piipiUiniKitoiis icarts (oesopha-
geal warts, verruca) (see Fig. 3620). These are usually
about the size of a pinhead'or bean, rarely larger, pro-
jecting above the mucosa, and are often multiiile or con-
fluent. They are found especially in old individuals.
In structure" these little growths consist of hyperplastic
papilla;, covered with thickened epithelium resembling
the condylomata. They rarely ulcerate, and only excep-
tionally may they oiler slight obstruction to the passage
of food. They are usually discovered only at autopsy,
but their presence in the oesophagus could be revealed
during life by means of the a>sophagoscope, should they
reach such a size as to cause symptoms.
Ne.\t in frecjuency occur fhruinuta. which usually take
their rise in the connective "tissue outside of the oesopha-
geal wall, but, through pressure, are finally forced to
occupy a position in the mucosa of this organ. The pre-
vertebral fascia, the periosteum of the vertebra', the peri-
Fiii. obHi.— Lower I'cjrtiun ol CEsopbapus Slmwiiij? the Prrsence ot
Both Thrush and Tuberculosis. (After Kraus.)
phageal wall is usually in proportion to the amount fif
infiltration, liy the parasite, of the muco.sa and underly-
ing structures.
Thrush of the oesophagus rareh^ gives rise to indepen-
dent symptoms, except when the growth is extensive.
Dys|>h"agia followed by aphagia is the chief symptom,
especially in the case of children. Occasionally liollow
or solid cylindrical casts of the oesophagus may be regur-
gitated. In those cases in which the masses of the
grnwth are firmly adherent to the mucosa death may re-
sult from the complete obstruction of the lumen of the
oesophagus.
Animal Pai!.\sites. — lu general tricliiuo.sis the en-
cysted worms may be found in the striped muscle of the
oesophagus wall. Their presence ma_y be regarded as ex-
plaining the painful deglutition occurring in the course
of trichina infection. Round worms (ascaris lumbri-
coides) may wander into the (esophagus from the stom-
ach; and "may be found occasionally in esophageal
diverticula. From the oesophagus they maj' reach the
respiratory passages, and entering the larynx may cause
severe or even fatal obstruction to respiration. Occasion-
ally other forms of animal life may gain accidental en-
tiauce to the oesophagus (flies, bees, wasps, leeches, hair-
worms, etc.); in the majority of cases no symptoms arci.
produced, the intruder acting as a simple foreign body,
except in the case of leeches and stinging insects. In the
case of the former hemorrhage maybe produced; and the
sting of the latter may give rise to a severe a'sophagitis.
PnooEEssivE Changes. — Jlypertrophy of the wall of
1
^
. 1
u
lis
%
{
^^^^
il
;*^»!»
''ttZHKHVl
W *^
V
;-^*
1
im
.1
h
'wi,-^ ^>j
Fig. 3620.-Papilliimata ■•! iIh- chs.ipi
(AfttT Kraus.)
ehondrium, the peria'sophageal connective tissue, and less
frequently the connective tissue of the mu.scle and sub-
mucosa of the oesophagus wall form the points of origin
343
<Esopha^ii!«.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
for these growths. They are usually diffuse lliiekeuings,
but maj' lie polypoid or sharijly cireuiuserilicil. The last
is usually of very small size. " Jlierosenpieally. the ffso-
^■■K^^H^H
^^^^^^v jBl* ^^uHt^r y Ml ^ ^it^^^^^^H
M^fwHH
^^Pwn' 9^i? '1^1
^^m
y^^yHlBjH
Hi,. :«il.— Carciuouja of the (Esonhagiis. (After Krau^.)
phageal libroinata present the appearame <if a fihroma
mMe and are usually well supplied with blood-vessels.
Their consistency is soft and elastic. The ]iiilypoid tlliro-
nia may reach a large size and may, during ell'orts at vom-
iting, present itself in the pharyn.x or mouth, wliere the
tumor ma}' be felt or seen. If the growth iiossesses a long
pedicle it may, when situated in the up|ier part of the
(esophagus, be caught at the entrance to the (esophagus,
and pressing upon the ejiiglottis give rise to severe symp-
toms of dyspn(ea and dysjihagia. Large growths may
more or less completely block the a'sophagus and cause
]iressure upon tlie trachea. In these cases there is a con-
stant feeling of pressure behind the sternum, increased
on eating, ju'ogressive dysphagia, jiain radiating to the
shoulder blades, dj'spnoea, etc. The growth is very likely
to tdcerate and a spontaneous cure may result iu rare cases
from such ulceration, or from the twisting or tearing of its
pedicle. The diagnosis of a?sophageal fibroma is" made
certain by means of the a'sophagoscope, by removal of a
jiortiou of tissue from the growth, and by microscopical
examination. The prognosis is on the whole imfavorable.
The patient usually dies of inanition or suffocation.
l.ipomntii of the O'sophagus occur very rarely in the
form of shar]ily circumscribed or polypoid growths arising
in t be s\ibmucous connective tissue, most frequently in the
neighborhood of the laryngeal and tracheal cartilages.
iliixiiiiia of the fesophageal wall has been observed in
the form of a polypoid tumor of small size.
ilijinHnta of theo'sophagus have been observed a num-
ber of times. They are usually leiomyomata, but a few
cases of rhabdomyoma have been described. The fcinner
may develop f n mi tlie museularis mucosa; or from the mus-
cular coats ; these growths may be circumscribed or poly-
poid and occur most frequently in the lower portions of the
(csciphagus in the neighborhood of the cardia. They are
fiiund at any period of life, are usually small, and do not
give rise to symptoms. In the one case of rhabdomyoma
which lias been carefully described, the microscopical ap-
jiearances were those of a rhabdomyosarcoma ; metastasis
into the neighboring lymph glands had occurred.
Primary sarcoma of the a'Soijhagus is very rare. Ah'e-
olar, spindle-cell, and round-cell forms have been observed
in the upper part of the organ, k^ss frequently near the
bifurcation, apparently arising from the tissues of the
(esophagus wall. In the niajorit}' of cases of sarcoma
involving the (esophagus, the tumor has extended from
some one of th(.' neighboring structures. Lj-mpbo.sar-
coma of the bronc liial lymph glands may thus compress
and invade the (esophagus. Finally, a widespread lym-
Iihosarcomatosis of the oesophagus wall may occur as
the result of such extension. Ulceration, hemorrhage,
etc.. may follow. The ulcer may be covered by a
growth of thrush; .secondary infection and gangrene
may result. Only one case of jirimary lymjihosaiwrnia
of the (esophagus lias been reported. The diagnosis of
sarcoma of this organ rests upon the presence of symp-
toms of tt'sophageal obstruction, the use of the (csopha-
goscope, ami the removal of a portion of tissue for micro-
scopical examination.
Dermoid cysts are very rare. They have been obser\ed
in the upper portion of the (esophagus or lower part of
the pharynx. The congenital cysts lined with columnar
cells, which have been observeil in the (esophagus wall,
ate to be classed as simple teratoid cysts due to anomalies
of development. They represent remains of the original
communication between (esophagus and trachea.
Carcinoma. — This is the most common and important
of the a'sopliageal neoplasms. It is almost alwa3's
sipiamous-cellcd in character [epithelioma, cancroid), aris-
ing from the si|uanious cells of the muco.sa. and exhiliit-
iug more or less horny change and formation of e])itlielial
]iearls, as is the case with the epitlnlioma of the skin.
Only in rate cases is the i)iimary cancer of tlie (esopha-
gus of the columnar-celled type (a(leno(.-arcinoma). In
such cases the growth takes its origin from the cells of
the mucous glauds, or from congenital cysts lined by
columnar cells and lying in the walls of the ccsophagus.
Occasionally the cancer arising from the gland cells may
take on the aiipearance of a carcinoma simplex, a car-
cinoma medullare, or a scirrhous carcinoma, etc.. but
these forms are very rare.
d^sophageal epithelioma (Fig. SfiSl) is not an infre-
cpient disease. It is found more often in males than in
females. The level of the bifurcation is most often in-
volved. It has a Icndeucy to grow in ring shape about
the lumen, and in this way graduall.v to cause stenosis.
As the cancer increases in size it ((iiickly ulcerates. In
this way a large part of the tumor may be lost and the
stricture reduced. About tlie ulceration, the muco.sa
shows carcinomatous intiltrations and small secondar.v
nodules, which may also ulcerate. In other cases the
edges of the primary ulcer ma}' be nodular, greatly thick-
ened, and firm, causing marked stenosis. The tesopha-
;',44
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES,
(ENophagus.
U::«oi>lia;L;:Ufi.
gcal wall above the cancer is usually hypertrophic and
the luineu dilated. Proliferation of connective tissue
about the ulcer may lead to the appearance of a scirrhous
cancer. Vcrv frequently a portion of tlie ^n-owth is .soft,
rapidly growins;-, and nccrolic, wliile the remaining por-
tion is very liard. comi>o.S('d largely of scar ti.ssue. The
greater the connective-tissue formation tlie more marked
the stenosis. In the majority of cases oidy one cancerous
nodule of large size is present ; only rarely are theie multi-
ple cancerous foci. The o-sophageal nuicosa about the
cancer, and ])articularly the mucosa of that portion of the
lumen wliicli is situated above the stenosis, usually shows
a marked chmuic congestion or inllammation,
(Esophageal cancer occurs most often between the
ages of lifty and si.xty years. Cases have been observed
in young individuals. The etiological factors are no bet-
ter known than are those of careinonia elsewhere. It is
significant that the most common seat of the growth is
at the narrowest portion of the lumen. The condition is
more common in smokers and drinkers, and it is probable
that elircjuic irritation here, as elsewhere, favors tlie de-
velopment of the neo]ilasni. Foreign bodies, burns,
healed ulcers, etc., have been regarded as etiological fac-
tors. The course of the disease usually extends over one
year, often over a shorter period. Death takes place usu-
ally from inanition due to the stenosis, to a perforation or
to hemorrhage, or from fatal complications due to metas-
tasis or extension of the tumor.
Beginning in the mucosa from a proliferation of the
epithelium the carcinoma cells infiltrate the submucosa
and musculature as far as the outer fibrous covering.
The wall first becomes thickened, its original elements
undergo atrophy, and the affected portion of the wall is
replaced by carcinoma tissue. Necrosis of the carcinoma
cells follows, ulceration of the surface occurs, and there
is a greater or less formaticm of scar tissue. As a result of
the ulceration perforation into the trachea, bronchi, lung,
mediastinum, pleura, ]ierieardium. or large lilood-vessels
may occur. Erosion of the vertebral column may be pro-
duced. Perforation into the trachea, bronchi, or lung is
of most frequent occurrence, death residting from gan-
grene or purulent pneiunonia. Occasionally the carcino-
matous induration may involve the trachea and bronchi,
or even the heart. Erosion of the aorta, carotids, or pul-
monary vessels may cau.se fatal hemorrliages.
In many ca.ses the cervical lymph glands and the con-
nective tissue of this region show extensive carcinoma-
tous infiltration, and the neighboring structures maj'
suffer greatly from jiressure. As a result of pressure
upon one or both of the recurrent laryngeals, either by
the primary tumor or by enlarged carcinomatous lymph
glands, paralysis of one or both vocal cords may result.
The changed character of the voice, in connection with
obstruction to the passage of food tlirough the U'sopha-
gus, is an im])ortant diagnostic symptom.
Metastases in distant organs occur first in the liver,
lungs, and bones. Excejit in rare ca.ses local metastases
in the bronchial, tracheal, and epigastric lymph glands
are always present.
The most extensive carcinomatous inliltration of the
frsophagus wall may exist without the occurrence of
symptoms directly referable to this organ. In some
eases the only symptom is progressive emaciation and
weakness. In the majority of ca.ses the earliest symp-
tom i» dysphagia, which progresses rapidly so that the
patient soon becomes emaciated. Regui-git'alion of food
takes place immediately after swallowing if the cancer
is situated in the upper portion of the lumen; after
some time has elapsed, when the growth is in the lower
part, particularly if the lumen above the stenosis is
much dilated. The regurgitated food may contain pus,
blood, or portions of necrotic cancer tissue. Pain may
be constantly present or entirely absent : or present
only when food is taken. It may be very .severe, of a
burning character, or there may be simply a didl press-
ure, located behind the lower part of the sternum, and
radiating to the shoulder Idades. Marked dyspna'a luay
result fiom the pressure upon the respiratory passages.
The enlargement of the cervical lymph glands may occur
early and indicate the nature of the disease. Pressure
upon the recurrent laryngeals, causing paralysis of the
vocal cords, is not infre(|uent. Disturbance of the svm-
pathetic may caii.se oculopupilhiry symploms (miosis,
retraction of the lids, narrowing of the palpebral fissure,
etc.). Erosion of the cervical vertebra?, ])re.ssure upoii
the brachial plexus, etc., may give rise to paralyses of
the upperextremity. The occurrenceof perforation into
the resijiratory tract, ijleura, etc., is followed by chaiac-
teri,stic .symptoms on the part of the region involved.
Emphysema of the skin of the cervical region and of the
mediastinal tissue may occur. Trophic disturbances in
the skin and nails have been observed. The urine usu-
ally contains albumin, indican, and pbciinl; in the late
stages of the disease
acetone, aceto-acetic
acid, and oxybutyric
acid.
The diagnosis rests
chietl_v upon the
case history and the
demonstration of a
stenosis of the a'soph-
agus. If in an in-
dividual past the age
of forty years there
occurs without evi-
dent cause a stenosis
of the esophageal
lumen, with pro-
gressive emaciation,
carcinoma is usually
indicated. Cicatri-
cial stricture or the
presence of foreign
liodies may be ex-
cluded b}- the his-
tory. Pressure from
without, due to an-
eurisms or neighbor-
ing growths, must
be eliminated. Car-
cinoma of the a?soph-
agus has some-
times been mistaken
for sjiasmodic strict-
ure. The writer has
seen two such cases,
and was able to make
the diagnosis of can-
cer in each case from
bits of cancer tissue
found adhering to
the bougies used in
dilating the strict-
ure. In doub tf u 1
cases in which the
stenosis is slight, tlie
(c s o p h a g o s c o |i e
should be used, and
a bit of tissue re-
moved for micro-
scopical examina-
tion. The use of
sounds, etc., shouM
be attended with
great care, from the
possible danger of
perforation. Auscul-
tation of the oesoph-
agus may also aid
in the diagnosis,
(iurgling sounds arisini
heard at a distanci
Fill. :JU2:;.— Splmlle-Foiiii lilUitHtion of
thi' (Esriplj:ii.'us .\hipvi' !i Scirrhous
Carcinoma. (.After Kraus.)
at the stenosis may sometimes be
from the patient. The constant
absence of the sound caused by tlie passage of food or
drink through the carilia may be taken as evidence of
the existence of a pathological" process interfering with
345
^I'lKopliaiuiiM.
Old Poliil <'<iiiiruil.
HEFEUENCE HANDBOOK OF THE MEDICAL SCIENCES.
the normal fiiiiftion of tlie musculature of the cardia.
lu complete stenosis the food passed into the a?sopha-
irus may gradually accumulate above the stenosis and
be regurffitatcd later.
The absence of hydro-
chloric acid, pepsin,
peptone, etc., may be
taken as evidence that
tlie food had not entered
t lie stomach. The prog-
nosis in all cases is hope-
less. Death may be
j)ostiioued by operative
measures.
Al/rER.\TIONS IN THE
LrMK.N. — Diliitiition is
usually secondar}' to ste-
iio.sis. Primary dilata-
tion of the (I'sophageal
lumen is very rare. The
dilatation in theacquired
rases may be genenil or
jKirtiiil, either the entire
oso])hagus or onlj- a
li'irtion of it, above the
steuo.sis, being enlarged.
The dilatation of a lo-
calized portion of the
wall anil not the entire
circiMuference, is known
as a diri rt/cubni/. Pri-
iiiiinj or niyijii iiHiil dilata-
tion is usually general —
the .so -("died spindle
form. This may also be
acquired, u sua 11}' in
chronic (usophagitis. or
u'so|ihagit is secondary to
spastic contraction of the
cai'dia. Till' musculature
is usually thicki'ned, and
1 1 f ten show s ti bri.iid areas.
The ectasia may be enor-
mous, the lumen meas-
uring as much as 30 cm.
or more in circumfer-
cTUM — as large as a man's
aim. At th(.: same lime
the length is increa.sed,
and the organ becomes
t (1 r t u o >i s. Seconddfy
dilatations develop
aliove strictures, but arc
not present in all cases.
(See Fig. 8622.) The
dilatation may be fusi-
liirm or cylindrical. The
muscular coats are usu-
ally hypcrtro])hic in the
dilated portion. Re-
.uurgitation is the chief
symptom of oesophageal
ililatation. Dyspua^a
may be produced by
jiressure.
Diverticula arc of two
forms: prtssi/re dirertir-
iihi and Iractioiidiverttc-
iihi. The lirst arises
from pressure witliin the
lumen, the latter from
c-xterHal traction pulling out the wall. Pressure di-
verlicula arc i-arc. They are found most frecjuently at
the junction of the pharynx and (esophagus, on the
posterior wall. They are also called d"r«i(l diivrtictila
in contrast to the Intend dirrrticiiln of the ])haryngeal
wall. They are rarely very long, and extend downwiird
between the u'sophagus and the vertebra'. The mus-
Fic. 3«23. - Dlverticiiliun of the
I^iiwer Tliinl of tlie rusniitiagus,
with Kilalittiou. (.\fter Kraus.)
cular wall is weakest normally at tlie point where
these diverticula occur. Local "bulging is first brought
about by trauma, swallowing of large and lirm pieces
of food, etc. The bulging is increased by pressure of
food, and gradually there is formed a sacctdar pouch,
the mucosa and submucosa bidging out between the
muscle bundles of the inferior c(.mstrictor of the piharynx
(pharyngocele). In some cases muscle fibres have been
found in the wall of the sac, and the condition lias been
regarded as an ectasia due to a disturbance in the clos-
ure of the ftt'tal cleft at this point. The latter view is
probably more generally accepted than the former. In
case the diverticulum becomes filled with food there
may result difficulty in swallowing, gagging, and vom-
iting. Decomposition of the contents of the sac may
take place, followed b.y maceration of the epithelium
lining it, secondary infci^tion. ulceration, and phlegmon-
ous (esophagitis or peria'sophagitis. If the sound is
])assed when the sac is filled, it is very likely to enter the
dilated sac; when the sac is empty, ilie .sound may pass
by the opening of the sac without entering it. When
]>assed down against the posterior wall, the sound is
more likely to enter the sac.
I'riictiiin dircrtirida are not rare. They occur usually
in tlie anterior wall, in the neighborhood of the bifurca-
tion, rarely higher or lower. (See Fig. 9623. ) They re-
sult from the extension of an inHammatiou of neighboring
lymph glands with adhesion to the a^sophageal wall and
subsequent cicatricial contraction, pulling out the wall at
the point of adhesion. The sac is usually short ; at its tip
the remains of a diseased gland are always to be found.
The lumen of the divert ieulu in may point downward, hori-
zontally, or upward. It communicates with the cesoplia-
geal lumen by a round, oval, or longitudinal opening of
varying size. The mucosa about the opening is often
IMicken.'d. Several diverticula may exist coincidently.
in the majority of cases the Ij'mph glands attached "to
the diverticula are tuberculous. The condition may
have its origin in childhood. LTsually traction diver-
ticula exist without synilitoms. Through |ierforation of
the sac chronic purulent perio'sophagitis may be set up,
with extension to pleura, pericardium, lungs, etc. In
this wa_v the most severe symptoms may arise and the
case reach a fatal termination.
Stenusis of the (csoiihagus may be congenital or ac-
(jiitred. In the latter case jiartialor complete obstruction
of the lumen may result fi-om foreign bodies, inflamma-
tory swellings, phlegmon, growths of thrush, tumors;
or cicatricial contractiim of the wall following corrosive
poisoning, syphilis, diphtheritic inflammation, trauma,
etc. ; or from changes in the neighborhdod of the cesoph-
agus, such as enlarged lymph glands, aneurisms, tu-
mors of the lung or iilcura, etc. A number of cases of
(esophageal stricture following ulceration of the a'sopha-
gus in typhoid fever have been observed. The charac-
teristic symptoms in all cases are dysphagia and regur-
gitation of food.
RuPTfuii OF ffisoruAius. — This condition is rare. It
may be due to trauma or to excessive internal pressure.
It is reported as occurring in the liealthy (esophagus as a
result of prolonged vomiting; usually after a full meal,
or in a condition of intoxication. It is probable that in
some of these cases some jiathological weakening of the
wall was present. The condition is invariably fatal.
FoHKKiN BoiuEs. — Among the foreign bodies reported
as gaining entrance to the oesophagus are bones, leeches,
needles, false teeth, etc. Needles may pass out tlirough
the walland befoundin other partsof thebody. Sharp-
pointed or rough bodies are most dangerous, as they may
enter the wall of the organ and give rise to a phlegmon-
ous a'sophagitis, which may extend to the lungs, pleura,
or pericardium. In other cases the foreign body may
lead to erosicm of the large vessels. Complete obstruc-
tion of the lumen may be caused by false teeth. Gan-
grene due to pressure usually results. The entrance of
foreign bodies into diverticula maj' lead to perforation.
The fungus of actinomycosis ma}' gain entrance through
the lodgment of bits of straw, chaff, etc., in the cesopha-
'.4t;
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
a-'Mo|>lia<£iiN.
Old Point Conirort.
geal mucosa, (For general treatmeut of diseases of the
oesophagus, see Stmnac/i, Surgery of the.)
Aldred Scott Warthin.
(ESOPHAGUS. (SURGICAL.) See Stomach, Surgery
(if tlic.
CESTRUS. See Infieets, Pammtic.
oVdIOMYCOSIS of the skin. See Dermatitis
OJAI HOT SULPHUR SPRINGS.— Ventura County.
California. Access. — Via tfoutliern Pacific Railroad to
Ventura, thence lifteen miles by stage to springs.
This resort is beautifully situated in Waterfall Canyon,
about tive miles from tlie thriving village of NonlliolT.
The altitude of this location is about one thcnisaud feet
above the sea level. The surrounding scenery is very
fine, and the vicinity affords excellent hunting and fish-
ing. Tbe springs flow about fifty thousand gallons per
hour, and have a temperature ranging from (jl) to 104 '
F. Several of the springs are carbonated, and others are
sulphureted. Among the well-known springs are tbe
Foimtain of Life, St. .Iaci>b's Well, and tbe Mother of
Eve Springs. These Ojai waters contain the carbonates
and sulpliates of sodium, potassium, and magnesium, the
carbonates of iron and lime, silicates, and carbonic acid
and sulphureted hydrogen gases. Many .stiff-jointed,
rlieumatic, and gouty jiersons repair to these springs for
relief, and it is stated that a fair percentage of them are
ncpt disa]:ipointed in their quest. Good accommodations
are provided for visitors. James K. Crook.
OJAI VALLEY, SOUTHERN CALIFORNIA.— This lit
tie valley, said to In- one of the neist beautiful spots in
Southern California, is situated in Ventura County, about
si.xty miles northwest of Los Angeles, and about fifteen
miles from the coast. It has an average elevation of
from nine hundred to twelve hundred feet, the upper
part of the valley being the highest.
It is about fifteen miles in Lmgth, and from two to four
miles wide. It is " entirely si .rrouuded by the San Rafael
and Santa Inez ranges, which rise on the east to a height
of six thousand feet. It is thus well sheltered from harsh
winds anil partly also from the .sea fogs " (Solly).
Nordboff is the principa'. tovvu with a population of
eight hundred or more, and is the termiiuis of a branch
railroa<l from San Buena Ventura. The upper Ojai is
noted for its orchards, while the lower Ojai is devoted to
beans and grain. Fiuits of various kinds al.so thrive
here. Tbe opportunities for camping and shooting are
abundant, deer, quail, and other small game being plen-
tiful. The liorsebaek rides are very attractive in this
"country of beautiful views."
The following table, compiled from data given by Solly
("Medical Climatology"), will indicate the character of
the climate :
CLI.MATE OF Ojai Valley, taken at or Near Nordhoff.
p
CO
•-s
^
£
<
1
1893.
,51"
189.5.
h'l
K>
m%
4
13.83
14
Temperature for 1892.
Average (degrees F.) mean.
Average mean
53*
oS"
54°
56«
B2°
,»»
189:1.
.W"
189.1.
.57
9.5
33
fAS
28
9.33
8
1893.
.58°
189.5.
Maxiiiiiim for 1893
78
79
St
83
31
100
3,T
..
Humidity—
Mean relative (January and
Fiit:s. iijiiriiings
37 84
liainv diivs
The climate, it will be seen, is a very mild, eqviable
one in the winter and spring, with a comparatively dry
air, and slight rainfall : in brief, it represents tlie well-
known characteristics of the Southern California climate
for resorts situated some distance from the sea, and. in
addition, the modifications produced by the peculiar situ-
ation of the valley, shut in as it is by mountains.
This climate is said to l)e esjieciali}- favorable for asth-
matics, and is also to be recommcmlcd for cases of pul-
monary tuberculosis, chronic bronchitis, chronic diar-
rhoea, and nephritis.
The accommodations are only moderate. According
to Solly there are pleasant boarding-houses and cottages.
Such a locality as the Ojai Valley is rather suited to those
who are well enough to take uji a permanent residence
there, and occupy themselves with the various pursuits
of an otttiloor life. Edward 0. Otis.
OJO CALIENTE.— Taos County, New Mexico. Post-
Office. — Ojo Caliente. Hotel.
Access. — Take Denver and Rio Grande Railroad to
Barrancas Station; thence twelve miles by stage to
springs.
These celebrated hot springs are located at an elevation
of about six thousaml fei-t above the sea level in the re-
gion of the ancient clitt dwellers, twenty-five miles west
of Taos and fifty miles north of Santa Fe. There is now
a commodious hotel at the resort, having accommodations
for about one hundred guests. The surrounding country
is broken and mountainous, and the climate of the usual
didightful New ilexico variety. The hottest summer
day recorded at the springs in recent times was 93° F,,
and tbe coldest winter day 30' F. The resort is kept
open all the year round. The springs are fifteen in num-
ber, and vary in temperature from 90' F. to 122" F.
Their flow has not been measured, but it is estimated by
Congressman Antonio Joseph, the proprietor, at about
forty-two hundred gallons hourly. The following analy-
sis was made by Prof. O. C. jNIarsh ;
One U.mtek States Gallon Contains:
Solids. Grains.
Sodium carbonate 91.. 53
MaffiU'Siuni carbonate 1.36
Iron cai late 5.90
Lithiiiin rill bonatt' 13
S...I1II1U .blorlde 22.18
(all ill til rarbonate 3.43
Pntassimii siil(>hate 3.00
Sudiuiii suli>hate 7.92
Silica 1 .22
Total 1:1.5. .54
An analysis, made in 1892, of the "New Spring" by
W. T. Hillebrand, acting chief chemist of the tfnited
States Geological Survey, showed the presence of large
(juantitics of carbonate of sodium, besides salts of lith-
ium, potassium, strontium, barium, magnesium, and
iron, with a considerable proportion of carbonic acid gas.
The waters here have a great reputatiim in the treatmeut
of advanced syphilis, chronic induration of the lymphatic
glands, gout, and rheumatism. James K. Crook.
OLD AGE.
T/u on',. ■<>■/.
See Sciiilili/, and Iknth, Phi/siolor/ical
OLD POINT COMFORT. NEWPORT NEWS, AND
VIRGINIA BEACH. -(Mil Point ( oi.ib.rt, Va., is situated
at the soutbeastein extremity of Vorktown Peninsula,
at tbe entrance to Hampton Roads, through wbieli the
James River empties into Cliesapeake Bay. Situated
thus it commands a view directh' out to sea between
Cajie Charles and Cajie Henry. Directly south of Old
Point Comfort, at a distance of about eleven miles, is the
city of Norfolk, Va. In a westerly direction from Old
Point, seven miles distant, as one passes up through
Hampton Roads to enter the James River, is situated
Xcw])ort News. "All vessels coming down the James
River from Richmond and Petersburg, and those enter-
ing and leaving tbe harbor of Norfolk (and the Ports-
mouth Navy Yard there situated) must pass close to Old
347
old Point roniforl.
Oiractory Nerve.
REFERENCE UAMDBOOK OF THE MEDICAL SCIENCES.
Point Comfort, while the entire seagoing commerce of
Chesapeake Bay passes it at no great tlistance on its way
to and from the ports of Baltimore, Annapolis, and Alex-
andria. "
Old Point Comfort is a government reservation, and
here is situated the famous fortitiealion of Fort Mon-
roe, the largest of its kind in America, commanding the
entrance to Hampton Roads and tlie approach to the
navy yard at Norfolk. The very extensive marine view,
the "attractions of a large mili"tary garrison, combined
witli a mild climate a considerable portion of the year,
render this resort one of the most popular ones in the
country. Moreover, it is very easily and comfortably
reached from the North, and affords excellent accommo-
dations, though expensive.
The accompanying climatic table based upon observa-
tions taken at Norfolk, will serve also to illustrate the
climate of (.)ld Point and Newport News, for the three
places are so near one another that there can be but little
difference in their climatic elements.
stable climatic conditions of a Northern .spring during
these months. One will find at this resort a large amount
of sunshine, a comparatively mild temperature, no great
amount of rain, and less wind than at Atlantic City.
When one considers the ready accessibility of "Old
Point" from the North, and its"favorable climatic feat-
ures, its value as a liealth resort must be regarded as
very considerable. The sources of amusement and di-
version are also many, and greatly enhance the value of
the resort. They are the ever-shifting panorama of the
ocean with the constant passing of various craft; the
fascination of the military life, such a predominant feat-
ure here; the freiiuent visits of warships: the Normal
and Agricultural Institute for colored people and Indians
at Hampton, two and a quarter miles distant; and the
National Soldiers' Home at the .same place; the various
shorter or longer excursions by water to Norfolk, Rich-
mond. Virginia Beach, the York River, etc. The Hamp-
ton Golf Club and the Country Club are accessible to the
guests of the hotels, and are said to be kept in excellent
Cllm.^te of Norfolk, Va., LATirrDE, 36° 51'
LoSGITrDK,
Years.
76° 17
Pekiod of OiiSEnv.\Tios, Thirteen
Temperature (degrees Fahrenheitl —
Average or normal
Average daily range
Mean of warmest
Mean of colde.st
Higtie.st or maximum
Lowest or minimum
Humidity-
Average mean relative
Precipitation-
Average in inches
Wind-
Prevailing direction
Average hourly velocity in miles
Weather-
Average number clear days
Average number fair days
Average number clear and (air days
i.
cd
^
«
«
^
3
o
40.8°
42. 9»
48.0°
.56.3°
67.1
79.6°
61.0°
14.8
16.1
16.9
17.5
17,8
18.1
14.5
47.5
53.2
57.7
64.0
73.9
8H.0
70.9
32.7
37.1
40.8
47.5
.W.l
70.9
.56.4
80.0
81.0
81.0
92.0
98.0
1(12.3
89.0
8.0
9.0
16.0
27.0
38.0
60.0
31.0
75. 5«
70.6;!
66.4it
68. 2J
68.8?
70. 3S
74. 7«
3.89
3.85
4.33
4.29
3.54
5.39
3.96
N.
N. E.
N.
S. W.
8. W.
s. -w.
N.E.
7.5
8.7
9.5
8.9
8.0
6.7
7.2
8.8
8.6
10.0
9.5
11.0
8.5
13.7
11.2
111.9
10.8
111.5
12.3
14,5
9,6
20.0
19.5
20.8
20.0
23.3
2:^.0
23.3
49.6'
14.9
58.7
43.8
80.0
20.0
72.7?
3.58
11.2
9.8
21.0
fl
a
S
c
S
1
CO
i
m
•<
S
g
42.2°
57.1°
77.4°
60.4°
41.8°
14.2
17.4
17.2
14.4
15.0
.30,9
;t6.7
73.(1
6.0
~\.i%
67. SS
71. 8S
74. 8S
72.6*
3.80
12.18
13.63
12.77
11.54
s. W.
S.'W.
S.W.
N.E.
N.
7.5
8.8
6.8
7.2
7.9
10.1
30.3
27.1
35.5
27.5
11.8
33.6
40.9
29.8
33.9
21.9
64.1
68.0
65.3
61.4
59.2°
16.0
71.8!<
52.14
S. W.
7.7
120.6
138.2
258.8
TEMPER.iTURE AND RAINFALL AT FORT MONROE, Va. LATITUDE, 37° N. ; LONG., T6° 19 W.
Mean temperature (degrees Fahrenheit)
Maximum temperature
Minimum temperature
Mean precipitation in inches
tc
i
I
i
C3
a.
•-3
s
i
Q
c.
3
f.
C3
41.81°
49.90°
55.99°
78.73°
61.90°
41.10°
57.34°
77.07°
61 .92°
41.77^
72.110
78.00
91.00
102.(H1
89.00
69.00
4.00
13.00
31.00
61.0(1
30. ai
17.00
2.72
3.;«
2.98
5.34
2.92
4.58
10.17
15.32
10.18
10.67
9. 52°
47.04
A comparison is also given of the temperatures of Nor-
folk, New York, and Boston for the niontlis of February,
March, and April, the season at which "Old Point" is
especiallj' resorted to by visitors from the North.
shape. The links overlook the sea, and at the attractive
dub house there is a tea room and cafi-, and music on
Saturday afternoons. There are also sailing, driving, and
bathing in the season. Attention should also be called to
February.
March.
.\PRII,.
Se.ison.
(degrees Fahrenheit.)
Nor-
folk.
New
York.
Boston.
Nor-
folk.
New
York.
Boston.
.\'or- New
folk. York.
Boston.
Nor-
folk.
New
York.
Boston.
.53. 2°
37.1
42.9
40.1°
2.5.9
31.3
38.6°
20.1
28.1
.57.7°
40.8
48.0
4.5.9°
31.3
36. S
43.2°
26.7
34.2
64.0° ' .56.3°
47.3 40.3
56.3 46.9
.53.2°
36.1
43.9
58.3°
41.8
49.1
47.4°
32.5
38.3
45.0°
27.6
33.4
Like Atlantic City. Old Poii
round resort, frequented ilurin
year moi'e especially by visitor
ing the summer by tliose fron
.said, and as is the case with A
February, March, and April ist
ern visitors and invalids who
t Com
i the C(
< from t
the S(
tlanlic
he pop
desire
fort is
)ldcr s(
he Nor
)Uth.
City, I
ular on
to esc
an all-i
asons o
th, and
As has
lie seas<
.■ for N
dpe tht
ear-
f the
dur-
been
)n of
irth-
un-
the grc
dren.
be recc
rigors (
find th
mental
ommei
at adva
Such a
mmen(
if a No
emselv(
ly. witl
ided foi
ntage of tlie be
climate and s
ed for thcM'- w
rtliern winter. ;
■s in a depress
lout being seri
convalescents
'ach as <
ich a re
ho witl
ind at t
ed con(
Hisly il
from \
I playg
sort ar
dirticu
leajipr
itioii. ]
. It is
arious i
-ound f
• espec
ty end
lach of
hysica
also to
icute d
orchil-
ally to
ure'the
spring
ly anil
be rec-
seases,
3-18
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Old Polut Comfort.
Olfactory Nerve.
for tliose who are recovering from tlie effects of an ojiera-
tion, and for scrofulous cliildren. For tlie aired, the fee-
ble, the neurastheuie, and for weakly children it offers, for
a portion of the year al least, a mild and pleasant asylum.
It is said to be immune from malaria. It can hardly be
recommended for those suffering from any seiious dis-
ease of the respiratory organs or from renal disease.
As a half-way station between the North and the more
Southern resorts in Florida, Georgia, and South Carolina.
"Old Point '■ proves serviceable in the late autumn and
in the spring.
There are two large and well-appointed hotels at "Old
Point." the "Chamberlain" and the "Hygeia," with en-
closed sun piazzas, affording excellent accommodations
the year round. It is jirobablc, also, that in the vicinity
private boarding-houses and cottages can be found for
those desiring less expensive acconmiodations than these
luxurious hotels offer. The methods of reaching this
resort are many and good. One can go by rail to Cape
Charles and from there liy steamer across the bay, or by
rail all the way via Richmond; or one can make the trip
from Boston, New Y(irk. Baltimore, and Washington b_v
water.
Newport News, while possessing a similar climate, has
less in the way of attractions to offer than Old Point, and
is not so pojudar a resort, though it possesses much of his-
toric interest. Here is located an extensive ship-building
plant, with an immense dry-dock. It is also a port of
importance. The Hotel AVarwick offers good accommo-
dations, and for one who desires a quieter existence than
that at Old Point, Newport News would ap])ear to be
the more attractive of the two. It is reached by boat
from Norfolk.
Virginia Beach is situated eighteen miles east of Nor-
folk, with which it is connected by rail, and six miles
south of Cape Henry. It hasa tine and extensive beach,
affording good surf bathing, and is protected landward
by extensive pine forests. The average winter temper-
ature is 54° F, and the extremes for tiie 3-ear 34° F.
The climate is equable and mild and the soil dry. The
Princess Anne Hotel is well appointed and offers excel-
lent accommodations and food. The attractions are boat-
ing, bathing, lishing, shooting, and hor.seljack riding.
This climate and resort "are adajited for cases of
chronic nepliritis, bronchitis, overwork, and neuras-
thenia." (Hinsdale.) Edicunl 0. Otis.
OLD SWEET SPRINGS.— Jlonroe County. West Vir
ginia. Post-Okfice. — Uld Sweet Springs. Hotel.
Al CESS. — Via Chesapeake and Ohio Railroad to Alle-
ghany Station, where Concord coaches meet al! passengers
for the springs. The location of Sweet Springs is more
open than is generally the rule in mountain districts.
They issue up in a valley of great loveliness, but are sur-
I'ounded by mountain scenery of surpassing grandeur.
The elevation is two thousand feet above the sea level,
and the climate during the sununcr months is of the usual
delightful character found in this region. The buildings
at the springs are of brick and of a very substantial char
acter, and at the height of the season liie place resembles
a miniature city. Eight hundred guestsare easih" enter-
tained at one time. The main building is about three
hundred feet in length, and no expense has been spared
to make it one of the best sununer liotels in the country.
The hotel projierty embraces a grass farm of two thou-
sand acres, which guarantees an abundant supplj' of
dairy products, while neighboring farms furnish the best
of poultry, mutton, etc. The water of the Sweet Springs
is not unpleasant to the taste, but its temperature (T'J F.)
renders it rather warm for general use in drinking. For
bathing, however, it is very agreeable. Two jiools liave
been provided — one for men, the other for women, — each
seventy-tive feet long, twenty-five feet wide, and from
three to five feet deep. The water is so clear that moss-
covered stones on the bottom are distinctly visible. There
are also warm and hot steam baths of both mineral and
freestone water. The following analysis of the mineral
water here was made bv Prof. Williain B. Rogers:
One United States Gallon Contains:
Solids. Grains.
Calriiim sulphate l-'!. ir>
JtaLnii'sHim sulphate 9.:^
S'Miunn sulphate 6.:ij
Calciuii] ■arlionate 'MMi
MaL'ut'siuui carbonate 80
Calriuni ilitijride .15
Sudiuin chluride .14
Magnesium chloride 31
Iron peroxide 15
Silica IT
Earthy phosphates. . . Trace.
Iodine Trace.
Total fiO.62
Gases. Cu. in.
Carbonic acid 83.86
Nitrogen 4.31
Sulphureied h.vdrogen Trace.
Ox.vgen Trace.
This is a very good alkaline-calcic water possessing
tonic, diuretic, alterative, and mild cathartic properties.
It is valuable in functional disorders of the stomach, and
is said to be employed with signal benefit in chronic diar-
rhoHa and dysentery. It has also produced good results
in rheumatism and in some forms of neuralgia, as well as
in renal and uifiiary disorders. James K. Crunk.
OLEIC ACID.— Oleic acid (HC, JlasO^) is the acid prod-
uct of the decomposition of olein. the fluid constituent
of natural oils and fats. LTnder the title, Acidiiiii Olei-
rmii. Oleic Acid, the United States Pharmacopoeia recog-
nizes the acid "prepared in a sutficieutly pure condition
by cooling commercial oleic acid to about .5' C. (41° F.).
then separating and preserving the liquid portion." Such
grade of acid is an oily licjuid. yellow or brownisli-yellow
in color, and having an odor and taste as of lard. On
exposure to air it absorbs oxygen and darkens in color.
Its specific gravity is about 0.900 at ordinary tempera-
tures. It is insoluble in water, but dissolves completely
in alcohol, chloroform, benzol, beuzin, oil of turiientine,
and the fixed oils. On cooling the acid first becomes
semi-solid, and at 4° C. (39.2' F.) congeals to a whitish,
crystalline mass.
The medicinally valuable property of oleic acid is that
while retaining tiie physical properties of a fixed oil. the
acid is yet of high diffusive power, and, accordingly,
u|)on inunction passes through the tinbroken skin into
the general circulation, and leaves behind a smooth, soft,
and supple, but not greasy condition of the integument.
Being an acid it forms salts with .salifiable bases, many
of which salts are soluble in excess of oleic acid. Such
solutions of oleates in oleic acid arc found to permeate
the skin as readily as the simple acid, and for this reason
such solutions form a class of medicines defined as "ole-
ates," and devised as means of medicating the general
circulation through the unbroken skin. Oleic acid is
iLsed exclusively for the manufacture of these pharma-
ceutical "oleates." Edward Curtis.
OLFACTORY NERVE.— I. Axatomic.\l P.\kt.— The
olfactory nerve is the simplest of the nerves of special
sense; indeed in its peripheral relations it is in some re-
spects the simplest and most primitive nerve of the bddy.
Its central relations, on
the other hand, are
most intricate and can-
not be understood
without reference to
its evolutionary his-
tory. In the larva of
the lowest vertebrate,
the amphioxus (Fig.
3(524), the anterior end
of the tubular central
nervous system opens
freely to the outer body surface by a distinct neur()]iori^
on the dorso-median surface of the head. In the adult
this pore becomes closed, but there persists a pit like de-
Fio. aiii. — Loutritudinal Section
Through the Brain i>t the Larval Am-
phioxus. c)i. Notocliord ; A^ neuri>
Iiore. or scusnrv pii.
34!>
olfactory Nerve.
Olfactory Nerve.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
prcssion of the outer skin, reacliinn; in to rest in con-
tact witli the surface of the brain. Tliis jiit i.-^ lined willi
ciliated epii helium and at
this stage of life it is dis-
placed so that it lies on
one side of tlie median
line. The appearance of
this structure, which is
known as tlie "olfactory
pit," is shown in the ac-
compauvins hjrure (Fig.
362.5). From this simple
beginning the entire ol-
factory apiiaratus of
higher animals has been
developed. The neuro-
pore in end)ryos of other
vertel)rates does not actu-
ally open to the surface,
but its position can some-
times be determined by
the appearance of a pit-
like forward projection
of the lu'ain wall in its
most cephalic boundary
at a point corresponding
to the lamina terminalis
of the adult (the lobus
olfactorius inqiar of von
Kupft'er) (see Fig. 3626).
Here, too, there is an in-
vagination from the outer
skin in the corresjinnding
region. From this invagi-
uation tliere is produc'cd
not only the nasal fossa
and the contained sensory
epithelium, but also the
hypophysis, the latter ro-
tating ventrally through
an arc rejire-
FIG. 36:i5.— Transverse Section
TlirouKh Region of Olfactory Pit
of Adult Amphioxus. (After
Lankester.) Tbe olfactory pit is
seen as an ectoderuiic inva^na-
tiou at the left of the brain, h :
(■/(, notochord ; /, lymph simce ,
my, tlrst niyotom ; /(, second
cranial nerve.
superficially the taste buds, and Blaue has assumed that
these "cilfaetory buds" are tlie derivatives of one of the
lateral Hue series of sense organs
which has wandered into the olfac-
tory fossa and there proliferated.
In spite of the inherent improbabil-
ity of this from tlieoretical grounds,
his view has foimd its way into
man}- of the current te.\t-books of
embryology. As a matter of fact,
however, Blaue was ignorant of the
development of the olfactory organ
of these fishes, and the embryologi-
cal history tlisproves his theoVy, for
the olfactory .sensory epithelium
does not exhibit the "olfactory
buds" until a verv late stage in the
ontogeny, showing that these are of
secondaiy rathei' than jirimaiy sig-
nificance. The truth is, that the
phylogenetic origin and relation
ships of the olfactory oi-gau nuist
lie left for future reseaieh to deter-
mine.
The later phylogenetic liistcny
is fortunately much clearer, anil it
is moreover of fumlamental impor-
tance to our theories of the oiigin
of the cerebrimi, for the whole
of the secondary prosencephalon in
the lowest vertebrates seems to be
related to this olfactory organ. As the oi)tic Inbes, gen-
iculata, etc.. have been evolved in ivsponse to the re-
quii-ements of the organ of vision, so the olfactory bulbs
and the earliest cerebral cortex seem to have l)eeu called
Fro. ;til^7.-linisal view
of the Brain of a
Young AlUgator.
(After c. L. Herilck.)
sen ted by the
arrow in I he
figure.
The fact
that the ol-
factory sensory thickening appears in the
olfactory depression at a very earlv stage in
its invagination has led to many attempts to homologize
the olfactory organ with oilier scnsury organs nf ecto-
dermal origin. In some of the fishes the adult olfactory
mucosa is broken up into sensory patches resembling
FIG. 3aa>.--51edian Sagittal Section Through tlie Head of Aniiiioivetes.
(After von KuptTer.) c?), Notochord : cc, ectoderm; tu, entoderm;
cp, epiphysis; K primary forehrain : H. itriniary tiiiidtirain ; iui,
hypophyseal invagination : hi, loliiis olfacloiins impar; M, i)rimary
nitdbrain ; n, nasal invagination ; jjwi, pre-oral gut ; st, stoniodunim.
Fir,. .T63S.— Diagram of the Olfactory Connections of the I,izard, as
seen in Sagittal Section. (After Edinger.)
forth by the necessities of the olfactory sense. Tlien
later in the evolutionary process the prosencephalic roof,
or pallium, became the seat of secondary eonncrtions for
other nerve sys-
tems, until in man
and other niieros-
matic mammals
the o 1 f a c t o r y
function has been
q u i t e overshad-
owed by these
secondarily ac-
quired functions
of a higher oi'der.
The distinction
between the rhin-
eneephalon and
the remainder of
the ]uoseneepha-
lon beciiiiii's more
and more marked
•iQ wp •laeeiid tlio F"'. 3629.— Section of the nifactorv Mucous
■isncascLuu lue Membrane. (After von lirunn.) The specl-
ammal series. ac olfactory cells are in black.
350
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
MIliK tor;' Norvo.
Olraclorr Serve.
Edingcr and otlicrs have bmugiit forth anatomical cvi-
(U'lice to sliow that the first truly functional cortex, or
pallinni. to appear in the phj'logenetic scale is tlie hippo-
campus, which is connected chietly with the olfactoiy
sense. With this is to be correlated the fact that
the olfactory conduction path becomes mcduUated
earlier in the development of the human cerebrum
than that of any other special sense. Since the
]isycliic functions in liiirber animals are associated
mainly, if not exclusively. Avith the cerebral cortex,
it follows with great probability that the olfactory
group of sensations was among the tirst to emerge
into clearly defined consciousness. This olfactory
cortex appears first in the Amphibia as a crescent of
superficial nerve cells iu the caudal and lateral
border of the cerebrum. In the reptiles tliere is
true cortex over the whole of the forcbraiu iu ad-
dition to a simple but typical hippocampal forma-
tion. In these forms the olfactorj' nerve is the
largest in the body and the whole system is enor-
mous. It is. moreover, laid down according to the
same general plan as in higher animals. The rela-
tions between olfactoiy bulbs and cerebrtuii in the
reptiles are indicated by the accompanying figure
of the brain of the alligator (Fig. 36-'7) and by the
diagram of the olfactory connections in the lizard
(Fig. 3628). This latter" scheme applies also with
no important changes save in the relative size of
the parts, to all vertebrates above the reptiles in the
zoological scale. In man, however, the sense of
smell is relatively so unimportant and tlu' higher
cortical centres are so highly developed that it has
proven a matter of the greatest dilficulty to unravel
the olfactory connections.
Anatomically tlie olfactory nerve differs from all
of the other nerves of the body in that its fibres arise
from perikarj'ons. or cell bodies, lying in the sen-
sorj- epithelium (Fig. 3U29). In other words, the
root ganglion for this nerve does not lie adjacent to
the central nervous sj'stem, but its cells are iu the
periphery, dilTusely scattered among the indifferent
supporting cells of the sensory mucosa of the nasiil
organ. This condition we find iu the case of no
other nerve am<ing the higher vertebrates, but it
appears to be a survival of a primitive invertebrate
condition. (See Crfininl SeiTes.)
The specific olfactory cells are distributed over a
relatively small area of the nasal inucos;i {about 2..5
sq. cm.) in the ujijier narrow part of the nasal sinus, part-
ly on the superior tiubinateil bone, and partly on the nasal
septum adjacent. Unlike the remainder of the nasal mu-
cosa this portion is non-ciliated. It is yellowish in color
and exceedingly vascular. The specific olfactory cells
are connnonlv described as ending in a short stiff bristle.
Recently Jagodowski has found (.Id^^ A»ze/r/er.vo\. xix..
p. 2.">7) in the fishes that each of the.se cells is provided
with a single long thread-like lilanient which projects
outward into the mucus of the nose and which may be
Fig. 3630.— The RiBlii (jlfacloi-y Nerve on the Outer Wall of the
Fossa, (.\dapted from Hlrschf eld.)
Fig. 3631.— Structure of the Olfaplory Fllann-nts ami Biilti. (After Ram<^n y
Cajal.) he. Bipolar cells of the olfaetory mucous ineinbraue; s»i. sub-
mucosa: et/im, cribriform plate of the ethmoid: oy, olfaeturv glomeruli:
»if , mitral cells ; ep. epithelium of the olfactory ventricle ; f<-, epithelial
cells of the olfactory membrane.
more than twice the length of the cell body fn mi which
it springs. The appearance of the fila ollactoiia arising
from these cells is indicated in Fig. 3630. These fibres
passing from the olfactory mucosa to the olfactoiy bulb
are commonly called the olfactory nerves, but it is
evident that if the so-called specific cells from which
they spring really correspond to the root ganglion cells
of the other nerves, then the fila olfaetoria correspond
rather to root fibres. These fibres are non-medullated
and are gathered info about twenty bundles, which enter
the cranium by separate apertures in the cribriform plate
of the ethmoid bone. The several strands enter the ol^
factory bulb and here terminate in ]ieculiar arborizations
in the glomeruli (Fig. 3631).
.Jacobson's organ (a peculiar diverticle of the ua.sal sac)
iu some animals receives a special twig of the olfactory
nerve, which rarely, as in Amblystnnia. arises from \\\i\
brain farther back (caudad) than tlie rest of the nerveand
pursues a distinct course to its terminus.
The comprehension of the cential relations of the olfac-
tory nerves is greatly impeded by a confused and very
inconsistent nomenclature. The te.m rhinencephalnu
was first used iu neurolog_y by Owen as a name for the
olfactory bulb and its peduncle. It has since been ex-
tended bj- different writers to include various parts of
the cerebrum which are concerned in the olfactory func-
tion, with, however, no uniformity in the extent of this
applicatiou. The only logical course is (as ]iointed out
b_v G. Elliot Smith, Jour. Armt. and P/ii/xini, xv., liiUl)
either to retain Owen's limited .application of the term or
351
Oiractory >erve.
Olfactory Nerve.
REFERENCE lIANDliOOK OP THE MEDICAL SCIENCES.
to extend it to iriplude all purls of the forel)rain, wbieli
aie directly connected with the olfactory fuuctiou, viz.,
the olfactoiy bulh, tract (or |ieduiiclc), tuber, the area
perforata, " parateriniiial body" (a term introduced liy
Elliot Smith for the area extending backward from the
olfactory ]ieduncle to the lamina terminalis and upward
to till tlie space between thecallosum and the hippocam-
pal commissure), and the whole pyrifonn lobe and hip-
poeampal formation. This u.sage will doubtless com-
mend itself to the majority of working neurologists, in
spite of the fact that a part of that which is commonly
reckoned as pallium is here included in the rhincucepha-
lon. This dilliculty is in large measure obviated by El-
liot Smith in the paper cited above, by a reconsideraticm
of the phylogeny of the pallium, from which he con-
cludes that the olfactory portions of the pallium should
be seijarated morphologically from the remainder of the
cortex, which is of more recent origin and hence may be
tcriuecl the "neopallium.'"
The classification of tiie rhiuencephalon, according to
Retzius, has been tabulated by Barker as follows;
1. Bi'lliim nlfdctoriiis.
2. 'I'ructus olfnetoriun.
?i. Trir/oiiiiiii rilfiie-
ioriiim fgyrus tuberis
(ilfactorii) .
4. 0 y r II s
tortus mcdialis.
to
to
<ilfiir- \
r
5, (r If r n fi
tonus liitiralia.
ii(fnc-
6. Gyrvsperforatus
(sen i n t e r m e d i us)
rhinenfiphitU.
\
T. (ri/run d/uf/onalis
rhiiteiiceiiliali.
Stria olfactoria lateralis
jyrus olfactorius lateralis.
Stria olfactoria medialis
gyrus olfactorius medialis.
Area parolfactoria Brocse.
Pars a n t e r i o r — Eberstaller's
gyrus trans versus insuke and the
limen insidiT.
Pars posterior. Extends from
angulus lateralis to anterior ex-
tremity of gyrus hippocampi and
terminates in the gyrus semi-
lunaris rhinencephali and the
gyrus ambiens.
Anterior, much ]ierforated,
part of substantia perforata an-
terior.
Posterior, less perforated, part
of substantia perforata anterior.
Corresponds to the diagonal baud
of Broca, which extends from the
I gyrus subcallosus to the anterior
I end of gyrus hippocampi.
8. Other port ioiin vf rliinenaplialuii.
(f/) (rijnix hipiiixinnid.
(A) r//.'»,v.
(r) (jijrux (?) iit'if'is.
(il) ai/rim uiti'ilimbicus.
(f) Oynisfiixciii/iirifi.
if) ^-^'J''' Aiidiriv Retzii.
iff) Ttiihisiiiiu t/riseuiii (including the striw lonrji-
tudinaliK mediiilis ft liitcni!ix\.
(/() fri/ri siihnill'i.si.
Reference to Fig. H031 will render unnecessary a de-
tailed exposition of the jiriinary olfactory connections.
The glomeruli are entangled knots of fibres, jiartly the
terminal arborizations of thetila olfactoria and jiartly the
dendritic tips of the neurones of the second order, whose
nuclei lie in the zone of mitral cells. Each mitral cell
usually sends a dendrite (in man) to but one glomerulus,
where it receives the terminal arborizations of many tila
olfactoria. The structun-s within the olfactory bulb are
stnititied, the following layers being encouniered as we
pass inward. First, a layer of tila olfactoria, bounded
within by the glomeruli arranged in a single series.
Then, after an interval containing chiefly nerve tibres
constituting the so-called molecular layer, are the mitral
cells, arranged in a thin layer typically but one cell deep.
Within this is the granular layer containing very many
cell bodies of tlie olfactory granules. Thise are nnnute
cells with feebly developed dendrites directed t.iward the
veiitricidar surface, and much branched neurites passing
out between the bodies of the mitral cells to arborize just
within the zone of glomeruli. Their functional signifi-
cance is unknown. Within this layer is the zone of nerve
fibres, containing the tracts directed toward the cortex
and composed chiefly of neurites of the mitral cells. Ol-
factory impressions entering by the tila olfactoria are
transferred to the dendrites of the mitral cells and by the
neurites of these neurones (the mitral cells constituting
the primary intracranial centre) are carried to their sec-
ondary centres via the olfactory tracts. These secondary
connections, which are very diverse and intricate, can be
briefly summarized as follows:
The olfactory tract connecting the bulb with the sec-
ondary centres contains three sets of tibres, the lateral and
mesial olfactory strise superlrcially placed, and the deep,
or ental, or precommissural tract. On their way part of
the latter fibres terminate in the gray matter distributed
along its cotuse, while otheis run tothe anterior commis-
sure, fornung its anterinr or olfactory jiart, and terminate
in various parts of the rhinencephalon of the opposite
siile. The mesial olfactory stria termitiates in the area
[larolfactoria and other gray centres near the median line
at the attachment of the cms olfactorius, effecting second-
aiy connections with the hippocampus through the indu-
sium griseum of the callosiun and by other paths. Others
of these tibres pass into the septum pellucidum and ul-
timately reach the hippocampus via the fornix. The
larger portion of the secondary olfactory tibres pass back
in the lateral olfactory stria to terminate in the cortex of
the uncus, giving oft collaterals on the way to adjacent
gray centres.
The reflex conuectiuns between the cortical olfactory
centres in the hippocampus and the lower regions of the
lirain are too complicated to be summarized here. The
fornix is the chief pathway for these tibres, and their
most impiirtant connections are the mammillary bodies
(liy way of the corpus fornicis, the 7V. Curt. iiKiuimil-
liiri's of Fig. 8638), and the nucleus habenuUc (by way of
the stria medullaris thalami. marked Cort. Jiabenulnris on
Fig. 3628). For the general relations of these tracts con-
sult Fig. 3632.
One is at once struck bv' the peculiar way in which
these olfactoiy tracts are distributed by widely divergent
paths to secondary centres, which are far separated in
space (tliough morphologically related). Upon comjiari-
son with the connections within the reptilian brain (Fig.
3628) the explanation is plain. There practically the en-
tire forebrain is devoted to olfactory connections, and the
cortical additions of higher types have been intercalated
in stich a way as to separate tracts and centres which
were primarily juxtaposed.
II. PiiYsir)i.ii(;ic.\i, P.\i;t. — The sense of smell in hu-
man beings, as compared with many of the lower ani-
mals, is very feebly devclojied. as will be made clear by
even a <'ursor_y examination of the comparative anatomy
and physiology of the organ. Animals are classified
with reference to this sense as osinatic and anosmatic.
and the former group is subdivided into macrosmatic and
microsmatic divisions, depending upon whether the .sense
is highly developed or but feebly so. Man belongs to
the microsmatic group, this sense playing a very subor-
dinate role, either physiological or psychological, in our
vital economy. Its unimportance is, however, more ap-
jiarent than real and is to be explained, as Zwaardemaker
points out, on psychological grounds.
As a matter of fact, olfactory sensations are always
with \is and our daily actions are profoundly influenced
by them, though this influence is largely unrecognized
as such. For these sensations are, in the case of human
beings, intimately connected with the somatic and or-
ganic functions, and have a strong emotional content
which obscures the ]irocess of ideation. This imperfect
comprehension of olfactory impressions is reflected in our
language, for our vocabulary of olfactory sensations is
very limited and almost all borrowed from that of other
senses. For our knowledge of the o\iter world we de-
]>en<l chiefly upon tlie other special senses, particularly
sight. With tlie macro.smatic animals, on the other hand,
352
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Olfactory Nerve,
Olfactory IVerrc,
/f.friJetlU
!lit> sense (if smell is undoubtedly in some cases more po-
lent in tile elaboration of linowledge of the outer world
than any other sense.
The physiology of the sense of smell is less perfectly
known than that of any of the other special senses, and
the same remark holds true of its psychology. "While
our knowledge of the anatomical arrangements of the
paths of olfactory conduction to and within the brain
has been greatly extended of late, we are yet ignorant of
the means even by which the olfactory nerve termini are
stimulated by the odorous substances. In particular, the
physiological process underlying the difEcrence between
smell and taste is ob-scure. It is commonly stated that
we taste substances in solution or in liquid form, while
only gases are perceived by the sense of smell. While
this is in general true, it nevertheless must be remem-
bered that the odorous gases do not come into direct
contact as such with the seii.sory end organs in the
nose, either in tishes, where the nasal cavities are
tilled with water, or in air-breathing vertebrates,
whose olfactory mucous membranes are always
bathed with mucus in which the odorous sub-
stance must always be dissolved before it can irri-
tate the sensor\' endings. Again, some siipid sub-
stances, such as hydrochloric acid, are also solutions
of gases, and .some solids in a state of fine division
seem to give rise to distinct olfactory impressions.
The fact that when the nostrils are tilled with water
carrying an odorous substance in solution the odor
cannot be perceived does not necessarily imply that
the failure is due to the fact
tliat the substance is in solu-
tion, but rather to an irritating
ettect of the li(iuid ujiou the
olfactory organ. This is indi-
cated by two facts : P^irst, that
all olfactory sensiition may be
temporarily enfeebled or even
entirely abolished for some
time after the close of the ex-
periment; and second, that if
nonual salt .solution instead of
water be used as a solvent,
then the dissolved sub.stance
can in some cases still be
smelled.
Tyndall discovered that
odorous vapors have a consid-
erable capacity for absorbing
heat, and that very niinute
quantities of the odorous sub-
stance in the air experimented
upon would produce surpris-
ing effects. At the clo.se of a
table giving the absorptive
powers of different odorous
vapors, he remarks : " We find
that the least energetic in the
list produces tliirty times the
effect of air, whilst the most
energetic produces one hun-
dred and nine times the same
<'ffect." The significance of these facts is still obscure.
We certainly are not able to allirm as yet, with Ramsay,
tluit the sense of smell is excited by vibrations of a
lower period than those which give rise to the sense
of light or beat, Ibnugh it luay well be that character-
istic molecular vibrations give to various substances
their distinctive odors. But in any case these move-
ments seem to be incapable of transference to the recep-
tive sense organ by the meditnu of ethereal vibrations,
and direct contact of the odorous particles with the ner-
vous organ seems indispensable. The ultimate stimulus
is probably electro-chemical — a matter of ions.
Olfactory sensations are aroviscd with dilliculty or not
at all by irritation of the peripheral end organ by ther-
mal, electiical, mechanical, or cither stinnili than the nor-
mal gaseous media, though tumors or other irritants of
Vol. VI.— 23
the central olfactory apparatus may call forth vivid sensa-
tions of smell. It is hardly true, as often stated, that air
containing odorotis particles must be in motion in order to
stimulate the olfactory organ. The truth is that in ordi-
nary respiration the air currents do not strike the sensory
surface directly, and hence olfactory iiupressions are called
forth by such particles only as diffuse themselves upward
from the respiratory portion into the olfactorj- fossji,
w hile in sniffing the direction of the air currents isaltered
so as to pass more directly over the sjiecific sensory area.
We are not as yet able to give a natural classification
of smells, nor have we any secure basis for such a classi-
fication. Even the division into agreeable and disagree-
able is subject to so great variation from one individual
to another that it would be of small value, even if it were
admissible on other grounds. Accordingly, the names
Fig. 3(5.33.— Schcmatlr Representaticm of Some of the Prinotpal Neurone Systems of the Olfaotorv Ton.
durtion Patb. ProiHti'd inl" sairitlal plane. Hftcr P.arliiT. I Rlifb. o//.. liullnis olfartc.riiis ; Coi-
/orji., coluiiina forniris; Co/. >■«;)., collirulus suitcrior : ( 'of/ox. «»(., comiiii>siira anierinr cerebri ;
Corp. mam., corpus iiLammiilare; Curp. pUi.. c<trpiis pincale; G. "./».. ganglion opticum tiasale;
G/. o//., ploincruii oifactorii; Gur. amh, rhiti.. tryius aiiibiens rhlneucephali ; Gitr. olf.lat.^
gynLs olfactorids laterdlis; Gyr. o. m., gyrus olfactoriiis iiie(tialis: Gyr. semiann. Vhiii.', gyrus
semilunaris rbinenccphali ; Gyr. snhcail., gyrus subcallosus; Lam. crib., lamina cribrosa ;
A', a. Wi., nucleus anlcrlor thalaml: JVh. o/f., nervl oifactorii : Nucl. hah., nucleus habenulae;
Ped. ccrc/tri. pedunculus cerebri; Str. ln?ni. 7/te(/., stria lonpitudlnalis medians; Str. mcdvlK,
stria Tui'dullaris ; J'j-act. o!/.. tractus olfactorlus ; Tract. i>pt., tractus opticus ; I. axones of mitral
cells L'oiiit: to stria olfactorius lateralis; /', a.\one of mitral cell tiTuiiiiatlnf: lu gray matter of tri-
eonuiii olfai-toiiiim; II. axone of mitral cell termlnallnp in ^'ray mutter, whence a.\one goes to
comiiiissuni anlcri'ir cerebri : /Z', axones t^' anterior ctjnimissure ; 77". centrifugal flbre terminating
ID bulbus olfact'irius: III. axone of mitral cell terminating in gyrus olfactoriiis medialis; /r,
axones of neurones connecting the olfartoiv poi-tion of the uncus (gyrus ambiens and gyrus semi-
lunaris) with the hippocampus; V, axones from hijittocaminis to fornix ; T', axone to commis.sura
hippocampi: t''. axones from fornix to se|iium pcllucnium: t'"', axones from fornix to corpus
mammillare; T", axone from fornix to niidi-us liaheiiulie by way of the stria medullaris ; VI,
fasciculus mammiilaris princcps; VI'. fasciculus llialamomammillarls Vic(t d'.^zyri; 1'/',
fasciculus pedunculomainmiltaris. pars tegmentalis lILiiilx nltiimlt I of von Guddeni; VII, fas-
ciculus pediincul(»mammillans. [jars basilaris (pedunculus cirpons mammiilaris) ; VIII, fasciculus
retrotlexus Mynerti extending from the nucleus faabenuhe to the ganglion interpedunculare.
of smells are usually taken from the objects which give
rise to them, with little attempt at classitication or corre-
lation of similais.
The number of smell qualities is very large. Some of
tho.se coiumonly recognized are compound, though au-
thorities differ as to the extent to which such mixture is
possible, or whether it is possible at all. If two distinct
odors aie mingled under experimenttil conditions, there
often results, not a fusion of the two into a blended odor,
us occurs with tastes, colors, and tones, but the stronger
will supplant the other completely, or there will be an
oscillation between the two. With some odors, again,
there appears to be a true compensation. Thus, if two
different olfactory stimuli of unequal sti-engtli are ap-
jilied simultaneously, one will usually overpower the
other completely ; biit if the stronger scent be diminished
353
Olfaft<»ry IN'tTvc.
Ollsoclii-oiiiifiiila.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
while tlie weaker is strpiiiillicncil, a point may be fonml
where tlie two lileinl into u siiii^le mixed odor. In other
cases, liowever. a point is found wliere tliere is no sensa-
tion, i.e., the 0(h)rs are perfectly eonipens.-iled. An in-
crease of either sliniulus results in the sensation appro-
priate to it and there is no mixture whatever. Tlie
olfactory organ is easily fatigued, more so by some odors
than by others, and it" is found that when completely
fatigued for one odor it may be insensible to some other
odors, ]>artially so to another group and wholly unaf-
fected in its sensibility with reference to still another
group.
Such experiments suggest points of departure for the
study of olfactory qualities, and enough progress has al-
ready been made to suggest that the modalities of smell
can be grouped into several graded series. The number
of sucirgroups will quite certainly be greater than those
known for taste, where we have siniidy the four primary
qualities, sweet, sour, salty, and bitter. Zwaardemaker's
nini' smell elas.ses are as follows:
(1) Ethereal scents; Fruit odors.
(2) Aromatic scents; Camphor and spicy smells, anise,
lavender, etc.
(3) Bal.samic scents: Flower odors, vanilla, gum ben-
zoin, etc.
(4) Ambrosiac scents; Aml)er. musk.
(5) Alliaceous scents; Garlic, ichthyol, vulcanized
ndiber. asafrotida. bromine, chlorine, etc.
(()) Empyreumatic scents': Toast, tobacco smoke, naph-
tha, etc.
(?) Valeric, or liircine .scents: Cheese, sweat, etc.
(8) Narcotic, or virulent scents: Opium, cimicine,
etc.
(9) Nauseous scents, or stenches; Decaying animal
matter, fa'ces, etc.
fhe ability to discriminate different intensities of odors
is not highly develoiied ; in general, the least observable
<liffereuce between two smell intensities of the same sub-
stance amounts U> about one-third of the original stimu-
lus. On the other hand, the olfactory organ is sen.sitive
to exceedingly small amounts of the irritating substance,
or as Ladd states it; "The sense has a great degree of
' sharimess, ' or jiower to be excited b_y small quantities
of stimulus, as distinguished from ' fineness, 'or power to
distinguish minute variations in the .sensations. " There
ate many familiar illustrations of this "sharpness." It is
stated, for example, that in a litre of air O.OOODO.") gm. of
musk can be jjcrceived. 0.000001 gm. of sid]ihuretetl
hydrogen and 0.(1000(1000.1 gm. of oil of peppermint.
The sense is more delii'ate if the air coutaiuing the odor-
ous substance is warmed.
It is learneil by suitable tests that the sensibility of the
organ of smell is much more acute than tiie perception of
odors. It was found in one series of tests, for example,
that upon the average 9 jiarts of camphor dissolved in
10(1,000 parts of water could be sensed Ijy the nose, but
without the percejitiou of a deliuite odor, it requiring a
solution of more than four times this strength before the
specitic odor could be recognized. Experiments made to
determine the relative sensitivciu'ss of men and women
in this res])ect liave tlius far yieldi'd coiillicting results.
With children it has been found that the sensibility (in
the sense used above) increases up to the age of six years
and then progressively diminishes. The delicacy of per-
ception, on the other liand, measured by graded solutions
of camphor, increases progressively with advancing age.
One source of pi'rplexity in the classification of odors
is the fac-t that some substances which have powerful
odors in a slate of great dilution are less elTeetivc in a
state of liigh concentration. For some perfumes there
ajipcars to be an optimum vapor density below or above
which the excitation is less strong. It has also been sug-
gested that for unknown pliy logenetic reasons some odors
may have greater affective values than others, or it may
be that fatigue of the sense of smell is ortfri'lui.t /uvibiis
less for those odors which have an element of utility to
the species.
It must not be forgotten that some odorous substances
affect the terminals of the tiigeniinus nerve in the respi-
ratory ]iart of the nasal jiassages, giving rise to tactile or
other general sensation which may be combined with the
olfact(n'y sensations. This can be proven by plugging
the olfactory sinus, when the trigeminal stimulus alone
is perceived. Classification is further imjieded by the
universal confusion of tastes and odors. We say a sub-
stance "smells sweet, " when as a matter of fact experi-
ment shows that the modality sweetness can be perceived
only by the sense of taste; and conversely most of tin;
tastes of common experience are greatly affected by
odors ,simultaneously sensed.
In the majority of persons (Toulouse and Vaschide)
the left side of the nose is more sensitive than the right.
With most of the other senses, on the other hand, then^
is au asymmetry in one-fifth of the cases in favor of the
right side (van Biervliet). The iliflVri'nce is ex]dained
by the fact that the left side of the brain is nicjre liighly
developed (in right-haudi'd persons) and that the central
olfactory tract does not cross before reaching its cortical
centres, while those for the other senses do cross.
The measurement of olfactory sensations cannot easily
be done absolutely in terms of the strength of the stimu-
lus, though examples of the results of some attempts at
the measurement of the threshold for smell in absolute
terms are given above. To arrive at a relative measure-
ment of olfactory values tliere are two methods chiefly in
use. According to the method of Passy a number of
flasks of equal size are provided and into each is put a
measured quantity of the odorous substauee, the quanti-
ties being arranged in a graded series. The substance
may be allowed merely to diffuse itself through the air
within the flask (which must be kept stoppered when
not in use), or it may be dissolved in water or some other
inodorous medium. By the use of a sutticientlv exten-
sive series, threshold values of dill'erent odorous sub-
stances may be determined aud various other researches
carried out.
The method of Passy is very laborious and for most
purposes, particularly in clinical work, the olfactometer
of Zwaardemaker is more convenient. In its simplest
form it consists of a glass tube, curved at one end for
insertion in the nostril and bearing a scale (preferably
in centimetres), which slides with eas}' friction into a
slightly larger tube which is lined with the odorous .sub-
stance to be tested. The inner tube jiasses through a
screen near its curved end. Now, when the outer tube
is sliiipedcomplefelj'over the inner tube so that its odor-
ous lining is wholly covered by the l:itter, air drawn into
the nostril through the inner tube will carry no odorous
particles. If, however, the outer tube is slowlv slipped
off from the inner tube, the air current will pass over
more and more of the cxpo.scd surface of the odorous
substance before entering the inner tube, until a point
will be reached at which tlie substance is just perceiv-
able to the sense of smell. lu this way the normal
threshold can be determined for various substances aud
numerous tests of physiological and jiafhological inter-
est carried out.
This simple apparatus has been modified in various
ways. A very sim|>le instrument which has the advan-
tage of relative permanence of adjustment can be con-
structed by using a section of ordinary red ruliber tub-
ing for the outer tube. This should be slipped inside of
a larger glass tube to prevent the odor from escai>ing
from the outer side of fhe rubber, and the odor given off
from the inner surface of the rubber tubing will remain
(piite constant for many months. For other odors the
outer cylinder may be made of porous earthenware,
whose pores may be filled with a solution of the odorous
substance. Commonly the olfactometer is made double
with a separate cylinder and breathing tube for each
nostril, and for the study of the compensation of odors
Zwaardemaker has constructed a very elaborate appa-
ratus with two separate cylinders (one for each of the
odors to be employed) connected with a single lireafhing
tulie and .so adjusted that the amount of odorous surface
exposed in each tube ma)' be easily varied during the
'.S-t
REFERE>'CE HANDBOOK OF THE MEDICAL SCIENCES.
4>lra<'l<»ry .\rrvr.
01i;£U4*liruiiiscnila.
experiment. With the varying adjustments one odor or
the other appear.s in consciousness alone until the proi)er
compensation point is reached, when both odors vanish.
The apparatus is provided with self -registering appa-
ratus for recording on the kyniograidi the force of respi-
ration in each cylinder and other data of the expeiimenl.
The iniit in all of these e.x]ierinients is the "olfactie."
or the stimulus necessary to produce the least perceiv-
able sensation. The position on the scale of the olfac-
tometer having been determined for this minimal value,
this value is taken as the imit, or olfactie, and otlier
stimuli are measured in multiples of this.
For the fuller consideration of the subject of this arti-
cle, see the work by H. Zwaardemuker, " Die Physiologic
dcs Geruchs" (Leipsic, 11^95), and llie article by the same
author entitled, "Les sensations olfactives, leurs coml)i-
nations ec leurs compensations," in L' Annec PKi/r//iili,-
giqne, vol. v., 1899, pp. 202-225. A complete bibliog-
raphy of the organ and sense of .smell up to January,
1901, has been compiled by Bawden, in The Jmirrailof
Comparatite yeurulogy, vol. xi., No. 1, April, 1901.
C. Juchon Merrick.
OLIBANUM. — Frnn/iineen.ie. TJins. Gummi, rcsina
oUhtnii. — A gum resin obtained from BosircUia Carterii
Birdw. and other species of Bosirdlia (fam. Biirseracece).
Olibauum is collected in northeastern Africa, chiefly by
the Somali natives, and is mostly exported via India. It
is produced by small trees similar to those which yield
myrrh, and is chiefly obtained from incisions made for
the purpo.se. It exudes as a thick milky juice, hardening
into the tears described below, which preserve their white
color much longer than those of other similai' substances.
Olibanum occurs in irregularly oval or subglobular
tears, separate, or occasionally somewhat agglutinated
in the poorer grades, usually 1.2o cm. (0.5 in.) or less in
diameter, from almost pure white to yellowish-white, oc-
casionally reddish-brown when long kept, the surface
powdery; breaking readily with a nearly fiat, waxy, lus-
trous surface, translucent in thin fragments; odor bal-
samic, slightly like turpentine; softening between the
teeth, aromatic and somewhat bitter. Triturated with
water, it forms a white emulsion and is almost wholly
soluble in alcohol. When burned, it emits a very strong
and pleasant odor, on account of which it is used as in-
cense.
Olibanum consists principally of resin, usually from CO
to 70 percent., or occasionally To per cent., with from
30 to 35 per cent, of gum and from 3 to 8 per cent, of
volatile oil. Its bitter princii)le has not been examined.
The volatile oil, which is an article of comitiercc for per-
fuming purposes, combines a slight lemon like odor with
that of the drug, and is of complex composition. The
resin is divisible into two portions, namely, BosircUic or
Soswellinic acid and olihano-reuii. The gum is more
like acacia than like tragacanth.
From a medicinal jioint of view, the uses of olibanum
are quite unimportant. It is no longer official in any
leading pharmacopa-ia and is but little used in profes-
sional medicine.
Owing to its fragrant properties, it is with some a fa-
vorite ingredient of plasters and ointments, and it is else-
where used for odori/.ing purposes. It has mild coun-
ter-irritant and disinfectant properties, leading to its use
as a vulnerary. Internally, it possesses the ordinary
stimulating diuretic anil expectorant properties of the
oleoresius, and it also has a considerable use, especially
among the laity, based chiefly on religious fancy, as an
emmenagogue. The dose is from 1 to 3 gm. (gr. xv.-
xlv.). It is tised chiefly, perhaps, in the form of the
emulsion, although the tincture is to be preferred.
Henry H. Itusby.
OLIG/EMIA. — Adecrease in the total mass of theblood.
The term is often used incorrectly as a svuonym for ana'-
mia. The latter term is u.sed to indicate a deficient sup-
ply of blood to a part, or a deficiency in the total amount
of blood within the body, or, most commonly, to designate
a decrease in the number of the red cells or a diminution
of the hajmoglobin. The expression general ana-mia may,
therefore, be regarded as expressing the same idea as that
conveyed in oliga^mia. The decrease in the total mass
of blood may be due to a ntmiber of causes, and the fol-
lowing varieties may be distinguished;
()liijiF7i)i(i Vera. — Trueolig«mia is due to a sudden loss
of blood through hemorrhage. A loss of half of the total
mass of the blood is invariably fatal, and hemorrhages of
even less degree may cause death. The red cells may
drop after a single large hemorrhage as low as two mil-
lion. After such a loss of blood there is a rapid fall in
blood pressure, the pulse becoming very small, frequent,
and irregular. In cases of hemorrhage of slight degree,
but continued through a long period of time, the defi-
ciency is luirtly made up by an increase in the fluids of the
blood, the true oliga;mia becoming thus converted into a
hydnemic oliga^mia.
(JUgwrnia llydrmmica or Serosa. — An oliga;mia with in-
crease of water in the blood, the red cells and albumin
being diminished, occurs after all hemorrhages, particu-
larly in the case of oft-repeated or prolonged hemor-
rhages of slight degree, as in bleeding piles, excessive
menstruation, etc., also in conditions characterized by
loss of albumin, as in chronic nephritis, dysentery,
chronic suppurations, prolonged lactation, tumor cachex-
ias, scurvy, malaria, etc. The hydntmic condition of
the blood leads to pathological changes in the blood-ves-
sel walls, favoring the i)assagcof fluids and the increased
production of lymph (ffidcma). Hydra-mia is, however,
not the direct factor in the production of tt'dema, but
only a favoring one.
OligtTniia Sicca (Inspissntio Sangiiiiris, Anhydi'cpmia).
— A thickening of the blood through loss of water may
lead to a decrease of the total mass. Such a condition
m.ay occur in cholera, dysentery, severe diarrhoeas, exces-
sive sweating, insufficient supply of water, etc. The
highest degree of oligamia sicca occurs in Asiatic cholera.
As a result of the circulatorj' disturbances thus produced,
and an insufficient sup]ily of blood to tlie nervous centres,
the characteristic syni|,toins of severe ana^nia may arise,
although the total number of led cells and total amount
of salts and albumin in the blood are not decreased. The
thickened blood becomes tea-like, the blood serum is
richer in albumin and in salts. The bod_y tissues become
very dry, and non-encapsulated serous exudates are re-
soibed.
Oligemia OligocytJitmnica. — A decrease in the total
blood mass due to a diminution in the number of red
cells (see Oligocytluvmia).
Oligivmia Ilypalbuminom. — A decrease of the blood
mass due to a decrease in the albumin of the blood. As
a result of such loss of albumin the blood becomes more
watery; the condition is therefore practically a form of
oliga>mia hvdra'inica. (See^lso Blood, Anaiitid, etc.)
AldredSott Warthin.
OLIGOCHROM/CMIA.— A decrease in the amount of
ha'inoglobin in tlir MhikI. This is one of the commonest
changes in tlie blood, and may occur eitlier w hen the red
cells are normal in ninnber or in association with an
oligocythiEinia. A simple loss of ha'inoglobin is the
chief change in chlorosis and the secondary ana'inias. In
chlorosis the number of the red blood cells may be nearly
normal, while the hainoglobin may be greatly reduced,
even to twenty or twenty-five per cent, or less. In the
secondary ana'inias the niunber of red cells is also dimin-
i.shed, but the h.Tmoglobin is reduced to a relatively
greater extent; thus, for example, if the number of red
cells be diminished to 2,.">0(),000, the hiemoglobin is usually
found to be lower than fifty percent. Thi' individual
red cells are, therefore, deficient in hemoglobin. This is
shown microscopically by the presence of a central clear
area in the red cell. This area may be of varying size
and .shape; in severe cases the haemoglobin-containing
portion of the cell may be reduced to a narrow ring, en-
closing a clear and transparent central area. In very ex-
treme cases some cells may contain no ba'inoglobin at all
355
Ollgorylhipnila.
Onientiim.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
(the so-called blood shadows). In other cases the central
clear area may not be enlarged, but small vacuoles occur
throughout the cell protoiilasm; the hiemoglobin maybe
preserved in the central jiart. and around this there may
be a clear ring of varying width. Often the central por-
tion stains very dark with eosin. and such cells are some-
times mistaken by inexperienced observers for nucleated
led cells. Inasmuch as the darker central area takes the
eosin and not the nuclear stain the mistake is inexcusable.
In still other eases no definite vacuoles or clear spaces are
seen within the cells, but their deficiency in hamoglobin
is shown by theii' lighter color and lighter staining. On
the other hand, in pernicious an;emia the amount of ha>-
moglobin is relatively higher than the red cells; as, for
example, if the red cells are 2,500,000 the lucnioglobin
is fifty per cent, or higher. Asa rule, however, both red
cells "and iKvmogloliin are greatly decreased in this dis-
ease. The explanation of the relatively high lucnioglo-
bin content is found in the jiresence of numerous large
i<'d cells (niacrocytes) containing more ha-moglobin than
flic normal red cell. This may be regarded as of a com-
pensut^iry nature. A pathological oligochronui?mia oc-
<'nrs in all forms of anremia, whether due to luemolysis
<ir deficient blood formation. In the latter case the indi-
vidual red cells may contain a normal amount of ha'ino-
gloliin, or even a greater amount. In .severe ana'mias the
iiMiiioglobin may be reduced to ten per cent, or less, but
it nuist lie borne in mind that the estimation of the low
p<'rcentiiges is attended by a greater or less error. A
jihysiological oligochroma'mia occurs in the new-born
<luring the mu'sing period, in the mature female after
menstruation, and in the later months of pregnancy and
the post-partmn period. (Sec also Ananu'n, etc.)
AM red Scvlt WartMii.
OLIGOCYTH/tMIA.— A dimiiuition in the number of
the rerl lilood cells, due either to lessened production or
to an increased destruction of the same. The condition
is of very frequent occurrence and may be due to a great
variety of causes.
A physiological oligocytha'inia occurs in hibernating
animals during th<' winter sleep ; observations made upon
the niarmiit showi'd a dimiiuition of the red cells from
7,000,000 Ic] 2,000,000 during the period from November
to February. There is also, according to some obser-
vers, a slight physiological vanation in man, the number
of red cells becoming slightly lower toward evening.
According to Vierordt, Lindicck, and others, the red
cells begin to diminish within one-half to one hour after
the ingestinn of a full meal, the niunber being reduced
between 2.JO.O0O and 7."iO,0O0 jier cubic millimetre, re-
maining so for a sliort time, and after two to four hours
gradually reaching normal again. The diniinution is
more marked after the ingestion of large (|uantities of
fluids, and is therefore regapled as due to the dilution of
the blood resulting from the absorption of fluid. Ac-
<'ording to some observers the red cells are increased in
number during lasting or starvation, but Hauni and Gia-
■witz noted a definite diminution of red cells in healthy
fasting men. Noi-mal menstruation does not reduce the
number of the red cells. After delivery there is usually
found a diminution of red cells lasting for from ten to fcnir-
feen days. Under ordinary conditions the ]iosf-iiartuni
oligocytlnemia is slight.
Pathological oligocythaniia occurs after hemorrhage,
and in many infections and intoxications. It is found
constantly in prolonged fevers, in li'uk;eniia, eaeheetic
conditions, malaria, syphilis, |ioisoning with mercury or
lead, and in carcinoma, ]iartieularly of the stomach. A
condition of oligocytha^mia may also be jiroduced by
many poisons, the most important of which are: aniline,
nitrobenzole. pyrogallic acid, tohiylenedianiine, potas-
sium chlorate, amyl nitrite, jihallin, helvellie aeid, mus-
carin, arsenic, antimony, picric acid, carbon <lisulphide,
sulphuric acid, glycerin, abrin, riein, etc. In ieferns the
presence of the salts of the bile acids in the lilood gives
rise to oligoeytha'iiiia The venom of jioisonous snakes
causes extensive destruction of the red cells. In ^'ellow
fever there is also a very marked destruction of red cells.
Pernicious anamiia is characterized by marked oligocy-
themia resulting from the destruction of the red cells by
some poison as yet unknown. It is not improbable that
the disintegration of red cells and the setting free of lue-
moglobin may give rise to certain bodies or ferments hav-
ing a ha;molytic action. In the oligocytha?mia associated
with infectious processes the specific poisons produced by
the infecting organs have in the great majority of cases a
decided h.-emolytic action. In certain conditions of the
bone marrow the formation of red cells may fall below
the normal, ha-matopoiesis not keeping pace with luemo-
lysis. On the other hand, in cases of increased ha'moly-
sis the bone marrow may present evidences of increased
blood foiniation, and in very rare cases there is a prob-
able similar compensation on the part of the spleen and
lymph nodes. The diminution of red cells in the bio d
of man may be so great as a reduction to .500,000 or less
per cubic millimetre. Such severe oligocytluemia is
characteristic of the later stages of pernicious ana"mia,
but may be caused by poisons. (See also Aiuemia. llamo-
ly.fis, etc.) Aldred Scott Warthin.
OLIVE OIL.— Olecm Oi.tv.b. Siteet Oil. Salad Oil.
— "A fixed oil expressed from the ripe fruit of Olea
Eiirojuva L. (fain. Ohy«-«r)." U. S. P.
Theolive is a small or medium-sized tree, witha much-
branched trunk and numerous slender branches. The
bark is gray, the wooti comiiact, rather hard, agreeably
scented, and susceptible of a high polish. Its fine yellow
color, variegated with brown, in addition to the above
qualifies, make it a favorite material for small wooden or-
naments and ]iieces of furniture.
The leaves of the olive tree are white underneath with
a layer of stellate hairs. The fruit, the well-known
olive, is an oval, pointed drujie, about 3 or 3 cm. (1 in.)
long, consisting of a firm, very oily mesocarp, and a
spindle-shaped, hard pufamcu, containing a single long
and narrow, also oily, seed. Its color when ripe is dull
blue or purple, its taste bitterish and oily.
This valuable tree is a native of Asia Minor, Palestine,
and other parts of the Levant, where its cultivation is of
the greatest antiquity, as the Old Testament and numer-
ous ancient records ,show. If was introduced info the
Mediterranean countries of Europe and Africa also at an
early date, and has become thoroughly naturalized in
some of them. In the course of time it apiieared in the
warmer parts of South America and elsewhere in the
tropics, as well as in California in this countiy.
The fruit of the olive has been improved in form and
size, as well as flavor, by cultivation, and there are several
well-distinguished varieties. The olive is one of the
most important jiroducfs of Spain and Italy.
For the table, olives are gathered while still green, but
fully grown, soaked in water or sometimes in lye to re-
move their natural bitterness, and finally pickled in a
.simple or somefinics flavored brine. For the oil they are
allowed to ripen, and then are ground and subjected to
|iressure.
The ([ualify of the product depends upon nicety in
every stage of the operation; for the best fable oil, fine
fruits of good varieties must be taken, and the iiressing
done at once, without heat; this yields a moderate quan-
tify of very clear, light-colored, generally slightly green-
ish, jileasant-fiavoreil oil, generally called "Virgin Oil,"
which is .sold for table use. The remaining cake is then
broken uji and heated or mixed with boiling wafer and
more strongly presseil. when a further product of darker
and .stronger tasting oil is obtained. This grade of oil,
which is called "foots," can be used for cooking or for
fuel. An ea.sy way, finally, for obtaining a large yield
of oil is to lay the olives in heaps iiufil decomposition
begins, when a very strong-snielling oil {hnilefennentee)
results.
Composition. — No other fruit contains so large a pro-
portion of fixed oil as this; it amounts generally to over
one half, an<l in good qualities to almost three-fourths.
Besides, the fruit contains considerable mannit, diminish-
350
REFERENCE HANUBUOK OF THE MEDICAL SCIENX'ES.
Olltfocytlnemla.
Oiueutuiii.
ing as it ripens and the oil increases. Olive oil of the
quality reiiiiircil for medicinal purposes is tlius described :
"A pale yellow, or light greenish-yellow, oily liquid, al-
most devoid of odor, having a nutty, oleaginous taste,
with a faintly acrid after-taste, and a neutral reaction.
Specific gravity, 0.915-0.918. Sparingly soluble in alco-
hol, but readily soluble in ether. When cooled to about
10° C. (50' F.), it begins to be somewhat cloudy from the
separation of crystalline particles, and, at about 5" C. (41°
F.), it begins to deposit a white, granular sediment; be-
low 2" C. (35.6° F.), it forms a whitish, granular mass."
The principal part, more than two-thiids, of olive oil is
the liquid fat ulein, or triolein; nearly all the rest \sjxil-
mitin, with a little stenrin. butiii, and ]ierhaps also chol-
esterin. Of the so-called "olive oils" in the American
market the cheaper ones, even bottled and labelled in
French as "Pure Olive Oil from Nice," etc., are at pres-
ent almost entirely better grades of cotton-seed oil, and
some of the more cxiiensive sorts are said to be adulte-
rated with it. This oil and other cheaper ones are also
used abroad extensively as substitutes for or adulterants
of this delicious and much-])rized substance.
Action and Use. — This can be disposed of quite
brietly, so far as its medical use is considered. Given in-
ternally, it is chiefly a fatty food, and is emulsified and
absorbed as other fats are. It is slightly, only very
slightly, laxative, and has no other i>hysiological action.
Locally applied it is a neutral jnotective from the atmos-
phere, as are other fats; but in this application it has
given place somewhat to cheajicr ones — suet, lard, cot-
ton-seed oil, etc., — and especially to the various petrola-
tum products.
It is rather frequently given as an injection, but rns-
tor oil is pieferable for this purpose. Like most other
fixed oils, it is destructive to insect life, and rectal injec-
tions and applications are often efticient in thw ti-eatnient
of ascarides. Many rejiorts have been published of the
efficacy of large quantities of olive oil, two to four gills
at a dose, in favoring the removal of gall stones. A lit-
tle cocaine may be added if there is a tendency to reject
it. Its most extensive employment in medicine is |ier-
haps in the composition of several liniments and of the
pharmaceutical soaps ; in this field it has also of late been
replaced in this country by the cheaper oil from cotton
seed .
Administration. — As a laxative, three or four table-
spoonfnls are required, — a dose that is apt to disturb the
stomach of one unaccustomed to oils. This, as stated
above, may often be prevented by the use o*' gr. } of co-
caine, given just before the administration of ^he oil.
As an injection, one or two teacupfuls, injected warm,
and retained an hour or so and then followed by
soapsuds, make a very elHcientconiposition for relieving
an overloaded rectum. H'. P. Bulks.
OLIVER SPRINGS. — Anderson (Vjunty. Teimessee.
Post-Okkick. — Oliver Springs. Hotel.
Access. — From Knoxvilie via Southern Railroad
(formerly East Tennessee, Virginia, and Georgia Rail-
road), thirty-five miles northwest to springs.
The Oliver Springs and the small village of the same
name are situated on the southern slope of the Cumberland
range of mountains, where the counties of Anderson,
Roam, and Morgan join their boundary lines. The sur-
roundings of the resoit are very pleasing, and the climate
is of a genial, attractive character. The average sununer
temperature at the springs is 73° F. , and of the winter
38° F., showing an unusually low variation. It is said
that malaria has never been known to exist in the vicin-
ity. There are nine mineral springs within the ten acres
occupied by the hotel grounds. They have not been
fully analyzed, but are said to contain iron, manganese,
litliia, magnesia, and sulphur. They are used consider-
ably for medicinal purposes, and, joineil with the beauti-
ful .scenery, the pleasant climate, and a comfortable, new
hotel, they serve to render this location a very attractive
one for the health or recreation seeker.
.Jit)ina K. Crook.
OLYMPIAN SPRINGS. — Bath County. Kentm.ky.
Post-Office. — Olymjiian Sjirings.
Access. —Via Lexington and Big Sandy Railroad to
Mount Sterling, thence l)y sta.ge.
These springs are ten in number, and are of the saline-
sulphureted variety. The waters are promptly diuretic
in their action. Anal3'sis was made by Dr. I{obert Peter
in 1858, and again in 1887. Following is the result of
the former analysis of the salt sulphur spring:
O.vE United States Gallon Contains:
Solids. Grains.
Ma^'nesiiim carbonate 7.3(J
Iron carhonjite Trace.
I.ini** curb'inate V^.%i
Pota.wuuii clilnride 1(1.67
So.Uuiii I hl^ .ride 166. Ul
Maj-'iHsiuin rliloride .5.^.;J9
Lini.
llphatc
Trace.
Iron and bromide Trace.
Alumina Trace.
Silica 1 .04
Water and loss 78.60
Total 332. 84
(iaaes: Carbonic acid, sulphureted hydrogen, not estimated.
A re-examination of the waters in 1877 showed essen-
tially the same results. The following additional ingre-
dients were found in minute rjuautities:
Baryta carbonate.
Stntntinm carbonate.
Soiliuin carhiuiate.
Calciinn .■lil.niiic.
Lltiiiuiii djluride.
Sodium bromide.
Sodium Iodide.
Sodium sulphide.
Boric acid.
Phosphoric acid.
Manganese carbouat*?.
Examination of the two other springs showe<l the pres-
ence (if sodium carbonate in the proportion of twenty
grains per gallon. One of them contains a little less than
two grains of iron carbonate to the gallon.
Ji lines K. Crook.
OMENTUM. PATHOLOGY OF.— The term omentum
(epiploon) is applied to the folds of peritoneum which
connect the stomach with its neighboring organs, the
liver, colon, and spleen. In structure similar to the
mesentery, each omentnin may be regardi'd as a special
mesentery connecting the stomach with the organs
named. They are usually designated respectively as:
lliislrohepalic or lesser omentum {omentum minus) ; ijastro-
c<i/ic or c/rent omentum {omentum nuijus or eptplvon); and
the r/<istro-splenie omentum.
The ffi(s(ro-/iepiitic (stomach-liver) omentum, or small
omentum, extends from the lesser curvature of the stom-
ach and the adjacent first part of the duodenum to the
portal fissure of the liver, enclosing between its two lay-
ers the hepalic artery, portal vein, bile duct, anil asso-
ciated structures, bound together by loose connective
tissue.
The r/iiitro-etjlie. (stomach colon) omcnt'im, or great
omentum, connects the greater curvature of the stomach
and the adjacent first part of the duodeniun with the trans-
verse colon. It is the largest of all the peritoneal dupli-
cations, and is composed of four layers of peritoneum ; it
is much more voluminous than is necessary for the mere
connection of the stomach and colon, and hangs down in
front of the small intestines like an apron.
The f/iislro-sji!enie(iiU)miich-sp\een) omentum is a double
fold of ijcritoneum pa.ssing from the dorsal surface of the
stomach, near its left border, backward to the hilum of
the spleen. It runs below into thegastro colic omentum.
It is often called the gastro-splenic ligament. It contains
the splenic vessels.
In structure the omental folds are composed of either
two or four layers of the peritoneal membrane, a base-
ment structure of very loo.se connective tissue, containing
a remarkable number of blood-vessels and lymphatics,
and more or less adipose tissue, the whole being covered
with endothelium. Small lym|ih nodes are not infre-
quently found in the great omentum, less frecjuently in
6i)t
Oineuluni.
Onieutum.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
the gastrosplenic. but arc almost constantly present in
the lesser omentum. These usually show the structure
of ordinary lymphatic glands, but h;emolymi)h glands
also occur. Accessory spleens are of common occurrence
in the gastro-splenie omentum.
The great omentum is liy far thr most important, both
physiologically aud patliologically considered. That its
function is of great importance, in so far as the protec-
tion of the peritoneal cavity is concerned, cannot be
doubted. It usually contains a large amount of fat tis-
.sue, and this fact, taken in connection with its "cover-
let" investiture of the small intestines, has led to the
view, advanced by both Aristotle and Galen, and com-
monly accepted even to-day. that the organ is of service
in preserving the heat of the liody and protecting the in-
testines against chilling. Sni'h function, doulitful as it
appears, is of slight impm-tance comjiared with the protee-
tive function of the omentum against intraperitoneal in-
fiM'tion. The remarkable richness of the organ in blood-
vessels and lymphatics — far in excess of the needs of the
structure itself, if intended only for a jirotcctive cover-
ing's structural evidence of thechief omental function.
The vessels form a rich ple.xus throughout the connective
ti.ssue beneatli the endothelial covering, the vessels them-
selves in many cases being sejiarated from the peritoneal
cavity by the endothelium alone. Numerous clinical
ob.servations tend to show that the transudation of lymph
into the abdominal cavity or the absorption of lymph
from the cavity is an important function of the omen-
tum. Many writers hold that, the omentiun is a modified
lymphatic ganglion. It has been shown experimentally
that, after the removal of the omentum, animals are
much more susceptilile to intraperitoneal injections of
micro-organisms than control animals whose omentums
have not been removed. The inference may be drawn
that micro-organisms oljtaining entrance to the peritoneal
cavity arc taken up Iiy the omentum and there rendered
harmless or are killed.
In local traumatism, or after ojierations involving the
lieritoncum, in beginning peritoneal infection, local peri-
tonitis from whatever cause, etc., the omentum is quite
coimnonly found attached to the afTected area, entirely
surroiniding it and shutting it off from the remainder of
the peritoneal cavity. This occurs iiarticularly in ap-
jienilieeal and tubal disease, following the beginning of
a local peritonitis, but it is also of very frequent occur-
r(;nce over the surface of liver, spleen, intestines, etc.
It would appear that the omentum is attracted to the
diseased area; the location of such adhesions deep in the
pelvis or in parts of the peritoneal cavity not usually oc-
cupied by the omentum would indicate such a movement
of the omentum to the affected part. The slightest irri-
tation in any part of the peritoneum is apparently suffi-
cient to cause the omentum to attach itself to the affected
area, and to shut otT the focus of infection from the re-
mainder of the peritoneal cavity. Even when micro-
scopic changes are not visible, alterations of the intestinal
wall permitting the passage of germs or of their prod-
ucts, are sufficient to cause such adhesions. The plas-
tic exudate thrown out by the omentum at the point of
lesion no doubt offers some jiurcly mechanical protection
against the spread of infection; it is also probable that
the secretion poured out from the omental vessels has
some bactericidal or antitoxic action. Furthermore, the
bacteria received into the lymphatics of the omentum are
either rendered less virulent or are destroyed.
Mai,formations. — Tlie great omentum may be entirely
absent, or only incompletely developed. V^iriations in
size and shape are common: partial (lefeets of large size
are not infrequent. Misplacements of portions of the
organ are found in connection with congenital hernias.
Congenital cysts of the omentum are of very rare occur-
rence.
CiHCULATORY DiSTnRB.\NCES. — The vascular relations
of the omentum are such a-s to make the circulatory con-
ditions of tins organ dependent upon that of the neigh-
boring structures. Infianunationsof the gastro intestinal
tract, lieruias, obstructions, tumors, dist\n'lianees of the
portal circulation affect the vessels of the nmeiitum to a
more or less marked degree.
Aetice lii/pei-cemin oi the omentum iccursin tla^ early
stages of epiploitis, also after the suilden diminution of
abdominal pressure after the removal of ascitic fluid or
of a tumor of large size.
Gciicnil jxissirccimpeMiori of the omental vessels follows
portal obstruction, either as the restdt of hepatic di.sease
or of pulmonary or cardiac affections. The vessels of the
great omentum may be markedljf congested in advanced
stages of cirrhosis, or in failure of compensation in val-
vular disease of the heart. In such cases the congested
omentum plays a large part in the production of the as-
sociated ascites.
Advantage has been taken of the dilated condition of
the omental vessels in cirrhosis of the liver, and of the
fact that the omentum readily forms adhesions with
other structures, by an attempt to set up a collateral cir-
culation between the portal and the sj'stemic veins by
means of " Murrison'H operntii'ii." This consists in the
establishment of an anastomosis between the vessels of
the omentum and those of thi' anterior alidominal wall
through artiticialh' induced adhesions. The i)rrilo:ieum
is tirst rubbed, aud the omentum stttured to tlie area so
treated. It is at present too early to speak of the value
of this procedure; but, very favorable results have been
reported. In a ease operated upon by Lens, venous
channels were demonstrahle in the adhesions that had
formed between omentum and peritoneum. Animal ex-
perimentation shows the jiossihility of the establishment
of such a collateral anastomosis. Similar results may be
obtained by ailliesions forme<l between the diaphragm
and the liver or spleen.
l{e)iuin-li<i(je. — Small ecchymoscs occur into the omental
tissues in extreme active or passive congestion, in severe
cases of the acute infections, in sepsis, in ejiiploitis, fat
necrosis, secondary carcinoma, hiemophilia. etc. Large
luTmatoniataarc rare ; they may occur in association with
fat necrosis in cases of acute pancreatitis, or in severe
epiploitis associated with appendicitis or salpingitis, or
very rarely in lufmophilia.
Infiirction. — Incarceration or torsion of the omentum
ma}', by shutting off the blood supply, give rise to an
anaunic necrosis. Ligation or thrombosis of the epiploic
artery will produce the .same result. In cases of resec-
tion of the omentum in herniotomy a thrombosis may be
induced in the omental vessels which may extend to tlie
gastric arteries. In cases in which the ligations are near
the epiploic artery, antcmic ulceration of the stomach or
hepatic infarction may occur, as the result of the exten-
sion of thrombosis into the gastric and hepatic vessels.
(Kdeinii of the omentum is of frequent occurrence. It
may be due to general or local passive congestion, ob-
struction of the portal circulation, epiploitis, etc. In
acute epiploitis associated with general peritonitis and
ascites the omentum may be very nuieh swollen. Asa
rule, fedema of the omentum is manifest in the resulting
ascites; the free interchange of fluid between the lynipli
spaces of the omentum and the peritoneal cavity relieves
the omentum, .so that it does not become swollen through
the accumulation of fluid in its tissue spaces, until the col-
lection of ascitic fluid in the peritoneal cavity reaches a
certain degree of tension.
Ascites. — The omental function of lymph production
aud lympli absorption is directly connected witli the de-
velopment of ascites. All conditions favoring an in-
creased formation of lymph by the omentum, as well as
those preventing the absorption of peritoneal fluids, lead
directly to ascites. Malpighi was ]>erhaps the tirst to
suggest that ascites may be causeii by a penning out of
fluid from the omental vessels. In a case reported by
Landgraf, an ascites intractable after fourteen tajipings
disappeared after the sloughing of a part of the great
omentum which presented itself in an omental hernia.
Similar cases have Ijcen observed. Eitel reports an inter-
esting case of marked ascites which had been repeatedly
tapped. A large tumor was f(mnd to be present in the
upper part of the abdomen. On operation tliis was dis-
H.o.S
REFERENCE HANDBOOK OF THE jrEDICAL SCIENCES.
Omentum.
Oinentiini.
<'ovcrc(l to be tlie great iimentum tightly rolled upon
ilsi'lf, its veins constricted and its circulation impeded,
it was iMU'oUed anil the ascites was cured. The cause
was attributed to the fact that the patient, a worker in a
<|uar(z niill, was in the habit of carrying a heavy box
of mill product pressed against his abdomen. Other
cases of a similar nature point to the omentum as a direct
factor in the pre>duction of ascites.
}li/iln/ps (Jiinnti. — The collection of fluid between the
layers oi the great onieutum is so designated. This con-
<lition occurs more frequently in cases of ascites in chil-
dren tlian in old indivicluals.
C/ii/loiis Ascites. — In cases of secondary carcinoma of the
<inientum or in chronic fibroid (unentitis, the ascitic fluid
may be white or milky, due to fat or albumin in suspen-
sion. The i)rcsence of these substauces may be due to
the fatty degeneration of desi|uamated endothelium or
lumor cells, or may ri'Sult from the olistruction of chyle
vessels. In the former case, when little fat is present in
tlie fluid, tlieconditi(->n may be designated as ;«c«(/u(V((/iy««
<tsr/t('s.
Rktkogr.\de Cii.\ngks. — Atro])hy of the omentum, as
sliown by total or marked tlisap|:iearance of its adipose
tissue, occurs in cachexias and wasting diseases as a part
of the general marasmus. Atrophy of tiie flljrous trabcc-
ula? may also occur. Cases have been observed in which
the atropli}- of portions of theoigan gives rise to large
open spaces between its coar.ser trabeculie.
JVecirisis of the omentum may be caused by incarcer-
ation or torsion, by ligation or thrombosis of omental ves-
sels, or it may be associated with gangrenous conditions
of the intestines.
Fat lurrasi's of the omentum occurs in acute jiancrea-
titis, in pancreatic carcinoma, ami in as.sociatiou with fat
necrosis of the abdominal fat elsewhere. The necrosed
areas are yellowish-white, slightly elevated and opaque,
and usually circular in outline. The omentum may look
as if it had been touched with a hot iron. The necrotic
areas may be hemorrhagic. In cases of longer standing
lime salts may be deposited in the necrosed cells.
Amyloid has been reported as occurring in the walls of
the omental blood-vessels.
Ilynline change of the walls of the omental arteries is
found in chronic fibroid omentitis, in association with
omental tuberculosis, in the neighborhood of inflamma-
tory adhesions, etc.
Calcification may follow fat necrosis, or occur in old
tubercles. In two cases of s[deuic ana'mia associated
with hepatic cirrhosis {Banti's disease) numerous small
nodules of calcitication were found by the writer
throughout the abdominal fat.
Infi,.\mm.vtion (Omiiititis or Epiploitis). — Inflamma-
tion of the omentum is essentially a part of a more or
less general peritonitis in the great majority of cases;
but in certain instances the omental inflammation pre-
ponderates, or appears to be primary; and further, as
mentioned above, localized peritonitis is almost always
associated with a localized cpiploitis, the omentum ad-
lieriTig to and shutting off the inflammatory process (see
Peritonitis). The character of the ejjiploitis is the same
as that of the geni'ral or local peritonitis with which it is
associated. \\7.. , fihri nous, purulent, rianyfenons. etc. Tlie
omental process is, however, in all cases characterized
by a greater tendency to proliferation and formation of
gramilalion tissue than is the case with the other por-
tions of the peritoneum. This is especially true of the
localized forms of cpiploitis with adhesion; the inflam-
matory process is essentially (ilastic in character (omenti-
tis adha?siva). As a result of very active inflammations
there may be formed such large masses of granulation
tissue in the omentum as to produce tumors which may
be mistaken clinically for neoplasms.
Infill inmntori/ Tumors of tlie Omentum. — As the result
of such excessive jiroduction of granulation tissue in the
inflamed omentum, thi're is not infrequently fouiul a tu-
mor-like thickening of the omental tissues. This may
occur in any part of the abdomen, but is most fre(|Uent
in the appi.'udi.x region. The thickening of the omentum
may he dilTuso or nodular, often limited to the portion
adherent to the peritoneum about the primary focus. In
other cases the omentum maj' be rolled up tightly above
the level of the umbilicus, forming a firm cylindrical
mass extending across the abdomen. The tumor mass
may develop very rapidly in acute processes, but more
gradually in chronic inlhunmations. After the inflam-
mation has subsided the tumor nuiy disappear through
the resorption of exudates and the contraction of the
granulation tissue, and the omentum may become de-
tached. In other cases, after the inflammation has dis-
appeared, the tumor remains and the omental adhesions
become hard and organized, in purulent cases the in-
flanunation may persist, and a chronic tumor then renmins,
composed of an inflaTumatory focus (abscess) surrounded
by thick omental adhesions of granulation tissue. In
other cases, after the termination of the inflammation, the
omentum becomes detached, the granulation tissue is
converted into libious tissue, and the omentum is greatly
changed in form by the production of diffuse or nodular
tibroid tliickenings (omentitis fibrosa). If there is nuich
retraction of portions of the new fibrous tissue the omen-
tal tumor ma)' be very small and irregular (omentitis
filirosa retrahens).
Inflanuuatdr}' tumors of the omentum also follow
laparotomy, in which either the normal or the inflamed
omentum has bi'en ligated and in part removed. Tor-
sion of the omentum may also give rise to an omental
tiuuor. In some cases, after an operation for strangu-
lated hernia, the omentum has become inflamed, though
not involved in the strangulation. In all these cases the
inflanuuatoiy tumor develops slowly ; in one-half of the
lecorded cases the period of development varied from
one to four months, and in some cases the interval was
much longer. The tumor is usually on the .same side
of the body as that njion which the operation was
performed, its location depending upon the amount of
omentum removed. It may or nniy not be adherent to
the abdominal wall. The tumor is usually about the
size of an orange, but may be much larger. When ad-
herent to the wall the tumor is inunovable; if non-adher-
ent it may be moved upward or laterally, but not down-
ward. The surface of the mass is usually smooth, the
consistence firm. It is tender on i)re.ssure. It usually
does not move with respiration, or only slightly. Per-
cussion gives a dull tympanitic note, often comidelely
dull. In the centre of the tumor may be found the liga-
tures used to tie off the omentum, and it is believed by
some that the use of silk ligatures in such operations
plays an important part in the development of the
tumor.
Clinicall}'. the inflannnatory tumors of the omentum
may bo mistaken for ovarian tiuiiors, misplaced liver or
spleen, malignant growth of the intestines, etc. In cer-
tain cases they have been regarded as malignant neo-
plasms (sarcoma) even after microscopical exanunation.
Coley mentionsa case in which a portion of the omentum
had been excised on account of its ])resencc in a left
inguinal hernia. The stum]) became inflamed, with-
drew, and gave rise to a ma.ss in the region of the
sjilenic flex\ire. Malignant disease was suspected, the
abdomen was opened, and a portion of tissue removed
for examination. The diagnosis was "probable spindle-
celled sarcoma." The patient died after a radical oper-
atir)n. The autopsy showed that the inflamed omental
stimip had become attached to the splenic flexure, and
the section for microscoiiical examination had been cut
from the very alnmdant inflannnatory tissue.
In two cases in the writer's ex iierience there were found,
in the region of the appendix, large tiunor masses that
clinically presented characteristics of mali.gnancy. Mi-
croscopical examination of tissue removed for diagnosis
showed a very cellular granulation tissue, rich in blood-
vessels, having relatively thick walls. In one case the
diagnosis of "omental granulation tissue" was given. The
liatient recovered, anil the tunmr completely disaiilieared.
In the other cases the first sections exanuned were pre-
pared by a quick method for immediate diagnosis. The
359
Omentum.
Omentum*
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
section sliowod a sarfoniatous-like structure of round and
spindle cells grouped ariunul blood-vessels, sutrgesting an
endothelioma. Study of the sections showed large num-
bers of plasma cells present, and the fact that all of the
blood-vessels had relatively thick walls. A diagnosis of
omental granulation tissue was then given. A year
afterward the t\imor was reported as having entirely dis-
appeared. There can lie but little doubt tliat some of the
so-called disappearing malignant tumors of the abdomen
belong to this class. The niicroscopical appearances of
small bits of tissue removed tor diagnosis may on first
glance strongly suggest a sarcomatous growth. In the
relatively thick .sections olitained by means of the freez-
ing microtome or by (piick enibcdding methods the liner
p(iints necessary to' a differential diagnosis are usually
not sutticiently clear for a safe diagnosis, and it is from
sucli sections"that the diagnosis of .sarcoma is usually
made. The writer holds that in carefully prepared sec-
tions the (lilTerential iliagnosis between such forms of
richly cellular granulation tissue and sarcoma may be
made without great dilticidty. The presence of numer-
ous ]dasma cells, the prominence of the small vessels, both
in numlier and in size, their relatively thick walls, the
liypertrophic character of their endothelium, the marked
endothelial proliferation, the typical character of the mi-
tosis, the jircsence of tibrin and small pus collections, are
all points establishing the diagnosis of suliacute or chronic
development of granulation tissue. The presence of adi-
pose tissue and coarse trabecuhe of fibrous tissue are also
of Service in fi.xing the origin as omental.
Oiiieiitdl Abscess. — An acute omental abscess may de-
velop without the association of a general peritonitis or
of any discoverable local change. In the majority of
cases, however, the appendi.\ is the seat of ]iriinary in-
fection. Omental abscess may be associated with salpin-
gitis, and very freciuently follows laparotomies or herni-
otomy. In those cases in which the omental abscess is
apparently of cryptogenic origin, or over.shadows the
primary lesion, it may be inferred that the resistance of
the omental tissues had been lowered, or that the organ,
tlirougli circulatory disturbances or for other reasons,
has been unable to overcome the virulence of the bacteria
taken up. The abscess may be found in any part of the
abdominal cavity, but as the omentum is commoidy rolled
up, it lies usually above the level of the umbilicus. It
may develop around ligatures which are used in tying
off the omentum. The organ is reddened, thickened.
and is usually adherent to the abdominal wall by a
fibrinous exudate, which is most marked over the ab-
scess. The latter not infrequently forms an encapsu-
lated pocket of pus between the omeutum and the ante-
rior abdominal wall, and may e.\tend into the tissues of
the latter. The clinical sytnptoms are those of sepsis,
with local iiain and tumor. In many cases the abscess
becomes chronic, a large amount of fibrous tissue is
formed about the enca|)sulated area, the adhesions be-
come hard and firm, and a gradual healing of the abscess
may take place. A more or less generalized peritonitis
may accompany the abscess. Occasionally the pus may
break through into the intestine and recovery follow.
Rupture into the peritoneal cavity may cause a severe
general ]ieritonitis which may be fatal.
t^.queliB fif Oincntdl Iiiflniiimiitioii. — As a result of in-
flammatory conditions of the omentum there may arise
adhesions between the organ and the various abdominal
viscera; these may cause stenosis, or snaring off of por-
tions of the bowel, obstruction of the ureter, pressure
upon the common duct or pylorus, abnormal position of
the pelvic organs, etc.
Progressivk Cii.\X(iES. — Either fibrous or fatty hyper-
plasia of the omentum may occiu- in the portioii oif the
organ included in liernial sacs. The hyperplasia niaj'
take on the character of a lipomalous growth. Cases
have been reported of such hyper|ilasias in hernial .sacs
which reached half-way to the knees.
The remarkable capacity Xeir ]>riilifrriititin possessed by
the omentum has been taken advantage of in plastic
operations in the abdomen, (for further details in re-
gard to this part of the subject, the reader should con-
sult the article next beyond this.)
TniDois. — Primary neoplasms of the omentum are rare,
Fibroiiia and lip'/mn have been described. In the former
class of cases tlie ai'tual disease may in reality have been
a localized fibroid thickening resulting from an intlam-
matory omental tumor. The so-called li]iomatousgrowtlis
have been, in the majority of cases, localized or diffuse
fatty hyperplasias.
Of the primary malignant tumors reported as occurring
in the omentum eiKhitlttUoma and riiyxosiircoma are the
forms whose origin in this organ is supported by ob.ser-
vation ; but it must be observed that the rarity of such
cases, and the imperfect descriptions given, leave us very
much in ignorance as to the occurrence and nature of
primary omental tumors. In the older literattu-e there
are occasional reports of "■primary eaiicer" of the omen-
tum, "scirrhus of the omentum," and "primary colloid
disease," "vesicular degeneration," "hydatid disease,"
etc. The e.xact nature of this peculiar growth of the
omentum, apparently primary in some cases, cannot at
present l)e stated. Primary epithelial growths (carcino-
ma) of the omentum of course do not occur. In .some
cases the growth may have been secondary to colloid
carcinoma of the stomach or intestine, or to cystocarcino-
ma of the testis or ovary. In typical cases the omeutum
is greatly thickened; its surface is uneven, fiocculent,
and slireddj'. this appearance being due to the projection
of Kuuided villuslike masses of gelatinous material at-
tached by shreds of tissue. The appearance strongly
suggests hydatid disease of the placenta. On microsco-
pical examination the mass of the omentum has a finely
spongy texture of connective tissue enclosing masses of
gelatinous material. Swollen cells are occasionally found
in the spaces. If we exclude the cases of true cMoid cancer
or cystocarcinomn. secondary to primary tumors in other
organs, there still appears to bc' a peculiar iu\'xomatous
growth of till- onieutuui, which according to the most care-
fid reports (Eve and others) must be cla.ssed as a myxoma
or iiiy.rdsarcoi/ia. No proof of its endothelial origin exists.
Matas has reported a case of primary myxosarcoma of
the omentum with secondaries in peritoneum and accom-
panied by a mucoid ascites.
The fiat or warty growths, originating from endothe-
lium, may be iirimary in the omentum as well as in the
]ieritoneum. Jlieroseopically, the primary endothelioma-
ta of the peritoneum consist of cords or strands of cells
in the connective tissue beneath the endothelial covering.
The cords of cells ajipear to follow the lymjdi vessels.
The growth may originate from the superficial layer, or
from the endothelium of the lymph vessels.
Omental cysts have also been reported, and have been
interpreted as "simple serous cysts," "distended lymph ves-
sels," " ciiiirjeiiital iniiltili'oilar eystama." etc. It is not
imiu'obable that the latter variety was a primary tumor
of the ovary, which after becoming adherent to the
otuentum, had been freed from its original attachments.
Such a process has tmdoubtedly occurred in the case of the
so reported dermnid cysts nf the omentnm. Though pri-
mary dermoids of the omentum may occur, it is liighly
probable that those observed have originated from pri-
mary ovarian dermoids in the manner described.
Secondary malignant growths of the omentum arc of
very common ocoirrence ; they represent most freqtiently
carcinoma metastases from primary growths in stomach,
intestine, gall-bladder, pancreas, ovaries, testis, uterus,
and prostate. A number of cases of melanotic sarcoma
of the omentum have been reported. ^Vhilc the growth,
in several of these instances, was regarded as primary, it
undoubti'dly was metastatic from primaries in the "skin
or choroid.
Psendi'my.mma. — The omentum as well as the general
peritoneal surface may be involved in the process known
by this name. It is due to rupture of an ovarian cysto-
ma, the discharge of mucoid or colloid material into the
peritoneal cavity. an<l the organization of the latter by
proliferation of the peritoneal ti.ssues.
Parasites. — Echi/wcuccus of the omentum has been re-
W)
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Onieiitum.
Ouienlum.
ported. Afterruptureof a primary liydatid cyst into the
pcritiiucal cavity tlie omeutum may l)e seooudarily in-
volved in conuectiiiu with the remainder of tlie perito-
neum.
7'ulierctihjsis of tlie omentum is of relatively common
occurrence. In many cases the infection of the perito-
neum appears to be primary in the omentum. The thick-
ened omentum may be tightly rolled up, forming a
tumor-like mass which may be mist^iken for a neoplasm.
In primary tuberculosis of the female genital tract, large
tubercles may be found in the omentum. (See also Peri-
tonitia. Septic and Tiiherciiloun.)
Syphilis. — ^A tibroid omentitis has been observed in
congenital syphilis, and in connection with syphilitic
cirrhosis and tibroid splenitis.
Foreign Body — A case is reported of an encysted needle
being found in the omentum. Gauze, sponges, ligatures,
or foreign bodies left in the peritoneal cavity during
laparotomy may become included iu omental adhesions.
Aldred Scott Warthin.
OMENTUM, SURGERY OF.— The omentum is com-
posed of two layers of peritoneum which are derived
from the anterior and posterior walls of the stomach.
They pass down%vard in front of the abdominal organs
into the hypogastric region, and are rellected backward
upon themselves and pass upward until they reach the
transverse colon. There they separate, and after covering
this portion of the intestine they come into contact behind
it, forming the transverse mesocolon. Thus the omen-
tum is really made up of four layers, but in adult life the
layers cannot be wholly separated, although this construc-
tion gives to the omentum a very loose and lobular char-
acter. In almost all persons the omentum contains a
good deal of fat. and in iudividuals who are very stout
the quantity of fat is jiroportionally large.
The function of the omeutum luider normal conditions
seems to be to allord protection to the underlying coils
of small intestine, and also to facilitate their movements.
Under pathological conditions it has the further fuuetion
of a]iplying itself to any wounded surface of the peri-
toneum within reach, so that it may even be able to oc-
clude a perforation and prevent fatal escape of intestinal
contents. By reason of its large serous surface it doubt-
less aids materially in the resorption of extra vasated
fluids from the peritoneal cavit}-.
The lesions of the omentum which are of surgical im-
portance are traumatic, intlammatory, parasitic, and neo-
plastic.
Traiimatis7ns. — If the abdominal cavity is opened, for
example, by a stab, the omentum will often be found
presenting itself in the wound. It freciuently serves a use-
ful purpose b}' protectiug other more important organs
from exposure to infection and traumatism in an open
wound. It may even protrude through a stab wound
which opens both the lower part of the pleural cavity and
the peritoneal cavity through the diaijhragm. It "is the
most common content of a hernial sac. The omentum
which is thus prolapsed into a wound may be uninjured.
or some of its ves.sels may have been opened by the trau-
matism, or it may become inflamed, or it may become
gangrenous either on account of the traumatism or
secondarily through its becoming strangulated in the
wound.
Intraperitoneal hemorrhage from a larger omental ves-
sel may prove fatal because the thin walls of its vessels
favor long-continued bleeding. In excising prolapsed
or injured or adherent portions of omentum the surgeon
should be careful to see that every bleeding vessel is se-
cured by a ligature. If the omentum which presents it-
self in a wound is uninjured and the wound itself is
clean, the omentum maj' be cleansed and replaced;
otherwise it .should be cut away.
Infletmiiintion. — The simplest form of inflammation
which can affect the omeutiun is of a traumatic charac-
ter. This is most frequently seen in coiuiection with an
omental hernia, where repeated slight traumatisms give
rise to local tibriuous peritonitis with the formation of
adhesions. The hernia will then become partly or
wholly irreducible and the omentum will be still iuore
exposed to slight injuries. This condition is often seen
in inguinal and umbilical hernia;. Iu operating upon
such hernia', it is customary to excise portions of omen-
tum which are badly malted together by adhesions, or
whose surfaces are deprived of their peritoneum when
the omentum is torn loose frorti the hernial ring. The
removal of more or less of the omentum does the patient
no harm, but the stump of the omentum may give rise
to serious trouble. It sometimes retracts, and becomes ad-
herent to the abdominal wall or some portion of the in-
testine, while adhesions take place about it to such an ex-
tent that a mass is formed that has more than once been
mistaken for a tumor. In one case within the knowledge
of the writer a section of this new-formed fibrous tissue
was removed and was ])ronouuced by a well known path-
ologist to be a spindle-celled .sarcoma. In consequence
an extensive resection of the descending colon, to which
the omentum was adherent, was performed, and from
the indirect effects of this operation the patient died.
Such an inflammatory tumor in the omental stump will,
like all ciatricial tissue, decrease in size iu the cour.se of
time, but it may give the patient a great deal of trouble
during the process, and the adhesions produced by it may
continue to give trouble long after the inflammation has
subsided.
Suppurative inflammation may develop in the omental
stump, usually as the result of an infected ligature. If
general peritonitis is avoided, an abscess may be pro-
duced within the omentum. The omentum under such
circumstances will attach itself to the surrounding parts,
including the anterior abdominal wall, so that it may be
possible to open the abscess without entering the geijeral
peritoneal cavity.
The more chronic inflammations, such as syphilis, tu-
berculosis, and actinomycosis, may involve the omentum,
usually in common with other portions of the abdominal
cavity. Omental echinococcus is also known, anil in
very rare instances an echinococcus cyst of the omentum
reaches a great size, although the lesions iu other por-
tions of the peritoneum are insigniticant.
Tumors. — A few primary tumors of the omentum have
been reported. They are for the most part liponmta,
sarcomata, or cystic tumors of congenital origin. Der-
moid cysts and teratomata are thus explained. Tln-re
are also acquired cysts of the omentum of a serous or
hemorrhagic character, the latter being secondary to
ha'matoma. Thus the tumors of the omentum are simi-
lar to those of the mesentery.
In addition to these primary tumors of the omentum
secondary nodules may develop on its surface and within
it in case of malignant disease of other abdominal organs,
while tumors of the transverse colon may grow down-
ward into the omentum so that they .sinuilate omental
tumors. A careful examination after the abdomen is
opened will usually show the starting-point of such a
tumor.
An omental tumor is characterized b_v a great range
of mobility as long as adhesions do not exist. For this
reason a small cyst may easily be mistaken for a solid
tumor. As tumors of the mesentery often have a great
mobility, it will scarcely be possibleto ditferentiate them
from omental tumors before the abdomen is ojiened.
The removal of an omental tumor requires no special
technique. On account of the thin walls of the vessels
all bleeding should be stopped by ligature before the ab-
domen is closed. Jlass ligatures cannot well be avoided,
but the amount of tissue included in each ligature should
be small. It is also worth while to approximate the peri-
toneal surfaces of the omentum by a continuous catgut
suture so as to prevent the formation of extensive adhe-
sions. If an echinococcus or epithelial cyst cannot be re-
moved in totii, it should be sutured into the abdominal
wound and drained.
Oi/iciital GrafLi. — The omentum has occasionally been
used to cover a defect in the peritoneum which c<iuld not
be closed hj' direct suture or as an additional safeguard
361
Ouycliia.
Ophlhalniometer.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
to cover a weak sulun/ of the stoiiuicli or iiitcsline. It
is especially adapted for such a piirpcise liccaiise of its
extensive peritoneal surface, its yreat ludbilily, and its
trie hiddd si-pply. Furl lierniore, tile ouieiiluni can be
sacritieed without especial injury. The advantage of
covering all wounded surfaces within the abdominal cav-
ity with peritoneum lias not been generally recognized,
yet when this is done repair is hastened and the risk of
sepsis is lessened as truly as is the case in covering
wounded surfaces of the "body with skin, while within
the abdominal cavity a raw surface has a third disadvan-
tage udt possessed by external raw surfaces in that it
gives rise to adhesions more or less dangerous, according
til their situation. Such adhesions can be partly or
wholly avoided if the raw surface is covered with peri-
toneum. The omentum has been used with success to
supply peritoneal grafts, wliicli may remain attached to
the omentum, or may be wholly cut from it and stitched
liver the wounded surface like a skin graft over a raw
external wiiund. The wound in the (imentuni itself
sliiiiild iif course be closed by suturing the cut edges of
the peritoneum.
ONYCHIA. See //.n»/.s- »/»/ /■
Eiliriinl Millim Facte.
't it'jrriy
(t,-
OPEN-AIR TREATMENT OF PULMONARY TUBER-
CULOSIS.—Tiie SI. rallnl "oiHii air" tnaliueiit i.f iml-
miiiiary tuliereulnsis lias been adverted In frei[Uently in
this IJANDnooK, notably under FnUanstiin, OncrherK-
(hirf, and Jhitllli R<s,>rts. It is the established treat-
ment of pulmonary tuberculosis at the present day,
and is most completely exhibited in the sanatoria. In a
word, it consists in atl'ording the patient iiiire outdoor
air to breathe continuously, both night and day, keeping
liim out of diiiirs by day and having his bedroom win-
dows open b_v night, or in man)' cases and places having
him sleep also out (if doors. It is hardly nei'cssary to
add that at the same time due attention should be ]iaid
to diet, rest, hydrolherapy, and to all that pertains to the
hygienic well-being of the patient ; hence this method is
also, and perhaps more correctly, termed the "hygienic-
dietetic " treatment. This treatment has been broiiglit to
such a degree of perfection that it may almost be said to
be independent of climate, that is, it can be suceessfuUy
carried nut wherever there are pure air fri'e from dust,
[U'otection from wind, and a moderate amount of sun-
shine— climatic conditions which are obtainable almost
everywhere oulside of large centres of ijopulation. It
seems a very simple matter to conduct such a treatment,
but exiierience has shown that constant supervision is
necessary, aided by the exani|ile of others, in order to
kec]) the patient u|i, d.ay after ilay, summer and winter,
to this treatment in all its strenuousness; hence the great
value of sanatoria and their constant and ra]iid increase
in number. Even though this treatment is in a measure
independent of climate, it is not to be asserted that all
climates are eijually valuable, for it is obvious that the
greater the number of favoring climatic elements, the
more perfectly the treatment can be conducted, and the
more successful it will be. Hence such resorts as Davos,
Colorado Springs. Idylwild (California), Aslieville, Aiken,
and many others of su|ieiior climatic excellence are espe-
cially favorable for this mode of treatment, provideil tlie
other essential factors, such as diet, etc., are at hand. It
may be thought that this treatment can be aceoniplislicd
by simply instructing the patient to kee)) out of doors;
nothing could be more fallacious than this. In the first
place, the iiatieiit will not keep out of doorsall day of his
own volition. If he is out for a few hours each day, he
is prone to think that he is fullilling his instructions.
Further, he is too often left to himself to determine
whether he shall remain at rest or take exercise while
in the open; geuerally he does the latter, sometimes
from ignorance, sometimes for the want of any proper
]dace where he can remain at rest. Here, again, comes
in the value of the sanatorium where all these details are
c.ari'fully looked after.
The theory of the outdoor treatment is, of course, evi-
dent; the object is so to improve the nutrition of the pul-
monary tissue and general system, and so to harden the
patient and thereby increase his resisting power that he
will no longer ]ire.sent a favorable soil for the tubercle
bacillus. It is also claimed for this treatment that it will
increase tissue metabolism, so that tibroid transformation
of tuberculous lung tissue may be hastened, or the en-
cajisulation of caseous areas efl'ected.
Are all cases of pulmonary tubercidosis suitable for
the oiien-air treatment? Obviously not, for all cases are
not suseeiitilile of an arrest or imiudvenient; and the ob-
ject of this treatment is to riirf. Although it is dilHcult.
if not impossible, iu many cases and in the various stages
of the disease, to form a probable prognosis, still iu gen-
eral it may be said that advanced cases with mixed in-
fection and septic symptoms — cases of very extensive
ilisea.se, those in whicli the tuberculous process is accom-
panied by acute symptoms, or tho.se in which the recu-
perative power seems to be lacking, and the whole
system appears to have collapsed — are unfavorable cases
and unlitted for the .severe regime of tlie ojien-air treat-
ment. Fresh air, of course, should be afforded all cases,
as to everybody else, sick or well ; but this can lie done in
a well-ventilated room, where the jiatient is made com-
fortable ami kept at rest. If some of these apparently
hopeless cases later exhibit more favorable symiitoma
and develop greater recuperative power, they then can
more properly be subjected to the open air treatment.
Lest there ma}' be some misunderstanding, it is well
again to state what may ,seem ,self evident, viz., that the
open-air treatment in all its rigorousness means practically
a continuous outdoor existence. Day after day in all
kinds of weather one must be exposed to the open air,
and the windows of his sleeping-room must be kept open
day and iiiglit. sumnuT and winter. This does not mean
that one shall sit out in a rain or snow storm, but on a
veranda forexamiile, which affords .shelter from the storm
and wind and yet is open to the air. The writer, for ex-
ample, had a patient at Ruthind, Jlass., wlio, during a
New England winter, spent eight hours daily out of
doors, always slept in a cool room, with open windows,
and bathed his chest every morning with cold water.
In Colorado Springs it is i|uite generally the custom
for consumptives to sleep (nit of doors, even iu winter,
with face and body well protected. This is more readily
done in warmer climates, as in Pliamix, Arizona, for ex-
amide, where the practice is quite general. It is also a
]U'actiee, with some, to sleep with the head out of doors,
well protected, while the body is within. As a rule, the
vitality and bodily vigor of a consumjitive are low, and
hence the greater |iart of the time out of doors is spent at
rest, best on a leclining or ship's chair. One of the com-
mon sights at the German sanatoria is the " Liegehalle "
or piazza, where are long rows of patients in reclining
chairs. Dettweilcr insists upon almost comjilete rest in
the open air, while other phthLsio-therapeutists permit
their patients who have no fever to take a limited amount
of exercise. As has been said above, a well -eij nipped
sanatorium affords the best opportunity for taking the
open-air treatment, and medical sujiervision is always at
hand to insist upon it ; at the same time it is practicable,
in very many cases, to devise at the home of the patient
an arrangement for this treatment. A properly protected
veranda, preferably facing the south ; a tent with a
wooden floor; a country hain with the large doors open;
a shed or wooden chalet simply and cheaply constructed,
serving also as a sleeping-room b_v night; — all of tlie.se
afford opportunities for the "treatment.'' If the physi-
cian is at all ingenious lie will readily invent some way
by which this can be accomplished, for there is almost
always something in or about the patient's house that can
be utilized for this purpose.
It is hardly necessary to .say that a iiatieiit used to an
indoor life, as the great majority of them are. must be
somewhat gradually accustomed to a constant open-air
exposure, but it is marvellous how iierfectly they estab-
lish the habit, and how coin]ilete is the endurance which
they attain. Knopf ("Prophylaxis and Treatment of
;!(!2
REFEKENCE HANDBOOK OF THE MEDICAL SCIENCES.
Onj-ohia.
Oplithalmometer.
Pulmonary Tuberculosis ") quotes Andvoid. of Tonsaa-
sen. Norway, as saying that he leaves his patients on
their chairs, wrapped in furs, for from live to uiue hours
a (lay at a temperature of 2.5" C. (— 13' F.).
The number of hours during which the patient remains
out of di>ors depends largely upon the location and lati-
tude of the resort. At Davo.s, for example, the sun rises
late and sets early, on account of the surrounding moun-
tains, so that a winter's day is only aljout four or live
hours long. In Falkenstein the patients remain out of
doors for from seven to ten hours a day all the 3ear
through; at Rutland, Mass., for about eight hours; at
Colorado Springs for from seven to eight.
The effects upon the jiatient of this prolonged stay in
the open air are striking. Appetite and weight increase;
cough and expectoration diminish; and if there is any
rise of temperature at any part of the day, this is likely
soon to disappear. The patient also experiences a sen.se
of well-being and invigoration, together with mental ex-
hilaration. After a course of open-air treatment one is
no longer content to live indoors or sleep with closed
windows.
It may be pertinently asked if patients do not catch
cx)kl under this constant open-air exposure. On the con-
trary, experience has proved that they are le.ss likely to
do so than when they live under constant protection with
the consequent unavoidable exposure to imimre air. The
constant exposure to pure germlcss air, however cold,
when one is properly clad, docs not render one suscep-
tible to catching cold, as Nansen so .strikingly proved on
his Arctic expedition.
In conclusion, it is well to reiterate that the open-air
treatment is not the whole treatment of pulmonary tu-
berculosis. In addition, there must be an abundance of
nutritious and properly prepared food; rest; a most care-
ful avoidance of over-exertion either mental or physical ;
moderate exercise under careful supervision, and in suit-
able cases; and due attention to the skin by the use of
various hydrotherapeutic measures. In brief, all the hy-
gienic mea.sures conducive to the invigoration of the gen-
eral system, must be adopted. Edicnrd O. Oth.
OPHTHALMIA, PURULENT. See ConjunrHi;i. Aff.c-
tiiihs of.
OPHTHALMOMETER.*— An instrument for measur-
ing the curvature of the refracting surfaces of the eye.
Thomas Young (1801)' was the first investigator to at-
tempt accurate measurements of the curvature of the
cornea in the living eye. By measuring the diameter
and the prominence of the cornea, he found the chord
and versed-sine of an arc of a corneal meridian ; from
these data he calculated the radius of curvature.
Young's estimate of the curvature of the cornea agrees
very closely with the results which have since heen ob-
tained by more refined methods.
Kohlrausch (1X40)- measured the image of a distant
object viewed by refiectinu at the anterior surface of the
cornea, as in a convex mirror, and thus laid the founda-
tion of ophthalmometiy in the moilern sense. The ob-
ject used by Kohlrausch was a pair of candle tlames
placed behind small openings in an opatjue screen. The
images of the two bright points were viewed through a
small astronomical telescope, constructeil fur obserxing
at a distance of from two to three feet, and their posi-
tions marked by two adjustable spider lines in the eye-
piece. The length of the image (distance separating the
images of the two points of light) was then read, through
the telescope, on a finely divided scale jilaced as nearly
as possible at the distance at which the image had been
observed.
Now the object and the image lie at conjugate foci iif
the cornea, considere<l as a convex mirmr. and the rela-
tions of the two focal di.stances is expressed by the equa-
tion
* The writer de.sires particularly to aoknowleds^e his indebtednt'.'^.s to
Dr. John (ireen, of St. Louis, for assistance most kindly rendered in
revising the present arliclf for the press.
1
/■
-
1
2
" r '
_
o
f
/■
■-'•■■/-/■• (^>
in which
/■ = the radius of curvature of the cornea;
/= the distance of the object from the surface of the
ciirnea;
7' — the distance of the image from the surface of the
cornea.
As the observing distance is taken at between two and
three feet, and the object is stationed at as great or at a
greater distance,/ is quite large in comparison with/':
it is admissible, therefore, without sensibly affecting the
accuracy of the equation, to disregard/ in the clcnomi-
nator of (1) and to write the equation in the simplified
form ;
r = 2fj^.=2f.* (2)
Again, the length of the object is to the length of the
image in the ratio of their respective distances from the
centre of curvature of the convex mirror (cornea).
Designating these distances by i/andi/' respectively,
we have
g ' length of image
g ~ length of object
But g' = r-f
and 9 = r -)-/"
wlience r — f length of image
;• +/ length of object '
length of image
'•-/=('•+/)
length of object
(3)
In the right-hand member of (3) neglecting r, which is
small compared with/ and in the left-hand member of (3)
substituting for/" its value -i r derived from (2), we have,
as a sufficiently close approximation, the simplified equa-
tion
,, ^ o ^ length of image .^ ^^^
~" ' length of object
' To test the error involved in the use of this siniplifled equation,
compare the values of r derived from (.1) and 12) in a special case.
For example :
Let / = 0.8 metre = 800 millimetres,
Let/' ~ 4 millimetres,
then by (1)
r = IGOO . -^ = 2.01 /' :
and by (2)
796
'■ = ■««»• W = 2-"«^'-
The value of r by (2) is therefore too small by 0.01 /' = 0,01 X I
millimetres = O.Ot "millimetre, which is within the limit of error in
observation.
t To lest the error involved in the use of (4) compare the values of
r derived from ('3) and (4), in a special case. For example, as in the
previous note :
Let f = 0.8 inelre = SOO millimetres.
Let/' = 4 niilliiiiftres.
Then by (3) [using for r in the ritrht-hand member and for/' in the
left-hand member their values as given by (1),]
'■ ,„„.^ , ^r.-. lencrth of imaffe
r - :r—T = 800+ 8.04 , , — .,. , , . , milUmetres,
2.01 length of object
whence
,™,o r^ length of image .„.
r = 1608.08, .. — . .,, ,. millimetres.
and by (4)
' length of object
,„__ length of image .,,.
r = 1600, ; — =— — - — rr^ millimetres
' length of object
The value of r by (4) is therefore too small by
-ri;—: = 0.003 = about H per cent
loiH)
It should be further remarked that the use of the eiiuatlon
-1-1 = 1
/' / '■
is permissible onlv on the assumption that the diameter of the convex
surface at which rays are reflected to form the virtual image is small
3G3
Ophlhalinometer,
Ophtbalnioinetor.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
a_
oTl:
The results obtained by Koblraiiseh, also by Senff
(1^46). ^ who canifd the investigatimi somewhat further,
correspond very closely with measurements wliieh are
now generally accepted. The later development of oph-
thalmometry has been in the direction of perfect-
ing: the instrument for purpo.ses of seientitic in-
vestigation, and of adapting it to clinical use.
The ophthalmometer was perfected, as an in-
strument of seientitic research, by Ilelmholtz
(18.54). ^ Willi the addition of a large graduated
circle, arranged to carry lamps, it was employed
by Donders and JMiddh-l)urg to measure the curva-
ture of the cornea in different meridians.
The ophthalmometer of Ilelmholtz is essen-
tially an adaptation of the heliometer of Clausen
(1841). * A divided plate of thick glass with
parallel surfaces is mounted in a cubical box
fixed in front of the objective of a small astro-
nomical telescope constructed for observing at a
distance of from 0.5 metre to 1 meter, so that
each lialf of the glass plate covers half of the ob-
jective. The two halves of the divided plate are
arranged to turn in opposite directions
on a coninion a.\is at right angles to
the axis of the telescope, and the
amount of rotation is read to tenths of
a degree on a graduated disc fitted with
a vernier. So long as the two halves ,f
of the glass plate are in the same
plane, perpendicular to the axis of the
instrument, an object seen through the
telescope appears without displace-
ment and single; but any rotation of
either half of the plate gives rise to a
displacement of the image formed by
the corresponding half of the objec-
tive, and this displacement increases
with the rotation. As the two halves
of the plate are rotated simultaneously in oppo-
site directions the displacement of the images is
also in opposite directions, and the total displace-
ment is double what it would be if either half of
the plate were rotated separately through the
same angle.
The object (three points of light dispo.sed in a
row) as seen by reflection at the surface of the
cornea is focussed by the telescope through the
glass plates in the zero position — i.e.. with both
plates set at right angles to the line of vision.
The graduated disc is then turned until the two images
are seen touching each other, but not overlapping, in
which position of the plates the displacement of each
image is exactly equal to half the length of the image.
The amount of displacement (j) of either image de-
pends ou the index of the refraction (») of the glass of
d Z 1
as the displacement of each image is equal to half the
length of the image, we have
length of image = 2 j = 2 A
sin {(j> — <;>')
(■'■>>
C In practice all calculation is dispensed with liy
„„7 — T-;niaking use of a table of successive values of 2 ./•
; corresponding to different readings of the ophthal-
mometer, as ascertained by experiment.
• As the distance of the object is quite large in
• comparLson with the radius of curvature of the
I cornea, it is admissible to calculate the latter by
j the use of the simplified e(iuafion
(4)
'■ = 2.f.
length of image
^
0
FIG. 36.34.
■which the plate is ma<le, the thickness (//) of the glass
plate, and the angle (o) through which the iilatc has been
rotated as expressed in the equation
■h
nin {(} — <p')
cot< ^
the value of*' being dependent on that of 6, as expressed
in the equation
sin li = n. sin (p'
in comparison with the radius of the sphere. This itnphes that the
image must be stiiall in cnmpiirisoii with tlie nuiins of rurvature of
tliH cornea, or, what amoiuu.s in tin- same tliinc, that the ohje<-t must
be small in comparison with its distance from the observed eye.
length of object'
Fig. 3633 shows the arrangement and the work-
ing of the glass plates, n' c' and (/ " r'\ represent-
ing the image n, r, as doubled by the rotation of
the two plates in opposite directions.
Fig. 3634 shows the arrangement of the three
lights, whose tlouble images are viewed by rellec-
tion at the surface of the cornea: the
image of 1 is brouglit by the rotation
of the plates into a position iiiid-
way between 2 and 3, as shown in
Fig. 3634.
It will be seen from (5), also from
insjiection of Fig. 3633. that the size of
the image is determined by the amount
of rotation of the plates as indicated by
the reading of the graduated disc, and
is independent of the observing dis-
tance; also that, from the ])rin(ipli' of
construction of the o]ihtlialmonieter,
the measurements may be made with
great accuracy and without being
materially impeded by slight movements of the
observed eye.
Helmholtz also made direct measuremeiit.s, with
his ophthalmometer, of the real image of a pair of
lights as seen by reflection at the jiosterior sur-
face of the crystalline lens, and by an ingeniously
devised indirect nietliod he measured with the
same instrument the much fainter virtual image
formed by reflection at the auterior surface of the
lens. By repeated measurements made upon the
same eye in a state of accommodative relaxation
and in accommodation for the near, he obtained
the necessary data for calculating the radii of curvature
of both surfaces of tlic lens in each of these two con-
ditions. The measurements of Helmholtz were repeated
with some modifications of the technique by II. Knapp
(I860).' Knapp also measured the curvature of the
cornea, mostly in the horizontal and vertical meridians,
in a series of cases of astigmatism (1862).''
To adajit the oidithalmometer to the measurement of
the curvature of the cornea in an}' required meridian.
FIG. .3635.
Donders and Middelburg (1863)' added a graduated cir-
cle, bearing lamps (see Fig. 3G3T). They measured the
curvature of the cornea in a large number of eyes in
twelve meridians, thereby adding greatly to what had
864
UEFK1{K.\( i: lIANDllooK OF THE MEDCIAL SCIENCES.
Opiitlialnio meter.
Ophtlialiuo meter.
Ijceii previously known lecarilinjr the different
loiins <if astitrmatisni.
Coeciiis (l.H(iT)' sulistitiiti'd a tixcil plate cut
from a doubly refracting ciystal of Iceland spar
for the movable fjlass jilates used by Ilclniholtj'..
The amount of displacement of the iinafre fonnec'
by IIk' extraoi'dinaiily refracted rays is deteriniued
by the thickness of the plate, and is constant; the
size of the ol)ject (distance separating the lights)
is therefore varied, until the two images arc seen
to toudi each other without ovciiajiiiing. The
radius of curvature of the cornea is I'oiiud from
the sini]ililie(l e(|Uation :
at the centre of curvature of the arc. A
more exact adjustment of the distance is
then secured by moving the telescope,
with its stand, until the doubled images
of the two targets are seen sharply de
lined liy reflection at
the surface of the cor-
nea; the telescope is
constructed for dis-
(4)
2/.
length of image
length of object.
The ophthalmometer of Javal-SchiOtz
(1881)'° is espi'cially designe<l for the clini-
cal investigation of the curvature of the
cornea in all meridians, and is admirably
adapte<l to its purpose. Two strongly illii-
miiiated targets (mires) of white enamel re-
place the lights, and the doubling of tlie
image is ctTected by means of a doubly re-
fracting prism of Iceland sjiar, which is
achromatized, and at the same time a little
more than neutralized for the ordinaiy rays
by tlic addition of a ]irism of tliiit glass
turned in the o]iposite direction. With this
conslruclion of the juism. tbi' two images
of the pair of targets, formed, the one liy the ordinary
and the other by the extraordinaiy rays, are displaced
equally in opjiosite directions; the aggregate displace-
ment of the imai;es for the distance at which the eve
Fig. Sti.'ir.— Ophtlialmonicier of Javal-Schir.tz. Original Model.
tinct vLsion at the distance of the image, wliicli is formed
about 4 mm. behind the centre of the cornea. The
doubly refracting prism is in the jiartof the tube marked
(r IC and the meridian in which the arc and targets
stand is read on tlie graduated disc at E. The eye
imder examination is directed upon the end of the tele
sei)]K-; the other eye is covered by the pivoted screen P.
.Vs the effect of the doul)ly refracting jirism (at the con
stant distance, /■=0.33 metre, of the targets from the
eye) is to separate the two images exactly 3 mm., it is
evident that when the length of the object (chord MM,
se|)arating the outer sitles of the two targets) is so ad-
justed as to allow the two images to touch each other
without overlap]nng, the length of the image must be
just ;i mm. We have then, a|)i)ro.\imately.
(1)
2/.'J^' = 700,
"object
'2U)0
chord M M
chord J/. y
millimetres.*
millimetres.
is observed is 3 mm. The two targets {MM. Fig. 3637).
are arranged to slide on a graduated arc of O.3.") metre
radius, turinng with the tube of the telescope. The head
of the patient is supported by the bead rest, so tliat the
centre of curvature of the cornea shall lie approximately
It will be observed that in this solution, 2/( = 2 x
II ;i.~> metre = 700 mm. and iiiiiige (= 3 mm.)are constants.
* II will liH reinarlii'd tliut. hv llie ronstnielion of \\\p .laval-SeliiOtz
.i|ihttiiiliiic.iiiitir. the dislainv of tlie tari-'t'Is fnini II lisiTVed eye la
lallirr' small, and the iniaL'e is rather lartje in eoiiipariSMii with the
ladiiis of curvature of the i.uruea isee pane ;i(j:!, fiiutimle). In the
iisr of eipiatlen (4) there Is. therefore, a eousiderahle ihart;rln of error,
ilii>iit:ti not enough to detract from the usefulness of the instnuuent
in rlinii-al work.
It will lie remarked that r, hy this solution. Is the radius of a cin-ular
an- whost^ ehord measures 3 mm. which are is assumed to be of the
^aniH curvalnre as a section of the corneal surface by a plane passed
ihronu'li the \isiial axis and the axis of the telescope. But the cfinHg-
iiiaiion of the roTiiea Is approximately that ttf a segment of a pro
late ellipsoid, and supposing the axis of this ellipsoid to coincide
Willi the axis of the ielesio|pe, r will lie the nidius of a circle whose
riit\alniv is eciiial to that ofthe elliptii-al secli.mof the cornea at the
two points in which the diiection of the ivtliiting surface determines
the length of the image, i.e.. at two opposite points on the elM|isoid
each 1..1 mm. distant from its axis. I'nder these conditions it is evi-
dent that r will be greater than the radius of curvature of the cornea
at its centre.
As a rule, the visual axis does not coincide with the axis of the
corneal ellipsoid, but makes an angle with it (angle a), which angle
Is sometimes as great as 12°. The axis of curvatuie of the cornea is.
therefore, not ordinarllv In a line with the axis of the telescope, and
the two points in whii'ii the direction of the corneal surface deter-
mines till' length of the itnau'e are not symmetrically placed with
n-fen-iire to till- axis of the ellipsoid. As the curvature of the ellip-
.soid at these two unsyiniiietrtcal points is unequal, it cannot be repre-
sented liv a spherical surface. In any case, however, the value of r
by eipiaUon (4i is greater than the radius of curvature of the cornea
at its centre.
Stio
Ophtlialmometor.
<>l>litlialnioNcopo,
REFEKENCE IIANUBUUK OF THE .MEUUAL SCIENCES.
cousequently r (the radius of curvature of IIk' foriica) is
!in inverse function of the chord M M' . The length of
this cjiord is read from the irnui nation on the arc. Tlie
radius of curvature of the cornea in dilfereut meridians
Object.
Fig. 36:i8.— (7, Tbe Targets; h, tlieir corneal images as seen through
the telesi-ope without iuterventlon of the prism of Iceland spar.
maybe calculated frimi mcasurenientsof the chord .V ,1/ ,
made after turning the telescope, witli the arc and tar-
gets, about its a.xis.
The great value of the Javal-Schiotz ojihthalnioiueter
is in its remarkable adajitation to the detection and meas-
urement of eoiueal astigmatism, and for such examina-
tion it has won general recognition as uidispeusable to
the ophthalmic practitioner. In astigmatism the essen-
tial thing to be considered is the difference in refraction
iu the two ]M'ineipal meridians, and it is for the measure-
ment of such differences in the corneal curvature that
the iustrument has lieen I'specially designed. In tlie use
of the ophthalmometer the length of the oljject (choril
MM) remains unchanged througliout the observation
of the eye in its two principal meridians, and it is only
the difference in the length of the image wlien the arc is
adjusted successively for the corneal meridians of great-
est and least curvature that is regarded. The observa-
tion consists iu simply noting the aiuount of overlapping
of the two images iu the second i)Ositiou of the arc, after
Iiaviug lirst brought them into exact contact iu the first
position.
The device for reading the amount of overlapping of
the images is shown in Fig. 3t)S8, //. The outer side of one
Fig. yt)39.— Corneal Images as Seen Thniugh Telescope and Prism.
Double images iu touching position.
of the rectangular targets is cut in the form of steps of
such width that each step approximately represents a
difference of corneal curvature corresponding to 1 D of
ocular refraction.* The number of ovcrlajiping steps is
* Ina.srnuch a^ different eyes present considerable variation in cor-
neal curvature, necessitating a corresponding variation in the separa-
tion of the targets in order t(t bring tlieir images int^t exact c<.ntact, it
is evident that a step on the target does not always re)>rcsent tbe same
fractional part of the chord 3/ 3/'. In tbe case of a relatively flat cor-
nea the targets must be set nearer together, and each step will then
taken as the number of dioptrics of astigmatism attribu-
table to inequality of curvature of the cornea iu its two
principal meridians.
Fig. i!l)39 shows the doubled images of the targets in
the jiosition of contact; in Fig. 8(i4() the same images are
shown with two .steps overlapping, indicating 2 D of
corneal astigmatism. It will be observed that in both
these positrons tin' images are rectangular, also that they
lie exactly in the same line.
This rectangular form and linear direction of the im-
ages of the four targets is seen whenever the curvature
of the cornea is symmetrical with reference to the plane
of the arc. When the cornea is a surface of revolution,
with its axis passing through the centre of the arc, this
condition is fulfilled f(u- all positions of the targets; but
when the cornea is of a coutiguration approaching an
ellipsoid of three unei|Ual axes, the position of the arc
□
□
Fig. 3640.— Overlapping of Double Images — As = 2 D.
rau.st be such that its plane shall bisect the ellipsoid in
one or the other of its two principal planes. In all other
positions of the arc the images of the four targets appear
more or less distorted, and the images of the two pairs of
targets are not in the same line (see Fig. 3641).*
This distortion and oblique displacement of the two
images, in all but two po.sitions of the arc, reveals at a
glance the jiresence of corneal astigmatism. To find the
meridian of greatest corneal curvature, the arc is turned
until the images are seen iu a line and most wiilely scjia-
ratedf The two targets are then moved inward or out-
ward on the arc until the images arc brought into the
position of contact. Lastly, the arc is turned through
an angle of 90', or until the images are again seen in a
line, and the number of overlapjiing steps, which repi-e-
D m D
Fk;. 3(U1.— Double Imae-ps ni>I on a Level—Astigmatism Present.
Are not, in n principal meridian.
seats the number of dioptrics of corneal astigmatism, is
noted. Tlie examination of the two eyes need not con-
sume more tlian two or three minutes. ,
The measurements of corneal astigmatism as made with.
the ophthalmometer agree remarkably, in most cases,
with the results obtained b\' the use of methods wiiich
show the total astigmatism of the eye. The agreement
in the direction of tlie principal meridians is esj^ecially
close, so that in b\- far the greater number of cases the
direction of the a.xis of the correcting cylindrical glass
may be taken directly from the reading of tbe instrn-
represent a larjrer fractional part of the chord 3/3/': conversely,
when the cnrnea is of greater than average cnrvaturv the tarpets
must beset wider apart, and each step will then represent a smaller
fractional part nf the same chnrd. It follows that in llif former case
each overlappintr ^ti'p in the tmace imist represent soini-what mnre."
and In the lattrr 'ii-^e, .smiu'What less, tlian 1 D of rorn<*n! aslitrnialisin.
It is well. Ilierefnrt*. always tn nnit' the length of the clmrd .1/ M', so
that a correctir.tn can he made for it if deemed necessary.
• For an analysis of the phenomenon of distortion of the image
formed by a mirror of asymmetrii'al curvature, also of the same phe-
nomenon as it <x-curs in the case of a lens of asymmetrical refraction,
see a paper by the writer: "Fin Beitrap zur Theorie der Cylinder-
linsen," (iraefe's Archlv. 1887.
+ Bv interchaiiirinL' the tarirets the imapes may be brought into the
positinn of roiifatt whfTi ttu- arc is set in the meridian of least corneal
4-urvature. and the itverlappinp steps counted in the second position of
the arc ; in pnictlce this is found tube more convenient, for the rejison
that the meridian of least curvature is, as a ruli-. approximately hori-
zontal, and it is easier to adjust tbe tarpets in the lji>rizontal and to
observe the overlapping of the images iu the veriical meridian.
5G6
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Opiillia lino 111 oter.
Opiitlialiiioscope,
ment. In respect to the grade of astigmatism the agree-
ment is less exact, for the I'eason tliat tlie observed cor-
neal astigmatism is often modified by an astigmatism
attributable to an olilique position of the crystalline len.s.
As a rule, the meridian of greatest corneal curvature is
Fig. 3643.— Javal's (iptitliiilTii. ni. 1. 1 with Attaohment for Electrical
Iliumiuaiiuu uf the Targets.
appro.ximately vertical, and the meridian of greatest len-
ticular retraction is appro.ximately horizontal ; the total
astigmatism is therefore generally somewhat less than
the corneal astigmatism when the meridian of greatest
corneal curvature is approximately vertical, and greater
when, contrary to the rule, it is approximately horizon-
tal.
In a comparatively small number of instances the total
astigmatism is found to vary very widely from tlie cor-
neal. For example, a relatively high grade of lenticular
astigmatism may so far dominate a corneal astigmatism
as largely to control both the direction of the principal
meridians and the grade of the total astigmatism. Again,
it is not uncommon to tind a low grade of astigmatism,
oftenest with the meridian of greatest refraction horizontal
or nearly horizontal, in the absence of corneal as3-inmetr_v.
Lastly, the ophthalmometer occasionally reveals an anom-
alous condition in which the corneal meridiansof greatest
and least curvatures are not at right angles to each other.
Not only has the Javal-Schiotz o])hthalmometer greatU-
advanced our knowledge of astigmatism, but it affords,
also, most important special information in every case of
investigation of the refraction of the eye.
The instrtiment-maker Kagenaar (Utrecht, 1887)" has
somewhat cheapened the original Javal-Schiotz ophthal-
mometer by substituting a |iair of weak glass prisms,
turned in opposite directions, for the doubly refracting
prism of Iceland spar. Leroy and Dubois (188^) '- have
also produced a low-priced oiibtbalmnmeter, in wliich
the doubling of the image is elVected by means of two
plates of thick glass as used b.y Helmholtz. In a sec-
ond and newer model '^ (see Fig. 3lj42) the shape of the
targets has been somewhat altered; and the diiection of
the meridians of greatest and least corneal curvature is
read on the reflected image of the darge disc which now
constitutes the most conspicuous feature of the instru-
ment. Carl luillei:
Bibliography.
■ Ptiilosojihical Transactions, 1801.
' Oken's Isis. 1S«1.
' Warner's Hnn<iwr.ri<'rbuoti der Physlologie, iii., 1.
' Arcliiv fiir iii'litlialiii"lni.'ie. 1. 2.
' Aslrnnonilsilie Nailim-htiMl. Nu. 4U.
• Ardiiv fiirOphtliaiiiMilnuii-. vi., 2.
' Archiv fur OplitlialnicplciL'ii'. viii.. 2.
' Jlidilelburg: De Zitplaats van bet astigmatisme, Utrecht. 1863.
" Coccius : Ueber den Mechanismus der Akkommodation des
menschlicUen .\u!J'hs. Lnipzitr. 1>^»7.
'» Annalfs d'liiiilisti.iuc l.xx.wi.. Juillpt-Aoilt, 18S|.
" Nederlandsch Tijdschnft vcmr Ueneeskuude, 1889.
'- Revue penerale d'optitahunldirie. vii., 2.
'^ Bulletin de TAcadcune de M^decine de Paris, 27 Aofit, 1889.
OPHTHALMOSCOPE: OPHTHALMOSCOPY,— fn.m
oipHa'/./ioc:, eye, and oku-ii.>, tn view. 'I'lir npiitliiilmosco))e.
German, (//;■ Aiigeiispief/e/. is an ojjtical device by means
of which the interior of the eyeball is rendered visible.
Ophthalmoscopy, in its « ider meaning, includes what-
ever pertains to the objective examination of the eye; in
a narrower sense, it is restricted to tlie examinationof the
interior of tlie eye by the aid of the ophthalmoscope.
The anterior segment of the eyeball, comprising the
cornea, the anterior chamber tilled with the aqueous hu-
mor, the front of the iris, and so much of the anterior
capsule of the crystalline lens as corresponds to the area
of the pupil, is accessible to direct inspection bj- the
naked eye, or through a magnifying glass. Even when
the pupil is strongly contracted," a cental opacity of tlie
lens capsule or of the immediately subjacent lens sub-
stance reveals itself bv a characteristic white or gray aji-
pearance. AVhen the puiiil is widely dilated, weniav
look deeply into or through llie ciyslalline, and may ob-
tain glimpses of a detached and disidaced portion of the
Fiii. ;mt.
retina, of a blood clot or other large foreign body in the
vitreous, or of the surface of a very prominent tumor
arising from the retina or choroid.
Let L (Fig. 3643) represent a pencil of parallel rays
emanating from a distant source of light and entering
the dilated jiupil tt a of the eye 0, so as to light up a
Fig. 304.5.
path through the vitreous, indicated by the cone n a' I.
The eye of an observer at A' will receive rays from any
object which may happen to lie within that portion of
this cone, near its base, which is bounded by the line
(I ii" . Outside of the limits n n n ', the whcile interior of
the eye is either in comparative darkness or is shut off
from view by the iris at a, a . If the pupil is contracted
367
0|>hllialni<»ei4>opi>,
OplithalnioM-upe.
KKFEKKNCE UAMHiooK OF THE MEDICAL SCIENCES.
to tlic diameter h h' , only siicli part of the pencil L as is
iiicliided within tlie dotted lines ean enl<'r the eve. and
only such objects as happen to lie within the smaller
If we annul the refrartion at the cornea by plunginsf
the iK'ad of an animal under water (Fii;. 3()47). the eyes
will be remlered ver}- strongly hypermetropic, and the
cone/'?/ ? will be illuminated; of this smaller eoiie the
greater portion is shut off from view by the iris at //, // ,
so that nothing can be seen outside tjie narrow limits
b fi' t)'. If we take the angle /, (> E smaller
(Fig. 3644), the points' will fall farther back
in the vitreous, and it will be possible to see
more deeply into the eye.
When the angle f, 0 AMs taken very small,
approaching zero (Fig. 3(i45). the illuminated
point I falls within the area e e . which re)i-
resents the field of view commanded by the
eye of an oliserver at A'.' luminous rays from
; will then enter the eye h\ and the pupil of
the eye 0 will be .seen lighted up — iliw Aiigen-
leuehten. The particular case indicated in
Fig. 3645 is. however, impossible, for the rea-
son that, in the assumed position of the ob-
server's eye, his head is necessarily interposeil
between the source of light and the observed
eye. For this reason, when two jiersons look
eiich into the eyes of the other, the pujiils (jf
all four eyes appear bliiik.
When the refraction of thi' oliserved eye 0
is hypermetropic, the illuminating pencil is
cut by the retina before reaching a focus (Fig.
3646), thus lighting up an area at the fundus
which will be larger or smaller according as
the pupil is more or less dilated and the pen-
cil is cut by tlie retina at a greater or less dis-
UiDce from ils focus. An observer looking
into the eye. at a very small angle to the axis
of the illuminating pencil, may receive rays of
light from this illuminated area, and will then
see the pupil of the oliserved eye ilbuniiiated.
To develoji this jihenomi iion liy daylight, the pupil of the
observed eye must be somewhat widely dilated, in order
both tliat the illuminatedareamay be aslar,ge as possible.
and that the iris at a, a' may cut oif as little as may be of
the view into the eye. The apiiearancc of a shining pu-
pil is best produced when the observer, with his back to
a window, looks into the face of another person, a few
feet away, whose eyes are directed toward a strongly
illuminated surface, such as a bright cloud in the sky.
Shining of the luipils is also very conspicuous, luider
particular condiliuns, in animals with ej'es <if hyperme-
tropic construction whose fundus isclothed by a strongly
reflecting layer — thetapctum. A familiar instance is the
glowing of the eyes of the cat, when the gaze of the ani-
mal, with jnipils widely dilated, is encountered by a per-
son entering a dark rixira with a lighted lamp. In jier-
sons with congenital or aeijuired absence of the iris —
iiniriflifi, iriihri mill — the eyes nuiy similarly be seen to
shine by lam))light. The viviil red color of the jiupils
of albinos is independent of the refractive condition of
the eye, and is a result of the lighting up of the whole
interior of the eyeball through the un])i.gmented and ab-
normally translucent iris and choroid; when the eye of
an albino is shaded by an opacjue card, the pupil, viewed
through a hole in the card, appears black, as in a nor-
mally pigmented e.ve (Donders).*
♦Ttie shilling of tlie eyes of certain animals in the dark \va.s, for a
long time, attribnted to a suppi^seil power of peiieratim; Iit;ljt. Pre-
Yost (1810) sbowed that tlie phenomenon i.s olwerved onl.v when the
eyps are illuminated by iipht falling directly upon them. Rudolplii
(181(1) called attention to the fact that it is necessary to look into the
eye in a particular direction. In aniridia in the human eye Beer
Fk;. aMT.
pupils may be seen to shine brightly by ordinary day-
light. In this experiment it is also possible to see some
of the details of the fundus through fhe widely dilated
pupil.*
If the observed eye is strongly myopic, the
illunnnating pencil will converge to a focus
(Fig. 3648) at some point in the vitreous hu-
mor, and, continuing on its course, will light
up an area 1 1 where it is cut by the i-etina. As
in the case of the hy])ernictro]iic eye, a por-
tion, e' I. of this illuniinati-d area will fall with-
in the field of view commanded liy the eye of
an observer at E, who will then see the luiiiil
of O lighted up.
If we take as the source of light a small in-
candescent electric lamp L (Fig. 3649), dark-
ened at the Viack antl sides, the retina of the
(unaccommodated) emmetropic eye 0 will in-
tcrei'pt the illuminating pencil before it reaches
its tocus, and a small area, I i, of the fundus
will be lighted u]). In thiscase, as in the cases
assumed in Figs. 3646 and 36-17, a considerable
liortiou, e !. of the illuminated area, I /', falls
within the region e <■', from which rays of light
can enter the eye of an observer at E. liehind
and a little to one side of the lamp, Inder
these conditions the pupil of O is seen strongly
illuminated. f
If we move the lam|i L nearer to the eye 0,
the angle L 0 A will become larger and larger,
and the portion e i of the illuminated area I i ,
falling within the field ee'. will become smaller
and smaller; whenever the angle L 0 E be-
comes so large that no part of I l coincides
with any jiart of e r , the pupil will cease to appear lu-
minous. If, however, wc lit a small refracting prism
1', to the incandescent lani]i (Fig. 36,5b), we may so
change the directioH of the illuminating pencil as to "turn
it upon the eye 0, as if emanating from L , thus permit-
ting an observer to look into the e.ve from E, at a very
small angle to the axis of the illuminating iiencil, even
though he approach to a distance of only a few centi-
metres from the cornea of the observed eye.
The most convenii-nt and effective way of lighting up
the fundus of the eye is by making use of a reflector.
This reflector may be made of unsilvered transparent
glass, in which case it may be set at an angle of about
forty-five degrees to the dii'cction of theaxis of the illumi-
nating pencil (Fig, 36ol). Of the incident rays, some are
(18.S9) saw tlie pupils red and shining when he looked at the eyes in
nearly the direction from which the light fell upon tticm ; W. t'uni-
ming (1846) and Briicke (ISt^ ) discovered. iiidc[ifndcnily of each
other, that the pupils of the uniniitilatcd human eye may be made to
shine under the same conditKins of illumination and inspection (cited
from Helmholtz ; " llaiidbuch der plivsiologischen (Jptik," llrst edition,
S. 189).
♦Mery (1704) first described Ibis experiment, in which probably the
first view of the bl i-ve>sels of the retina of a liying animal (cat)
was obtained. The visiliilitv of the details of the fundus in this ex-
periment was correctly iiscnbed by La Hire (1709) to the alteration in
the conditions <'f refr.iction. of wiii<-h. however, he failed to give an
exact ex|i|;iiiation (cited from Helintioltz. op. cif., s. 1901. By the aid
of the orthoscope of t zermak. a tittle trough of gla.ss, fixed to the
cheek and nose with wax, and tilled with water, the observation of
Merv may be repeated upon the luniian eye.
+ This arrangement of the light re[ire,seius essentially that employed
by Briicke i l.s47 I. Briicke used a lamp or a candle as the source of
light, and shut off the light from the eye of the observer by means of
a small opaque screen.
368
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
Ophtlialntoscope.
Oplilbalnioscope.
transmitted liy tlie transparent glass, and lost, -while other
rays are rejrularly retlected. and may be directed npnn tlie
pupil of the observed eye 0, as if they had emanatetl from
large convergent pencil from a greater distance (Figs.
36o7 and 3B.58).
If the illuminating pencil is made to pass through a
E- =
Fig. aJ4S.
L . So, also, in the ease of the efferent pencils, some of
the rays are lost by reflection in the direction of the light
L, while others are transmitted by the glass, to be re-
strong convex lens held in front of and at somewhat less
than its principal focal distance from the cornea of the
observed eye, a very large convergent pencil may be
Fig. a>49.
ceived b_v the eye of an observer looking through the
transparent mirror directly in the axis of the illuminating
pencil.*
A plane mirror of silvered glass, or of polished metal,
^
FIG. 3(530.
--•i^Eiu
may be substituted for the mirror of transparent glass,
with the double advantage of retlecting a much stronger
light into the ej'e and of permitting the lamp to be
]iiaeed by the side of and at any required distance
behind the patient's head (Fig. 36.52). An observer
looking past the side of the mirror, or. more conveni-
ently, through a small central perforation, sees the
pupil of the eye O more strongly illuminated than
■when an un.silvered glass mirror is used. The far-
ther the plane mirror is held from the observed eye
tlie smaller is the portion of its retlecting surface
from which rays of light can enter the pupil and the
weaker Ibe illumination (Fig. 3653).
By making use of a concave ^^
mirror held near the eye, we jj . ".:-.-.-.-.-:;;
may reproduce very nearly the
same conditions of illumination ■
as when the plane mirrnr is used (Fig. 3654), or, in- ;
creasing the distance of the mirror or of the lamp,
we maj' throw at will a parallel (Fig. 3655) or a con-
vergent pencil (Fig. 3656) into the eye. If we in-
crease still further the distance at which the mirror is
held from the eye, and from the lamji (Fig. 3657), a very
large convergent iiencil, reflected from the entire surface
of the mirror, may be thrown into the observed eye, and
when the lamp and the ]uipil of the eye, 0, come to lie in
conjugate foci of tlie niirmr (Fig. 365S), the size of the
illuminating pencil is limited oulv by the diameter of the
mirror, and the illumination at the fundus is correspond-
ingly intense. A concave mirror of very thin, silvered
glass, of a diameter of 33 mm. and a "focal length of
about 23 cm., with a central perforation of about 3.5 mm.
diameter, is found to be. on tlie whole, most convenient,
as serving both for such examinations as are required to
be made with the mirror held near the eye (Figs. 3654 and
36.56) and for tho.se in which it is required to reflect a
*The arrangement shown in Yig. 3<mI Is essentiallv that originally
employed (18.51) by Helniholtz, the inventor of the ophtlialmoscope.
Vol. VI.— 24
thrown into the eye and focussed at any desired distance
behind the coi tiea. With a convex lens of about 20 diop-
tries (5 cm. focus), held at a distance of about 4.5 cm.
in front of the cornea (Fig. 3659), the focus will lie in
the vicinity of the nodal point of the eye, and a large
area of the fundus, limited only by the angular diameter
of the convex lens, will be strongly illuminated.
If a weaker lens is employed, or if the lens of 5 cm.
focus is held nearer to the observed eye (Fig. 3660), the
focus of the illuminating pencil will lie at some point in
the vitreous humor, and the illuminated area at the fun-
dus will be larger or smaller according as the focus lies
farther from or nearer to the retina. When the focus lies
at a certain depth in the eye the diameter of the illumi-
nated area is further limited by the size of the puiiil, .so
that only a part of the illuminating pencil, corresponding
to a larger or smaller central portion of the convex
lens, can gain entrance into the eye.
If a stronger convex lens is used, or if the lens of
5 cm. focus is removed to a little more than its focal
distance from the observed eye (Fig. 3661), the focus
of the illuminating jieucil will lie a little in front
of the cornea, and the fundus will be illuminated
in an area ■which, as in the case assumed in Fig.
3659, is limited only by tlie
angular diameter of the con-
vex lens.
In all three positions, as
shown in Figs. 3659 to 3661,
nearly the whole of the illii-
niinated area of the fundus
falls within the field of view
commanded by the eye of an
observer at E. so that rays
emanating from a large area at
the fundus may enter the eye of the observer.
By combining the perforated concave mirror, of about
23 cm. focus, with a convex lens of 5 to 6 cm. focus (Fig.
Fig. 3(ai.
Fig. 3Cwi-3.
3662'), the maximum useful degree of illumination is at-
tained, together with the ability to regulate the diameter
of the illuminated area at the fundus by varying the dis-
369
Ophilialmoscope.
Ophtlialiiio8cope.
KEPEHENCE HANDBOOK OF THE MEDICAL SCIENCES.
tanco at wliioh tlie lens is lu-lil from the eye. The ob-
server lookiui,' through tlie central perforatiou in the mir-
found favor with some good observers. Other inventors
have employed a very small electrie bulb and mirror, both
L
FIG. 365.3.
ror. directly in the axis of the illuminating pencil, is
also in the most favorable jtosition for receiving rays from
the illuminated area at the fumlus.*
■-^l
^^:-:^
Fig. 3i).">t.
attached to the handle of the ophthalmoscope, or have
suppressed the illuminating mirror altogether.
A minor disadvantage in using oil or gas illumination
Fig. 3j».>}.
We have thus far, for simplicity of demonstration, con-
sidered the s<iurccof light as a luminous point, which we
have taken either at an intinite distance (Figs. 3643-3648),
or at some short distance, as indicated by the position of
the small electric lamp (Figs. 3649-3662), In practice,
however, we ordinarily make use of an oil
burner, in which case the area
of illumination at the fun-
dus corresponds to the in-
verted image of the flanre
(Fig. 3663). The maximum
intensity of illumination is
attained when the illuminat-
ing pencils are focussed e.\-
acily in the retinal image and
tlie i)U|iil is widely dilated.
The lamp ordinarily used
in ophthaluioseopic work is
an Argand oil lamp (the so-
called student's lamp — Figs. 367.5-3677), or an Ar.irand
gas-burner, with some arrangement for adjusting it to
the height of the patient's head. A petroleum lamp with
a broad tianie, or a bat-wing gas jet, may also tie used.
There is some advanta.sre in surrounding the flame by an
opaque screen, of metal or of asbestos, with an opening
Fig. 3fi.")0.
is the yellow color of the flame, which imparts to the
whiter portions of the fundus a somewhat unnatural tint.
The true color of the fundus
is best observed by indirect
sunlight, either from a bright
(doud or admitted into the
darkened room through a
hole in the window shutter
which may be glazed with ground .glass
or covered with thin white paper. Direct
sunlight is by far too intense to be .safely
thrown into the eye, even wlieu reflected
from an unsilvcred glass mirror; the light
of the full moon is insufficient, unless it
be concentrated by reflection from a very
large concave mirror.
The size of the bright image of the
flame is in an inverse ratio to the dis-
tance {LO, LO, L'O, Fig. 3663) of the
lamp from the nodal point of the observed eye, or,
when the plane mirror is u.sed, to the distance LE-\-EO
(Fi.gs. 36.')l-3653): when the illuminating pencils are im-
perfectly focus.scd, the ima.ge isspread (uit, at its borders,
in a width equal to the radius of the circle of confusion
in which any single pencil is cut by the retina. 'When a
^E
Fig. 3i;r)T,
of 2..5 or 3 cm. diameter. Many attempts have been made
to utilize dift'erent forms of electric lamps as substitutes
for oil or gas burners; a rather powerful incandescent
lamp with tlie bulb (d' ground glass, titled with a special
rheostat for controlling the intensity of the light, has
* The illumination by means of the perforated ooneave mirrnr. con-
joined with the einpluynient of the convex lens tit form an inverted
Iniatre of the fundus at or near its ant^^rior focus (Ruetf. 18,5-1, con -
stituti'S an invention second only in practical iinportance to that of
HelndKiltz. Fi^rs. :iH.")ii to ;3tlfil illustrate a develupnieut of Briicke'a
e.xpiTiuient, by lleluiholtz (1852,).
concave mirror is used, and the distance from the observed
eye is large (Figs. 3657 and 3658), the illuminated area is
practically the image of the mirror.
The e.\tent of the area at the fundus, which falls with-
in the field of view of the observer in the direct method
of examination — i.e., without the interposition of the
convex lens — varies directly as the size of the pupil of
the observed eye, and inversely as the distance from the
eye at which the observer is stationed; a fairly large pu-
pil and a near point of observation are therefore essential
to the enjoyment of an ample field. To secure a near
37(1
REFERENCE HANDHOOK OF THE MEDICAL SCIENCES.
4ft|ilitliaIiil<><<»<-opf.
4>|»li(lialiii4»Nr«»|»4'.
point of observation, we liold tlie ophtlialmoscopic mir-
ror as near as possible to the observed eye, and to prevent
contraction of tlie pupil under the stimulus of tlie light
retlected info the ey<'. we may inslil a droii (if a weak
In the indirect method of examination — i.i-., by the use
of the convex lens of about o em. foeus held at about its
focal distance in front of the observed eye — the size of
the pu]i!l plays a much less important part than in the
m}'driatie solution, or we may make use of a mirror
which reflects light of the minimum intensity compatible
with sutlicient illumination. If we employ a mydriatic
we choose, by preference, a .solution of cocaine (1 to 50), of
examination by the direct method, and in ri'itaiii jmsi-
lions of tlie lens it is almost completely eliminated as a
factor in determining the intensity of the illumination
and the amplitude of the field of view. This is practi-
Fin. 3659.
euphtbalmin (1 to .50). or of cocaine and euphtlialmin (1 to
100 each), either of which will suffleiently dilate the pupil
in the cour.se of from ten to twenty minutes, without sub-
jecting the patient to the inconvenience incident to the
eally the ease whenever Iiotli the foeus of the illuminating
pencils and the intersection, within the eyi', <il' Ihc^ lines
which defined the limits of the tiehl of view lie in or very
near the plane of the pujiil (Fig. 3662).
V]r.. :ii>(n.
prolonged mydriasis which follows the instillation of a
.strong solution of atropine, duboisine, or h3'oscyamine.
To reflect a weak light into the eye, we may use a perfo-
rated plane or convex mirror made of darkly tinted gla.ss.
Whenever the inverted image of the flame, at the
fundus of the observed eye, is smaller than and lies
wholly within the field of view connnanded by the
eye of the observer, the form of the image may be
or, still better, the original form of ndrror devised by
Ilelmholtz, which is made up of three or more plates of
thin, unsilvered glass. This compound mirror reflects
more light than a single plate of glass, and also polarizes
seen more or less distineily outlined, according as it
is itself sharply defined an<l us the refractive condition
of the observed eye is such as to admit of the elfeieiU
pencils being accurately focus.sed upon the retina nf
the reflected pencils; by its action as an analyzer, it also
extinguishes most of the rays reflected from the surface
of the cornea, which often interfere with the view of the
parts within the eye.
the observer. Outside of the limits of this bright
image, the fundus appears dark by contrast, although
in fact dimly lighted through the faint general illumi-
nation of the interior of the eve In' the bright image
1
O|>lllliallll4>»»<-o|ir,
OphtliallliON<>i>pc.
UKKKliKM K HANDBOOK OF THE MEDICAL SCIENCES.
itself, and also by a little ]i.i,'lit rcfleeted fmm the faee
of tlie observer.
When the ima.ce of llie llanie is larj;<T th;ii). and iii-
eludes the field of view, the entire visilili' area of the
fundus ajipears strongly illuminated.
When the (plane) mirror is slightly rotated, in any di-
rei'tion, the inverted inia>:e of the tlanie moves aeross the
fundus of the observed eye in the same direction. When
the observed eye is bypernietropie, or is focusscd for a
distance greater than that of the eye of the observer, the
apparent motion of the image is in the same direction as
its real motion; but when the ob.served eye is focussed
for a distance notably less than that of the eye of the ob-
server, the image ajipears to move in the ojijiosite direc-
tion. I'jion the observation of the direction of the ap-
parent motion of tlie illuminated area at the fundus, is
image, and indirectly, in the inverted image. In the di-
rect method of examination the eye of the observer is
brought very near to the observed eye, in order that the
field of view, as determined by the area of the pupil, may
be as large as possible (Figs. 36.51. 30.52. 3654. and 3656;
<•/. Figs. 36.53, 3655, 3657, and 3658). In the indirect
method the observer is necessarily statitmed at a much
greater distance, .say
20 cm. ornxire. beyond
the position of the in-
verted aPrial image
(Figs. .3067-3672).
In the direct method
of examination the vis-
ibility of the details of
the ftindus is afl'ected
in different ways ac-
cording as the refrac-
tion of the observed eye is normal (emmetropic) or ab-
normal (myopic or hypermetropic). These three prin-
cipal cases must be considered in order, the observing
eye being assumed to be emmetropic.
(a) The observed eye is emmetropic, and with relaxed
accommodation (Fig. 3604). Let a and b represent the
origins of two efferent jieucils. at two points within the
illuminated area at the fundus of the observed eye. As
both eyes are assumed to be emmetropic, the rays com-
J'
Fl(i. 3*Jli4.
liased a ready and very useftil method for the diagnosis
and measm-ement of ametro))ia (see Shadoir-Test).
In the living human eye the fundus appears ordinarily
of a vivid ivd color, which is the expres.sion of the color
of the blood of the choroiilal circidation showing thrinigh
and more or less mollified by the layer of hexagonal pig-
ment cells.* This color is most intense in albinos, very
bright in persons of blond complexion and light blue
eyes, consjiicuously darker in brunettes with deeply pig-
mented eyes, and least
intense of all in the
black races, in whom
the illumination of the
fimdus is often so
faint as to give off hut "i— ^j^
little light, except i ~~,
from the white disc of j
the o]ilic nerve and |
from the blood-filled /J'..--
vessels of the retina.
Under normal condi-
tions the red color is
almost wholly due to
the blood circulating
in the caiiillary layer of the choroid, immediately un-
<lerlying the layer of hexagonal pigment cells and hiding
the more dei'iily seated choroidal arteries an<l veins. On
this red background, which appears of a finely granu-
lated texture, the retinal arteries and veins show con-
s|iicuotisly, branching from the central artery and vein
on the nearly white optic disc (PI. XLVIL).
Under favoring conditions of refraction in the observed
and in the observing eye, the miiuitiT details of the fun-
dus are distinct!}' visible, both directly, in the erect
* After deatli tbe red color of the human fundus is losL
posing these pencils become parallel after refraction at
the cornea of the observed eye and, entering the eye of
the observer, are focussed at a and b' upon its retina,
where they form an invertW image h' a', equal in size to
n h. The observer looking through the pupil of the ob-
served eye sees the portion u b of its illuminated ftmdiis
in the erei't ]iositiou, and magnified as indicated by the
dotted lines drawn toward n" and b' .
{h) The observed eye is myopic (Fig. 3605). Let rt and
-.a'
FIG. 3803.
b again represent the origins of two efferent pencils. As
the observed eye is myopic, the rays composing these
pencils become convergent after refraction at its cornea
and would, if continued, converge to foci at a and /3.
Entering the e_ye of the observer they bike on increased
convergence, to cross at focal points in the vitreous,
from which they again diverge to be cut by the retina as
circles of confusion, thus forming a blurred image. By
the interpcisition of the concave lens ('. of a negative fo-
cal length ei|ual to the ilistance n C, the convergent pen-
cils are rendered parallel before they enter the observer's
eye, so that they can be focussed accurately in the points
CAL Sciences.
/ t
OPHTHALMOSCOPIC VIEW OF THE NORMAL FUNDUS OCULI.
REFERENCE HAJ^DBOOK OF THE MEDICAL SCIENCES.
Opiitlialnioscope.
UpIitUaliuoscope.
a' and b' at its retina to form a sliarply defined image,
somewhat larsrer tlian the objeet « h. Tlie concave lens
C, placed at the anterior focus of the observed eye-
about 13 mm. in front of its cornea — exactly corrects its
remains adjusted for parallel rays, we may interpose the
convex lens C, of a focal length equal to the distance a
C, and th\is render the divergent rays parallel before they
reach the eye. The convex lens C, placed at the anterior
^y
Fir.. 36m.
myopia, and is. therefore, equal to the concave spectacle
glass needed in distant vision. If the lens 6' is held a
centimetre or more in front of the principal anterior fo-
cus of the observed eye. as is generally the case in oph-
thalmoscopic examinations, the negative focal length of
the concave lens thus selected will be less than that of
the required spectacle glass, by just its distance from the
anterior focus of the eye. In low grades of myopia the
errorarising from a variation of 3 or 3 cm. in the distance
of the concave lens is inappreciable, but in the higher
grades (of 4 dioptrics or more) the distance of the con-
cave lens from the anterior focus must be added to its
focus of the hypermetropic observed eye. exactly cor-
rects its hypermetropia; if placed at a greater distance
from the eye than its anterior focus, this excess of dis-
tance must be subtracted from the focal length of the
convex lens. In low grades of hypermetropia small va-
riations in the distance of the convex lens from the eye
may be neglected.*
The details of the fundus of the hypermetropic eye,
viewed through a convex lens placed behind tlie ophthal-
moscopic mirror, are seen somewhat less magnified than
in the case of the emiiietropic eye.
In viewing the details of the fundus iu the erect image
FIG. 3G67.
(negative) focal lengtli. in order to insure the highest de-
gree of accuracy of which this method of examination is
capable.*
The details of the fundus of the myopic eye. viewed
through a concave lens placed behind the o]ililhalmo-
scopic mirror, are seen .somewhat more magnilied than
in the case of the emmetropic eye.
(c) The observed eye is hj-permetropic, and ivith re-
laxed accommodation (Fig. 3666). Let ci and b again
represent the origins of two efferent pencils. As the ob-
served eye is hypermetropic, the rays composing these
pencils emerge from the eye divergent, as if emanating
from points « and ,3 liehind the eye, and, entering the
eye of the observer, are rendered convergent, but not
the corneaand lensof the observed eye perform the func-
tion of a simple microscope. If we adopt the conven-
tional ruli' of referring the magnified virtual image to a
distance of 8 Paris inches (about 217 mm.), the enlarge-
ment will be rejiiesented very nearly by the ratio OIT : I.").
or about 14.5 diameters, in the case of an emmetropic eye
of average dimensions (Helmholtz).
Ametropia in the eye of the observer plays an impor-
tant part in affecting the distinctness of the view of the
fundus in the erect image. Thus a myope who. with
the unaided eye, can focus only divergent rays upon his
retina, do<"S not see the details of the fundus unle<;s the
observed eye is hypermetropic to a degree eqiiiv.dent to
or somewhat in excess of the measure of his own myopia.
:^Ep
FIcl. SOGS.
sufficiently to focus them at its retina. An imperfectly
defined image is therefore formed at b' a of somewhat
smaller size than the objeet (/ b. Here, however, the ac-
commo<lation of the observer's eye may come into action.
consciously or unconsciously, to focus the image upon
its retina, and thus a distinct view of the fundus at ii b
may be obtained. Assuming that the eye of the observer
• The use of a ('(incavi' lens tifliimt tlie mirror, of a negative powiT
sufficient t^i oorrpct, or sniiiH\vh;it to o\,.rcnrrt*ct. ttu' sum i-f thf mv-
opiaof the observed and Uie oUservmff eye, is apart of the on^jiual
invention of Helmholtz ilsol).
A liypermetrope, on the other hand, can, with relaxed
accommodation, obtain a clear view of the fundus of a
*Tlif prini-iple undiTlvlncr the nielhnd nf measuririi,' the refnieiive
condition of anv eve, t>v means of a enie-ave or el'n^■ex lens placed he-
hind tlieophthahu'osmpic mirror, is clearly sel forth in the lirst puhli-
cation of Helmholtz <I!S.51), but the practical employment of the
method on an extensive scale bepan with K. Jaeper llS.'i6). It wiuj
also earlv cultivated by Dondei^. and especially by Mauthner 11867).
Its peneral adoptii.n. as a part of the daily work of the ophthalmic
practitioner, dates from the introduction, by I.orinp (18(i9). of an in-
stniMient provided with a series of especially selected correcting lenses
arranged to admit of easy and rapid changes.
373
4>plilliaiiiio»»<-o|}<*.
O]>lillialniosrope.
KEFEHKNCK HANDBOOK OF THE MEDICAL SCIENCES.
tiiyo|)i<! cyi- in which tlic myopia iloos not exceed the
meiisurc of liis own hypermetroiiia. ami, by exerling his
aeeonimodation, he may be able to see the fundus of an
emmetropic or even of a liyi>ermetropic eye. A hyper-
verted real image (i a. An observer stationed at K. about
30 cm. beyond fi n, may accommodate for this real image,
and see the tiuest details of the fimdus sharply defiueil
and magnified, but in the inverted position. The prac-
Fk:. mat.
metro|)ic observer enjoys, therefore, a certain advantage
in respect of the facility" with which he can adjust liisac-
<-oinMio(l.:tion so as to sec clearly under (iill'crciii rcfi active
condiliorisof the observed eye, bul he labors under a spe-
cial (lisadvantiijLc when he attempts to measure its refrac-
tion, and this for the reason that it is generally impos-
sible for him either to estimate the degree to vvliich he
exerts his accommodation, or to control its exercise so
]icrfcctly as to hold it with even apjiroximate accuracy
at the |x>inl rc((nircd to make him virtually cnimelropic.
To obtain trustworthy measurcnienls of tlie refraction
by means of the ophthalmosco|ie by the direct method,
the hy|)ermetropic observer should first neiitrali/.e his
manifest hypermetropia liy means of the appropriate
convex glass, or else should subtract a quantity equal to
the measure of his Hm fi'om the value of the strongest
convex glass, or add the same quantity to the value of
the weaUcsl concave glass through which he is able to
see the details of the fimdus distinctly. Similarly, the
myopic obscrvr^rshoidd hist correct liis myo]iia by means
of a neutrali/inj: conca\<' irUlss. or else should sulitract
tical application of this method is greatly restricted by
the fact that it is adajilcd only to cases of myopia of
high grade, and that, at the best, the field of view is
very small. Moreover, the image is seen under very dif-
ferent degrees of enlargement, according as the myopia
is of a lower or a higher grade.
The indirect method is extended to the examination of
all eyes, irrespective of the state of the refraction, by
making both the illuminating and the efferent pencils
pa.ss through a strong convex lens, placed at about its
principal focal distance in front of the observed eve
(Figs. 3(!6S to 3(170; cf. Figs. :i(wi) to 3(i62). The effer-
ent pencils, whether parallel (Fig. 3(iGS), convergent
(Fig. 3669), or divergent (Fig. 3670), are foeussed by" the
convex lens either at its princiiial focus (in emmetropial,
a little within the princijial focus (in myopia), or a little
beyond the principal focus (in hypermetropia). An in-
verted image is thus formccl at or near the princijial fo-
cus of the convex lens, and may be viewed from a .sta-
tion E, taken at a distance of from 20 to 2.5 cm. beyond
the position of the principal focus.
a quantity equal to the measure of his myopia from the
value of the weakest concave glass, or adil the same
cpiantity to the value of the stningcst c<invex glass,
through which he is able to see the details of the fundus.
If the observer is astigmatic in any notable degree, he
will see the fundus in the erect image under the same im-
perfect definition as if astigmatism were present in the
observed eye. It is, therefore, essential to the highest
accuracy, in measuring th<' refraction by this method,
that the observer correct any astigmatism that may exist
in his own eye by means of the ap])ropriate cylindrical
glass.
In the indirect method of examination the observer
does not view the fundus itself, but an inverted aPrial
image of the fundus. The myopic eye forms such an
image at its far-point (pinifttnn n iiintiashiiuiii. r). Let n
and /' (Fig. 3G67) represent two points taken within the
illuminated area of a strongly myopic eye. and within
th<- lield of view of the observing eye at E. Inasmuch
as the points IT and i lie behind the princi|ial posterior
fo<-us of the observed eye, the iiencils originating from
these points emerge, respectively, from the eye as pencils
of convergent rays, to be foeussed at the distance of the
far point r, where they enter into the formation of an in-
The degree of enlargement of the picture of the fundus
in the inverted real image, when the convex lens is jilaced
at exactly^ its principal focal length in front of the nodal
point of the observed eye, is found by dividing the focal
length of the lens by the distance of the nodal iioint of
the eye from its retina (=1.5 cm. in the emmetropic
eye). With a lens of 4 cm. fficus the amplitication is,
therefore, 4:1.5 = 2.6; with a lens of 5 cm. focus it is
5: 1.5 = 3.3; with a lens of 6 cm. focus it is 6: 1.5 = 4; and
with a lens of 8 cm. focus it is H; 1.5 = 5.3. In ametropia
of the observed eye the second term in these several ra-
tios is either greater (in myopia) or less (in hypermetro-
pia) than the normal measure of 15 cm., so that the am-
plification of the inverted image is less in myopia, and
greater in hypermetro])ia, than it is in emmetropia.
In very high grades of myopia, in which an inverted
image of its fundus is formed by the eye at a very short
distance in front of its cornea, the convex lens must be
held very near the observed eye in order that it may take
part in the formation of the image. This implies tlic use
either of an excessively strong lens, in which case the de-
tails of the fundus will appear but little magnified in the
inverted image, or of a weaker lens, held at a distance
notably less than its focal length from the observed eye.
KEFEKENCE HANDBOOK OF THE MEDICAL SCIENCES.
<^plillialiiiosi-ope.
<»plitlialiiio8eope.
ill which case the boundaries of the field of view will be
irrcatly narrowed. In the highest grades of myopia a
iiiodilication of tlie indirect method of examination is,
therefore, to be preferred.
Fig. 3671 .sliows a greatly elongated eye, representing
a myopia of about 2") dioptrics, and, therefore, forming
an inverted image of its fundus at a distance of about -i
cm. in front of its nodal point. A convex lens of about
10 dii)|)tries power ( = 10 cm. focus) is held at about its
])rincipal focal length in front of the observed eye, and,
therefore, at a distance greater than that of the inverted
image. The observer, at E. views the image ,3 a through
the convex lens, and consequently sees it magnified by
at right angles to this meridian. It follows that, in
moving the convex lens farther from the eye, the size of
the inverted image increases in tlie direction correspond-
ing to tlie ocular meridian of greatest refraction, and di-
minishes in tlie direction of the meridian of least refrac-
tion, so that the o]itic disc is seen as an oval of progres-
sively varying form. In simple hypermetropic astig-
matism (Ah) and in simple myopic astigmatism (Am)
the change in the form of the inverted image of the disc
is the same as in mixed astigmatism, but the variation is
confined to the direction corresponding to the ametropic
meridian. In compound hyiiermet topic astigmatism
{H-|-Ah) and in compound myopic astigmatism (Jl-f
FlG. 3671.
the lens. In this position of the convex lens neither the
intensity of the ilUimination nor the extent of the field
of view is materially influenced liy the size of the pupil,
A convex lens of a focal length a few centimetres greater
than the distance of the image from the nodal point of the
observed eye, held at about its jirincipal focal distance in
front of the cornea, gives a fairly ample field of view, to-
gether with a convenient enlargement of the inverted
image. If the lens is moved nearer to the observed eje
— i.e., nearer to the place of the image— the field of view
will be more extensive and the amplification less; if, on
the other hand, the lens is moved farther from the eye,
the field of view will be less extensive and the amplifica-
tion greater.
luemmetropia of the observed eye the efferent pencils,
of parallel rays, are focussed by the convex lens at its
principal focus, irrespective of the distance at which the
lens is held in front of the eye. The amplification of the
image remains, therefore, constant for any particular
lens, whether the distance of the lens from tlie eye be
taken greater or less than its principal focal length. Only
the size of the illuminated area at the fundus and the ex-
tent of the field of view are affected by the change in the
])Osifi<m of the lens.
In ametropia, on the other hand, any change in the dis-
tance of the convex lens from the observed eye is attended,
also, with .some change both in the distance at which the
inverted image is formed in front of the lens and in the
amplification of the image. In hypermetropia, if we
move the lens farther from the eye. the amplification of
the image will be somewhat diminished. Conversely, in
inj'opia, any increa.se in the distance of the convex lens
from the eye is attended with some increase in the ampli-
fication of the image.
This change in the size of the inverted image in ame-
tropia gives rise to a characterisLic phenomenon in astig-
matism, namely, a change in the apparent form of the
disc of the optic nerve, according as tlie convex lens is
Am) the same change in form is observed as a result of
unequal increase or decrease in the two principal merid-
ians.
This change in the apparent form of the inverted image
of the optic disc in astigmatism is necessarily attended
with some indistinctness of outline, but tliis practically
adds to, rather than detracts from, the conspicuousness
of the phenomenon. In the case of the retinal vessels,
the definition varies according as they happen to lie ap-
pioxiniately in the direction of one or the other of the
principal diameters of the oval. Both the distortion of
the inverted image of the disc, and the inequality in the
definition of the vessels wliicli lie in the direction of the
two principal meridians, mav be made to disiippear bj'
the simple expedient of rendering the convex lens itself
astigmatic by holding it more or less obliquely to the
visual axis, according to the grade of astigmatism to be
overcome.
The ample field of view, conjoined with as strong an
illumination as can be utilized, the convenient degree of
enlargement of the retinal picture, the fact that the con-
ditions of visibility of the fundus are not ma erially
affected b}' hypermetropia, or by any but the highest
grades of mv'opia, and the facility with which the dis-
turbing influence of astigmatism may be annulled by
giving an oblique position to the lens, all comliine to
render the indirect method particularly available when-
ever we wish to obtain a general view of a large area of
the fundus. On the other hand, for the examination of
the details of the fundus under a greater magnifying
power, and especially for measuring the refraction of the
observed eye, the direct method oilers advantages which
are entirely its own. The two niethoils are. therefore, to
be cultivated side by side, each sup|ilementing the other;
the two together affording the means of studying the
fundus with a thoroughness not so perfectly attainable
by the use of cither method alone.
In order to be able to use both methods equally well.
Fig. 3672,
t-^
^--..::^::
teld at a greater or less distance in front of the observed
«ye. In mixed astigmatism (Ahni or Anili) the eye is
virtually myojiic in the principal meridian of greatest
refraction, and hypermetropic in the principal meridian
so as to obtain from each the best service of which it is
capable, it is of the first importance that the observer
eliminate any sources of error growing out of the uncon-
trolled exercise of his own accommodation. This can be
375
Oplitlialiii<»Hoope,
<>l>lilllaliii<»«('4»pr.
REFERENCE HANDBOOK OF THE jrEDICAL SCIENCES.
attained only liy tUe observer training himself to make
all examinations, as well by tlie indireet as by the direct
method, under the uniform condition of complete accom-
modative relaxation. And here tlie learner has, tirst of
all, to suppress an instinctive tendency to accommodate
for the short distance at which he knows that the object,
i..<':
Fm. 3073.
or its imafre, actually lies. Hence, in practising the di-
rect method, the learner sbotdd be made to feel that he
must look not so mticli into the observed eye as through
it, as if viewing an object lying far away. If myoi)ic,
he should accustom himself always to use the weakest
concave correcting glass, or if hypermetropic, to use the
strongest couvex correcting glass tlirough which be can
obtain a distinct view of the dctailsof the fundvis; if em-
metropic, he shoidd learn to observe the fimdus of an
emmetropic eye without a correcting glass, and, in ex-
amining a myopic or a h3'iiermetropic eye, to find and
make use of the jiarticular concave or convex correcting
glass which exaclty measures its myopia or h_ypennetro-
pia. In ]iractising the in(h'reet method the learner should
also aequiri' tlie hal)it of viewing the inverted image with
relaxed aceonujiodation, which be will accomplish, if
emmetropic, hy looking through a convex lens of about
5 dio|)tries ]iower(20 cm. focus) placed immediately be-
liind the hole in the mirror; or, if hypermetrojiic, by
substituting for this lens such other lens, of greater
jiower, as shall, in adilition, correct his manifest hyper-
metropia; if myopic, he should similarly employ the
convex or concave lens which accurately adjusts his own
far point (r) for the distance of 2U cm. ; and only in the
particular ca.se in which his far point lies at this distance
(II = ~) diojitries) sho\iki lie jiraetise the inilirect method
without a correcting glass.
The use of a convex correcting glass in the indirect
method of examination is shown in Fig. oG7'2 ; fi:r the use
aminations in a completely darkened room of consider-
able size, and preferalily with walls of a dark color. The
general darkness of the room is favorable to the dilatation
of the pupils, and the consciousness that he is in a room
of some size makes it easier for the patient to relax his
accommodation when he is asked to direct his gaze tow-
ard a large and faintly lighted object
upon the opposite wall. By observing
these precautions the causes which in-
cite to contraction of the pupils are in
a great measure eliminated, with the
exception of the direct influence of the
light reflected into the eye by the mir-
rnr. The light of a student's lamp, re
fleeted from the concave mirror of sil
vered glass and concentrated upon the
region of the optic disc, ordinarily ex-
cites but little pupillaiy contraction,
and, in fact, most of the routine exam-
inations by tlie direct method may be
made by the aid of this minor without
having recourse to artitieial mydriasis.
In searching for minute changes in the
region of the macula lutca it is, how-
ever, not infrequently advisable to make use of a weak
mydriatic, such as cocaine or cuphthalmin. If, for any
reason, it is judged inexpedient to instil a mydriatic so-
lution into the eye, the plane mirror of Helmlioltz, made
up of several layers of nnsilvercd glass, may often be
made to render excellent service.
In order to permit the patient to direct his gaze upon
a somewhat distant large object, it is important that his
view, with the eye not under examination, be not lait off
by the head of the observer. Hence the very useful rule,
of general application, that the observer accustom him-
self always to u.se his right eye in examining the right,
and his left in examining the left eye (Figs. 3673 and
3074).
The ophthalmoscoiiic annamentaritim, in its simplest
eflective form, includes (1) a perforated concave mirror,
of about 33 mm. diameter and 23 cm. focus, mounted on
a handle of about 13 cm. length, and titled with a rotat-
ing disc or other mechanism by which any required con-
cave or convex correcting glass may be easily brought
into place behind the hole in the mirror; (2) a convex
lens, of a diameter of about S.'t em. and a focal length of
.5 or (3 cm. ; and (3) a good lamp, which should be so
mounted as to admit of the eas}' adjustment of the flame
to about the height of the observed and of the observer's
eye. This simple apparatus, used in a well darkened
room, atlords the means of exploring the eye, from the
anterior epithelium of the cornea back to the retina and
optic disc.
FIG. 3674.
of a concave or convex correcting glass in the direct
methnd of examination see Figs. 3065 and 31)00.
A fairly large jiupil is always desirable in ophthalmo-
scopic examination, and in employing the direct method
it is often indispensable. Nevertheless, it is not always
either necessary or advisable to make use of a mydriatic.
As the puiiils contract both under the stimulus of strong
light and in connection with the exercise of the accom-
modation, it is best to conduct all ophthalmoscopic cx-
If we place the lamp a little in front of the ]ilane of the
patient's face, and concentrate a cone of light upon the
cornea by means of the couvex lens (Fig. 3675), the con-
ditions of illumination are very favorable to the detection
and observation of any slight irregularities or opacities
in the cornea, whether superficial or more decplj' seated,
and also of finely punctate deposits such as often oc-
cur in or upon the lining membrane of the cornea (mem-
brane of IJescemet). If we change very slightly the
?,7r.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
OplitlialnioHcope*
Oplitlialinesoope,
position of the lens, so that the cone of light shall fall
upon the iris, we may note slight changes in its texture,
and also any irregularities in the contour and
pigmentation of the pupillary margin. By
concentrating the light njion the region of the
pupil, we may similarly detect thin deposits of
lyinpli obscuring the anterior capsule of the
crystalline lens in the iiupillary Held, specks
of brown pigment detaclied from the posterior
surface of the iris and adherent to the lens cap-
sule, and also such
opacities as have
their seat in the
capsule or in the
anterior layers of
ithe crj'stalline. If
we have previ-
ously
Fig. 3<5T
eye under the influence of a mydriatic, we may detect
and carefully study any adhesions (synecliia') which
may have been formed between any part of the pupil-
lary border and the lens capsule, whether recent or of
indetinitely long standing. If the pu|iil is widely di-
lated, we may look deeply into the crystalline lens (<./.
Fig. 3643) and thus detect and observe'the various forms
of opacity incident to different, types of cataract, or we
may even look tlirough the crystalline into the vitreous,
and obtain glimpses of a niass'of effused blood or lymph,
or of a very prominent tumor growing from the fun-
dus. In many cases it is desirable to "make
use of a magnifying glass in connection with
this lateral or olilique focal illumination, for
which pin-pose there is nothing better than
an ordinary doublet of about 3. .5 cm. focal
length. By the method of lateral illumina-
tion all objects are seen by the
hght which they reflect "from
their surface, and, therefore, in
their actual color.
In using the mirror, the lamp
is placed a little behind the ]ilane
of the patient's face, and, pref-
erably, on the same side as the
eye to be examined. Having
placed a conve.x glass of about
5 dioptries (2(j cm. focn.s) be-
hind the mirror, we throw the
light upon the eye from a dis-
tjmce somewhat less than the
focal length of the lens. Look-
ing through the mirror, we see
the tkAd of the pupil brightly
illuminated, and of a vivid red color, whenever the
niedia are of unimpaired transparency and the fundus
is of its normal hue. In the presence of diffuse cloud-
ing of the cornea or crystalline lens, or a turbid con-
dition of the aqueous or vitreous humor, the red color of
the pu]Ml may appear conspicuously dulled, or may not
be seen at all, A circumscribed opacity, on the other
hanil, whether in the cornea, on tin-
anterior lens capsule, or in the sub-
stance of the crystalline, appears black
against the reil background of the
fundus. Motes and shreds in the vit-
reous appear, also, as a rule, imder
the aspect of black specks or threads,
intercepting the red light from the
fundus, but in rare instances, as in the
case of crystals of cholesterin. they
may reflect .so much light as to sparkle
briiliantly {syiichynis nciiitilhtns). If a
tixed opacity has its seat at or very
near the centre of rotation of the eye-
ball (about 13. .5 mm. behind the vertex
of the cornea), it will undergo little or
no change of position when the ob-
served eve is turned in different direc-
tions; if in front of this centre, it will
move in the direction in which the eye
is turned ; if behind the centre, it will
move in the opposite direction. The
greater the distance at which the l)ody
lies in front of or liehind the centre of
rotation, the greater will be the range
of its excursions. Thus a spot in the
cornea will move through a larger arc
than an opacity at the deinh of the
anterior lens capside, and this in turn
will move through a larger arc than
fine sitmited at or near the posterior
capsule. Inasmuch as the pupil and
the anterior lens capsule lie at the same
depth within the eye. an opacity sit-
uated at the front of the lens maintains a nearly con-
stant position with refer-
ence to the bright field
of the pupil, while a sjiot
on the cornea, or in the
deeper layers of the lens,
I'IG. oOTG.
makes conspicuous excursions across this field; in the
one case the movement is in the direction in which the
eye is turned, in the other case in the opposite direction.
377
Ophthalmoscope.
Oplilhalmoscope.
REFERENCK HANDBOOK OF THE MEDICAL SCIENCES.
Anotlipr point to wliicli tlii' motion of a visible bod}'
within tbi.' cyi'ball nuiy bu rctcrri-il is Ibc brij;lit image
of the Hume' us seen letleeted at tlie front of the eor-
nea. Tliis Jiiiglit reflex is always seen at the point on
the cornea wbieli lies nearest to llie eye of the observer,
and aH'ords, therefore, an approximately fixed point of
referenee.
Still holding the mirror at a distance of about 20 cm,
from the observed eye, it may liapjien that we obtain a
distinct view of the' details oV some part of its fundus.
This can occur only in myopia of a very high grade, in
which the observed eye forms an inverted image of its
fundus at some jtoint within a few inches of its cornea.
or in a somewhat bigli
grade of hypermc'
In such a case \v
inake a slight
movement of the
of the mirror, i
<'hange the position
image of the
11 a m e at t h c
fundus; as this
image passes
across the tield
of view in the
<li recti on in
which the mir-
ror is turned,
its inverted im
age, in front of
tlie eye (in my-
opia), will move,
across tlic pupil,
in the opposite
<lirectiou ; in hy-
permetrojiia the
movement of the
virtual image of the flame will be in tlie direction in
which the mirror is rotated. If, while looking at the in-
verted image, we bring the mirror nearer to the eye, we
presently reach a jioint at which the details of the ]iieture
arc lost. We next advance the mirror to the usual posi-
tion for the observation of the fundus in the erect image,
about .5 cm. from the ob.served eye (Figs. 3673 and 3670).
At this short distance the tield of view is nmch enlarged
(see Figs. 36.")!. 36."i3, and 36.J4; ef. Fig. 36.53), ami tlie
conditions are at the best for the detection and observa-
tion of fixed or floating opacities lying deep in the vit-
reous, as well as for the ob.servation of a detached reti-
na, or a tumor growing from the fundus. It may also
liappen that on approaching tlie observed eye the iletails
of its fundus are .seen sharply defined, indicating the
presence of hypermctropia of a grade in excess of the
power of the convex glass behind the hole in the mirror.
In such a case we may at once measure the degree of hy-
permctropia, by bringing jirogressively stronger convex
glasses into position behind the mirror. If. on ajiproach-
ing the eye. the deiails of the fundus are not seen, or are
seen but indistinctly, through the convex glassof 5 diop-
trics, we may change to successively weaker convex
glasses, or to concave glasses of progressively increasing
power, until, by noting the particular glass which first
ail'ords a perfectly distinct view, we have obtained a defi-
nite measurement of the refraction. If, in the course of
successive observations with glasses of different power,
we at first get a distinct view of only such of the retina!
vessels as correspond in direction to one of the ocular
meridians, and with some other glass we obtain an
equally distinct view of the vessels corresponding in di-
rection to the meridian at right angles to the former, we
liave both established the presence of regular astigma-
tism and obtaineil the data for the determination of its
type and the measurement of its grade. If, as some-
times happens, we .see the same vessels, or jiarts of ves-
sels, under dilTercnt degrees of definition, according as
we view them through different ]iarts of the cornea, we
have to do with a case of irregular refraction (irregular
astigmatism) dependent probably upon some irregularity
ill the contour of the cornea. In such a case tlie bright
reflex from Ihe cornea may show variations in size and
in shajje. dependent on differences in the con-
ffl tour of the reflecting surface. In keratoconus
(conical cornea), of even low grades, the distor-
tion of the retinal picture and the changes in
the form and size of th<' corneal re-
flex are especially eliaractcristic.
We may now withdraw the mir-
ror to a distance of about 4(1 cm.
from the observed eye, bringing at
tlic same time the convex lens
of about 20 dioptrics (.5 cm.
■us) into ]iosition at a distance
little less than its princi])al
■al length in front of the cor-
a (see Figs. 3672, 3674, and
77). At this stage the begin-
ner may encounter an obstruc-
tion to his view of the interior
of the eye aris-
ing from the
bright reflex
images of the
flame or mirror
formed by the
two surfaces of
the convex lens,
the one virtual,
behind the lens,
the other real,
in front of the
lens. When the
lens is held ex-
actly concentric
w i t h, and at
right angles to,
a line connecting the ]iupils of the observing and the
oliserved eye, the two reflex images lie ahso in this line,
and may thus completely cut off the view into the eye.
Both images are, however, easily got out of the way.
either by moving the <'onvex lens a little to one side,
or by slightly rotating the lens so as to displace the
two images in opposite directions. The strong con-
vex lens, held at somewhat less than its focal dis-
tance in front of the eye, considerably magnifies a
spot in the cornea, or in the field of the pupil, as seen
from behind the hole in the mirror, and the conditions
are favorable, generally, to the inspection of these parts
of the eye. We may next turn our attention to the de-
tails of the fundus as seen in the inverted image, at about
the position of the anterior principal focus of the convex
lens, looking at it, for reasons already given, through the
378
KEFKKKNCE IIANDBUOK OF THE MEDICAL SCIENCES.
Oplitlialnioscope .
Opiitlialinoscope
• disturbance from
movi'mciits of the
convex glass of about 5 (lioi)lrics (2(1 ciii. focusV placed
behind the hole in the mirror, llaviii!; unl rid of the two
rellex imajies formed by the eonve.x lens, either by mov-
ing it alitUe to one side or liy turiiini; it a little obliquely
to tbelineof sight, ^
we may encounter
a further obstacle
in the retlex im-
age formed by the
anterior surface of
the cornea. This
will, however,
give no serious
trouble, except in
the particular case
in which the ver-
tex of the cornea
of the observed
eye is directed ex-
actly toward the
hole in the mirror;
a slight turning of
the eye in any di-
rection sufficing
to displace the
bright reflex from
the central region
of the pupil. In-
asmuch as the inspection of the
region of the macula involves the
turning of the ob.served eye ex-
actly in the direction of the eye
of the observer, the indirect meth-
od i.s not favorable to obtaining a
good view of this part of the fun-
dus. Kevertheless, we may often
succeed in eliminating mueli of tlii'
the corneal retlex by making lateral
convex lens in dilfereut directions.*
It happens not infrecpiently that in moving the couvex
lens in a lateral direction a loop of a retinal blood-vessel
appears to change in form. This is an effect of parallax,
and is dependent on the fact that, by the lateral move-
ment of the lens, the line of sight is consideralily de-
tlected, so that we see the vessel as from a dilTerent point
of view. A loop of a retinal artery or vein, lying in a
jilane perpendicular to the general surface of the fundus.
may thus ajipear as a straight line when viewed directly
from in front, but will show something of its actual cur-
vature when viewed from cither side; the amount of the
apparent curvature de|)ending on the actual height of the
loop and the extent of the lateral excursions of tlie lens.
For the inspection of tlie fundus generally, in the in-
verted image, including the disc of the optic nerve, the
conditions are altogether favorable. To see the optic
disc, which is situated to the nasal side of and a little
below the posterior pole of the eye, the patient must
turn his eye in the same direction, which he will most
easily and surely accomplish by looking a little to the
temporal siile and slightly downward with the eye not
imder examination. To obtain a view of the peripheral
regions of the fundus, the patient must turn his eye in
the direction corresponding to the part to be examined,
the details of which, as seen in the inverted image, will
appear to move in the same direction.
If the concave ophthalmoscopic mirror is taken of very
long focus (about 75 cm.), and held at a distance from
the lamp and from the observed eye about eijual to its
radius of cvirvature (1. .'J metres), the illuminating flame
and the obser veil eye will be nearly at conjugate fticiof the
mirror, and the pupil of the latter will apjiear strongly
illmninated. If, now, the observed eye is myopic in any
*The geometrlral a.Kis of tlie cornea does iii)t e.xactiv coincide witli
the line of sluht. the latter cutlinc tin riii-a a litile tn the nasal siile
of its vertex. Hence the corneal retl.-.x does not, a.s a rule, exactly
cover the imace of the fovea. The anifle which the a.xis of the cornea
makes n. the line of si)?ht is known as the antrle a (Ponders); it is
Kreate,st in hypermetropic eyes, and least, sometimes even negative,
in myopic eyes.
degree in excess of one dioptiie. it w ill form an in vertex.
iifrial image of its fundus at a dislance of 1 inelre or less
anil some details of this image will be visible to an ob
server looking through the hole in the mirror. InasniucL
us, at the grea;
distance of tht
mirror, the visible
jjortion of the fun
'^ dus is very small
', the patient may
* have to turn hi;,
eye slightly ii:
diffcient dircctionr.
in order to bring one
of the retinal vessels
into view. The ob-
server looking
thrcuigh a convex
lens of 5 dioptrics
(20 cm. focus), placed
behind the hole in
tlie mirror, may cal-
culate pretty accu-
rately the distance
of the image from
the observed eye by
noting the distance
at which be sees the
blood-vessel sliarpi)'
defined. In simple
myopic astigmatism
(Am) and in mixed
astigmatism (Amh or
Ahni). only those ret-
inal vessels whose
direction is approxi-
mately at right angles to the principal ocular meridian
of greatest refraction are visible in the inverted image;
in hypermetropia (H), and in simple or compound hy-
permetroi)ic astigmatism (Ah or ll-)-Ab), the image is
virtual, and the method is inapplicable.'
A plane mirror, at the distance of 1 metre, gives but a
very small image of the
flame at the fundus, and
the field of view is also
very small (see Fig.
3053). Neglecting en-
tirely the details of the
fundus, and regarding
only the image of the
flame, the distinction be-
t w e e n hypermetropia
and mjopia may be
made by simply obseiv-
ing the direction in
wliich the image appears
to move when the dii'ec-
tuin of the illuminating
beam is changed by
slightly rotating the
mirror. This test turns
on the fact that in hy-
permetropia the image
wliich we see is virtual.
and is situated behind
the observed eye, while
in myopia it is a real
ima,ge, and is situated in front of the ob-
served eye. Hence, in b}'permetro]iia the
image is seen to move into, across, and out
of the field of view in the direction in
which the (plane) mirror is rotated; in
myopia the apparent movement is in the
opposite direction. As the details of the
image are disregarded, it is unnecessary to
use a correcting glass behind the mirror.
unless it be needed to correct a very high
grade of ametropia in the eye of the ob- fig. 36S0.
379
0|>htlialniu«<-<>|>e.
OpIitUalnioscope.
REFERENCE 1IANI)B0(JK OF THE MEDICAL SCIENCES.
server. In this test it amoimts practically to the same
tiling whether we speak of the movements of liie bright
image, or of the border of the nnilluminaled area sur-
rounding it. It happens, however, that the writers
who have especially cultivated this method have di-
rected attention rallier to the dark border (shadow) than
to the image of the tlanie; hence the name, .shnduir-texf,
by which this method is commonly designated (see t>/iiid-
oic-Tei't).
As a rule, an eye un<lcr oplithalmoscopic examination
rela.xes its accommodation. Hence measurements maiie
with the ophthalmosco|ie not infrequently show a some-
what higher grade of liypermetro])ia. or lower grade of
myopia, than is revealed by subjective tests made with
test letters without the resort to artificial mydriasis. In
the case of certain careless or obstinate patients, of some
illiterate persons, and especially of young children, the
ophthalmoscope is indispensable in the diagnosis of ame-
tropia in all its forms.
Two ]irinci|ial tyjjes of the ophthalmoscope are to be
distinguished, namely, those adapted to the examination
of the fundus l)y the direct method, anil tho.se in which
an inverted real image of the fundus is formed by the
aid of a convex lens. The former tyjie appears in a prac-
tically perfect form, in the original invention of Ilelm-
holtz (ly.-il); the latter type was evolved in its essen-
tial features by Ruete, in the course of the following
year. Tlie invention of Ilelmholtz consists essentially
in the discovery nf the fundamental fait that the fundus
can be seen by looking through a mirror from which
light is reflected into tiie ej-e; Kuete. by the combination
of a concave mirror and a eonve.x lens or lenses, demon-
strated the practicability of viewing the fundus in a
strongly illuminated real image. Helmhollz, in turn, Viy
a development of the experiment of Brlicke (see Figs.
3(i,'59 to aoiil), showed that it was possible to see the de-
tails of tlie fundus, in the iuverted image, by direct il-
lumination, and with no otlier apparatus tlian a screened
lam]) or candle and a convex lens. The subsequent de-
vclo|iment of the ophthahno.scope has been confined es-
sentially to changes in details, and to moditications de-
signed to facilitate certain special uses.
It is entirely praeticable to illuminate tlie fundus by
direct light, and view its rdleeted image in the mirror.
Tlius in the arraugeiueiit shown in Fig. 3().~)1, it is jiossi-
ble, thiiugb less convenient, to place tlie lamp at L , and
to view the image, as reflecteil on the mirror, from L.
With tlie lamp (preferably a small electric incandescent
bulb) at L or at L' . it is possible for two observers, sta-
Fii;. .■iiiSl.
tinned at L' and /., to view the fundus of Oat the same
time. Demonstrating ophthalmoscopes for two obser-
vers are based on this princi))le.*
* In every refleoting nphtlialnioscope tliere are two points of view at
wtiifti tlie eye of an ot\>it'rver may be stationed .so a.s t^> receive rays of
light from ttie illiiinin:iteH fiimtiis. namely, tlie usual and most fiivor-
aVile po.sition iuiuiedialely hctiiiid the mirror, and a less favnrable posi-
tion elose by the si<1e of Un- lamp. The use of an elertne lamp makes
it iiossihie to see tile delails of the fundus from a st.ilion in its im-
inediate virinity whenever the elfereni rays relleeted from the mirror
are parahel or divertn*nt, as is ordinarily the case «lien a plane pra
slightly convex mirror iii used. With a concave mirror of a focal
length less than its distance from the place of the inverted imatre, a
twice inverted d'.t'., erect) imaee of the fundus may be seen at some
point between the mirror and the lamp. A third point of view may be
Again, the cITercnt pencils emanating from different
parts of the illuminated area at the fundus may be
severally divided behind the mirror, so that each half,
after two retlections, shall enter I he corresponding eye of
the observer. The binocular ophthalmoscope, like the
binocular microscope, gives some degree of stereoscopic
clleet.*
Fixed ophthalmoscopes, as distinguislied from ophthal-
mo.scopes in whicli the mirror and the convex lens arc
held each in the hand, liave been devised in considerable
number: they litive been used in measuring the details of
the fundus, in making drawings of the fundus in normal
and pathnliigical states, and, especially, in demonstrating
tlie ophthahnoscopic picture to a number of per.sons in
succession.! Their prototype is to be found in the origi-
nal ophthalmo.scope of Kuete (Fig. 3C79). The camera
lucida may be used with any tixed ophthalmoscope.}:
t)|)lithalmoscopes have also been constructed with a
comliinatinn of mirrors, by means of which an observer
may, with one eye, see the fundus of his other eye. By
a dilleieut arrangement of mirrors an image of the optic
obtained by defleetinp: a part of the efferent rays at some point
between the observed eye and the mirror. This is effected in the
"ghost " ophthalmoscope of Laurence (" Klinische Monatsli];ilter fiir
.\u^'entieitkunde." s. SU, ISiilJ) by interposing a sheet of poiisiied
transparent ii:liiss, set at an angle of iri°^ in the path of the iiui.
minaiiiii: ami the efferent rays ; the latter are in pail iransmitied by
the sheei of glass, and in part relleeted at right angles to their original
course. Some of the rays which ha\e entered into the formation of
the inverted imaL'e iiiav he di-llerted to one side by reltection from a
small plane mirror in fn.nit of and partially <-^)vering the central open-
ing of tlie illuminatiiig mirror: or some part of the same rays may he
similarly detleeted by a small relleclor, preferably a totallyVeileciing
right prism, placed just behind the iliuiiiinaiing mirror, liemon-
strating i>phthalmoscopes of this construction ha\e, been devised by I)e
Weckeiand Riigei I" Kulletin de IWcadeiiiiedes Sciences," IsToi, and
by Si<-liel ///s (.vnnales d'l lcullsti(|ue, 1S7:,'). IJy slightly separating
the two toialtv leilecnng L'la.ss rhombs in the iiinocular o|ihthahno-
scopi' of liiraud-T'-uloii. and cutting them off square at their ends, an
ophthalmoscope for three oliser\ei-s has been constructed (Monoyer:
Revue niedicale de Nancy. ]s7t): a fourth observer may .see the fundus
reflected on the illuminating mirror in the ilireotion of the light.
* Cticcius was pri'balilv the Ihst |o cinstruota binocular ophthalmo-
scope; a small perloraied plane mirror, .set, at an angle of i't^, behind
the hole in the illmninaliiiL^ mirror, deflected a part of the elTeient
rays in a direction at right angles to the Mne of sight, and asec.md
plane mirror, parallel to and about si.\ ti cm. distant from the other,
relleeted tlit^se rays into the second eye of the observer. The two
retinal pictures were nece.ssarily of unequal size, but n<itwiih-
standing this defect, the instrument is said to have given a siuuewhat
better \iew than w hen but one eve was used (Snellen iiiid l.andolt :
(iniefe-saeiiiisrh. " llandbuch der gesammien .Viigenheiikiinde," iii..
i., S. llilh. The llrst binocular ophthalmoscope of good constructii.ui
is that of Ciraud-Teulitn, in which the rays which have traversed the
right half of the hole in the mirror are reflected to the right, and the
other half to the left, and both are again reflected, at rii.dit angles, to
enter the two eyes of the observer. .Ml this is vervsiiuplv accom-
plished by total retlection at the two obliquely cut ends of iwo rhom-
bohedra of glass enclosed wiiliin a small metallic bo.x behind the
mirror (Annales d'licuhstiqite, ,\lv., ISiill. By a slight change in the
construction of this instrimient, by Laurence and lleixh, it is made
of a little lighter weight, allhoiigh more fragile ami moie costly. \
fuither modillration, by Coccius. cniisists in the applicatiMn nf the
principle of tile common opera-glass, by which the imaL'-e is seen eoii-
siderablv mauMihled (Report of the Fourth International i iiihtlialmo-
loL'ical roiiL'ress, Limdon, 1S7:!). The latest change in this ophthal-
mosi ope IS b\ its inventor, who has notched the pro.ximal ends of the
Iwo rbomltMhedra so as to make a small central opening, behimi
which he has placed a very small electric lamp, thus dispensing with
the mirror (Giraiid-Teulou ; Annates d'Oenltistique, xcyi., December,
ISSli).
tTh. Ruete: "Der Augenspiegel iind das iiptonn'ter." fo'itiingen,
18.i3. Tlie Epkens-Donders oplithalmoseoi«. (ls,-):ii is a ll.xed ophthal-
moscope designed for the measuri*meut of the details of the fundus a.s
seen in the erect image. I'liich (Ileiile tiiid ITeultei's Zeitschrift fiir
rationeile Medicin. ls."):{i cnmbineil the miiror aiid object lens in a
short metal tube, to the side of which aeamlli' was attached, llasner
(Prager Vierteljalirsscliiifi. 1S.V)) made the tube Inugci- and used a
separate lamp. It. hiebreich tArchiv fiir ( iplitlialrin'lMLOe. I s.Vi) con-
structed his larger ophthalmoscope by mounting an instrument e.ssen-
tially like Hasner's upon a stamiard and tLxnig ihe heail of the patient
by means of a special rest. With Ibis oplithaliiiescope he made the
elaborate colored representations of the fundus tlgiired in his " Atlas
der iiphthalmoscopie" ( Berlin, IStti). Rurke ("iipbthalmoscope re-
Heeleiir," llaMe, ISTl 1 eonstrncted a flxed opbihahnosioiie in which
a seconil concave mirror, of 111 cm. focus, was siit'stitiited for the
usual obiect lens in e.xaniinations by the indiiect meibod. (Virter
llieporl (if the Konrlli Internatinnal (Ipbthalm.iloLncal CoiiL'ri-ss, Lon-
don. lST:ti mounted the sevenil parts of the ordinary hand ophthal-
moscope, all on an enlarged scale and with correspondingly increased
radii of curvature, upon separate standards resting on a table four
feet long.
"STlie camera lucida was used with the Kpkens-tlonders o|ihthalmo-
scope and with the targe opluijaluii'^mi f Licbreich : .\oves (Trans-
actions of the .\merican I iphthalmological Society, l.sTIi) also applied
It to the flxed ophthalmoscope of Carter.
380
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Oplttllalinosoope,
Oplitlialinoseope.
Fiii. stity.
disc is formed at the macula of the same eye. These are
curiosities of ophtliahuoscopy.*
The ophthahuoscopes whicli have won a ]iermauciit
place ill the arniameiitariuni of the ophthalmic practi-
tioner are all based di-
rectly u]u)n the sini])le
re dec ting ophthalmo-
scope of Helndioltz and
the compound ophthal-
moscope of Ruete. A
few tyjiical forms must
be briefly noticed.
The ophthalmoscope
of Helmlioltz (18.51). per-
fected in some of its
details by the instrument
maker Kekoss, is shown
in Fig. 3078. The two
revolving discs, at the
back of the mirror, have
each five openings, in
four of which are mounted concave glasses, giving
twenty combinations ranging from — 3 dioptrics to — IS
dioptrics. Tlie nurror, made up of three layers of very
thin glass, is set at an angle of M' to tlie plane of the
revolving disc. The lamp is placed a little behind tlie
plane of the observer's face, necessitating the use of a
screen, to shade tlie observed eye from the direct light.
The purjio.se of the concave glasses, in the two discs, is
to permit tlie details of the fundus to be distinguished
notwithstanding the presence of mvopia of the observ-
ing or of the oli.served eye, and also to neutralize any
disturbing etfect arising from the possible exerci.se of
the accommodation in either eye.''
The oiihtlialniosco])e of Ruete (1853) consists of a per-
forated concave mirror and two vertical standards for
holding lenses, all mcnint-
ed in line on a li.\ed hori-
zontal bar (Fig. 3(>79).
■With a convex lens of 4
cm. focus, mounted on
the first standard at a
distance of about 3 cm. in
front of the cornea of the
observed eye, an inverted
image of its fundus, mag-
nified about two and a
half diameters, is formeil
about 4 cm. in front of
the lens, and is viewed
by the observer looking
through the hole in the
concave mirwir. A sec-
ond convex lens, mounted on the second standard at a
distance somewhat beyond the position of the inverted
image, affords the means of viewing this image under an
increased ampliliiation. A concave lens, mounted on
one of the standards, is used in the examination by the
direct method.^
Coccius (lSo3) attached a convex lens to a plane mirror
in such a position that the illuminating rays pass through
the lens before impinging ujioii the mirror (Fig. 3680).
The conjoined effect of the convex lens and plane mirror
is essentially that of a concave mirror.''
Rncte's fixed o]ihthalmoscope becomes an ordinary'
hand ophthulmoscnpe when the mirmr and the convex
lens are dismounted, and are held in the two hands of
the observer.
* Helmtioltz (" licsctireihiintr eint's AiiL'cnspit'L'els." HiTlin. 1S.M)
(JesiTibwl a siiiijili- iiii-tlicrd hy wliirii an ..iwrvi-r inav. !■> Iniikiiifr in a
mimpr. sti-c ttn' ilhiniinalt.'il pnpil nf imt' of his nwn i-vfs wiili the otlicr
«ye. I'uccins i " fchcr (ilanki-ni, EntziiinlnuL' nml liie .^ntnp.vie niit
dera Aii.wnspicircl," I.pipzis.'. Is^Wi ilcviscil an anant'i' iit nf lifrlit
and mirror liv whifli an eye may re-i-i-iyL* a dellnt'd pi.tnri* nf its own
optic disc. Heymann ("iiie Autosliopie des Auees." Leipzig, ISW)
combined a perforated plane mirror, a redectinfr prism, and three
convex lenses in such a manner lliat with one eye a view is obtained
of the fundus of the other eye in a twice-inverted u'.f ., erect) picture.
Similar anantrcincnts liave been devised by tjiraud-Teulon (Aunaies
<i'i iculistiiiiic, xiix., ISiSi) and by Coccius.
Fui. 'Ai^.
■4^
Zehender (1854) substituted a convex mirror of 16 cm.
radius of curvature for the plane mirror in the instru-
ment of Coccius, thus making it possible to obtain fiom
a single convex mirror the effect also of a plane, or of a
concave, mirror (Fig. 3681).'
A convex mirror offers a slight theoretical advantage
over a plane mirror, as does the latter over a concave
mirror, in examinations by the direct method, and the
instruments of Coccius and of Zehender have been espe-
cial favorites with some excellent ob.servers. They are,
however, more difficult to manage than the concave mir-
ror, and are at present but
little used. In practice
the perforated concave
mirror of 23 cm. focus
suffices for most examina-
tions, whether by the in-
direct or the direct meth-
od; in a few special cases
the polarizing plane mir-
ror of Helmlioltz main-
tains its superiority over
all rival inventions.
The ophthalmoscope of
Helmlioltz, with the two
Rekoss discs, includes all
that is required for the
convenient measurem'ent
of the refraction by the
direct method, provided
only that the discs are
inaile larger, so as to contain a few
more glasses, and that the selection
of the glasses is made with refer-
ence to this use. This seemingly
obvious development was, however,
long deferred. Meanwhile a few
exceptionally careful ob.servers had
ophthalmoscopes made with a large
cli]!, to receive any one of the series
of glasses in the oculist's trial case
(Donders),* or with two such clips,
intended to hold a spherical and
a cylindrical glass (Noyes) f others
contented themselves with a smaller
series of glasses, fitted to a cell or
small clip at the back of the minor
(Jaeger).' |i|||
Loring (1869) was the first to fit
the ophthalmoscope with revolving
discs containing a series of glasses
sufficient for the accurate meas-
urement of the refraction.' 'U'ads-
worth (18T6) substituted a small
mirror, of 15 mm. diameter, for the
larger concave mirror in ordinary
use. setting it at a fixed angle of
20° to the plane of the lens-bearing
disc, and mounting it in such a
manner as to admit of its being
turned in any recpiired direction
(Fig. 3082). I" Following out this
sugge.stiou, Loring devised two
modifications of the mirror, one in
which a segment is cut off fi'om
one side of the mirror, which is
hinged at this border to a revolv-
ing setting (Fig. 3683); the other,
the so-called tilting mirror, in which
a segment is cut off from each side,
and the mirror is swung on pivots
at the two extremities of its ver-
tical diameter (Fig. 3087)." The ophthalmoscope of
Loring. as perfected by its inventor, is the tyiie of a
thoroughly good instrunient for all jiractiral uses; as
made under his direction, by Mr. H. W. Hunter, of New
York, it has not been sur|iassed as a model of good
construction and fine workmanship.
381
4>|>htlftaliiioHoui>(',
Upiuili.
KEPERENCE IIAM)iiiH)K UF THE MEDICAL SCIENCES.
Fig. 3tiS6.
The essential points in tlio eonstniction of a good opli-
thalmoscojie arc few anil siin|ile. The best material for
the concave mirror is silvered fi'iiss,
wliich should be very thin, in order
that the margin of the central per-
foration may encroach as little as
possible upon the etl'eetive area of
the opening when the mirror is turned
obliquely to the line of sight; any
excess of IhicUness above 0.8 nun.
is both xuHiecessar}' and injurious.
The central hole should be aiiout 3.5
mm. in diameter,* and its luipolished
margin should be coated with a dull
black iiignient; the alternativi' expedient of removing
the silvering from a small central area of the ndrror is
not lo lie commended. A mir-
ror madi' of |iolislied metal is
more ditllcult to keep in order,
and, vmless in very perfect
condition, retlccts much less
light than a mirror of silvered
glass. The focal length of the
mirror should be about 23
em. ; this is a convenient focal
length for examiualions by the
indirect method, and in the
direct method flic ctlect is not
very dilTerent from that of a plane mirror (<•/.
Figs. 3053 and 3H54). The mirror should be so
mounted as to admit of its being inclined about
25', to the jilane of the correcting glass, and it is
very desirable that it be so arranged that it can
be turned in its cell. For the latter reason, and
also because the mirror, when lying tlat in its
cell, is in closer proximity to the correcting
glass, the writer
p r e f e r s t h e
hinged mirror of Loring
(Fig. 36H3) lo his tilting
mirror (Fig. 36N7).
The correcting glasses
should be .so mounted as
to admit of tlieir auto-
matic centration, and of
the easiest possible
change from one glass
to another without inter-
rupting the observation
by removing the instru-
ment from the eye. The
series of lenses should
be sufliciently large to
include the entire range
of hypernietroiiia and of
myopia, with intervals
as small as can be taken
note of by the observer; a conunon
interval of 1 dioptric will sullice for
most practitioners, others may be
able to utilize an interval as small
as 0.5 dioptiie. A combination of
a larger and a smaller Hekoss disc,
or of a full disc with a (juadrant of
.another disc, is s\itlicient to meet
these requirements; the glasses in
the principal disc should be of
.somewhat greater diameter than
the hole in the mirror (about
5 mm.); those in the second disc
or (luadrant should be a little
larger (about 7 mm. in diameter). The two discs
should be as thin as the curvatvire of the glasses will
permit, and they should be mounted in the closest pos-
♦H.Knapp (Arcliives of Ophthalmology and Otology, 1v., i., p. 41,
tS74) niade comparative trials (if a nmnherof mirrors with holes vary-
ing from 1 to .5 mm.; " the liest illumination is obtained by an opening
in the mirror of 3.5 or 3,75 niiu. in diameter.'*
bu
jf the
sibic pi'oximity to each other iiiid to tin
mirrui-.
The handle of the ophlhalinoscope should be not less
than 14 or 15 cm, in length, measured from the centre of
the mirror, and it should be lai-ge enough to admit of its
being easily and firmly giasp<'il by the hand. As, with
this length of handle, it is somewhat ditbcult to reach
the edge of the jirincipal disc with tli<' finger, a rack-and-
[linion mei-hanism (Cretes), a cog-wheel (Loring), a train
of cog-wheels (Noyes), or a cog and cam device (Meyid-
witz), has been added; a very full series, of no less than
Seventy-four glasses, has been mounted, after the manner
of an endless chain, in the place of the usual revolving'
disc (Couper);'- a smaller .series, similarly mounted, is
used in the O|)hthalinoscoiie of .Morton.
If the observer is simply hypei'inetropic or myopic, he
Tin. 3687.
Fig. 3088.
may apply his personal correction to the
correcting glass found by observation (see
p. 374); if he is astigmatic, it may be nec-
essary to add to the ophthalmo.scope such
cylindrical glass or glasses as may be re-
(|uired to cori'ect his vision in either eye foi-
infinite distance. The glasses for this per-
sonal correction should be a little larger
than those in the second disc (about !)
mm. in diameter) and should be nuuuited immediately
behind it; in astigmatism, of even as low a grade as 1
dioptric, its correction adds appreciably both to the
sharp detinition of the picture and to the observer's
(luickness of perception.
Fig. 3084 .shows the back of an oiihthalino.scope made
for fhe writer, in 1870. by Hunter. '^ It is, in fact, one
of Loring's smaller ophthalmoscopes, with the addition
of a .second smaller disc— a construelion adopted, a little
later, by B:uial, in France. Substituting -f 13 and — 13
for + 14 and — 14, the order in which the glasses are
brought into use becomes precisely the same as in the
ophthalmoscope of Radal and in the later ophthalmo-
scopes of Loring; with -f-O.oand —0.5 in the )ilace of -f 7
and — 7, as figured, an interpolation of 0.5 ilioptrie may
be made between the limits -(-6.5 and — 0.5. A third
disc, with two glasses, serving also as a cover to the
smaller disc (Fig". 30S5), or a setting of the form shown
in Fig. 3080, affords the means of applying such correc-
tion as an astigmatic observer may fiinl advantageous.
The ophthalmo.scope of Loring, with the tilting mirror,
in fhe construction finall v adopted bv its author, is shown
in Figs. 3087 and 3088. ''" Jt>/>>i Green.
Plate XLVII., by Jaeger, shows the fundus of a normal eye as
viewed bv means of the ophthalmoscope.
' Couper: Report of the Fourth International Ophthalmological Con-
gress, London, 1873.
382
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Opiitlialnioscope.
Opiiini*
^ HelmhoUz: Besclireitninjr eiiif's Aiipenspit'eels. Berlin, 1851.
3 Th. Ruete : Der Aufft'iispicirt'l umi dsK'^ ( iptunifter, Gottingen, 18.52.
* A. Coccius: Ueber die .\in\fn<luni: tlt-s Augenspiegels nebst
Anprabe eines neuen Inj^iniineniHs. I>>'iiizic. l-s>i.
' W. ZellcmiiT : Anbiv fiir ( iplitliali]icilut.'ie, I., i., 18.54.
" F. ('. Doiulers : i Ml tlif Anomalifs cf Accommodation and Refrac-
tion of the Eye. Tlie New Sydenliam Society, p. lOti, London. 18ti4.
' H. D. Noyes: Transactions of the American Opiittialmological
Scx'ielv, 1869.
• Ed. Jaeger: Oeslerreiehlscbe Zeitschrift fOr pi-jctische Heilkunde,
7. Marz, 18.5(5.
" E. G. Loring: Transactions of the American Ophthalmological
Society, 1869.
'" (>. F. Wadsworth : Boston Medical and Surgical Journal, January
2.5th, 1877.
1' E. (t. Loring : Report of the Fifth International Ophthalmo-
logical CoULTcss. New ^■o^k. 1877.
i2(\,iiper: See liescription of Couper's new Ophthalmoscope, with
illustnitlon, in Juler's Handbook of Ophthalmic Science and Practice,
London, 1884.
" J. Green: Transactions of the American Ophthalmological Soci-
ety, 1878, p. 476.
^* E.G. Loring: Transactions of the American Ophthalm<^logical
Society, 1878, p. 4»9.
G.) SiiccHS ThehdicKS.
theba ic u m , Meco/i iu m ,
OPIUM.— (U. S. P. ; B. P. ; P.
/.i)c/iri/iiiii Fapaveris, Ej:tractuin
Laudanum.
Df.finition. — Officially considered, under the author-
ity of the United States Phannacopa'ia. opium is'Mlie
concrete milky
exudation ob-
tained by incis-
ing the unripe
capsules of Pa-
paper nomnife-
riini L. (P. (ijjici-
niile Grael. ; P.
a II) u III 31 i
fain. Papairra-
ceiT), and yield-
ing, in its uor-
m a 1 moist
condition, not
less tlian nine
per c e n t. o f
crystallized
morphine" when
assayed by the
United States
Pharmacojiaia
process. Tliis
definition is to be read
in connection with the
description given below,
whicli more closely de-
limits the article. It is
also to be consitlered iu
connection with the pro-
visions for Opii P'lli-is
(.see the section on Prep-
arations), which has a
different all^aloidal standard, and with those forthealka-
loidal standardization of the prepai'atious made from tlie
latter.
Fig. .%.S0.— The Opium Poppy (var.
nigrum). Plant much reduced.
(Baillon.)
Fi(i. 3690.— While Poppy, r^howing
the incisions made in the green cap-
sule for the extraction of opium.
(Baillon.)
The detiuitions of other pharmacopreias differ consider-
ably from that of ours. The German re(|uires. as ours
formerly did, that opium be produced in Asia Minor ; also
that it contain from ten
to twelve per cent, of
morphine and not more
than eight per cent, of
luoisture. The Britisli
Pharmacopceia requires
different amounts of
morphine for the o])iuiii^
used in the different
preparations; not less
than seven and a half
percent, for the tinctuir
and extract, and be
tween nine and a half
and ten and a half jier
cent, for other uses. For
diluting a higher with
a lower grade, the United
States Pharmacopceia re-
quires that the morphine
percentage of the latter
be between seven and a
half and ten per cent.
In view of the standard-
ization of the prepara-
tions, it would at tirst
thought appear super-
fluous to impose rigid
standards for the drug,
but important commer-
cial and tariff considerations are involved, aside from
the fact that large downward variations in morpliine per-
centages aie liable to be accompanied by imjiortant up-
ward variations in the percentage of other, perhaps un-
desirable, alkaloids.
Oiigiii. — All opium is now regarded as the product of
the one species named in ourdelinition, though some bot-
anists have been inclined to regaid its vaiieties as dis-
tinct species. Altliough the plant grows abundantly in
a wild state about the eastern Mediterranean, and in a(U
jaceut regions, opium is wholly the product of cultivated
plants. Although the tar. ylahrum, having red flowers
and usually dark seeds. Is preferred and more largely
grown in Turkey, and the ear. nlbiuu. with white flow-
ers, is more commonly grown in Persia, such distinctions
are not rigid, since flowers of all intermediate colors may
usually be seen in a Turkisli plantation. The opium
plant here figui-ed (Fig. 3ti89) is an annual herb, neaily a
metre (a yard) high, somewhat bninihed al)ove and bear-
ing fi'om five to twenty large flowei's and capsules (see
Fig. 3690). The latter is about as large as a small apple,
and j'ields the opium by the process described below.
(See section on Production.)
Almost every country possessing a suitable climate has
yielded opium of fair to good quality, including Europe
as far north as Sweden and North America as far north
as New England, though most of these operations have
been purely of an ex]ierimental cliaraeter. Financial
success iu opium pi'oduction requires a special combina-
tion of conditions affecting .soil, climate, poiiulation, and
cost of labor, and lias been attained, to a noteworthy ex-
tent, only in Turkey, Persia, India, China, and Egyi't.
Of these products that only of Turkey answers perfectly
to the official description, and it supiilies practically the
entire medical demand, except for purposes of mor-
phine manufacture. For this, any product rich in mor-
phine and easily worked is selected, the most of it, with
the exception of Turkisli opium, being Persian, so far as
United States manufacturers are concerned. All othei'
opium is consumed in the vicious practiix's of smoking
and chewing. Of this, the Egyptian product is probably
somewhat greater than the wlioleof the Turkish product,
though smaller now tlum formerly. That of India is
probably from ten to twentv times as great as that of
Turkey," and that of China iit least double that of the
3SS
Opliini,
Opium.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
rest of the world, including even the Indian. It will
thus be seen that the vicious use of opium is about fifty
times as {rreat as its medicinal use, in connection with
whicli it must be remembcreil that probably more than
lialf of that usually classed as medicinal is iu reality vi-
cious.
PniducHon and Pveparation. — The best climatic condi-
tions for poppy culture are those which prevail in the
warmer wheat-growing sections — conditions under which
it is practicable to sow in September, to t rust to a covering
of snow for the protection of tlie young plants through
the winter, and to gather in the crop late in the following
summer. Jlnre precarious, and generally less successful,
is the production of a crop during the summer of the
same year, the sowing being done in February or March.
The capsules are ready for incision when just be-
ginning to turn yellow, at whicli time the dense net-
work of milk tubes ramifying thidugh the entire thick-
ness of the pericarp is chargeil with a thick milky juice.
In Turkey the incisionsare niadein asomcwluit obliiiuely
or spirally transverse direction (Fig. SliSIU), iu India ver-
tieall\'. In both cases the knife jiossesses two or three
blades set near to one amither, and the incision is made
as deeply as po.ssible, care being taken that it shall not
penetrate the central cavity. This work is performed
in the late afternoon, i.e., at a time when the sun will
not interfere with the Ihiw of juice. In the morning, the
exudation will be foiinil to have thickened sullicieiitly
to admit of its colleetinn. It is considered that the
quality of the Indian ]iroduet is injuriously affected
by the prevalence of very lieavy dews. The oidum
is removed by a blunt scraping instrument, to which
it is jircvented from adhering in a troublesome degree
liy various devices; in Turkey, by the use of the saliva
of the collector, in Persia by the application of a
small ciuantity of oil. Owing to slight dilTerences iu tlie
use of the scraper, iiortionsof the epidermis of the cap-
side may or may nnt be remos'ed with the fipiuni. The
collection of the Smyrna product naturally adds frcJin
live to eight per cent, to the weight of the 0])ium from
this source, and this amount is usually very largeh'
added to. (See section on Adulteration.) As gathered,
the opium is transferred to a poppj' leaf helii in the left
hand, and the mass, when of convenient size, is laid away
in the shade f<ir a day's drying, which, if it has nut ad-
vanced too far, will jiei'mitof the moulding of the product.
When sufliciently diy it is enwiaiipeil in the l"'ppy leaf,
and such masses may then, without further ninditication,
be packed in Kumex capsules, to prevent their adhesion
to one another, and marketed. They may, on the other
liand, be subjected to very varied processes for various
intrposes. ConsidcraV)le of the Persian opium is subjected
to a long-continued kneading or beating process, with
exposure to the atmnsphere, so as to cause it to assume a
resemblance in apjicarance to Ciinstantino]de opium. The
latter variety is said to be similarly beaten up, so as to
make it of a more homcigeneous and finer structure.
Much of the high-grade Turkish opium, and almost all of
that of similar grade of other countries, is beaten up with
that of lower ])ercentage, to increase its bulk and weight.
It is even .said that some medicinal Turkish opium has thus
mixed with it that of other cotnilries. None of the oper-
ations above considered, though ilesigned to retluci' the
morphine strength, can be regarded as acts of adtilter-
ation, so long as they do not result in n'dueing the mor-
phine strength below olVicial standards. Persian and
Indian opium, instead of being wrapped in the poppy
leaf, are ustiallv wrapped iu jiajier, and, since they are
designed chiefiy for exportation to China, they fre-
quently bear inscriptions in Chinese characters. The
masses are of varied forms, lieing in s<|uares, cakes,
cylindrical sticks, balls, or in mas.ses similar to those of
file Turkish article. Instead of being paeki'il, like the
Turki.sh, in Runiex capsules, they are usually packed in
" poppy-trash," consisting of the chopped, dried capsules
and otiier ]xirts of the plants.
Adiiltertitiun. — The dilution of a high-grade, by the
addition of a low-grade opium has been already oonsid
ered. That by the addition of an excessive amount of
the epidermis of the capsule or of the chopped capsules,
or possibly of other parts of the plant similarly chopped,
sometimes amounting to a third of the weight of the
opium, or of an extract of the capsules, or of starchy
substances, all of which are in themselves practically in-
ert, may be considered, when they do not reihice the
morphine strength below the official standard, as on the
borderland between dilution and adulteration. The u.se
of an extract made from the lierbage of the plant is
clearly adulteration, and is rather common, as is that of
various gummy substances of an extraneous nature, and
of earthy substances, some of them elTervescing with
acids. The use of such heavy bodies as stones, nails, and
bullets, now less common than formerly, scarcely re-
ipiires mention. The custom still prevails, to a greater
or less extent, of diluting opium, after .arrival in this
country, so that it barely meets the official re(iuirement,
the pri>duct being known as PudOiiiri or Jh.itoii Opiiiin.
Deschii'Tion. — In irregularly globular, usually more
or less flattened masses, weighing from 2.10 to l,(i()0 gm.
(i to 3 lbs.), till' surface marked with the impri*sion of a
poppy-leaf u.sed for wrapping, and freciuently bearing
fragments of this, with some rumex fruits; of a chestnut-
brown or reddish-brown, changing to dark or blackish-
brown with long kee]nng; plastic and rather soft, or
gradually hardening from without inward, with age;
fractured surface exhibiting more or less tissue frag-
ments, together with small tear-shajied particles of
opium and, under the microscope, .some acieular crys-
tals, especially visible after moistening with benzene; of
a heavy narcotic odor and taste, the latter disagreeable
and bitter.
The requirecl mor]ihine percentage has been stated \m-
der Definition. Although the oHicial detinition would
permit the employment of the higher grades of opium
from any country, it will be seen that the descri|ition, in
view of what has lieeu said concerning the dirt'crent
methods of wrapping and packing, would exclude all
but the Turkish variety. Persian opium is light-colored
and eliaracteri7.e<l externally and internally by an oily
appearance. Egyiitian o|iium is packed much like the
Turkish, but is dark-colored and is almost if not quite
invariably behjw the official standard in morphine yield.
Indian opium is also dark-colored, usually possesses a
]ieculiar odor, said to be due to fermentation during the
long process of curing reciuired by the peculiar condi-
tions to which it is subject, and is commonly encased in
coverings m.ade by glueing together poppy leaves or
petals by a substance made partly from a dark-colored
exudation from the curing opium and partly from an ex-
tract of the jilaut. Very little of it is exported, except
to China {Pnnixion Opitiiii). and this small quantity is re-
stricted almost wholly to the Patna ]Hoduet. Chinese
opium is mostly of vcrv low grade, though of late some
of much better quality has been produced. It is not of
interest in materia medica.
Since it is recjuired that the determination of the mor
phine percentage beaccomiilishcd by the official method,
it is important that this process be here given:
Auxin/ I if Opium.
Opium, in any condition to be valued. . 10 gm.
Ammonia water 8.5 c.c.
Alcohol,
Ether,
Water of each a sufiicicnt quantity.
Introduce the oiiiuni (which if fresh should be in very
small jiieces, and if dry, in very fine powder) into a bot-
tle having a capacity of about oOOc.c, add KiOc.c. of
water, cork it well, and agitate frequently during twelve
hours. Then pour the whole as evenly as possible upon
a wetted filter having a diameter of 13 cm., and, when
the liquid has been drained off, wash the residue with
water, carefully dni]ipcd upon the edges of the filter and
the contents, until I.jU c.c. of filtrate are obtained. Then
3S-1-
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Opium,
Opium.
carefully transfer the moist opium back to tlie bottle liy
means of a spatula, add 50 c.e. of water, agitate tlior-
otighly and repeatedly during fifteen minutes, and re-
turn the whole to tiie tilter. When the liquid has
drained oil, wash the icsidue as before, until tiie second
liltrate measures 150 e.e. and finally collect about 20 c.e.
more of a thiril filtrate. The second filtrate, placed in a
tared capsule, is first to be evaporated until it represents
i>nly asniall volume; then to this is to lie added the first fil-
trate; and, finidly, after rinsing the vessel with the third
filtrate, theevapcu'ation is to be continued until the residue
-veighs 14 gni. Rotate the concentrated solution about
in the capsule until the rings of extract are redissolved,
i"ur the liquid into a tared Erlenmeyer flask having a
.ipacity of about 100 e.c, and rinse the capsule with a
lew drops of water at a time, until the entire solution
weighs 20 gm. Then add 10 gm. (or 12.2 e.c.) of alco-
hol, shake well, add 25 e.c. of ether, and shake again.
Now add the ammonia water from a graduated pipette
or burette, stopper the flask with a sound cork, shake it
thoroughly during ten minutes, and then set it aside, in a
moderately cool place, for at least si.x hours, or over night.
Remove the stopper carefully, and, should any cr3-s-
tals adhere to it, brush them into the flask. Place in a
small fiumel two rapidly acting filters, of a diameter of
7 em., plainly folded, one within the other (the triple
fold of the inner filter being laid against the single side
of tlie outer filter), wet them well w'ith ether, and decant
the ethereal .solution as completely as possible ujjon the
inner filter. Add 10 c.e. of ether to the contents of the
flask, rotate it, and again decant the ethereal layer upon
the inner tilter. Repeat this operation with anotlier ]ior-
tion of 10 CO. of ether. Tlien pour into the filter the
liquid in the flask, in portions, in such a way as to trans-
fer the greater portion of the crj-stals to the tilter. and,
when tills has passed througli, transfer the remaining
rry.stals to the tilter by washing the flask with several
portions of water, using not more than about 10 c.e. in
all. Allow the double tilter to drain, then apply W'ater
to the crystals, dro]) by drop, until the}' are practically
free from mother-water, and afterward wash them, drop
bj' dro]i, from a pipette, with alcohol jiri'viously satur-
ated with powdered morphine. When this has passed
through, displace the remaining alcohol liy ether, using
about 10 C.C., or more if necessary. Allow the tilter to
dry in a moderately warm place, at a temperatm-e not
exceeding CO" C. (140" F.), until its weight remains con-
stant, then carefully transfer the crystals to a tared
watch-glass and weigh them.
The weight found, multiplied by ten, represents the
percentage of crystallized morphine obtained from the
opium.
CoNSTlTUKKTs. — Not all of the alkaloids of opium here
described occur in all the varieties of opium, the presence
or amount of some of them depending upon varying con-
ditionsof production or preparation. Of the twenty nat-
urally occurring alkaloids, the identity of which has been
■established, morphine and codeine, as well as their deriv-
atives, apomorphiue and apocodeine, and also narcotiiie.
-are considered under those titles. Although several of
tlie others are sonie\\'hat used in medicine, they are not
sufticiently employed to be entitled to separate'consider-
ation, and they arc briefly discussed here and in the
.section on Properties and Uses. Besides these, quite a
number of alkaloids have been obtained artificially by
treatment of tlie others.
i/»/7)/(/H<' occurs in 0]uuin of different kindsand grades
in amounts varying from a small fraction of one per cent.
up to nearly twenty-five percent. Its ordinary percen-
tage varies from six or seven to twelve or fourteen per
cent. la the medicinal Turkish opium, probably as the
result of manipulation with that object in view, it oecuis
almost uniformly in from nine and a half to ten and a half
percent. It occurs in the drug as a compound with sul-
phuric acid or as one with meeonic acid. Codeine, which
exists similarly, rarely if ever reaches one per cent, in
amount and sometimes does not exceed onc-tifth of one
per cent.
Vol, VI.— 25
ynvmne (CrisHsaNOa -I-2H2O) resembles narcotine in
appearance, though the crystals are finer and more slen-
der and are slightly bitter." It melts at 145.3° C. (291.6°
F.), is insoluble in ether, but is somewhat soluble in
water and in alcohol. Nitric acid colors it yellow, though
the color is evanescent; iodine, in small amount, gives it
a blue color; Erdinann's reagent produces a deep yellow
tint, becoming brownish, then orange: finally, Frolide's
reagent produces a brownish green color which first turns
yellow and then red. Like narcotine, narceine is but
weakly basic. Its salts are crystalllzable and are mostly
incom|iatible with water, being precipitated in- decom-
[losed by it. Its hydrochloride is mostly employeil ami
is strongly basic.
Tliebaiiie (" paramorphine," CisHnNOa) usually occurs
in strongly hrstrous scales, but sometimes in jirismatic
crystals. It is soluble in alcohol, benzene, and cliloro-
lorm, and to a considerable extent in ether, and is insohi-
ble in water. Its melting point is 193.4" C. Sulpliuric
acid colors it blood red, changing to yellow, nitric acid
colors it red, Erdnianu's reagent orange-red, Frohde's
orange-yellow, slowly disappearing. It is decomposed
quickly by diluted acids, with a production of the two
isomeric uncrystallizable alkaloids thebnn'iic. and l/ie-
hiiicine. It yields readily cry.stallizable salts.
Papaverine (CgoHo,NO.i) occurs in colorless aeicular or
prismatic crystals, soluble in hot alcohol, chloroform,
and benzene, only slight!}' so in ether and cold alcohol,
and insoluble in water. Its melting point is 147° C.
(290.0' F.). It is colored purple or violet by warm
sulpliurie acid, violet-blue, becoming lihie, yellowish,
ami colorless by Frohde's reagent. It yields salts read-
ily and these are somewhat soluble in water.
The remaining alkaUiids occur only in very minute
amounts, and are merly objects of curiosity in materia
medica. They are:
Oodamiiie (CsoH~iNO.i), Cri/piDpineiC^i'H^s'HO!,), Grws-
enpine (Cs2Ha!NO0, Ilydrordtavnine (CisHuNOj), Lan-
tlu-upine (C23H2,^NOj), Lauclaninc (CnJI^sNO.,), Litndano-
xine (CjiILiNOj), Meranodine (C-jiILjaNOj,) 0.ri/iunroliiie
(("■jjHasNOf), Protopine (C.,„H,,.N()6), Pwnd/miorphtne
(CajHsaNoOs "Phormine" fir "' Oxydimorphine "), Bhoen-
dine (C,,Ho,NO»), Tritojiinc (CvJ'ImNoO,), and Xantha-
tiiie (C37H30N2O9).
Next to the alkaloids, the most important constituent
of opium is about four per cent, of meeonic acid (CtHj-
(>;). occurring free and in the alkaloidal .salts. It can be
extracted by the addition of lime, as calcium nieconate.
It occurs in colorless scales or prismatic crystals, soluble
in alcohol and in hot water. It is colored deep red by
ferric sails, the color not being destroyed by hydrochlo-
ric acid or by chloride of mercury or gold. It is tri-
basic and is decomposed, by boiling, into cumenic and
pijrocomenie acids.
A variable amount of lactic acid occurs in opium.
Mceonin and Meconoisiii are neutral principles. The
former ("opianyl ") is in colorless, odorless, shining, bit-
ter prismatic crystals, melting in the air at 110° C. (230'
F.) and is soluble in alcohol and ether, slightly in water,
ll gives a green color when evajiorated with sulphuric
:nid, with the addition of a little water. The latter has
a somewhat higher melting point and yields a red, chang-
ing to a purple color, on similar treatment with sulphuric
acid.
Among the less important constituents of opium
neither starch nor tannin occurs. There is a varying
amount of resin, a caoutchouc-like subslance, guin, pec-
tin, fixed oil, wax, glucose, coloring matter, and a volatile
odorous principle.
Action and Uses. — A consideration of the actions of
the more important constituents must preced<^ tho.se of
opium. Those of morphine, codeine, and narcotine have
already been considered under these titles. Of the minor
constituents, the odorous ])rineiple of o])iuni is often ob-
ji'Ctionablc to the senses, and is removed in the Opinm
Dii'doratnm or Detideirized Opinm (Opinm Deninrnfisntiim,
United States Pharmaeopana, 1880) by repeatedly wash-
ing with ether, and adding to the dried residue encmgh
385
Opium.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
sugar of milk to restore the inodiict to itsoriginul w<'iglit.
This treatment is supposed to remove also tlie nareotine,
and probably most of the thebaiiie, tlie latter result
greatly alTeeting its pli_ysiologieal action.
T/irhd i lie— Thh alUaioid is to be regarded as the pri'i-
eipal cou.stituent antagonistic to morphine, and hence to
the general action of opium. It is a powerfully poison-
ous irritant of the spinal centres, iiroduc'ing convulsions.
Therapeutical uses tor it have not been developed.
yaireiiie acts very similarly to mor|ihine, but is much
weaker; itsemijlovinent is vaguely stated to be free from
the disagreeable after-elTects of the latter drug, while
others regard it as practically inert. Probably much of
that useii" has been eontaminate<l with morphine, yet the
use of its numerous salts with organic and inorganic acids,
has fully ilemonstrated that it does possess activity. Its
dose is about the same as that of codeine 0.0'J5-(1.0,") gni.
(gr. A to gr. I). None of flic other alkaloids is known to
be of importance in medicine.
Memiiic Arid, though of noiniportanee physiologically,
has been considerably employed in compounding salts of
alkaloids, under the'impri'.ssi'on that tlwse, being the nat-
ural forms of occurrence in opiiuii. were more diftusible
and active than other salts. In tliis view, it was long
oflicial in the liritish Pharmacopceia, but the idea has
now been abandoned ami the sub.stance is little used.
Ojiiiiiii. — From the foicgoing it would ajipcar that the
action of o[)ium should be that of morphine. e.\cept for
the slight modilicatioii <lue to the presence of its thebaine.
In the main, this is true, yet practice demonstrates differ-
ences which cannot thus, nor in any positive way, be ac-
counted for. Doubtless the difference is partly due to
the substitution of juimary elleets, when tised in one
form, for secondary elleets when used in the other. In
o]iium, as in most nervines, such primary and secondary
etfeets are moreor less antagonistic, as sjiecially exempli-
lied in its effects upon intestinal excretion, where a dose,
relatively very small or very large, in consideration of the
condition of the patient, is liable to increase i>eristalsis
and discharge, wdiile the characteristic effect of a moder-
ate dose is to constipate. That o])ium should be less
]U'omi)tly hy|)notic. |)rodueing more of a iireliminary ex-
citation of the spinal and lower cerebral c<'nfres, com-
monly with irritable pid.se, can be readily charged to the
action of its thebaine. It is diflicuU, however, thus to
explain its great<'r intestinal astringeiicy or consti|)ating
effect or its peculiar diaphoretic prop<'rties.
From a theiapeutical standpoint opium can be used for
all the purposes for which morpliine is emjiloyed, though
the dose should be relatively somewhat larger; that is, a
do.se of opium shoidd contain more morphine thanwoid<l
be employed as a salt for the same ])urpose. Even with
this proviso opium is not to be sele<'ted in preference to
morphine for ordinary sonuiifacient pur]ioscs. since its
action cannot be .so accurately estimated, nor is it so
prompt. On the other hanil, there are cases in which it
is to be pri'ferred, even for sucli uses, since its after-
effects are not so disagreeable (jr lasting as tho.se of mor-
lihine. For cheeking intestinal discliarges. ojiiuni is
greatly to be preferred, though its continued use is not
.so constipating as that of morphine; often, in fact, it
tends to looseness of the bowels. When it is ueee.ssaiy to
maintain for some time an equable analgesic effect, as in
relieving abdominal pain in iieriti>nitis, for instance,
opium is usually to be prefen-ed, though it is sometimes
desirable first to get the patient under its influence by
the u.se of moridiine. Subject to the above moditlca-
fions, the specific actions and uses i>f oiuum should bi'
sotight under Morphine.
Speriid I'xiii (iiiil Dose.1 of tin' rirponilioiix. — (It is to be
remembered that the doses of opium and its lucparations
are subject to the same enormous s]ieeial variations as are
thoseof mor]ihine.) Of opium itself there isliut one offi-
cial preparation, namely, the Opii I'lilrin or jiowdered
opium, from which all flic other preparations are made.
This discrimination is of practical importance, since
]iowdered opium must contain between thirteen and
tifteen per cent, of moriihine, about a half more than the
lowest allowable (and usual) content in opium. It is
specitied that powdered opiiuii of too high a percentage
may be reduced to the proper strength by mixing in due
proportion with that of a lower grade." Whenever the
dose of opium is stated, it is powdered opium, which is
to be understood. For ordinary purjioses, this is fl.OfiS
gm. (gr. i.). The substance is often given without
change, nuic'h oftener in the form of the |)ills {I'ilnhr
Opii), each containing the above mentioned amount, with
a little soap, or in the deodorized form, mentioned at the
beginning of our paragrajih on Actions and Uses, its
strength and do.se being e(|Ual to lho.se of powdered
o]iium. Crude, undried oiiium is occasionally given in
pill form when slow .solution is desired, as in cases of re-
laxed intestine, diarrhiea of phthisis, and chronic dysen-
tery. Old and haril pills are sometimes written for"(and
many apothecaries keep them on hand for the purpose),
in the hope that thi'y will pass the stomach undissolved
and exert a local continuous influence upon the intestine.
This result is, however, not exactly within control, and
may he better attained by coating pills Aviih keratin.
More often still, when the effect of solid opiiun is desired,
the extract (Extrorliiiu Opii) is given, its morphini>
.strength being eighteen jjcr cent., and the dose from half
as large to as large as that of powdered opium. The
above-named are favorite forms for the administration of
opium when it is desired to produce a constijiating effect,
to restrain intestinal jierisfalsis and relieve the pain de-
pendent thereon, to relieve irritation dependent upon ex-
treme ]mrgation and irritant poisoning, and to stay nearly
all forms of abdonnnal intlainination. In these cases the
grain of o|iium is oltcn combined with three or fVan-
grains of lend acetate. In this connection, the external
employment of the " lead and opium " wash must not be
forgotten. Its eU'eet in relieving pain and averting or
reducing inflammation in and underneath the skiu are
sometimes magical. It is made by dissolving one liim-
ilred and twenty grains of lead accttate in about ti'ii
ounces of water, adding one-half a tluidounce of tincture
of opi\im, and water enough to make sixteen ffuidounces.
It slicndd lie shaken well before using.
Tlie sim[ile liijuid prepaiations are the tincturi' (77Hr-
tinui O/iiij, or laudanum, the deodorized tinture(7yHi"^inv'
Opii Demhiriitii), the vinegar (.l<'t'?(()H Opii), and the wine
(Vimim Op«), all containing ten per cent, of powdered
opium and between 1.3 per cent, and 1.5 per cent, of
morphine, and exhibiting no important difference in
]ibysiologieal action, the selection being based chiefly on
the basis of odor and flavor, and the ordinary dose of
each being ten minims. Laudanum contains its opium
in a mixture of eiiiial voliinii'S of alcohol and water.
The deodorized tincture bearstlie same relation to lauda-
num that deodorized oiiiuni does to powdered opium. It
is made from powdered opium, the deodorizing process
being jiart of its manufacture. The vinegar contains
three |ier cent, of nutmeg and twenty ]ier cent, of sugar
in dilute acetic acid. The wine is made with a mixture
of whiti' wine and fifteen per cent, of alcohol, and con-
tains one per cent, each of cloves and cassia cinnamon.
The action and uses of laudanum maybe taken as the
type of tho.se of this grouji. It is used in cases similar to
those in which oiiiuni is itself emplo\'ed, but where a
more prompt effect is desired. It is a favorite prepara-
tion for relieving the convulsions of puerperal eclamp-
sia, as much as a Miiiddrachm being often given and re-
peated once or twice if necessary. In some forms of
liemorrhage connected with pregnancy or delivery,
large doses are also commonly employed. Lauilaniiiii
constitutes a favoriie addition to poultices, for relieviiiii
.superficial i)ain, and it is frequently rubbed in with liiii
ment or applied with lime liniment to relieve pain when
not deeply seated. In spite of the fact that absorption
of morpliine by the skin is slight, such treatment is
of iindoiilited value. Laudanum is very commonly ap-
plied on pledgets of cotton to aching teeth or ears,
though the latter treatment is not always to be recom-
mended.
There are several mixed prejiarations of opium wliicl(
3Stj
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Opium.
Opiiini.
are i^f srreiit importauce. puregoric {Tiiiciura Opii Cmii-
phorntit) bciug perhaps the most so. This preparation
coutaius only 0.4 per cent, of opium, with the same
amount each of benzoic acid, cam])hor, and oil of anise,
tiisetlicr with four per cent, of slycerin in diluted alco-
liol. It has no alkaloidal standard. Paregoric consti-
tutes a most e.\cellent combination of a carminative with
an analgesic, and is of the greatest value in relieving
abdominal pains which present siu-b indications. It is
pre-eniincntly the form of opium for administration to
chililren; but it is to be borne in mind that its continued
administration, througli the inattention rather than the
direction of the physician, has freciuently been the means
of leading to the formation of an opium habit. The dose
of paregoric is 4-15 c.c. (fl. 3 i.-iv.).
The brown mi.xture or compound nn.xtiu'e of liquorice
(Mistiini Glyccrrhizw Compofu'lK) contains twelve percent,
of the camphorated tinctiue of opium with six per cent,
of wine of antimony, three ]ier cent, each of the extract
of lif|Uorice and the spirit of nitrous ether, live per cent,
of syrup, and ten per cent, of mucilage of acacia. The
dose is about 16 c.c. (fl. | ss. ). This preparation is in its
natiue somewhat similar to tlie Dover's powder, being a
nuich used expectorant and diaphoretic, with distinct
diuretic properties also.
Dover's ])owiler (Piiliis Ipecacntuihm et Opii) contains
ten per cent, each of powdered ipecac and powdered
opium in sugar of milk, the dose being 0.66 gm. (gr. x.),
and the corresponding liquid, often spoken of as liquid
Dover's powder (7V)irf';crt Ipecacuan/ur ct Opii), consists
of ten parts of the fluid extract of ipecac in one hundred
parts of the deodorized tincture of opium (corresponding
to ten per cent, of opium), the whole reduced by evapor-
ation to one Inmdred parts; the dose is ten minims. Tlie
last-mentioned two preparations constitute a remarkably
iisefid combination of a diaphoretic with an analgesic and
somnifacient action. lu this iliaphoresis both elements
play their own peculiar part. An approaching "cold "
can frequently be averted by a full dose of either, with
a few hours' rest. An irritable c<iugh, preventing rest,
is relieved by the hypnotic etTect, wliile the condition
itself is benefited by the diaphoresis. The troches of
liquorice and opium (Trochisci Glycyrrhiza; et Opii) each
contain 0. logm. {about gr. ij.) of extract of liquorice,
0.00.5 gm. (gr. y^) of powdered opium, with sugar, acacia,
and a little oil of anise to flavor. They are very useful in
allaying throat irritation and mildly promote expectora-
tion. By adding a little ipecac or tartar emetic the effect
of Dover's powder may be simulated in mild degree.
The following tatjle exhibits the preparations of our
Pliarmacopa'ia and the proportion of opium in each:
a clear description of the toxic effects of a "driidi pre-
pared from the tears which exude from poppy heads."
Dio.scorides, three centuries later, refers to the lethal
elfects of the poppy, and describes the method by which
opium was then obtained, a method which does not sen-
sibly differ from that which is practised at present.
Pliny (.\.D. TO) speaks of the toxic powers of opium,
and cites the instance of Post. Licinius Ca'cina. who,
disgusled with life, terminated his existence with opiiun
— an instance which was by uo means singular, as the
narrative concludes with "item plerosque alios."
In modern times (since 1600) we can tiud mention of
but twelve cases of liomicidal poisoning by opium or its
preparations or derivatives, of which two were by lau-
danum and the remainder by morphiu. Suicidal and ac-
ciilental poisonings by the opiates are of very frequent
occurrence. Probably thirty to fort_v per cent, of non-
homicidal poisonings in the United States and in Great
Britain we caused b}- these poisons. The widespread
vise of "soothing syrups" and other similar no.strums
containing opium is unquestionably a factor in tlie high
percentage of infant mortality.
Sy.mptoms. — The symptoms produced by opium and
its preparations, and b\- morphin — acute meconism —
are practically the same, whatever preparation of opium
or .salt of morphin may have been used. Other things
being equal, however, morphin and its salts are more
rajiid in their action than opium or the preparations
made from the crude drug.
The tiiiie at which symptoms manifest themselves is
usually from half an hour to one hour after the poison
has been taken. Frequently this period is much short-
ened. In children who have received large doses the
poison sometimes begins to produce its elfects within a
very few moments or almost immediately. When the
poison has been introduced bj- hypodermic injection, it
acts more rapidly than when taken by the stomach.
Opium in .solution acts more promptly than the .same
substance in the solid form, and the salts of morphiu
are more rapid in action than the alkaloid itself. Opi-
ates administered by the rectum are more rapid in their
action than when given by the stomach. The symptoms
appear earlier when the poison is taken while fasting than
when it is taken upon a full stomach. In exceptional
cases the interval between the taking of the poison and
the appearance of its effects is very much shortened even
in adults. Thus. 4.5 c.c. of Licjuor opii sedativus has
caused total insensibility in fifteen minutes, and death in
an hour and twenty minutes. Cases have also occurred
in which the action of the poison has been much retarded,
although taken in solution. Thus, instances are recorded
Opium (.vot less tha.v Nine Per Cent. Morphi.ve).
Powdered upium (thirteen to Bftcen per cent, morpbine).
Extract of opium (eighteen per cent, morphine).
Plaster of Troches of Ikiiiorice
opium and opium
(r^o ex. of (ex. of opium,
opium ) . 5>s grain each).
Deodorized
opium
(fourteen per
cent, morphioet.
Deodorized Tinct-
ure
(iS P. opium).
Tincture of ipecac
and opium
'I'l deod. tincture
opium. 1^ fluid ex.
ipecacj.
Pills of opium
(I grain in
eacli).
Camphorated
tincture.
(nHiii P. opium,
camphor, etc. ) .
I
Compound mix-
ture of liquorice
(i^o^ camiihor.
tincture opium,
tSj wine anti-
mony).
Tincture of opium Wine of opium
t-h P. opium). {-fa P. opium
and aromatics).
1
Vinegar of Powder of ipecae
• ipium an<i opium
(A P. opium (la P. opium,
and nutmeg). I'a ipecac).
Henry II. Rushy.
OPIUM HABIT.
Intoxii'ittimi.
See Insanity: Driit/ Habituation and
OPIUM, POISONING BY.— The poisonous nature of
opium, and of tlie poiqiy, was known to the ancients as
early as the time of Nicander (185-13.5 B.C.), who gives
in which no symptoms were produced in nine, twelve,
fourteen, and eighteen hours by 45, 15, 00, and 45 c.c. of
laudanum.
The clinical history of acute morphin or opium poi-
soning may be divided into three stages.
The first period, that of increased nervous excitability.
38T
Opiii III.
Opiiiiii.
REFERENCE ll.\.\l)n< lOK OF THE .MEDICAL SCIENCES
is usually of short duration in the acute form of poison-
ing, although Ciises are recorded in which it has lasted
fourteen and eighteen hrmrs. It is fre(|uently entirely
aliseut. when large doses have been taken. This stage is
marked by restlessness, great ]ihysic;d activity, loquac-
ity, greatly increased imaginative power, frequently to
thee.vtent of hallucinations, always of a jjlcasing char-
acter, and by increased cardiac action. In adult males
priapism .sometimes occurs during this stage. Vomiting
is also of occasional occurrence, and greatly improves the
|iatient's chances of idtimate recovery.
The condition of excitation pa.sscs, .sometimes rather
suddenly, into an intermediate stage of diminished excit-
ability. ' The patient l]cconies weary, incapable of pliysi-
eal exertion, dull, and drowsy. He complains of a sense
of weight in the extremities and an irresistible desire for
sleep, to which he finally \ieidsif not kejit awake. The
sleep is at first seeniingl_v normal, though profound. The
pulse and respiration are normal. Tiie patient maybe
roused and sometimes kejit awake by shaking him, by
the intliction of pain, cu' by loud talking. Tlie face is
pale, the lips are somewhat livid, the surface is covered
with perspiration, and the pupils are contracted. Dur-
ing this period tlie patient frequently experiences a vio-
lent itching of the skin. Avhich is sometimes followed by
the apiiearance of an e.xanthem which may be ]iapular.
red. bluish, or almost colorless, or resembling those of
urticaria or of scarlatina.
The conditi<in of siannolence is of short duration, and
passes quickly into the stage of narcosis. The patient
can no longer be roused, even bj- the most violent means.
He lies motionless and senseless, with eyelids closed or
partly closed. The surface is bathed in profuse perspi-
ration, which exhales the odor of opium in opium cases.
The face is pale, the lips are blue, the lower jaw is
dropped, and the muscles are completely relaxed. The
]niiiils ari' insensible to light, and contracted to the size
of piuheads until death occurs, when they dilate. A few
cases are. however, recorded in which the pupils were
said to be dilated. At first the superficial arteries, tem-
porals, and carotids are seen to pulsate fully, strongly,
and rapidly, while the respiration is slow and shallow
(eighty pulsatiousin the minute to four respiratory move-
ments have been ob.served). Later, the pulse becomes
feeble, slow, irregular, and easily compressible. The
respiration becomes slow, shallow, stertorous, and ac-
conqianied by mucous rtdes. Retention of tn-ine occiu's
early in tlie history, and continues until death or recov-
ery.
From this period, if the case do not yield to treatment,
the poisoning usually proceeds rapidly to a fatal termi-
nation. The surface of the body and even the exiiircd air
become cold. The skin is cyanosed and covered with a
cold clammy perspiration. The pidse becomes slower,
more feeble, and gradually imperceptible. The respira-
tion is more shallow and feeble, while the rales become
more pronounced. Lidivi<lual muscles, or groups of
muscles, are agitated by sbi.irt, clonic twitchings, and
occasionally convulsions and tetanus occiu'. Later, the
muscles become completely paralyzed, the resiiiratory
movements are made at longer intervals and finally cease ;
the circidation continuesafter the cessation of res])iration.
Finally, the action of the heart is arrested and the patient
dies quietly. Sometimes eiiistaxis and other hemorrhages
occurtoward the end; and in some instances death results
from cerebral hemorrhage.
Should recovery follow after the stage of narcosis, the
respiration gradually becomes more fre(pient and more
natural, the pulse becomes first perci'ptible and then
gradually passes toward the normal, while the condition
of coma passes into one of deep sleep, which may con-
tinue for from twenty-four to thirty -six hours longer,
although the patient can l)e roused.
In the great ma.iority of cases in which recovery iias
jirogressed so far that the patient may be rou.sed it will
lie complete Nevertheless, occasional instances arc re-
corded in wliich the victim has relapsed into a deeply
comatose condition and has finally died.
In cases of recovery the patient, on awakening, is
Weary, giddy, and uncertain in his movements. " He
may also sutler for some hours from nausea and liead-
ache, and for a lougei- time from loss of appetite and de-
rangement of digestion. In two cases Dr. Edes (British
Mcilii-iiJ tind Stiir/icid Juurmil, 1881, cv., 251) has ob-
served the presence of casts in the mine ; in one case,
accompanied b_v albumin.
DuR.-\TioN. — In cases of fatal poisoning by the opiates
death usuall}- follows in from twelve to eighteen hours
after the poison has tieen taken. Of 48 fatal cases, death
followed within twenty-four hours in -4^; within eigh-
teen hours in o9; within twelve hours in 2G, and within
nine hours in 20. The minimum duration of the poison-
ing was forty-five minutes: and the maximum, fifty six
hours.
Cases are recorded in which the symptoms of narcot-
ism have disappeared and the patient has died at a
greater interval of time than the above maximum. In
such cases, although the death ma}- have been ai-ce!er
ated by the action of the poison, the fatal residt is imme-
diately due to oilier causes. Thus, in a case quoted by
Tajior, a patient suffering from illsease of the heart took,
in four hours, two hundred drops of laudanum, and was
bled to the extent of thirt}- ounces. On the sixth day he
was sufticiently recovered to undertake a journey, and
died on the eleven th day. In this case the cause of death
was failure of cardiac action, aggravated at least as much
by loss of blood as by opium.
In cases of death in w hieh the patient has suft'ered from
a disease whose symptoms resemble those of opium poi-
soning, and has also received a large dose of an opiate,
the question of duration may become one of considerable
medico-legal importance. In a case which came under
the author's observation a physician had given a child of
four months gtt. x. of the Tinct. opii deodorata by mis-
take for Tinct. opii camphorata. The patient suffered
from well-marked s_ymptoms of opium poisoning, but
under immediate treatment improved, and in forty-eight
hours had apparenth' recovered. Death followed, how-
ever, in ninety hours from acute hydrocephalus.
Obviously, the same causes which influence the rapid-
ity of action of the poison, and those which mollify the
effects of unusualh' large or small dose,s, will also influ-
ence the duration of the case, whether it tenuinate in
death or in recovery,
Lp:th.\i, Dose. — As the action of the ojiiates is much
modified b)' conditions, such as age, habit, state of
health, form of administration, and idios_yncrasy, it is im-
possible to fix a lethal dose applicable to all conditions.
It may be said, however, that 0.06.5 gm, or gr. i., of mor-
phin, or 0.4 gm, or gr. vi. of ojiium, would cause symp
toms of poisoning in an adult not habituated to the
drug, and possibly would cause death. Several instances
of death from 0.2 to 0.26 gm. (gr, iij.-iv.)of morphia
(or laudauum equivalent) are reported. In other cases
death has followed after doses as small as 0.032 (gr. ss.),
but in these other causes were also operative or the report
is unsatisfactory (see Witthaus and Becker, "Medical
.Jurisiirudeuce," iv., 730),
On the otiier hand, nmuerous cases are on record of
persons, not addicted to the opium habit, who have re-
covered from very large doses. The largest quantitj- of
morphin certainly thus recovered from was 3.89 gm. (gr.
lx.)of the acetate (Wood, Boston Med. and Surg. Jo'irnal,
1876, 82). Although the relative immunity in these
cases of very large dose may be ascribed in some degree
to an idiosyncrasy of the patients, their escape has been
l^robably more largely due either to non-absorption of the
poison or to rejcciion of the major portion by vomiting.
Infants and children are peculiarly susceptible to the
jioisonous action of opiates, even in very minute doses.
Cases of death from small doses of laudanum are cited
as follows: Gtt. iv. (e(|uivaleut to gr. J, 0.011 gm.. of
opium) in a child of nine months: the same ((uantity
in a child of five weeks; gtt. v. (= gr. |, 0.013 gm )
per rectum in a child of eighteen months; gtt. viij., dur-
ing eighteen hours, in four doses (=gr. ^, 0.032 gm.).
388
REFERENCE HANDBOOK OF THE ^IKDICAL SCIENCES.
Opium.
Opliiiii.
ill ;i child of six weeks: gtt. iij. (- gr. -i. 0.008 gm.)
iu an infant of two weelcs; miss (=gr. -['ij' 0.0065 gin.)
in an infant of three days; gtt. ij. (= gr. -^, 0.0054
gni.) iu an infant of five days: the same quantity in an-
other of four days, ^. i. (=gr. -^, 0.005 gm.) in an iri-
fant of seven days: and gtt. i. (= gr. ^'j, 0.0026 gm. )
in an infant of six day.s. A dose of gr. iv. pulv. ipecac,
et opii (=gr. |, 0.026 gm., of opium) lias caused the
death of a child of four and a half years. Huseman and
Taylor refer to a case (Edwards) in which the amount
tiiat caused the death of a four-weeks-old child was as
low as 0.006 gm. (= gr. t!j^) of opium, taken iu the form
of the camphorated tincture.
Even during this early period of life occasional in-
stances of recovery from relativel}- large doses are met
with. A case is reported by Dr. Coibet, iu the Lancet,
August 29th, 1857, p. 220, in which an infant of one day
received ^, xxx. (=2.3 grains, 0.15 gni. of opium), 3'et
recovered within ten hours. This case is of interest, as
the age of the infant jirecludes the possibility of its hav-
ing liecome accustomed to the drug, as was probably the
case with a child of six months who recovered from a
dose of a teaspoonful of laudanum (= 4.6 gr.aius, 0.298
gm. of opium) (Simmonds), although treatment was de-
layed for au hour: and with another of nine mouths who
recovered from a dose of two teaspoonfiils (= 9.2 grains,
0.596 gm.) of the same tincture.
The dosing of infants and 3'oung children with officinal
or proprietary preparations of opium by mothers and
nurses is widely practised. One of the results of the
practice is the lai'ge percentage of deaths from opiates
among young children. A tabulation of 144 cases of
opium poisoning, taken chiefly from English and Ameri-
can journals, gives this result:
Total
cases.
Children
less than
one year.
Children
less than
Ave yeare.
Children
less than
ten years.
79
18
34
13
3i
9
3
10
25
10
5
12
26
Opium
11
5
13
Totals . .
144
46
32
.52
36
.54
Percentage of total
37.5
From which it ajipears that 'ibout one-third of the ri'-
porti-d poisonings b_y the opiates occur iu children less
than one j'car old.
The poisonous action of the opiates is very greatly di-
minished by habit, probably more than that of any other
poison. The amounts taken by adult opium-eaters, lau-
danum-drinkers, and raorpliininjectors are sometimes
enormous. Cases in which the consumption reaches 2
gm. (grs. xxx.) of opium, or one-half, one, or even two
ounces of laudanum (=0.5, 1, 2 gm.), in twenty-four
hours are of by no means uncommon occurrence. Such
cases sink into insignilicance when compared w'ith that
of De Quincy, whose daily draught of laudanum at one
time reached nearly nine lluidounces (= about 20 gm. of
opium). Krliger- Hansen relates the case of a jjatient
who consumed in one year over 300 gm. of opium, a
daily average of over 0.8 gm. (about gr. xiij.). Zeviani
cites the case ot a woman wlio. in thirty-three years,
had taken over 100 kgm. of opium, equivalent to a daily
average allowance of 8 gm. {— nearly gr. exxv.i; and as
the dose is gradually increased bj- opium-eaters, the daily
consumption iu this case must have been much greater
in the later years. Headland and Mvers lefer to instances
in which gr. xviij. (= 1.16 gm.) of morphin were taken
daily ; and the author met with the case of a young man
of twenty, of profligate habits, who had reached the same
quantity, when he terminated his career with a large dose
of potassium eyanid.
It is not 10 be inferred from these large amounts that
an opium eater can take an unlimited (piaiitity of the
drug without experiencing its poisonous action. It is
simply a question of quantity — a quantity necessarily
varying in each case, — and instances are of frequent oc-
currence in which the opium-habitue has experienced the
symptoms of acute poisoning, and has even died from the
elTects of au overdose.
The tolerance of opiates acquired by habit is not con-
fined to adults; it is also produced in quite young chil-
dren. A remarkable case iu point was jiublished by Dr.
J. L. Little (Amcrienn Jotiriinl of Oh.<<lctr/<:% 1878," xi.).
A male infant, suffering from acute inflammation of the
knee-joint, followed by an ab.scess, began at three weeks
of age with small doses of jmregoric. gradually increased
to a teaspoonful. Subsequently Tinct. opii was substi-
tuted, and then Magendie's .solution of morphin, in doses
gradually increased, until, when nearly eight months of
age, the child took in one day two fluidounces of Magen-
die's solution (equivalent to 3.07 gm., gr. xxxij.) of mor-
pliium sulfate.
Treatment. — The treatment in cases of acute opium
poisoning should be directed, first, to removal of
unabsorbed poison from the stomach; and, second, to
prevention of death by coma and cessation of respiration,
until the processes of elimination have removed that por-
tion of the poison which has been absorbed.
In the earlier stages of the poisoning, emetics are of
value — zinc sulfate or ipecacuanha; or, if the patient
be an obstinate suicide, apomorphin, hypoderniically.
On no account should tartar emetic, or any antimonial,
be u.sed as an emetic in this or any other form of poison-
ing. Stomach lavage is to be preferred to the exhibition
of an emetic; particularlj- iu the later stages, when, the
patient having lost the power of swallowing, a hj-poder-
mic injection of apomorpliiu usually fails to provoke
emesis. The siphon is to be preferred to an emetic, not
onlj' on account of its more certain and rapid action, but
also because its use does not tend to increase the cerebral
congestion as does the exhibition of the emetics. On the
other hand, in some exceptional cases, in which opium iu
substance has been taken, an emetic ma}^ be necessar}- to
remove masses too large to enter the pipe. In eases
likely to lead to litigation, the material removed by the
siphon should bi- ]ireserved. The stomach having been
emptied of its contents, the viscus is next to be well
washed out, preferably with a solution (1 to 1,000) of po-
tassium permanganate, about 500 c.c. of which are finally
left in the stomach. This procedure is to be followed
even when the poison has been taken hypoderniically, as
it is eliminated by the slomacli.
If the ease be seen before the stage of sopor has been
established, it .should be prevented, if possible, by keep-
ing the patient in motion — walking him between two
sufficiently robust assistants, preferalily iu the open air,
if location aud weather permit, but not iu the direct sun-
light. This '"ambulator}' treatment" has been benefi-
cially prolonged in some cases for from six to eighteen
hours. Under its influence sometimes the action of an
emetic which has remained inert is brought about.
If the patient be already iu a lethargic condition, he is
to be roused without delay. This is best accomplislied
by cold attusions to the head, the body being kept warm
and dry, flagellation to the palms and soles, or to the
back with damp towels, or the use of the faradic current.
When roused, the patient is to be kept awake as above.
Should the respiration have ceased or become very
slow, it may frequentlj- be stimulated by the application
of the induced current, the positive pole being applied
to the root of the neck over the point where the phrenic
nerve crosses the scalenus amicus muscle, while the
negative pole is carried laterally over the anterior attach-
ments of the diaphragm. If the faradic current be not
obtainable, or if it fail, artificial respiration is to be per-
formed. To be of service this must be persisted in. iu
some cases, for many hours, and until normal respiration
is again established. Dr. AV. F. Cheatham has published
(North Ciimlina Medical. Journal. 1886, 20) a case in which
this was the sole method of treatment. The respiration
had ceased and the pulse was liarely perceptible. Arti-
ficial respiiation was applied. In thirly-seven minutes
389
<ftpilllll.
optometry.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
tlic patient made an effort of lesjiiiation : in an hour and
forty minutes the resjiiratiou was five per minute,
1 lioujjh stertorous. In nine hours consciousness returned,
and recovery followed.
If the case lie at all prolon.ned. distention of the blad-
der and jiossiliility of reahsorption are to be prevented
by llic use of the catheter. If this be done in a case in
which there is the faintest possibility of litigation, the
urine so removed should be carefully preserved.
Little can be said in favcu- of the"ditferent drugs that
have been used as so-called physiological antidotes.
Atropin. which is so freipiently administered as an anti-
tlote to opium jx^isoning. nn(|Uestiouably dilates the im-
pils, but has little, if any. cll'ect ujion the respiration.
Cases are recorded in wliiili, although atropin has been
given until the pupils wire widely dilated, the respira-
tion has ceased, and the patient has subsequently recov-
ered by means of artiticial n'sjiiration (see paper of Dr.
Cheatham, (|Uotcd above).
Tinctura belladonna>, strong infii,sion of coffee by the
stomach or subcutaneously, extract of coff'ee, catteiii.
brandy, digitalin. chloral hydrate, veratrum viride, and
jaborandi liav e been used as antidotes. Tlie last named,
or ]iilocar]iin. may be of value to increase the elimina-
tion, and liius lessen the duration of the poisoning.
PosT-MoKTKM Appe.vkancks. — The autopsy reveals no
lesions which are characteristic of opium |ioisoning. ex-
cept, jiossibly. the odor of the drug. Obviously, if mor-
])hin Iiave been the substance taken, or if other more
jiowerttdly o<loroiis substances be present, this will nut
be ol.iscrved. The surface of the body is livid. Rigor
mortis is .said to be of shorter dm-ation than usual, al-
though an autopsy is reported by Tardieu at which rigor
mortis was well marked sixty-two hours aft<'r death.
Putrefaction is said to be more rapid than usual. The'
blood is fluid and dark. The vessels of the brain and
meninges are gorged with blood, and the cut surfaces of
the braiu substance lu'esent niunerous dark red s|iots.
The veins of the scalp are also tilleil with blood. Serous
effusions are frequently met with between the mem-
branes, mor<' rarely in the ventricles. The lungs are
usually congested. The stomach and other viscera are
normal, so far as the action of the poison is concerneil.
The bladder is generally full of urine.
The congestion of tlu' cerebral vessels and of the hmgs
are tlie most noteworthy apjiearauees. Yet, as they may
be alisent in opivun |ioisnning, and ma\' be present wlien
death has residtcd from other causes, they are only of
value as continnatory evidi'uce of the cause of death,
An.vi.ysis. — To detect the presence of morphin in the
vi.scera after death, or in articles of food, it is necessaiy
to separate that alkaloid in a condition of as near purity
as possible. In cases of oiiium poisoning it is furtlier
necessary to search fiu' mccoiiie acid, an<l, if possible, for
other of the opium alkaloids.
If the facts (if tlie ease do not point very distinctly to
oiiiuni or morphin as the pipisonous agent, the jirocess
of Dragendorlf should be followi'd for the .seiiaration of
till' tdkaloids (DrasrendorlT. "Ermittl. v. (iifteii." 4 Aufl..
lsi«, 149-l."i3l.
If the indications of opium or niorphiii iioisoniiig be
snilieieiitly direct, the following siniplilicil method for
the se|iaration of morphin and of meconic acid may lie
followed. The sulistances. if solid, are linely hashed and
extracted several times with water containing one per
cent, of hydrochloric acid at the ordinary t<'miierature (if
the materials be alkaline, the proportion nf acid is to be
increased to such an extent that tlic liquid, when in con-
tact with it, retains its a<Md reactinn). The aqueous ex-
tracts are filtered and shaken witli amyl alcohol tliree or
four times, and oftenerif necessary, until the aniylic al-
cohol is no lunger eolnred, and the alcoholic layers sepa
rated. If the substances uniler exaniinatiim ijc liquid,
they are to be rendered acid witli hydrochloric acid, fil-
tered, and the filtrate treated with amyl aleoliol. The
amylic solution now contains meconic acid, if present in
the objects examined ; and the watery solution, the alka-
loids as chlorids. To separate meconic acid, the ;imyl-
aleohol solution is shaken with successive portions of
water, which are separated, until the water is no longer
colored. The alcohol is evaporated over the water-bath ;
tlie residue extracted with hot water; the solution filtered
hot ; the water evaporated over the water-bath ; the resi-
due extracted with alcohol; the solution filtered, and the
aU'ohol evaporated. Thetestsfor meconic acid are finally
ajipliedloa jiortionof thelast residue. During this treat-
ment a .small portion of the meconic acid is converted into
com<'uie acid, which does not, however, interfere with thG
tests.
To separate morphin from the aqueous liquid above
mentioned, the hydrochloric acid is neutralized com-
pletely with ammonia, and the liquid rendered distinctly
acid with acetic acid, and evaporated over the water-batl:
to the consistency of a syrup. The residue is extracted
with four or five volumes of ninety-percent, alcohol and
filtered. The filtrate is freed from alcohol bj' distillation.
The residue, diluted with a small cjuantity of water, if
thick, is heated to 50' to 60' C, an equal volume of
amyl alcohol* is added and then sufticient ammonium-
bydroxid solution to render the solution distinctly alka-
line. The mixture is next strongly shaken at intervals
for half an hour, the amylic alcohol separated, and the
extraction of the aqueous liquid with amylic alcohol re-
peated three limes. The united amylic solutions are
evaporated to dryness; the residue is extracted seveial
times with warm "(not hot) water slightly acidulated with
sulfuric acid, and the solution filtered. U])on the acid
filtrate isHoated a mixtuicof ten parts absolute ether and
one part (ninety-five-])er-cent.) alcohol; ammonium-hy-
droxid solution is tidded to alkaline reaction, and the
whole strongly agitateil. The ether-alcohol layer is
siqiarated; the extraction of the. now alkaline, aqueous
liquid is similarly repeated Several times, and the ether-
alcohol evaporated in a number of small watch glasses.
To i)oitions of the resiilue so obtained, either dry or dis-
solveel in a few drops of water, as the nature of the test
may require, and now sufficiently freed from coloring
and other foreign substances, the tests for morphin are
to lie aiijilied.
Tests. — I. Mnrjihhi. 1. "With the general reagents
for the alkaloids, the morphium salts give reactions as
follows, the fractions indicating the maximum of dilu-
tion ill which the alkaloid is capable of reacting: With
ji]hisjili'iiiii)liiliilit' arid, yellowish, amorphous precipitate,
ZJii'T,'- with /"(//« ill jiiitiisaiiiiii-iiuliil siiliitiiiii, red-brown,
amorphous preei)iitate, -^^j; : with//"^/,w/w/H miil hisimith
iiiilii}. amorphous precipitate, subsequently changing
to silky needles, ji^'.-fT;; with nuric chhiriil. lemon-yellow
|)recipitatc, becoming darker; with plmxphitiiniislir acid,
fioeculent precipitate, Tv'iTii : with putiixtiiiim ind/ii/driiir/i/-
niti. yellowish, amoriihous preciliitate. jj}r,Ti'- with phi-
tiiiii' eliliii-id. .slowly, yellow. <-rystalliiie iireciiiitate, yjj;
with pirrir Ill-id. bright yellow, amorphous iirecipitate,
-f^; and with Iniiiiii- iirid, a faint cloudiness, becoming
soniewbat thicker on standing. For the above tests the
solutions of the alkaloidal residue are to be made with
very dilute sulfuric acid, and the reagents should be as
nearly neutral as their natures will permit.
i. Morphin dissolves in concentrated nitric acid with
an orange-red color, which gradually changes to yellow.
.Villi it ion of stannous ch lurid solution does not cban.ire the
color of the yellow solution to violet, as it does with the
similar color obtained with brucin. Limit, O.ltl mgin.
;!. Morjdiin dissolves in conctntratcd sulfuric acid,
forming a colorless soluti<in. If this solution be heated
over the water-bath for an hour, iuid allowed to cool, or,
]ircferalily, if it be allowed to stand in a desiccator
twenty-four hours, and then treated with a trace of nitric
acid or a minute granule of saltpetre, ii beautiful violet
color is ]irodiiced, which soon changes to purple-red, and
then gradually fades. Limit, 0.001 mgm. (A. Iluse-
niann).
A further |iortion of the sulfuric-acid solution, if
• It is absolutely essential tliat ttie amvlio alcohol used shoul'i be
purified, >ihiir1bi hi'fiin use, by rejieated redistiiliition. uutil a portion,
on evaporation, yields no residue capahle of ledueinsr iintir acid.
?,0(l
UEFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Opium.
Optometry.
trciiU'd, after warmiiifr and subsequent cooling as above,
with a small fragment of potassium (lichromate, assumes
a i«aliogiUiy-browii color (J. Otto).
4. A fragment of .solid inorpliiu moistened with a solu-
tion of ferric clilorid. as neutral us possible (best obtained
by dissolving the ehlorid obtained by the dry method in
water), assumes a brilliant blue color.
For the success of this test it is essential that the nior-
]iliin salt be as free from im])urities as possilile. that lit-
tle or no free acid be present, and that but a small quan-
tity of the reagent be used. The color gradually changes
to green and brown (Robiquet). Limit. 0.1 mgm.
■5. A fragment of morphiu moistened witli Friilide's
ri-ageut (a freshly prepared and colorless solution of 5
mgm. sodium or ammonium molybdate in 1 c.c. sul-
furic acid) colors the reagent violet in a short time. The
color diauges to blue, and tlien to dirt}' green, and,
tiiially. to faint reddish. Addition of water discharges
the color instantly. Limit, 0.000 mgm.
0. Dissolve a small quantity of iodic acid in a few
drops of water, in a small test tube, and agitate with a
few drops of chloroform; the latter must remain color-
less. Add the solution to be tested, and again agitate.
The cliloroforni, which settles to the bottom, has a violet
color, in the presence of niorphin. wliile the aqueous
layer is yellowish. Now float upon llic surface of the
licpiid dilute ammonium hydroxid, with as little mi.\ing
of I he liquids as possible: a brown band is formed at the
junction of the ammoniacal and aqueous liquids (Serul-
las, Dutlos, Lefort). Limits: For the violet color of the
chloroform, ^jsjyjs; for the dark band with anunonium
hydrate, rum-
Tliis reaction is also produced b.v reducing agents otiier
than morphin.
7. Dissolve the solid in warm, concentrated hydro-
chloric acid containing a little concentrated sulfuric acid,
and heat in an air oven at 110' to 120" C. In the i>res-
ence of morphiu a purple color is produced, still visible
in the presence of the accompanying carbonized matter.
Afier evaporation of the hydrochloric acid, a further
quantity of the dilute acid is added, and the mi.xtvire
iirulralized with sodium hicarbonale in slight excess; a
ilu-rry red color is proiluced. which changes to a dirty-
un-ciiish hue as the point of neutrality is reached. On
:idditiou of a few drops of a dilute alcoholic solution of
iiidin, the color changes to green, and the pigmentary
sulistance now dissolves in ether with a pui'ple color
(Pellagri).
The reaction is due to the formation of aiiomoriihiu,
and is conseciueiitly also observed with codein.
^lany other tests for nior|ihin arc in use; the above
are. however, sufficient. No one of them is in itself
characteristic.
II. ynivotut. The reactions of the alkaloids of opium
other than morphin are at present of but little toxico-
logical interest, as they are substances which are not
commonly met with, and hence are unlikely to cause
]ioisoning. For the purpose, however, of ilist'ingtushing
between morphiu and opium poisoning by analysis (a
distinction which may be of medico-legal importance),
the reactions of uarcotin and of meconic ac-id (see below)
are taken advantage of. Narcotin is cho.seu from among
till' otheropiumalkaloidsfor this jiurpose, partly because
it is more aluiiidant in opium, and jiartly because of the
sharpni'ss of its reaction with sulfuric acid.
If the Dragendorff method have been followed, uarco-
tin should be searched for in the residue of evaporation
of benzene from the alkaline solution.
1. Of the general reagents for the alkaloids. )ihos
jihomolybdic aciti, potassium iodhydrargyrate, iodiu in
pota.ssium iodid, and picric acid give precipitates in
solulionsof T^,'j^ lo^»5ij.
2. Moistened with concentrated sulfuric acid at the
ordinary temperature, narcotin produces an intensely
Velliiw sohiliou, which, on gradual heating, changes to
orange, then, beginning at the borders, blue-violet, and.
when the heat lias been raised to the point of volatil-
izing of the acid, dark red. The colors are presented
more .slowly, but more purely, by dissolving the resi-
due in dilute sulfuric acid" anci evaporating quite
slowly (Couerbe, Husemann). Limits: -sVirs. very evi-
dent; ,-^^^5, faint carmine only.
3. Dis.solve in concentrated sulfuric acid, let stand an
hour, and add a trace of nitric acid; a red color, which
for some time increases in intensity.
III. Mecrinic Aciil. 1. Crystallizes in white, glistening
prisms, either single and large, or small and arranged in
bundles, which at 100' C. lose their water of cry.stalliza-
tion and become opaque. If heat have been applied to
the solution in the presence of acids, the shorter, pris-
matic crystals of comcnic acid will be also observed.
2. Meconic acid, or a meconatc in solution, gives white
or yellowish precipitates with lead acetate, .silver nitrate,
merciuiius nitrate, and mercuric nitrate.
3. The characteristic reactiim of meconic acid is the
formation of an intense retl color when the acid or one of
its salts is moistened with a solution of ferric ehlorid
(Sertiiruer). The color does not disappear either on
warming or on the addition of hydrochloric acid, or of
auric ehlorid, or of mercuric ehlorid.
Comcnic acid gives the same reaction. It can only be
present as a product of decomposition of meconic acid.
.Acetic and thiocyanic acids and their salts also give a red
color with ferric ehlorid. The former may be present
as a normal food constituent, and the latter "is present in
the saliva in quantity sufficient to give the reaction with-
out any preliminary purification. The red color, how-
ever, produced by acetic acid is discharged by heat or
by the addition of hydrochloric acid, and that due to the
tliiocyanate disappears instantly on addition of auric
ehlorid or of mercuric ehlorid solution.
F.\i].URE OF Detection. — As morphin is oxidized to
oxydimorphin in the body, more or less completely ac-
cording to the magnitude of the dose, it is usually elinn-
nated in cases of ])oisouing as a mixture of oxydiinorphin
iuul morphin, both of which resjiond to the reactions
given above. This elimination is priuciiially by the ali-
mentary canal and only in traces by the uriiie, whatever
may have been the channel of introduction. Therefore
the stomach and intestinal contents, or the product of
stomach lavage, are the situations in w-hich the poison
will most probably be detected, and we may expect to
find it in the urine only when very large doses have been
taken. It has also been detected in the liver and kidnevs
in .several instances, but very rarely in the brain. The
detection of morphin is bj- no means certain, and care-
fully conducted analysis may fail to show its presence iu
the cadaver after undoubted poisoning by it, even when
the stomach has not been washed out and vomiting has
not occint'cd.
Although morphin is more subject to decomposition
than strychnin, it still withstands the influence of putre-
l.u'tion quite well. In a case cited by Woodman and
Tidy it was detected four months after" death; and Stas
gives an account of a case in which he detected mor-
]>hiu in all the organs of a body after thirteen months of
burial.
In cases of long burial, caution is required that lUo-
luaVns be not mistaken for morphin. as occurred in an
Italian case, in which Selmi showed that what a careless
analyst had taken for morphin was in reality a plomaiu
(Selmi, "Sulle Ptomaine," 1S78), Such a mistake is im-
]iossible, if the tests described above are carefully applied
(see Witthaus and Becker, "Med. .lur.." iv., 700-7(19),
Ruflulph A. M'itthidis.
OPTIC NERVE. See A>.
OPTOMETRY — from 0-7-, root of ui/™/u/, fut. of ipAu,
to see, and /urpoi.; measure — signified, in its older u.se,
tlie measurement of the range of vision (rlie (icfic/itx-
irc/'li). With the attainment of broader and more accu-
rate knowledge of the jihysiology and pathology of
vision, quantitative mi'thods have been apidied io the
investigation of other visual functions, and we now rec-
ognize, as parts of one geueral subject, the measurement
391
Oploinrtr}'.
UEFKKENCE lIANDHOUi; OF THE MEDICAL SflEXCES.
(1) of tlie acutenc'ss of the visvial |iiTcc'iilion of form
((■idoptoiiM'try).' (2) of tlip lu-iwption of liglit (phot
optomfti-y),' C3) of tl'c p(i-cc|ition
A
Fici. iW.II.
Kiiloj>tiiiiiit)ii — from
of colors (chr(.mut-
(iplomctry).' (4) of
lllr cxtullliUKl lillli-
Uitious of llio vis-
ual Held (pcrioii-
lomelry),' (o) (if
the acoommodative
and r c f r a c t i v e
states of the eye
(dioptometry).' and
(0) of the position
and movements of
the cyi'lialls (oph-
thalmoslatometry
andoplithalmotidp-
ometrj-). '
iiVir, lorm — deals witli tlie meas-
urement of the aculeuess of the visual perception of form
^i-i.tun. V. ; German, Slisclidrfi-. S. Assuming an ade-
qviate ilhnnination and a shai'ply defined ri'tinal image,
the physiological linnt of the acuteness of vision is dc-
tenniued by "the lineness of the mo.saic formed by the
cones of the retina at tlic fovea centralis. Let (Z rf (Fig.
3691, B. from Helndiollz) represent the mosaic of retinal
cones at tlie macula, and <i, b and c the images of three
vertical bars of a grating for which the eye is accurately
aeconunodated. When "the grating is removed to such a
distance from the eye that the image of each bar does
not much exceed the diameter of one of the retinal cones
the several iiTiages appear more or less distorted or bead<'d.
according as they haiipeii to fall upon one or another, <ir
perhaps Upon two, of tlie cones lying nearest to their
tracUs. With the bars and interspaces (d' the grating
each of a width of 0.4167 mm., the appeaninee shown at
.1 begins to be manifest when the grating is removed to
a distance of 1.1 to 1.3 metres (Helmholtz). This corre-
sponds to a width of about O.OO.j mm. in tliu retinal image
for each bar of the grating, and to a visual angle of
about 1.2'; it also indicates a very close apiiro.ximatioii
of thcMvidth of the image to the diamelcrcd' the retinal
cones at the macula ((K(l()4r) to 0.0054 mm.). Observa-
tions on the smallest angular distance at which two fi.xcd
stars of lesser magnitude (lIi>oUe)or the bars of a grating
(Helmholtz) can be positively distinguished by the naked
eve. iioiiit also to an angle of about 1 ' as the normal
liuiit of distinct retinal perception.
The tirst serious attempt to apply a system of exact
measuremi'iit to the clinical determination of the acute-
ness of vision was made by E. .Tacger. Jaeger's Stfirli-
tieutr'' consists of a series of lines diminishing in leugtli
and in width from No. 1, with a width of 0.-1597 Vienna
inch, to No. 80, with a width of 0.0037 inch; the meas-
ure of the acuteness of visual iierception is the narrowest
line which can be positively distinguished at the distance
at which the observation is made. Thus a normallv
acute eye sees No. 5 at 100 feet; No. 30 at 2t)feet; Ni).
80 at Ifool, etc. Unfortunately, the ratio of gradatiiai
adopted by Jaeger is .such that the numbers do not indi-
cate the relation of individual nieasureinents to the nor-
mal. Moreover, the delermination turns entirely on the
unehecUed statement of the person examined, th.-d he
sees the lines down to a certain place in the scale. The
results of numerous and characteristi(;ally careful meas-
urements made by J;ieger with this scale point to a visual
angle of about 1' as tlie limit of distinct recognition of
the individual lines by a normal eye.
Snellen-' was the tirst to work out a syslem of meas-
urement ade(inate to the needs of the oiilithalmii' jiracti
tioner. .Vssuming a visual angli' of 1' as the average
limit of distinct vision in tlie normal eye. Smdlen con-
structed, upon this basis, a number (d' capit;d letters of
sizes coiresponding to seventeen dilTcrent distances,
ranging from '200 Paris feet (No. ('O.)to 1 foot(No. J.i.
Each scpiare letter, vieAved from its ajipropriiitc distance,
subtends a visual angle id' 5 , and each letter is made up
of lines subtending eacli an angle of 1'. The ultimale
elements from w liich the several square letters are con-
structed are small scjuares, each subtending an angle of
1' ; and twenty-five of these smaller squares are equal in
area to the larger square in which the letter is in.scribed.
Only such letters are used as can be drawn approximately
witfiin the compass of a st|uare, and even of these scarcely
any two are of absolutely equal legibility; still, the dif-
ference; is not so great as to im|iair the iiraclical useful-
ness of the method, and the recognition of only a iiart of
the letters in any line affords the means of making a tiner
discrimination than if only the more easil_y recognizable
letters of the alphabet were u.sed. Furthermore, certain
of the letters often apjiear under cliaracteristically niedi-
lied forms when vieweil by an astigmatic eye ; 1) some-
times looking like !>. O like the numeral 8 or like S, H
like N, V like \V, etc. The test of perfect recognition
of f(jrm is the correct naming of all the letters at the dis-
tance corresponding to the numlier. Representing the
greatest distance at which all the letters in any given line
are recognized by <?, and the greatest distance at wliich
tlie .same letters are seen by a normally acute eye by D,
the measure of the acuteness of vision in any particular
case is expressed in the fractional form y-. The adop-
tion of this simple and very convenient system was im-
mediate and general; it remains tlie only method suited
to the daily re([uirenients of the practitioner.
The system of Snellen admits id' but little further de-
velopment; simide geometrical figures-' and rei)iesenta-
tions of familiar objects of characteristic outlines^ are of
use in examining children or illiterate persons. The sub-
stitntion of a scale' liased on distances taken in metres in-
stead of in Paris fi'ct was made liy Snellen in 1875 -' Tlie
sinipl(-r form cd' letters known to printers and sign paint-
ers liy the iuaiqiropriate name of "Uothic"" has been
tried instead of the "" block -letter " used b_y Snellen, and
a regular ratio of gradation in geometrical iirogrcssion '
has been emiiloyed in the place id' his somewhat arbi-
trarily selected series of numbers* (see Plate XLVIII); a
notation expressed in tenths of the normal, and therefore
capable of being ex|>i-essed in decimal form," has alsa
lieeii somewhat extensively used.
For testing the ]ierception of form at sliort distances,
printed texts ai-<' in general use; such texts -were tirst
liublislied by Jaeger' in a great number (d' different lan-
guages and in various kinds of type. Jaeger's smallest
type (No. 1, ="gem" or ■'brilliant"), read fluently at a
distance of one foot, is a pretty severe test id' normally
acute vision coiijoiiied witu good power of ac(-oninioda-
lion for the reading distance Jaeger's numbers have no
iletinite signitieaiK-e, lieyoud the fact that the higher
numbers indicate the larger sizes of letters; still it is
more coin-eiiient to employ even an arbitrary standard
than to use the somewhat nnc-ertaiii IiomeiK-lalure id the
type foundi IS.
Pliiilop1oiiiiti-ii — li-ompijr, liglit — is comparatively little
employed in the ordiiiaiy routine of ophlhalmie practice,
yet it is not witlioul positive value in llie diagnosis of
impaired function of tlie letina. Two principal types of
photoptometers have been used, each of Avhii-h has its
special applications.
A rapidly rotating disc, upon which a smaller or larger
sector (.Mas.soni,"' or a row of short lines arraugi-d along
a radius (I)onders)," is deiii<-ted in lilack upon a wliite
ground, or in while upon a black ground, presi-iits the
aiiliearance of a sliaded surface, or of a number of con-
centric shaded rings diminishing in intensity teiward the
perijdiery of the disc. Wbeni'ver tlie width of the black
line is less than ^j- id the eircumference id' an imaginary
* The card nf li-st-lelii'i-s shown in Plate XIA'III. is construeteil on
llielMsisot a eonstaiii ratio of frradation, 1/ 3 =J.36; Ilie Arabic
and Itonian nunuM-aN dennii', respectively, the distances in iu«tres
and in feet at. uliii-li llie lettere should he distinguished liy a normal
eye. For I'liiivenienie, ihc foot has been taken as equal to one-thiid
metre, which is a lutle more than ihe IViiis foot. In the amiusrement
here reproduced only a sinsile letier ]s!_'iven for each number of the
scale. The consiruclioii of the individual letters is slightly altered
from that adopted by Snellen, with a view to somewtiat more uniform
legibility of Uie iliHei'enl letters.
sya
REFERENCE HANDBOOK OP THE ilEDICAL SCIENCES.
0|»li>iii4-l ry.
<>|>tolll4't|-y.
circle drawn throiigli it. the sliadcd liag is ordiuuriiy so
faint us to he no lonsiT perceived l)y n normal e>e in
average dayliglil within doors (Helniliolt/).'-' The aetite-
ness of light perceiition. in any particular case, is indi-
cated by the number of the concentric rings seen when
the disc is rapidly rotated.
The photoptometer (y>«>/(te'n«)»f«scr) of Forster '^ is a
closed box one foot long, eight inches wide, and si.\ inches
high; at one end are two openings for the eyes, and ii
window, about two inches sqiiai'e, covered with translu-
cent white paper. Behind this paper diaphragm i.s a
small lantern, enclosing a candle of standard illuminating
power. The quantity of light wliich enters the liox is
determined by the area of the paper diaphragm, and this
is regulated by means of two notched plates of metal
sliding over each other so as always to leave a square
opening whose area maj' be read off from a graduated
scale. At the opposite end of the box is placed the test
object, a card showing alternate-black and white stripes
of from 1 to 3 cm. in width. The measure of the acute-
ne.ss of tlie perception of light (L) is the quotient of /(,
the smallest area of the window required for the recogni-
tion of the stripes by a normal eye, divided by H, the
smallest area whicli suffices for the recognition of the
same stripes by the eye under examination. According
to FSrster's observations, made with an in.strument of
the construelioii just described, A = 2 sq.mm., giving
the value, L = -n- — -rf-
C/ifomritiiptvmetn/ — from A'P"/«". color — as applied to
the diagnosis of defective color perception, has been dis-
cussed under the title Colnr Perception. Vol. III., pp. 208-
217. Ajiproximate measurements of the acuteness of
color perception may be made \\ith Snellen's test letters,
printed in vivid colors on a black ground ; or similar
white letters on a black ground may be strongly illumi-
nated by colored light.
The principle of simultaneous contrast may be utilized
as a qualitative test of color perception. Tlius the
shadow cast by any small opaque object upon a white
ground appears of a color complementary to that of the
light. Tlie test may be made in the dark room appro-
priated to ophthalmoscopical examinations, by placing a
sheet of colored glass in front of the lamp and directing
the attention of the patient to the color of the shadow
cast by a pencil, or by a small opacjue card, upon a
white screen.
Periopliiiiiitrii — from -£/», around — is properly the
measurement of the limits of the visual tield in its ,several
dimensions; it includes also the detection and measure-
ment of defects in the field of vision (scotomata), wher-
ever they may be situated. The simplest, and for many
purposes the best, method of testing tlie central portions
of tlie field, up
to a distance of
about ih' from
the point of tixa
tion, is by means
of a blackboard
or a large sheet
either of dark or
of white jiajier,
upon whieli a
central point of
ii X a tion is
marked liy a
small cross, -f.
The patient is
p 1 a c e d a t a.
nieas\ired d i s
tance from the
board (usually
one foot), and
is directed to
look with one eye (the other being covered) at the cen-
tral cross. A bit of chalk or crayon, fixed to the end of
a short wand of the same color as the board or paper, is
then moved fiom tlie peripliery toward the centre of the
biG. 31)9;
held, until it reaches a iioint at which it is seen by the
patient. The observation is repeated for other ocular
meridians in succession, until the lioundarics of the fielil
have lieen determined at a number of points sullicient to
admit of drawing a continuous outline through lliem.'''
For mapping the periphery of the tield, when of
nearly normal extent, a plane surface is insufficient, and
FiG.yHiB.
for all distances greater than 45° from the jioint of fix-
ation the distortion of the peripheral jiortions of the
cliart becomes excessive. Fori he projection of the en-
tire field, with all its parts in d\ie |)roportion, we require
a hemispherical backgroimd instead of a plane surface;
to this end we make use of the perimeter.^^ which is
merely one-half of a broad blackened hoop, upon the in-
side of wliich the augidar distance of tiny point of the
fundus, lying in the meridian corresponding to the di-
rection of the hoop, may be noted (Fig. 3692). By turn-
ing the hoopaboutacentral piv<it as an axis, itis brought
into the necessary ]iosi(ion for the observation of the ex-
tent of the field in different meridians; each point, as de-
termined, is transferred to a blank chart printed, in con
centric circles (Fig. 3693).
For the direct mapping of the visual field in its entire
extent the perimeter of Sclierk '* has been devised ; it
consists of a hollow hemisphere, of one foot railius.
lilackened on the inside. The eye to be examined is
jilaeed at the centre <;)f thi' sphere, and the limits of the
field are marked with chalk in the same manner as wlien
the blackboard is used. For greater convenience the
hemisphere is made inseparable halves, andthe mapping
is done for one-half of the field at a time.
Most of the perimeters, as foiuid in the sho]is. have an
arrangement of cords and pulleys, by means of which the
test object is moved along the arc; this is a comiilica-
tion of at least doubtful advantage. A further compli-
cation consists in a self-registering apparatus, analogous
to that employed m \\n'" I'lirifiiriiiatnir'^ useii by hatters
to prick a small diagrammatic; outline of tlie shape of the
head. For practical utility the arrangement in use at
the Utrecht clinic is to Ix; connnen<lcd; it consists of a
bhickboard. about three feet s(iu;ire, to the centre of
which is pivoted a remov;ible lialf-ljoo|i of one foot ra-
dius; the blackboard serves for the direct iii.a])iiiiig of
limitations of the field within the limits of 45' from the
]ioint of fixation, and the arc is used for peripheral meas-
urements. The divisions of the ai'c between 0 and 4.'i'
are projected upon the board in circhw whose radii are
eipial to the tangents ol the respective lingh'S." The
R!>:^,
Optollletr} .
Oploiiielry,
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
li;ilf-lioop of the jH'rimc'tcr is usually inuiic of brass, and
is ratlicT heavy; one-half of a lioo]) of a cheese-bos, stif-
fened at the back by a piece of thin board saw cd to the
proper curve, answers every jiurpose in practice; the
jioints are deterniinid by moving a bit of
H B chalk or a small sipiare df white cardboard
aloUK I be blackened arc.
Fni. 'M'M. Instead of the small square of cardboard
a small electric laniji, llie intensity of wiiich
maj" be rcgulatetl at will by means ot a rheostat or by
varying the interna! resistance of tlie battery, may be
used in determining the limits of the visual lield in cases
of cataract or other obscuration of the media; a caudle
may be used for the .same ]nirpiise.
For testing the limits of the rteld for color perception,
small jiieces of colored cardboard, usually 1 cm. square,
are used instead of the bit of clialk or si|uare of white
card. A small convex mirror of very short radius of
curvature, such as the bulb of a thermometer, may also
be used to reflect white or colored light from a lamp
placed a little aliove and behind the ]iatient's head.
The perception nf foiin in the ]icriplieral regions of tlic
retina is testetl by means of two .small black squares on
a. white ground, with an interspace equal to one of the
Squares (Fig. 3094). These squares, of sizes correspond-
ing to the thickness of the limbs of Snellen's test letters
(Nos. XX. to C. ), are moved aloug the arc of the peri-
meter toward the ei'Utre of the lield, until the white iu-
terval is seen between the two black squares.
Diiqiimiicirji — Iroiu <l'o. through — has to do with the eye
considered as an opli<'al instrument, with especial refer-
ence to the detection and measurement of the dilTerent
anomalies of refraction and accommodation. The detee-
tiou, measurement, and correction of the several anom-
alies of refraction and accomiuodatiou tire treated in this
H-\NDHOoii under ibe titles, Arniiiiiiioihition dud Uefrm--
tioji. Axtinmiitifiii. lliiiiiriiutri>j>iii.Mii<>iii'i, and I'l-ifhjiniiin.
Dio)>tomeliy is eit her objc'ctive or subject ive. aecoriling
as the investigation turns upon observations made by the
e.xainiuer or by the person examined. The objective
ini'thods are of the wider applicability, inasmuch as they
may be employed in cases in which the patient is inca-
]iable either of making acciu'ate observations or of accu-
rately reporting liis observations; subjective determina-
tions have, on the other hand, the special advantage that
they are the actual measurements of the function per-
foiiued bytlieeye undercxamination. t)bjeetive exami-
nation alfords, iu many cases, the readiest means of dis-
covering and of approximately measuring a refractive
anomaly, and is often of service as a guide to the ex-
aminer in the conduct of such tests as require tiie active
co-operation of the patient.
In objective examinations the chief dependence is upon
the iiphthalmoscojie (see Oj)}ilhiiUiii)saiiii\ also Slutdoir-
Ttxt). X .second method, based upon tile observation of
the images formi-d by reflection at tlieaulerior surface of
the eorne;i, ami then'fore suited to the detecticm of de-
viations from iionual curvature of the flist and most im-
]i"rlaiit of the refraetiiiii
sui faces of the eye, demands
n tit ice iu so far as it
may be employed in
clinical investigations.
Tile image of a lu-
minous ]ioint or small
flame, as it is seen mir-
rored by a cornea of
irregular curvature,
undergoes conspicuous
changes of form ac-
cording as the reflec-
tion is from one or
another part of tlu> corneal surface. This is especially
noticeable iu irregularity of contour resulting from the
cicatrization of a corneal wound or ulcer, or from dis-
tention of the corneal tissue as a rc'sult of softening
from disease. It is also very characteristic in kerato-
cimus (conical cornea), iu which afl'eetion the principal
image remains nearly in oiU' position, at the roundeil
Fli,
:!(i:i.',.
vertex of the cone, whatever the direction from which
the light is thrown upon it. When the light falls upon
the cone from the side, two images are often seen, the
one small and nearly central, corresponding to the ver-
tex of the cone, theother lateral and distorted, formed
by reflection on the side of the cone nearest the light.
In regular astigmatism, in which asymmetry of the
cornea is ordinarily the most important factor," the im-
age of the point of light appears drawn out in a di-
rection corre-
sponding to one
of the two prill
cipal meridians;
wlieu two lights ,
are used, their
images will be
seen to be ap-
preciably nearer Fig. ;)696.
together when
they lie iu the plane of the corneal meridian of great-
est refraction than when they lie in the plane of the
meridian of least refraction. Inasmuch as thi- distance
which separates the two images is determined b_v the
corneal curvature iu the meridian in which they lie, it is
possible, by measuring this distance, to obtain the neces-
sary data for calculating the radius of curvature. The
ophthalmometer of Helmholtz, "adapted by Donders and
Middelburg '■' to the investigation of the curvature of the
cornea in its different meridians, is an iuslrumeut by the
aid of which such measurements may lie made with al-
most the accuracy of an astronomical observation.
If a rectangular white card is held at a distance of a
few inches in front of an eye, the image, as seen reflected
on the cornea, will ajipear more or less ilistorted when-
ever the corneal curvature is either irregular or asym-
metrical. The most striking distortions are observed in
conical cornea and in astigmatism; iu the former condi-
tion the four straight sides of the card apjiear incurved
iu the direction of the vertex of the cone (Fig. oGSIo) ; iu
the latter condition a square card is reflected as a parallel-
ogram, anil a circular card as an _
oval.
This experiment is further de-
veloped iu the keratoscopic disc of
Placido,-" a circular card or metal
disc, about '23 cm. in iliameter, with
conceutric rings jiainted iu black
and white upon the side turned
toward the eye to be examined.
The observer, looking through a
central hole in tlie disc, sees an
image formed bv reflection on a
large central area of the cornea;
the effect of aiiv asymmetry or dis-
tortion of the reflecting .surface is revealed
by a characteristic asymmetry or distortion
of the image (Fig. 3l59(i).
In the "astigmometer " of De AVecker and
Masselon'-' a S([uare black card with a white
border 1.5 cm. in width is held before the
eye to be examined, and the form of the
image of the white binder noted, as shown
in Fig. 3G0.J. Fiti. 3i)!i7.
The oplitlialniometer of ,Iaval and Schi-
dtz ■"-' isa simpliticatiouof the Donders-Middelliuig modi-
fication of the ophthalmometer of Heliuholtz; instead
of lights, special test objects (inircf:) of enamelled metal
are used, and the images are viewed through a small
telescope w liich enntaius a doulily refracting jirisni. by
means of which the images are doubled and brought
into such relation to each other that their mutual dis-
tance can be ascertained at a glance. The several parts
of the instrument arc so proportioned that the refrac-
tion for any meridian may be read oft' in dioptrics with-
out the trouble of making calculations (see Uphthidnimji-
I't, r).
In the oplithaliiiopliakometer of Tscherning (1900),
small adjustable electric lamps are cairied on an are like
59i
UEFEKENCE HANDBOOK OF THE MEDICAL SClE-NC'Ei;
<>ltl€>liiolry.
Optometry*
that of tlic Javal-Schiotz opiitlmlmomcter. By means
(if this iiistriiiiient Tscherniug lias succeeded in nieasur-
in,;;' the curvatures of tlie posterior surface of tlie cornea
;um1 of the two surfaces of tlie crystalline lens. The oph-
t halnioiihakonieter.
like the oplitlialinoni-
eter of Helniholtz, is
adapted rather to ac-
lurate research work
ill the physiological
laboratory than to
clinical use.
The arc keratusco-
pique of De Wecker
fi«- 3«98. ,^n,^ Masselon (Fig.
3697)'*^ is a siiiiplitica-
tion of the ophthalnioraeter of Javal and Schiotz : a
number of small white discs, arranged at equal dis-
tances upon a blackened ai'c like the arc of a perimeter,
^ive reflections in which, the intcrsiiaces are nearlj' equal
when the curvature of the cornea is regular, but unecinal
when the curvature changes from the centre toward the
periphery (Figs. 3098 and 3099). The instrument is espe-
cially adapted to the detection of conical cornea.
In" subjective dioptometry we distinguish methods
wliicli turn \\\tm\ the recognition of the forms of test ob-
jects, such as the test letters of Snellen, and methods in
which the accurate reco.snition of form is not reciuired.
In any case in which the acutencss of vision is normal,
the detection and measurement of simple ametropia (li or
31) may be made by means of trial glasses used in con-
nection with the test letters of Snellen. Having placed
tlie patient at a measured distance of 5 metres from the
■card of test letter.s, "\ve note the smallest line of letters
which he is able to read correct!)^ with the unaided eye.
If by this test we find V.= \, the presence of myopia of
■any grade in excess of 0.03 dioptric is excluded, and the
eye is either practically emmelropic or hy]iermctropic
with aceommoilative power in excess of its hypermetro-
]iia (A > H). To decide between tlii'se two possible con-
ditions we jilace a weak convex .glass before the eye and
Dole whether there is any falling olf in the acutencss of
vision at the distance of the test card. If we still find
V=6. the presence of some degree of hypermetropia is
e-ilalilislied, and we exchange the convex glass for an-
other of greater power, until we havi; hit upon the
Strongest convex glass Ihrough which V remains at tin-
normal standard -5. The value of this convex glass in
dio])tries* is the measure of the manifest hypermetropia.
■\Vhenever. by the use of the test letters, we find V< "
we suspect the presence of myoiiia, and proceed at once
to try the effect of a weak concave glass. If V is im-
proved by this glass we try stronger glasses in succes-
sion, until we have found the weakest concave glass
through which V =5. The value of this concave glass
ill ilio]itriesf is the measure of the myopia (M), or pos-
sibly of the m.yopia augmented by some degree of abnor-
mal tension of the accommodation.
In order to measure the total hypermetropia (lit), and
sometimes, also, to obtain the true measure of a myopia,
it is necessary to bring the eye under the full influence
of one of the stronger mydriatics, and to rejieat the ex-
;miiiialion with tlie tesl-letters. The jiroblem is so far
siiiiplilied by the su]ipressiou of the accommodation that
it is now only a question of wliat glass, whether convex
or concave, raises V to its maximum at the distance of
the test card.
If no glass siifllces to raise Vto the normal standard of
|. and especially if the jiatient is in doubt as to which of
several glasses fif somewhat different ])ower gives the
best visual result, we may susjiect the presence of astig-
matism. The sjiecial methods used for the detection and
measurement of astigmatism have been described under
that title (see .■{/•th/iiif/tisin).
A large collection of trial lenses is an indispensable
•Less 0.2 dioptrie, as a correction for the distance of tlie test object.
+ Plus0.2dii'[nrie. as a correction for tlie distanceof tlie test oh.iect.
part of the armamentarium of the ophthalmic praeti-
titioner, and it is convenient to include in it the full range
of numbers as found in commerce, or for which grinding
tools are kejit by the working opticians. "With such a
scries of spherical lenses (in pairs), ranging (through
zero) from -|-20 to — 30 dio])lries, and a full series of
cylindrical lenses (in pairs), ranging from -)- 10 to — 10
diojitries, it is possible to correct almost any ca.se of sim-
ple hypermetropia, myopia, or astigmatism b}' means of
a single glass for each eye. and, similarly, to correct any
ease of compound or of mixed astigmatism by means of
a combination of two gla.sses for cacli eye. The lenses
of the trial case should lie accurately centred, and set in
brass cells turned with a thin judjeeting flange (like the
wheels of a railway carriage) so that any two may be
provisionally mounted, with the two flanges in contact,
in a trial frame made witli a single groove." In tlic
higher numbers of each series the lenses should be of the
plano-convex and plano-concave form, and tliey should
be so set in their cells as to bring their plane surfaces
very nearly in contact when any two lenses are used in
combination, thus making it ]iossible to build up any de-
sired double convex, double concave, or ])eriscopic'lens,
or by combining a piano-spherical with a jilano-cylindri-
cal lens, to build up any required spherieo-cylinilrical
lens with the same combination of surfaces as in the lens
to be prescribed.*
The trial frames should be of the lightest practicable
weight and of the simplest possible construction. For
most iiurposes a single groove, made wide enough to re-
ceive the thin tlangesof twolenses, issufficient. A dozen
or two of such frames, of difl^erent widths and height of
bridge, costs no more than one or two of the complicated
and less convenient trial frames shown in almost endless
viiriety in the catalogues of the manufacturing opticians.
By enlarging the seriesof test letters through the addi-
tion of a few numbers, so as to extenil its range to say
0.1 imtre. the ]iositi(Jii of the near-point (;)) may be ap-
proximatel.v determined by direct observation. "Oftener,
however, wo determine the position of ]i after having
provisionally corrected the eye for distant vision by
means of glasses; for practical purposes it is generally
sufficient to measure the distance (P~) of the binocular
near-point (j)^) from the anterior nodal point of the eye
(see Aceoiiiimiihition and Rifriiftinn).
It is po.ssible to use the- earil of li'st letters for the di-
rect determination of
the grade of myopia,
by noting the greatest
distance at which the
letters corresponding
to that distance are
distinctly recog
nized. In the lower
grades of myopia
good measurements
may soiiKtimes be
m.adein this manner.
but in the higher grades the convergence of the visual
a.\es is apt to be attended with .some exercise of the
accommodation, so that the measurements are often
somewhat in excess of the actiutl myoiiia.
*Thc fnilowinirspeciQcationolaseriesot trial lenses lias heeii found
satisfactiiiv in I'nictice :
Siiliciicai )eiiscs, in pairs: -i- 3.0 D, tlirough 0. t<.i — 2.0 D, with a
common interval of 0.13.5 D (thirty-three pairs) ; + and — ~:Zii I) to -i-
aiid — 7.0 D, with a common interval of 0.3;) 1) (foit.v pail's i: + and —
7.."> D to + and — 13 D, with a common interval of o..'i I) (twenty
pairs); -i- and - 13.0 D to + and - 3il.ll D, with a con m interval of
1 II D (sixteen pairs); * and -33.0D (two pairs); * and - 34 D (two
Iiairs) : -total, ll;l pairs of spherical lenses.
Cylindrical lenses, in pairs; + and - 0.13") D to -i- and - 3.0 D. with
a common interval of 0.13.5 D (thirty-two pairs): + and — 3.3.5 I) to -i-
and — T.O D, with a common intenal of 0.35 D (forty iiaiisi : -i- and
- 7.5 D to + and - 10.0 D, with a common interval of 0.5 li (twelve
pairsi ; -I- and — 11 D to + and — U I), with a common interval of
1.0 11 (eijrht pairs) :— total, 93 pairs of cvliiidiical lenses.
Tlie entire collection of 305 pairs of lenses, together with a series of
prisms, in pairs rangiiifr from 1" to VZ° anirie. is contained in a box
iiicasiirins47 ■, 43 ■ ij.5cm.; forconveiiience in keepinsrllie case free
fr dust, the lenses are arranRed in a bottomless tray which may
lie lifted Ota of the liox.
^-V.
395
4kpl4iiii<'lr>'.
Oploiiielry.
REFEREXCE HANDBOOK OF THE MEDICAL SCIENCES.
Optomutors for the moasuivment of tin; refraction. ;ind
also of the range of acronimodation. at some short dis-
tance, say. of one foot, liave been made in a great variety
of forms; they are. iiowever. of uiueli less value than
might l)e e.xpeeted, whether as regards saving of time in
observation oraecunicy of results. The biiiocularoplom-
eter of Javal (see Vol". I., p. 59-1), especially devised for
till' nieastiremeiit of astigmatism, probably still remains
the best instrument of its class.
A point of light, such as tlie Hame of a small taper or
gas jet. viewed from a distance of o metres or more, is
se(!n by an emmeti-oiiic eye as a bright pfiint, witli some
indication of bright ra\'s, as in the familiar picture of a
star (see Vol. I., .")9(}). The same distant bright poiul
is seen by a myopic eye, or by a hypermetrojiic eye in a
state of accommodative rela.xatioii. as a briglit spot (cir-
cle of confusion) of a greater or less diameter, dependent
on the grade of ametrojiia and the size of the pupil.
When the pupil is fully dilated by a mydriatic, the .size
of the circle of coufusicm is ajiproximately proi)ortionate
to the degree of ametropia, so that a jn-etly exact meas-
urement may be maile by simidy noting the distance at
which two tapers must be ])Iaced, one from the other, in
order that the two circles of confusion may touch each
other. Thomson" has devised as a|iparat\is (Fig. 3700)
in which two small gas jets are so arranged as to admit
both of varying the distance between the two lights and
of altering their direction to correspond to different oc\i-
lar meridians; tlie degree of ametropia is read olf from a
scale whii-li forms a part of the instnnnent.
By making the etfective area of the pupil \ery sm;Ul,
as in looking through a pinhole piieked in a blackened
card, the circles of confusion may be so reduced in size
as to admit of tolerably distinct vision even in high
grades of ametropia. If two pinholes are pricked in tfie
card, at a distance of, say, 4 mm. from each other, a
pretty distinct image will be formed by the rays passing-
through each of the ]iinh(,les. l)ut the two bundles of rays
will fall upon different p;irts of the retina whenever the
eye is adjusted for any (.listance other than that of the
object (Fig. 3701). This experiment, first descrilied by
Scheiner.'-'' has been utilized in the optomeli'rs of Poi'ter-
field •' and Young.-* and has been further develojied in a
method for the clinical investigation of ametropia by
Thomson.-'
When a colored test object, in a field of a contrasting
color, is viewed by an eye adjusted for some distance
other than that of the object, the circles of confusion.
re])resenting parts of the object and of the field adjacent
to the line of demarcation of the two colors, overlaji in
3l»r,
the retinal image and form the combination color projx-r
to the mixture. The experiment succeeds best when the
test object and the contrasting field are in transparent
colors and vieweil by transinitte<l light. A sheet of'
ground glass coated with varnish colored blue bv ultra-
marine, with a small central area similarly painted with
carmine, makes an excellent test object for this ])ur|iose;
the two transparent colors should be separated by a thin
black border. When the test object is liung iu a window,
and is viewed from the opposite side of the room, tin-
central (red) spot is seen in its actual color when the eye is
accurately focussed for its distance, but in a combination
(purple) tint whenever the eye is focussed for some other
distance. The difference between the carnune-red and
the combination-purple is es-
pecially striking in astigma-
tism, when the test object is
made up of radiating lines
of carmine, on a blue field'"
and the e.ye is corrected for
one of its principal meridians
by means of the aiipropriate spherical glass.
The absence of the usual phenomena of chromatic
aberration iu ordinary vision is not due to an achromatii
coriection, as in inir perfected dioptric instruments, but
is mainly to be explained as an effect of the simultaneous
impression made by complementary colors upon the same
retinal elements. If we look at a distant jioiut of liglit,
through a prism of, say, 60' angle, the spectrum of""the
luminous point will be seen under the forui of a triangle,
whose ajiex will l)e either in the red or in the vioh't, ac-
cording as ■■ the focus of the eye is adapted to collect the
red or the blue rays to a point '"' ; ■ ' in other w. >rds, accord-
ing as the eye is slightly myopic or hypernietro|ii('. In
emmetropia the spectnim is seen under the form of a
double triangle in which the narrowest part lies in the
very strongly lumiuous yellow region. The impi-ession
tuaile by a point of white light upon any single cone of
the retina is, therefore. Compounded of the spectral y<'l-
low and a composite yellow, made up of red and green.
This mixed yellow, superimi>osed as it is, upon a fi'eld of
diffused violet, is furtlier modified to apijroach wliite.
The chromatic aberration of the eve reveals itself veiy
plainly in looking at a point of light" of which all but the
blue and red rays have been extinguished bv the passage
of the beam through a sheet of cobalt-lilue glass. ^■- Look-
ing through siu'h a glass an emmetroinc eye, focussed for
the distance of the liglit. sees it of a nearly uniform juu'-
plish-blue tint, with an inconspicuous halo of a clearer
blue; a myopic eye sees the .same light red, with a blue
halo; and a hypermetropic eye, uncorrected bv accom-
modation, sees" it blue, with a" red halo. To measure the
grade of the ametropia it is sufficient to tiud the spheri-
cal (concave or convex) glass through wliich the light
appears of a purplish-blue bordered by a clearer bluer
Anemmetrope. looking at distant re"dand green lights,
sucli as are carried by vessels and used as railway sig-
nals, .sees the two lights of about the same magnitude; a
myope sees the green light as an aggregation" of circles
of confu.sion, and therefoic larger tiian the image of the
red light ; a hypermetrope, with imperf<'Ct accommoda-
Flii. 3;0f.
tion. sees the red light larger than the green. When the
vision is corrected for the distance of the lights tlie_v are
seen in their normal relation of equality in .size.-'**
*Tfie clifferenoe in file size .ind definition of tlio rotin,il image of a
reif and i>f a irreen ficlit i-; quii** j^nftfcient to enalilc a iiypi'iiiieti"[ii('
itT slifflitly nivnj.ic pitnf. i.f r'ailwav eniiiloyee. Tontilizf tins tlilTi-ii'n'H
as an aid tu the di>'Tiiiiinal jnn of lanli-rn siL''nals. t-M-n llmn-jli In- Ite
<'ol.)r-liiind.
REFKKENCE HANDBOOK OP THE MEDICAL SCIEMCES.
4>l>l(iiii4>lry.
Opioiiiotry.
Olilithalmostutoiiictnj — from o<pi)<iA,ii6(, eye, aud crro-,
root of 'idTt/iii, to stand — is tin- iiiciisurement of the [losi-
tioii of the eyes. The most iinportaut mcasuvements are
tliose wliicli"have lo do witli tlie two eyes in respect of
tlieir mutual distance and I he relative direction of the
visual axes.
Tlie distance between the two eyes maj' be rou^yhly
measured by looking the patient in the face and letting
liim direct his gaze aUernatcly upon the two eyes of the
observer, who in turn reads otf the position of tlie fix-
ing eye with his fixed eye upon a graduated rule held in
tlie hand or mounted like a spectacle frame. The right
or left corneal margins, or the right or left margins of
the pupils, may be taken as tixed points whose mutual
distance is an approximate measure of the true iuterocu-
lar distance. An inaccuracy of this, as of other objec-
tive methods of measuring the interocular distance, arises
from the fact that the visual axis does not exactly coin-
cide with the geometrical axis of the e_ve, but, as a rule,
cuts the cornea a little to the inner (nasal) side of its ver-
tex. The angle which the visual axis makes with the
axis of the cornea (angle a of Donders)"'' averages about
live degrees in the emmetropic eye; it is somewhat
greater in hyjiermetropic and less in myojiic eyes, and in
very high grades of myopia it may even be negative, so
that the visual axis may cut the cornea at, or a little to
the outer (temporal) side of, its vertex. Objective meas-
urements of the interocular distance are, therefore, ordi-
narily a little too large, though sufficiently accurate for
most practical (lurposes.
If we place a dia]ihragm, with a central perforation of
about 1 mm. in diameter, in each of the two clips of a
trial spectacle frame, and adjust the distance of each
from the median line of tlie nose so that a distant verti-
cal line shall be seen bisecting tlie small circular field as
defined by the margins of the perforation, tlie distance
between the centres of the two perforations will be the
true measure of the distance of the two (parallel) visual
axes from each other.''''
To measure any deviation of the optic axes fi'om paral-
lelism, when the patient fixes his gaze upon a distant ob-
ject, a lighted candle may be held about a foot in front
of the deviated eye and moved in different directions un-
til its image, as seen reflected on the cornea, occupies a
position central to the pupil when viewed from a station
just behind the light. The angle at which the light
must be held to one side of a line drawn from the ob-
served eye to the (distant) point fixed by the other eye
is the measure of the angular displacement of the devi-
ated eye; it may be conveniently measured upon the arc
of a perimeter, the eye whose deviation is to be measureil
being at the centre of curvature of the arc (Landolt).
Ophihalmotropometry — from o<j>da?i/i6c, eye, and Tpoiri/,
turning — is the measurement of the movements of the
eyeballs. Most important, from a clinical standpoint, is
the estimation of the interrelation of the recti intcrni
and recti extern! muscles.
In iusufticicncy tif the recti intcrni, not amounting to
strabismus divergeus, the phenomenon of double vision
(see Diplopia) does not ordinarily manifest itself so long
as it is possible to maintain the fusion of the two retinal
images through the forced exercise of the convergence;
if, however, we displace one of the retinal images upward
or downward, by means of a weak prism, any insulll-
ciency of the intcrni immediately reveals itself by a
crossing of the images, wliich then assume an oblique di-
rection, one to the other, instead of tlie vertical direction
proper to the action of the prism. The measure of the
insufficiency is the prism, with edge turned horizontally
outward, which is required to convert the oblique into a
vertical diplopia. This test, which may be applied both
at a long range and at shorter distances, reveals the state
of the convergence as related to tlie degree of accommo-
dation wliich is brought into play at the particular dis-
tance.
The "glass-rod" test of Maddox (see Vol. III., p. 492).
especially in its later form as developed by Its inventor,
is even more convenient in use, and is of wider appli-
cability than the vertical prism. By rotaling the disc of
tinted glass in front of one of the eyes, thi' n^sultant
bright streak may be given any desired direction, from
the vertical to the horizontal, thereby revealing a devi-
alionof the visual axes from parallelism in any direction.
The measure of the deviation is the iirism, or .sum of
two prisms before the two eyes, which brings tlie streak
through the flame.
Insufficiency of the recti externi, or preponderaiici^ of
the recti intcrni, is tested, mutatis mutaixlix, in the same
manner as insutticiency of the interni.
Binocular vision, conditioned on the simultaneous per-
ception and comparison of tlie two retinal images of the
FKJ. 3702.
Fig. 3703.
FIG. 3704.
FIG. 37nr>.
object upon which the two eyes are directed, is most
easily tested by means of the slereoscope. Rejecting all
representations of objects in whicli solid forms are sug
gested by perspective, as is almost always the case
with photographs of objects in nature, we make use of
diagrams of the simplest possible construction; a few
examples of tliese are shown in Figs. B70'2 to 3705.''*
397
Oraiig
Orbit.
REFERENCE HANDBOOK OF TilE MEDICAL SCIENCES.
Vicwctl ill the stereoscope Fijj. 3702 is seen as two discs,
the one vertically above tlie otlicr. but lyiug iu two dif-
ferent planesat (iill'erent disfiinces from the oliserver; the
more distiint of tlie two discs appearing also to be the
larger. Inveiting the slide in the stereoscoiK', the rela-
tive distances aiid sizes of lh<' discs appear reversed.
Fig. 3703 shows a circle and an ellipse, winch may be
considered as two dilfevent ])ersi)ectivc views of anotlier,
larger ellipse ; when the two images are ciniibined in the
stereoscope a horizontally elongated ellipse is seen ro-
tated aboid, its vertical diameter as an a.xis; inverting the
slide, the ellipse is seen rotated in the opposite direction.
In Fig. 37(4 llie ellipse is seen to tip backward or for-
ward, according as the slide is placed in the stereoscope
in the position shown in the plate, or inverted. Fig.
370.") shows a coniliination of a ring with a white centre
and a black disc of the same diameter; tlie elfeet is that
of a mirror or of a .shining surface jioli.shed with plum-
bago. Jiiliii Ori'cii.
• Snellen and Lanrtolt ill Griiefe-Saeniiscli Hanilbui'li ilersesammten
Aiiu'entifilkunfle. 1S74.
- K. Jiteernr: tielier Slaar unit Staaroperatinneu. Wien, 1S,^4.
^ H. Snellen : I.etterproeven ter liepalins der jrezijitssehei-pte,
Utrecht, ISIB.
' A. E. Ewingr: .^nierican Journal nf oplithalniolosy, Keliruary 7,
1!I03 ; Univei-saJ Te.st-t'har actors, |)ai-lii-ularlv applicable as Visual Tests
f(.r cliildren. St. Louis, i;. S. A., l!«t'.
■'• H. Snellen : dpiotypi ad visum deterniinandtun, I'trei-ht, l.sT.'».
"Test-letters oontritjuted bv .1. (O-een to Ueei-ut .Advances iu
Oplithalmlc Science, by II. W. Willlaiiis, Boston, U. S. A., laili.
' J. Creen ; Transaetious of the .American (^phthalniulo^iral Society
foi'l.S67; Report of the Konrth luleruational (iphthalmologioal C'oii-
frress, London, 187:;.
" Monoyer i.lS77i. '■' K. .laeper: Op. cil.
'" Masson : .\unales do chimio ct do Physiiine, lSt.5,
o Donders ; Vid. Snrllrii and Landolt tlUiraefe-Saeuiisch Handbuch
der iresamniten .Augi'iilnilkunde, iii., ii., S. ;Ht, 1S74.
'- Helmholtz : HandbucU der phvslolonischen ( iplik, s. :>lo, Leipzig,
18i;7.
'^ Forster; Klinische Monatsblatter filr .Anireiiheilkunde, ix., tS71,
'^ i:>onders: On the Anomalies of .\<'eommodation and Refraction
of the Eye, p. :iil7. New Sydeiihaui Society, Loudon, |,s|i4.
'^ .Aultei'taud Ftn-ster; Alehiv flir ( iphlhaluioloffie, iii., ii., S.40, 1S.57.
i** Scherk : Klinisctie Monatslilatter fiir .Antreuhedkunde, x.. ts72.
1^ Snellen and Landolt in Gi'aefe-Saeunsch Handbuch der pe-
sanimteu Au^'enlieilkunde, iii., i., s. r)7.
" Helmh.iltz: Arcliiv fiir (iphthalnioloKie, i., ii., S. 4, ISo."!.
'" Donders: (in the Anonuilics of Accouunodation and Refraction,
p. 4ia.
-" Pl.aeido : Periodico d'oftaluioloffia practica, ii., .">, (!. ISrtlt; Central-
Watt fiir praklische AiiKenheilkunile, vi., s. "*): ihiil.. S. .V.I, Iss:,'.
■-' De Weckir et .Masselon: .Anuali's d'Oiulisliiine, Lxxxviii., 18,82.
'" .laval and Seliiotz: Annates d'Oeulisliciue, Ixx.xvi., 1881: iliiil.,
Lxxxvii., lss:i.
^■'' Masselon : Precis d'Ophtlialnioloijie Chirurgicale. Paris, 1886.
Also De Wecker and Massejou, in Revui- Cliniquc d'dculistinue, iv.,
18M.
^''.I. Green: Transactions of the Ameriean Ophthalinolnaieal So-
ciety. 1880.
'-* Vf. Thomson: Transactions of the Auieriean iiphthaluiolon-ii-al
Society, 1878.
-*Scheiner: Ocnlns, Innslinirk, Hdti.
2' Portertleld: (in the Kvr. Ediiibnrch, 17")11.
'* Thomas Youns: Philosophical ■transactions, 1801.
=' W. Thomson : Amem-au .lourrial of the Medical Silences, Janu-
ary. 18711.
^° J. (ireen: Tran.sactions of ihi' Arnerii-an Ophthalmological So-
ciety, 18(i7 (iS.
3' Wollaston: Cited by Thomas Yonng in Pliilosophical Transac-
tions, l.soi.
32 Helmhollz : Handbuch der pliysiolojrisrhen Optik, S. 1:;7.
^^ J. Green : Transactions of the .Anicncan Oplithalniologlcal So-
ciety, 1874.
3< Donders: tin the Anomalies of .Vcronnuodation and Refraction
of the Eye, pp. 18a, LSi.
3^ Smee: The Eye in Health and Disease. Loudon. 1.8,54.
:"' J. (ircen : Traiisai-tions of the .Ameriean Ophthaimolotrical So-
ciety, 1876,
ORANGE, SWEET AND BITTER.- (See also Ciirii.'i.)
I. ('Unix Aiii'diitinin L., the sweet orange, is a fa-
miliar plant in sill warm conntrics. It is a small, rtither
slow-growing tri'e, with hard Avood, an upright, much-
branched trunk, bearing a well-rounded, rather close
head. Leaves numerous, thick, evergreen, smooth, and
shining, oval; the blade articulated to the distinctly
winged ijctiole. Flowers a.xillary, perfect, regular,
large, fragrant, white; calyx .short; petals live, long,
fleshy, spreading; stamens numerous; ovary free, eight-
or more celled, several ovules in each cell. The leaves
and petiils are fragrant, and sliow liy transmitted light
Etc. :i706.
- Sweet OraiiKe
(P.aillon.)
Flower.
pellucid spots indicating the large oil reservoirs iu their
parenchyme.
II. C. piili/iiri.1 Risso. the source of the bitter or Seville
orange, is a snudler tree, with a closer lu'ad, larger, mi»rc-
fragrant tlowers. and a
iniiglier. darker, siuir,
and bitter fruit. This
plant is also rather
more spiny than tiie
other, and propagates
more truly from seed.
The olIici:d products
and prc]iar:itions ari'
as follows:
Strut Oriinfic Peel.
A nrinitii Dnlein Corte.r.
"The rind of the fresh
fruit of C'itni.<< Aiirnn-
tiiiiii. L." The prep-
arations of this are the
five per-eent. S3-rup,
used wholly as a vehi-
cle and for flavoring, ami the twenty-per-cent. tincture,
chiefly used like the last, but a stimulant in do,ses of
i-8c."c. (fl. 3 ss.-ij.).
Jlitter Oraiuje Ped. Auriiiitii Amafir Corte.r. "The
rind of the fruit of Citrus vulgaris Risso."
I 'reparations, the fluid extract, dose 2-4 e.c. (fl. 3 ss.-i.)
anil the twenty-iicr-ccnt. tincture. do,sc2-8c.e. (fl. 3 ss.-
ij.). It will be observed that this peel may lie used dr}-,
Avhile that of the sweet orange must be used in the recciit
state. The bitter principle of this peel makes it an im-
portant aromatic bitter, as Avell as a flavoring agent.
Oil (if Orintge Peel. Oleum Aiirantu Cortich. " A vol-
atile oil obtained Ij^' expression from the fresh jiccl of
cither the sweet or the bitter orange." This is purely a
diffusive stimulant, but is almost Avholly useil for flavor-
ing. Its preparations are the five-per-cent. spirit and the
twenty-per-cent. compound spirit, made Avith five [ler
cent, of oil of lemon and tAvo percent, of oil of anise.
This latter enters into the aromatic elixir.
Oilof Orniide Fhiirer-^. Oilaf SeroU. OU urn Aiirniitii
Flortriii. A volatile oil distilled from the fresh flowers
of the bitter orange. (The flowers themselves are no
longer official.) This is tiscd purely as a perfumin.g and
flavoring agent. The following are the pirparations:
.^tnmr/er Ortiiir/e Fljunr Water (Ae/ini Annnitii Morum
Ftirti(ir) is obtaini'fl as a by-product iu the distillation,
being the Avater so used, saturated Avith the oil. From
this is made the Oninye Flower Water (Arpin Annintii
Florinii) by mixing it Avith an equal volume of di.stillcd
Avater. From this, in turn, is made the syrup, by add-
ing to iiTiO grains of sugar enough of the Avatcr to make
1,000 c.c.
Oil of Pi tit (lriiiii.1. not oflicial, is distilled from the un-
ripe fruits of the bitter orange, and is very similar to oil
cd' orange flowers, but much less agrcealile.
The use of orange fruit is like that of other laxatiA'e
fruits, with the special effect of citric acid. It is to be
borne in mind that, Avhile a moderate use of oranges is
Avholesome, the excessive use can bring on very stubborn
and severe dysjiepsia, especially in tropical countries,
111 iir/i 11. Uihihy.
ORBIT, DISEASES AND INJURIES OF THE.— These
iilfcctioiis have gnat intcicsl and impoit;iiice, not only
Avith reference to the iircservatiim of sight, but also on
account of the close topical and vascular connection of the
contents of this cavity with otlicr parts, particularly the
brain, and I lie difficult and .serious problems in diagnosis
and prognosis which they fretpiently offer. Tliey are,
comparatively, not very common. The one most fre-
cpiently met with is
OuBiTAL Cellulitis. — This is not generally diflicnlt
to recognize. It is usually an acute disease, and often
of a violent inflammatory character. Pain, Avhich is a
prominent symptom, is iu proportion to the degree of
SAvcUing and conseiiucnt pressure, :ind. when this is ex-
;i98
UKFEKKNCK HANDBOOK OF TlIK .MFDK'AL SCIE>X'ES.
Orange
Orbit.
ressive, it is very inti'iisc. It is refcnx'd to the ball and
orbit aud to the parts of the face to wbith the ramiticat ions
of the ophthalmic branch of the tifth nerve are distrib-
nted, and is always increased l)y the slightest backward
jiressure of the globe. Tlie conjunctiva is congested and
soon becomes chemosed, and the lids are swollen and anle-
matous and have an erysipelatous appei\rance.
The most striking s3"mptom is theexophthalmus, which
is decided, even in sliglit cases and in I he early stages.
The diplopia resvdting from displaeenu'iit of the eyeball
is sometimes among the first symi)toms. and may even
occur before the e.xophtlialmus attracts attention. In
severe cases, particidarly if an abscess is formed, the
protrusion of the ball may be so great that the lids can
no longer cover the cornea. The movements of the eye
arc, of course, restricted and jiainful. or it may be com-
pletely ti.xed in its unnatural position.
More or less constitutional disluibance is to be expected,
and the formation of pus is usnallj" announced by well-
marked rigors. Suppuration is the rule, but a few cases
end in resolution, a result said to be much more fre-
quent in children than in adults. This form of the dis-
ease is sometimes called "a'dematous cellulitis." AVhen
an abscess is evacuated spontaneously, the pus escapes
througli the skin of the lids, near the superior or inferior
orbital margin, or sometimes behind the lids, tlu'ough tlie
palpebro-oetdar fold of tlie conjunctiva. In the latter
case the disease is sometimes mistaken for purulent con-
junctivitis. In rare cases orbital cellulitis assumes a
chronic form, and ends b}' the escape of pus oidy after
the lap.se of months or years. There may be little or no
pain, and no decided symptom except the exoplithalmus.
There is likely to be periostitis or caries in such cases.
Eti'ilogy. — Idiopathic celhditis is so rare that I'agen-
stccher Is disposed to deny its occurrence, and to main-
tain that cases described as such have been due to the
extension of inflammation from a focus which liad es-
caped the attention of the observer (Arrh. of Opli.. vol.
xiii.). Primary cellulitis in healthy adidts must be con-
sidered, to .say tlie least, a very unusual atTeclion, but its
occasional occurrence in delicate children is generally ad-
mitted. Perhaps the most frequent causes are direct in-
juries of the orbital tissue and extension of local iullara-
mation from neighboring parts. Operations upon the
appendages of the eye. or even upon the ball itself, are
sometifnes followed by this conqilication. Bull (Jmu:
Med. Sci., July, 1S78) reports a case following excision
of a prolapsed iris, and one after iridectomy for glau-
coma. The most frequent cau.se of orbital aliscess is em-
pyema of the accessory cavities of the nose wit li caries of
their walls. Phlegmonous erysipelas of the face has ex-
tended to the orbital tissue in a number of cases. Finally,
orbital abscess may be the result of a metastatic process
in puerperal fever, phlebitis, typhus, carbuncle, etc.
While thrombosis of the orbital vein necessarily occurs
in orliital phlegmon, and may extend to the cavernous
sinus, orbital cellulitis may have its origin in su|ipurati ve
phlebitis of the ophthalmic vein. It is well known that
suppuration may be communicated to the ophthalmic
vein and cavernous sinus from abscesses of the lids or
lips, operations about the face, the extraction of teeth,
and especially from facial erysipelas. In a fatal case of
suppurative phlebitis of the ophthalmic vein and cavern-
ous sinus, following malignant abscess of the tonsil, Pro-
fessor Panas {Air/i. d' Oji/it/ial., t. v.) thinks that the dis-
ease was communicated fln'ough numerous anastomoses
which have been shown to exist between these vessels
and the sphenopalatine vein. Cases of orbital cellulitis
following diphtheria are reported bv Knapp and Ileyl
(Nettleship, "St. Thomas' Hospital 'Ueports," vol. xi").
Knapp (Arcli. of 0}ih., xiii.) has shown that orbital cellu-
litis is present in all cases in which blindness results from
facial erysipelas.
_ Diagnmi.i. — The conditions with which orbital cellu-
litis is most likely to be confotinded are periostitis of the
orbital walls and new growths in the cavitj'. In perios-
titis the progress of the disease is usually less rapid, and
the pain, though perhaps less .severe, is an earlier .symp-
tom and may even be the first. Except in cases in w liieh
only the deeiier jiarts of the orbit are affected, a tender
spot can frequently be iletected bj' passing the finger as
far back as possible and pressing against the wall. W'hile
in cellulitis the eye is usually protruded directly forward,
and its motions are limiteil equally in all directions, it is
likel}' to be given a special direction liy the more local-
ized swelling of periostitis. These two lesions may,
however, sometimes appear together, the iuflamination
extending from the periosteum to the orbital cushion.
The acute course of cellulitis will tisually distinguisli it
from orbital growths. The e_ve is rarely protruded di-
rectly forward by a timior. and the latter may often be
felt with the finger. The diagnosis is, however, some-
times extremely difticult, and may prove a stumbling-
block to the most skilful and careful observe]-. This is
well illustrated by a case which occni-red some j-ears ago
in the experience of no less an authority than Profe.s.sor
Jaeger. He was sent by the Emperor to ^lilan to ex-
amine Marshal Radetzkv, who ha<l been sulTering for
three months with a high degree of exophthalmus and
its accompanying symptoms. He reported that the pa-
tient, who declined any operative interference, was af-
fected Avith scirrhus of the soft parts of the orbit, which
would probably soon end his life. Not long afterward,
under homfenpathic treatment, there was a copious dis-
charge of pus, and the eye returned to its normal position
(Arniiilcs cV Ofiilisl., xxiii.. p. 14).
Pnirjnosis. — Thougli a large proportion of cases of or-
bital cellulitis recover without serious injury to the eye,
the disease is a dangerous one and places not oulj' sight
but sometimes life in peril. The most frequent causes
of loss of sight are injuiy to the optic nerve from press-
ure and stretching, and interference with the circulation
in the central vessels of the retina. The tense chemosis
may cau.se tiie cornea to slough, or panophthalmitis may
result from interference with the circulation of the cho-
roid or fi'om direct extension of the inflammation to that
membrane. The movements of the hall are sometimes
permanently impeded by cicatricial contractions or atro-
phy of the external muscles, or their paralysis from in-
jury to the nerves. Life is threatened by direct exten-
sion of inflanunation to the meninges, through the
spheui>idal Assure or optic foramen, by flow of pus into
the intracranial cavity, or by thrombosis of the ophthal-
mic vein. Accoj-ding to Berlin (Graefe-Saemisch, vol.
vi.), fatal pyaemia may residt without extension of
thrombosis beyond tlie orbit, or the thrombosis may ex-
tend to the brain sinuses. He thinks that the latter con-
dition may be diagnosticated positively if exoplithalmus
occurs suddenly in the other eye. Exo])htlialmus fre-
quently results from venous obstruction only, with little
or no inflammation of the orbital tissue, and is a constant
and important symptom of phlebitis of the cavernous
sinus.
Trmtmeiit will necessarily vary with the violence of Ihe
local inflammation and the general condition of (he pa-
tient. In traumatic cases, and others occurring in per-
sons in fair health, leeches may be applied to the temple
in the early stages of the affection before suppuration has
commenced. Even this kind of depletion, however, is to
be condemned in the large proportion of cases in which
the inflammation of the orbital tissue is a complication of
.some exhausting disease. Hot stupes will promote reso-
lution while there is hope of that termination; liut warm
fomentations or poultices should be aiqilied when if is
desirable to encourage suppuration. Extract of bella-
donna applied to the temples and brow is useful in re-
lieving pain, but most cases will re(|uire the liberal
exhibition of anodynes. When suppuration is eviilent,
there is no question about the jimpriety and urgency of
free incision, and when it is doubtful it is often prudent
to make an exploratory puncture. When great swelling
inflicts intense pain and threatens the integrity of the
eyeball and ojitic nerve, deep and free incisions should
be made without waiting for indit ations of siqipurafion,
and with a view to relieving the tension of the parts. A
narrow, straight bistoury or a long Graefe cataract knife
599
OrbH.
Orbit.
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
is entered near the Tipper or lower margin of tlic orbit,
and its point liept near the roof or floor, wliile it is passed
toward the apex of the orbit. It is well to keep the
\\oiind open by a tent of carbolized or borated lint.
Curetting of tlie inner wall of 1 lie orbit ami drainage
ilirough the uose may be iieeessaiy when the aecessory
sinuses are involved (see Transactions of the Americau
(iplithalmologieal Soeiety, I'JOO).
Te.n'onitis. — The capsule of Tenou is a tibrous envel-
ope of the ball, derived from the diiral sheath of the
optic nerve, and lined by a serous membrane which,
according to some authorities, is continuous with the
arachnoid. Tlie eyeball moves in this envelope like the
head of a Iioue in "its articular capsule. The recti mus-
cles pass through this ea|isule at the cijuator of the ball,
where it is intipiafely coimceted with their sheaths, and
ill the neighborhood of the corneal margin it is merged in
the conjunctiva and sulieouju'netival tissue. AVliile it
forius a barrier to the extension, within the eye, of inflam-
matory processes when they commcnee in the orbital tis-
sue, its ilirect connection, by means of the anterior ciliary
vessels with the iulra-ocular circulation makes this dan-
ger greater when Ihe caosule itself is inflamed. On the
other hand, it ]>roliably rarely entirely escapes participa-
tion in very acute and iulen.se intra-ocular inflammation,
and is the cause of the protrusion of the ball in panoph-
thalmitis. In enucleation in such cases the exten.sive
and tirm adhesions of the capsule and the muscles and
connective tissue about the ball often considerably com-
plicate the operation. Tenonitis is said to (>ccur occa-
sionally after facial crysiiiehis or as a rheumatic atfection.
but is usually the result of extension of inllammation
from the ball, or of direct injury. It has sometimes fol-
lowed operations, especially those upon the external
muscles. I have met with two cases: one after simple
division of a muscle for strabismus, the patient recover
iiig in the course of a few days, without injury to tlie
eye; and <uie after the advancement of the internal rcc
tus. In the latter case the disease ended in disorganiza-
tion of the ball.
The .ii/tit/jtoiiix are conjunctival and subconjunctival
c. ingestion, sometimes with chemosis, moderate exoph
ihalmus, reslrictiini of the movements of the ball, and
))ain, greatly increased li.y jircssing the eye backward.
The lids are less affected" than in cellulitis, and if pus
forms it escapes on the surface of tlie ball.
Triiititii lit will, c.f course, depend upon the cause and
the intensity of the inflammation. Rheumatic cases re-
quire hot stupes, cotton compresses, anodyne applica-
tions, and the apjiropriate internal medication. In the
early stages of traumatic tenonitis leeching at the tem-
ple, the local application of ice, and calomel interuall)'
may be ni'edcd.
I'kuiostitis of the orbital walls is sometimes difficult
to distinguish fiinu cellulitis, and indeed the two condi-
tions may exist together, or ]jhlcginonous inflammation
of the orbital eonneetive tissue may originate in periosti-
tis. The usual seat of jieriostitis of the orbit is near the
margin, where it can lii^ detected by pressure with the
flnger. The e.\ophtlialinus is not directly forward as in
nncomiilieatcd cellulitis, and the movements of the ball
are limited more in the direction of the seat of the dis-
ease than in other directions. When the disease is at the
apex, paralysis of some of the muscles of the ball is likely
to ensue from involvement of the nerves at their entrance
into the orbit. Periostitis usually, though not invariably,
ends in suppuration. Sometimes there are more or less
))ermanent localized thickening of the |)eriosteum and
consolidation of the neighboring tissue, which closely
simulate a tumor. I have met with several such cases.
In one there was a distinctly localized hard swelling in
the upper inner wall of tlie,orbit. extending as far back
as the finger could reach. An exploratory incision was
made, and when the finger was introduced into the
wound it was found that the swelling was much less
clearly defined than it had appeared to be — in fact, that
it was merely a localized engorgement of the iierio.steum
and neighboring orbital tissue. The part was freely
scarified and the wound was kept open with a tent. The
case soon ended in comjjlete recovery without suppura-
tion. In another case there was such a decided resem-
blance to a tumor in the region of the lachrymal gland
that extirpation had been advised by two experienced
surgeons. As tlie jiatient was known to have been un-
der treatment some months previously with an aggra-
vated attack of syphilitic pharyngitis, periostitis was
diagnosticated, and a rapid cure followed the administra-
tion of heroic doses of iodide of potassium.
Prdrjiioxia. — A large proportion of cases end favorably.
The bone may become involved in the disease. In a few-
eases death has resulted from direct extension of inflam-
mation from the periosteum to the meninges of the brain,
or from the escape of pus into the intracranial cavity.
The danger is, of course, much greater when the deeper
parts of the orbit are affected. In the chronic form tlie
lirogress of the disease is very slow, sometimes extending
over months or even years.
The fiivse may be traumatic or rheumatic, or the dis-
ease may be due to an extension of inflammation from
one of the neighboring cavities, but it is most freciuently
syphilitic. The local ircatvient is the same as in celluli-
tis, and when suppuration is suspected or when excessive
swelling endangers the eye or brain, early and free incis-
ion should not be neglected. Iodides and tonics are gen-
erally needed.
C.-^niES .\ND Necuosis of the orbital walls are usually
the result of periostitis when not due to disease of the ac-
ci'ssorj- sinuses. The scat of the disease is, fortunately,
most freciuently near the margin of the orbit, where the
danger of injury to the eye or of extension to the brain is
much less than when the deeper parts of the orbital cav-
ity are involved. The adherent cicatrix of the skin,
however, which invariabl}' forms, is likely to cause seri-
ous deformity of the lids by its excessive contraction.
This cannot be prevented, but must be remedied by
operation, as best it may, after the affection of the bone
lias run its cour.se. Abscesses shotdd be promptly evac-
uated and a free opening maintained. When they dis-
charge spontaneously the resulting sinuses will fre-
quently need to be enlarged. The cavity should be
frequently syringed with antiseptic solutions. The dan-
ger of reckless probing should be borne in mind, and no
forcible attempts to remove sefjuestra should be made.
Acute cases, which are often mistaken for eiysipelas of
the lids and face, may need local treatment. Iodide of
potassium is always in order, and should be given in large
doses if syphilis is suspected. Many patients require a
long course of treatment by ciuinine and iron and cod-
liver oil, and careful attention to diet and hygiene.
IlEMOuiiii.VGE IN THE Orbit is extremely rare from
other than traumatic causes. It has occasionally oc-
curred in scorbutic subjects, in sudden suppression of
file menses, and from violent coughing or muscular
straining. Permanent ha^matomatahave been formed by
repeated hemorrhages.
When hemorrhage occurs in the orbit after serious
injuries of the head, it is an almost certain sj'mptom of
fracture of the walls of the cavity; though intracranial
hemorrhage may flndits way into the orbit without fract-
ure. In a few cases of injuries bleeding has resulted
from rupture of vessels within the orbit. The symptoms
areexophthalmusand eechymosis of the lids and conjunc-
tiva. Theophthahiioseopicappearancesare those result-
in,g from siulden pressure.
Treiitmeiit. — Iced-wateror pounded ice should he ap-
plied while there is probability of further hemorrhage,
and afterward absorption may be hastened by a compres- [
sive bandage.
Emphysema of the orbit is still more rare than liemor- i
rhage. The symptoms are exophtlialmus and the char- I
acteristic crepitation on pressure upon the puffy lids, i
The causes are rupture of the lachrymal sac, or ;
communication between the orbit and the frontal sinus- I
es, ethmoidal cells, or nasal cavity. This communica- |
tion with neighboring air spaces is generally traumatic, '
but may be the result of ulceration. Rampoldi reports
400
KKFKUKNX'E HANDBOOK OF TlIK MKDIC'AL SCIENCES.
Orbit.
Orbit.
a case in wliicli tlic ciupliysc-inu ili'veloix-il, witliuut iii-
jiirj', from cliroiiic coiyza. Exoplitlialiims, with diplo-
pia, appeared wliciipver tlie i)alieiit sneezed or eoiiglied,
until he learned to prevent it liy siijipdrtin!;- the eye with
his hanil. Tlii' stury iv tuld ni' a i-cmviet wlio ])nidueed
exophthahnus liy intiodueiMi;' a i)in at the root of a mo-
lar tooth and foreini;- in air irom the nnmtl] ; and malin-
gerers arc said to li;ive jn'odneed the same residl by mak-
ing a piinclnre lieneatli the eyebjill ami blowinij in air
tlirongli a tube. Freneh joekeys have been aeensed of
resorting to I lie latter expedient to give a youthful ap-
pearance to old horses with siad\en eyeballs. "Ko trait-
vKtit is likely to be of much use. The ]iatient slioidd be
catitioned against blowing his nose and encouraged to
wait for the rent to close.
ExopnTii.M.Mrc (Joitric, often called Graves' disease or
Basedow's disease, is a complicated affection in which, in
its typical form, protrusion of the e_veball is associated
with enlargement of the thyroid gland, functional dis-
turbance of the heart, and marked nervous and nutritive
derangement. Though cases presenting this association
of symptoms had previmisly been reported by Parry and
others, the tirst systematic description of the disease now
known as e\i>i)btlialniic goitre was given by Graves in
1835, and his name is associated with it by English,
American, and some French authors: while the Germans
claim that Basedow was the tirst tode.scril)e it accurately
(Casper's W-y/iiiinr/n-ift) in 1840, and they always speak
of it as Basedow's disease.
The exoiilithabnus is not ustiall_y so excessive as that
met with in eases of ab.scess or tumor of the orbit, but in
a few instances it has been so great as to prevent the lids
from closing over the cornea. The effect of the protru-
sion of the ball is, in a large proportion of cases, height-
ened and the deformity nnieh increased In' an associated
affection of the lids, a symplimi to which attention was
first called by von Graefe. 'I'he upper iid does not follow
the movements of the ball as its axis is directed ujnvard
or downward, but remains fixed and more or less re-
tracted, exposing tlie sclerotic and giving a staring and
startled expres.sion to the patient. This is due to eon.
traction of the small, flat muscular fibres, extending
from the lid back into the orbit, which were discovered
by Miiller and are known by his name. They are of the
nnstriated kind and are under the control of the symi)a-
thetic nervi'. Sometimes, also, reflex contraction of the
orbicularis from irritation of the eye is diminished, and
winking is absent or incomplete. These lid .symjiioms
are not constant, but are sometimi'S found when the dis-
ease is but slightly developed, ami may be valuable indi-
cations in doubtful cases. The ball can be forced back
nearly or quite to its normal position by pressure with
the lingers, but it projects immediately when the press
ure is removed. Vascular lirnit has been detected with
the stethoscope by Snellen. Diploiiia from displacement
of the visuaJ axes may occur, even as an earlj- sym])tom,
and. in some advanced cases, continued stretebing ]irii-
duces paresis of the external muscles of the ball. There
has been mneb discussion al)Out the condition of the pu-
pil: some eases have been reported in which it was di-
lated, and a few in which it w:xs contracted, but, without
tlonlit. it is usually unaltered. Vision is not generally
impaired. The ophthalmoscope lias oeeasionally shown
retinal hemorrhages, and Becker {h'lin. MaiKiliihhitt fih-
Aiiijtnheilk., 1880) has observed pulsation of the relinal
arteries in .some cases, but, as a rule, there is little ov no
change in the fundus beyond a dilatation of the relinal
veins, and even this is not constant. Both eyes are al-
most invariidjly affected. Cases have been reported in
whicli one only was involved, but this is so rare tJial Eu-
lenlierg thinks that some suspicion must remain in respect
to the diagnosis. Slight keratitis, with conjunctivitis, is
common in .severe ca.ses, but blindness from ulceration of
the cornea is a rare occurrence. Some authorities attrib-
ute this ulceration to simple exposure of the cornea from
excessive exophthalmus, while others believe it to be an
instanceof so-called neuroparalytic keratitis, due toa dis-
turbance of nutrition resulting from the obscure neurosis
v.. I Vr~'iO
that lies at the bottom of all the manifold symptoms of
this disease. Tiie latter is the view taken by von Graefe
and others, who consider the corneal affection a result of
paralysis of the "trophic " fibres of the ophthalmic branch
of the tifth nerve; the corneal sensibility being lost or
retained according as all the fibres of the n<'rve, or the
tro]>bic only, are involved. Scmie authors, among them
Ch;ireot, are disposed to think that tlie corneal intiamma-
tion is ju-oduced by irritation of tlie nerve (see "Neiiro-
paralvtic Keratitis," Harlan, Am. Jcvr. of thr ifirl. t<ci.,
April", 1874).
In nine cases out of ten the subjects of tlic disease arc
females, usually adults luider tliirty years of age, but a
lew instances in children under ten have been recorded.
JIale ])atieuts are generally older and their attacks are
likely to be more severe. Most cases of corneal ulcer-
ation have occurred in males.
The exophthalmus usually disappears eutirelj' after
death, antl no constant lesion is discovered by post-mor-
tem examination of the orbit. Fatty degeneration of the
musc-les. from disuse and stretching, has been noted : and
hyiiertrophy of the orbital fat has been found in some
cases, but it may be considered an accidental result of the
v;isenlar engorgement which seems to be the can.se of the
pi'nirusion of the eyeball.
Tlw ji<i//ii'l„gi/. sytiiptijiiiaUtlon!/. ami treatiiicnt oi e\OT;}\\-
thalmic goitre will be discussed in a separate article in
Tin: Ai'i'ENDix.
I'ti.sATiNG ExoiMiTii.\i.Mts, a comprehensive term
basc'd on convenience rather than on scientitic accuracy,
is now quite generally used to include a large class of
c:ises whic h are de])endent u]iiin different |iathological
conditions, and which in the jiresent state of our knowl-
edge it is always dilHcult and generally impossible to dis-
tinguish positively during life.
Si/iiipfoms. — There is protrusion of the ejeball, and
]iulsation is evident to the touch and .sight. Above the
eye, and beneath the ujijier and inner margin of the or-
bit, is a rather firm, elastic tumor, also pulsating. The
jiatient cotuiilains of a imfiing or whirring noise in the
lu'ad, and an anenrismal liruit is heard, on auscultation,
over the eye and temple, and sometimes over the whole
side of the head. In some cases this sound has been audi-
ble at a distance of several feet from the patient. There
are usually distention and pulsation of the suju-a-orbital
vein, and sometimes of the infra-orbital also. When the
carotid is compressed in the neck the pulse and bruit cease,
I he tumor becomes soft, and the eye can be pushed back
iiili) the (irbit. The hollow between the ball and the
cubital arch is obliterated. The conjunctiva is congested,
and in many cases a tumor is formed by intense chemosis
of its lower fold, Avhich projects beyond the lid. There
niav lie no decided ophtlialmosco|)ic changes, but the ret-
inal vessels are usuall}' congested, and the disc is some-
times found swollen as a result of pressure upon tlie
optic nerve in the orbit. Pain ina\" be slight or severe.
Vision is not generally much affected in recent cases,
but the eye has of ten been destroyed by long-continued
and excessive pressure. The symptoms usually appear
sudilenly, after direct injury to the orbit or a severe blow
upon the head in traumatic cases: or during violent
effort, as in childbirth, in cases of spontaneous origin,
'I'liey have not been noticed, however, in a number of
traumatic eases until some weeks or months after the in-
jury.
In several spontaneous cases the patients ha\'e been
roused from sleep by a loud sound like the report of a
pistol.
Pmnrexs and Teriiiiiiatliin. — The ilerdrmity ami incon-
venience are so great, and the danger to the eye and to
life is so decided, that few ca.ses have been allowed to
pursue a natural course, unintcrruiited by more or less
active treatment. As a rule, the character of the affec-
tion is chronic, and some cases have undergime little or
no change in the course of years. In others the eye has
been destro3'ed by sloughing of the cornea and general
ophthalmia. The causes of death include ery.sipelas,
complications of brain and b.eart, and hemorrhage. Of
401
Orbll.
KEFKHENCE HANDBOOK OP THE MEDICAL SCIENCEri.
tlif last class, in the cases of Husscj' ami Critcliett (" Opli-
tlialniic Hospital Reports.'' vol. ii., p. 127; Med. Times
(I lid Utiz., December, 18o4). tlio jiatieuts died of hemor-
rliage directly from the orl)it. and in one of Nehtton's
ca.ses (Lniiirt. 1873). profuse epistaxis, resullin.LC from
fracture of tiie l)ody of llie splicnoid bone and rupture
of the carotid, was the eau.se of death. In 187(3 (Trans.
Internal. Jled. Cong.) I reported a case of spontaneous
Fiii. :1707.— .sc. The tUlated eavernous sinus, nijencj frxm above.
Within Ibis, llie iiitHrua! rai'oTid (r(n. wliii'h is rut open alx>ve Ut
show tlie perfttratiou iu Ihr untier ant! ouier sido of its wall (n; fl>,
tllH fi-artufc Iti thf s[ilifiinid boHi- : I'll, detai-lji'd spicula from the
point of tho petfoiis hoiH'; mK, siiuls eiioularls Ridleyi ; .s|».s, a part
'if tlif di laird suporior potl'osal siluis : oe. dilated oiilithaliuir vein ;
' i\ vi-ua tii>id:d!>; ",i, nphthatlnli- artorv; nn, uptif pent', (.\ftel'
la-I.Mis, I
cure, and gave alistraets of six (illii-r cises recorded in
litei'atuie u|) to tlitit time, ;iiul 1 lind tliiee idhers whieli
luivc been ie])orled sittee:
1. IJilseli (h'/iii. Muiiiitslil. f. AiKjeiilik., xvii., 1879):
E\o|i]itiialiiius, iniiriiiiu', ])iilsation. Probable sponta-
neous niptitie of ciirotid in cavernous sinus. Cure b\-
c.\tra- and iiititi uciilar intiaiiimtilion.
3. Oatil'tm {(lazrlle des Ilupiiiiii.r. October, 1SS3):
Aneurism of liotit orliits, caused by a tall ti|iiui the Itead,
cured spontaneously.
3. Ght.scott (Brit. Med. .hmr., November 'lh\\\. 1882):
'■ .Vrtcrio-veuous aneurism ot orbit," lasling two yctirs,
Spontaneou,s cure in the course nf phle^iiiotious intlaiii-
mation of the face tuiil head.
This nutkes ;i lottil of leti < uses. Iu wliieli might be
added several otiiers in wliieh the rlleel i>f remedial
mcasuics was doubtful.
Pnih(ilo(/)i. — The ty])ical symptoms of " pulsating ex-
ophtlialmus" ai'c protrusion of the eyeball, pulsation,
and aneurismal bruit, ami all cases pivsenting the.se
symptoms were forinerlj' classed as "orl.ital aneurism."
Following the view mainlaini-d b\ Travels, in his leport
of the first case in ISO!) (.Med.-Cli'irurg. Tians., vnl. ii.),
for thirty years writers generally helil that these cases of
so-called aneui ism of the orbit wereallof thetintistomotic
vai'iety. Then Busk's paper (ihid,, vol. xxii.) tlti'ew ti
doubt on this, anil most authors thought that tliey were
of the ordintiry sitontaneous or traiiniiitic kinds, ali'ecling
the ophtliidmic sirtery, until Nuimcley, in 18(14. main-
tained that in the great niajority of suclt casi's of |irotru-
sioii of the eveliall tlioic is tin diseti.se whatever in the
orbit, but that the syni)itoins depend on obslruelion to
the return of blood through tlic ophthalmic vein.
Though there is no positive proof that such a thing as an
aneurysm of the orbit has ever existed, it is, of course,
not an impo.ssilile condition.
A review of tlie now vei-y extensive literature of the
subject makes it seem probable that pulsating exophthal-
mus may be produced by true arteriovenous or anasto-
motic aneurism of the orbit; by aneurism of the carotid
artery, or of the o|ilithalinic at its origin ; by tincurismal
varix between the carotid and the cavernous sinus; by
thrombosis of the ophthalmic vein or cavernous sinus;
by dilatation of the sinus; or by obstrtictiou of the return
of venous blood liy growths at the bottom of the orbit or
lieliinil it. The protrusion of the bull is the result of
venous engorgement; while the pulsation and bruit are
communicated from the carotid, or are produced by the
ru.sh of lilood into diUited vcs.sels confined in a bony cav-
ity and with obstructed outlets, or are symptoms of an
aneurismal varix of the orbit due to a communication
between the carotid artery and the cavernous sinus.
Froiu a studv of the comparatively few post-mortem rec-
orils. and the histories of a large number of cases iu
which the patients have survived. 1 am couvinceil that
marked imlsatiou and bruit have most fi-eijuently been
produced by aneurismal varix of the orbital veins. In
three traumatic cases direct communication between the
carotid arteiy and the cavernous sinus was found after
death; and in three spontaneous cases post-mortem ex-
amination showed that theie had bi'cu rupture of diseased
carotid arteries in the cavernous sinus. In a number of
cases the diagnosis of artei'io-veuous communication in
the cavernous sinus has been made, with more or less
confidence, during life.
In a traumatic case, reported by Kiiapii, this diagnosis
was subseciuently contirmed as iiositively as it could have
been b}' a post-mortem examination. Ligature of the
carotid gave partial relief, liut. nearly two years after-
ward, there was a recuii'ence of the orbital disease, with
great increase of the pulsating tumor, enormous protru-
sion of the eye, and sloughing ot the cornea. After ex-
tirpation of the eyeball, the orbit was found to be tilled
with an irregular pulsating mass, which was removed
entire, ;iud was founil to consist chiefly of an aneurismal
varix (.\rcli. Op/it/iii/., vol. .xii.). The accompanying il-
lustration (Fig. 3707) shows the condition found, post
mortem in one of Nelaton's ciiscs (Sattli'r. (Jtaefe and
Saemisch ■' llandbiuli." vol. vi.. p, 848). Thcie was a
fracture of the sphenoid bone and of tlie petrous portion
of the tempoi'al. and a small hole in the carotiil com-
municating with the caverucuts sinus. Thesinusand the
ojihthalmic vein were dilated and tortuous.
It must be confessetl that serious objeelions can be
urged against the use of the terms " pulsating exophtlial-
nins" and " vascular protrusion," and perlia])s it may be
well to iliscard them when accuiute and driiniii- diagno-
sis is possible. It is quite true that, as !Mr. Curling said
iu opposing the inti'oductiou of these terms, "to class
affections of very tlifferent chai'acter under one common
head, taken from a prominent symptom, is not calculated
to advance suigical pathology and practice"; but it is
equally true tliuf such advance is not ]ii-omoled by feign-
ing a posiiiM' knowledge when we have it not, and giv-
ing a delinitc name to indefinite conditions. Confession
of i.gnorance is an essential lueliminary to the ae<iuisition
of accurate information, and the lesions ]iroducing the
prominent symptoms of protrusion of the ball and luil-
sation may be conveniently and profitably classified with
refei'euce to these symptoms, until the accumulation and
stud}' of iiosf-mortem recoi'ds throw more light upon tlie
subject.
Ill 187.-) (Trans. Am. Ophthal. Soc.) I itublished ah- j
sti'acts of fifteen cases, including the imperfectly reported I
one of Guthrie, in wliich postinoi-fem examinaticnis had i
been made. As in two of these cases ( Lenoir's and Ilani- i
ilton's) the symptoms had been produced by vascular
malignant growths of the orbit, this number should he I
reduced to thirteen. In the papers since published, of
4U2
REFERENCE IIAXDBuoK OF THE ."\IEDICAL SCIENCES.
Orbit.
Orbit.
Kiviiigton (Meil.-Chinirg. Trans., vol. Iviii., p. 282) ami
Sattler(Graefe-Saemiscb. vol. vi.), are quoted the follow-
ins two cases that escaped mv search:
1. Hirschfeld ( r/o^f^c des Hdpitaux, 1859, p. 51; Lim-
ed. 1873): Traumatic; post mortem, a bloodelot found
in the cavernous sinus, and this clot covered a small cir-
cular hole in the carotid, which looked as if it had been
punched out and was occupied b_va string of decolorized
clot about two inches long passing into the mass of co-
aguluni.
2. Oettinger (Sattler, ibid.}: Spontaneous; postmor-
tem, no change in the arteries, but traces of inflamnialory
processes in the retrobulbar tissues, anil obliteratirm of
the ophthalmic vein.
I can find only the three following reports of post-mor-
tem examinations recorded since 1875 :
1. Bli.ssig. 1876 (Sattler, ibid.): TrauTuatic: postmor-
tem, "decided dilatation of the internal carotid in the
cavernous sinus." As the common carotid whs tied eight
weeks after the injury, and the patient lived five weeks
after the operation, Sattler seems to think that the cause
of the dilatation may have been a wound in the artery
that had closed.
3. Schlaefke, 1879 (Arch. /iir Oplithal.): Traumatic;
post mortem, dilatation of the cavernous sinus and aneiir-
ismal enlargement of the cavernous portion of the carotid
artery ; all the orbital veins enormously distended and
the frontal and supra-orbital dilated.
3. Coggin. 1883 [Arcli. of Op/i.): Spontaneous; post
mortem, marked aneurismal dilatation of the cavern-
ous portion of the carotid artery, ophthalmic vein iiiT
nuich enlarged. In this case the pulsation and bruit
seem to have been communicated from the carotid an-
eurism.
This makes a total of eighteen post-mortem records, an
anal3'sis of which gives the following result:
True aneurism of both ophthalmic arteries in the orbits
(doubtful), 1 ; post-orbital aneurism of ophthalmic ar-
tery, 1; aneurism of carotid in cavernous sinus. 1 ; dila-
tation of carotid in cavernous sinus, 4; wound of carot-
id in cavernous sinus. 3; thiombosis of cavernous sinns
and ophthalmic vein. 5; dilatation of cavernous sinus
and ciiilitlialmic vein. 2; pressure on cavernous sinus and
ophthalmic vein by new growth, 1.
The case considered doubtful is that recorded by Guth-
rie (•• Operative Surgery of the Eye," p. 158, 1823"). The
following is his report : " I have seen one case of tiue
aneurism of the orbit which terminated fatally. Tin-
symptoms were similar to those above mentioned (cases
of Travers and Dalrymple), but no tumor could be per-
ceived; the hissing noise in the head could lie distinctly
heard. (_)n the death of the patient an aneurism of the
ophthalmic artery was discovered on each side, about the
size of a large nut. The vena ophthalmica cerebralis
was greatly enlarged and obstructed where it passes
through the foramen lacerum. in consequence of a great
increase in size which the four recti muscles had attained,
accompanied b}- an almost cartilaginous hardness, which
had been as nuich concerned in the protrusion of the eye
as the enlargement of the vessels." The description is
so meagre and loose, and the post-mortem appearances
reported are so very peculiar, that this case is not gener-
ally regarded as affording positive proof of the exist-
ence of true orbital aneurism.
An aneurism of the ophthalmic, the size of a hazelnut,
jnst at the entrance of the artery into the orbit, was
aceiilcntally discovered in a cadaver by Carron du Vil-
lanls (Sattler. ibid., p. 840). There w'as no history of
the case, and it is not even known that it was one of
puls;Uing e.xo|)hthalmus.
Finally, in one of Nunneley's spontaneous cases(Med.-
Cliir. Trans., vol. xlviii,, p. 28) a circumscribed aneu-
rism of the ophthalmic artery, as large as a hazelnut at
its origin from the carotid, was discovered. The jjost-
niortem was made nearly five years after a successfid
ligation of the carotid. The arteries of the orbit are de-
scribed as unusually small. These three cases comi)rise
all the post-mortem evidence of anv connectiou of the
ophthaliuic artery with the symptoms of pulsating e.x-
ophthahnus.
While the above was passing through the ]iress, I met
at last with a report of what seems to have been a veri-
table case of "orbital aneurism." carefully examined and
treated during life and verified by autopsy — the only one.
so far as I know, on record. The re])ort was read at the
last meeting of the British Medical Association by Dr.
Alexander Deiupsev. of Belfast, and mav be found in the
nritiah Medical Jonnml of September 18th, 1886. The
symptoms, which first appeared a few hours after child-
birth during violent vondting, differed little from those
observed in the reported cases of carotid aneurism which
have occurred under somewhat similar conditions. The
common carotid was tied, and death resulted from sec-
ondary hemorrhage from the wound in the neck and
from bleeding from the aneurism through the cornea.
There was an aneurism of the internal carotid artery,
at the point of origin of the ophthalmic, which had no
communication with the cavernous sinus. Its diameter
at its widest part was from one-half to three-fourths of
an inch. The orbital aneurism is described as follows;
"The ophthalmic arter_y, from its origin, was also very
considerably dilated, I should sa_y to fully four times the
size of the opposite one. and on tracing it into the orbit
we found an inuneuse sacculated aneurism developed on
its superior aspect. The sac would contain easily a man-
darin orange. In its centre there was a post-mortem
clot, but around its circuiuference there was a firm, lami-
nateil fibrous ante-mortem clot which was a complete cast
of the sac, except at its anterior part, where it was ojien
and communicated witli the eyeball by a large opening
at the upper, back, and outer part of the globe. The
contents of the glolje had escaped, when hemorrhage had
taken place, tiu'ough the cornea. The superior petrosal
sinus of the opposite side was distended. Ijut the other
sinuses of the brain appeared normal. The arteries of
the circle of Willis were dilated, especially the anterior
communicating. The veins of the orbit were all very
much enlarged, especially those at the inner angle of the
eye."
While it would seem that any obstruction to the return
of blood by the oplitlialmic vein may produce the symp-
toms of pulsating exoplithalmus, even complete obstruc-
tion by thrombosis of the sinus docs not, by au}- means,
always do so. In a case reported by Lloyd (0///;, life.,
vol. iii.. No. 37) there was aneurism of both the basilar
arterv and the internal carotid, and the cavernous sinuses
of both sides were lilocked with firm fibrinous red thnim-
bi; yet there had been but slight exophthahuus, which
lasted onh- a few days, and never any ]udse or bruit.
Lloyd attributes tlie reees.sion of the globe to the estab-
lishment of collateral circulation ; and Sattler says that
when an intracranial aneurism is fornu d gradually it
may cimipletely compress the ophthalmic vein and cav-
ernous sinus without juoducing either pulse or exoph-
thalmus.
Though fiiu'iirism by andstomoai/i was formerly the fa-
vorite diagnosis in cases of so-called "orbital aneurism,"
it has never been verified by post-mortem observation,
and more recently its occurrence has been doubted. The
following congenital case (Harlan, Trans. x\m. Ophlhal.
Soc, 1875, and luternat. Jled. Congress, 1876) seems
scarcely to admit of any other ]u-oIiable view than that
of aneurism by anastomosis, or eir.soid aneuri.sm. The
patient was a healthy man. twenty-five years of age.
The left eye had always been |irounnent and tlie left side
of the head larger than the right, Fioni his earliest rec-
ollection there had been a rushing sound in his eye and
head. The left eye was enormously protruiled and forced
downward and outward. No useful vision. Whole h-ft
side of face hy pertrophied. Above the eyeball, and lying
more to the nasal side, there was a distinct tumor of al-
most cartilaginous density. Pulsation was strong enough
to coiumunicatean evident motion to the head of the aus-
cultator; and a loud aneuinsmal bruit w;is not only an
annoyance to the jiatient, but eouhl be heard by others
some distance from his head. There was a donghj-
4oa
Orbil.
Orbit.
HEFKKKMCE IIAM>i;(H_)K OF TlIK MEDICAL SCIENCES.
swelliiiiT of tlic soft jiarts, exlrinliiigiilniut iiii inch above
the oiliit, ill wliicli strolls imlsalioii cimld lie fell. J^ri'ss-
iii'c upon ihc left ciirotiil slo|i|ic(i :ill |iiilsiili-oii. and the
tuinoi' became soft and conlil lie picssed back into tiic
Flo. oillS. — Cnll^'rllitill .Mli'UllMIl hv .A Ija^Lilnnsis iif (llhit.
orliil. Till' supra orbital a.d fmninl ai'lrrics ^vere iniieli
distended and pulsated s ronuiy. ami this aneuiisnial
condition e\lended down the angular branch id' tlie facial
(111 tlieiiLihl side. A \ ascniar tumor, fonneil by engorge-
ment and liypertrophy of the inferior eonjiiuetival fold,
almost concealed the cornea, and liad .several times bled
quite freel\ ; this was remiived by conslrietion with silk
ligatures. Some months latn. the patient iirescnti'd liim-
sell witli vinlcnt acute intlammation of the conlents of
the orbit. Thi' tumor was increased to twice its former
size, the e.\ophihalmus was enormous, the eye could no
longer lie cnvcred by the lids, and the cornea sloughed.
In a few" weeks the tumor had coniplclcly consolidated
and was rapidly diiiiinishing in size. In this case the
congenital origin, the hyiiertrophy of the whole side of
tile face, tin' inv.ih cment of the external vessels, and the
evident extension nf the diseasi' lieyondtlie orbit to the
subcutaneous tissue of llie biuw |ioint to aneurism bv
anastomosis, or eirsoiil ani'urisin. The only other possi-
ble supposition is a ruptur<' of an aneurism of the carotid
in the eaverninis .sinus and consecpient amairismal varix
of the orbit, liut the history of the case makes this more
than improbable.
^'ascular malignant growths n( the orbit may ]u'oduee
the symptoms of pulsating exophtlialmus, and in at least
two such cases the carotid artery has been tied for the
cure of orbital aneurism, 'i'lic lirnit in these cases niav
be very decided, luit is not likely to be so loiiil; the tu-
mor shows more leiideney to extend toward the tcMiiporal
side of the orbit, ami is iess reducible after compression
of the eominon carotid than in cases of Imlsating exoph-
tlialmus de]H'ndenl upon the causes that we have been
considering. Ofcour.se, multiple tumors and other indi-
cations of malignant disease sliould be carcfullv looked
for.
Traitiiieiil. — The long coutinuance of some cases willi-
<nit material change, and the recovery of a few without
interference, or with onl.y hygienic ctire and medical treat-
ment, should discourage resort to serious surgical pro.
eedure when there is no immediate danger or ilecided
sutTerin,g or deformity, though these conditions may,
]ierliaps, be considered exceptional. Milder remedies
should, at least, be ,given a trial first.
Ill a very decidi'd traumatic case rejiorted by Dr.
Holmes, of "Chicago (.4///. ,]oiir. Mai. Sci., July, 1864).
coiuplete cure followed the exhibition of veratrnin viride
and extract of ergot for two months; and Dr. Freeman,
of Canada {i/j/'d., 18(36), reports the cure of a spontaneous
case, in a few weeks. b,v application of cold, direct press-
ure on the swcllin.g, and the use of digitalis. In a few-
cases, digital compression of the carotid artery has ef-
fected a cure.
Compression of the common carotid has been frequentl,v
tried. In my owu traumatic case (Trans. Am. Oiili.
Soc., 18"))the patient himself kept uji intermittent com-
pression for several hours dail,\'. At the end of six months
there was decided improvement, in two years all promi-
nence of the eve had disapjieared, and some months later
lie was entirely cured. Of cours(!, this case is open to
the suspicion of spontaneous cure, but the patient always
e.>;perienceil great immediate relief from thecomiiression,
and w as confident that it was the cause of the final cure.
It is almost impo.ssible to a]i]il,v' instrumental compres-
sion elTectually. tind it has never been successful. Ac-
iiirding to Sattler, of twi'iity-nine cases treated by
I'Diuprcssion, couliuued or intermittent, permanent cure
can be claimed in only four, though more or less iin-
pidveinent followed iu five others.
CJalvauo-puncture lias been tried in two cases unsuc-
cessfully (Felrei|uiu, dnzetti' MeiUfiiU, 1846, and Bour-
eiiet. ihid.. ISo.")). In Petrequin's case the jiatieiit
died.
Acupressure, with hi>t needles, has failed in one case.
Inje<'lion of ergotin has been tried once without suc-
cess.
Injection of coagulating fluids has effected a cure iu
three cases (Bourguet, lac. cil.: De Sormeaux. quoted by
Kivington, Jled.-Chir. Trans., vol. Iviii. ; and Braiuerd,
Liiiifit. lyoS). Bourguet and De Sormeaux used tinct-
ure of the chloride of iron, and Braiuerd used the lactate.
Ligature of the common carotid has ]Ud\ed by far the
most elticient lueans of treatment, and a number of bril-
liant successes have been reiiorted. It must lie remem-
bered, however, that it is not without its chances of
failure and ils dangers (d" a fatal issue Sixty-three liga-
tions of the common carotid, performed on 61 patients,
in the treatment of pulsating exophtlialmus, have been
compiled by Sattler. in IT cases (26.98 per cent.) the
operation had little or no permanent effect; in 8 (12.70
jier cent.) it resulted fatally; and iu 38 (60.30 per cent.)
the result was favorable.
E.xtirpatioii of the orbital tumor is a bold procedure
and has a brief but favorable record. In his report of a
successful case of this operation Knapp (ArcJi. ./?' Ojih.,
Aol. xii.. No. 3) makes the ff)llowin.g reference to three
others: " Among the different methods recommeiuled and
practised, I cho.se the one, extirjiatiiai, w hieh I find men-
tioned in Sattler's compilation of one Inuulred and si.x
ca.ses only three times, namely : ( 1) Jlorton's case (Sattler,
No. 70), excision of the whole contents of the orbit, ex-
cessive hemorrhage arrested by glowin,g iron and cont-
pressiou, recovery; (2) Fiothingham's case (Sattler. No.
80), ligation of common carotid, retardation of increase
for three years, then rapid ,growtli, extirpation with very
considerable heniorrha.se; (H) Hanson's case (Sattler. No.
106), ligation of common carotid, return of symptoms as
early as the second day, three weeks later extirpation of
the tumor with preservation of the globe, profuse hemor-
rlia.ge arrested by jierchloride of iron. "
V.\SCUI.-\K PliOTIifsION, WITIIOtTT Pl'I.S/VTION. — As
has already been stated, in thrombus of the cavernous
sinus, though more or less exo]ihtliaInius is alnio.st in-
variable, pulsation Jiiid bruit may be absent; and this is,
perhajis, the rule, f'luvnu'iix tinimrs of the orbit have
been met with in a few cases. A typical one is described
by von Graefe (Ardt.fiir Oji/il/itil., t. vii.), in which the
404
REFERENCE HAXDI500K OF THE JIEDICAL SCIENCES.
Orbil.
■^#i*bit.
whole mass was removed with the eyeball. WccUev
(•■ Maladies dos Yeiix") extirpated a somewhat similar
tumor w ithout removing the ball. In each of tiiese cases
the tumor consisted of spoiig}' tissue encysted in a dense
capsule. There has never been pulsation in any well-
established case of cavernous angioma of the orbit. The
only remedy is extirpation. The exophthalmus in goitre
may be considered of the nature of vascular protrusion
without pulsation.
.SiMiM.E Axiao.MA (Telangiect.vsis) sometimes extends
into the orbit from the skin of the lids, forming a soft,
slightly compressible tumor. The best treatment is ex-
tirpation or electrolysis. Simeon Snell has lately re-
ported several successfid cases of the latter, and con-
siders it especially applicable when the disease extends
deeply into the orbit {Lancet, July, 1886). Frequent
repetition of the operation is usually necessary.
ExCEi'ii.\i.o('KLE. — Though eneephalocele, or meningo-
cele, of the orbit is extremely rare, it is important to bear
in mind the possibility of its occurrence. This is well
illustrated by a case described by Guersant (" .Alaladies
des Enfants," p. 246). The patient was examined by a
number cf the fellows of the Surgical Society of Paris,
who all agreed in considering the case one of vascular
tumor, and in advising treatment by setons. The pa-
tient died with cerebral symptoms, and a post-mortem
examination showed tliat the tumor conisisied of brain
substance, covered b_v membranes, which had passed
through the fronto-ethmoidal suture. It may be ex-
tremely difticidt to distinguisli such a tumor from a vas-
cular swelling, particularly as, if of considerable size, it
would be likely to pulsate; and, if situated behind the
ball, it would cause exophthalmus. Its congenital char-
acter should excite strong suspicion; it would be in-
creased in size bj' forced expiration and much diminished
by pressure. If the contained fluid, obtained by acu-
puncture, is found to be not coagidable, it is pi-obably
cerebrospinal. Other congenital defects would be likely
to occur in connection with it. In a case in which Oet-
tingen {Klin. MonaiAlntt, February, 1874) diagnosticated
a spheno-orbital meningocele associated with some angio-
matous tumor, there was also a small occipital meningo-
cele, which bulged out when the orbital tumor wns
pressed upon; and tapping the latter with the finger
communicated an impulse to the former. Even here,
however, the author could not feel quite sure of his diag-
nosis, and suggested the po.ssibility of a vascular tumor
communicating with the intracranial cavity by means of
absorption of the orliital wall.
TtlMORS OK THE Orbit. — Tlie remaining tumors of the
orbit maj' be classed as cystic and solid. The most
prominent ni/nijitDm, and one that, in greater or less tle-
gree, is necessarily constant when the tumor is situated
behind the ball, is exoiihthalmus, w hich will vary in ex-
tent and direction with the size, po.sition, and character
of the tumor. If the latter is situated outside the muscu-
lar pyramid, it will cause the ball to protrude in a direc-
tion opposite to its own position ; if within the pyramid,
it will press the eye more directly forward, and will par-
ticipate more in its movements. Diplojiia is a frequent
and sometimes an early symptom. The motion of the
ball is not necessarily affected by a small tumor, but is
limited by a large one; and, if this is outside of the mus-
cles, the limitation will be chietl}' in the direction of its
site. Com])lete immobility of the eye suggests malig-
nant growths, as their well-known tendency is to involve
and include the neighboring structures. Paraljsis of the
orbital muscles often causes squint, ptosis, etc., and com-
pression or stretching of the optic nerve may produei'
blindness in an otherwise sound eye; or. the nerve may
be involved in a luorbid growth. Injiiry to the ciliary
nerves may be sbo^vn by dilatation of the pupil, or may
result in sloughing of the cornea from neuroparalytic
keratitis. Finally, the eye maj' be destroyed by oph-
thalmitis resulting from interference with its nervous
and vascular supply. Pain is a very variable syuqitom.
being sometimes severe and sometimes absent. It is in
some cases referred to the })ottoni of the orbit, in some it
ajjpears as frontal or ciliary neuralgia, and in others as
general headache. The ophthalmoscopic apiiearances are
.sometimes negative, but often show simie signs of press-
ure upon the optic nerve, such as venous congestion and
arterial contraction, retinal hemorrhage, "choked disc,"
or optic atro])h3'.
Diagnosis between tumors of the orbit and periostitis
or phlegmon, vascular protrusion an<l disease of the
neighboriug cavities often presents serious difficulties.
The mode of onset of the disease, whether sudden or
slow, and whether accompanied or not by acute intlanmia-
tory .symptoms, is an important consideration, but will
not always be a safe guide in case of ebronic peiioslitis
or chronic abscess (p. 399). Vascular pi'otrusi(m mav' geu-
ei-all)' be distinguished by the fact tliat the ball can be
pressed back, by the effect of compression of the couunon
carotid, by the dilatation of vessels beyond the margin
of the orbit, and l)y the existence, in some cases, of pulsa-
tion and bruit. It must be remembeied that pulsation
and bruit have led to mistakes in eases of highly vascular
malignant growths. Careful inquiry should be made as
to predisposition to syphilis or malignant disease. Valu-
able information is obtained bj' careful exi)loration with
the finger pressed well back behind the bull. Os.seous
growths and solid tumors attached to the walls of the or-
bit, if not too deep in the cavity, can usually be distin-
guished in this way with a considerable degree of cer-
tainty, though perioslitis will sometimes simulate the
latter closely. An effort should be made to decide, by
palpation, whether the tumor is hard, elastic, or fluctuat-
ing, whether tixed or movable, and whether situated out-
side of or within the nuiscular pyramid. Eidargements
of the lachrymal gland, on account of their position, can
generally be recognized with comparative ease. It may
sometimes be necessary to dctermiiic th<' character of the
contents of a supposed cyst by puncture. The nasal
cavities and the vault of the pharynx should be explored
with the mirror.
Cystic Tumors. — The most common true retention
cysts fotmd in this locality are the sebaceous. They
probably arise from the skin, though their connection
with this ))oint of origin may not always be traceable.
■
^M
■
^M
1
kk. ^
s
^
^BR^tBBBPi.'
^1
T
•i
I
•f ■ ^
i'ir,. :i7li'J.— Conirenilal Cyst ol the Lower Eyelid witb Miorophthalmos.
Cysts of the lachrymal gland ("dacryops'') are rare.
They are due to retention of the tears "from obstruction
of the iducts. The swelling eidarges with increased se-
cretion of tears and its characli-r is not usually difticidt
to recognize.
405-
Oi-liil.
Oi'bll.
REFERENCE IIAXDI'.oolC OF THE MEDICAL SCIENCES.
DitopsY OP Tekon's CArsfi.K lias been describwl as a
fiinu (if exuilalion cyst, but its iiiitlidlogy is somewhat
(Icmlitful, and Its occurrence is, to say the least. e\-
trciiiely lai'c. S, runs ri/xlx have hi'cii attrilmted to dis-
FIG. 3710.— Orbltiil Sarccima.
ease of the bursa in the trochlea of the superior oblique
muscle, or of those sometimes found on the levator and
superior rectus; and WecUer considers it probable that
most serous orbital cysts arise in this way. This view is
probable, but lacks proof in ])athological anatomy. Con-
genital ikriiioid q/fts ai'c found more frenueiitly in tlw
orbit than elsewhere. It is generally stated that their
usual seat is near the external angular process of tlie
frontal bone, but of 51 cases collceled by Berlin 27 were
on the nasal side. 13 ou the temporal. 8 below, and 4
above. Tlieir walls are of a cutaneous structure, and
contain sebaceous matter and sometimes hair. Teeth
have also been found in theni. Weeker (if"!-. «7.)says
that serous cysts may form voluminous tumors, which
enlarge the orbit by excessive ]iressure, and extend
through foramina into the cranial cavity. He, however,
gives but one instance, quoted from Delpech. The cyst
was prolonged into the cranial cavity through the ojitic
foramen, which was sulliciently enlarged to admit the in-
dex linger. Inflammation of the sac, induced by incision
and exploration, extended to the brain and resulted in
death. It was found that a diverticulum of the cyst,
three inches long, had encroached upon the under surface
of the cerebral lobe, and had contracted firm adhesions
with the meninges. This case, which is also (inoted by
Mackenzie as one of hygroma, Berlin thiuU.s must have
been a meningocele. If serous tumors of very large size
have ever existed in the orbit, it is not likely that they
originated in diseased bursa', which are never known to
produce such tumors elsewhere, but it is more i)roI)able
that they were ci/nts of nein fitntintifn, similar to the so-
called hydrocele of the neck, who.se jiathology is not
well known. A rare form of cyst is tisually described as
"congenital orbital cyst with ano]jhtlialmos or microph-
thalmos." In a lew cases thi're has been entire ab-
sence of the eye. but generally there has been a rudimen-
tary ball. In the latter case the tumor ajipears beneath
the lower lid and is described as "lower-lid cyst." The
lower lid is bulged forward by an incompressible but
tensely fluctuating cyst, the bbnsh color of which is evi-
dent through the thin and distended skin. Fig. 3709
shows atypical example. Beliind Ihc cyst was a rudi-
mentary ball, hardly larger than a pea (Harlan, Trans.
Am. Oph. Society, 1«93 and 1903). The pathology of
these cysts is obscure, but it is generally beli<'ved "that
they are formed of embryonic elements intended for the
development of an eye. Iliematoma of the orbit has al-
ready been referred to in discussing hemorrhage. Echi-
iiiiciieci and cyntirevci have been found in the orbit.
Though some of the text-books refer to them as if not
very infie({uent. they are, in fact, extremely rare. Ber-
lin says that, with an ex|ierience of forty tliousand eye
patients, lie has not met with a single case of either, but
that thirty-nine more or less reliably reported cases of the
former are to be found in literature, while he has beenable
to find reports of only three rather doubtful ca.sesof cys-
ticerci in the orbit, though they are comparatively fre-
quent in the eyeball and its appendages. Furnaget has
collected eight cases. (Archiets of Oplithalinologij, xvi.,
p. (i.)
Solid Tumors. — As almost every form of tissue is rep-
resented in the orbital cavity, almost all kinds of tumors
arc possible there. In addition to tlie vascular and cys-
tic tumors referred to above, the following forms of more
solid growths have been described by authors: Lipoma,
tiliroma, enchondroma, carcinoma, osteoma, neuroma,
and sarcoma. A discvission of the histology and path-
ology of these various diseases is, of course, be\ond the
sc.ipe of the present article. Epithelioma may extend
into the orbit from the skin of the lids. Enchondroma
and carcinoma are very rare, and fibroma and iieiuciraa
not nuieh less so. Lipoma is frequently referred to in a
general way, but only a few cases have been recorded.
Osteoma is, comparatively siieaking, not very uncoiu-
nion. The larger proportion of solid tumors met with in
the orbit belong to .some of the numerous forms of sar-
coma. Berlin (luc. at.) says: "When we perceive in any
part of the orliit a Solid tumor with a nodulated surface,
which does not fluctuate or ])ul.sate, is not corapressil)le '
or stone-hard, is not in probable connection with tlie
brain, and does not arise from the lids, the ball, the
lachrymal gland, the optic nerve, or the neighboring
cavities, we may decide on the diagnosis that we have to
do with a sarcoma of the orbit."
Some of the most extensive growths that attack the
orliital tissue originate in the eyeball. By far the most
common inlra-iicular tumors are retinal glioma and chor-
oidal .sarcoma, and these, when they have once piassed the
fibrous envelope of the ball, extend rajiidly in the orbit.
The former generally ends fatally by direct extension to
the brain, or by metastasis to that or some other organ.
Orbital sarcomata sometimes grow to an enormous size
and make terrible ravtiges upon neighboring parts. Fig.
;j710 is from the photograph of a patient nine years of
a,ge at the Wills Eye Hospital. (Harlan, Trans. Am.
dph. Society, 1894.)'
Enliirgeiiierits of the Inchn/mal (/lititd may be due to
acute or chronic inflammation. In the ca.se of the former
there are redness and swelling of the upper lid. congestion
of theconjunctiva, and considerable pain. It frequently
ends in suppuration, which is sometimes followed by fis-
tula. In the chronic form the inflammation is usually
indolent, and the swelling may be mistaken for a ueo-
plasin.
Simide hypertrophy- of tlie lachrymal gland is rare.
It is said to result from repeated attacks of inflammation,
and to occur sometimes spontaneously or even congen-
itally. Exact ob.servations in regard to it are wanting.
Various forms of degeneration of the gland have been
met with, the most frequent of which, according to some
authorities, is the adenoid. There are a few well-estab-
lished ca.ses <if sarcoma and carcinoma. I exhibited a,
sarcomatous lachrymal gland as large as a hen's egg, at;
the meeting ni the American Ophthalmological Society,
in 1883, and Dr. Kuapji referred to one nearly as large,
which he had recentlj- removed. There were no adhe-
sions in either case and the tumors were easily enucleated.
The prognosis as to the probability of a return of tht,
disease is favorable. I
40(;
REFERENCE HANDBOOK OF THE MEDICAL SC'IENCES.
Orbit.
Orbit.
The position of such tumors malics their diagnosis com-
paratively easy. The ball is usuallj* forced downward,
forward, and inward ; but in the case referrctl to above
its direction was decidedly outward. This exceptional
symptom, wliieli is proliably unique, may be aceuunted
for by the unusual si/.eof tlie tumor audits develoiuuent
toward tlie inner side nt the orbit (Fig. 3711). The ball
resumed its normal position in a few weeks after the
operation.
T'imors of the optic iicn-e have been reported in thirl y
odd cases, and have consisted of glioma, myxoma, sar-
coma, endothelioma, and carcinoma. (Knapp, Trans.
Interuat. Med. Congress, 1876, Berlin, Graefe-Saemisch.)
Graefe reported several cases and gave the following
symptoms as diagnostic : Progressive protrusion of the
eyeball, parallel to the axis of the orbit, or a little out-
Avard ; preservation of the mobility of the e3'e ; pn.'serva-
tion of a layer of connective tissue between the eye and
the tumor, and the integrity of the centre of rotation:
soft consistence of the tumor; absence of pain; absence
of subjective luminous sensations, and rapid abolition of
vision. In some eases more recently reported there was
more loss of mobility of the ball than von Graefe seems
to have met with, and in several there was .severe pain in
the eye and orbit, and the timiors have not always been
of soft consistence. Valuable assistance in diagnosis can
be obtained by palpation — pressing the finger deep into
the orbit behind the ball.
thtcoinata nuij' grow imniediatelj' from the diplog of
the bone, or originate in intlammafor)' exudations from
the periosteum. In the fcirmer case the}' are likely to
extend at the same time into the orbit and into one of the
neighboring cavities. They var}' in size from a mere
nodule to a mass tilling the whole orbit, and may be of
cancellous structure or of ivory-like density. The latter
is much the more connnon form. They have, in a few
cases, occurred in both orbits at the same time. The eti-
ology of orbital osteoma is very obscure. Syphilis, which
might naturally be thought a freiiuent cau.se, is an ex-
tremely rare and even duubtful one. Bonj' tumors of
the orbit are of slow growth, and are injurious only by
their mechanical effects, which, however, are sometimes
serious enough. A few cases are reported in which a
cure resulted frotn necrosis and spontaneous separation.
(Lediard, Trans. Oph. Soe. United Kingdom, iii., p. 23.)
In the reiiHn-dl of urhitid tiniiors antiseptic precautions
.should be carefully carried out. If there is useful vis-
ion, or even a sound eye, the eyeball should be preserved
whenever possible, unless its retention renders imprac-
ticable the thorough removal of tissues involved in malig-
nant disease. It will usually be pos.sible to retain the
ball when the growth is outside the intramuscular space,
and sometimes even when it is within it. This has been
done, with satisfactory results, in the case of tumors of
the optic nerve, b}' Knapp and T)}- Grlining. (Arch. ofOpli-
thal., iv., p. 323, and v., p. .508.) To avoid the deform-
ity of the resulting cicatrix, it is usually better, wlien
practicable, to operate through the conjunctiva, and this
will, of course, be necessary in the case of tumors with-
in the muscular space. To gain room, the external can-
thus may be freely incised, the upper lid may be dis-
sected back, or the external wall of the orbit may be
temporarily resected, and replaced after the removal of
the tumor, by the methoil devised by Kronlein. (Knajip
in Norris and Oliver's "System of Diseases of the Eye."
viii., p. 918.) In removing tumors situated well forward
or attached to the orbital walls, or of large size, it may
be necessary to make the incision through the skin of the
lid. The handle of the knife will often be found of more
use than its edge in fi'eeing the growth from its attach-
ments, and much of the operation can most conveniently
be performed with a strong pair of blunt-pointed scis-
sors, curved on the flat. Extensive malignant disease
sometimes necessitates the removal of all the contents of
the orbit, and the application of the chloride of zinc paste
fo its bared walls. Though such cases are extremel_y dis-
couraging, in a few that were aiiparently desperate the
operation has succeeded at least in securing some vears
of comfort to the patient. According to Bull, surgical
interference in malignant orbital tumors is almost in va-
riably' followed by recurrence, the growth of the second-
arj' tumor is more rapid, and repeated operations shorten
the life of the patient. (Tr;ins. Am. Oph. Society, 1800.)
It may be necessary to resort to the actual cautery to
check "hemorrhage, though this can usually be accom-
|ili.shed by hot water and compression. AVhen extension
of the disease to neighboring cavities renders its complete
removal impracticable, the operation should never be
undertaken. Exostoses may be removed with compar-
ative safety when situated on the flofu' or on the inner wall
of the orbit, but the attem]it is rarely justifiable when the
deeper parts of the roof are involved. Of sixteen cases
collected by Berlin, in which exostoses of the orbital roof
were operated on, in six the patients died of meningitis.
Knapp reports several cases in which osteomata of the
roof, situated peripherally, were successfully removed.
(Trans. Fifth Internat. Oph. Congress.) It has occa-
sionally been found possible to cut these bony tumors
with the pliers or to wrencli them from their bases with
the forceps, but usually the chisel and mallet will be
found more efficient. The use of the dental engine has
been suggested and may be applicable to some cases.
The attachment of the base to the orbital wall is less firm
than the structure of the tumor, and in operating this
should be made the point of attack. The dilHculties of
the operation are greatly increased when the growth
originates in the diploP and extends on both sides of the
bone. Knapp (Arch, vf Ojih.. ix., p. 4ti4) describes a
method of shelling out such tumors within their perios-
teal envelope, by cutting, with the chisel, the orbital
wall encasing them and removing them entire. He
thinks the operation maybe performed with success even
though the exostosis project into the cranial cavity.
iN.ruisiEs OP THE OitniT derive their greatest interest
and importance from the fact that only a thin plate of
bone se]iarates this cavity from the brain. Punctured
wounds of the roof of the orbit may very easily pene-
trate the intracranial cavity. Such injuries were for-
merly sometimes inflicted by the sword, while in more
modern times the umbrella-stick has figured most promi-
FiQ. 3711.— Sarcoma
lirymal Glami.
neutly as the offending instrument. These, of course,
are very fatal wounds. Out of fifty-two cases of perfo-
ration collected by Berlin (Graefe-Saemisch, vol. vi.) the
patients survived in only eleven, and of these five suffered
from subsequent effects. Great caution should be used
407
Orbil.
Org:auutiiei*apy.
KEFKKK.NCE aA>.'UBOUK OF THE ilEURAL SCIENCES.
ill tile tn'iiliiiL'iit iiud piMj;iii)sis of sucli casus, us IIr' sur-
gx'dii is liable to be misled liy llie iiiiKieent iiiipearauee of
the e.xtei-ual woiiiid and I he absence ol' iiiiiiiediate syni])
toms of an alaiinin>;chaiacler. Mackenzie iclates several
cases in which the palienls walked considerable distances
after leceiviug the injury and then fell dead.
The result of -.i i/iui.s/iiit irmiKil of the o:;jit will ilepend
upon the direction that the ball takes, hi a large pro-
portion of cases the brain is injured and death ensues;
but a liall pa.ssin.ir obliquely through the temporal region
may di'stroy one eye (Jiily. and cases are reported in
which sight was entirely "destroyed, without other in-
jury, by balls crashing through both orbits behind the
eye's. I met with one' such case, during the civil war. in
which very little deformity resulted, and the external
appearance of the eyes was not affected.
Fractures of the base of the cranium fre<iu(nitly extend
into tlie walls of the orbit, generally the roof. In the
post-mortem examination of eighty-six cases of fracture
of the base, von Holden found" fracture of the orbit in
seventy-nine. (Berlin, lac. fit.) Blindness may result
immediately from rupture of the optic nerve, or from
liemorrhage in its sheath, or it may be subsequently in-
duced by "neuritis. Intracranial hemorrliage and hemor-
rhage and eniphy,sema of tlie orbil, as results of fracture
of the orbital wall.s, have already been referred to.
It is important to rememlier that fiii'iiijn hodiia. even
of considerable size, may easily escape detection in the
orbit. A numlier of striking instances of this have been
recorded. Mr. Carter has reiiorted a ease in which a piece
of iron hat-peg, nearly three inches and a half long, le-
mained concealed in the orbit for ,seveial weeks, without
the knowledge (d' the patient. It was removed, and the
eye remained uninjured. Heniien found a tlatteiied
musket ball which had lodged in the orbit, without in-
jury to the eye. Shot from fowling-pieces and chips of
iron driven with Sorrv, by the liammeror lathe sometimes
pa.ss through the ball and lodge in the orbit. Shot may
become encysteil and cause no irritation, and even larger
anil rough substances may give little indication of their
presence. A man presented himself at the Wills IIos[ii-
tal, in Philadelphia, with a wound near the corneo.scle-
rolic junction, but he was very positive that the foreign
body that inflicted it had rebounded. The eye was but
slightly inllamed, and the patient continued to improve
and would have been ilischarged if a little .sympatlietic
irritation of tlie other eye had not been noticed. In enu-
cleating the ball gri'at difficulty was experienced in cut-
ting the optic nerve, and a splinter of iron, one inch
long, was founil lying by its side.
.r-Ray examination may be made useful in detecting
the presence of a foreign body ami even in deterinining
its location.
Cases were formerly reported in which impaired vision
was attributed to injury of the supra-orbilal or infra
orbital nerve by blows upon the edgi! of the orbit, but it
is ])robable that the ophthalmoscope would have revealed
some infra-ocular lesion produced by concussion, or that
a fracture involving tlu^ apex of the orbit may have in-
jured the optic nerve. Confusion of these nerves is not
now recogriized as a cause of amblyopia.
Dtxlontliii/i iif the ii/iball may l)e caused Ijy a foreign
boilv thrust into the orbit behind it. It has fri'ipicnlly
been produced b}' the " gouging '' thumbs of brutal tiglit-
er.s. The ball lies, upon the malar bone and the orbicu-
laris muscle contracts behind it, retaining it beyond the
lids. The optic nerve is, of course, violently stretched,
but is not usually permanently injured if the dislocation
is soon I'educed.
In the (niitiiiiiit of injuries of the orbit it is important
to bear in mind the dangerous character of its anatomical
relations, and the serious mischief that may easily be in-
flicted by jirobing. It is better to treat many trivial
cases with unnecessary caution than to underestimate the
danger of one that may have a serious or even fatal
termination. C'omplete rest, cold applications, and sonie-
tinies leeching will be required in the early stages, and if
pus forms subse(|Uemly it should be alloweil prompt and
free escape. If incisions are necessary for tlie remova.
of foreign bodies, they should be made through the con-
junctiva rather than through the lids, to avoid the dan-
ger of ectropium or other deformity that might follow
the contraction of cicatrices. In reducing dislocation ot
the eyeball, the upper lid should be stretched and drawn
forward, while the ball is gently pressed back. It may
be necessary to divide the external conimissuie, A com-
press bandage will be required to retain the eye in posi-
tion for a few days.
DisE.\sEs OP THE NEKimsoRiNG SiNUSES may seriously
affect the oi'bit by pressure upon its walls or by extension
into its cavity.
The //■(;(/ A)i s/iiiix is sometimes greatly distended liv
the accumulation of retained muco-imruleut secretion in
chronic intiamination of its lining membrane. The iqi-
per and inner wall id' the orbit is bulged by pressure, and
the eyeball is forced downward and outward. These ac-
cumulations are sometimes very extensive, and involvi-
the etlinioi<l sinus or the frontal sinus of the other sidi-
by destruction of the intervening walls. Dr. Bull
(Trans. Am. 0|)li. Soc. , 1SS.5) rejiorts a case of chronic
abscess involving both frontal sinuses and the ethmoid
sinus of one side, the result of an injury received foui-
teen years before. The disease may also result from di-
rect extension of inflammation from the mucous mem-
brane of the no.se. The pus may tinall)' escape into the
nose, into the orbit, or externally, but the opening that
gives it exit is not likely to be free enough to lead to a
cure. The most conimon localit.v for spontaneous tlis-
charge is nl the inner canthus, above the tendo oculi, and
a iiermaneiit fistula is likely to result. When the boiK
over the swelling is very much thinned by distention and
absorption it yields to ].iressure by the finger with a kind
of crackling sensation, which has been well com|iared ti
that produced by pressure upon the lid id' a tin box, and
which will distinguish the case from one of solid growth.
The sinus should be freely opened with a strong knife,
or, if necessary, with a drill, near the inner canthus or
beneath the sujierciliary arch, and a .silver tube inserted,
through which the cavity can be washed out frequently
with disinfectant and stimulating solutions. It may ))■
necessary to o|ien the cells through the inner wall of the
orbit, remove all carious bone, and establish drainage
through the nose.
vSimilar distention of the /im.n'l/n/'// iintnihi by lluid ac-
cumulation forces the floor of the orbit upward. It may
result from any causetluit produces chronic inflammation
of the lining niembraue of the cavity, but the most fre-
quent Ciiuse is a diseased tooth. Pus may escape into the
nostril, through the alveolus at the canine fossa, or intii
the orbit. Wlien it eulers the orbit it causes an infiltra-
tion iUid swelling of the lower eyelid, iind finally a fis-
t\da. When there is a diseased tooth, the best plan of
treatment is to extract it and puncture the antrum
through its socket; or, if the abscess points in the al-
veolar process, an opening may be made behind the up-
per lip. in either case a tube shoidd In- inserted and
injections used.
A few cases of retention tumor of the i lliinnid rrllfi have
been met with. Dr. Kna|qi(Traiis. Fifth Internat. Oph.
Cong.) re|iorts one in which the wall felt .so dense tliat
he took it fin- an exostosis and |n-oceeded to remove it.
wdieu the chisel iderced a bony shell, and a quantity of
muco-]iundent discharge escaped. And a similar experi-
ence occurred in my own practice (Trans. Am. Oph. Soc..
1900).
Cj'sts. polyjii, or solid tumors of any of these cavities,
or of the nares, may press upon the walls of the orbit or
destroy them and e.\tenil into its cavity. A discussion
of all of these diseases would lead into too wide a field
for the limits of this article, and the reader must be re-
ferred to works on general surgery and to the elaborate
chapter on this subject in Mackenzie's treatise on "Di.s-
eases of the Eye." Intracranial growths sometimes in-
volve the roof of the orbit, and in chronic hydrocephalus
its cavity is narrowed by pressure, and the eyeball is
pushed forward. Geair/e (J. Harhni.
408
KEFEKENCK HANDBOOK OF THE MEDICAL SCIENCES.
Oi'bil.
Orgauotlierapy.
OREXIN. — (PliiMiyl-di-liydiu-qiiiuazoluic liydroelilo-
latr. ) 'I'lii^ is the trade uuiiie applied to a complex deriv-
ative uf ciuiui'liue. It forms in bright, colorless, lauc(u)-
late crystals, without odor, containing two molecules of
water, wliieli effloresce on exposure. It Las a bitter, pun-
gent, and almost caustic taste. It is freely soluble in hot
\vater. It is almost free from to.xic effects, as two grains
per pound weight were insufficient to cause death in a
rabbit.
(Jre.xin was introduced by Piofossor Penzoldt, of Er
langcu {I'licfdp. Miiitiit., February, 1890), as a stomachic,
as it was found to exert a tonic influence over the diges-
tive organs, and a stimulant action on the appetite. It
pos.sesses neither antipyretic nor antiseptic properties.
Penzoldt used it in a great uund.ier of ca.ses of anorexia
in liealthy individuals, as well as in others sutt'ering from
various diseases accompanied by loss of appetite. Its
use is contraiudicated Avlicn there are gastralgia, acute
catarrh, ulcers, or any condition in which there is h}'per-
seusibilit}' of the mucous lining of the stomach, on ac-
count of its local irritant action. The class of cases in
which it proved mo.st serviceable were those in which the
stomach w as not diseased, but in which the loss of appe-
tite was due to some general condition, such as anainiia,
phthisis, or debility. It was said to be of spet'ial value
in commencing pulmonary tubercidosis, its employment
being followed by a considerable increase in body weight.
The dose is from three to seven grains, once or twice a
day. Within the last few years the taiinatc of this agent
has been brought forward as being superior to the hydro-
chlorate. It is a yellowish-white, odorless, and almost
tasteless powder, solnl)le in water.
Although favorable reports of its use appear from time
to time, it has failed to gain the confidence of the profes-
sion and is rarely employed. Beaumont Small.
ORGANOTHERAPY. — (Synonyms: Ilistotherapy—
from 'oror, lissur; cytotherapy — from /irnir. cell).
History. — The oldest medical manuscri])t in existence.
the " Papyrus Ebers." mentions the use of animal extracts
in medicine. Among the writers of antiquit3' Homer,
Democritus (450 B.C.), Areta'us, Dioscorides, Galen (600
A.D.). among writersof the Middle Ages, Guido de Chan-
liac (1300 A.i). ), John Hunter, Burton (in his " Anatomy of
Melancholy ") all speak of the treatment of disease with
various animal products. It is interesting to iidle some
of the bizarre preparations that were recommended, e.ff.
(Dr. William Salomon, "New London Dispensatory,"
1677), human heart, cor hoiiniii.s, in powder for epilepsy,
human skull and human Inain, tinrtnni ennui, (.i.tentin
cranii hominis, spiritv.t eenhri Jnuixiiit, for a variety of
disorders, chicHy "debility."
Brown-Sequard. in 1869. advanced the hypothesis of
the "internal secretion "of the glands and tissues; he
held that all the cells of the body maimfacture specilic
soluble prodncts which, entering the blood, exercise "an
important if not necessary " influence on other cells.
Insufficiency of this function in certain organs, he argued,
produces certain definite disorders that can best Ije reme-
died bj' .supplying the deficient secretion. The extrava-
gant and sensational claims advanced by over-enthusiastic
disciples of this " method " have done much to discredit
<->rganotherapy. Of recent years, however, many clinical
and experimental data liave accumulated to show that
certain organs actually do maiuifacture internal secre
tious, and tljat these products profoundly influence me-
tabolism. The postulates of Brown-Sequard were in
part, therefore, correct and his method was not altogether
irrational.
It is manifestly a ])recarious and an uuscientiSc proce-
dure to introduce substances of ludvuown properties into
a sick organism without first determining tlieir effect on
the healthy body. Before organotherapy could be raised
above the level of crude empiricism and could attain the
dignity of a rational system of treatment, the power of
organ extracts to influence physiological processes had to
be studied. This inoblem was approached in two ways,
viz. : on the oni- hand, different animal preparations were
administered to normal animals m- human subjects and
the effects determined; on the other hand, diltcrent or-
gans (chiefly ductless glands) were removed and the per-
versions of function that followed established The
knowledge, moreover, obtained from operative ablation
of organs was in many instances suppleiuented by clini-
cal observations on human subjects in whom sjiontaneous
degeneration or atrophy of these organs had occurred.
In this way a fund of knowledge was acquired that based
organotherapy on a rational fotuidatiou. and furnished
concise iudicafions for the administration of definite or-
gan preparations in definite diseased states. Organo-
therapy was finally rendered still more exact by the dis-
covery and isolation of " active principles " that possessed
all the specific properties of the organs from which they
were derived; these, it was shown, coidd be advantage
ously administered in the place of the crude extracts, of
indefinite and uncertaiu composition, that were formerh-
employed.
I. The Ductless Glands.
1. Thyroid Gi.and. — The admiDistnition of iht/imd
,'/kiiu! in large doses accelerates proteid and fat metabo-
lism, causes increased elimination of nitrogen, phospho-
rus, and chlorine, and leads to an increased alisorption of
oxygen. Clinically, polyuria, polyphagia, polydypsia.
sweating, tachycardia, jialpifation, tremor, emaciation,
fever, and occasionally glycosuria are observed. This
sj'ndrome is called llii/roidisni. and has so many cardinal
features in common with exophthalmic goitre (Basedow's,
Graves' disease) that this affection is held by many to be
due to excessive activity of the thyroid gland, scil., hy-
pefthyroklism.
Iteiiioeal of (he thyroid gland is followed in a few days
or often after a longer time (as late as nine months) by
antemia and oligsvmia (eaehc.ria thyreupriea, if the nor-
mal gland is removed, carhe.ria, utrumiprim or operutite
niy.emdenia if the diseased gland is removed); there is
often an initial rise of temperature usuallj" followed by
a descent to subnormal; the growth of the bones is re-
tarded in young animals, and various trophic disturb-
ances develop; the rate of respiration increases; a va-
riety of nervous phenomena are observed that maj' be
either irritative or depressi\'e in character, viz. : at first
fibrillary twitchings of the muscles followed later by
tetany and contractures, or again paresis and diminished
•sensibilit}'. Other .symptoms are palpitation, tachycar-
dia, vomiting, loss of mental vigor, irritability followed
by languor and lassitude, apathy, and finally idiocy.
A similar syndrome is presented in uiyxoedema ami
cretinism (synonyms: infantile or foetal myxcedenia.
myxcedematous idiotism); my.xu'deina is undoubtedly
due to arrest or insuflicienc}' of thyroid function, .'<e:il..
atliyroidinnt. We witness the same arrest of development
of liones and external soft parts, the imjiairment of ii.S3'chie
and of nearly all somatic functions. The infantile type
is maintained throughout, the physiognomy is typical,
there are characteristic disturbances of the organs of
sense and of the infelk^ct, the skin is bloated, the sweat
glands are depressed, the heat regulation is disturbed.
There are general muscular quiescence, apath.y. and idiot-
ism. Exact metabolic studies have so far not been maile.-
In one case the oxygen absorption was found subnormal
and the nitrogen excretion reduced. If is prolialile that
metabolism becomes retarded after ablation or atrophy
of the thyroid gland.
The function of (he thyroid is either mitritive or anti-
toxic, i.e., it either supplies soiuething to the blood that
is necessary to uoriual life or it removes something that
is harmful. The most [dausible theory advanced to ex-
plain hyperthyroidism and athyroidism is the following:
The blood normally contains certain bodies that can in-
hibit metabolism; the origin of these bodies is obscure;
the thyroid secretion possesses the power of neutralizing
these substances and rendering them inert. Normally
metabolism is regulated in this way. Hyperthyroidism
causes complete netifralization of these inhibitory sub-
40!l
Or^'aii4>tlirra|»> .
Organodierapj.
UEFEKENCE HANDBOOK OF THE MEDICAL SCIENCES.
stances followL'il by acceleration of metabolism: atliy-
roidism, on the other hand, by permittintc the accumu-
lation of excessive quantities of tlie inliibitory bodies,
favors retardation of metabolism.
The aclire priiiciph: of tie thi/i-niil <ihiu(l is tbyroidiu
(iodothyrin). a proteid bod}' coiitainiiijr over nine per
cent, of iodine. Removal of tlie iodine renders this sub-
stance inert. lodoihyriu administered to healthy animals
l)roduces the same effects as fresli thyroid gland or thy-
roid extracts. When administered immediately after ab-
lati<m of the thyroid it is capable of arresting the convul-
sions that frequently follow this operation. The action
of iodothyrin is euinulative, but oidy of short duration.
In order "to do good it must be administered continu-
ously. When iodothyrin is given to dethyroidized ani-
mals all the iodine appears in f lie urine in a short time and
is wasted. In animals with a thyroid the bulk of the io-
dine is retained. The thyroid, therefore, seems to be con-
cerned in arresting and preserving the valuable iodine
that is ingested witli the food and that is intended to
jilay some physiological role.
It appears, from experiment.al investigation, that the
iodine body of the thyroid is an indispensiible regidator
of oxidation, and is also needed to preserve the normal
function of the brain and nervous system and pos.sibly of
other organs. The "colloid sub.stance " of the thyroid
that was long believed to be the active ingredient of the
gland has been shown to contain an organic iodine com-
jiound, probably iodothyrin.
Various iirepurirtiniis nfthijriiid y!/nid are in use in medi-
cine. Bircher in 1SS9 implanted a piece of thyroid gland
under the skin. Later different extracts were prepared
with glycerin alone, or with glycerin and carbolic acid
or thymol. These extracts were administered hypoder-
nncaily. The French favor fluid extracts made with
carbolized physiological salt solution sterilized under
pressure with carbonic acid gas and pressed through
clay candle lilters; this extract, too, is used for hypoder-
mic injections. Vermehren precipitates the .glycerin ex-
tract of thyroid with alcohol, gathers the sediment, des-
iccates it, and administers it in pill form (Vermehren's
thyreoidiniini). Jlauj- clinicians give the fresh gland
raw bj' month; some boil the gland to make it more
]ialatable, and claim equally good results as from the
raw (}rgan.
Still others give clysmata of thyroid gland. The mt)St
jiopular preparations nowadays are compressed thyroid
tablets made from the desiccated gland. These are less
disagreeable to the patient, and if prepared b_y a reliable
bouse enable the pliysician accuratel}' to determine the
dose. True, very little is known of the amount of active
principle wliicb they contain, but the same objection ap-
jdies to all the other iireparations. As it is essential to
individualize in tbymid medicatinu, it is at all events of
advantage to know that the qualitative and quantitative
composition of the tablets is approximately uniform.
For the many methods in use for preparing dry thyroid
extracts and tablets we I'eter to text-books of pharma-
cology.
The dose to be administered naturally depends on the
preparation emjiloyed. ^Many subjectsnianifest an idio-
.syncrasy for thyroid products, so tliat it is always well
to begin with very small do.ses and carefully to watcli
for symptoms of lliy roidism (see above). Dried thyroid
powders frequently contain ].itomains and peptonized
proteids that are toxic; the_v may conseq\iently give rise
to additional untoward symptoms. The best guide is
the pulse. Quickening of the heart beat and palpitation
should lead us to stop the administration of the drug un-
til the heart action becomes normal. Gastricdisturbances
or rapid loss of flesh should al.so put us on our guaril.
Occasionally a change of preparation or a different mode
of administration will enable the patient to tolerate the
drug, but it is usually best either to stoii its exhibition,
or at least materially to diminish the dose.
The fresh gland furnishes about twenty-seven per cent,
of ilry powder, so that each unit of powder corresponds
to about four times its equivalent in fresh gland. Manu-
factui'crs of thyroid tablets always indicate the amount
of thyroid powder contained in each tablet. Beginning
with a fraction of a tablet a day the dose may be grad-
ually increased to seven or eight tablets in the twenty-
four hoirrs. Of the raw gland one-eighth to two may be
given in the course of a day. The common dose of the
desiccated powtlcr is from one to five grains three times
a day.
TheriipeuHc.s. — Thyroid preparations are employed
most successfully in all those diseases which are due to in-
sufiiciencj- of thyroid function, viz., infantile myxoedema
{e ret hi ism), operative mj"xa'dema (rneJicria sirvmipriva),
and adult (sporiidir) hiiixiyileiiiii. Thyroid treatment in
these states is a true substitution therap.v.
In all forms of myxadema thj'roid medication as a rule
produces amelioration of all the symptoms; in a nnnoritv
of the cases only the main symptoms are relieved, while
the minor and probably secondary manifestations per-
sist. In adult myxcedema, for example, the swelling
may recede while the anaunia persists. In cretinism the
results are particularly brilliant. The skin becomes soft
and moist, the bloating di.sappcars. the physiognomy
clianges, healthy growth of the bony structures and of
the soft tissues is sliuiulated, normal development of the
teeth sets in, and the mental condition improves.
The younger the subject the better apparently the re-
sult, although all ages seem to react favorably. A case
is on record, for instance, of a woman of seventy-two
years who had been a sufferer from mj-xa'dema for
twenty-six years, and who was completely cured in three
months. Some authors maintain that the older the dis-
ease the more rapidly does it yield to thyroid tlierapy.
The sex of the patient is without influence. Each indi-
vidual seems to react ditt'erently.
In a very small proportion of cases tliyroirl treatment
is willR.ut result, and one or two cases are on record in
which the disease was aggravated. The unsuccessful
cases constitute not quite two per cent, of all the cases
reported in the literature. As it is not excluded that in
some of these instances the thyroid preparation employed
was worthless, this is a remarkably good showing, and
one that warrants the use of thyroid, with the precau-
ti<ins outlined above, in all cases of m3-xoedematous dis-
ease.
Thyroid preparations have also been employed in a
large number of other diseases; the indications for the
exhibition of thyroid being based either on our knowl-
edge of its i)hys!ological effect or, in many instances, on
pure speculation. In .some diseased states the results ob-
tained have been sulliciently favorable to warrant record-
ing.
As trophic disturbances of the skin are common in
sporadic and operative niyx(C(lema, thyroid preparations
have been used in the treatment of many skin diseases.
The best results have been obtained in psoriasis. The
sphere of usefulness in this disease is, however, limited,
and thyroid should be employed as a last resort, only
after all other standard remedies and measures have
failed. In lupus, cutaneous tuberculosis, lepro.sy, ke-
loid, alopecia, eczema vulgaris, acne rosacea, ichthyosis,
thyroid has also been tried with varying effect. The
results are often negative and uncertain throughout.
Scleroderma does not yield to thyroid therapj-. It is
probable that thyroid gland acts favorably in some cu-
taneous affections by stimulating the circulation of the
skin. Improved vascidar supply leads to improved nu-
trition, increased activity of the cutaneous glands, and
increased vitality of the epidermal laj'er, all tendencies
that must act benelicially in correcting the trophic per-
versions that form the basis of many skin lesions. Thy-
roid preparations, either in the form of the dry powder
or as an ointment, have also been applied locally to ser-
pigim/us iilrers. suppurating buboes, syphilitic and soft
e/iaiiere,^. Good results are claimed for this method.
Loss of weight is a common rcsidt of thyroid medica-
tion. This observation has led to the employment of
thj-roid glaiul for the reduction of ijhe.iitij. A loss of fat
undoubtedly can be brought about in the majority of
410
REFERENCE IIANDROOK OF THE MEDICAL SCIEXCEt^
<^r^ii no I lM-i'a|»y,
Oi*;''auoIlkcra|>y.
cases. PiUit'iits witli antemic obesity are more suitable
for thyroid therapy than patients witli pletlioric obesity.
In the latter tlie resvilts are as a rule inililTereut ; in the
former oxidation is increased, as shown by the increased
amount of o.xj'gen tliat is absorbed and the greater
amount of carbon dio.xide that is eliminated. Together
■with the fat some pmteid is, however, always lost in
these cases, so that fmni this point of view alone thyroid
medication is to be condemned in the treatment of obesity.
As obesitj', moreover, is frequently comijlieated by vari-
ous cardiac disoiders, gout, diabetes, and kidney lesions
(all conditions in which thyroid preparations may do
harm), this therai)y is dangerous also ou these grounds.
It must further be remembered that as soon as the
a<!ministralion of thyroid gland is discontinued the fat
returns; consequently the drug must be taken contin-
uously. This leads to the indiscriminate use of thyroid
I)reparations by the laity, a procedtue that is mani-
festly dangerous. Finally, the exhibition of thyroid is
totally unnecessary in obesitj', for correct dietetic treat-
ment produces results that are cfiually favorable, more
constant, more permanent, and not at all dangerous. In
carefully selected cases which are rigorously supervised
by the physician small doses of thyroid, together with
rational dietary regulations, produce satisfactory results
and may be permitted.
In insaniti/ the results of thyroid therapy are not con-
stant; some cases are strikinglj- benefited, others are not
affected at all. It is probable that in many sufferers
from melancholia, recurrent mania, delusional insanity,
-and the insanities of adolescence, the climacterium, and
the puerperiura there is at the same time some derange-
ment of thyroid function, and that these cases preciseTv.
and possibly these cases alone, derive benefit from the
use of thyroid preparations. The insanities of myxcpdc-
ma, needless to say, often improve under thyroid medica-
tion. The largest statistics on the subject show that of
1.08i such cases 16.8 per cent, recovered, 24 per cent,
were improved, and 59.3 per cent, remained unimproved.
The results, therefore, in this particular form of mental
derangement are fairly good.
Because infantile myxu?dema and radiitis are Ijoth
characterized by disturbances of the bony development
thyroid medication has been employed in the latter dis-
ease. The relation between the two diseases is, however,
purely superficial and their pathogenesis radically differ-
ent, so that we need not be surprised to learn that thyroid
therapy has led to absolutely negative results in rickets.
There is a superficial resemblance between acromegoh/
and myxcedema, and in some cases of acromegaly the
thyroid has been found degenerated or atrophied. Some
experiments are also on record that seem to show that the
pituitary body hypertrophies after removal of the thy-
roid. These observations have led to the employment of
thyroid in acromegaly. The results of this treatment are
not satisfactory. A few isolated cases are on record,
however, in which thyroid medication seemed to do good
after all other measures, including the exhibition of jii-
tuitary extract, had failed. The method deserves fur-
tlier tiial.
Simple goitre often yields to thyroid treatment. Some
statisticians report improvement in two-thirds of the
cases. Yoinig persons, it is claimed, arc more benefited
than older subjects. It is necessary to continue the ad-
ministration of the remedy for a long time, as otherwise
the goitre is liable to return. The swelling rarely if ever
disappears completely. The treatment must be consid-
ered symptomatic and in no case curative. The treat-
ment is useless in goitre that has undergone secondary
degeneration (colloid, cystic). The simple parenchyma-
tous form is the most suitable for treatment with thyroid
gland. Of 60 cases of the latter kind 14 were cured, 29
improved, and 19 not benefited. One author reports im-
provement in all of a series of 79 cases, another one im-
provement in 92 per cent, of a large series of cases.
The treatment of Basedow's Disease (exophthalmic goi-
tre) with th3-roid preparations seems altogether paradoxi-
cal, for, as we have seen, the cardinal symptoms of this
disease are actually produced by the adminisiraiion of
thyroid. To expect a cure would be to avow faith in the
homoeopathic " law " of similars. Xevertheless tin- rem-
edy has been extensively euqiloyed in this disease either
empirically or from ignorance of the physiologic action
of the thyroid extract, and finally on the basis of various
hypotheses that are not worth recording. The consensus
of opinions, as was to be expected, is that thyroid has a
tendency to do harm in this disease. In many instances
no effect was noticed when small doses weregiven. A
few cases of improvement are also reported, chiefly by
American and French authors, but the case reports (which
have been carefully studied by the author) do not show
that the amelioration of symptoms covdd in any way be
attributed to the action of the fh_yroi<l preparations given.
In exophthalmic goitre, therefore, the use of thj'roid
should be discouraged as useless.
A more rational method of treating Basedow's disease
has recently been tried, apparently with good results.
It consists in injecting the serum of dogs whose thyroid
has been removed. This method is at least based on
sound physiologic reasoning. It warrants further trial,
for of the nine cases treated all improved.
Thyroid preparations have at one time or another been
fried in nearly every known disease. Benefits have been
claimed in tetany, the various disorders of lactation
(galactagogue action), certain middle-ear disorders, mus-
cular and osseous dystrophies, hemorrhages in uterine
diseases, cancer of the breast, and .syphilis. Very little
value, however, attaches to isolated case reports," for in
the majority of them grave sources of error are not ex-
eluded, and no conservative judgment in regard to the
therapeutic value of the thyroid preparations adminis-
tered can be rendered.
2. The Sn»R.\HENALGL.\XDS. — Injectiou of suprarenal
cxti-act produces a very marked rise of blood pressure.
This is primarily due to vaso-constrictoracfion, for supra-
renal extract exercises its chief effect on the peripheral
circidatorj- apparatus. This is made manifest after sec-
tion of the medulla or the cord (even complete removal
of the cord), section of the vagi, of peripheral nerves, or
paralysis of the nervous end apparatus with atropine, for
all these operations d(.) not hinder the rise in blood press-
ure after injection of suprarenal extract. Direct appli-
cation, moreover, to mucous surfaces causes rapid con-
traction of the blood-vessels of the part. It is not
established whether suprarenal extract acts directly on
the muscle cells of the arterial muscularis or ou the gan-
glion apparatus of the vessel walls. Suprarenal extract
also acts directly on the heart, causing retardation and
strengthening of the heart beat, and in this way, too, a
rise in blood pressure. It seems tliat the extract directly
stimulates the heart muscle and at the same time irritates
the vagus centre. The former action strengthens the
heart beat, the latter retards it. If the medidla is de-
stroyed or the vagus severed, the heart lieat is greatly
accelerated after the exhibition of suju-arenal extract,
more so than after simple section of the vagi. Applied
to the excised heart of a frog suprarenal extract also
causes cjuicker and more forcible contractions. The <li-
nvt effect of the extract on the heart muscle is accelerat-
ing, in other words, excitory, as in the case of the arterial
muscidaris.
Other effects that follow the injection of suprarenal
extract are: (1) The excretion of dextros<' (suprarenal
glycosuria); (2) local pigmentation around the point of
injection; (3) destruction of red blood corpuscles and de-
posit of haemosiderin in the spleen and lymph glands; (4)
excretion of pigments relatetl to bile pigments.
T!£ moral of the suprarenal glands, a very diflictdt oper-
ation, is invariably followed by the death of the animal.
If one gland alone is removed or if accessory adrenals are
left behind, compensatory hypertrophy of the remaining
organ occurs and the animal may survive for months or
even years.
The statements made by different authors in regard to
the effect of removal of tlie adrenals on general nutrition
are conrfadictory. The same applies to the effect on the
411
Or<^aii4»lli4'rsi|>)'.
Ortrauotlierup)-,
REFERENCE IIAXDHOOK OF THE MEDICAL SCIENCES.
ti'Miiioraliire; hniinc irport a rise, smiu' im ihiuigc. some
subuorniiil toiiiiK'iatui-os. Tlie effect on tin' iictvdus s_vs-
Iciu is iiiarkc'd. All aulhors as''''!-' lliat degi'iicrativc
cliaiigesiu tlio braiu, cord, and syniiiallictic plexuses fol-
low iX'iMoval of 1 he adrenals. Tliestatenients in regard lo
the eliuieat nervous phenomena ol>serve(l are not uniform.
There is always «:nat niuseular asthenia. The digestion
is always inipaired : there ai'einereased peristalsis and diar-
rliiea.. The blood pressui'i' always falls. No uniform
changes in the pulse rate or the respiration have been
noted. Occasionally, when tlie animals survived for a
period of several nionllis. abnormal pigmentation of mu-
cous and cutaneous surfaces has been noted. The nujst
marUed changes occur in the cliemieal eomiiositiou of the
blood. (The statements in regard to changes in the Inemo-
globin content and tlie nundier of red blood corpuscli'S
are absolutely I'onlradictory.) The blood of an animal
whose adrenals have been removed bi'comes verj' iioison-
ous and acts like curare on healthy aniinal.s. It acceler-
ates the deatli of other animals whose adrenals have been
removi'd, wheriuis the injection of ncu-mal blood into such
animals improves their condition. It apjiears that after
removal of the adrenals certain substances accumulate in
the blood th.it paralyze the motor endings of the nerves
and maybe the muscles themselves. We are justitied in
assuming, therefore, that one of the fuuetious of the
suprarenals is to di.sint.o.xicate the blood. There is nuich
e.\perimental evidence to show that the to.vic prineijjle
which the adrenals normall}' arrest or neutralize is a fa-
tigue product of muscle ami nerve activity.
Ourknowledgeof the fmietii/ii of the suprarenal glands
is supiilemented by clinical studies in Addison's dis<'ase.
Here we find in the majority of cases s]ioiitaneous degen-
eration of the adrenals (usually tuberculous) and a sy mji-
tom comple.K which corrcspemds in many features with
some of the symptoms that follow n iiiural of the adic-
nals. viz., asthenia, cardiac weakness. In other features
AddLson's disease resembles the syndrome following //i-
jivtiun of ailreual extract diigmen'tation. glycosuria).
This observation makes it probable that the function
of the suprarenals is twofold, viz., that on the oni' haml
they supjdy a substance that stimulates the synipatlielic
ganglia and strijicd and uustri|ied muscle fibre; on the
other hand, that they arrest or disintoxicate certain ]ioi-
.sonous prineiiiles which are the jiroduet of nervous and
muscular activity. The latter fatigue products, we
must imagine, when present in excess produce asthenia,
blood impoverishment, and occasionallj' pigmentation
and glycosuria. Only on this duplex basis can we ex
plain bow insulficiency of suja'areual function or absence
of the glands (an produce the whole syndrome of Addi
son's disease.
The '' itrtiee jiriKi'iph:^' (if the suprai'enal glands has re-
cently been isolated: it is called adrenalin. Older im-
pure pre]iaratious are sphygmogenin(a syru])ousli(|uid),
suprarenin, and epinephrin (both albuminoid bodies).
Other substances (lecithin, jeeorin, pyroiatechin, neuriu,
etc. ) that have been isolateil fioni adrenal extracts, do not
possess the specitic properties of the fresh glands. With
the discovery of adrenalin and its manufacture on a
large scale all the other preparations have been super-
seded with the cxceiition possibly (jf the desiccated and
[lowdered gland itself.
Ihisc iiiul Ailiiiiiiixtrdiioii. — In oiu' case of Addison's
disease a piece of fresh gland was implauted under the
skin of the patient. No effects were observed and death
occurred in three days. Tli.e dry powdered extract is
given by mouth in capsules or in compressed tablets, in
doses varying from twenty to forty grains a day. The
gastric juice does not destroy the action of suprarenal
|ireparations. It must be remembered, however, that
the drug when given by mouth exercises no effect on the
blood pressure.
For hyjiodermic use. for administration by mouth, and
for local application adrenalin is the most convenient, tlie
most accurate, and the safest preparation at our disposal.
It is usually dispensed in the form of the hydrocliiorate
(adri'n.-ilin chloriile) as a white crystalline powiler. It is
a most powerfid I'l-niedy. One part to ten thou.sand
blanches the conjunctiva in from thirty to sixty sec(mds;
I). 001)008 of a grain, injected intravenously, causes a rise
of blood pressure that is (Mpial to the effect of 0.005 gm.
of the dry powdered extinct: 0.0000014 gm. i)er kilo-
gram of body weight exerci.ses a distinct physiological
effect. It is the most powerful baunoslatic and astringent
known, and the strongest stimulant of the heart.
The preparation is non-irritating and non-cumulative.
It is generally employed in the strength of 1 to 1,000
for hy iiodermie an<l local as well as for internal use Hy-
podernucally a few drops (two to ten) usually suffice "to
bring about the desired immediate effect (see below). By
the mouth, fiom tive to ten drops .should be given every
fifteen to thirty minutes for two or three times, and then
eveiy three hours, as needecl.
1 /i('irijwii//':s. — In Aildisiiii '.s (lj'.v<t.ie suprarenal prepara-
tions have been extensively employed. The results are
not altogether unfavorable. In many instances improve-
ment seemed to be maintained as long as the drug was
exhibited. In one case the patient improved for two
years under adrenal treatment. As soon as the remedy is
stopped in these cases relapses .are liable to occur: they
are often sudden and severe, and may even terminate fa-
tally. In the majority of cases the remedy is altogether
without effect. In a few cases the patient's condition
seemed to grow worse. No case of acomplete cure is on
record.
A niunber of statistics on the treatment of Addison's
disease with suprarenal preparations have been pidjlished,
but they are essentially without value because the stage
of the disease, the time during which the cases were lui-
der observation, the <piality of the suprarenal preparation
are not included in the tabulation. In many instances
the dia.gnosis is not even positive. One series, the most
accurate one. includes 48 cases. Of these 6 were greatly
imiu'oved. 03 .slightly improved. 16 were not affected,
and 3 grew worse. The residts obtained so far are withal
sulficiently encouraging to stimulate further trial.
Suprarenal iircparationsare the most riipid i-a rdiac ton fr
which we possi-ss. In sudden heart failure due to shock
or hemorrhage, nan-olics. ana'sthetics. etc.. hypodermic
injections of adrenalin are very effective. The action of
adrenalin is very transitory, however, so that in chronic
heart lesions it cannot take the place of nitroglycerin,
digitalis, or strychnine, but should merely be employed
as an adjuvant to these remedies.
As raj)id and iiowerful nisD-n/n.'strirttir.^ suprixrensil pre-
jiarations have a large sphere of usefidness. They can
l)e given by mouth for the arrest of inlcriial /lenmrr/iar/i's
of all kinds (luemopty.sis, luemophilia. etc.), and can be
apjilied locally as hivtiiost<itiri< to all bleeding .surfaces. In
the treatment of cpistaxis adrenalin is particularly useful.
In utjta III Illation of tlie ninj'iiirtim depletion of the en-
gorged vessels Avith relief of pain and redness is rapidly
brought about b\' the instillation of a few drops of adre-
nalin solution into the eye. In ylouroiua. (piscleritis, w,v-
cular kenititia. and /n riitn-conjiincfirilix suprarenal gland
is a valuable adjuvant to other treatment. In opfirition>t
on the nose or other mucous surfaces the application of a
spray of adrenal extract in- of adrenalin will produce
rapid ischa?niia of the parts and consequently render sur-
gical interference practically bloodless. Whenever it is
desired to apply cocaine to intcn.sely inflamed surfaces
suprarenal extract may be first applied with profit, as it
relieves the congestion of the tissues and in this way
reniiers the action of cocaine more jiowerfid. For the
details of the employment of suprarenal preparations in
ophthalmology, in intratympanic surgery, and in nose
and throat work we refer to special articles on these sub-
jects.
Suprarenal gland has been u.sed in the treatment of difi-
beles (this use being based on the view tliat certain forms
of disturbed carbohydrate metabolism are due to "lack
of vaso-motor tension "). but the results of this treatment
have been quite unsatisfactory. In view of the fact that
tluctuations always occur in the condition of diabetic
subjects, the reports in regard to temporary amelioration.
41;
REFERENCE IIAMDHOOK OF THE 5IEDICAL SCIENCES.
<ki*;^all<>lli«-rui>y*
Orgaiiotliorapy.
followinj; tlie use of siiprarcnal cxtraft, must be juilgcil
with cautiou. The disoovcry of suiiiaioiial glycosuria
has also led to the cniphiyiiieiif. of ailrcualiii in diabetes,
but the fesiilts obtained are nltoyethei' iieaativ<' so far.
Ill a few eases tlie dextrose exeretioii was e\en increased
for a short time.
Ill iisthiiiii with vaso-iiiotor ataxia oecuning in neurotic
^objects the drug apparently has a certain application,
and beneficial results from its adinini.strat.ion are reported.
In {\ie (istlii'iiiK. o\ certain nervous di.seas(^s. both func-
tional and organic, the drug may do good as a muscle
Ionic. It is said to cause the feeling of iirofouiul fatigue
so frequently comi'.lained of by neurastlienics to disap-
pear. It also acts on the uterine muscles, and has been
successfully employed to stiniiilali' uterine contractions
and to arrest uteriiu^ bleeding.
Other conditions in which suprarenal iirejiarations are
re]iorted to have exercised favorable eifects are acute
maniacal excitement with low blood pressure, cyclic albu-
minuria, and the pain of cancer of the breast and the
(es(^phagus.
o. Thymus Gi..\nd. — Remonil of the thymusm animals
in \s"hicb it persists during life is not followed by any
cliaiacteristii^ perversions of function. In man the gland
spontaueonsly decreases in size from the second year,
and is almost totally obliterated in adult life. The organ
is therefore not essential to life, nor apparently of physi-
ological importance in adult man. Of its functiou we
know nothing.
lir/irtioii iif tlii/iiiiin i.rtnii-t pioiluces a fall of blood
pressure, acceleration of tlic ]iiilse rate, rcstlessne.ss, dysp-
ncra, and in large do.ses colUipse and death.
No (idire principle has been isolated. The gland con-
tains iodine in smaller quantity than the thyroid. Dogs
who are fed on thymus excrete a peculiar purin body,
and the theory has conseipiently been advanced that the
thymus is concerned in the metabolism of nuclein and
the genesis from uuclein of uric acid and its < liemical
■congeners.
Tlieffe«t'of Ihymiis is miicli larger than the safe dose of
thyroid. From ten grains to several ininces of the fresh
gland have been given per day. Of the dry extract the
•common dose is from twenty-tive to sixty grains a day.
No thymus |irei)aratiou is used hyiiodermically.
TJin-iijii iitii-s. — Thymus is jiarticularly useful in simpl,
,goitre. In this disease it acti very much like thyroid,
only not so energetically. The stalistics in regard to the
etiicacy of thy inns treatmen tot simple goitre vary .greatly
In many of the succi'ssfnl cases rejiorted other treatment
was given at the same time: and some of the cases were
not kept under observation for a sutliciently long time to
justify Jinal conclusions in regarfl to a cure. The con-
sensus of (qiinions is, however, very favorable. A criti-
cal review of the whole literature of the subject seems to
show that about one half the cases of simple goitre are
mneli beni'tited by thyiiins. In seveial instances thy-
mus brouglit iiniiroveineiit after thyroid had failed.
In t'.voplithidiiiic Cjditre the reports are very much at va-
riance. A few aiuliors report ag.gravation of all the
symptoms; otliers rei>ort altogether negative and iiidif-
fer<'nt results; a few report improvement. One author
studied twenty cases of Basedow's disease treated with
thymus, aii<l contrasted with them twenty eases treated by
various otlii'r means. The lialanceiii regard to the retarda-
tion of the |iulsi' rati', the decrease of the thyroiil swelling
and of the exo]ihthalmus inclined toward treatment with-
out tliynius. The statistics as a whole are better than for
thyroid treatment, but not as good as im- other standard
methods of treating exophthalmic goitre.
4. PiTriT.\RY Gr.AND. — Renioriil cf the pilnituiii hiuJi/
constitutes an o]ierative inroad of such magnitude that
only very few statements in regard to the effects of alila
• tion of this organ are recorded in the literature. All the
:Symiitoms ileseribed, ntoreover, are ambiguous, and may
be ascribed to shock or to injuiy of neighboring vital
parts. From this source, then, we gain no reliable infor-
mation. Spontaneous degeneration consisting in liy]iei-
trophy of tile connective-tissue portions, cystic degener-
ation, sclerosis, atrophy, and tumor formation on the
otlier hand is almost invariably followed by the syndrome
of acromegaly. One case of hyiicrtroiihy of the pituitary
body is on record in which acromegaly was absent, anil
a few cases of acromegaly are reported in which the
gland was not found diseased. The connection between
disease of the organ and acromegaly is nevertheless suf-
ficiently apparent to warrant the employment of pituitary
preparations in the treatment of this disease. In two
cases of adiposis dolorosa the pituitary is also reported
enlarged.
I/ijcctioii of the infundibular portion of the organ |ud-
duccs a rise of blood pressure. Injection of the hypoph-
yseal portion doi-s not produce such a rise, but merely
retardation of the imlse beat that persists to a certain ex-
tent, even after divisicm of the vagi. A sulistance has
also been isolated from the gland that causes contraction
of arterioles and augmentation of the heart beat.
The function of the gland is not understood. Some
authorities claim that it regulates the intracranial blood
pressure, and is also concerned in the regulation of gen-
eral metabolism. It is finally lielieved to exercise some
etTect on the growth and development of the bony struct-
ures and the cutaneous tLssucs of the body.
No iirti re principle has been isolated.
The .gland is usually administered in the form of atrit-
iirat ion or desiccated as a powder (" hypophy.sin "). The
diise varies from one and a half to ten grains" a day
ThcriipeiiticH. — Pituitary gland is used exclusively in
iti-romrgfily. It seems to exercise no effect on the course
of the disease, but does seem to be efficient in relieving
some of the most distressing sym]itonis, as, for example,
the headache, the neuralgic pains in the limbs, the general
lethargy, and the loss of memory. In a series of thirteen
cases .seven showed relief of symptoms, five showed no
improvement, and one case grew worse. Some authors
claim to have seen marked benetits accrue from the com-
bined use of pituitary gland and thyroid, ]iarticularly in
regard to the relief of lieadaclie; but it is difficult to de-
termine how much of this good effect must be attributed
to the thyroid (see above) and how much to the iiituitary
gland. It is best in the present state of our knowledge
to give sinTerers from acroinegal}' the benefit of the com-
bined use of thyroid and pituitary, in connection, of
course, with other established measures for the relief of
symptoms.
II. TiiK I5t.ooD-F(inMiN(; Oi!(I.\ns.
The role which the s]ileen. the lym|ih glands, and the
bone marrow play in blood formation has suggested their
employment in various di.seases of the blood. Extracts
made from the three organs are used rather indiscrimi-
nately, either singly or in combination. Very few clini-
cians in administering these preparationsapparcntly have
clear conceptions in regard to the plu'siologic function
in blood formation which these different organs perform.
.V summary of our present knowledge in regaril to the
iKeniatopiiietic function of the spleen, the lymph glands,
and the bone marrow^ reads as follows:*
The spUcn plays only an insignificant part in lilood
formation. It is not at all concerned in tlie formation of
red blood cor]iuscles (in maul) nor in tlie formation of
gianiilar mononuclear and polynuclear leucocytes, nor
of eosinoiihile leucocytes. It ajijiears to manufacture a
small proportion of the lyinpliocytes. Its chief role is
to arrest the fragments of red an(i white corpuscles that
are carried to it in the blood of the splenic artery (spodo-
genic tumor of the sjileen in infections).
The tt/niji/i f/liindii manufacture only lymphocytes and
have no other function in h;eniatopoiesis. The lymph
glands are closely related to the spleen; both contain
lyni])lioid tissue.
The lji>ne marrow forms the granular mononuclear and
polynuclear leucocytes, and in all probability the red
* Ttie views held by (litterent iuittiors are greiitl.T at varianop iu somo
ri'.si)e('ts. I liavp in the uiaiu futlowed Khiilch, who is fdc'dc pvin-
II I'xin thisllMld.
413
Or£aiiol1iora|>3'*
Or«;a uot lie i'H|>y«
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
l)lonil cells. It is not related to the spleen and lymph
glands and consists largely of myeloid tissue.
'I'here are then two types of leiicoeytc- forming tissue —
the lymphoid (spleen," lymph glands) and the myeloid
(bone marrow). Metaplastic vicarious transforraatiou of
lym]ihoid to myeloid tissue may, however, occur. In
myelogenous leukaniia. for example, large (piautities of
my<'loid tissue are found in the lymph glands and the
spleen. Under these conditions, therefore, the spleen may
lie said to play an important part in blood formation.
1 . The Spi.eex. — E-vliriuttiun of the nji/o ii is invariably
followed by vicarious hypertropliy of numerous lymjih
glands, an(i in many instances by eidargemeut of the
thyroid. A colossal lymphocyto.sis develops very soon,
but no increase is witncs.sed in the number of mouonu-
<-Iear and polynuclear granular leucocytes. If the animal
survives fnra year or longer, marked eosinophile leuco-
cylosis devcdops.
T/ie iiijirtfiiii i>fs///i'nic (.rtrartx produces a fall of blood
]iressure followed by a continuous rise and often by ele-
vation of temperature. Splenic juice is irritating and
ma_v ])roduce abscesses when injeete<l hy]jodernneally,
and inHannnation of the U])per digestive tract when
given liy the mouth. "Eurythrol" is a salt-water ex-
tract of s]ileen that is given in the dose of one or two
teaspoonf\ds a day, and is said ti> lie n(in-irritating and
not disagreeable to the taste.
Till riipi iilirs. — On phy.siological groumls splenic ex-
ti'aet should be administered only to increase the l)-ni-
jihocytes. The spleen, however, contains much nuclein,
and it is we'll known that this substance produces a
marked general leueocytosis. From this jioint of view
s]ileen may be used to produce general leueocytosis, but
il .seen\s much more simple an<l expedient toeni]>loy pure
nuclein for this purpose.
It is very ditHcult to render conservative judgment in
regaril to the eflicacy of splenic extracts iu diseases of
the blood. Innumerable reports have been published,
but very few of them are free from ambiguity.
The most careful and exact observers report very little
benefit. In the majority of cases other preiiarations
Were used together with the organ extract, so that no
liosltiveeonclusions iu regard to the latter can be reached.
How splenic extract should produce an increase of red
blood corpuscles, .as some writers claim, or how, c.c/.. red
bone marrow should cause a marked lymjihocytosis, as
others relate, it is ditlicult to luiderstand on the basis of
the phy.siological considerations we have outlined above.
In h iihirniiii. in which disease we have a relative de-
crease of lym])bocytes. and also often a decrease of Jioly-
nuclear m-utniphiles, splenic extract might be ex])eeted "to
act beneficially. Physiologically, tbesup])lyingof spleen
Avould raise the uumlierof lymphocytes: ehenucally. tlie
presence of nuclein would raise the number of granular
leucocytes. What elTect, however, splenic extract would
have on the development of the myelocytes that are so
colossally increased iu tliis disease, w hat elfect finally on
the primary ]u-iieess. it is hard to foresee. Some good re-
sults have been <-lainied from this tbeiapy, notably in re-
gar<l to the increase of polynuclcars (nviclein!) and the
imjuovement in the subjective .sen.sations of the ]iatient.
It does not appear from the case reports that the course
of the disease is appreciably modified.
In other lihiml ilisc uses no valid reports of good results
are on record. In iijphoiil fiii_-ram\ in ?i;/«vc/7/W.vs])lenie
extract has been given, apjiarently Avith .soiue benefit.
We are inclined to attriluite this to tlir nuclein leueocy-
tosis.
As the spleen is occasiemall}' found enlargeil in ojier-
ative anil sporadic iiiii.rinkiiiii, splenic extract has been
employed iu this condition. It seems to improve the
general condition of the patient and to ameliorate the dis-
tressing mental symptoms, ('ond)ined with thyroid it
seems also to enhance the eflieacy of the latter. In this
disease sjdeen has lieen given in tlie form of the dry desic-
cated organ (four Iiundrcd to six hundred grains a week)
and as fresh gland (twenty grains per dose three times
daily in capsules).
A few cases of cj'ophthalmic noitre and of jiithulinin {i-n-
r/icxie fiidndienne) are on record in which great beuetits
were claimeil from splenic medication.
2. Ly.mph Gl.vnds. — Tuldl fxlirijiition of all the lymph
ijIhiiOk is manifestly impossible. In many clinical eases,
however, the lymph glands are found extensively degen-
erated or involved in tumor formation. In all such cases
the number of lymphocytes is greatly reduced.
What has been .said in regard to the ]ihysiological func-
tion of the spleen applies with eciual force to lymph
glands: they, too, may possibly inci'ease the lympho-
cytes, and they, too, contain much nuclein and couse-
([Uently can produce leueocytosis. Theoretically, there-
fore, lymph gland extract is indicated wherever splenic
extract is indicated iu blood diseases. As a matter of
fact, lymph-gland preparations have not been exten-
sively used. All the case reports describe the adminis-
tration of lymph-gland extract in combination either
with spleen or with bone marrow.
3. Bo.vE Mahrow. — lldiinriil of nil the bone mari-oir is
of course impossible. Comparative counts of corpuscles
in the afferent and efferent bloo<l-vessels of the marrow
have yielded essentially negative results. In clinical
cases in which the bone marrow was largely displaced
by other tissues (malignant tumor formation), the num-
ber of polynuclear leucocytes was found greatly de-
creased. In the lione marrow are found prelimiuary
forms of red blood corjiuscles, and after great loss of
blood the yelloAV marrow of certain bones is converted
into red marrow, showing that a process of regeneration
is stimulated here. It seems, therefore, that bone marrow
should be employed to st iuudate the formation of red blood
corpuscles and of leucocytes other than lym|ihocytes. In
adililion itcont;iius iron in organic condjination, and many
clinicians recommend its use on these grounds. They
argue that the inui in the form found iu bone marrow is
more readil\' assinulable than iron in other eomliinations
or metallic iron.
These claims are juobably exaggerated, and are not
based on experimental or clinical evidence ot value. In
fact, the majority of clinicians obtain equally good and
e()ually bad results with the standard inorganic prepara-
tions of iion.
Bone marrow is either given raw in doses of several
ounces a day or in the form of glycerin extracts. As the
marrow of young animals is more active in blood forma-
tion than the marrow of adult animals, it seems advan-
tageous to employ the former alone. The anterior ex-
tremities of the ribs are crushed so as to expo.se the-
canccllcnis tissue. The fragments of bone are then ex-
tracted with glycerin for a number of days, the extract
is filtered off antl given iu teas|)oonful doses from three
to six times a ilay.
What good effects have been claimed from bone mar-
row can hardly Vie attributed to any ingredient that
nught be utilized to build up corpuscles, or, as we have
seen, to the iiou which it contains. We must hypotheti-
cally assume the presence of some body iu bone marrow
that is capable of stimulating blood formation.
In leiiriiri/lhiriiiiii (leuka'mial the employment of bone
marrow is altogether irrational, because in this disease
we have already hypertrophy ;uid overactivity of the
bone marrow.
la proijirxsin' penurious luniiiiiu some good results are
claimed. No case is on record, however, in which bone
marrow was given aloue. The best that can be said,
iherefore, is that as an adjuvant to other remedies it may
be tried. It certainly cannot replace arsenic.
In chlorosis and iu secoudary nniiiirins the results have
been more favorable than in the primary anaemias. Here
again it may be used in comliinalion with iron, but can-
not replace the latter.
In pseodoleiil.-ii'mio (Hodgkiu's disease) the best results
have been recorded. The exhibition of bone marrow is a
more rational procedure iu this disease than in all the other
diseases of the lilood. for here the spleen and the lymph
glands are extensively diseased and the bone marrow, we
must suppose, vicariously ; "Sumes the greater portion of
414
REFERENCE HANDBOOK OF THE -MEDICAL SCIEXCKS.
4>r;i;uiiolli<'i'n|>}-.
Orgauotliorapy,
the hitmatopoictic fuiictinn. AnytJiing that can stiimi
late tilt' bone mai'rciw to ineieaseii blood formation is in-
dicated. It is not impossible that bone marrow does this
(see above). The best results are reported from tlie com-
bined use of bone marrow, thyroid, and arsenic.
III. The Generative 0rc4.\ns.
The use of orchitic and of ovarian extracts is of his-
torical interest. Brown-Sequard, when an old man, per-
formed his first experiments with ^' sue testiculaire'" on
himself, and claimed to experience "a return of vital
energy and rejuvenescence with renewed and etlicient
peristalsis and control over the bladder and sphincter."
His conclusion was that the testicles secrete into the blood
ii substance that profoundly influences nervous and ]ios-
sibly muscular luetabolism and increases mental vigor.
There can be no doubt that the ridiculous claims of clinr-
latanistic advocates of this particular application of the
"Brown-Sequard method " have done much to bring or-
ganotherapy into disrepute. Nevertheless, the use of tes-
ticular and ovarian extracts, if we carefully weigh all the
clinical evidence, cannot be absolutely condemned as use-
less. Favorable symptomatic resiilts at least, that are
not due to suggestion, are obtained without cjuestion in
certain conditions.
1. The Testicles. — liemoml of the tcstiehs in children
exercises a very marked effect on growth and develo]!-
ment. The voice remains treble, the subjects usually
grow obese, show lack of mental vigor, and manifest
psychic perversions of various kinds (euntichs). The
injertion. of testicular extract into normal subjects jiro-
duces indifferent results.
Several so-called active piinciples liave been manufac-
tured from testicles. The best known is spermin. There
are two different kinds of spermin. The one can be con-
verted into its polymer piperazin (dispermin), the other
cannot. Poehl discovered the latter, and claims the most
startling effects from its exhibition. His statements are
liorue out by many Russian and some Fi-ench authors,
but the reports are not convincing. Tlie majority of
conservative French and German authorities failed to
witness any physiological effects from Poehl's spenuin
and report negative results from its administration in all
the morbid conditions for which it is recommended.
Brown-Sequard states that spermin is not the active
ju-inciple of testicular extract. Charcot's crystals which
are found in testicle juice are ])hosi)hate of spermin.
Testicular extract is best made from th-o testicles of
young animals by maceration of the glands, extrac-
tion with normal physiological salt solution, to which
may be ailded a little carbolic acid, thymol, or glycerin.
The extract is sterilized according to d'Ar.sonval, umler
pressure with CO-- and filtered through a clay candle
filter. No uniform data in regard to the concentration
of this extract nor the exact dosage are given by the dif-
ferent authors who have written on the subject. The
best results are claimed from hypodermic injection, and
Brown-Sequard states that testicular extract is inactive
when given by mouth.
The most interesting results are claimed in the treat-
ment of loconii>t<ir ataria. The destructive sclerotic le-
sions of the sjiinal cord that form the anatomic basis of
tabes cannot of cotn-se in any way be influenced by the
injection of testicular fluid. A cure is, therefore, a prion'
out of the question. It appears, however, that many of
the symptomatic manifestations of the disease can be
ameliorated by orchitic medication, so that the remedy
may be tried. The statistics ptililisbed are altogether
contradictory. Brown-Sequard and d'Arsonval have
pubhshed the most comj^rehensive tabulation of results.
Three hundred and forty-two cases were treated. All
improved, and some, they claim, were "cured" (!).
Other French authors report eighty-five and ninety per
cent, of successful cases. German clinicians, on the
other hand, claim essentially negative results throughout.
In neurasthenia, hysteria, hyijoehondriasis, melan-
cholia, and kindred jj/jschusis transitory impr(jvement is
'[■
reported by many writers, but the element of suggestion
can hardly be excludrd in cases of this character^
In general debility from wasting disease and in seuiliti/
a certain tonic effect is conceded by nearly all authorities.
It appears, therefore, that the chief therapeutic sphere,
and probably the only sphere of testicular extract is to
act as a tonic to the cerebrospinal centres. This power,
it seems, is also inherent in luany other organs, though
possibly not to such a marked degree as in the testicles.
Whether the latter produce a siieeifie internal secretion
that is distributed to other organs, or whetlicr all organs
.secrete such a tonic principle, cannot be determined."
For the arrest of suiface Juiiiorrhnge minced testicle,
locally applied, has been found to be of value.
1. The Ov-\iues. — Rcmoral of tlie omries before the
age of ]iuberty prevents the appearance of the character-
istic phenomena of puberty. The jielvis does not en-
large, menstruation fails to appear, the mainm;e and the
genital organs atropliy. and occasionally certain male at-
tributes develop. In adults, aside from the cessation of
menstruation (a few cases are recorded in which periodic
titerine bleeding persisted even after removal of the ova-
ries) and atropliy of the genital organs, a variety of dis-
tressing nervous phenomena and in many patients obesit_y
are apt to develop. In cows removal of the ovaries
causes the milk to become richer in fat.
The aituii/iisfratioii ,f ornrinn crtriict to healthy ani-
mals has been known to cause death from hemorrhage
into the spinal coril. JIales are claimed to be more sus-
ceptible to this influence than females.
No actiee principle has been i.solated.
OvaiT is adiuinistered as dry jiowdered gland in ekiscs
of from one to five grains. The powder is conveniently
dispensed in compressed tablets. Glycerin extracts have
also been recommended for hypodermic use.
Tlirrnpciilics. — Ovarian extract is a useful remedy for
all the symptoms following double oi'iiliorcctomi/. 'The
nervous and vaso-motor disturbances (in.somuia, headache,
])sychoses, flatulence, lumbar pains, etc.), of the climac-
terium and of certain uterine disorders also often yieM to
ovarian medication. The drug is not, however, reliable
in all cases, and it is impossible to lurdict in any given
case whether or not ovary will do good.
S'liilc dchil ill/ in old women seems to be counteracted
by the use of ovary. Of sixty-four old women treated in
one of the Paris hospitals all, we are told, were greatly
benefited and rejuvenated.
In /ii/.iteria good results are also related. In a young-
child hysterical contractures disapjieared after a few
iloses; " iiuiis rjiic n' obtient-oii pas ihiiis I'/ii/stirie .' "
In chlorosis ovary is of greater benelit than sjileen,
lymph glands, or bone marrow. It is believed by leading
authoiitiesthat the ovaries secrete asubstance that stimu-
lates blood formation, and that in chlorosis this f miction
is insufficient. On these grounds they sujiply ovary and
claim very favorable result.s.
Ovarian extract has finally been given with .success as-
an ojihroilisiio'.
IV. The Nervous System.
IJraiu cortex, cord, and nerve tissue liave lu'eu em-
ployed either singly or in combination in many nervous
or mental disorders. The most comuiou lueparatiou
used is a sterile glycerin extract that is injected hypo-
dermically.
All nervous tissues contain cliolin and neurin. two
bodies that are highly toxic. They are proliably cata-
bolic jiroducts of brain and nerve activity, tor in nervous
diseases in which nerve metabolism is increased the cere-
brospinal fluid contains abnormally large tpiantities of
eliolin. It is probably due to the action of the latter
substance that the injection of nervous extracts often
ju-oihices a rise of temperature, leucocytosis. increased
absorption of oxygen, and increased excretion of nitrogen.
In addition to this toxic action nervous tissu<', and jiartieu-
larly liraiii cortex, seems to exercise a distinct tonic eft'ect,
/.(.. in healthy subjects 8. f' ling of exaltation and of in-
415-
^^rllioforiai.
KEFERENCE HANDBOOK OF THE MEDICAL .SCIENCES.
■ rrased onergj-. There is uo recoi'd of any iuHueiice
luiving heeu e.xerled ou the |nilse and respiration.
Thcmpruliris. — Tile best results, it is claimed, arc ob-
tinned in iiemuin/hciiid, but suysestion cannot be e.x-
cluded. In i/ii/i'jisi/ and in a ease of liulhiir jidhy one au-
llioritv re]iorts e\<'ell<'nt efTeets. In iiitiitii/ tlixKiurs thi:
|isycli'oiiatliiedisordevs seem to remain uualTeeted. wliere-
as'llie physical eondil ion of theiiatienls improved greatly
under this treatment. Of eleven cases of tubes treated
with nervous extracts seven are re|iorleil lienefited.
As asainst many favorable re|iorls we tiuil an eipial or
even greater imnilier of abscplulely nejr.'itive results.
Nerve-tissue extracts jirobalily possess tonie properties
for the nervous system and merit I'Uiploynient in tliis
sense. .Many other remedies that we po.ssess are, how-
ever equally ellieaeious. so that nei-ve extracts are by no
ineaiisan inilispensalileacljuvant to our therapeutic arma-
mentarium. Chailatans in and out of the iirofession have
utilized these preiiarations extiaisively to impose on a
credulous laity, so that their employment has fallen into
considerable tlisrepule among couservafive physicians.
V. Tut; Si:iui;ti>o (Ji.ands.
.\side from I heir external secretion some of the glands
of the body snau to fui'iiisb an "internal secretion" that
plays an imimrtaut part iu intracellular di.gestion. In
the" case of the jiancreas and the kidne.ys this maybe
liractically considered established; in the ease of the
liver, the intestinal glands, the mamma', and the salivary
glands it is highly probable.
1. The P.\ncI!H.\s. — (!omplele extir|ialiou (jf the pau-
ci'eas is invariably followed by tlie com])letc syndrome of
diabetes mellitus. If a small jxirtion of the gland is left
behind, or if a jiieee of the extirpat,e<l lianereas is sidi-
sequeutly grafteil umler the skin, diabetes does not de-
velop. "Ligation of the ipancreatic duct does not cause
diabetes. There are numerous thcm-ics in re.gard to the
lole of the pancreas in carboliydrali' mi-tabolism; they
Cannot all be discussed in this ]da< e. The iirejionder-
auce of experimental evidence points to the secretion by
the pancreas of a glycolytic, /.<.. dextrose-destroying
tVrment. If this secretion becomes insuliieient or is ar-
lested, tlie blood sugar is not deslroyed. consequently it
.•iccumidales. This leads (o bypergljcainia and glyco-
suria. Diabetes may also be due to other causes. De-
licneralioii of ihc jiaiicreas iu man may and may not jiro-
duee diabetes. From very recent in vest igations it appi'a is
tliat in nearly all ca.ses of diabetes certain cell groujis iu
the pancreas (the " islands of Langerhans'')are found de-
generated. These cells are not connected with the elTer-
cnt ducts of the gland, liul pour their secretion into the
lymph spaces. It is probable that they furnish the spe-
cific internal secretion. Ligation of the ipancreatic duct
causes atrophy of the cells furnishiirg the external secre-
tion, whereas the islands of Lan.g<'rliaiis remain intact for
a lon.g time. The writer is at presiait enga.ged in study-
ing the ell'ects of pancreas prepare<l in this way, i.e., of
"isolated" islands of Langerhans in carbohydrate me-
tabolism, both /// ii'lni -dud in rirn. It is ex]iected that
thi'se researches will throw light on the nature of the in-
ternal pancreatic secretion, and will advance Ihe organo-
therapy of dialietes. For the jiresent this method of
treatment, although so clearly indii'ated on theoretical
grounds, has furnished essentially nc.galive results. This
may be due to the fact that all pancreatic extracts contain
<ligestive ferments and certain nucleoproteids that are
toxic and jirodut-e local necrosis when in jecl<'d hypoder-
mic.ally; thromboses, pyrexia, tachycardia, iru-reased
diuresis, and increased N excretion when admiiusterji'
intravenously. The admiinstration by mouth is negative
ill diabetes. It is jirobable that the trypsin contained in
lianereas extracts destroys the "internal secretion " as it
<lestroys the fat-siililting enzj'me that we /;<«//• to lie
luesent. An extract of pancreas containing no digestive
terments, prepared as suggested above, may ai'l more
favorably.
The administration of pancreas by mouth is practised
for the relief of isl((iton-h(vti and other inteKtiiwl disorders
that ai-e due to jierversion or absence of the ex'ternal
secretion of the gland. Tiiis treatment is not, however,
organotherajiy proper, and will therefore be discussed
under other headings.
3. The Kidneys. — Complete anuria may persist for.
many days without causing the development of urtsmic
symptoms (I'.g., hysterical anuria). If a double nephrec-
tomy is ])erformed in a dog and kiduej' extract is injected
intravenously, the life of the animal will be prolonged
beyouil that of a nephrectomized control animal that is
not treated Avitli renal extract. The onset of ura^niic
symptoms can be delayed iu this way. From these ob-
servations the conelu.sion has been drawn that the kid-
neys furnish an internal secretion that is disintoxicating
for certain urinary bodies, and that prevents the occur-
rence of uraaiiia. It has also been shown that the toxic-
ity of the blood of urannic animals is greatly reduced by
its passage through healthy kidneys. Uiwrnia is not,
therefore, considered to be due to the retention of urinary
bodies alone, but also to insutlieiency of the internal dis-
intoxicating secretion of the kidneys. In harmony with
this theory kidney extract has been employed in the treat-
ment of a considerable number of ura;mic cases, appar-
ently W'illi good results. Kidney therapy is too modern,
and case reports are too scanty to warrant extended
analysis. The subject, however, seems capable of fruit-
ful development.
3. The Liver. — Liver extract contains many sub-
stances with active phy.siologic and to.xic jiropierties,
and no less than ten well characterized ferments besides.
It is dillicult therefore to understand bow those who em-
ploy liver extract for the .sake of an hypothetical internal
sei'retion of the hejiatic cells can exclude the action of all
llii'se boilies. It has been claimed that the virtues of cod-
liver oil are due to tin- presence in this product of an in-
ternal secretion. A few good results are re|)orted from
(he use of beiiatic extract (prepared according to d'Ar-
sonval's method) ill dirdiitrs. The preparation is said to
stimulate the liver cells to iucreased activity in the sense
that it enables them to store moi'e glycogen. A great
reduction in the sugar excretion has been reported by re-
liulile clinicians. Some authors have also used liver cx-
li;ict synqitomatically for ''^licpiitif iii.'^'ifficieiiri/^' follow-
ing alcoholic cirrhosis, and report improv-emeut of many
of the subjective synqitoiiis.
4. .MamM-MSY Gl.vnd. — Mammary gland extracts are
believed to exercise an influence on the female generative
organs. Desiccated sheep's maninia has been given by
mouth in twenty-grain doses for vti'rine hemnrrharies. It
is said to cause contraction of the uterine muscles and to
arrest bleetling. Good results are also claimed from this
therapy in the leucorrlKea and irregular bleeding of sub-
iiivolulion, and in benign tumors of the uterus it is said
to relieve many of the reflex syniiitoins. to control the
leucorrliiea and bleeding, anil to improve the general
health of Ihe patient.
5. Intestine. — There issonic experimental evidence to
show that the intestinal wall neutralizes many of the
toxica ])roduets that are generated in the bowel lumen,
Insulliciency of this function would lead to autochtonous
intestinal intoxication. It has also been shown that the
injection of sterile fa'ces does not produce death so rapidly
in animals which have been treated with intestinal extract
as in animals which have not. The disintoxicating action
of the cells of the intestinal wall is believed to be carried
out with the aid of a .soluble internal secretion which they
)iroduce It does not seem improbable that the violent
systemic disturbances of intestinal strangulation, volvu-
lus, and inva.gination are in part due to insiitbcieney of
this function and the resulting self-intoxication. The
siime apiilies to certain ana'n.:as. p.sychoses, etc., which
may be attributed to auto-intoxication from the bowel.
Extract of intestine has, in fact, been employed with
some success iu r/ilonwis, and in several cases of stercoriE-
mic poisoning following sfnini/Nhilinii of intestinal her-
nias. We are told thai in a few of the latter eases the
u'cneral condilinn of the |i:itients improved so much un-
REFERENCE HANDBOOK OF THE ilEDICAL SCIENCES.
4»ri;-Hiiot]ierapyf
Orlliut'oriii.
dcr this treatment tluit operative interference was ren-
dered more safe. This field of organotherapy also merits
further cultivation.
(i. Parotid Gland. — The parotid gland and the ova-
ries appear to stand in some sympathetic relation to one
another. Parotid extract has been used witli success by
■eminent clinicians in Germany and Scotland for the relief
of certain symptoms due to i>varian ilisorders, notably
the pain and reflex mauifcstatinns of ovaritis in cases
in which the glands were enlarged and prolapsed.
VI. jMiscei.laneous Tissues.
Nearly every tissue of the body lias at some time been
made to yield an extract. No exhaustive experimental
or clinical data relating to their employment are, how-
ever, recorded excepting in the case of muscle tissue,
lung tissue, and lieart. We will therefore discuss these
three alone.
1. Muscle Tissue. — ^Muscle extracts contain abundant
quantities of potassium salts and consequently are toxic
when given h}'podermicall_y. In addition, muscle juice
has a distinct thermogenic action and can produce sali-
vation. Reliable investigators claim that small (juanti-
ties of muscle extract prepared in the cold and sterilized
under CO2 pressure act as distinct muscle tonics.
Muscle extract has been employed apparently with
some success in all primary mj-opal hies in whicli there
was no injury to the anterior horns or the peripheral
nerves. A leading French neurologist recommends its
use in all " (li/stmp/iies miisciihiirt'S progressives" with le-
sions of the hbrillo! of the muscle and connective tissue.
2. Lung Tissue. — Pulmonary extract has been success-
fully employed in the treatment of pulmonary arthrop-
athies. It is believed tiiat destructive lesions of the
lungs, in addition to interfering with the respiratory in-
terchange of gases, inhibit the formation of an internal
secretion of the pulmonary cells, and that the lack of
this secretion in the blood leads to the development of
the osteo-arthritic lesions of lung disease. Very good
results are reported from pulmonary therapy in a case of
Marie's disease (usten-iirtJirnpathir /ii/pertrnjihiaiitc prieii-
moniqiu). The arthritic jiroeess was arrested, the dyna-
mometric pressure rose from 9 kgm. to 19. .5 kym., and
the generalhealth of the jiatientwas markedly improved
after the twent3--ninth injection. In pleuro-pulmonary
suiipuration with ostco-arthritis pulmonary extract is
also said to act beneficially, and recently " pidraozyme,"
a ])idmonary preparation, has been advised for the treat-
ment of lesions of the lungs themselves. Case reports
are scanty and results not uniform, so that judgment
cannot as yet be rendered on this therapy.
3. Heart. — Heart extract was extensively used a few
years ago in the treatment of a large variety of disorders.
The effects claimed from the injection of this preparation
were, among others, an increase in the pulse rate, a rise of
arterial ])ressure, increased diuresis, and a general tonic
effect. The extract used by the chief advocate of cardio-
therapy unfortunately contained apju'eciable quantities
of alcohol, so that we need not be surprised to learn that
it exercised the above effects. The literature on cardio-
therapy is large and many cures are reported. A care-
ftil analy.sis of the case reports, however, reveals the
method to be utterly devoid of value and the claims of
its advocates to be unfounded. Cardiotherapy is men-
tioned only to be condemned. Alfred C. Croftan.
ORPHOL. See Naphtol-bismuth.
ORRIS ROOT.— {nftizn7iin Iriilis. Ph. G. ; Iris de Flor-
eui-c. Codex JNIed.) The peeled rhizomes of three or more
species of Iris are cultivated for this object in the south
of Europe, especially in the vicinity of Florence. They,
and a few other species also, are familiar garden flowers
both there and in this country. The three following are
recognized as the soiirces of "Orris": /. florcntinn L.,
with very sweet-scented, white, or pale slaty-blue flowers;
1. Germanicti L. , with dark, violet flowers; and/, pallida
Vol. VI.— 27
Lam., with flowers light blue, very large, and fragrant.
They all resemble each other in respect to the more im-
portant particulars, The former is a native of the south-
ern and eastern Black Sea regions, the others of Europe ;
all have been cultivated for a long time.
The rhizomes are gathered in the latter part of sum-
mer, trimmed and peeled, and then dried in the sun, and
afterward separated into grades, according to size, sym-
metry, and ap|)earance. The pieces are more or less
long and flattened, with rounded surfaces and ends, often
curved or twisted in drying, of a nearlj' white color, a
hard but brittle texture, and a yellowish fraetiue. Pieces
with the branches attached are called "hands"; the de-
tached branches, "fingers." The scars where the roots
have been cut aWay may be seen on the lower surface.
Taste bitterish, aromatic, and shar]!. Odor, for which it
is valued, mild and jileasant, recalling that of violets.
Orris which has been kept for one or two years is more
fragrant than that just dried. This product has been
for centuries used as a perfume, and less generally as a
medicine, and is mentioned by most of the classical writ-
ers upon medicine. It yields, upon di.stillation, about
0.1 per cent, of a so-called volatile oil, "orris camphor "
a buttery-looking substance. This consists chiefly of
myristic acid, with a trace of imne, a liquid with a violet-
like odor. Iridin is a glucosidc, occurring in aeicular
crystals, in" very small amount. There is a specific ama-
roid, giving the bitter taste. Orris contains also a little
resin and fixed oil, and a very little tannin. Starch is
abundant.
Action and Use. — Internally given, orris, like our
Blue Flag {Iris tcrsicolor L.), is a cathartic and occa-
sional emetic, but it is almost never employed in this
way. It is a common ingredient of tootli powders, as
well as of sachet powders (violet), and is otherwise used
as a perfume. The oil is also used in tooth washes.
Large, tine pieces are now and then gi\'eu to teething
children to chew upon, lleiiry II. Ihi-tby.
ORTHIN. — This is one of the numerous compounds in-
troduced for its anti])yretic properties. It is a combination
of hydrazin and jiara-oxybenzoicacid ; the base is an un-
stable body, but the hydrochlnrate is a staljle prepara-
tion, and is the salt supplied under the name of orthin.
It is very .solidile in water. The solution should alwaj'S
be freshl}' prepared and preserved from the light. It is
recommended as an antiiiyretic in typhoid fever, pneu-
monia, rheumatism, and all febrile disorders. Kobert,
who introduced it into therapeutics {Deutsche wed. Wo-
clieii., 1890), claimed that it was non-toxic and free from
all ill effects. Its use, however, has been aceoiupauied
by sweating, prostration, and other symptoms of poison-
ing. The dose advised by Kobert is from five to eight
grains. Beaumont iVrnall.
ORTHOFORM — meta-amido-para-oxybenzoic methyl
ester(('.,lU.(»II.XH,;.C00CH3)— isa white powder witii-
out oilor or taste, and permanent in the air. It is soluble
in alcohol, ether, chloroform, and some of the oils, but
very slightly soluble in glycerin or water. It is precipi-
tated, but not rendered inert, bj' formaldehyde and mer-
ctiric bichloride (Luxenburger), produces a lirown color
with bi.smuth subnilrate, and decomposes silver nitrate
and potassium ijermanganate. It is not affected by zinc
oxide, iodoform, .salicylic acid, carbolic acid, Ij'sol, alu-
minum acetate, or iodine, and may be safely combined
in prescription with most of the ordinary antiseptics and
dusting p(jwders. It is said to remove most of the odor
of an equal amount of iodoform.
Acting on the sensory end-organs, orthoforin produces
a local ana?sthesia, which, owing to the insolubility of
the drug, is mild and long continued. This slow action,
together with a distinctly antisei)tic power, makes it a
valuable dusting powder for raw surfaces. It is there-
fore applied to burns, fissures, painful ulcers, ulcerating
hemorrhoids, etc. The ana'sthetic effect from a ten-per-
cent, powder or ointment lasts for from two to forty-eight
hours (Kindler). As the tlrug has no penetrating pow er,
417
Orthoform.
Osteitis.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
it is (if little use on unbroken skin or mucous membrane.
Blondcl used a few drops of a saturated solution in forty-
per-cent. alcohol fortissured nipples. In zoster or herpes
with ruptured vesicles much relief is obtained.
In throat and nose work its use is chiefly limited to
ulcerative conditions, though Cheatham reports good
results in rose fever. Garnaud's formula for laryngeal
tuberculosis is: Menthol 3.0 (gr. xlv.). cocaine alkaloid
0.5 (gr. viij.), orthoform 2.7 "(gr. xl.), expressed oil of
almonds. 100 ( 3 iij. 3 i,].). It is also used as a spray in
five-per-ceut. solution iu alboleiie. In ]winful cancer and
ulcer of the stomach it has been administered in dose of
0.5 (gr. viiss.) several times a day with relief from the
pain and without any systemic effect. Suspended in
water it has been thrown into the bladder for painful
cystitis. In dentistry, its .slow anaesthesia tits it for allay-
ing the ache of an exposed nerve.
Orthoform is u.sed in five to twenty per cent, powder,
ointment, collodion, or solution in oil. Injected hj'po-
dermically in alcoholie scilutiim it acts like cocaine, but
the latter drug is generally preferred.
Ruhemanu. H. II. Wilson, Vogt, Decker, and others
who have extensively employed the drug, report the oc-
casional occurrence, from its use, of a peculiar vesicular
dermatitis resembling that from poison ivy and very re-
sistant to treatment. Broeq observed hypcra'mia and
pruritus. Miodowskj* had a moist .gangrene following
the application of a five-per-cent. ointment, and Fried-
liinder collected fifty cases of local or general poisoning
and eczema. II'. A. Bastedo.
ORTHOFORM, POISONING BY. See Synthetic Poi-
sons, Organic
OSMIC ACID. — In medical parlance i\\ct\t\e osmic. acid
is given to the bodv osniir trtfo.vidr. OsOj. True osmic
acid (H.;0s04) is not known in the free state. Osmic te-
tro.Nideisa volatile crystalline substance, softening at a
moderate heat like wax, and melting at a lower temper-
ature than does that body. It dissolves slowly but com-
pletely in water, forming a colorless solution, which,
however, on exposure to light, rapidly darkens, even to
blackness, by decomposition of the tetroxiile with forma-
tion of the tetraliydroxide, Os(OH),. Osmic tetroxide is
a powerful oxidizer, and, to living tissues, is excessively
irritant. Its odor is powerful and disagreeable, and ils
vapor intolerably pungent and poisonous, with a peculiar
faculty for exciting irritation of the conjunctiva. In the
event of the inhalation of fumes of osmic tetroxide, hy-
drogen sulphide (" sulphureted hydrogen ") has been rec-
ommended as a chenncal antidote, to be taken by inhala-
tion ; but since iu this ease the remedy is itself a powerful
poison, the greatest care would be required iu its employ-
ment.
Osmic tetroxide is of peculiar service to the histologist,
by reason of a faculty it possesses of staining nerve tissue.
As a medicine it has been used, by hypodermatic injec-
tion, for the i-elief of peripheral neuralgias. The results
have been quite variable, but a certain amount of efHcaey
for the remedy seems to have been demonstrated. A one-
per-cent. aqueous solution of the tetroxide is u.sed, and
the same shoidd be made only in small quantities when
wanted, and kept in the dark. Of such a solution, quan-
tities from 0.20 to 1 gm. (from iijiij. to iTixv.) have been
injected at a dose. The injections are made as near as
possible to the painful spot. The operation is often
severely painful, is occasionally followed by temporary
swelling and thickening of the tissues at the site of the
puncture, and, practised over an etTcrent nerve, has in
one instance been followed also by paralysis. No consti-
tutional effects have followed these injections.
Edirard Curtis.
OSPEDALETTI, ITALY, a town of one thousand inhabi-
tants, with nearly a mile of frontage toward the .sea, is sit-
uated midway between Pionligbera and San Remo. It is
a quiet Riviera resort, lying under the spurs of the Ligu-
rian Alps, well sheltered from the winds and with a south-
ern exposure. "There is no doubt," says Dr. Wendt, in
an article upon this resort in the previous edition of the
Handbook, "that little Ospedaletti is more effectually
protected frotu winds than almost any other resort on this
coast. Moreover, it gets the sun early and keeps it late.
There is less blinding calcareous dust there than, for ex-
ample, at Hyeres, Cannes, or Nice."
■■ Ospedaletti spreads out for something like a mile
along the head of a small crescentic bay. The eastern
headland of this bay is formed by Cape Nero, and the
western extremity, nuich farther from the village than
the former, by Cape Sant Ampeglio. Thickly planted
olive hills surround the place, relieved in the" plain by
orange and lemon trees, and the usual array of graceful
palms. Successive girdles of mountains protect it from
the icy north blasts, but less in a northeasterly than in a
northwesterly direction. It is fully exposed only to the
warm westerly marine breezes." "Immediately behind
this village there rises a hill of gentle slope, and a num-
ber of mountain torrents of mild proportions trace their
undulating course seaward. " " The place is so hedged in
as to constitute a veritable sun trap." "For undergoing
a course of absolute quiet and repose," continues Wendt,
"in a sunny, well protected situation, no more suitable
place has yet come to my notice on the Riviera."
The hygienic conditions of Ospedaletti appear to be
good ; the town is spoken of by Linn as having a particu-
larly clean and neat appearance. The drinking-water
comes from the same mountain source as that which sup-
plies San Remo, and is "soft, sparkling, and pure." The
mean temperatureof five winters is given by Linn ("The
Health Resorts of Europe," by Thomas Linn, U.I). . 1901)
as follows: .lanuary, 49.82" F. ; Februarv, 51.02° P.;
March, 53.43" F. The mean relative humidity is 62
per cent., and the numlier of rainy daj's, 32.
There are several hotels and pensions of moderate price,
well kept, and very comfortable. There is also a tine
casino. Medical service can be had there. A short dis-
tance from the village are some hot sulphur springs.
"Gouty and rheumatic elderly people," says AVendt,
"should do particularly well at Ospedaletti." Linn
states that this place is rapidly coming into favor as a
resort, and it seems to combine very many favorable con-
ditions for a winter health station, viz., its tine natural
situation, its pleasant surroundings, its excellent protec-
tion from cold winds, the large amount of sunshine, its
near proximity to San Remo and Bordighera, and the
quiet and repose obtainable there. Moroever, it is said
to be two degrees warmer than its neighbors, Bordighera
and San Remo. ''Edirard 0. Otis.
OSTEITIS, OSTEOMYELITIS. PERIOSTITIS.-
I. Osteitis. —Intianmuition of bone may be induced by
simple traumatism — as a fracture or stripping away the
periosteum, by thrombosis or embolism of a nutJ'ient ar-
terj', by extension from a periostitis, by extension from
arthritis, by exposure to cold or to the action of certain
poisons — as phosphorus and mercury, by ,s\'phili.s, by
pressure — as the rarefying osteitis of aneurism, by the
eruptive fevers, and especially by t_vphoid fever. While
these feveis maj- possibly act as primary causes, it is
quite certain that tlie_y predispose to the development of
an osteitis. Lastly, certain germs play an important part
in the causation of an osteitis. They are either intro-
duced through compound injuries, or else they are car-
lied to the bones by way of the circulation. The em-
phasis which should be laid upon this last factor in the
causation of osteitis cannot be exaggerated.
It isof little clinical vabic toclassify the inflammations
of bone, from an anatomical standpoint, into osteitis, os-
teomyelitis, and periostitis, since primary periostitis,
with the exception of the traumatic and the syphilitic
varieties, is very rarely observed ; and, on the other hand,
every case of myelitisleads, sooner or later, either rapidly
or slowly, to involvement of the periosteum in the in-
flammatory process.
Regarding the firm bony substance itself, when com-
pared with the marrow and the periosteum, it may be
418
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Orlliororni,
Osteitis.
truly said not to take anj- active part in inflammation;
and therefore osteitis, in a narrower sense of the word,
as compared with myelitis and periostitis, is unimpor-
tant. The lirm bone, however, is pa.ssivelj' afl'ected, as
we shall subsequently notice; and clinically the death of
the bone, or of a part of it, may prove to be an affair of
the greatest gravity. So much is this true that it has
been customary to study acute osteitis under the title of
one of its most frequent results — necrosis— and a certain
form of chronic osteitis under the heading of caries.
II. Periostitis. — Periostitis, like osteomyelitis, ma)'
originate from traumatism, either simple or compound,
and in character may be simple (that is, aseptic) or seji-
tic (from the presence of micro-organisms). The syphi-
litic variety of the disease should probablj' be classed
under this latter heading, although we cannot to-day
speak with certainty as to its germ origin. Tiie perios-
teum is lirst affected during the secondary stage of
syphilis, that is, the stage of invasion following the in-
cubation of the syphilitic virus in the system. Those
bones which are subcutaneous seem especially liable to
periostitis — for example, the tibia, sternum, and ulna;
but the others are not exempt. In severe cases there
sometimes appears to be a simultaneous involvement of
most of the bony sheaths of the body, with consequent
almost unbearable osteocopic pains. These pains are
distinctl}' worse at night, and seem to be increased by
■warmth; but I am inclined to think that sufferers from
osteitis and periostitis of other than syphilitic origin also
complain most at night.
The syphilitic periosteum is quite tender, and I Jiave
many times noticed pitting on pressure. In this disease
it is rare for the jjeriosteum to become separated from the
bone by exudations; and consequently necrosis, from
failure of the superticial blood supply, is very infrequent
in this form of periostitis.
In the later or " tertiary " stages of syphilis, nodes,
usually flat, and of sharply detiued extent, sometimes
make their appearance. They are caused b_v infiltration
of the periosteum with small round cells, and, like all
gummata, tend to soften and break down. Their course,
and the probability of bone involvement, seem influenced
for the worse if the medical attendant, finding fluctu-
ation, use the knife instead of rapidly pushing the
iodides or other appropriate medicines.
In acute periostitis, when aecompanie<l by free exu-
dation of fibrin, serum, and pus. the cortical lamella' of
the Haversian systems maj' be separated from their vas-
cular supply ; and unless the surgeon promptly realizes
the state of affairs, and makes free incisions down
through the dense, unyielding periosteum to the bone, a
necrosis of more or less superficial character may, and
often does, result.
The clinical jiicture of acute periostitis is best studied,
as it will be later, together with osteomyelitis; for these
two diseases are commonly associated together.
A rather rare concomitant of an acute osteomyelitis,
usually of a mild type, is a periostitis with exudation of
a simple serous character between the periosteal sheath
and the bone. Because of the abundance of all)umin in
this fluid, Oilier here adopted the title of "osteitis albu-
minosa."
Chronic, non-infective periostitis may be either fibrous
or ossifying in character. In the furnier there is much
increase in the amount of connective tissue, and the
thickened membrane adheres unusually closely to the
bone. In the latter we have as a residt an ossific deposit,
which may go on increasing for months or even 3'ears,
ultimately producing exostoses or osteophytes. The
new bone of inflammatory origin is not deposited in a
regular system of lamelloe, probably owing to faulty nu-
trition; and it is sometimes alisorl)ed. and disappears, the
abnormal activity of the osteoblasts ceasing. This va-
riety— ossifying periostitis — may be associated with either
rarefying or condensing osteitis.
With regard to tuberctdous periostitis I may state
that it is especially apt to appear in the subjects of the
so-called scrofulous diathesis, and in the poorly nour-
ished, and to be accompanied by tuberculous osteitis.
The discussion of its symptoms, course, and treatment
need not be dissociated from that of the latter disease.
III. Osteomyelitis. — The terms osteitis and osteo-
myelitis will here be considered as one. Where the vas-
cular changes greatly predominate, where pus, fibrin,
and serum are abvmdantly produced, where the brunt of
the inflammation is felt by the marrow and contents of the
Haversian spaces, the latter term may be applied with es-
pecial propriety. And, on the other hand, those cases
in which changes in the firm bony structure itself form
the prominent feature, may properly be designated as
cases of osteitis. However, the two go haud-in-hand.
Changes in the relative density of the bony structure can
occur only through cellular activity in the marrow
spaces and vascular canals. These changes are of two
kinds: osteoporosis, or rarefying osteitis, and osteoscle-
rosis, or condensing osteitis. In the former the character
of the bone changes from compact to cancellous, and if
the process continue the bone may even entirely disap-
pear, its place being taken b)' a mass of granulation tis-
sue. This variety of osteitis is verv common. It is one
of the essential phenomena in tuberculous osteitis; it is
the process by which the rough, ossified callus following
fractures is rotmded off; and when a bone is subjected
to pressure — as by a growing aneurism — it is a rarefying
osteitis by which it is eroded.
In osteosclerosis, on the other hand, the bone grows
more compact, and may even — as maj- be observed in
some exostoses — become as dense as ivory.
It often happens that both osteoporosis and osteosclew
rosis are going on at one and the same time in different
parts of the same bone; an osteoporosis within, for ex-
ample, and an ossifj'ing, even condensing, periostitis ex-
ternally ; and as a result the bone may become widely
expanded, although it is a mere shell filled with granula-
tions or with inflammatory deposits.
Or, again, following an osteoporosis, the opposite proc-
ess ma_v be inaugurated, and the cavities caused by the
IVn'mer morbid process may become filled with new "bony
deposit, perhaps of even abnormal density. We do not
yet know why inflammation of bone terminates sometimes
in one and sometimes in the other of these conditions, (t
is supposal)le that in condensing osteitis the osteoblasts
have an undue activity. In rarefying osteitis the absorp-
ti<jn of bone is thought by some pathologists to be caused
b)' the presence of certain large, multinucleated cells —
the myeloplaxes of Rol>in ; cells which are also by rea-
son of the power which they are supposed to possess
called osteoclasts. In subacute osteomyelitis ragged
holes, opening from the marrow spaces and Haversian
canals, are formed in the solid bone. These cavities are-
known as the caverns or lacuna: of Howship. They con-
tain many of the so-called osteoclasts, which, if not the
cause, are certainly the witnesses of the ostcoiiorosis.
Other pathologists repudiate the idea that these large
cells possess any such power, and attribute the ab.sorp-
tion to the influence of the new granulation tissue which
is present in these cases, and which lies in contact with
the bone. In agreement with Billroth they hold that
just as a granulating synovial fringe erodes the articular
cartilage against which it rests, "like ivy eliniljing over
a ruin," so here in bone the granulations possess a simi-
lar di.'iintegratiug power.
In acute osteomyelitis the vascular changes are of the
deepest import, since obstruction of the nutrient arteries
means death of the bone en »i(i.'<.<ie. Let us study the com-
mon cases of apparently spontaneous origin. Here the
maiTow tissue is at first of a deeper red, from intense
congestion. Sometimes it is mottled with hemorrhagic
spots. Later, a grayish hue appears, due to the presence
of great numbers of pus cells; and occasionally little
medullary abscesses develop. In bad cases not only does
thrombosis of the nutrient vessels occur, but gangrene
of the marrow and of the contents of the Haversian ca-
nals also takes place, with rapid liquefaction. The bone
cells being no longer nourished die. The infection may
spread rapidly, involving the whole length of the bone.
41!)
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
or. in the milder cases, it ma\" remain limited to a com-
paratively small area.
Usually tlie process begins in Ihc bone, and extends
thence along' the course of the nuiiient vi'ssels to the
periosteum, which Iheu becomes involved. Some sur-
geons Ibiidi lliat the iufeelion spreads also through the
canali<'uH, from l)onc cell to bone cell, and from centre
to snrfaci-'.
Sometimes the reverse is the case, the periosteiini being
first attacked. lutlannnatory products— pus, fibrin, and
serum — rapidly strij) the swollen and (edematous perios-
teum from the bone, inducing tlie most frequent form of
necrosis, that of tlie .suiierricial lamella'.
The pressvu-e caused by the e.\udations is very great;
so much so that fat contained in the medullary tissues
may be forced out, and can sometimes be seen in glob-
tdes u]iou the surface of the pus (Roser).
The pus finally breaks through the periosteum at .some
point of softening and disintegration ; it enters the inter-
muscular connective tissue, and may finally reach the
surface. In that ease the jius can sometimes be seen to
pulsate from its contact with the richly vascidar medul-
lary substance.
When the osteomyelitis is near a joint, the articular
lamella may become involved by extension, perforation
through the cartilage maj- occur at some point, and the
most dreadful arthritis ensue. In the very 3'oung, sepa-
ration of the epi].)hysis from the shaft maj-, after a week
or two, occur. Tiie cartilaginous epiphysis, from ils
comjiarative lack of vascularity, is not so subject to at-
tack as is the adjacent bone; yet even this may die.
Those parts of the bone which are cut olf i'rom their
blood Bupplj' die inconsequence; and this necrosed bone,
upon its subsecjuent .separation, is called a seqncstniii.
Next in frequency to the cortical sequestrum is the cen-
tral sequestrum — that composed of the bone surrounding
the main medullary canal. In extreme eases tlie whole
thickness of the bone, or even the whole bone, may die.
This separation of living from dead b(me occurs, how-
ever, only at a much later jieriod. On an average from
three to live months is required for the complete sepa-
ration in the ease of a young adult. Tlie length of this
period of time also varies according to the extent of the
involvement and the degree of vascularity. In the el-
derly, the same .separation may need, perhaps, as long a
period as one year for its accomplishment.
Along the line of demarcation between living and dead
bone, granulations spring up; they start from the blood-
ves.sels. The granulation tissue seems to possess the
power to erode and alisorb tlie dead bone with which it
is in contact, until at last the sequestrum lies loo.se upon
a bed of granulations s|iringing from the sound bone. In
the ])rocess of solution of the dead osseous substance,
whereby separation is efTected, certain salts — such as
calcium phosphate — which are not soluble in an alkaline
medium, are dissolved and disappear. Hence it is
thought that the granulations evolve an acid. Formerly
it was believed that lactic acid was the solvent. Till-
manns' later researches seem to show that it is the active,
nascent carbonic acid contained in the blood which dis-
solves the dead bone tissue; and that, in the accomplish-
nient of this, aid is derived from the activities of the
osteoclasts.
Uufortunatelj', this iirocess of absorption is extremely
.slow, .so that we can hardly hope for the comjilete disap-
jiearance of even a moderate-sized se(|Uestrnni. Evi-
dences that a certain amount of absor|ition has already
taken place are found, however, ujion almost all loose
jiieces of dead bone.
When a secpiestrum lies near the surface of the body,
nature is .sometimes able to extriule it. ami new bone, the
iiii'oliicniin, is formed from the granulation tissue, and
pushes the sequestrum out. More connnonly, however,
it cannot escape. The greatest growth of involuernm
springs from the periosteum, save in those cases in which
the bone-forming layer of the periosteum has been de-
stroyed by the suppurative process: and this new bone
of periosteal origin, while it strengthens the shaft as a
whole, prevents the escape of the sequestrum. The rea-
son for the failure of a central sequestrum to be ejected
is obvious.
For mechanical reasons, therefore, nature cannot, as a
rule, complete a cure after separation of the .sequestrum.
Consequently, if the surgeon do not interfere, there 'will
continue to be, for an indefinite length of time, a dis-
charge of pus through more or less tortuous openings,
called cloiiC(C. As regards the kind of interference which
is needed, I will simply state briefly that the surgeon
must chisel, saw or drill through the ensheathing in-
volucrum (involving the transverse diameters as little as
ma_y he) and release the imprisoned dead bone. It is very-
unwise to delay interference after the cast-oft' bone is
found to be loose in its cavity, since the patient is thereby
subjected to serious danger from exhausting suppuration,
from amyloid degeneration of the viscera, from involve-
ment of the neighboring joints in the infiammation, and
from hemorrhage, through mechanical erosion of some
large nutrient vessel by tiie jagged sequestrum.
Vnusiition. — Although we have discussed to some ex-
tent the [jathology of acute suppurative osteomyelitis,
we have not as yet dealt with its true cause. The ques-
tion arises. Have we not liere to deal with microbes?
Numerous accurate investigations of the pus obtained
either directly from the medidlary canal or from the
depth of the tissues immediately in contact with the
bone, and subse(|Uent pure cultivations, have settled this
<luestion definitely. "It is not due to a specific poison,
however, as was believed to be the case for a long time,
but it ma_v be caused by any kind of micro-organism which
excites acuteinfiammation and suppuration " (Tillmanns).
Among these the variety most frequently found in cases
of this nature is the staphylococcus pyogenes aureus ; less
often the staphylococcus albus and staphylococcus ci-
treus; and rarely the pneumococcus, the bacillus com-
munis coli, Eberth's bacillus, the typhoid bacillus, the
bacillus [lyogenes fcetidus and pyocyaneus, and the mi-
crococcus pyogenes tenuis and tetragenus. Although I
mention the pyogenic streptococci last, they are far from
being the least in importance. They are found chieCy
in the osteomyelitis of young children, and this type of
the infection is very apt to prove prom]itly fatal from
sepsis.
How are we to explain the entrance of germs into the
bone without an apparent traumatism as a doorway?
The only plau.sible assumption seems to be that they
pass into the blood through slight abrasions of the mu-
cous or other tegumentary surfaces of the bod\- and
eventually find lodgment in the bone. Clinical facts
support the theory that, jireceding osteomyelitis, patients
will be found to have sutfered from bronchitis, enteritis,
etc. (Koclier).
The majority of cases of this disease, with the excep-
tion of supinirative myelitis in connection with compound
fracture, occur during the time of the development
of the skeleton — i.e., during childhood and adoles-
cence. One is inclined to think that the physiological
growth of the bone predisposes to infiammatorj- processes.
This theory finds supijort in the fact that in most cases
of acute and chronic myelitis the disease is found to be
near the epiphyseal cartilage, and therefore in the most
newly formed bone. It furthermore seems to apiiear
with greatest freciuency in that end of a long bone which
furnishes the greatest amount of growth, and in which
the current of blood is least active. It is commonest in
the upper end of the tibia and the lower end of the fe-
mur; and in the upper end of the humerus and the lower
end of the radius and ulna. It will be remembered that
the nutrient arteries of the long bones of the lower
extremity run aimii from (he knee; and in the upper
extremity they run toward the elbow.
The selection of the youngest bone tissue as the favor-
ite nidus of the microbes seems dependent upon the pe-
culiar form of the developing blood-vessels. It will be
found upon investigation that the sprouting blood-ves-
sels of the growing long bone correspond to wide, hollow
spaces close to the epiphyseal cartilage. It will be easily
420
REFEREXCE HANDBOOK OF THE MEDICAL SCIENCES.
Osti-Itls.
seen tliat tlip blood curreut grovs k'ss rapid in these la-
cuna'. \vliiTe the capillaries enlarge, thus giving tlie cncci
contained in the blood a better opportunity to adhere and
remain. It is further stated (Ho_ver, Kindheisch) that the
blood of the medullary canals flows unenclosed by any
tunic in these spaces, and thereby the cocci are brought
into direct contact with the bone.
Schiller has demonstrated by a series of experiments
that coloring matter introduced into the circulation is
retarded in its course and deposited in the blood-vessels
of the j'oungcst bone tissue; thus showing, as Hueter
saj's, that there is a tendency for the cocci contained in
the blood to be left at this point as a sediment. This
being so, we can readily uuderstand how the infection of
the young medullary substance occurs.
Clinical Picture. — Sometimes exposure to cold, a
wrench or a blow, exhaustion from eruptive fevers, etc.,
may act as predisposing causes, detennining either the
tinie or the seat of the attack, or both. Or, again, no
cause whatever may be discoverable. In any case of
acute, su]ipurative osteomyelitis the actual and exciting
cause is probably always bacterial.
The disease usually begins with one or more chills,
followed by fever, which is often very high. In a child
delirium is common, and tlie little sufferer may not be
able to point out the seat of pain, which, however, rap-
idly becomes severe.
With the intensity and mode of infection, and the de-
gree of vital resistance possessed by the patient, the
symptoms vary. He may even die within a day or two,
overwhelmed l)y the poison. To rather less severe cases,
from a resemblance in the violence of their onset and
symptoms, Chassaignac has given the title "typhus des
metnbres." Later, and iu more insidious cases, typhoid
fever may be simulated. There may be some slight re-
semblance to a cellular erysipelas. In not a few in-
stances, owing to the fact that the constitutional mani-
festations alone were taken into account, a dozen other
diagnoses — some of them quite absurd — have been made.
Repeated rigors and pyemic temperatures may point
to the involvement of more than one bone, or to suppu-
rating foci elsewhere, and pyainia, septica'mia, ulcerative
endocarditis, etc., may develop in the worst cases, espe-
cially in the absence of prompt surgical intervention.
Biiujnoidii. — The disease with which that under consid-
eration is most often confounded is acute articular rheu-
matism, and this mistake is especially likely to occur
when more than one long bone is attacked. The local
symptoms, however, will soon clear up the diagnosis,
unless, owing to delirium of the patient, or to the fact
that he is too young for speech, attention is not called to
the real seat of sullering. Rather near tlie articular end
of the bone, as a rule, a distinct swelling is soon observed.
This is caused first by the great congestion and opdenia
of the periosteum and adjacent tissues, and later by the
separation of the periosteum from the bone by inflamma-
tory products. While the tenderness over this swelling
is very marked, it does not extend beyond the limits of
the tumor. Furthermore, unlike what is observed in
acute rheumatism, motion of the neighboring joint is
not specially ]iainful. The skin over the swelling is not
reddened at this time; it may even be paler than normal.
Later, when the pus is about to escape through some
disintegrating point of its dense sheath, the skin becomes
reddened, softened, and gives way.
Acute Epiphysitis. — Acute epiphysitis presents prob-
lems of the gravest importance. In addition to the risk
of a suppurative joint trouble, by extension, the focus
of infection — whether it begins in the shaft or in the
epiphysis — is commonly close to the nairow line of car-
tilage which connects the two. The importance of this
lies in the fact that if the cartilage become severely
involved in the inflammation there may residt a dias-
tasis— i.e., a separation of the epiphysis from the shaft.
with dislocation, a condition which demands the utmost
care and the most skilfid splinting to prevent a final
deformity from union in a bad position. Even when
the involvement of the cartilaire is .somewhat less grave.
if the normal cellular activity in the vicinity of this
nari'ow line of cartilage be permanently impaired or de-
strojed, growth of the bone, so far as this end is con-
cerned, will cease. And the seriousness of this cir-
cumstance is still further enhanced by the fact that the
greater portion of the growth of the long bones takes
place normally from that end which is mo.st subject to
attacks of acute osteitis. For example, in the case of the
long bones of the extremities the ends which are nearest
the knee, and farthest from the elbow, supplj- most of
the growth, and are also more subject to acute osteitis
than are the opposite ends. And — to mention a single
instance only — von Bruns has collected evidence which
shows that. diastasis of the femur from all causes occurs
in the jiroportion of twenty-eight cases of separation of
the lower epiphysis to one of the upper. And according
to Oilier, the development in length of the thigh bone is
about two-thirds from the epiphyseal cartilage of the
lower end and one-third from that of the upper end.
When it occurs in a little child, a diastasis of the lower
end of the femur, even though the separated parts are
projjerly replaced and adequately splinted until bony
union sliall liave taken place, ma.y result in a shortening
of as much as nine inches; whereas if the diastasis oc-
curs at the upper end, the records show that only about
half this amount of final deformity results. Tliese are
facts, therefore, which it behooves the physician in
charge to know in order that he may, for his own pro-
tection, and especially in view of the possibility of a suit
for malpractice, give timely warning to the parents.
Treatment. — As regards the treatment of acute epi-
phy.sitis, prompt surgical intervention and careful splint-
ing to prevent diastasis are the only means worth men-
tioning. On the other hand, the proper management of
the sequel* will depend upon the precise character of the
pathological conditions left by the acute disease. A prob-
lem very difiicult to solve is that which is presented
when the epiphyseal cartilage of only one of the two
bones (of either the foreanii or the leg) is involved by
the disease. In such a case growth will be entirely
arrested in one bone while it will continue to take phice
in the other. Under such conditions the ultimate result
— if the parts are left to themselves — can scarcely fail to
be a dwarfed and grotesquely twisted limb. Surgical
intervention may be resorted to at a relatively earlj'
period, with the idea of preventing the evil to which
attention has just been called, or surgical measures may
be adopted for the correction of the deformity after it
has been fully established.
In the former case the surgeon, having to do with a
ease of diastasis, should — afterall suppuration has ceased
— chisel through the thin plane of cartilage of the neigh-
boring or sound bone of the same extremity. This stops
the growth of that bone, and results in a straight though
shortened limb. On the other hand, if interference is
postponed until the deformity shall have reached its full
meastu'c of development, the surgeon will have to tax
his ingenuity by the employment of various means (chis-
elling, aseptic fracturing, resection, etc.), to overcome iu
a measure the extreme deformity so commonly found at
that time.
Something further needs to be said about the treatment
of acute osteomyelitis in its incipient stages. In the fu-st
place, it must be borne iu mind that the inflammation, in
a case of this nature, has already produced, or is soon tr>
produce, pus, and that this pus is confined beneath dense,
unyielding tissues. The indication is therefore plain; the
knife must be tised, and that too with as little delay as;
possible. A free cut should be made through the |ieri-
osteum, clear down to the lione; and with a dressin.g for-
ceps entered closed ami withdrawn opened, the wound
should be enlarged for free drainage. Then it shoidd be
irrigated with some antiseptic solution — bichloride of
mercury 1 to 2,(J00, for example — and, if the incision has
been made through deep tissues, a ilrainage tube is to be
inserted down to the bone. Otherwise the wound may
lie jiacked loosely with wet antiseptic absorbent gauze.
When, in lt:'54i Chassaignac and other French surgeon.s
421
'Osteitis,
Osteitis.
REFERENCE HANDIiOOK OF THE MEDICAL SCIENCES.
advocated a similar free incision, tlicir advice was fol-
l(jwed by disastrous results: f;enerally by jiya-mia and
death. That was before the days of antisepsis. To-day,
any surgeon who knows what surgical cleanliness means
can make such an incision without thrcat<ijing the life of
liis patient; and it is, in fact, his iluty to employ the
knife. Whether this incision alone willbe of much value
will depend upon whether llie infective nidus was situ-
ated in the periosteum, or wlietlicr that meniliraue was
only .sccoudarilv involved by extension of intlammation
from the marrow. The latter supiiosition is in most cases
the correct one, and may be considered almost a (crtainty
if drops of free oil be observed between the periosteum
and the bone— it evidently having been forced out by the
tremendous pressiu'e within the bone.
It is well to wait a very few hours after cutting down
to the bone, rather than to jienctrate at once to the mar-
row; unless indeed the violence of the onset seems to the
ojierator disproportionate to the amount of trouble thus
far discovered, in which case delay would add to the
peril. If, at the end of this period of delay, the local
and general symptoms seem aggravated, or at least not
diminished in inteusit_v, showing that the trouble is
within the bone, and not mainly periosteal, then the tre-
phine should be used, or the burr or chisel, and the mar-
row should be e.\posed, curetted just as far as it appears
to be diseased, irrigated, ami freely drained. This should
be done at several places if the disease seems to be e.\-
tensive; and it should be followed by continuous irriga-
tiou with solutions of bichloride of mercury, or of ace-
late of aluminum, of appropriate strength — this irrigation
to be kept up until the more severe symptoms shall liave
subsided.
Such treatment seems radical, but is really conservative
of the patient's limli, and veiy possibly of his life.
The constitutional ti'eatinent consists simply of meas-
ures iiUeuded to supjiort the patient's strength. It is,
perliaps, of little avail to give antiseptics; still, the safer
ones — as benzoate or salicylate of soda — may be em-
ployed. It may also be well to use free inunctions of
the Crede liqvnd silver ointment. The writer's e.\peri-
vnce has not been favorable to the injection of antitoxin
.serums in such cases.
As regards those cases Avhich are seen at a later stage
and in which the disease is complicated by the presence
of a certain extent of necrosis of the bone ti.ssue, the
])ractical questions which present them.selves are these:
How is the existence of such a bone necrosis to be ascer-
tained? and. What steps are to be taken for the relief of
the condition after we have discovered its existence? By
tile intelligent use of the liexible silver probe — or. in cer-
tain cases, of two probes — the surgeon should have no
ditticulty in ascertaining tliat a necrosis exists, and also
occasionally in determining how great is its extent, and
■whether the necrosed ])ortion is or is not loose. In other
instances, hovvi'vcr, he will be forced to resort to an ex-
plorative operation in order to determine to how great
an extent the bone is necrosed, and whether the seques-
trum has become sutlieiently detaelied to warrant the
adoption of railical siugical mi'asures for the removal of
tile dead bone. Furthermore, in reaching the latter de-
cision he will have to weigh very carefully the question
lii>w far the patient's health is lieing undermined by the
constant discharge of pus which invariably accompi'anies
till' separati(^n of the dead from tin- living bon(^
The late Prof. Thomas M. .Markoe. in his article on
" Necrosis" in the first edition of the II.\ndbooic, expressed
him.self as follows in regard to the ste|is wliieli should be
taken in the presence of a necrosed condition of the bone:
"Having now settled the question as to the propriety
of operation, the time of its performance may be con-
sidered. As a general rule, it is better to remove the se-
<iucstrum just as .soon as itcan be asceitained tobe loose.
But if tlie patient be nuich reduced in health, if the season
be unfavorable, and if the discliarges and the sufferings
from the local disease be not excessive or exhausting,
then it is quite proper, and generally <(uite .safe, to wait
until, by careful attention to nutrition, by fresh air and
exercise, perhaps by change of air and surroundings, we
secure a better reparative condition of thesysteni, in view
of the often serious operation which is contemplated. If
there be no considerations of this nature, the operation
should be undertaken without unnecessary delay.
"The operation itself consists in releasing the seques-
trum from its mechanical continement within the tissues,
and removing it. The operative procedure will vary,
therefore, with the extent and solidity of the tissues
enclosing the sequestrum, and with the accessibilitj- of
the sequestrum fnjm the surface. In most eases of su-
perficial necrosis, or exfoliation, it is only neces.sary to
divide the soft parts covering the tlead piece in ortler to
remove it with great ease. This, however, is not always
the case in exfoliation, for it sometimes happens that the
dead ]5late extends on the sides of the bone far from the
surface, and it occasionally occurs that a thin jilate of su-
perticial necrosis surrounds completely certain |iortions
of the shaft of the bone, thus producing a c<mtlition of
things which renders operation extremelj' tedious and
.severe, and, not infrequently, even then the entire re-
moval of the deepest portions of the sequestrum is not
accomplished.
"To take a typical case of necrosis of the shaft of the
tibia, where the diagnosis is clear, the involucruni suffi-
cient, and the sc(iucstrum entirely separated, the steps of
the operation may be dcsciilied as follows: A free incis-
ion is made on tlieanteiior surfaceof the limb, where the
bone is most su])erficial, and this incision should extend
as far as the supposed limits of the necrotic action, and
may be crossed by another at about its middle, so as to
give easy access to the surface of the involucrum. The
flap then being dissected up clean from the expo.sed bony
surface, we select the most favorable point for attacking
the bone case enclosing the sequestrum. This is gener-
all}' to be found at one of the larger cloacK, which, being
further enlarged by the chisel or gouge, soon gives us
access to the cavit}' in which the dead bone lies. By
means of this first exposure of the cavity ■we learn the
size, the degree of freedom, and the extent of the seques-
trum, and we take our measures accordingly. If the
sequestrum prove to be very long, then the incision
through the involui-ruin must be extended so as, if pos-
sible, to release it without breaking off any of the irregu-
lar and slender processes in which it terminates. About
this the ojjerator should be extremely careful, as, if any
of these fragments are left in the bottoiu of the wound,
they are apt to give trouble, and if we cannot reach and
remove them with slender forceps they are frequently a
long time in making their way to the surface, during
which time, of course, the wound will not heal. In ex-
posing one of these large sequesti-a. it should be borne
in nnnd that restoration of the involucral bone which we
ai'e cutting away takes place to only a very limited ex-
tent, particularly in those who have passed the earlier
periods of life. It must be remembered that nature has
already, in forming the involucrum. accomplished a very
elaljorate and extensive restoration of bone, and if we
destroy this new formation she will hesitate about re-
peating the process. In point of fact, we find that the
cavity left after these operations does not, except in very
young subjects, fill up with bone, but rather with a firm,
"fibrous, cicatricial tissue, which, while it rills up the gap
left in the bone, contributes very little to its strength.
We nuist be carefid. therefore, not to weaken the bone
by any unnecessary cutting in its transverse diameter,
though in the longitudinal direction we may proceed
with more freedom. The cutting is done most satisfac-
torily, I think, with a gouge, though if a cloaca is not in
a favorable position for enlargement a small trephine an-
swers a good purpose in making the first opening through
the involucrum. The gouge and the rongeur, liowever,
will be all that in most instances will be required. After
the removal of the se(|uestrum a careful examination
should be made with the finger and the probe, to make
sure that no fragments remain, anil that no cavities are
left without suHleient o|)enings to secure drainage."
By way of supplementing the remarks quoted above I
422
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Osteitis.
Osteitis.
will state that it is important, after laying bare the bone,
to curette away the entire granulating surface, and to
sterilize the living bone, thus laid bare, by peroxide of
hydrogen or other effective means. Often such curetting
lays bare theentrauce to more than one chamber contain-
ing sequestra. There may even be a chain of such run-
ning along the marrow. And unless the operator makes
sure by probe and curette that this is not the case, his
work, in removing the first sequestrum exposed, may
prove by no means a success; and a continuing discharge
of pus will show that lie has not removed the whole
cause. Following these steps, it is possible by at least
nme different ways to treat the bony cavity in an en-
deavor to hasten its healing. (1) The old-fashioned way
of simply packing with gauze to compel healing from
the bottom. (2) Neuber's plan of "deep canalization."
(3) Schede's healing by the moist blood clot. (4)
Thiersch's skin-grafting directly upon bone, (o) Liicke
and Bier's "osteoplastic necrotomy." (6) Healing b}'
aid of decalcified bone cliip.s. (7) Autogenetic fresh bone
chips (human). (8) Hetei'ogenetic fresh bone chips (rab-
bit or calf or lamb, for example, have been used). (9)
Heteroplastic fillings. These are still largely in the ex-
perimental stage; but we may mention sterilized plaster-
of-Paris, bone charcoal, iodoform starch, dental gutta
perclia, and Richter's cement. Upon the skull the
writer has successfidly u,sed a specially prepared cellu-
loid plate, deprived of all excess of nitric acid, and sub-
stituting in its composition a little synthetical urea for
the more irritating camphor, to give resiliency. The
lack of space permits us to discuss briefly only two or
three of the.se nine methods.
According to Neuber's plan, which has for its object
a material shortening of the tedious healing by granula-
tion, the integument and subjacent connective tissue,
for a short distance on either side of the wound, should
be stripped up in the form of flaps, and then these should
be stretched in such a manner as to cover, either entireh'
or at least to a large extent, the excavation left in the
bone by the removal of the sequestrum. They may be
retained in place by nailing them to the bone. The deep
trough-like depression in the skin which remains after
healing takes place soon grow-s shallower through the
development of connective tissue between the bone and
the skin ; and eventually this connective tissue is sup-
planted to a greater or less extent by newly formed bone.
A still more recent method is that for which Sehede
deserves the credit. It consists in allowing the wound,
after removal of the sequestrum, to fill entirel_v with
blood clot. This, under perfect asepsis, does not break
down or putref.y, but undergoes rapid organization,
blood-vessels springing into and permeating it from all
sides. This idea, in properly selected cases, proves an
excellent one. It is. of course, unsafe unless accom-
panied by absolute sterilization of the cavity and by pro-
tection from atmospheric germs.
Thiersch's method of skin-grafting directly upon the
bone is frequently successful in hastening a cure. As
with Neuber's plan, nature, in the course of time, depos-
its new bone beneath the skin, and to a large extent fills
up the deep depression left by the removal of the se-
questrum.
Still another recent plan which deserves to be mentioned
here is that of Liicke and Bier. It is spoken of as " osteo-
plastic necrotomy." In the execution of this plan the long
bone is sawn transversely with the wire saw, half-way
through at two points, viz., just above and just below
the seat of the necrosis. These transverse lines are con-
nected, on one side, by a longitudinal one, and along this
latter line the chisel is used, until the cavity of the bone
is opened : then, by depressing the handle "of the chisel,
the rectangular flap of bone and superjacent parts is
broken loose along a line opposite to that made by the
chiselling, and is temporarily turned back like the lid of
a box; and, finally, as a last step, the .sequestrum is
to be extracted. The cavity in which it lay must next
be well curetted and irrigated, and theu, after provision
has been made at the most dependent point for free
drainage, the lid-like flap mentioned above is to be re-
stored to its natural position.
There are certain subacute and chronic cases of osteo-
myelitis, limited in extent and indicating a mild degree
of bone infection, which deserve mention. They are ac-
companied by more or less pain and tenderness of the
bone over a small area, and this may continue for
months and years witli slight or no constitutional symp-
toms. In some of these cases, called "Brodie's abscess,"
the pus may finally reach the surface, or may remain per-
mancntl}' surrounded by compact bone ; an" osteoporosis
has occurred, sufficientijf great to hollow out a pus cav-
ity, usually lined with granulations; but commonly no
necrosis — no death en nnifise — takes place. It may be
that a few of these abscesses represent the site of soft-
ened and broken-down gumraata of late syphilis.
The treatment is self-evident. By means of the tre-
phine the cavity is to be reached and drained. Even
supposing the diagnosis to be erroneous; supposing the
case to be in reality that uncommon disease, a neuralgic
osteitis — one in which a chronicall.v congested vascular
state in the bone .seems to induce nerve dystrophia and
consequent neuralgia, — experience proves that penetra-
tion of the bone gives the surest relief, and is a safe oper-
ation.
RirEUM.\Tic Osteitis does occur, but is very infre-
qiient, and is apt to be secondary to rheumatic periosti-
tis. The coexistence of rheumatism elsewhere in the
fibrous framew-ork aids the diagnosis. Heat, counter-
irritation, and, as a la.st resource, opening the bone, give
the greatest relief, and should be conjoined with the
usual purely medicinal and hygienic means of treatment.
Syphilitic Osteitis prese'uts itself chiefly as a result
of gummatous involvement in the later stages of the dis-
ease. It is also, however, to be noted as one of the mani-
festations of inherited syphilis. The osteochondritis of
infants, first described by Wegner, is a frequent mani-
festation, as is also dactylitis syphilitica. Regarding the
former, Taylor states that it is often the only^ign of this
inheritance; and that at other times its presence decides
the .syphilitic nature of coexisting lesions. It involves
chiefly the shafts aud epiph_yseal junctions of the long
hemes; and is usually found at birth or within the follow-
ing month. The swellings are rather distinctly limited,
as a rule, and the baby suffers when they are" handled.
In bad cases separation of the epiphyses, suppurative
nstcomyelitis, and necrosis may develop.
Tile dactylitis when present affects mainly the first
phalanges. It differs from the tuberculous variety in
this regard, as also in the fact that when luetic it is apt
to be multiple, and to appear upon both hands.
"Parrot's nodes," involving the two halves of the fron-
tal bone and the two parietal bones, are found in infancy,
and are due to the same cause. The.se swellings, upon
all sides of the anterior fontanel, are very characteris-
tic, and are caused by both a periostitis and an osteitis of
these bones.
In later childhood and in adolescence are found the
bony irregularities, hypertrophies, and asymmetries
which often are so characteristic of syphilis. In the
face, the nasal bones are those which suffer most. As a
result of necrosis of the bony support the nose undergoes
shortening, the lower pavt retreating toward the upper
part ; or else the bridge is sunken. Of the remaining
parts of the skeleton the tibia presents the most striking
of these late bony inflammatory changes due to syphilis.
It may be greatly thickened, its crest being no longer a
mere ridge, but broadened and swelling forward, so that
when seen from one side the tibia presents the character-
istic shaix" of a sabre.
For a fuller study of the bony stigmata of this disease,
including the pathology and clinical cour.se of gtunma
of bone, the reader is referred to the article upon ■'^i/]i/i-
ilin.
Necrosis of the Jaws Dependent vpon thh: Ac-
tion OP Phosphorus. — This is a condition which the
surgeons of the present geueration rarely have the op-
portunity of observing. I may therefore be permitted
423
Oslrititi.
OMeoina.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
again to quote from Professor Markoe's article on " Ne-
crosis" in the first edition of this work.
"These cases occur almost exclusively among the oper-
atives in match factories, who are living in an atmosphere
containing the fumes of phosphorus and phosphorous
acid. The workmen most lialjle to be affected are those
employed in the dipping-room, and in the packing-
rooms." In the tirst there is a constant prevalence of the
fumes of the volatilized phosplior\is, and the air in the
second is still further vitiated by phosphorous acid from
the frequent burning of the matches while being counted
and packed. It is believed that these phosphorous ema-
nations, which are quite soluble iu water, are dissolved
in the saliva, and thuscome in contact with the teeth and
gums, \ipou which latter the poison seems to e.xert its
primary intiueuce. Why these particular parts are se-
lected "by the poison in preference to tlie rest of the buc-
cal and to the Schneideri;ui membrane, which are equally,
if not more, exposed to its action, is a pathological fact
which we are not able to explain. That the poisonous
action is a local, not a general, one seems finiher proved
by the fact that constitutional cacliexia does not often
appear as a condition preceding the local outbreak; and
still more strongly by the fact that if the teeth be sound,
and the gums uniirciken, the disease is rarely developed.
On the other liand, it ought to be stated that there arc
sometimes evidences of slow systemic poisoning by phos-
phorus, terminating in necrosis; and also that it is rarely
those wlio have been for only a short period subjected to
the poison who de\-elop necrosis, but rather those who
have been some years in the occupation. Again, it has
been recorded that the prolonged internal use of phos-
phorus may lead to typical necrosis of the jaw, as in a
case recently reported Ijy Jlr. Hutchinson. It may,
therefore, in the light of our present knowledge, be as-
sumed that the action of the poison, at least in most
cases, is purely a local one, though the system is prob-
ably predisposed to the local outbreak by a constitu-
tional infection from tiie poison slowly introduced into
tlie blood, either by inhalation of the vajior or by the in-
gestion of the drug as a medicine. It acts bv inflaming
tirst the gums and the linings of the tooth sockets, from
these spreading to the alveolar processes of the bone,
and finally, b}' extension by coutinuit}', involving a large
part, and not infrequently the whole, of the bone. This
destruction of the entire bone is sometimes found in the
lower jaw. In all the cases I have seen affecting the
upper jaw, the ravages of the disease were mainly con-
fined to the alveolar arch."
(For further information in regard to this subject con-
sult the articles on Orcupation, IhjyUne vf, and on PIi"k-
phortis, Piiiaiiiiinn hi/.)
Osteitis Dkporm.\ns. — This essentially chronic condi-
tion is, though recognized and studied since 1876, still
illy understood as to its etiology. It occurs most often
in middle age, and involves ]ierhaiis more frequently the
long bones, but also at times tlie sk\dl, jielvis, and verte-
brae. Hypertrophy may go hand-in-hand with soften-
ing, resulting iu malformations which give the disease
its name. Nevertheless, it does not advance to the ex-
tent of causing fractures. Some authors — Tillmanns for
instance — differentiate two clinical varieties, the painful
and the painless. The former is the more frequent, usu-
ally involving the bones of the lower limbs. Tlie pain-
less is believed to occur moie often in the ujiper limbs,
and in females rather than iu males. Generally several
bones are involved, thus indicating a systemic rather
than a local cause. Treatment has thus far proved of lit-
tle avail; and since we cannot definitely ascertain the
real cause and direct our treatment to that, the only
course which remains to us is to alleviate pain or other
symptoms.
Ti^BiiKCirLous Osteitis. — Under this title we shall dis-
cuss that inflammation of bone which, until within a few-
years, writers have studied under the nam<- (jf caries;
paying more attention, as in necrosis, to tlie result of the
process than to the causative agent.
This is a chronic malady, affecting mainly the red-
marrowed, cancellous bones, such as the bodies of the
vertebne and the carpal and tarsal bones. It is essen-
fially an osteoporosis, with tuberculous deposit as its
cause and accompauiment, and it results in molecular
death of the bone. Sometimes, by extension, the com-
pact tissues are involved, but here the bone tirst changes
its character, becoming cancellous through osteoporosis;
and later even the remaining bone trabecuke may disin-
tegrate, and a supjiurating cavity be left. Tlie lime
salts are dissolved, and the remaining membranous or
gelatinous bone breaks down under the devitalizing in-
fluence of the tubercles.
It ma3' be objected to the term tubeirtiloiis that caries
is not always of this nature. It is undoubtedly true,
however, that chronic, granulating, rarefying osteitis is
commonly so, and at the present day the cases of caries
in which careful investigation fails to find the bacillus
tuberculosis are very few, and are becoming fewer.
The bone frequently expands in one or both of its di-
ameters Avhile becoming a mere shell filled with pus, bony
detritus, and granulations. Apparently the growing mass
of granulation tissue forces out the walls of bone when
they become tliin enough to permit it. A rather conunon
example of this condition is found in "spina vento.sa."
Here the bone — a luetacarpal, for instance — may gradu-
ally assume the shape of a spindle. Syphilitic dactylitis
may produce the same distention; this latter inflamma-
tion, which is usually a result of inherited syphilis, most
often involves one of the first phalanges.
The deposit of tuberculous material in bone may or
luay not present all the ordinary appearances of a focus
of tuberculous disease. It may undergo caseation, or it
may, as it usually does, soften and liquefy. Some sup-
puration is probably always present, but this varies
greatly in degree. In the caries of children it is almost
always a feature. Pott's disease, for example, is accom-
panied bj' the formation of so-called "cold abscesses" of
varying size, aud the pus starting from the disintegrat-
ing bone follows a downward course, governed by grav-
ity and the path of least resistance, and may tinally find
an exit for itself upon the surface. Or, in cases with less
discharge, the pus may become chees_y, its ensheathiug
connective-tissue covering may imdergo a change into
calcareous material, and the abscess may never descend
far from the diseased vertebral bodies which gave it ori-
gin. Such an abscess may be discovered only at the au-
topsy.
In elderly individuals the formation of granulation tis-
sue and a slow advance of the disease, with but slight
discharge — a "caries sicca" — are generally to be ex-
pected.
Tuberculous osteitis may occur at any age, but it de-
velops more commonl}' in early childhood than at any
other time. Its onset is usually insidious. The patient
may, after a time, complain of a little tenderness or ach-
ing after exertion. Later, some swelling of the bone may
perhaps be noted. Theskin isnot involved at first; after
several weeks — possibly months — it becomes distended,
looks inflamed, breaks down at one or several points, and
gives exit to pus. This pus varies in consistenc_y. and is
sometimes gritty to the feel, containing nu'nute spicula
of bone. A probe introduced may — if the sinus be mod-
erately straight — touch liare bone, and may liy moderate
pressure be made to tix itself tirmly in the cancellous tis-
sue; this could not be done in the case of the compact
sequestrum of necrosis. Tlie lips of the sinuses and
their walls soon become lined with flabbj', inactive
granulations, in whicli the bacilli are sometimes to be
discovered. Meanwhile the patient may be subject to
more or less fever, night sweats, and similar signs of vi-
tal depression.
By extension a caries may involve an adjacent joint,
with resulting "white sw'elling" and all the manifesta-
tions of tuberculous osteoarthritis. Or, conversely, a
jirimary joint tuberculosis nm' lead to erosion of the ar-
ticular lamella of the bone, aud then to tuberculosis of
the cancellous tissue.
Caries commonly, though not invariably, makes its ap-
4:2i
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Osteitis.
Osteoma.
pcarauce in individuals of the so called scrofulous diathe-
sis— i.e., those who are especially subject to alfeetions of
the glands, skin, and mucous surfaces. Often a f ainilj' his-
tory of tuberculosis may be obtained, or it may be learned
that the parents died from some imuained lung trouble.
The patient is apt to be pale and anajmic in appearance,
although this is not always the case. In adults the bone
disease is sometimes a reappearance of inflammation
which existed there for a time during childhood, and
then remained for years quiescent.
At any stage in its progress the disease may come to
an end, and reparative processes of varying degree begin.
Caries does not necessarily go on to the complete destruc-
tion of all the cancellous bone involved. If the patient's
general condition can be improved, so that the vitality of
9ie bone is enabled to resist the encroachment of the tu-
berculous disease, suppuration may cease, fistulous si-
nuses close, and new bone form to some extent. This is
the rule in Pott's disease. The bodies of one, two, or
sometimes more vertebne melt away, the comparatively
sound bodies above and below come in contact, and if
the patient continues to live, as be commonly does, the
disease is brought to an end, and the vertebral bodies
near the focus of the disease, but wliich have escaped,
unite by firm bony union. In some bones — the calca-
neum for example — there is very little tendency to bony
repair. The space once occupied by bone becomes
partly filled by simple connective tissue.
It is important to bear in mind that a mere local bone
tuberculosis mav at any time give rise to a general tuber-
culosis. Although such a catastrophe is quite exceptional,
it does sometimes occur. Therefore, when it is possible
to remove bj' surgical means the diseased boiu'. it should
be done. It has even been suggested, of late, that in
spinal caries an attempt be made to scoop away the dis-
eased tissue and thus hasten recovery ; if need be, resect-
ing one or more ribs to allow thorough work. But
whether this become a recognized practice or not, in all
readily accessible regions the proper treatment consists in
the free use of Volkmann's sharp spoon; the most thor-
ough work under these circumstances being always the
best. As with suppurating tuberculous lymph nodes,
so here this treatment may save months of effort on the
part of nature to remove the tuberculous dcpo.sit.
It goes without saying tliat surgical cleanliness must
be strictly observed during and after the operation.
It is to be expected that, in many instances, one such
scraping will not suffice entirely to put a stop to tlie dis-
ease. Perhaps the step may have to be repeated a num-
ber of times before all the affected tissue is reached and
eliminated. During the dres.sing of bones or of sinuses
wliich have been operated upon for caries, iodine should
be our main reliance. In irrigation we may wLselv em-
ploy a one- or a two-percent, solution of the compound
tincture, wliich does not jjrecipitate as does the simple
tincture upon dilution with water. This strength will
stain the tissues a yellowish hue.
The gauze used for packing and drainage should be
first moistened, and then well rubbed witli some one of
the numerous powders which depend for their value
chiefly upon the iodine which they contain— such as (in
order of strength) iodoform, iodol, uosophen, aristol, and
europhen. The author rather inclines to aristol, and
considers it practically as effective as iodoform without
the objectionable odor of the latter.
In obstinate cases of caries, after the vigorous use of
the sharp curette or gouge, it is well to cauterize also,
before beginning the iodine treatment. Perhaps the ap-
plication first of pure carbolic acid and then of strong
alcohol is as eflfective a measure as anv that can be
adopted. The severity of this procedure may be easily
regulated by shortening or protracting the time during
which the pure acid is allowed to remain in contact willi
the parts before the neutralizing action of the alcohol is
brought to bear uiion them.
The prognosis in children, after such thorough treat-
ment, is fairly goo(i. In adults it is distinctly more dilli-
cult to eradicate the disease completely. In the tarsal
bones, for example, it is questionable whether in adults
it is not wiser to excise entirely the affected bone or bones
in order to prevent a relapse.
■When des])ite thorough local treatment the disease ex-
tends and jjerhaps involves an entire extremity, am]Hita-
tion at some distance above maj' be our only remaining
resource.
Regarding medicinal treatment, cod-liver oil, iron, and
good nourishment are to be administered in the hope of
improving the general condition. In the phlegmatic
temperament cold bathing daily is of more value than
the oil. These means, however, will not remove the ba-
cilli from the bone marrow. They are merely useful ad-
juvants to the proper local treatment.
liohcrt E. .V. Diiirban,.
OSTEO-ARTHROPATHY, HYPERTROPHIC PULMO-
NARY. See Acromegaly, and Hands and Finger.^, etc.
OSTEOCHONDROMA. See Chondroma.
OSTEOMA. — .Vn osteoma is a tumor consisting of bone
tissue.
Not every bony new formation is an osteoma. The
bones occasionally found in the deltoid muscles of infan-
trymen, caused by the pressure of the rifles, and the
"riders' bones" forming at the attachment of the adduc-
tor longus in cavalrymen are not true tumors, nor is the
new formation of bone at the site of a fracture an oste-
oma, even though the callus formation be exuberant. A
true osteoma may, however, arise from a callus. Fur-
thermore, inflammatory new growths are not true tu-
mors. Thus the newly formed bone aroimd a seques-
trum in osteomyelitis, and the osteophytes, periostoses,
and hyperostoses resulting from ossifying perio,stitis are
inflammafor}- new growths and not osteomata. It .seems
probable that the so-called "osteomata " of the choroid
and vitreous should be looked upon as inflammatory new
growths. The absence of sufficient, evident etiological
factors and the luirjioseless character of the new growth
are to be emphasized as two important criteria of oste-
omata.
Osteomata are most usuaH.y found in connection with
bones. Pi^ither long bones or flat bones may be affected.
In the long bones the trnnors are especially apt to arise
near the epiphyseal lines. As a rule the bony tumor is
formed from a connective-tissue periosteum, after the
manner of the cranial bones; less often the o.steoma is
formed by the transformation of cartilage, while osseous
tumors in other tissues are less common, being found oc-
casionally in the membranesof the brain and cord, in ten-
don, ligament, muscle, in the mammary, parotid, adrenal,
thyroid, or prostate gland, in the tracheal mucosa, pleura,
or lung, and rarely in the skin. Osteoma in the corpora
cavernosa is rare.
In addition to simple osti-omata. bony tissue is also
found in the mixed tumors of the parotid and testicle, in
osteosarcomata, osteochondromata, etc.
Osteomata may lie single or nudtiple. "Cortical oste-
omata '■ or " exostoses '' are bony tumors on tlie surface of
bone; a "central osteoma " or " enostosis " is a bony lumor
in the interior of bone. A " continuous osteoma " is di-
rectly continuous with bone; a "discontinuous osteoma''
is se))arate from adjacent bone. " Dental osteomata "
spring from the cement substance of the teeth; "subun-
gual exostosis " is employed to designate the osteoma
occurring beneath the nail of the great toe.
There is much confusion in the use of the terms "ex-
ostosis," "enostosis," or "endostosis," "hyperostosis."
"periostosis," and "osteophyte." Although it is custom-
ary to give the ternnnation "oma " to all tumors, the use
of "exostosis" and "endostosis" to designate certain
osteomata is so common that it seems necessary to con-
tiniie to employ these terms. The terms "osteophyte,"
" periostosis," and "hyperostosis," however, should be
applied onlv to the inliauunatory new formations of
bone, such as occur in ossifying perio.stifis. Since cer-
tain true tumors are called "exostoses" and "enostoses."
425
Osteomalai-ia.
Ostcoillulaoia.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
it would I)P well if llicsp terms were not applicil to otbor
bony jirowtlis. but, in :i(lditioii to llujh more limited sig-
nificance, tbc terms are geuerall)- applied to almost any
irregularity on or in bone. In tbis article, "exostosis"
signifies an osteoma situated on the surface of a bone;
"enostosis," an osteoma situated in the interior of a bone.
Osteomata have in the main tlie structure of normal
bone, though they liave not the regular architecture of
the trabecule, nor the tyjiical arrangement of tlie vascu-
lar and medullary canals and bone corpuscles,
Virehow classi'lied osteomata according to their struct-
ure as osteoma eliurneum, osteoma spongiosum, and os-
teoma meduUosum.
'•Osteoma ebuincum," oi' "eburnate osteoma," or
'"ivory exostosis" is a tumor consisting altogetlier or for
the most part of dense osseous ti.ssue. In this form the
tumoris made up of nearly parallel or concentric branch-
ing layers of compart hone, containing possibly a few
small Vessels, and covered l)y a connective-tissue jierios-
teum. Tlie number of bone corpuscles is usually not
great.
"Osteoma spongiosum." or "spongy osteoma," consists
of looser, cancellous bone. In the spaces between the
trabecnlic there may be marrow.
"Osteoma meduilosum," or "medullaiT osteoma," has
an outer shell of compact bone covering cancellous bone
and a central marrow cavity, the tumor having the struct-
ure of a long bone. At times the marrow cavity com-
poses the greater part of the tumor. The marrow in the
osteomata may lie either normal red or white marrow, or
a my.\omatouschan,ge ma.y occur, such as is seen in oste-
omalacia, etc.
Th<' eliurnate osteomata are more frequently found on
the bones of the head than elsewln-re; they are usually
multiple, rarely attain a .greater diameter than 1 or 2 cm. ;
and occur as small, flat, rounded outgrowths from the
bones. The eburnate osteomata of the orbit and frontal
bone, and the osteomata occurring near the epiphyses of
the long bones may grow to the size of a man's list or
larger. These tumors have a verjf rough, irregidar sur-
face; they may be very firndy or loosely attached to the
bone. The midtiple osteomataof the dura and arachnoid
are small and very rough and spicnlated. The midtiple
osteomata of the skin are the smallest medullated oste-
omata. They occur a.s platelets the size of a grain of
sand in tlie cutis or subcutaneous ti.ssue. Skin osteomata
are more common in old people.
It is at times imiiossible totell wliere normal boiie ends
and osteoma begins; in other ca.ses a slight attachment
gets severed, the osteoma becomes necrotic, and is dis-
charged as a foreign body. This has ha]iiieued in the
case of some of the tumors arising in the diplof of the
frontal bone.
The tumor formed from cartilage, "osteoma cartila-
ginea," is covered by a more or less incomplete layer of
cartilage. These tumors are found on the long bones, es-
pecially on the humerus, tibia, and feimir. Tliej' ma.y
be progressive and form tumors as large as a man's head.
In the early stages tliey are usually made u]i of compact
bone; later they may be spon.i;y. It is often impossible
to distinguish lietween osteomata of cartilaginous origin
and os.sifying enchondromata.
The following are the chief etiolo.gical factors:
1. Misiilacement of embryonal bone elements. Al-
though formerly it was considered the most important
factor in the etiology of tumors, the tendency of the pics-
ent day i.s to attribute importance to this factor only in
those rare cases of multiple osteomata w liich are iireseut
from birth.
2. Post-natal disturbances of development are sup-
posed to be of much more importance, t'nder this heai.l-
ing rachitis is of special interest. It is supposed that, as
a result of the irregular growth which takes jilace in
rachitis, small bits of cartilage are nijiped off and come
to lie behind the growing line of the bone. These islands
for some unknown reason develop into enchondromata or
osteomata. Usually osteomata arising in this manner are
multiple. According to Otto Miiller, this post-natal mis-
placement of cells is most apt to occur in cases of recur-
ring rachitis, iliiller traces the different jiossiliilities
which may result from misplacement of these cartilagi-
nous elements. The focus may disappear, or persist un-
altered, or it may persist as a tumor-like centre without
sufficient vitality to cause it to grow; the focus may de-
velop into a chondroma, or an osteoma; into a rapidly
growing myxo-enchondroma, or into a malignant tumor
(chondrosarcoma, etc.).
3. Trauma is a factor in the jiroduction of some oste-
omata.
4. Heredity lias been observed to be of etiological im-
pfjrtance c|uite often. Reinecke collected from the liter-
ature thirty -six cases of multiple osteomata which occurred
in families. In one instance the condition was transmitted
through five generations; in two instances to the fourth
generation; in fifteen instances to the third generation;
and in twelve instances to the second generation. It has
been observed that the inheritance is more common
among the n-.ale members of a family. Inheritance is of
iin|)ortance chiefly in connection with multiple osteomata.
5. An osteoma may arise secondarily. In the case of
some of the osteomata of the membranes of the biain and
cord it appears that a soft, fibrous tumor of the arachnoid
may impinge ujion the periosteal dura mater, and a new
.growth of bone from the dura limy then replace the
fibrous tumor.
a. The opinion which prevails at the present time is
that the osteomata ari.sing in gland, muscle, lun.g, tra-
cheal mucosa, etc., are best accounted for on the hypoth-
esis that they ai'ise from a metaplasia of cells.
7. It must not be forgotten that heredit.v, trauma, dis-
turbanei'S <if development, etc.. are of themselves not
sufhcient to account for the presence of osteomata, and
in ever}' case there is some luiknown inlluence at work,
which gives the decisive impulse to ttnnor formation.
Diagnosis. — An osteoma is a painless, beni.gn, slow-
growing tumor, usually small, in most cases arising from
bone, appearin.g, as a rule, during childhood or early
youth, that is, during the developmental period of bone.
The tumors are seldom seen in very young children, and
are rare after the third decade. Tumors found in older
people have their origin earlier in life. The .irrowth of
osteomata is slow and ceases after middle life. The ex-
ostoses at the epiph.vses do not enlarge after the .growth
of the skeleton is complete. Osteomata occur more fre-
([uently in males than in females. The tumors are some-
times symmetrical, as in the nasal osteomata. The posi-
tion, the consistence, and the features that have been
mentioned will usually give the basis for a diagnosis. It
is often dillicult to distinguish between "dental osteoma."
which arises from the cement substance and is found at
the root of the tooth, and "odontoma," which arises from
the dentin and may be found also on the shaft or crown
of the tooth.
PuociNosis. — All osteomata, even the progressive oste-
omata, are benign. This of course does not appl_v to the
mixed tumors containing bone. No osteoma is dangerous
excejit as a result of its ])ressure u|ioii neighboiing ]iarts.
The ifoiital or orbital osteomata may jircss upon the brain
or eye; an osteoma of the pelvis ma.y obstruct labor; an
osteoma ma.y press upon vessels or nerves, or the skin
over the tumor may beiii.iured and a chronic ulcer result.
Unless treatment is indicated to relieve pressure, the
tumor should not be attacked.
Ti!E.\TMENT is altogether operative. Owing to the
firm attaehment and dense structure of some osteomata,
it is often dilticult to remove them without in.jur.y to the
adjacent soft parts. IJiirri/ T. jfarshall.
OSTEOMALACIA. — (Synonyms: Mollities ossium;
maliicosteon ; halistercsis ossium.)
P.^TiiOLOoy. — Under this name is recognized a disease
in which an unusual softening of fully formed, hanl bone
develoiis; this softening liein.n followetl by great deform-
it.y of those bones uiion which strain is placed, either by
the action of muscles or by the mere weight of the body. i
The softening is caused by an insufficient amount of in-
426
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
OBtPonialacia.
Osteomalacia*
organic salts. Whether this insufficiency of salts is due
to absorption (decalcification) or to failure of calcitication
during the regeneration of the bone, lias not been fully
determined. Recent investigations seem to indicate that
both proces.ses go hand-iu-hand. B\' the absorption of
the calcareous matter in the bones the medullary sub-
stance encroaches upon the bone. Two forms of the dis-
ease have been distinguished — viz., osteomalacia cerea,
or waxy osteomalacia, in which the whole shaft is softened
and conse<iuently bends like wa.\ ; and osteomalacia fra-
gilis. or brittle osteomalacia, in which the inner portion of
the bone is affected, and there remains a thin bony shell
which is very liable to fracture.
In the spongy parts the process starts in the medullary
spaces, and in compact bone from the periphery of tlie
Haversian canals: in the latter case the affected area
constitutes a margin of bone in whicli the calcareous
.salts are absent, although it still retains its connections
with the calcified portions. The limits between the de-
calcified and tlie normal bone may be quite regular, oi'
they may present an irregular or even a zigzag outline.
The affected margin of bone stains red in Van Gieson's
mixture. At first, when the salts of lime begin to dis-
appear, the basement substance still presents a finely
fibrillated or a homogeneous appearance, with the origi-
nal-laraellation still preserved; but after a time the de-
calcified tissue may disintegrate and be absorbed, its
place being occupied by new-formed marrow or granu-
lation tissue. The canals either disappear or persist as
small, oval vacuoles. The canaliculi along the softening
margin become irregularly widened and enlarged, and
appear like " latticework " spaces, star-shaped and feath-
ery. Large and small smooth-walled cysts may be
found in decalcified areas: the_y are filled with mucoid
material, resulting from the enlargement of the Haver-
sian canals and spaces, and they may extend into the
marrow itself. Canals perforating the bone trabecular
also appear in considerable numbers, but osteoclasts and
Howship's lacun^'B are not present any more numerously
than in normal growing bone.
The marrow is variously changed. In some places it
is yellowish and fatty, in others it contains reddish
lymphoid tissue with giant cells, while in still other
places there are gelatinous areas. It may also contain
cysts. Constant and characteristic changes do not oc-
cur; in fact the marrow may even become quite fibrous.
Some areas are very ana'mic while others are distinctly
hyperffmic. Pigment and hemorrhages are frequently
found in the marrow, and there may be a great accumu-
lation of small spheroiilal cells.
The periosteum is thickened in many places and has a
fibroid structure with few nuclei. When it is stripped
off, the underlying bone is found to be rough, and often
is perforated by openings from which marrow escapes.
Simultaneously, or subsequently, there takes place
a more or less extensive formation of new osteoid tissue,
which in many instances is excessive, and which,for the
time being may remain uucalcified. This new tissue is
produced by the osteoblasts, and may be quite dense and
contain only fine spaces; it may piesent a lamellated ap-
pearance, or more frequently an interwoven, fibrillated
structure, with large corpuscles. This new tissue is
formed most extensively at points of flexion and of fract-
ure of the softened bone; the callus formation ma}' be
prolific, but it is not followed by perfect calcification. It
also forms to an excessive degree at the points where the
bone is exposed to mechanical strain, i.e.. wliere strong
muscles, tendons, and ligaments are attached. This new-
formed osteoid tissue is easil.y distinguished from decal-
cified old bone, as it contains larger, better formed cells.
Owing to the softness and pliability of the bones which
are acted upon by the superimposed weight, by the re-
sistance of ligaments, and b_y the traction of muscles,
there is sure to be produced a series of deformities.
These consist of curvatures of the spine, sternum, ribs,
and long bones, of partial and conqjlete fractures of va-
rious bones, and of contractions and alterations of shape
of the pelvis. Fractures refuse to unite properlj' and
false joints result; or if they do unite, angular deformi-
ties occur.
Tlie chest is flattened laterally, its antero-postcrior di-
ameter increased, and the ribs and sternum are much dis-
torted. Softening of the clavicle allows the weight of the
limb to rest on the thorax, and a corresponding depression
in the wall of the chest results. The bones of the arm are
usually fairly' free from marked deformity, owing to the
absence of pressure. Tlje li5wer ribs may come into con-
tact with the crests of the ilia. The spine is variously
altered. The normal curves maybe accentuated, or new
ones produced. In some cases there is a simple curve of
the column backward, a condition of kyphosis; or this
may be accompanied b_v a compensating curve inward in
the ujiper part of the column, or the curves may be ex-
clusively lateral. For this reason the stature of the pa-
tient is nuich decreased.
The abdomen bulges and is very prominent. The de-
formities in the pelvis are characteristic. The iliac bones
may yield when pi'essed together, and spring back when
released. The pelvis is usually ver}' fiat, the promontory
being on the same plane as the pubis and pressed forward
and downward. The sacrum is strongly curved longi-
tudinally, the apex being turned forward. The acetabu-
la are pressed inward and approximated, the ascending
branch of the pubis being bent inward. The pillars
forming the pubic arch are also pressed inward and ap-
jiroximated, so that the symphysis pubis protrudes for-
ward in a beaked form. The tuberosities of the ilia are
brought nearer to each other, and may even come in
contact. The brim of the pelvis has the shape of the
h'tter Y. In some cases, in consequence of these de-
formities, the cavity of the pelvis may be reduced so as
scarcely to allow the passage of the natural evacuations
through it.
The early deformity of the bones of the lower extrem-
ity consists in an exaggeration of the normal curves of
the bones, but in the later stages there will lie bends and
twists which are due to the Traction exerted by certain
muscles. Fractures at the angles are frequent. Imper-
fectly healed masses of callus are found about these
points of fracture, and these contribute greatly to the
deformity of the bone. In the femur, as a rule, the
greatest deformity is found in the angle of the bone just
beneath the great trochanter. The pressure of the body
above causes the bone to give way at tliis point, so that
the trochanters may be higher than the head of the bone.
It is characteristic of the puerperal form that the bony
changes almost alwa3's begin in the pelvis, and from here
advance upward u]ion the spinal column; while in the
other form of the di.sease, which occurs in both men and
women — after the puerperal jieriod in the latter, — the
disease usually begins in the lower extremities. In order
of frequency the various bones are affected as follows:
most frequent of all is the pelvis, next the sternum, then
the upper extremities, and lastly the lower extremities.
While the proportion of inorganic to organic matter in
normal bone is about two to one, this is reversed in
osteomalacic bone until the proportion is as one to two.
The nervous system is found post mortem to be free
from gross lesions, but histo-])athological examination
has revealed in the cord organic changes whicli appear
to begin in the cells of the anterior cornua. These are
not inflammatory in character, and clinical evidence shows
that they are capable of repair.
The weakened muscles show, post mortem, fatty de-
generation, multi]ilieation of nuclei, and other changes
similar to those observed in progressive muscular atro-
]diy. The chest and abdominal organs usually are not
altered.
The urine presents no characteristic changes and is of
little importance for diagnostic purposes. The presence
of lactic acid in the urine cannot be regarded as proven.
The same holds true of albumose. In some cases the ex-
cretion of lime salts has been very great, leading to the
formation of gravel and small calculi. Albumin has been
found in some cases.
The microscopical examination of the blood is of no
i27
Of<itO(>iiial;M-la.
Oiiiteoiualai'ia.
UEFERENCE IIANDISOOK OF THE MEDICAL SCIENCES.
importance in the in;ittfi- of diagnosis. Under \arious
conditions there may be u sliglit increase in the eosino
phile cells in the blood, bnt variations in the nnmliercif
these are not an uncommon oceurrenei' in normal indi
viduals.
The ovaries have been thou;j:!it to have an intlueuce on
the disease. In some cases ol' osteomalacia they were
found in a hyaline condition, in others in a fibrotis or
otlii'r pathological condition, hut in many they were per-
fectly normal. Perhaps tlie ovarian internal .secretion
play's a part of some importance in the chemistry of the
organism. Kemoval of tiie ovaries has seemed in a nnin-
ber of cases to have been followed liy a surprisingly bene-
ficial result,
Etioi,<i(;v. — The real cause of this rcMuarkalile affection
is unknown. It is a siiigtdar fact that the disease is
much more frequent in certain regions than in others. It
is very common along the Rhine and in Westphalia, in
Eastern Flanders, in Schutt Island in the Danube, and in
Northern Italy. This suggests that thei'e is some specific
cause for the "disease, endemic in certain localities. It is
in addition found occasionally in almost every coimtry in
Europe, but in North Aineri< a Dock was able to collect
records of only ten cases. It is mainly a disease of
adults, occurring between the thirtieth and the fortieth
years, but it may e-xceptionall_y be found later or earlier
in life. The disease attacks females almost exclusively
during the child-bearing period. Isolated cases have been
found in men. but are extremely rare. Among exciting
causes, child-bearing is certainly tlu' most important, for
both the tirst signs of osteomalacia and also fresh exacer-
bations of the disease usually date from a pregnane^'.
It has, however, been found in women who have never
had children, and it may begin after the menopause.
The relati(]ns of osteomalacia to the sexual processes are
.so close that there is some justification for the supposi-
tion that osteomalacia is direclly dependinit for its de-
velopment upon disturbances of metabolism in the
ovaries.
Individuals in all classes of society may be alTected, bnt
the disease appears to lie favored liy damp and unsanitary
surroundings. Various the(n'ies have l)een put forward to
account for the disease, but none of them is satisfactory.
Lactic acid has been found in the bones, and the solution
of the lime salts in the bones has been attributed to this
substance. It has, liowever, been conclusively shown
that the acid may be in excess without pro<lucing the
disease, and efforts to cause the malady in the lower ani-
mals by feeding them with lactic acid have signally
failed. Micro-organisms again have been carefully
searched for, but witli no constant residt, and there is no
ground for believing that bacteria are instrumental in
producing this condition. Fehling's theory is that there
is a trophoneurosis, due to relU-x irritation from the ova-
ries, and the remarkalile results of castrati<ni in osteoma-
lacia .seem to eonlirm this theory; but while tlie facts
cannot be iloubted, there is a growing ti-ndency to ques-
tion the theory. In some eases in which recovery fol-
lowed the operation of castration, no alinormality could
be discovered in the uterus, ovaries, or vessels. The dis-
ease has also been attributed to affections of the nerve
centres, but anatomical observations on the nerve centres
are very scanty and inconclusive. Virehow asserted that
the disease was of an intlanunatory or hyiiera-mic nature,
but studv of the bones gives lise to strong doubts about
the validity of this theory.
There are on record a niuuber of cases in which, while
the symptoms were somewhat similar to those of osteo-
malacia, multiple myeloid tumors were found in the
bones. In osteomalacia the bones are softened, owing to
the removal of the earthy salts by absorption. In nud-
tiple myeloma the osseous tissue undergoes atropliy with-
out at the same time lieing changed in its chemical
coiniiosition. The atrophy, in this case, is due to the
development of a new growth in the marrow spaces and
to its spread cnitward, cau.sing absorption of the hard
parts of the bone, ami idtimatoly leading to fractures
and deformities. Ther(^ can be no doubt that ea.ses of
multiple myeloma have been confounded with osteo-
malacia, but the}' are distinct conditions, and not depen-
<lent in the slightest de,gree on each other. According
to Bradshaw, the cases of multiple myeloma may be
divided into those with and those without albumosuria.
Of tliese latter there are seven cases in the literature.
The first case of this albumosuria was reported by Bence
Jones in 1847. Most of these cases were considered to
be osteomahicia. and were supposed in some way to de-
pend on the albumosui'ia; hence the origin of the theory
that osteomalacia was due to an albumosuria. This view,
it is needless to .say, is incorrect, for it has been shown
that they were not cases of true osteomalacia at all, but
the allnnnosuria occurred in persons affected with nmlti-
ple myeloid tumors of bone. The Bence Jones albumose
lias never yet lieen found in a case of jmre osteomalacia.
Tills couditi<iu, known as multiple myeloma, has been
variously designated in the literature, some calling it
sarcoma, others (e.(j.. Marchand) calling it "general mar-
row hyperplasia with disiippearance of the bone sub-
stance." Schouenberger reports a case of osteomalacia
in which there were found, as complications, multiple
giant-celled sare<imata and multiple fractures.
ilirschlierg reports a .similar case, as does also von
Reckliughanseii. The publication of all these cases seems
to render improbable the theory of the neoplastic origin
of osteomalacia.
Symptoms. — In the lieginniug the disease is obscure;
it starts very gradually, in most cases, with an ill-
detiued, deep-seated iiaiii, most often felt in the sacral
region of the back, in the pelvis, and down the thighs,
and at times even in the legs. Pressure seems to increase
the pain. This pain is more or less constant and per-
sistent, is increased by movements, and is usually diag-
nosed as rheumatic. An important feature of the pain is
that it usually starts in the latter part of pregnancy,
ceases after delivery, and recurs with subsequent preg-
nancies. While the pain continues, motion becomes
gradually impaired, and there is more and more difficult}'
in walking, partly because of the pain and ]iai1ly be-
cause of the niuscudar weakness. This weakness in the
muscles of the thigh and pelvis may be present before
any bony deformity is discoverable.
Attacks of painful sjiasm are often present, particu-
larly in the adductors of the thigh. Owing to weakness
of the ilio-psoas muscle as well as to deformity of tlie
pelvis, the trunk is thrown from side to side to enable the
foot to clear the ground in walking, and thus a peculiar
waddling gait restdts. In other cases the steps are shfirt,
slow, uncertain, and almost hobbling, the lower liinl)
and pelvis being jerked forward as if they were one
].)iece. There is tremor of the muscles, the knee jerks
are increased, and ankle clonus often is present. After
a longer or shorter time walking becomes absolutely im-
possible, and the patient is permanently bedridden.
Even then severe pain persists in most ea.ses, often spon-
taneiius in character and mtich increased by pressure of
bell ( lothes, etc.
While these syniiitoms are going on, various distor-
tions of the body occur, sufficient to cause a decided
alteration in the appearance of the skeleton. Deformity
of the spinal column is usually the tirst to be noticed.
As a rule, there is kyphosis, less often some other de-
formity, an<l the head generally becomes more and more
bent on the sternum, resulting in tlic patient growing de-
cidedly shorter. This may help in diagnosis because the
patient is a]it to remark that she has to keep shortening
her gown in front. If the patient becomes bedridden
early in the disease then the extremities become less dis-
torted and are less often fractured. The softened bones
are usually painful when pressed upon, and they may
bend under pressure The bones of the face and skull
are almost never involved. The tliorax becomes barrel-
shaped anil pressed toget her lateral!}' , so that the sternum
has an almost horizontal position. The abdomen be-
comes Very prominent. Tlie teeth become carious or are
lost. Thepielvis is deformed asdescribed above. In the
muscles several observers have noticed trembling and
42S
REFERENCE HANDBOOK OF THE SIEDICAL SCIENCES.
Osteomalacia.
Osteomalacia,
fibrillary contractions, also paresis and sometimes com-
plete jiaralysis. In a few reported cases the softness of
the bones of the extremities was so extreme that one
could beud the limbs at will, like wax, and give them
the most extraordiuaiy positions.
The internal organs perform their functions well for a
long time, and the appetite remains good. Fever is ob-
served only when the disease is undergoing some marked
temporary exacerbation. With regard to changes in the
urine, it is a fact that a great many statements have
been made, but their significance is extremely doubtful.
It is said, for example, that the amount of pbosjihoric
aeid excreted is diminished. With regard to the amount
of lime, no definite statement can be made. Lactic
acid has been repeatedly detected in the urine, as has also
albumin. Concretions of lime have been found in the
bladder and the kidneys. Microscopical examination of
the blood gives no aid in diagnosis. Neusser has found
myelocytes and an iuci'ease of eo.sinophilc cells in the
blood in some cases; but these results in general do not
seem to have been confirmed by other observers. Women
affected by the disease are said to be more fruitful than
otliers. Eiseuhart found the average number of chililren
born in Germany to be 3.9, whereas it was 6.4 in tlie suf-
ferers from this disease; abortion is also more frequent.
Prognosis. — The cour.se of the disease is a chronic one,
most cases lasting for years and undergoing remissions
and exacerbations. Pregnancy has a very deleterious
eflect. always liglitiug up a fresh attack. Tlie progno-
sis now is much better tliau it was twenty -five years ago.
We know that the disease is curable in some cases, and
we have gained considerable control over it b_v medical
and surgical means. The most important part of the
treatment depends upon the possibility of jireventing
conception. The more frequent termination of tbe dis-
ease, however, is in death, after a duration of time seldom
less than two or three years, although in some cases this
event may be jiostjioned for five, ten, or even a greater
number of years. Death results either from general de-
bility, or, more often still, from the d_yspncea caused by
the compression of the lungs, or by some such disease as
lobular pneumonia. Death sometimes occurs in labor
and is then due to the rupture of the uterus, or it follows
one of the more or less dangerous operations for the ex-
traction of the cbild.
Di.\GNosis. — This is somewhat difficult to make in the
sporadic cases in the earlj- stages. It is almost always
called rheumatism, on account of the pains which are
located in tbe pelvisand lower extremities, and wbicli are
made worse by bad weather. More careful examination
and a rigid inquiry into the history will elicit points — such
as sensitiveness of the pelvic bones to pressure, increased
knee jerks, and muscular weakness, etc. — from which a
diagnosis may lie made. At the outset the symptoms
may suggest incipient disease of the cord or of the verte-
broe. Strl'impell mentions the fact that he has repeatedly
seen eases in which women, as a sequel to ])regnancy or
even apparently spontaneously, have developed paresis
in the lower extremities, particularly in the psoas and
iliacus muscles, associated with pain and exaggerated
tendon reflex, and in which diagnosis at tirst was very
difficult. At any rate, it is important to know tliat even
before there are demonstrable changes in the bones there
maj' be paralysis, probably due to an early involvement
of the muscles in tlie morbid process. As soon as bone
tenderness and deformity arise, the diagnosis is rendered
easier.
From peripheral nervous diseases osteomalacia is dis-
tinguished by a careful examination of tbe bones. In
the latter disease the tendon knee reflexes are increased,
while in almost all peripheral nervous lesions the tendon
reflex is diminished or entirely aboli.shed.
Not very infrequently tlie complaint of the patient at
tbe start is regarded as hysterical.
As the disease is almost entirely confined to adults we
are seldom in danger of confounding it with rachitis. In
addition, osteomalacia does not produce swellings of the
epiphyses or changes in the bones of tbe skull. Ex-
aminations of the urine and blood do not help us in diag-
nosis.
There may be diflSculty in differentiating the disease
from malignant tumors of the bone — for example, from
primary sarcomata and especially from iliffuse carcino-
matous infiltration of the bones, and there is little doubt
that the older writers confounded these conditions with
osteomalacia. According Jo Kohler, who carefully in-
vestigated cases of the latter type, they are to be dis-
tinguished from cases of osteomalacia, l3rst, by tbe fact
that the growths occur only in the bones of the trunk,
and second, by the absence of muscular weakness and of
any unnatural elasticity of the bones. In multiple mye-
loma the disease mostly occurs in men in the latter half
of life, the bones of the thorax are those chiefly affected,
the patient is able to leave his bed until near tbe end,
deformities are not extreme, and fractures are common.
Tre.\tment. — If the case be seen early in pregnancy,
in view of the gravity of the labor and tlie bad influence
of pregnancy upon the disease, abortion should be pro-
duced if the ftt'tus can easil.y be removed by tbe natural
way.
The patient should then occujiy a dry, sunny house,
and should be put on a very substantial diet, of which
milk should form a large part. The chief remedial agent
is phosphorus, one-twentieth to one-fifteenth of a grain
three times a day. Extract of red bone marrow, a talile-
spoonful three times a day, is also highly recommended.
Others advi.se the administration of cod-liver oil. quinine,
arsenic, etc. Above all things subsequent pregnancies
must be avoided. Phosphorus seems to be the most effi-
cient drug and jjroduces at times strikingly good results.
If a woman becomes affected with osteomalacia during
the nursing of a child, this must be at once stopped, as
it is found to e.xert an injurious eflect upon the disease.
If in spite of all treatment, diet, etc., the disease pro-
gresses, recourse should be had to surgical means — i.e.,
the ovaries should be removed, or. what is probably
better, a Pono operation — supravaginal amputation of
the uterus — may be performed. Either of these opera-
tions fulfils two conditions, viz., it prevents further preg-
nancies and apparently often arrests the disease. Im-
provement sets in sometimes surjirisingly early, the pains
being relieved within forty-eight hours. Many from
being bedridden recover so far as to ^^•alk and perform
their ordinary duties. Of 44 cases collected by Baumann
in wliich Porro's operation was performed. 18 died and
2(5 recovered. Of the latter, 3 died from other tliseases,
and 2 were lost sight of. Of the remaining 21 ca.ses, 17
were cured or maikedly improved. Finley collected the
histories of 40 cases, and the after-histories of 16 of these
were traced ; 12 of these were cure<l and 4 improved.
If a case be seen late in iiregnaney, the jirocedure to
be adopted will then depend on the degree of the deform-
ity. If this be slight, then premature labor may be in-
duced. If. however, it be very great, Caesarean section
should be done. If the patient be found in labor, tlie
procedure will likewise depend on the condition which
is found on examination. If it is found that the child
will be able to pass with some help, we may use forceps;
or if it may pass after some reduction in size we may per-
forate, crush tbe head, and extract the child. Even this
latter may not be pos.sible. and we are then forced to per-
form C;esarean section. In case this is done the ovaries
sliould be removed, or hysterectomy performed, so as to
prevent future pregnancies, and also in order favorably
to influence tbe disease. AVliat the relation between the
ovaries and the disease may be is at present inexplicable.
W^e know that there is a close connection between the
various processes of nutrition and certain organs of the
body. This has been shown in the case of the pancreas,
the thyroid, and other glands, but what the influence is,
or how much is exercised Iiy the ovaries, is entirely con-
jectural. Claniife Arthur JIc Williams.
Referexcks.
iSchmaus and F.winp : Pathnlocy and Pathol. Anatomy.
DelatleUl and Prud<li'n : Patliolocy.
Hektoen-Uiesuian : An American Text-book of Pathology.
429
Osteonij'xonia.
Ovaries.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Garrigues : A Text-book of Obsletrios.
Dock : Araer. Jour. Mcil. Srii-nii's. May, 1895.
Twentieth Centur'y Prai-ine of Medicine, vol. iii.
StiTimpell: Text-book ..f Mi-ilicine.
Looiins-l'li.iiiipson : Aiin-ririin System of Practical Medicine.
Brailsli;iw : Mcdico-Cliiniipical Transactions, ISiW, vols. Ixxxi., Ixxxil.
Schoncnlicrtrcr: VircljnwV Archiv. liXll. vol. dxv., p. 189.
von Reckliniihaiisen : \'ircho\v's Archiv, October 13tb, 1891.
Hirschbeig : Ziegler's Beitrage, vol. vi., 1889.
OSTEOMYXOMA. See Myxoma.
OSTEOPOROSIS. Sec Atrophy.
OSTEOPSATHYROSIS.— Tin's term is used in a general
sense to (iesignate the condition of excessive briUlencss
of the bones, and is practically synonymous \x\{\\ froyil-
itiigossium. It may occur as the result of senile or ca-
chectic atrophy, prolonged activity, pressure ati-ophy,
neuropathic atrophy in "such diseases as paralytic de-
mentia, locomotor ataxia and syringomyelia, and in syph-
ilis, leprosy, osteomalacia, and rachitis. In rare cases the
condition appears in an idiopathic form, apparently of
congenital origin, and may be inherited. The etiology
and pathology of this form are uuknown. Senile osteo-
psathyrosis "is the result of the old-age osteoporosis.
The skeleton as a whole, or only certain portions, maj'
be involved. The bones usually become fragile and are
easil.v broken: but in other cases the bones lose Iheir lime
salts" to such an extent that they may be easily bent or
may be cut with a knife. A similar condition may occur
in the cachexia of various chronic diseases. In syphilitic
infection of long standing and associated with marked
cachexia, there often occurs a marked osteopsathyrosis of
the long bones and .also the bones of the cranium. In the
great majority of syphililics there is an increased fragil-
ity of the skeleton. In leprosy there is found in a certain
class of cases a very characteristic osteopsiithyrosis (lep-
rous osteomalacia) affecting cliietly the bones of the hands
and toes. The plialanges, one after another, may be af-
fected until all the lingers and toes are destroyed, or they
may be irregularly involved. (See also i?w«c«, Osteomala-
cia, Leprosy, >Syji/dHs, Atrophy, etc.)
Akh-ed Scott Warthin.
OSTEOSARCOMA. See Sarcoma.
OTTAWA, CANADA.— Ottawa, the capital of the Do-
minion of Canada, issitiiated upon theriverof that natne,
in the eastern part of the Province of Ontario, about one
hundred and ten miles west of Jlontreal. It has a popu-
lation of alxiut lifty thousand, and is the centre of a large
lumber tralRc. The extensive government buildings are
noteworthy for their architecture and material; and in
the vicinity are various jioints of scenic interest — the
Chaudiere and Rideau Falls, and the Rideau Canal with
its .series of looks. A journey down the Ottawa River to
Montreal (ten hours) is one of great interest, and affords
constant views of imposing scenery. The climate is a
cold one, comparable with that of northern New York
and New England ; the winters are long and there is
much snow.
The accompanying chart will indicate the various
climatic features. Edward 0. Otis.
OUABAIN. — This name has been applied to at least
three distinct ghicosides, by different chemists, under the
impression that they were identical, all derived from
African arrow poisons, or from the substances used in
their manufacttire. The name was derived from "Oua-
baio," " Wabei," or " VVabajo," in relation to the Indians
who used the arrow poison referred to. Eraser, in order
to eliminate this indetinitene.ss, proposed for one of these
substances, that generally employed, the name Aeocan-
?/«'Wft (C3(,Il4oOi2HoeO). It is derived from a species of
Acocanthera, almost certainly A. Scliimperi (A. DC.) B.
et H. (Carissa S., A, DC, fain. Apocynacea), though the
present article of commerce is believed to be derived
cliietly from a species of Strophanthvs (" S. glabcr"), ot
the same family. This glucoside occurs in colorless,
transparent plates, if ciystallized from water, or in tine
tufted acicular crystals, if from alcohol. Nearly one per
cent, dissolves in water and nearly two and a half per
cent, in alcohol, but it is insoluble in ether and chloro-
form. The aqueous solution is tasteless. Sulphuric acid
turns it red, afterward becoming green. Its primary
effect is to slow and strengthen the heart. If the dose is
very small, there is little effect upon blood pressure; if
large, the latter is greatly increased, ajiparently through
the vaso-motor effects. It powerfully stimulates un-
striped muscle. In toxic doses it is an extremely active
poison, 5-10 mgm. producing death in animals in a
very short time. It is estimated that gr. -^^ introduced
into the blood of man, would prove fatal. There is an
early rise of blood pressure accompanied by increased
cardiac action, which is followed by weakened contrac-
tions of the heart, rapid pulse, and paralysis of the
vaso-motors. For further reference to the physiological
action of ouabain see P/iarm. Jour., 1888, 163; London
Lancet, xi., 1888, 392; Thcr. Gaz., November, 1891; Br.
Med. Jour., i., 1893,27; Virc.how's Arch., Bd. cxxxiv.,
1893; Piairm. Jour, and Trans.. .July, 1895; Berlin, klin.
Wocli., Mar. 31, 1902.
The local application of ouabain produces a condition
of ana'Sthesia, and it has been found that a few drops of
a 1 to 1,0110 solutiiin, instilled into the eye, cause an insen-
sibility of the conjunctiva and cornea. This lasts for
one or tn-o hours, the ptipilat the same time being power-
fully contracted and the tension of the eye increased.
The medicinal uses of ouabain have not been developed,
though they would undoubtedly be almost identical with
tho.se of strophanthiu, with which ouabain was for some
time believed to be identical. The dose of ouabain is
Cli.mate of Ottawa.
Latitude, 45° 26' N. ; Longitude, 75° 41' W.-
Years (Broken Periods).
-Period op Observation, Fourteen
Teniperatnre, Degrees Fahr,—
Avcrag<' or normal
Average range
Wean of warinest
Me;in of coldest
HiL'lic-t or inaxininm
Liiw St or mlDimuiii
Huiniilitv —
Average relative
Pr cipitation—
Average in inches (rain or snow)
Wind
I*reva11ing direction
Avemge hourly velocity iu miles
Weather-
Average number of clear days
Average nundier fair days
Average number of cleai" and fair days
10.6°
1S..'S
3.5. ;3
ir.n
.5.3,1
-33.0
883
2 81
NW. &
NE.
8.1
10.;
17.'
20.. 5"
16..->
43.3
26.7
55.1
-32.0
SS,%
3.02
6(.y°
19.8
76.2
.50.4
9fi.3
34.7
73!?
2.08
W., E.
4.9
10.7
13.7
■M.i
65.7"
18.9
79.9
61.0
98.5
34.1
1.81
w.,
NW.
3.8
12.3
13.3
25.6
45.0°
18.5
62.9
44.4
80.4
17.0
82«
2.73
NW.,E,
5.1
6.5
9.7
16.2
38.3°
'i%
NW.,E.
6.6
27.0
32.7
59.7
73^
5.79
W..E,
4.2
31.0
41.0
72.0
43.9°
82*
W.. NE.
5.4
18.7
;!3.2
51.9
88^
8.64
NW.
7.6
17.9
27.7
43.6
40.3°
80*
29.40
NW.&
NE.
6.0
94.6
1.34.6
229.2
430
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Osteomyxoma.
Ovarlfu,
commonly given at from gr. ^^ to gr. ^. It is really
probably much larger, though its little known character
requires that it be used with great caution.
Ouabain has been employed as an antispasmodic iu
whooping-cough, by Dr. William Gemmell, of Glasgow
(British Midical Ju'iirnal, Ajjril 26th, 1S9U). He reports
the treatment of forty-nine cases, of which tweuly-live
had been dismissed cured, four had died, and the re-
mainder were under treatment. The fatal terminations
were due to diphtheria, meningitis, and progressive
emaciation. From his observations, he arrives at the fol-
lowing general conclusions: 1. Ouabain is of marked
benefit during all stages of whooping-cough, and if care-
fully used produces gratifying results. In the first stage
it cuts shbrt the attack ; in the second, it reduces the vio-
lence and frequency of the cougii, and diminishes the
number of whoojis; and in the third, it Iiastens conva-
lescence in a remarkable manner. 2. Ouabain is a drug
which does not appear to be cumulative; its administra-
tion can be stopped suddenly without any ill eJTect be-
yond an exacerbation of the whooping-cough: it can be
as su(klenl)' resumed. 3. It should be given, at tirst at
any rate, in a dose of gr. xii'trTF every three iiours (gr. j-tj
daily). 4. For children under one year of age the dose
should not exceed gr. yjj'j^ every three hours. 5. In chil-
dren of from six to twelve years of age, if the cough be
very violent and the whoops arc numerous, gr. ^J^
may be given in each dose, but the action of the drug
must be carefully watched. 6. Ouabain may be given
alone, dissolved in water, or in combination with potas-
sium bromide, or with chloral hydrate. The simplest
way is to dissolve one grain iu distilled water, so that each
minim of the solution shall be equal to gr. xt'su ouabain,
as: I^Sol. ouabain, v\, xlviij. ; syr. aurantii. 3 iv. ; aq. ad
3 vi. M. Sig. : A teaspoonful every three hours. 7.
Under the administration of ouabain, it is found that the
temperature, pulse, and respiration are. iu uncomplicated
cases, slightly below normal. When the drug is pushed,
the respirations become very slow indeed; iu one patient,
aged four, they were often as low as sixteen per minute.
It is from this that danger is to be expected. During the
administration the action of the .skin is promoted, the
amount of urine is increased, and the movements of the
bowels become more regular. Ouabain has also been
used with equally satisfactory results by Dr. J. Lindsay
Porteous, of Yonkers, N. Y. {Nein York Medical Journal.
vol. liv., 345). He gave it in three cases, one adult and
two children, and in all marked improvement was imme-
diately noticed. To a child of fifteen months gr. ^-^ku was
given every three hours; to a child of four years, gr. ^Tnnr
every four hours, and to the adult, gr. j^^ every three
hours. In all these ca.ses the patient was entirely well at
the end of a week. Beaumont Small.
OURAY SPRINGS.— Ouray County, Colorado. Post-
OFFicii. — Ouray. Hotel and cottages.
Access. — Via Denver and Rio Grande Railroad (narrow
gauge) from Denver, Colorado Springs, and Pueblo.
The town of Ouray is situated in a picturesque aiuphi-
theatre of the Rocky Mountains, 389 miles from the city
of Denver. The altitude of the town site is 7,500 feet
above the sea level, but the neighboring mountain peaks
tower several thousand feet higher. Mount Snefflis.
five miles west, reaches an elevation of 14,225 feet,
while Uncompahgre Peak, ten miles east of the town,
attains the superb altitude of 14,440 feet above tide
water. The famous and beautiful Bear Creek Falls are
two miles south of the town, and near them is the
wonderful piece of toll-road, cut in walls of perpen-
dicular (|uartzite. All about the neighborhood are
rich mines of gold and silver. There are also many
other natural features of interest, including caves, water-
falls, cations, peaks, lakes, and gorges, reached by good
roads or mountain trails. The climatic conditions about
Ouray are quite unexceptionable, sunshine being the
rule, with warm and pleasant days during the summer,
followed by cool, refreshing nights. The highest sum-
mer temperature is about 90° F., and the lowest winter
minimum 5° F. ; but owing to the rarity and dryness of
the atmosphere, these extremes represent much less va-
riation than in most localities of the East. The number
of springs in the town limits is estimated at more than
one hundred, the temperature of their waters ranging
from 130° to 140° F. No analysis has been made.'but
we are informed by the proprietor of a number of the
springs that the waters contain lime, soda, manganese,
and iron, and some of them sulphur. Two bathdiouses
have been fitted up, and are much resorted to in the
treatment of rheumatic affections. It is said that the
internal use of the waters has been found beneficial in
cases of dyspepsia, indigestion, constipation, and blood
and skin disorders. The town of Oura_v has about
twenty-five hundred permanent inhabitants, and is well
supplied with pure anil wholesome water from mountain
springs by water works constructed on the gravity plan.
The city possesses a complete system of sewerage, and
is always in a clean and healthful condition. The cli-
mate is said to be very beneficial to persons suffering
from bronchial and pulmonary troubles.
James E. Crook.
OVARIES, DISEASES OF.— The ovaries are two small
ovoid or roumled bodies, one of which is attached to the
posterior surface of the broad ligaiuent just interna! to
and below the fimbriated extremit.y of each Fallopian
tube. They are of a pinkish color and vary in size and
sha)ie, even iu health, without being actually malformed.
The average measurements are: Length, 30-50 mm.;
breadth, 15-30 mm. ; and thickness, about 12 mm. Ova-
ries greatly exceeding the above in size are rarely met
with, but Altoukhov reported before the members of the
Moscow Obstetrical and Gynaecological Society the case
of a patient whose right ovary measured 35 x 13 X 7 mm.,
and the left one 80 X 14 X 0 mm., and at the Siune time
luentioned a patient of Nega's iu whom the left ovary was
54 and the right 108 mm, iu length. In the latter case
the uterus was infantile and the patient a pronounced
nymphomaniac; but whether or not the enlarged ovary
caused the nymphomania it is very hard to say. Prob-
ably excessive irritation of the vulva caused the hyper-
trojjhy of the ovary.
The function of the ovaries of producing and <lischarg-
ing ova has long been known, but of late they have been
credited with producing an internal secretion which al-
leviates or prevents the troubles of the menopause.
Aiisi-'.NCE OP OvAKii:s. — One or both ovaries may be
congenitally absent. AVlien both are wanting there is
usually a lack of development of the mamma; and other
sexual organs, and when only one is missing the corre-
sponding side of the uterus is poorly developed. When
a woman has absolute amenorrlio?a, without any molim-
ina, and sterility, you may suspect that she has no
ovaries; but as long as one ovary and tube are present
maternity and menstruation will likely go on undis-
turbed. The only way to make sure about the presence
or absence of both sets of appendages is to open the ab-
domen and explore the pelvic cavity.
Ti!.\N'SPL.\NTATiON OP OvARiES. — On account of the
serious results, matrimonially and otherwise, of the ab-
sence of both ovaries, either congenitally or as a result of
operation, the procedure of transplanting ovaries is of
considerable interest. J. Lankaslievitsrii interchanged
ovaries between rabbits, dogs, etc. The operations were
carried out with the strictest aseptic precautions. Each
ovary was removed along with its mesentery, the cut edge
of which was attached to the broad ligament of the new
host near the spot from which the corresponding ovary
had been taken, but sufficiently far from the cornu of the
uterus to avoid compression. In a few instances, how-
ever, the ovary was fastened to either the mesentery or
the peritoneum of the abdominal wall; the sutures used
were fine silk and were placed very close together.
The only dog used was killed nine mouths after oper-
ation, and the transplanted ovary was found firmly ad-
herent in its new situation, and to be but slightly dimin-
i.shed in size. Caiiillarles and muscular tissue ran from
431
<>* arles.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
the ovary to the subjacent tissue. Geriniual epithelium
was seen in places and a few normal folliiles lay in the
corte.x side by side with others which had undergone
atrophic change. Yellow areas of degenerated tissue
were scattered hei-e and there throughout the organ.
In the case of animals which were liilled two or t hree years
after operation, the large ovaries reniaiued. wliercas the
smaller ones had almost entirely disappeared; and in the
latter case the genitals also had" become atrophied if the
animal's own ovaries had been removed. Conversely, it
may be stated that the transplantation of large (i.e., from
large animals) ovaries exerts an iuhiljitory action upon
theratrophy of the genitalia, and also ujion the deposit of
fat in the pelvis which usually accompanies the meno-
pause.
B. A. Katsch has also investigated this subject, and
practically obtained similar results to the above.
The ages of the animals from which the ovaries are
tal<eu have an important bearing upon the result as re-
gards rapidity of regeneration of the follicles, etc.. this
rapidity of regeneration being inversely inoiiortional to
their age. When the ovaries are first implanted their tis-
sues tend to degenerate to some extent in the following
order, viz.. connective tissue, germinative ti.ssue and its
derivatives, and lastly, the medullary layers, the Graafian
follicles undergoing a change similar to that which occurs
at the menopause. Their death takes place ceutripetally,
but they may become regenerated from the germinal epi
t helium. When this rejuvenescence of the ovaries, as one
might call it, does not take place, the genitals atrophy.
In none of the animals operated upon did pregnancy
follow, although ample opportunity for this to take place
was given.
The conclusions to be drawn from the consideration of
tlie above facts are ; (a) Ovaries can be transijlanted from
one animal to another; (i) ovaries from the carnivora will
take the place of those of herbivora and rice rersa ; and
(<•) the transplanted organs flourish and partially func-
tionate. These reported results open up visions of the
practicability of performing the same operations upon
women, but the field of feasibiiitj* would necessarily be
very lindted by the difficulty of obtaining absolutely
liealthy ovaries to transplant, as well as for other reasons
which it is unnecessary to mention.
R. T. Morris adds as further proof of the po.ssibilities
of this operation that the occurrence of pregnancy after
oiiphorectomy is due in many cases tot lie transplantation
of ]iortions of the ovary. As early as 1.nO"> Morris began
ovarian gr.afting in the human being, having had twelve
cases up to 1901. He places the ovary in normal saline
solution at a temperature of 100' F. In his early cases
he made a slit in the fundus of the uterus and placed the
ovaiy in it, but in his more recent ones the ovary was at-
tached to the broa<l ligament as near the seat of attach-
ment of the patient's own ovary as possible. The result
thus gained is tlie avoidance of a jircmature menopause,
thus showing that the ovarian graft lias retained its vital
ity. In one case pregnancy resulted, Ijut an earl}' abor-
tion occurred.
Accessory or Third Ovaries. — These have been
described, but were probably nierelj' pieces of an ordi-
nary ovary, which had become separated from the rest
of the organ by fissures. It issigniticaut that during the
thousands of co'liotomies which have been ]ierformed of
late years, no competent observer has definitely reported
a case in which more than two ovaries have been found
in any one patient.
Drsi'L.\CE.MENTS OF THE Ov.\RV. — While the ovarics
are developed in the abdomen they usually descend into
the pelvis, but now and then one or both tail to do so and
remain at the level of the pelvic brim. This malposition,
however, gives rise to no symptoms, but will pnvent the
l)hysician from feeling the organ during an ordiuaiy bi-
manual examination. It may be diagnosed by not dis-
covering the ovary in its usual place, or in thin subjects
by feeling it at the pelvic brim during dee]) abdominal
palpation.
IIern'I.\. — A more important form of dis]ilacement, on
account of the discomfort to which it may give rise, is
hernia of tlie ovary. Here it descends along the round
ligament and lies in the sac of an ordinary inguinal her-
nia, or it may lie in one of the labia majora, or even form
part of a femoral or obturator hernia. In addition to the
usual symptoms of a hernia, one gets an exacerbation of
pain at the menstrual jieriod and also an increase in size
and tenderness al the same time. Pressure gives rise to
a peculiar nauseating pain, which is almost pathogno-
monic of pressure on either an ovarj' or a testicle.
TreatmeDt. — If in a position in which it is subjected to
much irritatiou or pressure, the ovary may be protected
by a cap or pad; but if these fail, it may be removed by
an ordinary herniotomy operation.
Prol.\pses of the Ov.vry. — In health the ovary lies
to one side of the uterus, at the level of or slightly below
the fundus. In certain conditions, however, it falls con-
siderabl_v below that level, at which time the position
may be considered to be pathological. It is due to a re-
troposition of the fundus dragging it out of place, or to
adhesions due to an old pelvic peritonitis, acting in a
similar manner. A .general want of tone of the parts or
juolonged ovarian congestion will also cause the ovary to
liecome prolapsed. Other causes of this condition are
sudden strains or any enlargement of the organ.
The symptoms are caused by the congestion consequent
ujjon the displacement of the organ and by the disturb-
ance of and pressure upon it by the distended bladder or
rectum, and the various movements of the pelvic mus-
cles. These all cause a dragging, aching pain in the pel-
vis, which is exaggerated at the onset of the menstrual
congestion. More or less severe paroxysms of pain are
caused by coitus and the passage of hard fa'cal matter
along the rectum.
When the organ is not eiubedded in adhesions, the diag-
nosis of a prolapsed ovarj' is comparativel_y easy. On
making a vaginal examination a tender ovoid, mobile
body is to be felt, either low down behind the uterus or
in one or other lateral region of the pelvis.
The trciitiiuid consists in finding and removing the
cause wherever possible. If the uterus is prolapsed or
retroverted, restore it to its normal position, and keep it
there by tampons or a pessary. If there is a general
want of tonicity in the parts, try to improve the condi-
tion by hot douching, local counter-irritation per vagi-
nam, and the insertion of a boroglyceride or glyeeride of
fannic-acid tampon, as well as by the local use of elec-
tricity, especially faradic. The bowels should be kept
regular, and gentle exercise (walking) be encouraged.
Some writers advocate pelvic massiige for this condition,
and claim to have obtained striking results from this line
of treatment. It is questionable, however, if the doubt-
ful good obtained is not entirely eclipsed by the ill effects
which the necessarily prolonged handling of the genitals
produces.
When the ovary is adherent, and the above treatment
fails to relieve the pain, etc., an operation will be re-
quired. The indication will then be to separate the ad-
hesions and possibl)' stitch the ovary in a more favorable
position on the broad ligament. In order to prevent the
formation of fresh adhesions the raw surfaces may be
covered with Cargile's animal memlirane or with a small
portion of oiuentuiu, which may be cut off and carefully
sutured over them. The abdominal route is the one rec-
ommended for this ojieration, as you are able to expose
the parts thoroughly, and treat any small pockets of pus
which are so ajif to be present in old cases of pelvic peri-
tonitis. You can also stitch the ovary in place better by
the abdominal than by the vaginal route.
Atrophic Disturb.vnces. — Atrop/ii/ of Hie o ran/ may
be physiological (as when it follows the menopause) or
pathological. Pathological atrophy is apt to accompany
excessive obesity, while |>rolcmged pressure by adhesions
or tumor, interference with the vascular supply and re-
moval of the uterus, are also causes of this condition. It
is also said to follow alcoholism, acute exanthemata,
rheumatism, etc., but fhe condition then is not one of
true atrophy but of cirrhosis.
432
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
Ovaries*
Ovaries,
111 rirrhosiK of the oKinj there is au increase in the filirous
tissue of the organ at the expense of the glandular and
muscular elements. In the early stages the ovary is of
normal size, but is firmer than usual; while later it is
small and very hard, its surface is glistening white and
thrown into brain-like convolutions by contraction of
the fibrous tissues.
The sympUjins are pain, sterility, antl various reflex
neuroses, the patient often complaining of gastric dis-
turliance. visual defects, and headaclie. The pain is
usually related to menstruation, or is of a peculiar dull
sickening nature, coming on from ten days to two weeks
before the onset of the flow. Local examination of the
pelvis is not apt to reveal very much, as the ovaries are
too small to be felt except in particularly favorable cases,
when they are felt to be very hard, painful, and small.
In the way of tnatinent, not much can be done, al-
though in the earlier stages electricity may possiblj-
cluck the condition. When fully established, however,
oophorectomy is indicated.
The etioliMiy of the condition is unknown.
lIvPERTROPny. — This is caused by an^'thing which
produces chronic congestion, or by any inflammatory
process which stops short of the formation of jius. As
examples of those causing congestion ma_y be cited
chronic constipation, prolapsus ovarii, too frequent
coitus, etc. Pure hypertrophy, however, is where there
is an increase of all of the constituent parts of the ovary,
and is extremely rare, the above conditions being much
more likely to be followed by cystic or fibrous enlarge-
ment than by true hypertrophy.
The ni/'iiptimi.i of hj;pertrophy of the ovary per* are
practicallj' nil, but will be those of the condition giving
rise to it; consequently no treat ment is necessary.
Infl.v.mm.\tion of the Ov.\ry. — In the ovary, as else-
where, congestion is an early stage of inflammation. Just
as in other regions, it has its own symptoms and ma}' be
checked without going further.
The causes of congestion are exposure to cold, espe-
cially during menstruation; chronic constipation, in
which case the left ovary is the one chiefly affected,
owing to its proximity to the rectum; excessive sexual
excitement, prolapse of the ovary, inflammation of neigh-
boring structures, bacterial toxins or germs (invasion by
the latter rarely stops short of producing pus), and twist-
ing of the pedicle of the ovary. Sometimes the removal
of one ovary produces an hypertrophy of the other,
which, as a rule, is transitory. It may, however, go on
to chronic inflammation and cystic formation; but if
promptly, properly, and patiently treated bj' rest, hot
douches, and boroglyceride tampons, the congestion
should subside in a few months' time. One can readily
understand how disappointed a patient is when the re-
moval of one ovary has simply resulted in the transfer-
ence of her pain to the opposite side. She will often
blame the operator for not having removed both ovaries,
and want him to perform a second oophorectomy ; but if
he is firm in his refusal to do so until a more or less pro-
longed course of local treatment has been tried, both he
and his jiatient will time and again be rewarded by the
return of the diseased ovary to health and usefulness.
Besides the above pathological forms of congestion a
physiological variety occurs during menstruation, preg-
nancy, and sexual excitement, but this does not reqiiire
consideration in this article.
Oophoritis, or inflammation of the ovary, maybe either
acute or clironic, the former usually passing on to the
chronic variety if untreated, and if the infection is not
s\ifiieiently acute to carry off the patient before the affec-
tion reaches the chronic stage.
Acute ociphoritU is practically always caused by the
presence of germs. These may be carried to the organ
by the blood or lymph vessels from some more or less
remote source of infection, or else mav attack it by a
more direct route, as where there is an acute infectious
inflanuuation of the Fallopian tube, or where the ovary
is adherent to the rectum, appendix, or other portion of
the bowel, and the germs reach it from thence.
Vol.. VI.— 28
The two most common forms of infection are gonor-
rha'a and puerperal septicaemia, both of which may
cause a most severe disease. In addition to these, how-
ever, acute inflammation may be set up by injury, by
poisons, such as arsenic and jihosphorus, by the acute ex-
anthemata, mumps, acute rheumatism, etc. The writer,
some years ago, saw a woman who was suffering from
an ordinary attack of typhoid fever; she was quite sud-
denly seized by a sharp pain in the region of the right
ovary, the pulse became more rapid and the temperature
rose. Ajipendicitis and perforation of the bowel having
been excluded, the abdomen was opened and the right
ovary was found to be enlarged and acutely inflamed.
The removal of the organ was followed by relief of all
pain, with ultimate recovery of the patient.
Syoijitoms. — The patient suffers from an acute agoniz-
ing pain in one or other ovarian region, the pain radi-
ating up toward the umbilicus into the loin, down the
leg, etc. More or less nausea is present. Defecation and
micturition are frequently painful. Examination of the
lower abdomen reveals great tenderness over the affected
region, and the same will be found per vaginam, by
which passage also one can feel the ovary to be some-
what enlarged if the parts are not too tender.
Treatment. — Absolute rest in bed is distinctly indicated,
as is also the application of ice, or, if thai fails, heat,
over the lower abdomen. The ])arts ma}' be too tender
to allow of hot douches being useil, but they usually give
great relief. The water ought to be as hot as the patient
can possibly stand it, and at least one gallon should be
used. The force of the water maj' be regulated by the
height of the douche pail above the patient's bed. and
ought not to be too strong. Lavage of the rectum is often
of service, especially when the left ovary is the one af-
fected. Blistering the abdomen over the diseased area
will often be of service.
The tincture of aconite, given in doses of one or two
drops every hour, often benefits the condition by quiet-
ing the circulation, but there is no drug which has any
specific action upon the malady. The bowels should be
well emptied early in the attack and then kept at rest.
The best way to influence them is by sulphate of magne-
sia in drachm doses every hour for five or six hours; the
drug being dissolved in hot water. After this has taken
effect keep the bowels closed by tinctura opii, or by a pill
plumbi cum opio. As regards diet, it should be fluid,
light, and non-stimulating, consisting principally of milk
and its preparations.
Prof/nosift. — If the patient is seen in time and if the in-
fection is not too virulent, the above treatment suffices to
cure the vast majority of cases. But the disease may pass
into the chronic variety, or else an abscess maj' be formed.
This ab.scess if not interfered with may either resolve, re-
main quiescent, or rupture. If the organ has become ad-
herent to either the bladder or the bowel, it may rupture
into them and its contents be discharged externally. Oth-
erwise it will rupture into the general peritoneal cavity,
causing acute inflammation of its lining membrane and
the death of the patient. After the escape of the contents
through either the bladder or the rectum the sac may refill,
and should then be removed by the surgeon ; in fact, when
an abscess of the ovary exists which will not yield to mild-
er measures, the surgeon must interfere. It is better if
he can wait until the virulence of the germs is lessened, as
this greatly reduces the risk of the operation and occurs
within a few weeks, probably not more than five or six.
Diagnosis. — This is sometimes a matter of great diffi-
culty and imporlance. The conditions with which it is
most likely to be confused are: (a) appendicitis (when
the right ovary is attacked); (/*) intussusception; and (c)
pelvic tumor with a twisted pedicle.
In appendicitis the pulse and temperature are more
liable to be interfered with, theie is more vomiting, the
tenderness is higher in the abdomen, and it is more than
probable that a vaginal examination will give a negative
result, whereas in acute oophoritis the examining finger
will probably feel the diseased ovary.
Intussusception rarely occurs in adults. It gives rise
433
Ovaries.
Ovaries.
REFEUENCE HANDBOOK OF THE MEDICAL SCIENCES.
to a sausagc-slmped tumor, anil eillier to complete con-
stipation or to bloody and inucuid stools.
A tumor with a twisted pedicle makes itself evident
either to sight or touch, if not to both. An ovary en-
larged by an abscess would give a more cln-ouic history.
i.e., it would not give rise to tlie sudden acute pain which
torsion of a pedicle causes.
Chronic Odphorilis is much more conunon than the acute
form which it may follow. It frequently, however, comes
on quite independently of the acute variety, and is much
more insidio\is in its onset. Women are most liable to it
during tlie period of greatest se.\ual activity, from which
statement it may be correctly inferred that it is much more
common among married than among single women. Ex-
cessive sexual excitement, especially without gratification
of the desires, is one of theconunouest causes of this con-
dition. In addition to this, mumps, ma.sturbat.ion, oper-
ations upon the cervix (?), and prolonged ccjngestion of
the ovary are prolific causes.
Pirt/Kifofi!/. — When an ovary which is the seat of chronic
intlanunation is examined, it is found to be somewhat en-
larged, and to contain more or less numerous small cysts.
The organ is tirm, and its peritoneal covering is tough
and thickened. There is also an increase in the librous
tissue.
Si/mplnms. — Chronic intlamniation of the ovary pro-
duces pain in one or both sides of the pelvis, according
as to whether or not one or both ovaries arc affected.
When the disea.se is unilateral, the left is the one usually
the seat of the trouble on account of the proximity of the
rectum. This pain may radiate down the thighs, across
the abdomen, or up toward the umbilicus, and is aggra-
vated by defecation, by any sudden movement, as on
taking a jump or misstep, by jolting, coitus, etc. It also
becomes more marked a week or ten days before the
menstrual flow appears, being relieved by the local de-
pletion which is thus caused, in proportion to the amount
of blood lost, A sharp pain in either one or both
breasts, and especially in the left, is often experienced.
Pressure through the abdomen over the diseased organ
causes pain, as does also coitus. On making a local
vaginal, or, better, rectal examination of the pelvis, the
ovary is felt to be enlarged, tender, and often more or
less prolapsed.
The diiii/iwsis is not difficult as a rule. The location, in
the ovarian region, of a pain which becomes more severe
several days before menstruation ; the reflex mammarj'
pain ; painful defecation and the presence of an ovoid
tender mass in the region usually oecujjied by the ovary,
will point .strongly to chronic inflammation of the ovary.
Of course the inflamed organ may be plastered against
the pelvic wall by ailhesions, in which case j'ou will have
to be guided by symptoms alone.
Treatment. — This consists in fluding and removing the
cause wherever this is possible. Regulate the bowels and
diet and limit the |iatient's exercise. This may require to
be entirely proliibiled in obstinate cases, the patient being
confined to bed. Stop excesses of all kinds, whether
bacchanalian, gastronomic, or sexual. The domestic
duty most likely to aggravate, or at all events keep up
the trouble, is working the treadle of the sewing-machine,
which should be strictly forbidden. Depletion of the
pelvis may be elfected by accelerating the action of the
bowels by means of sulphtite of magnesia or one of the
many aperient waters, by hot dcniehing, by hip baths, by
medicated tampons, or by vaginal cones or bougies. For
the douehings plain boiled wati'r cannot be improved
upon. Iiut it must be used in qtiantilies of not less than
a gallon, and nuist be as hot as the patient can possibly
bear it. The vagina, not being a very sensitive organ,
can tolerate a nuicli higher temperature than the skin of
the perineum and vulva, but these parts may be protected
by a towel wrung out of warm water. The tampons are
better if they are made small, about the size of a large wal-
nut, using two or more if necessary. They will tints fit
more snugly and cause the patient less discomfort than
if a single large one is used. While tatiipnns saturated
with boroglyceride or pure glycerin are useful, the em-
ploj'ment of a ten-per-cent. solution of ichthvol in gly-
cerin, or a combination of ichthvol. tinctureof ioiline, gly-
cerite of hydrastis, and boroglyceride is to be preferred.
Counter-irritation through the skin of the abdomen, or
per vaginam, is a valuable adjunct to the above course
of treatment. The first may be carried out by painting
the skin of the abdomen with the tincture of iodine, or
blisters may be employed. When these are used a small
blister should be placed over the centre of the painful
area. When this one heals a second is to be placed at its
.side, and so on until the first one has been completely sur-
rounded; each one being allowed to heal before applying
the next. The counter-irritation per vaginam is best ef-
fected by painting the lateral fornices with a mixture of
equal parts of the liniment and tincture of iodine.
Little can bedone in the way of internal medication for
this condition. The bromides, especially a combination
of those of anunonium and .sodium, have been highly
commended and may be of some use in quieting the cir-
culation and pain. The chlorides of gold and sodium
have also been employed with benefit. Temporary ex-
acerbations of pain must be combated by the local appli-
cation of heat and the administration, by the medical
attendant himself, of morphine. Alcohol should be
absolutely forbidden as it only aggravates the condition
eventually, although it may relieve the pain for the time
being.
The above line of treatment ought to be conscientiously
persisted in for many months before abandoning it as
useless — that is to say, when the woman can give up the
time for it. When she cannot do this, and it is necessary
to cure her quickly so that she may return to her ordi-
nary sphere of usefidness in a comparatively short time,
as also in those cases in which all non-operative means
have failed, removal of the offending organ is the only
resource left. This tna)' be done per viatn abdominalem
or per vaginam, but this operation will be fully described
in another article. (Cf. Orariutomy,)
Heemaloriui of the Orary. — During the course of acute
fevers, as a result of injury or pressure upon or torsion
of the broad ligament containing the ovarian vessels, one
of the capillaries within the stroma of the ovary or wall
of a Graafian follicle may rupture and give rise to a col-
lection of blood, which is called anha'matoma ovarii. It
may also be caused by the impregnation and rupture of
an ovum in the ovary, the possibility of the occurrence
of which has been but recently demonstrated. Ha?mato-
ma of the ovary is not at all uncommon, but is rarely of
any clinical significance. On inspection the ovary is seen
to have a larger or smaller bluish-red mass projecting
from its surface, which mass is semifluctuating. Micro-
scopic examination reveals a mass of blood clot lying
within a more or less well-formed capsule.
Ovarian hannatoma rarely gives rise to any symptoms
or calls for any treatment. If .symptoms are present they
are usually those of chronic ovaritis and call for the same
treatment, except that where operation is indicated noth-
ing should be removed but the diseased portion of the
ovary.
Ov.\BiAN Pregnancy. — In Clifford Allbutt's "System
of Medicine," published as recently as in 1896, the writer
on "Diseases of the Ovaries" says: "It is extraordinary
that belief in the occiu'rence of ovarian pregnancy should
have obtained currency," and that "until some specimen
is forthcoming in which an eaily embryo in its mem-
branes can be demonstrated in a sao inside the ovary, we
need not trouble ourselves to discuss ovarian pregnancy."
Only three years later Croft and van Tiissenln-och each
reported an undoubted case, and since then at least three
other cases have come to light, viz., tho.se of Anning and
Littlewood in 1901, Mayo Robson in 1903, and Thompson
in 1903. It is a curious fact that of the five cases no less
than three occurred in Leeds, England.
tSynipto/ns. — Ovarian ]iregnancy gives rise to very much
the same symptoms as those of ordinary tubal gestation,
except that, as a rule, rupture is not preceded by the dull
aching pain in the side, to which the latter gives rise.
The absence of this pain may be ascribed to earlier rup-
434
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Ovaries.
Ovaries.
ture and to there being no firm muscular fibrous tube
wall to (iisteiul.
The patient passes her time by a week or ten days, or
else her last period has been replaced by a dribbling of
blood which has persisted. This is followed by a sudden
sharp pain in one ovarian region, accompanied by faint-
ness, with possibly actual loss of consciousness, b}' sigh-
ing respirations, pallor, a cold clammy sweat, and rapid
thready pulse. Although the temperature is usually
subnormal, some elevation of it is quite compatible with
the condition, as was recently seen in a case which the
writer had under his care in the Montreal General Hos-
pital.
On examining the patient the surgeon will find some
tenderness over the affected organ, slight duluess in the
flanks, and the seat of the effused blood will be warmer
than the rest of the abdomen. Attention was first drawn
to this sign by Grandin, and while it cannot be always dis-
tinguished, the writer has seen it in at least one case since
the publication of Grandin's paper. Vaginal examina-
tion will reveal an oozing of blood from the vagina, a
softened velvety cervix, normal uterus, and a rather
vague mass in one fornix.
The etiolorjii is still subjudice. As shown by tlie fact
of only five undoubted cases having been reported, preg-
nancy occurring in the ovar}- is extremely rare: but it is
quite possible that many of the cases of hematoma of the
ovary which have been reported have really been cases of
ovarian pregnancy, it being probable that villi and other
signs of gestation would have been observed if they had
been carefully searched for. On the other hand, it is al-
most certain that many of the oUier cases of reported
ovarian gestation have really been nothing more than
hoematomata. as proved by microscopic examination. In
order to be certain tliat the gest<ition is ovarian, it must
be shown that the original attachment is inside the ovisac,
and that the ovum derives its nourishment from thence.
This can be done with certainty oulj' in the very earliest
weeks of pregnancy, as the ovarian tissue is liable to be-
come so displaced in cases of tubo-ovarian pregnancy as
to appear to have been the original seat of implantation
of the ovum. In a true ovarian gestation the ovum im-
mediately upon impregnation attaches itself to the wall
of the ovisac ; villi are thrust into this wall, and by this
means the ovum is nourished. In the majoritj- of cases
the ovum continues to grow until between the fifth and
sixth week, at which time it ruptures into the peritoneal
cavit}'. This is followed by severe intrajieritoneal hemor-
rhage, although, judging from the small numbers and
size of the vessels, one would not expect such a result.
In at least two of the fully reported cases the abdomen
was found to be filled with blood at the time of oper-
ation.
Trefdm(nt.—'Vh\% will vary according as to whether or
not hemorrhage has ceased and the patient can be kept
under observation and constant readiness for operation,
and also whether or not the clot is undergoing absorption.
If se(?n some time after rupture has taken place an<l
if the patient can be kept under close observation, tem-
porizing measures may be adopted. In such a case one
of the most important points to be remembered is that all
cardiac stimulants are absolutely contraindieated, as their
exhibition is very liable so to increase the force of the
heart's action that the clots, which are plugging the
mouths of the ruptured vessels, will be forced out and a
fresh hemorrhage take place. The very best way to im-
prove the patient's condition is to use decinorma! saline
solution, either per rectum, or subcutaneously, or intra-
venously, according to the acuteness of the symptoms.
It is only in the most urgent cases that the latter method
is required, as the solution is very quickly absorbed from
either the bowel or the submammary region. Absolute
quiet and rest in bed are strongly indicated, and the cir-
culation and pain may be calmed by the subcutaneous
injection of morphine. Ice should be applied to the ab-
domen over the point of rupture, and hot va.ffinal douches
may be begun some days after cessarion of the bleeding.
The diet should be nutritious but non-stimulating.
Where under this treatment the clot does not become
absorbed within a reasonable time, it may be cleared out
by means of an incision through the posterior vaginal
wall.
When the patient is seen soon after rupture, or when
she cannot be kept under observation, the quicker the
abdomen is entered, the bleeding controlled, and the ges-
t;ition removed, the better it will be for the patient, shock
or no shock. This condition of shock is to a very great
extent due to loss of blood, and will not be lessened by
allowing this to proceed. While some few of these pa-
tients will recover ■without operation, a much larger per-
centage of recoveries will take place if the knife is used
early, energetically, and judiciously.
Tuberculosis of the Ov.\ky. — Tuberculosis of the
ovary is extremely rare, the ovary being only the thinl in
order of frequency of the female genitals to be affected.
In fact so rare is the disease that the older writers did not
deem it worthy of consideration in their works. The
rarity and almost impossibility of occurrence of primary'
ovarian tuberculosis can be readily understood when one
realizes that in order to have such a condition the bacilli
would require to enter the body from the exterior and
then traverse a more or less complicated system of blood-
vessels or lymphatics before entering the ovary. No case
of primary tuberculosis of the ovary in the human sub-
ject has yet been reported. Although Acconi experi-
mentally produced it in animals, Spaeth, Blebs, Oppen-
heimer, Sippel, and others have recorded cases in which
the ovary was the only genital organ to show the disease
in patients who were otherwise tuberculous. In the
majority of cases it was the superficial part of the organ
which was the seat of the disease, the presence of which
in the deeper layers wasfrequently unsuspected until the
ovary was examined under the microscope.
The form of tuberculosis present is the miliary form,
and it may affect either the superficial or the deep layers.
AVhen the latter part is affected, the disease is apt to pro-
ceed until an abscess is formed, and this may rupture
into the peritoneal cavity. The germs may reach the
ovary either tluough the blood or the lympli current by
direct continuity, as in the case of tuberculosis of the peri-
toneum or tubes, or by bacilli working their way through
a weak spot in the bowel wall and falling upon and in-
fecting the ovary.
No age is exempt from this disease, but those rjuder
fifty are the most liable to be attacked. Out of IT cases
reported by Griffith 5 were under fourteen, 8 were be-
tween fourteen and twenty-five, 3 between twenty-five
and forty-five, and 1 was fifty -five years of age.
lihediaicid hiMori/ is very vague and there is no symp-
tom or series of symptoms which can be considered to be
at all pathognomonic of this condition. There may be
absolutely no symptoms or el.se those described as occur-
ring in chronic oophoritis may be present. Where such
is the case and you have a semifluctuating, rounded,
n(m-sen.sitive mass occupying the region of the ovary,
together with an evening rise of temperature, in a young
woman who is otherwise fairly healtliy, and who has not
been exposed to the two common causes of pelvic ab-
scess, viz., gonorrhoea and sepsis, you may suspect the
presence of a tulierculous abscess of the ovary. Anj'-
tliing short of abscess formation cannot be definite!}'
diagnosed previous to operation, as both physical signs
and symptoms are too indefinite. Menstruation may or
may not be affected, but when it is interfered witli
amenorrhoea is the form usually taken, and is more the
result of the general than it is of the local condition.
Once diagiwsed the only timtwcnt to be adopted is re-
moval, butlhis can be advocated only in the absence of
extensive disease of other organs.
Tumors op the Ov.\ut. — The ovary itself may bc> di-
vided into tlie oijphoron which contains the ova, and the
paraoiiphoron or part nearest the ovary. Although this
latter is anatomically i|uite distinct, it might be consid-
ered clinically to be "part of the ovary. Of these three
parts, the oophoron is the most active as far as the for-
mation of tumors is concerned. From it are derived : 1 .
435
Ovaries*.
Ovaries,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Fibromata; 2. Jlyomata; 3. Sarcoiiiiita; 4. Carciuomata;
5. Cysts; fi. Aiicuoiiiata; 7. Dermoids.
The paraoijplioron gives rise to papilloiiiatoiis cy.sts.
am! from tlie parovarium are developed uiiiloeular, tliin-
walled cysts. Of tlie above tumors cystomata form about
uiuety-tive per cent., tlie multilocular cysts beiui; the
commonest.
1. FihnimaUi. — Tlicse arc tlic rarest of all ovarian tu-
mors, muscular tissue beiu';- found alon.i;- with librous iu
most benign solid ovarian tumors. When pure, these
tumors consist of many hands of white tibrous tissue
which interlace and include in spaces rouud cells, and
Jiere and there among the fihvrs a few small spindle cells
are seen. No blood-vessels or nerves are found iu the
substance of the growth. Fairbairn divides them into
three groups: (1) Where the whole ovarian stroma is re-
placed; (2) where part of the stroma only is alTected;
and (3) where a pedunculated tibroid springs from tlie
surfaci^ of tlie ovary.
Fibroids of the ovary are more likel}' to develop in
women who have |)a.sse<i the menopailse than are libroids
of the uterus, and they occur twice as often in manied as
in single women.
ileriiert Sjiencer found the tumor to originate in the
Hbrous capsule of the Graalian follicle iu three cases.
Peter Horrocks asserted that when carcinomatous and
sai'comatous tumors are bisected the cut surface remains
flat, whereas in fibroids it becomes concave, owing to the
■elasticity of the fibres. But this diagnostic sign is un-
trustworthy. The disease is usually unilateral, but Clee-
nian recently reported before the I'hiladelpliia Obstetri-
cal Society a case in which a |iurc fibroma of each ovary
was found in a patient. Ascites was also present.
Si/iiijituws iitv often absent until the tiuuor lias been
present for a long time. The patient may, however,
fomplain of dysuria, dragging pain in the pelvis, dys-
lUienorrha'a, and enlargement of one side of the lower
abdomen. Ascites is frequently jiresent, but it does not
form a constant sign. Local examination reveals au e.\-
tremely hard, firm tumor of ovoid shape, situated to one
side of the uterus; it is non-sensitive and usually mobile.
The only trcatiiunt is removal, and this ought to be
I'tfeeted as soon as the tumor is discovered, on account of
the (litHculty of diagnosis between it and sarcoma.
The ;<;'"j)/«,vi'.v is unfavorable if the fibroids are not re-
moved, as, unlike uterine libroids, they are liable to take
on active growth at any period of the iiatient's life.
2. MjioiiuiUi. — Tumors of the ovary composed wholly
of muscular tissue arc almost as rare as pure fibromata.
They usually develoji from near where the ovarian liga-
ment joins the ovary, as this ligament contains an abun-
dance of muscular ti.ssue. In IHytiGessner found a small
tibroid tumor on the ovarian ligament, situated at an equal
distance from both the ovary and the uterus, and he in-
ferred from this " that a myoma of the ovarian ligament
might invade a healthy ovary and convert it into a myo-
ma of the ovary." Baldy. in "American Gyna'cology,"
reportsa case which occurred in a married woman, thirty-
si \ years of age. Operation revealed multiple uterine
tibroiiis, and that the right ox'ary was replaced by a
(ibroid mass of the sliape and size of a lemon. This mass
was attached to the posterior layer of the broad ligament
and had the Fallopian tube running over its upper sur-
face. The fimbriated extremity of the tube ended on the
external surface of the capsule of the tumor. This latter
itself was composed of smooth muscular tilires and a lit-
tle connective tissue. A band composed of connective
tissue and large blood spaces separated it from the true
ovarian tissue which was apparently normal.
3. Sarcmniitii. — The ovary is not infrecpiently affected
by tumors of a sarcomatous nature. Ajiarl from regular
sarcomata, masses of tissue indistinguisliablc from .sarco-
ma sometimes occur in dermoids, the remov.il of which
in these cases may be followed by malignant cli.sease of
the pelvis. When the ovaries are atlected by these
growths the disease is frequentl_v bilateral, here (iift'eriug
from what takes jilace in other parts of the body where
the afTection is usually unilateral.
The ovary may be invaded by either the round- or the
spindle-celled variety. The fcn-mer is usually found
when both sides are affected and iu young patients. At
tlie Wurzburg Frauenklinik, out of 295 cases of ovarian
tumors 20 were sarcomatous; the ages of the patients
ranged from twelve to sixty-three, 7 being over tift.y
years old. Out of 4 wliicli occurred in females under
twenty, 3 were of the round-celled variety. Seven died
after operation, 3 within the first four days and 4 before
six miuiths had elapsed.
Colin states that their occurrence iu relation to ovarian
cystomata is as 1 to 100, and that they form ten percent,
of all malignant tumors of the ovary. In 400 cases of
ovarian tumors of all kinds, including endothelioma, he
found 5.38 per cent, to be sarcomata.
The tumors may grow either i-apidly or slowly, and
often attain a weight of from twenty to thirty pounds.
Their consistence varies, some being hard (the spindle-
celled variety), and others (the round-celled) soft and
brain-like. They are surrounded by an outer wall, which
sometimes is very soft and friable. The pedicle is usu-
ally short, and it is but seldom that adhesions to neigh-
boring organs are formed, but ascites is usually present.
On section the surface may be yellowish-white or pink-
ish-gray, this depending upon the number of blood-ves-
sels present as well as cm tlie structure. Small cysts are
often seen, and are due either to hemorrhage into the
tissue with sub.sequent softening or else to fatty degene-
ration of the tumor cells.
Of the two varieties, the small round celled is the most
malignant; the greater the|amount of librous tissue pres-
ent, the less danger is there of any secondary trouble.
This secondary infection attacks structures in the follow-
ing order; viz., peritoneum, ouK'ntum, stomach, pleura,
lungs, uterus, liver, diaphragm, and kidneys. The tumor
may undergo degeneration, the commonest being fatty
and myxomatous.
The symjitoiiis arc few at lirst, but ascites may develop
early, and this forms one means of dilTerentiating sarco-
mata fi'om fibromata fir myomala of the ovary. Pain
and disturbance of menstruation are also more frequent
than iu benign solid ovarian tumors. Physical examina-
tion yields similar results in both fibroma and sarcoma
ovarii. Metastases are indicated liy ascites, a'dema, en-
larged abdomen, and rapid decline in the patient's health.
The only treatment is prompt and thorough removal of
the all'ccted organ, and it is also wise to remove the ovary
of the opposite side, as it may be affected without show-
ing it macroscopicall_v.
Post-operati\'e prurimms as regards recurrence is not
good, but is better than when the ovary is the seat of
cancer. When both ovaries are diseased or when the
round-celled variety is found, the prognosis is decidedly
more grave than when one side only is affected or when
the growth is compo.sed of spindle cells.
Eiidi'thilioiiKitii. — These are malignant tumors which
begin by a proliferation of the endothelial lining of the
blood or lymph vessels of the ovary. The}' may be said
to occupy a place midway between carcinoma and sar-
coma, ditfering from them in structure but possessing
similar clinical features. Billroth regarded them as be-
iu.g as malignant as carcinomata.
Endotheliomata were thus named on account of their
origin, by Marchaud, who first described them in 1879.
They are usually soliil, but may contain spaces. The
surface is smooth, but may present tuberosities, com-
jiosed of tissue wliich is of a brain-like or spongy consis-
tence. They occur mostly at middle age. altliough Leo-
]iold has seen one in a girl of eight, and Olshauseuone in
a .girl aged seventeen. In size they vary from that of a
closed fist to that of a fcetal head. Usually they are uni-
lateral and rounded, but may be bilateral and lobulated.
The pedicle is short and the tumor |)roue to form adhe-
sions.
On section, the cut surface may be either gra)', or yel-
low, or white, the tissue being soift and friable and easily
torn by the fingers.
Pick differentiates endotheliomata into three types, of
r,w
REFERENCE HANDBOOK OF TIIE MEDICAL SCIENCES.
Ovaries*
Ovaries.
which the first is of a rosary like form, consisting of
chains of celis in rows lying iu narrow clefts of tiljrous
tissue. The borders of the rows are parallel and fre-
quently anastomose. Iu the secontl form the structure
resembles glands and it is difficult to distinguish it lui-
crcscopicall}' from adeuo-carcinoma, the spaces being cn-
croacheti upon by several layers of jjolymorphous cells.
In the third variety the cells are grouped as in alveolar
sarcoma. All three forms may occur in the same tumor.
Endothcliomata may occur in connection with other
tumors, Pfaunenstiel reporting a case in which an endo-
thelioma and epithelial cyst-adenoma were present in the
same patient. These tumors may degenerate, the usual
form of degeneration being either hj-aline or my.xoma-
tous, but colloid and fattj- have been seen to take place.
Canhimmi. — Cancer <if the ovar}- may be either pri-
mary or secondary. The latter usually accompanies
malignant disease of tlie uterus, but it may complicate
an affection of the stomach or mammar}' glands. It may
originate iu either the Graafian follicle or the germinal
epithelium. It is convenient to divide cancer of the
ovary into medullary carcinoma and adeuo-carcinoma.
I. Jledullary Carcinomata. These are solid tumors
which are usually oval or rounded, but are also often
nodular. They vary in size, but are rarely larger than
the head of a full-terra fcptus. Tliere is usually a pedi-
cle which is short and thick, but at times they are intra-
ligamentous. Both ovaries are but seldom affected.
Medullary cancers liave a dense, well-defined, fibrous
capsule, and on section the cut surface is seen to be more
or less homogeneous, of a yellowish or grayish-while
color. At times extravasations of blood into the sub-
stance of the tumor produce a mottled appearance. De-
generations, especially caseous or fatty, are common,
resulting in the formation of cyst-like cavities with irreg-
ular walls and turbid or yellowish contents.
IIistologicall_y the growth consists of carcinomatous
cells infiltrating a fibrous stroma, which may predomi-
nate and form alveoli filled with cancer cells, but usually
the cellular elements predominate.
II. Adeuo-carcinomata. Adeno-carcinomata are tu-
mors which closel}' resemble ordinary serous cysts of the
ovary. They are oval or rounded, and rarely exceed an
adult head in si/c. They usually have a short pedicle,
but may develop between the layers of the broad liga-
ment and often form adhesions to neighboring .structures.
Although they may appear to be unilocular, they are
usually multilocular. The disease is generally bilateral.
In about half of the cases examined, Pfanneustiel has
seen papilke on the surface. The cyst wall is composed
of connective tissue which is quite friable. This wall
may be thickened in sjjots, owing to the development
of carcinomatous nodules. Papillary and cauliflower
growths may spring from the internal surface of the cyst
wall and nuiy nearly fill the cavity. The cyst contents
may be clear, turbid from cellular elements, or blood-
stained from hemorrhages into the cj-st.
Cystic carcinoma of the ovary is usually papillarv,
the papilla; usually resembling ordinary papillomata, hut
OD section the microscope reveals the presence of cancer
cells, and the carcinomatous structure may at times even
be observed by the naked eye. Any individual tumor
may contain masses which vary greatly in structure from
one another. One form consists of a diffuse infiltration
of a medullar}' character. Slore often the masses arc
composed of papilla and glandular structures with their
lumen still apparent. An atj'pical proliferation of epi-
thelial cells is everywhere seen and the papillary growths
are covered with several layers of cells asymmetrically
arranged. A similar arrangement of the epithelium is
seen in the glandular forms of the disease, this giving
rise to their alveolar ajipearauce. Lime salts become
deposited in the tumors, especially those of a papillary
nature, and give rise to psammomata.
It is almost impossible to tell when an adenomatous
tumor of the ovary is benign and when malignant, as the
gradation from an ordinary cyst-adenoma to primary car-
cinoma is so gradual. Ziegler holds that no clear line of
demarcation between the two can be drawn, and Pfan-
nenstiel estimates that one-half of ovarian papillomata
are carcinomatous. He, however, is rather an extremist,
claiming that tumors which become carcinomatous should
be classified as primary carcinomata, whereas most writ-
ers would consider these to be merelj' cases of carci-
nomatous degeneration of benign growths. Metastases-
frequentl_y occur, affecting, in the following order, the
peritoneum, omentum, liver, stomach, intestine, the
ovary of the opposite side, and, but rarely, the pleura.
DtjfLrential Diagnosis of Solid Uriirinu Tiniinrx. — Dur-
ing the following brief consideration of this subject, it
must be remembered that it will often be quite impossi-
ble to differentiate between a solid ovarian tumor and a
solid subserous tumor of the uterus with a long pedicle,
as, even where this is felt on palpation, the pedicle may
be mistaken for the Fallopian tube, unless it be thicker-
than is commonly seen in the case of a long pedicle. A
kidney maj' be prolapsed into the pelvis and give rise to
some difficulty in the diagnosis, but it can usually be re-
placed.
First, these solid ovarian growths have to be distin-
guished from tumors of other organs; and secondly,
from one another. The tumor is one of the ovary be-
cause (1st) it is situated in one side of the pelvis or lower
abdomen ; (2d) it is unconnected with any other abdomi-
nal organ, as ascertained by palpation and percussion;
and (3d) uterine movements are not influenced by those
of the tumor.
A. fibroid is the hardest, slowest-growing, and least lia-
ble to produce other than pressure S3'mptoms of anj' tu-
mor of the ovary. It is more liable to appear after the
menopause than a fibroid of the uterus.
SfircoDuita are firm, and may be quite hard, but they
grow rapidly, occur at an early age, and produce ascites,
emaciation, secondary deposits, etc. They usually alsO'
have longer pedicles than the next variety.
f The mnliynant solid orrnian tumors are more apt to
be nodular than the above and produce the other signs of
malignancy (ascites, emaciation, etc.) more quickly.
Ov.\Ri.\N Cysts. — Cystomata of the ovaries may arise
from infolding and downward prolongations of the ger-
minal epithelium, or else by enlargement of follicles
which have failed to rupture, this failure frequently be-
ing due to inflammatory tliickening of the outer coat of
the ovary. Herman says that tliis latter " is such a simple--
and natural way of explaining the development of ova-
rian tumors that one would tliink that any other must
only apply to exceptional cases." and there is much wis-
dom in this statement. Why these follicles develop intO'
large cysts in some cases and not in others is not really
known, although various theories have been advanced.
They may occur at all ages and iu every condition, but-
are more often seen in women who have borne few chil-
dren than in those who have large families.
Hydrops foUieidi is a condition in which one or more fof-
licles become distended by fluid to the size perhajis of a
cherry, retaining their globular form. One variety of
this affection has been called Kokitansky's tumor, which
consists of many distended follicles which have become
pedunculated in some cases or compressed laterally in
others. They contain a thin serous fluid and sometimes
ova. This variety of tumor is both bilateral and rare.
Neoplastic Ci/sts. — Most ovarian cysts are of the prolif-
erating variety, which Walde3'er divided into the prolife-
rating glandular and the proliferating paiiillary cysts;
but this is merely a clinical division. A more scientific
classification is that of Pfanneustiel. He found that the
contents of the two varieties differed from each other.
In one there is a clear, thin, serous fluid, while iu the
other class the fluid is dark and turbid and contains a.
substance called pseudo-mucin. Using this fact as a
basis, he named the two groups pseudo-miicinous and
serous.
The pseudo-muciiionsiire the most numerous of all ova-
rian cysts. They are usually unilateral and the sir.e may-
vary from that <if a hen's egg to a tumor weighing two
hundred and forty pounds; but one rarely now sees au
4:^T
Ovaries,
Ovaries.
REFERENCE HANDBOOK OF THE IVIEDICAL SCIENCES.
ovarian cyst woigliing over thirty or forty pounds, as
they are usually removeil as soon asdiscovcri'd. No age
beyond puberty is exempt from these growths, but they
are more liable in attack women between the ages of thirty
and forty-five, especially if they are sterile or uumanied.
The shape is usually ovoid and the surface may be either
^ even or lobulated, the latter being most often seen in the
case of the smaller tumors due to the presence of daugh-
ter cysts. The color is usually bluish or purplish-white
and glistening, with here and there blood-vessels running
over the surface. At times bands of unstriped mu.scle
are also seen upi>n the surface, on which jiortions of ova-
rian tissue may become liatlened out.
When opened up. the tumor may consist of one large
sac with its contents, but if the interior is carefull_v ex-
amined bands of tissue, the remains of the walls of pre-
viously existing loculi, will usually be seen. Jfore fre-
quently many smaller cysts with their walls agglutinated
together are" discovered making up the large tumor.
The contents of these numerous loculi may vary from
a thin .serous fluid to that of a jelly-like consistency.
The inner surface of the cyst wall is usually smooth, es-
pecially if the tumor is of large size, this pressure caus-
ing atrophy of the epithelium; but in the small cysts,
small papillsE and other excrescences are often seen.
This lining is composed of a single layer of cylindrical
mucous-like cells, which stain very readily with eosin
and luvmatoxvlin. These cells are implanted upon a
layer of connective tissue and at times ovarian or un-
.stri])ed muscular tissues. Outside this again is a la3'er
composed of germinal epithelium.
The xeroi/s cysts are much less common than the above,
nor are they so large, rarely exceeding the size of a preg-
nant uterus at term ami usually being much smaller.
Externally they resemble the pseudo-muciuous. but have
a greater tendency to adhere to the surrounding organs
by means of bands. They are usually multilocular, but
contain fewer divi.sious than do the pseudo-mucinouj
cysts. They contain a clear, thin, j'ellowish or greenish
fluid, in which albumin is i)resi'nt to a large extent. This
fluid is produced partly from the blood-vessels and partl_y
by .secretion by the glands in the lining membrane. The
composition of the cyst wall is the same as that of the
pseudo-mucinous; the cells of the epithelium are colum-
nar and ciliated.
i^ymptuiiis of Ovarian Cysts. — The patient may merely
liave a vague sense of fulness of the abdomen or of weight
in the pelvis, or else she may experience no .sensations
whatever until she accidentally discovers a lump in the
lower abdomen. There may be no interference with
menstruation, so that when it ceases suddenly one should
always be on guard lest pregnancy has occurred. At
times the flow is increased, in which case an endometritis
may be found to exist.
The physical signs will vary according to the size of
the tumor. Where this is small and contined to the pel-
vi.s, a bimanual examination will reveal an ovoid, tense
cystic swelling to one side of the utei'us. Rarely it may
occupy the middle line, as occurred in a case of the writ-
er's, the tumor lying in front of the uterus, where it
was held by an adhesion on one side and the Fallopian
tube on the other. A tumor of this size wovdd cause a
downward bulging of the vaginal fornix and could lie
easily felt by the linger in the vagina, as would also be
the case when the contents of a large tumor were very
fluid or the cyst was unilocvdar. When, however, the
tumor has risen out of the pelvis it rests upon the brim,
and the only .sign of its presence to be made out by the
examining finger is the depression of the uterus. On in-
specting the abdomen, an enlargement is to be seen of
the lower part and usually to one side, this enlargement
being either regular or uneven. Upon palpation the
mass will usually be felt to be tense, hut (luctuating,
though vvlien tlie contents are gelatinous the sensation
may be similar to that caused by a soft myoma. AVhen
the tumor is imiloculur. or one locidus is esiiecially large
with very lluid contents, a thrill may be obtained by
flicking the mass with the linger on one side, while the
other hand is placed on the opposite side. This may be
intensified by requiring an assistant to exert pressure on
the mass by means of the outer edge of his hand placed
mesially on the abdomen. Percussion will show that the
intestines are pushed into the upper part of the abdomen
and to the sides, and turning the patient on one side pro-
duces no change in the areas of dulness, an ovarian cyst
differing in these two points from free abdominal ascites
in which the percussion note is clear in whatever part of
the abdomen happens to be uppermost at the time.
Diar/mm's of small ovarian tumors {i.e., while they lie
wholly iu the pelvis) is not as a ride dillicult. Tlie pe-
culiar tense, semitluctuating sensation imiiarted to the
examining finger by an ovarian cyst is felt in practically
no other conditions than hydro- and luvmato-salpiux and
encysted peritonitis. In the two former conditions the
mass is elongated or sausage-shaped instead of ovoid as
in the case of a cyst. Encysted peritonitis is fixed and
has not the clearly defined margin of the ovarian tumor.
When the cyst is adherent the diagnosis is more ditficult,
but space forbids further consideration of the subject.
Of course, a jiarovaiian cyst may be mistaken for an ova-
rian growth, but the treatment is the same and a definite
diagnosis can be made only by opening the abdomen.
When the tumor has risen out of the pelvis it may be
mistaken for ascites, a distended bladder, a tumor of the
uterus (fibroma, myoma, or fibro-cyst), cyst of the mes-
entery, ovarian dermoid, renal cysts, "hydronephrosis,
lihantom tumors, cyst of the parovarium, and pregnancy
with hydramnios.
In ascites, unless encysted, the flaidis bulge and the
enlargement does not stand up prominently, as in the
ease of an ovarian c_yst. Percussion will give a clear
note over the highest point in the abdomen. That is to
say, with the patient on her back a tympanitic note will
be heard in the region of the umbilicus, while the note
in the fianks will be dull; whereas if she is turned on
her side, the tiank which is uppermost will yield a clear
note. Exceptions to this rule, however, occur now and
then, as was well illustrated iu a case which came under
the writer's observation some years ago. An immigrant
woman was brought into hospital and found to have a
swelling of the abdomen which progressed rapidly. The
fluid impact wave was readily obtained and percussion
gave a dull note all over the abdomen, except just below
the sternum. Posture made no change in this note.
The uterus and vaginal fornices were depressed. The
heart, liver, and kidneys were healthy, and a diagnosis
of a rapidly growing parovarian cyst was made. On
opening the abdomen for its removal a large quantity of
fluid was removed from the general peritoneal cavity and
the pelvic organs were found to be healthy. Shortness
of the mesentery preventing the intestines from floating
to the .surface and the excessive quantity of fluid present
accounted for the absence of the clear percussion note
from its usual situation.
A distended bladder occupies the median line of the
lower abdomen and appears as a tense pyramidal mass
above the pubes. There is generality dribbling of urine,
and careful catheterization of the bladder will clear up
the diagnosis. For this little operation a male metallic
instrument is the best, as something may be pressed
against the bladder diagonally, thus cutting off the part
into which the ureter of one side opens. A rubber catheter
will coil up in the free part of the bladder, and this also
will be the only part of the organ which can be emptied
by the ordinary short glass catheter, while the long me-
tallic instrument can be cautiously guided past the ob-
struction into the dilated portion.
Mynmata and Jihrnmata of the ulerus are hard, and pal-
pation fails to elicit any fluctuation. They move with
the uterus, the cavitj' of which is enlarged. If they are
interstitial or submucous, menstruation is increased.
h. fihro-rysl of the uterus gives fluctuation, but moves
with and is evidently attached to the uterus. It is a very
rare form of neo]ilasm, and if it is punctured and if the
fluid is allowed to stand spontaneous coagulation quickly
supervenes.
438
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Ovaries.
Ovaries,
Cysts of tlw mesentery have a clear percussion note all
around them, if they are not large enough to fill the
whole abdomen, in which case a history of the growth
having proceeded from above downward and not vice
versa, as is the case of ovarian affections, can usually be
obtained.
A dermoid of tlie ovary is of slow growth and may oc-
cur in a very young girl.
Renal cystic tumors and hydronephrosis give a history
of progressive enlargement from above downward and
can usually be separated from the pelvic organs. In the
case of a "hydronephrosis ureteral catheterization will
usually clear up the diagnosis.
Phantom tumors disappear when the patient is anjcs-
thetized.
Pregnancy with, hydramnios may be diagnosed by ob-
serving the rhythmical uterine contractions, by ausculta-
tion, and by the softening of the cervi.x and the changes
in the breast coexistent with pregnancy. There will
also be the history of amenorrhn-a, and when all else
fails time will clear up the diagnosis.
A cyst of the parovarium grows quickly, is never nodu-
lar, and, owing to its being unilocular and containing
very limpid fluid, gives the wave impact very distinctly.
Complications of Ovarian Cysts. — Any organ or struct-
ure in the body may become diseased contemporaneously
with tumor formation in the ovary, but the most com-
mon complications are albuminuria, ascites, adhesions,
pregnancy, rupture of the tumor, and torsion of the
pedicle.
The coexistence of pregnancy and ovarian cyst is grave
and requires care before, during, and after labor. If the
cyst is large an abortion is very apt to result. The tu-
mor is very liable to rotate, causing torsion of its pedicle
after labor, owing to the change in the intra-abdominal
pressure. Infection and consequent sup]iuralion of the
cyst are also apt to occur. When pregnancy goes to full
term the fa?tal and maternal mortality is high. In 371
cases of ovarian tumor complicating labor, there was a
maternal mortality of 25 per cent, and a fa^tal of 7.5 per-
cent., while Zitter and Litzmann place the maternal death
rate at 30 and 43 per cent, respectively.
Torsion of the pedicle is a not infrequent complication
of ovarian cysts; dermoids, probably on account of the
difference in consistence and weight of various sections
of the growth, being the variety most often .affected.
Its onset may be either acute or gradual, the former be-
ing naturally the more grave.
The symptoms of a twisted pedicle are a sudden, acute
pain, followed by rapid enlargement of the tumor. The
abdomen becomes tender and the patient may show evi-
dences of most profound shock, the respirations becom-
ing rapid, the pulse small, thready, and rajiid, with later
on a rise of temperature.
When the onset is more gradual there may be few or
no special sj'mptoms. There may be an increase of the
previous pain and some enlargement of the tumor. The
rapid increase in size of the tumor is due to congestion,
which may be so great as to cause hemorrhgae into the
tumor substance or even into the peritoneal cavity.
The only treatment is to operate without delay.
Ascites may accompany an ovarian tumor, especially if
it be malignant. Its chief importance lies in the proba-
bility of there being disease of the heart, kidneys, or
liver, and in its rendering the diagnosis dithcult.
Albuminuria should he looked for a.nd cured if possi-
ble before any operative interference is carried out. It
may be caused by pressure of the tumor on the ureters,
in which case it will disappear after removal of the
growth and no casts will be found in the urine.
Adhesion of the tumor to neighboring organs forms a
serious complication when an operation is called for.
These adhesions may be so intimate as t(j olTer sutlicient
nourishment to the tumor even after it has been freed
from its usual attachment, as sometimes occurs in torsion
of the pedicle. They also complicate the diagno.sis, as.
for instance, when the tumor becomes adherent to and
moves with the uterus.
Rupture of the cyst may occur and maj- be followed by
permanent disappearance of the growth, or this may
refill. When the contents are either irritating, as in the
case of a dermoid, or malignant, a general peritonitis or
■secondary infection of the peritoneal cavity will follow.
In some cases a blood- vessel will be torn through and a
more or less severe hemorrhage into the peritoneal cavity
may take place.
Prognosis. — If left alone ovarian cysts are apt to in-
crease in size until they prove fatal through interference
with the alimentary, cardiac, digestive, and respiratory
systems.
Treatment. — Removal of the cyst by either the abdom-
nal or the vaginal route is the only treatment indicated.
Formerly frequent tapping of the tumor and withdrawal
of the contents were practised, but ovariotomy is now so
safe a measure as to have no rival in the treatment of this
condition. Tapping is not only useless, but is distinctly
dangerous, as it sets up adhesions and may allow leak-
age into the peritoneal cavity, is liable to cause sepsis,
and puncture of bowel or bloinl-vcssels may occur, and
the tluid tends to accumulate more rapidly afterward.
Even when the tumor has ruptured spontaneously oper-
ation may be indicated by peritonitis or by hemorrhage.
In a case of the writer's, rupture took place half an hour
before the time appointed for ojieratiou, and on opening
the abdomen the cavity was found to contain a large
quantity of fluid blood which had escaped from a vessel
that had been torn across.
Ov.\Tii.\xDEKMoiDS. — In women dermoid tumors have
never been found growing from any other organ in the
abdominal cavity tlian the ovaries. They are compara-
tively rare, onlv between three and four per cent, of all
ovarian tumors being of this nature. They may occur at
any age, but are more liable to occur before puberty than
any other form of ovarian tumor. Usually only one
ovary is affected, but now and then the disease attacks
both'
Until recently it was maiutaiued that they were due to
inclusion, in the developing ovary, of cells from the other
layers, but Wilms has lately suggested the probability
of their being caused by some eccentric development of
ova, and he supports this theory by the facts of their being
found occasionally in the foi'tus, and of the tumor con-
taining traces sometimes of nearly every organ in the
bodj', which is not the case with dermoids situated else-
where.
Ovarian dermoids are not large tumors, rarely being
seen larger than a man's head. They contain a cheesy
material, in which may be found almost any organ of
the body, sometimes in a very rudimentar}' state. One
of' the commonest structures found is hair, which may
measure five feet in length but which is ustially short.
In addition to these substances, teeth are often found
embedded in the cyst wall, where also rudimentary mam-
m;e may be seen. A heart with a mitral valve and chordae
tendineae has once been described as having been found
in a dermoid of the ovary. The more fluid contents are
extremely irritating to the peritoneum, and if they escape
into the peritoneal cavity they are almost sure to set up
a most intense inflammation of its lining.
An ovarian dermoid gives rise to the symptoms of an
ordinary ovarian cyst, from which it may be diagnosed
by its slow growth and the pecidiar want of elasticity
which it imparts to the examining hand. An ovarian
tumor seen in a girl before puberty is nuich more likely
to be a dermoid than one of any other variety.
The proper treatment is to remove the ttunor.
P.\riLLOMATous TuMOKS OF THE Ov.\nY. — This varie-
ty of ovarian cyst is of sufficient importance to warrant
some special consideration, and is divided into two
groups, according as to whether the papillomata occur
inside the cyst or on the outside of its wall.
1. Papillomatous cystoma of the ovary may be shortly
described as a cystic tumor of the ovary containing
masses of papillae"; from the tendency to form secondary
growths, it may be looked upon as malignant.
Olshausen, iii 1877, noted the difference between sim-
439
Ovarioloniy.
OTariotuuiy*
REFERENCE HANDBOOK OF THE lAIEDIC'AL SCIENCES.
pie cysts and those containing papillary projections.
Inspection of tlie tumor with the nakcil eye reveals
numerbua papillse on the inner surface of the cyst wall.
These may be few in number or else so numerons as
completely to fill the cavity of the cyst and even at times
cause its "rupture. The pa|)ill;ie are pedunculated and
vary from a simple projection to a most complicated
branching structure. Ni')t only does this shape vary, but
the color may range from almost white to a pinkish hue,
this depending on the sujiply of blood going to tlie pa-
pilla; and also on their consistence. They are usually
soft, but may contain .sand-like bodies which cause the
growths to fee! gritty. After perforation of the cyst
wall the peritoneum and other organs may become in-
fected.
The.se cy.sts usually contain a clear, thin, watery fluid
of a yellow color and alkaline reaction. It has a specific
gravity of from 1.00.") to 1.040, and does not coagulate on
standing. It responds to the tests tor albumin. On ex-
amining the fiuid witli the microscope, it may be seen to
contain epithelial elements, compound granular bodies,
and sometimes cholesteriu and ha'uiatoidin crystals. In-
stead of the tluid being clear, however, it may be dark
and turljid or even grumous, the character varying at
times even in different parts of the same ttimor.
Microscopical Appcai'anccs. — In a pedunculated cyst
the wall has an outer layer which is tliin and dense. It
is composed of laminated tissue, a few cells, and occa-
sionally non-striped muscular tissue may be .seen. The
next layer is thicker and more cellular. Both contain
blood-vessels. Internal to this second is a third layer,
composed of epithelium which sometimes rests upon a
thin homogeneous basement membrane. The epithelial
cells may be cuboidal, cylindrical, or, in fact, almost anj'
shape. Cilia may or may not be present, and even in the
same tumor some cells may bear cilia wliile their neigh-
bors do not, their absence or presence being ]5urely acci-
dental and having no bearing upon the case (J. W. Wil-
liams). These cells may be in one layer or in several, and
in small cysts they are not usually so high as where they
simply cover papilla;, the low merging gradually into
the high. Iii the smaller cy.sts also, part of the outer
wall may be replaced by true ovarian tissue. The stro-
ma of the cyst wall, which may Ije dense and well formed,
or else somewhat myxomatous, continues uji through the
pedicle into the papilhe, and is usually well supplied
with blood-vessels, which are thus enabled to pour out a
portion of their serum and so contribute their quota
toward the fluid contents of the cyst.
The .sand-like bodies, above referred to, are called
psammomata, and consist of particles of carbonate and
phosphate of calcium arranged in concentric rings.
Papillomata may extend from their primary site by
three methods. They may do so by direct extension to
contiguous structures, liy the attachment of small lirokcn-
off fragments of the growth to the pcritoneuiri, and lastly
by true metastatic formation.
In tlie early stage no diagnosis of the exact nature of
the patliological process is possible. This is clear only
wlieu the ascites can be made out, when the jisammomata
can be felt per vaginam, or wlien iiapillomatous mas.ses
burst into the bladder or rectum. Freund considers that
the simultaneous apiiearance of ascites and h^-drothorax
favors the diagno.sis of papilloma ovarii.
These cysts are apt to burrow between the layers of
tlie broad ligament, both toward its base and laterallj-
toward the uterus. They occur most frequently between
the ages of twenty -five and fifty.
2. Siipcrflcinl pitpiUomnta of the omri/ are more rare
than intracystic growths, and like them are nearly always
bilateral. Tliey .are formed of branrhcd, usually pedun-
culated masses, springing from the surface of the ovary.
Their histological structure resembles that of the intra-
cystic form of the disease, the epithelium being continu-
ous with tiie germinal epithelium, as is also the case in
some intracvstic growths, although the etiology of the
latter is uncertain.
The trciitiiiiiil of jiapillnmalous disease of the ovary is'
prompt and thorough removal of the diseased structures,
and tin's is usually followed by permanent relief.
K A. L. Lockhart.
OVARIOTOMY.— Ovariotomy (from the Latin ova-
rium, ovary, and Greek touij, cutting) is to be classed
among the unsatisfactory terms which unfortunately are
too common in medical nomenclature. Leaving out of
consideration its hybrid formation, the word by no means
expresses the removal of the ovary. In this sense oopho-
rectomy (u6<j>opov. ovary, ckto/jt/, excision) is far more ap-
propriate: and if the Fallopian tube be also removed,
salpinrio-viiphorcctomy should be employed.
Under the heading "ovariotomy" most text-books
consider the operation for tumor formations alone of
the ovary, ignoring the inflammatory and other con-
ditions for wiiieh identically the same procedure is more
frequently undertaken. In accordance with custom,
liowever, the first class of cases will be dealt with
here.
HisTOHY. — The history of this procedure is of consid-
erable interest. The kings of ancient Lydia are sai<l to
have had it performed upon women either for the jiur-
pose of preserving their yoiitliful characteristics, or in
order that they miglit be employed in the place of eu-
nuchs. The actual nature of the operation, however, is
somewliat doubtful, as in some instances in all inobabil-
ity only the clitoris was removed, although from the
scanty details procurable it may lie inferred that at k-ast
some genuine ovariotomies were performed. During the
seventeenth century a Hungarian sow-gelder is said to
have removed the ovaries from liis daughter as a punish-
meut for her frequent lapses from virtue. In the eigh-
teenth century, althougli suggested much earlier by con-
tinental surgeons, the jiossibility of the operation was
seriously discussed, more particularly by John Iluuterin
England and John Bell of Edinburgh, although, owing
to tlie high mortality of all intra-abdominal operations,
these men lacked the courage of their convictions and
were unwilling themselves to undertake a hitherto un-
tried procedure. Their teachings, liowever, bore fruit,
and the first ju-earranged and successful ovariotomy was
accomplished in 1809 by Ephraim McDowell, of Ken-
tucky, who liad been one of Bell's students in Edin-
burgh. It must of C(nirse lie conceded that the ovaries
had been removed by operation previous to this time, but
in the majority of such cases, if not in all, the real nature
of the procedure had not been recognized until later.
Moreover, in several other instances ovarian C3'sts had
been tapped through an abdominal incision, and portions
of the sac walls had been resected. Nevertheless, it is im-
portant to recognize the fact that all such ojierations had
lacked the careful pre-arrangement or the successful issue
of AFcDoweH's case.
In the United States the operation was repeated by the
originator twice before 1817. Nathan Smith, of Connec-
ticut, unaware of McDowell's cases, performed it in 1831 ;
Rogers, of New York, in 1829; Billinger in 183.5; and in
1843 Dunlap, of Ohio, and the Atlee brothers, of Pennsyl-
vania, obUrined favorable results. From this time on, the
operation gained in favoi' in America, and the excellent
work of W. L. Atlee and of Peasleedid much to popular-
ize it.
In Great Britain Lizars. of Edinbiu'gh, performed, the
operation four times in 1833, but no other attempts were
made in Scotland until 1845. In 1833 Jeaffreson, of Fram-
lingham, obtained the first successful result in England,
although Granville had liad two failures in 183(i and
1837. Interest in the procedure was revived in 1842 by
Clay, of Manchester, who soon became noted for his work.
Spencer Wells from 18.58 to 1871 performed the operation
440 times, and his total numlier of ovariotomies reached
nearly 2,000. His succes.sors, Keitli and Tait, also ob-
tained splendid results. The first successful operation in
Europe was performed by the German surgeon Clirys-
mar in 1820, a similar case in the previous year having
terminated fatally. In German}', until 1S50, only 23
ovariotomies with 7 successes had been done, and until
440
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Uvarlutoiuy,
Ovariotoiujr.
1870 there had been only 180 with a mortality of 105,
or over 58 per cent.
It was not until 1844 that Woyerkowsky scored the
first success in France, but here as in Germany the pro-
fession were so opposed to the operation tliat it made but
little headwaj', and was not recognized until long after
it had been established in America and England.
Following the introduction of the principles of antisep-
sis and asepsis the mortality was reduced to a remarkable
degree until, instead of being regarded, as it was by manj-
leading surgeons of lift}' years ago, as almost the equiva-
lent of murder, the procedure is now looked upon in un-
complicated cases and in the hands of a skilful operator,
employing a rigid aseptic technique, as one of the sim-
plest of abdominal operations. The gradual development
of ovariotomy is very fully presented by Peaslee ("Ova-
rian Ttmiors,"" 1872).
Indications. — Internal medication and local treatment
are futile in cases of ovarian tumor, and the days of sim-
ply tapping cysts are now past. So soon as the diagno-
sis is made, operative measures should be instituted.
Some operators jirefer the vaginal route, wherever
possible, and in suitable cases this answers the purpose
admiral)h'. The relative merits of the two methods can-
not be discussed here, but to-day, as a rule, the abdominal
incision is chosen; .since by its employment the tumors
can be rendered plainly visible and accessible to close ex-
amination, and the (jncstion of complete or partial re-
moval of one or both ovaries is consequently more easily
decided.
It is true that in many instances an ovarian tumor may
exist throughout a patient's lifetime, without detriment
to her health, or without producing any symptoms what-
ever, so that its discovery is often more ordess accidentjil.
But despite this well-recognized fact we must always
take into consideration the comparative frequency of
maliguaucy in these tumors, and the liability to the occur-
rence of secondary iinplanlatious aud metastases, even at
a period when the main growth is causing no unpleasant
manifestations. Moreover, the possibility of certain ac-
cidents, as torsion of the pedicle, or rupture of a cyst with
perhaps a resulting hemorrhage or peritonitis, is worth)'
of consideration. Infection of the cyst contents from an
adherent bowel may also occur aud greatly increase the
danger. Adhesions are likely to form, rendering oper-
ation at a later date moredifticult, and secondary changes
in other organs may begin insidiously and make consid-
erable and rajiid progress.
Age as a rule seems to make but little dilfereuce. Gen-
erally speaking, elderly women bear the operation very
well. In children we must always bear in mind the rela-
tive frequency of sarcomatous tumors.
The coexistence of pregnancy does not modify to anj*
extent the indications for operation, inasmuch as statis-
tics show that fatalities to the mother and f(etus are
much more likely to occur when the ovarian tumor is
allowed to remain undisturbed than when it is removed
even during the pregnancy. In the case of a malignant
tumor the dangers incident to expectant treatment are
even greater than in the non-pregnant state, since tlie
physiological congestion tends to promote rapid growth.
The liability to torsion of the pedicle is naturally in-
creased as the enlarging uterus crowds the tumor, often
rotating it. in its attempts to occupy the narrowing
space to the best advantage. Thus in one series of
one hundred and nine cases of ovaiian tumor with
pregnancy torsion occurred ten times. Large tumors
in the pre.sence of the additional bulk of the uterus may
lead to pressure symptoms, sufficiently severe to en-
danger the life of the mother, and growths of relatively
small size have been known to cause the death of the
foetus. Smaller tumors, especially if solid, may become
impacted in the pelvis below the growing uterus, the
accident either leading to abortion or giving rise to an
impassable obstacle to delivery at term, thus necessitat-
ing a Cesarean section or other radical measures. The
pregnant uterus maj- al,so be crowded backward inidcr
the promontory of the sacrum, so that its development is
hindered, and ..bortion is very likely to occur. Adhe-
sions of the ovarian tumor to the uterus may prevent the
.symmetrical enlargement of the latter, leading to abor-
tion or sometimes to a mal|)Osition of the fatus. The
adhesions may be torn apart by llie traction exeited by
the uterus, sometimes in conjuncti(ui with a sudden tra li-
ma. In such cases alarming or even fatal hemorrhage
has been known to take place. Rupture of an ovarian
cj'st is also liable to occur from pressure or trauma, in
the latter case because there is less room for the move-
ment of the tumor, so that even a slight blow might suf-
fice to cause such an accident.
The question of the advisability of operation during
pregnancy is very ajit to present itself, since a tumor
that has existed unknown to tlie patient may attract her .
attention as soon as it is displaced upward, into the ab-
domen, by the growing uterus. The physician may also
discover it during an examination in a case of apparently
normal pregnancy.
If the tumor be discovered only in the later months, es-
pecially if it be small and cause no trouble, and if after
it has been carefulh' watched for some time it shows no
signs of enlarging, operation may be deferred until after
delivery has taken place. All the various factors, how-
ever, in the individual case must receive careful consider-
ation. If a C3st causes disturbances oidy during the last
four weeks of pregnane}', or after the onset of labor, tap-
ping maj' become necessiiry, and the short respite thus
obtained may tide the patient over until a more favor-
able time for a radical operation. There is also the pos-
sibility that the cyst niay not refill. In the earlier
months, inasmuch as pregnancy is less liable to be inter-
rupted by operation, interference is clearlj' indicated.
The operation should be done as rapidly as is consistent
with proper precautions, aud during all the various
manipulations the pregnant uterus should be protected
from trauma, and the pedicle carefuU)' ligated. In view
of the stretching that may be exercised by the enlarging
uterus, the tissues should not be too tightly bunched; it
is far preferable to employ several ligatures, each includ-
ing a small portion of the pedicle. The case should be
treated afterward as if abortion were imminent, aud opi-
ates should be administered if necessary.
The onl\' absolute contraindicatiou to the operation
may be the enfeebled physical condition of the patient.
Thus in torsion of a pedicle with resultiug collapse it will
sometimes be very difficult to decide whether a postpone-
ment is not justifiable iu the hope tliat tlie patient can be
tided over the acute attack, and not submitted to oper-
ation until some days later when her condition is im-
proved. JIan)' unfavorable symptoms ajjpareutly con-
traindicating operation may be due entirely to the tumor,
and disap|iear after its removal. Among the most
important of these are ascites, circulatory and even re-
spiratorj' changes induced by pressure, albuminuria, and
in some cases glj'cosuria. In several instances sugar,
which had been present in the urine of patients suffering
from ovarian cysts, disappeared entirely after removal of
the tumor.
Even in apparently hopeless cases unexpected results
are sometimes obtained, and recortls are found of cases of
widespread papillary' adenocystomata and endotlielicimata
with peritoneal metastases, in wliicli these latter cau.sed
no furtlier trouble after the main tumor had been re-
moved. Moreover, in densel.v adherent cases which at
first seem to defy even an expert operator, by patience and
careful work the tumor may probably be freed and then
removed. At times in almost morilmnd jiatients radi-
cal measures may be indicated, and unless the condition
be due to cachexia brought about by a malignant tumor,
after prompt and active stimului ion and infusion or intra-
venous transfusion of deciiiornial salt .solution, operation
will sometimes save. ^lore particularly is this true in
eases of torsion or ru]:iture of a cyst or when the symp-
toms are due to pressure.
In brief, then, the indications for treatment in cases of
ovarian tumors ma}' be summed up as follows; Operate
as soon as you are satisfied of the presence of such a tu-
441
Ovariotomy*
Otarlotomj.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
mor, imless there is good reason for believing that the
physical resistance of the patient may be materially im-
provefi by waiting a few days.
Technique.— Too much stress cannot be laid upon a
rigid technique. In view of our present knowledge it is
absolutely criminal knowingly to transgress its well-rec-
ognized principles. The whole subject is dealt with in
detail elsewhere. Suffice it to say here that we must
bear in mind that asepsis not only regards our actions in
the operating-room and our surroundings there, but also
includes the'careful preparation of the patient as con-
(■erus the field of operation, the cvacuaticm of the bowels
and all other details the proper conduct of which will put
her in the best ccindition [lossible for the operation. In
the room itself everything should be as clean as possible,
' and all materials coming in contact with the Held of oper-
ation should be sterile. " Especially does this apply to the
hands which, although they cannot be rendered abso-
lutely aseptic, can at least be made innocuous by means
of diligent scrubbing, by the employment of antiseptic
solutions, and bylhe additional |)recaution of using rub-
ber gloves. Instruments should be boiled in soda solu-
tidiirall dressings, towels, etc., should be sterilized with
steam, preferably in the autoclave. Sea sponges, owing
to the difficulty of satisfactorily disinfecting them, had
better be discarded. Frequent rinsing of the hands in a
basin of sterile water during the course of the operation
is to be i-ecommended. for by so doing we are less liable
to transfer infection from one part of the field of oper-
ation to another, as for instance if the hand has become
contaminated by the eoulents of a cyst during evacu-
ation.
Inntnimeiits. — For an ovariotoiuy the instruments used
in an ordinary abdominal section are required, and in
addition several others devised more especially for this
operation. The choice of instruments is largel_y an indi-
vidual matter, and in simple cases one can manage with
but veiy few. Nevertheless it is always best to be pre-
pared for every contingency and the routine sterilization
of a few extra instruments, even if they are only occa-
sionally recpiired, will sometimes save no little vexation.
The following list of instruments will suffice;
Scalpels 2
Dissectintr forceps, toothed 3
Dissectiiiijr fon-eps, tootbed, lonj? 1
Artery fon-eps, siiiall 12
Artery forceps, long 6
Retrai'tors 3
Transllxion needles 1
Needleliolder 1
Needles (a.ssorted size^^J 6
S('is.surs, straitrht 1
Scissors, curved on Uie Hal 1
Mtisetix forceps 3
Sponi^e holders 4
Liijatures and sutures, trocar with rubber tubina-.
Cvst forceps 2
Catheter.
SyrinRes, dressings, (irainajre gauze, cautery, portable electric
light and other accessories of an operating-room.
The above instruments are all well known and need
not be described here; the jiattern is immaterial so long
as each is satisfactory to the individual surgeon. The
long dressing forceps will be found useful in repairing
injuries deep down in the pelvis. The needles, liga-
tures, and suture material will varj' with the ijredilec-
tions of the operator. Tlie writer prefers full-curved
sharp needles of three sizes for suturing everything, ex-
cept the bowel, for which full-curved round needles are
used. I generally employ Chinese silk twist for the
pedicles and close the abdomen in layers, losing a con-
tinuous catgut suture for the peritoneiun, mattress su-
tures of silver wire for the fascia, and a subcuticular
catgut suture for the skin. The Museux foiceps pmves
of value when traction has to be made on a sulid tumor,
and the cyst forceps serves a similar purjiose if the
growth is cystic. The trocar and ruliber tuliing should
be of I'ather large calibre, since the cyst fluid is often
thick and tenacious and is liable to clog a narrow lumen.
Sponges are preferably made of gauze, and must be care-
fully counted before and after the operation, to guai'd
against the possibility of leaving one in the abdominal
cavity. The cautery is used in searing the pedicle, to
lessen the chance of the formation of adhesions; more-
over, its employment will often control oozing from
denuded surfaces where it may be impossible to pass
sutures.
Ancesthetic.—T\ie relative merits of ether and cldoro-
form as an anaesthetic, and the cases most suitalile for
each, cannot be discussed here. The main point is that
the patient remain deeply narcotized throughout the
operation, and that there be a condition of complete
muscular relaxation. It is very disturbing to have the
patient vomiting or straining during an abdominal oper-
ation, and the ana'sthetizer should have served a thor-
ough apprenticeship in giving anesthetics for minor
procedures before being entrusted with this duty in ab-
dominal sections. The administration of nitrous oxide
gas with oxygen until the patient is completely uncon-
scious and then continuing with ether is a very satisfac-
tory plan. With the fdrnier the muscular relaxation is
not so complete as with ether or chloroform, and as yet
we have not sulbcient data to warrant its use alone for
ovariotomy, although in certain cases ana'sthesia has been
piolonged for several hours. Local anaesthesia with co-
caine has also been used for abdominal sections, but is
applicable only to exceptional cases, and general anaes-
thesia is almost alwaj's prefei-able.
Incision. — Everything being ready for the surgeon, so
that he may proceed with the operation, the iiatient
should be put in the Trendelenburg position, which fa-
cilitates the exposure of the pelvic organs. The abdomi-
nal incision should be in the median line and should be
short at first; if it be necessary to enlarge it later, this
can be very easily done, while in many cases of large
ovarian cysts it may be possible to remove the sac, after
evacuation of the contents, through a very small open-
ing. Before the incision is made the bladder should
be catheterized, and it is a good rule to pass a sound in
all cases of pelvic tumor in order to determine whether
the viscus has been carried upward. Not infrequently
the bladder lias been opened in making the abdominal
incision through neglect of this simple precaution. The
skin and subcutaneous fat are divided and the bleeding,
which is usually slight, is controlled by hajmostatic for-
ceps. The fascia is then divided in the median line. In
doing this very frequently the sheath of one rectus will
be opened, but this is a mattei' of no great moment.
The adipose and areolar tissue having been separated
down to the peritoneum, the latter is carefully picked
up between two pairs of dissecting forceps and a small
nick made in it. Through this the air enters, allow-
ing the intestines to fall away, after which the opening
can be enlaiged as much as necessary. When the
parietal peritoneum is adherent to the tumor, the in-
testines, or the (iinentum, great care must be exercised
in opening it in order not to injure the structuies lying
beneath. It is imjiortant to see that the peritoneum is
actually opened before attempting to separate the adhe-
sions, as a mistake ma}' lead to a widespread separation
of the peritoneum from its attachment to the abdominal
wall. Occasionally it will be found possible to get in
above the adheient area through an opening made a little
higher u]). During the progress of the ojieration the
incision luay be enlarged as much as is found ueces-
.sary, it being borne in mind that when we meet with
a cyst, a small opening may suffice, while even solid
tumors with a little judicious manipulation may often
be delivered through a relatively small incision. The
operator must not, however, handicap his efforts by try-
ing to work through too small an aperture. Two fin-
gers are now introduced, or if need be the whole hand,
and the nature of the tumor, its location, the presence or
absence of adhesions and their extent, are then deter-
mined. If it be a cy.stic growth the question of evacu-
ating the tluid will have to be considered.
Kinpijiinij a Ci/xt. — If the c.yst be small enough to allow
readily of removal through the incision, puncture is not
necessary. If, however, it be large and free from ad-
442
REFERENCE HANDBOOK OF THE IVIEDICAL SCIENCES.
Ovarlolonijr.
Ovariotomy.
hesious, it had better be emptied. On the other hand, if
it be iulliei-eut it may bu easier tirst to separate the adlie-
.sions, as tlie contour and rehitions of the tumor are then
more easily recognized than wlien it is collapsed. Usu-
ally it is best to empty it at once, otherwi.se it is liable
to "rupture during manipulation. In the case of a large
cyst there will also be more room for working, and the
site of the adhesions can be moi'e readily exposed if it is
first emptied. It is important to avoid contaminating
the abdominal cavity with the cyst fluid, inasmuch as we
can never be sure that the contents are innocuous. Thus
in the case of a papillary adenocarcinoma, the escape of
the cj'st contents into the abdomen would be very likely
to cause secondary implantations. Or, again, the contents
may be the greasy product of a dermoid cyst which may
possibly be infectious in character, and at any rate will
be e.xtremelj' difficult to remove if once they become dis-
tributed in the abdominal cavity. To guard against such
accidents gauze sjjonges are carefully packed around the
presenting tumor to wall off the peritoneal cavity and to
protect the edges of the incision. The patient is turned
slightly on one side so that the escaping fluid may be
more readily prevented from soiling the tield of oper-
ation, and a C3-st trocar with rubber tubing attached is
then plunged into the tumor. If the tumor wall be too
resistant, a small nick with a scalpel may greatly facili-
tate mailers. In making the puncture the large vessels,
which can be plainly seen coursing over the cyst wall,
should always be avoided. As the sac wall collapses it
is gradually drawn out with the hand or with a pair of
cyst forceps, and the remaining part squeezed ; or jjress-
ure is made u]30u the abdominal walls in such a manner
as to get rid of as much of the fluid as passible. A lat-
eral position of the patient is also of advantage in this
connection. Any comjiartments in a multilocular cyst
are usually broken down with ease As soon as the sac
has been emptied as far as is possible, the trocar is re-
moved and the opening closed by grasping the edges in
a pair of haemostatic forceps, or by tying a ligature se-
curely around it. The surrounding part of the wall
should be carefully cleansed and the whole enveloped in
a piece of gauze which has been saturated with sterile
hot salt .solution.
Adltenions. — Ovarian tumors that are not adherent or
that have not grown downward between the layers of the
broad ligament can usually be removed without much dif-
ficulty. The tendency uf the growth at lirst is to drop
down into the cul-de-sac, or later, if there be much en-
largement, to ascend out of the pelvis into the upper ab-
dominal cavity, where there is more space for it. Either
of these displacements tends to produce an elongation of
the broad ligament, to the posterior fold of which the
ovary is attached, and also of the infuudibulopelvic and
ovarian ligaments, at the outer and inner poles of the
ovary respectively. In this way a pedicle is formed
which allows the "tumor to be delivered through the ab-
dominal incision, and which can be ligated and then
severed.
True ovarian tumors rarely extend between the folds
of the broad ligament, such growths being usually of
parovarian origin. If there be no inflanunatory action
tumors of the latter class, as a rule, can be shelled out
from between the folds by sjilitting the peritoneal cover-
ing and stripping back the two layers of the ligament.
After the growth has been removed the tw'o edges may
be sutured with catgut. Hemorrhage is rarely severe,
but any excessive bleeding can be controlled by clamping
or ligating the ovarian vessels in the infundibulo-pelvic
ligament, and the communicating branches from the
uterine ves.sels at the coruu of the uterus. On the other
band, if chronic inflanuuatory changes exist, the removal
of the uterus together with the tumor may fie necessary.
In these cases it is well to begin with a supravaginal
hysterectomy on the side oppo.site the growth. "The
uterine vessels on the affected side are ligated and di-
vided and the tumor is attacked from below. Removal,
even in this manner, may at times appear too risky, in
which case an incomplete operation must be done. For-
tunately, however, in .such instances drainage per vagi-
uam is usually a feasible procedure.
Adhesions to the surrounding viscera form the most
frequent complication of ovarian tumors. These vary
from a few spider-web-like strands to masses of dense,
organized connective tissue, requiring division with the
scalpel or scissors. The method of dealing with these ad-
hesions varies. If the.v are of recent origin they may be
separated with the lingers, or pushed apart with a gauze
sponge. If they are more resistant, the handle or "blade
of the scalpel may be required to divide them. Whenever
possible, the separation should be done under the eye of
the operator. By dragging the collapsed cyst well out of
the incision with a pair of cyst forceps, or with the fin-
gers covered with a gauze sponge to prevent slipping,
or by making traction on a solid growth with a ]\I\iseux
forceps, theatlherent structures can usually be drawn up
also and separated in plain view. On the other hand,
when the adherent viscera are fixed, it is .sometimes im-
pn.ssilile to expose the site of the adhesions satisfactorily,
even with the aid of retractors and by packing aside the
intestines with gauze. This complication is likely to oc-
cur when a large solid tumor is adherent posteriorly. In
such cases it is necessary to deal with the adhesions by
the aid of the sense of touch, and the knowledge of the
anatomical relations. The site from which the tumor
has been separated should be examined at the earliest
possible moment to ascertain if there has been any dam-
age done, in order that instant repair may be instituted.
Adhesions to the parietal wall, which b.avc been men-
tioned already, occur only in connection with tumors of
considerable size.
Omental adhesions are rarely troublesome since, if need
be, this tissue can always be sacrificed. It can usually
be peeled off fiom the surface of the growth, but when
more resistant it can be ligateil and cut away. Even small
omental vessels, if left luiligafed, are apt "to continue to
bleed; hence the umentum should be examined carefully
for any hemorrhage before closing the abdomen.
Bowel adhesions represent the most serious comjilica-
tious, and great care must be exercised in dealing with
them. In eases of inflammation of recent origin no
trouble is apt to be found, as the adherent bowel may be
gently peeled back with the finger or a S|)onge. If the
adhesions be older and firmer, an occasional touch with
the scalpel may be retjuired, and if no line of cleavage be
apparent, part of the tumor tissue may be left adhering
to the bowel. In carrying out this manipidation a cyst,
which has not been previously emptied, is liable to rup-
ture at the weakened spot, anil the operator must be pre-
pared for this accident. If the intestinal wall be injured
it must be immediately repaired, a round-pointed needle
being employed for this purpose, and care being taken
that no undue narrowing of the lumen of the liowel be
lirochiced. Free oozing from the outer surface of the
bowel may continue for a short time, but unless the mus-
cularis itself or the mesentery be injured it will .soon
stop. If the bleeding persists, however, measures must
be taken to control it. When the injury has been severe
and there is doubt as to the success of the repair, the
question of drainage comes up. This will be <liscussed
laf<>r.
The bladder is seldom apt to be injured, as it is less
likel}' to be drawn up out of the pelvis than is the case
in uterine tumors. The necessity of obtaining a positive
assurance on this point has already been mentioned. The
same rides, as to the separation of adhesions and repair
of injuries, apply to this as to other important organs.
The ureters are rarely involved unless the growth be
intraligamcntary. If they lie liable to injury, their rela-
tions must be esfablishcil eilher hy following llicir course
down from the pelvic lirim over the pelvic floor, or by
means of catheterization through the bla<ldcr.
Adhesions in the cul de-sac, and posterior to the broad
ligament, are often very troublesome They are sepa-
rated most easily by getting llie fingers below the tumor
and working upward. By following the posterior sur-
face of the uterus downward from the fundus and then
443
Ovari<»l4*iiiy,
Ovariotomy.
REFERENCE IIA.NDBOOK OF THE MEDICAL SCIENCES.
sepamtiiig the adliprent surfaces laterally, this can often
be quite reaililj' accciniplislied. Ilenionlia^r may lie I'lo-
fuse and may reiinirc tlie placing of clanijis or ligatures
on the ovarian vessels and at llie cornu. If pi'ogress be
not satisfactory at any one place another point of attack
should be selected.
Ligntinfj the J'edide. — As soon as all adliesions have
been dividcvl, the oiieration lias been much simplified.
If the pedicle lie long enough the ma.ss is now delivered
through the abdominal inei'sion; othcrwi.se the ligatures
are passed ihrough tile pedicle within the abdomen. If
there be oozing from the raw surfaces of the viscei-a or
pelvic walls, sponges wrung <iut of hot salt solution
may be packed against them while the tumor is being
reinoved. Silk is generally considered to be the most
suitable ligature material If properly boiled it is
sterile, <loes not slip or swell like catgut, and verj' rarely
causes any trouble. The broad ligament is transfixed in
the thin area below the vessels, and a double ligature is
carried through. Without being interloeki'd, one is tied
externally over the infundibulo-pelvic ligament, while
the other comes close to tiie uterine cornu. When the
pedicle is large and thick more ligatures may be required
and the tissues tied in three or four divisions. The liga-
tures having been secured, th(^ pedicle is severed at least
1 cm. outside them, as the stumjiis ajit to retract througli
the grasp of flie ligatures, an accident which has often
been followed by seriovis or even fatal hemorrhage. Tiie
stump may be seared with the Paquelin cautery to lessen
the liability of adliesions forming to it, or the peritoneal
edges may be approximated with catgut. Silk ligatures
for the pedicle have proven so satisfactory that the use
of the angiotribe or electric cauterization does not seem
necessary.
Inmmplete Ovariotomy. — After opening the abdomen
and carefully examining tlie conditions present we may
find it utterly impossible or inadvisable to remove the
tumors completely. The difiiculty may be due either to
the character and the extent of the disease or to the dense
adhesions binding the growth to important viscera. Pajv
illary malignant disease may be so far advanced that
the removal even of the main mass is evidently impossi-
ble, or an atterajit to do this may be attended by profuse
hemorrhage, even after the preliminary ligation of the
main vessels, .so that it only remains to pack tightly with
gauze and not proceed further. In these malignant cases
the marked cachexia, which is often present, may con-
traiudicatc a radical fiperation. Even if removal of the
main tumor beacc<implislied, it is impossible to deal with
the metastases upon the peritoneum, whicli, although oc-
casionally disap|ieariiig, as a rule cause death. Where
there have been inllamniatorv complications, and espe-
cially when chronic suppuration has occurred, the adhe-
sions may be so linn llial the time wasted in separating
them and the attendant liemorrhage may injure the pa-
tient far more tlian the adoption of one of the alterna-
tives at our disposal. Attempts to release a growth
densely adherent to intestines, bladder, ureters, or ves-
sels is liable to cause damages that may be irreparable or
that may necessitate a prolongation of the operation
which may prove fatal in tlie case of a patient whose
vital energies are already exhausted.
When complete ovariotomy is impossible, various ex-
pedients come under consideration. In the case of a
cyst we can resect as much of the walls as possible, and
suture them to those of the abdominal incision. The in-
terior of the cyst is then packed with gauze which acts
as a drain and tends to destroy the epithelial lining of
the walls and thus favors the formation of granulation
tissue. In course of time this process leads to a union of
the surfaces whicli thus etfects a cure. A similar proce-
dure may be carried out from the vagina. If the cyst
walls cannot be brought up to the abdoininul incision or
down to the vaginal vaidl, the tluid should be evacuated,
and an attempt made to destroy the lining epithelium by
the application of carbolic acid, searing with the <'aiitery,
or even curetting lightly. A gauze drain is then inserted,
the end being brought out tlirough the abdominal incis-
ion or into the vagina. The principal indication in these
incomplete operations is to see that all hemorrhage is
controlled, and for this purpose gauze packing is often
required. In the case of solid tumors that have to he
left or can only partially lie removed, if there be no ooz-
ing, the alidomen can usually be closed.
Not infrequently the question of conservatism arises,
especially in the case of young women. In malignant
conditions, it is best to remove both ovaries as the disease
is often bilateral, although but one ovary may present
gross pathological ap]iearances. In retention cysts, fol-
licular hypertrophy, corpus luteum cysts, as well as in
some dermoid tumors, it is often possible to .save a por-
tion of the affected ovary. If the other one be normal,
there is no absolute necessity for this ; but in bilateral dis-
ease a sjiiall jiortion of ovarian tissue should lie saved if
possible, for the reason that even if pregnancy does not
occur, a young woman may avoid a stormy menopause,
not to mention the mental sutt'ering tliat niay be engen-
dered by the knowledge of her condition. The Fallopian
tube, if not seriously diseased, should also be saved. At
times by resecting the diseased ]iortion, enough of the
healthy tube may be left to permit of a future concep-
tion.
Drninage. — In this respect the jirogress in surgical
technique has been somewhat revolutionary. Whereas
formerly drainage was regarded as indispensable in al-
most all codiotomies, at the present day it is employed
very much less, and very seldom in cases of ovarian tu-
mor. By drainage we leave an avenue for infection
which may cause the contamination of a sterile abdomen,
and moreovi'r drains partially or wholly fail to accom-
plish our object. That this is often the case is proved
by the rush of fluid that not infrequently follows the re-
removal of the drain. Besides the fact that such devices
ma)- be more dangerous than useful, their removal causes
shock and jiain to the patient, and their emploj'ment
sometimes not only produces an elevation of teiuperature,
nausea, and other unpleasant sym]iloms, but also tends to
retard convalesciMice. Moreover, if a drain be employed,
it is impossibli- to make use of tlie "peritoneal bath," by
which is meant the leaving of .500 c.c. of sterile salt solu-
tion in the abdominal cavity before closing the incision.
Nevertheless, drainage is occasionally required in cer-
tain cases complicated by the presence of pus, which
cannot be entirely removed, in persistent and daugemus
oozing to meet which we are obliged to keep up compres-
sion for a certain length of time, after .severe injuries to
the bowel and in incomplete ovariotomy.
Fortunately, pus is encountered only in rare cases of
ovarian tumor, and wlieu present, as a rule, it is of shght
virulence. Drainage may be considered necessary if it
has been iinpossible to protect the general peritonal cav-
ity from' contamination by packing gauze around the
]ius focus before evacuating it. If, however, tlie pus as
it escajies be caught on sponges, and if the jielvis or the
site of the abscess be tlushcd out with salt solution and
then sponged iliy, by omitting drainage we have the ad-
ditional safeguard of tilling the abdomen with decinormal
salt solution, to dilute any contaminated material that
may remain, and to assist in its absorption. If the pus be
considered virulent, as for instance when cover slips ex-
amined at tlie time of operation show streptococci, or
when there is a communication with the bowel, drainage
is usually indicati'd. A diffuse general peritonitis will
often require similar measures. In the writer's experi-
ence the presence of gonococci in the pus has not proven
an indication for emiiloj'ing the drain.
Persistent oozing from raw surfaces left after separat-
ing adhesions rarely requires drainage, but when it can-
not be controlled by ligating the individual bleeding
points, or by ap]iroximating the edges of torn areas, by
the employment of mattress sutures and by tiglitl\' pack-
ing in sponges wrung fiut of very hot water, by touching
the bleeding area with the actual cautery or by using
some astringent iron solution, then a gauze drain applied
to the bleeding area may give excellent results.
Injuries to tlie bowel wall sustained during the sepa-
444
REFEREN'CE HANDBOOK OF THE JIEDICAL SCIEXCES.
Ovariotomy.
O\'ari4tloiiiy.
ration of dense adliesions should be repaired as soon as
recognized. In these cases the tissues are apt to be so
inlilUated and friable that sutures will not hold unless
so much tissue is included as dangerously to nariow the
Innien of the bowel. In such cases, when subsequent
rupture of the coats of the intestine is to be feared, a
drain should be inserted. In injuries to the sigmoid tie.\-
urc and to the lower rectum, which are frequently impli-
cated, vaginal drainage is most suitable.
AVheii incomjilete ovariotomy has been performed,
drainage may be required to permit the escape of the
fluids or the breaking diiwu tissues. The gauze thus ap-
pbed facilitates tlie obliteration of tlie cavities of the
cy>ts. which cannot be removed. For the same reason, if
sii|)puratiou has occurred, and the abscess wall cannot
be removed completely, a drain may be required.
In instituting drainage we have the choice of two
routes, the abdominal and the vaginal. The latter is
usually to be preferred, since it provides an e.xit at the
most dependent point of the pelvis. The abdominal si*
nus which is left after removing the gauze, even with
the greatest care and tlie Ix-st technique, is very liable to
become infected, and as a result a track is left which
must close slowly from the bottom. The drain inserted
through the abdominal incision requires to be removed
much earlier than one used through the vagina. The
mental effect upon the patient is not unimportant, and
the old saying, "Out of sight, out of luiml " is not with-
out weight here.
As regards the form of drain used, e-xjiericnce goes to
shew that glass tubes should be discarded. Gauze either
in the form of strips or a " Mikulicz drain " answers very
well. If strips be used, they maj- be tied end to end,
forming one long continuous wick; but if left separate,
the end of each should reach the external opening and
the first to be removed should be identified in some way,
as by tying a piece of silk around the end or by knotting
the gauze itself.
Toilet of the Pcritoni'inn. — Having removed the tumor,
the surgeon's next duty is to inspect the field of oper-
ation very carefully, to see that everything is in order.
After first satisfying himself that no hemorrhage is in
progress, he should examine the pedicle, and then
inspect the broad ligaments, the pelvic walls, and any
other situation where he has had occasion to separate ail-
hesions. If there be any 0(.)zing, measures to control it
must at once be instituted. The bowel must also be
examined, more especiallj' the rectum and the sigmoid
flexure, as these are the parts most likely to be injured.
The omentinn is drawn out of the incision and laid ujion
a gauze sponge, when any bleeding points will be indi-
cated by the staining of the material, and can readily be
secured. Any holes in the omentum should be sutured
and anj' ragged ends shiudd be ligated and removed.
Owing to the occasional iiuplication of the venuiform ap-
pendix in pelvic disease, it should be examined as a mat-
ter of routine and, if necessarj-, removed. All bleeding
having ceased, the abdomen is to be thoroughly flushed
out with decinornial salt solution, and then sponged
dry. This can be done by holding the uterus forward
and the intestine back, while an assistant pours the ster-
ile salt solution down into the cul-de-sac. Occasionally
the employment of a funnel and rubber tube will pro\-e
more convenient. All clots or fluid having been removed
by this procedure, the sponges and instruments shoidd be
counted to prevent the possibility of any being left in the
iil)domen. If drainage be indicated, the gauze is now
inserted ; otherwise the abdomen is filled with decinor-
mal salt solution and the incision closed b.y the method
in favor with the operator.
Dressing. — The incision having been closed, the sur-
rounding skin is sponged with a bichloride solution
(1 to 1,000) and afterward with alcohol. A small amount
of sterile iodoform or boric-acid powder may be dusted
along the line of the suture. Several la_yers of fine gauze
are then placed over the wound, and above this a liberal
amount of absorbent cotton. To retain the dressing in
place wide strips of adhesive plaster are used, reaching
well around on the sides of the abdomen, and extending
from the pubes for some distance above tlu^ umbilicus.
Over tills is placed a scultetus bandage reaching from
just below the trochanters up to the costal angle, and
held down snugly in jilaee by means of two strips pass-
ing around the inside of the thighs. The scultetus band-
age maybe changed daily, or as frequentlj- as it is soiled.
Unless the skin show considerable irritation from the ad-
liesive plaster, the latter may be left undisturbed for ten
days. By this time the skin incision will be well united
and the subcuticular catgut suture absorbed. If, how-
ever, there be a rise of temperature, and pain along the
incision be complained of, the whole dressing should be
removed, in order to ascertain if there be suppuration in
the wound.
With an abdominal dressing firmly applied in the
aliove manner, there is less danger of the sutures tearing
out during the vomiting. Distention also seems to be
lessened bj- it, and there is no danger in turning the pa-
tient on her side, as soon as the nausea has diminished.
The change of posture is one of the most welcome privi-
leges allowed to a patient after a cadiotomy. Care must
lie taken that the dressing does not become drawn away
from the pubes, as the lower end of the incision is not far
above this point and exposure of it ma.y lead to suppu-
ration and the breaking down of the wound. After the
first ten days a small strip of gauze held in jilace bj' two
strips of adhesive plaster is a sufficient protection.
After-Treiitment. — The after-treatment is that usually
carried out after any abdominal section, and the details
will vary with different operators. It is a very good
plan to have a definite scheme of procedure written down,
10 be given to the nurse in charge of the patient. This
ma}' be suited to a moderately severe case, but can be
modified as desired. Even if the operaticm has been a
simple one and the shock slight, the patient will not suf-
fer from the extra precautions taken.
Before the patient leaves the operating-room the stom-
ach may be washed out, and it is a good plan to adminis-
ter a stimulating enema composed of an ounce of brandy,
five grains of ammonium carbonate, and one-twentieth
of a grain of strychnine sulphate in a pint of decinornial
salt solution. This is rapidly absorbed, and while greatly
diminishing the thirst, also promotes diuresis, diluting
the urine which otherwise is apt to irritate the bladder
from its concentration. On reaching her room the pa-
tient is put into a warm bed, and hot-water bottles are
placed around her to counteract any shock. These must
be carefully protected so as not to burn her. The foot of
the bed is elevated fourteen inches to facilitate the ab-
sorption of the salt solution which has been left in the
abdomen. With the hcati low. as in this position, the
nausea probabh' will be less. An attendant 'must re-
main at the bedside until the patient is perfectly con-
scious, as she is very apt to try to get out of bed when
coming out from the anaesthetic. Shock must be com-
bated by the use of stimulants, and of these strj'chaine
is the most satisfactory; one-thirtieth of a grain may
lie given hypodermically as soon as the patient reaches
her room. If the pulse remain over 120 to the minute,
this had better be repeated every hour for four or five
times; otherwise every two hours {w three or four doses
is sufficient, and after this every four to six hours, ac-
cording to the character and rate of the pulse. It is
probable that the work now being done on the determi-
nation of the blood pressure will ultimately give us more
definite data for the employment of stimulating drugs
under these circumstances. For the nausea notliing
much can be done; drugs as a rule arc useless, and sips
of hot or cold water only aggravate it. A hot turpen-
tine stupe ora small hot water hagapplied to the epigas-
trium above the level of the dressing, often affords some
relief. Gastric hivage at tlie time of operation acts as a
preventive, and may also be employed after the first
twenty -four hours in persistent cases. As soon as con-
sciousness returns the first complaint will be probably of
thirst, but beyond moistening the lips and wiping out
the mouth with a moist piece of gauze nothing much can
U5
Ovarj-.
Ovum.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
be done for some hours. Wlien, liowever, tlie uaiisea
has subsided, water in small quantities may be given
every few miuutcs. Hot water is iireferable to cold, and
the qviautity may gradually be increased if uo ill elTects
are seen. As has been sai<l" before, the administration of
the enema and leaving SOU c.c. of salt solution in the ab-
domen will lessen the thirst very considerably. For the
pain, if severe, a small dose of morphine or codeine may
be given hypoderniically. It is much better to avoid
opiates whenever possible, and their routine use is to be
condemned. Besides augmenting the nausea, in many
patients they are apt to retard theojiening of the bowels.
Rubbing witli chloroform liniment will often relieve the
severe backache, and a change of position is always
grateful. With the abdominal dressing described above
there is no risk in moving the patient from one side to
the otlier.
It is advisable to have the patient urinate naturally,
and unless there is some contraindication, such as trauma
to the bladder wall dtu'ing the operation, from eight to ten
hours may be allowed to jiass without an evacuation of
urine. After this time, if her ctt'orts to void naturally
have failed, she shoidd be cathetcrized with the usual
aseptic jirecautioiis. This should not be repeated unless
it is absolutely necessary. If she have much distress
referable to the bladder, it may be em]5tied earlier.
Most of the discomfort incident to abdominal oper-
ations is due to the tympanites, which is usually worse
in those ea.ses in which the structures have been adher-
ent, and in which there has been much handling of the
bowels. It is also frequently due to neglect in properly
emptying them before the operation. This complication
can be relieved very often bypassing the long rectal tube
and applying heat to the epigastrium. Tincture of cap-
sicum in three-uunim do.ses may lie administered after
the cessation of the nausea. In neurotic women a good
deal of discomfort is usually the rule.
The patient generally feels much easier as soon as the
bowels have been well nuivcd. Eighteen or twenty
hours after the operation two grains of calomel may be
given. Eight or ten hours later a turpentine enema will
often produce a .satisfactory evacuation ; if ineffectual it
may be repeated in four hours, or a glycerin enema may
be given in.stead. If therc^ be still no results small doses
of magnesium sulphate may be given.
The temperature, jiulserate, and number of respirations
should lie taken every three hours at tirst, and later every
four or si.v hours, according In the progress made by the
patient. A careful chart should he kept so that her con-
dition from time to time may be readily ascertained.
In the matter of diet nothing but water had better be
given by mouth until the bowels have been moved, but
nutrient encmata consisting of peptonized milk, with the
whites of two eggs and twenty grains of table salt, may
be administereci every three hours. As socm as the
bowels have moved satisfactorily milk with lime water
or carbonated water, albumin water cu' broth may be r(!-
tained if given in small (luantilies at first. After the
first three or four days, if .satisfactory progress is being
made, the patient may take .soft food, and after about
two weeks an ordinary light diet may be ordered.
Where there is no siispicion that suppuration is occur-
ring in the abdominal wound, the dressing need not lie
disturbed for ten days; but if through-and-through su-
tures have been u.sed for the abdominal incisionras in
cases in which speed in closing the wmind has been neces-
sary, or if unabsorbable sutures have been employed for
the skin alone, an earlier examination is advisable, and
if any redness be found around the suture the offender
had better be removed. All of them can be taken out as
a rule on the seventh day. If the incision be lirndy
united, a small pad of gauze over it will be suffKient ;
transverse strips of plaster may be used to hold this in
place, and at the same time prevent any stretching of the
newly formed scar tissue. The .scidtelus bandage is worn
until the patient is out of bed. after which a special elas-
tic abdominal supporter should be provided. If no com-
plications occur, the patient may sit up in bed on the
sixteenth or eighteenth day after the operation, and get
out of bed on the nineteenth or twenty-first day. Un-
doubtedly in many cases a shorter time than this is suffi-
cient, but it is far better to be on the safe side.
Mortality. — The mortality depends upon a number of
factors, such as the skill and experience of the operator,
his facilities for carrying out an a.septic technique, and
also the care of the palieiu. alter the operation. Granted
that these have been all that could be desired and that
the cases are tmcomplicated. the percentage of deaths
frimi the operation should be almost nothing. It is very
difficult to determine the real mortality since statistics
are notoriously misleading.
The results are steadily improving. A few references
to the mortality in the early days of the operation have
ahead}' been made, and half a centtu-y ago it was over
fifty per cent. Owing to an aseptic technique, and to our
knowledge gained by experience, the average mortality
in cases subjected to operation for ovarian tumors at
the present day is below ten per cent. Individual op-
erators will have far better results than this. Law-
sou Tait a number of years ago reported a series of 139
ovariotomies without a death, and the results to-day are
better than at that time. Even in cadiotomies for all
sorts of pelvic diseases, including pelvic abscess, ectopic
gestation, etc., records of series of over 100 consecutive
cases without a death have been reported. The author
has reeentl.y had two such series, one of 108, the other of
114 consecutive successful operations in a hospital prac-
tice, in which all conditions, including pus cases in a
large proportion, were encountered.
The average skilful operator, taking cases as they come,
and having every facility for good work, should liave a
mortality of not over three to four per cent, in ovari-
otomy. Hunter liobb.
OVARY (ANATOMICAL), ^ee Se.vual Organs. Female.
OVULATION. See Menstruation.
OVUM. — (Greek i.>Ai\ Latin ovum, an egg.)
The oriini, or egg jiroper, is a cell capable under cer-
tain conditions of giving rise by subsequent cell divisions
to a complete multicellular organism. This definition
applies to the female germ cells of plants as well as to
r/i.l.
Fig. 3712.— Diasrammatie Section of an I'nMiculjatHii Hen's Ekk. hi.,
Blasiodcnii ; km/., wliite yolk; y.y.. yellow yolk; r.f., vitelline
nii'iiitirane: (r.allmnien: c/j.L, chalaza; (f.c/h, air cljamber: i.,s.H).,
iinier shell niembrane; .s-./h.. outer shell membrane; s, sbell.
(From Balfoui', modiUed from Allen Thomson.)
tho.se of animals. Frequently the terms ovum and egg are
used loosely, however, not oidy to include the envelopes
surrounding the egg proper, but even to designate the
embryo and its fcetal membranes.
446
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
Ovary.
Ovum.
Iliitorirnl. — Although a heu's pgg has been probably
one of the most familiar of olijects since long before man
Fig. 371.3.— Rabbit's Ovum, from a Graatlan Fr41icle measuring: 2 mm.
a, Disrus pn>Iigerus; ?*, zniia radiata ; ('.nucleus: (/, nuclerilus: f,
yolk-granule in the cytoplasm. Highly magnlfletl. (From Wal-
deyer.)
ever thought of domesticating wild animals, it remained
for the anatomists of the nineteenth century to discover
its trvie nature; and although investigators of tliis sub-
ject were never before so active as during the last decade,
and have carried on their work with a refinement of
technique not dreamed of in earlier years, tliere is still a
great deal to be learned.
Slodern embryologieal observations ma}' be said to have
begun with "William Harve\', who published his results
in 16.51. The best microscope that lie could obtain was a
simple lens, and with this he was able to make out the
general outline of a chick embryo during the second day
of incubation. His view of the ovum was that it con-
sisted of a fluid
niatri.\ in which
tlie embryo ap-
peared by a
process of spon-
taneous genera-
tion. The fe-
male s e .\ u a 1
product was
supposed at that
time to be a fluid
secreted by the
"testes mulie-
brcs," the term
■■ ovarium " not
having been in-
vented by Sten-
son until some
years later.
R e g n i e r d e
Graaf published
in 1077 a d<'-
scription of tlie
follicles, which
have since borne
his name. He
found that the.y contained a fluid which was capalile of
being coagulated by heat into a tirm, white substance.
He discovered also that in the Fallopian tubesof a rabbit
killed seventv-two liours after coitus there were to be
Fig. 3714.— Graafian Follicle and Ovum from
the Ovary of a Rabbit Four Wi-pks Old. On
the left of the ectr nuclous i> the attraction
sphere containing two ceiitn>stinies and below
is a small yolk nucleus. Highly magnilled.
(After Winiwarter.)
found a number of eggs which were vesicles and con-
tained a fluid that could be coagulated bj- heat, like the
white of egg, and, moreover, these corresponded in num-
ber to the empty follicles found in the ovaries of the same
subject. He concluded, therefore, that the Gratitian fol-
licles were ova. But the chain of evidence was not com-
plete becau.se all trace of the eggs was lost between the
time of coitus and the end of the third day, and, more-
FiG. 3715.— Cross Section of an Embryo Dogfish 2.7.5 mm. Long.
A-li. Blastodermic rim containing all the germ cells ; Eii, endo-
derm. X 38. (After Woods.)
over, the blastoderms iu the Fallopian tubes w-ere not so
large as the empty follicles. During the same year,
1677, Leeuwenhoek announced the discovery of sperma-
tozoa, and there followed a long dispute as to whether
the spermatozoon is the true germ and the egg a matrix
Fig. 3716.— Cross Section of an Embryo Dogfish. 3.5 mm. Long.
En, Endoderm ; tTr, germ cells. X 38. (After Woods.)
for its nutrition, or whether the germ dwells originally in
the egg itself (see article Erolntion).
It was not until 1827 that Carl Ernst von Baer was able
to show that the Graaflan follicle is not the ovum; but
that the ovum is a minute body em-
bedded in the follicular epithelium.
And it was not until 1838 that
Schwann was able to declare the egg
to be a cell with the same fundamen-
tal structure as the other cells of the
body.
Morphology. — ^The ovum is usually
a more or less spherical bod_y, but
may be flattened or elongated, as is
the case with most insect eggs.
The protoplasmic cfmtents of the
egg consist of a nucleus and a mass
of cytoplasm, as in all cells, and, in
aildition, the cytoplasm usually con-
tains a greater or less amount of yolk,
or ih'uioplasm.
The cytoplasm of the eggs of echi-
noderms and other invertebrates has been shown to have
a distinctly vesicular, or foam-like, structure, and it is
probable that all eggs will show a similar structure. It
is within the vesicles of the foam that the deutoplasm is
deposited, sometimes in the form of clear oil globules, as
in some worms and flshes, more often as more or less
opaque yolk granules. In the hen's egg there are two
principal kinds of j-olk granules, the j'ellow and the
white. The white granules are gathered together in the
form of a small flask-shaped body, extending from the
centre of the ovum to the upper pole, and the yellow
yolk forms concentric layers surrotmdiug this and al-
ternating with thinner layers of white yolk (Fig. 3712).
These may be seen in a carefully made section of a hard-
boiled egg. Where the white yolk approaches the sur-
face there is in the tintertilized egg a portion of the
cytoplasm comparatively free from yolk and containing
the nucleus.
Fig. 3717.— Cross Sec-
tion of an Embryo
Dogfish, 5 mm.
long. En, Endo-
derm : Vr, germ
cells. X38. (After
Woods.)
447
Or II III.
O^'iiiii.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
The size of the egg, the position of the nucleus, and
the subsequent course of development, especially in the
early stages, depend to a large extent upon the [ircsence
or absence of a burden of food yolk within the cytoplasm
of the ovum. For example, the eggs of
reptiles and birds are heavily charged
with yolk and are very large, while all
mammals, except the jlonotremes, have
egg.s almost free from yolk, and they are
very minute, measuring about 0.2 mm. in
diameter.
Eggs are classified according to the ab-
.sence, presence, and position of the yolk,
into three groups: (1) AUcithal eggs, hav-
ing very little or no yolk; (2) teloUritlml
eggs, in which there is a large acciimu-
latiou of yolk at one pole; and (3) aiitm-
leetthal eggs, in which the accumulation
of yolk is at the centre and is surrounded
on all sides by a purely protoplasmic layer.
Eggs of this type are especially charac-
teristic of the arthropods. In tclolecithal
eggs the pole that is the richer in yolk is
called the regetatii-c pole. The nucleus
lies nearer the opposite, or animal pole,
and the purely protoplasmic portion surrounding the
nucleus may be confined to a very small area, the genn-
iiiid disc, near the surface, as in the hen's egg.
The nucleus is usually a spherical body surrounded by a
delicate nuclear membrane, and is still frequently called
by the okl name, germinal nxicU; although it presents all
the ordinary fi-afures of a cell nucleus (Fig. 3714), includ-
ing liuin network, chromatin granules, and nucleolus,
the latter is called in the older books the germinal spnt
(see article Cell). The ccmdition usuall}' described is but
one stage of a pretty detiuite series of changes which the
chromatin and nucleolus undergo diu'ing the course of
development of the ovum, and which will be referred to
later.
In many eggs there may be seen near tlie nucleus an
"attraction sphere " of finely granular protoplasm sur-
rounding a very minute, darkly staining spot, the ccn-
trimiiiie. The eggs of many animals of various groups
often somewhat resembling
Fir,. 3718,
Portion
\h mm.
Vr, germ
Woods.)
-Section of the Ventral
of au Embryo Dogfish,
Long. Bn, Endoderm ;
cells. X 3S. (After
contain also another bod}\
a nucleus and hence called
the yedk nucleus (Fig. 3714).
Fig. 3T19.-Part of a Sagittal Section of an Ovary of a New-born
Child, a. Ovarian epithelium ; ft, comnuMK-frm-ntof oneof Pfliiger'a
cords; c, c, "primitive ova" in the ej)illielium ; W, i/. and <\ f, ger-
minal involutions witli developing ova and young follicles ; /, young
follicle; (/, g. blood-vessels. Magnified. (From Waldeyer.)
It is also called, after the author who first described one
of these bodies, the corpuscle of Balbiani. It is probable
that the bodies classed together under this name are far
from all having the same morphological or the same
physiological significance.
The Envelope.'<. — The most primitive type of egg to be
met with anywhere in the animal kingdom is that char-
acteristic of the sponges and hydroids.
In these groups we meet with eggs that
are not only wholly naked, but also show
the power, at least within the maternal
body, of active amoeboid movement. Na-
ked eggs are found in representatives of
other groups of caOenterates ; and the eggs
of some echinoderms, at least, are without
envelopes when discharged from the ovi-
duct, although an envelope is formed im-
mediately after the entrance of the sper-
matozoon.
In all the higher groups of animals the
egg is provided with one or more cover-
ings. These are divided into three prin-
cipal classes. First we have the primary
envelope or ritelline membrane, which is
essentially a cell wall formed by the cyto-
plasm of the egg. This is found in rep-
resentatives of all groups of the animal
kingdom. It is genei'ally thin and struc-
tureles.s, but it may consist of several layei-s or be pierced
by radial pores forming a zona radiuta (h. Fig. 3718).
Sometimes the vitelline membrane is incomplete at the
point where the egg is attached to the wall of the ovary,
leaving an opening, the inicrnphyle, which serves as a
passageway for nutrient material during the ovarian life
of the egg and later for the
entrance of the spermato-
zoon.
The secondary envelope is
found only in eggs that are
surrounded in the ovary by a
follicular epithelium, which
gives rise to this envelope;
and it is especially character-
istic of the eggs of insects
and mollusks. In these forms
it is called a. chorion, a term
used also to designate a very
different fecial membrane of
mammalia.
After leaving the ovary the
egg may receive one or more
<e/'ft'(//7/ envelopes, which are
secreted by the walls of the
oviduct or by glands con-
nected with it. These enve-
lopes may be protective or
nutritive in function or both.
For example, in the hen's egg
(Fig. 3712), the ovum, com-
monly known as the "yolk,"
covered by a thin vitelline
membrane, lies embedded in
a mass of albumen that
serves as food for the em-
br_vo chick. But at opposite
poles of the ovmn there are
attached much denser strands
of albumen, the chalnsa, that
undoubtedly serve also as a
sort of packing to prevent
the ovum from coming into
too close contact with the
ends of the shell. Outside of
the albumen ai'e two shell
meiTibranes and then the hard
calcareous shell. The egg
when it emerges from the ovary is provided with only a
vitelline membrane. The albumen, shell membranes, and
.shell are tertiary envelopes and aie secreted in succes-
FiG. 3720. — Diagram of the
Derivatives of the Germinal
Epithelium in Mammalia. 1,
Medullary cord; 2. germinal
involution containing ova and
follicle cells; 3. invaglnated
epithelium (Pfluger's cord)
and covering epithelium.
(After Winiwarter.)
siiin by the wall of
ward.
the oviduct as the egg passes out-
44•^
HEFEREXCE HANDBOOK OF THE MEDICAL SCIENCES.
Ovum*
Ovum.
(^^
V. -.
r
.•%■
The outer coverings of the eggs of the different groups
of animals show much diversity of form and structure,
and many of them present wonderful adaptive modifica-
tions. But to treat of this fascinating branch of the sub-
ject would carry one far beyond the possible limits of the
present article.
Early Development. — In the sponges, some ccelentcrates,
and some of the lower worms the development of eggs
is apparently not localized, but may occur in various
parts of the body. In
the higlier forms, on the
contrary, the germ cells
alwajs imdergo their
development in certain
well-defined regions or
organs known in the fe-
male as the ovaries ; and
in all animals possessing
a distinct body cavity,
or ccplom, the cells of
the ovary are originally
continuous with the
peritoneal epithelium.
In vertebrates the por-
tion of peritoneum con-
taining the primitive
germ cells, the germinal
ejiiUielivm, is in the dor-
sal part of the body
cavity, usually on the
inner side of the Wolf-
fian body near the mes
enter}'. In the devel
opment of the ovary the
germinal epithelium
thickens, and the con-
nective tissue beneath
it also grows outward
into the bod}' cavity, so
that the two together
form an elevation upon
the Wolffian body known
as the g e n Hal ridge.
From this the definitive
ovary is formed.
We have called at-
tention elsewhere to the
very early appearance of
distinctly germ cells in
the worm Ascaris (see
».T\.K\e Heredity). It has
been shown recently that
in vertebrates the
germ cells may ap-
pear at a consider-
ably earlier stage
than had been
thouglit possible.
Jlinotin 1894 and
Kabl in 1896 liad
shown that what
appeared to be
germ cells, or prim-
itive ova, may be seen
•-•«-'i- '/ > ,-"1 'V"^^ :G-^' .^ -^ ■' ... form
' /*5fS^^"- " ^ . • r- . - - ^- ''^ wall
/ W.'^ '■■ ■■ ' ■ ■ : , ■ , . •:■,;--, the me
i..^
n early stages of the embryo ly-
ing in positions far distant from the genital ridge. " More
recently (in 1902) Woods has published the resiTlts of his
studies upon tlie embryosof the common marine dogfish,
Squalns acantliiits, in which he has been able to "trace
the history of the germ cells back to a mass of seemingly
indifferent cells forming the rim of the blastoderm (see
article Area Etnhryonalis). At first these cells are all
alike, but in an embryo of 2.75 mm. length they have
become differentiated 'into somatic cells and so-called
primitive ova, that is, primitive germ cells which may
become finally either ova or spermatozoa (Fig. 371.5).
The germ cells retain their primitive embryonic charac-
ter, while the somatic cells begin to change into forms
characteristic of epithelivun, niesenchyma,"and the like.
Vol,. VI.— 29
At a little later stage when the embryo is beginning to
fold off from the blastoderm, the germ cells are found
in a compact mass in the mesoderm near where it joins
theendoderm (Ur. Figs. 3716 and 3717).
From this point the germ cells begin to migrate, appar-
ently by their own ama-boid movements, toward the re-
gion of the future genital ridge. When the embryo is
between 6 and 8 nun. long the unsegmented mesoderm
divides into two sheets with the body cavity between.
After "this the germ cells
^ -^5 ;,. .S*"^T^"c-7?,. are practically all found
'^ *Vr^£l '•'''"' --^r^lr!^ ~'''\^-' '" *'"'' tuner sheet, or
' luehnopleure, which
" irms the mesoder-
portion of the
of the gut and
the mesentery. In an
embryo of 1.5 mm. (Fig.
3718) germ cells are still
to be found in the
splanchnic peritoneum,
but by the time the
embryo has reached a
length of 19 mm. these
i-ells have very nearly
all congregated in the
genital region. While
at present this is tlie
only case on record of
sucii a migration in a
vertebrate, it is probable
that more extended re-
search will reveal many
similar cases among this
group.
Development of the
Ovary. — As has been in-
dicated, the ovary is
formed by the enlarge-
ment and further differ-
entiation of the genital
ridge. In it we may dis-
tinguish two principal
parts — the cortical layer
and the medullary por-
tion. The cortex is de-
rived from the iirimitive
germinal epithelium,
and from it are formed
the peiitoneal, or epi-
thelial, covering of the
ovary, the Graafian fol-
licles, and the definitive
ova. The medul-
"^^ lary portion is de-
rived from the
underlying mesen-
chyme cells, which
form the connec-
tive-tissue stroma
and the blood-ves-
sels of the ovary,
and within it are
embedded the nerve fibres that supply these vessels.
In tlie mammalia the medullary portion contains also
during the early stages a large lunnber of strands of
cells of a more or less epithelial character, forming
what are called the medullary cords, and these have
given rise to a considerable amount of discussion. For
it has been seen that in the embryo these medullary
cords may sometimes be found in contact with the
glomerulic of the Wolffian body, and it has been sup-
posed that they were formed by outgrowths fi'om the
renal tissue into the ovary. Moreover, there are indi-
cations that ova may be developed in the medullary
cords, and, if this were generally true and the cords
have the origin .supposed, the ova of mammals would
have an entirely dillereut origin from those of other ver-
c.mn.
Fig. 3721.— Part of a Section of tlie (J\;ir> 'rl u lu
Covering epithelium: />, protobroohal nuclei of oogonia and follicle cells; c, deuto-
brochal nuclei ; d, leptotiEnian nuclei ; c, synapsis stage : j/i, oOgonia in mitosis ; k.
nuclei undergoing degeneration : cm., medullary cord; cm.;)., medullary connective
tissue. X 450. (After Winiwarter.)
Hiiif
I lay atler Birth.
4:4:9
Ovum.
Ovillll.
REFERENCE HANDBctOK OF THE MEDICAL SCIENCES.
tebrates — from the renal epithelium instead of from the
lining of the body eavity. This dilticnlty seems to have
been cleared np very satisfartnrily liy the recent work of
.•V--'
\\
Fig. 3722.— Nuclei from tlie rivarv of a Human Foetus of about Seven Montlis. B,
Two ooKonia nitli pnitobroclial nuclei ; ('. nucleus of an oocyte of the flrsi order
In the deutobroclial stage; », nucleulus. :■' 171*1. (After Winiwarter.)
von "Winiwarter (tflOO). In his study of embryo rabbits
he finds that the medullary cords are not formed as out-
growths of the glomeruke, but are the first ingrowths
of the germinal epithelium. They penetrate first the
stroma of the ovary and then push through the hilum into
the Wolfiian body] where they may come into contact sec-
ondarily with the glomerula\
In the ovary of an embryo rabbit taken from the uterus
twenty-three days after coitus, von Winiwarter distin-
guishes two principal parts in the primitive cortex. The
outer one is tlie germinal envelope, which is continuous
over the whole surface of the ovary and may be subdi-
vided into a supeilicial distinctly epithelial layer and a
deeper germinal layer. The inner part of tlie corte.x is
made up of the germinal involutions (lioi/n n.r genin'/mf/fs),
wliich are simply thickeningsof the germinal layer sepa-
rated fiom one another by strands of the ctmnective-
tissue stroma of the medullary portion of the ovary. In
their deepest parts the involutions are not j-et sharply
Fig. 3723. — Nuclei from tbe Ovary of a Itiunan Fo-tus of about Seven
Months. Consecutive stages in the dcvelopiueni of the oocyte: Z>,
leptot£eniau : E. synapsis: F. pa<-byla'uian ; a, iliplotieuian ; h.,
nucleolus. >: 171X). (After Winiwaricr.)
separated from the medullary cords, wiili wliich they
were originally continuous. In the subseciuent stages,
by the combined ingrowth of the germinal lu\er and out
growth of the connective tissue, the involutions become
more separated from one another and from the outer epi-
thelium, until in a new born child or a rabbit five weeks
after birth the involutions are connected with the epithe-
lium only bv narrow cords of cells, the so-cidled egg tubes
_^ " of Ptluger(Fig, 3ri9)(P//«,(7(?ra-/«-/t.'>c/(W»;c/(e),
Von Winiwarter's conception of the relations
of these structures of the ovarian cortex is
shown diagrammatically in Fig. 3720,
Dtefliijiiiii lit of the Dejinith-e Ota. — The
development of the ova in the later embry-
onic and early post-natal stages of mammalia
(rabbit and man) has lieen descril>ed with
great detail by von W'iniwarter. and we will
follow his accoviut, except so far as it may
be necessary to supplement it by reference to
other forms in order to complete our general
description of the later stages.
During its development the ovary is cov-
ered by a layer of epithelial cells with nuclei
elongated at right angles to the surface.
These nuclei (it. Fig. 3721) have a finely retic-
ular structure with a few irregularly ])laced
masses of chromatin. In an embryo rabbit of twenty-
three days practically the whole cortex is composed of
similar cells. Those beneath the epithelium differ only in
having nuclei a little more rounded and more coarsely
reticular (/., Fig, 3721 and B. Fig. 3722). This is the
prolohivcluil (-/liJToc. tirst. and .(-Vo.f'f. mesh) stage in the
development of the nuclei and the cells are oogonia.
Fig. 3724.— oocyte of the First nnlcrat the Betrinning of the Second
Period, from a Young Rabtat. The follicle cells are tew and much
flattened. X ITUO. (After Winiwarter.)
That they are in process of rajiid mtdtiplication is shown
by the presence of numerous mitotic figures among them
{lit. Fig. 3721). A large number of the jirotobrochal
nuclei remain unchanged and the cells finally form the
Graafian follicles (Fig. 371J), Others which are at first
apparently exactly like them belong to the true oogonia,
which finally cease dividing and begin to enlarge. They
then become the oitfiitis of the first ortlev.
The ovarian history of the oocytes may be divided into
two stages: first, before the foi'inatiou of the GtiUlfian
follicles; and, second, after that event. During the first
stage the nucleus of the oocyte undergoes a curious series
of trausforniatious.
The nuclei gradually enlarge and become globular in
shape. At the same time the chromatin becomes more
coarsely reticular, forming the (htitohroclial stage ('if crfpof,
second), and one or two nucleoli appear within the nu-
cleus {c. Fig. 3721 and C, Fig, 3722). In the ne.xt
stage (d. Fig, 3721 and D. Fig, 3723), the chromatin
ceases to have a reticular appearance and is in the
form of slender threads distributed evenly through-
out the nucleus in more or less p;irallel pairs. From
this the nucleus passes gradually into the synapsis stage
((Ti'i'dTrw, to reunite, to condense), in which the chromatin
threads are withdrawn from the greater ]iart of the
nucleus and arc ctmdensed into a tangled mass, generally
near one side of the nucleus (c, Yig. 3721 and IC. Fig.
450
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
«>viini,
Ovum,
3733). Wlieu the taiiglo i.s unravelled, tlie eliromatiu
emerges as a thick, beaded cord without any appearance
of doublinj5 (/'' Fig. (5723), Whether this is really a sin-
gle tilament or is composed of several, is ditticult to de-
termine. In the next stage, however, the chromatin is
distiucll\' divided into segments which are double,
often forming rings or figure eights ((;, Fig. g
3733). Finally, when the oocyte becomes .s\ir-
rounded by the follicle cells, the nucleus re
sumes a coarselj' reticular structure (Fig.
3724). It will be noticed tliat during
these stages the nucleus has increased
very much in size (compare Figs.
3723 and 3724).
In the embryo rabbit of twenty
three days there are alrcaily a
considerable number of oocytes
in the deutobrochal stage l.ving
in the deep parts of the genital
involutions. In the newly born
rabbit the oocytes are much more
numerous, and tho.se in the deep-
est parts of the ovarian cortex
have reached the sj'napsis stage
(e. Fig. 3721). Tlie earlier stages
(c, d. Fig. 3721) may be seen
lying nearer to the periphery.
The Graafian follicles begin to
be formed in a rabbit when about
ten days old ; but they are al-
ready present in a human fojtus
of seven months.
The egg f oUicle has a different
structure in each group of vertebrates. In manunalia it
is at first a single layer of tiattened cells ^Fig. 3724).
But these cells soon increase in number until they form
several layers surrounding the oocyte. Then a fissure
appears filled with fluid which incompletely separates
the follicular cells into an outer and an inner sphere.
The outer one is the so-called tunica (jrauulvsa, and the
inner one, which surrounds the egg, is the discus -pn:-
ligerus and is continuous with the granulosa on one
side, usually the side toward the centre of the ovary
(Fig. 3726). This is now a typical Graafian follicle.
In the mean time the connective-tissue stroma has so in-
s
canals through which there is supposed to l)e protoplasmic
connection between the oocyte and the surrounding fol-
Ptt^^^^l^i^^^'
Fig. 37a>.— Spftiiin of the Ovarv of a Cat. 1, Outer coverinB and free
border of thp ovary; 1'. attar-hed liorder. or hilum : 2. the central
ovarian .'^tronia, presenting a fibrous and vasPtilar stnicture; 3. pe-
riphenil stroma; 4. blood-ve.sspfs ; h. small (iraaflan follii^lcs lyuit'
near the surfaee; (i, 7. 8, more advanced fi>tlicles, whk-h are em-
bedded more deeply in the stroma; 9, an almost maturt- fullirle.
containing the ovm'n in its deepest part : 9', a follicle from which
the ovum has accidently escaped ; 10, corpus Ititeum. X (i. (.\fier
Quain, from Schron.)
vaded the germinal involutions as to isolate the folli-
cles and form a connective-tissue capsule, the theca funi-
culi, around each one.
At the time of the first appearance of the follicle cells the
outline of the oocyte appeal's to be clearly defined, ]iroli-
ably by a thin cell wall. When the discus proligerus is
established the oocyte is seen to be suiTounded by a clear
membiane, apparently containing extremely fine ratlial
Fig. 3726.— Portion of the Section of the Cat's Ovary, represented in the preceding figure, more
highly magnified. 1, Epithelium and outer covering of the ovary ; 2, 2', fibrous stroma ; 3, 3'. less
fibrous, more superficial stroma; 4, blood-vessels ; .5. smalt (jraaOan follicles near the surface ; 6,
one or two nioie deeply placed : 7, one further developed, enclosed l>y a prolnnijatinn of tin* ilhn>us
stroma; S, a follicle further advanced ; 8', another, which is irregularly i-ouipie.ssed ; !', (lart of
the largest follicle; (t, tunica granulosa; b, discus proligerus ; c, ovuiii ; i/, gerniiual vesicle;
e, germinal spot. (From Schron, in Quain's Anatomy. J
licular cells. This membrane is the zona radidtu, or mem-
hriuia pelliicidii. Whether it is a true vitelline membrane
formed by the oiicj'te or a secondar}- envelope formed by
the follicular cells is still a matter of dispute.
After the follicle is developed the" egg not only contin-
ues to increase in size, but also begins to acquire yolk
material or deutoplasm. This is small in amount in man
and other mammals, but in most other vertebrates a com-
paratively largo amount of yolk is formed.
The final discharge of the egg from the ovary in mam-
mals is brought about by the bursting of the Graafian
follicle. This allows the egg with the .surrounding fluid'
to escape into the body cavity whence it enters the Fal--
lopian tube. For the de-
tails of this process see
article Mi/istrmition.
Before the egg can be
fertilized, however, it
must pass through two
cell divisions of a pe-
culiar character, which
constitute the process of
milt)/ nit ion. During the
period of growth the egg
is an "oocyte of the first
order." At about the
time the egg is dis-
charged it undergoes a
very unequal cell divis-
ion, forming the fr.st pti-
liir body and the "oocyte
of the second order."
The latter soon under-
goes anolher division
into the seanul polar body, and the definitive, or ripe ovum.
The details of the processof maluration will be considered
in connection with a similar process in spernuitogeiK'sis
under the title Itcdiiction Dirision.
Robert Poi/iic lliycloir.
BinUOCR.tPHICAI, Kkferk.sces.
Balfour, F. M. : On the Structure ami Development of the Venebi-ite
ovarv. Quart. Jour. Micro. Sci., vol. .wiii.. 1.S78. pp. 38:3-437.
Horn, O. : Die Entwickelung der (ieschlechtsdrusen. Ergehnisse der
.Anat. und Entwick., v..l. iv., I.S94. pp. .592-61B.
Korschelt, E., und Heider, K. : Lehrbuch de rvergieichenden Entwicke-
FIG. 3727.— Egg of a Leech (Xephclis),
three-<}uarters of an hour after be-
ing laid. Formation of the first
polar body. iMagnifle.l. (After Ileri-
wig. I
451
4>AV('II« l^ilkr.
Oxalic Acid.
REFERENCE HANDBOOK OF THE iLEDICAL SCIENCES.
limL'-ci'siliicbte der wirbellosen Tbiere. Allgememer Theil, 1903,
li|i. -'.">(i :«li;.
GuTwiiscti, A.: Ideosom und Centralkorper im Ovarialcic der Siiuge-
tbiere. Arcb. f. mikr. Anat.. vol. Ivi., IlKlii. ]>\i. ^77-'.V.a.
Winiwarter, Hans von : Recbercbpssur l'i>v<ror]iV.> I'l I'orfranogenJse
de I'ovaire des Mammlftres (Lapin ft Hoiniut'i. Arcbives de
Biolojjie. vol. xvii., liilHi, pp. 33-1!)',).— NachtraK zu meiner Arbeit
iilier Oogenese der Siiugetblere. Anat. Anz., vol. xxi., 1903, pp. 401-
407.
OWENS LAKE.— Inyo Cminty. Californhi. This sec-
ond (Iciiil seu in California is loc'atcil at tliu soutl)ern end
of Owens Valley in Inyo Ccninty. It is eighteen miles
long and ten nii'les wide. Its surface embraces one hun-
dred square miles. The waters are leniarkably rich in
.saline and alkaline ingredients. The following analysis
was made by Professo'r Phillips, of London, in 1883: One
United States gallon contains: Sodium chloride, gr.
2,4.50.81 ; sodium carbonate, gr. 797.01 ; sodium sulphate,
gr. 2,427. G9: potassium sulphate, gr. 29.77; potassium
silicate, gr. 11().23; organic matter, gr. 14.11. Total,
5.830.02 grains.
We are informed by Dr. I. J. Woodin. of Indepen-
dence, Cal., that uiimei'-ous fresh- water springs are found
along the shores of the lake, some of which are cold and
others boiling hot. At the southwest end of the lake
there is a valuable white sulphur spring which has not
so far been improved. At a short distance from this
spring is a mountain formed in great part of suljihur, of
whicii Dr. AVoodin sends us a hauilsome specimen, com-
]iosed probably almost entirely of the pure element.
The aspect of the country is mountainous, the elevation
of the lake being three thousand feet above the Pacific.
The region oilers many attractions as a liealth resort,
and it Nvill no doubt soon be developed.
Jdiiies K. Crook.
OWOSSO SPRING.— Shiawassee County, Michigan.
P<l.sl-Ol'KUK. — Owosso.
Access. — Owosso is a station on the Detroit and iMil-
waukee Railroad, seventy-nine miles northwest from
Detroit.
Tlie following analysis was made by a chemist whose
name has been lost; One United States gallon contains;
(Calcium biearbcmate, gr. 2."). 07; magnesium bicai'bonate,
gr. 19.09; iron bicaibouafe, gr. ].'5.92; sodium chloride
and potassium chloride, gr. 2.10; alumina and silica, gr.
O.ttt. Total, (53.40 grains.
This water, as shown by the analysis, is ver}' Iieavilj'
impregnated with iron. As the name of the analj'st is
not known, the analysis is not reliable.
,7innes K. Crook.
OXALIC ACID. — Oxalic acid, having no medicinal vir-
tin's, is not ollieial in the United States Pliarmacopn?ia.
Its importance depends entirely upon its toxicological
relations. " E. C.
OXALIC ACID, POISONING BY.— The salt obtained
by evapoiation of tlie juice ot (J.nilis iiCilosiUd, and now
known as hiiio.rnhile of imtiiKlt, salt of norrcl, or iwilt of
leinnn, was known at least as early as the middle of the
seventeenth century, as Duelos niaki-s mention of it in
the "Jlemoirs of the Academy for 1008." A century
later (in 1773) o.Kalic acid was obtained from this salt by
Savary. Subsequently Scheele showed the oxalic acid
obtained from sorrel to be identical with the oeidofimf/iir
oht;nned by Bergman, in 177('), by the action of nitric acid
upon sutrar.
Tile first case of poisoning by oxalic acid, of which we
lind record, occurred in England in 1814 {Loud. Mid.
llrpiisitiirn. i., 382). In this case the acid was taken in
mistake fcn-Ejisom salt, a mistake which has subsequently
become the most frequentcause of oxalic acid jKiisoning.
Attempts at homicide by oxalic acid are of raic occur-
rence, owing to the difficulty of disguising the taste.
Christison mentions one as having occurred in England
in 1827, and others have been sidisequently reported
from the same country, the acid having been ini.xcd with
gin. colTee. suuar, tea, or buttermilk.
Notwithstanding the very extensive use of oxalic acid
and the oxalates in the arts of dyeing, calico-printing,
etc., they are as yet innocent of industrial poisoning.
As many articles of vegetable diet— beet, spinach, rhu-
barb, sori'el, etc. — contain oxalates, their use in excessive
quantity lias been supposed by some to be attended with
some danger of poisoning. As, however, the amount of
hydropotassic oxalate present is only 0.7o per cent. (= 3
grains per ounce) in fresh sorrel (Mitscherlich), and
much less in the other vegetables, their use in any rea-
sonable cjuantity may be regarded as unattended with
danger.
A more probable cause of poisoning is to be found in
the adulteration of citric acid with oxalic acid, and the
use of the adulterated product in the manufacture of
medicinal elTervescent drinks or of cheap "lemonade."
Poisoning by oxalic acid and the oxalates is of very
rare occurrence in France, while in England, Germany,
and the United States several cases occur annually. The
reason for the greater frequency of oxalic poisoning in
the last-named countries is to be found in the very exten-
sive use in them of oxalic acid and salt of lemon for house-
hold purposes, to clean metallic vessels and to remove
ink and fruit stains from fabrics, as well as in the popu-
lar habit of "taking a dose of salts" at certain times of
the year. Oxalic acid and magnesium sulfate resemble
eacli other very closely in appearance, and hence the
former is frequentl}' taken by mistake for the latter.
Sympto.ms. — Oxalic acid is both a corrosive and a true
poison, one or the other acticm predominating according
to the size of the dose and the degree of concentration of
the solution. If it be taken in the solid form or in con-
centrated solution, as is usually the case, the symptoms
of corrosion are the first to appear and may be the only
ones observed. But if the poison be taken in dilute solu-
tion the symptoms of corrosion may be entirely absent.
In a typical case of oxalic-acid poisoning, the dose
being in the neighborhood of 1.5 gm. (Jss.), taken in
concentrated solution, the patient experiences the first
eflects of the poison either immediately, during the act
of swallowing, or within a few moments. In exceptional
cases the first appearance of symptoms has been delayed
ten or twenty minutes, although largerdoses w-ere taken.
The strongly acid taste is observed and is followed by
a sense of heat in the mouth, throat, and stomach. This
rapidly increases in intensity until it becomes an intense,
burning pain. In some cases the pain is accompanied by
a sense of constriction of the throat and of impending
suffocation. The act of swallowing is performed with
difficulty, and later the voice becomes fainter and
husky, and sometimes completely extinguished. With-
in ten or fifteen minutes violent and persistent vomiting
begins in almost every ca.se. The vomited matters are
most frequently of a "coffee-ground" character, and
separate on standing into two layers: the upper a clear,
yellowish, and strongly acid liquid; the lower a thick,
red-brown sediment of altered blood. Occasionally true
Inematemesis is observed. In cases in which the poison
has been taken in small quantity and in dilute solution,
the vomited matters may be free from blood. In some
cases persistent vomiting and pain, and later persistent
purging of a blood}' material are the only symptoms, and
they may continue, with or without intermission, for five,
six, orseven days. Death finally occurs from exhaustion
in from five to ten days.
When very large doses have been taken (30-60 gm. =
;i.-ij.), the patient, after vomiting, niaj' go into a
state of collapse and die within five minutes.
The lips, mouth, and fauces are, shortly after the poi-
son has been taken in solution, reddened, swollen, and
painful. I^ater they become paler, and finally, some-
times within an hour, of a dirty, ashen-white line, either
throughout or in patches. The tonsils and uvula are
much swollen. There is severe thirst.
Soon the symptoms due to the true poisonous action of
tlie acid are added to those catised by its immediate cor-
rosive action upon the alimentary canal. The counte-
nance is pale, anxious, and haggard, the upper lip trem-
4.^)2
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Owens Lake.
Oxalic Aeid*
Wing, the lower jaw relaxed. The surface is bathed in a
cold, clammy perspiration. The lingers are semide.xed
and rigid, and the nails blue. The eyes are glazed and
the pupils contracted. There is sometimes persistent
hiccough. The pulse is small and thready, sometimes
intermittent or imperceptible. There are general numb-
ness and a sense of tingling or cramps in the upper and
lower extremities. Alidomin;il pain is no longer com-
plained of, although the abdomen may remain tender to
pressure; but the patient sufl'ers violent lumbar pains,
shooting down into the lower extremities. The respi-
ration is quick and labored. The skin in some cases is
marked witli an exanthem resembling that of roseola.
The urine is frequently retained, and that removed by
the catheter contains albumin in large cjuantity, epithe-
lium, granular or hyaline casts, and crystals of calcium
oxalate. Sometimes, in cases of recovery, the urine re-
mains purulent for several weeks.
Sometiiues there are violent spasms of a tetanic char-
acter; more rarely delirium. lu cases of recover}', spas-
modic twitchings may continue for a month.
In exceptional cases (usually, though not always, cases
in which a small dose has been taken) the patient rapidly
becomes stupid, .somnolent, and unconscious. This con-
dition has been known to pass into one of coma, terminat-
ing in death (Tidy: L,ijtat. 18T3, ii., 41).
Like the mineral acids and alkalies, oxalic acid may
cau.se death secondarily, after partial recovery, by star-
vation, due to extensive destruction of gastric and intes-
tinal mucous membrane. This was ob.served in an early
case by Eraser (Edinh. Med. Jouni., xiv., 1818, p. 607).
in which death by inanition followed in fourteen days
from the clTects of a dose of 3 ss. (lo.S gm.) of the acid.
The immediate cause of death in oxalic-acid poisoning
may be, therefore, either collapse, or paralysis of the
heart, or inanition.
DuR.\Ti0N. — The duration of a case of oxalic poisoning
is usually short if it terminate in death; but if the patient
recover the illness is generally protracted through several
days. Of 32 cases ending in death, 9 died within lialf an
hour, 3 in from one to twelve hours, 3 in from twelve to
twenty-four hours, and. 7 in from two to fourteen days.
Of 14 ca.ses terminating in recovery, in which the time
of discharge is mentioned, 3 recovered within one day, 4
in from one to five days, 4 in from live to ten days, and
3 in from ten days to three months. The shortest re-
corded duration of a fatal case is three minutes, the long-
est fourteen days.
Lkth.\l Dose. — The following tabulation of 51 cases
will illustrate the difficulty of fixing this quantit}' defi-
nitely:
Quantity of Oxalic Acid Taken.
Recovery.
Cases.
Death.
Cases.
5
1
3
1
fi
U
0
7
1
]
11
4.1)0 pm. - ( 3i.i
I
7.75 trm. — ( 3il.)
I
11.66 Km. - ( Jiii.)
1
15. .50 gin. — ( 3 iv.)
21.33 gm. - (3vi.)
.»
27.22 gm. - ( J vii.)
1
Sl.OOgin. - ( 5i.)
38.8.T gm. - ( 5 lt4)
0
46.65 gm. - ( 3 iss. )
0
25
26
From this it will be seen that one-half of tIio.se who have
taken over 4 gm. ( 3 i.) have died : and that tlie deatlis and
recoveriesare nearly evenly balanced with all doses below
30gm. (li.).
Tre.^tment. — The first indication, and one which ad-
mits of little delay, is the neutralization of the acid in
such a manner as to bring about the formation of an in-
soluble oxalate, and tlius prevent further corrosion and
absorption. For tliis ])urposethe alkaline carbonates are
useless, because, although they neutralize the acid and
thus prevent further corrosion, the salts fiirmed are solu-
ble and as poi.sonous as the acid itself. The old direction
to "scrape the wall " and administer the scrapings, was
well enough .so long as whitewashed walls were in vogue;
but to administer the scrapings of a modern jilasterccl
wall is of no benefit, as the calcium sult'ati^ so given is
incapable of neutralizing oxalic acid, or of converting it
into an insoluble salt. The best antidote is syni]) of
lime, or a similar preparation of magnesia. Precipitated
chalk is more frequently available and ma_y be given, as
the corrosion is not sufiiciently extensive to render the
generation of gas dangerous. For the same reason the
introduction of the stomach tube and lavage are not at-
tended with the same degree of risk of perforation as ex-
ists in corrosion by the mineral acids. Emetics are rarely
called for, as persistent vomiting i.s one of the most char-
acteristic effects of the poison. In the rare ca.ses, how-
ever, in which vomiting does not occur as a result of the
poisoning, emetics may be given, but only after early
neutralization of the acid. In no case should warm
water be given with a view to producing emesis: and.
until the acid has been neutralized, the amount of liquid
of any kind taken by the patient should bo as small as
possible. Opium may be given to allay pain, and stimu-
lants in the stage of collapse.
PosT-MORTE.M ArPE-\i!.\NCES. — The lips, tongue,
mouth, and esophagus are of an opaque, yellowish-
white color, sometimes marked with patches of a reddish
hue. The stomach is contracted, and in many cases con-
tains a thick, gelatinous, reddish-brown and acid liiiuid,
somewhat similar to the " coft'ee-ground " material vom-
ited during life. The peritoneal surface of the organ, as
well as the mesentery and the greater portion of the peri-
toneal surface of the intestines, is marked by blood-ves-
sels filled with dark, fluid blood. The nuicous surface of
the stomacli is strongly corrugated, and in most cases
presents a uniform, bright red color in the elevations and
depressions, except in so far as it may have been changed
to brown, or even black, by post-mortem action. In
some cases the mucous surface is, either in part or in
whole, pale, opaque, or translucent, and marked with a
coarse, ramiform vascularit}' of the submucous tissue.
The mucous membrane, where it remains, is soft, pulpy,
and easily detached. Although perforation has been ob-
served, it is of rare occurrence. Crystals of oxalic acid,
or of hydropotassic oxalate are not frequently found in
the stomach, although Lesser figures a case ("Atlas,"
t. viii., Fig. 1), in which the patient died within ten min-
utes; and the almost uniformly pale and much con-
tracted stomach was found plentifully lined with crystals
of hydropotassic oxalate. Jlicroscopic cry.stals of cal-
cium oxalate are, however, found in many cases in the
stomach and intestines, particularly in cases in which
death has followed, not within a few moments, but in
the course of from three to six hours. A microscopic ex-
amination of a section of kidney reveals the presence of
amorphous and crystalline oxalate in the tubules, even
in rapidly fatal cases (Lesser, loc. cit., PI. vii.. Fig. 3).
An.\lvsis. — The parts to be examined are the stomach
and intestines and their contents, the liver, kidneys, and
urine, also vomitc.'d matters.
The contents of the stomach and the vomited matters
are strongly acid in reaction, unless antidotes have been
administered, in which case they may be neutral, or even
alkaline.
In a systematic analysis the acid, or its salts, are to be
found in the residue of the portion exauuned for prussir
acid and other volatile poisons, or in the acpieous li(|uid
which has been treated with solvents for the .sejiaration
of glucosids and alkaloids. If oxalic acid or oxalates
alone are to be sought for, the materials are to be treated
directly as below.
It must be remembered that the acid sought may be
present either in the free state, in combination as a solu-
ble oxalate, or, in consequence of the administration of
antidotes, as the insoluble calcium oxalate, or the very
sparingly soluble magnesium oxalate.
The substance under examination, if acid, is to be first
extracted with water, the solution filtered, the tiltrate
evaporated over the water-balh, the residue extracted
453
Oxaplior. [Spring
Paeitit; <^ougress
IIEFEIIENCE HANDBOOK OF THE HIEUICAL SCIENCES.
with alcDliol, the tiltcrcd alcoliolic solution evaporated,
und thf ivsidiR' rcdissolvt'd iu a small (luaiitity of water.
Tliu solution so ol)taiurd (No. 1) will coutaiu any free ox-
alic arid which may have been preseul. Tlu' material
left uodissolvrd by alcohol in the preparation of solutiou
No. 1 is ne.xt to be extracted Avith alcohol, acidulated
with hydrochloric acid, the solution filtered und evapor-
«,ted, and the residue redissolved iu a small ([uantity of
water. This solutiou (No. 2) will contain any o.\alic acid
which nia_v have been present in the form ot a n'diiUe ox-
alate. Lastly, the sub.stauce left undissolved by water
iu the prejiaration of solution No. 1 is to be treated with
a sutlicieut aniouut of solution of potassium carbonate
(not hydroxid) to render it distinctly alkaline, and boiled
for two hours. The soluticui is tillered and evaporated,
the residue extracted with alcohol acidulated with hydro-
chloric acid, the solution tillered and evaporated, and the
residue redi.ssolved iu water. This solution (No. 3) will
contain oxalic acid, if it were present in the form of an
iniiiiliibh'. oxalate.
The tests for oxalic acid are then to be applied to the
three solutions.
The urine, contents of stomach, and vomited matters
slioidd also be examined microscopically for crysUils of
calcium oxalate.
The detection of a ino-r truce of oxalic acid cau only be
of value as c<irroborative eviileuce in a case of suspected
jioisoning by that substance, owing to the normal jires-
j'nee of oxalates in articles of food and iu the huiuan
cc(Uiomy.
TissTs. — 1. A solutiou of a calcitnn salt produces, iu
neutral or alkaline solutions, a white precipitate which
.a'edissolves in hydrochloric acid.
2. Argentic nitrate solution produces a white precipi-
tate which dissolves in aunuouiuni hydroxid solutiou aud
also iu nitric acid. If the licpiid crmtainiug the precipi-
tate be boiled, the latter doesuot darken. If tl4e ju'ecipi-
tale be collected, dried, and heated upon a strip of plati-
iiuiu foil, it explodes.
3. Lead acetate solution, iu solutions of oxalates which
are not too dilute, produces a white precipitate which is
soluble in nitric acid, but in.soluble in acetic acid,
limhilph A. Witthaus.
OXAPHOR. Sec Oxi/nnnphor.
OXFORD MINERAL SPRING.— New Haven County,
l!ouueclieut, I'osr-( )FFi( !•:. — I )xford.
Good Imtel withiu one-half niile. This spring has been
well known to residents of the ueighborhooil for many
years, but it has only recently beeu brought to the attcu-
tion of the public. Its mediciual properties are supposed
to liave beeu known to the Indians, as arrow heads and
oilier evidences of aboriginal life are frequently fouml
near it. The spring yieUls about one aud a half gallons
of pure, sparkling water jier minute. An analysis by
Prof. George F. Barker, of the Sheffield Scientitic 'School,
in 1873, residted as follows: One United States gallon
contains: Sodium chloride, gr. 0.35; sodium stdphate,
gr. 0.49; potassium suljihate. a trace ; lithium sidpliatc,
a trace; niagnesiiun siilpliati>, gr. 0 02; calcium sulphate,
gr. 1.01; iron carbonate, gr. 0.01; silica and iusoluhle
luattcr, gr. 1.33; organicmatter.gr. 1.22; loss iu aualv-
sis, gr. 0.10. TotaC 0.18 grains. "
The path of the streaiu can be easily traced by the
abundant bright yellow deposit of hydrati' of iron". In
the short time since this water was brought before the
public it has risen high iu jiopular favor as an invigorant
and general tonic. It is useful iu conditions of debility
aud ana>mia, aud in stomach, liver, aiul renal disorders,
etc. The water is u.sed coininercially, and is said to be
ac(}uiring an extensive sale. Juiins K. Cnxik.
OXYCAMPHOR — (CJImCOCHOH), a product of
the oxidation <>t cam]ilior — is prepared by reducing cam-
])h<u' orthO()uinoue with zinc ]iowder and acetic, sul-
phuric, or hydrochloric acid. It is a white crystalline
powder of bitteri.sh, peppery taste, aud without odor.
It fuses at 204' C. (400° F.), and is soluble in fifty parts
of cold water and freely in hot water, alcohol, ether,
chloroform, and the oils. Its Iwo-per-ceut. solution co-
agidates albumin, reduces haemoglobin, and is strongly
bactericidal.
To this drug is attributed the special power to over-
come dyspna'a by diminishing the excitability of the re-
spiratory centre in the medulla. Physiological experi-
ments with 0.5-per-cent. solutions aud clinical usage by
Rutlner, Ehrlich, Marlier, and others have demonstrated
that oxycamphor tends to lessen the frequency of the
respirations, to increase their depth, to slow the pulse,
and slightly to increase the blood pressure. It improved
the breathing in cases of tuberctdosis, bronchitis, emphy-
sema. Bright 's disease, auicmia, and heart disease.
Expo.sed to light and moisture the powder becomes a
soft, slimy, sticky, yellowish mass. It keeps fairly well,
however, in tablet triturates made with sugar of milk,
and is stable in tifty-per-cent. alcoholic solution. This
solutiou, known as ii.nipknr, is given with uuich water in
dose of O.Ti-l.O c.c. (niviij.-xv.). II'. .1. Basteilo.
OXYGEN. — Oxygen is not recognized in the United
States I'harmacopo'ia as a drug, but yvt is used in medi-
cine to a certain extent, generally by inhalation, either of
the pure gas, or of the same mingled with from one to
four volumes of atmospheric air or of nitrogen monoxide
(nitrous oxide gas). Oxygen is a colorless, odorless, and
tasteless gas, and is, when pure, distiuctly irritaut to
sensitive parts. Its main medical interest centres upon
the phenomena which follow the inhalalion of the gas in
greater concentration than is the case iu the atmosiihere.
Continuously inhaled, pure, the irritant effects of oxygen
are consi<lerable ; mice immersed in an atmosjihere of pure
oxygen die after three days with congested and inflamed
lungs. With inhalations too short to excite local mis-
chief, the question naturally arises whether an atmos-
phere abnormally rich in oxygen docs or does not tend
to determine abnormal absorption of the gas into the
blood, and so a quickening of the oxidations concerned
in vital processes. Opposite opinions have been held on
this question. The one view (Kegnaull and others) is that
with healthy lungs the blood normally takes from the
ordinary atmos]ihere all the oxygen that it is physiolog-
ically capable of absorbing, so that the presentuu'nt to it
of an air containing an increased proportion of the gas
can have no effect on the absorption rate. But a con-
siderable number of experiments and observations of va-
rious kiuds seem to oppose this view, and lead to the be-
lief that crowding the lungs with oxygen does also crowd
the blood with the gas. Thus, during oxygen inhala-
tions granulation tissue has been observed to grow
quickly ruddier iu hue (Demarquay), ex|ured carbon di-
oxide to double in amoiuit (Allen and Pep_vs, Limousin),
and excreted uric acid to lessen in qiuintity, presumably
by undergoing oxidation withiu the system (Kollnmn).
Whichever answer to the ciuestion be the true one, no
marked symptom pointing to any serious derangement
of physiological processes occurs when a moderate inha-
lation is practised liy one in health. The gas. even when
jnu'c, is jileasautly respirable, and from lifteen to thirty
litres (from four to eight gallons, about) can be inhaled
with Utile other obvious effect than a feeling of general
warmth and nervous exhilaration, with occasionally a
little giildiness and quickening of the pul.se rate. But
while the effects in health are coni]iarativel3' negative, it
is far otherwise when an oxygen inhalation is undertaken
by one sulTering for want of a sulfieicncy of oxygen be-
cause of some impediment to the full exercise of the re-
spiratory fimction, such as may be caused b_v asthma, eui-
physeuui, cardiac disease, croup, diphtheria, etc. In
such case the distress, because of the insufficiency of the
air supply, tends to be compensated by the higher oxy-
genation of the same, and the dysjma-a may be greatly
abated, or even, for the time, wholly abrogated. And
the relief may per.sist, of course in keeping with the char-
acter of the case, for a longer or shorter time after discon-
tinuauce of the inhalation. Similar relief by respiration
4:,4
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Oxaplior. ISiM-ingN.
Pacific Coagreos
of oxygen is afforded in cases of asphyxia from irrespir-
able or noxious gases, such as carbon monoxide or the
poisoned air of sewers.
Tlie therapeutic applications of oxygen are, first in im-
portance, tlie administration of the gas by inhalation lor
tlie relief of dyspntea or asphyxia in the circumstances
above described. Inhalations have also been practised
with the view of quickening the proces.ses of physiologi-
cal chemistry and so determining better nutrition in
chronic cachectic states, such as ana'uiia, chlorosis, tu-
berculosis, etc. The results of this latter therapeusis,
however, have not been very striking. Under any cir-
cumstances tlie existence of ulceration or active inflam-
mation within tlie air passages liad better be accepted as
contraindicating oxygen inhalation, unless the gas be
well diluted. In appropriate cases, from four to six-
teen litres (one to four gallons, about) may be inhaled at
a sitting, two or three times a day, pure or diluted with
air, from one to four volumes, according to the urgency
of the case. The gas must be known to be pure, in the
chemical sense of the word, and is best administered by
means of the bags devised for the giving of nitrous oxide
gas. But whether the gas be drawn from a bag or from
a gasometer, the inhalation should be by means of a
mouthpiece so fitted with valves that the products of ex-
piration shall not pass into the apparatus to mingle with
the gases to be respired. In order to obtain dilution
with air the simplest expedient is to leave the nostrils
open to inhale the atmosphere, while the mouth inhales
oxygen.
Oxygen has been administered also by passing the gas
into the stomach or the rectum, and with reported prompt
relief of dyspniea, the same as when given by inhalation.
Four rectal injections of five litres each are said to have
been absorbed in an hour. Oxygen has also been used
locally for the vivifying of tissues disposed to ulceration
or gangrene, with reported benefit. The practice is cer-
tainly not a common one in the United States. The gas
is applied in jet upon the affected parts.
Oxygen is supplied for medical use in iron cylinders,
generally condensed so that a cylinder holding from one
hundred to two hundred gallons is of a size easily han-
dled and stored. From such reservoirs a tiag or gasome-
ter is charged for the individual inhalations. Where
these cylinders are not procurable, oxygen may be ob-
tained by the usual procedure of heating potassium chlo-
rate with admixture of a little manganese dioxide — this
addition in some way determining the decomposition of
the chlorate at a lower temperature than would other-
wise be required. The manganese compound must be
free from adulteration with carbon (such as occurs in
some commercial samples by the accidental or intentional
addititm of pounded coal), else a dangerous explosion
may result. It is best, therefore, to test an untried sam-
ple by heating a little of it with a little potassium chlo-
rate in a test tube, where the small scale of a possible
explosion will do no serious mischii'f. For the making,
the mixed substances are heated in a closed retort or
flask, from which a tube leads through an intervening
wash bottle, containing caustic soda solution, to a gasom-
eter or jar filled with water and inverted in a pneuma-
tic trough, or to the bag from which the inhalations are
made. The first portions of gas that come over should
be allowed to escape before connection is made with the
wash bottle. And this wash bottle is an all-important
feature of the apparatus, the passage of the oxygen
through .soda being necessary to free the gas from con-
tamination with carbon dioxide and chlorine. The con
necting tube of the apparatus should be of good size,
since the gas, when once it begins to disengage, comes
over in great volume. For the same reason the heat
should carefully be watched and regulated during the
operation, to avoid too furious action. For each litre
(about one quart) of oxygen re(mired, 3.46 gm. (about
gr. liiiss.) of potassium chlorate will be needed. The
salt must be well powdered, and mixed with one-eighth
of its weight, or tiiereabouts, of powdered and pure black
oxide of manganese. Edward Curtis.
OXYQUINASEPTOL.— (Diaphtherin— CoH.[HOC„n,-
NllOj-iSU... ) — a registered comp<niiid introduced as a
powerful antiseptic for .surgical purposes, but which has
not been much employed. It was reported upon by Prof.
R. Emmerich, of Munich, at the Eleventh Congress for
Internal Medicine, held at Leip-sic in 18!)3.
It forms in amber-yellow transparent hexagonal crys-
tals, which, when powdered, are soluble in one part of
water, also soluble in dilute alcohol, very sparingly solu-
ble in absolute alcohol. It melts at 185' F. w itliout de-
composition, but is not altered chemically at 313° F.
It is recommended as an antiseptic dres.sing in surgical
practice, and for the treatment of ulcers, wounds, etc.
A solution of one-half to one per cent, is said to be suffi-
ciently strong for a lotion or to saturate dressings. Lo-
cally it has been employed in solutions as strong as fifty
per cent, without any injurious effect.
The sole drawbacks are said to be a tendency to act on
instruments, causing a black deposit, and a tendency to
discolor the skin and clothing. Beaumont Small.
OXYURIS VERMICULARIS. See Mmatoda.
OZ/ENA. See JS'itmit Carities, Diseases vf: Chronic
hipiiiniiHition.
PACHYAKRIA. See A,-r»megaly.
PACIFIC CONGRESS SPRINGS.— Santa Clara County,
California.
Post-Office. — Saratoga. Hotel and cottages.
Access. — Stages connect at Los Gatos with Southern
Pacific trains leaving San Francisco morning and even-
ing. Time, three hours and fifteen minutes.
These sjirings obtain their name from their resem-
blance to the well-known Congress Spring at Saratoga,
N. Y. The Santa Clara Valley is celebrated for its
excellent climate and dry, pure, and invigorating air. A
large and coniniodious hotel and several cottages have
been established at an elevation of 735 feet above the
sea level. The springs are located about one hundred
feet farther up the mountainside. The drives about
these springs are among the finest in the State. There
are on the premises several Sliriiigs which flow in great
profusion. The waters belong to the alkaline-chalybeate
class. They are valuable for table purposes. The fol-
lowing analysis was made by Anderson in 1888 :
One United States Gallon Co.ntains:
Solids. Grains.
.Sodium chloride 115.76
Sodium carbonate 130.43
Sodium sulpljiite 12.95
Potass! 11 Ml r:iiltouate 2.06
MaKni-siiiiii rarlmnate 26.34
Ma^Miosiuiii siilpliate , 14.17
Calrimii cai l»Mi;ite 16.03
('alcunu suii'liatt- 14. 19
Ferrous carbonate 13.87
Alumina 4 ..50
Silica 3.98
Organic matter Trace.
Total 344.27
Free carbonic acid gas 44.17 cubic inches. Temperature of water,
.50' F.
It will be observed that this water is much less densely
mineralized than is that of its New York namesake.
The Saratoga Congress Sjiring contains over 70Q grains
of solid ingredients to the United States gallon and over
393 cubic inches of carbonic-acid gas. The CaliSornia
Congress waters are, however, much more strongly chaly-
beate than are those of Saratoga. Their action is de-
cidedly tonic, owing to this large infusion of iron. They
are also mildly aperient (from the presence of Glauber's
and Eps(nn .salts), diuretic, and anti-acid (from the pres-
ence of alkaline carbonates). The springs have gained
considerable celebrity in the treatment of anaunia, dys-
pepsia, liver and kidney troubles, irritability of the blad-
der, rheumatism, gout, and cutaneous affections. The
waters are shipped to all jiarts of the coast.
James K. Crook.
455
PjM-iiiiaii <'or}»iiai-l4'.
Pain.
KEFERENt'E HANDBOOK OF THE MEDICAL SCIENCES.
PACINIAN CORPUSCLE. See Knil-Orginu, Xerrmis.
PACINIAN CORPUSCLES, PATHOLOGY OF.— Very
few obscrv:itious have been niacle u|i(iii llje oceurrcuce of
pathological ehauges in the Pacinian corpuscles.
Virchow noted the possil.iility of the ilevelopment of
the so-called laniellatcd libroma fiom Pacinian corpus-
cles, but regarded such origin as being of the nature of a
pathological curiosity.
Osier (Proceedingsof the Pathological Society of Phila-
dclpliia, IS86) reported a cas(^ of hemorrhagic pancrea-
titis in which the Pacinian corpuscles were enormously
swollen and ie<leniatous and the neighboring tissue was
infiltrated.
Przewoski (Arch.f. path. Aunt. ii. Pln/s., Bd. 03) de-
scribes live cases of a'dema of the Pacinian corpuscles
■which occurred in mitralinsufficiency, in chronic nephri-
tis, in emphysema, and in two cases nf chronic ]iulmi)nary
tuberculosis. In the first two cases general o'llcma was
present, but not in the other three. He claims to have
been the first to observe this condition.
Rattone {AirhhHo per le sdente mcdicfie, Torino, vol.
ix.) also describes a case of local O'deina of the Pacinian
corpuscles. In a case of scoliosis, in which no other
pathological changes of note were found, the Pacinian
corpuscles about the jiancreas showed an extreme grade
of O'deina. He, as did Przewoski, at first took the cyst-
like bodies to be cysticereus cysts, but microscopic ex-
amination showed them to be Pacinian corpuscles. In a
case of fibroma of the mamma, occurring in a young
male, he found a much compressed Pacinian body. The
chief symptom of the case had been agonizing neuralgic
pain, and Rattone believes that this was caused by tlic
changes produced in the Pacinian eorpusele through
pressure. There were no evidences of inllaiiunatiou in
or about the corpuscle.
The most extensive observations yet made ujjon the
pathology of the Pacinian corpuscle an^ those reported by
the writer (Phil. Manthlji Med. J<nn:, February, 1899). In
nine cases pathological changes were found in Pacinian
corpuscles embracing the following conditions: conges-
tion, o'dcma, hemorrhage, changes in vessel walls, acute
and chronic inllanunatory processes, mucous and colloid
degeneration, hj'aline deposit, calcification, and necrosis.
In one case of pulmonary gangrene great numbers of
hyaline or cy.stic bodies, varying in size from a piuhead
to a small clierry, were found in the mesentery, particu-
larl}' in the neighborhood of the pancreas and semilunar
ganglia. The majority were transparent, jell.y-like, and
fluctuating, suggesting parasitic cysts. Microscopical
examination showed these to be Pacinian corpuscles in
various stages of cystic change. The interstitial tissue
of the lamella? contained large cyst-like spaces in which
a mucin- or pseudomucin like substance was present.
These changes were confined to the corpuscles, and wei'e
apparently primary. In some of the corpuscles the
presence of congestion, small hemorrhages, and small-
celled infiltration would apiiear ti> justify the diagnosis
of a primary intiainmatiou (I'aeinitis) of the Pacinian
corpuscle.
In a case of chronic parenchymatous nephritis, mitral
insufficiency, and general tedenui, a similar <-ondition of
o?dema and cystic change was found, which was re-
garded as sccondaiy to the general o'llema.
In four cases hyaline change of the Pacinian corpuscles
was found: in two cases in the peritoneum and mesen-
tery, in the other two in the region of the prostatic
plexus. The hyaline bodies showed transition stages to
an appearance similar to the lamellated fibi'oma, as de-
scribed in the literature. In two other cases similar
hyaline bodies were found, but they were .so changed
that their genesis could not be determined.
In a case of femoral thrombosis chronic inllanunatory
changes were found in and about the Pacinian cori>u.s-
cles ])resent in the vessel sheath. The process was re-
garded as an extension from a chronic inllanunatory proc-
ess involving the sheath of the ves.sels and the vessels
themselves.
In a case of hemorrhagic pancreatitis necrosis, a?dema,
and Ijeinorrhage were found in the Pacinian corpuscles in
the neighborhood of the pancreas. These changes were
regarded as secondary to the pancreatic di.scase, the
marked liijuefaction necrosis of the nerve structure being
due to the action of pancreatic ferments. The involve-
ment of the Pacinian corpuscles and nerve trunks may
be the inuuediate cause of death, as .suggested by Osier.
Since the report of these cases the writer has observed
four other cases in which pathological conditions of Pa-
cinian corpuscles were found. (Edema and cystic de-
generation were observed in the corpuscles in the neigh-
liorhood of the pancreas, in a case of valvular disease of
the heart with general a'dema, and in a case of colitis
without general ledema. In a scirriious carcinoma of the
mammary gland a much compressed Pacinian corjiuscle
was found, completely surrounded by carcinoma tissue.
In contrast to the case observed by Rattone this patient
had never suffered pain. In a second tumor of the mam-
mary gland, a cystadenofibroma, a much compressed
Pacinian corpuscle was found extending across a large
cyst filled with serous fluid. Though surrounded on all
sides by fluid, the corpuscle sliowed no change beyond
that of compression. The tumor in this case was pain-
ful.
It would appear from the above cases that oedema or
cystic change is the most common primary, as well as
secondar}', pathological condition of the Pacinian cor])us-
cles. The exact significance of this condition cannot at
present be stated ; nor in the primary cases is the genesis
of the condition clear. In these cases the cedema is prob-
ably to be referred to some local circulatory changes,
probably to changes in tlie blood-vessels of a sclerotic or
inflammatory- nature. In the othei . es tlie secondary
nature of the aUeetion is clear.
Inasmvich as the physiology of the Pacinian corpuscles
is still in doubt, the clinical significance of these changes
cannot at present be known. The presence of large nuju-
bers of the corpuscles about the pancreas would indicate
that they serve some imjiortant sensory function, probably
relating to intra-abdominal pressure; and we are justified
in assuming that anj' extensive disease of these bodies
would ju'oduce important disturbances and give rise to
clinical .symptoms. The intense abdominal |iain oceiuring
in acute pancreatitis may be e.x-plained by the involvement
of the Pacinian corpuscles and the nerve trunks in the
vicinity of the pancreas. As Osier has sug.gested, death
in these ca.ses may result from shock caused by such in-
volvement. That compression of the Pacinian corpuscle
does not always give rise to sevei'c pain is shown by the
case of scirrhous carcinoma of the manuna. This ease
may, liowever, be explained by the asstunption that the
nerve trunks had been destroyed by carcinomatous infil-
tration, the more resistant corpuscle remaining preserved,
The paucity of observations and our lack of knowledge
regarding these structures make desirable more careful
investigations as to their physiology and pathology.
Aldrcd Scott Warihin.
P/EONY. See Rinniiiciilamv.
PAGET'S DISEASE OF THE NIPPLE. See Caiicer.
{Cli Iliad.)
PAGOSA SPRINGS.— Archuleta County, Colorado.
PosT-Oi'FicK. — Pago.sa Springs. Hotel and boarding-
houses.
Access. — Via Denver and Rio Grande Railroad to
Amargo, N. M., thence twenty-eight miles by daily
stage over a good road to the springs.
This resort is located in a picturesque, lieavily wooded
mountain region, at an altitude of about seven thousand
f(^et above the sea level. Bear, elk, deer, and wild tur- |
keys aboiuid in the neighboring mountains, and it is said i
that a basket of trout may be taken at any time without
going beyond the village limits. The country is new, j
but is fast being developed, and hundreds of people from |
different parts of the United States camp out in the !
456
REFERENCE HANDBOOK OP THE 5IEDICAL SCIENCES J""""""" <on>u8fIe.
Pain.
neighborhood every summer in order to avail themselves
of the salubrious climate and many other attractions to
be found here. . There is considerable snow in January.
February, and March, but durmg the remainder of the
year the weather is clear and beautifvil. The summer
temperature reaches 90 F. at times, but owing to the
bracing atmosphere no discomfort is felt. The nights
are always cool. There is but one mineral spring at
Pagosa. It is situated on a small elevation and froui it
the water issues through crevices in various directions.
The water supply is quite inexhaustible, as it is esti-
mated that the combined currents from the spring woidd
form a stream three feet deep and six feet wide. Dr. H.
(i. Ha.xley, of the springs, furnishes us the "following
analysis, supposed to have been made under the auspices
of the United States Government when it maintained
a fort at this point:
Pagos.\. Hot Springs.
O.NE United States Gallon* Contains:
Solids. Grains.
Sodium chloride 01 .St
Sodium carbonate S3. 27
Sodium sulphate 1.50.21
Calcium carbonate 41.76
Magnesium carlxiuutf 6.65
Litliiuui carbonate 3.28
PoLi-ssiiuii carbouatc 3.80
In in iMi .li 'xule 16
MauL'aiifsp protoxide 11
Calcium tlu..ride 30
Calcium phosphide 0.3
Silica 71
Total 351 .09 •
Temperature of water, 155° F. Elevation, 7,000 feet.
* Converted from grams per litre.
The waters are said to possess valuable properties in
the treatment of rheumatism, gout, syphilis, and ana?niic
conditions. Dr. Haxley informs us that he has seen ob-
stinate cases of chronic rheumatism cured or greatly bene-
fited by a two weeks' course of the hot baths.
James K. Crook.
PAIN.— From a restricted philosophical view pain may
be regiirdeii as a reaction of the organism, in part or as
a whole, to harmful inliuences; giving a warning iu con-
sciousness that some activity prejudicial to the health of
the tissues is operative.
The movements of expansion and contraction in proto-
plasm, the biologists stiy, are primordial expressions of
the pleasure-pain sense; expanding in response to pleas-
ure-giving (healthful) and contracing in reaction to pain-
giving (harmful) imjjidses. These reactions are con-
sidered the germ of the idea wbicli by numerous
multiplications, complications, and added" phenomena
have come to make the many-sided tigure of the human
pleasure-pain .sense.
The pain of trauma, in a bruised bone, or the discom-
fort of a niechauieal process, as the pressure of an exu-
date or transuiiate, the irritation of an inorganic or organic
toxic agent, the pain of ulceration or of necro.sis — these
are of the types of painful sensations, viewed in a nar-
row sense, which the physician most often is called
upon to treat. But there may be jiain in consciousness
connected with more couijile.x" processes than those just
mentioned. The pain of fear, of anxiety, of dread, of
anger, even the peculiar (laiii of the "sick" .soul " and the
ecstatic states, and of other and various emotional condi-
tions, are no less real pain than those of an irritated or
injured sensory nerve. Even these manifold and com-
plexly intricate emotional states, however, are posited
by the terms of some descriptive psychologists as the
results of organic viscei-al reactions, mostly reiiresented
in the sympathetic nervous plexuses and "in the extra-
cortical or subliminal mental activities.
Of the intricacies and 1 he extraordinary width, tu'cadl li.
and depth of the pleasure-pain .sense only a most exten-
sive study of the ancient and current literature of an-
thropology, neurology, psychology, and sociology can
give an adequate idea, and the present discussion is
limited in scope to the narrow field of that which may
be termed pain in the common-sense view of the term—
the reaction of the sensory nervous system to a prejudi-
cial activity. It will be limited to the painful sensations
of the periphery (the epiblastic substances— the skin and
external mucous membi'anes), of tliose organs and sur-
faces which are formed by involution cif the primary epi-
dermal structures— as the intestinal canal, the bladder,
the pleurae; further, to those pains which occur in the
mesoblastic structures — the muscles, the bones, the vis-
cera, etc.
V.\RIETIES OF Paix. — Froui simple discomfort to
agony the gradations of ]iain are many, but a few types
seem to be associated with recognizable types of lesion.
Two types of pain may be distinguished tit the out.set—
iicnte and chronic — indicating in a general way, first,
the more violent reaction of the sensory nervous" system
to an irritant ; and, secondly, that of the more profonged
and habitual protest of nature against the harmful intlu-
ences o,f a chronic process. Acute pains usually call for
immediate diagnosis, if not immediate treatment ; chronic
pains, as a rule, demand a study of the more involved
and intricate pi'ocesses of nature.
Pain, again, is spoken of as periodic, recurrent, alternat-
ing, or continuous.
As to character, acvte darting pains are characteristic
of the neuralgias, myalgias, and neuritides— such pains
are frequently paro.cijsiiial or remitting iu type, coming
and going with great suddenness and leaving no trace
of their presence, save at times a certain sense of soreness
after frequent attacks. Such pains, moreover, are dis-
tributed usually in definite anatomical areas, which fact
is of the utmost intportance in their diagnosis and treat-
ment. In many instances this type of \>a.m is recognized
as shifting in its distribution. At one time the nerve
distribution in the foot is alfected; again, the same nerve
area of the thigh, then the leg representation ; again, the
painful sensations may be distributed over a definite seg-
ment area: on one side or on opposite sides of the body.
Colicky Pains are cbaraeleristic of affections of the
hollow viscera. The stomach colic of poisoning and of
cliolera morbus, the abdominal colic of flatulency, of
distention and obstruction of the intestine, the tenesmus
and pain in the ureter and bladder from urethritis,
pyelitis, cystitis, etc., are the results of the cramp-like
muscular activities of these organs, usually enga.ged in the
process of ejecting, orti-yingtoeject, a liarmftVl occupant.
in the diagnosis of tli"ese pains the sense of muscular
effort is often present in the patient's consciousness and
is a useful guide. Careful questioning of a discriminat-
ing patient will often reveal much. In the treatment of
these conditions the carrying out of nature's indications
is rational. Thus, at the present time, catharsis and
enteroclysis are more frequently employed for the initial
stages of cholera moi'bus, diarrheas, and dysenteries than
are narcosis and muscle paralysis bv opium and similar
drugs.
Boring or growing pains are deep-seated, illy defined
pains frequently found in viscei-al disease. The bones,
the muscles, the meninges, the spinal column, the liver,
or other deep-seated viscus may be involved. Aneurisms,
new growths, and other lesions in these moi-e remote
localities are often the caiise of dull pains. It is usually
advisable to regard them at their worst if regrets of faulty
diagnosis are to be avoided. IMany of tlie brilliant diag-
noses of the specialist may be anticipaled by the family
practitioner, if suHieient consideration is given to all dull
pains of a persistent chi-onic or remittent nature. The
so-called growing pains may be classed iu this category
and too frequently prove to be precursors of acute or
chronic joint lesions, which on development entail much
misery and sulTering on the young. Mocenunt pains are
those which are increased by motion of the joints or of
the muscles and are indicative of some lesion in these
structures.
457
Palisade \\ 4>riii««.
Pancreas.
KEFEHENCE HANDHOOK OF THE ME1)K:AL SCIENCES.
Pain Appreciation. — If ]iaiu he regarded as a reaction,
evidently two factors, at least, are involved in its ap-
preciation. The cliaracter or intensily of tlic inducinir
agency and tlie individual's snsce]itibility. Since eacli
individual's own experience is tlii^ only guide to the
physician's estimation <if the intensity of the (lainful feel-
ing, much judgment and sympathy are needed correctly
to" gauge the patient's susceptil)ility. Pain to many is
but an incident. Tliey are either aiia'stlietic or stoical,
either really feeling little or able to control their expres-
sions of pain: others, again, are hyiicra'stlietic or exag-
geratioual; either they really are extremely susceptible
or they possess little "or no control over tiieir feelings.
At all' events the grade of the patient's own feeling is
the true measure of the pain for themselves, but it may
not be a useful guide in the diagnosis of a disease proc-
ess.
It has become ]iopular. since the studies of Lombroso
and his school, to generalize regarding pain susceptibili-
ties among individuals in certain occupations or ]irofes-
sions. or among the peoples of a country. Thus the
Teutons are reputed to be relatively non-susceptible;
that thieves, prostitutes, and the like are auajsthetic.
Such generalizations are founded on the most flimsy evi-
dence and are based purely on half-truths at best. More-
over, the ipiestion of control over one's expressions of
pain is rarely taken into account by many of these stu-
dents.
Pain that is acute and severe in character usually
causes a well-known picture of contracted muscles,
dilated pupils, cold wet hands and feet, a picture closely
resembling and indeed inducing at times tlie well-known
act of fainting.
Pain Location. — For the most part the feeling of pain
is referred to the diseased area, and when lesions are
found to be superficial and within reach it is ea.sy at
once to distingtush their true nature and to locate them
correctly, and then to a|iply the ]iro|ier treatment. When
no superficial lesion is found, the ([uestion ari.ses whether
the pain sensation is in direct relation to an adjacent
organ or whether it is a referred sen.sation from a more
remote viscus.
Of the facts which help to a correct judgment the grade
of pain intensity is one of the most important. Those
pains which are U'ss intense and more illy defined are
more liable to be referred pains from a more remote area.
By the researches of Dana and Head* the mapping of
areas of referred scnsaticms has become an ahnost detinite
matter. Head has shown that a tliseased viscus very
frequently, if not always, sends sensory impulses to the
si>iual cord, wliicli impulses are felt as irregular pains,
usually <lull, at times very acute, in the skin area sup-
plied by tlie sensory nerve of the spinal-conl segment
related to the viscus .segment. By means of the work of
this author and others many of the earlier charts illus-
trating referred pains are being revised, and more definite
conclusions are now possible, although as yet many of
the ascertained facts have more importance in neurologi-
cal than in general diagnosis.! Smitlt Ehj JcUiffe.
PALISADE WORMS, ^rv yamitmh,.
PALM BEACH, FLORIDA.— This popular and fashion-
able winter resort is situated in Southern Florida on the
east coast, in latituile 20' .57 . about two luuulred and
eighty miles south of Jacksonville. It lies uptm a nar-
row strip of land between Lake Wcuth and the Atlantic
Ocean. The vegetation at this latitude isnaturall}' tropi-
cal and luxuriant, and art has added to the natund beauty
by ]iarks. gardens, and paths running through groves of
|ialms and tropical trees. Flowers aliound, anil such
tro|iical fruits as the banana, pineapple, guava, tama-
rind, and mango are found here. Incleed. nature and art
have combined to render this spot peculiarly attractive
and fascinating. The accommodations are luxurious and
* Head and Camiibefl, " Brain," vol. 2:!. 19rin. p. .■J.'B.
+ Pain : James Maclieiizie, M.D., "Bram," Autumn, 1902, p, :i(i.H.
consequently expensive. There are two large hotels af-
fording every comfort, and several smaller and less ex-
]iensive ones. There are also numerous tine private resi-
dences. Many means of recreation are offered the visitor:
bicycling througii the many beautiful paths; fishing,
ALABAaMA
^-^^^'"St^
Flli. 3728.
rowing, sailing, shooting, surf bathing, swimming in
a large salt-water pool, and golf upon the tine and exten-
sive links. Hot .salt-water baths are to be had in some of
the hotels. Palm Beach is easily ami comfortably reached
direct by railway from Jacksonville. One is referred to
the article upon Fhrridum thisH.\Ni>BOOKforan extended
consideration of the climate of Florida, including this re-
gion. In this article will be found the climatic data for
Jupiter, which is only seventeen miles north of Palm
Beach, and which therefore has essentially the same cli-
mate as that of Palm Beach. The average mean temper-
ature (Fahrenheit) for the months of December to March
inclu.si\e is: December. 07.2' ; January, 63.4° ; February,
06.7°; ^larcli, OS. 8'. The maximum temperature for the
same months is: December, 82° ; January, 80': February,
84.7° ; March, 8.5. .5". Jlinimum, December, 41' ; Januarv,
38.5" ; February, 39.8° ; l\Iarch, 44.8°. The average rela-
tive humidity is 82 per cent. Tlie average number of
clear and fair days is: December, 23.9; Januarv, 24;
February, 22.1; Slarch, 27.1. Theaverage precipitation
is: December, 2.88 inches; Januarv, 3.43: February,
2.72; JIareh, 3.59.
The distinguishing characteristics of the winter cli-
mate of Palm Beach are warmth, sunshine, eciuability,
and moisture. It is a warm, moist, m;irine climate.
Such a climate is well suited for elderly and feeble per-
sons, convalescents of a certain kind : for ]iersons affected
with neurasthenia or with chronic bronchitis, and for the
valetudinarian in geniTal, but not for those who are af-
fected with pulmonary tuberculosis. For one who de-
sires to escape the inclemency and strain of a northern
winter and live an outdoor existence in the midst of at-
45S
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
PaliMado Worms.
Paiii-rea8.
tractive surroundings, and who, moreover, is able to pay
for luxurious accommodations. Palm Beach can unqiiali-
tiedly be recommended. Further, it is easil}' and com-
fortably reached from the Nortli. Good medical service
is at hand, which is a matter of the hrst importance in a
healtli resort. The season extemls from December to
March.
Sixty-seven miles south of Palm Bcacli is Midini, the
terminus of the East Coast Railway and the port of de-
parture for Nassau, Havana, and Key West. It is a
town of aliout tliree thousanil inhabitants. "The Royal
Palm," a large and luxurious hotel, is situated here in
the midst of a large tropical park. The climate is essen-
tially the same as at Palm Beach, and much the same sort
of outdoor life and amusements are afforded the visitor
here as at the former place. Edward 0. Oti-t.
PALMYRA MINERAL SPRINGS.— JefTerson County,
Wisconsin.
Post-Office. — Palmyra Springs. Hotels and sani-
tarium.
Access. — Via Chicago, Milwaukee and St. Paul Rail-
road to Palmyra, 118 iiiilcs north of Chicago and 20 miles
west of Waukesha. The sanitarium stage meets trains.
Palmyra is a pretty little town of 1.000 inliabitants,
nestling in the foothills of the famous Kettle Range of
Wisconsin. The location is 850 feet above tide-water,
and it combines many of the features sought after by the
summer seeker for health or recreation. This entire .sec-
tion isfavori'd withasalulirious ('limate, and is altogetlier
free from malaria. The soil is dry, sandy, and porous,
overlying glacial deposits of gravel, which affonls the
best natural facilities for through drainage. The scen-
ery here is noted for its tramiuil beavity and loveliness.
In his attractive brochure on "Summer in the North-
west" Mr. W. J. Anderson informs us that the bea\itiful
little Spring Lake, or Palmyra Lake, as it is generally
called, " ma}' be classed as one of the gems of Wisconsin.
Its bottom is covered with mosses, ferns, and other aquatic
plants, which in mid summer bloom and blossom as a
garden. It is fed by numerous mineral sjiriugs in the
vicinity, and affords an enticing prospect for the angleror
the lov'er of boating." Seven miles distant is the Scup-
pernong trout pond, which is said to contain milHons
of trout of all varieties and sizes. Many other beautiful
lakes are within easy driving distance, over excellent
roads. The Palmyra Sjirings Sanitarium is delight-
fully situated on the margin of Palmyra Lake, of which
it commands a charming view. This is a substantially
bnilt brick structure, four stories in height, containing
spacious halls, wide verandas, and all the modern acces-
soriesfor the health and comfort of its occupants. There
are facilities for the administration of electricity in its
various forms, massage, etc. The baths embrace salt,
shower, shampoo, Turkish, Russian, and natural mineral-
water baths, the rooms being spacious and luxuriously
furnished. All kinds of facilities for indoor and outdoor
diversions are at the option of the guests. Directly op-
posite the sanitarium is a forty-acre forest of native oaks —
the "Sanitarium Grove." Its winding walks and shaded
nooks add no little to the attractiveness of the place. At
a distance of one mile and a half from the sanitarium is
the great Geyser Spring. It is thirty-eight feet in depth
and tifty feet aero.ss the surface, and supplies ten mil-
lion gallons of water per day. The water is soft, pure,
and palatable, and is believed to possess remedial value.
The mineral springs at Palmyra are very numerous. A
cluster of half a dozen in the spring park, which could
all be covered by a canvas forty feet S(iuare. are ijuite
dissimilar In taste, of varying temperature, and of differ-
ent analysis. One spring is sliglitly thermal, having a
temperature of 72' F. : another, ten feet distant, is a little
cooler (62. .5° F.l; while others vary in temperature from
50° to 52' F. Back of the sanitarium, and fo\ir hundred
feet from it, is another group, known as Magnesian
Springs. They are remarkably pure and free from
organic matter. Following are analyses of three of the
springs. No. 1 being by Prof. W. S. Haines, of Rush
Medical College, Chicago, and Nos. 2 and 3 by Prof.
Bode, of Milwaukee :
Spring JS'o. 1. — One United States gallon contains: So-
dium sulphate, gr. 0.94; potassium sulphate, gr. 0.23;
calcium bicarbonate, gr. 15.70; magnesium bicarbonate,
gr. 10.94; magnesium chloride, gr. 0.18; iron bicarbo-
nate, gr. 0.5; calcium phosphate, a trace; alumina, a
trace; silica, gr. 0.70; organic matter, a trace. Total,
28.74 grains.
iSpriiig AT). 2. — One United States gallon contains:
Sodium chloride, gr. 0.21; sodium sulphate, gr. 0.(i4;
sodium bicarbonate, gr. 0.16; calcium sulphate, gr.
0.30; calcium bicarbonate, gr. 9.86; magnesium bicar-
bonate, gr. 7.91; iron bicarbonate, gr. 0.6; alumina,
gr. 0.19; silica, gr, 0.61; organic matter, gr. 0.35. Total,
20.29 grains.
Spring No. S. — One United States gallon contains:
Sodium chloride, gr. 0.43; sodium sulphate, gr. 0.40;
sodium bicarbonate, gr. 0.18; calcium sulphate, gr. 0.80;
calcium bicarbonate, gr. 12.84; magnesium bicarbonate,
gr. 10.14; alumina, gr. 0.23; silica, gr. 0.90. Total,
25.91 grains.
Tliese waters all possess mild diuretic and antacid
properties. The water of Spring No. 3, being entirely
free from organic matter, is well adapted for carbonating
and bottling. The numerous topographical, climatic,
and other advantages of Palmyra render it a suitable
resort for a large variety of ills and ailments. The spring
waters exert a beneficial influence, especially in rheuma-
tism and dyspepsia, although their use is also extended to
functional hepatic disorders, the early stages of Bright's
disease, and to eczema, pityriasis, and other skin troubles.
James K. Crook.
PANACEA SPRINGS.— Halifax County, North Caro
liua.
Post-Office. — Littleton.
Access. — These springs are situated three and a half
miles from the town of Littleton, at an altitude of 380
feet above the sea-level.
The location is in a beautiful valley surrounded by
picturesque hills covered with rocks of immense size,
and still clothed in their primeval forest growth of
gigantic oaks. The meteorological conditions which
prevail here are of a salutary character, there being
neither long droughts nor excessive rains. The springs
are fifteen or twenty in nimiber and flow about five hun-
dred gallons of water per hour. The following analj'sis
was made some years ago by Dr. H. B. Battle, of the
State Experiment Station. The bases and acids only are
given: C>ne United States gallon contains: Iron, gr. 2.18;
alumina, gr. 0.32; calciuin, gr. 1.11; magnesium, gr.
0.20; manganese, gr. 0.01; potassium, gr. 0.70; sodium,
gr. 2.23; hj-drochloric acid, gr. 0.82; .suphuric acid, gr.
0.42; phosphoric acid, gr. 0..53: silica, gr. 1.18. Total,
9.70 grains. (Carbonic acid, large amount; not deter-
mined.)
It is evident that the acids and bases would unite in the
form of carbonates, chlorides, sulphates, and phosphates.*
The waters are very useful in chronic diarrh(ea and the
debility which usually accompanies the disease. They
are highly recommended in the debilitated states attend-
ing uterine and ovarian diseases and in restoring anaemic
and puny children. James K. Crook. ,
PANARITIUM ANALGICUM. ■tiee Murrair.t Disease.
PANCREAS, ANATOMY AND PHYSIOLOGY OF.—
1. (!i!oss Anat(i\iv. — Till' pancreas isau elongated gland
of a re<ldisli-yellow color. The size is somewhat vari-
able indifferent individuals, but the gland is usually from
* Aoeording to E. E. Smilti, M.D., Ph.D.. of New Tori;, to whom we
have submitfeil this analysis, tlie i-oiiitiinations would result as fol-
lows. In oni" ITniicil stiites pallon there would he : Sodium chloride,
gr. 1.31: sodiuMi sulphate, gr. d.tiS; sodium liiiarhonaif. pr. ll.'.ti;
potassium liirarhonale, gr. l.(B; i-alcium bicarbonate, gr. 4.8.5: mag-
nesium bicarljouate. gr. 1.21; manganesium bicurbouate. gr. O.U.'S;
iron bicarbonate, gr. :).flS; iron phosphate, gr. 0.83; alumina, gr. li.;il;
silica, gr. 1.18. Total, gr. KMi.
-t59
Pancreas,
Psiiiorcas.
REFERENCE IIANUISOOK OP THE MEDICAL SCIENCES.
five to six inches in length, from lialf !\n inoh to an inch
in tliickness, and wciglis from two ami a lialf to three
anil a half ounces (00 to 90 siiii.).
The pancreas, like the liver, is mouldcil in shape by
the organs willi wliich it is in relalionsliip, so that it is
irregularly prismatic in shape, especially in its miilillc
|iiirtiou or body.
The pancreas lies in the loop of the duodenum and is
hence deeply placed in the abdomen, stretching across
the posterior abdominal wall nearly transversely at the
level of the first and second lumbar vertebra', and is
almost concealed by the stomach uhicli lies in front of
it. Regionally the' pancreas lies almost com|)letely in
the epigastrium, but the I i]) of the free end or tail, which
comes into contact with the iiuier surface of the spleen,
lies in the left hyiiochondrium.
For the description of relationshijis. it, is usual to con-
sider the gland as consisting of head, neck, body, and
tail, although these parts are not very clearly marked
oil naturally from one another.
The larger rounded right extremity of the gland forms
the head, which accurately tits into and fills the concave
Aaria
MiU
Fig. 37^.— I)iaffranini:iti(' Pirture Slinwinir tlie Uelatinns of the
Pancreas to Ibe Stdiiiacb, DnuatMiuiii. ami lilnoii-vt'sscls. (After
Kuene.) a./*., Arteria liepatiea ; 1'./j., vi-na porta' ; «/.(■/(., dut'tus
ctloledocbus ; «.(., splenic jtrttTV (art. licnalis); t'./.. splenic vt'in;
y.j».*'., superior mesenteric vpin ; ^4.i/(.s., superior mesenteric
artery; G.UL, gall-bladder : irlur, liver ; JlfayfU, stomach ; Milt,
spleen.
side of the sharp curve formed by the second and suc-
ceeding parts of the duodenum. The neck is a portion
about an inch in length which curves upward, forward,
and to the left, from the anterior |>oition of the head, to
unite it to the body and tail at abmit a right angle. In
this angle are placed the superior mesenteric vessels,
which lie in fi'ont of the head and ai'c covered, as they
pass upward towai'd the cceliac axis and jjortal vein, by
the neck, which lies in front of these main trunks. The
body and tail, which together measure from four to live
inches, cannot really be differentiated from each olher,
the tail being merely the extremity of the body which
turns upward toward the spleen.
'I'he interior vena. cava, left renal vein, iind aorta lie lii--
hind the head of the gland, and the origin of the superior
mesenteiic artery, the crura of the diaphiagm, the splenic
vein, left kidnev, and siipi'arenal gland are the chief
posterior relations of the bod}'. In front, the pancreas
is separated from the overlying pylorus and stomach by
the lesser omental .sac, and the lower portion of the head
of the gland is cnis.sed by the transverse colon an<l its
mesocolon. The transverse mesocolon is attached pos-
teriorly to the lower border of the gland and splits here
into two layers, one being reflected upward, ovi'r what
is known as the anterior surface of the body of the pan-
creas, while the other passes back over the narrow in-
ferior surface and is then reflected downward, so leaving
the ])osteiior surface of the body free from peritoneal
investment.
The pancreas is richly supplied with blood from three
different sources, which freely anastomose with one
another, viz.: 1. By the siiperlor jinucredtico-diiodenal
artery, a branch of the f/antrd-diiofkniil and hence of tlie
liep<itic artery, which curves round between the head of
the panci'cas and the duodenum. 3. By the inferior
panereatieo-ilnoth'iKil. a bi'anch of the nupcn'or mesenteric,
which courses round the head of the i>aucreas in the
direction opposite to tliat of the superior pancreatico-
duodenal and finally communicates with it. 3. By the
aplenic artrry, which in its wavy and tortuous course tow-
ard the spleen, grooving the ujiper border of the pan-
creas, gives off to that glantl many small twigs called the
piinnriifinr piiriv, in addition t(5 a larger branch near its
termination, the piuicreiitien miii/im, which penetrates the
gland and passes back from left to right parallel and
close to the chief paucieatic duct.
The main pancreatic duct or canal of Wirsiing runs
deeply embedded in the substance of the gland, some-
what neater the lower than the upper border, from left
to right tlu'oughout the length of the gland. It is
easily distinguished by ils white glistening appearance,
and the best guide for finding it is the artery which, as
above described, runs parallel antl close to it. It com-
mences by the union of many small duets from the
loliules of the tail, and, being joined by ducts from the
lobules on all sides, increases in size until near its termi-
uati(m at the duodenum, where it measures about one-
tenth of an inch. It follows the course of the gland
described above, bending downward, backward, and to
tlie riglit, as it courses through the neck, and passing
t<iward the posterior part of the head where it enters,
in comiuon witli the bile duct, into the second part of
tlie duodenum, between three and four inches below the
pylorus, upon a slightly raised papilla.
A second duct, calletl the aeeessori/ duct or duct of fian-
torlni, is found in the majority of bodies. This duct is
usually much smaller and runs from near the orifice of
the luain duct to open separately about an inch nearer
the pylorus: but in exceptional cases it may be large
and take on the functionsof a main duct, the extremity of
Wirsung's duct being then much smaller than usual.
The presence of two ducts arises from tlie development
of the gland as tw^o separate outgrowths from the
duodenum.
Tlie smaller of tlicse two outgrowths arises clo.se to
the comiuon bile duct, and its original duct forms at a
later ]ieriod the ))roximal end of Wirsung's canal. The
other larger growth arises nearer the jiylorus, and the
accessory duct of Santorini is formed from the jiroximal
end of its duet. At about the sixth week of develop-
ment the two ducts fuse, and, the upper duct afterward
develo]iing less rapidly, the main pancreatic duct conies
to be formed of the ci'ntral end of tlie lower duct and
the peripheral parts of both the others.
2. !Mim:tf, AxA'roMY. — The inincreas is a compound
racemo.se gland which, in its general arrangement and in
the appearance of its cells, closely resembles a serous sali-
vary gland. It may be distinguished, however, by the
longer, tubular, and somewhat convoluted alveoli, wliich
are often cut in oblique or longitudinal section and then
present the appearance of long columns of cells lining
the central ducts. This appearance is never evident in
salivary gland sections, because their alveoli are not
elongated. The ducts also serve to dift'crentiale the
jiancreas from the salivary glands, for they are much
less numerous in the former and the cells lining them do
not show any of that longitudinal striation which is
present in the cells of the ducts of the salivary glands.
The ultimate branches of the ducts wliich pass to the
individtial alveoli are very narrow :ind are lined by flat-
tened cells.
4(30
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
Pancreas,
Pancreas.
The alveoli in the loaded condition of the gland arc
compactl_y tilled by the charged cells so that no distinct
lumen is visible, but after active secretion the cells
shrink considerably iu size and the lumen becomes ob-
vious.
By special methods of treatment, such as injection
under pressure backward from the main duct, or per-
haps better by the Golgi method of staining with silver
chromate, it can be shown that intercellular canaliculi
exist which branch off from the lumen of the alveolus
and pass between the constituent cells. The Golgi
method, when the result is good, further demonstrates
intracellular canaliculi which penetrate into the cells
themselves and drain off the .secretion from their interior.
The secreting cells present characteristically different
appearances according to whether the gland has been
resting and has hence become charged with secretion, or
whether it has been recentl3' active and as a result is ex-
hausted of those materials which contribute the solids of
the secretion. These materials are deposited in a gran-
ular form during the period of rest, and are hence visible
under the microscope, and give b_y their amount an in-
dication of the condition of the gland.
Even in the fully charged condition of the gland
the granular deposit never quite tills the cell, a clear
finely striated outer zone always being left, which takes
stain readily and hence appears deeply colored in ])re-
parcd sections as compared with the central granular
zone.
In the fully charged cell about three-fourths of the
cell substance lying toward the lumen is completel\'
obscured by a thick granular deposit which hides the
nucleus and the outlines of the cells so that the lines of
division are invisible in fresh .sections.
The first effect of secretion is an increase in voltmic of
the cells, probably due to water and salts being taken up
from the surrounding lymph; but this is quickly fol-
lowed by a diminution in size, accompanying which
there is a rapid diminution in the amount of granular
deposit present in the cells. The granules become fewer
in number in the central part of the cells toward the
lumen, where thej' are still present, and the outer gran-
ule-free zone becomes greatly increased in width and
comes to occupy nearly the whole cell. These changes
are shown in hardened and stained sections Ijy the greater
amount of cell which becomes deeply stained.
As a result of the gradual clearance of the granules
from the protoplasm the cell nucleus and its outlines
become more clearly visible. These granules seen in the
cells do not consist of deposits of the enzymes found in
the secretion of the glands, which are deserilied liclcjw,
but probably of other substances which form precursors
of these, the- so-called zymogens.
The zymogens are inactive until they have been
changed into the free enzymes, as is shown by the fact
that neutral extracts of the fresh gland are almost inac-
tive, but become active when treated by dilute acetic
acid (one per cent ), or a dilute solution of sodium car-
bonate (two per cent.) in presence of oxygen.
Recent research has further demonstrated that the
fresh pancreatic juice as it flows from the gland duct
contains a large percentage of its zymolytic material in
the inactive form of zymogens and that it is only in the
intestine itself that the change into active enzyme is
completed (i:ide ii(frit). In addition to the nucleus a
body called IXk paranvdctat can be demonstrated histolog-
ically in the pancreatic cells. Tiiis structure surroiuids
the nucleus of the cell and is shown by its property of
staining inore readily than the rest of the cell proto-
plasm. It is supjiosed to arise from the nucleus by a
process of extrusion, and the view has been advanceii
that the zymogen granules are manufactured in this part
of the cell.
3. Secretion. — The rate of secretion of the pancreatic
juice varies with the state of digestion, being inost rapid
during the earlier periods after a heavy meal and then
gradually diminishing. During prolonged inanition the
flow practically ceases. It commences toward the end
of the next following meal and attains a maximum rate
within the first two hours; it then falls off rapidly up to
the end of the fifth hour. A secondary increase in the
rate then occurs which attains its maximum at about the
tenth hour, but is never so high as the first maximum ;
after this the flow once more falls off and practically
comes to a standstill in the eighteenth hour after the
meal. The richness of the secretion in ferments is in-
versely proportional to the rate of flow, the more rapidly
secreted fluid being more diluted with water.
These variations in the rate of secretion are probably
in part under the reflex control of the nervous system
and in part are due to chemical stimulation of the pan-
creatic cells, by a sub.stance secreted by the cells of the
duodenal mucous membance and carried in the blood to
the pancreas.
Regarding the reflex nervous influence upon the secre-
tion, it is probable that the (iffcniit channels are con-
nected up to the medidla from the mucous membrane of
the stomach and duodenum; at any rate it is an experi-
mental fact that chemical or electrical stimulation of
these surfaces causes a flow of pancreatic juice. The
chief (iffei;ent nerve affecting the pancreatic secretion is
the vagus.
This fact is rendered somewhat difficult to demon-
strate, iu the first place by the important disturbances of
the cardiac mechanism, and other organs, which foUow
stimulation of the vagus, and secondly by the fact that
the vagus contains both excitatory and inhibitory fibres
for the pancreas, and hence the net effect of stimulating
the nerve upon the pancreas varies according to the rela-
tive excitability of the two kinds of fibres. At times a
stoppage of secretion results and at other times an in-
crease in the rate of flow. Until this had been demon-
strated many contradictory expeiimental results regard-
ing the action of the vagus in this respect had been
published bj' different ob.servers.
Pawlow and his pupils first clearly demonstrated that
the vagus can act as an excitatorj' nerve for the pan-
creatic secretion. These observers got rid of the disturb-
ing influence iqion the heart bj' severing the vagus three
or four da^'s before placing tlie cannula in the duct of
the pancreas to observe the rate of secretion and stimu-
lating the peripheral end of the vagus. The cardiac
fibres are the first to degenerate and become completely
inexcitable at a period when the excitatory fibres of the
pancreas are still active. Apparently the inhibitory
fibres to the gland cells also suffer early degeneration,
for in all cases a positive result of increased secretion
was obtained. Similar results were obtained by stimula-
tion of the thoracic vagus below the place of exit of the
cardiac fibres from that nerve. Popielski later discov-
ered that the action of the vagus depended iqion the rate
of secretion which was already going on at the moment
when the vagus W'as called info activity. This observer
utilized the discovery of Dolinski, that application of
acid solutions to the duodenal mucous membrane causes
a copious flow of pancreatic juices (fide infra), to study
the effects of stimulation of the peripheral end of the
vagus during active secretion, and found that a stoppage
of secretion was the invariable result.
It is probable, then, from these experiments that the
vagus contains secreto-inhibitory fibres for the pancreas,
in addition to secretomotor fibres as shown by Pawlow.
The action of injection of fluids of acid reaction into
the duodenum in provoking an outflow of pancreatic
juice is a subject which at the present time is exciting
a good deal of attention, and although tlie matter is still
siih judice, many interesting results have already been
obtained.
Popielski found that the effect w.-is still obtained even
when both vagi and sympathetics were divided. He
further found that the elfect was obtained when the stom-
ach was separated from the intestine above the level of
the pylorus, but jwt when the section of stomach from
intestine was carried out below the pylorus, and from
these experiments he came to the conclusion that the
action was due to a local nervous mechanism, the nerve
•161
Pancreas,
Paucreas.
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
cells for which lay iu the intestinal wall close to the
pylorus.
More recently still I'ayliss and Starlini; have discov-
ered that an execcdinjrly cnjnoustlow of jiancreatic juice
is evoked when an extract of uuicons meiuliranc of the
duodenum is made with a dilute acid, and then neu-
tralized, filtered, and intravenously rejected. This effect
follow.s, according to tliese observers, even when all
nerves to the pancreas have been carefully severed. The
result is obtained only by using extracts of the mucous
membrane of the duodenum or of tlie upper end of the
jejimiun and is not given by exactly similar extracts
from other parts of tlie intestine. Tiie substance giving
this elVect is not an enzyme or a protcid body, since it is
not destroyed liy lioilin'g in acid sohition. The name of
sirretin luis been given" to the body by its discoverers,
but it has not yet been isolated.
From the foi''<'going description it is obvious that secre-
tin is quite distinct from tlie peculiar enzyme termed
eiitero/iiiiriw. which has recently liccn shown by Dele-
zenne, to exist in extracts of intestinal niueous memljrane
or iu the siieriii; enteiiciis. This enzyme can be obtained
from (fill/ jKti-t of the intestinal mucous membrane, and,
like all enzymes, can be destroyed by boiling solutions
containing it.
It acts upon the pro-ferments present iu the pancreatic
juice, and converts them into tlie active ferments. Fresh
pancreatic juice collected by means of a cannula inserted
into the pancreatic duct is practically inert when tested
by its action ujion tibrin ; but when a solution of eu-
tcvokiiuise, or, in other words, siienis enfi riciin, or an ex-
tract of intestinal mucous membrane, is also added to
the mi.xture the fibrin is then rapidly attacked and dis-
solved.
Bayliss and Starling regard the .«ef;'<!<i'o/) elicited b}' the
action of acid u|ion the mucous membrane of the duo-
denum as being <lue to a chemical stimulation of the
jiancreatic cells b)' scrretin taken up by the blood from
the columnar cells of the duodenum ami carried to the
pancreatic cells, and not to any nervous action either
central or local. According to these authors the main
regulation of jiancreatic secretion takes place by chemi-
cal means through the meilium of the blood stream,
which acts as a carrier of the stimulating chemical prod-
ucts.
Thus, upon this view, the cells of the mucous mem-
brane of the duodenum during a pei'iod of rest, corre-
sponding to the period when the stomach is empty, store
up a preciu'sor of secretin which may be termed pro-
secretin. On the passage of acid chyme from the stom-
ach into the duodenum, the cells discharge secretin into
the blood stream, and this body beins carried to the
pancreatic cells induces secretion of alkaline pancreatic
juice
The pancreatic juice so secreted is almost inert, so far
as action upon proteid is concerned, until it lias become
mixed with the siicciis eiitericns in the intestine. Here
the action of Delezeune's enterokiniine plays a coniple-
mental part, changing the ])ro-ferment into active fer-
ment, for Bayliss and Starling find that the activitj' of
the secretion produced by the injection of sohitions of
secirtiii into the blood stream is greatly increased by the
addition of extracts of intestinal mueons membrane."
It is obvious that the amount of jianeren tie flow can
thus be nicely regulated to the amount of digestion per-
formed, for tiie stimulus to secretion will be proportion-
ate to the quantity of acid gastric chyme tlirown into the
duodenum to cause evolutiou of secretin from tlie duo-
denal cells, antl again the stimulus to secretion will be
automatiially removed when the quantity of alkaline
jiancieatic juice secreted is suilicient to neutralize the
a<-id which gives the stimulus.
It is a discovery of high imjiortanee to our knowledge
of Jiancreatic secretion that a material can Ije extracted
from the duodenal mucfuis membrane and jieculiar to it
alone, which is cajiable of evoking a cojiious tlow of pan-
crealic juice, but a few words may judiciously be olTered
iu criticism of the view of the authors that the process is
a purely chemical one, and that this method is the most
important and naturally occurring one by which pancre-
atic secretion is regulated.
In the lirst jjlacc, the exjieriments of Pawlow and Po-
pielski, quoted above, undoulitcdiy j)iove that the pau-
creas jiossesses a nervous mechanism which is capable of
regulating its secretiim both in the direction of excitation
and in that of inhibition, and this even while a strong aj)-
jilication of acid is being made to the duodenum. It is
also obvious that no such treatment of the cells of the duo-
denal mucous membrane with acids can normally occur
in the jirocess of digestion as takes place when they are
extracted in a test tube with acid. In fact, at the height
of Jiancreatic secretion, the reaction of the contents of
tlie duodcuum is normall_y alkaline, or they jiossess an
acidity due to dissolved carbouic acid only, for the acid
of the gastric juice is neutralized at once by the mixture
of pancreatic juice and bile into which it is received.
Hence there never can be any free acid iu the duodenal
cells, which must be still less acid than the contents of
the intestine, so tliat any flow of secretin from these cells
into the blood which may occur cannot be caused by an
acid reaction.
Again, it is exceedingly difficult to prove that secretin
acts directly on the gland cells and not through the cen-
tral nervous system, even admitting that this substance
is normally secreted into the blood stream. For it is ex-
jierimentally impossible to prove that all the non-medul-
lated nerves passing to the pancreas have been severed;
a convincing proof of the peripheral action of secretin
can in fact be given only by showing a secretorv effect
of this substance when jierfused through an excised jian-
creas, and this has not yet been given.
In whatever way this peculiar substance found in the
cells of the duodenal mucous membrane may eventually
be shown to act, there is no doubt, however, that its dis-
covery has awakened a new line of thought as to the
mode of secretion of pancreatic juice and probably of •
other .secretions, for there is no reason why the pancreas
should be jieculiar in this respect. AVe have also here
another beautiful example of that interdejiendence of one
organ in the body upon another, and of the usefulness of
the products of the metabolism of one cell for the life
work of another, situated in a different jiart of the body,
and ajijiarently not even remotely connected with it.
4. Chemistry of the 1-'.\N('re.\tic .JnOE. — It is im-
possible in tlie jiresent state of develojimeut of the ex-
perimental technique for olitainiug jiancreatic juice to
give any reliable figures as to the quantitative composi-
tion of that fluid. Tlie irritation set up by tlie necessary
ojierations for the collection of the secretion causes the
flow, within a few hours, of a jiaralytic secretion, which is
many times more ililuted and consequently jioorer in or-
ganic constituents than that which flows within the first
few hours. For this reason it is also impossible to obtain
any information exjierinientally as to the average quan-
tity secreted in the twenty-four hours, and as the tables
of total quantities and quantitative corajiosition are cjuite
illusory they are not here quoted.* The secretion ob-
tained inuiiediately after the production of a temporary
tistula of tlic pancreatic duct is a clear, viscid tluid of
strongly alkaline reaction, ecpiivalent to (l.i!-().4 per cent,
of NaOII, due to the presence of carbonates and phos-
phates of sodium. It undergoes spontaneous coagu-
lation in the cold, and being very rich in coagulable
proteids (eight to ten per cent.), which cannot be distin-
guislied from serum globulin and serum albumin, it
undergoes heat coagulation and sets to a solid white
mass when heated to 7.5' C. If kejit in a water bath at a
temjierature of 40^ C, its own coagulable jiroteids un-
dergo digestion by the tryjisin jiresent {ride iiifrii)'n\\.o
albnmoses and peptones, and the secretion is then no
longer coagulable by heat. Alcohol precipitates both
the jiroteid and the enzymes.
The inorganic salts present are practically identical
with those of blood serum.
* See Schiiter : " Textbook of Pliysiology." vol. 1.. p. 366 ct seq.
462
KEFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pstnoreas.
Pau(-r4'a»i.
White blood corpuscles showing sluggish amaboid
movements are present in tlie fresh secretion.
Traces of leucin have been detected in the fresh se-
cretion, but tyrosin is absent. The most important
constituents of the pancreatic juice from the point of
view of the physiological chemist are the enzymes to
which it owes its powerful digestive action upon all
three classes of food.stuffs.
There are four enzj-mes known to be present. These
possess in each case all the general reactions which are
characteristic of this class of bodies, anil hence need not
here be detailed (see article on Enzymes), and accordingly
only the peculiarities of each will be recorded.
No complete sejiaration of these enzymes has as yet
been accomplished, that is to say, no one has succeeded
in obtaining from the mixture present in the pancreatic
juice solutifins wliich contain one enzyme only. Hence
the belief tliat each specific action of the pancreatic juice
upon a foodstuff is due to a separate enzyme rests upon
the partial proofs, first, that there is no known example
of a single enzyme which acts upon two dilferent va-
rieties of foodstuff, and, secondly, tliat in certain cases,
according to the method of extraction used, extracts can
be prepared from the gland which are relatively rich in
one enzyme and poor in another, although this has not
been done for all four. For example, from tln' |)ancre-
atic ti.ssue, after completely drying by alcohol, the dias-
tatic enzyme can be extracted by anhydrous glycerin,
while the proteolytic enzyme does not jiass into solution.
It is hence extremely probable that four distinct sub-
stances or their precursors are present in the gland cells
and secretion whicli have been named as follows: (1)
Amylopsin, a diastatic enzyme: (2) steapsiu, or pialyn. a
steatolytic or fat-splitting enzyme; (3) trypsin, a proteo-
lytic enzyme; and (4) an unnamed enzyme which has
the property" of curdling milk.
It has been clearly demonstrated that trypsin is pres-
ent in the gland cells, and also to a large extent in the
fresh secretion before it is acted upon by the succus en-
terieuK in an inactive form, which is known as trypiii>io-
gen. It is at present unsettled whether steapsin and
amylopsin possess similar precursors.
There are two views as to the action of the comple-
mentary enzyme called enttrnkinaKe of the sueois iiifer-
icvs. One view is that this tirst attaches itself to the
proteid, and renders it in a catalytic fashion more easily
attackable by the pancreatic enzyme. Tlie other and
more probable view is that the enterokinase acts upon
the trypsinogen and sets free tryp.sin which then attacks
the proteid.
Atiiyhipmii. — This can be extracted from the fresh
gland by most extractives, such as chloroform water,
twenty-(:ve-per-ceut. alcohol, to which a trace of acetic
acid has been added, tifly-per-cent. glycerin, saturated
solution of sodium chloride, saturated boric-acid solution.
Its action upon starches is verj- rapi<l, and closely re-
sembles that of other diastatic enzymes. The action is
h3'drolytic, and leads to the formation of a mixture of
achroodextrins and maltose. One part of amylopsin (im-
pure) iscapableof hydrolyziugover forty tliousaud times
its weight of starch (see article on Dtf/estidii).
The action is at a maximum at a temperature of 30'-
45° C, decreasing gradually as the temperature is lowered
down to 10' C, at which it is stopped, as long as the
temperature is kept at that level, but recommences on
warming. The temperature of destruction is about 60'
to To° c:
Aniylo]isin acts best with a neutral reaction or in jires
ence of an excessively minute trace of acid, the optimum
according to Melzer coinciding with 0.01 percent, of liy-
drochloric acid. By greater amounts of acid than this,
not only is the activity lessened, but the ferment is itself
rapidly destroyed: it is less susceptible to the fixed alka-
lies withstanding the action of one per cent, of sodium
carbonate, but is ra])idly destroyed by free alkalies.
Sliiipxiii. — Thh enzyme is exceedingly unstable, and
hence great care is required in obtaining active extracts
from the gland substance. In any case, a good deal of
the enzyme is lost in the process of extraction, and hence.
as shown by Rachford, the fresh pancreatic juice is al-
waj's more active than any extract of the gland, and
should be used in experimenting upon the action of this
enzyme. It was formerly believed that this ferment acted
only upon a small fraction of the fat of tiie food, because
the action of extracts of pancreas upon fats was so slow
and incomplete; but this arises from the great loss of ac-
tivity in the process of extraction, and it is now known
that the steapsin has suflicient power to split up the en-
tire fats (Rachford), and it is probaljle that fats are taken
up in solution (see article on Diyentiu/i).
That the action is truly enzymic is shown, first, by its
stoppage on boiling: and, secondly, by its taking place
when bacteria are excluded by the presence of antiseptics.
If extracts of the gland containing steapsin are desired,
thefrcih gland must be taken and extracted with a very
dilute (1 to 1,000) solution of sodium carbonate, or a
ninety-percent, solution of glycerin, containing 1 per
mille of sodium carbonate.
Such solutions, or the fresh pancreatic juice, act upon
neutral fats, hydrolyzing them, and forming free fatty
acids and glycerin. A similar hydrolyzing action has
been noted upon other synthetically prepared esters.
The action is increased by the presence of bile (Rach-
ford). Tlie effect here is probably a physical one. the
bile .salts or bile acids disstilviug the fatty acids which
are a product of the hydrolysis, and so allowing fresh
portions of neutral fat to be attacked.
The optimum temperature is 38' C. , and at this tem-
perature the acticin is twice as rapid as it is at 18' C.
Ti-jijmn. — This enzyme acts upon |iroteids more pow-
erfully and cinnpletely than any other known to us,
forming in succession alkali-albumin, deutero-albumose,
peptone, and a large number of amido-acids. Priuiary
albunioses do not seem to be formed, or. if they are formed,
the}' at once pass into more completely hydroly zed forms,
and the action is both more rapid and complete than is
that of pepsin. The ferment can be extracted by any of
the usual extractives from the gland. It is insoluble in
strong alcohol or glycerin, and the latter of these two
reagents has been utilized for its differentiation from
am.yIopsin.
xiccording to Sir 'William Roberts its activity goes on
increasing with the temperaiure up to 60 C, and it is
destroyed at a temperature of "I'r to 80° C. These fig-
ures do not agree with those of Biernacki, who found it
to be destroved at a temperature of .50° C. when in solu-
tion in five-tenths per cent, sodium carbonate, and when
in neutral solution at a temperature of 4.5' C.
Trypsin acts best in an alkaline medium, the usual
optimum given being that of a one-percent, solution of
sodium carbonate. It, however, can act in a neutral
solution or even in the pre iuce of a faintly acid reac-
tion, provided no free inorganic acid is present. A small
amount of hydrochloric acid, combined with proteid. does
not stop its action, but much acid, creii ir/iai coinbined
with pniteid, has a destructive effect.
The Milk-Curdh'ini Fenm i,t. — The jiresence of a milk-
curdling enzyme in the pancreas was first discovered by
Kiiline, and has since been confirmed by other observers.
More recently the subject has been re-investigated by
Halliburton and Brodie, who found that the coagulum
produced by this enzyme differs considerably from that
obtained by the action of the rennin of the gastric juice.
Tlius, instead of a jelly-like coagulum which is obtained
in the water bath at a temperature of ;3.")"-40 C. a finely
granular precipitate is obtained by the action of pancre-
atic juice or pancreatic extracts, which does not at this
temperature interfere with the tluidity of the mixture.
But on cooling to the temperature of the room a coherent
curd is formed ; if this be now heated to bod.v temperature
it again becomes fluid, and on cooling a second time it
again sets to a clot, and this process can be repeated in-
definitely. Further, tlie coagulation by means of the
pancreatic enzyme differs from that by rennin in that it
is not prevented by excess of ammonium oxalate, and
hence does not require the presence of calcium salts.
463
Pancreas.
Pancreas.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Tlie use of this pancreatic enzyme is difficult to under-
sfcxud, since any milk taken by the mouth would be co-
agulated in the stomach by the renniu there present. A
similar difficulty exists regarding the ]iurposc of renniu
in the gastric secretion of tishes and other animals from
whose food milk is absent, as also regarding the iiresence
of milk-curdling ferments in the juices of certain plants.
A possible explanation is that such ferments may have a
less obvious action upon other forms of proteid, a fact
which yet remains to be discovered. Benjamin Moore.
PANCREAS. DISEASES OF THE.— The great impor-
feince of di.^easesol Uie pancreas was not generally recog-
nized by the medical profession until within compara-
tively recent times, but that pathological alterations of
the organ not uncommonly exist was known to all of the
older pathologists. That "changes in the pancreas some-
times occur in individuals who have diabetes mellitus
was first recognized by Cowley in 1T8S. liut prominence
was not given to the matter until 18TT when Laneereaux's
work was published, and the relation between the two con-
ditions has been recently definitely proven by the experi-
mental work of von Mering and Jlinkowski. Spiess in
18G6 recognized hemorrhage into the pancreas as being a
frequent cause of sudden death, and Zenker some years
later accentuated this relation; but its great importance
was first fullv recognized by Draper, who particularly
directed attention to'it in 1886. In 188!) Draper's fellow-
townsman, Fitz, in a most admirable paper, opened up a
new field to the clinician in bringing together a great
mass of isolated facts concerning pancreatitis, and co-
ordinating them in such a masterl_y manner that since
this time intlammations of the organ have been brought
within the list of those diseases which may be diagnosti-
cated. Several years before the appearance of the article
by Fitz, Senn. of Chicago, very thoroughly reviewed the
subject of pancreatic cysts. In the article that follows
the writer wishes particularly to express his indebtedness
III the various papers upon this subject written by Fitz,
to the chapter on these diseases in Osier's "Practice of
Medicine." and to the recent monograph upon the sub-
ject by Koerte.
F.\TTY ;V>.i> Hy.\line Changes in the P.\kcre.\s, and
Amvloid Infiltration.
Fatty Changes. — The fatty alterations that occur in
the pancreas may be divided into {(() fatty degeneration,
and (A) fatty infiltration,
((/) In many acute diseases, cspeciall_y in those accom-
panied by high temperature, fatty (hrjcneration occurs
in the pancreatic cells. Happily, the condition is one
that passes away with its cause, and is not generally
supposed to give rise to serious or permanent change
in the organ. There is no symptomatology of the con-
dition.
(b) Fatty Infiltration. — This condition is frequently ob-
served in obese individuals, and is not generally believed
to produce any serious interference with the functions of
the organ, though cases of diabetes have been reported
in which this lesion was present in the pancreatic tissues
to a marked degree. In these instances it is likely, as
in a case recently observed by the writer, that the fatty
changes were secondary to interstitial pancreatitis and
that they were not responsible for the diabetic condi-
tion.
Hyaline Degeneration. — In a very interesting paper
Opie has recently called attention to the fact that diabetes
sometimes occurs in whicli the only alteration found post
mortem is hyaline degeneration of the islands of Lauger-
hans in the pancreas. 'Whether or not there is an.y con-
nection between the two conditions cannot as yet be
stated with certainty.
Amyloid Infiltr.\tion. — Amyloid infiltration (jf the
coats of the blood-vessels of the pancreas occurs in those
conditions in which tliis material is being proihieed in the
body. So far as is known it does not give rise to any
serious alterations of the pancreatic functions.
Pancreatic He.morrhage.
Pancreatic hemorrhage is a condition that occurs to a
slight degree in quite a number of different affections,
but the term is here limited to those siulden and jirofuse
extravasations of blood into the organ that are commonly
known as pancreatic apoplexy.
Etiolo'iy. — In the vast majority of instances those suf-
fering from severe pancreatic hemorrhage have passed
middle life, and the disease appears particularly to affect
corpulent individuals. In many instances those who
have had the disease have been addicted to the contin-
uous use of alcohol. It commonly occurs al.so in those
who have previously suffered more or less with " indiges-
tion," and in many cases there appear to have been pre-
vious mild attacks. It is more common in males than in
females. In some instances it has followed injury. As
to the exact nature of the condition of the blood-vessels
that predisposes to this disease we are still in great ignor-
ance, careful microscopic studies being much needed to
elucidate this rather obscure morbid state. It has been
assumed by some that syphilitic disease of the blood-ves-
sels is the most common cause of the malad_y, but ade-
quate proof of this has not as yet been brought forward.
That minute hemorrhages occasionally occur in the pan-
creas as the result of chronic induration of the organ
there can be no q\iestion, and extravasations of a similar
kind are occasionally found in connection with obstruc-
tive diseases of the circulation — such as are produced by
organic heart lesions, emphysema, antl tumors pressing
upon the inferior vena cava. Recently Chiari has shown
that minute hemorrhages are sometimes prodiiced in the
jiancreas by what appears to be post-mortem digestion
of ])ortious of the organ.
ilorhid Anatomy. — In cases of severe hemorrhage into
the pancreas the entire organ may be blood-stained, and
be either of an almost black, dark purple, or browuish-
red hue. In Ijy no means all instances, however, does
the gland as a whole present this appearance, as all de-
grees of hemorrhage are met with from the complete in-
filtration of the organ to single, minute ecchymotic spots
situated in some part of the substance of the gland. In
the affected region the pancreas is usually distinctly in-
creased in size, thotigh in some instances it apjiears to be
normal in bulk. The organ may be of normal consist-
ence, distinctly softened, or quite friable. It is of inter-
est to note that in no instance has any one succeeded
in finding the blood-vessel from which the hemorrhage
came. Under the microscope the tissues of the pancreas
may present a practically normal appearance, though,
especially in obese individuals, more or less fatty infiltra-
tion is generall}' present. Blood in vari<ius stages of dis-
integration is found lioth within the interstitial tissues
of the organ, and within its parenchyma in the diseased
legions. In some instances the tissues of the pancreas
present evidences of extensive necrotic change, as was
observed by the writer in one instance in which the nuclei
of all of the cells in the affected areas entirely failed to
take basic stains. It not uncommonly happens tliat the
hemorrhage does not remain confined to the pancreas,
but extends into the surrounding retroperitoneal tissues,
even so far as the li'ft kidney, and it occasionally forces
its way into the fat of the omentum and mesocolon.
Symptoms. — The disease comes on in almost all instances
witli extraordinary suddenness, the individual having
usually been in perfect health previous!}', though in rare
cases the condition is preceded by slight prodromal pains
in the upper part of the abdomen. In most instances the
pains are confined to the region of the pancreas, but in
some cases they ma\- be dilfused throughout the abdo-
men, and have been sometimes mistaken for colic in the
beginning. Following the pain there arc usually nausea
and vomiting of a most persistent kind, and occasionally
there is an urgent desire to defecate. Along with these
symptoms a profoimd depression of the vital powers in-
variabl}' occurs; the pidse is small, feeble, and exceed-
ingly rapid. There! is jironounced and oftentimes urgent
dyspnani, the patient tosses from one side of the bed to
464
REFEKENCE UANDBOOK OF THE AIEDICAL SCIENCES.
Paiicroas,
Paucrt'as,
the other, is bathed in cold perspiration, tlie countenance
exhibits great anxiety, and there is every symptom of
impending dissolution. In a comparatively short time
the abdomen not uncommonly becomes swollen, and ten-
derness develops in the epigastric region. The temper-
ature is either normal or subnormal. Constipation is
quite frequent. If the hemorrhage is at all extensive
the patient rapidly grows worse, and death usually oc-
curs within a few hours. There c:.'n be no question that
recovery sometimes follows the milder forms of the dis-
ease.
Diagnosis. — Pancreatic apoplexy is distinguished by
the sudden onset, with excruciating pains in the epigas-
tric region, nausea and vomiting, and rapid collapse. It
is differentiated from intestinal obstruction by the sudden
onset, and by the extreme urgency of the symptoms. In
biliary colic the history, the absence of excessive vomit-
ing, and symptoms of collaijsc serve to distinguish be-
tween the two conditions. In gastric and duodenal ulcer
perforation is preceded by frequent attacks of severe pain
in the epigastric region, tenderness over the site of the
nleer, and the vomiting of blood. Moreover, ulcer gen-
erally occurs in anicmic young women.
Prognosis. — In all cases of severe hemorrhage death
follows in a verj' short time, the patient not, as a rule,
surviving longer than two or three hours. On the other
hand, when tlie amount of blood effused is small, recov-
ery may occur, though in these cases the condition very
quiekl}' becomes one of pancreatitis. Patients have sur-
vived even very severe hemorrhages, as is conclusively
shown by the fact that recovery has occurred in .several
instances in which the diagnosis was made by an explor-
atory incision.
Treatment. — The nature of the lesions in this disease
makes it, of course, impossible for drugs in any way to
influence the local condition, and the treatment is there-
fore necessarily entirely of a .symptomatic kind. Mor-
phine should be given to relieve tlic pain, and the col-
lapse should be treated in tlie usual way by the applica-
tion of warmth, and by the hypoderuiatic injection of
strychnine and atropine. For the reason that death in
this condition cannot be produced merely by the loss of
blood, but is brought about hy the pressure exerted upon
the surrounding nerve structures, it has been suggested
that free incisions aroimd the pancreas might relieve this
condition, and thus be the means of saving the patient's
life.
Acute Pancre-\titis.
There are at least three more or less separate and dis-
tinct varieties of acute inflammation of the pancreas: («)
the acute hemorrhagic, {h) the acute suppurative, and {/)
gangrenous pancreatitis, each of which demands sepa-
rate consideration.
(rt) Acute Hk.\iorrii.\gic P.\ncre.\titis. — By the term
acute hemorrhagic pancreatitis is meant that condition of
the pancreas in which the hemorrhagic lesion is accom-
panied by evidences of so-called inflammation. This
condition cannot be clearly separated from that of sim-
ple pancreatic hemorrhage, the latter merging insensibly
into the former.
Etiology. — This disease is much more commonly ob-
served in per.sons past middle life than in the young, but
instances ha^e been reported in which the malady oc-
curred in children, the sufferer iu one instance being only
nine months old. It is more common in males than iu
females, though the numbi^' of recorded instances of the
disease is not as yet sufficiently great to determine its
relative frequency in the two sexes with certaintj'. It
occurs more commonly in obese individuals than in those
whoarelean. In quitea large percentage of therecordcd
cases the subjects have been alcoholics. Like pancreatic
apoplexy this condition has been frequently observed to
occur in individuals who had previously suffered for a
greater or less length of time with derangements of the
digestion, and in some cases there has been a clear history
of previous attacks of the malady. It is also notewortliy
that many of those who have had the disease had pre-
VoL. VI.— 30
viously suffered for a period of years with unmistakable
symptoms of gall-stones and inflammatory states of the
gall-bladder. In view of the fact that in conditions of
this kind bacteria are always present in the gall-bladder
and ducts, the investigations of II lava, Williams, and
Flexner, who produced experimental inflammations of
the pancreas by the injection of various bacteria, seem
to be of special significance.
Morbid Anatomy. — In acute hemorrhagic pancreatis
the pancreas presents much the same macroscopic ap-
pearances that it exhibits in pancreatic apoplexy. The
organ, wholly or in part, is almost black, of a purple
hue, or of a dark red color, and in the affected regions is
considerably swollen. The tissues of the gland are in
some instances softened and quite friable. Tlie amount
of hemorrhage varies in different instances. It may be
confined to tlie head, body, or tail of the organ, or may
be diffused throughout its entire extent. Not uncom-
monly the hemorrhage extends into the retroperitoneal
tissues, and is frequently found present in the omentum,
mesenteiy, and mesocolon. The spleen may be enlarged.
Within the pancreas itself there are not uncommonly
found small areas of a dull whitish opaque appearance
that are made up of fat which has undergone a peculiar
chemical alteration. This change iu the fat is known
as/>?< necrosis, and is dependent upon the fat-splitting
ferments elaborated in tlie gland. Williams describes
the appearance as follows: "Frozen sections of the
white necrotic nodules showed them to be made up
of coarse granules and masses, globules and crystals,
and a small amount of masses of brown pigment. Many
of the opaque masses were about the size and shape
of fat cells, and evidently represented altered tat cells.
The surrounding tissues were mildly congested; a few
small extravasations were noted; the fat cells appeared
normal. Sections of the same embedded in celloidin,
and stained with haunatoxylin or carmine, give similar
results." It is notewothy that tetroxide of osmium is
not reduced by the structures composing these necrotic
tissues. It has been shown by Langcrhaus that the
areas of fat necrosis are made up of a substance that
results from the combination of lime with certain fatty
acids. Osier speaks of a case in which death was the
result of Bright 's disease, and in which the lobules of
the pancreas were entirely isolated by areas of fat necro-
sis with extensive deposition of lime salts. In hem-
orrhagic pancreatitis it very frequently happens that
areas of fat necrosis are found in the fatty tissues of the
omentum, mesentery and mesocolon, and in the adipose
tissues situated behind the gland. It should be remarked,
however, that minute areas of fat necrosis are sometimes
found in the living human being where there is no disease
of the organ, and Cliiari has shown that post mortem
there are often found in the pancreatic tissues minute
alterations that appear to be the result of auto-digestion
—alterations which bear a close relation to the necrosis
that occurs iu the fatty structures. Bal.ser, who first ac-
curately described the condition iu man, has also shown
that it not uncommonly occurs in the fatty tissues around
the pancreas in healthy swine. This observation has been
recently confirmed in this countrj- by AVilliams, who has
also shown that it occasionally occurs in the abdominal
adipose tissues of the cat. It is very interesting to note
that experimental fat necrosis in connection with hemor-
rhage into the pancreas has been produced artificially by
a large number of investigators, among whom are to be
especially mentioned Hlava. Langerhans. Hilderbrand,
Dettmer, Williams, Flexner, Ro.senbacb, and Opie.
These investigators have .shown lliat the condition may
be induced in dogs aud otlicr animals by the injection,
into the pancreas or its ducts, of bacteria, acids or alka-
lies, by ligation of the organ, b\' simply injuring it or
by injuring it and at the same time infecting it with
liacteria. and by the introduction of sections of fresh
pancreas into adipose tissue.
Symptoms. — The initial symptoms that uslier in an
attack of acute hemorrhagic pancreatitis are those of
pancreatic hemorrhage. There is a sudden onset with cx-
465
Paiicroas.
Pau<Tcas.
REFERENCE HANDBOOK OF THE JLEDICAL SCIENCES.
cruciating )iain iu tlic upper part of tho abdomen, vomit-
iug, and all indications of collapse. However, in some
instances the disease does not begin with such violent
symptoms, there being a period of days or even weeks
during which there are slight, oftentimes colicky pains
in the abdomen, combined with a certain amount of ten-
derness; constipation is, as a ride, present. The tem-
perature, which in the bi-ginning may be normal or .sub-
normal, becomes somewhat elevated as the so-called
inflammatory phenomena develop in the diseased organ ;
but, as a rule, the fever does not go above 103° F. About
the time that the fever begins, chilly sensations are not
uncommonly complained of. and even pronounced chills
are occasionally encountered. The pulse is always rapid.
and as a fatal termination is approached, it becomes
weaker and weaker, ami finally uncountable. The respi-
ration is almost in all instances shallow and decidedly
hurried. In most ca.ses after the disease has existed for a
short time the abdomen becomes distinctly swollen, and
is exceedingly tender in the epigastric region. In some
instances it has been po.ssible to feel the swollen pancreas
through the abdominal walls, though this cannot, as a
rule, be accomplislied.
Dingnnsix. — Although this disease was alwaj's over-
looked until a comparatively short time ago, the diagno-
sis, thanks to the brilliant work of Fit/,, has been recently
made in a large number of cases. Where a previously
health}' person is suddenly seized with intense pain in the
upper part of the abdomen, with nairsea and vomiting,
and with pronounced symptoms of collapse, this disease
.should be always suspected. Of ;dl the conditions .simu-
lating acute hemorrhagic pancreatitis, acute intestinal
obstruction is perhaps the one that may be most readily
mistaken for it; but the former malady may be distin-
guislied by the suddenness of the seizure, by the pro-
nounced symptoms of coUajise, and by the absence of
distention of the intestine in the early stages. The
further fact is of importance that olistructiou of the
small intestine in the region of the pancreas is very infre-
queut, and the patency of the large intestine can be al-
ways readily deternnned by inflation. Biliar_v colic may
also Vie mistaken for pancreatitis, but may be generally
distinguished from it by the history of previous attacks,
by the situation of the pain, and by the absence of pro-
nounced .symptoms of collapse. It should, however, be
remembered that several instances of paucreatitis have
been record<'d in which the patient had previously suf-
fered from biliary enlic. In I he later stages of acute hemor-
rhagic pancreatitis intianuuatory exudates collect in the
lesser omentum to such an extent that the condition some-
what resembles that of pancreatic cyst, but the history
of the case and the prouoimced septiea-mie stale that often
occurs in connection with it will serve to make the diag-
nosis clear. In case of doubt the physician may resort
to aspiration, which will determine the true nature of the
condition with certainty. The symptoms that occur in
connection with perforation of the stomach or duodenum,
restdting from ulcer, somewhat resemble those which are
found in this disease ; but generally the two may easily be
distingui.sbed by the history of severe pain following the
taking of food, the vomiting of blood, and the increa.sed
secretion of hydrochloric acid that are so characteristic of
the former couililions. Irritant poisons might give rise
to some of the syniploms usually observed in paucreati-
tis. but the history of the case and the absence of the
evidences of corrosive action in the mouth and throat and
the character of the vomit, will generally servo to make
clear the true nature of the condition.
Prognosis. — Although acute paucreatitis is a very fatal
disease, there are luunerous instances on record inWhieh
recovery occurred even from the severer forms of the
malady. If the patient survive the first few days of the
disease there is always hope for idtiinale recovery, though
even in these cases a death from sei)ticainia aiul exhaus-
tion generally occurs in from two months to a year. In
the latter stages abscesses in and around the pancreas not
uncommonly occur, and inflammatory exudates often
collect in the lesser omentum to a considerable extent.
In these instances laparotomy and the establishment of
proper drainage are absolutely essential to the preserva-
tion of the patient's life, and as we learn to make the
diagnosis w itb more certainty there can be no doubt that
fatal terminations will become less and less frequent.
Cases have been recorded in which diabetes followed tue
disease.
(/') Acute Suppurative Pancre.\titis. — Acute sup-
purative pancreatitis is a condition that fortunately is
rarely observed, it being much less frequent than the
hemorrhagic form. Pus may be diffused throughout the
organ, or it maj' be localized. Not uncommonly the neigh-
boring viscera are secondarily afl'ected, and the abscess
may perforate into the stomach, into the small intestine,
or into the peritoneal cavity. Secondary abscesses in the
lesser omentiun have iu a numlier of instances been ]iro-
duccd, and thrombosis of the portal vein has been noted.
The spleen is often enlarged. This disease has in some
instances followed injury ; but iu (juite a number of cases,
further than that the ]iatient had previously suffered with
disturbances of the digestion, the origin of the affection
was not apparent. It should also be remembered that
this condition maj' be encountered as a sequel to the
acute hemorrhagic form of the malady.
The sytnptoms of this disease are by no means so char-
acteristic as those that are encountered in the hemor-
rhagic form of the affection; although there is always
more or less pain localized in the region of the organ, it
is never so intense, and does not come on with such sud-
denness as iu the hemorrhagic form; and vomiting, al-
though cjuite common, is not so persistent. Intense pain
in the sciatic nerves may occur. Patients suffering with
this disease very ([uickly develop the sj'inptoms of sa-
prsemia or septicannia. usually having irregular rises and
falls in temperature, profuse sweats, and chills, and they
present the profound depression of the general sj'stem
that is so characteristic of blood poisoning. In a num-
ber of cases it has been possible by palpation to discover,
in the region of the pancreas, the presence of a tumor;
and this discovery, whenever it can be made, is of the
utmost importance from a diagnostic standpoint. Javm-
dice and sugar in the urine have been noted in some
instances,
(c) Gangrenous Pancreatitis. — Gangrenous pan-
creatitis usuall)' follows the acute hemorrhagic form of
the disease, and may be partial or complete; it has been
known also to follow the suppurative variety of the affec-
tion, and has in some instances residted from injury.
Under these circumstances the pancreas becomes to-
tally or in part necrotic, and the diseased parts are
soft, have a foul odor, and present a dark, slaty appear-
ance. In many instances the diseased tissues have com-
pletely sloughed awa_v from the remains of the organ;
they then commonly lie along with masses of pus and
broken-down tissue in the cavity of the omentum. Not-
withstanding the extremely dangerous situation in which
a ])atient must, under these circumstances, be placed,
instances of recovery after operation are not wanting;
and Trafoyer and Chiari have reported cases iu which
sloughs of the pancreas made their way into the cavity
of the intestines, and were discharged from the bowels.
As this condition is usually secondary to acute hemor-
rhagic iiancreatitis, its early symptoms are those of this
disease. After the necrosis iu the tissues occurs there
follow septiea'inic symptoms, in combination with ten-
derness in the upper part of the abdomen and evidences
of a tiunor-like mass in the same situation.
Treatmtnt. — The treatment of acute hemorrhagic pan-
creatitis in the beginning is that of pancreatic apoplexy.
The agonizing pain requires the exhibition of full doses
of morphine hyiioderniatieally. and the symptoms of
collapse should be treated by the subcutaneous injectioa
of strychnine, atropine, and whiskey, and by the appli-
cation of external warmth to the body. Following this
the treatment shoidd be entirely symptomatic. The dift
should be relatively free from fat. The administration
of portions of raw jiancreas, with the food, has been rec-
ommended by some, as the food is in this way brought
466
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Panoroas.
Paiioreas.
more or less in contact with tlie pancreatic juices which
are so necessary for proper digestion. Diastases are also
useful if they be administereii immediately after food is
taken, as they take the place of the pancreatic juices in
a measure. In tlie suppurative and gangrenous forms
of the affection laparotomy offers the best hope; for the
ultimate recovery of the sufferer. In the latter stages of
all forms of the disease the patient requires a supporting,
nourishing diet, with the administration of stimulants and
tonics.
CnUONIC P.\NCRE.\TITIS.
By the term chronic pancreatitis is meant the gradual
increase of the fibrous and elastic tissues that are nor-
mally found in the pancreas, this change resulting in the
compression and ultimate destruction of a greater or less
amount of the glandular structure of the organ. Such a
chronic inflaniniation is a matter of very great import-
ance, inasmuch as it is very commonly associated with
diabetes mellitus.
Etiiihif)!/. — Birch-Hirschfeld showed, a number of years
ago, that chronic fibroid thickening of the pancreas not
unconunonly results from congenital syphilis, and his
conclusions have been recently confirmed in a most ad-
mirable article by Schlesinger. It has been also assumed
by some that acquired syphilis is likewise callable of in-
ducing chronic induration of the organ, but its causal re-
lation to the present disease lias not as yet been conclu-
sively shown. Quite a number of cases have occurred
in those who have been addicted to alcohol, and the in-
ference therefore seems justifiable that tins habit may in
some way predispose to this morbid state. There seems
good reason to believe that catarrhal conditions of the
duodenum, leading to changes of a .similar kind in the
common and pancreatic ducts, give rise in some instances
to this affection, and we have abundant proof that clos-
ure of either of these ducts by means of gall-sfones, pan-
creatic calculi, or in other ways, results in chronic indur-
ative change in tlie organ. Experiments on animals have
also shown that ligation of the duct of Wirsung is fol-
lowed by an increase in the fibrous structures of the
gland. "Fibrous thickening of the pancreas is even as-
sociated with ulcer of the stiimach or duodenum, tumors
of the stomach or suprarenal capsule, aneurism of the
aorta or cn>liac axis, or with disease of the spine " (Fitz).
Dilatation and obstruction of the pancreatic duet is not
uncommonly tlie result of chronic induration of the organ.
The writer has recently recorded a case in which diabetes
quickly followed mumps, and the theor_y was suggested
that an acute pancreatitis was in this case produced by
the poison of this disease, and tliat subsequently chronic
changes occurred, giving rise to glycosuria.
Morbid An/ituiiiy. — Filiroid thickening of the pancreas
is most frequent in the head of the gland, but the disease
may be limited to other parts of the organ, or may in-
volve it throughout. Opie has recently written a num-
ber of interesting articles upon the subject of chronic in-
duration of the pancreas, and he recognizes two different
varieties of the disease : (1) Interlobular pancreatitis, char-
acterized by the proliferation of fibrous tissue between
the lobules wliich are invaded from the periphery ; and
(2) interaeinar pancreatitis, where tlie new!)- formed
fibrous tissue is more diffusely distributed between the
lobules and individual acini. This writer asserts that
the interlobular form of the disease is that variety which
follows occlusions of the pancreatic duet, and, although
the parenchyma of the gland is in a large measure re-
placed by fibrous tissue, the islan<ls of Langerlians are
for the most jiart unaffected, and diabetes is but rarely
observed. In the interaeinar form of the malady the
areas of Langerhans are on the other hand quickly de-
stroyed, and in these instances diabetes always occurs.
It was suggested many years ago liy Laguesse, and later
by Schaefer and Diamare. that Langerhans' bodies exert
the important function of controlling carbohydrate me-
tabolism, and Ssobolew has recently brouglit forward as
experimentiil proof of this the fact that after feeding
animals with carbohydrates in considerable quantities
the cells of the islands becar' more granular than usual.
There is therefore some exp,;riniental evidence that Lan-
gerhans' islands are in some way associated with the as-
similation of carbohydrates. There is even stronger path-
ological proof of this relation in the human being. The
experiments of von Mcring and Minkowski, by which
the close relation of diabetes mellitus to alterations of the
pancreas was so clearly shown, are so well known, and
have been so frequently cited, that it does not appear nec-
essarj- to consider the matter at length in this article. In
all cases in which the fibrous change has advanced to any
great extent the pancreas is found distinctly diminished
in size, and its surface is more or less roughened and
nodidar; on the other hand, where the changes are not
so pronounced the organ may be but little smaller than
normal, and its surface may be comparativeh' smooth.
On section its consistence is found to be considerably in-
creased, and its tissues are, as a rule, even paler than
normal. The subperitoneal tissues surrounding the pan-
creas are in some instances likewise thickened. Fatty
changes are oftentimes extreme, and, as in a case recently
observed by the writer, the entire organ may present the
macroscopic ajipearance of a mass of ordinary fat, though
on micro.scopic examination the fibrous tissues are found
to be greatly increased. In some instances these fatty
alterations are not so extreme, there being merely small
yellowish spots scattered throughout the organ. In
some cases hsematoidin crj'stals, crystals of fatty acids,
and calcareous granules are found scattered throughout
the substance of the gland.
The fibrous changes not uncommonl}' result in constric-
tion of the pancreatic ducts at various points, cau.sing
them to appear dilated and tortuous, though this does
not always occur.
Symptumn. — Progressive loss of flesh and strength and
the various indications of alteration in the digestion are
the symptoms that are most commonly observed in
chronic pancreatitis. There are usually loss of appetite,
belching, pyrosis, nausea, and a sense of weight and fid-
ness in the epigastrium, and occasional vomiting. Diar-
rhoea very commonly exists, and the faeces are frequently
fatt_y, and may be colorless even when no jaundice exists.
The sclerotic changes have in some instances compressed
the common duct, in which case jaundice, of course, su-
]iervened. In connection with the influence of the i)an-
ereatic secretion on the chemical changes occurring in
the fattj- foods ingested the observations of Mueller are
very interesting. He has shown in three cases of pan-
creatic disease that the fat contained in the fa?ces was by
no means decompo.sed to such an extent as is the case in
health. He found that normalh" 8-1.3 jier cent, of the fat
contained in the stools is split up, forming free fatty
acids and .soaps; and in a number of instances this per-
centage was practically that found in the dLschafges of
individuals suffering from other diseases than those of the
pancreas. On the other hand, in instances in which the
pancreatic secretion does not reach the intestine he found
that on an average only 39.S per cent, of the fat occurred
as fatty acids and soajis. It is, of course, obviotis that
such a pronounced variation from the normal must occur
onlv in those instances in which there is suppression of
the greater part, or all. of the pancreatic secretion, and
that in cases in which the stenosis of the paiicrcalie duct
is only partial, tlie proportion of altered fat in the fa-ces
will be considerably greater. It is therefore clear we
cannot assume that the greater part of the fat will ap-
pear as such in the stools in all cases of ]iancreatie dis-
ease. Notwithstanding this, .an analysis of the di.scharges
will probably be found of value in obscure ca.ses. The
examination is conducted as follows. The fa-ces arc-
heated at a temperature of 100 C. until thoroughly dried,
and then finally are pulverized. This pcjwder is then
treated with alcohol, acidulated with hydrochloric acid,
and boiled. This causes the soaps to become again free
fatty acids, the neutral fats remaining unaltered. The
mass is then thoroughly dried, and is treated with ether
for three days in a Sohxlet apjiaratu.s. The ethereal ex-
tract is then filtered and evaporated, dissolved in abso-
4(1
'Pancreas*
Pancreas.
KEFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
lute etlier. again iiltcn'd, driud. and wciijlicd. This de-
li-rniincs the animiut of neutral fat. and liolh the free
fatty acids and those tiiat were in coniliinalion forming
soaps. A weiglicd portion of tliis mass is tlien dissolverl
in warm aleoliol contuininn; a small ammnit of ether, and
a few drops of an aleohol solution of phcnolplithalein are
then added, and the solution is til rated with canst ic potash
in alcohol. From tlieresultsof lldstitrulion we estimate
the amount of free fatty acids ]ii-csent iu the entire res-
idue, and this, sulitracted from the total weight of the
mass, gives the amount of neutral fat.
Since the time of Cowley it has been luiown that dia-
betes nicllitns is not uncommonly associated with ultcr-
jitions in the pancreas, and a large number of observa-
tions made witliin recent times show beyond i.iuestiou
that the relation is not an accidental one, and that dia-
betes is in many cases the result of disease of tliis organ,
interstitial pancreatitis being the lesion most commonly
found. The brilliant invesligalicuis of von Jiering and
IMinkowski have shown experimentally that diabetes
may be produced in the dog and other animals by the
extirpation of tlie jianereas, and instances are not want-
ing where tlie removal of the organ in man has resulted
in severe glycosuria. Tlie theor_v has been suggested by
-Alinkowski that the pancreas elaborates "a glycolytic
fcM'ment " by means of which the sugars arc cliemicall)'
•changed in the body, and that •when the pancreas is re-
moved or destroyed, this ferment being no longer pres-
ent, glycosuria n'sidts. It has been thought by others
that this exiierimental diabetes is the result of disturbed
tissue-metamorphosis pi-odueed by the absence from the
intestine of I he pancreatic juices — a view supported by
the fact that dialietes may follow ligature of the duet of
Wirsimg. Des|)ite the fact tliat diabeles freiiuently fol-
lows organic alterations in tiie pancreas, it is but proper
to stat(^ that this condition by no means always results;
and, further, that there areou record man_y instancesof xli-
abetes in which uoclianges could be found in this organ.
It is of interest to note that Picenti and Gerhardi have
claimed that the percentage of indican in the urine is
nincli lowered in diseases of the jiaucrcas.
Diiii/iidsis. — The diagnosis of this di-scasc is exceedingly
<litlieult, for it never gives rise to symptoms that arc in
any way characteristic. The condition ma}', liowevcr,
be suspected when the iialicnt is found to suffer from
long-continued derangements of the digestion, loss of
strength and llesli, in combination with the presence, in
the fa'ces, of an increased amount of fat, which, accord-
ing to Mueller, exists in a stale of free neutral fat, and
uot broken uj) into fatty acids. In conjunction with
these glycosuria, when present, is of course of great im-
portance in deciding the true nature of the disease,
though it should never bo forgotten that this condition
may occur when the pancreas is iu no way aiTected. For
the reason that salol is not decomposed in the intestine in
the absence of the pancreatic juice, the failure of carbolic
acid to appear iu the urine after tlu^ administration of
full doses of this drug would be strong presumptive evi-
dence of either the total desi ruction of the secreting
structure of the organ or of the occlusion of its duet.
PiminiixU. — ^As regards recovery the jjroguosis is, of
course, hopeless, for we are accpiaintcd witli no ni<'ans
\>y which the process in the pancreas may lie cured or
even stayed, llowever, on accotint of th(^ fact that the
disease progresses very slowly, and that great destruction
of the parenchyma of the organ is necessary before pro-
nounced symptoms are prod\iced, those suffering with
the alfectiou generally survive for a considerable period
of time.
Trcritmcnl. — The treatment of chi'oinc pancreatitis nec-
essarily resolves itself into sec'ing Ihiit the |>atient lives
under proper hygienic conditions, takes a sullicieut
amount of outdoor exercise, and gives the necessary at-
tention to the diet. Inasmuch as fals and starclies are
digi'sled by the secretion from this organ, il is of nuich
iniporlance that these articles be eliminalcd in a large
measun^ from the diet of the sulTcrer, and the necessity
for a precautitm of this kind is often accentuated by the
coexistence of glycosuria. It is practically impossible
entirely to withdraw carbohydrates from the dietary.
The administration of some diastatic ferment with the
food is of decided value, or small pieces of raw iiancreas
may be substituted, inasmuch as it has been shown that
the digestion of foods and starches is greatly promoted
by its use under tln'se circumstances. Other sj'mptoms
have to be treated as they arise.
Pancke.vtic Calculi,
Calculi are occasionally formed in the pancreatic ducts
where theymay remain, or from which they may be dis-
charged through the duct of AV'irsung and common duct
into the duodenum.
Etiuhyy. — Pancreatic calculi are occasionally encoun-
tei'cd post mortem, and there are several instances in
which the passage of the stones through the ducts into the
duodenum has been diagnosticated in life. The condi-
tion, hoAvcver, is one which is rarely encountered, being
much less frequent than cholelithiasis. Concerning the
causation of this affection it is generally assumed that
catarrhal changes in the ducts mo.st frequently give rise
to it, but in all proliability it may be also associated with
the lith:emic diathesis.
yiorhid Anatiimy. — The calculi are usually quite small,
being, as a rule, not larger than a grain of sand, though
instances have been recorded in which stones of this kind
were more than an inch in diameter. Tiiere may be
only a .single calculus or there may be large numbers,
more than one hundred having been found in a single in-
stance. The_y are usually rounded or oblong, but they
may be quite irregular in form. In many instances their
surfaces are smooth, though they may be decidedly
roughened. They are iis\ially of a light color, and con-
sist generally of carbonate of lime, though they may be
composed of phosphate of lime, or a stone may consist of
a combination of the two. In some instances tliej' con-
sist of organic maleiial.
In cases in which the calculi becfune im]iacted either in
the duct of AVirsung or in the connnon duct, great dila-
tation of these canals results, and these distentions may
be so increased in size that they present the appearance
of being cysts. As a result of the stoppage of the pan-
creatic duct chronic interlobular pancreatitis is sooner or
later produced, and in rare instances suppuration of the
organ occurs. Fistulous openings have sometimes re-
sulted, the dilated ducts communicating wiih the stom-
ach, duodenum, or peritoneal cavitj'. The irritation
produced I.iy these stones is supposed by some to lead to
the development of cancer.
Symptoms. — In the few instances in which the passage
of pancreatic calculi lias been diagnosticated during life,
the symjitoms came on somewhat suddenly with severe
pain in the epigastric region, somewhat to the inner side
of the left manimaiy line. From this point the pain
generally extended around the border of the ribs on the
left side to the spine, and later radiated into the left
.shoulder. During the lieight of the al lacks vomiting
has been noted, and in the case of Cipriani there were
salivation, polydipsia, glycosuria, fatty diarrha-a, fever,
and great weakness. Following the attacks thirst and
hunger liave generally been pronounced. In the case
just referred to, there were repeated attacks, and the
diagnosis was confirmed liy the timling of a stone in the
faeces. In the case reported by Poliakoff the patient
comiilaiued of severe jiain in the abdomen for two and a
half months, the pain being sometimes accompanied by
vomiting. The sutferer developed hunger and thirst,
and sugar was found in the urine. The symptoms are
not, however, in all instances so characteristic, for in the
case recorded by ^Minnieli the patient could not distin-
guish between attacks of pancreatic and tho.se of biliary
colic, be having previou-^ly repeatedly suffered from Ihe
latter affection.
In those instances iu which the calculi lodged in Uie
duct of Wirsung, causing retention of the ])ancreatic se-
cretion and secondary changes iu the organ, the symptoms
■iGS
REFERENCE HANDBOOK OP THE MEDIC VL SCIENCES.
Pancreas.
Pancreas.
that followed resembled those which occur in chronic
paucieatilis. There are siiiiDar digestive disturbances,
accompanied by loss of llesli and weight, and diabetes
occasionally develops. The fat in the fa'ces is generally
increased, and is not split up into fatty acid.9 to the same
extent as in health. Jlicroscopic examination of llic
ffeces will frequently show the presence of much undi-
gested food, unaltered muscle fibres being especially
numerous. In those instances in which the ducts become
greatly dilated a tumor may be occasionally felt in the
region of the pancreas, and when this can be done the
presence of such a tumor may be considered of the ut-
most diagnostic importance.
Diagnosis. — The diagnosis of pancreatic colic is made
by noting that the patient is suddenly seized with severe
pain in the left epigastric region, the pain radiating
around the lower border of the ribs to the spine on the
left side, and oftentimes passing up into the left shoulder.
Vomiting and glycosuria in some instances have accom-
panied the passage of the stone. After about two hours
the pain usually ceases suddenly, and the patient develops
marked hunger and thirst. From biliary colic the condi-
tion maj' be usually distinguished by the facts that in the
former condition there is tenderness in the region of the
gall-bladder, and tluit the pain is not confined in such a
pronounced way to the left .side of the bod)'. It cannot
be questioned, however, that a diagnosis between the
two cannot always be made with certainty. From acute
pancreatitis it is distinguished by the facts that the vomit-
ing is not so severe, that the symptoms of collapse are
not so pronounced, and that the pain ceases in the course
of a comparatively short time.
In those instances in which the excretory duct of the
pancreas is occluded, the .symjitoms will resemble those
of chronic interstilial pancreatitis, though the relation of
a calculus to the condition may be inferred when there is
a previous history of possible pancreatic colic.
Prognosis. — In pancreatic colic the prognosis is good,
as imder proper exercise and diet the condition that lies
at the bottom of the attacks may usually be entirely re-
lieved.
In those instances in which the concretions have lodged
in the excretory duct of the organ, the jirognosis is much
more unfavorable, as sooner or later chronic interstitial
pancreatitis develops. In some cases, however, recovery
has followed as a result of the establishment of fistulous
communications with the neighboring viscera and the
consequent discharge of the stone.
Treatment. — For the relief of the intense pain that ac-
companies the passage of a calculus, morphine should be
freely administered subcutaneously ; and, if necessary,
ether or chloroform may be given. The application of
heat to the abdominal wall may be also of considerable
service. In the case of Cipriani the patient recovereil
under the internal administration of hydrochloric acid,
a vegetable diet, baths, and gymnastics. It has akso
been asserted that the hypodermatic injection of 1 c.c. of
a one-percent, sohition of pilocarpine three times a week
has resulted in the disappearance of attacks of pancreatic
colic. After the sfone has lodged in the excretory duct
of the organ medical treatment is, of course, no longer
of avail ; but it seems highly probable tliat recovery in
these instances would frequently follow intelligent surgi-
cal intervention.
The treatment of chronic interstitial pancreatitis re-
sulting from the stoppage of the excretory duct of the
gland is entirely symptomatic, and is in every way sinii
lar to that already reconnnended for a jiancreas which is
chronically indui'ated as a result of any cause whatever.
PaN(;i!EATIC Cvsts.
By the term pancreatic cysts is meant the presence in
the organ of collections of "fluids due to a variety of dif-
ferent causes. Fitz thinks that many reported cysts of
the pancreas were circumscribed collections of fluid
wholly outside of the organ.
Etiology. — Pancreatic cysts occur with about equal fre-
quency in the two sexes, as of 121 cases of the disease
operated upon by surgeons, Koerte found that 01 were
males, 56 females, and in 5 the sex was not mentioned.
The affection is rather more common after middle life
than before, though instances have been reported in whicli
the disease occurred in an infant six mouths old. As.
several cases have been reported in very young children,
it is highly jirobable that pancreatic cysts are occasion-
ally congenital, though the more frequent cause is be-
yond doubt the obstruction of the excretory duct of the-
gland. Trauma is also recognized as a frequent etiologi-
cal factor in the production of cysts of the pancreas, as
out of 121 cases collected by Koerte, in 33 instances the-
lesions had followefl blows or injuries. Retention cysts-
which have developed from the smaller ducts of ther
gland — through their becoming occluded either by a con-
striction or by the pressure exerted by a calculus or by a
tumor <if some kind — are sometimes encoimtered. In a
remarkable case rejjorted Ijy Durante a c-_yst resulted from
the obstruction of the duet of Wirsung by a roimd worm.
Parasitic cysts are sometimes likewise found. It is
highly probable that in many of those instances in whicli
pancreatic cysts are supposed to have followed injury
the condition is really one of inflammation of the ti.ssues
surrounding the organ, with the accumulation of inflam-
matory products.
Morbid Anittomi/. — Cj'sts may occur in any part of the
pancreatic tissues, though they are most commonlj' en-
countered in the body and tail of the organ. They vary-
in size from those that are merely microscopic to enor-
mous collections of liquid, an instance having been re-
corded in which the tumor contained fourteen (inafl'ts of
fluid. The c.ysts maybe single or multiple. Their walls
are, as a rule, smooth, but in some instances papillary
new formatiims spring from them. The inner walls of
the cj'sts are lined by cylindrical epithelium. The fluid
is usually of a clear grayish hue, antl is slightly opaque,
though not uncommonly it is clear and of a straw color;
ill a lew cases, however, and particularly in those of a
traumatic nalure, it may be blood-stained. The reaction
of the liquid is alkaline, the specific gravity varying from
1.010 to 1.024. In many in.stanees the fluid will emulsify
fat, convert starch into glucose, and digest albuminous
substances, though not uncommonly, especially in older
cysts, these properties are entirely wanting. Under the
micro.scope the fluid is found to contain leucocytes, epi-
thelial cells, cholesterin, and small drops of fat.
In many cases the tumors gradually increase in size at
the expense of the parenchyma of the pancreatic struct-
ures, and this is sometimes so extreme that the gland
maybe praclically destroyed. As the cyst enlarges it
usually ])ushes the stomach upward and the transverse
colon downward, though the latter visi-us may lie di-
rectly in front of it. In rare instances the cyst lies above :
the lesser curvature of the stomach and pushes the or-
gan downward : and in other cases it develops below botli
the stomach and the transverse colon. In some instances
the walls ot ihe cysts are firmly attached by adhesion
to neighboring viscera. The cysts may rupture into
Ihe peritoneal cavity, into the stomach, or into the iu-
ti-stines.
,Si/mp/oms. — In quite a number of instances the first
evidence of the existence of a iiancrealic cyst has been
the detection of a tumor-like mass in the abdominal cav-
ity, although, as a rule, before these cysts reach a
noticeable size other symptoms manifest themselves and
first direct attention to them. In the traumatic cases
there are usually in the beginning inflammatory symp-
toms, consisting of pain, vomiting, and more or less
pronounced collapse. In all varieties of these cysts usu-
ally the most pronounced .symptom is pain, which may
occur in attacks lasting only a short time, or may he
persistent and continued for weeks, months, or even
years. The pains are present in the region of the jian-
creas, and, as in other alVections of this organ, they have
a tendency to radiate toward the left side, and into the:
left shoulder. Not unconunonly these |)aiiifnl paroxysms
are accompanied by symptoms of deranged tiigestion, and
■4()»
Pancreas.
Paucreasi,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
as the disease progresses tlie patieut loses iu -weiglit aud
strength. As the cysts enlarge they appear as localized
promiuences in the upper portion of the abdomen, usu-
ally in the left hypochondriac region, thougli tliey may
lie present below the navel. The tumcn-s are globular
in shape, smooth, and oiler considerable resistance. In
most instances they are but slightly movable, and are
not, as a rule, afl'ecfed to any great cxtcnl. by the respira-
tory act, but instances have' been recorded iu which they
were pedunculated and could be moved into almost all
parts of the abdominal cavity. The cysts are, of course,
dull on percussion when not covered by the stomach or
intestine. The pulsation of the alidominal aorta is not
uncommonly transmitted, though the cysts ar<' never ex-
pansile, oil auscultation a systolic soufHe may be dis-
tinctly heard in some instances. The tumor by its
pressiire may .seriously interfere with the fviuetious of
neighboring organs in addition to its destructive action
on tlie pancrea^ itself. The pressure iu .some instances
has been so extreme that symptimis of intestinal obstruc-
tion have occurred, and jaundice in some cases has been
jiroduci'd. Sonietinii'S the cyst diminishes iu size, as in
aca.se re])orlcd by llalstcd, iu which the girth of the ab-
domen dei'reascd' to the extent of twelve inches iu ten
days. If the (entire gland be destroyed, or if its duct be
so compressed that the pancreatic juices cannot be dis-
charged, the faeces may contain considerable quantities
of fat, glycosuria may be present, and the amount of
indican iu the urine may be decreased. Salivation, as in
other diseases of the ]iancrcas, is sometimes uoted.
Didtjiiosis. — Cysts of the ]iaucreas should be suspected
in all cases in which successive attacks of severe paiu oc-
ctn- iu the epigastric region, especially if they be accom-
panied by pronounced symptoms of collapse. The diag-
nosis, however, must always remain problematical until
a tumor is discovered in the aU'ected region, in which
case, conjoined with the sj'inptoms just referred to, the
probability of pancreatic cyst should always be consid-
ered. Should iloubt exist, aspiration maybe resorted to,
anil thelluid ol)tained tested for pancreatic ferments; but
it should always be reiuembered that iu (piite a propor-
tion of cases the Huids that occur iu these possess no
digestive properties, and ou the other hand that other
liipiids .sometimes do. From aneurism the cysts may be
diirerentiated by the fact that even when they show pul-
sation it is non-expansile, aud that in the knee-elbow
position it entirely di.sai)pears. Collections of fluids in
the pancreas may lie mistaken for ovarian cysts, but may
be generally diaguosed by the facts that iu the latter con-
dition the increase in the abdomen is from below upward,
and that on aspiration tlie contents of tlie tumors are
rarely bloodstained, do not emulsify fat, and contain no
digestive ferments. Cysts of the gall-bladder differ in
that they are continuous with the liver, and that on
puncture the fluid found corresjionds to bile rather than
to the juices elaborated by the pancreas. Solid tu-
mors may be distinguished by the fact that they contain
uo liquids. Cysts of the lesser peritoneum, or mesen-
tery, are diffei'entiated witli great difficulty from like
collections of fluid occurring iu the pancreas, but the
absence of digestive properties iu the liquids removed
from these situations, and the lack of symptoms indi-
cating interference with the pro]ier ]ierformance of the
fuuctions of the paucreas may serve to make tlie diag-
nosis clear.
Progiums. — Cysts of the pancreas not uncommonly ex-
ist for long periods of time without jiroilucing any serious
results, but they may cause luarkeddisturbaucesbj' press-
ing upon the neighboring organs. Diabetes is sometimes
produced Iiy them, though this is conqiaratively rare.
The particular danger is rupture of the cyst into the
ueighlmring cavities.
Traitijiciit. — Of oneliunilred and one cases collected by
Koerte, which were opened and drained, four deaths fol-
lowed as a direct result of the operation, and one case
ultimately ended fatally from infection of a ti.stidous tract
resulting'. In fourteen cases the cysts were extirpated,
with twelve recoveries.
New Growths of Pancreas.
Tumors of the pancreas are exceedingly rare, but the
neoplasms that occur iu the organ are in most instances
malignant. Of the tumors that develop in the gland
carcinoma is the most common, but sarcoma, adenoma,
lymphoma, gumma, and tubercle are occasionally en-
countered. For the reason that most of the tumors that
occur in the organ belong to the grouii of carcinomata,
and inasmuch as the symptoms of other tumors of mo-
ment are practically identical with those occurring iu
this form of the disease, cancer will be alone considered.
Carcixo.ma of the Pancreas. — Notwitlistanding the
great amount of work that has been recently done upon
the subject of the etiology of cancer, there is as yet no
satisfactory explanation of its causation, aud we shall
therefore have to be contented with pointing out that
carcinoma of the pancreas usually occurs between the
ages of thirt_y and fifty, aud that it appears to be rather
more frequent in men tliau in women. The rarity of the
condition is evident by the fact that in 3G,.541 post-mor-
tems the disease ixas found iu only 17-1 instances.
M'/rhiil AiiKti/iiii/. — Carcinoma of the pancreas may oc-
cur in any part of the organ, but its most frequeut site is
in the head of the gland. The tumor may be very soft,
or, when containing much fibrous tissue, of almost car-
tilaginous consistency. Iu some instances the ueojilasm
is circumscribed and remaius confined to one part of the
organ ; but in other cases it is diffused throughout the
entire substance of the gland. It may be very small or
quite large, sometimes attaining the size of a cocoanut.
The disease does not remain coutined to the pancreas,
but is prone to extend into the surrounding tissues, no-
tably into the walls of the duodenum. The lymph nodes
in the vicinitj' are sooner or later involved, and second-
ary nodules may occur in the spleen or liver.
Si/inj)fi>in.s. — Until the tumor reaches such a size that it
can be palpated, the diagnosis of cancer of the pancreas
is exceedingly dillicult, and is indeed generally impossi-
ble, as the sj'mptomatology of the disease in its incip-
iency is apt to be vague and misleading. In most cases
the first manifestations of the affection are disorders of
the digestive functions, which iu the course of weeks or
months are followed by paroxysms of epigastric pain, not
uncommonly accompanied by nausea and vomiting. As
the tumor increases in size the common duct is in most
instances compressed, with the result that jaundice of an
iuteuse and persistent kind is induced, and on account
of the retention of the bile the gall-bladder is generally
greatly dilated. Jaundice sometimes develops slowly,
and in other instances with suddenness. On account of
the absence of the pancreatic and biliary secretions the
fteces are apt to be white, and in rare instances to con-
tain an increased amount of fat. The fares when ex-
amined microscopically are apt to exhibit many undigest-
ed muscle fibres, even in instances in which constipation
exists. In some cases the urine is found to contain sugar,
and indican is said by some to be considerably diminislied
iu amount. As the "tumor increases in size it sometimes
causes obstrucliou of the duodenum, with the result that
the stomach aud ujiiier jiart of this viscus become con-
siderably dilated. If it be very large it may impede the
portal circulation with the production of ascites, or by
pressure upon the inferior vena ca\'a dropsy in the lower
extremities ina.y be develo|ied. In rare cases hydrone-
phrosis has been produced iu the left kidney as a result of
the compres.sion of the left ureter. Aftertlie tumor be-
comes quite large it may be felt, especialh- if perfect re-
laxation of the abdominal muscles be brought about by
the means of general ana'sthesia. It should, however,
be remembered that the tumor must be quite large in or-
der that this may be accomplished, for it has not been
palpated iu more than ten per cent, of all cases in which
the disease was undoubtedly present. If carcinoma ex-
ist the tumor is deeidy seated, and is hut slightly mov-
able. It maj' or may not be tender. In some instances
the neoplasm causes hemorrhage into the peritoneal cav-
ity or into the intestine, and this ma}- be so profuse as to
+ 70
REFERENCE HANDBOOK OF THE JLEDICAL SCIENCES.
Pau<>r*>an.
Paufreas,
cause death. In the beginning the appetite and general
health may be but liltle changed, and. indeed, increased
hunger and thirst may occur, especially if diabetes exist.
As the disease progresses the patient, as is usual in all
forms of carcinoma, becomes anaemic and loses flesh,
which condition may be extreme in tlie latter sbiges of
the affection. The temperature is apt to be somewhat
below the normal.
Diagnosis. — Carcinoma of the pancreas is most likely
to be mistaken for carciuoma of one of the neighboring
viscera — the liver, the transverse colon, the pyloric end
of the stomacli, or the duodenum. From carcinoma of
the liver it is distinguished by the facts that in the for-
mer condition the disease is in almost all in.stances sec-
ondary to cancer of some of the otiier abdominal viscera,
that it is often associated witli enUirgemcnt of the liver,
and that an ascites frequently exists. The tumor in can-
cer of the liver is situated somewhat higher up than are
those of tlie pancreas, and it is, as a rule, more easily
movable. In both diseases jaiuidice occurs, but is much
more common in cancer of the pancreas. In cancer of
the transverse colon obstinate constipation as a result of
the obstruction usually exists, and this is generally asso-
ciated with the production of a large amount of indican,
quantities of which appear in the urine. In these cases
the tumor is more superficial, and is more frequently
movable, and the disease is not accompanied by jaundice.
In cancer of the pyloric end of the stomach there is com-
monly a history of intense pain developing an hour or so
after taking food, and examination usually reveals the
fact that the stomach is greatly dilated, contains much
lactic acid, and but little hydrochloric acid. Not un-
commonly it will be found that the patient suffering with
this malad,y has vomited blood freely, and jaundice is not
so apt to be present. From cancer of the duodenum it
is practically impossible to distinguish carcinoma of the
pancreas, as the two conditions commonl}' give rise to
symptoms in every way similar. Cancer arising in either
of tliese situations is, moreover, very apt to extend to the
other. The symptoms of cancer of the pancreas that are
of greatest diagnostic importance are the presence of a
deeply seated but slightly movable tumor in the situation
normally occupied by the head of the gland, the exist-
ence of intense and persistent jaundice, pain in the af-
fected region, rapid emaciation and loss of strength, di-
minished'excretion of indican in the urine, and especially
the presence of sugar in this excretion. The absence of
the pancreatic juice in tlie intestine, according to Mueller,
results in the diminished splitting up of the fats ingested,
and this, if true, in all probability will prove of much
value in enabling us to make the diagnosis in obscure
cases. For the reason that salol, when taken by the stom-
ach, is decomposed only in the presence of the pancreatic
secretion, the absence of carbolic acid in the urine after
the administration of full do.ses of this drug points to
obstructive lesions of the excretory ducts — a condition
which is usually present in carcinoma of the organ.
Prognosis. — When surgical interference is not invoked,
death in practically all instances results from carcinoma
of the pancreas, but the practicability of removing tu-
mors from this organ has been recently clearly shown;
and in cases in which the diagnosis can be made early
enough, the 0|)eration would offer some hope for the life
of the jjatient.
Treatment. — As we have no drugs that act specificall)'
on carcinomatous processes, treatment is to be entirel_v
of a sj'mptomatic kind. Diastases and small pieces of
raw pancreas may be administered with the food with
advantage, but the only effect that can follow this is an
improvement in the digestive functions. In the earh'
stages an operation may be the means of saving the pa-
tient's life, as, according to Koerte, recovery has followed
in several cases of this kind after the removal of the
tumor. Henry Fauntleroy Harris.
Bibliography.
Birch-HirsclifPld : .\rch. f. Ileilkiindp. 18T.i, xvl., p. 174.
B(ias: Berl. klin. Wci-lii-nsciir., ISlll. .\xvili., p. 40.
Cipriani: Therapeutist, London, 1898, vUi., pp. 256-258.
Cowley : London Med. Jour., 1788, \^.. p. 285.
Dettmer : Inaug. Diss., Goettingen, 1895.
Diiimare : Internat. Monatsclir. f. Anat. u. Phys., 1899, pp. 1.55, 177.
Draper: Trans. Assn. Am. I'livsicians, 1880, i., p. 243.
Durante: Allg. med. Centr.-Ztg., Berl. (Abs.), 1891, Ixiii., p. 427.
Fitz : Boston Med. and Surp. Jour., 1889, cxx., p. 181 ; also Allbutt's
System of Medicine, pp. 262-278.
Flexner : Contributions to tbe Science of Medicine by the Pupils ot
W. H. Welch, 1900.
Oerhardi : Vircliow's Arcliiv. Bd. 106.
Hlava : Bull. Internal, de I'Acad. des Sciences de Bohferae, 1898.
Koerte : Die chirurgiscben Kraukheiten u. die Verletzungeu des
Pankreas. Stuttg., 1898.
Laguesse : Compt. rend. Soc. de Biol.. 1893, 9, S. v.. p. 819.
Lancercaux : Bull. Acad, de M^d.. Paris, 1877, p. 12, et 1888, p. 588 ;
also Train; des Mai. du foie et du pancreas, 189il.
Langerbans : Virchow's Arch., 1890, Bd. cxxii., p. 2.52.
LlcbUieim : Berl. klin. Woehenscbr., 1894, xx.xi., p. 185.
von Mering and Minkowski: Arch. f. exper. Path. u. Phaniiakol.,
1889-90, xxi., p. 85.
Minnich : Berl. klin. Wochen., 1894, xxi.. p. 187.
Opie : Jour, of Exper. Med., 1901, v., p. 397 ; also Jour, of Exper. Med.,
1901, v., p. 527.
Osier: Principles and Practice of Medicine. 1901, pp. o88-o95.
Picenti: Virchow-Hirsch, Jahresbericbl, 18S8.
Polyakoft : Berl. klin. Woehenscbr., 1898, xxxv., p. 237.
Scblessinger: Arch. f. path. Anat., 1898, cliv., pp. 501-528.
Senn : Am. Jour. Med. Sciences, July, 1SS5, p. 17.
Ssobolew : Centralbl. f. allg. Path. u. path. Anat., 1900, xi., p. 202.
Trafoyer : Wien. med. 'Wocbenschr., 1.S8II, xxx.. p. 139.
Williams: Report of the Lab. of Path. Univ. of Buffalo, No. 1. 1900.
PANCREAS. (SURGICAL.)— An.vtomical Consider-
ations.— The paiiri(:is lii s transversely across the upper
part of the abdominal cavity, behind the stomach, on a
level with the first and second lumbar vertebra', and
three inclies above the umbilicus. The head is contained
in the loop of the duodenum, the body lies on the crura
of the diaphragm. To the left the posterior surface is
in contact with'the left kidney and suprarenal capsule.
The tail touches the lower part of the inner surface of
the spleen. Its average length is from five to six inches,
and it weighs from two and a half to three and a half
ounces.
The blood supjdy is from the splenic artery and from
the inferior mesenteric and hepatic by the inferior and
superior p;increatico-duodenal arteries. The blood is re-
turneil into the portal vein by means of the splenic and
superior mesenteric veins.
The lymphatics terminate in two glands which lie on
the superior mesenteric artery. The nerves are branches
of the solar plexus which accompany the arteries enter-
ing the gland.
The pancreas is a compound racemose gland, soft in
texture, and of a pinkish-cream color (ilorris ').
The secretion of the pancreas is carried by short canals
or ducts to the main duct, the duct of Wirsung, which
they join at nearly right angles. The duct of Wirsung
turns down through the head of the pancreas and opens
into the second portion of the duodenum, together with
the cominon bile duct. The lesser duct, or duct of San-
torini, collects the secretion from a portion of the neck
and head of the pancreas, and opens into the duodenum
2.. 5 to 3.. 5 cm. nearer the stomach. Brewer- states that
the older anatomists were wrong in teaching that the
duct of Santorini, or smaller duct, usually atrophied;
according to him it is practically always present in the
human subject.
The pancreas is developed between the two layers of
the posterior mesentery from two offshoots from the in-
testinal tube just below the gastric dilatation. Brewer'
calls especial attention to the fact that the pancreas is at
this time completely invested by peritoneum, "and only
becomes a retroperi'toneal organ by the absorption and
conversion, into areolar tissue and fat, of the several layers
of the posterior mesentery." He then draws attention to
the fact that the areolar "tissue surrounding the pancreas
is continuous with that surrounding the left kidney and
the areolar tissue lying behind the colon on the left side.
Accessory Pancreas. — Tieken states that fourteen
cases of accessory pancreas have been rejiorted. This
results from lack of fusion of the separate diverticu-
lums. These accessory glands may be found in the
walls of the stomach "or duodenum, or in the mesen-
terv. It has been suggested that these accessory glands
ma"y cause diverticulums of the intestine. They have
471
Paucroas.
Paucreas.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
been found at the tips of such processes. The "pa:
creas minus" is merely an accessory pancreatic lobu
springing from the head of the main gland and it us
illy extends along tlie wall of the dnodenum. Hya
The "pan-
lobule
usu-
att
Fig. 373U.— Shows tlin .Nuniiijl lii'lalioiis of the Pancrea.s to the
Stomach, C"l"ii ami reiltniiemn, as thL-y .\|i|)ear in a Louffitialnial
AntenvPost^rinr Sei'tionnf ihe'l'i'iink. (BYoin Kehr.) a. Liver; /',
stomach; c, transvt'i so colon ; f". foianicn of Winslow : /.oiiientuni;
7n, omentum minus ; n, ]iancte;i.s ; o. imrsa ouientalis ; j), duodenum.
speaks of a (laitial division of the gland by tlie mes-
enteric vessels during development. Tiie most impor-
tant surgical anomaly is dcscrilied by Tiekeu as follows:
The neck was of normal size, the head somewhat
enlarged. "Fi'om the head two bands of glandular
siibstaiiee extend forward in such a manner as to sur-
round the lower jiart of the descending duodenum, form-
ing a complete ring about its circumfei'ence. . . . The
duodenum is greatly constricted at this portion, and ad-
mits the tip of the inde.x linger with dilticulty. . . . The
duodenum above the constriction is greatly dilated, form-
ing asacculatiou ucai'ly one-half thesizeof the stomach."
Similar cases have been i-eported by Ecker, '" Auberg,"
Symingtoii,'- and Genersich.''
"The anatomical lelations of the common bile duct and
the duct of Wirsung aie well known. The common l>ile
duct descends towani the diioderiuiii alongside the head
of the pancreas, occasionally emlieddei! in its substance,
and comes in contact with the duct of Wirsung, beside
which it lies for a short but variable distance before en-
tei'ing the WiiU of the intestine. The two ducts pene-
trate, side by side, thi' coats of the duodenuiii. and after
passing obliiiuely a ilistance of about '3 cm. and causing
a papill-a-like elevation of the mucous membrane, unite
to form a short cavity — the diverticulum of Vater. Near
its termination at a point where the two ducts are in con-
tact, the common duct becomes constricted, and it is heie
that a foreign bodv passing downward, lends to lodg(^"
(Opie=).
Both ducts may enter the duodenum independently of
each other and tlie hepatic duct. In one case the duct
of Santorini entered the stomach.
The paiicreas is a ti.xed organ and docs not di'scend
during foi'ced inspiration. Nevertheless, it has lieen
found in diaplu'agmatic hernias, in congenital umbilical
hernias, and iu Band's'' case the duodeniun, panci'eas,
and a portion of the ileum and colon were invaginated
into the descending colon.
Total extirpatjou of the pancreas in animals is usually
followed by true diabetes, and partial extirpation by
temporary or alimentary diabetes.
Persistence of fat in the stools in the absence of jaun-
dice and diarrliO'a is an indication of disease of the pan-
creas, particularly when accompanied by great emacia-
tion.
Tr.\u.m.\tism. — The pancreas, from its position, is sel-
dom injiu'ed alone. The liver, stomach, and transverse
colon lie iu front, and if the liver should happen to be en-
larged and if the stomach and colon should be full at the
time when the injury occuri'ed, the pancieas could Itardly
escape a frontal attack. It might jiossibly be injured
fi'om behind from a penetrating wound or from a frac-
tured vertebra. On the other hand, the pancreas, as
mentioned by Robson,* is soft iu consistence and easily
bruised. The lobules are not well supported as iu the
parotid. Blows upon the abdomen or a kick or a fall
against a hiird object m.ay, under certain circumstances,
injui'e the pancreas. Robson relates the case of a butler
who slipped and fell against a knife board projecting
trom the end of a table at which he was woiking. The
blow was not severe, the man did not even fall to the
ground, but acute hemorrhagic pancreatitis followed and
the patient died. An exploration for peiitonitis followed
by an autojisy, revealed the true cause of death. Gener-
ally the neighboring oi-gans, the stomach, colon, liver,
spleen, and lungs are injured at the same time.
The diagnosis of injury to the pancreas alone is impos-
sible. It can only be inferred from the nature of the
accident anil fi'om symptoms of shock and hemorrhage.
After the abdomen is opened, injuries to ueighboiing or-
gans will piobably be found in addition to that of the
pancreas. If the pancreas is torn, an attempt should be
made to close the rent by stitches. Hemorrhage may be
controlled by gauze packing. It is obviously inadvis-
able to ligature the supeiior mesenteric artery. Repair
may take place; cysts may subsecjucntly develop. Gan-
giene of the pancreas has followed injury to the paren-
chyma.
Perforating wounds of the pancreas are not common.
Koerte has collected six eases. They generally result
from gunshot or stab wounds, and ar(^ nearly always fa-
tal from the complications, such as injui'ies to the stom-
ach, spleen, lungs, or liver. A definite diagnosis can
be made only by an exploratory incision. If the compli-
Flli. .•iT3I.
-Auuular Paiiereas wiUi Sac<-ulaIion of the Duodenum.
(FYom Tieken.)
eating injuries and the condition of the patient permit,
the wouiid in the pancreas might be closed. The most
perfect asepsis should be attained.
Prolapse of the pancreas is difficult to understand, but
cases aie repoifed by Kehr.'' The tail is the most mov-
able part of the organ. It may be replaced and main-
4Y2
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pancreas.
Pancreas*
tained in position, until adhesions have formed, by ster-
ilized gauze packing.
As hemorrhage of the pancreas (or pancreatic apo-
plexj'). acute hcmoniiagic pancreatitis, and fat necrosis,
are alfections which belong to the domain of the ph_ysi-
cian rather tlian to that of the surgeon, the reader is re-
ferred, for information with regard to them, to the article
immediately preceding this.
Necrosis of the P.\nci5EAS. — Necrosis or gangrene
of the pancreas may result from ditlerent causes. The
whole gland may necrose, but more frequently the ne-
crosis involves only a portion. The tail and body are
often in vol ved in this process. In other cases the affected
areas are numerous and small. The necrfitic area may
be infolded by peritoneiuu and ultimately an abscess
may form at this point. In two cases reported by C'hiari
recovery ensued after a portion of the pancreas liad been
passed per rectum. " In other cases the pancreas is con-
verted into a dark, slaty-colored mass lying nearl)' free in
the omental cavity or attached by a few shreds" (Osier).
The causes of necrosis are to be found in inflammatory
suppuration and hemorrljagic conditions of the pancreas
itself. It may arise from infections entering from the in-
testine or through a perforating ulcer of the stomach, as
in a case reported by Chiari.'" Syphilitic disease of the
blood-vessels and arteriosclerosis are also assigned as
causes. Fitz and Koerte have reported about fort}' cases.
A fatal ending is common.
^j/i/ipii/iiis. — Many pathological lesions of the upper
abdominal region are closely simulated by necrosis or
gangrene of the pancreas. A very careful study of the
clinical history may throw light on the case. Perforat-
ing ulcer of the stomach, gall-stone colic, or perforation
of the bile passages may give rise to similar symptoms.
A diagnosis of intestinal obstruction has been made on
several occasions and laparotomies have been performed
without, of course, revealing any obstruction. Pain,
tenderness, vomiting, and collapse are present in severe
cases, and later, with the formation of pus around tlie
necrotic area, there will probably be an intermittent tem-
perature, a dry tongue, and a feeble pulse. If the patient
survives there may develop such complications as perito-
nitis, pulmonary embolism, metastatic pleurisy, pericar-
ditis, leptomeningitis, and pyoeraia. The different courses
taken by the pus after abscess for mation will be referred
to tmder Supptn-ative Pancreatitis.
Diiif/nosia. — A detinite diagnosis is possible only after
a portion of the necrotic pancreas has been passed per
rectum or found by exploratory incision. Kidney lesions
miglit be excluded by an examination of the urine.
TreatmeHt. — During the acute stage but little can be
done except to relieve pain; and, if collapse is present,
stimulants may be administered judiciously. After en-
capsulation and pus ffu'ination have taken place, surgical
interference may be indicated. The abscess may be a])-
preached from behind, through the loin or through the
pleura, or by an anterior incision thnmgh the abdominal
wall. Some patients remain well, but dialietes has occa-
sionally developed a year or two afterward.
Aci'TE Suppup,.\TivE Paxche.\titis.— In 1688 Blan-
card reported finding small abscesses in the pancreas of
a child that had died of variola, and cases have been de-
scribed in increasing number during recent years. Os-
ier'* has analyzed 46 cases; of these 28 were men and 11
were women. The age was given in 30 cases. The
greatest niunber occurred between the ages of twenty
and fifty, the largest number, 11, between twenty-one
and thirty. There may be one or inniunerable abscesses.
Several small ones may coalesce and form one large ab-
scess. In 24 cases there was a single abscess and in 14
numerous small ones (Osier).
The causes are divided, by Dieckhoff, into three groujis.
In the tirst the infection is brought to the pancreas by the
blood stream; in the second, the infection comes from
some adjacent focus, as, for example, the base of a stom-
ach ulcer which has become adherent to the pancreas be-
fore perforating; in the third, the infection passes in from
theduodenum through the ducts of Wirsung or Santorini.
It is now quite generally thought that the cause is an in-
fection. The colon bacillus, first found by Welch in the
pancreatic ducts, and many varieties of micro-organisms,
are now known to be present in the ])us. In some cases
there is a history of gastroduodenal derangements and of
pancreatic and of biliary calculi. Thrombosis of the por-
tal and splenic veins with abscess formation in the liver
and spleen are not uncommon. The spleen may not be
enlarged even when the splenic vein is obliterated. In-
flammation of the peritoneum in the immediate neigh-
borhood is common, that of the peritoneum below the
transverse colon rare. When that covering the diaphnigm
is involved the inflammation may extend to the pleura
and pericardium (Fitz).
The abscess formation is seldom confined to within the
capsule of tlie pancreas. Outside tlie pancreas the pus
may collect between the layers of the juesentery or omen-
tum, or in the lesser peritoneal cavity (the foramen of
Winslow being closed), or it may extend back into the
loins. Sometimes it burrows down behind the descend-
ing colon to tlie pelvis (Koerte). Fat necrosis is rare in
sup]nii-ative pancreatitis (Fitz).
Symptoms. — The onset is generally sudden and charac-
terizecl by severe pain in the epigastrium. The pain and
tenderness may be referred to one or the other side of the
median line if the lesion is limited to the tail or head of
the organ. In some cases there is no pain. Vomiting
is usually present. There may be constipation or diar-
rho-a, sometimes colliquative. The temperature varies.
Absence of fever is rare. Chills are frequently present.
According to Fitz more or less jaundice is present in
one- fourth of the cases. Alliumin and sugar in the urine
are sometimes found, but fat in the .stools seldom.
Koerte in four of his cases observed a grayish-brown
discoloration of the skin. In one case Bloodgood--' ob-
served a leueocytosis of 19,000, tumor formation, blood
and pus in the stools.
Di/iyiinsi'x. — Thediagnosis of anab.scess confined within
the ]iancreas is inipo.ssible. The symptoms are not dis-
tinctive. The discovery of a tumor in the pancreatic re-
gion is suggestive. If by inflating the stcmach and
transverse colon it can be demonstrated that the tumor
lies between them and is free from either, it would be
evidence of pancreatic origin. The absence of any cliin-
cal history of gastric or d\iodenal ulcer and the presence
of a history of gall-stones would be suggestive. Fluc-
tuation is seldom to be directlj- made out. If there is
bulging in one loin and an examination of the urine gives
no evidence of kidney lesion, Koerte thinks it might be
justifiable to use an exploratory needle. The diagnosis
is generally made by an exploratory incision.
Kehr-^ states that in tlie great majority of cases the
course is chronic. Cases are reported which have run a
course of nearly a year. On the other hand, some cases
are very acute and end fatally within a few days. Abscess
may be said to be always fatal unless the pus escapes
spontaneously into the stomach or intestine, or is evacu-
ated by the surgeon. Koerte •■' emptied these abscesses
through an incision in the loin and in other instances by
anterior incision. The lumbar incision is to be chosen
when there are indications that the pus is near the kidney.
The .anterior incision should generally be made in the
middle line. If, however, a palpable tumor lies to one
side, the incision is best made over the prominence. If
the anterior wall of the sac is adherent to the anterior ab-
dominal wall the cavity may be washed out and packed
with gauze; otherwise great care shoul<l be taken to pre-
vent the spread of infection by careful packing with steri-
lized gauze ]iads. If possilile tlie wall shovild be .sutured
to the abdominal incision. If this is not feasible careful
packing with gauze around a large drainage tube, or the
liuilding of a drainage canal from omentum, is the only
resource. The operations are very simple. If. however,
the abscess is confined within the capsule of the pancreas,
the operation, as remarked by Boeckel," is more delicate,
laborious, and restrained; delicate, because the p.ancreas is
deeply situated and is surrounded by numerous imiiortant
vessels the wounding or ligaturing of which might prove
473
PaiK-roas.
Paii4'r4>as.
REFERENCE HANDBUOK OF THE MEDICAL SCIENCES.
fatal (superior mescntericus) ; and restricted, because
only a small portion of the pancreas can be reniove<l with
safety ami freedom from tlie danger of a fatal diabetes.
Chronic Paxcheatitis. — Altlious'li suppurative pan-
creatitis may run a slow and cluouie course, tlie term
chronic pancreatitis is used to designate a liardcning of
the pancreas, witli enhirgruK'nt or sluiul<ing. Perliaps
the terms liypertropluc cirrliosis and atropliic eirrliosis
would beappro])riate. A part or tlie wliole of the gland
may be involved. Opie " recognizes two varieties. In tlie
interlobular form the intlammatory jirocess is localized
chiefly at the ])eripliery of I he lobule ; in the interaeinar the
|iroeess isdilTuse. involving I he lobules and separating in-
ilividual acini. Of great interest is the relation of chronic
pancreatitis to the islands of Ijangerhaiis and the occur-
rence of diabetes. The islands of Langerhans, as defined
by Opie, are composed of cells having the same origin as
those of glandular acini, but forming structures wliieh
are independent of the secreting apparatus, and in inti-
mate relation with the vessels. In the sjilenic end of the
cat's pancreas they have a (h^tinite position within the
lobule, each of which contains one of those structures.
In the human pancreas lliey are more numerous in the
splenic extremity than el.sewhere. Opie claims that pro-
longed stinudation of the gland does not, as claimed by
Lewasehen, transform groups of acini into islands of
Langerhans.
In the interlobular variety of clironic pancreatitis the
islands of Langerhans do not usually sutler, nor do they
when the infective agents come by way of the ducts with
wliich the}' are not connected. In the intralolndar or in-
teraeinar variety they may atrophy as the result of press-
ure. In this way the presence or absence of sugar in
the urine in di.seases of the pancreas maj' perhai)s be ex-
plained.
KliiiUiijll. — The causes of chronic pancreatitis are not
satisfactorily determined. 'I'hey are probably varied,
rndoubtedly localized indurations may arise from lesions
of the neiglilioring organs, such as ulcer of the stomach
or duodenum. A general involvement of the gland may
result from h.'eiuatogenous infection, from a mild form
of acute pancreatitis, from diseases of the blood-vessels,
or from obliterating enilarteritis. Opie-' reports two
instances of congenital .syphilitic pancreatitis in which the
patients die<l respectively three and four hoursafter birth.
In one of the cases it was believed that the ili.sease repre-
sented an active stage of a chionic intlammatory proc-
ess; in the other the process was more advanced and
was no longer active. The islands of Lati.gerhans were
surrounded by newly formed .stroma, but in neither case
were they invaded liy it.
Clinical experience would seem to indicate that in the
maiority of cases the condition arises from an infection
entering through the duets, secondary to a gastroduode-
nal catarrh and a comjilete or partial stasis of the flow of
the pancreatic secretion. Numerous operating surgeons
have noticed the fre(iuent association of jjaucreatitis with
cholelithiasis. The jiancreatic duct may be completely or
partially obstructed by a gall stcaie or a pancreatic stone ;
the result may lie eitlier a narrowing or an obstrvictive
dilataficm. The enlargement and hardness found at the
operating table have often given rise to a diagnosis of
malignant disease. Alcohol has been thought to be a
cause. The disease sclilom occurs in drunkards, and
when it does it is probably secondary toagastroduodenal
catarrh. It may follow mild traumatism.
PutholMjiral Anittoiinj. — The characteristic picture is
the fibrous thickening of the connective tissue generally
throughout the gland or only in limited areas. The lieail
of tlie inmereas may be much enlarged and of stony hard-
ness. In other instances the gland is diminished in si/e
from contraction of the interstitial tissue. The surface is
sometimes smooth and .sometimes nodular and of a gray
color. There may be an a.ssoeiafed condition of fatty or
<-alcarcous degeneration. The duct of Wirsnng may be
ililated, tortuous, or of normal appearance.
Siiinptoriis. — There are no pathognomonic symptoms of
chronic pancreatitis. Its presence has usually been dis-
covered during operations or in the autopsy room. Dis-
orders of digestion, pyrosis, vonuting, pain and tender-
ness in the epigastrium, constipation or diarrha'a, and
emaciation are tlie symptoms usuallj' present and they
are certainly not dislinefivc. There may or may not be
some elevation of temperature. Icterus may be present
if the common bile duet is pressed ujion. Sugar maj' be
present in the urine. Fat in the stools is rare and lipuria
still more rare. AV'alker has shown "tliat the alisence of
].)ancreatic secretion from the intestine, altliough bile were
juesent in the intestinal canal, led to pale-colored stools."
Mr. Cammidge has found " tliat if the urine of patients suf-
fering from pancreatic disease be boiled for a short time
with an oxidizing agentand then the phenyl hydrazin test
l>erformed, au abunilant crop of delicate \ellow needles
arranged in sheaves and rosettes was produced " (Rob-
son'). A iiistological examination of the blood may
show marked diminution in the number of blood plates.
The presence of a hard, palpable, immovable tumor in
the region of the pancreas would be a very important
symptom.
Pruf/iimiK. — The prognosis is grave. Many patients,
however, known to be the subjects of chronic pancrea-
titis, live for years in good health, and the same remark
is true of patients who have lost a part of their pancreas
through suppuration and necrosis. Experiments upon
animals liarmonize with clinical experience ; some animals
can live with one-tenth of their pancreas. The associa-
ticiu of .s}'])hilis, arterio.selerosis, or obstructive heart le-
sions would render the prognosis less favorable.
Tniitnu'iit. — "Tlie treatment of chriaiic pancreatitis is
by abdominal section and drainage: but in this case the
drainage is indirect and is obtained by draining the gall-
bladder by cholecystotomy, cholecysfenterosfomy, or
duodenocholedochotomy. The exact line of treatment
cannot be determined until the abdomen is opened, and
for this purpose I )irefer, as in all my gall-bladder oper-
ations, a vertical incision through the upper part of the
right i-ectus. s]ililting tfiat muscle to whatever extent is
necessary in order to obtain a good view of the diseased
region, and to affcn-d plenty of room for manipulation.
■' If merely cholecystotomy on a distended gall-bladder
is necessary, au incision of one or two Indies will .suffice;
but if the gall-bladder be contracted or if tlie ducts have
to be attacked, an inei.sion of from four to six inches will
bere(piired ; and if the .several layers of the abdominal wall
are sutured .separately, there is no fear of .subsequent
liernia. This I can atlirm b}- ample experience. It saves
much unnecessary dragging on the parts wdien operating
on the common duct or duodenum to have a free incision,
and there is no retractor eipial to the hand of a skilled
assistant, who with a flat sponge inter])osed between the
spread-out lingers of his left hand and the vi.scera, will
at the same time afford the ojierator a good view of the
field of operation, and with liis right hand help in the
further steps of tfie operation.
" If the right costal margin or the edge of the liver be
obstructing the view, another assistant may with advan-
tage retract it cither by digital manipulation or bj' means
of a wide retractor with a long handle, so that he can
stand back a little and avoid embarrassing the operator.
"As a matter of experience I seldom find a second assist-
ant necessary. A s]ioiige in the pouch to the right of
the common duct, and one iiushed down over the right
kidney, help to catch all escainng fiuids and to keep the
]ieritoneum clean. When the duetsor the duodenum are
opened, sterilized gauze pads are employed to mop up
the fluid as it cscajies, but none of these is allowed to re-
main even temporarily in the abdomen. When there are
gall-stones (U'esent they should be removed, unless the
patienfis tooill to ])eriuit of the complete operation; but
in every case drainage must be secured, if possible by
cholecystotomy, as in nearly all my successful cases.
Moreover, the drainage must not be stopped before the
bile has become healthy, and not before the greater
amount of liile is bein,g passeil by the bowel, which will
be certain to occair as soon as the swollen pancreas has
subsided, if the duct be otherwise clear of obstruction.
-iVi
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
Paiioreas,
Pancreas.
" It might be thought that cholecystenterostomy would
be the ideal operation in these cases, but experience says
that it is not; for instance, in one of my cases the oper-
ation brought .so nuich relief that a cure was being an-
ticipated, yet in the third nioiitli relapse occurred and
death ensued, apparently simply owing to closure of the
new opening between the gall-l)laild(r and duodenum. In
one of Mr. Barling's cases in whicli the gall-bladder was
joined to the duoden\im, he states ' that although the
sym]itoms were relieved, eulargement of the pancreas
persisted. '
" Possibly in some cases the manipulations of the in-
ilurated tumor may have detached calculi impacted in
the pancreatic duct, and thus led to a subsidence of the
pancreatitis, then to an opening of the common duct by
the relief of tension, and so to a cure of the patient. The
simulation of malignant disease of the head of the pan-
creas by chronic interstitiid pancreatitis would make one
hesitate to decline operation in any case of distended
gall-bladder, where the ]iatient is in a condition to bear
it, or even in any case of chronic jaundice without dis-
tention of the gall-bladder, where the geneial strength is
deteriorating as, though it should be recognized that if
the disease be really malignant, very little good will l)e
done, and life may even Ije shortened or only prolonged
for a short time: yet if the disease prove to be chronic
pancreatitis, a real and jierinanent ciu-e may be brought
about. If a calculus be felt emiiedded in the head of the
pancreas or impacted in the pancreatic duct, it may be
reached through the second part of the duodenum by
laying open the papilla and exploring the duct, or by di-
viding the peritoneum passing between the duodenum
and hepatic tle.xure of the colon, and then cutting
through the overlying pancreas on to the concretion. If
the papilla common to the bile and pancreatic ducts be
incised in the duodenum, it does not require suture: and
in the cases in which I have explored the ducts by the
duodenal route there has been no serious hemorrhage.
The anterior duodenal opening only requires closing by
a mucous and serous suture. Drainage of the rightkid-
ney pouch for from twenty-four to forty-eight hours is
advisable, though not always necessary, and this is best
done by a stab wound at the most dependent part.
" The result of treatment in Ibis class of cases has been
most encouraging, as out of twent3'-t\vo cases operateil
on oidy one died tlirectly from the operation, antl in that
case the patient's lite was only very slightly shortened,
since he was reduced to the last stage of exhaustion be-
fore surgical operation was sought. Of those recovering
from operation, with the exception of two who died a
few months later, complete and perfect recovery ensued.
These results contrast very markedly with the surgical
treatment of cancer of the pancreas, where nearly half
of the cases operated on have died direct 1\- as the "result
of the operation, and iu those who have survived life has
only been prolongeil for a comparatively short time."
The above is from Mayo Robson's address before the
American Surgical Association in 1901.
Another very important jioint has been raised by Sir.
Rob.son, and that is the tendency to troublesome hemor-
rhage during operation in cases of chronic pancreatitis,
particularly when associated with jaundice. This was
at one time thought to be due to the chohi^mia. The
suggestion that it is due to the glycerin set free in fat
necrosis is not generally accepted. He has found the ex-
hibition of chloride of calcium most useful as a prophy-
lactic. He administers calcium chloride in thirty- "to
sixty-grain doses, thrice daily, for from twenty-four to
forty -eight hours previous to operation; and by enema
in sixty-grain doses, thrice daily for forty-eight hours
afterward. This he nearly always finds successful in
_^con-ecting the hemorrhagic tendency.
The close association of ]iancreatitis and angiocholitis
is confirmed by Ferguson, of Edinburgh, who ob.served
in cases of death that he could express a few drops of
pus from the duct of Wirsung. It would seeiu that the
indirect drainage of the pancreatic ducts was as rational
and successful as drainage of the bile pasages iu iufective
conditions. Kehr has suggested an anastomosis between
the intestine and the duct of Wirsung. The technique
would be very difflciilt.
Cystic Tu.mous oi-- the Pancre.vs. — Cysts of the pan-
creas are rare; their nature and origin are obscure. It
may be said that probably the majority are retention
cysts. The most common cause is generally thought to
be chronic indurative pancreatitis. The co"nnective tis-
sue in some part of the gland so presses upon or so dis-
torts the excretory duct that the outflow from a part of
the gland is arrested. Senn thinks that in addition there
is an alteration in the character of the secretion whereby
it becomes no longer absorbable. Another cause may be
the obstruction of the duct of Wirsung from pressure of
neighboring organs, as for instance from a stone in the
common bile duct, or from an obstructive swelling of the
duodenvun at the point where the duct enters. A catarrhal
inflammation of the duct of Wirsung may cause obstruc-
tion. A new growth iu the head of the pancreas may
act similarly.
Minier suggests that cystic degeneration may occur in
the jjancreas in much the same way that it does in the
kidney, testicle, and mammary gland. That cysts may
result from hemorrhages into the pancreas is not yet
proven. The frequent finding of blood in the cyst con-
tents has suggested this cause. It is probable that small
hemorrhages may be entirely absorbed, leaving onlj' a pig-
mented stain (Orth). On the other hand, it is quite prob-
able that hemorrhages may occur into cystic tumors, and
it is generally thought that most bloody cystic tumors of
the pancreas are in origin retention cysts. Trauma is also
assigned as a cause. Cysts are more frequent in the tail
than in the body or head of the pancreas. In an analysis
of 134 cases Osier" found in 90 cases that the situation
was not given; in 14 that the whole pancreas was in-
volved; in l.i the tail; in 11 the head; in 4 the body.
Koerte" states tliat of 1'21 cases operated upon by sur-
geons, 60 were in males and .56 in females ; in 5 the sex
was iK)t given. Sixty-six of the cases occurred in the
fourth decade.
There may be multiple cysts. This should be borne
in mind when considering the prognosis and possibility
of recurrence. Pancreatic cysts vary greatly in size.
Those found in autopsy rooms are usually couqiaratively
small. Surgeons report, however, that .some of the cysts
contain from 1 to 20 litres. The tluid is generally of a
light-brown coffee or reddish-brown color, seldom clear
(Osier). Gussenbauer found in tlie fluid altered red and
white blood cells and pigment. Fresh blood has also
been found. The chemical reaction as a rule is alkaline,
but may be neutral or acid, with a specific gravity of
1.007-1. "028.
The lining of the cyst wall may be smooth or saccu-
lated; it is generally surrounded by blood-vessels. In
developing the cyst may assume veiy variable relations
to adjacent organs, particularly the liver, stomach, and
transverse colon. It may lie behind and push forward
the stomach; it may project between the .stomach and
liver; it may appear between the stomach and transverse
colon, or lie behind the colon. The displacement of these
organs is sometimes very great. In one instance the
transverse colon was pushed down behind the symphysis
pubis. Besides tlie displacement and dragging of "the
viscera mentioned, other serious cotuplications may arise
from the pressure of the tumor. The common bile duct
may be so pressed upon that jaundice results. Pressure
may cause obstruction of the duodenum or ureter, and
cases are reported of pressure resulting in ascites.
There are no symptoms which can be called character-
istic of cystic tmiior of the pancreas so long as it remains
small and not palpal)Ic. .\s might be expected, from
what is known of its etiology, there is generally a history
of indigestion, of indiscretion in eating and ilriiiking, imd
occasionally of trauma. Pain in the epigastric region is
common, its severity depending on the situation of the
tumor and its rate of growth. There may be nausea and
vomiting. The vomitus may contain blood if it occurs
subsequently to rupture of a cyst into (he stomach. If
-tT5
Pancreas.
Pancreas.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
rupture into the intestine occurs, blood may appear in the
stools. There is sometimes very great aurl rapid loss of
weight. Pancreatic salivation (increased How of saliva)
is rare. Sugar in tlie urine would indicate very extensive
Fig. 3733.— Showinsr thp Appearances wlijch were Presented, in a
Case of Larf^e I*aniTeatir Cvst. when the .\lKl'iinen was (Opened and
its Contents Freely Exposed to View. Tlie evst. in its growth, hail
forced its way forward between the stomach and the colon, and was
putting the ligamentum gastrocolicum upon the stretch. (After
H. Kehr.)
cirrhosis of the jrland. Fat in the stools is seldom found.
Icterus may result from pressure. The development of
a palpable tumor is the most suggestive symptom. The
discovery of ferments in the sac contents is noted.
JJiar/iu/sis. — Clearly a cyst of the pancrtas can be rec-
ognized only after it has reached a size that can be pal-
pated. A palpable cyst is the most easily diagnosed of
all the diseases of this deeply situated gland. The pres-
ence of a fixed fluctuating tumor in the median line
above or below the umbilicus should certainly suggest
pauci'eatic cyst.
The tirst fact to be clearly established is the relation
of the tumor to the adjoining viscera, especially to the
stomach, colon, and intestines. The inflation of the
stomach and colon with air or gas will give great assis-
tance in the determination of tlus relationship. If the
cyst has passed forward between the stomach and colon,
pushing before it the gastrocolic omentiun. a clear per-
cussion note should be heard aliove and below the tumor
if it is a large one ; and if it is small, the distended stomach
and colon may meet togetber in front of it. If tlie tumor
projects forward below the liver and above the stomach,
the dull pei'cu.ssion note of the liver may be continuous
with that of the tumcir. The dittieultj' of dilTereniiating
a pancreatic cyst thus placeil from a distended g;ill-ljlad-
der or an echiuoeoceus cyst, or other fluid collection
couueeted with tlie liver, wnuld be very great, and prob-
ably could be accomplished only liy examination of the
contents removed by a Pravaz syringe. Possibly bj' ex-
amining the patient in the erect position, a lineof tym-
pany could be found between the liver and cyst. A
pancreatic cyst would not move during inspiration or
expiration.
If the tumor projected forward below the colon, the
dull note of the tumor should be easily elicited between
the lyiupauy of the colon above and tliat of the small in-
testines below.
It may grow Ijehind and push forward the stomach,
or it may pass forward between the layers of the meso-
colon, in which case tlie stomach or colon would lie im-
mediately in fi-ont of the tumor. When so situated it is
generally possible, after inflation, to establish the mobility
and freedom of the stomach or colon from involvement
in the body of the tumor.
The dilferential diagnosis between a cystic tumor of
tlie pancreas and a solid tumor of the spleen should not
be difficult. To differentiate a C3'St spi'inging from the
tail of the pancreas from an echinocoecus cyst of the
spleen — the only cystic growth involving the spleen —
may be very difficult, and perhaps impossible except by
an e.Namiuation of the cyst contents.
Great difficulty may be found in differentiating between
a pancreatic cyst and hydronephrosis. In hydronephri>-
sis the bulging is generally in the lumbar region. There
maj' also be a history of renal colic, of tlie passage of a
renal calculus or bhiod, or other urinary derangement.
An examination of the urine ma}' throw light on the
case. A cystoscopic examination of the bladder might
show that no urine was entering from that side.
From large ovarian cysts the history should show that
the growth began low down aad laterally. Cysts of the
mesentery are movable. Aneurisms of the aorta or its
branches are pulsating and expansile.
The asiuration of cysts for diagnostic purposes is a
questionable procedure. There is always a danger of
puncturing a flattened-out overlying viscus, of wound-
ing some abnormally placed vessel — and the walls of a
pancreatic cj'St are sometimes very vascular, — or of per-
mitting the escape of infective contents, — as, for instance,
hdoklets in the case of echinocoecus cysts, — or of patho-
genic organisms. An exploratory incision is now so safe
that it is to be recommended as an almost universal rule
in place of puncture. When the fluid is obtained, its ex-
amination may be far from satisfactory. The ferments
may be present, but diastatio and fat-emulsifying fer-
ments occur in various other exudates. The only posi-
tive sign would be the presence of the ferment which
digests fibrin and albumin, and it is often absent. The
presence of blood would be verj' suggestive. It occurs,
however, in ovarian cj'sts with a twisted pedicle. Kils-
ter thinks the [u-esence of fat globules is characteristic of
Fig. 3733.— Shows the lielations which the Pancreatic Cyst Bears to
the Neighboring Organs in the Majority of Cases. (From Kelir.) a.
Liver ; />, stomach ; c, transverse colon : rf, pancreatic cyst.
pancreatic cyst. "A remarkable feature often noticed
hits been the transitory disappearance of the cyst. In
Halsted's case the girth of tlie abdomen decreased from
47(5
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Pauoroas*
Paucroas,
forty-three to thirty-one inches in ten days, with profuse
diarrhoea. Sometimes the disappearance has followed
blows" (Osier).
Prorjnosis. — The rapidity of the growth of paucrt-atic
cysts is ditiicult to ascertain, because the date of their
commencement can seldom be determined. They are
,.. li
Fig. 3731.— Shows the Ri-hiijon> v,hi.-h the Pancreatic Cyst Bears to
the Neighboring Organs m u .suiuller Group of Cases. (From Kehr.)
a. Liver ; b, stomach ; c, transverse colon ; d, pancreatic cyst.
probabl_v of slow growth as a rule. When following
trauma or acute inflammator\' processes, however, they
may develop into palpable tumors in two or three weeks.
Their duration is also uncertain; instances of their being
present for thirty or forty years are reported. Tliey
sometimes rupture spontaneousl}' into the stomacli or in-
testine, as evidenced by the vomiting, or passage by rec-
tum, of a quantity of bloody fiuid. Their occasional dis-
appearance and reappearance may possibly be explained
by the assumption that in this way they periodically
empty themselves into the stomach or intestine. Echi-
nococcus cyst of the spleen is very rare. One case is
reported by Heller. Rupture of a pancreatic cyst may
occur into the peritoneal cavity.
Treatment. — .Medical treatment is useless. Preventive
treatment can influence onl_v the most common cause of
cyst development, viz., chionic indurative pancreatitis.
The surgical methods which have been adopted are.
puncture, application of caustics to the cystic cavity,
emptying of the cyst and stitching of the cyst wall to
the abdominal incision at one or two operations, opening
and drainage of the cyst through a lumbar incision, and
excision of the cyst wall, partially or wholly.
Puncture of the sac is to be condemned for the reasons
given in the paragrapli on diagnosis, and because it is
insufiicient.
The application of caustic to tlic interior of the sac
wall in the case reported proved fatal.
The method which has been einployed in the greatest
number of cases is that tirst adopted by Gussenbauer,
viz., the opening and emptying of the sac followed by
immediate suture to the edges of the abdominal incision
and drainage by means of gauze or drainage tube, or
both. The incision is best made over the most prominent
part of the tumor. The cyst wall should be very care-
fully uncovered, as far as possible, by blunt dissection.
Great care should be exercised in the ligature of overly-
ing vessels, that none e.ssential to the blood supply of
the colon are interfered with. The wall of the sac is
sometimes very thin and must be handled gently.
After carefuUj' protecting the peritoneum by the place-
ment of sterile gauze pads, the cj'st may be incised or
punctured with a trocar having a tube attached to con-
vey the fluid into a receptacle. After the cyst wall is
stitched to the abdominal incision the cavity shouU: be
packed with strips of plain sterilized gauze; iodoform
gauze is to be avoided, as there is a possibility of iodo-
lorm intoxication. The fluid that escapes tends to irri-
tate and digest the skin. This should be prevented by a
liberal use 'of zinc ointment. Boeckel" reports ninety-
nine cases treated by this method, with ninety-two re-
coveries and seven deaths.
The subsequent history of these cases in some respects
is satisfactory. The nvitrition improves wonderfully and
quickly, although pancreatic juice may continue to flow
from tiie wotmd. There is sometimes great difficulty in
getting the tistula to close. If it does not close in live or
six weeks it may remain open for years. When the open-
ing persists, closure may be efl!ected by the application of
nitrate of silver or chloride of zinc.
The above method carried out in two stages has not
been adopted in as many cases, but the results have been
very good. Boeckel " reports sixteen cases and sixteen
cures.
Drainage through a lumbar incision is indicated only in
those cases in which the cyst lies far back in the hiiu. An
anterior exploratory incision may show this to be the
best route by which to approach the tumor.
Complete excision of the sac wall, while perhaps the
ideal method, is possible only when the sac wall is well
Fig. 3Ta5.— Reiiresenls a Ca.-c in wlii<-h the Pancreatic Cyst has
Developed between the Lanunaj of the Mesocolon, coming Forward
between the Transverse Cohm and the Small Intestines. (From
Kehr.) a. Liver ; h, stomach ; f. transverse colon ; d, pancreatic
cyst.
<let3ned and not too closely united by adhesions to the
neighboring organs. If the cyst is pedunculated, its
total extii-pation might be indicated. The difficulty
arises in dealing witii the adhesions, the blood vessels,
and the point of origin from the pancreas. The vessels
are generally numerous and large. Another great diffl-
-177
Paiioreas.
Paucreatiu.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
culty is to avoid iujuring or tearing vessels essential to
tlie nourisliment of the colon. Koerte has colleeted 21
cases with 6 deaths. In 7 cases the dillieulties were so
great that the operation could not be completed ; of these,
4 died. BoecUel reports 23 cases of total or partial ex-
cision, with 21 cured and 4 deaths. If the sac is excised,
the space from which it lias lieen removed slioidd lie
packed with gauze and drained through the abdondual
Fig. 3736.— Shows the Cyst Developed Between the Lamina; of the
Transverse Mesocolon. The colon lies directly in front of the cvst.
(From Kehr.l a. Liver: /», stomach: c, transverse colon : (/, jiau-
creatic cyst.
incision, or through a stab wound in the loin. It may
be said that excision should be undertaken in favoi'alile
cases only, when adhesions are absent or ai'e easily sep-
arated bj' blunt dissection, and when the blood-vessels
involved in the sac wall ai'e small and unimportant. It
is certainly a much moie gniveopeiation than the simple
incision and di'ainage of the sac.
TuMOUS OF THE P.VNCREAS. — Tubercle, gumma, lym-
phoma, and s;ii'ccima may 0''cur in the ]iaiici'eas. but they
are veiT rare. Primary eiireinoma of the jiancrcas is
stated by AVilligk and Lebei't to occur in about .si-\ per
cent, of all cases. It is moi'c fi-equenlly found in the
head than in the tail or body of the ghind. The most
common vai'iety is scirrlius.
The si/mptoiiis ai'e at lirst exceedingly indelinite.
Later, fatty diarrhcra and vomiling occur, with tender-
ness on pressuie over the gland, .laumlice is an e:u'ly
symplom, and is nioi-e ])ei'sistent and less vaiiable fi'om
day to (hiy than when due to stone. The stools are ])ei'-
sistently c!;ty -colored. In obstrui'tinn fi-om stone the
color may vaiy. Diabetes is selilnm jncsent. An im-
portant diagnostic point, accoi-ding to CourvoisicT and
Ecklin, is the condition of the gall-hladilcr. In slone
the gall-bUidder is usually .small and shiiinken, while in
carcinoma it may be vei'y much distended and jialpable
as a tumor. When stone and caiciiiom:i exist together
the dillieulties in diagnosis ai'e veiy great. An examina-
tion under an ana'stlietic should be of gi-eat a.ssistance.
Emaciiition is rapid and extreme. A palpable tumor is
seldom found imtil the disease and its attendant emaci-
ation are well ;«ivanced. The examination of the stom-
ach contents, together with the comjiai'iitively good
functionating power of that organ, should enable one to
exclude carcinoma of the stomach. The tumor some-
times becomes adherent to the stomach, and in some cases
the disease has perforated the stomach wall. Ha'matem-
esis might give evidence of this complication.
Treatment. — The treatment of carcinoma is most diffi-
cult and unsatisfactory. In the primai'y coui'sc of the
disease the diagnosis is wcllnigh impossible. If the dis
ease is localized in the tail, its lemoval may in favorable
cases be feasible; but extirpation of the whole gland,
even if the patient recovei'ed from the operation, would
be followed by a fatal diabetes. Extirpation of the head
of the gland jiresents technical difticulties that are almost
insurmountable. Thei'c is the danger of iujui'ing the
vessels necessaiy for the nourishment of the colon, duo-
denum, and spleen; and if both of the panci'eatic ducts
ai'e tied, diabetes and atriipli_y of the remaining gland tis-
svie follow. There is also the difficulty of dealing with
the common bile duet. Cholecystotoniy may give relief
fiom the icterus; and if there is gi'eat pressure on the
duodenum, a gastro-enterostomy woidd relieve the ob-
structive symptoms, vomiting and inanition. Koerte re-
ports ten cases of opei'ation on solid tunioi'S of the pan-
creas with si.x recoveries.
P.\NcuE.\Tic C.^LCfLi. — Pancrcatlc calculi maj' be
single or innltiiile. They are composed of carbonate of
lime and phosphates. In shape they may be round,
oval, or angular, and in color an 0]ia([ue white. Osier
states that in one thousand autopsies at the Johns Hop-
kins Hospital there were two cases. In 1885 Johnston
Collected thirty-live cases in the literature. They had
been found in the pancreatic ducts and in pancreatic
cysts and abscesses.
As to their ctiolor/t/ but little is known. They may
result from inspissatiou of the secretion or from an ob-
struction in the ducts, or be liue to some imdetermined
action of bactei'ia, Proliably, as in the liver, both slow-
ing or obstruction in the outflow of the secretion and
bacterial infection are etiological factoi-s.
The i-esults arc found in the gland itself. They are:
intlammatoiy indurations, cyst and ab.scess formation, a
piedisposition to the development of malignant disease,
:ind obstruction to the common bile duct from pressure
upon, or the blocking of, the ampulla of Vater at the
duodenal opening.
A detinite (/ini/nosis is seldom possible. The pain
could niit be dilferentiated fi'om gall-stone colic. Pain
in the left hypochoudrium is thought to be suggestive
of pancreatic calculus. Pain, vomiting, fattj' stools,
diabetes, and the passage of carbonate of lime stones
would I'cuder the diagnosis probable. Carbonate of lime
calculi, however, ai'e sometimes formed in the intestines.
A stone might be removed from a cyst or abscess or
from a dilated duct. If jaundice is present and the ob-
struction cannot be found and removed, cholecystotomy
would be indicate d. George E. Armatrung.
References.
' Murris: Human .\natoniy, 1S99.
- Bl'pwer : Transartiitiis .\i[it'i-ii-:tn Surtrical Assn., 1901.
3 Opie: The AniiTiraii .lourn. "f tin- Med. Si-i„ Januiiry, 1901,
* Kelir: Handluirh di-i' praktlNcht'n Cliirurgie, vol. ill., .572.
& Robson : Trans. .\nu'r. Surg. Assn., ItlOl.
^ Draper: Trans. Assn. of Amer. Physicians, 1886.
' Fitz: .\llhutt's .System of Medicine, vol. iv.
8 Prince : Boston Med. and Suilt. Journ., vol. cvii., p. 5.5.
• Tieken: American Mcduinc Novcmlier 23d, 1901, p. 826.
'» Eckcr: Henle n. PfeiilTri's Ztitschrift fur rat. Med., 1802, xiv.
" Aulierg: guotpd by (;cniTiscli.
1- Symington : Joiirn. of .Vnatotiiy and Pliysiology, 188.5, xi.x.
^3 Generisch : Intf-niational Medical Congress. 1891. ii.
" User: Notliiiagefs Si.eci. '11. •Patliolngii-undTherapie.rtii., 2,1898.
1^ Brewer: Trans, .\nier. Su^L^ Assn.. I'.Hll, p. 172.
"* Flexner: riti\ersitv Medical Magazine, vol, xiii., p. 780.
1' Katz and Winkler: gnoted by Flexuer.
"*Cammidge: Qunteil bv Robson.
'» tlsler: Practice of Medicine, 1898.
■° Ohiari : Handbuclider praktischen Chirurgie, 1900, vol. iii..p.370.
-' Dieckhoff; NothnagcPs Specielle Pathologic uud Therapie, viii.,
2. 1898.
23 Bloodgood: Progn-ssive Medicine. December. 1901.
23 Kelir : Handbncii dec praklisrhen clni urgte.
-* Koerte: An-liiv fiir Miniscbe chirur';!.'. l!d. xlviii.. 1894.
■" liaeckel : lleviie de I liiiuigie, September 10th. 19(Kl.
2'' lipie: Jonrn. of F.xper. Med., January, 1901.
2' Koerte : Quoted by osier.
478
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Panrri'RM.
PaiK-reutin.
PANCREATIN. — Pancreatinum. "A mixture of the
enzymes natuiuUy existing in the pancreas of warm-
blooded animals, usually obtained from tiie fresh pan-
creas of the hog (Sus scrofa Linne; class, Mammalia;
order, Pachj'dermata). A .yellowisli, yellowish-wliite, or
grayish amorplious powder, odorless, or having a faint,
peculiar, not unpleasant odor, and a somewhat meat-like
taste.
"Slowly and almost completely soluble in water, in-
soluble in alcohol.
"Pancreatin digests albuminoids, and converts starch
into sugar; prolonged contact with mineral acids renders
it inert.
" If there be added to 100 c.c. of tepid water contained
in a Hask, 0.28 gm. of pancreatin and 1.5 gm. of sodium
bicarbonati', and afterward 400 c.c. of fresh cow's milk
previously heated to 38° C. (100.4° F.), and if tliis mix-
ture be maintained at the same tempeiature for thirty
minutes, the milk should be so completely peptonized
that if a small portion of it be transferred to a test tube
and mixed with some nitric acid, no coagulation sliould
occur.
"Peptonized milk, prepared in the manner just de-
scribed, or even when the process is allowed to go on to
the development of a very distinct bitter flavor, should
not have an odor suggestive of rancidity."
The pancreas contains four distinct enzymes which arc
known by their action : the proteolytic — trypsin ; the
diastasic — amylopsin ordiasta.se; the milk-curdling; and
the fat-.splitting. No one of these ferments has been iso-
lated. The proteolytic enzyme converts prnteids with
equal or greater facility than jtcpsin, but it differs from
pepsin in respect to the media iu which it exerts ils
activity, and also in respect to the final products of its
action. Trypsin bears no relation to an alkaline medium
which corresponds to the dependence of pepsin upon
acid; it acts with equal facility in a neutral or a faintly
alkaline medium. Alkalies, more particidarly sodium
carbonate or bicarbonate, up to one percent, of the di-
gesting mass, are gemrally stated to be most favorable
to the action of trypsin; the writi'r, however, has not
found in digestion in vitro that sodium bicarbonate in
0.1 per cent, to 1 per cent, has given better results than
parallel tests in wluch the alkali was omitted, while more
than traces of free alkali were found unfavorable. Tryp-
sin in antiseptic solutions (with thymol) containing as
small an amovmtasO.l percent. anhy<lrous sodium car-
bonate, has been found to undergo rapid deterioration
at ordinary room temperature. While the pancreas juice
obtained from living animals is alkaline, the pancreas
gland, as soon as it may be conveniently treated upon
removal from the recently killed animal, will be found to
give an acid reaction. A(|ueous infusions, glycerin or
hydro-alcoholic extract, from such gland are invariably
acid to litmus, and the acid jiresent in thc.'se solutions
does not in the slightest ilfgree interfere with the pan-
creas enzymes in vitro; tliis acidity is reasonably to be
attributed to nucleic acid, and imdoubledly the proteid
is bound u]) in the cell with acid. The ash is invariably
acid, containing phosphoric acid and potash, presumably
acid phosphate. Minute percentages of mineral (0.03
per cent. HCl) and organic (0.25 per cent, acetic) acids
do not interfere with the action of trypsin, but have been
observed slightly to enhance it. Furthermore, the latent
mother ferment, trypsinogen, is developed by the influ-
ence of the acid constituents of tlie gastric juice, and
probably likewise of foodstuffs, for in the treatment of
the gland itself it is found that the addition of minute
amounts of organic acids yields the ferment in an active
form from the trypsinogen. Trypsin, liowever, is vi ly
sensitive to more than traces of free mineral acid, 0.1 per
cent, to 0.15 percent. HCl destroj'ing it immediately, and
subsequent neutralization failing to revive it. So far,
therefore, as may be gathered from these facts there is no
evidence in support of the impression which has gained so
much credence — that pancreatin depends upon an alkali
for activity or in any way bears such a relalion to an
alkali as pepsin does to acid.
Trypsin converts native proteids into soluble and dif-
fusible forms of albumo.ses and peptones which differ in
no known way from those derived from peptic action, and
causes by prolonged digestion a further cleavage of these
proteids into simpler nitrogenous bodies — the amido-acida,
leucin, tyrosin, etc., and hexone bases, ammonia, etc.
Recent researches have led to the opinion that the devel-
opment of these proteids into these crystalline bodies is
essential to their complete utilization in nutrition.
Trypsin exhibits a special alhnity for the digestion of
certain native forms of proteids — fibrin, muscular tissue,
bolh raw and cooked; these are promptly digested by
the trypsin, whereas its action upon coagulated egg al-
bumen is very slow in comparison with that of pepsin.
The products of peptic digestion (those intermediary
between raw proteid and true peptone, syntouin ami al-
Inunoses) are likewise, after neutralization, quickly con-
verted into peptone by trypsin. I^apidity of action
seems to be tlie natural function of trypsin. It exhibits
a peculiar afllnity for the casein of milk, as natively ex-
isting in milk, peptonizing this proteid with great celer-
ity without the intervention of an alkali.
Certain difl'erences in the physical jihenomena observed
in tryptic and peptic digestion have led some to suppose
that trypsin exerts a peculiar erosive action. The swell-
ing of ti.ssue, the gelatinous cliaracter which fibrin almost
instantly assumes under pejjsin acid digestion, is not to
be accounted for by any jieculiar action of the pepsin
itself; it is due to the influence of the hydrochloric acid
which combines with raw proteins to form sj'utonin —
this being very penetrable by the enzyme. In tact, one
is struck with the similarity in adaiitaticm to digestion,
between gelatinous starch and this swollen, gelatinous
fibrin. Boiled albumen presents no visible difference in
its digestion with trypsin or with pepsin, for the acid does
not swell the coagulated allnimen. Tryjisin (like pepsin)
acts only by effecting the solution of the surface exposed
— by conversion into more soluble forms.
A peculiar eft'ect of trvjisin upon milk is the conver-
sion of casein into a form which becomes coagulabie at
the boiling point. This partially peptonized casein has
been termed "metacasein," wliich, upon more complete
conversion, loses its coagtilability. This behavior of
milk lias been suggested (Hoberts) as aconvenient means
of testing the activity of pancreatin, simply by ascer-
taining luider certain conditions the time at which this
"onset" point of conversion occurs. This is an extremely
interesting reaction, and significant of the peculiar nature
of casein, which, unlike other forms of native proteid, is
not coagulabie by heat, probably owing to its peculiar
combination with inorgauicconstituents, losing this char-
acterLstic, after a certain amount of digestion and again
becoming nou-coagulable like other peptonized proteids.
By rendering milk slightly alkaline by tlie adililion of
sodium bicarbonate or potassium bicarbonate, this meta-
casein reaction is prevented, and the nulk then at any
]ieriod of peiitonizafion may be heated to the boiling
point without curdling.
The starch-converting ferment of pancreatin, connuonly
known both as amylopsin and as diastase, very rapidly
liquefies starch paste, converting starch into maltose.
]{aw or uncooked starch is sinnlarly converted, though
less rapidly, the action being proportionate lo thedifiu-
sion of the starch, to the surface presented to the diges-
tive ferment, completely cooked gelatinous sl.'iich being
with great I'acilily brought into eonii>leti' contact.
The products of pancreas digestion of starch are ap-
parently identical with those of diastase from other
sources — the achroo-dextrins, dextrins, and maltose.
Amylopsin is extremely su.sceptible to the influence of
chemical reagents. Its action is not enlianced in the
slightest degree in alkaline media; indeed, it is greally
enfeebled by free alkali; it is also weakened by acids
(mineral and organic) beyond a very slight percentage.
Acids which tend to ]u-oniote the development of trypsin
exhibit no corresponding behavior on amylopsin. In
vitro, in neutral media, or as found in its nornsal assoeia
tion with the acids of the pancreas gland or iu extracts or
479
l*a 114- real ill.
Pa|>ai%' Juice.
liEFERENC'E IlANnBOOK OF THE MEDICAL SCIENCES.
infusions therefrom, anij'lopsin exerts enorniovis energy
in the conversion of starcli. It nodoulitexistsprefornied
in tile pancreas gland, and there is ground for llie belief
that it differs in its constitution from the jiroteolytic
enzymes.
The fat-splitting and emulsifying agent of pancreatin
(steapsin" or lipase) is the most delicate of the enzymes;
it is rapidly destroyed liy all acids, except the fatty, and
hy strong alcohol. Steapsin rapidly liberates the fatty
acids, and this can be very readily observed by the addi-
tion of a few drops of a neutral solution of pancreatin to
a neutral solution of butter in ether, to which a little
litmus has been added. The natiu-e of the ferment, its
suseciitibility, and the so far insuperable diliiculty of
separating it in any degree from the other ferments of
the gianct, complica'te its study and have precluded the
estaiilishmcnt of accurate, conclusive data concerning it.
The coagulating ferment behaves in a manner similar
to that of the rennet. When added in a sutlicieiit quan-
tity to pure milk at a temperature of 100' F., the charac-
tei'isticmilkciu'd is almost instantly formed. This casein
curd, however, is not permanent, and cannot be sepa-
rated so freely as that obtained by the action of rennet;
if the milk be" maintained at an ordinary temperature the
trypsin will rapidly attack the casein, and by stirring
the mass, solution can be readily effected.
The milk-curdling ferment often escapes detection ow-
ing to thi- rapid pepti>nizing action of trypsin upon the
casein.
Althougli pancreatin is ollicially defined as "a mixture
of the enzymes naturally existing in the jianercas," no
official test is given for other than the proteolytic fer-
ment, and tills is determined by its action on milk under
conditions which are ap|iroxiinate to those common]}-
employed in the preparation of peptonized milk. The
provision against the development of rancidity in pep-
tonized milk is especially important, for pancreatin,
which produces this result, is distinctly objectionable, —
it yields a milk which is unlit for food, especially for the
sick.
The term '"pancreatine" in the past has been apjilied
to indefinite preparations of the pancreas and more often
idriit.ified witli the emulsifying ferment — the function of
the gland which was first oliserved and thought to lie
its chief and important characteristic. The official adoji-
tion of this title, however, now makes it applicable onl_y
to a product which contains all the pancreas enzymes.
Thisof course is in distinct opposition to scientific nomen-
clature of the enzymes, for the term might best be applied
to some one jiarticular ferment, in conformity with the
use of pejisin for the jirotcolytic ferment of the stomach.
"Pancreatine" was originally applied to the starch-
converting agent of the pancreas .iuice by Bouchardat
and Saudras, to the ferment obtained by them from infu-
sion of pancreas with water and prccipitateil with alcohol.
Tiie pancreatic enzymes, certainly the proteolytic,
amylolytic, and curdling, are freely soluble in water, and
are readily extracted from the gland by infusion, by di-
lute glycerin, by hydro-alcoholic menstrua. It is not
possible, however, "to iirepare a liquid extract of the
gland which will retain for any lengthy period all the
several, chief enzymic propertiesof the jiancreas. AVhat-
evcr the reaction of the mingled ferment solution may
be whether due to the fresh gland acid constituents or
to added acid or alkali, the diastase especially loses its
activity. This will cither be due to unfavorable reaction
or to the influence of the tiyiisin, should the conditions
be favorable for its action. The |iancreatic liquors (orig-
inally suggested by Roberts) have not been found by
any means so etfective and agreeable and convenient for
general purposes, especially for the peptonization of
food, as the extract in a dry form. The activity of pan-
creatin, whether in a dry or a lii(uid form, simple or in
combination with other agents, is rearlily tested by ap-
plying it to the digestion of proteids in an alkaline medium
(a procedure which dilTerentiates tryplic action from that
of iicpsiii) ; and its ctTcct upon sttircli may be tested by the
Very simple method which establishes the presence of di-
astase,— by itsaction on starch mucilage at 100" F. The
proteolytic ferment may be tested upon fibrin or milk,
using the United States Pliarmacopa-ia test. Negative re-
action in any respect with these tests is absolute evidence of
the absence of the ferment which is thus to be indicated.
Pancreatin is so susceptible to change and enfeeble-
ment that it should not be prescribed in solution with
soluble chemical agents — mineral acids or alkalies. Pep-
.sin-acid solutions are partic-ularly incompatible with pan-
creatin; even that degree of aiid which is suitable for the
jire.servation of the pep.sin weakens the activity of the pan-
creatin, and this is increased by the inlluence of the pepsin,
under the commercial conditions to which a pharmaceu-
tical product must be submitted, and for which it must be
suitable by a reasonable degree of permanency. Alkaline
agents are indi(-atcd and freely prescribed with pancre-
atin, and this is best accomplished in dry mixtures — tab-
lets, capsules, powders, etc. While in certain conditions,
for instance, in the peptonizing process, the salts of the
alkalies (sodium bicarbonate, etc.)fulfil auseful purpose,
alkaline solutions of pancreatin do not retain their activ-
ity at ordinary temperature; they arc suitable only for
immediate use.
The liquiil preparations of the pancreas gland, there-
fore, should as a rule be prescribed alone, separate from
the remedies to be used in association. In the dry form,
however, complete freedom of combination of any rem-
edy indicated is afforded, for tlie dry enzymes are very
stable.
The wliole relation of the enzymes of the different
digestive glands mixed in artificial solutions may perhaps
best be summed up liy this fact: that the ferment for
which the reaction of the solution is most favorable will
exert an injurious action upon the other enzymes; in
other words, the actire cnzyme-proteid will convert the
other enzyme-proteids which are in the unfavorable envi-
ronment.
Therefore, from a pharmaceutical standpoint, we have
to keep strictly to the ascertainment of conditions which
are favorable to the extraction and production of these
enzymes in a form of reasonable stability, and to the
avoidance of incompatibles, these being simply agents
wiiich are positively known to injure the ferment in
vitro; and to the adoption of certain definite standards
of activity, and the development of pro|icr methods for
utilizing their digestive properties either in laboratory
operations or in the artificial digestion of peptonized
food for the sick. It must be ever considered that these
data do not by any means offer a clear picture of, or
arbitrary conclusion as to, the relation of the enzymes in
the whole digestive scheme, where the enzymes in natu-
ral association are mingled under exceedingly complex
conditions; finst as to the influence of the constituents of
the juices on the several enzymes thereof; secondly as to
the influence of each secretion in its entirety upon the
other, and as to the influence of the food constituents in
their native form and as converted by gradual and suc-
cessive digestive changes.
The study of the enzymes in vitro and of tlie entire
digestive secretions warrants the conclusion that the fer-
ments bear a dill'erent relation to. and influence upon,
each other when mixed together simply with water and
with reactions obtained by acids or alkalies, than they do
in their physiological interaction. For instance, pancre-
atin will continue to act in an alkaline medium in the pres-
ence of food, and pepsin will continue to act for a long
time in the presence of acid albumin, while aqueous solu-
tions of these ferments of the samedegree respectively of
alkalinity and acidity liy simple exposure to ordinary
conditions of temiierature are rapidly deteriorated.
Pawlow, after his recent elaborate and original stud-
ies of the digestive secretions, calls especial attention to
the importance of his experiments concerning the "in-
teraction of the digestive juices." lie says: "Hence the
chemical a.gencies of digestion form an alliance of a
complicated nature in which the individual members are
linked together mutually to relieve and sujiport each
other"; and he insists that it is indispensable in physio-
4SU
REFEKE^X•E HANDBOOK OF THE MEDICAL SCIENCES.
Pauerealin.
Papaw JuU'C.
logical inquiry to bring into view the " whole train of
normal occurrences " ; that '" to constantly remember that
all Jiarts of the organism work together sheds a bright
light over the special field under review."
Ko official method is given for pancreatin. It is com-
monly obtained by mechanical and chemical means — by
the precipitation of an infusion, or a mixture of the pan-
creas gland with water freed as much as possible from
the fat ami connective tissue by mechanical means, tliLs
mixed with alcohol in excess, and the precipitate col-
lected, expressed, and dried. Pancreatin is also prepared
from the animal jiaucreas by freeing the gland in so far
as possible from connective tissue and fat by careful trim-
ming, reducing to pulp, passing through a sieve, desic-
cating and powdering, and further jmritying by extrac-
tion with suitable solvents of fat. coloring matter, etc.
A liquid diastasic extract of the gland may be obtained
b}' treating the pancreas as soon as possible after removal
from the animal, the gland meanwhile kept refrigerated,
in which state the trypsinogen remains unchanged ; rapid
extraction and clarification yield the amylopsin in an
exceedinglj' active form, and by repeated filtration an
agreeable, efBcient pharmaceutical product is finallj- ob-
tained.
Pancreatin as a remedy in intestinal indigestion is usu-
ally administered iu two- to five-grain doses, about three
and a half hours after meals and at bedtime, iu capsules
or tablet form. It is also given with soda bicarbonate
(ten grains) an hour or so before breakfast or at bedtime,
taken in a glassful of water as hot as can be convenient!}'
sipped, say, 115°-130' F., this particularly in catarrhal
conditions and in biliousness. Pancreatic extract with
oxgall, ipecac, and bismuth has gained repute in disor-
ders of intestinal digestion. The elixir or essence of amj-1-
opsin is much used as a remedy in salivary or intestinal
indigestion; in the former case it is given immediately
before food, or mixed at table with farinaceous food.
Inasmuch as tlie full pitch of gastric acidity does not ap-
pear until about half an hour after eating, this diastase
certainly has the same ph3-siological conditions for its
activityas that normally mingled with the food in the
saliva. The diastasic essence is given at the completion
of stomach digestion to promote intestinal starch diges-
tion.
In the artificial reinforcement by pancreatic ferments,
the essential consideration is obviously to protect them
from action ill (/astro ; and clinical experience, with the
various expedients used, has shown that the pancreatic
ferments exert distinctly beneficial action.
The pancreatic ferments are peculiarly and happily
fitted for the preparation of partially or completely di-
gested foods for the sick; under their influence and by
very simple means and methods, the chief and complete
foods of almost every variety are readily peptonized in the
household. These foods may be so prepared as to con-
vey the ferments in an active form, thus promoting fur-
ther digestion, or the digestive agent may be destroyed
at any desired stage by raising the temperature of the food
to 160° F., or, more simplj', to the boiling point.
Special products and devices, such as peptonizing
tubes, are much used ; milk, either cold or bj- the warm
process, is thus adapted to the varying requirements.
The peptonized milk gruel deserves more extensive use,
as the simultaneously converted farinaceous foods —
wheat, arrowroot, etc. — increase the nutritive value and
convey a very agreeable taste, masking that of the milk
Porridge of oatmeal, wheat, etc., is easily made more
digestible by adding, at the proper temperature, a small
quantity of the diastasic essence to a portion as served at
the table; for the aged and for infants this is an etBcient
method. (See also article on Dietetic. )
Trypsin as a surgical solvent is peculiarly serviceable
in cases in which acid is undesirable or alkali necessary ;
in such situations, and where fluid cannot readily be kept
in contact, the trypsin powder is preferable, adhering as
it does to moist surfaces, and being thus exceedingh' ac-
tive; in nasal diseases, in diseases of the throat, urethra,
etc., the trypsin powder is successfully applied. By its
Vol. VI.— 31
use in diphthem, great relief is often afforded to the
distressing local manifestations, in addition of course to
the specific constitutional treatment. The pancreatic ex-
tract has been used with marked success as a solvent in
abscess cavities of the liver, hip joint disease, etc.
Trypsin is used as the essential agent in the prepara-
tion of an artificial human or humanized milk from cow's
milk, for the reason that cow's milk proteids, under the
regulated influence of the enzyme, become practically
identical in .solubility with the proteids of human milk;
in consequence of this change a cow's milk mixture with
percentage composition adjusted to the standard of hu-
man milk becomes notably thinner, of a grayish-yellow
color, and acquires a marked resemblance to h\iman milk
in physical and physiological characteristics and deport-
ment with all reagents. This milk so converted by tryp-
sin gives minute, diffusible coagula with gastric juice,
and with acid of normal gastric percentage ; it corresponds
iu digestibility in vitro to human milk with pepsin and
acid, and is not coagulated by rennet. The enzyme
itself, as the physiological factor in the process, is in-
stantl}- destroyed by simply heating the milk to 160" F.
or by boiling it after the enzymic action has been util-
ized ; the enzyme thus becomes so much inert proteid,
so minute in amount as to be a negligible quantit}- in the
food and quite incapable of in any way influencing the
digestibility of the milk.
This use of the enzyme iu infant feeding is based on
the unquestionable postulate, confirmed hy all dat^i.
chemical, physiological, aud clinical, that the radical
difference in digestibility and deportment between cow's
aud human is milk attributable to the nature of their re-
spective proteids — largely casein in cov>-'s milk, and solu-
ble, non-coagulable peptone-like proteids in human milk ;
it is also based upon comparative aualyses and observa-
tions of this humanized milk and many specimens of
average, normal humau milk. Theoretical objections
based upon presumed defects in this method, as present-
ing a food unnaturally digestible or conveying a diges-
tive agent, are obviously erroneous in view of the fore-
going facts. The enzj'me may. however, be so used as
to secure a degree of digestibility beyond the normal
where this is required, by simply prolonging the subjec-
tion of the casein to the proteolytic agent or the enzvme
administered in the food, by chilling the milk instead of
pasteurizing or sterilizing it when the desired degree of
digestion is accomplished. In fact, this is like the use
of the enzyme as a means of aiding the digestion of
mother's milk itself by giving pancreatin in a few one-
grain doses immediately after nursing.
Beiijaiuin T. Fuirchild.
PANCREON is a combination of pancreatin with tan-
nic acid, said by Gockel to possess the tryptic, amylo-
lytic, and emulsifying powers of pancreatin. but to be
uualTected by the gastric juice. Out of 100 gm. of al-
bumin subjected to the action of 1 gm. of pancreon for
fifteen minutes at 40° C. (104° F.) in a weak alkaline me-
dium, 85 gm. were digested. The dose of pancreon is
0.3-0.5 gm. (gr. v.-vlij.) three times a day.
TV. .4. Bastedo.
PAPAW JUICE.— Papaya. Carica. The milk juice
obtained from the nearly ripe fruit of Carica Papaya L.
(fam. Papuyac^(p).
This interesting plant is the well-known melon tree of
tropical America, now widely introduced into other
tropical countries. AUof its parts contain a latex or milk
juice, which is more abundant aud more milky in the
nearly ripe fruit than elsewhere. This milk juice pos-
sesses a bitterish and very acrid taste, is irritant to mu-
cous membrane or to the abraded skin, and has consid-
erable detergent power. It possesses the property of
peptonizing albuminous substances, after the manner of
trypsin, and of softening an additional portion which is
not truly peptonized. By reason of its possessing this
propert}-, it has been largely used in its own home for
application to tough meat to render it more palatable and
4:81
Pai>a\«' J nice.
Paral»*o Hut S|>riii;j
UEFERENCK llANDlSoi >K oF THE MEDICAL SCIENCES.
diirfStihle, a fact wliicli lias led to ils i-.\aiiiinulii}u by
chuinists and phj-siciaiis witli a view of (lutiTiiiiiiing its
availability for use as a digeslant. Its difrcslaiit |iriiici]ilc
has eluded isolation, as have all similarsubstaiiecs. It has
been found possible, howcvei', to concentiate the activity
in a peculiar extract called caricin (Aloncorvo), |iaiiain
(Wurtz). or papayotin (PccUolt), which is extracted with
water, the solution tillered and the liltrate i)recipitate(l
with alcohol, and jierhaiis asrain dissolved and repreciiii-
tatcd for somewhat furl her concentration. The fresh
juice, which consists largely of water, yields also con-
siderable resin, divisible info two portions, nearly live
per cent, of a kind of caoutchouc, a little fat. malic acid,
leuciu, tyrosin, and other unimportant matters. The
leaves, from which the ]iapain can al.so be obtained,
yield the crystalline alkaloid curpaine (CnHjsXO;),
which is most abundant in the young leaves, constitut-
ing about one-fourth of one per cent, of their weight
when dried. The seeds, whicli are pungent and which
are used for their ta'uicidal properties, contain a resin
which shares the pungency, though the latter is said to
be due to a volalilc |)iinriplc- allied to the volatile oil of
mustard.
Action and I'sks. — Since about the year 1H80, great
attenti(m has been given in Europe and America to at-
tempts to employ papain as a digestant. Reports as to
the energy, and even as to the manner of its action, vary
most widely, even when presented by carefid experiment-
ers, and the conviction is forced that the market prepara-
tions employed l)y them must have diifered in cliaracter.
It aj.ipears very likely that some of these preparations
were nnxtun-s of diflerent digestive ferments, the results
being such as ndght be expected from an adndxture to
the |)apain of pancreatin or pepsin. Much of the infor-
mation which has lieen siijiplied to physicians, and which
lias foimd its way into pirofessional journals and books,
has been smuggled under the guise of scienlific literature
from interested commercial siuirces.
It has been definitely estaldished that as a digestant
papaya is wholly proteolytic. It disiulegrales, softens,
and li(pielies albumen in the form of white of egg, mus-
culin, librin, and casein, and considerable of the jn'oduct
is peptonized. This action takes place in au alkaline or
neutral medium. Davis (1893) and Hobein (isy4)have
shown that it is inactive in an acid medium, the papain
employed by the second-named authority having been
prejiareil by himself from papaya. Fairehild. using
specimens tlie identity and |iiirity of which were aulhcn-
ticate<l by himself, has full}" coulirnied this conclusion.
Nevertheless, some eminent authorities claim that there
is a slight activity in acid media. Dr. Lafayette B.
Mendel, who takes this view and wdio has made s|ieeial
researches in this direction, has funushcd us with the
following account of Ihe jiroductsof jjapain digestion;
"The products of the reaction of p.ipain with proteids
consist in large ]iart of proteoses. Peptones — /.c, com-
pounds not prccipilable with ammonium sul])hate, but
still giving the biuret reaelion — arc also formed. The
papain proteoses resemble the I'elated Jiroducts obtained
by gastric digestion. Regarding the occurrence of fur-
ther products of proteoly.sis, such as Icucin, tyrosin,
tryptophan, and other characleristie derivatives of
tryptic digestion the evidence is somewhat uncertain.
ITnderhill and the writer have usually faili'd to tind leu-
ciu, tyrosin, and tryptophan in appreciable quantities, at
least under conditions in which they are readily formed
in large quantities by other tiyjitic enzymes. " Emmer-
ling has succeeded in isolating sm.all quantities of these
substances from the products formed after very pro-
longed digestion, although even under such conditions
proteoses predominate Papain accordingly resembles
trypsin in dissolving protei<ls in media of \ariotis reac-
tions, thus differing from ]iepsiu: ils resemblance to the
latter lies in the similarity of the prodm-ts formed by the
two enzymes. Harlay has made comparalile observa-
tions with the enzyme of the related (Juried luistifalia.
Kurajeff has found that commercial preparations of pa-
pain induce the formation of peculiar prolei<l ijrccipitates
in solutions of proteoses such as the widely used ' Wille-
]iepton. ' The reaction corresponds with that described
for rennin as ' plastein formation,' by Danilewski and
his co-workers. The importance of this proteid-clottiag
or jirecipitating function of enzymes can only be conjeiv
tured at present. Thus it may pUiy a lole in proteid
synthesis and regeneration; and the signiheauce of such
au enzyme in plants at ouce becomes aiiparent. On
milk jiapain preparations exercise a clotting or curdling
action. AVhetherthe.se properties are all <lue to the same
enzyme, or whether more than one unorganized ferment
is present in the plant, are questions which liave not yet
been .settled."
Riedel, who in 1894niaile a very elaborate series of ex-
periments to determine the most favorable conditions for
the activity of papain, concluded that the most favorable
temperature was about that of the body; that one part
of papain to one lumdred of albumin was the most favor-
able proportion; that the more concentrated the papain
solution the greater the activity, and that the capacity
of papain for digesting egg albumen was about one hiiii-
dred times its own weight. The answer to the last ques-
tion depends natundly iijiou the degree of concentration
of the ])apain; yet it has been found impossible to carry
tills concentration more tl^an a little way. The activity
of a definite portion of the dried papaw juice itself i*
much greater than that of the papain extracted from it;;
a single instance is recorded in which such a juice, very
carefully prepared, digested one thousand times its owii
weiglit. The difficulty is that this action is extremely
varialile; so much so that it is not at all probable that
cominercial diied i>ap;iw Juice could ever be brought tO'
a uniform standard of strength.
As a general statement, it may be said that a good
average sample of ])apain is capable of digesting front
fifty to one lumdred times its own weight of albumen,
under favorable conditions. It is also veiT noteworthy
that it loses its power rapidly upon lieing kept. If kept
w ith ordinary c;ire in well-stoi)i)ered vials it will ordi-
narily have but little value at tlie end of a year.
As to whether pa]iaiu possesses any diastasic action in
the conversion of starch, we have also discordant reports,
but are obliged to conclude that it has none. As to its
milk-curdling power, it certaiul}' possesses a small and
variable degree; but this is of a peculiar character, the
liroeess and the coagulum differing distinctly from those-
resulting from the use of rennet.
Pa|)aya is a powerful irritant to denuded tissues and
to mucous membrane. So powerful is this action that
if a large amount be taken into the stomach in concen-
trated form it acts as an irritant, cu' even as a caustic
emetico-cathartic poison. Applied to a raw surface it
acts as an cscharotic, and is very apt to be followed by
putrefactive processes. Papain, prepared as aliove de-
scribed, is less active in this direction, though still irri-
tant. Desjardins states that the irritant ]u-opcrty is
almost completely destroyed by boiling, which also
produces a new substance, having a powerful lumbricidal
action, similar to that of the seeds.
The principal native use of papaya has been stated
above. Owing to its locally stimulant action, it has also
been used as a cosmetic, to remove pimples and similar
roughnesses from the skin, and to produce a smooth,
healthy surface Its irritant ])roperlies have been uti-
lized in the form of caustic applications to cancerous and
other morbid tissues, but the praci ice cannot be consid-
ered .good. Its dissolving action upon albuminous sub-
stances has been utilized by applying it to diphtheritic
membranes. For this purpose a five-per-cent. solution,
preferably made alkaline with O.o per cent, of bicarbonate
of .soda or potash, is applied at short intervals with a
brush, or in the form of a spray. The results appear to
be highly irregular and uncertain. A similar solution,
but twice as strong, is applied to warts, corns, and other
cutaneous indurations. Almost its entire use in Europe
and America is for internal administration as a digestant,
either alone or combined with other ferments. Owing to
its irritant effect it shoulil be administered when the
482
KEFEREXCE HANDBOOK OF THE MEDICAL SCIENCES.
Pa pail Jiiii-i*.
ParaiMO Hot Sprlugs.
stomach is full of food, and dilution with milk-sugar
or other neutral substance is desirable. Opinions ditl'er
widely as to the dose, but the best evidence is in favor of
I lie use of a considerably larger do.se than that of official
jiepsin. Where there is an irritable condition of stomach
or bowels, the dose should be reduced, and the drug
shoiild not be used in case of an ulcerated condition of
those organs.
Allied Drugs. — The juice of the fruit and leaves of
the pineapple has similar properties and uses, already
referred to under TiniiiiiliiirnT . JItriry II. liuxhi/.
PARA -ACET-AMIDO- PHENOL ETHYL CARBON-
ATE, a tasteless, white, crystalline powder, insoluble in
water and -readily .soluble in alcohol, is administered in
dosage of 0.5 gm. (gr. viij.) as an antipyretic, analgesic,
and iiypnotic. H'. ^1. Basteilu.
PARA-CHLORALOSE. See Chlomhse.
PARACHOLIA.— The term used by Pick to designate
the hy|iuthetical secretion-anomaly by which the bile
leaves its accustomed channels and pa.s.ses into the blood,
giving rise to icterus. By a number of recent writers
icterus is regarded as due to a diseased condition of the
liver cells, the process being analogous to the secretion
of albumin in diseased conditions of the kidney cells.
Normal liver cells should secrete bile into the bile vessels,
and urea and sugar into the blood capillaries. According
to Minkowski it is. therefore, not without analogy that
the liver cells in diseased conditions should give off the
bile into the blood-vessels. Such a process is designated
by him as partipedesu. Liebermeister and Pick also ex-
plain many forms of icterus as due to functional disturb-
ances of the liver cells, either with or without evident
anatomical changes, the former designating sucli a dis-
turbance as diffusion or akaihcttic icterus, the latter as
paracliolia. Pick believes that the pathogenesis of the
obscure forms of icterus may be explained by this hj-poth-
esis. He accordingly dislingiu'.sbes three classes; ncr-
tvus paracliolia, to.vicp<inicJndia, and infectious p/arae/iolia
{Wie}ier kUn.Wocheii., 1894). Aldred Scott Warthin.
PARADISE SPRING.— Cumberland County. Maine.
PosT-UFFii K. — Brunswick. Hotels and inns.
Tills spring is located about one mile from the centre
of the village of Brunswick and tive hundred feet from
the Andro.scoggin River. It is reached by way of the
Maine Central Railroad to Brunswick, and thence by Jor-
dan Avenue. The country about the place is level — a
sandy plain, covered by pines extending to beautiful
Casco Bay, three miles distant. Concerning the meteoro-
logical conditions prevailing about Brunswick, we are
indebted to Prof. Leslie A. hcc, of Bowdoin College, for
the following d(*scription : "The climate of Brunswick is
peculiarly agreeable. Fair weather predominates, the
annual number of cloudy days averaging not more than
eighty-si.K in a long ])eriod of years. The prevailing
winds are from the southwest during the summer and
from the northwest during the whiter. On this account
the air is much drier than would be e.\pected from the
proximity of the village to the sea, and fogs rarels'
occur."
Scattered throughout the town are large areas of pine
forests, which give a resinous and balmy quality to the
air. The average annual temperature is 44.40' P., rising
to an average of 65.11' P. in the summer, and falling to
a mean of 22.63' F. in the winter. The temperature of
the spring water is about 45' in summer and 43' F. in win-
ter. The outflow of water is abundant, being estimated
at twelve thousand gallons perday. Tlic following analy-
sis was made by Prof. Henry ("armichael, of Bowdoin
College: Reaction neutral. One United States gallon
contains: Silica, gr. 0.38; iron oxide, a marked "trace;
calcium sulphate, gr. O.OG; calcium carbonate, gr. 0.07;
magnesium carbonate, gr. 0.06; sodium chloride, gr.
0.03: sodium carbonate, gr. 0.36; potassium chloride,
gr. 0.04. Total. 0.99 grain.
A more recent analysis by State Assayer Franklin C.
Robinson shows a somewhat larger proportion of solids,
viz.. 1.05 grains per L'nited Stales gallon of inorganic
salts. The water is remarkably free from organic mat-
ter, containing, according to Robinson's analysis, but
0.07 of a grain per United States gallon. This organic
matter was found by examination to be (jf vegetable ori-
gin, only a minute trace of nitrogenous material being
detecteii. The water is excellent for table use. and lias
been supplied to the .students of Bowdoin College for
some time past. It is used commereiall}'.
James K. Crook.
PARAFFIN INJECTIONS. Hix Reparative Surgery.
PARAFFIN-XYLOL is a solution of 1 gm. of paraffin
in 10 c.c. of X3'lol, and is used as an antiseptic var-
nish for the hands in surgical operations.
11'. A. Bastedo.
PARAFORM — paraformaldehyde, triformol, triox}'-
methyleue (HCOH)3 — is a polj'mer of formaldehyde oc-
curring as a white, insoluble, crjstalline powder. It
tends to decompose slowly with tlie production of for-
maldehyde gas, and, when acted upon by heat, as in
some of the formaldehyde generators, may evolve the
gas rapidl.v and in large quantities. On account of its
slow and steady evolution of formaldehyde, it is used by
physicians as an intestinal antiseptic and by dentists for
disinfecting cavities. The dose is 0.5-1 gm. (gr. viij.-
XV.). Unua prescribes: V, Paraform 2 gm. (gr. xxx.),
ether 3 c.c. (m xxx.), and flexible collodion 15 c.c.
(|.ss.)as the best application for pityriasis versicolor,
erythrasma. and other .sai>ro]5hytie skin diseases. Mense
uses a three-per-cent. paraform collodion as a slow caus-
tic for warts and other small cutaneous growths.
Parafciim enters into the composition of eka-iodoform.
IF. A. Bastedo.
PARAISO HOT SPRINGS.— >Ionterey County, Califor-
nia. Post-Office. — Paraiso Sjirings. New Cottages.
Access. — Take 8:15 a. .m. Southern Pacific train from
the corner of Third and Townsend streets, San Francis-
co, reaching Soledad station at 1:43 p.m. Thence by
stage a drive of one hour and a half to the springs.
"Paraiso Springs." says Mr. E. S. Harrison in his his-
tory of Monterey County, "were the property of the
Mission Soledad, which lies about five miles northeast of
the springs. The title of the present owner was obtained
from the Church of Rome, to which a patent was granted
by the ilexican Government in 1778. In the records of
the Mission Soledad the healing and invigorating quali-
ties of these waters are duly set forth. The springs ,are
situated in a picturesque alcove of the Santa Lucia 3Ioun-
tains on the western border of the Salinas Valley, about
one hundred and lift j' miles soutli of San Francisco. The
altitude of the location, being nearly one thou-sand feet
above the valley, renders the atmosphere dry. bracing,
and invigorating. Below the resort, and for miles be-
yond, the eye scans the fertile valley, traversed by the-
gi-and Salinas River and Arroyo Seco, and the far-away
Gabilan 3Iountains, forming a picture of great charm
and glory. The commodious hotel and cottages com-
bine all the luxurj' and comforts that can be found'
anywhere. On the premises are several valuable springs
flowing about two thousand gallons of water per hour,
and consisting of sulphur, soda, and iron waters. The-
temperature of the springs varies from 100' to 118° F.
We give below the analyses of the waters of the two-
principal springs, the Paraiso Sulphur Spring and the
Great Paraiso Hot Soda Spring.
The Paraiso Sulpiiiir Sjmny, — According to the analysis
made by Dr. Anderson in 1889, one United States gallon
contains: Sodium chloride, gr. 2.7(i; .sodium carbonate,
gr. 1.15; sodium suljihate, gr. 37.10; iiotassium sul-
liliatc, gr. 0.83; magnesium carbonate, gr. 6.09; magne-
sium sulphate, gr. 2.19; calcium carbonate, gr. 0.89;.
calcium sulphate, gr. 4.40; ferrous oxide, gr. 0.73; sil-
ica, gr. 2.55; organic matter, gr. 7.35. Total, 66.04
grains. Gases: carbonic-acid gas, 2.04 cubic inches;
483,
f*araUoralosiM.
Paralysis Agltaus.
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
sulpliureted li}-drogeu, 9.25 cubic iuclies. Temjiera-
ture, 114 F.
This is said to be one of tlie bcsl batliiug waters on the
coast.
The Great Paraim Hot Sxin Sprimi. — One United States
gallon contains; Sodium chloride, trr. 3.37: sodium car-
bonate, gr. .5.06; sodium sulpliatc gr. 34.00; potassium
chloride, gr. 0.32; potassium sulphate, a trace: magne-
sium carbonate, gr. 0.T.5; ma.iruesium sulphate, gr. 1.10;
calcium carbonate, gr. 1.3U; calcium sulphate, gr. 6.4.5;
ferrous carbonate, gr. 0.89; alumina, gr. 0.56; silica, gr.
2.90; organic matter, gr. 4.15. Total, 61.45 grains.
Free carbonic-acid gas, 2.95 cubic inches. Temperature
of water, 118° F.
Qualitatively this water closel_v resembles the famous
Carlsbad Spriidel water, but is less highly mineralized.
Thousands of visitors, invalids, and pleasure-seekers visit
Paraiso Springs yearly, and the excellence of the mineral
waters, the salubrity of the climate, and the picturesque-
ness of the location bid fair to make Paraiso one of the
most prominent health resorts in California.
James K. Crook.
PARAKERATOSIS. See Cornifieation.
PARALDEHYDE. — Parethylaldehyde : 3 (C.H4O) =
CeH 1 -O3. Paraldehyde is a poly meride of common ethy-
lic aldehyde, producible by the action of a considerable
number of substances upon such aldehyde. Paraldehyde
is, at ordinary temperatures, a liqviid, colorless, of a burn-
ing taste and powerful and penetrating ethereal odor. It
dissolves in 8.5 parts of cold water and in IG.o parts of
boiling water. It mixes in all proportions with alcohol,
ether, and fixed or volatile oils. At 0' C. (32' F.) paral-
dehyde solidities to an ice-like cr3-stalliue mass, or may
crystallize in distinct prisms. It .should be kept in weli-
stoppered, dark amber-colored bottles, in a cool place.
Paraldehyde is peculiar among ethereal bodies for pos-
session oi' the property of determining sleep, with a mini-
mmn of by-effects. The sleep producetl by the medicine
seems a quite perfect imitation of natural slumber, since
the subject under the influence of the hypnotic is as
easily awakened as from ordinary sleep. No worse de-
rangements occur from the medicine than a little dryness
of tiie throat and thirst, and a trifling reduction of pulse
rate and arterial tension. The most disagreeable circum-
stance attending the use of paraldehyde is a persistence
of the taste of the drug upon the palate, and of the odor
in the breath, often for a number of hours after the tak-
ing. Also it may disorder the stomach. The sleep pro-
duced by a perfectly legitimate dose of paraldehyde may
begin within fifteen minutes after the swallowing, and
last five, six, or .seven hours. The medicine is used ex-
clusively for tlie procurement of sleep, and is applicable,
without special contraindication, for any case in which
that therapeusis is projier. A quantity of from 2 to 4 gm.
(from III XXX. to Ix.) is the average dose, and the same is
best given dissolved in 30 gm. (fl. 3 i.) of an aromatic
water, sweetened. Edimrd Curtis.
PARALYSIS. — The term paralysis, in its more limited
sense, demites complete or very pronounced loss of mus-
cular power. The term paresis is sometimes employed
to designate lesser degrees of loss of power. Paralysis is
the result of functional or organic changes in the nervous
system (central or peripheral), but in a comparatively
rare group of diseases it is due to primary changes in the
muscular fibres (pseudohypertrophic paralysis and allied
forms).
Loss of muscidar power maj- vary widely in its distri-
bution. When confined to a single limb or part of a
limb, it is known as monoplegia: when it involves one
side of the body it is called hemiplegia. If the hemiple-
gia is present on both sides of the body, the term diple-
gia is used. Paraplegia is paralysis of both lower limbs
(usual form), of both upper limbs, or of all the limbs.
In ascertaining the existence of paralysis of any part
of the body, we must not be siitisfied w ith merely noting
the absence or diminution of motion in the suspected
part. We must also make sure that there is no mechani-
cal obstruction to motion, sucli as ank3-losis, fracture or
di.slocation, and that it is not inhibited by pain. Fur-
thermore, the patient must be in a condition to un-
derstand our directions. Even when the patient is
profoundly comatose, we may usually diagnose the exist-
ence of paralysis b}' noting the increased lesolution and
flaccidity of the parts when compared with the corre-
sponding ones on the opposite side of the body.
Various instruments, called dynamometers, have been
devised to test the amount of muscular power, but they
are unnecessary for practical purposes and for the most
part imreliable. If the paralysis is veiy marked, the
loss of function is forthwith noticeable. If the loss of
power is not so pronounced, the patient is directed to
oxercome the resistance to various movements offered by
the phj'sician. For example, in order to test the power
of the quadriceps femoris the patient is directed to flex
the thigh on the abdomen, against the resistance offered
by the physician. This is then compared with the re-
sistance otiered on the healthy side (it must not be for-
gotten that the right limbs are usuall}- somewhat stronger
than the left). Incases of paraplegia we must rely upon
our knowledge of the degree of resistance which should
lie offered normally, taking into consideration the mus-
cular build and haliitus of the patient, his general nutri-
tion, intelligence, etc.
We must alwa^'s he on our guard against mistaking
jiaral.ysis for the immobility due to painfid affections.
For example, a case of acute articidar rheumatism in a
child was sent to us with the diagnosis of jiaraplegia.
tlie apoarent paralysis being due merely to the pain in
the joints.
We must next determine whether the paralysis is func-
tional or organic. Functional paralysis is usually hys-
terical and fhe general condition of ihe patient exhibits
the evidences of that neurosis. Hysterical paralysis
rarely affects individual nerves. It generally involves
nuiscles in functional groups, not according to strict ana-
tomical distriliution. Some symptoms are usually found
which point directly to anon-organic origin. For exam-
ple, in the recumbent posture the paralyzed legs may be
capable of certain voluntarj' movements, or they may he
moved involuntarilj' during excitement, while on at-
tempting to walk the lossof power may appear absolute.
Fiuthermore, hysterical paralysis is often preceded by
undoulited hysterical seizures, and it may change very
rajiidly in degree. Sensory disorders are very common
and, like the lossof motion, are not confined strictly to
the anatomical distribution of individual nerves. They
consist very often of hemiana'sthesia, accompanied by
concentric narrowing of hoth fields of vision.
The differentiation of iieripheral from central paralyses
is usually not a dilticidt matter. The muscles affected in
the Iieripheral forms are sup])lied b_v one or more nerves,
and a knowledge of the functions of the muscles will
enable us to recognize these nerves. As the majority of
the motor nerves are mixed in character, the distribution
of the attendant sensory disturbances will aid still further
in localizing the lesion. In mild cases there may be no
change in the electrical reactions of the muscles; in se-
verer cases there may be all possible gradations between
simple diminution of electrical irritability and complete
degeneration reaction. The latter is also observed, how-
ever, in certain forms of spinal-cord disease.
Atrophy of the nuiscles is common in peripheral paraly-
sis, but extremely rare in cerebral jiaral.vses : it is a con-
stant symptom of diseases of the anterior horns of the
spinal cord.
Paralysis of spinal origin usually takes the form of
paraplegia, and is attended not infrequently by interfer- !
euce with micturition, defecation, and the sexual function.
The limbs may or may not undergo atrophy, and they j
exhibit the degeneration reaction, according as the ante- |
rior hornsare implicated or not. The patella reflexes may 1
be lost, but if the lesion is situated high up in the cord, 1
the tendon reflexes as well as the cutaneous reflexes may !
484
REFERENCE HANDBOOK OF THE .ALEDICAL SCIENCES.
Parakeratosis,
Paralysis Agltaus.
be greatlj' exaggerated. Coutracturcs are upt to develop,
antl are perliaps more prououuccd thau in any other forms
of disease.
Cerebral paralysis is usually hemiplegie in character,
and its onset is generally attended by symptoms of apo-
plexy ; sensory symptoms are subsidiar}-. Ilemiarnvs-
tbesia is sometimes present at the beginning of the seiz-
ure, but usually disappears in a few days. The paralyzed
muscles rarely undergo atrophy and the electrical reac-
tions are unchanged. Contracture of the muscles de-
velops after a while and, like the paralysis, is more
marked in the upper limb.
In the majority of eases the diagnostic features de-
scribed aliove will enable us to locate the lesion which
has produced the paralysis, but in exceptional cases a
))robable diagnosis alone can be made, after giving due
weight to the attendant .symptoms, etiology, etc.
Tlie prognosis and treatment of paralysis will depend
upon the primary disease, and will be considered in the
vario\is special articles. Leopold Putzii.
PARALYSIS AGITANS.— (Synonyms: Siiaking palsy,
Parkinson s disea.se.)
ExiOLOCiY. — Paralysis agitans is one of the diseases of
advancing years, and the large majority of cases develop
after the age of forty to forty-tive years. It is a mistaken
idea, however, to regard it as an indication of senility.
In a few exceptional instances the disease has begun at a
much earlier period, and cases have been reported at the
age of twenty, seventeen, twelve, and even three years.
It is very often difficult to determine the exact period at
which it begins, because tiie inception is usually very
gradual and is often unnoticed hy the patient.
Unlike other neuro.ses, heredity plays a verv .slight
part in this affection. Onl_v a few cases have "been re-
ported in which other members of the patient's family
suffered from this or some other form of nervous disease.
Paralj'sis agitans is a rare disease. Among 4,600 pa-
tients under my observation, during a period of eleven
years, at the Clinic for Nervous Di,seases in the Beileviie
Outdoor Department, there were 30 examples of paraly-
sis agitans, 19 of which occurred in males, 11 in fe-
males.
It has been said that the Anglo-Saxon race is especially
predisposed to the disease. At all events there can be
DO doubt that reports of cases are comparative!}^ rare in
the otherwise very prolific German literature on nervous
affections. We ma_v also state, with regard to New
York, that the disease is frequently mistaken here for
senile tremor or multiple cerebrospinal sclerosis.
Prominent among tlie exciting causes stands emotional
excitement, usually of a depressing nature, such as fright
and anger. Several cases of this kind were observed
among the inhabitants of Metz and Strasburg during the
sieges experienced in the Franco-Prussian war. Lorain
(Arch. Oe M/d.. vol. i., 1873, p. 214) reports the following
striking example: A girl, aged seventeen, was frightened
by the bursting of a shell in the cellar in which she had
taken refuge during tlie siege of Paris. This was fol-
lowed immediately bj' tremor of the right arm, which
soon extended to the rest of the body. At the end of
five years she was still suffering from parah'sis agitans.
Long-continued worry and grief appear to act in the
same wa_v as sudden emotions.
Living in damp rooms, or protracted exposure to wet
and cold, is also said to give rise to the disease, and in
our experience this has seemed to be the most efficient of
all the etiological factors. Some patients inform us that
the tremor began inmiediateh' or shoitly after catching
cold, from a single exposure to wet or cold, but it is
doubtful whether there is any real connection between
the two events.
X number of cases have been reported in which the
disease had a local origin in an injury to the arm or leg
(sometimes, perhaps, as the result of a peripheral neuri-
tis). In such cases the tremor begins usually in the in-
jured part, but then spreads to the i-est of the body and
pursues the ordinar}' course of pai-alysis agitans.
Ball claims that |iaralysis agitans and insanity are as-
sociated more friMjucntly than is commonly believed.
The insanity, according to this writer, is always of a de-
pressive character, general!}' melancholia, with suicidal
impulses and numerous hallucinations. In some cases a
condition of dementia and of "demi-stupor " predomi-
nates.
Clinical, History. — When the disease begins slowly,
as usually happens, it is sometimes preceded by pro-
dromes. These consist of wandering pains in different
Fig. 37.37.— Position of the Bi«ly in I'araly.sis .Agitans. (Fioiii Seiiler:
" Diagnostik u. Therapie d. Nervenlirankheiten.'')
parts of the body, occasional formication, or a feeling of
weakness in the parts that are attacked at a later period
by the tremor. In some instances the tremor does not
remain constant after its first appearance, but subsides at
times until again provoked by some exciting cause. In
rare cases the disease begins suddenly, as we have seen in
the section on etiology, and may spread quite rapidly to
the entii-e body.
In tlie majority of cases tremor first a|)pears in an arm
or leg (usually the former), and then extends to tlie otlier
limb on the same side. After a longer or shorter time
(sometimes several years) it spreads fo the other side of
the body, generally attacking the latter in the same or-
der. The head and trunk may also become involved.
Charcot claimed that the apparent tremor of the head
was always the result of the ti'ausmission of the move-
ments of the trunk and limbs. This has been disproven
by numerous cases, and several instances have fallen un-
der our own observation. In rare cases the tremor first
attacks the arm of one side and the leg of the opposite
side, or it assumes a parajilegic form, involving both
lower limbs. But sooner or later it extends to the rest
of the bod}'.
Coincident!}' with the tremor (in some cases even pre-
ceding it) the muscles of the body acquire a certain de-
gree of i-igidity, and tin- liody assumes a peculiar, almost
pathognomonic, position, as shown in Fig. 3737.
The motor power of the limbs remains comparatively
unchanged for a long time, even for many years, but in
the last stages general paraly.sis sets in. Sensation is un-
affected throughout the enliie course of the di.sease. The
■185
ParalystM Af2:itaiis,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
reflexes arc- uiieliunged. Unless life is termiiiatcd bj-
some iiitcTcui'i'eiit disease, the patient linally lajises into
u condition of mental hebetude, becomes beilridden. and
Icses power over his limbs; then the functions of the
bladder become impaired, bedsores devi'lop, and tinally
death ensues.
We will now enter into a more detaili'd examination of
the various symptoms.
The tremor, which is one of the most striliing features
of the disca.sc, and the one from which, in fact, it derives
its name, consists of very (piicU, uniform, and limited
excursions of the atl'ectcil |iarls during- repose. There
are usually four or five oscillations in a second. In the
first stages the iiaticnt is able to control the tremor for a
time by an cfl'ort of the will, or by e.\c<'Utinga voluntary
movement of the jiarls. lint, as the disease advances, this
power is dimiidshed, and. linally, while the jiatient may,
for u very brief interval, moderate the severity of the
tremor, a voluntary ell'ort is soon followed by increased
violence of the inovemeids. Thctreinor sidisides during
sleep, but the I'atients arc very restless at night and do
not remain lou,if in one po.sitioii. The cessation on vol-
luitary effort was regarded b_y Charcot as a pathogno-
monic diil'crcntial sign, distinguishing the disease from
the tremor of niidti[ile sclerosis. But Wcstidial has re-
ported a case in whiih the tremor of sclerosis presented
the .same characteristics as that of ]iaralysis a.gitans; and
a similar case, in which an autopsy was obtained, lias
come under mj- own observation. Magnan has also re-
ported a case of paralysis agitans. iu which the movc-
tiients did not occur unless the (laticnt performed some
voluntar.y act which rcc|uirc<l a certain degree of atten-
tion on his part. As a rule, the fingers and forearm are
the parts most affected: next follow the foot and leg.
In the large ma,tority of cases the head also presents
rhythmical movements, but these are ,gciierall.y convej-ed
from the trunk and limbs. Iu not a few cases, however,
certain of the facial mu.scles, particularly of the lips and
chill, present tremulous movements similar to those of
other parts. In still rarer cases the tongue, when pro-
truded, also presents oscillatory movements, but these
are never so jironoimccil as in otiier muscles.
Rosenber,g has reported a rare case of tremor of the
velum palati and epiglottis. The laryngoscope showed
that the vocal cords came together, promptly on phona-
tion. but the tension of their cd.ges clian.ged. the ga]) be-
tween them being sometimes linear, sometimes a broad
(■llipse The body of the vocal cords showed twitching
movemi'Uts, which had the .same rapidity as the general
tremor. AVhen the ]iatient wasdirected to bold a note as
long as possible, a rhythniical change from high to low
pitch became noticeable.
The a])i)earanee of the body, when the disease is fully
developed, is highly characteristic, and, indeed, almost
pathognomonic.
The face has a peculiarly stolid, rigid appearance.
The eyes have a dull, lack-lustre look, and their move-
ments are slow, us if the museles were ri,i;id like those of
the face and rest of the body. Two ca.scs have becu re-
ported in which so-called ocular lateropulsion was ob-
served. The ])atients, while reading, experienced a cer-
tain amount of difficulty in directing the .ya/.e from the
end of one line to the beginning of the next line. This
is most noticeable if lh<- reading matter is arranged in
columns. When they have arrived at the end of a line,
the eyes involuntarily seek the corresponding line in the
next column, liecause the oeular museles cannot be
moved with the normal rapidity.
The facial tnuscles have lost their emotional play al-
most entirely, and the face therefore looks as if covered
with a mask. At times the muscles of the mouth and
chin present tremulims movements similar to tho.se ob-
served in the extremities. The mouth is sometimes kcjit
slightly open, and the saliva may dribble constantly in
advanced cases. Speech is slow, labored, and extremely
monotonous. It sounds as if the innseles cd' s|x'cch hail
to overcome some unusual resistance Ix'tori' the words
can be enunciated. The speech is unchanged liy emo-
tional excitement, and, if we may use the expression, ap-
|iears to be covered by a veil. According to Buzzard,
the idping voice of old age is really a .symptom of paraly-
sis a.gitans. and not of senility. In certain cases the
words sound as if they were .ioltcd out of the patient'.s
moutii, like the conversation of an unskilful rider while
on horseback.
The head is held forward, and the chin may even be
(closely apjiroximated to the sternum. The muscles of
the neck are usually rigid and offer considerable resis-
tance to passive motion. Three cases, I believe, have
been reported iu which the head was drawn backward
instead of forward. A fourth one has come under my
observation. In some cases the muscles of the neck pre-
sent independent tremor, but their movcmentsare usually
conveyed from the trunk. In the latter event the head
will remain quiet if the movements <:)f the body are forc-
ibly restrained. The trunk is generally iu a condition of
anterotlexion. as shown in Fig. 3737. The arms are usu-
ally drawn slightly forward, and the elbows arc slightly
separated from the side of the chest. The forearms are
strongly Hexed, partly pronated, and they ordinarily lie
across the abdomen. These parts are in a stale of constant
tremor, though this is not so vigorous as in the liand.s.
The tiugersare usually flexed, the thumb isadducted, and
also very slightly tiexed. The thumb and index linger
are continually moving to and from one another, as in the
act of writing, or making pills; the other lingers are in a
condition of constant fine tremor. In other cases the
jiosition of the fingers resembles that of arthritis defor-
mans, but the joints are not swollen as in the latter
disease.
The lower limbs are moderately llcxed at the thighs
and knees, and the latter are drawn inwaril. The feet
are in the position of equino-varus. The toes are ex-
tended at the first phalangeal joint and flexed at the
other phalangeal joints.
The ])atient's gait is also vciy characteristic. Upon
attcinptiug to rise from a chair a certain amount of diffi-
culty is exjierienced. as if he were compelled to overcome
some resistance. He stands still for a moment, as if to
steady himself, ami then makes short, slintHing steps.
The ,!:ait giaduali.v increases in rapidity, and may soon
pass into a sort of slow dog-trot. In many cases the
(laticnt loses his balance and falls, unless supported.
Others measure with the e_ye the distance between the
starting-point and their objective point, and learn to
regulate their muscular effort in such a way as barely to
reach their desmnation in safety. This so-called festinat-
ing gait has been attributed by most writers to the for-
ward displacement of the centre of .gravity of the body,
so that the bod\' is, as it were, hurried along iu order to
catch the centre of gravity. This explanation is insurti-
cicut, as is shown by the phenomena of propuLsion and
retropulsion. In some cases, if, while the patient is
standing still, slight traction in a forward direction is ex-
ercised upon his clothes, he will be irresistibly impelled
to move f(U ward in the peculiar manner described above
(]U'opulsion). In rare cases, if the traction is exercised
backward, the |iaticiit will move iu this direction iu a
similar manner (retropulsion). In still rarer cases, the
patient exhibits a tendency to move to the side (latero-
pulsion). In retropulsion, indeed, he is moving in a
directiim opposite to that of the action of the centre of
,sravit_y. Retropulsion and propulsion have also been re-
garded as forced movements, like those produced by irri-
tation of the cerebral i)cduiicles.
The muscular power of the patient is not much dimin-
ished until he becomes bedridden, but he is very easily
tired by muscular exertion. Furthermore, an unusually
long time elapses before the iiatient is able to execute
any voluntary movement, and when this has been begim
it cannot be discontinued as abruiitly as in health. This
may be readily detected by directing the patient to
stpieczc one hand lirmly and rapidly, and comparing this
aetiiui with that of a healthy individual. Although the
dilferenee is often i|uitc decidi'd, the dynamometer may
fail to leveal any real lose of power.
-1-S(^,
UEFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Paralysis A;;ilan8.
Paralysis Agltaus.
Manj- patients suffer constantly from a feeling of
lieat in the skin, or from sudden flashes of heat. In
addition, they complain of an iudeliuable internal rcst-
lessnesswhicii impels them to change position very fre-
quently. This is often very distressing at night, since
many of I he patients are unable to turn voluntariU' from
side "to side on account of the rigidity of tlie muscles of
the trunk.
The cutaneous and tendon refle.\es and sensation are
unaiTected, but in a few cases increase of the knee-jerk
lias been reported. The suiferer maj- complain occasion-
allv of pains in the limbs, but the pains are felt chietiy in
tlie back. As the disease advances, the muscidar ])ouer
of ilie patient is gradually impaired, and linall_v he is com-
l<elled to remain in bed. Then bedsores ma_v develop, tlie
sphincters of the bladder and rectum become paralyzed,
and the ])atient dies of exhuustion. In these cases the
mental powers are also apt to undergo very marked de-
terioration.
Probably in the majority of cases, however, death is
tiie result of intercurrent diseases, among which pneu-
monia seems to play an important part.
In rare cases paralysis agitans runs its course with-
out tremor. Such patients present all the other evi-
dences of the disease — muscular rigidity, characteristic
position of the body, fcstinating gait, speech disturb-
ances, the sensation of superticial heat, etc. — but the tre-
mor is entirely absent, or is observed only at times to a
mild degiee.
Within the last few years a few autopsies liave been
made with the aid of the most approved methods of ex-
amination. Kelscher found that the ganglion cells
of the cord were strongly pigmented, with granular
degeneration in places; degeneration of the nerve
fibres, particularly in the posterior columns and in the
peripheral nerves; in jilaces the muscular libres ex-
liihitcd atrophy and fattj' or hyaline degeneration. The
interstitial tissue in the cord, the peripheral nerves, and
the nuiscles was increased; the glia of the spinal cord,
especially in the cortical layer and around the vessels,
was thickened, particularly in the posterior and lateral
columns. The walls of the vessels showed thickening,
in places miliary aneurisms and hemorrhages.
Sander found, in addition to glia ]n-oliferation in the
white std)stance. a similar condition in the gray matter
throughiiut the cord; this was most pronounced in the
anterior horns and in Clarke's cohunn.s. There were
marked arteriosclerotic changes in thetinest vessels, with
periarteritic and eudarteritic processes. In the parts most
severely alTecte<l there was distinct degeneration of the
niedidlary sheaths of the nerve fibres.
Dana t'oimd connective-tissue proliferation in the re-
gion of the ocviliimotor nucleus, very marked atrophy of
the cells of the nuclei of the ninth, tenth, and eleventh
nerves, and slight atrophy in the facial nucleus; also
thickening of tlie spinal pia mater, dilatation and thick-
ening of the walls of the vessels, especially in the anterior
horns of the cord, with atrophic changes in the ganglion
cells.
It is Very probable that all of the changes fmind in
these autopsies are non-specitic in character. They are
similar to the senile changes which are commonly found
in the central nervous system, and which have also been
observed in chronic alcoholism.
Nor must it be forgotten that not a few carefully
observed eases havc^ shown entirely negative findings.
Hence the disease must still be regarded as a ftmctional
neurosis.
Diagnosis.— When the disease is fully developed the
diagnosis is extremely easy. But in its early sta,ges it
may be mistaken for multiple cerebrospinal sclerosis,
senile tremor, or toxic tremor, especially after mercurial
poisoning.
Multiple sclerosis is distinguished by the following
symptoms: The tremor is coarser and not so rhythmical
as that of paralysis agitans. anil, with the exception of
very rare cases, it occurs only during the performance of
voluntary movements. The characteristic jxisition of
the body and the peculiar apiiearauce of the face are
wanting, while nystagmus, diplopia, and various other
cerebral symptoms of .serious import arc present.
Senile tremor may be as uniform and fine as that of
paralysis agitans, but it generally begins in the nmscles
of the head and neck, and is uninfluenced by repose or
motion. The head may be bent forward, but rather as
the result of bowing of the back. The patient does not
sutler from the peculiar restlessness of paralysis agitans,
and the muscular rigidity incident to the latter is want-
ing. There are also other evidences of senility in the
general condition.
In mercurial tremor, examination will always show
that the affection has been preceded by the buccal symp-
toms of mercurial poisoning. The disease is also attended
by greater impairment of muscular power and general
prostration. The tremor is much more marked during
action than during repose. In severe cases it is said to
be attended at times with profound deterioration of the
mental faculties. This affection appears to be extremel}'
rare in New York, and the very few cases which have
come under my observation have occurred in looking-
glass makers.
Posthemiplegic chorea sometimes appears as a fine
muscular tremor, and at first sight may be mistaken for
paralysis agitans, especially in view of the fact that
there is considerable restoration of muscular ]30wer in the
paralyzed side before the tremor begins. In addition,
there is alwa^'s rigidity of the affected parts. But the
clinical history shows that the disease began with an
apoplectic attack, and. in additinn. the tendon reflexes
are alwa.vs exaggerated. Finally, the subjective symp-
toms of paralysis agitans are wanting.
Prog.N'Osis. — No authentic case of recovery from this
disea.sc has been heretofore reported. Indeed, recovery
might be looked upon as convincing proof of an error in
diagnosis.
During the first stages of the disease temporary remis-
sions sometimes occur, but after a time it shows slow but
uninterrupted progress.
The patients usually die of an intercurrent disease, and
in many cases life does not appear to be shortened by the
malady. Cases have been reported in which it continued
for more than thirty years.
Tke.\tment.— Tiie most that can be hoped for from
treatment is to juciduce a certain degree of palliation of
the symptoms. In our own hands slight benefit has been
derived, in a fewc^ses, from the use of galvanism, nitrate
of silver, hyoscyamine, and prolonged rest in bed. Elec-
tricity has been employed by me in the form of the con-
stant current of moderate strength, one electrode being
placed on the upper cervical spine, the other on the lower
dorsal region; sittings three times a week, each one of
from five to ten minutes' duration. This ]ilan of treat-
ment must be continued for a long time in order to ju'o-
duce any good results whatever. Nitrate of silver may
be given in pill form for a year or more ccnisecutively,
but it is well to intermit its administration from time "to
time. The dose may vary from gr. J to gr. ^ t.i.tl.
Hj'oscj'amine sometimes ]irodu(CS very rapid and bril-
liant temporary results in diminishing the tremor. Even
when the tremor is very violent and widesjiread, it may
subside almost completely in a few days. The initial
dose should not exceed gr. j-ls- l^"' tl"S '"^.v 'j^' gradually
increased until the physiological effects are producetl.
But unfortunately the good effects of this remedy cease
as soon as it is discontinued, and it does not seem to us
to be eutirel}' safe to give it c<intinuously in sufficient
do.ses for any length of time.
Absolute rest in bed may also exert a favorable influ-
ence, but it is very difficult, on account of the great rest-
lessness of the patient, to secure his consent to prolonged
treatment in this wa_y. Susjiension has been employed
in treatment, but its effects appear to be very fleeting,
and in some cases it produced harmfid results. In the
majority of cases we are finally compelled to resort to
morphine in order to relieve, in a measure, the sufferings
of the patient, Lcopcjld Pi/tzel.
4ST
Paralysis.
Paral3'»iis.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
PARALYSIS, ARSENICAL.— Puiiilysis due to arscuical
l")isciiiiii!; is licit vciv laic. Tlie larger number of cases
have the appearance, aud are, doul)tless, niere instances
of multiple neuritis. Most te.xt-books do not allude to
arsenical paralysis otherwise than liy simply mentioning
arsenic as one of the causes of niulti|ilr neinilis.
Etiology.— Usually the jmralysis results from acute
arsenical poisoning-, the poison bcins taken either de-
signedly or by accident. The jiaralysis cori-espond.s in
some measure to the intensity of the general poisoning.
Not infrerpieutly the paralysis follows the repeated ad-
ministration of t"he drug. It has been observed after the
ordinary medicinal doses; for instance, after taking from
three to" ten drops of Fowler's solution three times a day
for a number of weeks. In these instances the paralysis
is usually of a mild grade. A few years ago there was
quite anepidemic of arsenical paralysis in some British
towns, Liverpool, 3Ianchester, and other places, which
occurred in drinkers of beer, the examination of which
revealed the presence of ar.senic. In these instances the
alcohol may also have played a part in jiroducing the
paralysis, Init the sufferers were mostly moderate drink-
ers, aiid the pain attending the paralysis was more severe
than that usually found with alcoholic neuritis.
Paralysis occurs, but less frequently, from the external
use of arsenic (salves, baths, etc.), and from contact with
fabrics (wall paper, carpets, and artilicial flowers) which
contain arsenic. Barton rejiorts two cases, in husband and
wife, with paralysis following acute poisoning, the man
having for some years been rubbing a mixture of four
liaits 4if arsenic an<l three parts of plaster-of-Paris into
the skins of animals and birds, while his wife cleaned the
room twice a week. Similai' cases, from dcalin g in stuffed
birds, working with arsenical draperies, or living in rooms
where there were draperies or wall )iaper containing ar-
senic, have been reiKirted.
SY>rPTOM,\TOLoiiv. — In cases of acute (loisouing the
paralytic manifestations appear shortly afti-r the disap-
jiearance of the severe gastro-intestinal disturbance. Pa-
ralysis of twenty-four hours' duration immediately after
the ingestion of the ar.senic has been spoken of, liut must
be rare or must escape detection. Tlie onset of the pa-
ralysis occurs usuall_y from several days to several weeks
after the jioison has been taken. It is connnonly pre-
ceded by sensory symptoms, tingling, uumbness, intense
pains, etc. The paralysis itself begins more or less grad-
ually, Xot uncommonly its (mset is not observed, but
when the acute symptoms have subsided and the patient
attempts to get out of bed, it is found that he cannot
walk or cannot bold anything in his hands. Occasion-
ally the i)araly.sis is comidete, or at least no longer pro-
gressive, at an early period, but usually some weeks
elap.se before it reaches its greatest intensity. Almost
always, when observed from the beginning, it has been
found to commence at the distal ends of the extremities,
the lingers and toes, \isually first in the lower extremi-
ties, and thence extend upward. The parts below the
knees and elbows are most profoiuidly paralyzed. In
bad cases the muscles of the thigh are also jiaralyzed,
and not infrequently the t runk is more or less paretic.
The extensor muscles — the radial .snnipin the upper and
the anterior tibial irrnup in the lower extremities — are, as
a rule, most profoundly atbcted. When the jiaralysis is
complete the paraly/.eil muscles are quite tla<cid, and we
tind wrist-drop, foot-drop, etc. At a later pei'iod tlu're
are very frequently contractures, more or less strong,
atTecting particularly the least paralyzed nuiscles. Tre-
mor, often fibrillary in character, is not infrequently ob-
served in the affected muscles. The jiaralysis just
described, affecting the four extremities, the lower more
than the upper, is that usually fouml. In rare instances
it is otherwise distributed; sometimes in bemii)legie, and
more rarely in nionoplegic form. In almost all instances
we tind great loss of flesh and a general wasting, in ad-
diiion to pronounced atro]iliy of the paralyzed muscles.
The electrical reactions are those of peripheral iiaralysis.
The reaction of degi-neration becomes more or less jiro-
nciunced a few davs. or a few weeks, after the ociurreinre
of the paralysis. At a later period, if the paralysis be
profound, all electrical reactions may cease. In .some
instances slight cl^^nges in the electrical reactions may be
observed before there is any manifest paralysis, particu-
larly in so far that it re<juires a stronger faradic cur-
rent than usual to produce muscular contractions. In
lighter cases such electrical responses, especially in the
anterior tibial group of muscles, may be the only indica-
tion of incipient paralysis.
Tlie sensory symjitoms are at times even more pro-
nounced than the motor paralj'sis. These s}'mi)toms are
paricsthesios of various kinds, tingling, numbness, cold-
ness, etc. ; pains, tenderness, and anac'sthesi*. As a rule
the tingling aud uumbne.ss, and very frequently the ]>ains,
precede the paralysis. The pains are often intense ancl
constitute the most distressing symptom of the disease.
They are usuallj' described as burning, cutting, boring,
etc., and are often accompanied by sudden starts, cram|)s.
or spasmodic movements of many muscles of the body.
They are usually more or less paroxysmal, and are
likely to be worse at night anil to keep the patient
awake. They occur most frequently in the feet and
hands, sometimes appear to be in the joints or bones, and
occasionally are in the course of the nerves. Tenderness
of the affected muscles is akso a common aud prominent
sj'uiptom. The tenderness may be so great as to make
the handling of the patient extremely painful. In some
instances the tenderness is observed to be in the course of
the nerves, but g<'nerally it is so diffused that it is bard
to state that it is especially over the nerve tracts. Often
hypera;sthes!a or hyperalgesia is observetl. although this
may be only an expression of the great tenderness. Loss
of or impaired sen.sation, ansTSthesia, is also a common
symptom. It is found most frequently in the feet and
hands, and especially in the finger tips and toes or soles of
the feet, although it corresponds somewhat to the extent
of the motor paralysis. Rarely it occurs only in the dis-
tribution of certain nerves. Au;ie.sthesia is found in all
bad cases of paral.ysis. and not infrecpiently in mild cases.
Loss of tactile sensation is most common; the loss of the
senses of temperature and of pain is also common; and
muscular sense is not infrequently impaired. The knee-
jerks are usuall}' abolished. This is often true even when
the paralysis is slight. Vaso-motor and trophic symp-
toms, such as (vdema, particularly in the feet, profuse
perspiration, loss of nails and hair, pigmentation of the
skin, her[)es, and nniscular atrophy, are common.
On the other hand, the cranial neives and bladder are
very rarely affected. In some instances the pulse is more
rapid than seems consistent with the patient's general
condition ; a fact which may be due to an affection of the
vagus or of the cardiac ganglia.
As has alread}' been staled, us\ially several days or
several weeks elapse before the' disease reaches its acme.
Then after an interval, which may be of only a few days'
duration, but which .sometimes runs into months, the pa-
tient begins to improve. The aniesthesia begins to dis-
appear before the motor paralysis. It disappears in the
reverse order of its appearance: first from the trunk and
the upper part of the extremities, remaining longest in
the fingers and toes. The motor paral.ysis disapjiears in
the same manner: first in the upper jiart of the extremi-
ties, then in the muscles below the knees and elbow.s.
The flexors usually improve more rapidly than the ex-
tensors, until finally the only motor symptoms which re-
main, in the mild cases, are [laraly.ses of the extensors of
the feet and toes, and of the extensors and small muscles
of the hand. At a late jieriod thei'e are liable to be con-
tractures in the still paralyzed parts. The pains also be-
come modified in intensity after the lapse of some time,
but unfortunately thev are likely to persist with a greater
or less de,gree of severity throughout the whole course
of the disease. The vaso-motor and trophic symptoms
(cedema, pigmentation of the skin, etc.). usually disaji-
pcar at a comparatively early period. The whole dura-
tion of the disease is extremely variable. Alexander jiuts
it as from eight days to a nundjer of years. It may be
stated in L'cneral that mild cases irsuallv L'et well within
488
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
Paralysis*
Paralysis.
six moutlis, possibly in au even sliortei' time, whereas iu
severe cases one or two years elai^se lieforo there is com-
plete recovery, or. in those cases iu which a cure I'cmains
incomplete, before there is a definite cessation of im-
provement.
In some cases of arsenical paralysis muscular inco-
ordination, ataxia, is a more prominent symptom than
jiaralysis. and to this group of cases the term jiseu-
dotabes has been applied. Tlie pains. ana?stliesia, ab-
sence of knee-jerks, together with the ataxia, make that
term seem very appropriate.
The disease so far described is tliat following acute
arsenical poisoning. In some cases following chronic
poisoning the sj'mptoms are much the ssime. only the
onset is !ikel_v to be less sudden and the symptoms less
severe. In other chronic cases the symptoms are very
slow in appearing, and may liave been in part masked
by those of gastric irritation. The pains are likely to'
be proportionatel}' greater, and the paralysis slight in
degree. But, even when the paralysis is slight, the
changes in the electrical reactions are likely to be found.
In such instances the motor manifestations ma_y be rather
like those of ataxia than of paralysis. Sometimes a sense
of profound prostration is the only indication of motor
impairment.
There is another class of cases in which the poisoning
appears to have been exceedingl}' slow and insidious.
The symptoms in these cases are usually very obscure.
and the cause is commonly to be found in arsenical wall
pajjers or the like. Among the symptoms arc. gastro-
intestinal irritation, neuralgia, headaclie, insomnia, gen-
eral prostration, mental depression, impairment of mem-
ory and mental endurance, and epileptiform convulsions.
As this article is devoted to the subject of arsenical pa-
ralysis no further attention will be given to this cla.ss of
cases.
Pathology. — In the larger number of cases exaiuincd.
only neuritis was found. In a few instances disease
has been found in the centra! nervous system, iu the
spinal ganglia, in the cord, and even in the brain. Ex-
periments have been made on various animals, but the
results are not all in accord. In some instances neuritis
onlj', in others, inflammation in the spinal ganglia, in the
anterior cornua of the cord, and in other parts of the cen-
tral nervous S3'stem was found. The probabilit}' is that
the peripheral neuritis and the affection of the central
nervous system, when present, occur at the same time,
but that neuritis is the more frequent and of a higher
grade of intensity. The clinical picture indicates tliat
the characteristic condition in mo.st instances is multiple
neuritis, and if further pathological changes are present
they do not contribute to the symptoms presented.
In tho.se rare instances of incontinence of urine, etc.,
and those with profound and lasting paralysis, the symp-
toms are probabl_y due to central disease.
Diagnosis. — When it is known that the patient has
been poisoned with arsenic, as is usual in acute cases, the
cau.se of tlie resulting paralysis is apparent. When
there is no such knowledge, the history of severe acute
gastro-intestiual disturbance preceding the kind of paral-
ysis just depicted should be almost enough to make the
diagnosis certain. The picture of the paralysis is fairly
characteristic. The four extremities are usually affected,
the lower ones being more often and more extensively
involved than the upper ones. The paralysis is always
greatest in the digital extremities and is attended bj' atro-
phy and altered electrical reactions. In addition there are
the intense pain and extreme tenderness, and the absence
of knee-jerks, of bladder symptoms, and of bed sores.
When the paralysis is less marked, and the whole array
of symptoms less conclusive, the greatiT prominence of
the .sensory symptoms and the presence of altered elec-
trical reactions in the slightly paralyzed muscles (in this
instance it requires a very careful examination to reveal
such reactions) may arouse a suspicion of the true con-
dition.
The cases with ataxic gait may suggest locomotor
ataxia as the correct diagnosis, and Seeligmueller men-
tions a case of his own w-hich was falsely looked upon as
one of locomotor ataxia. The severe pains and lost knee
jerks heighten the resemblances of the two diseases. But
with careful examination sucli errors will rarely occur, for
it will usually be found that the diftieult gait is rather
])aretic than ataxic ; and. furthermore, symptoms on the
part of the bladder and the eyes (such connnon and early
manifestations in locomotor ataxia) are absent.
In cases of chronic poisoning the detection of arsenic
in the urine may assist materially in the diagnosis. In
acute cases the arsenic has usually been eliminated before
or soon after tlie jiaraly-sis appeared.
Prognosis. — Jlild cases may get well in a few montlis,
though rarely in less than six ; but when there has been
profound paralysis, recovery cannot be expected in less
than one or two j-ears.
In not a small proportion, possibly in one-lifth, of the
cases of extensive paralysis, complete recovery does not
take place.
TuEATMENT. — The treatment is that of multiple neu-
ritis. Philip Zenner.
PARALYSIS. DIPHTHERITIC. — This is paralysis
Avhich occurs dining or alter diphtheria, and is due to
changes in the nerves or muscle fibres.
The statistical frequency of diphtheritic paralysis has
varied greatly according to different writers. The
American Pediatric Society's collective investigation'
showed that it occurred in 9.7 per cent, of all cases of
diphtheria. This is rather low, some figures running as
high as twenty-five per cent, or even higher. It is prob-
able that at least ten per cent, of all cases of diphtheiia
in private practice, jiroperlv treated, may be expected to
show this complication.
EtioIjOgv. — That the pathological lesions upon which
the symptoms of diphtheritic paralysis depend are due
to the action of the poisons of the disease on certain of
the tissues there can be no question, since both the le-
sions and the symptoms have been produced experimen-
tally in animals by the injection of the toxins. '•' Para-
lytic syiuptoms may follow diphtheria of all degrees of
severity, and in.stances iu which it has complicated ca.ses so
mild that the causative sore throat has been unnoticed or
forgotten by the patient are sometimes seen in large clin-
ics. As to wliether it is more common after the severe
cases than after the mild ones there is a difference of
opinion. Gowers^ and Henoch'^ believe that its fre-
quency does not depend upon the severity of the original
disease. Goodall ' and De Gassicourt believe that it
does. The former reports a series of cases which seem
to show that its frequency is greatest in the cases show-
ing the most extensive membrane.
The influence of the antitoxin treatment tipon the fre-
([tiency of the paralysis is also a matter of doubt. Cer-
tain statistics have shown that the use of this remedy has
been followed by an increased numlierof ca.ses of paraly-
sis: but such studies are iTiisleading, since under the use
of this method there are many severe cases of diphtheria
which recover and have paralysis, — cases that would
otherwise die before the time at which the palsy generallj"
begins. It is .said that the condition is comparatively rare
among cases in which the larynx is the part mainly af-
fected by the diphtheria. 3Ialcs appear to be slightly
more susceptible than females. As to age, Gowers*
agrees with Laudouzy that adults are much more fre-
quently affected. Goodall* and Ross'-' find that it is
relatively' more common in children.
Pathology. — Lesions are found in the central nervous
system, in the perijiheral nerves, and in the muscles, but
there is no doubt that the dominant lesion— the one upon
which the clinical picture, at least .so far as the peripheral
palsy is concerned, mainly depends — is degeneration of
the lower motor neiu'ones, i'.i\. peripheral neuritis. Ac-
rurding to J. .J. Thomas and ollicrs who have made
careful studies of the nervous .systenL using modern his-
tological methods, the process is one of fa^ty degenera-
tionr which begins in the myelin sheaths. The axones
afterward became beaded, break up and disappear. Both
489
l'araly#»lM.
FaralyslN.
HEFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
iiKitor and scDsory nerves are alToeteil. These changes
woukl appear to be much more freciiient tlian the palsy,
since they are very generally found at aulopsy, even
tliougli no paralysis has been noted before dealli. In all
<if Thomas' cases the vagus nerve showed more or less
anarked degeneration. Others have observed the same
tiling, as well as similar changes in the cardiac ple.vus,
the iifth cranial net vi. the nerves supplying the laryn.x.
. .'ind elsewliere.
The effect of the to.xic substances is not coidined to the
]ieripheral nerves, as there is a diffuse parenchymatous
degeneration of the nerve fibres of the spinal cord and
brain. Several observers, notably Bikcles, have found
tliat these changes were most marked in the posterior
columns and in the posterior ni'rve roots, a fact of inter-
est in connection witli tliose ca.ses which show ataxia as
a symptom. As to the effects on the nerve cells opinions
(iiffer, .some authorities even considering that the charac-
teristic symptoms are due to primary degeneration of the
motor nerve cells in the anterior horns, rather than to
changes which are primary in flie peripheral nerves.
The weight of e\ idence is strongly against this view,
however, and the changes in the nerve cells are probably
of relatively slight iniportanie and degree. The brain
a;id cord often sliow hyi)era'mia, and in rare cases mye-
litis or heiniu'iiiages. the latter sometimes being severe.
But the .symptoms in most cases depend on changes in
the peripheral nerves ratlier than in the central nervous
.sj'stem.
Of the muscles, the one in which the changes are of
tlie greatest cliiucal signiticance and in wliicli they have
been most carefully studied is the heart. According to
Councilman, Mallory, and Pearce'' degeneration in the
myocardium is one of the most common conilit inns found
in diphtheria. The simidest form is fatty degeneration,
which is found in the majority of all cases, and which
seems to ju'ecede the more advanced forjus of degener-
ation which lead to complete destruction of the muscle
fil)res. In these there is destruction of the sarcous ele-
ments, which bee(Jiue swollen, broken tip, and converted
into hyaline masses. Tlie degeneration may become so
extensive as to account fully for the impairment of the
heart's action. Acute interstitial lesions are also found,
and occasionally cardiac thrombo.ses and less important
vascular lesions.
Changes are also ()b>;crve<l in the skeletal muscles. It
is probable that, as Bagiiisky ■'' believc'S, the paralysis of
the palatal mus<-les reiiresents a myositis due to the direct
effects of the membrane in their close proximity, rather
than a neuritis. But w<' must also remember that the
vagus nerve, which sui)])lies these muscles, is almost al-
ways involved. Councilman, ^Jlallory, and Pearco'cb-
.served marked fatty degeneration of the tongue, dia-
phragm, and various muscles of the extremities, and they
Kl-onclude: "It seems probable that in all cases where
fatty degeneration of the heart anil nervous system has
occurred, a sinnlar cliang<' will be found in the skeletal
muscles. ''
The changes iiroduced in the nervous system by diph-
theria are thus summed up by Thomas:'' "(1) A marked
parenchymatous degeneration of the peripheral nerves,
.sometimes accompanied by an interstitial jiroeess, and
hypera'uuaaud hemorrhages. (2) Acuti', ditVuse, i>aren-
chymatcais degenerations of the nerve libres of the ccud
and brain. (3) No changes, or Iiut slight ones, in the
nerve cells. ^4) Acute parenchymatous and iidcrstitial
changes in the nniscles, es]iecially the heart muscle, (.j)
Occasional hyjieraunia, or infiltration, or hemorrhage in
the brain or cord ; in rare cases severe enough to produce
permanent troubles, such as the cases of multi])le sclero-
sis and of hemiplegia whicli liave br>en observed. Fi-
nally, the probability that the cases of sudden death from
heart failure in diphtheria during the disease or conva-
lescence are due to the effects of the toxic substances pro-
duced in the disease upon the nerve structures of the
heart." The changes produced in the nervous system,
then, involve chietly the lower {spino-muscular) segment
of the motor ])ath.
The sv.MPTO.MS in tlie ordinary peri])heral form of pa-
ralysis may begin as early as the fourth da}', while the
patient is still ill and while the meiubrane is still present,
or they may be delaj'cd for many weeks. The usual time
is from one to three weeks after the disappearance of the
membrane.
The distribution of the paralysis may be judged from
the following figures of the American Pediatric Society's''
189 collected cases: Throat, 124; extremities, 22; eyes,
11; respiratory muscles, 5; heart, 32; neck, 1; general,
8. Ross''' collects ITl cases, distributed as follows: Pal-
ate, 128; eyes, 77, of w-hich .'54 involved the muscles of
accommodation; legs, 113; arms, GO; trunk or neck, 58;
respiratory nniscles, 83. In Goodall's* 12.5 cases the
palatal muscles were invnlved 1(13 times, the ciliary mus-
cles 50 times, the legs 52 times, the external ocular mus-
cles 26 times, the arms 21 times, and the pharyngeal
muscles 11 times. Obviously the throat is the region
most often affected and the eyes and extremities next.
When the extremities are involved the disease is charac-
teristically more common in the legs than in the arms,
which, in severe cases, are involved later.
The symptoms begin gradually, and usually a number
of difl'erent partsare involved successively, improvement
taking plac<' in one while the di.sease advances in another.
It most commonly begins in the throat, and the palate
may be the only part affected. As a result of the in-
volvement of the palate the nasal cavity is not shut off
from the nasojjharynx in swallowing or in speaking.
The child is observed to regurgitate its food, a symptom
which may become .so severe that deglutition is impos-
sible. The voice becomes nasal in character. Extension
to other museles of the throat and mouth may lead to
inability to blow, whistle, suck, or gargle. The muscles
are bilaterally or rarely unilaterally involved. Paralysis
of the constrictors of the cesophagus is eviilenced by the
entrance of food into the glottis. Cough, hoarseness,
aphonia, and paroxysms of dysjino-a are seen when
the larynx is involved. There may be difficulty in ar-
ticulation or in protruding the tongue. Facial par-
alysis is rare, as is also paralysis of the tongue or (esoph-
ag\is,
AVhen the eyes are involved dimness of vision fcu' near
objects is noted, and is due to loss of the power of ac-
commodation from paralysis of the ciliary muscles. The
patient usuallj' first complains of dimness of vision. The
failure of accommodation leiiches its height in a few days
and generally lasts two or three weeks. The pupil may
be dilated. Ophthalmoplegia externa — squint or double
vision — and ptosis are rarer. Sometimes most or even
all of the muscles of the eyes become parah'zcd. In-
volvement of the hearing, taste, and smell are recorded,
but are rare.
When the extremities are involved there is gradual loss
of power, beginning almost always in the legs, afterward
extending to the arms in severe cases or even to the trunk
and neck, so that in the worst cases the patient becomes
a helpless mass. But such cases are rare, and the loss of
power is seldom absolute. The distribution is usually
symmetrical. In contrast to flic alcoholic form of neu-
ritis subjective sen.sory symptoms are ordinarily slight.
There may be numbness, tingling, liypen^sthesia, or an-
!estliesia; but in most cases these symptoms cause little
distress. According to Gowers^ ana'sthesia is always
most severe toward the extremities of the limbs, and lie
mentions cases in which sen.sjition was lost only in the
finger-tips. As in all forms of degeneration of the lower
motor neurone, the muscles beeonie flabby and atrophy
occurs. The knee-jerks are commonly lost, and lost re-
flexes are sometimes the only evidence that the nerves of
the extremities are involved. It is said that in some
cases the)' are retiiined. During convalescence there may
be increased knee-jerks and ankle clonus.
The electrical reactions are variable; according to
Northrup so much so that they are of little value in diag-
nosis or prognosis. As a rule they are altered, the mus-
cles showing decreased reaction to faradism with tli<'
reaction of degeneration, and the nerve tnniUs shirwing
-!r90
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Paralysis.
Haralysis,
di'civast'd irritability to both cum-nts." Tlic blaildi.'r
auil rectum arc rarely iuvolved.
Reference has already been made to the occurrence of
ata.xie symptoms in diphtheritic paralysis, and to the view
of Bikeles, which explains them as due to degeneration
of the posterior columns of the c<ird. These symptoms
are clumsiness in the use of the limbs and unsteadiness
in walking. The gait is .seldom so markedly ata.xic as in
true talies. The Romberg symptom is jMoniinent. Lack
of knee-jerks and sluggish pupillary reactions complete
the picture, which, however, is often masked by the mus-
cular weakness.
One of the most serious complications of diphtheritic
paralysis is extension to the muscles of respiration. It
occurred in 3iJ of Ross' ITl cases.'-' and 21 times in 375
cases reported by Jleyers. ' ' Either the diaphragm or the
intercostals may be involved. The average time of onset
in Meyer's cases was the thirty-seventh day, but it oc-
curred as early as the eleventh and as late as the fiftieth.
Pysjma'a is a marked symptom, and is seen in the form
<if asthma-like paroxysms or in spasmodic attacks due to
the accumulation of mucus. There are anxiety and men-
tal distress with a sense of impending suffocation. When
the diaphragm is involved abdominal breathing is re-
versed, the abdomeu sinking in on inspiration, and i-ice
versa.
The symptoms of cardiac paralj'sis occurring in diph-
theria are of the greatest importance, owing to their fre-
quency, seriousness, and bearing upon questions of treat-
ment. " Their exact cause is a matter of doubt. Changes
are found at autopsy both in the myocardium and in the
nerves controlling the heart. As has alreadj- been said,
the myocardium ^iia.y show degeneration sufficient to ac-
count in full for all the symptoms. Some, however, be-
lieve that the nerve changes are primary. Thomas and
Hibbar(l.'"in an exhaustive investigation of the subject
of heart failure in diphtheria, favor Hesse's view.'- that
heart failure results directly from the effects of the poi-
sons of the disease rather than from Ihe degenerative proc-
esses which they cause in the tissues; but tliey consider
that tlie.se toxins act through the nervous mechanism. It
.seems probable that the origin of the heart symptoms may
be due either to changes in the myocardium or to changes
in the nerves controlling the heart, or to the effects of
toxins on the nerve centres. In any given case the ex-
act cause of heart failure can be stated only after death,
but it seems fair to suppo.se that those due to the direct
•effect of the diphtheritic poisons will occur early in the
disease, just as they do in oilier acute conditions, wliile
those due to organic degenerations may occur later.
Cardiac svmptoms are observed in diphtheria at a rela-
tively early date as compared with the other palsies; ac-
cording to" ■\Voodhead,'* mostly between the fifth and
tenth days. The average in jleyer's cases" was the
seventh." But sometimes the}- aiise late in convales-
cence. Occasionally they are overlooked, and sudden
death after slight over-exertion takes place in a case ap-
parcnlly well. As a rule, some aljnormal condition of
the pulse first calls attention to the heart. It is unusu-
allj' rajiid or unusually slow, or ofteuer it is irregular or
intermittent. The heart, wiien mapped out liy percus-
sion, generally shows some enlargement. Systolic mur-
murs, most of which are temporar\'. may be heard.
Pallor, cold extremities, dyspncca, and cardiac distress
are noted. Vomiting is an important symptom, whose
occurrence, tinlcss otherwise explained, in diphtheria
should always call attention to the heart. Its associa-
tion with cardiac failure is supposed to depend upon
the common relationship of the vagus nerve to both the
lieart and the stomach. Death may occur within twenty-
four hours after the onset of cardiac symptoms, or, as
has already been said, it may take place suddenly with-
out warning. In most of the heart cases there is evidence
of paraly.sis elsewhere.
Brodie," as a result of animal experimentation, and
Biernaeki ■-'' from clinical observation, consider that the
fall of blood-pressure occurring in diphtheria is a result
of paralysis of the muscular walls of the vessels. It is a
([uestion, however, whether the action is local or central,
and to what extent impairment of the heart's action is
responsible for the phenomena noted.
■There are other forms of paralysis which are sometimes
associated with diphtheria, but they occur more rarely
and they need but brief mention. One is sudden cere-
bral hemiplegia, due generally to embolism, more rarely
to hemorrhage or thrombosis. Meningitis is sometimes a
sequel of diphtheria, and cases of multiple sclerosis have
been reported by Scluinfeldt. The paralytic symptoms
which they cause could hardly be mistaken for the com-
uifin form.
Diagnosis. — This depends on the recognition, during
an attack of diphtheria or in convalescence from the
same, of a peripheral neuritis or. in some cases, of a myo-
sitis. The most significant peculiarities of the diphthe-
ritic form of neuritis are the frequenc}- of involvement of
the throat and eyes, the process often beginning in the
former, the symmetrical distribution, the tendencj' to
involve the legs before the arms, the slightne.ss of sen-
sory symptoms, and the frequency of cardiac mani-
festations.
In making the differential diagnosis other forms of
peripheral neuritis must be excluded, especially in cases
in which the causative diphtheritic infection has escaped
recognition, in which more than one cause is i.)resent, or
in which the palate and eye symptoms have been slight
or lacking. The chief forms of neuritis to consider are
those due to alcohol and to lead. Alcoholic neuritis is
rare in children, does not involve the throat, and has
more prominent sensory symptoms. Other evidences of
alcohol are usually present. Lead palsj- begins gener-
ally in the arms, involving the extensors and giving the
characteristic wrist-drop. It is usually associated with
other evidences of lead poisoning, such as the blue line
on the gums, the cachexia, colic, traces of lead in the
virine. and granular degeneration of the red corpuscles
of the blood. Other forms of neuritis may be ruled out
on similar lines. Jlixed forms occur, but in such cases,
apart from questions of prophylaxis, the cause is rather
of academic than of practical impoitance. Cases of
diphtheritic paralysis .showing luarked ataxia ma}' be
mistaken for tabes dorsalis. The post-diphtheritic dis-
ease, however, develops more rapidly ; true lightning-like
pains are not experienced; and the loss of motor power
with atrophied and flabby muscles is absent in true tabes.
Acute poliomyelitis is also of importance. Here the on-
set is more acute, paralysis is not symmetrical, and the
sensorv symptoms are lacking. H}"sterical palsy seldom
involves "the palate, as diphfheritic paralysis almost al-
wa.vs does. In hysteria the knee-jerk is retained. The
greatest difficult}' arises in cases in which a true diphthe-
ritic paralysis is combined with hysteria.
Pkogxosis. — This will depend upon the site of the
paralysis, the severity of the case, and the previous con-
iliiion of the patient. Of Goodall's V2'> patients IT died:
4 in the acute stage of diphtheria; C fatal cases were car-
diac, 4 respiratory, 2 vomiting and cardiac. 1 convul-
sions.* Of Ross' 171 patients 4.j died : 8 from intercurrent
diseases, 8 from sudden syncope, II) from heart failure,
14 from respiratory paralysis, and 2 from the aspiration
of food into the trachea.''' According to Cowers.-' the
sooner the paralysis begins after the diphtheria the
greater the danger to life.
Paralysis of the extremities of itself causes little dan-
ger to life, and recovery may be predicted, even though
it may be months before power is I'ompletely restored.
The duration is often from six to eight weeks. The
loss of knee-jerks is generally the last sign to disajipear.
In the throat cases there are "two sources of danger. The
first is that arising from thi' frequency with which jiala-
tal involvement isassocialcd with heart symptoms. The
second danger arises from the dilbeulty of deglutition,
patients dying from inanition on this account, or from
the aspirat'ion"'of food into the trachea with resulting as-
phyxia or bronchopneumonia. In respiratory eases tlie
outlook is always more duliiovis. Jleyers'" reports 21
patients affected with diaidiragmatic palsy, of whom 11
4!)1
Paralysis. [tiplox.
l*araiiiyoc1ouu8 lYIiil-
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
ilicd, this being 13.7 per cent, of all ileaths from dipli-
thcritic paralysis in his series.
Cardiac ]iaralysis is even more fatal. Statistics are of
little value, as dilTerent observers vary so greatl3' in flie
criteria vipon which they base their diagnoses. All 33
cases collected bv the American Pediatric Society' were
fatal. Hihbard '"' reports 47 per cent, of deaths in cases
with irregtdar pidse. Vondting during convalescence
from diphtheria generally means heart failure, is an un-
favorable sign, and occurred in over half of Hibbard's
fatal cases. "According to Burrows '- it is especially to
be feared when it occurs in a jiatieut whose heart is
irregular, or who presents other evidences of nerve de-
generation. A very slow pulse is also unfavorable, espe-
cially in children. "The patients may die witliiu twenty-
four" hours of the onset of cai'diac sym]3toms, or later
during au exacerbation. Sudden death from heart
faihu-'e witliout jirevinus symptoms may occur in the
acute stage, or it may snddi'uly and imexiiectedly ter-
minate acase after cnnvalescence has appeared to be
completed.
TiiK.\T-MENT. —The varying results of statistical studies
as to the effect of antitoxin have already been mentioned
in connection witli the subject of etiology. It seems
probalde that the early and vigoro\is use of antitoxin in
any given case will decrease tlie likelUiood that this com-
plication will occur, liut (iidy in so far as it lessens the
severitv and duration of the causative di.sease. That
this view is correct is proven on the experimental .side
by the work of Ransom,' wlio shows tliat doses of the
toxin capable of pniducing paralysis iu animals are neu-
tralized in this respect by antitoxin injected simulta-
neously and modified, though not prevented, by large
enough doses given from tifteen to twenty-two hours after
those of the toxin. On the clinical side the report of the
Loudon Clinical Socict}--' shows that the frequency of
paraiy.sis as a complication of diphtheria is less when
antitoxin is used on the first two da.vs of the disease than
when its use is delayed. After the injury to the nerves
or muscles has been done, it is not probable that antitoxin
will have any effect in restoring tliem to the normal con-
dition. The same conclusions probably hold in regard
to the heart manifestations. In oiher w^ords, antitoxin,
given early and iu large doses, has some value as a pro-
phylactic iu preventing the paral.ytic complications of
diphtheria.
On the peripheral neuritis no form of treatment lias
much effect. The case should be managed like a neu-
ritis from any other cause. Rest, careful nursing, lib-
eral iliet, tonics, massage, and electricity are of some
value. Strychnine is much used, but its intluence in re-
storing the degenerated nerves and mu.scles to their nor-
mal condition is at least questionable. In palatal, and
especiall.y in pharyngeal antl laryngeal cases, great care
shoidd be taken in feeding the patient to prevent the
entrance of food into the larynx. The oesophageal or
nasal tube may be used if needed, great care being taken
to avoid introducing it into the larynx and to get the end
well below the glottis. In some cases it will be better
to feed by the re<-tum. Forced feeding had better not be
delayed in hope that tlie child will Ijegin to eat, especially
in cases in which the patient is much debilitated by a se-
vere attack of diphtheria. Proper and sufficient nourish-
ment is of importance Ijothinthe treatment of the general
depressed condition and in that of the paralysis.
One precaution shovdd be insisted upon. Every case
of diphtheria .should be wat(/hed closely for the occur-
rence of cai'diac or respiratory symjitoms, especially
when evidences of palatal paralysis are present.
Thomas and Hibbard '" advise that every case of diph-
theria, however mild, should be kciit in bed till the
tlu'oat is clear, and, if there has been any prostration, for
at least two weeks more. After four %\'eeUs with no
heart symptoms there is little danger. If heart symp-
toms arise, the greatest care must be taken to keep the
patient qinet, morphine being used for this purpose if
needed. Carefid feeding is of impoitance. Medicines
are of value only iu meeting special synqitoms. Alco-
hol, digitalis, and strvchnine may be of service. In the
respiratory cases strychnine is the most valuable remedy.
Electricity may also be used. Ralph C. Larrabee.
4.35.
References.
Ransom ; Journal uf Pathology and Bacteriology, 1900, vol. vi., p.
^ Welch and Flexner : Bulletin ol the Johns Hopkins Hospital, 1.S91,
vol. ii.
3 Gowers : Diseases of the Nervous System, second edition, vol. ii.,
p. sue.
* Thomas: Boston City Hospital Medical and Surgical Reports,
ninth seiies, l.ssts, p. 52.
' Baffiiisky : Niilhnagel's Specielle Pathologie und Therapie, lid. ii.
^ t'ounrilinan, Mallory, and Pearce : "Diphtheria," 1901.
" American Pediatric Society, Collective Investigation: Transactions,
1896.
' (ioodall : Brain, 18a5.
" Northrup : Nothnagel's System of Practical Medicine. American
edition.
'° Thomas and Hibbard : Boston City Hospital Medical and Surgical
Reports, eleventh -series, 1900.
"Hibbard: Boston City Httspital Meilical and Surgical Reports,
ninth series, 1S9S.
'2 Burrows; American Journal of the Medical Sciences, February,
1901.
13 Henoch : Lectures on Children's Diseases, vol. ii., 1S89, p. 300.
n Ross: Me.li.'al Clinillicl.-, 1.S90.
>' \V(.o.|lii;i,l : Uritisli Me.liral Journal, September 3d, 189.S.
>• Tn-vrlvaii : Lancet, I'.KKI. ii., p. 14fi2.
" Meyeis : Lancet, 1900, ii., p. 869.
'^ Hesse : Jahrbuch fiir Kinderheilkunde. 1.S93, Bd. sxxvi.. S. 19.
" Brodie : British Medical Journal, November 4th, 1899.
™ Bli-rnacki : British Medical Journal, December :Wth. 1899.
= ■ Lond..ll Clinical Society: Report on Alitito.xin. 1S9S.
(For fui'tliHr biblio^-rajiliy cnnsnll tin- arucles of Nmlhrup, Ross, and
Thomas. )
PARALYSIS, FACIAL. See Fadal Paralysis.
PARAMUCIN.— Mitjukoff has obtained from the mu-
coid contents of ovarian cysts a mucin-like sub.stanco,
which differs from pseudomva'n and iinn'in. chiefi^' in tho
fact that without previous boiling with dilute mineral
acids it will reduce an alkaline solution of copper.
("UeberdasPai-:imucin," Airh.f. Gyii., Bd. 49. 189.5.)
'Aldretl Scott M'arthin.
PARAMYOCLONUS MULTIPLEX.— (Synonyms: Myo-
clonus iniilliplcx, Myocloni:!, I'olycloiiia.) Originally
deserilied by Friedreich' in IsSt, this disorder has been
recognized by clinicians in Germany, France, Italy, Eng-
land, and America. Its existence as a di.sease has been
questioned, some asseiting it to be a variety of hysteria,
others of chorea. Still others cut the Gordiau knot by
claiiuing that both a true form and a hysterical form of
the disease exist. However, the preponderance of au-
thority as well as of evidence at tlie present day appears
to favor its validity as a clinical entity.
It is a I'are disease. Gowers- states that he was able to
collect but fifty-two cases in the literatui-e up to July,
189.5, of which only thirteen were considered by him
true examples.
One of the best accounts of the di.sease accessible to
American readers is that of Starr,'' which is also accom-
panied by a bibliography.
The disease is characterized by paroxysms of clonic
muscular contractions, sliock-like, bilateral, and symmet-
rical as regards the two sides of tlie body. Tlie inilivid-
ual contractions ai'e frecpient. varying in rate from thirty
to one hundred or more per minute. The duration of
the paroxysms may vary between five or ten minutes
and some hours. Likewise the frequency of jiaroxysins
in a day may vary from one or two to twenty or more.
The muscles att'ected in typical cases ai'e the intrinsic
truncal uiusclesandtho.se connecting the trunk and ex-
ti-emities; those moving the face, hands, and feet being
seldom, if ever, affected (see Fig. 3738). Iu one case ob-
served by the writer,' the diaphragm and laryngeal mus-
cles were involved at times, causing short, sharp, invol-
untary exclamatory sounds.
Negative characteristics are: consciousness is not af-
fected; mental defects are absent as a rule, but, if pres-
ent, are transient; voluntary movements of the face,
hands, and fei't are not abolished, even during a parox-
ysm, tiiough the musciihir power is much '■educed; dec-
4(»2
REFERENCE HANDBOOK OP THE JEEDICAL SCIENCES, •^"'•"'y'*- (tiplox.
Fa rail!} Oil oil II 8 Mill-
trical i-lmugt's of dcgfiierative siguifii-auce are absent, as
is tibrillaiy twitching. Seusatiou is uot ilimiuishcd or
lost, but a decided liyperseusibility to souud aud touch
has been observed by tlie writer iu oue case.= A jirofound
sense of fatigue was also uoted iu that case. The con-
vulsive movements cease during sleep, and are brought
on, or, if ijresent, increased iu violence, by eniotioual ex-
citement, b_v irritation
of the skin, by cold,
etc., and by manipula-
tive procedures gener-
ally.
Oppenheini'' recog-
nized a hysterical type
as distinguished from
the true form, but ad-
mits the difficulty of
separation.
Unverricht. Weiss,
Kreiver, and Sepilli
(quoted by Oppen-
heini) describe cases
of a familial type and
associated with epi-
lepsy {he. cit.).
Cavs.\tion. — The
patients are usually
neurasthenic. A ma-
iority of cases reported
were of the male sex.
The ages of patients
liave varied between
thirteen and forty-
eight. Mental worry,
fright, injury, and
physical strain are ac-
credited causes. Of
two cases reported Ijy
the writer one was at-
tributable to mental
worry combined with
la grippe. The other
was distinctly due to
fright. A third case,
observed by the writer
through the kindness
of Sir William Gowers,
followed a fall from a
considerable height
without palpable in-
jury. Fry'scase' was
due to overexertion.
Stand's' to strain in
lifting. Removal of
the thyroid iu dogs is
said sometimes to cause
symptoms of this dis-
ease.
The p.\THOLOGV is
unknown. Autopsy
in one case (Schultze)
revealed no nervous changes. Friedreich, who was the
first to describe the disease, believed it to be based on
overexcitability of the spinal motor elements. Some
have surmised that the cause of the faulty action lies
in the muscles themselves or in an abnormal state of
the nerve endings. To the writer its psychic anteced-
ents, marked hemiplegic preponderance at times (in oue
case); its aggravation by mental and emotional states;
the marked, though transient, mental changes in two
cases; and the heightened muscle reflexes, would all
suggest that the disease is to be viewed as the visible
expression of a state of ^'inhibiiory insuffl^iency,'^ prob-
ably cortical in seat.
Diagnosis.— This is to be based on "the sudden shock-
like character of the muscular contractions, their bilateral
symmetry, and the comparative freed'om of the extremi-
ties." (Gowers.') This view is also concurred in bv
Walton'' iu a recent paper on the myospasms in general.
Hysteria is ruled out by the absence of the stigmata and
of the characteristic emotional state. There ajiijears to
be no tendency to simulation or desire for sympathv in
jiaramyoclonus. Cliorea is excluded by the non-invo'lve-
ment of the face aud hands. Dubini's "elccliical chorea,"
a disease endemic in a certain locality in Italy, is to
-1.— Fruut View.
FIG. 3738.-^1 and B. Paramyoclonus
B.— Rear View.
MuUipl(>x. Distribution of myoclonic spasm indicated by plus marks.
be separated by its unilateral beginning, nerve aud mus-
cle degeneration, and a fatal termination in a few months.
The PROGNOSIS is variable, according to different au-
thors. Friedreich reported that some of his patients re-
covered. Oppenheim considers the juognosis grave.
In all the American cases reported to date the patients
have recovered. Relapse may occur, but does not pre-
clude ultimate recoveiy.
The duration may vary from three or four months to a
j'ear or more. In one of the writer's cases the convul-
sions ceased on the one hundred and second day, but re-
curred in twenty-four hours, to disappear again iu eight
days. There has been no recurrence to date (four
mouths). In the case re|nu-ted by Starr {loc. cit.) the pa-
tient recovered in about a year, as did also the patient in
the first case reported by the writer. ^
Tre.\tment. — The drug treatment followed h:i*i been
•i93
Para|»li iiiiosis.
Para|il«'y;ia.
HEPERENCE IIANDISOOK OK THE .MEDICAL [SCIENCES.
so diverse as to suggest tliat it has luui little to do with
the recovery. Chloral, bromides, hyoseiiie and other
.sedatives, arsenic, quinine, thyroids, and galvanism luive
all been followed by improvement and recovery. Tlie
factors of rest, feeding, and time wo\dd appear to be the
important ones. Sedatives may be used to mitigate the
severity of the spasmsand iiromotethe patient's comfort.
Nutrient medication, in the form of glyccrinophos-
pliates, iron preparations when indicated, and support-
ing measures generally, are advisal)le.
F. ]1". l.iiu'jdon.
Ekfkkknces.
' Friedreich : Virchow,"s .\rchiv, nd. Ixxvi., 421.
= W. R. Gowers : Clinical Lecture ; .National Hospital for the Tar-
alyzert and Epileptic, London, ISSfi (iinpuhlislied).
"3 M. A. Starr: Familiar Forms of Nervous Disease. New York.
William Wood and i onipanv. 18111, 2t4 ; also Journ. Nervous and Men-
tal Disease. 1SS7. 4H> (tile same case).
' Oppenlieim : Pisea.sesnf the Nervous System. American edition
(Maveri. Lippincott, Philadelphia. \vm.
=■ F. W. l.anedon: Paramyoclonus Midtiple.x. Cinoinnati Lam-et
and Clinic. ISiW, 14."); .lournai Nervous and Mental Dis.. liXK, 541.
■^ F. R. Fry : A Case <)f Paramvoctonus Multiplex. Journal Nervous
and Mental Disease, Wss, :«7.
■ W. R. Gowers : Manual of Diseases of the Nervous System, 1899,
ii.. 630.
• G. L. Walton : Contribution to the Study of the Myospasms, etc.
Journal Nervous and Mental Disease. 1902, 4()3.
PARAPHIMOSIS. Sec t^iimd Orqans, Mn',, Dixcaxes
<'/■
PARAPLEGIA. — Tlie term paraplegia specitics a symp-
tom, ucd a di.sease. It indicates, in the first place, an
impairment of motility, namely, akinesis or paralysis,
and secondly, parah'sis of a certain distribution. Thus,
it is customary to indicate a paralysis involving one of
the extremities by the term tuonopli'tiiii . a paralysis of
lioth extremities on one side of the body, that is to say,
of longitudinal or unilateral distriliulion, by the term
!it/ii/jilt'f/i<i, while a transverse distiibutiou or symmetri-
cally bilateral paridysis of the bod_v is classified as a
pa I'd pit'!/ 1 (I (pitra, Gr. Trapa, side by side). Usuallj-, the
lower extremities and tlie caudal portion of the body are
the parts involved. The term is not restricted, however,
to paralysis of these parts alone, but niaj' be tipplied to
the involvement of any transverse section of the body.
When the upper extremities are involved, the term
cevcictil jiiinijilir/iti is applied. In this condition, usually,
though not alwaj's, paralysis extends to all parts below
— camlad. The term /iciiii-par<iplir/ia refers to jiarah'sis
of one lower extremity, accompanjed by ana'Sthesia of
the opposite member. It is, strictly speaking, a crural
monoplegia. The term double hemiplegia is synony-
mous with cerebi'al piaraplegia, both indicating a para-
ple.gia of intraciunial origin, involving the cerebral motor
tracts, Tlie term ocular pai'aplegia has been used,
rarely, to indicate paralysis, in both eyes, of syninietri-
cal ocular muscles. Tlie term diplegia is to be iireferred
in cases in which a single pair of nerves on each side is
paralyzed ; as facial diplegia, instead of facial paraplegia,
.Taccoud introdui-ed the adjective puniphf/iforin to indi-
cate bilateral disturbances of motility other than true
paresis or paralysis, but which resemble the latter iu
disturliance of locomotion; as, for example, that pro-
duced by incoordination, and spastic conditions.
In paraplegia (it being defined as paralysis of a certain
distrilnition) we have an important symptom of various
pathological conditions, forming by its as.sociation with
other symptoms some of the most striking clinical pict-
ures of disease. Its proper study involves the consicicra-
tion of the localization of function, the impairment of
which produces paraplegia; the nature of tho |iatliologi-
cal [iroccss causing such impairment ; the varitttions in
disturbance of function due to involvement of dilferent
segments of the body ; the other syniptonis wliich may
accompany it; and the diagnostic and prognostic signiti-
cance of the grouping of such symptoms, together with
indications for remedial measures.
From this standpoint paraplegia forms a convenient
centre from which may be analyzed a great luiniber of
di-seases of the nervous system, mostl_y of spinal origin,
hut also including some cerebral iuid peripheial nervous
tiftections. As we have a motor imjiairment to consider,
I he motor tracts of the nervous system must be called to
mind. From their periphery in the motor end-plates
they ])ass through the mixed peripheral nerves, the ante-
rior roots of the spinal cord, tlie root zones in the anterior
columns, to the anterior cornua of the cord, where the
motor nerve fibres are suiiposed to terminate iu cells-
ananged in groups or scattered through the gray matter^
of this poriion, and by means of which they form refle.x
connections with sensoi-y nerve tracts, commissural con-
nections with
the motor ti-acis ( v^
of the ojiposite
half of the cord,
and with differ-
ent levels of the
cord above anil
lielow : and, in
addition, c o n-
nection with the
motor tracts in
the lateral col-
umns of the cord
known as the
crossed )iyrami-
dal, cerebral, or
voluntary tracts,
and the direct
pyramidal tracts
in the anterior
columns. After
decussation of
the crossed pyr-
amidal tracts in
the medulla,
both crossed and
direct tracts pass
through the an-
terior (ventral)
portion of the
pons, continue
through the
crura cerebri,
then ujiward,
forming a part
of the internal
capsule, and on
to the so-called
cortical motor
areas. Associ-
ated tracts
through the
ceiclielluni, the
ceiebral gan-
glia, and the
nuclei of the
cranial motor
nerves complete
the S3'stem. In
order to produce
paraplegia, not
onl_y must some
part of this mo-
tor system be
affected, but the
lesion must be
symmetrically
bilateral, must
involve both
halves of this
duplex system.
The general di-
vision may be
made, tlierefore, into peripheral, spinal, and intracranial
(cerebral) paraplegia. The divergence of the right and
left motor tracts iu their perii>heial and cerebral por-
FIG. 3739.— Diagram Showing the Relations of
the Spinous Processes to the Bodies of the
Vertebni?, and of these to the Points of Origin
of the Spinal Nerves, (From Gowers.)
4!»4
REFERENCK JIANDHOOK oF THE MEDICAL SCIENCES.
I'»riipliitii(>ftfA»
l*ai*ai>loy.ia.
tions, ami their ai)])roximatioii in tlie spiual cord, me-
dulla, and pons, admit of their frfqucMit bilateial involve-
ment from lesions in the latter regions, and liut rarely
iu the first-named divisions. Con.sequeutly, the lesion
producing parajdegia is usually a spinal-
cord lesion. Yet it is possible to have a
tumor develop in the longitudinal tissiire
between the hemispheres, which will in-
volve the motor areas for the leg.s in each
hemisphere, thereby producing a sj'uj-
metrical and bilateral paralysis of the
lower extremities, namely, a cerebral para-
plegia. On the other band, it is now well
known that a peripheral parajdegia nuiy
be produced by a multiple neuritis in-
volving the i)eri])heral nerves of both
lower extremities in such a .symmetrical
manner as closely to resemble spinal-cord
lesions. Compression within the spinal
cord of the bundle of peripheral nerves
known as the cauda eq\iiua may also give
rise to paraplegia. In the latter case, and
al.so in multiple neuritis, we have the
phenomena which attend irritation or de-
struction of a mixed nerve, namely, motor,
sensory, and trophic disturbances in the
parts supplied by the nerves involved.
Hut motor, sensory, and trophic disturb-
ances ma)^ also occur when the lesion is
in the spinal cord, provided it be exten-
sive enough to involve both motor and
sensory tracts, and at a level from which
the upper or lower extremities receive their motor in-
nervation, namely, tlie anterior conuia in the cervical
and lumbar enlargements. Lesions between these en-
largements, or above the former or below the latter, do
not produce the trophic disturbances which result in de-
generation of peripheral motor nerves of the extremities,
and the consequent atrophy of the muscles which they
supply ; although voluntary power and sensation may
be lost through interruption of the cerebral motor and
sensory conducting tracts traversing the section of the
cord involved by disease.
Myelitis affecting the entire transverse area of the
cord, but limited in its longitudinal extent to some por-
tion between the cervical and lumbar enlargements, com-
monly known as transverse dorsal myelitis, furnishes an
example' of this form ; while involvement of the lumbar
enlargement will serve as a typo in wiiich motor degen-
eration and atrophy are added. Similar residts may fol-
low a meningitis, or meningo-myelitis involving the
sensory and motor nerve roots or root zones at the level
of the lumbar enlargement. Paraplegia, unaccompanied
by loss of sensation, may be conceived of in case the
meningitic or myelitic process remains limited to the an-
terior periphery of the cord, or to the auteriorhorus of the
lumbar enlargement, by which the motor tract would bo
involved ami the sensory tracts escape implication.
A similar process alTecting the cord at its cervical
enlargement alone might produce bilateral paralysis of
the upper extremities without involving the lower ex-
tremities, as long as the mj'elitic process did not extend
deeply enough to invade the pyramidal tracts in the
lateral columns. Should it so extend, however, the
lower extremities would exhibit paraplegia without loss
of sensation and without mu.scular atrophy; while with
a complete transverse lesion at the cervical enlargement
loss of sensation in all parts below the upper extremities
would be added, but still withovit degenerative atrophy
in the lower part. The meningitic process might be
extensive enough to involve both cervical and lumbar
enlargements, affecting chiefly the anterior periphery of
the cord, producing a paraplegia involving both upper
and lower extremities with muscular atrophy in both,
and even a transitory loss of sensation; or the gray
matter of the anterior horns may be involved through-
out the cord on both sides, as in poliomyelitis an-
terior, with similar results. Finally, we may have in-
volvement of the cerebral (pyi-amidal) motor tracts in
the lateral colunms of the cord at any height, cutting-
o(T voluntary innervation to all parts supplied below
the lesion, but without producing trojiliic disturbance.
J'oifwo
Fig. 3740,— Diagram of a Sertion of Uie Spinal Cord in the Cervical Region. A.C.,
Anterior commi.ssure ; P.C.^ posterior commissure; /.Cf..s., intermediate gray sub-
stance; P.cor.^ posterior cornu ; c.cjy.^ caput cornu poslerioris ; _L. L. L., lateral
limiting layer; A.-L. .1. T., antero-lateral ascending tract, which extends along
the periphery of the cord. (From Ciowers.)
These examples show the necessity of keeping before
us a mental picture of the topographical anatomy of the
nervous system, and a recollection of the funt"tions of
the different tracts to the extent known, in all our
attempts to localize a lesion from the symptoms found.
The disturbances which accompany the bilateral pa-
ralj'sis constituting paraplegia will vary (1) ncciirding Id
the, Icrd of the lesion thi'ough intei'ference with the vis-
ceial, vaso-motor, sensory, and reflex functions of the
segment involved; (2) accoriliny to the e.rteut of the lesion
traiiseenel!/ in, (he conl, through involvement of different
ftmctional tracts and centres; and (3) aceonlin'i to the
predominance of an irritatiee, or of a deistnictiee pathologi-
cal process constituting the lesion, producing increase,
diminution, or perversion of function. The first and
second factors concern the localization of the lesion, the
third its nature and course. To aid in the considera-
tion of the former, diagrams and tables are given, and a
brief resume of certain anatomical and plivsiological
data.
The spinal canal is longer than the coid, the latter
terminating in man at the upper border of the second
lumbar vertebra. The exits of the several spinal nerves
do not, therefore, correspond to their levels of origin in
the cord, nor do the bodies of the vertebras correspond to
their spines. Gowers' diagram (Fig. 3739), showing the
relations of the segments, nerves, and bodies of the
vertebrte to the s])inous processes, together with the
table (Fig. 3741) showing the functions of the dilTerent
segments, are valuable aids to diagnosis. The cervical
enlargement corresponds to the lower five cervical spines ;
the lumbar enlargement to the tenth, eleventh, and
twelfth dor.sal, and first lumbar spines.
The ascending tracts of the spinal coid ai'e (1) the an-
tcrodateral ascending tract of Gowci's, supposed by him
to conduct painful sensations; (2) the dii'ect cerebellar
tract, whose function is unknown ; and (3) the posterior
columns, which conduct tactile and muscular .sensations.
Fibres serving the latter function, it is thought, occupy
pait of the median division of the posterior colunms
(columns of GoU), and do not decussate, while other sen-
soi'v fibres do. The external columns (columns of Bur-
dach) include the posterior i-oot zones and fibres having
a short cotirse up and down the cord, probably decussat-
ing at higher levels, or connecting different levels of the
cord. The ascending tracts degenerate upwai'd from the
495
Paraplegia.
Paraplegia.
ItEFERENCE HANDIioolC OF THE >1EI)KAL SCIENCES.
level of a destructive lesion. The desccndiug tracts are
tlie direct and crossed ii_vraini<lul tracts, coucernctl in the
transmission of cerebral inijiressions downward to the
motor centres in the anterior horns. They diminish iu
size downward, going chiefly to the cervical and lumbar
eiilai-genient ; tin- direct tract mostly to the former.
Tlie remaining parts of the anterior cohunn and the
lateral limiting tract are suppo.sed to contain commis-
sural conductors of motor imimlses between different
levels of the cord on the same side. Tlie anterior roots
originate in llie gray matter of the anterior cornua as
already described,' tra"verse the anterioi- columns (anterior
root zones), and go to the muscles. In connection with
the sensory roots througli the gray matter, they consti-
tute the "Vetle.x arcs," interrui>tiou of either the motor
or sensory division of which aljolishes retiex action in
that segment. Destruction of any portion of the motor
division from the muscles to the cells of the anterior
cornua, including the latter, besides producing paralysis
and abolition of reHe.v action, also causes atrophy in the
muscles and the corrcs]ionding motor tracts up to the
point of li:iiion, which is characterized by tlie electrical
reaction of degeneration. Tliis does not follow a lesion
of any other part. Destruction of the pyramidal tracts
causes a degeneration of the column downward from the
point of lesion, but this does not usually go beyond the
connections of these tracts with the cells of the anterior
horns. Atrophy, and the reaction of degeneration are
absent . The retle.x arc is not cmly preserved, but refle.x ex-
citability is increased. Impairment of voluntary power,
and exaggerated motor reflexes frequentl}' amounting
to clonic oi' tonic spasm, characterize lesions of these
tracts. Lesions of the cervical region may be accom-
panied by tlistuibances of respiration, of the cardiac
functions, of the eilio-spinal centre (radiating fibres of
iris), and by vaso-motor phenomena, showing either in-
creased or diminished functional activity, as the lesion is
irritative or destructive. Lesions iu the lower segments
of the cord interfere with certain functions of the blad-
der, the rectum, the sexual, and the vaso-motor appara-
tus in a similar manner, serving as aids to localization.
As disturbances of the bladder and rectum are usually
important features in the paraplegic state, their complex
functions should be referred to. Each of these organs
has two sets of muscles, which are opposed to each other
in action — the detrusors, which expel the excretions, and
the sphincters, which oppose expulsion. Besides the
local nervous apjiaratus which are found in the walls of
all hollow muscular organs, and which probablj- consti-
tute a reflex apparatus between the mucous membrane
and the subjacent muscular, vascular, and glandular
apparatuses, in a manner not fully known, these organs
have their oppo.si-d muscular movements represented in
the cord by motor centres situated somewhere between
the origins of the second and fifth sacral nerves, and a
reflex arc is established through sensory fibres from
their mucous membrane and muscles. In addition to
this there are sensor_y connections (i)osterior columns)
with the brain, and voluntary paths from the brain
(pyranddal tracts), by which a certain amount of control
is obtained over the spliineters and detrusors, the mech-
anism of which is but iin|ierfectly uudenstood. The im-
portant facts for pathology are that, as iu the involve-
ment of other motor organs, lesii^ns above the motor
centres in the cord simply cut off the sensory impres-
sions from these organs to the brain when the ascending
tracts are destroyed, and interrupt voluntary impressions
to them when the pyramidal tracts are destroyed. In
the former case, there is no consciousness of the neces-
sity of micturition or evacuation, and therefore no
attempt to restrain it. In the latter, tiiere is conscious-
ness of the necessity, but inability to resist the expulsion.
When both paths are cut oft' there is neither desire nor
power to expel the excretions — involuntary and uncon-
scious evacuations take place through the retiex mechan-
ism in the cord; but when the lesion destroys the motor
centres of the bladder and rectum, expulsive power and
the power of the sphincters are lost, and the retention of
excretions results, except evacuation due to the mechani-
cal expulsion of liqviid fteces and the dribbling of urine.
In most of the examples given to illustrate the ques-
tion of localization of the lesion, destructive lesions have
been assumed — that is to sa}', abolition or diminution of
function, rather than the intensified activity of an irrita-
tive lesion. It should be borne in mind, however, that
in most cases, before a pathological process becomes
destructive, an irritative stage has existed; and that the
irritative and destructive stages ma}' so vary iu their
course and duration that both processes go on at the
same time in different areas involved by the lesion.
Thus paralysis may be preceded by clonic or tonic
spasm; antesthesia, b}" pain and by paiivsthesia; aboli-
tion of reflex action, by an exaltation of the reflexes;
vaso-motor paresis and failure iu nutritive processes, by
functional exaltation. Or, as instanced in paraplegia
from transverse myelitis, between the focus of disease,
iu which function is lost, and the healthy portion, there
is usually a region of increased activity — an irritated
zone. The balance between these opposite conditions,
which shade into each other, and the degree and extent
of each, will vary with the nature and rapidity of the
pathological process producing it.
MOTOR (N-ERVES).
CI
St. mastoid,
Upper neck »
muscles, j
Upper pari j ^
Trapezius .
( Small rotators of
i" head
iiapuls
Tiapeiiu!
Trapezius
aud Dorsal
muscles
i Diaphragm
'. F
) Supinators J tn "
* Ex(. wrist A tingers.
I Ext. elbow
'. Flex, wrist & trngers
) Prouatora
;. Muscles of hand
t Intercostal!
1
10 J
11
12
Ll
, Abdomioal mus
Lumbar
muscles
Peroneus I. f
Flex, of J I
ajifcle.Eit. J
' . Cremaster
J Flexors of Uip
'- Exti-nflorsof knet
' Adductors of tiip
j f Ext. A abduit.of hip
. ,' Flexors of knee
t Intrlosic muscles of
i i foot
i
Co.
,- Perineal and
} muscles
I Sealp
2[ 1
Neck and upper
t partof chesl
Ha [ill
(ulnar u. lowest)
Front of thorax
} Ensiform area
Abdomen
(Umbilicus
lOth)
|_ Buttock,
I upper part
Groin .ind scrotum
(front)
Thigh
5 Leg, i
oul«r side
front
f Buttock, lower
1 part
^, Back of thigh
1 Leg ( f except
[_& foot ) inuer part
i [ Perineum and anus
' I Skin from coccyx Ui
i anus
n Scapular
. \ Epigastric
> Cremasteric
^ I Knee'
I Jerk
I Gluteal
} \ Foot
i cl07lU4
Co.
Fig. 3741.— Table Showing the Approximate Relation of the Various
Motor, Sensory, and Reflex Functions uf the Spinal Cord to the
Spinal Nerves.
Conceiniug the nature of the pathological process, the
common division into structural and functional will
serve our purpose ; meaning, by the latter, that in which
no perceptible change exists— abnormal variations in
those molecular movements wliich constitute functional
activity, and which arc, therefore, dynamic rather than
static in character. This class comprises many of the
defects due to unstable molecular conditions, partly
496
KEFEHENCE HANDBOOK OF THE MEDICAL SCIENCES.
Paraplegia.
Paraplegia,
inlieiitcd, partly acquired, and frequently dependent
ujion imperfect nutritive processes in the neural tissues,
<'itlier assimilative or excretory. From this extreme, we
have a gradation into coarser forms of molecular derange-
ment, and. finally, intt) those in which the microscope,
or the eye alone, distinguishes derangement in structure.
Taking the latter first, as being more tangible, wo find
that nearly all structural neural disease begins in non-
neural tissues. True, we may have direct traumatisms,
as cutting, cru.shing, and compression of neural tissues;
and there may bo degenerative processes originating pri-
marily in nerve fibres and cells, and direct toxic effects
from organic or inorganic poisons conveyed by the
nutrient fluids; but there is a larger group of disorders
which are secondary to infianunation, acute or chronic,
in the connective-tissue structure which forms the frame-
work or support of the neural elements, or to vascular
disease, such as hemorrhages, thrombosis, embolism, or
proliferative occlusion.
Leaving the consideration of these elementary propo-
sitions, we pass on to consider the actual clinical forms
of disease which result in producing paraplegia.
Taking the disease which most frequentlj- produces
paraplegia, myelitis, as a type, let us study its most
conunon form — namely, transverse dorsal myelitis. Tiiis
name imjilies that the entire transverse area of the section
is more or less involved in the inflammatory process, and
does not include the more limited centres of myelitis,
termed fucal lesions, which may be located in one-half
of the cord, and rarely produce parajilegia; thougli this
may result when independent foci in\(iive motor tracts
of tlie anterior horns or root zones, at the same level, or
the pyramidal tracts e\'en at dirt'erent levels. Where
several mj'clitic foci exist, the term iUsm-mi noted focal
'iiii/ditis is used. While the term " transverse " implies
that the longitudinal extent of the lesion is limited, this
is not construed in a narrow sense, and may be properly
applied when the lesion invades both the lumbar enlarge-
ment and the dorsal segments. When tlie entire length
of the cord is involved, the term iliffn.se mi/elilin in ap-
plied; this may be general— /.c, involving both wliite
and gray matter — or may be limited to the latter, when
the term diffuse piliomydit is (myelitis of gray matter)
is used. The terra poliomyelitis anterior indicates that
the anterior cornua alone are invaded; while the term
central myelitis, or diffuse ceiiti-ol i»//<"i/7/.s (according as
it is local or general), is applied to poliomyelitis origi-
nating about the central canal and invading anj- portion
of the remaining gray matter. Other adjectives are in
use — such as hemorrhae/ic lui/elitis, when secondary to a
hemorrhage within tlie cord ; coiiijiressiini iinjelitis, when
secondary to compression of the cord, as from tmnors,
iutlanunatory exudations, and fractures or dislocations
of the vertebra?; mcningouiyelilis. whuii the intlarama-
tory process invades the membranes and cord. The
terms acute, subacute, and chronic prefixed to these
various terms, specify whether the onset has been sud-
den, gradual, or slow.
1. Acute Transvekse Dohsai., JIvei.itis (involve-
ment of an}' segment of the cord bctAveen the cervical
and lumbar enlargements).
iSyiiiptoMs. — Paraplegia residting from this disease is
usually characterized by the rapid onset of motor weak-
ness of the lower extremities, preceded by numbness and
painful tingling in the extremities; formication and
other pancsthesiic, moderate or severe; pain in the back
and limbs, of a boring, tearing character; irregular
twitching of muscular fasciculi; painful tonic spasm
(cramps), and tremor of some of the muscles of the ex-
tremities; besides, in many cases, general febrile symp-
toms, usually of a moderate grade, and in lare cases
eclampsia, particularly in young subjects. Tlie motm-
weakness may be hours or days in reaching its highest
degree, and this may be gradual, or by a succession of
sudden accessions with intervals of ])artial recovery.
Before it becomes complete the gait is similar to that
of double hemiplegia of cereliral origin, for it is due to
involvement of the pyramidal tracts. The superficial
Vol,. VI.— 32"
(skin) and deep (tendon) reflexes of the extremities are
preserved, and the paralyzed muscles respond to such
reflex excitation and also to electrical stimulation; the
reaction of degeneration is absent, and the muscles of
the extremities do not undergo atiophy except from
disuse. Later, the reflexes become increased, often to a
high degree. Spastic conditions and contractures may
follow, and frequentlj' become permanent. The lower
trunk muscles maj' be involved and flaccid, showing
diminished response to faradic excitation ; there is reten-
tion of urine at first, followed by incontinence from re-
flex action. The spliinctcr ani is also cut off from cere-
bral control.
The pulse is usually rapid. Sensation is rapidly lost;
anresthesia takes the places of the painful para-sthesia,
though frequently a condition of hypera'sthesia exists,
particularly in the distribution of the nerve coming from
the limit of the lesion, where it may form a zone produc-
ing the sensation of constriction about the trunk. The
dorsal spines may also be sensitive to pressure at this
level, but the pain and hyperaesthesia are not increased
by active or passive movement. All sensation in the
parts supplied from below the upper margin of the lesion
may be cut off. If recovery takes place, sensation is
usually regained before motion. Death may result from
general exhaustion, though mj'clitis limited to the dor-
sal region is the most favorable form for recoverj-. If it
extends to the cervical region, resiiiratory failure may
follow; or if it invades the lumbar enlargement, bed-
sores, cystitis, and nephritis may hasten death. The
course and duration, as well the acutene-ss of onset, are
very variable. Mouths maj- ela])se before recovery takes
place ; or sensation may be [lartiallj- recovered, and there
may be some return of iiowcr, but with spastic condi-
tions which may persist for years. But .some patients re-
cover so completely and rapidly that after a few months
no trace remains, except an increased patellar tendon re-
flex.
When the myelitic proce.ss involves the lumbar enlarge-
ment, either primarily or by the extension from the dor-
sal legion, we have — •
3. Acute Transverse Dorso-Lu.mbar Myelitis.—
Here additional phenomena are present, due to the de-
.struction of the motor and reflex connections for the
muscles of the lower extremities, and for the bladder,
rectum, and sexual apparatus. In place of increased re-
flexes we have both skin and tendon reflexes abolished.
The i-eflex functions of the liladiler and rectum are
lost, as already described. Alkalinity of the lu-ine, cys-
titis, and suppurative nephritis may follow. The mus-
cles of the extremities are llaccid, undergo atrophy, and
after a time the reaction of degeneration is found (fre-
qiienllv not before a week or two after jiaralysis).
Trophic disturbances in the skin and subcutaneous tis-
sues, in the form of bedsores, frequently occur over the
sacrum and the buttocks, and sometimes suppuration in
the pelvic cellular tissue. The .skin of the extremities is
often oedematous, livid, and, in late stages, subnormal in
temperature, although at the onset it ma\- be supernor-
mal— it may be dry or moist.
3. Acute Transverse Cervicai, Mvklitis. — In this
form the lower extremities and pelvic vi.sceraare affected
as in the dor.sal variety; and, in addition, changes occur
in the upper extremities similar to those described in the
dorso-lumbar variety for the lower extremities — namely,
trophic changes in the muscles and nerves, and in tlie
electrical reaction and the reflexes; besides, vaso-motor,
]uipillary, cardiac, and respiratory disturliances occur;
painful rigidity of the cervical muscles, pallor or flushing
of the face and neck, contraction or dilatation of tlie pu-
pils, and slowness or rapidity of the pulse, acconliug to
whether the irritative or destruclive stage jirevails. Op-
tic neuritis has been found associated. Priapism is a
more frequent condition in this than in the dorso-lumbar
variety. The upper extremities are paralyzed first. If
the process remains strictly a ceiilral myelitis, the lateral
column will not be invad'eil ami the lower extremities
will not be involved, should the section involved lie
497
Paraplr^iia,
l*ara|»lo:^la.
liEFEUHXCE IIAXnnodK OF THE MEDICAL SCIEXCE.S.
above tlic cervical enlargement, the upper extremities
would l)e affected like the lower ones — namely, preserved
and exalted reflexes, and absence of trojihic changes in
the muscles. Respiration, deglutition, articulation, and
the diaphragmatic functions (origin of ]ihrenic nerve)
may exhibit great disturbance, death usually resulting
from respiratory failvn-e.
The morbid anatomical changes which constitute the
basis of these synijitoms are the result of irritative and
destructive inflammatory processes in the cord : the irri-
tative stage being represented by hypera-mia. exudation
from the vessels, proliferation of lymiihoid elements,
minute c:ipillary extravasation, and frcMiueiitly by hem-
nrrliage from small aileries. Lalei'. the myelin of the
medullated fibres undergoes swelling, graniilar degener-
ation, and disorganization. The axis cylinders and nerve
cells may become swollen, opac|ue, or granidar, some un-
dergoing complete disorganization — this representing the
stage of destruction. The latter process may confiiuic
until complete softening occurs, showing, on section, a
softened or liipiefied state, and, under the microscojie,
the debris of nerve cells, brokiai cell processes, myelin
drops. lym|)hoid bodies, red blood cells, and the so-called
granule cells — tjodies many limes the size of lymphoid
elements, filled with highly refractive granules. When
the process stops short of com|ilete disorganizaticm and
a more chronic stage is reached, and also in the earlier
stages of chronic myelitis, the neui-oglia proliferates,
forming more numerous and thicker bands; the walls of
Ihe vessels ai'e thickened; lymph spaces may be obliter-
ated or choked with lymphoi<l cells; so-called spider cells
(Deiter's cells), larger connective-tissue cells, with larger
and numerous processes, are scattered thiougb the tis-
sues, and the so ealleii corpora amylaeea are numerous.
This condition is known as sclerosis. It presents a
grayer appearance in unstained .sections; deeperred with
carmine, and a paler color with tlie Weigerf piocess, than
fhe normal tissue. The naked-eye appearance, where the
cold has undergone softening, has been divided into red,
yellow, and white softening, representing snccessive
stages during which the extra vasated red blood cells are
being ab.sorbe<l. The more vascular ]iarts of fhe cord are
usually the first to undergo softening. These are on
either side of the central canal in the gray matter, the
process usually extending out ward to the white columns,
freijuently along I ilood- vessels or coimective-f issue trabec-
uhe. The appearances of softening or sclerosis on .sec-
tion are often ([uite irregular, particularly in tlie wliite
matter.
Si.MPi.E Softening of tue Cokd is met with, prob-
ably due to occlusion of the vessi'ls from arteritis, embol-
ism, or thrombosis. There are fewer signs of an active
inflammatory process, while or yellow softening being
found. It is characferizeil liy the alisence of marked
irritative symptoms, which [irei'ede tlie destiiictive stage
of fhe inflaiiiiiiaforv variety,
riEMOEUiii.voic Myelitis is characterized by a more
sudden onset of the paraplegia than occurs in the in
flammatory form, frequently beeomin,g comiilete hi a
few minutes. The occurrence of tratunatic cimditions,
as concussion, injuries to the vertebr.-e. etc.. will fre-
(|uentl_y lend support to this diagnosis. The later
changes are similar to the forms already described. A
hi'moniiage maybe so small and so located as to produce
only unilateral paralysis at first, as in llie anterior cor-
nua. ]iaiaplegia recurring later from a more general
myelitis, secondary to the hemorrhage.
Comi'KESsion Myelitis presents the usual features of
a fransver.se myelitis, except that i.iaraplegia may be pre-
ceded for a longer time Iiy irritative syniptdius than in
the common inHammalory form, as cmiipression is usu-
ally slow, Ijeing due to tumors in I lie membranes, or to
vertebral disease. In its common form it is known as tlie
piiritph-riia of Putt's diseane. The iiaraplegic symptoms
are those due to irritation of the sensf>ry and motor
nervcsat their exit from the membranes, which may pre-
sent pachymeningitis, or from the verfebral foramina,
giving rise, chietly , to bilateral pains in the trunk or upper
extremities, in the course of the sensory nerves involved,
and being frequently accompanied by hyperaesthetic or
ansesthetic areas. Herpes zoster sometimes occurs. The
reflexes and the functions of the sympathetic may be dis-
turbed (pu]iillary. vaso motor, sweating), and even mu.s-
cular paresis and atrophy of the upper extremities fol-
low, from this cause. The chief diagnostic features are
evidence of localized bone disease, curvature, spinal ten-
derness on movement, and reflex muscular spasm at fhe
region involved on flexure of the spinal column. Para-
plegia, when it does develop, may appear suddenly.
The distribution of the paralysis is usuallj- that of fhe
dorsal or cervical varieties, and presents the variations in
localization of lesion described for these conditions.
It is considered one of the most favorable forms of
myelitis as regards a partial recovery.
In Co.mphession by Ti'Mors |)ain is suci; a prominent
feature that C'ruveilhier was led to characterize the pa-
ralysis which it produces as piiriiptiyin ilnlurnsa The jiain
is lancinating, at first intermittent, but finally becoming
constant, and increased by movement. It is of a more
severe character than fhe jiain of vertebral caries. All
varieties of localizafion may lie ]U'esenfed, and all possi-
ble variations in mode of onset, and in slowness or rapid-
ity of course, dependin,g on the location, size, and rapid-
ity of growth of the neoplasm, various symptoms
becoming lu'ominent according as different functional
tracts are chiefly involved. Sarcomata (including glio-
mata) are the most frequent; guinniat;i and tubercle are
about equally common, while careinnniata and hydalids
are among the neoplasms occasionally found.
Meningo-mvemtis may result from an extension of
the myelitic |u-ocess outward to the membranes, or of a
meningitic process info the cord.
Meningitis, both acute and chronic, may produce
paraplegia by involving the antericu- roots. When the
entire circumference of fhe cord is involved, fhe sensory
roofs being also afl'ccted, we have a condition similar to
involvement of a mixed iieripheral nerve.
The lancinating pains, constrictive bands, muscul.ir
rigidity, and convulsive twitching are greater than in
simple myelitis, and usually serve to distinguish one
from the other. In cervical meningitis the paraplegia
will be confined to the upper extremities, as the jiyrami-
dal tracts will be free unless there develo]) a meniimo-
nn'clitis. when thesi' tracts may be involved.
As numerous examples have already been given, it will
be unneces.sary to review all the ijossibilitiesthat may fol-
U)w, or to consider all tlie varieties of meningitis. With
a ('tear appreciation of the anatomical relations and func-
tions, the extent and location of the lesion may lie con-
cluded from th(^ symiitoms, or ricf lyrxa. Trniniiiitinins
may also lie left out of con.sideration, after ■svhat has lieen
said on compression myelitis.
Poliomyelitis .Vntehiou (infantile and adult si'lnal
paralysis) may lU'oduce a parapli'gia; usually, howevi'r,
tlie lesion in this case being limited toihe anterior cornua
and their neighborhood in the anterior columns, certain
cell groups succumb, while others survive, leaving an
irregular distribution, not symmetrically bilateral, and
therefore not paiaidegic, Tlie anterior grouji of (Uie leg
is most, frequently involved. Nearly one-half the cases
are iuonoplegi<'. and when bilateral the jiaralysis is fre-
quently not symmetrical. It should be stated, however,
that often during fhe first hours, and sometimes days, of
this sudden paralysis, there is complete paraplegia, the
trunk and all four extremities being involved ; but if is
distinguished from transverse myelitis by the absence of
marked sensory or vesical symptoms, and by abolished
reflexes. The statement concerning fhe unsymmetrical
distribution of the paralysis also applies to the subacute
form of this disease, and in fact to chronic degeneration
of the anterior cornual cells, which produces progressive
muscular atrophy.
The condition known as Landry's acute ascending pa-
ralysis, and also the lateral amyotrophic paralysis of
Charcot, which may produce jiaraplegia, are so rare as
fo warrant no more than their menti(Ui.
■i9S
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Paraplej^ia.
Paraplegia.
The parapk'giforiu affection due to the ataxia of tabes
dorsahs may give place to a true jMraplcgia by an exten-
sion of the <legeuerative process to the anterior coriiua,
producing muscular atrophy, or, in the form combineil
with sclerosis, by involving "the pyramidal tracts, it may
develop spastic and ataxic paraplegia.
Sp.\stic P.\r,\pi.egia results, as we have seen, from the
symmetrical involvement of the pjraraidal tracts in any
part of their course, and is usually secondary to a trans-
verse myelitis, or to a transverse lesion of the pyramidal
tracts in their intracranial portion, or, particularly in in-
fants, to arrested development of the cortical motor areas,
in both liemispheres. It is sometimes termed double
hemiplegia. It may affect chiefly the arms, or the legs,
and hasthe usual characteristics, namely, spastic move-
ments, exaggerated reflexes, and absence of sensory and
trophic changes. Primary sclerosis of the pyramidal
tracts in the cord is a rare condition, if it occurs at all.
Intracranial tumors, by pressure upon the crura and
pyramidal tracts in the pons and medulla, or in the cere-
bellum, may produce paraplegia or i)ara|jlegiform symp-
toms, in soiue cases being ataxic rather than paretic, or a
combination of both.
P-\K-\i"i.Koi.v Fi!o.M Multiple Neuritis is character-
ized bj- both motor and sensory impairment involving all
the extremities, and ascending the members from periph-
ery to trunk, also by pain, hypcrtesthesia, tenderness of
the nerve trunks to pressure, trophic changes in the mus-
cles, the reaction of degeneration, o'dcma of the extremi-
ties, the absence of visceral disturbances (bladder and
rectum), and the absence of a constriction band. It is
most common in those addicted to alcoliol, but is also a
manifestation of certain endemic diseases, such as beri-
beri or kakki.
PsEUDO-HYPERTRopiiic Pak.\lysis produces a form of
paraplegia somewhat similar to poliomyelitis anterior,
and is considered by some to be a form of that affection,
by others to be a connective-tissue disease of the mus-
cles. The increase in size of the muscle (usually the
calves) and its hardness, serve to distinguish it from or-
dinary poliomyelitis anterior.
There are several forms of paraplegia usually elassitied
under functional disorders of the nervous system, namely,
hysterical paraplegia, paraplegia depending upon idea,
reflex paraplegia, malarial paraplegia, anaemic |)araple-
gia, alcoholic paraplegia, and toxic paraplegia.
IIysteric.m, P.\r.^plegi.\ is a less frequent form of
hysterical jiaralysis than that of hemiplegic or monopU'-
gic distriliution. It is less apt to Ijc confounded with
paralysis of organic origin than the other varieties, for
the reason that hysterical paralysis resembles in its sym]i-
toms a lesion of cerebral motor tracts in the brain and
cord, rather than one in the remaining portion of the mo-
tor tract in the cord and peripheral nerves. The reaction
of degeneration is absent in hysterical paralj'sis. Atro
phy may be present, but it is that form which is dejiend-
ent upon disu.se. The volume of the muscles may be re
diiceci in such ca.ses, and may give a feeble reaction to
electrical excitation ; but, what is of the utmost imjjor-
tance, fai'adic excitabiUtii is prcsciTeif, and thecoutrdctionx
lire quick. The skin and muscles may be cold, livid, and
flabby, resembling paralysis from pcriiiheral or corntial
disease, and contractures may form as in degeneration of
the pyramidal tracts, though in many eases the muscles
and skin appear nornial, except that voUmtary control is
lost. The tendon reflexes are rarely lost; usually they
are increased, sometimes excessively so. The bladder and
rectum are not usually affected, though voluntary control
over these organs may be lost. Thus, paraplegia from
transverse myelitis of the lumbar enlargement would not
be confounded with hysterical paraplegia on account of
the absence in the latter of trophic and electrical changes
in the muscles and nerves, bedsores, and atrophic changes
in the bladder: liut the latter might elo.sely resembli'
paraplegia from transverse dorsal myelitis in which these
signs are absent. The presence <if a constriction band at
the level of the segment involved, and the sensory, mo-
tor, or reflex disturliances in this zone would exclude
hysterical paraplegia. Hysterical paralysis of all the
extremities might simulate cervical paraplegia of mye-
litic origin, but would be differentiated from it by the
presence of trophic changes in the muscles of the upper ex-
tremities, and by the vaso-motor and visceral symptoms
which accompany organic lesions of this region. Again,
the onset and course of the two classes of disease are usu-
ally sufficient to distinguish one from the other. The ir-
ritative stage of most acute or subacute organic diseases of
the cord, in which jiain, hyperesthesia, and slight motor
irritation precede the paretic and ana'sthetic period, is not
usually present in hysterical paraplegia. In the latter,
sudden development of the paraplegia, and sudden va-
riations in its distribution and intensity, often serve to
indicate it. Ana'sthesia and analgesia uwiy have a dis-
tribution inconsistent with the lesions jiroducing para-
plegia of structural origin.
It must not be forgotten that hysteria may accompany
organic lesions, and should not, therefore, be taken as
proof of the hy.sterical nature of the paralysis, unless or-
ganic lesions can be excluded.
P.\R.\PLEGi.\ Dependent upon Ide.v is a form de-
scribed by Dr. J. Russell Reynolds. Though closely
allietl to hysterical parah'sis, it may be independent of
hysteria, hypochondriasis, and simulation, though fre-
quently associated with functional debility, anxiet.v, and
a morbid imagination. "Manj' cases of paraplegia fol-
lowing railroad accidents," .says Re_vnolds, ''may be
classed under this head; the attention of the victim
being influenced in the most unfortunate manner by the
stories of friends, inquiries of his plijsician, the talk of
his attorney, and the sober face of the compan3''s phy-
sician." Pain, distributed in a manner inconsistent with
the anatomical relations, on the supposition of an organic
lesion ; spasm, which, however, is sometimes relaxed in
a remarkable way when the patient'satteution is directed
elsewhere; and |)aralysis. which is rarely complete, and
almost identical with a voluntary attempt not to move
the parts, or to move them with care, as in simulation,
are the chief features of the affection. The removal of
the morbid idea, i.e., that the patient is paralyzed, or has
a severe disease, results in improvement or cure. An
award for damages has also frequently proven a valuable
therapeutic agent in such cases.
Reet.ex P.\R.\PLECii.\, termed by older writers urinary
paraplegia, was shown by Brown-.Sequard to follow irri-
tation not only of the genito-urinary tract, but also of the
intestines and other viscei'a in animals. lie attributed it
to an ana'Uiia of the cord, due to contraction of the blood-
vessels, while Charcot considered the motor weakness
due to inhibitory action of the sensory irritation. While
we must admit the possibility of this form of paraplegia,
it shoidd not be forgotten that organic lesions may have
been lost sight of, or might be sufficiently slight to be
transitoiT. The positive evidence of .some f(jrni of per-
ipheral irritation, the removal of which has been followed
by recovery, is the only basis on which it should be ad-
mitted, and then only in the absence of indications of or-
ganic di.sease.
JI.\L.\Ri.\L OR Intekmittknt P.\r.\plegi.v is a curious
form of poliomyelitis anterior, which recurs with the
lieriodicity of intermittent fever. Alcoholic iiarajilegia,
when not due to nuiltiple neuritis, is a temporary affair,
following an alcoholic debiiueh.
An.emic Par.\plegi.\ follows Ischamia of the cord,
from pressure on the abdominal aorta, and from ]iressine
or occlusion of the iliac arteries within the pelvis, or
isclia>mia of muscles; rare conditions.
The indications for treatment, where paraplegia ex-
ists, are those adapted to the correction of the various
pathological inxicesses concerned in the diseases which wc
have considered. More than a brief resume woukl carry us
beyond the proper limits of this work. In the irritative
stage of acute mcningitic and myelitic processes, rest is
the lirst essential. The reduction of hyperamia, by
means of agents supjiosed to cause vaso-motor contraction,
such as ergot and belladonna, and the relief of pain by
means of cutaneous irritation (tin' actual cautery, blis-
-499
ParasiteM.
ParaKilos.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
teis, sinapisms, cupping, etc.), and also by moipliiue,
maj' be attempted. Tlic use of oold to i-cduee intiani-
Illation in spinal-cord ilisease i.-; an uneertaiii proeed-
ure, concerning the real effects of which we know but
little.
In the destructive stage of these conditions, wlien par-
alytic and ana'Sthetie |)henonieua arc present, rest may
still be an important factor. The use of mercury, and
of potassiiiiu iodide, may be of service in this period to
promote the absorption of exudations.
In later stages and in chronic eases the use of tonics, of
iron, strychnine, arsenic, etc.. is called for. Nitrate of
silver may be indicated. Electricity is usually to be
avoided in the irritative stage of an acute affection; or,
if used, as for the relief of pain, it sliould be in the form
of a gradually increased galvanic current, avoiding inter-
ruption. For tlie paralysis, the intcrrui)ted galvanic and
the faradic curieuls, to produce muscular contractions,
and spinal applications of the uninterrupted galvanic
current, are of ^•alue, as are also massage and passi\'e
movements. For anaesthesia, the faradic brush is ofteu
serviceable,
E.\treme care and cleanliness are essential in all cases
of paraplegia, and the avoitiance of pressure and irrita-
tion oxer ihe buttocks and sacrum, on account of the
danger and freciuency of bedsores. Attention must be
paid to the bladder and rectum. Catheterization, con-
ducted with extreme cleanliness, may be necessary, and
also antiseptic irrigation of the bladder. Constipation
must be pi'evented l)y cathartics, enemas, etc. Compres-
sion myelitis from caries, dislocations, fractures, and other
traunialisiiis rci|nii-es Mii[ii(ipriale surgical treatment.
ir. h' BirdyiiU.
PARASITES. — A parasit<> is an <irgaiiisiu which lives,
temporarily or permanently, within the body oron the .sur-
face of some other li viug thing ujion which it fecd.s. Evi-
dently, then, not only may there be both phytoparasites
and zooparasites, but also that form which is parasitized
upon and is known as the host may be equally either
plant or animal. Among forms which (iiid in man at .some
time or in some region a subject for attack, the pliyto-
IJarasites include the prominent group of bacteria wfiieli
have received attention elsewhere, and a few fungi
of etiological importance, in dermal affections chietly,
which have also been discussed. Hei'e will be given" a
brief discussion of the animal parasites of man, with
especial reference to their liiological and etiological rila-
tions.
It is important to notice first the wide range in degree
of parasitism exhibited and the manner in which the va-
rious grades merge into one another, producing a scale of
dependence in which almost every stage is represented.
Most indejiendent of all are the temjiorary jiarasites, like
the mosquito, bedbug, or leech, which stay by the indi-
vidual host only long enough to secure a single meal, and
which present clearly the structure and habits of free
living organisms. Some leeches suggest most plainly
the close relation between the carnivorous and the jiara-
sitic habit since tliey often devcjur bodily small aquatic
forms, but when favored by opportunity extract the
blood of larger animals. .More dependent are such forms
as the fleas which can change their host and often do so,
and yet their structure has been highly modified in the
loss of wings which are generally characteristic of insects
and by the development of powerful leaiiing and grasp-
ing organs. Somewhat further modified in the direction
of parasitism are the lice, which, moreover, lack special
means for effecting a change of host, and may be in-
cluded among the list of stationary parasites— /.V., those
that remain with a single host (•(jiistanlly, or at least for
considerable periods of time.
All of the forms thus far noted are jiarasitic upon the
exterior of the host, and consequently are denominated
Epizoaor ectoparasites. All human ectoparasites belong
to the group of Arthropoda. and include lioth mites {i-f.
Anic/iiiiifii) and true insects (<■/ liist'iix). Among the
watei-livuig aiiiuials, however, soft-bodied foiiiis, >;ueli
as flat worms (Trematoda) and unicelluhir animals (Pro-
tozoa) occur as Epizoa. With the gradual assumption
of an aerial or terrestrial existence on the part of the host
such parasites were necessitated, if they bad not already
sought more sheltered regions, now at least to abanthm
the external surface and to colonize internal organs
where thin mucous membranes attorded facilities for ex-
tracting nourishment similar to those which existed on the
thiu outer skin of the acpiicolous animal. The choante,
pharyn.x, gills, lungs, alimentary canal, and even the
bladder were thus inviided by forms whose kinship to
the ectoparasitic species on these lower animals is too
plain to fail of recogniticm.
The Entozoa or eudoparasites of man, however, do not
even belong to the .same branch of the animal kingdom
as the forms ectoparasitic upon him, with the single
exception of the rare and aberrant Linguatnlids, now
usually regarded as highly degenerate arachnids (<?./■.).
though formerly classed with the Cestoda. The human
Entozoa include Protozoa. Trematoda, Cestoda, and
Nematoda, and many of them are highly modified in
adaptation to the parasitic mode of existence, as com-
pared to the related free living forms which, however,
arc entirely wanting in the second and third groups
listed.
The term helminthology has been used as synonymous
with animal parasitology, and yet this is a c-onsiderable
extension of its original meaning. The Helminthes or
intestinal worms included the pre-eminently parasitic
groups, such as Trematoda, Cestoda, and Nematoda,
while the Protozoa. Arthropoda. and even the few para-
sitic Terbellaria, which are in fact closely related to Tre-
matoda, were omitted. The term became thus one of
convenience rather than of scientitic accuracy.
It is necessary to emphasize the fact that neither Hel-
minthes nor parasites constitute a grou]) of systematic
value At most the forms are related in a biologic
sense and not structurally, for they are comprehended in
several distinct branches of the animal kingdom, and a
.given form is often more closely related to free living
species than toother parasitic forms. Even the narrower
term Helminthes embraced forms of little similarity to
each other and rightly to be distributed with their re-
lated free living species into .several distinct groups,
nainclj-. the Linguatulida to the Arachnida. the Tremato-
da and Cestoda to the Plathelniinthes, and the Nematoda
to the Neniathelminthes.
Lijcatiiiii. — While the majority of endoparasites inhabit
the alimentary canal and its adne.xa, there is no organ
which is immune to them. The following list of human
[larasites arranged according to the organ inhabited will
serve to indicate the extent of the parasitic hal.iit, and
will assist in the identification of a given form. The
records givi'U apply only to the human host. Parasites
ale entered under the normal location of the species, and
in the most frecjuent erratic location only; a few forms
of doubtful standing, as human parasites or of uncertain
location in this host, are omitted.
Re-
ParasiiM.
Stage.
Tvpe of
Normal
corded
parasitism.
haliitiit.
in
r.s.A.
Skin and siil«]Hrnial tissue.
lA'ptoilera Mellvi
Larva..
Accidental.
Europe
No.
(Tiiatlinstciiia siaiiiensH . .
Ailuit..
Oi-casional .
Siam
No.
I-'ilaT'ia iiiethni'ii.sis
Adult..
Normal —
Africa
Ye.s.
I'Mciliaria iluedenale
Larva..
(?)
Cosmopoli-
tan.
Ves.
Eve.
I'-ilaria loa
Adult..
Normal —
Africa
Yes.
Filaria leniis
Adult. .
Adult..
O)
Occasional .
IV)
Europe
No.
Filaria conjunctivae
No.
Cvsticercus cellulose
Larva ..
Erratic ....
Europe
No.
Echinncoccus polvmor-
Larva..
Erratic
Europe
Yes.
plius.
Brain and meiiiliranes.
Cvsticfivus raiviiiosus=
Larva ..
Ei'ratic
Europe
Yes.
celliiltisa'.
Cysticcrcus ac-antlii.lrias.
Larva ..
Erratic (?).
U.S.A ....
Y'es.
Keliiniicoocus polvmur-
Larva ..
Erratic
Europe
Yes.
pliiis.
5011
REFERENCE HANDBOOK OF THE 3IEDICAL SCIENCES.
I'ara»»ite8«
JParasites*
Stage.
Brdin and niemhranes.
Paragouimus Wester
manni.
Connective tissue.
Fascioia hepatica
Bothrioceplialiis Mansoni
Cysticercus cellulosae —
Cysticercus acantbotrias..
Echinococcus polymor-
phus.
Filaria loa
Paragonimus Wester-
manni.
Muscles.
Cysticercus cellulosa? —
Cysticercus acantliotrias..
Triehinella spiralis
Heart.
Filaria Magalhaesi
Cysticercus cellulosfe —
Ecbinococcus polymor-
pbus.
Blood-vessels.
Fascioia hepatica
Schistosoma haemato-
bium.
Echinoccus polymorphus.
Filaria iramitis (?)
Filaria embryos (see key
under Nematoda).
Lyinph vessels.
Filaria Bancroft i
Filaria volvulus
Filaria lympbatica
Lungs.
Fascioia angusta
Paragonimus Wester-
mauni.
Cysticercus cellulosae
Echinococcus polymor-
phus.
Strongylus apri
Liver.
Fascioia hepatica
Opisthorchis (elineus
Opislhorchis sinensis
Opisthorchis noverca —
Distonia Ratbouisi
Dicroco-Iium lanceatum.
Cysticercus cellulosa; —
Echinococcus polymor-
phus.
Paragonimus Wester
manni.
Small intestines.
Fasciolopsis Buski
Opisthorchis felineus —
Opisthorchis sinensis —
Heterophyes beterophyes
Dibotbriocephalus latus..
Dibothriocepbalus corda-
tus.
Diplogonoporus grandis
Dipylidium caninum —
Hymt-n* 'lepis nana
Hyint'iitil.-j.is iliininuta .
Hyuienolt'pis lauceolata .
Davainea madagascaren-
sis.
Taenia solium
Adult.
Adult .
Larva .
Larva .
Larva.
Larva .
Adult.
Adult.
Larva.
Larva.
Larva.
Adult.
Larva.
Larva .
Adult.
Adult.
Larva
Adult.
Type of
parasitism.
Erratic
Erratic
ticcasional.
Normal
Normal
Normal
Normal
Erratic
Normal
habitat.
Normal..
Normal. .
Normal..
(?)
Erratic . .
Errati;' . .
Erratic .
Noi'mal.
Asia
Europe
China
Europe
U.S.A....
Europe
Africa
Asia
Europe . . .
U. S. A . . .
Cosmop 0 1
itan.
So. Amer.
Europe . . .
Europe...
Europe ...
Africa —
Taenia saglnata
Taenia africana
Taenia confusa
Strongyloides stercoralis
Triehinella spiralis
Strongylus subtilis
Uncinaria duodenalls . .
Uncinaria americana . . .
Pbysaloptera caucasica .
Ascaris lumbricoides . . .
Ascaris canis
Ascaris maritima
Oxyuris vermicularls .
Adult..
Adult..
Adult..
Adult. ,
Adult. ,
Larva .,
Larva.
Norma! Europe.
Occasional. Europe..
Normal.
Normal —
Normal
Occasional ,
Erratic —
Normal
Normal
Normal
Adult..; Occasional
Adult.
Adult.
Adult.
Adult.
Adult.
Adult.
Larva.
Larva.
Adult.
Adult. ,
Adult. ,
Adult.,
Adult.,
Adult.,
Adult.,
Adult.
Adult,
.^dult-
Adult.
Adult.
Adult.
Adult.
Occasional .
Normal
Nonnal
Normal
Occasional!
Normal
Normal
Normal....
Erratic
Tropics.
Africa..
Europe.
Africa...
Asia
Normal
Erratic . . .
Erratic
Normal
Nonnal
Occasional .
Occasional.
Occasional .
Normal (?).
Occasional .
Occasional .
Occasional
CO.
Noruial —
Europe .
Europe .
Europe .
Europe .
Russia .
Asia
Asia....
Asia....
Europe .
Europe .
Europe .
Asia
Re-
corded
in
U.S.A.
No.
Yes.
Yes.
Yes.
Yes.
No.
Yes.
Y'es.
No.
No.
Yes.
Yes.
Yes.
*
Yes.
Yes.
No.
No.
No.
Yes.
Asia
Russia —
Asia
Africa
Europe . . .
Greenland
Adult..! Nonnal
Glgantorhynchus gigas. ,
Gigantorhynchus monili
formis.
Adult.
Adult.
Adult.
Adult.
Adult.
Adult.
Normal
Normal (?).
Normal —
Nomial
Normal
Normal
Adult..
Adult..
Normal . . .
(?)
Adult..
Normal...
Adult..
Adult..
Adult..
Occasional
Occasional
Normal...
Adult. .
Occasional
Adult. .
Occasional
Japan . .
Europe .
Europe .
Europe .
Europe .
Africa..
Cosmopoli-
tan.
Cosmopoli-
tan.
Africa
U. S. A . . . .
Asia
Cosmopo-
litan.
Africa
Cosmopoli-
tan.
America . .
Caucasus...
Cosmopoli-
tan.
Europe
Greenland.
Cosmopoli-
tan.
Cosmopoli-
tan.
Cosmopoli-
tan.
No.
No.
Yes.
No.
No.
*
No.
Yes.
No.
No.
No.
No.
Yes.
No.
No.
Yes.
Y'es.
Yes.
No.
No.
Yes.
Yes.
No.
Yes.
Y'es.
Yes.
No.
Yes.
Yes.
No.
Yes.
No.
Y'es.
No.
No.
* Present in the United States of America in some other host, hence
easily possible in man, although no record of its occurrence in the hu-
man host was found.
Parasite.
Stage.
Type of
parasitism.
Normal
habitat.
Re-
corded
In
U.S.A.
Large intestine.
Gasti-odiscus bominls
Tricbocepbalus tricbiurus
Oxyuris vermicularis —
Kidney.
Ecbinococcus polymor-
phus.
Dioctophyme renale
Bladder.
Adult..
Adult..
Female.
Larva ..
Adult..
Adult. .
Adult. .
Occasional
(?).
Nonnal —
Normal —
Normal —
Occasional.
Accidental.
Accidental.
India
Cosmopoli-
tan.
Cosmopoli-
tan.
Europe —
Europe
Europe
U. S. A . . . .
Yes.
No.
Yes.
Yes.
*
No.
Anguillula aceti
Yes.
SPCTIM— Eggs.
Parasite.
Fascioia angusta
Fascioia hepatica (
Fascioia magna, etc 1
Paragonimus Wester-
manni.
Strongylus apri
Frequence.
Size in microns.
Recorded once.
Not observed,
but possible.
Frequent
Few cases .
14.3-l.il X 82-88.
Given below un-
der Faeces.
88-103 X 5.3-«8.
.tO-100 X 39-72.
Plate E.
Fig. a.
SPCTr.M— Embryos.
Filaria, many species possible (see key under NematoiUi).
Urixe— Eggs.
Parasite,
Fascioia hepatica I,
Fascioia magna, etc \
Schistosoma btematobium
Filaria Bancrofti
Dioctophyme renale. . .
Oxyuils vermicularis+.
Frequence.
Not observed,
but possible.
Frequent
Recorded once.
Few cases
Common
Size in microns.
Given below un-
der Fa?ces.
ia>-lli(l X 55-66.
2.5-28 X 15 (or
35?).
64-tJ8X 40-49.
50-54 X 20-27.
Plate E.
Fig. c.
Fig. (), ()'.
Fig. rf, (f
d", d'".
Urixe— Embryos.
Filaria, many species possible (see key under Nematoda) .
The eggs of the other kidney parasites will not batch as long as kepv
in urine.
Adult forms, like accidental parasites of the Nematode type, are sa
small as to be easily taken for embryos (see Autfuillula aceti, etc.
under Nematoda),
F-ECES— EGGS.
Parasite.
Gastrodiseus houiinis
Fascioia hepatica
Fascioia magna
Fascioia angusta
Distoma RathouLsi
Fa.siiolnpsis Buski
Opisthi >rchis felineus
Opisthorchis noverca
Opbthorchis sinensis
DicrocoeUum lanceatum. .
Heterophyes beterophyes.
Paragonimus W ester -
luanni.
Dibothriocepbalus latus..
Dibotbriocephalus corda.
tus.
Diplogonoporus grandis . .
Dipylidium caninum
Hymenolepis nana
Hymenolepis diminuta . .
Hvmenolepis lanceolata.
T;pnia .solium
Tii'nia saglnata
Taenia africana .
Frequence.
Size in n^icrons. Plate E-
Recorded once.
Several cases . .
Not recorded . .
Recorded once
Recorded once.
Several cases . .
Several cases . .
Recorded once.
Several cases . .
Several cases . ,
Frequent
Frequent
Frequent
Reported once
Few cases . .
Few cases . .
Frequent
Several cases .
Recorded once
Frequent
Common
Recorded once
Taenia confusa Two cases .
Strongyloides stercoralis.. Frequent . .
Tricbocepbalus tiicbiurus. I Common
1.50 :■ 72.
1.30-172 X 72-80.
109-16S X 75-96.
143-151 X 82-88.
1.50 X 80.
120-126 X 77.
26-30 X 11-15.
31X21.
27-30 X 15-17.
40-45 X 22-30.
28-30 X 15-17.
88-103 X 53-68.
68-71 X 45
75-80X50.
63 X 48-.50.
4.3-50, embryo
32-36.
39, or 43 X 31
70->S6, embryo
36 >, 28.
,50 X 35.
»)-35, embryo 20
(Yolk m e m-
brane 70) 30^0
X 20-33.
31-31 round, or
34 X 39.
30 X 39.
67 X 37.
.T0-.54 X 21-23.
Fig. e.
Fig. aa.
Fig./.
Fig.jf.
Fig. o.
Figs. /i,/i'.
Fig. J.
Fig. fl.
Figs. k.h'.
Fig. ;.
Fig. m.
Fig. n.
Figs, o, (/.
Figs.p.p'.
Figs, y, q'.
Fig. r.
Fig. s.
Fig. (.
Figs. u.tt'.
♦ Present in the United States of America in some other host, hence
easily possible in man, although no record of its occurrence in the hu-
man host was found.
tOnly in female tbrougb infection of vagina from rectum.
501
Parasites.
Parasltrs.
IJEFERKXC'E IIANHBOOK OF THE MEDICAL SCIENCES.
F.«CES— EGGS.— C'Jiid'nHfii.
Parasite.
Strongylus subtilis
Strou^ylus apri
T'lU'iiiaria diiodenalis . .
Vnciuaria araericana . . .
Physaloptera cauca.sica .
Asoaris lumbricoides . . .
Ascaris canis
Oxyuris vermicularis
Frequence.
Several cases .
Few cases
Frequent
Kj-equent
Reported once,
Coutmou
Few cases .
Common.
Gigantorliynclnis sigas. . . Few cas'
Gigantorhyncbus niouili-' Few easi
forrais.
Size In microns.
ffl KO X :S.'i-41.
,iu-io(j X m-r-i.
r>ri-tir> x .n-m.
64-72 X ai-io.
57X39.
50-7.5 X 40-50,
fertilized.
63-'J.H ■■ 31-77
unfertilized.
■3-fi.s. spherical.
.5(1 X 10-20.
.'<o-liioionff,oval
.s."> 40.
Fig. w.
FiKs..r,r',
x",:r"'.
Fig. y H".
Fig. II'.
Fig. 2.
Figs, ri.d',
(I", r/"-.
Fig. ihl.
F.ECES— Embryos.
Filaria.*
Strongyloides stercoralis.
TricliiiieUa spiralis
Frequence.
Common .
Kiire
Size in microns.
aXMOO long,
SKUOO -■: 0.
* Many siiecies possible (see key under Nematoda}.
Oue inaj' recognize among Ihcse parasites tliosc whiclt
occur in tlicir normal liost but in an unusual location,
like the brain cysticerci or a liver fluke in a svibcutaueous
cyst; there are also mau_v of the species listed which can-
not be regarded in any way as cliaracteristic of the Im-
:nau host." Such are the occasional parasites which are
species of true pai'asitic habit and can attain normal de-
velopment in the livmiau host, but ordinarily do not tind
conditions favorable for their introduction. As an in-
stance of such species may lie mentioned Fiisa'ola, hepat-
icfi. the common liver tluke of the sheep, which in manj-
regions of the world is extraordinarily abundant. That
it can thrive in the human system is demonstrated by the
score or more of cases of its occurrence there definitely
recorded ; but its infrcqueuee is equal evidence of a gen-
eral immunity on the part of man, lacking in these par-
ticular cases, or of special features in its life historj'
which make the infection of tlie human liost difficult.
That the latter is the probable e.xplauatiou may be in-
ferred from the fact that the oercaria larva, liberated
ficim the intermediate host, encysts on gi-ass, and hence
oould reach the human alimentary canal only luider un-
usual circumstances. Similar examples ma.v be taken
from other groups of parasitic forms, such as the rare
occurrence in man of Stmiii/yliis apri. one of the com-
monest parasites of the pig in Europe, or of Dipi/lidiiim
caniiuim, the cosmopolitan tapeworm of both dog and
cat, which has been reporteil only rarely from man.
Such occasional parasites often occur under abnormal
conditions; thus a fish nematode, Astyirifi chiralii, was
discovered once in the hollow tooth of a man. Here the
position was probably acciilental, but in other cases it is
the result of the action of the parasite itself. So the
"red spiders," or "jigger " mites of the Central States
bur}' themselves in the skin of man, altliough such a
position is so clearly abnormal that in fact it destroys
the chance of further development and costs the parasite
its life. A small leech. Liiiniotis niloticii, common in the
Circummediterranean area, is often drawn into the throat
of men and other animals drinking at way.side pools. It
usually retains its position, causing serious difficulty,
until removed by operative interference; hence it has be-
come an occasional parasite of man rather than, as in the
case of most leeches, a temporary parasite ; or one may re-
gard it as falling in the next following gioup of acci-
dental parasites. This example shows most clearly the
narrow and somewhat artificial limits which sepai'ate these
groups of parasites from one another. Of the mites also,
wliicli have been reported a few times as olitained living
from stomach, bladder, and rectum, it is difficult to .say
whether they are occasional or accidental ]Mirasitesof man.
There are also rarely forms which commonly occiu'free
living, but which b\' chance are introiluced into some or-
gan in wliich conditions are such that the_y can thrive.
They become thus accidental [larasites, a group difficult
jiractically to distinguish from the last, the occasional
parasites, and yet pi'csenting somewliat difi'erent liiologi-
cal conditions. The recent iliscovery by SI lies and
Frankland. as well as others, of the vinegar eel, Aiiffnil-
I'l/d iii-eli. as an apparently successful colonizer of tlie
bladder in a female patient illustrates the tj'pe under
consideration. There is little doubt that this parasite
was introduced through the use of vin<'gar in vaginal
douches and effected a successful colonization, possibly
by virtue of the trace of altnimin present in the urine
which furnished it with nourishment. Equally striking
is the case of Scheiber, who discovered Lcptodera pdlit) in
the urine of a female patient in Hungary. This typical
sliine-iiihabiting nematode gained entrance, no doubt,
through the ajiplication of mud poultices, which are
commonly employed by pea.sants in that region. It
should be noticed that such accidental parasites are nec-
essarily confined to those groups of animals which have
free-living forms. Such are Protozoa, Nematoda, and
perhaps Insecta iu the larval contlition, while Cestoda
and Trematoda, which live only as parasitic forms in
some host, woidd become rather occasional parasites of
man should they stra_y into the human system in some
i-hance manner and find favorable conditions for exist-
ence.
Quite distinct from the types just considered are pseu-
do-jiarasites, which rank high in clinical importance.
.Vmong them one may recognize several very distinct
classes. First, those which are actually free-living ani-
mals, introduced by accident, usually in food or drink,
into the human alimentary canal, exciting there abnormal
conditions which induce their more or less immediate and
forcible expulsion. Thus Botkin found in the vomit of
a Russian numbers of a small nematode which he wrongly
l)elieved to be a human parasite. In fact it li\-es noi--
mally in the onion, and its introduction into the stomach
with this food excited the untoward symptoms noted.
Similarly Blanchard records a case in which coleopterous
larva^ were found in the vomit of a child.
That such may be the result of introducing a true
parasite from some other host is indicated by several
cases, like that of Auraris mai-t'tii/m, wliich Leuckart de-
scribed from a single specimen vomited by a child in
Greenland, and which this author noted was very similar
to .-1. traiiiifii</i( of the brown bear. In all pi'obability it
was ingested with the viscera of some animal (seal?),
though it may have been a species which had strayed into
this imusual host, only to make its appearance under the
circumstances noted.
Of similar Import are the cases of Oordins, the hair
snake, which have been reported from man. In the adult
condition this is normally a free-living species, but about
a dozen specimens have been taken from man after a sup-
posed sojourn of fiom a few hours to fourteen days.
Some of these have been vomited and others passed per
anum. This form has often been passed otT upon the
physician as a true parasite, and in one celebrated case at
least as the Guinea-worm.
In the same way one may find the explanation for other
isolated cases of parasitism, even when the parasite is re-
ported to have been passed from the alimentary canal.
ThusCobbold reported that larva" of Bfujis iiiorlinni/n, the
English churchyard beetle, were found in fecal dis-
charges, and many authors have recorded the presence
of dipterous larv;e in the alimentary canal. |
The majority of such observers have inclined to regard
these larv;e as temporary endoparasites, and to consider
that they have accommodated themselves to the condi-
tions present in the human host. The cases seem to show
that these larva.' live for some time in the canal, and they
often appear to evoke serious or even fatal disturbances;
and yet the conclusions are open to grave doubt, for Ca-
landruccio experimented extensively on two families of
flies to which many of the supposed" accidental parasites
502
REFERENCE HANDBOOK
OF THE
MEDICAL SCIENCES
PLATE E.
EGGS OF HUMAN PARASITES
(MAGNIFIED FIVE HUNDRED DIAMETERS)
REFERENCE HANDBOOK OF THE StEDICAL SCIEN'CES.
Parasites.
Parasites.
belong, ami found that the ingested larva; were regularly
and promptly evacuated, dead or dying, and in no case
did they secure a footing in the canal.
Among the rayriapods about fortj- recorded cases of
pseudoparasitisni have been brought together and dis-
cussed by Blauchard. lu the large majority the animal
was taken from the nasal fossa;, thougli in a smaller
number it was actually obtained living from the alimen-
tary canal, where it undoubtedly can exist for a brief
time in spite of tlie untoward environment. The inges-
tion of such forms is purely accidental, the symptoms are
those of helminthiasis in general, and their stay at most is
very limited. They never show any evidence of adapta-
tion to the new environment.
In some such accidental fashion other forms are some-
times introduced into various organs not connected with
the alimentary system. Thus Trouessart reported the
occurrence of a species of detricolous Sarcoptids in the
human testicle where the mites formed an old colony in
a painless cystic tumor.
In contrast with the living animals of the types noted,
the second class of pseudoparasites includes a large num-
ber of other structures which have been described as
parasites. These may be considered conveniently in a
few groups, the first of which includes bodies which are
parts of the so-called host animal itself. Thus fragments
of the arteriahyaloidea have been described as eye worms
(Filaria lentis, F. ocnli humani, etc.), the organisms of
whooping-cough are nothing more nor less than ciliated
tracheal cells torn from the wall and found in the sputum
in distorted form, while groups of small a.xillary and in-
guinal glands, hydatid moles, and Pacchionian bodies
from the arachnoid have been frequently put on record
as hydatid cysts.
Parts of substances used as food, both of plant and of
animal origin, which have not been destroyed by the ac-
tion of digestive juices are also among the pseudopara-
.sites of man. The radid;e of the common limpet have
l)een reported several times from stools; the seeds of the
mulberry were duly baptized as parasitic worms; and
plant vessels and other similar undigested structures of
peculiar appearance appear periodically as new helmin-
thes. That a differentiation of such structures is not
simple appears from the account given by Stiles of the
partially digested banana fibres which closely simulate
minute "tapeworms. Some years ago Leuckart entrapped
a group of research students in helmintholog}' with the
pulp vesicles of an orange which were found in a fecal
examination.
In all of the cases considered above it should be kept
in mind that theaninialsor these other structures actually
came from within the luiman body. There is, however,
another class of objects of which this cannot be said.
In determining the nature of unusual forms reported
from man it should always be kept in mind that in the
absence of positive persona! evidence, suspicion in case
of neurasthenia at least favors the deceitful introduction
of doubtful bodies. In many cases on record such tilings
as earthworms, chicken entrails, etc., have been forcibly
introduced into the rectum or vagina, and have been sub-
sequently reported by the attending physician as un-
doubted human entozoa of a remarkable character!
Here as elsewhere the appearance of unusual structures
should at once arouse the suspicion of the physician and
call forth a most searching examination of the case in all
its factors, that any deceit be disch«ed, or that in tlie
event of the discovery of some rare parasite all conditiniis
connected with itsappearancebeput on record for future
use. The large number of parasites in other animals
which some unusual combination of circumstances may
liring into the human system makes it imperative al.so
that any supposedly new species be submitted to the
judgment of a specialist before it is described as such.
Only in this way can the discoverer avoid adding to the
long list of synonyms, which already burden the liter-
ature of this subject. au<l render it so difficult for the in-
vestigator not a specialist in this particular line to find
his waj' aright. Furthermore, it is important to preserve
the fullest data in regard to any substances associated
with the supposed parasite, as well as the food of the
patient, whether usual or unusual, since in this way some
hint as to its introduction may be found.
Effect upon the Host. — In the belief of the medical pro-
fession two hundred years ago there was no disease, real
or imaginary, which was not due to the presence and ef-
fect of some kind of parasite. Each ailment had its par-
ticular "worm" in its characteristic location. This was
a direct result of the endeavor to reduce every malady to
some definite cause, and of the joining of the unknown
sickness with the parasites of which they knew as little.
Under the influence of study and of increasing knowledge
regarding the parasites such a theory was seen to be un-
tenable, and the movement in tlie opposite direction be-
gan, a tendency which may be said bj- this time to have
passed its height.
It is true that internal parasites are very widely dis-
tributed, and that scarceh" any individual is entire!}' free
from them. They are, however, usually present in lim-
ited numbers, and are believed to be harmless if infre-
quent or of small size. This does not seem to be strictly
correct, for while it is doubtless true that the effect of a
single parasite, or even of a considerable number of mi-
nute size, is small and difficult to measure or estimate, it
is cquall}- clear that even this is a certain drain on the
host. Furthermore, the tax on the host is in proportion
not only to the number and size, but also to the habits of
the parasites present. Thus there is a great difference
whether the parasite is active and growing in thealimen-
iaxy canal or some other cavity in the body of the host,
or passively resting in the midst of the tissue of some
organ.
While encysted parasites exercise a continued and
sometimes serious pressure on adjacent tissue, yet the
draft on the host by free parasites is much the greatest,
and manifests itself in three ways. The parasite re-
quires a certain amount of food for its support; this it
takes directly from the host, either from that which the
latter has digested for its own use, if the parasite be in
the alimentary canal, or from material which the host has
formed to perform certain work, as in tlie case of blood
parasites, or from the tissue of the host, as in the case of
some intestinal worms which feed on the cells composing
the wall of the intestine. In anv case the host expends
at least the extra energy necessary to procure and digest
the food taken by the parasite, ami this extra labor will be
directly in proportion to the amount of food taken, or in
general to the size of the parasite and to its fertilit.y.
In the second place the parasite occupies a certain
amount of space, and correspondingly reduces the calibre
of the tube in which it lives. Unless a considerable num-
ber are present this is hardly a practical stoppage for the
alimentary canal, although in several recorded cases death
has followed occlusion of the canal by a mass of ascarids,
and in the case of the blood system a vessel maybe closed
or a clot formed by the presence of even a very few para-
sites.
In the third place active parasites will, by their move-
ments, give ri.se to a certain amount of irritation and in-
flammation of the membranes over which they move.
This is in some ways, perhaps, the most serious trouble
which a few parasites can cause, and it is much increased
if in the special case the parasite obtains its food at the
expense of the tissues of the host, that is, if it tears or
consumes the walls of the cavity in which it lives. A
secondary, though possible, result of this manner of liv-
ing is the liability of rupturing some blood-vessel, with
consequent serious results, as in the case of certain lung
flukes which may chance u]ion some large blood-vessel
and in this waj- produce even fatal hemorrhage. In the
alimentary canal a single ascaris may perforate the wall
and induce fata! peritonitis, as has been observed several
times in recent years. It is evident, then, that no nioie
than a single active parasite may be dangerous, and that
it is always some tax on the domestic economy of its
liost. Of course, the effect of a microscopic worm in the
alimentary canal of an ele|>liaiit will be so small that it
503
Para^Ues.
HEFEREKCE JIANDHooK OP THE MEDICAL SCIENCES.
could hardly be calculated in any way ; but this reason-
ing should not be extended too far. The disturbance
produced in tlie luiman system bj" a single tajieworm is
snilicient to call for jirompt measures to remove it.
Recent studies have demonstrated the presence of hae-
moglobin in the alimentary canal of many nematode
pai-asites, the pathological elfects of whose activities
must be counted much more important than heretofore
estimated by reason of this blood-sucking habit. Thus
in cases of uncinariasis the amount of blood lost fiom
myriads of minute hemorrliages imjiarts a characteristic
reddish-brown color to the fa'ces. the intestinal wall be-
comes seriously affected and affords jdaces of easy attack
for any pathogenic germs which may be present. This
indirect damage may be very serious in the individual
instance, and may include piimarily or secondarily unde-
sirable retrogressive or ]irogressive histological changes,
inflammatory processes, and disturbances in the circula-
tion.
Another source of danger from parasites is one which
has long been surmised but only recently demonstrated.
A number of investigators have shown that various Ces-
toda, Acanthocephala, and Eunematoda contain definite
poisons (toxins) whicli when extracted and employed ex-
perimentally affect particularly the nervous system and
the formation of blood. The continued formation and
giving oft' of such a substance woidd explain the appar-
ently excessive results of parasitism in some instances,
results which are shown prominently in retlex nervous
sj'mptoms such as have been noted under Argas {ArarJi-
uida), and Taenia (Cestoda). In a certain proportion of
cases pernicious anemia is the result of this toxic effect,
and is accompanied by a mortality of seventeen per cent.,
according to one report regarding Botlu'ioeephalus,
AVhether tlie jioisou is elaborated by the parasite or is
]ii'oduced by ixithological processes in the worm or by
its death, as well as tlie ground for the variability in the
toxic action of different specimens, are questions as yet
undecided. It has been shown, however, that extracts
from different species of lielminthes varj' considerably in
toxic power. Vaullegrard has isolated two toxic princi-
ples, one of which acts tipon nerve centres and the other
ui)ou muscles, and many symptoms produced experi-
mentally by the injection of these substances are analo-
gous to those manifested in parasitic disease. According
to this chemical theorv, the troubles caused by parasites
are due to the formation of toxic sulistancesmorc rapidly
than tlieir elimination by the host, and their consequent
aecumidatiou in the system.
It is noteworthy that eo-sinojihilia has been recorded as
a frequent if not imiver.sal syni]5tom in parasitic infec-
tions. From 15 to .")() per cent, of cosinophiles in trichi-
nosis, 10 per cent, in uncinariasis, 1.5 per cent, in oxyuris
infection, and 20 per cent, in ascarid infection are aver-
age figures. The percentage varies greatly and does not
appear to be constant, while it is present in other path-
ological conditions as well.
Life Hiatiiry. — Normal parasitism is related to the life
history of the jiarasite with jieculiar intimacy. Among
accidental jiarasites the animal seems to continue the
usual method of multiplication under the changed condi-
tions. Thus Oerley was abh- to colonize Lejitodn-it jicllio
in the vagina of mice where they reproduced normally.
But in case of the well-known WkiIhIoiw/iih nigroreiioKiiiii
of the frog the parasitic generation alternates with a free
living generation, and the two are distinguished only
slight!}' in structure but radically in method of repro-
duction, since the one is dia>cious and the other herma-
phroditic. In the case of the parasite of Cochin China
dysentery also, Stroxfjyloidcs steriyiriilis,tbt;Tu is a herma-
phroditic parasitic generation and a diiecious free-living
generation, in which the individuals differ noticeably
from the first. Alternation of generation is not infre-
quent among true parasites, but it usuallj' bears a differ-
ent relation to the life history, and one which will be
clear after the examination of the simpler cases.
In the .simplest case which is exemplified by many of
the Nematoda parasitic in the alimentary canal the eggs
reacli the exterior with the faeces of the host, and in them
or in water undergo devclo]5ment until after a brief pe-
riod of growth, either still enclosed in the protecting egg
membranes, as is the case in Ascaris bniihricuides, the
common stomach worm, or as a free-living form in the
water, the larva is ready to be reintroduced into the hu-
man alimentary canal. Then it undergoes its transfor-
mation into the adult, which is usually only growth, and
the formation of the reproductive organs which are pres-
ent in the larva in the form of a single cell or grou)) of
cells near tlie centre of the body, often so insig-nificant in
the unileveloped condition as to escape observation. This
type of development maybe somewhat complicated by
the sojourn of the parasite in one region of the canal,
where it passes through the earlier stages of develop-
ment and Ijccomes sexually mature before seeking its
definitive location. Sucit is the case in the pinwonn,
Oxyuris nnnicnliiris, which grows to sexual maturity in
the ileum, while the pregnant females migrate to the rec-
tum in order to make periodic excursions to the perineum
for oviposition.
A more complicated development is illustrated by the
Guinea-worm, Filana iiiedinensis, in which the embryos
set free into the water seek out a new liost and enter its
body in order to pass through the early stages of develop-
ment there. After having attained a certain stage of
growth in this host the lai'val jjarasite is ready for intro-
duction into tlie final Imst, in which it reaches sexual
maturity-, and this change is effected probably by chance.
Tiie host in whicli the sexually mature para.site occurs is
known as the primary, while the secondary is that in
which the larva is found.
In tlie extreme case the life history is so modified that
the parasite never reaches the external world, Init jiasses
from one liost to anotlier directly. Here the ultimate ex-
treme of the parasitic habit has been attained. As illus-
trations of this several species of Filjuin and TrirhineUn
may be instanced. In FHitrin Baiieivfti the adult is
parasitic in lymph glands and the embiyosare .set free in
the blood stream. From tliis they are sucked out into
the body of a mosquito and there undi-rgo early develop-
ment, only to be reintroduced at a later stage into the
body of a new ho.st where the mos(piito is biting. In
Triclii iuI/k .•ipi nilis the encysted larv.a' in flesh are set free
in the stomach by processes of digestion. They wander
into the duodenum, and after attaining sexual maturity
the female penetrates a villus and sets free the embryos
which, rcacliing the muscle tissue through the agency of
the blood current, encyst there and await transference to
a new host. Thus in both cases no part of the life his-
tory takes ])lace in the external world, and the transfer
of the |iarasite is dependent upon the carnivorous or
blood. sucking lialiit of the animal which functions in
the one case as secondary host and in the other alter-
nately as primary and secondary host, but in different
organs.
A still more complicated relation is found in the ma-
jorit_v of Trematoda and in some Cestoda when the change
of host is associated also with an alternation of a sexual
with- an asexual generation. In most Cestoda the eggs
develop into an embryo which in the secondary host
gives rise by metamorphosis to a jieculiar larva, the
bladder worm; and tliis after its transfer to the primary
host develops into the adult tapeworm. The relation be-
tween primary and secondary host here is geuerall.v that
of food and feeder. Thus the bladder worms of the two
most common human eestodes aie found in the flesh of
cattle and hogs respectively and develop when intro-
duced into the alimentary canal of man into the adult
tapeworm. Though somewhat comjilicated by radical
changes in form, the process is generally regarded merely
as a metamor]3liosis. The case is somewhat different in
those forms, as, for instance, Tania ecliinvcdcciin, in which
the bladder worm proliferates, forming not a single head
merely, but several or many, from each of which when
introduced into the proper host there may develop an
adult cestode. Here the larva in the secondary host
multiples asexually, while the adult in the primary host
.^04
REFERE^'CE HANDBOOK OF THE MEDICAL SCIENCES.
Parasile*.
Parasllp*.
reproduces sexually. The change of hosts is accom-
pauiefl by an alternation of generations or metagenesis.
lu the' Trcmatoda one tinds the same alternation of
generations coupled with change of hosts, only that the
asexual generation may be repeated and the life history
further complicated by the introduction of a new host,
the tertiary, in wliich a stage of the development is
passed. Among those forms of which the life history
has been ascertained great difference obtains in detail ; of
the species parasitic iu man the development is as yet
known only in part so that the general statement may
suffice andreference be made for details to the special ac-
count of the group given elsewhere.
Mode of Introduction. — The life history often gives a
clew to the means by which the parasite gains introduc-
tion into the human" host. Thus the discovery of blad-
der worms or of larval TrichinHla in pork suggested at
once the manner of infection, namely, by eating the flesli
containing these larval stages without the Hesh having
been subjected during preparation to conditions such as
to kill the larva;. This method of infection, namely, the
introduction of encysted larva;, is characteristic for the
Cestoda. Those species most common as adults in man
among civilized nations are obtained directly from arti-
cles of food, as Tcenia mginatairom. beef, BibotUriocepha-
luslatos from tish ; other less frequent species as Ilymeno-
lepis diminuta, Dairiinea madngascarensis, and others of
which the larval stages are found in insects (cockroach,
beetle, meal worm) owe their introduction jjerhaps to the
chance inclusion of such infected insects iu bread, pud-
dings, or other similar articles of food.
Disregard of personal cleanliness on the part of the in-
dividual, the habit of biting the linger-uails, and among
children the practice of sucking fingers or toes serve to
infect such with the eggs or embryos of many parasites
or to increase an infection already acquired. In this way
there is introduced the larva of Dipi/lidium caninvm
which lives in the dog and cat fleas, the eggs of Ascaris
cams, the dog and cat roimd worm, eggs of Oxyuris vcr-
micularis which are deposited upon the perineum of the
liost, eggs of C'y-iticcreus ctllulosm when the adult is pres-
ent iu the same host, and manj' other species. Contami-
nation of hands with eggs from dirt and consequent
infection of the individual is common iu children and
field laborers, and may introduce any form of which the
eggs are capable of causing the direct infection : these
forms are Axcaris lumbi-icoidfs, Trkhocephulns trii-hiuris,
and other Nematoda.
The introduction of eggs and embryos takes jilace iu
the majority of cases, no doubt, through the contamina-
tion of theWater supply. Almost all the eggs of the
helminthes develop in standing water, and primitive
methods of obtaining drinking-water from pools alford
the best means of disseminating the species. Salads and
other foods eaten uncooked servo as further means of in-
fection, especially in those regions where it is customary
to use human excrement to enrich the soil, or where the
water supply of the village is dependent upon infected
sources.
Among the important parasites which reach the human
system as eggs in water or on uncooked vegetable food
are of the Cestoda: Cysticercus celhilosm, the larva of 7>f-
nia solium, Echinococcus polymorphus, the larva of Tccnid
echiiwcoccus ; of the Nematoda : Ascaris himbricoides, A.
canis, Oxyuris vermieularis, Tnchocephalus triehiuris ; of
the Linguatulida: Pentastoma denticulatum, Poivceplialus
constrictus.
Of those which as larva- attain the human host in the
same manner one may list all the Treniatoda parasitic iu
man, and of Nematoda Strongyloides stercoralis and possi-
bly Vncinaria duodenalis, though according to the studies
of Looss the latter seems to bore its own waj' actively
into the body of the host.
The part played by chance in the introduction of para-
sites is very large. Grubs, hairworms, maggots, and
even tapeworms have been taken from wells and from
running water. The same forms occur frequently in va-
rious kinds of fruit ; others in old or carelessly handled
meat, also mites in cheese and fruit; and any or all of
these may at times reach the human alimentary canal,
where according to their adaptability they become occa-
sional, accidental, or pseudoparasites. Their presence
may be made known at once by adverse conditions, or
the}' may remain long undetected so that their source is
fully unknown. They may reach peculiar locations, as
is shown by the flesh fly maggot taken from an abscess
iu the middle ear, which it had in all probability reached
by active migration through the Eustachian tube, having
been introduced into the throat with a piece of meat.
Factors Controlling t/ic Abundance of Parasites.— The
life of man in communities led at first to a large increase
in the number of parasites and to frequent epidemics:
and both of these results were due to conditions resulting
from the commimal life. Of primary importance is the
impure water supply which semicivilized communities
are wont to draw from the nearest pool. The minute,
well-protected eggs of parasites distributed in fecal mat-
ter everywhere (for such communities are not exacting in
their demands for the disposition of waste) are carried by
rainwater and distributed over large areas contiguous to
the settlements and contaminate generally the surface
water of the district. In case the parasite develops di-
rectly, the human host becomes infected by the use of
this surface water; and if it is a form requiring a second-
ary host, the same conditions give it easy access to the
forms which serve as such, siuce these are largely domes-
tic animals. The close relation of the abundance of
parasites to the water supply is well illustrated by the
case of Bothriocephalus latus. This form is veiy common
in a few regions in Europe, all of which are proximate to
bodies of water. The intermediate host is a fish, and the
verj' means adopted by civilizeil comnumities for remov-
ing danger of contamination from waste, namely, the
sewage system, became the medium through which the
eggs and embryos were carried into the lake. There they
found suitable secondarj' hosts iu the fish which subse-
quently reached the city markets further to infect the
populace. The life cycle was complete within narrow
geographical limits, and the eleraeut of chance which
plays a large part in limiting the numbers of parasitic
animals was reduced to lowest terms.
The dangers of parasitic infection in communal life,
which pays little attention to the amount and character
of surrounding surface water, is also illustrated by the
spread of malaria, elephautiasis, and yellow fever, which
depend upon the abundance of mosquitoes bred in this
casual water. It has been abundantly shown that crimi-
nal carelessness on the part both of individual and com-
munity has mtdtiplied breeding places and contributed
materially to the spread of these diseases. Even the in-
vention of protective screens has not been able to cope
with these aggravating carriers of disease.
The habit of the isolated individual is also that of the
community, even such as may be well advanced in the
social scale, namely, to deposit human excrement indis-
criminately. This method, which even to-day is practised
in some parts of the United States, is well calculated to
give to eggs of parasites a maxinunn opiiortunit)' for de-
velopment. The same opportunity is afforded when the
Chinese gardener employs for the enrichment of his gar-
den patch human excrement from the neighboring vil-
lage.
The same massing of individuals which has made the
community more liable to parasitic infection plays its
part in the infection of the secondary hcjsts, especially
those which are domesticated animals. If the groimd on
which cattle are grazing becomes infected by tapeworm
eggs, the entire herd may receive bhulder worms. The
infection of a single hog with trichintc means the con-
tamination of the entire group if tlie pernicious habit is
followed of feeding to others the remnants of a slaugh-
tered animal. Just here is the chief reason for the strong
condemnation which has been visited upon local slaugh-
ter-houses. They regularly feed the offal to hogs, and
by so doing further the spread of such parasites. In the
large packing establishments the requirements of modern
505
Parallij roid^,
Pui'al>|»li4>i4l Ft'\<'r,
KKFEHENCE HANDBOOK OF THE MEDICAL SCIENCES.
iDtliistrial success are met by vegvilations which cure the
evils referred to. All reinuants are used and are sub-
jected to pnjcesses which desti'oy whatever parasites
inay be included. Under tliese conditions one may
safely predict the gradual i.lisa]ipearaiice of parasites, es-
pecially w-ith the co-operation of certain factors not yet
mentioned.
In addition to municipal features as noted, personal
habits play an important part. Cleanliness of person
and hands," coupled with careful ablution not only of the
person l)Ut also of tlie various articles of food, reduces
the percentage of parasitic infection. A simple iufec-
tiou of Trk-1wfcplii(liis becomes manyfold greater by the
accidental transfer of eggs from the skin near the anus,
where they are deposited, to the mouth. The reality of
such supp"osed auto-infection is proved by the high de-
gree of iufcction among insane and defective classes
which are known to e.vereise little care over personal
cleanliness. No doubt many eggs of parasites are intro-
duced on salads and other uncooked foods which are
eaten without sullieicntly careful cleausiug previously.
The emphn'iuent of footgear and hand coverings is in-
fluential also, because it reduces directly the likelihood of
infection from eggs of parasites contained iu earth, etc.,
which with uncovered hands become temporarily im-
prisoned beneath the finger nails of the field laborer.
These coverings maj' also play a considerable part in
preventing infection with Unciniiria if the observations
of Looss are confirme<i that the larviT- enter the body by
an active migration thniugh the skin, cbiefiy of the
hands and fet't, with which they come in contact in the
case of Held laborers.
Another factor which has tended to reduce the percen-
tage of parasitic infection is the less intimate as.sociation
of the more highly civilized individuals with domestic
animals, especially dogs. The parasites of these ani-
mals, and iu particular one species, Tanid echinococciin.
possess great clinical importance for man. Not only is
it apparently less frequent than jireviously, but also its
frequence is certainlj- greatest now in those regions in
which the inhabitants live most familiarly with their
dogs. It should be noted also that the initial infection
of the dog is prevented by keeping from it the offal from
slaughtered cattle and sheep.
Proliably more influential than any other factor iu de-
termining the reduction in degree of parasitism is the use
of cooked fooil. A large part of the flesh food of semi-
civilized man is eaten raw or only partially cooked, iu
which condition the larval parasites are capable of de-
velopment to the adult on reaching the alimentary canal
of the new host. Were all aniuuil footi eaten only when
thoroughly cooked, the common tapeworms and the
dreaded Trii-hinclJn would cease to have clinical impor-
tance. The aliundanecMif Tieiiia Kngiiidta, the beef tape-
worm, where beef is eaten raw, of T. solium, the ]iork
tapeworm, where raw ham is a delicacy, and of Bihothri-
ocep/taliis latiis, the broad tapeworm, where partly cured
tish is eaten uncooked, furnishes the demonstration of the
proposition advanced. And so long as pork is eaten un-
cooked cases of trichinosis will oec\ir, whatever means
may be taken to reduce tlie <Luiger tiy meat inspection.
That factor which is about to be ef)usidered is destined
to play the greatest role in the limitation of parasitism;
it is the intellectual, and b_v it is brou.ght about tlie deter-
mination of a rational hygiene and its application by the
individual. National prejudice or established custom
can oppose its introduction only temporarily, and it must
ultimately succeed in reducing to lowest terms the para-
sitic infectious of man and the important food animals.
Ileiiry B. Wiird.
IiIBl.IOOR.\PHY.
References to ttie important works cnnsiilteii may tit> found under
AravhnitJa. Cisltntii, tlintdiii' tj, Mosiinilins in ificir lidatmn to
liitinnn l'iith<<ln,^iti. Xi iiuiIikIh, /';-"/(. -nu. and Trt inntudn.
PARATHYROIDS. (NORMAL AND PATHOLOGICAL
ANATOMY.)— In isso Sandstrom discovered the pres-
ence of small glandular organs ou the posterior surfaces
of the lateral lobes of tlie thyroid. He found these to be
of constant occurrence, and from their structure regarded
them as embryonic thyroid tissue ; he accordingly named
them glandiilip pitrnthjirnkkiT. A 3'ear later, the same
organs were independently discovered by Stieda in em-
bryos of the pig, and by Baber in difl'erent animals. The
former regarded them as carotid glands, the latter as em-
bryonic thyroid tissue. But little attention was paid to
these glands until 1891, when Gley asserted their impor-
tance. In the few years immediately following, his state-
ments were supported by numerous observers. In 1895
the first careful study of the minute anatomy of the para-
thyroid was given liy Schaper. Numerous experimental
investigations followed, both in normal and thyroidecto-
mized animals, .showing the physiological importance
of these structures. Various names have been proposed
for them: " epithelial bodies.^' " accessory ylands." " acees-
siirji tluiroids," " glandules t/ii/mirjues," etc: the original
dL-slgnation parat/iyroid has the advantage, however, that
the organs are not thereby confused with the accessory
glands having the true thyroid structure.
As to the physiology of the parathyroids and their
functiou no absolute knowledge has yet been obtained.
It was first believed that they had a direct connection
with the thyroid, and could compensate for it. Later
experimental investigations in transplantation and extir-
pation, as well as in feeding with gland substance, have
shown that the parathyroids have a function distinct
from that of the thyroid. The loss of the thyroid leads
to a chronic disease, that of the parathyroids to an acutely
fatal disease. Feeding with gland substance is effective
only in case of the administration of the same gland sub-
stance as that of the organ affected ; tbusithyroid feeding
is of value only in case of the loss of the thyroid, and
parathyroid feeding only in case of loss of the parathy-
roids. In transplautati(m, both thyroid and parathyroid
preserve their characteristic structure.
The various investigators are not yet agreed as to the
embryology of these glands, but it may be regarded as
]uoved that the parathyroid bodies lying outside of the
thyroid have an independent Anlage in the fourth gill
pouch. In some animals there occurs constantly an epi-
thelial body included in thyroid tissue, which probabl}'
arises from the third gill pouch. This internal epithelial
body occurs so rarely in man that its presence may be
regarded as a probable anomaly of development. Fur-
ther, the jiaratbyroids arise from single symmetrical An-
lagen, and their occasional multiplicity is to be ascribed
to a secondary snaring off.
The parathvroids occur usual!}- in pairs; sometimes
one on each side, or two on one side and one on the other.
The writer has also found three upon one side. The to-
tal number observed has ni-ver been greater than four.
In size they vary greatly, but they are usually very
small; the average, as found by the writer, being about 7
mm. long. 3-3 mm. broail, and 1..'5 nmi. thick. The aver-
age weight is about 0.2-0.3 gm. The}- are often almond-
shaped, having one end recurved : but the shape not infre-
quentl.v suggests the spleen. At other times they may-
be Hat, cylindrical, or round. Their color is usuallj' pale
brown, but may Ije brownish-red or bluish, so that they
are easily mistaken for li;emolympli glands. They usu-
ally lie behind the lower poles of the lateral lobes of the
thyroid, separated from the thyroid tissue b_y connective
ti.ssue, their convex surfaces Ijing iu slight depressions
on the under surface of the lobes. Not infrequently they
are found below the thyroid, even as low- as the level of
the clavicle. It is often very difficult to recognize the
liaratbyroids at the autopsy ; therefore all of the glandu-
lar structures in this region should be removed for mi-
croscopical examination. It is of advantage, in case the
organs are not easily found, to take out the neck organs
in toh> and fi.x them in formalin. After fixation the dis-
section of the region behind and below the thyroids usu-
ally results in the determination of the exact location and
relations of the parathyroids, their brown color becoming
more promiuent in contrast to the white adipose tissue
about them. By following up the branches given off from
506
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Paratyphoid Fever.
the inferior thj-roici artcrj-, just before the vessel passes
into the thyroid, the parathyroids are usually easily dis-
covered. They derive their blood supply from these
branches. Their veins empty into the veins on llie sur-
face of the thyroid, or directly into the inferior thyroid
vein. But little is known of the nerve supply. Saeer-
dotti and Anderson have traced nerve fibres along the
vessels and between the epithelial cells.
The microscopical appearances are those of a gland
liaving a delicate capsule, from which thin connective-
tissue septa pass in, supporting the larger blood-vessels,
and sei)arating the imperfectly developed lobides. The
general appearance of the gland may vary greatly.
Often it appears as a single mass of closelj- placed cells,
between which run numerous delicate capillaries, form-
ing a network in the meshes of which lie the cell groups
or alveoli. No connective tissue accompanies the capil-
laries. In other cases the lobular arrangement is nuieh
more marked, the cells showin.g a more decided cord-like
or alveolar arrangement. The anastomosing columns
may consi.st of a single row or of several rows of cells,
arranged upon the capillaries. In other specimens the
<;ells may be grouped into round follicles. Not infre-
quently all three types are found in one gland.
The cells vary in appearance, so that three chief va-
rieties may be distinguished. The majority are some-
what larger than those of the th3'roid ; the nucleus stains
deeply, the protoplasm but slightly. The boundaries of
these cells are visible as fine lines. Besides the.se, there
are large polj'gonal cells with deeply staining nucleus,
very granular protoplasm which stains deeply, and with
sharp cell outlines. The third type of cell is low, colum-
nar, and is arranged upon a basement membrane in such
a way that the cells radiate toward the centre of the
group, giving it the appearance of a follicle. In the
centre of this a definite lumen niaj- often be made out.
It usually contains a finely granular substance, but may
contain a colloid-like material. Occasionally the follicles
are cystic. Between these three types of cells there are
all possible transition forms.
Many of the large pol3-gonal cells stain heavily with
eosin. resembling closely tlie acidophile cells of the hy-
pophysis. In others fine fat droplets are often present.
Tlie follicular arrangement of the cells is always more
marked when the lumen-like opening, containing gran-
ules or colloid-like material, is present. The different ap-
pearances presented by the cell indicate most probably
different stages of functional activity.
The circulation of the gland is sinusoidal in character,
the epithelial cells being separated from the blood by en-
dothelium only, connective tissue as a rule not accom-
panying the capillaries. The secretion of the gland, as
clearly shown in a hypertropliic jiaralhyroid obtained by
the writer in a case of acromegaly, is into the lymph
vessels.
According to Benjamins colloid is constantly present.
The writer has not found this to be the case, but has
found constantly in the open follicles a finely granular
substance. He agrees with Benjamins that the parathy-
roids are individual and constant organs, differing in
structure and function from both the fa?tal and the ma-
ture thyroid: and that the differences in size, form, and
staining reactions represent different stages of functional
activity.
Pathology. — Variations in size, shape, and niuuber of
the glands occur. Cysts lined with columnar or tlatteued
epithelium may be found near or in connection with the
parathyroids, as congenital "rests" of the gill pouch or
of a diverticulum of the same. Benjamins suggests that
this is an analogue of the ductus thyreoglosms, and should
be designated as the ductus parathyroidewi. The writer
has observed in one case in man a blind duct, lined with
low columnar cells, passing into the parathyroid, its epi-
thelium being directly continuous with that of the gland.
Near the entrance of the duct into the iiarathyroid there
were several large cystic follicles containing colloid-like
material.
Circulatory Disturbances. — In general venous conges-
tion the capillaries of the jiarathyroids are dilated; in
general anaemic conditions they arc collapsed and contain
but little blood. Local ana'uiia may be caused by press-
inc of strumous thyroids. Hemorrhage, a'dema,"and in-
Ihimmation may also be caused by struma.
llctror/rcssire Clianr/es. — I'ressinr iitidyliy may lie caused
by slruiua of the thyroid. Fattii (itrnpliii occurs in old
age and in cachexias. Benjamins has observed hydntjiic
diijerieraiion in groups of cells, occurring in two cases in
which the organ was hypenemic. The writer has ob-
tained a reaction for mucin in the C3sts found in one
case. lie further regards the presence of calloid material
in such cysts as being of the nature of a degeneration.
I/yperlropIiy.— In a case of acromegalj' with adenoma-
tous tumor of the hypophysis the w'riter foiuid great
enlargement of the parathyroids, the right parathyroid
weighing L5 gm., the left l.T gm. ; the right one being
iiearlv 2 cm. long. Both were deep bluish-red. The
microscopical examination showed the follicles to be for
the greater part cystic, and containing finely- granular
material staining deeplj' with eosin. No colloid was
found. All transition stages could be observed, from the
closed follicle to the cystic ones. The dilated cy.stic fol-
licles could be seen to possess direct communication with
the Ij'inph vessels. The thyroid in this case showed in-
terstitial increase of connective tissue.
Benjamins has seen an interstitial h3'perplasia of the
connective tissue of the parathvroids in a Ciise of Base-
dow's disease associated with cirrhosis of the liver.
In struma of the thyroid, according to Benjamins,
there is no increase of size in the parath3'roids; on the
contrar3", the3' are often smaller, and are eitlier normal
oi- show retrogressive changes i-ather than progressive.
Tliese changes are to be referred to the pressure of the
enlarged thyroid.
With the exception of the one case mentioned above,
Benjamins found no changes in the parathyroids in Base-
dow's disease.
Benjamins describes a tumor attached to the right lobe
of the thyroid, which in structure he regards as closely
resembling that of the parathyroid, and regards its origin
from the latter as possible.
Functional delation between Thyroid and Parathyroid.
— The evidence at present is against the existence of any
close functional relationship between these organs. In
conditions of extensive thyroid disease the parathyroids
are normal or onl3- secondarily affected. In a case of
cretinism with total defect of the thyroid, reported b3'
JIaresh and Peucker, the parathyroids were normal,
other disturbances of develojimeut of the lh3'roid occur,
in which cases the parathyroids are found to be normall3'
developed. In a case of pigment atroph3' of the thyroid
Benjamins found the parathyroids normal. According
to Vassali and Generali, if the parathyroids be removed
at the same time with the thyroid tetany results. If the
parathyroid on one side alone be removed, the tetanj- is
transitorv. If the parathvroids are not removed, ca-
chexia strumipriva or m3'xa'dema follows.
Whether the case of hypertroph3' of the parathyroids
in acromegaly is to be regarded as a compensatorv h3'-
pertroph3' on the part of these organs for the h3'poph3'-
sis. or is to be explained as a part of the general hN'per-
trophj' occurring in the disease, the writer is not able to
decide. The evidences of excessive secretor3' activity
would favor the former view. (See Benjamins. "Ueber
die Glanduhe parathyroida\" Beitruge tur pathch>(iischen
Anritomie. 31. \'M2.)' Aldred t^colt Warthin.
PARATYPHOID FEVER— Up to the time when the
Gruber-Durham-Widal reaction came to be used as a
routine method in the diagnosis of typhoid fever no hesi-
tation was felt in classing all the cases presenting certain
symptoms as typhoid fever; but with the use of tliis
method it has been recently discovered that in some cases
the characteristic serum reaction fails. In these it has
been found possible to isolate from fajces, urine, blood,
and various other situations, organisms which have been
carefully descjibed b3' a number of workers, and which
501
P;irrirn Ui'iiia.
Parotid (;laucl.
ItEFKHKXCK llAM)i:t)()K OF TIIK MKUK'AL SCIENCES.
agree in morpliological and cultural characteristics closely
enougli to be at least classed in one group, if notactually
identitied witli one anotlier. Such organisms have been
sjiokeu of as " typlioid-like bacilli " or " paratyplioid ba-
cilli." and the clinical phenomena in sucli infections may
perhaps, from their resemblance to typhoid fever, be
suitably spoken of as paratyphoid fever.
Tiie "disease has occurred, sometimes in small epidem-
ics, in several places in Ein-ope, notably in Paris, Bremen,
etc., and has also been observed in American cities. It
seems to attack persons of any age, but the average in a
number of cases was abiuit twenty-seven years. The
symptoms resemble veiy closely those of typhoid fever —
indeed, one cannot point out any symptom of pathogno-
monic importance, so far as our knowledge yet extends.
The onset is, as a rule, with headaclie and general malaise,
with some stupor. There is a continuous, if irregular,
high temperature lasting throughout the illness and ter-
minating gradually by Tvsis, after a duration generally
of about four weeks. The spleen is, as a rule, not mark-
edly swollen, and often is not at all palpable. In-
testinal symptoms arc not characteristic — there may be
diarrhfea, or constipation may persist throughout the
course of the illness; in some cases there has been intes-
tinal hemorrhage. The blood shows no typical changes
— the leucocytes are, as a rule, not increased. Rosesjiots
are very often — indeed generally — present. Various
complications, such as bronchitis, abscesses in various
localities, sliglit hemorrhages, etc., have occurred. an<l in
one case (that of Cushing) there was a costo-chondral
osteomyelitis from which the organism was isolated.
The prognosis on the whole seems veiy good, as of
twenty -si.\ or more reported cases only a small number
were fatal and two or three autopsy records only are at
our command. Most of the cases have terminated by
lysis — convalescence progressing much as after typhoid
fever, while in one or two described by Kurth a sort of
crisis occurred.
At aut0]5sy it is found in these cases that there is no
intestinal lesion whatever; the Peyer's patcdies and .soli-
tary follicles are not swollen and show microscopically
no lesion. The spleen is .somewhat enlarged and soft,
and on section has a dtdl, o])aque, grayisli-pink color.
Microscopically there is no great proliferation of the en-
dothelial cells, and no red-corpuscle-carrj'ing cells are
seen, although the lymphoid cells of the splenic ptilp are
more abundant than normal. In one case focal necroses
have been des<-rilicd in the liver.
Little characteristic as the symptoms and pathological
lesions are, the bacteriological findings are fairly definite
and serve well to outline this group of cases. There
have been isolated by various workers (Gwyn,' Cushing,'^
Schottmiiller,^ Kurth,* .Johnston, =■ Hewlett,' Longcopc'
and others) bacilli designated under various names and
still closely enough related to be classed, with some ap-
proach to unanimity, as a group standing half- way in its
properties between llie liacillus tyiiliosus and the B. coli.
and very closely related indeed to the so-called group of
Gartner, the type of which is the B. enteritidis, a form
associated with the epidemics following meat poisoning.
Morphologically these paratyjilKiid bacilli cannot be dis-
tinguished from the typhoid. On the ordinary culture
liiedia, such as agar, gelatin, bouillon, etc., their growth
is jjractically identical with tliatof typhoid. In litmus
milk they produce, as a rule, acid at first with terminal
alkalinity if exposed to the air and they do not clot the
milk. Unlike the B. typhosus they ferment glucose with
the production of acid and gas, while with lactose media
they produce no gas. In these latter respects they most
closely resemble the group of B. enteritidis. The produc-
tion of indol is very slight and even .somewhat doubtful.
Far more definite, however, than the results of these
cultural methods of differentiation are the serum reac-
tions. It is found that the serum of such a patient will
never agglutinate the typhoid bacilli ; it will, however,
in great dilutions, agglutinate the bacilli isolated from
the patient's blood, and sometimes even the bacilli from
other cases. Some of the organisms described, however,
such as those of Gwyn and Cushing, practically identi-
cal as they are culturally, refuse to be agglutinated by
one another's sera. Similarly, while it is pos.sible to im-
munize laboratory animals from each of these bacilli, so-
that their .serum in the greatest dilution will agglutinate
tlie bacilli u.sed, it is often found that the bacilli from
another epidemic or from another case will not be agglu-
tinated by this serum. Nevertheless, it seems justifiable
to consider these organisms e.\tremely closely related, if
not quite identical, and even if, as has been suggested,
they are merely the results of altered environment on ty-
jilioid or colon bacilli, they have acquired such charaeteVs
as to secure them a specific value.
To resume, therefore, we havein this recently described
group of cases a disease I'linieally in every respect resem-
bling a mild typhoid fever, but in which the general
septicemia is not as in typhoid associated, so far as we
know, with such definite, localized pathological lesions.
The serum reaction fails with the typhoid bacilli, but is
])ositive in great dilution with the eharacteiistic bacilli
which can generally be isolated from the blood and fsces,
and wliich morphojogically and cidturall}' are closely re-
lated to the group of B. enteritidis and to the B. typho-
sus, and from this relation are designated paratyplioid
bacilli. William G. UacCtiiliim.
RKKEREX'CES.
' (iwvn : Jcilin.s Hopkins Hospital Bulletin, 1808, vol. i.\., j). oi.
■ Ciisliint' : Ibid., laOO, vol. xi., p. I."j6.
a S. liottiniillei-: Deutscli. med. Wocbenscbrift, 190(1, No. 32, Ztsoh. f.
HykI'iio, liKil, Bd.m, p. ;«s.
' Kurtli : Deul.scb. metl. Wochenscliritt, 1901, Nos. 30 and 31.
•^ Johnston : Anieri(^an Jouniai of Medical Sciences, August, 1903.
» Hewlett : IhitJ.
: Lonjrropf: Ihid.
PAREIRA BfiA\ A— Ptimm. U. S. P. ; Bireinp nuUx.
B. P. The root of VlioitOnnUiulroii tomentusnm Ruiz et
Pavon (fam. Mcnispeniiafeif).
Tliis drug is derived from a tall woody twiner of Brazil
and adjacent parts of tropical ,South America. It was
first introduced to the notice of physicians in Europe
about two hundred years ago, an<l after a period of neg-
lect was again brought forward in the early part of this
century. It is very little used at present — at least in this
country. During this jieriod .several other closelj' re-
lated products from allied genera have been imported as
pareira brava, adding much to the botanical confusion
in regard to its source. The "false pareiras" appear to
have about the same slight degree of usefulness as the
genuine.
Pareira occurs in subcylindrical, knotty, and some-
what tortuous, hard, heavy, and tough pieces, of indef-
inite length and l-(i cm. (J- to 2J^ in.) thick; externally
dark brown or blackish, longitudinally wrinkled anil
bearing transversel}' elongated protuberances or incom-
plete annular ridges, as well as constrictions, or occa-
sionally fine fissures ; the dried transverse surfaces exhibit
several equilaterally concentric circles of interru])ted,
porous wood wedges, projecting be_youd the markedly re-
tracted intervening tissue of the rather large medidlary
rays: internally pale brown or yellowish-brown, when
freshly cut having a waxy lustre; inodorous and bitter.
Of the several sinirious pareiras, all have a gray or
grayish-brown surface instead of the blackish color of the
genuine, and are less, or not at all, knotty and roughened.
None cuts with its wa.xy lustre, and all are ligliter in
weight and less solid.
Pareira contains from three-fourths to one per cent,
of an alkaloid which is probably pelosine, .similar to, if
not identical with, Inixine of box, and biberine of green-
heart bark. A little tannin also exists, together with
starch, gum, and about eight per cent, of ether-soluble
fat.
Action and Uses. — What we know of the constituents
of pareira and their actions does not support the thera-
peutical ideas upon which its use is based. It is known
to be a fairly good bitter tonic, and slight anti-periodic
properties may be reasonably assvimed. Its use, how-
ever, is chiefly as a liiuretic, and in inflammatory diseases
608
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
I^itrcira Brava*
Parotid Gland.
of the genito-urinary organs, more especially in orchitis.
While it does appear tohavc a slight diuretic action, the
idea of its use in this way probably depends upon admin-
istering it iu decortion well diluted with water. Cer-
tainly, the idea of its having the great diuretic value once
asciibed to it lias been conVpletely abandoned. There is
ijood clinical evidence of a moderate degree of usefulness
m the other directions named, although such action is by
no means certain or uniform.
The Pharmacopoeia provides a fluid extract made with
ten per cent, of glycerin, of which the dose is a flui-
drachm. For its diuretic effects, the five-percent, decoc-
tion is best employed.
Allied Drug. — The drug which is, in the United
States and England, 4-egarded as the principal adulterant
or substitute of pareira is that wholly or partly specified
in some pharmacopeias, namely, the root of Cissampehjn
Pareira L., a plant of similar habit and growing in the
same region, though much more widely distributed, and
l)elieved also to grow in India. The root is generally
smaller than pareira and is of a brown or gray-brown
<;olor; longitudinally much grooved and transversely
Ussuved, and readily losing its bark when kept in stock.
The alkaloid of this drug has been proven to be pelo-
siue. Cissampelos is believed to act much like pareira,
though it is more generally used as a tonic.
A number of other tropical American drugs are locall}-
known as " pareira." but they bear no resemblance to the
genuine article. Jlcnry II. Rushy.
PARIS CHALYBEATE SPRINGS.— Lawrence County.
Missouri. Post-Uffice. — Paris (springs. Hotel and
cottages.
Access.— Via Kansas City, Fort Scott, and Gulf Rail-
road to Ash Grove, thence two miles by stage to springs.
The springs are delightfully located in the Ozark
jMountains, the surrounding country being interspersed
Avlth beautiful glens, green meadows, dense forests, and
orchards. The elevation (1,500 feet above the sea level)
is sufficient to assure freedom from de]iressing heat in the
summer time. The spiingyields aboutone hundred and
twenty gallons of water per hour, having a temperature
of 52°"F. a qualitative examination sliowed the pres-
ence of oxide of iron in solution, besides the carbonates
of lime and magnesia, the chlorides of sodium, potas-
sium, and iodine. A complete qualitative analysis is de-
sirable. Patients suffering from disorders of liver, kid-
neys, stomach, skin, and nervous system have found
great benefit from a sojourn at the springs. The tonic
properties of the water have been well shown in the
debility of ana?miaand in various disorders of the female
sexual system. .hiinfn K. Crook.
PARIS, PARISETTE.— A European plant, Paris quad-
rijoliii Linn., l)elongingto the order Liliarcir, and closely
allied to the Trillium, which is so common as an Ameri-
can wild tlower. Experiments with an extract prepared
from the entire plant show that it exercises a direct action
upon the medullary centres. It at tirst produces a short
period of excitation which is followed by a diminution
of sensibility and reflex action, and a slowing and weak-
ening of the respiration and heart beats.
It was suggested that it might prove of value as a
substitute for aconite, but it has failed to obtain any rec-
ognition as a therapeutic agent. Branmont Small.
PARKER MINERAL SPRING.— :\[cKean County, Penn-
sylvania. l'o>i-0.'-mK. — Gardeau. Hotel and sani-
tarium.
Access. — Gardeaii is a station on the "Western New
York and Pennsylvania Railroad, four passenger trains
daily stojiping at this point.
This resort is located in the Alleghany Mountains, on
the headwaters of a branch of the Susquehanna River.
The elevation here is about 2,000 feet aliove the sea level.
The country in this part of Pennsylvania is still wild and
sparsely settled. Dense forests of hemlocksare freiiuent,
and bear ami deer mav yet be found to reward the
hunter's pursuit. Mountain trout streams abound. It
is scarcely necessary to add that the climate in this wild
and rugged region is bracing and salutary. In i860 the
present mineral well was drilled on the site of an oil
spring. M 650 feet a vein of water was struck that
flows from the top of the well in an unvarying current
of about seventy gallons jier hour. After some delay a
bathhouse, sanitarium and hotel were built, and "the
place has developed into a very comfortable and attrac-
tive resort. An analysis of the water hy Henry Trimble,
analytical chemist of Philadeljihia, resulted as follows:
One L'nited States gallon contains: Magnesium chloride,
gr. 109.84; calcium carbonate, gr. 11.95; calcium chlor-
ide, gr. 221,92; sodium chloride, gr. 282.55; potas-sium
chloride, traces; silica, gr. 1.33. Total, 627.59 grains.
Temperature of water at spring, 50 F.
This is a richly impregnated saline water of the mag-
uesic-sodic-calcic variety. When used under proper med-
ical supervision it ought to exert a very beneficial influ-
ence in a variety of disordered states of the physical
economy. It should always be taken at first in small
quantities. The water has been found to possess active
cathartic and diuretic properties. It is also a stimulant
to the gastric mucous membrane, promoting the flow of
gastric juice and aiding the process of digestion. The
best effects of the water will be observed in atonic dj's-
pepsia, torpor of the liver, abdominal venosity, constipa-
tion, in nephritis with scanty, highly colored" urine, and
in irritable states of the bladder. At the resort it is also
used in the form of baths in a variety of conditions. The
water is bottled and shipped to any desired point.
James K. Crook.
PARK'S SPRINGS.— Caswell County, North Carolina.
Post-Office. — Pelhani.
These springs are located six miles cast of Pelham, but
they do not seem to be used much as a resort. The
waters, however, are u.sed commercially, and are highly
recommended by physicians of North Carolina and the
neighboring States in chronic constipation, dyspepsia,
and portal congestion. The following analysis was made
not long ago by Prof. Alliert R. Ledoux, Ph.D., of the
State Agricultural Experiment Station at Chapel Hill:
One United States gallon contains Magnesium sulphate,
gr. 1.50; sodium sulphate, gr. 1.48: iron oxide, gr. 3,50;
rdumiua, gr, 3,50; uncombined sulphur, gr. 0.15: cal-
cium carbonate, gr. 4.80; silica, a trace; sodium chloride,
a trace. Total, 14.93 grains.
In itschemical constitution the water bears some slight
resemblance to the well-known Hunyadi-.Ianos water of
Huugar\'. It is a valuable chalybeate, but must be taken
iu considerable Ciuantities to secure a purgative action.
James K. Crook.
PARONYCHIA. See Hands and Fingers, elr.
PAROTID GLAND, DISEASES AND INJURIES OF.
— I. Ix.iURlES. — The parotid gland may be injured from
the outside through the cheek or from the inside through
the month or pharynx. The more common injuries in
the reported cases have been the lesult of blows and
sword thrusts and have proved of little importance.
However, occasionally hemorrhage, venous or arterial,
may be alarming, and if it cannot be controlled by press-
ure" one or more vessels will have to be ligated. The
internal and external carotid and the vertebral arteries
have been severed in such wounds; when this occurs, if
it is found impossible to ligat(! the arteries in the wound,
the common carotid should be at once exposed and tied.
Hemorrhage may always be temjioraril}' controlled by
pressure. "Associated i"ujury to the facial nerve maj
cause a more or less complete unilateral facial paralysis
with areas of anaesthesia, and in such a case an attempt
should at once be made to suture the ends of the divided
nerve.
An injury to the gland substance is usually demon-
strated by the flow of saliva from the wound after the
hemorrhage has been cDiilrolU'd. The escape of the fluid
5(»9
Parotid <;lan<1.
Parol ill Gland,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
seci'eted is usually augmented, in sueli u ciisc, by the
movements of the jaws in mastication ami by tlie rellex
stimulation caused by the ingestion of food.
Injuries to Stensok'ii duct are ini))ortant ou account of
the conditions to which they give rise and of the difficul-
ties which stand iu the way of siiccessful treatment.
The duct is more often divided or lacerated on the mas-
seter, where it is more ti.\ed. than on the buccinator,
where it is moderately movable. Tlic fad of its having
been divided is made" evident by ihe tiow of saliva from
the wound. Occasionally spontaneous healing occurs,
but the results to lie feared are either the formation of a
fistula, the eonuuoii termination, or tlie obliteration of
the duct, a set|Uel of more rare occun-ence. Stenosis of
the duct may lead to the formation of a cyst and event-
ually, as stated by some aiithorities, to complete atrophy
of the gland.
The tnritmoit of injuries to the parotid and its duct
demands tirstof all the control of hemorrhage. Ligation
of a vessel in the wound is dillicidt if it is large, and,
if it is not po.s.sible to Ijgatethe internal and external car-
otids singly, the conunon carotid should be tied. The
vertel)ral artery has been ligated in its first part and also
in the vertebral canal after remox'al of a transverse proc-
ess. It hemorrhage from eollaferals persists, pressure
and cold ajiidieations will be found sufficient to control
it. The possiliility of tlie formation of a fistula and the
danger of secondary infection of the gland ati'ord us two
sjiecial reasons for seeking ]irimary imion in wounds of
tliis locality.
Immobility of the liead and jaw should be secured with
stan'h or plaster sidints, and for a few days fluid food
only slio\ild b<' adniinistereil through a tube. Talking
should be forbidden.
II. Pahotid FisTf!..\. — Parotid fistula is a couditiiui in
wliich the normal secretions of the gland escape through
an abnormal opening on the side of the face or into the
mouth , in the latter case the lesion is of no |iathological
importan<-e. Among the causes may be mentioned
wounds involving tlie gland or Stenson's duct, either
accidental or made during the removal of diseas<'d lym-
phatic glands or tumors, abscess formation and ulceration
following calculus or necrosis of the jaw, and involve-
ment of till' gland or duct in a tuberculous or syphilitic
process.
In a case of fistula there are usually, on the outside of
the cheek, a small opening surrounded by a few granu-
lations and a <-ircumscribed area of reddened and irri-
tated skin. If thi-re is no obstruction in tlie duct the
fistula often heals spontaneously: but at times the fistu-
lous condition is very persistent and obstinately resists
treatment.
Slight weeping of tlie gland from injury to the glan-
dular substance lieals spontaneously in a few da_vs.
Tiyittineiit. — This consists primarily in removal of the
cause of the abscess or ulceration by local and constitu-
tional measures, and the reduction of the lesion to a sim-
ple fistula. If the jiatieiit is seen soon after the injury
has been infiicted a small silver probe may be passed
through the orifice of the duct in the month and into the
pro.\imal portion of the severed iluct, and an attempt lie
then made to suture tlie ends of the duct with fine catgut
sutures, this material being more easily absorlied and less
liable to liecome infected than silk. The sutures should
not enter the lumen of the duet. The external wound
should then be carefully closed.
If the fistula has e.visted for some time the edges of
the artificial o|)ening may lie freshened and <losed,in the
hope of forcing the saliva into its normal channel.
Another method is to passa stout thread soaked in bal-
sam of Peru through the fistula into the mouth, bringing
it out at the angle of the mouth and tying the ends on
the cheek. After the lumen is by this means well rees-
tablished, tlie duct and external wound may be clo.sed
as above. Homer"s method is to make a hole with a
punch through the cheek into the mouth, this hole in-
cluding the orifice of the fistula. After this the external
wounil is closed.
III. Niiw' Growths. — There are a certjiin number of
growths which, while they do not involve the substance
of the parotid gland, lie in close proximity to it, ami
shoulil not therefore be passed unnoticed in a c(msidera-
tion of ttmiors of this region. These, as a rule, lie with-
out the capsular limits of the gland ; but at times, partic-
ularly when they are of vascular origin, they penetrate
the gland substance. These penetrating tumors are seba-
ceous cysts, dermoids, enlarged lymph nodes, lipomata,
n;tvi, angiomata. and lymphangiomata. The}' do not
differ from similar growths in other regions. The writer
has recentl}' seen, in a case of multiple venous angiomata.
an angioma occupying the site of the right parotid gland.
When the patient was in the recumbent position the
tumor was the size of a goo,se egg and of a deep purplish
hue ; but with the patient in the erect position the con-
tents were discharged, the tumor entirely disappearing
and the skin regaining its normal hue. The left parotid
was not similarly affected. These vascular tumors may
be removed by pressure, b.y ligation of the vessels, or by
extirpation, tlie others by extirpation.
Netijilasms of the parotid are very rarelj' of a single
type. IMixed tumors are more common here than iu any
other i)art of the body excepting the ovary. "It is not
tmusual." says Sutton, "in sections from parotid sarcoma
to meet with spindle cells, cartilage, myxomatous tissiu-,
and glandular acini iu an area two centimetres square.''
It will be convenient, however, to group these growths
according to the tissue which is predominant in each vari-
ety and to outline the general characters of each. The
neoplasms vary greatly as to their malignancy, but in
general it may be stated that the mixed tumors grow
rapidly, attain a large size, and tend to infiltrate the ad-
jacent tissues, involving both blood-vessels and lym-
phatics, thus proilnrini; secondary deposits in other parts,
and more particularly in the lungs. The growths when
small are usually painless: they become painful oiih- when
in consequence of their size tlie pressure on the nerves is
considerable, (u- when the nerve sheath is involved in the
process of infiltration. Involvement of the skin with
ulceration is characteristic of the later stages of the more
malignant varieties. Pressure may cause a facial jialsy.
occlusion of Stenson's duct, interference with the blood
supply of the parts dependent on the carotids, and, when
growing deep into the neck, obstriictimi of the cesojilia-
gus and difficulty of deglutition. Facial palsy is more
often the result of infiltration than of pressure, and is
accordingly more common in malignant growths.
EiichdiHjriniiiitti. — Cartilage enters intothe formation of
nearly all parotid neoplasms. Enchondromata are en-
countered in two forms: those composed of pure hyaline
cartilagi', and those in which the cartilage is associated
with other tissues. Enchondromata of the first variety
are of slow growth, attaining the size of a walnut in the
course of several years. It is only in rare cases tliat they
exceed an egg in size. The tumor is firm in consistence
with a surface smooth or nodular, at times adherent to
.surrounding tissues. It is benign, and does not return
when removed. Extirpation is usually not difticult.
The other variety consists of small mas.ses of cartilage
associated with connective, mucous, adenomatous, or car-
cinomatous tissues. It assumes the character of a mi.xed
tumor, is more malignant than the first variety, grows
more rapidly, and tends to recurrence after removal.
Adi niiiiKilii of the parotid are rare : they are encoun-
tered during the period from fifteen tr> tiiirty years of
age. They have a distinct capsule, and may appear in
any part of the gland. They are usually small, painless
tumors, easily shelled out. If large they are movable
and loosely connected with the parotid tissue. The sur-
face is irregular and nodular, hard in places, but often
elastic or Hiictuating on account of the presence of asso-
ciated cysts.
Sairomala found in this region may be spindle-celled,
solid, or cystic. They are rarely pure, and are mixed
with cartilaginous, myxomatous, or fibrous growths.
They are more common than the carciuomata, and come
next to these in malignancv. The soft varieties occur
510
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Parotid Olaiid.
Parotid Ulaud.
more commoDly in youth, the harder types in middle life.
They infiltrate all the surrounding structures, growing
deep into the neck, inward behind the pharyn.x, and
liucUward behind the ear, and involving the sheaths of
the blood-vessels. The rapidly advancing ones involve
the skin which siibsequently ulcerates. A fatal issue
follows dj'sphagia, implication of the pharyn.x, ulcera-
tion into some large vessel, or secondary growths (due to
emboli) in more distant organs. Tlic.v are removed with
considerable dilliculty and tend to rapid recurrence.
Mi/a/inmtrronuita occur very rarely. They are rapidly
growing neoplasms, early involving the entire parotid
gland, and invading the neighboring lymphatics and
overlying skin, which latter is prone to ulcerate.
^[y.roln(^(ll, when they occur in the parotid, are usually
associated with sarcomatous tissue and cartilage. They
contain a thick transparent fluid, and ma)' be delinitely
circumscribed or they may merge gradually into the sur-
rounding structures. They are soft, gelatinous, and
11 actuating.
Carcinomata of this region are rare. Thej- belong to
the period of advancing years. Their growth is at tirst
slow, but later very rapid. Usually they have no cap-
sule and infiltrate surrounding structures in very much
the same manner as do the rapidly growing sarcomata.
Secondary infection usuallj' occurs by way of the lym-
phatics. Carcinomata are the most malignant tumors
found in the gland, and they almost invariably recur
after extirpation.
EndullieliotiKtta are also rare. The}- are derived from
a multiplication of the endothelial cells lining the lym-
])Iiatics and blood-vessels. Some of these endothelial
overgrowths are succeeded by fibrous tissue, while in
others mucoid degeneration takes place.
FihriHiiiita are usually associated with other neoplastic
tissues, Ijut have been met with as pure fibrous growths.
Many of them contain cysts. They are liard resistant
t\imors, usually nodular. They should be excised, and
when purely fibrous they do not tend to recur.
Lipomata rarely occur as pure growths in this region,
but areas of lipomatous tissue are not infrequently found
in the mixed tumors.
IVialnhinn/omatii . — Pruddcn has reported a case of rhab-
domyoma of the jMirotiil. The tumor was composed of
muscle fibres, without sarcolemma, irregularly arranged.
In this same tumor there were lobules of small spheroidal
or polyhedral cells in a well-marked reticulum of an un-
usual character.
Trtiitiiient. — Excision constittites the |iroper treatment
of parotid neoplasms. The gravity and dilticulty of the
operation vary with the size and mobility of the growth,
the extent of infiltration of the surrounding tissues, the
age and general condition of the patient. Removal of
tiie whole gland is a formidable operati(m. It was first
performed by Warren of Boston in 1798. The removal
of a tuiuor should be undertaken at the earliest ijossible
moment, as this offers the greatest hope of a permanent
cure. It should not be forgotten, however, that some
tumors, especially the melanosarcomata, arc often dis-
semiiuited by operative jirocedure. Iij the case of a
ttimor which is already advanced in growth the possibil-
ity of temporary relief from the dangers and discomf<n'ts
of ulceration and pressure may justify a partial or total
removal of the growth. The production of a .salivary
fistula and the occurrence of facial palsy are complica-
tions which may attend the least of these operations, and
of this possibility the patient should be warned in advance.
Cyxtn. — Cysts of the parotid usually occur in associa-
tion with other tumors, and, according to their extent in
relation to the other tissues, thej- modify the consistence
of the tumor.
Less rarely single salivary cysts are met with. These
grow slowly, at times attaining the size of a hen's egg,
fluctuating, elastic, slightly movable, and not adherent
to the skin. They result from tlie obstruction of Stcn-
son's duct by a calculus or by a stenosis, and they usuallj'
represent a dilatation of one of the branches of this duct.
They are lined with cj'lindrical epithelium wliich in time
becomes tessellated. The salivary cysts are filled with
clear, amber-colored, slightly viscid saliva; the contents
of the simple cysts are more watery. The diagnosis, if
doubtful, may be settled by means of an aspirating needle.
Treatment consist.s in opening the tumor and destroying
the lining metnbrane with zinc chloride (forty grains to
the ounce) or with pure carbolic acid. C3'sts maj' be
dissected out, but there is danger of injuring the facial
nerve. The calculus or other obstruction to the duct
should of course be removed.
Cysts due to the dilatation of Stenson's duct have been-
met with in glass-blowers. These are best left un-
treated.
Echinocoecusoi the parotid is excecd-ingly rare. Schuh
reports a case in a woman eighty-three j'ears of age.
The tumor increased to the size of a hen's egg, attaining
these dimensions in about one 3-ear. The tumor is cy.stic,
and the diagnosis from other cysts can be made only by
a microscopical examination of the contents of the tuinor.
Treatment consists in opening the ttimor and destroying
the walls of the cysts with the curette.
IV. C.\i.cuLi. — A. few cases of calculi of the parotid
have been reported. They are less common than concre-
tions in the submaxillary glands. They are the result of
a change in the constitution of the salivary secretion
which tends to precipitate the carbonates ordinarily held
in solution. The calculi vary greatly in size; they may
be as small as a grape seed, wliile one case has been re-
ported in which the concretion weighed 18.6 gm. The
chief constituent is calcium carbonate associated witli
organic substances, variable in amount, which remain
after treating the concretions with In'drochloric acid.
The calcidus may be located in the gland proper or in
the duct where it may be felt with a probe jiassed up the
lumen. It occurs asanodule of variable sizeaud exceed-
ingly hard. Sometimes it obstructs the flow of saliva
from the affected side, and may thus ]iroduce a cyst, or
it may, by the irritation which its presence causes, set up
a chronic parotitis. Calculi of this kind should be re-
moved by an incision, to be made from the inside of the
mouth whenever this is practicable.
V. P-\ROTiTis. — Mumps, or acute infectious parotiiis,
has been di.scussed in another portion of this work. (See
article on Mnmjia.) Other iiitlammatory conditions of the
parotid gland include chronic idiopatliie parotitis, toxic
parotitis, and secondary parotitis.
Clironic Idiopathic. Pnivtitis. or sialodoeliitis fibrinosa,
is an affection of unknown cause. It is sometimes associ-
ated with xerostomia, and rarely it complicates gout. It
usually commences with a catarrhal inflammation of
Stenson's duct, which becomes plugged with mucus, and
later develops into a chronic interstitial proiluctive in-
flammation of the gland, the connective ti.ssue replacing
to a greater or lesser degree the secretory cells. The
lesion is bilateral. The glands of both sides are swollen,
firm, slightly elastic, painless, and not tender. The
course is very chronic. The supply of saliva is much
diminished so that the mouth may become dry and
parched, and as a result swallowing and chewing ma)'
become difficidt.
Treatment is very unsatisfactory, but the duets should
be kejit open by frequent expression of tlie mucous
plugs, and every effort should be made to stimidate the
secretory function of the glands by the use of galvanism
and the administration of pilocarpine and similar drugs.
Raymond .Johnson lias descriiied five cases of indura-
tion and swelling of the parotids, coming on during a
meal, due to a collection of saliva and obstruction of
Stenson's duct. There was consideralile pain during
mastication. In one case there were .several relapses, in
another suppuration ensued. Massage sometimes caused
evacuation of the Jibig.
Toxic Parotitis. — Hypertropliy and inflammation of
the parotid have been reported in a number of toxic con-
ditions such as lead, copper, and mercury jioisoning. and
ill ura'mic states. Comby rejiorts the occurrence, in a
case of lead poisoning, of a synimetrieal enlargement of
the jmrotids. soft, painless, ami pc rsi^leiit, and ruiiiiing
.511
Paroliil <;laiicl.
I'aroi'ariiiiii.
REFERENCE IIANDBOOIC OF THE MEDICAL SCIENCES.
a very chronic course. lu mci'cui'ial poisouing the parot-
ids and svibmaxillaiy glands bcfonii' enlarged and tender
and tile How of saliva isexeessive. I'ilatcral enlargement
of the paroti<ls following the adniinistiation of potas-
sium iodide has been reported by Coniby, Miss Bradley,
Requier. and Villar. in these eases there were also
•cedema of the eyelids, coiy/.a, laelirymation, and saliva-
tion.
After the withdrawal of the i)ois(iii the atlected glands
usually reeover their natural size and function.
Si'm'iii/iii'i/ Panilitis. — Ne.\t tcj muni|is this is the most
common form of inllamnialion of llie parotid. It is as-
sociated with many local and geneial infections, such as
maxillary osteitis, inflammation of the teniporo-niaxillary
joint, abscesses, erysipelas, lyjihoid fever, typhus fever,
cholera, diphtheriri, smallpox, bubonic plague, yellow
fever, cerebrospinal fever, relapsing fever, puevunonia,
syphilis, intluen/.a. and gout. Paget has collected 101
cases of parotitis ((impliealing various infectious and
functional disturbances of the ]ieritoneal anil pelvic or-
gans. Of these, 50 occurred in cases of injury, disease, or
temporary derangement of the generative organs, with-
out suppniation. In this list were included cases of
pregnancy, childbirth, aliortion, jielvic cellulitis, hanna-
tocele, and operations on the vagina and uterus. In 10
instances the <lisease develu|ied alter the introduction of
catheters and .sounds in male patients and after blows on
the testicle; in 18 the disease was as.soeialed with injuiy
or diseaseof thealimentary tract, inv<ilviiig tlie stomach,
pancreas, etc. ; and, linally, in 2:! there was disease or in-
jviry of the abdominal wall. In these cases thecour.se
Avas. as a rule, rajiid and suppuration occurred on the
fourth or fifth day. Donkin h;is reported three cases of
unilateral jiarotitis complicating gastric ideer, and Pe|)-
l)er has also icjiorted a similar case. Deljout d'Estrees
has collected the reports of twelve cases of parotitis in
gouty subjects.
The nnite of infection is in many ca.si'S obscure, but it
is probable that in some cases, as in tyiihoid fever, it is
through Stenson's duct, while in others the metastasis
takes place through the blood-vessels and lymphatics.
Ilanau studied the genesis of Ave cases of suppurative
]iarotitis which occurred as a secondary ]irocess in septic
infections. In all these instances the organisms present
were staidly lococci; they were always finind in the ab-
scesses and ducts, while the blood-vessels and lymphatics
were free. In one fatal case Dietrich found tlie staphy-
lococcus pyogenes aureus in the duets, but not in the
blood-vessels. The mouth is, without doubt, frequently
the direct source of the infection, for iu many diseases it
offers conditions peculiarly favorable to bacterial multi-
plication.
In tiiiiltiiid fever jiarotitis occurs in a variable per-
centage of cases. Osier rejiorts the conqdicatiou as oc-
curring 4.') times in 2,000 cases in ^Munich; of 2,000 jia-
tients with tyidioid fever in the London Fever Hospital,
l:i had parotitis: at Hasle, of 1,000 cases of typhoid fever
there weie 10 cinuplieated tiy sup|iurative ])arotitis. In-
fection is usually through Stenson's duct, and when aris-
ing in Ihis manner it is ]n-obably not so serious a form as
when it occurs asainetastatic process (Osier), Keen has
reported two cases in which Eberlh's bacillus was recov-
ered from the pus in the glands; iu one case there was
a mixture of staphylococci. This coinplieation gener-
ally begins during the third or fciurth week; one case is
reported as appearing on the tenth day. It is usually
unilateral, but sometimes both glands liecome infected,
eoineidently or successively. Siippnraliou almost in-
variably ensues.
Asa rule, jiarotitis is seen only in .severe ca.ses of ty-
jdioid fever; it is in itself a serious complication, tlie
mortality being placed at about thirty per cent. Seven
of the Basle cases ended fatally. The complication is
said to be less common since the introduction of antipj'-
retic treatment, but it seems to the writer that lh<' atten-
tion which has been paid to the care of llie mouth in
reci'iit years may be the more important prophvlactic
measure.
In typhus fever parotitis occurs in many epidemics
to the extent of even twenty per cent, of the cases, being
a more frequent and more dangerous complication in this
disease than iu typhoid fever. Both glands may be af-
fected, but the disease is more commonly unilateral.
Suppuration is usual, and the gland breaks down and is
discharged iu small necrosed fragments. Extensive in-
filtration and burrowing have caused fatal exhaustion.
Pei)I)er has seen death from parotitis after all danger
from the original attack of fever seemed over.
Finkler reports 12 cases of parotitis iu 55,363 cases of
iiifliii'iir.(i. 1 le thinks that iu these cases there is probably
mixed infection.
Pill iiiiionia is occasionally complicated hy parotitis,
which is then usuallj' suppurative. Pneumococci have
been found iu tlie resulting exudate b}' Testi and by Fitz.
It isailaugerouscomjdicatiou, and the prognosis in these
cases is bad.
Parotitis is a rare sequel of relapsiii;/ feirr, clmlera,
hiihonie plitgiic, yclloir fi'irr, and epidriiiie cerehroapinal
iiioiiiigitis.
The sj/mptnmx of secondary parotitis are often masked
by those of the primary disease. The parotiil region at
first becomes hard and swollen; associated with this there
is pain on moving the jaw and in swallowing. The area
tlien becomes o-dematous, later softening somewhat, and
the surface becomes red. At the end of three or four
days there is an elastic non-tluctuating tumor. At this
point the swelling may begin to subside, but more often
it goes on to suppurafiim. The inflammation may be
limited to the gland or it may spread to the surrounding
ti.ssues, involving the muscles and the periosteum. The
pus burrows beneath the strong fascia for some distance
before it points at the skin. The pus ma,y pa.ss down-
Avard into the cli<-st, backward along the pharyngeal
wall, upward ahiug the sheath of the blood-vessels to
the meninges, lo the articulation of the jaw, or backward
into the middle ear. The blood-ves.sels may be injured
by ulceration, and the facial and jugular veins or the
cavernous sinus may become thrombosed. There may
be a neuritis with or without destruction of the facial
nerve. Rarely the process terminates in gangrene. The
pus may discharge spontaneously through the cheek,
mouth, or external audilory meatus, more rarely into the
(esophagus or anterior metliastinum.
The priir/iwsi's depends largely upon the condition of
the jiatient at the onset of the complication. In cases in
which the patient is much reduced, as iu the third week
of typhoid fever, a superimposed parotitis is an exceed-
ingly grave matter; iu a series of collected cases of this
nature the mortality was thirty \in cent. If the disease
develops after convalescence has been well established,
the prognosis is much less grave. Early recognition and
evacuation of pus may obviate extensive iutiltration and
burrowing and distinctly lessen the gravity of the situa-
tion. C!ommou sequela' are induration and eniargement
of the glands ; less freqiiently there remains a facial palsy.
Death results from general exhaustion, septica-mia, men-
ingitis, or cerebral ihronibosis.
The /iriiii/ii//iii-/ii- ti-iiitiiii'iif of secondarj- parotitis con-
sists in diminishing the danger of infection through
Stenson's duct. In typhus, tyiihoid, and other infec-
tious di.seases care should lie taken iu keeping the mouth
clean and as free as possible from bacterial growths.
When infection of the gland has occurred, an attempt
should be made to obtain resolution or prevent suppura-
tion by the application of ice, leeches, iodine, or mercu-
rial ointment. One should be on the outlook feu- the
formation of pus at all times, and as soon as its presence
is recognized it should be evacuated. The gland should
be drawn forward and an incision made parallel with the
main In-anches of the facial nerve; the iucisiiai should be
made well forward so as to avoid injury to the carotid
vessels. An efficient drain should be kept in place so
that the abscess tuay lical friun the bottom.
VI. XEii()STOMr.\, or dryness of the mouth, is caused
by a detieieiit secretion of saliva. It may be physiologi-
cal ill infancy. Il occurs iu neurolic individuals, partic-
512
REFERENCE HANDBOOK OF THE JEEDICAL SCIENCES.
Parotid island.
Parovarium.
ularly in women suflfering from hysteria or liypoclion-
driasis. Sometimes a friglit may ajipear to be the main
etiological factor, and frequently the cause is entirely
unknown. Excessive loss of water by the kidneys, as
in diabetes and chronic nephritis, rapid evaporation in
mouth-breatheis, and febrile diseases often cause a simi-
lar condition. It is not infrequent in the aged. Chronic
iutlanuiiation of the salivary glauds and obstruction of
their ducts may result in an insutlicient supply of saliva
and consequent xerostomia. The nioulli becomes dry and
glazed, and it presents the color of raw beef. The tongue
may be parched and deeply tissured, and speaking, mas-
tication, and deglutition become difficult.
In cases due to obstruction of the duets, relief may be
obtained by expressing the tenacious plugs of mucus." In
the ueiirotic cases pilocarpine and the galvanic current
have been found helpful; in these cases also general tonic
treatment is always of importance, and any causes of
reflex nervous irritation should be looked for and re-
moved. Temporary relief may be obtained by moisten-
ing the mouth with hot water or with a solution of albo-
lene. Cabot has found that the eating of small pieces of
oatmeal cracker gives considerable temporary relief in
some cases of xerostomia complicating diabetc's.
VII. Ptyalism. — (Synonyms; Salivation. Sialorrhoea.)
Ptyalism may be deiined as a pathological increase in the
secretion of saliva.
In the adult the normal amount of saliva .secreted in
twent}--four hours is from two to three pints. Patholog-
ically the amount may be increased to ten pints in tlie
twenty-four hours. Such saliva is viscid and glairy; its
specific gravity varies from l.OOOto 1.059; it contains lit-
tle sulphocyanideof potassium and lessptyalin tlian nor-
mally.
Physiologicall}-, the secretion of saliva is increased liy
the reflex stimulation caused by the taking of food and,
in children, during dentition.
Ptyalism is caused by a pathological reflex stimulation
of the secretory fibres of the nerves supplying the sali-
vary glauds. It is met with in women diu'ing pregnancy
and at the menstrual period; in psj'chic disturbances
such as hysteria and insanity; in infectious diseases, par-
ticularly in rabies and smallpox; in lesions of the medulla
and jious. It follows the ingestion of certain drugs, such
as mercury, gold, silver, copper, arsenic, lead, pilocar-
pine, jaborandi, muscarine, potassium iodide, and to-
bacco. Bohn describes instances, in children, in which
the excessive flow of saliva occurred only in the daytime
and ceased at night ; the cause was unknown, but he
believed the ptyalism to be a form of neurosis. Sialor-
rhcea has been met with in affections of the liver, spleen,
pancreas, anil genital organs; it is believed to be due to
reflex irritation from these parts.
The excessive secretion of saliva necessitates constant
swallowing and may interfere with speech, or the fluid
may flow from the mouth. In pregnancy it may persist
until delivery has occurred. In mercurial poisoning the
patient becomes emaciated, the bowels are constipated,
and the amount of urine is diminished; the parotid and
salivary glands are enlarged and tender. The ptyalism
may persist for from one to three weeks after the removal
of the drug.
Diarjnosis is difficult only when a paralysis exists which
interferes with swallowing and thus simulates iityalism;
actual measurement of the amount of saliva will defi-
nitely settle the question.
The prognosis depends upon the cause and the possi-
hilit)' of its removal.
Treat men t consists in the removal of the underlj-ing
cause, the use of an astringent mouth wash containing
alum, gallic acid, or tincture of myrrh, and the adminis-
tration of atropine, one-sixtieth of a grain every four
hours until there is a sensation of dryness of the throat.
In cases of ne])hritis, the administration of mercurials is
especially liable to cause .sialorrhcea. During the admin-
istration of mercury .salivation can be prevented in many
cases by keejung the mouth and teeth carefully cleansed ;
if soreness and tenderness of the gums, tenderness of the
Vol. VI.— 33
teeth on striking, or the " mercurial foetor " of the breath
arises, the administration of mercurv should be stopped
at once. " T. .Stuart Hurt .
Ueferexck.s.
SiiUon: Tumors Innocent and Malignant, p. 111.
Prudden : Amer. Jour. Med. Sciences, April, 1S8:1
Haiumai"sten : Physiological Chemistry. Euj;. Trans., p. 261.
Kavmond Johnscm : Haryeian Soc. of I^ondon, April 16th, 1896.— Lan-
cet, vol. i., urn. p. vm.
romby : La France medicate, 1882.
Paget: British Med. Jour., 1., 1887, p. 613.
lionkin: Lancet. Decenil«T VMi, ISUl.
Debout d'Estrees: Univ. Mnd. Mas;., March, 1895.
Pepper: Amer. Text-lionli .if Mi'iiicinc. vol. i., p. 'Mt. 14.5.
Lftjert: Zicmssen's Eucyc. Mi-d. Ct'rans.), yol. i., p. 331.
Duplay: Le Bulletin medical. January 14Ih, 1.S91.
Curtis and Phocus : Arch, inovinc. dc lucd., i., 1S99.
PAROVARIUM.
(ANATOMICAL.) See Sexual Organs,
PAROVARIUM, DISEASES OF.— The term parova-
rium is applied to a series of from six to eight closed tu-
bules whieli lie lietween the two la\'ers of the broad liga-
ment. They radiate out from the ovary toward the
Fallopian tube, terminating in a large tubule which runs
parallel to and beneath the Fallopian tube.
The pathological changes to which it is liable consist
practically of only two vai'iefies, viz. : cystic disease and
carcinoma, the latter being secondaiy to similar disease
elsewhere, and so rare as not to merit consideration in so
shoit an article as this.
Pakovahian Cysts. — Tliese arise from dilatation of
one of the tubules of the jiarovariuin, and are therefore
intraligamentous. Frequently they remain so, in wdiich
ease their removal is an exceedingl}- grave proceeding,
but at times they stieteh the ligament to such an extent
that they become abdominal with a well-formed pedicle.
In the latter case they ate freely movable and o\oid in
shape, while in the former they are fixed in the pelvis
and have often an irregular outline. When peduncu-
lated these cysts have a complete covering of perito-
neum; while at the point where they split the layers of
the broad ligament only the ujiper surface is covered by
this membrane. This peritoneum is smooth and glisten-
ing, and the blood-vessels may be seen beneath it. These
cysts are nearly always unilocular and cont;rin, as a gen-
eral thing, a very thin and limpid fluid; but in the case
of older cysts this fluid may be thicker and turbid, espe-
cially if any hemorrhage has taken place into the cyst.
The inner surface of the cyst is lined by ciliated colum-
nar epithelium which may be accompanied by some cells
of the cylindrical variet)'. Next comes a layer of con-
nective tissue and unstriped muscular fibres, and lastly
comes the peritoneal coat.
Siiiiiptorns may be absent in the pedunculated variety
until the cysts become sulliciently large to interfere with
the heart and respiration, when dyspntea and palpitation,
as well as the swelling of the abdomen, will be complained
of. When the cyst is sessile, however, one early gets
pelvic di-scomfort or even pain, and the action of both
bladder and bowels will be interfered with.
An abdomino-pelvic examination of the patient, in a
case in which the tumor is jiedunculated, will give the
signs of an ordinary unilocular ovarian tumor, except
that the fluidity of the contents will not be so evident in
the latter. When the tumor is sessile, however, a fixed
and fluctuating mass is felt to one side of the uterus,
which is displaced to the opposite si<le of the pelvis. No
hard nodules are to be felt in this mass.
The tumor may ruptui'c. and this may be followed hy
refilling and repeated rupture, b}' cure, by hemorrhage,
or by sepsis ancl death.
The treatment is removal. In the case of the cyst with
a pedicle this is very simple, but when the broad liga-
ment has been split up and the tumor has reached the
jielvic floor, the treatment is a <liflicult matter. Here
there is such risk of hemorihage when one tries to remove
the tumor b\' itself that a cle;in sweep of the pelvis is ad-
vocated by most operators. Hall tajis the cyst after hav-
613
l*ar<»variiiiii.
Pari lie u«>j^eue!»is.
REFERENCE IIAXDIJOOK OF THE MEDICAL SCIENCES.
ing opened tlie abdominal cavity; he then ligates the
ovarian arteries — tliat of tlie affected side to the outer
side (if the tumor, and that of tlie opposite side on the
uterine side of the ovary if that is In be left, to its outer
side if it is to be removed. The jieritoneum is divided
across the top of the bladder, which is separated from
the uterus. The uterine artery on the healthy side is
tied and divided, after which the cervi.v is divided across.
The other uterine artery is then clamped, ligated. and
cut. The tumor capsule is incised in front and behind,
and the tumor is then shelled out and removed with
the uterus. The peritoneal Haps are united by a con-
tinuous catgut suture. F. A. L. Luckliart.
PAROVARIUM, TUMORS OF. See Ovaries, Diseases
of.
PARTHENOGENESIS.— (6r. TO/jflfwc, a virgin, and
yfvsa.r. inoduction, I I'Mrthenogenesis is reproduction by
means of uutertili/rd eggs.
Occiirreiic,. — This means of perpetuating the species
occui s normally in several widely separated groups of ani-
mals and in a few plants. It was really discovered first
in the plant lice, aphids. l)y Bonnet through a series of
experiments begun in 1T40': although Albrecht had re-
corded a single case of parthenogenesis in the silk-moth
as early as ITOl. In the Apliida- tlie eggs which have
lasted "through the winter liatcli in the spring, giving rise
to parthenogenic females, which in many species are
winged, and in others are without wings. These are
viviparous, the eggs developing within the oviduct.
After a number of parthenogenic generations sexual indi-
viduals are produced, the males being winged, the females
always without wings. After copulation the females laj-
fertilized eggs, which remain dormant during the winter
and hatch into asexual individuals in the spring. In this
group parthenogenesis is thus combined with an alterna-
tion of generations. But sometimes some of the par-
thenogenic individuals live through the winter, thus pro-
ducing two parallel cycles of development. In some of
the aphids the life history is complicated by the fact that
the sexual and asexual generations inhaliit different liost
plants.
Parthenogenesis occurs normally also among the worms
— in the liver flukes, larv.T o( JJ/stinii 1/711 lopaticuin. and
in the rotifers. In the Crustacea it is found in certain
genera of the Entomostraca, namely, Cypris, Daphnia,
Piilyphemus, Artemia, Apus, Lepidurus, and Limnadia.
The phenomenon is widely distributed among the insects,
being especially characteristic of the Ilj-menoptera — saw-
flies, gall-flies, ants, bees, and wasps: "the Thysanoptera;
and the Apliida' and Coccida', — plant lice and .scale bugs.
It is founil rarely among the ninths, as in the genera
Apteronia. Psilura, ami Solcuobia; and in one genus of
gnats. C'hironomus.
Among plants parthrnogenesis is described as occur-
ring in C'/iara nitiihi. 'J'/iiilir/nimfciulltri and ptirjruras-
ceiis. and some fungi, as SaiU'olegnia.
Cktssificaiion. — The forms of parthenogenesis have
been classified by Geddes and Thomjison. and later by
Delage according to their mode of occurrence into sev-
eral groups. Of these the nuJSt important are: (1) Occa-
sional parthenogenesis, of which the only authentic ex-
ample appears to be the silk-moth. It has been known
for a long time that once in a while a female silk-moth
may be found capable of laying eggs, some of which will
develop witho\it fertilization. Geddes and Thompson
include in this group a form of parthenogenesis that they
also call partial and that Delage distinguislies as (2)facnl-
tatire. This form is characteristic of the bees, ants, and
wasps. The queen bee, for example, as was first shown
by Dzierzon, appears to be able at will either to fertilize
the eggs as they are laid by means of spermatozoa stored
in the sperm sac or else to withhold fertilization. The
eggs develop equally well in either case, but fertilized
eggs always develop into workers or queens, while the
unfertilized eggs invariably give rise to drones. This is
proved partially by the fact, noted by Hensen, that when
a queen bee has been Impregnated by a drone of another
variety, the female offspring, workers and queens, will
all be hybrids, while the young drones will show purely
the characters of the maternal race. Moreover, queens
that have been prevented from receiving the male, old
queens whose sperm sacs have become exhausted, and
the workers that occasionally can produce eggs but have
no copulatory organs, all produce male offspring only.
Finally, von Siebold was unable to find any spermatozoa
in eggs from drone cells.
(3) Seasonal jiarthenogensis accompanied by an alter-
nation of generations is common with the Entomostraca
and Apliida'. In the Aphiihe the parthenogenic young
are born alive as already described. That this process is
dependent upon seasonal conditions is shown by the ex-
periment of Reaumur and Kyber, who, by maintaining
artificially summer conditions in a glass case, were able
to obtain fifty continuous parthenogenic generations ex-
tending through four years. In tlie Entomostraca the
summer eggs which develop |iartlienogenetically are
smaller, have less yolk, and tliiiin<-r shells than tlie fer-
tilized winter eggs, which are well provided with food
yolk and covering to withstand drying and cold. This
form of parthenogenesis is also characteristic of the gall
flies, but in most of these there is but a single partheno-
genetic generation between two sexual ones.
(4) JiicenUe parthenogenesis has been taken to include
the summer reproduction of the aphids. But that view
no longer prevails, for theparthenogenetic females appear
to differ from the perfect forms chiefly in the absence of
certain accessory reproductive organs. So the only real
case seems to be that of a species of the gnat. Chironomus,
in which the pupa produces parthenogenetic eggs. In a
closely related group, the gall-midges, Cicidomya, there
is a form of pjiedogenesis that appears to be distinct from
parthenogenesis. While the larvjt; may contain rudi-
mentary ovaries or testes, the offspring are produced
from clumps of cells formed in connection with the fat
bod}'. This appears to be a sort of internal budding.
Finally, we have (5) total, or e.irlusice, parthenogene-
sis. That is, in many rotifers, some of the Entomostraca,
and a few insects, no males have ever been found, and it
is inferred that in these cases there is perpetual repro-
duction by unfertilized eggs only.
(6) Artificial parthenogenesis, which maj' be quite a
different thing fnun the normal process, will be discussed
in another paragrapli below.
Another classification of the phenomena of partheno-
.genesis is that of Taschenberg. who distinguishes three
divisions: (1) T lielyotoliy . when the unfertilized eggs give
rise to females only, as in the summer generations of the
aphids; {i) Arrhenotoky. when males only are produced,
as in the case of the queen bee: and (3) Denttrotokji, when
the offspring are of both sexes, as witli the gall-iiies.
Cijtoloijii. — It was first suggested in ISTT b_v Minot on
theoretical grounds tliat parthenogenesis might be due
to a failure of the egg to produce polar bodies (see arti-
cles Ovum and Reduction Dirision). Balfour in 1880 and
later Van Beneden maintained that the extrusion of the
polar bodies in eggs destini^d for fertilization is a special
provision to prevent parthenogenesis. Theory also led
Weismann to investigate the question of parthenogene-
sis, and he observed in 1885 that in the parthenogenetic
eggs of Polyphemus, one of the Daphnid;e, but one polar
body is formed. In 1888 Blochmann made the important
discovery that in the plant-lice, aphids, parthenogenetic
eggs produce but one polar body, while the fertilized
eggs produce two. Weismann subsequently found this
to be true of the eggs of ostracodes and rotifers, and was
led to infer that the differences observed in these forms
is one that distinguishes all parthenogenetic eggs from
those destined for fertilization. But doubt was thrown
upon this view by the observations of Blochmann (1888-
89) and Plainer (1889), who discovered that in the honey-
bee and in tlie moth Psilura (Liparis) theparthenogenetic
eggs produce two polar bodies. The difficulty has been
met by Brauer's brilliant research, in which he discov-
ered that there are two types of parthenogenesis. Both
614
REFERENCE HANDBOOK (JF THE MEDICAL SCIENCES.
I'iir4»%'ariiiiii.
FarlUeuogeue*»i8«
Fig. 374;;.— rii-st Maturation
Spindle in Partliencigenetic- Epg
of Artetnia mlina. X lutiu.
(After Brauer.)
types occur in the eggs of Artemia. In each case the
first maturation spindle contains eighty-four chromo-
somes in the form of typical tetrads (Fig. 3743), which
divide so that eighty-four
dyads are removed in the
first jiolar body and eighty-
four remain in the egg (Fig.
3743). There are indica-
tions of an attempt to form
a second polar spindle, but
no division takes place, and
the eiglity-four dyads give
rise to a reticular cleavage
nucleus (Fig. 3744).
In the second type, whicli
is less fre([uent. a second
polar spindle is formed and
the eighty -four dyads di-
vide, producing two groups
each containing eighty-four single chromosomes (Fig.
3747). Ordinarily these remain in the egg, producing
two small reticular nuclei (Fig. 3748). Prep:iratory to
division two centrosomes
appear, whether by the
division of a single one
or not is not known.
But, at any rate, they
form a single spindle in
which the one himdred
and sixty-eight chromo-
somes arrange them-
selves in two distinct
equatorial plates (Figs.
3749 and 37.-)0). In rare
cases, however, Brauer
observed that the sec-
ond polar body is actually extruded, and then its nucleus
returns into the egg and presumably undergoes the
changes just described. This furnishes an explanation
of the apjiearances oliserved in the
bee and Psilura, suggesting that fur-
ther investigation will show that tlie
nucleus of the second polar body re-
unites with the egg nucleus to form
the cleavage nucleus in a manner
similar to the imion of the sperm nu-
cleus with the egg nucleus (see lin-
jn-eguatioii). If tiiis be true, it will
be established as a general fact that
the parthenogcnctic egg contains the
same amount of chromatin as the
Spindle Remaining ordinary egg does after union with
cen^o«,n.f has™. "'« spermatozoon. The forniation of
vlded. X490. (Aft- the second polar body ajipears to re-
er Brauer.) duce the amount of chrcimatiu to a
point where under ordinary condi-
tions the egg is unable to undergo further division. But
if the amount of chromatin be restored by tlie entrance
Fig. 374.3. — Ex(rusion of the First
Polar Body of tbe Same. X 1060.
(After Brauer.)
Fig. 3744.— Egg Nu-
cleus Derived from
Ualf of the First
'"'^saii>>-
FiG. 3745.— Egg Nucleus of the First Type at the Beginning of the
Formation of the Cleavage Spindle. X 490. (After Brauer.)
of the spermatozoon or by the return of the second polar
nucleus, then the egg may start upon its new cycle of
development.
Brauer made the further observation, which is of con-
siderable imixirtance for the theory of the individuality
of the chromosomes (see Chronuisumes), that so far as he
was able to trace them through the first few cleavages,
the chromosomes reappear in subsequent cell divisions in
the same number that was present in the first cleavage
nucleus. That is.
f^ljfl-^rt ,
Spindle of the First
(After Brauer.)
he found eighty -
four when no sec-
ond polar nucleus
had been formed
and one himdred
and sixty-eight of
half size when a 'i&v,.
second polar nu- ''- ■
c 1 e u s had been
formed (ef. Figs. Fig. 3746.— Cleavage
374.^) and 3749). Type, x 490.
Very recently
(1902) Petrunke witsch has studied the maturation of the
winter eggs of Artemia. and he faileil to find Brauer's
second type, but further investigation is necessary to
throw serious doubt on the positive results of Brauer's
very careful work.
Heredity. — We are indebted to Dr. Ernest Warren for
the only observations
made so far upon her-
editv in parthenogenesis.
The forms that he stud-
ied are Daplinia (1900)
and an aphid, Ilynlnp-
terus Irir/u'iliis (1902).
From 23 individuals of
Daphnia he obtained 96
young, and from 60
aphitls he reared 455 otf-
spring. Measurements
were made of parents
and offspring of both
species, and the coeffi-
cients of heredity were calculated by the methods de-
scribed in auotlier place (see article Heredity).
The results of direct inheritance were found not to
differ very much from those obtained in sexual repro-
duction; taking the mean of Daphnia and the aphid, the
coelficient for parental inheritance
was found to be 0.41, and for
grand-parental 0.24. But in col-
lateral inheritance there seems to
lie considerable difference. The
mean fraternal correlation for the
two species is 0.C6, considerably
higher than the average for sex-
ual reproduction, which Pearson
places at 0.49 or 0..50. It is gen-
erally supposed that sexual repro-
duction tends to increase the vari-
liility of the race, but Warren
found no significant difference in
that particular between these
species and sexual forms. But
the whole subject of heredity and variation of asexual
forms needs much more investigation before generaliza-
ti<ms of importance can be made in regard to the differ-
ent effects of sexual and asexual reproduction.
Artificial Parthenogenesis. — It has been known for a
loiiij time that
FIG. 3747.— Second Maturation Spin-
dle of the Same, x \mi. (After
Brauer.)
Fig. 3748.— Two Egg Nu-
clei Derived from Halves
of the First and Second
Spindles. X 490. (After
Brauer.)
gOr^T-^"^
J
- <,ij"<»/>5<^ the ova of ani-
1 mals that re-
> produce by the
^ sexual method
only will some-
times undergo
an irregular
segmentation.
R . B o m e t
(1900) has giv-
en an exhaust-
ive review of
these phenomena as observed in vertebrates, and con-
cludes they are pathological in character. The seg-
ij^i-
Fig. 3749.— Egg Nucleus of the Second Type at the
Beginning of the Formation of the Cleavage
Spindle. X 490. (After Brauer.)
515
Palclla.
KEFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
/
It;
Fir. 3750.— Clcavasre Spindle of the
Second Type. X -190. (After
Brauer.)
mcutation observed is a fragmeutation of the cell lead-
iug to dissolution. He places in this calegoiy the early
experiments of Dewitz (1887), who I'mind that frogs' eggs
treated with corrosive sublimate would undergo segmen-
tation. Similarly TicliomirotV (188(i) was able to induce
the development of unfertilized eggs of tlie silk-motli by
treating them for a few
minutes with sulphuric
acid, but this is a spe-
cies ill which occasional
])arthenogenesis is
known to occur.
In 189!), however,
"Loeb made the remark-
able discovery that by
tlie use of a solution of
magnesium chloride of
a certain strength (a
mi.xture of --/'u MgCU
and sea-water lu eijual
parts for two liours) he
could induce develop-
ment in tile unfertilized
eggs of a sea-urchin (Arbacea), a group in which normal
parthenogenesis is tuiknowu, so that the egg not only
divided but continued through the blastula and gastrula
stages, and eventually formed normal pluteus larva?
(Fig. 37.51), At lirst he attributed this result to the spe-
cific elTect of the magnesium ions. But later researches
showed (1900) that other salts and such organic sub-
stances as urea and cane-sugar could produce the same
result. Locb then concluded that the cause of develop-
ment was not the specific effect of certain ions, but that
it was due to an increase of osmotic jiressure. Espe-
cially he noted that the reagents used .seemed to cause
a liquefaction of the nuclear membrane, and he rcgariied
that as a prerequisite for cell division.
This idea was taken up by Mathews (1900), and he
found that varicius agents that caused the li(iucfaction of
protoplasm, such as lack of oxygen, slight increase of
temperature (from 32" to 38" C. for two to four minutes),
ether, chloroform, and alcohol would all induce segmcu-
tation in sea-urchin eggs. Later Jlathews (1901) found
that the eggs of a starfish, Atiteiius foi-bcsii. could be
<-aused to develop by shaking or by simple remoxal from
one dish to another by means of a pipette, provided the
eggsare taken at the right time, namely, from two to four
hours after they have been shed, wlieu " both polar glob-
ules have been extruded and the female pronucleus has
re-formed and reached a cousidcralilc size." From eggs
treated in this way he was alile to rear some larvjie to the
late gastrula and early bipinnarian stages. Locb (1901) has
been able to obtain artificial iiarthenogencsis also in an
annelid, Chtetopterus. By treating the unfertilized eggs
with solutions of sodium, magnesium, and calcium chlor-
ides and with cane sugar he obtained development into
swimming trochophore larva'. Fischer (1902) has obtained
swimming larva' from unfertilized eggs of two other an-
nelids, Amphitrite and Nereis. From tlie former by treat-
ment with calcium nitrate, and from (he latter by using
.solutions of potassium chloride having considerably
higher osmotic pressure tlian the sea-water.
B)' extracting the spermatozoa of sea-urchins Gies
(1901) tried to obtain an enzyme that woukl cause the
eggs to develop. But his results were negative. And
lie was led to critici.se the positive results previously ob-
tained b}' Fieri, which he attributes to carelessness in
the non-removal of spermatozoa; and the results of
Winkler, which he regards as due to osmosis.
After all, the iihysiologists have done little more than
to establish the fact of artificial parthenogenesis. So far
they ha\'e been unable to formulate any clear general
statement as to the cause of the phenomenon, and they
have told us next to nothing in regard to the internal
conditions of the egg during tliis i)roce.ss.
The first one to approach this ijroblem from the inside,
as it were, was R. Hertwig (1896), who found that in un-
fertilized eggs of sea-urchins, Echinus and Spharechiuus,
treated with dilute solutions of strychnine, the nucleus
might give ri.se to a bipolar mitotic figure. Sometimes
the chromosomes would divide, and sometimes two com-
plete nuclei would be formed, and in a few cases irreg-
ular or incomplete cleavage stages were observed. I' sing
mainly unfertilized eggs of Arbacea, T. H. jMori;au has
made a series of stud'ies (189(J. 1899, 1900) up(m"tlie ef-
tects of .Solutions of sodium and magnesium chlorides
and also dilute strycliniiie upon the cytoplasm, his "prin-
cipal discovery being that the eggs become filled with
' artificial astrosphercs ' (asters) containing deeply stain-
ing centrosome-like bodies, which may become connected
with the nucleus and " seem to act as anchors for the
chromosomes and moveout into theegg with thechromo-
soines attached to them. ' "
Our principal knowledge of the internal phenomena
of artificial parthenogenesis is due to the beautiful work
of E. B. Wilson (1901), begun soon after the publication
of Loeb's first paper. He completely confirmed Loeb's
general result, finding that "unfertilized eggs of Toxo-
pneustes (a sea-urchin), when treated with a mixture of
eipial volumes of sea-water and twelve per cent. MgCL
ami then reidaced in pure sea- water, may segment, give
ri.se to actively swimming blastuUu and gastruUv, and in
many cases to plutei." The different stages, however,
showed a large number of abnormalities and monstrous
forms, and even the most perfect specimens were not ex-
actly like those produced from fertilized egg.s.
As to the internal changes observed in tliese eggs, we
have space here for only the briefest possible summary
of the most important results. The first change noticed
in the eggs was the apjicarance of a \'ague primary radi-
ation centring in the nucleus. In many eggs a varying
number of secondary centres of radiation (cj'tasters) were
formed at various jioints in the cytoplasm. Then after
a reduction of the rays almost to tlie vanishing point and
their rea]ii)earance nuclear division proceeds as in ferti-
lized eggs; but the division of the cytoplasm may be
delayed until several nuclei are formed. Serial sections
.showed that no sperm nuclei were present. The internal
changes, while sliowing an interesting parallel to those
occurring in fertilized eggs, were unmistakably differ-
ent from the latter. During cleavage many of these eggs
show but nuc-fiiilf the normal number of chromosomes,
namely, eighteen instead of thirty-six, and most of the
Fi(i. .17.51.— Nornml Plutei Reared from Unfertilizeil Esgs: treated
with eiinal parts uf a Vn MgCla solution and sea water. Magnified.
(After Loeli.)
eggs failed to form any trace of a vitelline membrane,
which in fertilized eggs is formed after the entrance of
the spermatozoon. Both the primarj' and secondary
asters are forineil de noro and subsequently multiply by
division; and both may act as centres of cytoplasmic
division. But, as a rule, complete division does not take
516
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pa rl lie iiogenesis.
Patella.
place except when the asters are connected with clironio-
somes. Even in enucleated fragments of eggs, produced
by shaking, asters may be formed in tlie magnesium solu-
tion, and these, like the others, may contain at their cen-
tres deeply staining bodies resembling centrosomes.
Delage (1901) has also investigated the internal phenom-
ena of artificial parthenogenesis, using eggs of species of
sea-urchins and starfish. He obtained development in
the former after both polar bodies had been formed, and
in the latter after only one polar body had been formed
as is the case in normal parthenogenesis. He claims also
that the number of chromosomes present is the same as
in fertilized eggs. But Boveri (1902) has shown this to
be an error, the number of chromosomes found by Delage
in the sea-urchin being really half the normal number,
thus confirming Wilson.
Robert Payne Bigelow.
Bibliographical References.
Bonnet, C. : Considerations sur les corps organisi5s, vol. ii., 1762. pp.
119-1;B.
Bonnet, R. : Glebt es bei Wirbeltieren Partbenogenesis ? Ergeb. d.
Anat. u. Entwlek., vol. ix., 1899, pp. 82(1-87(1.
Brauer, A. : Zur Kenntniss der Reifiiug des parthenogenetisch sil-Ii
entwlckelnden Eles von Artemia salina. Arcblv f. mikr. Anat.,
vol. xlili., 1893, pp. lti2-222.
Delage, Y. : Etudes experimentales sur la maturation oytoplasmique
et sur la partht^nogenese artiflclelle cliez ie.s t?chinodermes.
Archives de zool. exper. 3, vol. Lx., 1901, pp. 2K5-326.
Fiscber, M. H. : Further Experiments on Artificial Parthenogenesis in
Annelids. Amer. Journ. Physiol., vol. viii.. 19rr2, pp. :M1-3U.
Geddes, P., and Thomson, J. A. : The Evolution ol Sex. Revised edi-
tion. 1901.
Gies, W. J. : Do Spermatozoa Contain Enzyme having the Power of
Causing Development of Mature Ova ? Amer. Jour. Phys., vol. vi.,
1901, pp. 53-76.
Loeb, J. : On the Nature ol the Process of Fertilization and the Arti-
ficial Production of Nonual Lan'a». Amer. Jour. Physiol., vol. iii..
1899, pp. 1:35-138.— On the Artificial Production of Normal Larva-
from the Unfertilized Eggs of the Sea-Urchin. Amer. Journ. Phys.,
1900, iii., 431-471.— Further Experiments on .\niflcial Partheno-
genesis, l. c, 1900, iv., pp. 178-184.— Experiments on Artificial Par-
thenogenesis in Annelids. Amer. Journ. Phys., 1901, iv.. 9, 42:^4.59.
Mathews, A. P. ; Artificial Parthenogenesis Produced by Mechanical
Agitation. Amer. Journ. Phys., vol. vi., 1901, 142-1.54.— Some Ways
of Causing Mitotic Division in Unfertilized Arbacla Eggs. Amer.
Journ. Pbys., 1900, iv., pp. 34:3-347.
Overton, J. B. : Parthenogenesis in Thalictrum purpurascens. Bot.
Gazette, 1902, vol. xxxiii., p. Mi, 2 pi.
Petrunkewitsch, Alex. : Die Reifung der parthenogenetischen Eier
von Artemia salina. Anat. Anz., vol. xxi., 19(>2. pp. 256-26:3.
Sharp. Da%id : Insects. Camb. Nat. Hist., vols. v. and vi., 1.^9.5-99.
Warren, E. : Observation on Inheritance in Parthenogenesis. Proc.
Royal Soc, London, iy*», vol. xlv., pp. 1.54-1.')8. — Variation and
Inheritance in the Parthenogenetic Generations of the .\phis "Hya-
iopterus trirhodus " (Walker), Biometrika I, 1902, 129-1-54.
Weismann, .\.: Essays upon Hereditv and Kindred Biological Prob-
lems, London, 1889-92, 2 vols.
■Wilson, E. B. : The Cell, Second edition, 19:10, pp. a8ft-284.-Experi-
mental Studies in Cytolog.y, I. A Cytological Study of Artificial
Parthenogenesis in Sea-Urchins' Eggs. Arch. f. Entwick. d. Or-
ganismen, 12, 1901, pp. 531-596.
PARTURITION. See Laior and Gestation.
PASSION FLOWER.— Pa*s«>n/. The rhizome of
Pdssijiora incarnata L. or of P. lutea L. (fam. Pasujlo-
raeea).
The herbage is also sometimes employed.
These are soft woody vines, climbing high over shruli-
bery and trees in the Southeastern United States, where
the edible fruit of the first-named is considerably used
under the name jNIay-pop.
The elongated rhizome, usually known commerciallj-
as "Passion flower root," quite closely resembles meni-
spermum in appearance, being elongated and cylindrical.
It rarely reaches a fourth of an inch in thickness and the
nodes are rather obscure. It is 3-eUowish or light brown,
often with a greenish tinge, and finely stri.ated. It has
a siiiall hollow centre surrounded by a greenish or yel-
lowish, finely radiated wood zone, and a moderately
thick, purplish bark section. Both odor and taste are
slight and indefinite, the latter somewhat fatty and dis-
agreeable. The constituents have not been examined
with any care. A trace of alkaloid lias been reported.
Passionflower has been exploited bv commercial inter-
ests, and most of its literature has been compiled with a
view of creating a demand for it. P. incarnata has been
considerably employed in eclectic and homa'opathic prac-
tice. These authorities attribute to it mild sedative and
even hypnotic powers, while larger doses are said to be
emetic. Its use by these practitioners in numerous grave
conditions, as well as their minute doses, involve obvious
absurdities. Whatever benefit may be derived from its
use may result from the administration of from 2 to 4 c.c.
(fl. S ss.-i.) of the fluid extract. Ihnnj Il.,Rusby.
PATCHOULI, OIL OF.— Olernn FoUornm Patclwuli.—
A volatile oil distilled from either the fresh or the dried
leaves of Pogostemon Ueyneanus Benth. (P. Patclwuli
Pell. ; P. stiavis Tenore. Fam. Labiatm).
The Patchouli plant is native and cultivated in the
East Indies, especially in the Straits Settlements, and the
drug or the oil distilled from it is mostly exported from
Singapore. The oil ranges from pale yellow to brown-
ish, usually with a greenish tinge, and is occasionally of
a deep brown color. Its specific gravity varies from 0.97
to 0-99, even when pure. With ninety-percent, alcohol,
it yields a clear solution which usually remains clear
upon the addition of more alcohol (Gildemeister and
Hoffman). The oil has a characteristic and very intense
and persistent odor. Its composition is not well known,
though it yields a peculiar camphor known as Patchouli
camphor. This oil is little, if at all, used medicinally,
though it has the ordinary aromatic stimulant properties
of its class. It has very important uses in perfumery.
Henry H. liiisby.
PATELLA, AFFECTIONS AND INJURIES OF.— The
patella is a sesamoid bone developed in the quadriceps
tendon, and is therefore a part of the extensor apparatus
of the knee. Some anatomists have considered the pa-
tella homologous with tiie olecranon process of the ulna;
but there are serious objections to this view, and it is not
indorsed by Poirier and Cliarpy in their recent work.
The first rudiments of the patella appear about the
tenth week of fanal life, and ossification usually begins
from one centre about three years after birth; but the
.r-ray often fails to cast a shadow tmtil the sixth year.
The principal functions of the patella are to increase the
leverage of the quadriceps muscle and to protect the
knee-joint anteriorly. It seems to be, however, a luxury
rather than a necessity, since its congenital absence may
produce little or no disturbance of function. The kan-
garoo, which has no bony patella, is noted for its power-
ful posterior limbs.
Fractures and traumatic dislocations of the patella,
and prepatellar bursitis are discussed in other sections of
this work: there remain the congenital and developmen-
tal anomalies, and certain diseases, deformities, and pain-
ful affections which follow.
Absence and Retarded Derelopnient of the Patella isa not
unfrequent accompaniment of congenital deformities
involving the knee, especially of absence or imperfect
development of one or more bones of the leg, and of
congenital flexion, hyperextension, and ankylosis of the
knee. Of these conditions the one which has attracted
most attention is the so-called congenital dislocation of
the knee, where the child is born with one or bi^th knees
in hyperextension, and the tibia luxated forwaril. In a
large proportion of these cases no patella is discoverable
in infancy; but in many, if not most, it develops later,
and may reach normal projiortions. Such a case, ob-
served by the writer,' had no palelhe at seven months of
age; but they could be felt as very small nodules six
months later, and at three years of age were well de-
veloped. At thirteen years this boy was active, and had
gootl functional use of the knees and perfectly developed
patellfe.
Many of the cases in the literature are reported too
yeung to determine the fact of permanent absence.
Rectiflcation of the deformity and orthopedic treatment
seem to exert a favorable effect on the development of
the patella in these young eases. Potel ■ has collected 78
eases of congenital" knee luxation, of which about half
were bilateral; in 50 of these cases the condition of the
51T
Patell
Pau.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
patella is noted, of which 18 were normal; in 16 the pa-
tella was absent, in 10 atrophied, and iu 3 anomalous.
Potel reports in addition ~0 cases of absent or rudimeu-
tar}- patella accompanying other deformities of the
knee. Little- reports 42 cases of absent or rudimentar_v
patella, not including a remarkable group of IS cases in
four generations of one family, who had no jialclhe and
no thumb nails. Other family groups have been reported
by Wirth ' ami Wolf. Many of Little's cases are on Po-
tel's list and on the later list'of Thorndike." Some of the
individuals iu whom the i)atella never develops are never-
theless active and even athletic, and unconscious of any
defect. While extremely raie, cases of complete absence
of the patella\ due to devclo|imental defect, and uncom-
plicated by other anomalies, do exist. Joachimsthal*
proved by ,r-ray examination that Wirth's case was in-
disputable. As absence of the patella is usually a syn-
drome rather than a ]>atliological entity, the treatment
is that of tlie primary atfection, and in the case of con-
genital luxation and "some other deformities it is usually
clTectual. The following advice, given in a recent work
of reference,' is erroneous: " When the patella is absent
it is usually necessary to produce an artificial ankylosis
between the femur and tibia." On the contrary! it is
rarely if ever necessary to have recourse to this operation
for tiiis reason.
Sjdit I'dteUd. — Very rare are the cases of congenital
split patella. Grliber^ reports a case in which both ]ni-
tella" were divided into a small superior external and a
large inferior internal segment separated b_y a groove.
JoacliimsthaP reports a case of horizontal and another
of vertical fissure in which fracture was excluded.
Ciiiif/enital Didocations of the PiitiUn. — While this con-
dition is uncommon there is a considerable literature on
the sul.iject. Steindler' reports sixty -one cases of out-
Avard ;md two fif upward dislocation. This deformity is
freiiuently comliined with genu valgiun, liut such com-
biiialions are not always congenital: moreover, tliere are
many cases of congenital dislocation in which no genu val-
giun is present. The affection seems to be usually due
to imperfect development of the anterior part of the ex-
tern;d condyle. Alsl)erg '" reports three cases in one fam-
ily, father, son, and daughter, in which the displacement
was outward and bilateral. In two of these cases there
was practically no disaliility.
Cases of congenital dislocation are also reported by
Potel.- Bergmimn," Elliott,'- Drehmann.'^ Gallet,'^
Cayre,'*and McLaren." The so-called congenital di.slo-
cation upward is rather an elevation than a luxation of
the patella, as has been pointed out by Blencke."
Piit/ioloi/inil lli'sjiliiceiiifiits of the PnlcUa. — The com-
monest of these is displacement upward from elongation
of tile ligamcntum patella'; tliis is rarely congenital,
though a certain congenital laxity of the ligaments may
predisiiose to this affection. Shaffer'* has pointed out
that elongation of the patellar lig;iment and displacement
of the patella upward may bi' an important factor in the
production of certain kiu'e disabilities, and has recently "
indicated its connection willi slipping patella and dis-
))laceinent of the semilunar cartilages. Shaffer states
that with the knee flexed at ninety degrees and the
(inadriceps tense, the distance from the apex of the tibial
tubercle to the lower edge of the patella in an adidt is
normally not over two inches, and is often less. In his
cases of upward displacement the patellar ligament was
often three inches or more long.
In rupture of the ligament tlie patella is drawn upward
l>y the quadriceps, and in mixture of the c|uadriceps at
its insertion the patella dro])s downward. Schulthess-"
has shown that in congenital spastic parajdegia the liga-
mentum patella' is elongated, and the ]iatella displaced
upward, probably from the continued traction of the
spastic quadriceps. With the knee flexed at ninety de-
grees, the inferior border of the patella makes a sharp
projection in front of the knee in these cases.
According to a recent investigation of Peltesohn-' the
patella was elevated iu eleven out of fourteen congenital
spastic cases.
The posterior surface of the patella is concave owing
to its abnormal relation to the end of the femur.
SUji]iiiiy Pdtilht : Iiitcrjiiittent Dislocation of the Piitellii.
— In this affection, either from congenital defect, laxity
of the ligaments, trauma or genu valgtmi, the patella be-
comes displaced outward, and the malposition tends to
recur more and more frequently in spite of reduction ; it
finally- may become permanent. Shaffer believes that
this condition is often associated with elongation of the
ligamcntum patelhB, and that this is an important factor
in the affection. In several cases he found an exostosis
iu tlie intercondylar groove, due, as he supposes, to the
absence of the patella from its normal position. Wie-
muth'''-' reports 66 cases, of which 32 were of congenital
origin. 1-t traiunatic, and 20 pathological. Schanz,-'
Fried lander,'-^ and others report cases.
In the milder cases various knee-caps and appliances
may be used to hold the patella in place, or to prevent
abnormal movement at the knee, but in inveterate cases
one or more of the following operative procedures may
be necessary :
1. Genu valgum, if present, should be corrected,
though this will not always prevent the displacement.
2. Tlie tibial tubercle with the ligamentum patellae
may be detached with a chisel, and sutured or ntuletl at
a i.ioint farther inward on the tibia,
3. The intercondylar groove may be deepened, and an
exostosis, if present, removed.
4. The capsular ligament on the inner side of the pa-
tella may be folded and sutured (Le Dentu).
T). Artificial bow leg may be produced after a supra-
condylar osteotomy (Chiene).
6. The patella may be excised (R. Fowler).
Aiiki/l'ixis (f the PirteUii.— After inflammation of the
knee-joint involving the contiguous articular surfaces of
the patella and femur, the patella may become adherent.
This (if course prevents voluntary motion at the knee.
Where the joint surfaces between the femur and tibia
are good, or where it is necessary to do so in order to
correct the position of the knee, the patella may be sepa-
rated by the fingers, mallet, or chisel (.see papers by IlUb-
scher -^ and Cramer *').
Atroph)/ of the Patella. — The patella follows the usual
law of bone growth, increasing in size and density ac-
cording to the work put upon it; active muscular indi-
viduals have large and strong patelhe. The patella also
adjusts itself to the shape and pressure of adjacent struct-
ures; hence its size and shape are altered in various
pathological conditions. If the function of the leg is in-
terfered with, the development of the patella is retarded
or checked, and later atrophy may set in. Individuals
with clubfoot, congenital dislocation of the hip, and
other affections which limit the use of the limb, show less
development of bone as well as of muscle on the atTected
side. In infantile paralysis the effect on function and on
bone growth ismuchmore marked, and has been thought
to be largely due to interference with trophic centres in
the cord. It is well known that chrouic joint disease has
a profound effect on bone growth. In osteitis of the knee
and hip all the bones of the affected limb are shortened,
thinned, and narrowed, and this is due to atrophy as well
as to retardation of growth. In a series of liip and
knee cases measured by the writer,-''- '-' the patella was
found to be from one-eighth to one-half inch narrower
on the affected side within two years of the onset of
the affection. The bone Avas markedly diminisheil in
bulk, in many instances being less than half the size of
its mate.
Uiihi-n' Pailful Patella. — Rosenberger-' has recently
described a jiainful affection of the patella observed in
cavalry and niomited otticers, who have worn tight, stiff
breeches ami have licen continuously in the saddle. The
inner border of the patella, which has little adipose pad-
ding, and which is most exposed to pressure in riding, is
the most painful part. There is at first more or less
disability, which together with the pain soon passes off
on rest anil relief of the pressure. No other symptoms
were observed by him, but according to DUms^" there
518
REFERENCE HANDBOOK OF THE MEDICAX SCIENCES.
Patflla.
Pau.
Fig. 37.52.-Tuberculi)US
Cavities in Patella.
{From Volkmana.)
may be inflammatory swelling of the quadriceps tendon
with crepitus.
Diseases of the Patella : Primary Tnhercilosis. — Fibrous,
fattj', sarcomatous, and other tumors of the palella or
of parts adjacent to it have been reporti d. and syphilitic
and staphylococcic infections may
occur, but the most common and
important disease of the jjatella is
tuberculosis. Secondary infections,
especially of the articular surface
proceeding from tuberculous or
other inflammation of the knee-
joint, are not infrequent, and are a
common cause of adherent or anUy-
losed patella. Infection maj- also
occur from disease of the prepatel-
lar bursa. Primary tuberculosis of
the patella has been described by
Volkmann and others, and has lately
attracted considerable attention.
Gross ^' in an e.xccllent paper re-
ports 36 cases, including 4 of his
own. In 33 the age was known, of
which 13 were under and 20 over
tlie age of twenty. There is spon-
taneous pain in the patella in the
daytime and often at night, with
extreme tenderness on pressure; the
subcutaneous surface of the patella
may be uneven to the touch; dur-
ing the early stages the functions of
the knee are but little interfered
with. The knee is usually held in
extension or nearly so. The most
significant symptom is cold, prepa-
tellar abscess of slow formation.
Such an abscess is much less mov-
able than a bursal swelling, and puncture or exploration
should clear up doubtful cases. Later on, sinuses may
form, leading to cavities in the cancellous tissue. Volk-
mann^'' depicts (Fig. 37.52) such a case in section. If it
is overlooked or neglected extensive disease of the knee-
joint usually results. The treatment consists in the re-
moval of diseased tissue, by eridement oi the focus, and
when necessary by excision of diseased synovial mem-
brane. In the late cases, in which the joint is seriously
infected, the latter will require appropriate treatment.
Gross' conclusions are that primary tuberculo.sis of the
))atella is more frequent than is usually sujiposed: that
treatment is usually too long postponed; that it is a se-
rious affection rapidly perforating into the joint; that
with an early diagnosis a relatively simple operation will
cure it; the procedures ordinarily employetl are erith-
iiient of the focus, and in the later cases subperiosteal or
total ablation of the patella, with synovectoni}' orarthrec-
tomy when necessary. Absence of the patella inter-
feres but little witli function, and it may be reproduced
after total subperiosteal ablation. He reiuarks that : " If
one bears the possibility of tuberculosis of the patella in
mind many knees will be saved."
Other papers on primar}' tuberculosis of the patella by
Francois, ^^ Forget, ^^ Menard,"^ Ribas,^* Schluter,'' Rum-
mer,-'* and Kocher^' may be consulted.
Henry Ling Taylor.
Rkferenxes.
' H. L. TaTlor : Transactions American Orthopedic Association,
1895, viii., 2S0.
^ Potel ; Etude sur des malformations contjenitales du eenou, Lille,
1897
= Little : Lancet, .September 2.5th. 1897.
* Wuth : Archiv fiir klinische Chirurpie. Iviii.
^ Thomdike : Transactions American Orthopedic Association. 189S,
xl.. 2(J6.
* Joachimsthal : Archiv und .^tla-^der iKirmalen und pathologischeu
Anatomie in typischen RontL'i'nbiltit.rn. Haiiilnirp, 19()2.
^ F.ncyclopedia medica; Kiiff-toini. l)iseases of. vi.. 111.
^iiruber: Archiv fiir patholotrische .\natoinie. l.SS;i 3.58.
' Steindler; Archiv fiir klinische Chirurgie. l.viji.. H. 2.
'" Alsberg: 17te Ver^ammlung des Aerztenvereins, Ca.'^el.
"Berpniann: Monatschrilt fiir Unfallheilkunde und Invaliden-
wesen. viii.. 214.
" Elliott: Medical News. IflOl. l.\.\vii.. &«.
'2 Drehmann : Zeitschrift fiirorthopadlsche Chirurgie. 1900, vii., 439.
■* Gallet : Lyon. Lesrendre et Cie.. 190U.
' ^ Cavre * Paris 190(J
'« McLaren : Annals of Surgery. KMri, .\x.\i., 679.
" Blencke ; Zeitschrift fiir ortliMpacliMiie I'hinirgie, 1902, x, 523
's Shaffer: Medical Uecord, .laiiuarv liiili. \>s'.t>. .59.
".Shaffer: .Annals of Sursri-ry. l."*Us, .\.\.\iii., 417.
^" Schulthess; Zeirsctirift fiir orthopadische Chirurgie, vl.
'" Peltesohn: Leijisi. . l'.«il.
^'' Wiemuth : Deutsr-lie Zi-itschrift fiir Cbinirgie. Lxi.. H. 1 and 2.
2= Schanz: Zeitschrift fiir ortlinpiitiis.-hi- ( Ijinirfrie, 19iio. vii., 531.
=< Friediander: Archiv fur kliiiis.li.' i liirurs.'ie, UK)1. l.xiii., 24.3.
2' Hiibscher: Correspondenzlilatt (iir Siliuvizer Aerzte. 1901, 24.
'" Cramer: Verhandlung der Dcutschen Gesellschaft fiir Chirurgie,
Berlin. 1901. xxx.. 575.
= ■ H. L. Taylor: Philadelphia Medical Journal. .lanuary 26th. 1901.
'" H. L. Taylor: New York Medical .lournal, April 19th, 1902.
'» Hosenberger : Munchener medicinische Wochensehrift, 1900,
xlvii., 247.
^'> Diims: Handbuch der Militarkrankheiten, Leipzig. Besold. 1896.
75.
!" Gross : Revue m(?dicale de la Suisse Romande. March 20th. 1900,
109.
=2 Volkmann : Specielle Chirurgie. E. Leser, 1902, 937.
" Frani-ols : These de Lyon, 1888.
2' Forget : Lyon.
35 Menard: Association francaise de la Chirurgie. Proces verbal.
1896, 734.
" Ribas : Revista de Medicina. Chirurgla y Famiacla. 1901). xiv., 74,
" Schliiter : Deutsche Zeitschrift fiir Chirurgie, xxx., 90.
3^ Kummer : Revue Medicate de la Suisse Romande, 18,89, ix., 721.
3^ Kocher: Volkmann's Sammlung klinischer Vortrage, 1876, 102.
PAU. — The city of Pau. chief town of the Department
of the Basses-Pyrenees, France, stands upon the north
or right bank of the river called the Gave de Pau. at the
height of 130 feet above the river-bed. and 620 feet above
sea level. The latitude of Pau is 43' IT' N. ; its longi-
tude is 0' 23' AV. The population of the town is about
thirty-three thousand. Its situation, on the edge of a
plateau iinmediately above the river-bed. and the loca-
tion, at the brink, as it were, of this plateau, of the old
castle with its tenace, of the Place Royale, the Boule-
vard du Midi, and the Pare ^c•ontaining thirty acres of
ground and beautifully planted with shade trees) render
the town a decidedly pictui-esquc place in apjiearance,
while the view of the Pyrenees Mountains, whicli may be
had from all the points just mentioned, is remarkably
fine, and is said 1)}- 5Iurray to be similar to, although iii-
ferior to. the famous distant view of the Alps which is
obtained from the idatform at Berne.
The reputation of Pau as a winter health resort is no-
toriously great, and its hotels are excellent, especially
such as lie in that part of the city which is nearest the
edge of the plateau, and from which the view just men-
tioned is obtained. This portion of the city, at least, is
well drained ; of the rest I cannot speak positively. The
soil at Pau is .sandy.
The mean temperature of each of the five months,
November to JIarch, is given by Dr. .Julius Hann as fol-
lows; November. 47.84' F. ; December, 43.34' F. ; Janu-
ary, 42.26° F.; February, 44.42 F. ; Jlarch, 48.20' F. I
have no data at hand to illustrate either the extreme or
the average daily maximum and minimum temperatures;
but theaverageinontlilv range durin.s the season in ques-
tion is 36.5° F. (Hann's "Handbucli der Klimatologie.")
Dr. Yeo tells us that ''frost and snow and ccjld nights
are not uncommon in winter"; and it is evident that the
climate of Pau at this season cannot be jironouuced a very
warm one. In "Murray's Guide-book" we read that
•• though the climate is mild the variations in teiuper-
ature are often sudden." On the other hand. Dr. A.
Rotureau (in the " Dictionnaire Encyclopedique des
Sciences Medicales"), although giving for the monthly
means of November, December, and .lanuarv tigures
which are lower than those of Dr. Ihiim, ami although
admitting that the temperature (|uite fre(|uently falls
l)elow the freezing point, nevertlieless appc:irs to re.srard
the winter climate of Pau as one characterized ratlier by
equability than by variability of temperature, and Dr.
Weber tells us that the nyctheineral ran.ge of temper-
ature seldom exceeds 16' F.
The mean annual rainfall is 42.7 inches, of which 11.3
inches falls in winter (Hoturcau), and during the six
months from November to April the average number of
519
Pavlliou Sprinf!
Pellagra.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
days on which rain falls is between eighty and ninety
(Weber). A.s to the manner in which rain habituallj'
falls, we are told by Dr. Rotureaii that, although falls
of rain are frequent, they are not usually of long dur-
ation, and commonly occur in the early part or toward
the close of the day. The relative humidity of the at-
mosphere at Pau is eonsiderable ; according to Dr.
Weber, it is on the average from 80 to S,T per cent. Dr.
Hann's figures for the live months, November to March,
derived from observations taken only twice a day (viz.,
at7.\.M. and at '2 p.m.), are as follows: November, 7.5
percent. ; December, TG percent.: January, 74 percent. ;
February, 72 per cent. : March, 70 per cent.
The leading characteristic in the climate of Pau, and
the feature to which it largely, and no doulit deservedly,
owes its popularity as a winter resort, is the prevailing
stillness of the atmosphere. The great chain of the
Pyrenees Mountains, distant onlj' fifteen or twenty miles,
acts as a barrier to protect the region about Pau against
southerly winds; while we are told by Dr. Yeo that "a
series of" plateaux rising behind the town " afford a good
degree of protection from northerly winds. The west
and the east are the quarters in which least protection
against wind is afforded; but Dr. Rot ureau claims that
the liills known as tlieCoteaux de Juranr;on and the trees
of the Pare serve in some degree to break the force of the
westerly winds, and that the easterly winds are modified
in character by being obliged to pass over a district of
relatively' considerable elevation before reaching the town
(sont mitiges par les hauteurs du terrain sur lesquelles
ils doivent passer avant d'atteindre la ville). He also tells
us that the east wimi at Pau is a fair-weather wind and a
dry one. The "mistral" of Provence and the Riviera
does not exist at Pau, although the northwest wind is a
bringer of cold and dry weather. The westerly wind is
damp and warm. In Dr. Rotureau's article will be
found other interesting facts concerning the winds of
Pau, and concerning the comparative windlessness of its
climate. Suttice it to say, in this place, that, while oc-
casional wind-stoi'ms of considerable severity are there
experienced, the climate is nevertheless one properly to
be regarded as e.xceptionalh' free from winds.
IIu n tirifjton Uichartls.
[The diseases for which the climate of Pau is regarded
as beneficial are the various catarrhal conditions of the
respiratory passages: dry bronchitis with irritable cough,
emphysema, and nervous complaints of an erethistic na-
ture. Fornieriy Pau enjoyed a wide reputation as a win-
ter resort for cases ot |)ulmonary tuberculosis, but at tlie
present time it is considered too moist for the successful
climatic treatment of this disease. There is, however, in
the neighborhood ot Pau a small sanatorium (The Tres-
poey Sanatorium) six hundred and ninety-five fei't high,
for the treatment of pulmonary tuberculosis; it is open
from the middle of ()ctober to the middle of Jlay. One
can find at Pau good facilities for golf, polo, tennis, and
cross-country racing. There are four English churches
and a .Scotch one. There has recently been o]iened a
winter palace of much magnificence, where operas, etc.,
are uiven. English phvsicians are also to be fo\md
here,—/-;. 0. O.f
PAVILION SPRING— Berks County, Pennsylvania.
Post-Offr'K. — Weniersville. Sanatorium.
Access. — Via Boiuid Brook route. Central Railroad of
New .lersey. Lelianon Valley Railroad, or Philadcl]>liia
and Reading R:dlroad to W<Tnersville; thence one and
three-qiutrter miles by private conveyance to spring.
The Pavilion Spring is not itself a resort, but its wa-
ters are used conunercially, and locally it is used to s\ip-
ply the Grand View Sanatoriuiu, It is located on the
grounds of the .sanatorium, near Wernersville. iind nine
miles from the city of Reading. The situation of the
sanatorium is on the South ^loimtains. about one thou-
sand feet above tide water, in the midst of charming and
picturesf[uesurrcpundings. Thisinstitution is an old and
well-known health resort, bavins; been eslablisheil in
1847. The buildings have been greatly enlarged and im-
proved recently, and the resort is now fitted up with all
kinds of appliances and conveniences for combating
morbid conditions. The Pavilion Spring was analyzed
in 1885 by Prof. Otto Luthy, analytical chemist, of
Philadelphia, with the following results;
Reaction neutral. One United States gallon contains;
Potassium sulphate, gr. 0.18; sodium sulphate, gr. 0.02;
sodium chloride, gr. 0.06; sodium carbonate, gr. 0.^3;
calcium carbonate, gr. 0.23: magnesium carbonate, gr.
0,12: iron oxide and alumina, a trace; silica, gr. 0.1)4;
organic and volatile matter, gr. 0.10. Total, gr. 1.98.
This water is very lightly mineralized, containing, in-
deed, fewer solid ingredients than that supplied to many
of our larger cities. It is remarkably pure, however,
and well adapted for table purposes. The water con-
tains a considerable amount of carbonic acid gas and at-
mospheric air. James E. Crook.
PEDICULOSIS. See Inwcts, Parasitic.
PELIOSIS RHEUMATICA. See Moi-biis Maculostis
M'cj'UtoJii, and Purpiini.
PELLAGRA. — (Synonyms: Lombardian leprosy: ery-
thema endemicum; Maidismus; Mai </t' ww/'c [French] ;
Mailiindisr/ie Itvf:e [German]; Jlal roxo [Spanish]; Mai
rosso; Scorhvto Alpino [Italian]).
Defixition. — An affection, limited to certain countries,
of the temperate zone, which has been most jirevalent
where maize or Indian corn is the principal article of diet.
It is thought to be a trophoneurotic disease of toxic ori-
gin, affecting mainlv the digestive tract, cerebrospinal
centres, and the skin.
The disease was first observed in Spain in 173.i, and it
still exists to a limited extent in that countr}', although
it is mainly encountered in Northern Ital_v, in the country
about Rome, in Southern Austria, in the Tyrol, and in
Roumania, while Manson reports the disease as prevalent
in Egypt. No cases have appeared in this country, al-
though it is sometimes imported with immigrants coming
from countries where the disease prevails.'
Symptoms. — The disea.se occurs in both men and wom-
en, and it has usuall}' been observed in adidts, althougli
children are by no means exempt. It first makes ils aii-
pearance in the spring or early summer ; continues dur-
ing the summer months, and then subsides as winter ap-
proaches. The first symptoms refer to the digestive tract
and consist mainly of loss of appetite, thirst, vonuting,
together with intestinal disturbances which give rise to
diarrhiea; or, more rarely, constipation may be at first
complained of, but this is usuallj' followe<l by obstinate
diarrhcea. As might be expected in this condition the
tongue is furred, and epigastric pain is not infrequently
complaineil of. In addition, there are lassitude, some-
times dizziness, noises in the ears, headache, and sleep-
lessness. These symptoms are soon followed by ana'inia,
palpitation on slight exertion, and sometimes tcdema.
Pains occurring either in the joints or in the lower part
of the spine may likewise be complained of. In the course
of a few- months, or it may be not tmtil the summer fol-
lowing, the skin shows signs of being implicated in the
disease. At first there may be a general jiallor, or even
jaundice, which is so(m followed by an erythema. The
erythema often develops somewhat suddenly, althotigh
less abruptly than is usually the case with simple ery-
thema, and its iluration is more prolonged. The paits ex-
posed to the sun's rays are at first, and throughout the
whole course of the disease, the regions mainly invulved.
The changes consist of an erythematous blush which may
be uniformly distributed over the area involved, or the
eruption may appear in the form of patches of various
shapes and sizes. These are generally first noticed on-
the backs of the hands, the face, neck, and forearms in
laborers who are accustomed to go in the sun bare-armed.
The same may be observed on the feet and legs of
children who are wont to go barefooted: and it lias
been observed by Raymond- to recur in parts once af-
520
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pavilion Spring.
l*<'IIa" ra.
fected, althovigh subsequently protected from the direct
rays of the sun. The eruption at first bears some resem-
liliince to an ordinary sunburn. In vuiusually severe
cases tlie cutaneous eruption is often of a livid red color
which disappears on pressure, and in some instances
hemorrhagic petechia' are encountered ; bul];e have like-
wise been observed, ami marked anlema of the parts af-
fected is not an uncommon symptom. The subjective
symptoms complained of in the skin are slight burning
or itching, although the latter symptom is usually de-
scribed b}' the patient as merely prickhng or tingling,
rather than the well-defined itching experienced in ecze-
ma. These constitute what may be called the first stage
in the cutaneous manifestations.
Toward the last of the summer, however, the skin as-
sumes a dark, sometimes muddy, color; it beccmies rough,
the epidermis being thickened and slightly scaly, and
not infrequently e.\coriated patches are encountered.
These are occasioned by the rubbing ami scratching in-
dulged in by the patient. The iluration of the eruption
is variable.
Usvially the active cutaneous symptoms begin to sub-
side witliiu a few weeks, or soon after midsummer, wheu
the patient apparently recovers, and as cold weather ap-
proaches no vestige of the disease may be apparent. In
this case the patient remains free from the disease un-
til the following spring when the symptoms return usu-
ally with greater severity than characterized those of
the preceding year. More frequently, however, tlie
symptoms do" not wholly subside upon the approach of
winter. With the recurrence in the severity of the erup-
tion the skin soon becomes thickened and fissures occur
about the small joints; this is accompanied by marked
exfoliation and constitutes the second stage of the erup-
tion. The severity of the disease varies in different sea-
sons and in different indivi<luals, but it is usually com-
mensurate with the privations to which the patient is
exposed. Year after year the erythema returns and
finally there takes place marked atrophy of the derma,
the skin becomes shrivelled, and the fingers assume a
semiflexed position, constituting the third slage of the
cutaneous lesions.
During the second 3-ear the nervous system shows more
unmistakable signs of implication. At this time changes
in the reflexes are seldom wholly ab.scnt. In 165 cases
examined by Sandwith,* the knee jerk was found to be
normal in only 3, in 45 it was slightly exaggerated, in
70 very brisk, in 15 feeble, and ab.sent in 23. In addi-
tion to" this the patient complains of pain and tenderness
in the dorsal region, the pain sometimes radiating to the
extremities. According to Crocker* the third nerve is
freqiienily paralyzed, and changes have been observed in
the fundus oeuli. These symptoms are followed by de-
liriimi, and after many years by melancholia, mania, and
a tendency to suicide, while insanity is not infrequently
the final sequence. It is estimated that about ten iier
cent, of the patients finally drift into the lunatic asylums
of Italy (Billod). In young people bodily defects are
sometimes attriljuted to this di.sease, especially defective
development of the organs of generation, while it is said
that the mental powers may be imnaturally precocious.
Other sj'raptoms noted late ia the couise of the disease
are paralyses of various parts of the body, those most
frequently reported involving the legs and arms; while
atrophy of vaiious internal organs is often observed post
mortem.
P.iTHOLOGT. — According to Lombroso-^ the princijial
factor in the causation of pellagra is undoulitedly some
toxic effect on the sympathetic system and the vagus
nerve. The first change observed in the skin is hvpera?-
mia. which goes on to exudation and consequent hyjier-
trophy. Similar changes have been best observed in the
meninges of the brain, as well as in the liver, spleen,
kidneys, and lungs. When, as is usually the case, death
occurs late in the course of the disease, atrophic changes
hare been for the most part observed. The most con-
stant post-mortem changes are. therefore, general ema-
ciation, atrophy of the skin, which presents a shrivellcil.
sometimes furrowed appearance, together with marked
atrophy of the liver and spleen. In some instances these
ehangi'S have been noted in the kidneys. Symmetrical
sclerosis has been oliserved by Tuczck in the jjosterior
colunms of the cord and in the pyramidal tract; while in
some cases fatty degeneration of various internal viscera
is the most conspicuous feature. In one hundred and
thirteen autopsies Lombroso found exudation into the
liver, kidneys, spleen, and the meninges of the cord.
He likewise found atrophy of viscera supplied by the
vagus, fatty degeneration of the liver and kidneys, and
pigment changes in the cells of the brain and cord.
Etiology. — It was formerly supposed that the exclu-
sive use of unwholesome maize as an article of diet was
the cause of pellagra. There can be no question, how-
ever, that l)ad hygienic surroundings together with ex-
posure to the sun are the most important factors in the
etiology of the disease. According to Lombroso {loc.
cit.), the immediate cause of pellagra is a toxic influence
analogous to ergotism, and further that maize when de-
composed gives rise to a fatty oil or extractive which
has been denominated pellagrozein. In experiments
made with this oil on both men and animals it has been
shown that symptoms somewhat analogous to pellagra
have followed its administration. On the other hand,
many cases of pellagra are reported in which the inges-
tion of maize has plaj'cd no part. Thus Hardy,'
Sehreiber," and others have rejiorted cases of pellagra in
which maize had not entered into the dietary. Alcohol
and syphilis have likewi.se been looked upon as etiologi-
cal factors. While it must be acknowledged that they
may be contributory in producing the debilitated state
essential in its causation, there is no positive ground for
believing that they ever give rise to the disease perse.
It is well known that maize as an article of diet is per-
fectly wholesome when sound and properly cured ; but,
like r3'e, maize may becoiue affected, giving rise to a po-
tent toxic poison analogous to ergot. Dr. Zampa." medi-
cal officer of health in the province of Rome, claims to
have traced a direct connection between the disease and
certain topographical conditions, although malaria seems
to have no part in its causation. The disease is most
commonly met with among the agricultural class, al-
though in rural districts it does not spare the artisan or
those engaged in other pursuits. According to Zampa,
damp, dirty, ill-ventilated habitations, scarcity of pure
drinking-water, and a large consumption of " polenta " (a
porridge made of maize seasoned with a little salt) as the
chief article of diet, are the chief causes of pellagra.
Crocker very aptly summarizes the cause of pellagra
into "peasant life, poverty, and polenta." The tlisease
is not contagious nor is it inherited. The age at which
the disease is most commonly met with ranges between
thirty and fifty j-ears.
Di.\«NOSis. — Like luany infectious diseases the diag-
nosis of pellagra is not difficult when it is encountered in
connection with other cases of the same nature, in com-
munities where pellagra is known to be endemic, or in
those known to have suffered from previous attacks of
the di.sease. On the other hand, in sporadic cases or in
countries where the disease is seldom encountei'cil. its
recognition niav be somewhat ditlieult. The first point
to be considered is the nulrition of the jiatieut, for malnu-
trition is essential to the development of the affection.
Gastro-intestinal disturbances, together with erythema
appearing on the backs of the hands, on the face, more
rarely on the forearms and dorsal surfaces of the feet as
warm weather comes on, might be mistaken for ordinary
sunburn. The association of gastrointestinal disturb-
ances, however, should put one on guard, while the per-
sistence of the erviption wovdd soon lead to a more
thorough investigation, when the association of other
symptoms or the history of previous attacks would enable
tiie physician to make a positive diagnosis. Later in the
course of the disease the occurrence of nervous symptoms
wotdd be conclusive to one fainiliar with the salient feat-
ures of pellagra. Finally, with the continuation of the
eruption year after year, together with great debility.
)21
Pcllilory.
Pelves.
REFERENCE HAXDIiOOK OF THE JIEDICAL SCIEXCES.
despoudeucy, an inclination to mclancliolia, and aberra-
tion of reflexes, an error in diagnosis need not occur.
Prognosis. — Tlic prognosi.s will depend upon the
severity of tlie disease and tli(' extent to wliieli it lias
advanced. Durins; tlie first attack the pro;;nosis may be
said to be favorable, provided the patii'nt can obtain
siiitalile nourishment, and provided the impidrment of
the iligcstive functions be not sullicieiitly grave to inter-
fere \vitb normal nutrition. On the other hand, after the
disease has existed one or more years and getieral impair-
ment of nutrition becotues more marked, together with
involvement of the nerve ccidres, the prognosis is always
extremely grave. When the disease goes inichccked the
final fatal t'ermination may be expected in from three to
twelve years, the average being about five. In all cases
the prognosis will depend upon tlie ability of the patient
to jilace himself under the most favorable conditions for
recovery.
TiiE.vrMENT. — There are no drug specifics in the treat-
ment of pellagra, and regulation of the diet should be the
first consideration. In conjunction with this, pniper at-
tention should be jiaid to the digestive tract, which may
ret|uire sedatives or southing medicines, such as olive oil
or albolene, together with opium, bismuth, etc. The
food selected should be light and easy of digestion, and
it should be given in small (|uantities at frequent inter-
vals according to the strength and general condition of
the patient. .Milk, eggs, and meat broth are usually in-
dicated in severe cases, and as the strength increases a
meat diet with vegetables and bread obtained from well-
ripened grain should Ix' given. Next in importance to
the diet are the h.vgienic surroundings of the patient.
As lias Ijcen shown, most cases occur among those who
have, been subjected to tlie vilest h_ygieiiic conditions;
therefore it should be seen that the room occupied by
the patient be sufficiently large to insure pure air to-
get her with free ventilation ; dampness should be avoided
by selecting a rocnn to which the sun gainsaccess at least
during .some portion of the day. Massage and rnbbin,g
with salt may be of benefit. By way of further medi-
cation, after the more pressin,g symptoms have been al-
layed, tonics and vegetable bitters, such as quinine and
iron, together with cod-liver oil, should be prescribed.
In some cases the administration of arsenic is followed
by markeil imiirovenient. The cases in which this rem-
edy is iiicjst liable to prove beneficial are those which
have extended over several years and in wiiich the dis-
ease has assumed a chronic stage. To quiet the appre-
hension of the patient, esiiecially when the nervous mani-
festations assume a serious aspect, opium may be given.
M'illiiiin T/iuiuas Corlett.
Uekerk.ncks.
' S. Shcrwcll : Trans. Am. Dcnii. As.sii., VMtl.
2 Paul ituviii.iiMl : Annates de D.Tiii. ft Sypli.. 1889, p. 627 ct seq.
s F. M. S;in.iwitli : Brit. Jour. ci( I)Hniint<ili.i;v, 1H»8, p. 39.5.
« H. llailclifli/ (TuclitT: Iilsfii.si.s «t tin' Skill, Pliiladelphia, 1893.
^ C. Loiiilirusic Lt'lire vipn der I'l-tlatrm, Berlin, 1898.
» A. Hardy : Traitr dfs mat. dc la in-au. Paris, 18KB, p, 1107.
' Scbrellier: Ari'liiv fur Dcnii. u. Svpli., 187.5, p. 117.
'Zampa: Lancet, Oi-iciln'r-'Ttli, llHiii.
PELLITORY.— /'.'//■'//(/•»/«, U. S. P.; Pijrethri radix,
Br. P.: Sjuiiiiah I'liliturii ; i</ui/thJi Cli<imoniUe. The
dried root of AMici/rhix J'l/rct/iniiii (\j.) DC. {Anthoiiis
P. [L.J fam. Vompiisitir.)
The pellitory plant is a pretty little perennial herb,
which somewhat resembles the chamomile, whence one
of its common names. It is a native of the Mediterra-
nean basin, where it is cultivated not onlj- as a drug, but
also as a garden Hower.
From 5 to Vi ciu. (3to.T in.)longaiid 1 to2cm. Q-i in.)
thick, nearly straight and unliraiiched, cylindraceous,
tapering or slightly fusiform, bearing a few tough, hair-
like, yellowish rootlets and in the centre of the crown
usually a tuft of cottony or silky, whitish, fibrous tissue:
externally deep brown, or slightly grayish-brown, incon-
spicuously annular near the crown, very roughly wrinkled
and |iitted, harsh to the touch; fracture short and sharp;
bark thick, the inner layer brown, containina about three
circles of dark red resin cells, the outer layer tlark brown ;
wood yellow-brown, finely radiate, containing four or
more circles of resin cells; inodorous, pungent, and acrid,
producing a prompt and strong sialagogue etfecl.
The acridity of pellitory is due to a number of constit-
uents, or possibly to some one which is carried in the
former. These are a resin and two fixed oils, all present
in large amount, as well as the alkaloid pyrethriiw. The
latter is readily decomposed into a derivative alkaloid,
believed to be piperidine, and piperic acid. The resiu
contains a small amount of the alcohol-soluble body, jkI-
Utoiiii. The substance which has been sold as "jiyre-
thrin " is merely a fatty and resinous extract. Tannin
and volatile oil are present in small, and inulin in large
amount.
Action and Use. — These have been but little investi-
gated, notwithstanding thiit the powerfully iictive \>to\)-
erties of the drug warrant a thorough experiineutiil
study. It is one of the most powerful of sialagogues, a
property wliicli we iiave not yet learned to utilize, in
spite of the important digestive functions of the saliva.
It is at least possible tluit so powerful an action uptm
the salivary glands is associated with a similar action
upon the pancreas, but no observations are recorded
upon this point. The most general application of the
drug is as a dental anesthetic and counter-irritant, and
it enters into numerous "toothache drops" which have
themselves lar.gelj' gone out of use. There is a twenty-
per-cent. official tincture, made with alcohol, the dose of
5vhich is a fluidrachm.
Allied Dkuo. — Oeriiuin pellitory or pyrcihiuia is the
root of ^-1. iifficiiiKnnn Hayne, the nativity of which is
not certainly known, but which is a product of cultiva-
tion. The root is very much more slender and elongated
than the other, and usually conies to market with long
portions of the stem attached. It has a circle of large
resin cells in the bark, but there are none iu the medul-
lary rays. Its constituents and action are practically
identical with those of the official variety.
Henry II. Ilusby.
PELVES, DEFORMED.— Any marked deviation in size
or symmetry from tlie normal pelvis may be regarded as
constituting a deformity of the pelvis, whethi'r the effect
on the course of labor be serious or not.
A deformed jielvis may be due to an error in develop-
ment, to local disease, injury, or new growth, or indi-
rectly to injury, disease, or maldevelopment of the ad-
joining skeleton. Thus from errors in development
there are the abnormally large pelves, called justo-ma-
jor; the justo-niinor, or disproportionally small, some-
times of a persisting infantile type; and the pelves of
the masculine type, large and ihick-boned. but with a
narrowed jiubic arch and pelvic outlet.
Frmu local errors in development there are the rare
varieties, where one or both of the sacral ahc are lacking,
giving the Naegele (oblique) or Robert (transversely
contracted) pelves. The split jielvis is one in which
there is failure of meeting of the pubic bones at the
sym]diysis.
From constitutional disease or errors of nutrition caus-
ing softening of the bones, there result the pelves de-
formed by rachitis and osteomalacia. From local disease
there may be caries of some of the pelvic joints, with ar-
rest of development and later ank3'losis. The sacro-iliac
joints, if diseased in early life, may cause extreme deform-
ity. Following injuries there may be pelvic fracture
with formation of callus. New growths may limit or
oliliterate the |ielvi(' cavity — a primary sarcoma or sec-
ondary carcinoma, or some fiu-ni of enchondioma or ex-
ostosis.
Any injury or lualdeveloiunent iif |);irtscif tlie skeleton
adjoining the pelvis, especially during early life, may
have an imiiortant bearing upon the subsequent develop-
ments of the Jielvis, and leave indirectly its stamji on the
general contour of the latter. Thus, for example, polio-
myelitis, causing a paralysis and subseqtieiit atrophy of
tme limb, leaves the pelvis on that side comparatively
522
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pellltory,
Pelves.
Fig. 3753.— Baudelocque's Pelrtmeter.
undeveloped. As a further result of the shortening of
the limb there must be compensatory scoliosis, with its
effect upon pelvic growth.
Other forms of paralysis of the lower extremities, or
joint diseases of hip, knee, or ankle, may aft'ect the pelvis
in the same way. A congenital liip-joint dislocation may
seriously affect the
normal growth of the
]ielvis. Other results
iif skeletal deformity
upon the pelvis are
not infrequently seen
from defects in the
spinal oohimu, such
as simple, compen-
sator3% or rachitic
scoliosis, caries of
the vertebra-, and,
lairly, the anterior
ilisloeation of the
bodies of tlie lumbar
vertebra', known as
spondylolisthesis.
Senile cliauges in the
pelvis before the end
of tlie child-bearing
period sometimes
cause oljstruction
by ankj'losis of the
C(jccyx with the sa-
criun.
Habits of living
must always be counted upon as etiological factors.
Tlie jjoorly nourished and poorly hou.sed are the ones
who jireseut pelves deformed from laehitis and tul)er-
culosis. For this reason the percentage of deformities is
small among our native country classes, large among the
dwellers in cities, especially of the slums, and greatest
among the immigrant population. Abroad, where the
sanitar)' conditions of life are worse, still higher pro-
portions of deformity are found, and osteomalacia is oc-
casionally met with.
Theie are racial peculiarities in the shapes of the pelvic
brim. The Caucasian normal tyjie is one which is wide
trausverselj- ; the outline of the Au,stralian pelvic brim
is almost circular; while the African pelvic brim is one
which is relatively constricted transversely, and has a
long antero-posterior diameter. This type of pelvis, if af-
fected b\' the unsanitary conditions in which the negroes
commonly live in this country in cities, supplies a large
proi^ortiou of bad pelvic deformities. Thus one author
lias reported seven per cent, of deformed pelves in wliites
in a city hospital service, as against twenty-one per cent.
in blacks.
The recognition of the deformity is imjiortant. One
"must learn pelvimetr_v if he is to do intelligent obstet-
rics." Much can be ascertained by inspection of the
patient. The facial appearance, form, carriage, height,
gait, or obvious deformities of spine or lower extremities
may lead to suspicions and put one on the track of a ]iel-
vic defect, A careful questioning may elicit a history
of diseases such as rachitis or tuberculous bone disease,
or bring out 'information concerning previous ditllcult
labors.
But the history may be lacking, and all external ap-
pearance of deformity absent. >[oreover, in all cases,
no matter how olivious the deformity, its true extent and
its obsteti'ic signiticance can be ascertained tjnly by care-
ful jjelvimetry, through palpation, vaginal examination,
and instrumental jielvic measurements. External meas-
urements, except in some cases of great obesity, are of a
certain value in determining the types of deviation from
the normal. Of greater importance is the exploration by
vaginal examination of the pelvic cavity.
For external measurements there liavebeen chosen cer-
tain easily recognized bony landmarks. The distance be-
tween these points is taken by a form of calipercalled the
pelvimeter. Of the couunouer types perhaps those of
Baudelocque and Breisky are best known. The essen-
tials of a good pelvimeter are compact size and an accu-
rate and legible scale. ])refenilily in ceutimetn'S.
The first measurement usually taken is the distance
between the anterior suijerior sjiiiies. For this measure-
ment the patient should lie Hat on the back, with all but
the thinnest clothing removed from about the hips and
lower abdomen. The tluunb and forelinger should
steady each tip of the pelvimeter. The thumb should
now be allowed to rest in tlie miteh below the spines and
the tips of the pelvimeter be lightly jiressed against their
outer side and the reading made. Taken in this way the
measurements will be fairly constant when made by dif-
ferent individuals. The average intersiiinal diameter is
34 cm.
The next measurement should be the distance between
the crests of the ilia, this measurement being made be-
tween the points which are most widely separated. The
patient lying in the same ])(isilioii, the tips of the pel-
vimeter are slipped back along the outside edge of the
crests, and the widest jioints of divergence noted and
measured. This is called the intercristal measurement.
It should average about 28 cm. These two distances
furnish an indication of the transverse diameter of the
pelvic brim, especially if taken in consideration with the
so-called external oblique iiieasurenients.
The ratio of the interspinal measurements to the inter-
cristal has a distinct value in the study of certain types
of deformitj-, especially the rachitic.
The external oblique measurements are those taken
from one posterior superior si)ine to the opposite anterior
superior spine. To take the left oblique measurement
the doctor stands on the right of the patient, who lies on
her left side. The distance from the left ijosterior supe-
rior spine to the tip of the right anlerioi' superior spine is
measured. The posterior spines are uot very prominent,
but are usually indicated by the presence of a dimple on
either side of the sacrum from one and one-half to two
inches frotn the median line. The patient now lies on
the right side, and the right oblique measurement is
taken. The average length of these measurements is 33
cm. The right oblique is commonly 0.5 cm. larger than
the left. The oblii|iies furnish a fair idea of the oblique
diameters of the pelvic brim. Any marked deviati<in of
their normal relation to each other is a good index to ob-
lique pelvic contraction.
For estimation of the antero-posterior diameter, or so-
called conjugate of the pelvic brim, a measurement is
taken which is called the
external conjugate. This
is the distance from the
tip of the last lumbar
spine to a point about
oue-ijuarter of an inch
below the upper edge of
the pubic symphysis in
the median line. Some
authorities give the de-
pression just below the
last lumbar spine as the
jiosterior landmark, but
this gives less constant
and exact measurements.
The last lumbar spine is
usually the most promi-
nent spine in that region.
It is found about 3 cm.
above the level of a line
drawn through the two
posterior superior spines.
This measurement calls
attention to contraction.^
in the antero-posterior di-
ameter of the pelvis. In
the normal ]ielvis it measures from 20 to 21 cm. Any
jielvis measuring less than IS cm., even if justo minor,
shiiuld be regarded as tlat. Tliere ai'e, however, i.iossi-
bilities of error in this measurement. Occasionally a
Fig. 37»).— BreiskT"s Pelvimeter.
)23
Pelves.
Pelves.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
pelvis which has an external conjugate of large size
will show flattening upon internal pelvimetry.
One other external measurement is sometimes of im-
portance; that is, in the type of pelvis where there is
ohstructionat the pelvic outlet due to a narrowing of the
pubic arch and an approximation of the tuberosities of
the ischia. Tliis is called the lii-isehiatic diameter. It
is easily taken, while tlie patient is in the lithotomy posi-
tion. The tuberosities may be readily fi'lt, and the dis-
tance between them taken "by tape measure or pelvime-
ter. If the distance be below 9 cm. the narrowing is
dangerous.
The most valuable information is furnished the phy-
sician by vaginal examination. After he has acquired
some experience he will be aljle to make out variations in
the size of the cavity of the pelvis. If he can readily with
the tiuger touch the sacral jiromontory, flattening is cer-
tain. Fairly accurately to estimate the internal conju-
gate, the first and second flii.gers of the riglit hand are in-
troduced until the middle finger rests against the prom-
ontory. At the point, wliere the index finger inter.seets
the symphj'sis a mark is made by tlie finger nail of the
left forefinger. Tlie internal o))lii(ue conjugate is the
distance between this mark and the tip of the middle
finger. Subject to slight variations the true internal
conjugate may be estimated by the stibtraction of 1.5
cm. from tliese figures. The normal internal conjugate
is 11 cm. Any conju.gate below 10 cm. indicates a dan-
gercmsly flattened pelvis.
or the v;i,ri(ius types of deformities which are perhaps
most commonly seen are the pelves of normal .s3'mmetry
but of extremes of size. The justo-major pelves are those
of exaggerated size. They occur usually in women of
robust type, who have an otherwise large frame. These
women are often tall, but they may be of normal stature.
The etfeet of such a pelvis upon labor is slight. Certain
authors suggest that fnnn the lack of Ijony resistance
there is a tendency to precipitate labors and resulting
lacerations. There may be an increased proportion of
uterine disjilacements from lack of bony support. The
practical obstetrician may disregard this deformity. The
diagnosis of this condition may l)e made in those cases
in Avhich the oblique diameters measure 34 cm. or more.
The justo-minor or equally cout.racted pelvis is of
more serious moment. It is usually found in smaller
women, but may occur in women of otherwise normal de-
velopment. It may be classified as one of symmetrical
shape, liut with external obliques measuring 20 cm. or
less. The etiology of this condition cannot always be
explained. It is of great frequency in the African race.
In this class, however, the deeper conjugate acts some-
what in compensation. In some cases the justo-minor
pelvis is (nily a part of a ilwarfed general system. In
some cases it seems to go with under-developed pelvic or-
gans, a retention of tlie juvenile type. Unfavorable sur-
roundings in childhood or during intra-uterine life may
have alfected development unfavorably. The effect
upon labor depends necessarily upon the degree of the
deformity and the size of the child's head. In tlio.se pa-
tients who are naturally small the child will be in pro-
portion, except where the father is of large size or where
jireguaucy has been jirolonged beyond the normal time.
In these cases the only safety for the child depends on
strong uterine contractions and a capa<-ity for extreme
moulding of the fcetal head. In the African race, as the
ftt'tal cranial bones are notably soft, and tlie uterine
pains usually verj' efl:ective, tlie head moulds extremely
well. The justo-mincn- pelvis, therefore, in the negress
has little significance exeei)t in those cases in which some
other kind of deformity is added to the general contrac-
tion. In the Caucasian the larger and tinner head of the
foetus causes trouble, and may necessitate very active
interference.
The mechanism of the labor in the justo-minor pelves
is as follows: The liea<l, unalile to engage by moderate
flexion, becomes more and more flexed until the occipital
bone presents. The external occipital protuberance may
be felt. Engaging in one obliciue the head gradually de-
scends, under the influence of strong pains. The over-
lapping of bone at the lambdoidal sutures is an index of
the amount of moulding accomplished. If the obstruc-
tion is so moderate that the pains can accomjilish the
delivery, after a rather protracted second stage the head
reaches the pelvic outlet. Obstruction occurs until the
head is well past the mid-pelvis. During this time the
suffering from the pressure against the pelvic bones may
be very severe. At the time of the uterine contraction
the patient cries out as if suffering intensely. Between
the pains there is aching discomfort from the continued
pressure of the impacted head. Rarely, after the head
has safely passed the pelvic brim, the shoulders may fur-
nish some obstruction.
It the pains are not effectual in advancing the head,
and artificial assistance be not fortln-oming, the muscu-
lar force may diminish. Weaker and infrequent contrac-
tions may cause labor to linger along until the patient
suffers from extreme prostration; or the pains may be so
severe as soon to develop a tonic uterus, with retraction
and migration of the muscular fibres to the fundus and a
thinning of the lower uterine segment. The end result
of such a case maybe spontaneous rupture of the uterus.
Should the breech present in a patient with a justo-minor
pelvis, the complication for tlie child is apt to be fatal;
for while the bodj' moulds easily into the pelvis, the de-
scent of the head can be accomplished only by moulding,
which is impossible in the short space of time that safety
permits for the extraction of the after-coming liead.
There are cases on record in wliieli the force neces.sary to
deliver the head through a justo-minor pelvis has caused
a diastasis of one or more of the pelvic joints.
The manfuline ti/pe of pdris is most often found in
women with large muscular frames. The external meas-
urements maybe even justo-major. The bones are un-
usually thick. The peculiar deformity in this type of
c:i.se is in the narrowing of the pubic arch. The pelvis
may be shallow or deep. In the latter case it is best de-
scribed as funnel-shaped. The true funnel pelves, how-
ever, are more extreme cases than those of the masculine
type, and usually occur in connection with some spinal
deformity, especially kyphosis.
The diagnosis is an easy one to be overlooked, because
of the otherwise large development of the patient. In-
deed, in many instances the case is allowed to go on until
the obstriicticiu during the seconil stage of labor calls at-
tention to the <leformity. It is upon the vaginal exam-
ination that the diagnosis must be based. The pelvic
walls are felt to be drawing nearer together as the outlet
is approached. At the outlet the approximation of the
ischial spines and tuberosities to each other should be
recognized, and also the sharper angle of the pubic arch.
In the maseuline pelvis labor progresses normally, even
to the time of the appearance of the caput in some cases.
And tlien as the head encounters the bony obstruction
all progress ceases, or very slowly and by increased ex-
pulsive effort the head is moulded past the outlet. The
narrowed arch forces the head posteriorly, and, thus in-
creasing the tension ujion the perineum, causes a liabil-
ity to extensive lacerations. These lacerations nia.y in-
volve not onlv the perineum, but sometimes run up on
eithi'r side of the vulva, along the line of the pubic rami.
Where they extend into the venous plexuses of the ves-
tiliule, lu'morrhage may be very persistent. Prom the
prolonged pressure various necroses of the vagina or the
cervix, or a trauma to the bladder, may be caused.
The pelvic narrowing sometimes causes faulty flexion
of the head. The occiput may be forced to rotate jios-
teriorly. Sometimes rotation is so interfered with that
the head is liorii obliquely or even transversely.
The treatment is usually by assistance with low for-
ceps. It this is not sutlieient, symphyseotomy may be
of especial value in this deformity. But the fact that
the prolonged pressure in the second stage may have in-
jured the cliild beyond hope of recovery must be taken
into consideration before any major surgical operatiiin
on the mother is undertaken.
The ximjik fat pclrit is a fairly common type of de-
52-t
REFERENCE HANDBOOK OF TUE jMEDICAL SCIENCES.
Pelves.
Pelves,
formity, and one whicli may have a serious effect on la-
bor. It occurs usually in pelves with measurements
otherwise normal. If this del'ormitj' be engrafted on a
justo-miuor pelvis, the consequences are most serious.
The cause of this condition is not always plain. A slight
degree of rachitis, the carrying of heavy burdens, exces-
sive standing on the feet, prolonged illness in bed in
«irly life may all have some effect. This flattening is
most often met with in the lower classes and the foreign
horn.
The deformity may be anything from a simple jutting
forward of the promontory to a marked approximation
of sacrum to symphj'sis, changing the cordiform outline
of the brim to a shape more reuiform. There is a com-
pensatory slight widening of the pelvic brim trans-
FlG. 3T.35.— Position Assumed by the Head iu a Flat Pelvis. (Alter
Simpson.)
versely. Nothing about the general appearance of the
individual in most cases would lead one to suspect the
difficulty. The external conjugate in some eases shows
no shortening. The internal measurement is therefore of
greatest importance. The flattening, if of much signifi-
cance, will allow the promontory to be easily reached by
the examining finger. The extent of the deformity may
be readily ascertained by the method suggested above.
If the narrowing be of slight extent, normal sponta-
neous delivery is possible, but there is a tendency to dry
labors and a slight modification of the meehauisui. The
head engages transversely, poorly flexed, but slightly in-
clined laterally, so that the anterior parietal bone pre-
sents. Occupying the direction of least resistance the
occiput slips to one side, thereby causing the bitemporal
diameter to engage the conjugate rather than the bipa-
rietal. During the time of moulding the woman suflers
severely from the pressure of the head against the sa-
crum.
As soon as the widest part of the head has passed the
constriction advance may be rapid. Because of the poor
flexion of the head rotation of the occiput to the front
occurs late if at all. The head is often born oliliquely.
sometimes even trausverselj-, or with the occiput still
posterior. The shoulders and hips are apt to be born
transversely. If much moulding has been necessary, the
posterior iiarietal bone may show a grooving parallel
with the coronal suture, caused by the pressure of the
head against the promontory. The posterior parietal
bone is overlapped by the anterior.
The effects of the flat pelvis upon labor may be only
those mentioned above. If the child be small, attention
ma3' not be drawn to the deformity. The well-known
tendency of women to have larger children in succeeding
pregnancies, however, often brings the first manifestation
of a flat pelvis in a later pregnancy in a woman who has
already had several normal deliveries.
If the deformity be more serious the head engages, but
cannot mould sufficiently to jiass the brim. After a rea-
sonable length of time artificial assistance must be em-
ployed. In the cases of greater flattening no engage-
ment occurs and exhaustion soon supervenes from the
futile efforts of the uterus at expulsion. The head rides
high above the pelvic brim. The uterus tends to fall for-
ward, causing a pendulous abdomen, which makes the
efforts at engagement of the head still more ineffectual.
The flattening, preventing the fitting of the head in
the pelvic basin, may cause malpresentations. The lack
of adjustment between head and jielvie brim may cause
a prolapse of the cord. In the earlier months of preg-
nancy the projecting proiiiDUtory may force the uterus
into retroflexion and ultimate incarceration in the hollow
of the sacrum. Where tiie head cannot engage or descend
into the pelvis the dilatation of the cervix is incomplete
because the presenting jiart does not reach it to cause
pressure against it. Insteail of tlie usual meniscus-
shaped bag of membranes a cylindrical-shaped bag forms
which is ineffectual as a dilator and very prone to early
rupture.
The flat pelvis may be the cause of a breech presenta-
tion, and when this condition occurs in a pelvis which by
measurements other than the conjugate is shown to be
ample, the breech labor seems to be the safest. The rea-
son for this is that the after-coming head enters the pelvic
canal, with the smallest part of the wedge first. The
larger part adjusts itself to the most roomy part of the
pelvis. The occiput slips toward one side of the pelvis,
and in so doing causes the bitemporal diameter to engage
the conjugate, instead of the biparietal, as is usual in ver-
tex cases. The bitemporal diameter has the advantage of
being at least 1 cm. smaller than the biparietal. The
force which mu.st now be apjilied from below, bj' trac-
tion on the child, will comijlete the necessary moulding
in the safest possible waj'.
It is for this reason that the method of delivery by
version and breech extraction is often considered and
safely emploj'cd in a labor case with a flat pelvis.
A kind of pelvis which alwaj'S shows flattening and
yet is quite distinctive in tyjje occurs in those women
who have suffered from rachitis in infancy or childhood.
The rachitic jielvis shows the effect of various pulling
and pressure forces upon the difl'ereut bones.
The extent of the deformity varies with the severitj' of
the disease and depends somewhat upon the position oc-
cupied by the patient during the course of the disease,
■i.e., whether lying in bed, sitting up, or walking about.
One other factor is the arrested general development
wliich occurs at that time.
The weight of the pelvic viscera combined with mus-
cular traction tends to flatten the ilia and to prevent the
inward curvature of the ci'ests to the anterior superior
spines. In this waj' the spines are thrown outward. In
severe cases the ilia flare to the spines. The intercristal
diameter is thus smaller than, or of the same width as, the
interspinal. About two-thiids of the way to the posterior
spines on the crests there is frequently a sharp angle
where the crests turn in toward the sjiines.
The brim of the pelvis is diminished in the conjugate
by the pressure of the weight of the trunk ti'ansmitted
along the spine to the sacrum, and forcing it down and
forward on its transverse diameter. The lower half of
the sacrum tends to be thrown backward, but the tip is
pulled forward in compensation, iu shar)) flexion, b.y the
sacro-sciatic ligaments. The sacrum is further changed,
so that its anterior surface instead of jireseuting a con-
cavity from side to side is convex or Hat. Sometimes
there is a sharp bending backwaril of the lower part of
the sacrum at the juncture of the first and second sacral
vertebrte, causing the second vertebra to form a false
pi-omontory, which in estimating the internal conjugate
must be accepted as the woiking promontory.
There is a widening of the pubic arch from muscular
traction on the ischial tuberosities. If the patient be al-
lowed to walk during the disease, there may be some con-
striction of the pelvis tiansversely by pi-cssure over the
acetabula. In general the size of the pelvis is restricted.
The flattening is the worst feature. The pelvic brim
presents a reniform outline, with a slightly increased
transverse diameter. The pelvic cavity is usually ample
and the outlet wide. The symphysis forms a wider
angle with the plane of the sacrum. All degrees of de-
formity are met with.
Thediagnosis of the extreme cases is easy. In slighter
deformities the history of the patient is of some help—
525
Pelves.
Pelves,
REFERENCE HANDBOOK OF TIIH MEDICAL SCIENCES.
late walking, late dentition, unhygienic siiii'oundings.
There may be evident the square tdreliead, riekety
chest, bowlegs, or any of tlie rachitic skeletal changes
ajiart friini the jielvis. Ijocally, there is I'oiind the
changed ratio of the
iiiters]iiual to the
intercristal meas-
urements; the eas-
ily felt promontory,
with ])erliaiis a false
promontory at the
junction of the first
and second lumbar
Nei'tebrre ; the sa-
ciiim convex from
side to side ; and the
wide pubic arch.
The elTect of
ntrhitix on labor
de|iends on the ex-
tent of the deform-
ity. Even in cases
of sliglit deformity
the elfective work-
ing space of the
bony pas.sagcs is
circumscribed. In
lesser cases the
mechanism may re-
semble that of a
simple flat pelvis.
In worse cases a
sjiontaneous deliv-
ery or even engage-
ment of the head is
impossible.
OsUomalaciii, or
iiiiilaeostenn. is a dis-
I'.i.se whieli cau.ses
a softening of the
jiehie bones by the
alisorption of tlie
lime .salts. It de-
velops during preg-
nancy or lactation ;
more usually the
latter. The condi-
tion is rarely met with in this country. Nothing is
known of its etiology other than that it is a disease of
nutrition. The softening of the bones, however, is the
occasion for an extreme collapse of the pelvic basin.
The sacrum and the regions of the aeetabula are crowded
in so that the pelvic brim is triradiate in shape. This
collapse leaves the symphysis projecting like a beak,
giving the pelvis the name of the "rostrate pelvis."
The pubic arch is mueli narrowed. Severe cases of
rachitis show a similar deformity. For differentiation,
in tiie cases of ost(^omalacia the ilia are curved like
scoops and the crests are more sharply curved, while in
rachitis the ilia tlar<' and the spines are widely separated.
The history <if eases of osteomalacia is characteristic.
The trouble develops during the child-bearing period.
There are dull aching pains in the extrennties and lum-
bar legion, with dilHculty in walking and rotation of the
bod}- as one foot is advanced in fnmt of the other. The
stature is appreciably diminished <luring the course of
the disease. There may be tenderness over the anterior
pelvic wall. Examination reveals the l)eaked jielvis, the
narrow pubic arcli, and, if the linger can reach so high,
the triradiate pelvic brim. Such a pelvis, unless in the
earlier stages and quite soft, will not allow any form of
con.servative operative delivery pc?' i^ia.i ndturales. The
Ca=sarean operation with extirpation of the uterus fur-
nishes the best solution of the difficulty.
Kyphosis developing in early life from caries of the
vertebne. possibly from rachitis, leaves its stamp upon
the pelvis, producing the tvpe known as the kiiphntic
pelvis. This was first described by Breisky in \>*(i~>.
Fig. 37ji''.— Hacliitji- x.-trrt-ss Di-livercil l.y
CH'saroiin s.-rtidii :ii the sloaiir Matpr-
nily Hospital, New Vurk City. i.Seryice
of Dr. Edwin B. C'laBiu.)
The difference in the direction of the pressure, trans-
mitted through the sjiinal column on the saenun, is de-
pendent upontheloeatinnof the kyphos. The deformity-
is most marked when the kyphos is low down. In the
upper dorsal region spinal deformity will affect but
slightly pelvic development.
The characteristic kyphotic pelvis has a displacement
of the upper end of the saenun backward. This gives
an unusually deep conjugate. The lower end of the sa-
crum is thrown forward. There is an approximation of
the postei-ior superior spines and of the ischial tubei'osi-
ties. There is a narrow pubii' arch. The sacrum is
long, narrow, and straight. This pelvis presents there-
fore the funnel type. The pelvic bi'im is deep and am-
ple, but the outlet is nuich narrowed. Combined with
kyphosis there is usually some scoliosis, causing some
])elvic obliquity. Some of these individuals have
smaller measurements in general, due to arrested de-
velopment.
A kyphotic pelvis does not affect the course of the
labor to the extent that would be anticipated from the
examination and inspection of the patient. The success-
ful outcome of labor in these dwarfed women is often a
surprise to even the experienced.
There is always a pendulous abdomen with anteflexed
uterus and a tendency to malpresentation. which is usu-
ally cori-ected by the onset of pain's. Engagement of the
head in the first stage nia\' be delayed. As soon, how-
ever, as the head is engaged progi'e,ss is normal until the
outlet is reached. Here the bony obstruction may be
such that prolonged moulding or assistance by forceps
becomes necessary for
the extraction of the
head. The narrowing
may prevent the foi--
ward rotation of an oc-
ciput posterior, or even
cause an anterior posi-
tion of the occiput to
turn into a posterioi-.
Four per cent, of cases
are reported to present
by the face. In this de
formity the biischiatic
measurement is of im-
portance in prognosis.
If it is below 8.5 cm.
there is piobability of
serious difficulty.
Oblique ilifcrmities iif
the pelvis of the extr(;me
type are due to failui-e
of growth of one of the
sacral al«. To this de-
formity the name f)f
Naegele, who first de-
scribed it, has been giv-
en. The oblique meas-
urements vary widely.
The short obli(|ue is
that of the normal side.
The sacrum, which is
narrowed, faces from
the small side. The pu-
bic arch is asymmetrical.
The sacrum is narrowed.
Vaginal exannnation
shows the front of the
sacrum and ])romontory
facing toward the dis-
eased side. The ischial
tuberosity is higher on
that side and the corresponding posterior superior spine
is higher, lying closer to the sacrum. The subpubic
angle is asymmetrical and looks toward the diseased
side.
The failure in growth may be due to a congenital de-
velopmental defect or to disease. -If it is due to a con-
FiG. :iT.-iT. — Sail- View of Same
Sboniiif! Pendulous Abdomen.
526
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pelves,
Pelves.
genital defect, the deformity is not evident until after
walking has occurred. Pressure then causes the crowd-
ing up, in, and back of the innominate bone on the dis-
eased side, and the
rest of the asymme-
try noted above. If
it is due to disease of
the sacroiliac joint,
tuberculosis, or some
acute arthritis sec-
ondary to the general
disease, must in early
life have been suffi-
ciently extensive to
destroy the bony nu-
clei of the ala of the
sacrinu on that side.
.Ankylosis of that
joint is the usual ac-
roiupaniment of the
deformity, but is not
the absolute rule.
The diagnosis is
easily made by means
of the pelvimeter and
the vaginal examina-
tion. If disease be
an etiological factor
the presence of a
scar or sinus over the
affected iliac joint
aids in the diagnosis.
The effect pro-
duced by this de-
formity upon labor
in the less extreme
Ciises may not be
serious. But usually
the distortion is so
extreme that the nat-
ural delivery is im-
possible. Tii(^ deliv-
ery, if possible, is
FIG. 3758. — High Dorsal Kyphosis. accomplished by ex-
(Service of Dr. Edwin B. CraRin, freme Hexinn and
Sloaue Maternity Hospital.) moulding of the
head, as in the gen-
erally contracted pelvis. Abnormalities of rotation ami
flexion are apt to occur in the lower pelvis.
The forceps may be tried, and if these fail craniotomy
or the CfEsarean section may be performed. Symphyse-
otomy is contraindicated on account of the probable an-
Isylosis of the sacroiliac synchondrosis on the affected
side.
Where both sacral ate have failed of development
that rare deformity, the doxihle. obliquely contrtictcd peli-is,
is found. In 1843 this type ef pelvis was described by
Robert, and has since been known as the Robert type.
Very few cases of this type have been reported. From
the same causes as in the Naegcle pelvis, the sacral ahe
are both absent or only partly developed. There results
the extreme type of transversely contracted pelvis. The
pelvic brim presents the outline of a long narrow ellipse.
The conjugate is of normal or only slightly lessened size,
the obliques are much shortened, and the transverse
diameter excessively narrow. The sacrum is long, nar-
row, and oblong rather than triangular. Both sacro-iliac
joints are usually ankylosed. The posterior superior
spines are very close to each other. The pubic arch is
narrowed. Unequal development, due to partial growth
of one ala. mav cause a slight degree of obliquity.
The effect of such extreme contraction must be com-
plete ot)stj-uction to the passage of a vialile child.
Another rare type of developmental deformity is that
in which the pubic rami have not developed sufficiently
to meet at the symphysis. This is called the xjilit pdris.
It furnishes no obstruction to delivery.
The lesser degrees of obliquity, which rarely have much
effect on the mechanism of labor, are due to scoliosis; to
injuries or disease of hip, knee, or ankle-joint; to failure
in development of one limb from some kind of paralysis,
usnallj' poliomyelitis; or to club-foot.
In cases of «v)?('o.>i/.s extra pressure is transmitted through
the lower acetabulum and there is consequent shorten-
ing of that oblique. Sinqile scoliosis is common, but it
often accompanies rachitis or vertebral caries. If there
is rachitis, there are the other rachitic effects on the pel-
vis and a greater obliquity. It scoliosis is combined with
Pott's disease, there is merely slight obliquity added to
the typical kyphotic jielvis. This is the so-called kypho-
ifcoliotic pelris. The slight obliqiiity caused by such sim-
ple scoliosis is of no significance, but the shortening of
the spinal column may cause a pendidous abdomen,
which will give trouble in the engagement of the head
at term.
Any cause which acts so as to limit or do away with
the use, in early life, of one of the lower extremities, reacts
upon the pelvis by throwing greater pressure upon the
well side. Tuberculous disease of the hip, knee, or an-
kle-joint is the most common disease affecting the lower
extremities. Local deformity of the pelvis has been en-
countered from erosion of the acetabulum and displace-
ment of the head of the fenuir through into the pelvic
cavity. Ankylosis of one or both femora in adduction
may cause an obstruction to <.leli\ery.
A congenital hip dislocation causes the pelvis to de-
velop with one short obli(iue from pressure on the
healthy side. An anterior displacement of the femur
may drive in the anterior wall of the jielvis. The head
of the femur may project over the ramus into the pelvic
outlet. If both femora are dorsally displaced there is
a shallow pelvis with
wide outlet.
A rare deformity,
but a most serious one
from an obstetrical
standpoint, is that
known as spondt/lolix-
tkesis of the lumbar
vertebrse. It was de-
scribed by Rokitansky
in 1859, and later by
N e u g e b a u e r. The
bodies of the vertebra'
are dislocated forwaid.
There is some IuuiIk]-
sacral dislocation per-
mitting a slipping of
the body of the last
lumbar vertebra in
front of the sacrum.
Here it becomes anky-
losed. Then exagger
ated lordosis occurs,
and possilily there is a
descent of the fourth
and third lumljiir verte-
bra', so that they pro-
ject over the pelvic
brim. The sacrum is
p u s h e d d own and
back. In compensa-
tion the. s y m p h y s i s
rises, lessening the in-
clination of the brim.
There is narnnving of
the brim, with antero-
posterior limitation,
which will prevent the
passage of the head.
This deformity may
be started by disease,
especially lumbar ca-
ries, or bv injuries, or
perhaps it may date from intra-uterine life. For diag-
no.sis we must'depend upon the history of the case — the
527
Fifi. ri7.')ll.— Low Dorsal Kyphosis.
(Service of Dr. Edwin B. Cragiu.
Sloane Maternity Hospital.)
Pelves.
Pelves.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
stoiy of injury from a fall or accident, or of spinal dis-
ease; perhaps the fact of cariying lieavy weights.
There are extreme shortening and a pendulous abdo-
men. Examination shows tlie ribs lying ckwe to the ilia.
The shoulders are carried well back, as the patient stands
in lordosis. There may be lumbar crci)itus, felt while
walking. The vulvar opening, due to the change iu pel-
vic inclination, presents anteriorly as the patient is stand-
ing or sitting. By vaginal examination the bodies of the
projecting vertebrte may be easily felt and the contracted
outlet also noted. The limitation at the ]ielvic brim pre-
cludes an_v possibility of a normal fcetal head engaging.
Tumnr.i of the pdch may be of large size and may al-
most obliterate the pelvic cavity, or they may be merely
bony excrescences springing from the region of the pel-
vic brim. They may grow from the inner surface of the
symphysis, from the sacro-iliac joints, or fnuu the ileo-
pectiueal line. If sharp they form what is known as the
pelvis sjiinosa. The projecting bits of bone may cause
dangerous circumscribed pressvu'e on the child's head.
The larger tumors ma.y be euchondromata, sarcomata, or
carcinomata. They necessitate embryotomy or Ca>sarean
section. Fractures of the iielvis rarely may cause de-
formity from the growth of callus.
Ankylosis of the sacro-coccygeal joint, which normally
occurs after the menopause, may happen prematurely
and furnish some resistance to the passage of the child's
liead. The uterine contractions are usually of suflicient
force to fracture the bone. Sometimes the head is held
by this deformity until the bone is artificially fractured
or the forceps is applied. 'With the fracture a .snap is
sometimes plainly
heard and the head
thereafter advances
readily. The fract-
ure of the bone
should be accom-
plished under chlor-
oform, the thumb
and forefinger of the
accoucheur grasping
the coccyx.
The consideration
of pelvic deformities
is incomplete with-
out a word concern-
ing j)ro/>7i^Z<j:i7'«. The
)»jssibility of the re-
sults of rachitis upon
the pelvis should
make the mother
careful about the
feeding of the infant,
its general hygiene,
and especially about
its allowance of fresh
air. Early attempts
at walking should be
forbidden, especially
if the infant is heavy.
The effect of disease
nr deformity of the
skeleton of the fe-
Miale child upon the
(H'lvis is an argu-
ment for early con-
sultation witli the
orthopedic surgeon
and the early correc-
tion, if possible, of
existing deformities.
AVhen the deform-
it}' exists in the child-
bearing woman the
obstetrician must be able to recognize the deformity, and
by trained judgment determine its]irobahle etfect on labor.
The question may arise whether the patient is warranted
in entertaining the hope of having children at all, or, if
Fig. 3700. — Lumbar Kyphosis. (Sen'ice
of Dr. Edwin B. Cragin, Sloane Ma-
teruity Hospital.)
she be in earlier pre,gnancy, whether the deformity calls
for an induction of premature labor. Should the patient
be in labor, other conditions must be taken into account.
These are: the ex-
tent of obstruction
presented by the
soft parts, the re I
ative size of the
child's head and its
capacity' for nrouh 1
ing, the force of the
labor pains, and
lastly, the ability
of both mother and
child to withstand
the strain of deliv-
ery. The history of
previous labcu's is of
value, but it must
be remembered that
the size of the chiM
tends to increase U]!
to the fifth or sixth
pregnancy.
If the child is
small or premature,
slight pelvic de-
formity may ha\r
no signiticance ; and
yet with a child
above normal size
this defect may
constitute a serious
obstruction. Such
cases of overgrowth
of the cliild are oc-
casionaUy met
with, and are the
result of a large
father, overiuitri-
tion of the fa'tus
from the mother,
and sometimes of
the prolongation of
pregnancy one or
more weeks beyond
normal.
Those cases of sliglit obstruction, in which delay oc-
curs iu the second stage, justify a waiting policy.
Nature with time will accomplish sufficient moulding in
a safer way than if forceps were used. Good judgment
requires that one know how long it is safe to allow this
moulding to continue. Too long comjiressiou of the
head gives danger of intracranial hemorrhage. Too long-
continued pains expose the mother to exhaustion and
shock, and ulti-
mately to a tonic
uterus with possi-
ble rupture, or an
exhausted uterus
with resulting post-
p a r t u m h e m o r-
rhages. On the
other hand, early
interference before
the head has had
time to mould will
expose both mother
and child to need-
less trauma. Ac-
count must be
taken of the force
and fi'equency of
the pains: the maternal pulse, and evident amount of
suffering caused by the pains: the rate and force of the
fu'tal heart: and the amount of moulding, as shown by
the caput and overlapping suture, and by the advance
of the child's head.
Fig. 3761.— Kyphosis so E.xtreme as to
Necessitate Caesarean Section. (Service
of Dr. Efhviu li. Cragin, Sloane Mater-
nity Hospital.)
Fig. 3763.— Cibliquely Contracted Pelvis.
(After Duncan.)
628
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Pelves.
Pelves,
Fig. 3763.— Robert's or Double-Obliquely
Contracted Pelvis. (After Duncan.)
In some cases the severity of the pains or the poor con-
dition of motlier or child niuy necessitate (iperative deliv-
ery before the jjatient has been in the sccimd stage an hour.
In other cases in wliich the uterine contractions have
been of poor quality some good may be accomplished by
a delaj' of several
hours. Uterine ac-
tion may be stimu-
lated meanwhile by
t o n i c s, s u c h a s
strychnine or qui-
nine. The erect pos-
ture increases the
force of the pains.
In cases with a Hat
pelvis some in-
crease in the con-
jugate, from 0.5 to
1 cm., may be ac-
comjilished bj' the
Walcher position.
The patient lies in
the dorsal position
with the thighs extended over the end of the table, and
the feet barely touching the floor. If there is some ad-
vance of the head, pressure on the fundus, during the
pains, may be tried.
F(n- the more extreme degrees of dystocia, due to de-
formity, there may be used the forceps, podalic version,
usually combined with breech extraction, tin- induction
of iiremature lal)or, symphy.scotomy with forceps, the
CiPsarean section, craniotomy, or, in the cases of extreiue
contraction, crani-
otomy with evis-
ceration.
The low forceps
operation for de-
formities of the
pelvis is usually
necessary in those
eases of limitation
of the pelvic out-
let, as in the ky-
l>hotic cases or
those of the mas-
culine type. In
the worst kypho-
tic cases symphy'
seotomy may be
necessary. The
medium forceps
operation is more
common in the
generally con-
t r a c t e d pelvis.
For the flat and
generally con-
tracted pelves
high forceps may
be needed. In
justo-minor pel-
ves, the only pos-
sibility of safe
delivery by the
natural route lies
in extreme mould-
ing of a well-
flexed vertex.
In the flat pel-
vis the indication
for high forceps
is not always so
plain. The head
in these cases com-
ing ooM'n in the transverse diameter must often be
grasped by the forceps with one blade applied to the
occiput and one bJade to the face. The effect of trac-
tion then is partly to mould the head so that the bi-
Voi,. VI."— 34
no. 376.1. — Obliquely Contracted Pelvis,
Following Coxitis. (Service of Dr. Edwin
B. Cragin, Sloane Maternity Hospital. )
parietal diameter tends to widen. As has been described
abo\e, the after-coming head in a breech extraction ac-
commodates itself iu such a way that the bitemporal
diameter engages
the narrowed cou-
j ugate. For this
reason version and
breech extraction
are frequently re-
sorted to, in cases
of flattening, with
good result.
If the head, in
case of a flat pelvis,
is engaging well,
forceps may be
tried gently. If
the head jiersists in
not engaging, ver-
sion is preferable
provided there is a
reasonable possibil-
ity of bringing the
head through. If in the case with the head engaged
the forceps fail to accomplish advance, the head may be
disengaged and version tried. It must be remembered
that the version is of value only in the simple flat pelvis
which is ample in other measurements. In a flat justo-
minor pelvis version is worse than u.seless.
Where the conjugate is quite short, tlie head may be
prevented by the deformity from descending far enough
to dilate the cervix. In such a ca.se, before any operative
Fig. 37i)t.— Pelvis in which the Pubic
Rami Fail to Meet at the Symphysis.
(Schauta.)
Fig. 3766. -Simple Si'tilir>sis. PaiiiMii OiHimmi-cI Iv Icjvv forceps.
(Service of Dr. Edwin B. Cragin, Sloane Maternity Hospital./
delivery is attempted, the cervix should be carried to full
dilatation by means of the hydraulic bags or by digital
stretching.
The induction of premature labor in selected cases is
529
Pelvic i'olliilltis.
Pelvic C'elliilillN.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
an operation which has a most important field of nscfiil-
ncss. If the pelvis is small ami the head seems to he rid-
ing high, or if a woman habitually has larger children
than can safely be born, it is ]ir(>per carefully to watch
the patient
during the last
two months of
gestation and
to terminate
jiregnaucy at
any time when
the ch i Id's
head seems,
relatively to
the pelvis, a
close tit. Once
a week the patient
should be examined,
and by the bimanual
method the ratio be-
tween the size of the
held and I he diameter of the pelvis care-
fully estimated. There will be a cer-
tain pre ipiirtion of disappointments, but
what might be otherwise fatal dystocia
will be avoided, and in many ca.ses a
healthy child secured.
As a rule any child of over eight
months' gestation will do well with
projier care. an<l sometimes one even
younger will thrive. The success de-
pends on the judgment of the physi-
cian, who should allow to the infant every week of intra-
uterine life that is possible. An error either way is bad.
If the operation is delayed too long, the premature infant
■will resist very poorly the manipulaticm necessary for
an operative delivery. If lalKjr is induced too early, the
child is robbed of just so nuich vitality.
The operation of si/mjj/i/txui/tnni/ has lost favor in the
last few years becau.sc of tlie risk of infecting the mother,
or of leaving her permanently crippled from failure of
union of the symphysis, and because of its uncertain re-
sults as comjiari'd with the good results of f. properly
performed C;esarean section. It must be restricted to
cases in which the possible separatiini of the ptd)ic bones
of 7. .5 em. will eidarge the pelvic canal .sutlieiently to al-
low th(^ head to pass. It is of no value in thcise cases in
which the saero-iliac sj'uchondroses are ankylosed. The
tedious convalescence of the mother is a serious matter.
FiG.^re:.— sponiiyi-
olisthesis. (Neii-
gebaut'i.)
Fig. 37t)H.— Enoliondroma of tlie Sacnnn of sucti a size as tn Diminish
very trreatly tlie Capacity of Iht; Pelvic t'avity. (Belini.)
Compared with tlie Ca^sarean seelimi, il is Ihe nioii- dan
gerous, more uncertain of the two, and nf greatly re-
stricted range of application.
The Vdxdrcnn section must be enijiloyed in those cases
in which there is no other possible method of ileliv<'ry of
the child living or dead (the absolute indication), or it
may be em])loyed (the relative indication) in ca.ses in
which delivery of a living child is possible only by lapa-
rotomy. The indication has been extended, by some,
even to those cases in which delivery of a living child is
improbable except by laparotomy.
This operation in properly experienced hands seems to
promise great usefulness. Every year the indications for
this operation are enlarged. 'Whereas a few years ago,
on account of the great mortality of the CiEsarean section,
only the al.isolute indication for the operation was con-
sidered valid, now, granted good surgical facilities, the
question of a cmiservative laparotomy in the interest of
both mother and child may be decided in tlie affirmative
in cases of obstructed labor. If the deformity is so great
that a successful induction of premature labor in a later
pregnancy is im]irobal.ile, the uterus should be removed
at the time of operation.
The mutilating operation on the child, commonly
'known a^ Cfiiniotiiiiin, is indicated where the obstruction
is absolute and the child dead, or where the condition of
the mother, or the lack of facilities for operating, pro-
hibits surgical interference. The crushing followed by
traction on the head is usually sufficient to elf'eet deliv-
ery without much additional shock. Rarelv, if the child
is of large size, evisceration or further mutilation of the
child must be resorted to, Franklin A. Dorman.
PELVIC CELLULITIS.— Definition.— Pelvic celluli-
tis is an iiitlamiiialicin of the pelvic cellular tissue which
may or may not go on to abscess fm'mation. The same
condition is also described sometimes as parametritis,
perimetritis, pelvic abscess, etc.
An.\to.my. — Before describing pelvic cellulitis, a few
words as to the anatomy of the pelvis will be necessary.
Rosthorn defines the functions of the pelvic cellular tissue
as follows: 1. It serves as a material to fill in empty spaces
between the organs. 3. It serves to connect the perito-
neum to the underlying organs. 3. It serves as a sheath
for the bhiiid and lymphatic vessels. 4. It serves as lig-
aments, holiling the various organs one to the other and
to the surrounding bony structures. "VVe can .see, tliere-
fin-e, that the connective tissue is freely distributed
through the pelvis and forms the loose framework in
which lie the organs. The denseness of this tissue va-
ries according to its function and position. In places
there is a distinct thickening, forming, if we may call
it so, a species of curtain, which divides one portion of
the pelvis from another and tends to localize infection to
one part of the pelvis, though when an abscess forms
it may be easily imagined as breaking through the septa.
These septa or curtains are difficult to demonstrate by dis-
section, and the most striking way of showing their re-
lations is by the inje<'tion of material which will harden
in. situ. By this method three main regions are found to
oecu]iy each side of the pelvis. (1) The anterior region
comiirises the cellular tissue around the bladder and
that lying anterior to the cervix, there beim; a connec-
tion between these regions on the two sides through
the cellular tissue binding the jiosterior surfaces of the
bladder to the anterior portion of the cervix and uterus.
(2) The next region is bounded anteriorly by the above-
described partition, posteriorly by a .second curtain which
extends from the uterus outward along the iiifundilmlo-
pelvic ligament, giving to this area a rough triaiigtdar
shape with the base <liiected toward the pelvic wall and
the apex towai'd the uterus, and including practically all
of the connective tissue lying in the fold of the broad liga-
ment and continuous with the cellular tis.sue filling the
iliac fossa. (Ji) The third, or posterior area, surrounds
the rectum and is continuous with the cellular tissue of
the retroperitonc^d area.
Besidi'S these three main divisions, anatomists describe
several less well-marked areas where an infection may bo
localized.
Etiology. — Infection of the cellular tissue is always
due to the attack of one of the pathogenic bacteria, and,
according to whether the bacteria gain entrance directly
to the cellular tissue thi-ough a wound or by lymiihatic
infection, or whether the infection follows bv direct ex-
530
REFERENCE HANDBOOK OF THE ilEDICAL SCIENCES.
Pelvic C'ellnlltls.
Pelvic rellulitis.
tension from inflammation of the tube or other pelvic
structures, we divide the cellulitis into the primary and
the secondary forms.
In the primar}- forms the cellular tissue is invaded
directly by the disease-producing bacteria, generally
through a tear or wound in the cervi.\ or uterus, or by
directlymphatic extension.
In the secondary form the seat of infection primarily
is the tube, ovary, bladder wall, or rectum, the cellular
tissue being invaded b}' contiguity. The primary cellu-
litis is the rarer of the two, and for some years its possi-
ble occurrence was denied.
Wounds of the cervix are not frequent in any eonditiou
save that of childbirth, and this is by far the most fre-
quent etiological factor in primary cellulitis, the bacteria
being introduced by the unclean finger and advancing
directly into the tissues. In an occasional case the infec-
tion also residts from a wound of the cervix from careless
dilatation, or from the use of the uterine sound or other
instrument in such a manner as to cause a puncture
through the vaginal wall of the cervix or the uterine wall.
Secondary cellulitis of some part of the pelvic tissue
accompanies almost every case of distinct inflammation
in any of the pelvic organs. Most frequentlj' the condi-
tion follows salpingitis or pyosalpinx, the tube being the
most frequent site of inflammation in the female pelvis.
MouBiD Ax.\TO.\iy. — The pathological picture pre-
sented in this disease varies according to the type and the
degree of virulence of the infecting organism. Most of
the cases of primary cellulitis are due to invasion of the
tissue by the streptococcus, and naturally the picture of a.
virulent infection is given. If the tissues be examined
early enough all that will be noticed is a brawny intiltra-
tion of the loose tissue, which on minute examination is
found to be due to a rapid proliferation of round cells and
to the effusion into the tissues of sermn and leucocj'tes.
Later, we find distinct small abscesses scattered through
the tissues, the size of the abscesses varying from the point
to the head of a pin. Still later, if the infection continues
and the patient lives, we find that the numerous small
abscesses have become conglomerate, and that a distinct
abscess has been formed. Not infrequently, however, an
abscess does not form, but, instead, the tissues appear to
gain a certain amount of resistance against further break-
ing down, and in place of the conglomerate abscess a slow
absorption of the minute abscesses present and a gradual
liealing take place. In the secondary infectious we are
less apt to find abscess fonnation, especiall3" if the infec-
tion is due to a not extremel}' virulent species of micro-
organism (the gonococcus, for example). Naturally, when
the tubal or ovarian disease is due to infection by the more
virulent organisms, we find more frequent abscess for-
mation, generally in the folds of the broad ligament. As
already stated, in the primary forms the streptococcus,
either alone or in compauv with one or more of the other
organisms, is the cause of infection. In the secondaiy
cellulitis the gonococcus, the staphylococcus p^-ogenes
albus and aureus, the typhoid bacillus (rarely), the pro-
teus and certain other rarer fonns, have been isolated
from the tube or ovary and evidently would be foun<l
in the focus of secondarj' infection.
SvMPTOM.^TOLOGY. — PHmiiry Cellulitis. — In this form
the symptoms are usually quite well marked. Generally
three or four days after a labor in which careful asepsis
has not been observed, or in which there has been mucli
handling, the patient will have a distinct chill, the tem-
perature rising to 102° or 103' F. She will complain of
general malaise, violent headache, possibly nausea, and
of acute pain in the lower abdomen, generally located in
one side or the other. On examining such a patient the
lower abdomen will be found somewhat full, and pal-
pation will be impossible from the amount of muscular
spasm iircsent. In making a vaginal examination a sense
of resistance will be found at the base of one of the broad
ligaments, the uterus will also be found to be somewhat
more mobile than it should be, and tlie patient will com-
plain of extreme pain when we attempt to move the
uterus or make pressure upon the lateral fornices. After
a day or two a distinct induration will be felt through the
vagina, and on bimanual palpation a moderately -sized
mass will be felt lying in the broad ligament; in some
cases this indurated mass can be easily felt above Pou-
part's ligament as a dense hard tumor.
Semndary Cellulitis. — The syinjitoms of this form are
commonly masked by the primary disease, and it is prac-
ticallj' always the primary disease that we are called
upon to treat, for, unless an abscess of the cellular tissue
be present, the curing or the removal of the primary point
of infection will be followed by a slow amelioration or dis-
appearance of the cellular inflammation.
I)i-\Gxosis. — The diagnosis of the primary form is
based partly on a study of the symptoms, but chiefly on
the results of the abdominal, the vaginal, and the biman-
ual examinations. For if we find on abdominal examina-
tion an indurated mass extending up along the anterior
abdominal wall; if on vaginal examination the lateral
fornix of the same side is found to be hard, dense, and
brawny, or possibly depressed toward the outlet ; and if
on bimanual examination we can outline a distinct mass
between our hands, separate from the uterus or enclosing
the uterus in its outlines, we maj' feel reasonably sure
that whatever else is present we have an inflammation
and probably an abscess in the pelvic cellular tissue.
The diagnosis of the secondary form is not of so much
importance if the diagnosis of the primary focus be made,
as we may be sure that with pyosalpinx, ovarian abscess,
or any collection of pus in the peritoneum, there will be
more or less involvement of the contiguous cellular tissue.
Treatment. — Primary Cellulitis. — In this affection
we must be governed by the inflexible surgical rule that,
if pus be present, it must be evacuated by the .shortest
available route, and it only remains for us to decide which
would be the shortest route for its evacuation. In many
cases it is difficult to be absolutel_v certain as to whether
pus is present, or whether the tissues are merely densely
infiltrated, and fortunately this need not greatly bother
us, as the best results are gotten b}- breaking down and
draining such an exudation. Hence in every case of pri-
mary cellulitis, whether the exudation has broken down
and pus has formed, or whether merely a dense indurated
mass is present, the indication is clearly to provide effec-
tive drainage.
There are two paths by whicli we may get at such
a mass and drain it; first, through a vaginal incision;
second, through an abdominal incision. The best drain-
age is undoubtedly gotten through the vagina, as it is
the most dependent part, and this avenue of attack is se-
lected in those cases in which the abscess or the indurated
mass is distinctly palpable through the vaginal vault, or
in which the abscess is distinctly pointing in this direction.
The abdominal route is selected in the cases in which it
may be diflicult or dangerous to make the vagiual punct-
ure, or when the mass is distinctly pointing above Pou-
part's ligament. To make the vaginal puncture the pa-
tient, after being anaesthetized and after the vagina and
surrounding parts have been made surgically clean, is
brought to the edge of the table with the buttocks protrud-
ing slightl}' over it and the thighs flexed on the abdomen,
where they are held by an assistant or l)y one of the many
leg-holders. A final careful examination is then made to
outline again the pelvic mass. A Simon's sjieculum is in-
troduced into the vagina, the posterior lip of the cervix is
grasped with the tenaculum, and the posterior vaginal for-
nix put on the stretch. Then with the knife orscissorsa
little incision is made in the vaginal vault through the
vaginal mucous membrane just back of the cervix. The
speculum then having been withdrawn, the forefinger of
the left hand should be introduced into the rectum, and the
thumb of the same hand iiUo the vagina, the tip of the
thumb resting against the incision made in the vaginal
vault. Then a sharp-pointed pairofsci.ssors should be car-
ried into the vagina, and umierthe guidanceof the thumb
the pointed end of the closcil scissors should be placed in
the small incision in the vault and at the proper moment
plunged boldly into the jielvic mass. The presence of
the forefinger in the rectum serves not only to indicate
531
Pelvic Perllouilis.
Pelvlo Pi'ritoiiilU.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
the exact position of tliis organ, but also to guard it
against possible daniage. If an abscess be punctured
liy this nianiruvrc, tlicre -will be a gush of pus into tlie
vagina and the scissors can lie witliilrawu. Tlien the
oiiening into the abscess may be widened by careful cut-
ting or by tearing with a jiair of Goodell dilators, and
after this "the cavity should be explored with the linger
1o estimate its size and jiosition, and to make sure that
no more unopened abscesses remain behind. If no pus
follows the puncture by the scis.sors tliis instrument is to
be withdrawn and the finger is to be carried into the track
of the punctm-e. By tliis mauceuvre one may oftentimes
succeed in finding an'aljscess which was not opened by the
scissors. If uo abscess be present the brawny indurated
tissues are broken down with the finger so that a moder-
ately large cavity remains where the indin-ated mass was
before. The opening into this cavity must also be widely
dilated so as to prevent undue uarrowing before complete
healing has taken place. Then either the abscess or the
artificially made hole in the indurated tissues is to be
firmly iKicked with iodoform or subiodide of bismuth
gauze, and this gauze is allowed to remain in place for
some days unless untoward sy miJtoms appear. After the
lapse of live or six days the .gauze is slowly removed, a
little bit being taken out caeli day until the wjiole shall
liave been removed. In some cases it may be necessar}'
after this to pack again.
If the path through the abdomen is chosen, the abscess
or the mass of indurated tissue luust be reached and
<lrained in precisely the same manner as would be adopt-
ed in the case of any other collection of pus in the ab-
<lominal cavity. Tlie incision is generally made parallel
to and just above Poupart's ligament, care lieing taken
to avoid the deep epi.gastric artery which runs direetlj'
under the incision. When the aliseess is reached the pus
escapes through the opening thus established. Then
either a glass or a rubber drainage tube should be carried
down to the bottom and gauze packed aroimd it. On
the other hand, if simply a mass of indurated tissues is
found, then this is to be broken down in the .same way
as through the vaginal incision.
In some cases it is desirable to combine the two meth-
ods of proeed\u-e; that is to say, we ma_y establish drain-
age both through tlie vagina and through the alidomeu.
yuch double drainage is usually followed by a more
rapid healing of the abscess cavity, but it leaves an un-
sightly scar on the abdominal wall, and the sinus will
.sometimes remain open for some months before final heal-
ing takes place.
The treatment of the sfomdnn/ cellulitis resolves itself
into the ti'eatment of the associated primary condition,
and needs no special notice.
Prognosis. — The prognosis of pelvic cellulitis will
necessarily vary according to the virulence of the infecting
organism. In any event, liowever, the prognosis, in a
case of the primary form, must always be very guarded, as
the patient may linger along for weeks and finally ilie of
exhaustion even though the abscess has been thoroughly
opened and apparently good drainage obtained. At the
same time, if tlie patient survives the formation of an
abscess, we may rightly expect that the free incision and
the establishment of drainage, in combination with care-
ful general treatment, will be followed by a final recov-
ery. Otto G. liiiinsiiy.
PELVIC PERITONITIS.— Definition.— Pelvic peri-
tonitis is an inliamniation of the visceral or parietal pel-
vic peritoneum, and either remains confined to this por-
tion or extends upward into the general iieritoneal cavity.
Pelvic peritonitis should not pro])erly be described as a
separate and distinct disease, for it is due to the same
catrses as those which excite an intiamm.-ition of the gen-
eral peritoneal cavity, and the effects which are produced
are also essentially the same. Because, however, of the
situation and peculiar anatomical relations, intlanunation
liere is much more commonly localized than is infiamnia-
tion in oilier parts of the peritoneum, and for this reason
we are justified in describing it separately.
Synonyms. — (Pelveo-peritonitis; parametritis; peri-
salpingitis, etc.)
Y.\iiiETii;s. — There are three varieties of pelvic perito-
nitis, viz., (1) acute or fresh pelvic peritonitis, (2) chronir
exudative peritonitis, and (3) chronic adhesive peritoni-
tis. Except in those cases in which there is tuberculous
disease, we rarely see the chronic form except as the out-
come of a preceding acute infianimation. The converse
is not necessarily true, viz., that the acute form of inflam-
mation is always followed by chronic manifestations: at
the same time it is not conunon to have an acute pelvic
peritonitis clear up entirely without leaving some few-
slight adhesions, or a certain amount of roughening and
thickening of the pelvic peritoneum.
Etiolooy. — Acute pelvic peritonitis is alwa3's the re-
sult of bacterial infection, and practically always second-
ary to some acute inflammation elsewhere, as iii the tube,
the ovary, the uterus, the bladder, or the rectum; or pos-
sibly it may ilevelop from an appendicitis.
The most frequent causative micro-organism is un-
doubtedly the gonococcus, which, so far as danger to life
is concerned, maj' rightlj' be considered the least malig-
nant. The streptococcus pyogenes is another organism
which causes pelvic peritonitis. Owing to its greater
malignancy, however, this micro-organism gives rise to
an inflammation which rarely remains localized in the
lesser cavity, but extends upward to the general perito-
neum. Pelvic peritonitis has also sometimes been due
to the presence of the staphylococci, of the colon bacilli,
or of some of the micro-organisms which in exceptional
cases play a part in exciting tubal inflammation. As
other possible sources of infection may be mentioned an
ovarian abscess, or a focus of infection located in the
cellular tissue or in the network of lymphatic ves.sels.
MouBiD AN.iTO.MY. — The reaction of the pelvic peri-
toneum to irritation is exactly the same as that whieli
takes place in any serous membrane. The only features
to which, in the limited amount of space at my command,
I need to call attention, are the following: There is a de-
cided tendency, in an inflammation of this character, to
the throwing out of plastic lymph upon the free peri-
toneal surface, and, at the points where this occurs, adhe-
sion between the contiguous parts is almost sure to fol-
low. In a few cases, however, the exuded lymph may
undergo alisorption, and the altected serous surfaces may
eventually return to a normal state. In the majority of
instances the pelvic peritonitis, after the subsidence of the
more actite manifestations, assumes the characteristics of
either a chronic exudative (a- a chronic adhesive peritoni-
tis. The chronic ex\idative form is characterized by the
exudation of serous fluid, which, as a rule, is found in a
sort of cul-de-sac that is walled olf from the general cavity
by a roof of adherent intestines. This sac, in the early-
stages, contains a clear serous fluid, but sooner or later
tills fluid becomes purulent in character, by reason of the
wandering in of leucocytes. In the chronic adhesive
form, instead of a serous exudation, there is thrown out,
as already stated, a more plastic lymph which glues
together all the pelvic structures. This is the furm of
the disease which is most frequently observed and in
which the adhesions may be so numerous that the tube,
ovaries, and uterus are bound together in one indistin-
guishable mass.
Sy'MPToms. — Acute peritonitis gives rise to w-ell-
marked symjitoms. The patient complains of acute pain
localized in the lower abdomen, and with the pain there
is a distinct rigidity of the lower portion of the abdomen
and probably some abdominal distention. The tempera-
ture is foimd elevated, sometimes reaching 103° or 104°
F. ; the ptilse is rapid; and there maybe nausea with
vomiting. On examining such a patient we are almost
sure to find that acute tenderness is present over the
lower abdominal zone; and a vaginal examination, al-
though it may fail to reveal anything very distinctive, is
sure to cause acute jiain w-hen iiressure is made on the
forniees, or w-hen any attempt is made to move tlie ute-
rus. The iiatient, it will also be noticed, lies perfectly
quiet on her back with the legs drawn up, as any move-
532
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pelvic PeritoultIg„
Pelvic Peritonitis.
ment causes greatly increased pain. General!}-, after the
lapse of three to four days, the symptoms decrease in
severity, the abdominal distention and muscle spasm dis-
appear, and the temperature falls. In those cases in
which the disease assumes a chronic character it is as-
tonishin.K to note in how many instances the severity of
the symptoms is out of all proportion to the small extent
and slight degree of chronic inflammation present.
These patients, as a rule, complain of much menstrual
distress; bacliache is very common, and jiain is often
complained of in one or the other ovarian region. These
patients are also apt to complain of headache or of some
form of nervous, gastric, or intestinal disorder.
The chronic exudative form of peritonitis is character-
ized by the presence of an exudate, and with this may
be associated the symptoms of a pelvic abscess. In cases
of the latter nature acute local pain is present In the ear-
lier stages ; there are also decided abdominal tenderness,
rapid pulse, and fever, and yet it is to be noted that, in
the later stages, fever is not necessarily present. We
find on local examination a fluctuating mass which
pushes the uterus forward and which is very tender on
pressure. It will also be observed that the more dense
and indurated the walls of tliis mass are, the more apt
are we to find a collection of pus rather than one of
serum.
Diagnosis. — The diagnosis of an acute pelvic peritonitis
is not difficult, and is based on the acute pain, the spasm
of the muscles, the rise of temperature, and the local find-
ings. In the chronic form which is characterized by ad-
hesive inflanmiation, the diagnosis rests on the lessened
mobility of the organs, on their abnormal positions, and
on thefact that we can actually feel the presence of
more or less distinct bands of adhesions.
In the chronic form which is characterized by the
presence of an exudation, the differential diagnosis may
have to be made between it and a pelvic hematocele.
This, however, is usuall}' an eas_v matter, as the histories
of the two affections are very different, and besides, on
examination, we can satisfy ourselves, in the case of the
ha'matocele, that we are handling a solid tumor, which
often, under the pressure of the finger, yields a crackling
sensation, owing to the breaking down of the clot.
Treatment. — -In the treatment of acute pelvic peri-
tonitis two very important objects should be kept in
view : First, that life may be saved; and second, that the
local changes resulting from the disease may be dimin-
ished as much as possible both as regards their extent
and as regards the seriousness of their character. The
therapeutic measures to be adopted must vary according
to the nature of the infection. Inasmuch as most of the
cases of acute pelvic peritonitis are gonorrheal in origin,
this fact will be one of the first to be thought of when
the questions of etiologj' and prognosis are taken up for
consideration. In these cases, as a rule, life is not in ex-
treme danger, because the tendency of gonorrhopal peri-
tonitis is to remain localized in the pelvic cavity.
A patient who is sufferirig with an attack of this char-
acter should be put to bed and advised to remain as
quietly as possible on her back. The object of this ad-
vice is to prevent anj' sudden movement which might
■cause a breaking down of adhesions between the end of
the tube and the surrounding structures, and so prevent
the outflow of bacteria-containing secretion from the
freshly opened end. The inflammation is also to be com-
bated by the free use of salines such as Rochelle salts,
or by frequently repeated doses of Carlsbad salts. The
pain may be relieved by the use of hot moist applica-
tions, or, if the attack is seen in the very early stage,
cold applications may give more relief, and may possibly
abort the attack. Opiates are dangerous remedies, and are
not to be u.sed unless the pain becomes extreme, in which
case good results may be obtained by the use of supposi-
tories containing extract of opium and extract of bella-
donna. Hot vaginal douches are also of value, if thej'
can be given without causing the jiatient great discom-
fort. The patient should be put upon an extremely
jight bland diet, and she should also be allowed the free
use of liquids. Such a patient should be kept quietly in
bed for at least a week after all acute symptoms have
disappeared. This precaution will be found to be a
great help in preventing a recurrence of inflammation.
Operative iuterference. during an acute attack, is in-
dicated only when the symptoms are somewhat urgent.
The abdominal cavity should then be opened from above,
in the usual manner, and free drainage established, or an
opening may be made into the cul-de-sac from below, by
way of the vagina.
In chronic exudative pelvic peritonitis, the exudate
lies in the cid-de-sac, and can be most easily reached
through the posterior vaginal fornix, as it generally
points most distinctly in this locality. Before the oper-
ation is begun, the vulval area and the vagina should be
thoroughly scrubbed and disinfected. The patient's legs
being flexed on the abdomen and held in this position by
a leg-holder or by assistants, the surgerai should intro-
duce the forefinger of the left hand into the rectvim, and
the thumb into the vagina, the tip of the latter being
kept pressed against the fluctuating swelling in the cul-
de-sac. Then the pointed end of a closed pair of sharp-
pointed scissors should be plunged into the mass under
the guidance of the thumb, the forefinger in the rectum
acting both as a guide and as a means of preventing
puncture of the rectum. The insertion of the sharp-
pointed instrument into the cavity is followed by a gush
of clear or purulent fluid. The blades of the scissors are
separated and withdrawn from the cavitj-, and the open-
ing thus established should then be made still larger by
.stretching and tearing its sides with the Goodell dilator.
Finally, the cavit_y should be washed out and packed
with gauze, and the latter should be allowed to remain
in for five or six daj's or even longer imless there be
S3'mptoms indicating that it should be removed sooner.
In the treatment of chronic adhesive peritonitis the
use of frequent hot douches, in conjunction with the ap-
plication of the tincture of iodine to the fornices, and with
the introduction of cotton or lambs' wool tampons soaked
in glycerin, often proves very helpful. Besides these
local measures pelvic massage, regular exercise, and a
general tonic treatment will sometimes be followed by an
apparent cure, though such patients are very apt tp have
a recurrence of the disease after any imprudence.
The question whether an operation should be advised,
or whether better results may not be obtained from the
employment of the palliative methods of treatment, is
always difficult to answer; the proper answer will depend
on circumstances. In the first place, it must be remem-
bered that the operation is always attended with a cer-
tain amount of danger, and that this danger must be in-
eurre'd not for the saving of life, but simply for the relief
of symptoms. On the other hand, if the patient has to
work for her living, the surgeon cannot rightlj' refuse to
place her under the best possible conditions for success-
ful work. For this reason he is scarcely justified in ad-
vising a patient who.se family is dependent on her exer-
tions for their support, to undergo the long-continued
applications, etc., which are required under the paUiative
method of treatment. On the other hand, in the case of
a woman who can command everything necessary, pallia-
tive measures may be followed by splendid results.
On the whole, the results of operations in the pelvic
cavity have thus far been very satisfactory.
Prognosis. — The prognosis of acute pelvic peritonitis,
so far as life is concerned, is generally good, but cautioa
should always be observed in promising a complete re-
turn to normal health.
In the chronic exudative pelvic peritonitis, the progno-
sis, after the cavity has been opened and drained, is fairly
good. In most cases the patient will regain health, and,
if the tubes have not been completely destroyed, she may
in course of time bear children. In the adhesive form a
complete cure must not nflen be looked for as the result
of simple palliative treatment; and even when an oper-
ation is resorted to, the degree of completeness of the
cure will depend on the condition of the pelvic struct-
ures. Of G. Rammy.
53S
Pelvi
Pi'lvl
REFERENCE HANDBOOK OP THE IVIEDICAL SCIENCES.
PELVIS.— (Latin, derived from the Greclv -f/./c, a ba-
sin, tiie same root as Eng., pail: Fr.. hiimii ; Ger.,
/j(f /•(';/ ,• It., haciiw. The apiiropriatcncss of the appel-
lation will be evident on placins; a luunan pelvis on a
table in a horizontal position, when it will be seen to re-
semble a somewhat deep wash basin, with the rim broken
away in front and behind.) In a restricted sense, the
bony and ligamentous .skeleton of that portion of the
trunk to wliich are attached the abdominal limbs. To-
pographically the term is used to designate the whole
region for which the bony jx-lvis serves as a framework,
comprising, in this sense, the whole of the inideudal,
perineal, sacral, subinguinal, co.\al. trochunteric, and
gluteal regions, and a pari of tlie pubic and iuguinal
regions.
The importance of the skeletal framework is great and
twofold. First, because it is through it that the weight
of the body is supported, and from it that arise the
powerful muscles that move the posterior limbs; second,
beeau.se it forms a bony canal which contains an impor-
tant portion of the genito-urinary apparatus, and through
which the matured fcetus must jiass to reach the outer
world. The lirst of these considerations is architectural,
the second obstetrical, while both have important surgi-
cal hearings.
Bo)iH(tniits. — This portion of the trunk is defined on
the surface of the body by certain landmarks and fur-
rows. Above, there may be noted, in well-nourished in-
dividuals, crossing the median line in front, a shallow
depression, concave upward, separating the pubic emi-
nence (mons pubis, mons veneris) from the general super-
ficies of the abdomen. This may be called the pubic
furrow and extends from groin to groin. From either
end of this the shallow but well-marked inguinal furrow
(sulcus or plica inguinalis) may be followed upward and
otitward to the anterior superior iliac spine. The crest
of the ilium may then be easily traced along the flank
backward as far as the depression which marks the pos-
terior superior iliac spine. From this a line should be
drawn to the spinous process of the fifth lumbar verte-
bra, which for topographical purposes is usually in-
cluded in the pelvic region, and is characterized by a
well-marked depres.sion. This boundary, drawn on each
side, will mark the limits of the pelvis above.
Below, it is best defined behind by the well-marked
gluteal fold (sulcus gluteus) that indicates the lower bor-
der of the nates or rump. An arbitrary line drawn hori-
zcmtally outward from the outer end of this fold, around
the thigh to the inguinal fiu'row, will roughly include
somewhat more than ma_v properly belong to the pelvis,
as it takes in the u|)per part of the femur with the great
trochanter, usually regarded as belonging to the crural
region.
Surface Miirkitu-is. — Within the area thus delimited
there is in front the pubic eminence, covered with hair in
the adult and resting upon the pubic bone. It is more
prominent in the female. On either side of this the in-
guinal furrow follows the cour.se of Poupart's ligament
from the anterior superior sjiine of the ilium to the spine
of tlie pubis. It is maintained by fibres pa.ssing from this
ligament to the skin, resembling in this respect the axil-
larj' fossa. Shallow and broad when the subject is stand-
ing erect, it is deep when the thigh is flexed. Above, it
is continuous with the iliac furrow ; below, it ends in the
genito-femoral furrow. In females and well-nourished
persons a second furrow is usually seen, corresponding
more nearly to the flexion of the thigh. This terminates
before reaching the anterior superior iliac spine at a de-
pression corresponding to the separatinn betAveen the sar-
torius and the tensor of the fascia lata. Below, it runs
into the inguinal furrow.
In muscular persons, not too fat, the outer edge of the
rectus abdominis, well defined upon the abdomen, may
be traced down to the inguinal furrow, which it cuts at
an acute angle. It is at this point (the inguinal trigone
of Henke). immediately above and external to the spine of
the pubis, that is found the external or superficial ab-
dominal ring from which the spermatic cord in the male
and the round ligament in the female may be easily
traced to the scrotum and the labium majus respectively.
The internal or deep abdominal ring is a little more than
half an inch (15 mm.) above Poupart's ligament, and
midway between the anterior superior iliac spine and the
symphj-sis pubis.
The spine of the pubis (tuberculum pubicum) lying, as
it docs, between the course of an inguinal and that of a
femoral hernia, beccmies an important i)oiut to determine.
In fat persons it cannot be felt with ease except by push-
ing up the skin of the scrotum or labium, but mayalways
be found by tracing up the tendon of the adductor longus
muscle, made tense by adductiug the thigh. The spine
is nearly on a level with the top of the great trochanter,
and this enables us to determine its position when it is
desired to avoid external manipulation. Between the
spine and the symphysis pubis the pubic crest may be
made out.
Another important point is the anterior superior iliac
spine, always easily felt. It is used as a point of refer-
ence in judging of deformities and injuries to the pelvis,
and in measuring the relative length of the two limbs.
Although situated much farther from the median line
than is the spine of the pubis, it will be seen, when the
pelvis is viewed laterally in its normal position, to be in
the same frontal plane. A line connecting the anterior
superior spines of opposite sides passes just above the
level of the promontory of the sacrum. In females it is,
when the pelvis is normally placed, at the .same height as
the middle of the third sacral vertebra, and very nearly
on a level with the upper edge of the great sciatic notch.
In males it is 1 or 2 cm. higher.
Below the pubic eminence appear the external organs
of generation, separated from the thigh by a deep
groove, the genito-femoral furrow, more fulh- seen on the
perineal aspect. The angle of the pubis, where the two
pubic bones unite at the median line, may be obscurely
felt from without. In the female it is much more obtuse
than in the male, and is easily accessible by vaginal ex-
amination. In the normal position of the pelvis its ver-
tex is on a level with the lower bonj- edge of the obtu-
rator foranten and with the middle of the posterior surface
of the tuberosity of the i.schium.
It the pelvis be looked at from the side, it is seen to
be limited above b}' the crest of the ilium, whose general
situation is indicated b_y a slight superficial depression,
the iliac furrow (sulcus coxa;). This does not, however,
exactly correspond with the underlying crest, the differ-
ence depending on the vaiying length of the aponeurotic
fibres of the external oblique muscle of the abdomen,
which is in.serted on the outer lip of the crest. The mid-
axillary line produced passes through the highest point
of the crest (punctum coxale), the most prominent part
of the great trochanter and the lower part of the tuber-
osity of the ischium (punctum ischiadicum), and bisects
a line connecting the anterior and posterior iliac spines.
When the arm is extended at right angles in front, the
.scapula is so rotated as to bring its inferior angle into
this vertical. The level of the crest of the ilium is usu-
ally a little lower than the umbilicus, corresponding to
the disc between the fourth and fifth lumbar vertebra;,
though it may reach as high as the body of the fourth.
On this aspect the situation of tlie great trochanter
should be noted. Usually a distinct prominence, more
in relief than the crest of the ilium, in fat persons, owing
to the tendinous insertion of the gluteus maximus, it
may be tnarked by a depression. Its top is on a level
with the middle of the acetabulum, and when the thigh
is at rest, with the muscles relaxed, it just touches a line
drawn from the anterior sujierior spine of the ilium down-
ward and backward to the tuberosity of the ischium
(Nelaton's line). It may rise somewhat above this line
when the thigh is fully abducted (Sheild).
The most prominent features of the pelvic region, when
viewed from the rear, are the rounded masses forming the
buttocks or nates. While the main body of these pro-
tuberances is formed by muscles they owe their rounded
outlines to a thick layer of fat. For this reason they are
534
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pelvis.
Pelvis.
better developed in well-nourished persons, in the young,
and in women, than in athletes, and are frequently the
seat of lipomatous tumors. In some African tribes the
deposit of large quantities of fat in this region seems to
be normal, espeeially among the females, and it forms a
large projecting mass (steatopygy). The underlying
masses that influence surface form are tlie gluteus maxi-
nius nearest the median line and the gluteus medius
lateralh'. In muscular individuals in good training the
separation between these two muscles is usually observ-
able on the surface. They are especially important for
keeping the trunk upright; and since man is the only
animal that habitually walks erect, the prominence of the
nates is peculiar to him.
The nates are separated from each other by a well-
marked cleft, the intergluteal furrow (crena ani), usually
quitedeep. At its bottom is found the tipof the coccyx.
a little lower than the horizontal line drawn through "the
top of the symphysis pubis, and about a linger's breadth
farther forward is the margin of the anus, hidden from
sight except in emaciated persons. Here the furrow
ends in the male; in the female it becomes continuous
with the beginning of the genital cleft.
Below, the nates are limited by a sharp crease, the glu-
teal fold (fold of the nates, gluteo'-femoral fold, sulcus glu-
teus), caused by the attachment of the integument to the
deep fascia by means of fibrous bands, which prevent the
fat of the buttock from sliding down into the thigh when
the sitting posture is assumed, thus making of it a verit-
able cushion. This fold does not correspond to the edge
of the gluteus maximus, which runs obliquely down-
ward and outward to its femoral insertion, but is nearly
or quite horizontal when the subject is standing erect.
When he is resting on one leg only and allowing the glu-
teus maximus of the free member to become stretched,
the fold assumes more nearly the direction of the muscle.
Externally each natis is defined by a broad, shallow de-
pression (lateral gluteal furrow), due to change from
muscle fibres to aponeurosis of insertion.
The nates are bounded above by the crest of the ilium,
which terminates toward the middle line in the posterior
superior spine, on a level with the spine of the second
sacral vertebra, and at a point coi-responding to the mid-
dle of the sacro-iliac synchondrosis. Innnediately above
the spine is a small area of bone quite free from muscle
fibres, and therefore marked externally by a depression,
especially noticeable in females. Below this the converg-
ing masses of nates leave between them a flattened tii-
augular area which extends down as far as the fourth or
fifth sacral vertebra. This flattening extends upward as
far as a depression just below the spine of the fifth lum-
bar vertebra, and taken altogether the area constitutes a
rhomboidal field (sacral rhomboid, Kreuzraute of Wal-
deyer) of which the two upper sides are much shorter
than the two lower ones. In females the upper angle is
3-4 cm. higher than the line connecting the posterior su-
perior spines. Through the middle of this there extend
from above downward on the median line the coalesced
spines of the sacral vertebrae (sacral crest, crista sacralis
media), the most prominent pait of which is the third
sacral spine.
The general direction of the gluteus maximus is indi-
cated by a line drawn from the posterior superior iliac
spine to the most prominent part of the great trochanter.
The juncture of the first and second thirds of this line is
at the level of the great sciatic notch, where the gluteal
artery emerges from the pelvis.
The tuberosity of the ischium, on which the bod_y rests
when sitting, is readily felt beneath the gluteal fold. It
is situated in the same frontal plane as the transverse
process of the fifth lumbar vertebra, and its middle is
nearly the same horizontal distance behind the centre of
the acetabulum that the anterior superior spine of the
ilium and the spine of the pubis are in front. A line
drawn from the posterior superior spine of the ilium to
the outer part of the tuberosity of the ischium crosses the
posterior inferior spine at 4 cm. and the spine of the is-
chium at 10 em. distance, and the sciatic and internal pudic
arteries make their exit from the pelvis at the juncture
of its middle and lower thirds. The tuberosity is well
padded with fat contained in small loculi formed by
fibrous bands that pass between it and the skin. Several
small bursa; are frequent near it, one, under the tendon
of the biceps and semitendinosus, being quite constant.
There is, besides, another aspect of the pelvis almost
wholh' concealed when the subject is standing erect with
the thighs approximated, being then reduced to a mere
furrow. This is the inferior or perineal aspect, corre-
sponding to the outlet of the pelvis. To examine it the
thighs sliould be flexed and abducted when there will be
displayed a rhomboidal space known as the perineal re-
gion, iying between the thiglis, having its angles at the
angle of the pubis in front, the tip of the coccyx behind,
and the ischial tuberosities on either side. Its sides are
formed in front by the ischio-pubic rami, behind by the
great sciatic ligaments, which ma_v in this position be
felt in thin subjects on deep pressure along the edge of
the gluteus tnaximus.
It will be seen that the gluteal fold encircles on each
side the inner aspect of the thigh and ends in the genito-
femoral furrow. Frequently an accessory furrow is
found running parallel to it. " From the rounded protu-
berance of the tiates a pointed process extends forward,
bounded laterally by the gluteal fold on the outer side,
mesially by a furrow (gluteo-periueal furrow) that sep-
arates it from the external genitals and ends in front by
uniting with the genitofemoral furrow.
In both sexes the external genital organs impinge upon
the anterior part of this space, the area occupied by them
being known as the pudendal region. The retnaining
space is usually divided for topographic purposes by a
line drawn arbitrarily between the anterior part of the
tuberosities of the ischium (interischiadic line). It has
been pointed out by Waldeyer and others that a more
suitable line, from a morphological point of view, is
formed by curving somewhat forward to where the uro-
genital trigone, or triangular ligament, meets the pelvic
diaphragm (line of the perineal septum). This .separates
a urogenital region through which the urogenital orifices
pass, from an anal (ischio-rectal) one through which the
alimentar}- canal discharges.
In this region there may be noted, in the median line,
tlie tip of the coccyx, often marked by a slight depres-
sion; the anus, its" centre about 3-4 ctn. in front of the
coccyx in the male and a little farther in the female;
then the median raphe of the perineum, extending in
the male from the anus to the .scrotum, in the female
lost almost at once in the genital cleft. The point where
the raphe crosses the line of the perineal septum is called
the tendinous centre of the perineum (centrum perineale),
where the two layers of deep fascia and the triangular
ligament meet. It affords a point of origin for several
muscles. A slight swelling in front of this tnarks in the
male the underhing bidbof the urethra, situated 1-1.5
cm. from the anterior edge of the anus.
The Osseous Pelvis. — Of the bones composing the
pelvis two, the sacrum and the coccyx, belong to the
spinal column; and two others, the so-called ossa inno-
minata, or hip bones, belong to the limbs and constitute
the pelvic girdle, which differs remarkably from the tho-
racic girdle in that it is articulated firmly with the sa-
crum, thus affording a firm basis of support.
The Sacrum. — This bone is said to owe its name to the
use made of it by nations who offered human sacrifices,
it being held to "be particularly sacred to the gods, be-
cause it was used as an olTering re|)reseuting the entire
victim, it being evident that the subject must be dead if
the sacrum was offered. It is reputed to be found en-
tirely uninjured when other portions of the skeleton have
dcca'ved, and a rabbinical tradition holds that it is the
esseiitial or sacred part of tnan, which is to be preserved,
and from which the entire body is to sprout at the judg-
ment dav. Hvrtl, whose authority on such matters is
entitled 'to we'ight, considers, however, that these are
mere etymological fantasies, and that in the phrase os
sacrum the adjective is used in the sense of great or im-
535
Pelvis.
Pelvis.
REFEKENCE HANDBOOK OF THE MEDICAL SCIENCES.
portant, because it is the largest bone i)f the spinal col-
uniu.
The bone presents the appearance of an irreguhir pyra-
mid, the axis of which lias been curved so that the
concavity looks downward and forward, the base pre-
senting upward, jointing with the last lumbar vertebra,
the ape.x downward, jointing with the coccyx. Laterally
it articulates with tlie innominate bones. Even a super-
ficial examination shows it to be conipcsed of coalesced
vertebra-, normally five in number, six or four being oc-
casionally found ;" but this is u.sually accompanied by a
corresponding increase or decrease of the vertebral ele
ments of contiguous regions of the spinal column. Ac-
cordingly the main descriptive features of the sacrum
depend upon its composite character. There are, on the
anterior surface, transverse lines showing the original
divisions; on tlie posterior, vestiges of the sijiuous and
articular processes, and of the lamina' ; on both surfaces
Fio. 3769.— Antero-Superior Aspect of the Pelvis. fFrom Testut.)
1, Sacnim ; 3, coccyx ; 3. sacral canal : 4, internal iliac fossa : \
anterior superior spine of the ilium; 6. symphysis put)is ; 7, sacro-
iliac articulation ; 8, acetabulnui ; 9, spine of the ischium ; 10, ob-
turator foramen.
The liotteil lines indicate the diameters of the superior strait.
^,--1', I'onjuKate diameter; T^ T\ transverse diameter; O, 0\
oblique diameter.
foi-amina for the exit of nerves from an axial canal, a
continuation of the spinal canal of the lumbar region.
Anteriorly, oblicjuely cut grooves lead from the sacral
foramina outwaid, afl'ording, to the saci-al nerves that lie
in them, some protection from sliding pressure.
The non-;irticular vertebra diminish rapidly in size,
their characters are more obliterated, and tiiey curve for-
w^ard much more than the others. The summit of the
curve foriiK'd by the sacrum is therefore in the third sa-
cral vertebra, the spine of which projects in the median
line. The luominence of the spine is not, however, a
good guide to the convexity of the ciu've, which varies
much in dill'ereut individuals. The deptli of the curve
from a line sul)tending the arc averages 18. S mm., hav-
ing a maximum of 44 mm. ami a minimum of 4 mm.
The curve is developed during iutra-uterine life, being
probably due to an adaptation of the spinal cohunn to the
pelvic viscera. Cunningham found it in a f(etus40 mm,
long (about ten weeks). It is also seen in anthropoids.
Jleyer calls that part of the sacrum which articulates
with the iliiun the pelvic portion, tlie remainder tlic peri-
neal portion. Broca has [loiuled out that, in consi<lering
the question of the number of bones that form the tail of
a vertebrate animal, we should not make the division at
the sacrococcygeal joint, as that is a chai';icter which may
be considered merely a matter of special anaugement for
each animal, but should I'ather begin to count at the non-
artictdar portion of the sacrum. Viewed in this manner
the ;irtic\ilating vei-tebra> would form a true sacrum, and
tho.se which follow would belong to the tail, and lit^ <li
vided into tnie cauihil, having a spinal c;uial, anil fahe
ciiiiilfil, reduced to centi'a only. Accoirling to this view,
almost all the lower apes have three sacral vertebra\ as
has man ; and man has a tail formed of from six to eight
pieces, resembling in this respect the anthropoid apes,
they varying merelv in the unimportant circumstance of
ha\'ing a few segments more or less.
The rectum reaches the spinal column at the third sa-
cral vertebi-a and thence continues along it. Rose there-
fore designates the portion of the spinal column thus re-
lated as the rectal cover (Mastdarmdeckcl). As it may be
necessary to remove some of these vertebi'a; in operations
for tumors, it becomes important to know how liigh it is
safe to go. While the spinal cord terminates far above
this, its envelopes continue down within the sacral canal,
and the sac containing the cerebro-spinal fluid may reach
as low as the third sacral vertebi'a. It is therefoi'e allow-
able to remove the fourth and fifth sacral vertebrte ; and,
since the sac is pointed, to encroach laterally upon the
third. In children the sac is lower than in adults. The
width of the sacrum at the upper limit of surgical inter-
ference (between the second and third sacral vertebra-) is
8-11 cm. {3i-4J in.). In the last two vertebrie the arch
becomes deficient behind, leaving the sacral canal covered
by raembi'ane. This is, therefore, a weak point, and
sloughing bedsores niiiy here invade the canal and induce
a meningitis. At the sides of the coalesced vertebife
fused costal elements form strong bars known as the lat-
eial masses of the sacrum.
As compared with other animals the sacrum of man is
broad in proportion to its length. The same holds when
the sacra of Europeans are compared with those of the
lower races of man. In order to express this Sir William
Tvirner has devised the siicral inc/ex, obtained by multi-
plying the breadth of the sacrum by 100 and dividing by
the length. The following are the average I'esults of
many measurements; Euro]iean, female, llti; European,
male, 113; negro, lUG; Australian, 99; Andaman Islander,
94; Orang, 87; Gorilla, 72.
Sacra having an index above 106 are termed platy-
hieric; those between 100 and 106, subplatyhieric ; those
below 100, dolichohieric. The variations in width ap-
pear to depend mainly upon variations in the hiteral
masses.
T/ie Ciirrffj: — This is also an assemblage of from four
to five coalesced vertebra', and coi-responds to the tail of
lower mammals; and in very rai'e instances it may, like
that, be enclosed in a fold of skin. The vertebral char-
acters of its elements are very much reduced, there being
but little more than the centra or bodies, with two vestig-
ial articular processes called the cornua, which articu-
late with the sacrum. It is triangular in form and
continues forwaid the curve of the sacrum, making to-
gether with it an almost complete ciuadrant, so that the
apex points directly forward. It may be readily felt in
rectal or vaginal examination.
The number of vertebra; in the coccyx is subject to
considerable variation; five is considered the normal
number in the male, four or five in the female, while six
are sometimes found. In vertebrate animals the nmnber
of caudal vertebra' varies greatly, from two liundred and
seventy in some sharks to
two in the gibbon and Iruit-
bat.
The Innominate Bone. —
This is a complex of thi'ee
originally distinct elements,
the ilium, the isehium, and
the pubis. When cnmplete
it resembles in sli;ipe two
of the twisted blades of a
propeller extending ladially
on opposite sides of an axial
depression, the acetabulum,
which receives the head of
llie femur. The upper
expanded and somewliat
longer Ijlade is the ilium;
the lower one, which has a
large fenesti'ation called the
obturator oi- thyroid foramen, is formed by the combined
ischium and pubis, the pubis forming the anterior por-
FiG. 3770.— Innominate Bone of
Allifniior, .showinir the Rod-like
character of the Separate Ele-
ments.
536
REFERENCE HANDBOOK OF TUB MEDICAL SCIENCES.
Pelvis.
Pelvis.
tion, the ischium extending backward and downward to
afford support while sitting. The narrowest part of the
bone (tlie isthmus coxse of Waldeyer) is just above tlie
acetabulum, l.ying between the greater iliac notch of
Henle (from the anterior inferior iliac spine to the sym-
physis pubis) and the great sciatic notch.
A study of the characters of the boue throughout the
vertebrate series shows that its components were origi-
nally rod-liUe in form. This is shown in a striking man-
ner "in the alligator (Fig. 3770). and is also indicated by
the course of ossification in the human be me, for accessory
points form at the crest of the ilium, the symphysis pu-
bis, the tuberosity of the ischium and within the acetab-
ulum, that is to say, exactly where terminal epiphyses
would form at the extremities of long bones. Even in
the higher mammalia the rod-like character of the bones
is still apparent (Fig. 3771). "When the upright position
begins to be assumed, lateral expansions becomes neces-
sary to support the weight of the viscera. A transition
form is seen in the pelvis of the gorilla (Fig. 3772).
The thickness and strength of the different parts of the
innominate bone vary according to the weight and strain
to which they are subjected. While a person is standing.
Fir,. 3771.— Pelvis of the Horse.
the weight of the body is supported by the upper lip of
the acetabulum, whence it is transmitted to the symphysis
pubis on the one side and the sacro-iliac joint on the other.
Hence a strong bar of bone extends from the .symphysis
along the upper edge of the acetabidum and the ilio-pcc-
tineal line to the posterior superior spine of the ilium,
where it ends iu a protuberance called by Waldeyer the
tuber glutitum posterius. This l)ar may be called the
pubic trabeculum. AVhile an individual is sitting, the
greater portion t)f the weight is borne by the tuberosity of
the ischium, and is transmitted through tlie thick strong
body of the ischium (sujjerior ramus of many authors)
and the posterior edge of the acetabulum, directly up-
ward to a thickened portion of the crest of the ilium (tube)'
glutit'um auterius of Waldeyer). This also is a thickened
bar, and may be called the ischial trabeculum. These
bars cross each other at about right angles near the axis
of motion of the hip-joint.
The upper edge or crest of the ilium is sinuous and
thick, and gives attachment in front to the great, sheet
like muscles that form the parietes of the abdomen, and
behind to the muscles of the back. Below the crest is a
comparatively thin portion caused by the hollowing out
of the substance of the bone within, for the attachment
of the iliaeus muscle, forming the internal iliac fossa,
and without, for the attachment of the glutei muscles,
forming what is sometimes called the external iliac fossa
(ala ossis ilimn). The internal iliac fossa supports the
weight of the intestines laterally and forms in the articu-
lated pelvis the lateral portion of what is known as the
false pelvis, separated from the true pelvis by a ridge
(iho-pectineal line, linea terminalis) passing from the crest
of the pubis backward and upward.
The acetabulum or cotyloid cavity appears a little be-
low the middle of the external surface of the innominate
bone. It is hemispherical iu shape, formed by portions
of the ilium, ischium, and pubis, and receives the head of
the femur. It may become jierforated by suppuration
within the cavity, and thus inflammation of the intrapel-
vic structures may be induced. Below, the edge of the
cavity is incomjiletc, giving passage to vessels that sup-
ply the joint. This notch is usuallj' directed downward,
and it therefore af-
fords a means for
establishing the
normal position of
the bone.
The united ischi-
um and pubis con-
stitute the side of
the true pelvis.
They here form
three bony bars that
surround the large
obturator foramen,
closed in, during
life, by a thick sheet
of fascia called the
obturator mem-
brane. This is de-
ficient above, af-
fording, between it
and the bone, a
passage about an inch long, w-alled in above by the
bone and below by the membrane, the obturator mus-
cles and some masses of fat. Tliis passage, the ob-
turator canal, contains the obturator vessels and nerve.
The membrane is reinforced near the canal by indepen-
dent bands attached to small bony projections on the-
edge of the foramen. Three of these projections hav&
been distinguished as fairly constant. They are named
by Waldeyer according tcj their situation — the tubercu-
lum obturatorium lateiale .superius, the tuberculum ob-
turatorium laterale inferius, and the tuberculum obtura-
torium mediale. Tlie arrangeineut of the fibrous bands
and the shape of the canal have important effects upon
obturator hernia.
Tlie two anterior bars enclosing the foramen are known
as rami, the upper one being the horizontal ramus of the
pubis, the lower one being the .descending ramus of the
pubis above, the ascending ramus of the ischium below.
It may be remarked that these terms apply rather to the
artificial position of the pelvis given when it is set upon
a table than to its true position in the body during life,
as the "horizontal" ramus is far from being horizontal,
varying from that by as much as 30° in some subjects.
Along these bars are attached the muscles of the perineal
Fio. 3772.-Pelvis of a Gorilla.
Fig. 3773.— The Articulations of the I'.-ivis as Seen from the Front.
1, Anterior common ligament; i, ilio-Iunil)ar linanient: 3. lumljo-
sacral ligament ; 4. anterior sacro-iliac liirniciit : \ great sciatic liga-
ment; 6, its external border; 7, its internal herder; 8, lower sacro-
soiatic ligament: 9, symphysis pul)is,
floor and the urogenital diaiiliragm, on the inner side the
muscles of the abdominal wall, below the adductors and
rotators of the femur.
537
Pelvis.
Pelvis.
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Behind, the ischium expands to a large tuberosity
that gives origin to tlie great hamstring muscles (biceps,
somitendinosus, semimeml)ranosus), and allords attach-
ment to the great sciatic ligaments. A jiiiiiited process
(spine of the ischium) divides the posterior border into
two notches, the greater and lesser sciatic.
ArlicKhUioiis.— The pelvic bones are joined together
by five joints, all of which are syncliondroses (Figs. 3773
and 3774). Two of these are vertebral joints, viz., the
Fig. .3774.— Posterior View of tlip Ligaments of the Pelvis. 1. 2, 3. 4, .5,
Interspinous ligaments ; 6, 7. ligamenta sul)llava ; H, iiio-hinihar liga-
ment: !», posterior saero-iliac ligament ; lit. its nliiiqiu' puition, con-
tinuou.s e.\ternally with tbe great sacro-s<uitir ligaineiit ; 11, pos-
terior superior spine of the ilitim; 12. tulierele repre.senting ttie
transverse process of the fourth saeral vertebra; 13, deep layt'iof
the posterior sacro-iliac ligament ; 14, insertions of the Siiiiie; to. it>.
lateral ligaments of the sacro-coccygeal artirnlation ; 17. posttTi-tr
ligamiMit of tlje same ; 18, great saci"o-sciatii- ligament ; V-K its s;ht:i1
insertion; 2(1, its iliac insertion; 21. its ist-iiiatir insertion; 2:.'. w-
llected portion; 2^i, lesser saero-sciatie insertion; 24, its attachment
to the sacrum and coccyx; 25, great sciatic notch converted into a
foramen by the sacro-sciatic ligaments ; 2H. lesser sciatic notch,
forming with these ligaments a triangular orillce.
lumbosacral and the sacro-coccyge.al ; there is one on
cither side of the sttcrum where it unites with the ilia;
and one in front, where the innominate bones join, called
the symphysis pubis.
At tlie lumbo-sacral joint we have the same genei'al
features as in other spinal joints, viz., a union bj' means
of tibro-cartilage between the bodies of the last lumbar
and the first .sacral vertebra, and a pair of arthrotlial joints
between the articular processes of the two bones. Tlie
anterior common ligament of the spine passes downward
upon the sacrum in front, iind within the spinal canal the
posterior common ligament does thesanie. Besides these
the anterior lamina of the liimliar fascia becomes thick-
enetl to strong bauds, which, sjiringing from the trans-
verse i>rocesses of the fourth and fifth lumbar vertebra',
pa.ss to the inner lip of the crest of tlie ilium (ilio-lumbar
ligament) and to the brim of the true pelvis and the base
of the sacruiii (himlio-saeral or sacrodiimb;ir ligament).
The joint is indicated by a well-marked angle, the prom-
ontory of the sacrum, slightly greater in females tlnm in
males, being determined by Cunningham as averaging
137° 40' for females as against 133' G' for males. This is
not usually the most anterior part of the spine, for that
must be sought in the forward projection of the lumbar
curve, that is to sa)', in the fourth lumluir vertebra or
even as high as the disc between the fourth and the
third. Externally it may be felt fin deep pressure of the
relaxed abdominal wall if the subject is lean. It is one
of the landmarks by which a contracted pelvis is known,
and cannot, in a iiroperly formed pelvis, be reached by
the finger through the vagina, but can easily lie felt in a
rectal ex.amination.
The joint between the sacrum and the coccyx is very
simple, being entirely similar to that between the bodies
of the vertebroe. The articidation is usually sufficiently
free to permit the apex to be displaced some 2 cm. or
more, and there is sometimes a midcoccygeal articulation
between the first and second coccygeal vertebra". Move-
ment usuall}' occtus during defecation and labor, but the
bone ma_y be so firmlj- aukylosed to the sacrum that it
offers an obstacle to the delivery of the head of a child.
In the male pelvis the joint is frequently obliterated
quite earl}-. A number of ligamentous bands have been
described, but they ajipear to have no )iractical impor-
tance beyond that of an investing capsule.
The joint between the sacrum and the iliac bones on
either side possesses an incomplete synovial cavity. The
ear-shaped articular surfaces may be divided into two
parts — an upper which is clothed with cartilage and
synovial membrane, and a lower whose surfaces are in-
terconnected by means of an interosseous ligament. The
joint is a veiy strong one, as the entire weight of the
triuik is thrown upon the articulation. Owing to the
wedge-like shape of the sacrum it is often described as
the keystone of the jielvie aixh. It should be noted,
however, that in the natural standing position the bone is
somewhat narrower behind and above than below and in
front, so that it would seem that the weight of the body
resting upon it from above might tend to displace it.
This is pi'cvented, (1) by the sinuous character of the
articular surfaces; (3) by the extremely strong sacro-
iliac ligaments that bind the sacrum clo.sely between the
two iliac bones, so that any displacement forward tight-
ens the joint; (3) by the sciatic ligaments that stretch
from the sacrum and the coccyx to the tuberosity and
spine of the ischium and counteract any tilting forward
of the upper end of the sacrum. The interosseous liga-
ment that closes the joint behind is very thick and
strong, while the anterior ligament that closes it in front
is thin. Hence it is easy to open the articulation from
the abdominal cavity, but difficult to do so from behind.
Injury to it is rare, but when it occurs it is of a serious
nature, owing to the weight the joint carries in the stand-
ing posture.
The articulation usually affects the three upper sacral
vertebra?, but variations from this frequently occur.
The following are the results of 26.5 cases observed by
Paterson and Waldeycr:
s 1 -)- 2 21 times.
Sl-(-2-h3 242 •■
Sl-f2 + 3-t-4 3 "
S -24-3 3 "
S -2 + 3-1-4 3 ••
L.i-t-Sl-f2 1 ■■
I,.5-fSl-|-2-t-3 4 "
Lfi-fS 1-1-2 2 "
L(i-t-Sl+2-f3 1 "
Total 280 "
The total amounts to 280 instead of to 2(5.5 for the
reason that in 15 cases the articulation differed on one
side from that on the other. It will be noted that the
second sacral vertebra is always involved in the articu-
lation.
As alreadj' mentioned, the sacro-sciatic ligaments act as
resti'aining bands to this articulation. (See Figs. 3773
and 3774.) The great or posterior sacro-sciatic ligament
(ligameutum sacrotuberosum) appears as if a continua-
tion of the sacro-iliac, passing to the lateral parts of the
sacrum and the coccyx and then to the external surface
of the tutierosit}' of the ischium. It is somewhat nar-
rower in the middle than at either extremity, and in its
course becomes twisted upon its axis. At its lower in-
sertion it runs as a thin sharp band (falciform process)
along the ramus of the ischium and protects the internal
pudic artery. Its interlaced fibres are somewhat exteu.si-
ble, so that it offers no considerable resistance to the
moderate movement of the coccyx during labor. It is
believed to represent a former continuation of the biceiis
and semiteudinosus muscles whose tendons pass directly
into it.
The small or anterior sacro-sciatic ligament (ligamen-
tum sacrospiuosum) lies in front of the great ligament
538
REFERENCE HANDBOOK OP THE JIEDICAL SCIENCES.
Pelvis,
Pelvis.
and is partlj' covered by It. Triangular in form, it
passes from the side of the sacrum and coccyx to the
spine of the ischium. It blends at its insertion with the
coccj'geus muscle and is regarded morphologicalh' as a
fibrous reduction of it.
These two ligaments convert the sciatic notches of the
innominate bone into foramina, through which pass im-
portant structures. The greater sciatic foramen, above
the spine of the ischium, is nearly filled by the pyri-
FiG. 3775.— The Interior Strait of the Pelvis. (From Testut.) 1,
Sacrum : 2, coccyx : 3, 3, external iliac f ossoe ; 4, 4, anterior superior
spines of the ilium : 5. 5, acetabula ; 6, symphysis pubis : T. 7. tuber-
osities of the ischium ; 8. spine of the ischium ; 9. great sciatic
notch ; 10, posterior inferior spine of the ilium ; II, ischlo-pubic rami.
The dotted lines indicate the diameters of the inferior strait. _
A, A,' conjugate or coccy-pubic diameter; T. T', transverse or bi- '
ischiatic diameter ; 0, 0', oblique diameter.
formis muscle, small intervals being left above and be-
low— the suprapyriform and infrapyriform foramina of
Waldeyer. Through the former pass the gluteal vessels
and the superior gluteal nerve; through the latter the in-
ternal pudic vessels and nerve, the sciatic vessels and
nerves, the inferior gluteal nerve and the muscular
branches of the sacral plexus. Tlirough the lesser sciatic
foramen, below the spine of the ischium, pass the ob-
turator interuus muscle, and the internal pudic nerve
and vessels re-entering the pelvis.
The two .pubic bones are united in front bj' a fibrocar-
tilage that forms a slight eminence on the pelvic aspect
of the joint. During pregnancy this swells and relaxes,
and there is thus obtained a mobility that may persist for
some time after delivery. Traces of a synovial cavity
are occasionally found as a small slit lying near the pel-
vic surface, not lined with synovial membrane and ap-
parently being a simple lymph space. This is found in
both males and females, "though it is larger and more
constant in the latter, and is not dependent upon preg-
nanc3'. It is not found in young children. Four per-
ipheral ligaments are described : anterior, posterior, supe-
rior, and inferior. The investment is strengthened by
fibrous expansions from the recti muscles of t be abdomen
and the adductors of the thigh. Malgaigne considered
that the height of the s_ymphysis increased considerably
after the menopause, being 38 mm. at forty-five years,
and 45 mm. at seventy and eighty years. The arrange-
ment of the abdominal muscles in their insertion about
the joint is such as to draw the ends of the bones to-
gether, so that during the bearing-down pains of labor
the joint is strengthened.
T/ie Ligamentous Pebis. — Taking now the pelvis as a
whole, we find it to be divided into two well-marked parts
by a line, the linea terminalis, made up of the promontory
of the sacrum, the rounded angle between the upper and
the lower surfaces of the sacrum, the ilio-pectineal line, the
pecten or crest of the pubis, and the upper surface of the
symphsyis pubis. The part above this line which sup-
ports the abdominal contents is termed ihefulse pelvis ; the
part below it, containing the pelvic viscera, the true
pelvis, forming the bon}' ring through which the foetus
is expelled.
The superior opening of the true pelvis is termed the
inlet or the superior strait (apertura pelvis superior). (See
Fig. 3T69.) Its shape is reuiform in the female, cordiform
iu^he male. Similarly the lower opening, by which the
foetus isexpelled, is called theoutlet, or the inferior strait
(apertura pelvis inferior). (See Fig. 3775). Itisboundecf
b)' the ischio-pubic rami in front, on the sides by the
tuberosities of the ischium, Ix-liind by the sciatic ligaments
and the coccyx, only about half of its circumference
being bony. Its form is elliptical, slightly encroached
upon by the coccyx.
That part of the pelvic canal between the inferior and
supei'ior sti'aits is called the cavity of the pelvis. It is
customary to divide this into four regions, an antei'ior. a
posterior, and two lateral. The anterior comprises the
symphysis pubis, the posterior surface of the body of the
pubis, and the obturator foi-anien with its membrane. It
is limited by a line passing from the tuberosity of the
ischium to the ilio-pectineal eminence. The poslerior re-
gion is formed by the anterior surfaces of the sacrum and
the coccyx ; the lateral regions are between the anterior
and the "posterior. Each is again subdivided into two
portions called the anterior and posterior inclined planes.
The anterior comprises the internal face of the ischium
and the interior surface that corresponds to the acetabu-
lum. Its direction is oblique, downward, and backward.
The posterior inclined plane is entirely composed of soft
[larts, and is directed downward and forward. The
[danes meet at a line passing through the ischial spines.
JSormal Position. — When standing erect the pelvis is
tilted forward, so that the anterior superior iliac spines
and the spine of the pubis lie in the same vertical plane.
The promontory of the sacrum is then 9.5-9.9 cm. (3f-3|
in.) above the upper edge of the symphysis pubis and at
about the same level as the posterior superior iliac spines
and the interspace between the first and second sacral
spines. The frontal plane tangent to it cuts the middle
Fig. 3776.— Axes and Inclinations of the Pelvis. (From Testut.)
-4, A', Plane of the superior strait ; if, B', plane of the inferior
strait; D, Z)'. axis of the superior strait; i,', A", axis of the inferior
strait ; H. H', the horizontal plane, with which the plane of the
superior strait. A, A', makes an angle of from .'w" to 60°.
of the acetabulum and passes close behind the angle of
the pubis.
In this position the planes of the pelvic inlet* and out-
let are inclined to the hoi-izontal jilane. the first making
* strictly speaking the limits of the superior strait do not lie In the
same plane, as the promontory never coincides with the plane of the
hnea terminalis (ilio-pectineal Hue).
539
Pelvis.
Pelvis.
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
an average angle of about 60° (from ^m^ to 05', Naegelil,
the second an angle averaging about 12". (See Fig.
3776).
Meyer proposed to measure the iuclination of the pel-
vis by taking that of a line drawn f i om llie summit of the
curve formed by tlie sacrum (at the Ixidy of the third
saeral vertebra, see
tiiitf) to the upper bor-
der of tiie symphysi.s
(normal conjugate).
He tliouglit this angle
to be more ecjustant
than that made by the
plane of the inlet, and
estimated it as averag-
ing 80'.
MerisnrfmenU. — For
obstetrical and surgi-
cal purposes it is im-
portant that the aver-
age dimensions of the
pelvis should be accu-
rately known. Of these
tlie diameters of the in-
let and the outlet are
the most general! v use-
ful. Tlie older obste-
tricians, considering
these openings as ap-
pro.ximatel.v elliptical,
ajiplied to them desig-
nations tlerived from
the diameters of an
ellipse ; so the antero-
posterior diameter is
often spoken of as the conjugate, the others as the trans-
verse and tlie oblique diameters.
The conjugate of tlie inlet might be measured from
the middle of the promontory to the top of tlie sjnnph)'-
sis (anatomical conjugate), but for practical purposes
the shortest line between the promontory and the sym-
physis is taken (true conjugate, obstetrical conjugate)
which strikes the symphysis below the u]iper edge, usu-
ally about the junctiou of the upper and middle thirds.
The transverse diameter is the longest tians\erse line that
can be drawn between two symmetrical jioints of the
brim. These points are usually situated about the junc-
ture of the posterior and middle thinis of the circumfer-
ence, immediately behind the acetabula. The obliijue
diameter is measured from the sacro-iliac articulation to
the point on the opposite side where the linea termiualis
meets the ilio-pectineal eminence. (See Fig. 37(10.)
At the outlet the conjugate is measured from the tip of
the coccyx to the angle of the jnibis, and is increased by
Fig. 3777.— Method of Measuring the
Conjugate Diameter of the Superior
Strait in the Living.
FIG. 3778.
-Method of Measuring Baudelorque's Diameter In the
Living.
about 2 cm. by moving the coeey.x backward. The trans-
verse diameter is measured lietween the middle points of
the posterior bonh'i's of the ischial tuberosities. No satis-
factory oblique diameter of the outlet can bi' measured.
When stated it is con.sidered to be the shortest distance
from either ischiopubic ramus to the great sciatic liga-
ment of the oppo.site side. (See Fig. 377.5.)
The calibre of the cavity of the pelvis varies somewhat
from that of the brim. The widest part (aniplitudo
pelvis) is in a plane passed through the midpoints of the
acetabula. the synostosis between the second and third
sacral vertebra' and the middle of the symphysis pubis.
Th(^ narrowest part (angustia pelvis) is between the lower
end of the sacrum behind, the summit of the jjubic arch
in front, and tlie two ischial spines on either side. The
contraction here is caused by a slight elevation (angulus
ischiadicus. Waldeyer) that runs on either .side from the
ischial spine to the lateral tubercle of the obturator fora-
men, separating a supraspinous from an infraspinous
plane.
While these measurements are especially important as
relating to normal labor, the following are commonly
used for ascertaining pelvic deformities:
The Exttriiiil C'Diijiigiite (Baudelocque's diameter).
The distance between the upper edge of the symphj'sis
pnbis and the tip of the spinous process of the "lifth lum-
Ijar vertebra. This is readily measured with calipers in
the living. (See Fig. 377.S.) When less than 19 cm. the
pelvis is too narrow for safe delivery.
TJic Diayoniil Conjugate. Distance from the vertex of
the pubic angle to tlie promontory of the sacrum. This
may be measured by means of a pelvimeter or closely
approximated by measurements made by introducing
two lingers into the vagina. (See Fig. 3777. ) In a normal
pelvis the promontory cannot be reached b)' introducing
a single inde.x linger.
The distiinee hetirefii the anterior superior spines of the
ilium.
The f/reatest dislaure hefireeii the ilieie erests.
■ Tlie urentest clistnnee between- the greeit trochiinters.
77/(' e.rtenml cirnnuferenee of the pelris measured from
the spine of the fifth lumbar vertebra around to tlie sym-
physis pubis on either side, passing between the iliac
crest and the great trochanter.
The following table of ineasurenients is from the deter-
minations of Waldeyer, C. Krause, and Schriider:
Inlet.
True eonjugate dianieter
Transverse diameter
Oblique diameter
Oiithl.
Conjugate diameter
Transvei-se diameter —
Auiiililitihi.
Conjugate diameter
Transverse diameter
-■1 HfiuMia.
Conjugate diameter
Transverse diameter
E.\ternal conjugate
Diagonal eonjugate
Distanee between anterior superior spine;
liistani-e ln't^\t('n illar crests
Distance hetwccu great trodianler-s
External circumference
DotT^al length of sacrum
Ventral length of sacrum
Height of symphysis pubis
U1..5cin.
I2..5
12
7.5 (9.,'j)
11
11
n..5
s
18
26
26
31..:
13..5
ll.nem.
13..5
12.7.5
9 (11)
11
12.75
12.5
11.5
10.5
20
13
26
29
31.5
s«
12.5
12
4.5
The n.ris of the superior strait is a line perpendicular
to the plane of that strait at its central point. (See Fig.
3776. ) It nearly coincides with a line drawn from the tip
of the coccyx to the umbilicus. The axis of the inferior
strait is similarly obtained, and when produced reaches the
promontory of the sacrum. The axis or traction line of
the pelvis is one that bisects all possible conjugate diame-
ters. It is ]ir!ictically ]iarallel with the curve of the sa-
crum and coccyx, and therefore, in the female pelvis,
nearly straight above and sharply curved below. It is
important to bear in mind its direction when attempting
54-0
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pelvis.
Pelvis.
traction upon the fa'lus aud wlii-ii iiilrodiiciug iustru
ments.
Jiidice^. — The method of proportional measurements or
indices, first devised for the cranium, has also beenapiilied
to tlie pelvis. Two of these are used, first tliat whieli
Topiuard calls the general index of the pelvis, fouuil Iiy
comparing the greatest width between the iliac crests
with tlie lieiglit taken from the pnnctum isehiadicum or
lowest jjoint of the ischial tuberosity to the punctum
-coxale or highest point of the crest ; second, the index of
Fig. 3779.— Pelvis ol aa Andaman Islander. (Garson.)
the superior strait, found by comparing the anatomical
C(m jugate diameter with the transverse diameter of the
inlet.
By the first method the height is taken as 100, and the
index expresses the proportionate breadth. Topiuard
obtained the following averages:
4t) European males ISfi.fi
17 Afriran negroes, males 121 .3
II Natives of Ureaiiiea, males 1^^.7
Hi 1,111.. peaii females )W.9
1(1 .\ fiieaii iiejrivsses VM.-i
III Nativi n of Oceanica, females i;J9.u
LI I Mil III n|». ids ltB.6
111 Kiiininants 77.2
l:i I'arniviires fW.l
i liiiilents «)■»
4 Kangaroos *>^.'>
2 r.dentates Gl .4
These figures appear to show that as we rise in the
scale of races the pelvis broadens. It sliould be remem-
bered, however, that exceedingly heavy animals, like the
: I
Fig. 3780.— Pelvis of an Aino. (Hennig.)
elephant and rhinoceros, have a proportionately wide
pelvis to permit of the insertion of the mu.scles necessary
for sustaining their enormous weights. Some authors
use the breadth of the pelvis as the'basis of comparison,
whicli changes the figures without altering their serial
relation. It will be noted that in all human races the fe-
male |ielvis is broader in proportion to its height than
that of the ma'°
By the second method the breadth of the superior strait
is taken as 100, and the index e.xjiresses the proportionate
value of the conjugate diameter. Sir William Turner
Fig. 3781.— Diagram of European Pelvis, seen from Above. (Garson.)
used this index in his investigation of the bones brought
back by the Challenyer. He devised the terms doUcho-
■pellie for pelves having an index above 95, mesatipellic
A
s,
■*
Fig. 3783.- Pelvis of a Young Maori. (Hennig.)
for those from 90 to 96. and phitypellic for those below
90. The Andaman Islanders appear to have the inlet
most nearly circular of any yet examined. Garson finding
Fig. 37S?.— Pelvis of a Negnw. (Henni?.)
the index 99 in an average of i;i ea.ses. Figs. 3779 and
3781 show a comparison between tliis pelvis aud that of a
541
Pelvis.
Poiuplilgiis.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
European. Other peoples hitherto investigated may be
chissitied as follow.s:
Bnlic/wpeUir.—AustraManfi. Buslimcn, Hottentots, Kaf-
firs, niaiiv Polynesians, Malays.
.V,.«,^y«?//V-.— Negroes, Tasmauians. New Caledonians,
many Jlelanesians.
P/,/^(//«W/>.— Europeans, Mongolians, East Indians.
This relates to male peU'es only, as novyheredo females
possess doliclioiiellie pelves. Anthropoid apes liave
markedly dolicliopeilie pelves, mueh e.\ceeding ni this
eharaeter any hiinum forms. Indeed, as eompared with
lower animal's, the |iclvis of man is much broader and of
greater capacity. Tlicse dilVcrences are occasioned by
Fig. 3TS4.— Pelvis
.*»J~
of nil Iniliviilual Beluuging to tbe Stone Age.
(Henuig.)
the erect attitude, which necessitates an effective support
of the viscera. In some races of men slight peculiarities
aiipear which may lie considered to be transitional forms.
(See Figs. 3780, 3782, and 3783.) The Veddahs of Cey-
lon, for example, have pelves in which the inlet is re-
markably contracted in front, so that the inlet appears
almost wedge-shaped.
Se.i'ual Dtficrciiirn. ^Fvtim what has been .said above it
will be seen that the higbest and best developed forms of
pelvisarenot found in the human male but in the female,
contrasting markedly with other sexual characters which
usually tend toward embryonic or undeveloped forms.
This a"lso is a natural result from the erect attitude. In
the quadrupedal position comparatively little weight i.s
hung from the jielvic arch, and a marked separation of
the bones during parturition does not necessarily impair
to any consideralile degree the stability of the support of
the liody. In the erect position, however, .so great a
weight "is thrown ujioii the arch that no considerable
amount of separation is practicable, and there comes to
be an antagonism established between the constantly in-
creasing size of the child's head and the diameters of the
pelvic straits. The female pelvis therefore becomes
comparatively wider, shorter, smoother, and more ca-
pacious than that of the male. It has been described as
a short segment of a long cone, that of the male being a
long segment of a short cone.
The following table, mainly from Waldeyer, gives the
principal sexual difTerences in the articulated pelvis:
Portion.
Male.
Female,
Sacrum
Curvature
Promontory —
Coccyc
Rfliitivfly longer and
narrower. Average
index 103.5.
(Generally more marked,
uniform.
Relatively shorter and
widtT.
Usually less; Hatter
above, more curved
below.
More frequently has Ave
VfTtebne. (.'o-ossiflca-
cjirlier, projects for-
ward more.
HitJher. narrower; placed
more obliquely, Ineli-
luition of borders to
each cither = r>:i^.
Tliicker, roufflier, more
sinuuus.
More frntiuentlv has four
vertebra*. Syncbon-
drosr.s ri'iiiajn later;
protects forward less.
Lipwer. broaiU'r, h'ss ob-
liquely placed ; inclina-
tion averayt's .tIC-'.
Narrower. less rough.
less siuiioiis.
Portion.
Posterior su-
perior spines .
Fossae
Isdiium
Tuberosities . . .
Ischio-pubic
rami.
Pubis
Symphysis .
Joint cavity .
Spines
Crests
insertions of
graciles mus-
Ohturator fora-
infK.
Acctatiula
Great. KCiatic
notch.
Distance from
body of ischi-
um to pos-
terior Inferior
Iliac spine.
True pelvis. . .
Superior strait
Inferior strait..
Inclination
Male.
Averase distance apart
50 mm.
Deeper
Stronger, thicker
Nearer together, inflexed
Margins inure eveited.
Arch pointed, more an-
gular (70° -7U.9.5»). An-
iiulu.^ pubis.
Deeper. At birth its
width is narrower than
or equal tu its height
(Fehhng).
Raif
Nearer together
Shorter
Nearer together
Higher, more oval, ob-
turator canal narrower.
Nearer together, show
less in front.
Lower, more oval
Averages -iO mm .
Deeper, narrower, more
funnel-shaped, capacity
less.
More heart-shaped and
dolichopellic, transverse
diameter less, plane less
inclined.
Narrower —
Less marked .
Average Sistance apart
40 mm.
Shallower.
Less massive.
Wide apart, evert«d.
Margins less everted.
Arch rounded, arch-
like (90°-100°). Arcm
pubis.
Shallower. At birth its
width is greater than its
height (Fehling).
Frequent.
Farther apart.
Longer.
Farther apart (Cleland).
Lower, almost trianpii-
lar, obturator canal
wider.
Wider apart, show more
in front.
Higher, more circular.
Averages .50 mm. (Cun-
ningham).
Shallower, wider, not
markedly funnel-
shaped, capacity
greater.
More elliptical (reni-
form) and platypellic,
transverse diameter
greater, plane more iii--
cliued.
Wider.
More marked.
-Sacrum of a Child of Eleven
1, 1. ( issiHc points f^ir bodies;
2, 3, lateral points ; 3, 3, intervertehnil
ligaments.
Deivlo}mie»t.— Each of the three or four upper verl,e-
bric which form the sacrum are developed from eight cen-
tres, three of which
are primary and like
those of other verte-
bra', namel}', one for
the liody appearing
at the fourth to the
eighth month, and
two for the neural
arch. (See Figs. 378.5
and 3786.) Prom
these latter grow out
the articular and
transverse processes.
There are also five
secondary centres,
two for 'the epiphy- Fie.. STS-I.
seal plates, that from Months,
the tenth to the thir-
teenth year form
along the upper and lower surfaces of the body of each
vertebra, one for the spinous process, and two situated
hiterally and ie|iresenting costal elements. The lower
vertebrae usually lack
6 these. In addition,
there are formed in
the seventeenth or
eighteenth year two
marginal epiphyses
on each side, the up-
per ones being con-
nected with the auric-
ular facets. The
bone is complete
from the nineteenth
to the twenty -first
year.
Each coccygeal vertebra ossifies from a single primary
centre, which docs not appear until from four to nine
years after birth, and tlnTc ajipcar later secondary cen-
Fic. 378(1.— Ossillcation
Vertebra. 1,1. Body; ^
4, 4, centres for arch.
of First Sacral
, -', lateral points;
542
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pelvis.
Penii>lilgus.
tres representing the upper and lower eiiiphyseal plates,
and in the upper vertebra two additioniU centres for the
cornua. (See Pig. 3787.)
The hip bone is formed from three cartilages that origi-
nate separately, the one forthe ilium appearing latest. (See
Fig. 3788.) Ossi-
fication occurs by
three primary and
nine secondary
Fic. nrnr. — Dfveiiip-
nieut of the Cot'ey.\.
1, 1, Centres for
bodies ; 3, 3, articu-
lar processes ; 3, .5,
epiphyses.
centres, the pri-
mary ones being
Fig. 3788.— Development of the Hip Bone.
(From Testut.) 1. Ilium; 2, ischium: 3,
pubis; 4. epiphyseal point for the iliac
crest; 5, epiphyseal point for the antt-rior
infeiior iliac spine; 6, epiphyseal poini at
the symphysis pubis; 7, epiphyseal puint
for the isc-hiuin ; H, Y-<"irtilage uniting the
three primitive portions of the hip bone.
first separated in
the acetabulum
by a Y - shaped
piece, the triradi-
ate cartilage. In
rare cases an in-
dependent centre,
the OS acetabuli, may remain in the acetabulum ununited.
Marks of the original composition remain on the developed
bone: (1) at the ilio-pectineal eminence; (3) on the ischio-
piibic rami, at the seat of origin of the corpora cavernosa ;
(3) as a thickened bar extending from the posterior border
of the acetabuUun to the great .sciatic notch. Ossifica-
tion occurs in the order shown in tlie following table:
Centres.
Time
of appearance.
Time
of union.
Priinaru.
3d to 4th month.
4th to 5th month.
5th to 7th month.
12th year
12th year
13th year
15th to 16th Tear.
18th Uj 2Uth year.
15th to Kith year.
loth to 16th year.
IStli to 20th year.
16th to 16th year.
17th to 18th year
17lh to 18th year
17th to ISth year.
18th year.
1.5th to 16th year.
15th to 16tli yi'ar.
Sccondai-y.
Epiphyses acetabuli.
Between ilium ami pubis
Between ilium and ischium. . .
Between ischium and pubis. . .
Epiphyses marpinales.
•Mb to 21st yeai-.
fl7th lo22dv<'ai-,
I female.
|21stto24thyear,
I male.
16th to 17th year.
Tuberosity of ischium
Anterior inferior spine of ilium.
17th to 18th year.
Pi'iink Baker.
PEMPHIGUS. — The word pemphigus does not convey
to tlie ndinl the idea of a clear-cut disease. The pem-
phigus diseases have been divided into a number of
groups whose only common bond of union is the occur-
rence of bulla? at some time in their couise. Any par-
ticular grouji of bullous affections may differ in every
other respect from the other groups. Although these
bullous diseases differ widch' from one anotlier, yet
owing princijially to the obscurity of their causes, it lias
been found ditficiilt to .segregate them or to remove any
particular gi-ouj) from the conglomerate class of peni|)lii-
gus diseases, and put it imder a distinct heading. Duhr-
ing and Brocq liave done much to simplify the study of
pemphigus by removing altogether from "this class the
group of cases that Duhring has called dermatitis her-
petiformis, and Brocci has called dermatitis polymorpha
dolorosa. Broccj, under the term dermatitis polymorpha
dolorosa, includes rathi.'r more cases than Duhring does
under the term dermatitis herpetiformis. Some of
Brocq's cases are not hcri)etiform at all.
Pe.mpiiigus Neon.vtordm. — Pemphigus neonatorum
is an instance of what has been before mentioned of
groups of cases being removed from the class of pemphi-
gus diseases and classified untlera different head. This
disease in future will have to be described under the
heading impetigo contagiosa, to which class it really be-
longs. It is described here for two reasons: first, its
name is still a familiar one in medical literature, and,
secondly, its most striking symptom, sometimes its sole
symptom, is a bleb, leading the observer most naturally
to look for its description under the heading jsemphigus.
Pemphigus neonatorum is an acute contagious disease
characterized by tlie occurrence, during a limited time,
of crops of blebs.
Symptoms. — In otherwise apparently healthy infants of
from three to eight days old, blebs suddenly arise. They
vary from a pea to a hazelnut in size, or they may be
even larger. They aie at first tensely filled with clear
yellow serum, and are scattered anywhere over the cu-
taneous surface, and s|iring from an apparently normal
or a reddened skin. After a short time the bullaj become
flabby and the contents grow turbid. Tlieu shortly the
delicate covering of the lilcb gives way, exposing a red
weeping surface upon which the epidermis has more or
less perfectly formeil, according to the time, whether
early or late, at which it has broken. The blebs arise,
become turbid, burst, and heal in a few days. The dura-
tion of the disease is from one to two weeks, in which
time it produces .several crops of bulUf. This constitutes
the whole disease, which ustially affects only the skin,
and seems but rarely to have an influence on the consti-
tution. It may, howevei', run a severe course, and cause
death in a very short time.
iMost of the recorded cases are reported as epidemics in
foundling asylums. It is probable, however, that even a
larger number occur scattered throughout the commu-
nity, but are left unnoted. The si'oradic cases are usually
seen onl_y by the obstetrician or midwife, who, .seeing that
the general health is not affected, adopts some indili'ereut
treatment under wlucli the jiatients generall_v recover.
Diiiymmn. — In the hereditary bullous syphilide the
bullous eruption is partictdarl.y marked on the palms
and soles, situations that remain free in pemphigus neo-
natorum. Besides this, in syphilis the base of the bulla
is infiltrated and frequently ulcerated, and the eruption
is polymorphous, consisting of papules, pustules, and
large erythematous iufiltratious. In addition, in syphi-
lis, there are snuffles, mucous patches, tmd condylomata.
In varicella the lesions are vesicles rather than bullie and
are rarely large. In Ritter's disease the ei-ythcma, usu-
ally beginning near the mouth and spreading over large
areas or the whole cutaneous surface, is the piincipal
symptom. The bullaj are subsidiary to this. Besides,
in Ritter's disease the ccmnection between the horny
layer of the skin and the rete Malpighii is loosened as
in pemphigus foliaceus, so that the horny layer either
comes away spontaneously or can be taken oft in large
masses or ribbons by a stroke of the finger. It must be
mentioned here that Richter, in a recent and careful study,
has concluded that Ritter's disease is not an independ-
ent affection at all, but an unusuall}' malignant variety
of pemphigus neonatorum.
Pathology. — The opinion is gaining ground that pem-
phigus neonatorum, souKt cases of pemphigus febrilis,
impetigo conta.giosa, and possibly Ritter's disease are
identical affections. The pronotuiced conta,giousness of
pemphigus neonatorum, its conlinement to the very sur-
face of the skin, its frequent lack of constitutional symp-
toms, its self-limitation, and its duration, all correspond
-A^
PolU|>lll<;u«,
Peiuphl^u^.
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
to wliat we know of impetigo contagiosa. We know also
that impetigo contagiosa, even in adults, may be a bul-
lous disease, and that it is particularly apt to be so in
Fig. 3789.— Dr. H. M. Sheniiairs Case of Acutp rHiii|iliin-us, I'loliahly Infective, In Fnll
Eruiiliun.*
the tropics. In infants, who arc ahvuys kept vcrj' warm
and whose skin is delicate, the tendency to form' bulhc,
even in temperate climates, is marked, "it is also urged
in favor of this view that if an infant is infected from an
adult who has impetigo contagiosa it gets pc-mphigus
neonatorum, and vice versa if an advilt is infected from
*The instance nf aonte bullous eruption, the snhjert of tliese photo-
gTa|)lis (l-i|_'s. ;);s'.l arid ;JT',IU), oecuriea In tlie praetlee of Dr. H. M.
Slieianan of San Franeisco. Tlie i>atient was a boy. seven years of age,
wile had 1 n nperated upnn for ttiheri-ulosis of "the ri^Mit knee-joint.
Sul'seqiiently to the iipefation sinuses formed, ijisetiatudnij: a bright
pieen pus, 'I'lie eruption then a|>peari^d lieliitid Itje ears and on tlie
ii'-rk. and s|tread rapidly o\er tlie head, triinl<. and extremities, even
to the tlni:ers and toes. The eruption consisted of hlebs only. The
cont'-ntst'f these blebs were clear at the stall, and remained clear
tliroiiiiliout their entire course, and there was no evidence of any in-
tlanimatory reaction of the skin. There was no rise of teniperature.
noi' was there any distiirlian if the general health ; the em pi inn dis-
Jippeared at the end of a few days. N<> hactenoloL'ical exaiiiinatinii
was made. This was probably an instance of an acute infecti\ e pern-
phigus, the exact nature of which Is not known.
an infant having pemphigus neonatorum he gets im-
petigo contagiosa (Matzenauer). Luithlen has .shown
that the bleb in pemphigus neonatorum is caused b}-
separation of the horny layer from the
rete Malpighii. This anatomical find-
ing of the superficial situation of the
bleb corresponds with wluit we know
of its clinical appearance and behavior,
for it will be remembered that the bleb
has a tliin delicate covering and heals
with great rapidity, and it also corre-
sponds with what we know of the very
superficial character of the lesions in
imjietigo contagiosa.
TreatniiHt. — It has been founti that
pempliigus neonatorum occurs with
noticeable frequency in the practice of
uncleanly midwivcs and nurses, and
tlierefore a thorough personal disinfec-
tion of these should be required. It
is with a view to getting on tlie track
of such disease carriers that the Berlin
authorities have ordered all cases of
pemphigus neonatorum to be reported
to the health office.
If it be true that pemphigus neona-
torum and Hitter's disease are simply
forms of impetigo contagio.sa, then
the parturient woman and the in-
fant sliould be carefully shielded from
this very prevalent disease. Atten-
tion is here drawn to the facts that
many cases of what are commonly
called barber's itch in men and im-
petiginous eczema in children are
really impetigo contagiosa, ami that
impetigo contagiosa is so frequent,
particularly in children, that a skin
clinic is scarcely ever without ex-
amiiles of it.
As the infants attacked rarely suffer
from constitutional syniptonis, and
the disease is generally short and .self-
limited, no internal treatment is re-
quired. If, however, constitutional
sym])toms do arise, such as fever and
exhaustion, they must be treated on
the principles obtaining in such cases,
as no specific treatment is known. As
the malady is contagious and is scat-
tered over the entire cutaneous sur-
face, a general cutaneous antiseptic
treatment is indicated. The antisep-
tics chosen, however, must be those
that will neither injure the infant's
delicate skin nor by absorption cause
constitutional symptoms. In regard
to absorption, it must be remembered
that the thin skin of the infant more
readily tdjsorlis medicaments than the
stronger, thicker skin of later life. As fultilling these
indications, two antiseptics come to mind : alcohol and
boracic acid. Boraeic acid may be used in the infant's
bath in the proportion of about four ounces to the gal-
lon, and a lotion consisting of a .saturated solution of
boraeic acid in dilute alcohol, may also be used its a rub-
down. This solution, by the way, is one of the best
to use in any case of jiyogeMic infection of the skin.
It may be readily made by the family in the following
way: A bottle is half-filled with alcohol, then nearly
filled up with water, and then boraeic acid is poured
in until some of it remains undissolved in tlie bottom
of the bottle after shaking. The supernattint fluid is
of course a saturated solution of boraeic acid. When
an ointment is necessaiy or desirable, as on the face or
in the tle.xures. a weak ammoniated mercury ointment is
tlie l.ie^t ; it is made b\' adding five grains of ammoniated
mercury to an ounce of vaseline. When crusting takes
544
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Penip]ii<;u8.
Peiiipliigus,
place, the crusts must be removed before either lotions or
ointments may be expected to be of any use. Tliis is
best done by applying boracic acid starch poultices.
These are made by adding hot water to ordinary laundry
starch while constantlj' stirring, to make a moderately
thicl< paste. To a large teacupful of the paste a heap-
ing teaspoonful of boracic acid powder is added, and it
is then poured into a thin muslin bag and applied.
AcDTE Febrile Pe.mphigds.
Acute febrile pemphigus is a very rare disease of wliich
Kiibner has formulated the following requirements: After
brief prodromes, and after fever has begun to show itself,
blebs appear on the previouslj' healthy skin. The fever
continues with exacerbations and remissions, and at the
same time there are repeated outbreaks of blebs. The
blebs are not confined to any particular
region of the cutaneous .surface, but oc-
cur in a scattered manner. After tliree
or four weeks the bullous eruptions
subside completely and do not recur.
No blebs should appear at a time when
no fever is present. It will be ob-
served that the only real point of dis-
tinction between pemphigus neonato-
rum and generalized bullous impetigo
of the adult on the one hand and acute
febrile pemphigus on the other is a rise
of temperature in the latter. Richtcr,
however, has shown that there may be
even a severe constitutional disturb-
ance with fever in pemphigus neonato-
rum, and it is not improbable that in
.some instances of generalized bullous
impetigo there taay be fever, so that
these three diseases may be identical.
There is, however, a still much more
severe febrile bullous disease, which
has been described by Fernet and
Bulloch. Their cases were acute sep-
tica-mias; in both instances they oc-
curred in butchers, and followed knife
wounds. Probably in the same class
are the bullous septicaemias occurring
in inflammatory diseases of the um-
bilical cord, or the bullous septicaemias
in the new-born, coincident with septi-
caemia in the mother. The affection on
the skin in such cases may look like an
extensive burn with scalding water.
The.se grave bullous diseases seem in
manj' instances to be different from
what is understood in speaking of pem-
phigus neonatorum.
No specific internal treatment has
been outlined for pemphigus febrilis.
The external treatment would be that
advised for pemphigus neonatorum.
Pemphigus Chronicus Vulgaris.
Definition. — Pemphigus chronicus
vulgaris is characterized bj- the ap-
pearance of blebs on the skin and
also on the mucous membranes. Pem-
phigus foliaceus and pemphigus vege-
tans are to be looked upon as varie-
ties of pemphigus chronicus vulgaris.
They arc worthy, however, on account
of their peculiar clinical appearance
and course, of a separate descrip- Fio. 3789.-
tion.
Etiology.— Tim cause of pemphigus
is unknown. That it is not merely a local, but a con-
stitutional, disease is shown by the fever that accom-
panies it, and also by the more or less rapid deterioration
in the general health of those afflicted with it. That
Vol. VI.— 3.5
few blebs on the surface of the body should cause ca-
chexia and death is not to be thouglit of as a possibility.
The blebs are only one symptom of a general con.stitu-
tional disease. Take, for example, pemphigus vegetans
when at times the blebs cease to appear. "This tempo-
rary cessation of the appearance of the blebs does not
seem to retard in the ieast the general course of the dis-
ease.
The occurrence of blebs in diseases of the nervous sj'S-
tem, in nerve injuries, and in neural leprosy has led
man}' to think that pemphigus is a disease of the nervous
system. These are the only facts, however, that favor
this view. That the di.sease is due to some toxic sub-
stance that acts through the nervous sy.stcm, in some
such way as an intoxication with rotten fruit will cause
urticaria, is not impossible.
Symptoms. — Pemphigus vulgaris frequently commences
Stage of Convalescence from the .\ttack of .Acute Pemphigus,
tliat shown in Fig. 371K3.)
(Same case as
with general as well as with cutaneous symptoms. The
general S3'mptoms are fever, malaise, gastric disturbance,
sleeplessness, and decided nervousness. With these
symptoms there appears on the skin a greater or less
545
l*(>iii|»Iei»'iis.
Pelil|>lki;;'lls.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
miinlier of blebs, which may come in crops, each crop
being' accompanied l)y an exacerbation of the constitu-
tional symptoms. The course of the disease may present
great variations. In (he Jirst plac(^ tlie initial crop of
blebs and those following may lie accompanied by very-
little rise of temperature or none at all, or there may be
much constitutional disturbanc(^ with very little erup-
tion, or the rever.se. The outbreak of blebs and the con-
stitutional disturbance may be continuous, reducing the
patient's strength very rai)idly ; or tlu^ disease may be-
gin acutelj' and stornuly, gradually linger on for weeks
OT montlis, and tinallj- die tlown altogether, po.ssibly to
Fig. oTOl.— Chronic PemiJliiBUs Vulgaris. In the picture the bjiUse
can be seen with pre:it distinctness to lie full, tense, hemispherical
and oval, variable in size and springing fioni a skin, which is, to
all appiMninccs, healthy. In sonic places tlu-re are vestiL'es o( old
bull;e thiit have Konc Ihrongh their evolution: some are broken,
others are dried down. Tliere are no evidences of .scratching.
(From a iilale iu I,. Brocq's article on Pemphisrus in "I.a Pratiipie
Dermaioi<»^i(|iie" iiar Krnest llcsnicr, L. lirocii, and I.. .lacqiiet, t.
iii., p. 77d. This Mgiire is a reproduction of an aquarelle in Caze-
nave's collection in the Museinn of the Hopilal Saint Louis, and had
alread.v been puhlislieil in the "J.ei.ons sur les maladies de la peau "
par Alphee Cazeuave, l.'^^O.)
start up again at some future time. The blebs arise
either from what tippears to bo a uormttl surface or
from a reddened spot, and ai'e at first tilled W'itli a fluid
either tis clear as water or of a yellow serous appeai'auoe,
or red or brown or blue from mi.\tui-e with blood. In
any case this fluid quickly becomes turbid, then puru-
lent. The blebs Uiay be the size of a jiea or it hen's egg,
or even larger. After a time the blebs either diy down,
forming a .scab, under which healing t;ikes |ilace, or
they m;iy bi-eak spontaneously or be liroken, leaving a
non-intiltrated eroded surface upon which then' forms a
flat, yellow, brown, or black sctil). In due course this
scab falls off, letiving a more or less deeply tinted brown
pigmented patch, but I'ai'cly a sc:ir. At times, after
iiealin.g, milium bnilics, flrst tlescribcd by Mat Bilreu-
sprung, ari' foiiiid in the epithelium.
On the mucous membranes the lesions ai'e rarely seen
as blebs, because the delicate and moist epithelial layeis
soon burst, leaving non-intiltrated erosions, which" are
either red or covered by a yellowish coating. The cir-
cular or polycyclic form of these erosions, together with
the taltei's of ejiitheliuni around their bonlers, show
their oi-igin as blebs. On either the skin or the mucous
membranes any individual lesion mtiy stop .shoi't of form-
ing a bleb or an erosion as the case may be. On the skin
such a lesion would be merely an erythematous siiot,
while on the mucous membranes it would show itself
as a whitish-gray epithelial thickening. In pemphii;iis
there m;iy-be no eruptiim whatever on the mucous meni-
bnmes, or the outburst on the mucous membranes may
pi'ecede, be simultaneous with, or follow the eruplion
of blebs on the cutaneous surftice. JMosler and Kiibuer
have seen pemphigus of the mouth e.\)st for four years
bcfoie thci'c wtis an outbreak on the skin.
As has been said, it is very rare for scarring to follow
pemphigus blebs on the skin. It is also rare, Imt not so
rare, for scarring to occur on the mucous membrtines.
What is equivalent to scarring occurs on the conjunctiva,
constituting what has been called essential shrinking,
but this w ill be considered later on. Sometimes the ero-
sions on the mucous membranes, es|)ecially of the mouth,
ulcerate. Proliably these ulcerations are not an essential
part of the disease, but adventitious from the iuci-eased
vulncrabilitj- of the eroded surftices, and also from infec-
tion, usually with staphylococci or .streptococci. In the
same way pemjihigus may be accompanied by lyin-
phaugitis ami adenitis, the biokeu mucous membi-ane
being the open door for the entrance of bacteria. It is
said that ulceration in the cheek pouches may result in
so much cicatricial tissue as to interfere with" the tiction
of the lower jaw. Pemphigus of the throat may cause
hoarseness, suH'ocation from swelling of the glottis oi' of
the mucous membrane of the larvn.x, a feeling as if :i fish
bone had lodged in the throat, or a di.sagreeable feeling
of rawness. In pemiihigus of the mouth or throat the
interference with mustication and the ditliculty or ini-
po.ssibility of swallowing solid food add to the miseiy
and weakness of the patient.
As in |ieinpliigiis of the other mucous membranes
blebs on the conjunctiva are very seldom seen. It may
be thiit they very larely form, or tliat if they form they
quickly burst. The iiemphigus lesion as .seen on the
conjunctiva consisis of an inegular-shaped membian-
ous exudation of grayish-white or grayish-yellow color.
Pem]ihigus of the conjunctiva is almost tilways followed
by cicatrization. It is not meant by this that every
pemphigus lesion on the conjunctiva is followed by scttr
formation. In fact almost all the lesions here, as on the
skin, heal without leaving a seal'. It seems necessary to
scar formation that a number of pemphigus lesions
should oceui- successively at one place (^lichel), and, as
this often happens, scar formation fretjueull}' results.
The seal's may be localized, or they may involve al-
most the whole of the conjunctiva. If they are th\is gen-
eralized, the conjunctiva will be turned into a dii-ty gray
or whitened, thickened, cutis-like membrane, w ith a dull
di-y surface. This is the condilioii that has been called
"essential shrinking." "With much shrinking the entiie
conjunctival .s:ic may be obliterated, and one or both
lids may be enlropioned, or drawn tight down on the
edge of the cornea. In such cases the cornea itself is
diseased fi'om cxiiosure, and from the eyelashes of thi'
cntrojiioned lids sweeping o\'er it. It is while and
opal|U(^ ;ind its surface is dull and dry, and covered with
.scaling e|iitlielial cells. Michel never has seen a bleb of
the cornea itself, but he quotes Se.ggel as having seen
one, and ^Mueller as having .seen an ulcer covered with ;i
membranous exudation on the upjicr border of the cornea
and on the neighboring conjunctiva; Pei'gens has also
seen u broken bleb of the cornea in an infant.
Pemphigus of the conjunctiva may exist alone or
with pem|ihigus of other mucous membranes such as the
mouth, pharynx, trtichea, or bronchi, or with pemphigus
of the skin. It is held that a diagnosis of pemphigus.
r,ii
kefere:vce iiaxdbook of the :mkdical scienc-es.
Poiii|»lii^ll«,
Poiiiplii»'U»*
when the mucous membranes alone are efTected, cannot
be made. It seems, however, that tlie clinieal picture is
clear enough, and that such lesions are pemphigus is
shown by the fact tliat after existing for a longer or
shorter time jiemphigus of the skin may supervene.
Just as tlicre can l)e a pemphigus of the sld'n alone willi-
out pemphigus of tlie mucous membranes, so also can
there be a penipliigus of the mucous membranes without
pemphigus of the skin (Kaposi).
Eosinophilia, either in tlie blebs or in tlie blood of tlie
general circulation, seems to have very little value as a
symTJtom.
Diagnosis. — lu dermatitis herpetiformis tlie mucous
membranes are not apt to be affected ; tlic lesions on the
skin are multiform and consist of erythematous patches,
papules, wlieals, vesicles, and bull;e: the itching and
pain are severe and occur in distinct attacks ; and tlie gen-
eral healtli is undisturbed.
In epidermolysis bullosa the disease occurs in families
and is hereditary; the bulla occurs when an injur}' has
been received, even a slight pressure, as on the feet and
hands, may cause it; and the general health is unim-
paireil. Colcott Fox has, however, reported a case in
which the disease resembled epidermolysis in every par-
ticular except that it was not hereditary, and he warns
against drawing too tine distinctions between it and pem-
phigus. In epidermolysis bullosa the nails also fre-
quently grow to be deformed, and the disease is probably
something more than a mere over-sensitiveness of the skin
to pressure. Another instance showing the intimate re-
lationship between these two diseases is the case reported
by Mertens, in which there was pemphigus of the moutli,
throat, and conjunctiva. Blebs appeared also on the
skin, but only after trauma.
The vesicular and bullous eruptions that sometimes
follow trauma and also those that sometimes follow vac-
cination, and that in either instance may last for years,
resemble more closely the type of dermatitis herpeti-
formis than that of pemphigus. Just where they stand,
however, in a classification, has not yet been determined.
Quinine, iodine, bromine, and copaiba may all caus('
bullous eruptions that have to be difrereiitiated from
pemphigus.
The blisters caused by the external application of
drugs must also be considered. Sometimes such drugs
are applied with the intention of deceiving. The occur-
rence of the blel-.s exclusively on the skin in an hysterical
person in situations easily reached by the putieut may
cause suspicion. The wings of the Spanish tly Iiave
been found on the blebs.
Hardy mentions the occasional occurrence of blebs on
the hands and feet in eczema. I have seen this occur in
two separate attacks of eczema in the same patient.
Bulhe may also occur in lichen planus (Whitfield). The
differentiation would here be made by the presence of the
lichen papuies and by I lie itching.
In impetigo contagiosa the eruption, as has been
previously mentioned in the section on acute pemphigus,
may be bullous even in the adult. This is particularly
apt to occur in the tropics. The swift course of the
disease, its marked contagiousness, its non-interference
with the general health, the very large yellow supertieial
crusts, and the occurrence of pustules should put one on
one's guard.
Prni/nosis. — Pemphigus is one of the few diseases of
the skin in which the life of the patient is threatened.
In such a capricious disease the prognosis is always
uncertain. Cases that begin benignly may end malig-
nantl_y, and vice versa. Nevertheless there are indications
that jioint to a good or bad course of the malady.
Luithlen, for instance, divides pemphigus, in regard to
prognosis, into two classes of cases. In the first chiss tin-
blebs appear on erythematous patches, and there is no
ri.se of tem])erature. In these cases tlie blebs are situated
in the epithelium, and the rete is not raised away from its
bed on the papillary layer. The prognosis here is favor-
able. In the second class of cases the blebs arise on the
perfectly souud skin, and their eruption is accompanied
by fever and exhaustion. In this class the blebs arise
under the rete and lift it completely away from the
paiiillary layer. The prognosis hero is always unfa-
vorable.
AV hen the blebs are tense and filled with a clear white or
amber-colored fluid this fact is viewed as a favorable sign ;
while, on the other hand, when the blebs arct slaekly filled
and pus quickly forms, collecting as an liypopj'on in the
dependent portion of tlie hanging bag, the outlook is bad.
In pemphigus of the mouth and throat tliedilficulty or
impossibility of .swallowing solid food interferes with the
patient's nutrition. Independently of this, however, the
occurrence of pempliigus of the mucous membranes may
be looked upon as an ominous sign. In general, in those
cases in which the mucous membranes are affected at tlie
very first or early in the disease, the prognosis is the
worst; but no matter at what time in the course of the
malady the mucous membranes are affected the symptom
is a bad one.
Pemphigus Foliaceus.
That form of pemphigus which is called pemphigus fo-
liaceus has for its chief clinical characteristic the exfolia-
tion of the skin. There may be very few blebs; indeed,
when the disease is well under way and the exfoliation is
active there may be no blebs at all.
Pemphigus foliaceus may attack either sex, at any
age, even in childhood. The disea.se appears in all coun-
tries, and does not seem to depend in any way on climatic
influences. It is neither epidemic nor contagious.
It is said that prodromal symptoms are either absent
or are not at all well marked, and tliat when present,
they consist in a feeling of general lassitude and a sliglit
rise of temperature. The first symptoms of the disease
proper may appear on any part of the skin, or on the
mucous membrane of the mouth. The blebs in pemphi-
gus foliaceus, even at first, generally differ from those in
oi'dinary pemphigus. Instead of being large, clear, and
bubble-like, thej' are small, slaekly filled, and slushy, with
a delicate covering that soon breaks. The blebs often
have a reddish tint from the red color of the injected
blood-vessels shining through the thin layer of fluid and
th(^ very delicate covering of the bleb. The erosion left
by the first bleb that appears in a given locality enlarges
by undermining of the surrounding epidermis, and,
moreover, new blebs form in ever-widening circles about
the site of the first, which by this time will probably
have healed. But when this healing takes place it does
not end the process. It is just at this point that the
most prominent characteristic of the disease and the one
to which it owes its distinctive title of foliaceus begins.
Serous exudation continues to be poured out rather into
than under the newly formed, but by no means uormally
formed, epidermis. This exudate and the epithelial lay-
ers into which it is poured form leaflets resemliling French
pastry; hence Cazenave's epithet foliaci'us as a])plied to
this form of pemphigus. The loosening of the attach-
ment between the hiyers of the epidermis is also a re-
markable phenomenon in pemphigus foliaceus, and may
be demonstrated by drawing the finger firmly along the
apiiarently sound skin. The top layers of the epidermis
will slip off, leaving an excoriation. This slipping of
the epidermis is found in other forms of pemphigus, liut
is ]iarticularly well marked in penipliigus foliaceus.
l>y the spread and coalescence of iliseased patches the
wlicile cutaneous surface tends to become involved. This
generalization may take place in a few days, or may not
be completed before several months have elapsed.
From the above description one can understand that
the aiipearauce of the patient will differ widely accord-
ing to the stage at which the disease is seen. There
may be groups of circiuate jiatelus of miseralily I'ormed
bulla', or there may be circular iiatches covered with
yellow crusts, or the whole skin may be bluish or
iirowni.sh-red and actively desquamating, with here and
there raw patches, but yet with very little weeping.
The skill in pemjihigus foliaceus is only moderately or
not at all thickened.
5i7
Peniphlgu',,
Peiiipliigus,
KEFERENX'E HANDBOOK OF THE MEDICAL SCIENCES.
Gradually other clianges occur. The hair falls out.
The eyelids become ectropioned and their lashes fall.
The nails atrophy.
At first the general health of the patient remains un-
alTected. but gradually, through tlie unccimfortable con-
dition of the skin, the occasional fever, the sleeidessne.ss
aggravated by severe attacks of itching, the constitution
becomes undermined. The patient becomes thin and
poorly nourished, then through complications, either in-
the lungs, or intestines, or kidneys, he is carried off.
It is said that pemphigus foliaceus. after existing for a
longer or shorter time as such, may turn to the type of
pemphigus chronicus vulgaris (Kaposi).
Diaffiiosis. — ^The most imjiortant disease to differentiate
from pemphigus foliaceus is dermatitis herpetiformis in
its generalized exfoliative form. The two diseases are at
this stage so closely alike that only a very clear history
or a continued observation of a patient enables one to
come to a definite conclusion. Severe attacks of itching,
the occurrence of the vesicles or bulhe in groups, and
only slight interference with tlie general health should
lead one to suspect the disease in tiuestiou to be dermati-
tis herpetiformis.
Pemphigus Vegetans.
In pemphigus vegetans the denuded areas left by the
blelis, insteail of healing over, sprout peculiar vegetations.
This is one of the chief characteristics of this variety of
pemphigus, and the one to which it owes its distinctive
title of vegetans. It is, however, not the only point of
difference between it and ordinary pemphigus. The in-
dividual cutaneous lesion is usually smaller and more
flabby, the contents are more turbid, and the covering of
the bleb is more delicate than in pemphigus vulgaris.
The blebs and tiie subsecjuent erosions may, however,
resemble those of pemphigus vulgaris in every respect
up to the time when the vegetations sprout.
The bulhe appear suddenly on an ajiparently health}-
surface, and are generallj' delicate and soon break, leav-
ing smooth, deep, red excoriations exuding an abundant,
foul-.smelling serum. The border of both the bleb and its
succeeding excoriation remains sharply limited, and there
is no infiltration. The vegetations may be present before
the bleb breaks. Iiut more frequently they appear in the
erosion, at first as a rounded, prominent, dirty white ele-
vation, in the centre of which the vegetations sprout.
This process slowly extends out over the entire excori-
ation and even beyond it. This growth is surrounded by
a zone of dark red erosion, which in turn is bounded by
a collar of loosened macerated epithelium. The vegeta-
tions are closely bunched, their free surface is necrotic,
excoriated, and dirty, an<l they have in their substance
many pinhead-si/.ed pustules, giving them a stippled
look.
Many of the vegetations are flattened across the top,
and, although larger than the broad condylomata of
syphilis, look strikingly like them. By individual in-
crease in size neighboring lesions coalesce with one an-
other, forming large patches with serpiginous boundaries
of tattered, ragged epithelium. As a rule the lesions on
the tongue and mucous membrane of the mouth and lips
resemble those seen in pemphigus vulgaris, but they may
also become vegetative, although these vegetations do
not reach anything like the size or extent of those seen
on the skin.
The disease may begin by the ap].>earauce of blebs on
any part of the skin or nmcous membranes, but it is par-
ticularlj' apt first to show itself in the moiith. Spiegler
has recently said that of twenty-eight cases of which
he had known, eighteen began with lesions in this situa-
tion.
It is only in bad cases that all the lesions on the cuta-
neous surface become vegetative. In certain regions, as
in the nasolabial and labio-mental grooves, in the arm-
pits, groins, and navel, and on the belly, the lesions are
particularly apt to sprout vegetations.
The constitutional symptoms, such as sleejilessness,
fever, and loss of strength, are present as in pemphigus
vulgaris, but are usually more marked.
The prognosis, although commonlv far worse than in
pemphigus vulgaris, is by no means fixed.
In all medicine there is no disease witli a more dramatic
course than that of pemphigus vegetans. For instance,
a man consults a physician in regard to an insignificant
erosion in the axilla. A simple treatment is prescribed.
He appears shortly again with some vegetations on the
erosion. These may be cauterized, and the patient dis-
missed without any thought of the serious nature of the
malady. The lesiim, however, does not heal, and new
excoriations and blebs appear, especially about tlie pri-
vates, with coincident dirt}' white patches in the mouth.
At the same time the patient gives off a most horrible
carrion-like odor. He shortly becomes a miserable, fid-
some, horrible object to himself and others; and, to add
to his miseries, there is often the moral degradation of
being thought to have s_vphilis. Inanition from refusal
of nourishment, fever, exhaustion, marasmus, spinal irri-
tation, and acute tcdema of the brain succeed one another
rapidly, and in a few weeks or months the patient dies.
Where the lesions first appear is a matter of importance
in the prognosis, for in those cases in which the lesions
begin on tlie lips, in the mouth, on the scalp, or on the
genitals the prognosis is bad.
Not all the blebs in a case of pemphigus vegetans be-
come vegetative, and when only a few of them sprout
vegetations the prognosis approaches more tliat of pem-
phigus vulgaris — that is to say, it is serious, but not nec-
essarily fatal. On the other hand, the more blebs there
are that become vegetative, the more quickly does the
disease terminate in death.
Necrosis of the surface of the vegetations is the rule,
and the more marked the necrosis the worse the outlook
for the patient. If, however, this necrosis does not take
jilace, and the vegetations tend to become covered with
horny epitheUum, the patients may recover and live for
years (Neumann).
It is not an absolute rule that a pemphigus vegetans
should remain as such throughout its entire coiu'se. In
general, the vegetations cease appearing as a fatal ter-
mination approaches, and Kaposi has demonstrated a
jiatient in whom pemphigus vegetans healed, but the
disease returned some time afterward as a pemphigus
cachecticus.
As above shown, the estimate of the course wliich a
given case should take may be modified by a number of
considerations, such as the severity of the constitutional
disturbance, the localities where the lesions first ajipear,
and the abundance and tl^e dirty necrotic condition of the
vegetations. The beneficial effects of treatment have
also helped to modify the immitigatedlj- bad opinion pre-
viously entertained of the course of pemphigus vege-
tans. Under drying disinfecting powders the prognosis
has improved, and Kobner, JIueller, Kaposi, and Jlracek
have reported cases showing at least temporary relief
or cure.
The resemblance of pemphigus vegetans to syphilis is
striking. The white patclics in the mouth resemble ab-
solutely the mucous patches of syphilis, and the vegeta-
tions, especially the liutton-like ones, differ in no respect,
except in their larger size, from the broad condylomata
that were at one time supposed to be found only iu
syphilis. These symptoms, together with the situation
of the patches, especiall}- those in the groins, in the folds
Ijctween the thighs and the scrotum, and in the anal
fold, all go to form a picture that is in the highest de-
gree deceptive. There are differences, however, which
aid in distinguisliing the two diseases. For instance,
the growtlis in pemphigiis are always surrounded by
the tatters of the blebs, while in the confluent condy-
lomata of syphilis the patches are bounded by sharp infil-
trated borders. Furthermore, the condylomata in syphilis
always occur at an early stage of the disease and are ac-
companied by other symptoms of syphilis. In syphilis
the growths when left to themselves tend to subside,
while in pemphigus the longer the disease lasts the more
548
REFERENCE HANDBOOK OF THE MEDICAX SCIENCES.
Pcinplil^us.
l*fiii|*hi<;iis.
FIG. STX'.—
tlic jrrowtbs increase; and while they grow, the general
condition of the patient becomes worse and worse. Fur-
thermore, iiemphigus vegetans is a disease of adult life,
and the presence of blebs is unknown in the course of
syphilis of adults.
" Post-bullous vegetations are not absolutely pathogno-
monic of pemphigus vegetans, as in rare instances tliey
occur in several other affections, such as in dermatitis
herpetiformis, impetigo contagiosa, and in the iodine
(Hallopcau) and bromine (Wallhauser) eruptions. Post-
buUous vegetations also occur in impetigo
lierpetiformis, but imjietigo herpetiformis is
by many observers now considered a clinical
variety of pemphigus vegetans.
Treatment. — The outlook for the cure of
any given case of pemphigus, through either
internal or external medication, is not good,
yet much may be done to alleviate the symp-
toms and to staj' the progi-ess of the disease.
Arsenic. — So many have praised the effect
of arsenic in pemphigus that it should be the
first drug to receive a trial. The favorite
way of giving it is as Fowler's solution, in
increasing doses, beginning with six drops,
and, as some advise, running up to twenty
or thirty drops a day. Very high doses of
arsenic are of questionable benefit as they
depress. H such high doses are used it is
entirely for their specific effect, and as soon
as they are found valueless they should be
stopped. On the other hand, small doses, on
account of their tonic effect, may be con
tinned for a long time.
Strychnine. — Neisser has recommended
stryclinine. Its onlj' effect seems to be that
of a powerful tonic, u.seful in combating the
great exhaustion, which is so frequently a
marked feature of the disease.
Quinine. — Mosler has reported an apparent cure after
taking 40 gm. of muriate of quinine in five weeks
(Jarisch). In most cases, however, it acts simply as a
bitter tonic.
Aciils. — Dilute sulphuric acid, acetic acid, and citric
acid have been recommended, but no specific action can
be attributed to them. They probably act as tonics.
Opium. — Opium besides being a .soporific is said by
Malcolm Morris to be one of the best curative agents we
possess.
Chloral hydrate is an excellent drug for the sleepless-
ness which is a marked symptom in some cases of pem-
phigus.
Ordinarily the siiuplest measures may be employed to
relieve the local conditions. Fre(iuently a mild antisep-
tic powder, made, for instance, of equal parts of boracic
acid, starch, and oxide of zinc, is all that is required. If
the tension of the blebs is uncomfortable they may be
opened, and the above powder luay be used to soak up
the ,secretions, and to jjrevent the excoriations sticking
to the bedclothes. If there are much heat and inflanmia-
tion, or if pus is retained under the crusts, mild antisep-
tic lotions or salves ma_y be the best topical aii])lications.
Lotions will be mentioned after speaking of baths. A
red oxide of mercury salve is excellent: 1^ Ilydrarg. ox.
rub., 3 ss. ; lanolini, vaselin. alb., aa 3 ss. JI. S. : A))-
ply on cloths.
Carbonate of lead, employed as a salve, is also good:
V, Plunibi carbonat., 3 i. : lanolini, vaselin. alb., aa 3 ss.
Baths. — Till- continuous bath, when it can be obtained,
is of the gie.atest coinfort in severe cases. It relieves the
tension and pain, softens the crusts, mitigates the fever.
and induces sleep. With its help a patient may be car-
ried through an eruptive attack that would otherwise
have killed him. Hebra's water-bed is excellent for tlje
purpose. (Fig. 3T93. ) It consists of a box or bath lineil
with zinc, with a plug and overflow pipe at its foot, and
the feeil ])ipe with hot and cold water mixed, entering at
the liead of the bath near its bottom. Th<' lemperatuie
should be maintained at about 36' or oT' C.
The patient rests on a wire netting over which are
thrown woollen blankets. This wire netting may be
raised and lowered as wi.shcd. After the i)atient is low-
ered into the water the bath may be covered over with
blankets for the purpose of retaining the warmth.
When such a bed is not obtainable, the patient may be
put in a bath for several hours a day. Soothing or anti-
septic medicaments may be added to the bath, as for in-
stance one or two drachms of permanganate of potassium,
or a couple of ttunblerfiils of boracic acid powder, or
biborate of soda, or bicarbonate of soda, to
sixty gallons of water. It must be remem-
bered that there are people to whom baths
are debilitating, and on M-hom, in such an
Hel)r:i's Contrivance for Administering a Continuoiw Batli. (From
Janscla's " Hautlirankheilen," in "Xotbnagers System.")
asthenic disease as pemphigus, their use would be par-
ticularly disastrous. In such ca.ses we must content our-
selves with compresses either wrung out of simple water
or wet with medicated lotions. These compresses may
be covered in either with oil silk or with rubber tissue.
Hutchinson's lotion is an excellent one for allaying in-
flammation, irritation, and itching. It consists of: IJ
Liq. plumb, subacetatis, 3 ss. ; liq. carbonis detergentis,
5 iiss. M. S. : A teaspoonful in a pint of water, to he
used as a lotion.
Other solutions to be used on compresses are those of
acetate of aluminum, saturated solution of boracic acid,
and liquor plumbi subacetatis. Carron oil, made with
equal parts of lime water and olive oil, with the addition
of four per cent, of boracic acid, is one of the best appli-
cations in pemphigus, and is especially useful in the dry
scaly condition in pemphigus foliaceus.
Tretdment of Peinp/iigux Ver/etans. — Unna introduced a
treatment of pemphigus vegetans which consisted of
painting the lesions with tinctiiri' of iodine. This treat-
ment is so painful that the patient must be auiesthe-
tized, and on awaking must receive full injections of
morphine. Kiibner fir.st curetted away the vegetations
or burnt them down with the thermo-cautery : then
afterward he treated an}' vegetations that appeared with
tincture of iodine.
Jarisch said he saw the lesions in atypical case of pem-
lihigus vegetans clear up with wonderfid celerity under
a paste consisting of: R Sulphur, prsecip., zinc, ox,,
amyli. aa 10.00; vaselin. flav.. 30.00. M. S. : Spread on
linen and ai)ply or rub into ]iatches. and dust witli some
indiffei ent powder, such as oxide of zinc and starch.
In pemphigus vegetans, however, these measures fqr
controlling tiie vegetations, no matter liow successful
locally, have no effect on the course of the di.sease. The
general symptoms of sleejilessness and exhaustion go on
unchecked. In fact it is the rule for the vegetations
spontaneously to cease appearing as the fatal termina-
tion approaches.
Neumann found solutions of salicylic acid apjdied on
549
Penis.
Penzance.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
cotton an excellent deodorant for tlie foul odor |iresent
in ]M'ini)liigMS vegetans. A jjowder made of I'ljual jiarts
of tale and saliejiic acid may also l)e iised-
In looking over the literature of lliedi-ugs and ai)i)lica-
tions used in i)emiiliigns, one cannot fail to note every-
where a tone of helplessness, with perhaps a slight
brightenitiir n]i "hen the continuous bath is mentioned.
The uooil CiTc'et of all the inlernal renicdies may. in al-
most all insl.anees. be reduced to their toine or sedative
action, and of the external remedies to their soothing
ell'ects. their power to diniinisli len.sion and burning, or
to control the evil odors and the undue activities of the
pvoijerne bacteria. Tlie trcutnienl. it is true, is still far
froin our ideiil of what etfeclive treatment should be.
Nevertheless, we have grounds for claiming that the
actual advance made in the Irealnicnt of pem|diigus is
by no means so small as upon fn-st thought it would
seem to be. Tlianks lo X<-umaiin's discovery of the true
nalureof pcinpliigus vegetans we are now able to save
many a ])alient from the niental worry an<l humiliation
of being Ihoughl to have a syphilitic dis<'ase. and from
the phvsicul snifeiing which he would have to undergo
bidore'it could be demonstratc'd by treatment that this
diagnosis was incorred. J>o>ii/liiss II'. Mdiitf/diiifn/.
PENIS, DISEASES OF. f^w Si.ni,il Ori/nns. Mitlr. D/'s-
PENNYROYAL. AMERICAN OR MOCK. — Htdrnma.
•'The dried leaves and lops of J/iiii,„iiii j,ii/ii/idi//ci< (h.).
Pers. (Miiithd ji. L. ; fam., Lnhiata)." U. H. ]'.
This is a slender annual herb, very abundant in dry, es-
pecially rocUy meailows and pastui'es throughout Eastern
and Ccnlral North America. The base of the stem is fre-
quently decundienl. The upper |)ortionis usually much
bnuiched, llie branches are slender, erect or ascending,
and iiuadrangular. the leaves opposite, slenderly petioled:
blades usually less than 3.5 cm. (1 in.), long, and 1 cm.
(i? in.) broad, oblong ovate, narrowed gradually into the
petiole, obtuse, distantly and slndlowly serrat<'. ]iale or
grayish-green, thin, with few, strongly ascending sec-
ondary veins, and the lower surfaces besi't with small,
circular, de|)i'e.ssed glands, which are usually golden-yel-
low and shining under a strong lens; (lowers several in a
leaf axil, peili( elh'd, the calyx tube cyliudraceous, some-
what contractt'd at the mouth, strongly nerved, its tube
two lipped and slenderly and sharply five-toot he<l ; corol-
la tubul,ar. two lipped, Jialc blue, S]iotted; stamens four,
two of Ihem st<'rile; odor strong, somewhat mint-like;
taste aromatic and pungeid.
With a lilile taiuiiu and bitter extractive it c<intains
nearly one jier cent, of a \(ilalile oil, ollicial under the
title Oli'iiiii llnhniiiiP, which is its active jioi'tion.
American pennyicyal possesses the carminative, aro-
matic, and dilVusive stimulant |n-oi>erties of the mints in
general, and is sinnlaiiy employed. There is no ollieial
preparation, but an infusion is jirobably the liest form of
administration. One of the imi)ortant properties of this
plant and of its oil is that of rcjielling mosquitoes, to a
considerable and useful extent.
Oil of ])i'nnyroyal is thus described: .\ pale yellowish,
limpid li(pnd, having a characteristic, piuigent, mint-like
odor and taste. Specific gravity, (;.!)a)-l'l.ill() at W C.
(50 F.). The oil should form a perfectly clear solution
with twice its volume of a mixture of three volumes of
alcohol and one volume of Avater. this solution being neu-
tral or slightly aeiil to litiiuis jiaper. It is also readily
soluble in carbon disidpliide, or in ghu i.al acetic acid. It
consists chiefly of pulegone. The dose is l-."> minims.
The geniiine or European pennyroyal is .)/, ullin Piilrgiuin
IL, {l'iili\'/iiii/i ru/r/(iir yiiW.) in the same lanuly. It lias a
sitnilar taste ami odor, ami contains an almost identical
volalileoil. Ill I, III II. Hiislii/.
PENTAL (Tri iiutlnil-ctliylene). a imiilied aiuylene, in-
troduced by .Mering as an ana'Sthetic. It is a eohnicss
liqni<l with a shar]i penetrating odor, but not irritating
to th<' imic<ms miiulnane. Speciiic gravity, O.tiTS; boil-
ing point, 100.4' F, It is insoluble in water, but mixes
fre(dy with alcohol, chloroform, and ether.
I'ental is administered in the same manner as ddoro-
form. Ana'sthesia is produced in three or four minutes
and lasts for about four nunTites.
Following ils introdm:tion |)ental was employed by
many as an ana'slhelic, with very satisfactory results,
but experimental work upon aiumals proved that it was
a powerful cardiac depressant, and al.so jnoduced marked
renal irritation. j\iany instances of dangennis dejiression
during ils use and several deaths were soon reported, and
it rapidly fell into ilisuse. JjcKviiiinit iSiiniU.
PENTASTOMA. See Ayw-J,ni</„.
PENTOSURIA is the term ap]ilied to the occurrence of
sugars of the live-carbon series (pentoses) in the urine.
The ])entoses (CslIuiOj) inchide the carbohydrates arabi-
nose, xylose, and rhanmo.se (CoHnOi). the latter lieing a
methyl jieutose. The appearance of sugars of this type
in the urine was lirst detected by Salkowski and .Tastro-
witz in the urine of a morphine habitue. Since then
similar observations have been m:ule on various individ-
uals. In some of these instances the pentosuria has been
founil to pi'rsist unchanged for many months and even
for several years. The jjentose cither occurs as the only
carbohydrate present in noticeable amount, or it may ac-
conqiany dextrose, the sugar of lu'dinary glycosuria.
Various methods of testing for jientoses in the urine
liave been ])rojK)sed. Of these the following are most
widely used ;
Tdl/iiif' Ikiictinii in'l/i P/iloiiif/liii'iii iindUCX. — A small
quantity of iihloroglucin is dissolved in 7-8 c.c. of HCl
(specilic gravity, 1. Vij with the aid of heat. After cool-
ing, ten drops of the urine are added to one-half of the
reagent, and the nuxture is immersed in a boiling water-
bath. In the presence of pentoses a cherry -red coloration
ipiickly residls. An immediati; spectroscopic exauiina-
tion reveals a characteristic absorption band between the
D and E lines. The remainder of the reagent is used for
a control comparison with normal urine. The presence
of dextrose may interfere with the reaction. (Siilkowski's
modification.)
7'ijUiiis' Jimi-tioii- irith Orrin and IICl. — The urine is
mixed Avith an equal volume of fuming IICl containing
orcin (instead of phloroglucin) and heated. After cool-
ing it is shaken with amyl alcohol, which assumes a
gre(>nisli tint. In this reaction the characteristic spectral
absor])ti(m band is betw'een C and I). Salkowski prefers
the orcin test to all others.
Henrtiiiii in'lh AhlUiu-iicetiile Pu)irr. — The urine is
treated with an eqmd volume of fuming IICl and lieatcd
to boiling. If a strip of filter pajier, moistenecl with ani-
line acetate, is now immersed in the fluid, it is (juickly
colored cherry-red by the finfurol formed from the pen-
toses present.
JJIjinitiuii of Fii rfii ml hi/ DiMilhilinn irith IICl.— The
method is essentially the same as that used in the estima-
tion of the pento.sans in foods. The furfin-ol may be de-
tected in the distillale by the use of aniline-acetate paper.
Normid urine or urines containing dextrose or lactose do
not ordinarily give any positive reaction.
I'trjiii riitiini nf n Pi iitnsitzoiii'. — Theosazone is jireimred
willi pheiiylhydrazin and acetic acid as in the ordinary
tests for sugar. (See Vn'm'.) The pentosazone ischarac-
teriz<'d by: (t) lis greater solubility as compared with
glucosazone; and (-) ils melting ]ioint, l.")(i -100' C,
When large (luantities of dextrose are presi'Ut, tlu'y may
lireviously be removed by fermentation with yeast. The
pentosi's do uol ferment, but the_v reduce alkaline copper
solutions,
Pripiiriitiiiii iif till- Benzoyl Fntrr.—'Vhv benzoyl esters
are |irepared from .jOO c.c. of urine, then saponified with
.sodium ethylale. and the mixture istilteredat once. Tlie
tili.rat(^ will give the orcin reaction for pento.ses (see
above), and glycuronic acid is said to lie excluded.
When ileXIrose is ju-esent slight inodifiealion of the
method is desirable, (von .Ml'lliaii.)
r).)(l
REFERENCE HANDBOOK OP THE SEEDICAL SCIENCES.
Penis.
Penzance.
In consideriiifi the possible origin of the pentost' found
in tlie urine, tlie wide distribution of tlie five-earbon oar-
boliydrates in the vegetable kingdom, as shown by Tol-
lensand others, must be recalled. In the form of jiento-
sans they may enter into the diet. Such jiiecursors of
the pentoses occur in certain fruits, like cherries and
plums for examiile. In animal tissues precur.sors of the
pentoses are also found, notably ir the pancreas, from
^yhich the carbohydrate may be obtained, combined as a
glyconucleoproteid. Neuberg has shown the pancreas
pentose to be ^xylose. When fed as such, the pentoses
are apparently not well assimilated. Regarding their
occurrence in the urine, it seems probable f rom'thc^ meagre
data at present available that we must look to metabolic
processes for au explanation. For there is no evidenc<^
that the diet in the cases on record was particularly rich
in jientoses, and in one instance at least jtentoses were ex-
creted for a long period on an ordinary diet. Further-
more, the urine pentose is the optically inactive racemic
arabinose, and is probably a synthetic product. The
pentosuria seems comparable to those perversions of me-
tabolism which are seen in severer forms of diabetes in
which the sugar excreted is independent of the diet. In
accord with this are the observations of Kid/, and Vogel
on diabetic patients and on dogs suffering fiom experi-
mental diabetes. They wd'e able to detect pentoses in
company with the dextrose jiresent in the urine in several
cases. Regarding tlie immediate precursor of the urine
pentose in the body nothing deliuite is known at |)resent.
Lafayette B. Mcndil.
Refere.xces to tue More Impouh.xt Papers o-x Pentoses in
the l'kine.
Salkowski and Jastrowitz ; Centralblatt fiir die medicinischf^n Wissen-
sehaften. lst|2. No. I'.l. No. 32.
E. Salkowski : Berliner klinisrhe AVochenscIirift, 1895. No. 17, p. ;««.—
Zeitsoliritt fiir plivsiolnirische Cheniie, 1S99. xxvil., p. .507.
F. Bluinenlbal : Berlmer kliuische Wochenscbritt, 1895, No. 26: 1S97,
No. 12.
Kiilz and Vofrel : Zeitsrhrift fiir Biologie. 1896, .x.xxii., p. 185.
Reale : Jalire.sl)enc-iil fiir Tliic-rrlieniie, 1894, xxiv.. p. 627.
Colombini : Jalii"esberi'-bt fiir Thit*rclieiiiie. 1897. xxvli., p. 7;i3.
von Alftlian : Archiv fiir experimentelle Palliologie uud PUamiako-
logie. 1903, xirii., p. 417.
Bial : Zeitschrlft fiir kliriisphe Mediciu, 19110, xxxix., p. 475.
Meyer : Berliner kliniselie ^Vor■llenschrift. 1901, No. 30.
von Jaoksch : Zeitscbrift fiir Heilkunde, 1899, xx., p. 195; Deutscbes
.^rchiv furkUniscbe Medicin, 1899, Ixiii.. p. 612. (.Alimentary pen-
tosuria.)
Neuberg: Beriobte der deutsi'ben cliemisoben Gesellschaft. ISKXI,
xxxiii., p. 224:j. (Nature of tlie urine pentose.)— i(»it/., 1902, xxxv.,
p. 1472. (Tlienretieal eonsiderati^ms.)
PENZANCE AND THE SCILLY ISLANDS.— Tliese
two localities on the extreme southwestern coast of Eng-
land, although jmssessiug no great xalueas health resort s.
are taken as representatives of the mild winter marine
climate of the south of England. "Penzance appears to
be warmer in the winter than any other place on the
mainland of England from ■which we have records " (Dick-
inson, "Climate and Baths of Great Britain"), and the
temperature of the Scilly Islands for the same season is
still higher. Ulildness tuid equability of temperature is
about all that can be said in favor of such resorts as the
above, as ^yell as of others in the same county of Corn-
wall and in the adjoining one of Devonshire, the most
noteworthy of which is Torquay. Such a climate has
been resorted to by consumptives and by patients htiv-
ing other iiiHammatoi-y respiratory affections, notably by
those patients with bronchitis who require a moist air.
As will be observed from the climatic chart of Pen-
zance, the temperature range throughout the year is
comparatively small. It is neither hot in sumnier nor
cold in winter. Ki-ost and snow are rare. The mean
temperature for the three winter months is 43' !■'., while
the mean of the coldest is 411' P. The relative humidity
for Penzance is not obtainable, but it probaldy does not
differ much from that at Falmouth, twenty-tivc miles to
the East, which is eighty-two per cent. ' At the same
place (Falmoulh) the amoimt of sunshine is said to be
greater than at any other place in England except Jersey,
and it is therefore a fair inference that Penzance is also
similarly favored, althouirh it is said to have more mist
than Falmouth. Everywhere in England tJiere is rain
enough, and Penzance, it is seen, has its share, the an-
nmil rainfall being 4"3..">9 inches. The winds from the
nortli and .south are equally common, while tho.se from
the west are more prevalent th;ui tho.se from the east.
Prmzance has a southeastern exposure, and is shellered
from the prevalent west wind by the higli coimti-y alioiit
the Land's End, and "very coin|)letely fi-om the north
by elevations of from five hundred to seven hundi-ed feet
within four miles. It is exposed, howe\-er, to the east,
although some protection can be obtained by a choice of
residence" (Dickinson, loe. cit.). With so "many unfa-
vorable climatic features — the large amountof rain; the
high humidity: the wind aifd the relativ<'ly sm;ill num-
ber of sunny days, although large for England — such re-
sorts as Penzance cannot compare with nuiiiy other mild-
wiuter marine ones except asregai'dsc(iuabiiity ; such, for
example, as those on the Mediterranean coast, on the Pa-
cific coast of Southern California, on th(^ (Julf juid Atlan-
tic coasts of Florida, and many insular resorts. For the
inhabitant of England, however, who desires for any rea-
son a mild and equable winter climate, it offers an easily
accessible retreat.
CLI.MATE OF Penzance, England, Latitude, 30° S' North.
Years.
Ten
Temperature (degrees F.)-
Mean monthly average . 43.2*
Mean daily range 6.0
Mean of wannesi | 46.3
Mean of colde.st ' 40.2
Higliest or maximum ... 5S,0
Lowest or minimum ... I 21.0
Precipitation —
Average in incbes 10.81
Wind— '
Prevailing dii-eetion ' 8. W".
=:
c
■Es|
a:
c
52.4°
.59.8°
47.7''
9.7
9.5
6.1
.57.4
64.6
.50.6
47.5
.5.5.0
44.5
77.0
76.0
64.0
33.0
39.0
26.0
6.65
9.54
15.59
N. W.
S. TV.
N. W.
Year.
50.7°
7.8
54.7
46.8
77.0
21.0
42.59
S. W.
The situation of Penzance is very iiictiiicsque, as in-
deed are so many of these se;iside towns in Cornw;ill and
Devonshire. Theieax' :ilso numerous attractive excur-
sions in the neighborhood and in the adjacent district of
Land's End.
The vegetation of Penzance and its neighborhood is
yer3' luxuriant and rich, and it seems quite extraordinary
that in the latitude of .50', that of Southern Labrador, one
should find exotics flourishing in the open air, even in
winter; geraniums and fuchsi:is attaining the dimensions
of large shrubs; aloes liourishing, and hollyhocks, mi-
gnonettes, magnolias, and roses blooming, sometimes even
iu .January . Potatoes are cultivated extensively, and sent
to London and elsewdiere during the winter months. A
marked difference is noted between the north and south
coasts, although only ten miles ajiart, not only in the
vegetation, but also in the character of the climatic effects.
On tlie north coast, the vegetation is far less luxuriant
and the climate is more bracing and exciting.
The Scilly Islaiuls, although but little resorted to bj^
invalids, represent an interesting phase of climate, and
present many attractions from their |iictures(iue situa-
tion, as well as from the fact that the Bishop lighthouse,
which marks the group, is the first evidence of land
which greets the Transatlantic voyager as he enters the
Engli-sh Channel. The grotip. consisting of forty isl-
ands, some only tiny specks, lies about forty miles S(nith-
west of Penzance, from w hicli il is re:iched in four hours.
But five islands are inhabited, and but one, St. Mary'.s,
possesses any satisfactory accommodations. This island,
which is the largest of the group, contains sixteen
hundred acres, an(i no ])art of it is a mile from the sea.
The scenery is of a peculiar and weird grandeur, girat
masses of granite clilTs standing out again.st the se;i iind
storms. In this country the Isles of Shoals, olf the New
Hampshire coast, would aj'pcar to bear a close resem-
551
Pepper.
Peppor:iiIut.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
blance to the Scillies both in situation, iu tlic open Atlan-
tic, and in their granitic formation and bold rugged
scener_v. "'I'lu' air here (Scilly) is as marine as on the
deck of an Atlantic steamer. " Every sight and sound
tells of the sea, the influence of wliicli is here paramount
iu every shape " (Dickinson, " The Climate of Cornwall,"
in "Climates and Baths of Great Britain"). Tiie ex-
posed portion of the island of St. ilary's is treeless and
bare: but in the valleys, and wlicrcver artilicial protec-
tion is afforded, the vegetation is luxuriant and almost
tropical. Myrtles, fuchsias, geraniums, and aloes grow-
in great profusion, and jialms and bamboo are abundant.
"In the gardens of Treseo, unprotected except by the
eontiguration of the ground, a mass of tropical vegeta-
tion presents itself which I sujipose has no equal in Eu-
rope " (Dickinson, /",■. cit.). The cultivation of the nar-
cissus for Coveut Garden is the chief industry of these
islands. Tlie climate is relaxing and soothing, a type of
a mild, moist, marine on<', with great equability. From
the chart the mean yearly tenqieiature is seen to be 53.4",
the highest in England. The mean for the three months,
January, February, and jNIarch is 4."). 3". The relative
humidity is high, and the rainfall large. The islands are
fully e-xposed to the east and west winds. The former
are especially felt in spring. Whatever value such a
climate has must consist in its wariuth, equability, and
humidity, together with the marine influence. About
the only conditions which appear to be favurably influ-
enced by such a climatic combination are intiaiumatory
atfeetions of the respiratory organs other than ]ilitliisis.
esjiecially bronchitis. Chronic renal disease may also do
well in such a climate, although the humidity is not a
particularly favorable factor. A very charming dcscrip-
tiim of the' scenery of the Scilly Islands will be found in
Sir Walter Bcsant's " Aniorcl of Lyonnesse."
Several other resorts in Cornwall and Devonshire, pos-
sessing .somewhat similar climatic features, may be men-
tioned in this connection. On the south coast are Fal-
mouth, Mara/ion, Torquay, Sidmouth, and other small
resorts. On the north coast are St. Ives, Newquay-,
Tintagel, and Boscastle iu Cornwall, and Ilfracombe.
Lynniiiuth, and Lynton iu Devonshire. The resorts on
tlie north coast are frequented only in the spring, sum-
mer, and autumn.
Climate ok the Scilly Islands, England, Ten Years.
ffl __ ~
April
to
June.
July
to
Septi'inber.
n
Year.
TemptTaturenli-trreesF.)—
Mean iiumthly averaert*..
Mean tlaily raime
Mean i>f warmest
•tS.T
•ll.s
.57.0
2a.(J
ST?
7.(K
W.
S.U
.■».',)
4T.9
73.0
36.0
S4^
5.,54
N.
62.9°
8.0
63.4
.T.5.4
7.5.0
44.0
8.5!«
7..53
W.
49.7°
6.3
53
46.7
65.0
32.0
85?
11.52
W.
53.4°
7.1
.5.5.2
47 i*
Highest or maximuiu ...
Lowest or miniiimm —
Humidity—
7.5.(1
2SI.0
85S
Preciiiitation—
Average in incbes
Wind-
Prevailing direction —
32.23
W.
Edinird O. Otis.
PEPPER, or BLACK PEPPER.— /^//Jfc, U. S. P. : Pi-
per Air/rum. Br. P. The dried, uearly ripe fruit of Pi'jkr
nigrum L. (fam. Pipernnii').
The pepper plant is a native of India, but commercial
pepper is wholly the product of cultivated plants, and
comes chiefly from the East Indies, that of Penang being
preferred. The plant is a woody climber, and is trained
chiefly to the betel tree. The fruits are produced in
aments. somewhat resembling strings of currants. Upon
ripening tliey turn tinst red. then yellow. After the lat-
ter change their properties are largely lost. They are
tlierefore gathered and dried when they begin to change
color.
Descuiption. — About 4 mm. (J in.) in diameter, nearly
globular, blackish, very strongly reticulate- wrinkled,
bearing a low style base at the summit and consisting of
a thin fleshy pericarp and a crustaceous, whitish puta-
mcii containing a more or less undeveloped seed ; odor
characteristic, strong ; taste strongly aromatic and pun-
gent.
A transverse section of pepper shows a layer of large
resin cells near the surface, and beneath this a soft paren-
chyma (shrivelleil in the dry state) containing starch and
oil drops. The inner portion of the pericarp contains
large oil cells and the seed shows lirownish masses of
amorphous piperin.
Piper Allniia, or Wliiie Pepprr, is pepper with most or
all of the fleshy portion removed, either before drying or
by subsequent grinding. One variety consists of the
very young fruit dried entire. Its pungency varies ac-
cordingly. If nearly ripe when gathered, it is less pun-
gent than it is when the innermost layers of the .sarcocarp
have been rubbed or ground away, since these are rich
in the active constituent.
Composition. — Tlie pungency of pepper is due to the
presence of ten or twelve per cent, of soft, very slairp-
tasting resin, which is contained, as indicated above,
mostly in the cells just beneath the surface. An essnifiuC
nil of clear white color, having the full fragrance of the
spice without its biting taste, exists to the extent of one
or more per cent. The third and most peculiar ingredient
is the neutral, crystalline, tasteless, and inodorous sub-
stance piperin, which exists to the extent of from two ta
eiglit percent. It was discovered by Oerstedt in 1819.
Piperin is scarcely soluble in w-ater, but dissolves moder-
ately well in chloroform, ether, and alcohol; at 212° F.
it melts to a yellow, oily liquid. Besides these, starch,
mucilage, and albuminous matters are found, as in other
vegetable tissues.
Action and Use. — Applied to the skin, pepper is rube-
facient, and finally painfully irritant. It is occasionally
sprinkled over the surface of other applications for this
effect. In water it is a popular but painful gargle for
"sore throat." Taken internally, it is in small do.ses a
stimulant, in large ones an irritant to the stomach — that
is, it acts like most other spices. It has been given as a
specific in the treatment of hemorrhoids, but is out of
use for this purpose. As an antipcriodic it is also obso-
lete, although piperin is occasionally mentioned in this
coimection. Whole |ieppers were formerl}- swallowed for
the cure of some cases of dyspepsia. Dangerous .symp-
toms— "rigors, convulsions, and delirium" — have been
said to follow the immoderate use of pepper (Phillips).
Although a typical spice, pepper is much less em-
ployed in medicine than ginger, cardamon. and cinna-
mon.
ADMiNisTR.vnoN. — For dy.speptics or others needing
spices, there is no better way than to eat it on the food,
or if a larger quantity is indicated than is agreeable to
the taste. 0..5 gm. (gr. vij.) or less may be given in pills
or in a bolus, with honey, two or three times a day; or
four or five drops of the nleoresin. (Oleoresina Pi juris,
V . S. P.. strength about y) may be taken if a more com-
pact and stronger dose is needed. Dose of piperin, 0.5
gm. or less.
Allied Plants. — The genus is a very large one. of six
hundred sjiecies. of exclusively tropical plants, mostly
shrubs, and frequently, like the present one, climbers.
Many of them have pungent fruits. P. ftffieinitnnii Cas.,
D. C'., and P. hmgum Linn., are the sources of " long pep-
per," which comes in compact spikes one or two inches
(3-5 cm. ) long, and about a sixth (0.5 cm.) in diameter.
Its constituents are identical with those of the above, but
its flavor and strength are inferior. Long pepper is never
sold at retail in this country, yet it is a common article
in wholesale hou.ses; it is iirobably used as an adulterant
of black pepper. P. hetU Linn, is an East Indian vine
whose leaves are chewed witii ari'ca nuts as a masticatory
(or a habit) by many aboriginal tribes i>f the great Poly-
nesian Islands (see also L'abeti. Maticu, and Kam).
\V. P. BoUea.
552
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pepper,
Peppermint.
PEPPERM[N^.—^fent/la Piptrita.—"rhe dried leaves
aud tops ul Mentha Piperita L. (fam. Lahiata)," U. S. P.
Peppermint is a slender, nearly smootli. perennial herb,
native of Europe, widelj- naturalized in temperate regions
and cultivated upon a great scale for the herbage, for
culiuarj' uses, for tiavoring and perfuming, for medicinal
employment, and for the distillation of its oil aud the
preparation of menthol. It spreads by runners, produc-
ing frequently dense beds of slender stems about a j'ard
long, ascending from a prostrate rooting base, quadrangu-
lar, frequently purplish, and bearing leaves and flowers
described below. The stems and leaves are very spar-
ingly' and obscurely hair}', the hairs short and stout, usu-
ally contiiining menthol crystals in one or more cells;
leaves opposite; exstipulate, petioled, the petioles winged
toward the suiumit, the blades usuallj' less than 5 cm.
(3 in.) long aud about half as broad, ovate, witli the
rounded base very abruptly produced into the petiole,
acute, sharply serrate, thin, wrinkled, of a bright aud
usually light green; flower spikes oblong or oval. 1-2 cm.
(I~5 '"• ) hroad, with rounded summit, dense, or somewhat
interrupted at the base; flowers about 6 mm. {^ in.) long,
the calyx tubular, ten-nerved, scarcely two-lipped, five-
toothed; corolla light purple, nearly equally four lobed,
or one lobe (consisting of two united) a little larger;
stamens four, short, equal; fruit of four ovoid, smooth
nutlets; odor strong, but not heavy, characteristic; taste
characteristic, pungent, and cooliug.
The leaves bear numerous globular oil glands and slen-
der, several-celled hairs which often contain menthol
crystals.
The drug contains, with a little tannin, about one per
cent, of a volatile oil, which is tlie active constituent, is
official under the title OJe'nn Ment/uf Piperita!, and is de-
scribed as follows in the Pharmacopoeia:
A colorless, yellowish, or greenish-yellow liquid, be-
coming darker and thicker by age and exposure to the
air, having the characteristic, strong odor of peppermiut.
ana a strongly aromatic, pungent taste, followed by a
sensation of cold when air is drawn into the mouth.
Specific gravity, 0.900-0.920 at 15' C. (59° F.).
The oil dues not fulminate witli iodine.
It forms a clear solution with an equal volume of alco-
hol, becoming turbid when somewhat further diluted, and
is soluble, in all proportions, in carbon disulphide, and in
glacial acetic acid.
The alcoholic solution of the oil is neutral to litmus
paper.
If five drops of the oil be added to 1 c.c. of glacial
acetic acid, and the mixture gently warmed, the liquid
will assume a blue color, with a red fluore-scence.
If 2 c.c. of tlie oil be mixed with 1 c.c. of glacial acetic
acid, and one drop of nitric acid added, the liquid w ill
soon acquire a green, greenish-blue, blue, or violet tint
Tvith a copper-red fluorescence.
If 1 c.c. of the oil be dissolved in 5 c.c. of alcohol, 0.5
gm. of sugar and 1 c.c. of hydrochloric acid added, and
the mixture gentlj' heated, a deep blue or violet color
will gradually be produced.
If to 5 c.c. of nitric acid one drop of the oil be added,
and the mixture gently agitated, and allowed to stan(i
for about three hours, it should have a yellowish, but
not a bright red, color (absence of oil of camphor and of
oil of sasmfras).
If a portion of the oil, contained in a test tube, be
placed in a freezing mixture of snow (or pounded ice) and
salt for fifteen minutes, it should become cloudy and
thick, and after the addition of a few crystals of men-
thol, being still exposed to cold, it should soon form a
crystalline mass (distinction from detiientholized oil).
When heated on a water-bath, in a flask provided with
a well-cooled condenser, the oil should not yield a distil-
late having the characters of alcohol.
This oil contains as its active portion the peculiar sub-
stance menthol, considered separately under that title.
A good article has been foimd to contain about sixty per
cent, of total menthol, about one-fourth of it occurring
as ester, the remainder free. However, the percentage-
and composition of the oil, as produced in different coun-
tries, and even in different parts of the same country, va-
ries widely, not only as to the percentages, but even as
to the nature, of the compounds.
Action and Use.— Notwithstanding that menthol is
the active constituent of peppermint and its oil, yet the
action and uses of the latter and of that constituent re-
quire separate consideration.
Peppermint and its oil are, from their taste and agree-
able action, the most generally liked of all the mints, if
Fic;. £^793. — Peppermint
Plant, .tliout one-half
(liailldu.i
natural size.
not of all carminatives. This oil is warming and stimu-
lating to the stomach, very seldom irritating. It is a
favorite household remedy for nausea, flatulence, and
colic; applied to the skin and evaporation prevented, it
is a mild stimulant, useful in neuralgia aud rheumatism;
applied to the forehead and temples it produces a grate-
ful, cooliug feeling, with a little tingling that occasion-
ally relieves slight headaches; this property is mostly
due to the menthol it contains. The most common em-
ployment of peppermint oil by physicians, however, is as-
a flavor, vehicle, or adjuvant of other medicines, espe-
cially of cathartics, whose griping it imdoubtedly dimin-
ishes. Like most mints, peppermint is frequently used
in hot infusion in colds, etc. It is also a favorite flavor
for candies.
The powdered drug is sometimes given in doses of 1-2
gm. (gr. xv.-xxx.). There is, properly speaking, no
553
PppNin.
Pcp^iu,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
official prei)aration of it, thoujih the official spirit rou-
taiiiS'oiK' per ci'iit. It is often ^iven in llie form of tlie
infusion. Tlii^ common form of iidniinisliation is that of
the oil (dose 1-5 m.), or of (lie followinn- preparations of
it; The Spirit or Essence (Spiritiiy Mail/in' I'ipri-iiu) con-
tains ten per cent, of (he oil, and tliere is tliree and a
half percent, of it in (lie popular nii.\tiire of vhnbarlj
and .soda. The dose of (he spirit is(l.:!-l c.e. (niv,-.\v.).
Peppermint water (Ar/i'/i Miiilhir iV/w/vYir) contains 0.:3
]ier cent, of the oil and is given in dd.ses of l.VliO e.c.
(tl. rss.-ij.). The official troches eaeli contain 0.01 c.c.
(ahniil, lit','.) of tlie oil. //' "/// II- Ii'ishi/.
PEPSIN. — A/«//"////, r. S. 1'. "A proteolytic fermeut
or cn/\ me olilaiiied from the s'siU'l"''"' layer of fresh
slomaehs from healthy (li^js. and ca])ahle of digestinj,'-
not less than three thousand tiini's its own weight of
freshly co.auulated and disiiilcyrated eg;; albumen when
tested by tiir jiroecss ghcn below."
Our presi'iit kiiiiwledge and conception of pe|isin have
been arrived at liy the inevitable, slow, intermittent
prourcss in .science, niarUed by brilliant epochs and re-
tarded and cloudeil by faulty and incomplete observ.a-
tions and erroneous theories. The investigation of fer-
ineiils and termcnt action liiis necessarily involved the
whole field of problem and ini|uiry in biohiiry. The his-
tory of pepsin, therefore, is biuiid in the voluininoiis re-
((irded labors of a host of workers. In briefest po.ssible
mention it begins jierhaps with the first perception by
Rorelli. three centuries ago (ICOS-lGTiV), of the existence
of secreting glands in the stomach and of the value of
gastric jiii(-c; then the studies of the gastric juice of re-
gurgitating birds, which estalilished the inde|iendeiice of
digestion of inechanieal jxiwer (an early theory) and of
chemical change produced on food (Itenumur, 1752). In
1772 Hunters observations estalilished the fact oF the
post-mortem digestion of the stomach by its own juices,
it was in 17S3 (hat tla^ first demonstration in titm with
imre animal gastric juice obtained by ingenious devices
from living animals (S|iallau/.ani) was made. At about
this time also were made the first recorded clinical re-
sea'.i h s in regard to gastric juice as a surgical solvent
and as an internal remedy — researches which were in-
spired by Spallanz.ani and made by bis colleagues, Juriiic,
Carmiiiati. Senebier. and others. !Many interesting and
singularly clear and detailed observatinns are recorded in
relation In the gastric juice of beasts and liirds, its pro]!-
crties, behavior with various foods, etc.. and its aclinii
when used as a topical apiilicatioii; anil it was oliserved
to have the ]iower "to remove all disagreeable smell from
fetid ulcers, to give them a clean apiiearance. to change
the iiuanlity and i|Uality of su|ipin'ative inafter, and
obtain a speedy cieatri'/.atien." It w.as employed thus
.successfully for tiiiiKus. ulcers, gangrem'. old sores, ab-
scesses. I'tc, and interiinlly witn benetit in "weakness of
the stomach and all iIki'-c rilfeclioiis (irodnced by faults
in this tliiid and |ia!ticularly by its diminution in point
of {|iiantity and energy for the purpose of digestion."
Very remarkable elTeils were particularly noted in a "case
of grailual emacialion with cuntiniial nausea and vomit-
ing. "
111 1H2t Prout, Tiedemann, and Gmelin discovered hy-
drochloric acid ill the gastric juice. In 1S34 Rcanmont
made bis classical oliser\alions, and drew the faulty con-
(diisioii that gastric juice was the soli' digestive Huid and
formed gasi rites \\itli food. In I he s.iine \'eai" an im]»etus
was given to thi' study of gastric juice by f^herle's sugges-
tion anil useof infusions from the stomach glands. This
led (o (he brilliant and careful researches of Schwann
(iis;!(i) upon the active principh' of the gastric juice— its
behavior, iiieory of action, method nf scpm.-itinn, etc.
He gave to this principle the name "pepsin." In 1843
I.ehniann )iiiblisiieii ills theories as to the protein nature
and cellular origin of pepsin, and its action in the trans-
formal ion of albuminoids into alisorliiibli' substances.
AVasmann also pui forward at the same time Ihe theory
that pipsiii is the granular matter of the c I! .,r tlie sub
stance from which il is binned. In Is5^-."iS Coivisart
and Reale suggested the use of pepsin itself in medicine.
In 180-4 Hop])e-yeyler classified the various forms of pro-
teids according to their solubility and precipitaliility by
various neutral alkali salts, this classification, by reason
of the similarity of jiepsin in these lespects to other pro-
teiils, leading to the present methods by which pejisin is
]iroduced by these reagents. Schotrer's suggestion and
develo])ment of sodium chloride as a pepsin ])recipitant
were inspired by his observations of this reaction of pro-
ti'ins.
Pepsin is now ]iroduced from tbesbiniaeh willi the same
fieility as quiuiiie is made from bark; for. in view of its
peculiar origin and nature and siiscei)tibilities on the one
hand, it is singularly capable of extraction and utilization
in a iiractical way as an article of commerce. During
the last half of the twentieth century, with its accurate,
scientific methods of research, and especially during the
jiast thirty years in which [leiisin lias been increasingly
utilized, it, as well as the gastric extract and gastric juice
itself, has been the subject of elaborate investigation, and
we have now exhaustive data concerning pepsin from a
pliarmaceutieal stand ])oint.
Great therapeutic interest attaches to the very recent
methods of Pawlow for obtaining pure gastric juice from
the living aniinal (dog), to his ]irofound studies thereof,
anil to the free administration, by Fremont and his col-
leagues, of this juice in eases of disease of the stomach.
They gavi; it in ipianiities that sometinies amounted to
as much as 500 c.c. per day, and the results which they
obtained were at times brilliant. They also used gastric
juice as a topical application, noting its solvent, healing
and sedatives action; this latter quality was also attrib-
uted to it wiien administered internally. Freuiont con-
siders this animal gastric juice to be especially adapted
to all cases of hy]>osecretion of the stomach, whether re-
sulting from glandular ulceration, from acute or chronic
infeetiou, or from disease of the liver, heart, lungs, and
nerve centres. Under its influeuce dyspeptic phenomena
have disap]ieared more or less promptly, and a remark-
able gain in weight and strength has taken place. Pa-
tients who liave sullered acutely from dysjiepsia, and
who have become extremely emaciated, liave also ob-
tained complete and permanent relief under the use of
the remedy.
Pawlow csiiecially calls attention to the fact that gas-
tric juice is now pharmaceutically available as a clinical
agent. Others have argued t hat with a corresponding free
use of iie|isin and acid similar results may be obtained.
Inasiir.ieh as the healthy stomach of recently killed
animals affords a resource for gastric juice in a very con-
centraled form, rendered iierfectly ]iiire by simple means
of clarification and filtration, sterile, and free from objec-
tionable odor and taste, there is good ground for the (ire-
siimiition that the fullest therapeutic (lossibilities of the
gastric juice maybe realized without the elaborate meth-
ods resorted to in obtaining (lie secretion from the living
animal. These observations, which re|iresent the last
Avoid of modern achievement in this p.artieiilar field, give
great interest and significance to the early discoveries of
Spallanzani and bis colleagues, and to the fact that they
attracled no further attention and were thus barren of
result.
Pepsin is found in the gastric cells of all animals, but
the gastric juice of the earnivorais iiiiieh more powerful
in proteolytic action. Peiisin itself, however, has no
liartieular degree of energy or iieculiarity of acdon from
any iiarliciilar source; its "strength" is strictly in ratio
to its degree of isiilation from the associated noii-]ieptic
materia! of the gastric cell or juice, and from the agents
used in its sc]iaralion therefrmn. The licpsin, obtained
from one creature, tliercfnre, is not stronger than that
obtained from aiiotlier. In the gast tic juice of the dog,
it is to be iioled that the peiisin is associated with a (le-
culiarly high )ierceiilage of HCl.
Pepsin is norma I ly ussdcialed also with another distinct
ferment — the milk curdling enzyme — which is very ener-
getic ill the sm kling animal. The ultimate coiii]iosition
of [lepsin, the inethoil of its ela.boratiini from the cell, the
REFERENCE HANDBOOK OF THE IffiDICAL SCIENCES.
Pepsin.
Ft-psin.
nintio of its action, and Its relutiou to the otlier couslilii-
euts of the gustric juice, protcid, liydrochloric acid, aud
inorganic salts, liave been the subject of laborious re-
search and of specidatiou. and arc receiving increased
attention in the progress and practical interest of biologi-
cal study.
Pejisin is a sol\d)le, unorganized ferment, an enzyIll'^
liaviug the properly of converting native ]noleids into
.soluble, highly ditVusible, uon-coagulablc proteids. Its
action is exerted only in an acid medium, most freely in
the presence of 0.2 per cent. ab.solute acid, slight varia-
I ions from this not sensibly iidluencing its action ; if the
]iroportion of acid, however, be materially increased —
say, to 0.3 per cent. — the en/yme is mu<-li enfeebled.
Pepsin e.\erts freely its chaiacteristic action in the
presence of organic acids in general — lactic, tartaric, cit-
ric, (!tc. Notwithstanding the fact tliat the fei'ment is
.so closely and characteristically related to the IICI. the
mineral acids in general are not favorable to its action,
phosphoric being the only one which approximates at
all to the HC'l in its affinity to the enzyme ; nitric and in-
tro-muriatic acids are distinctly tmfavoiable.
Pepsin exhibits considerable activity at a temperature
much below the physiological, converting albumen
slowly even at ordinary room temperature (00 -70 F.),
and its action is completely arrested only at a temjier-
ature of about 40 F., aud greatlv accelerated at 120'-
130' F.
Pejisin does not exist preformed in the gastric cell, but
is developed from the mother substance, pejisiuogen, aiul
under the intluence of the acid simultaneously secreted
in the gastiic juice. This view lias for a long time bei'ii
enl<'rtained, and very recently peiisinogen has by Glae.s.s-
ner been ]H'epared free from ))e]isin and found to be de-
void of proteolytic piower. This pepsinogen was found
pi-omptly to dcTclop into pepsin iiniler the intluence of
both mineral and orgaiue acids; while oxygen and neu-
tral salts were without cfTcct, and alcohol, ether, and
chloroform proved destructive.
" If it be desired to u.se a diluent for reducing pepsin of
a higher digestive power to that required by tlic Pliarma-
copceia, sugar of milk .should be employed fortius pur-
pose.
" A fine, white, or yellowish- white, amorphous powder,
or thin, pale yellow or yellowish, transparent or translu-
cent grains or scales, free from any olTensive odor, and
having a mildly acidulous or slightly alkaline taste, usu-
ally followed by a suggestion of bitterness. It slowly
attracts moisture when exposed to the air.
'"Soluble, or for the most part soluble, in aliout one
hundred jiarts of water, with more or less opalescence;
more soluble in water acidulated with hydroeldorie acid;
insoluble in alcohol, ether, or chloroform.
"On heating a, solution of pepsin in acidulated water
to 100° C. (212 F.) it becomes milky, or yields a light,
fidcculent preci]iitate, and loses all proteolytic power.
In a dry state it can bear this temperature without in-
jury.
"Pepsin usually has a slightly acid reaction. It may
be neutral, but should never be alkaline."
I'lpKiiiiiiti SiicrlKirtiliiiit. U. iS. ]', — "Pepsin trituraleil
with milk sugar in such proportion that the restdtant
saccharated product shall digest three hundred times its
own weight of coagulated egg albumen underthe United
Slates Pharmaeoi)0'ia method of valuation for pe|isin."
Pepsin of the I'rilish Pharmacopo'ia is of 1-2.000
strength. The United States Pharmaeop" ia method of
valuation (that of the lirilisli Pliai'maeopfcia is similar) iu
brief is this: O.OO;! gm. of liejisin is re(p.'ired conit)iet(ly
to digest 10 gm. of liard-l)oile<l eumminuted egg albumen
in 100 c.c. of a 0.2-])er-cent. solution of absolute HCI
iu distilled water, tlu' mixture ni.'.iutained at a tempera-
ture of 100'-104' F. for six liours, and the llask shaken
gently every tifleen miinites. At most only a few thin,
in.soluble Makes should be left, pi-psiu lluids nn;st be
assayed aceordiug to the United .States Pharina('op(eia
method, the conditions jirescribed being sti idly adliere<l
to, but use being made of a corresponding projiortion of
the fluid to represent the amount of ferment necessary to
digest tlie 10 gm of albumen.
Pepsin of the United States Pharmacopoeia and Brit-
ish Pharmacopada requirements is obtained by precipi-
tation, with neutral salts, of the alkalies froiu purified
infusions of the fresh, healthy stomach glands, and the
precipitate purified by mechanical means — by rcpreeipi-
taliou and dialysis. By tliis means mucus is whollv, and
non-peptic proteids an<l peptones well, separated.' The
vKtioniiJc of the process w ill ajipear in the consideration
of the nature aud behavior of the enzyme.
No official method is given in the United States Phar-
macopadaor in the Briti.sh Pharmacoixjcia; their stan-
dards make obsolete the cruder, earlier forms. It is to be
regretted that European standards ai-e so greatly inferior,
for a uniform, definite, adequate jiharmacopceial stand-
ard for pepsin of commerce is absolutely essential. In
the past pepsin lias been too commonly of insignitieant
value — even inert; and variable and ap"]iarcntly"contiiet-
iug results aud theories are iucvilable when pepsin still
means in various countries a product of from 1 to 40 to
1 to 3,000 standard ; moreover, there arc offered in com-
merce, in the United Slates, pepsins of even Ktiiled diges-
tive value below the obligatory pharmacopieial standard.
Both physiological aud chemical data almost irresis-
tibly lead to the concltision that pepsin is a uucleoiiro-
teid and sharply distinguished from all other forms of
protcid by its proteolytic action, exhibited tmder condi-
tions which are iu tlieni.selves incapable of ctTecting these
chemical changes without the intervention of theeiazyme.
The degree of isolation of pejisiu is necessarily only to
be judged by the energy of the product which is" ob-
tained by the exclusion of foreign substances capiable of
separation and identitiealion Iiy cheiuieal proees.ses and
dialysis. The enzyme so far isolated exhibits the char-
acteristic behavior of a nuclco-proJcid. It is freely soluble
in water, is non-dialyzable, readily precipitated by the
neutral salts of the alkalies and by strong alcohol in ex-
cess, and is coagulated iu solution at IGO F. both iu ucu-
tral and in acid media; it is destroyed in solution at this
temperature (160° F.) whicdi, it is interesting to note, is
the coagulating point of albumen and destructive to
organized ferments; it is destroyed in alkaline solutions
at any temperature; ils action is strongly inHuenced by-
various rcagcuts which do not in themselves efl'ect any
known change in the enzymic substance; and, finally,
when once destroyed its vitality cannot be restored by
any means whatever. A striking examijle of its physio-
logical relatious is found iu its l-.ehavior with common
salt; the presence of .sodium chloride in so sniall a quan-
tity as one per cent, of tlie digesting mass completely
retards digesticm in ritm, yet we have the fact that pep-
siu may be precipitated by means of common salt (in
saturated .solution), aud kept iu contact with it fora long
time without impairment of its activity.
The most perfectly isolated pepsin yet ju'oduced is
found to be a nitrogenous liody with the chemical consti-
tution of a proteid, and this ]ie])sin protcid contains phos-
]ihorusand iron like other nucleiu bodies. The fact, then,
that the chemical comjiosition of pejisin remains yet to
be absolutely established is of little signitieauce from a
therapeutic standpoint, for it impioses, iu the light of all
the material and important facts known, no limitations
upon the complete utilization of the enzyme.
The physiological test for iiepsiu is as coiulusive and
reliable as auy chemical test liy which we cstalilksh the
presence or identity of any cficiuieal subsbuice. It is
by tlie physiological test ihat we readily measure the
sirength of any specimen of iicpsin; and it is by it, fur-
thermore, that we have deleniiined the iiilluencc of me-
dicinal and food substances upon pepsin, and have gained
accurate data as to the conditions which are favorable and
unfavorable to its action or deslruclive to the life of the
enzyme. These data clearly reveal that physiological
considerations are as conebisivc in relation to the enzymes
as are chemical reactions, both in theory and in practice,
in relation to the use of other agents of the materia niedica.
Pepsin behaves as a tru(^ ferment whose jiectdiar form
>&o
Pepsin,
Pericardium,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
of energy is capable of liberating latent energy in com-
plex labile substances — the proteids, breaking tlieni down
into simpler, more stabile bodies. We have had the
statements that pepsin actually loses its activity in this
process, and that it remains luialtered. There can be no
doubt, however, that pepsin undergoes no change in
exerting its energy, for this is readily demonstrated.
A pepsin having been subjected to the usual digestive
test— upon acid albumin mixture — may be made repeat-
edly to exhibit its action upon the addition of fresh vol-
umes of water and alliuniin and when the requisite per-
centage of acid is maintained, thus ])ri'venting saturation
of the digestive fluid with the solutile products formed.
In this way the writer has found pepsin to digest several
hundred thousand times its own weight of albumen with-
out exhaustion of energy. Interesting as this may beasto
the marvellous power of tlie enzyme, it seems, however,
to be without therapeutic bearing, in view of the fact
that the gastric juice is normally discharged into the in-
testine with the Cdmiiletiiin of llie stomach digestion.
Pepsin in the dry form, if non-liygroscoinc. retains its
vitality for years at oidinary temperatiu'e. In solution
it may be readily preserved without serious impairment;
alcohol and gl\cerin comliined form the best preserva-
tives, from both the medicinal and the jiharmaceutical
standpoints ; for general use, aliout fifteen per cent, abso-
lute alcohol and glycerin being the amount required.
The anhydrous glycerin does not readily take up the
enzyme; wlien diluted with water, to the extent of about
forty ]ier cent., it affords a useful veliicle. Elixirs, es-
sences, and glycerites are comnionl}' and very conven-
iently made with pepsin. There is no pharmacopa;ial
method or standard for these products ; they are variable,
and distinctly inferior in therapeutic utility to fluids
made direetl)' from the fresh stomach.
Cliemical ju'eservatives — salicylic acid, boric acid, etc.
— are obviously objectionable. Absolute alcohol precip-
itates pepsin, and by long contact distinctly weakens it;
but the presence of alcohol up to about fifteen per cent,
exerts no sensible influence upon the ferment, the en-
zyme being freely extracted by such hydio-alcoholic
menstruum. In citrn alcohol, when it constitutes ten
per cent, of the mediiun, scnsibl)" affects the digestii-e ac-
tion of pepsin ; and it checks this digestive action, not by
altering the ferment, but simply for the reason that alco-
hol is not a competent medium for the ferment in any par-
ticular. The products of enzymic action are insoluble in
alcohol and are of lessened solubility in hj'dro-alcoholic
media in direct ratio to increased percentage of alco-
hol. This, however, concerns digestion in ritvo solely,
for alcohol as present in any proper peptic fluid be-
comes in this res])ect a negligible quantity by dilution
with gastric content anil its free absorption. The in-
ert or feeljle nature of many of the vinous and alcoholic
preparations has been due to the insignificant amount
of pepsin actually contained in them and not simply
to their alcohol content. The intimate relation of pep-
sin to hydrochloric acid has naturally led to the impres-
sion that this and other mineral acids may be freely
admixed with the ferment; but this is a serious error.
Tlie acid of the gastric juice is bound up in a pecul-
iar manner with the proteids, and thus the enzyme
seems to be protected from the acid, whereas pepsin in
solution with pure water and the normal content of abso-
lute IICl (0.3 per cent.) rapidly deteriorates at ordinary
temperature. This constitutes a striking evidence of the
fact that a solution of pepsin and water and HCl is not
gastric juice; it represents the proteolytic ferment, and
cxhiliitsabsolutely the proteolytic action only of the gas-
tric juice. Other mineral acids are distinctly injurious
to the ferment in any fluid form. It is not possible to
mix a mineral acid in medicinal quantity with pepsin in
a fluid mixture of convenient volume of do.sage without
distinctly injuring the ferment even for extemporaneous
use ; while combined in a percentage much aliove that of
the gastric juice content, such mixtures are distinctly
incompatible with the normal activity of the ferment
and unsuited for pharmaceutical products. Fi ir instance.
if we take live minims as a moderate dose of official dilute
HCl, this in two flindrachms would yield an acidity of
0.42 absolute HCl, which is twice the acidity of normal
gastric juice and fatal to the enzyme.
Pepsin fluids should have an acid reaction; but when
acids per se are indicated medicinally, it is the best prac-
tice to exhibit them separately by such vehicle and
means as are most desirable in conjunction w^ith the pep-
sin preparation. If the preparation has an alkaline re-
action, this is conclusive evidence of its inertness.
Pepsin is incompatible with bisiuuth ammonio-citrate
in solution. If the mixture has a neutral or an alkaline
reaction, the ferment cannot retain its activit_v; on the
other hand, if it is acid, it is impossible to maintain the
bismuth in solution. Owing to the unstable and insolu-
ble nature of the salt, its sohition is usually effected by
the addition of ammonia, which is obviously incompati-
ble with pepsin. The therapeutic value of elixirs of pep-
sin, bismuth, and strychnine necessarily cannot be at-
tributed in any degree to pepsin; devitalized pepsin
cannot in any way add to the value of a medicinal com-
pound.
Pepsin and pancreatin are incompatible in solution, for
the reason that if the menstruum be of such acid nature
as to preserve the pepsin, the pancreatic enzyme will be
in time destroyed ; while if it is neutral or feebly alkaline,
the pepsin will be destroyed. Acid-pepsin fluids are un-
suitable for the admixture of all ferments except the
milk-curdling: the pepsin will be the only enzyme of all
those originally combined which will retain its activity.
jNIixtures of the ferments in solution are readily subject
to recognizc^d tests for the presence of any one of the
ferments. If a fresh and feebly acid infusion of the
stomach, or solution of pepsin, be mixed with an aque-
ous infusion of the pancreas, each one of the fernu.-nts
contained in this mixture may be immediately made to
exert its peculiar action un<ler the proper conditions; the
mixture will exhibit the digestive action of pepsin, of
trypsin, and of diastase. But upon keeping this mixed
ferment solution at ordinary room temperature for a
few weeks, it will be found upon systematic assay to
have gradually and rapidly deteriorated in respect to one
or another of its ferments.
The fact that a number of ferments are mixed in any
fluid does not in the least interfere with the method of
assay for testing or determining the presence of any one
or of each separate ferment in the fluid mixture. When
it is desired to combine gastric and pancreatic ferments in
solution, they are best directed in extemporaneous mixt-
ure of preparations which have been obtained directly
from the stomach and the pancreas gland, and thus they
will maintain their individual action for such length (if
time as will ordinarily be required by the patient.
The therapeutic use of jiepsin is ]>rejudiced and com-
plicated by the prevalence, in the past, of inefficient jirod-
ucts and incompatible combinations, a condition which
does not exist concerning any other agent or class of
agents of the materia medica, owing to the fact that with
the definite and standardized chemicals and galenical
products there has been presented no such obstacle in es-
tablishing therapeutic action and scientific dosage. The
increasing knowledge and ajqilicalion of physiological
chemistry in therapeutics, and the accumulation of labo-
ratory and clinical observations with regard to the action
of animal gastric juice, have strongly confirmed its ra-
tional and obvious utility and promise, and have ad-
vanced its repute and use as a therapeutic agent.
Pepsin exhibited in adequate doses aids gastric diges-
tion, with effects apparent in the relief of various dys-
peptic symjitoms and in the promotion of nutrition ; it
affords a rational remedy to which the pliysician may
have recourse in cases of feeble and readily disturbed
digestion. The beneficial effects of pepsin are not re-
stricted alone to the improveiuent of gastric disorders;
there is abundant evidence that each step iu the chain of
digestive action is of essential importance, and defective
stomach digestion cannot but influence the entire diges-
tive process.
556
REFERENCE HANDBOOK OF THE >IEDICAL SCIENCES.
Prrioardiiim.
The pancreatic ferments attack with great facility the
soft and iiartiall3' converted proteids anil starches in the
form in which they normally reach the intestinal tract,
breaking them down into their most soluble and diffu-
sible forms, and the development of the latent pancreas
enzymes waits upon the influence of constituents of nor-
mal gastric juice. Coagulated protein food in masses
is but very slightly attacked by pancreas juice in con-
trast with peptic action, and thus the complete conver-
sion of food is absolutely dependent upon the interaction
of both gastric and intestinal digestion. Disorders even
of the intestinal tract are frequently benetited by the ail-
ministration of pepsin. Pepsin in doses so small as to
seem a slight factor in the physiological process, and ad-
ministered either just before or immediately after eating,
produces results which can be attributed only to the
theory advanced that it imparts an impetus to peptic se-
cretion and action. Pepsin is used to promote the toler-
ation of drugs which impair the appetite and disturb
digestion. For all these purposes the gastric juice, ex-
tracted directly from the fresh stomach in proper phar-
maceutical form, is found most generally useful. This
preparation renders available at once all the properties
of the gastric juice, both its enzymes (the peptic and
milk-cm-dling) and its acid in proteid combination — the
entire organic and inorganic content in natural associ-
ation. Tliese enzymes are thus less susceptible to unfa-
vorable influence than is the precipitated ferment.
Pepsin is given in scales, powder, tablets, and capsules,
ordinarily in doses of from one to live grains; the scales
are readily soluble in water — plain or with acid ; the gly-
cerite, especially the glycerin extract from the stomach,
is useful, and if properlj^ prepared is far more agreeable
than the scale itself taken in solution. Tlie essence pre-
pared from the gastric juice is the most efficient and
agreeable preparation, and its grateful qualities enhance
the effect of the digestive principles contained therein.
The desired dose of drug, for instance sodium salicylate
or iodide of potassium, is prescribed in the proportion of,
say, five grains to each teaspoonful of the essence of pep-
sin, and this added to two or three tablespoonfulsof warm
milk gives instantly a firm curd. The milk may be pre-
viously sweetened or flavored if desired, the object being
to present the drug in a small bulk for convenience; even
this serves well to disguise the medicine.
When pepsin is given simply to jiromote digestion, it
should never be administered in a disagreeable form, and
when given to facilitate the exhibition and therapeutic
action of disagreeable drugs, the essence is not only
valuable as a vehicle, but should be given immediately
after the drug if it is desired to obtain its best effect.
The essence of pepsin is much used in combination
with savory, soluble, and diffusible food products, the
prepared peptonized foods, and it should be mixed in
about equal quantities therewith; this combination
proves of peculiar value in acute forms of indigestion and
intolerance of food ; in seasickness, for instance, it is es-
pecially useful. Essence of pepsin is also much used in
combination with pure phenol, which is thus well masked
and well borne, and this mixture, which is both antisep-
tic and sedative to an irritable gastric mucous membrane,
does not in medicinal proportion unfavorably influence
the gastric enzymes.
The gastric juice essence is more especiall)' found ser-
viceable as a drug vehicle, and in conjunction with it
maximum doses of mercurials, iodides, salicylates, etc.,
are peculiarly well tolerated. It is also valuable for the
production of junket — a jelly-like, diffusible form of
pure milk — which is also a carrier of drugs which blend
with it and thus lose much of their disagreeable taste
and effect. Junket affords an agreeable and wholesome
variety of food, and is serviceable in convalescence where
liquid foods have become distasteful and are no longer
required. It is made as follows :
Junket. — Jnto a clean saucepan put one-half pint of
fresh, cool milk, heat it lukewarm (not over 100 F.);
then add one teaspoonful of essence of pepsin, and stir
just enough to mix ; divide quicklj' into small cups or
glasses and let stand until lirmly jellied, when the junket
is ready for use, just as it is, or with sugar; it may be
placed on ice and taken cold.
^¥hel|. — \fte-- preparing the junket by the above
method, let it stand until tirnily jellied, then beat with a
fork until it is tiuel_v divided; now strain and the whey
(liquid part) is ready for use; keep in a bottle near ice.
Pepsin digestion lias long been observed to effect the
solution of dead tissue, pus, necrosed bone, etc. The
availability of the gastric juice in an active, sterile, and
stable extract of great potency, has recently led to its ap-
plication as a surgical solvent in the bladder, urethra,
eye, ear, nose, and throat, and in pus cases in general —
sores, abscesses, carbuncles, gangrene, leg ulcers, etc.
Gastric juice is thus found to possess peculiar and valu-
able properties as a solvent, healing, antiseptic, deodo-
rizing, and sedative agent. It is painless in its action and
incapable of attacking normal tissue, and has caused
a speed.y cure in cases which were so aggravated as to
have resisted other treatment, thus rendering siu-gical
interference unnecessary. In genito-urinary diseases it
promises, from the most conservative estimate of the
clinical trial which it has already received, to afford a
remed}' of great importance.
Benjamin T. Fairchild.
PEPTONURIA. See Urine, etc.
PERFORATING ULCER OF THE FOOT.— This is a
rare affection, caused l)y pressure or injury where there is
a degenerated nerve supply. It is found in leprosy, lo-
comotor ataxia, lues, and alcoholic and diabetic neuritis.
The most common location is where there is great press-
ure, as over the metatarso-phalaugeal articulation of the
great or little toe, or over the ball of the toes. Occa-
sionally there are several lesions existing at the same
time in one or both feet. A similar condition may also
occur on the hands.
The process is very slow. It begins as a thickening
of the skin resembling a corn, under which suppuration
occurs: and later, when the horny plug is cast off, an ul-
cer is left. The destructive process extends downward
imtil it reaches the bone, which may also become af-
fected. The condition now is more that of a sinus than
of an ulcer. The skin surrounding the opening is usu-
ally much thickened, and there may be granulations at
the orifice. The diseased parts are generally painless
and the neighboring parts are usually anasthetic. Dis-
tortion of the toes, as well as trophic changes in the nails,
may occur later ; they are usually accomjianied by an in-
creased growth of hair, pigmentation, and hyperidrosis.
The patients frequently complain of cold feet and neural-
gic pains.
The prognosis is unfavorable, even if the lesions should
heal, on account of the liability to recurrence, which in
tuin is due to permanent nerve lesions.
Perforating ulcer has to be differentiated only from a
suppurating corn, which latter is painful and is accom-
panied by abnormal sensitiveness of the surrounding skin.
In the case of a suppurating corn the results of surgical
treatment are always satisfactory.
Prolonged rest will occasionally lead to healing of the
lesion in the early stages, but exercise will cause the sore
to recur. Packing the sinus with lint wet with a satu-
rated solution of salicylic acid in glycerin, and the em-
]>loyment of mechanical devices to prevent pressure will
frequently produce a temporary cure. Free opening of
the sinus or stretching of tlie nerves which supply the
part has been followed by good results in some cases. In
the later stages excision of the ulcer is useless and am-
putation of riie foot is necessary. Even then the ulcer
may recur in the stump, unless the limb is removed at a
point far from the lesion and above the line of anesthesia.
Howard Morrow.
PERICARDIUM, DISEASES OF THE.— History.—
Anatomical alterations in I he pericardium were known
long before diseases of the heart proper received careful
567
Pt-rit-:ir<Ciiii]i.
Pi-i-irartliiiiii.
KEFEHENCE ll.\NI»I!()OK OF THE MEDICAL SCIENCES.
study. Galea was familiar with ixMicaidial ciTu.sion in
auiiiiaLs, and suspected it in men.
The fables abcjtit the oecnrrenee (if li.iiiv hearts in men
of remarkable sirength and daring ar( (hmluless liased
upon tlie discovery of strinjjy (ihrin deiiiwlcd upon the
lieart. Uondelet described pericardii is as liavinu; .symp-
toms of fever, dyspncca. pain under tiie sternum, and at-
taclis of syncope.
In the ci.shteeuth century llie authors i>f works upon
diseases of the lieart made liumerous anatomical observa-
tions upon di.seases of the i)ericardinni.
Vieussens often met with adliesion of the heart to the
pericardium at autopsies, and as.signed certain functional
disturbances whicli occur durin.!; life to the existence of
this condition. In earh'er times it was thought to be a
congenital defect. Albertini appreciated the difficulties
of a symptomatological recognition of pericardial effu-
sion. "Morgagni believed that on accotuU. of the diffi-
culty of diagnosis, the day was yet remote when we
sboilld have recourse to tlie'inmcture of the ]ierieariliuni
as suggested by Hiolan. Senac realized that it was im-
possible to make a diagnosis from the indelinite sympto-
matology, but thought that in hydropcricardium he rec-
ognized an undulatory movement between the third and
the tifth ribs. Corvisart thought that he could feel this.
Both were in error. However, Corvisart first dislin-
gnished between iiitlammatory exudations and drop.sical
effusions, but could not lay down any fixed rules for
ditferenlial iliagnosis. Avenbruggcr was the first to state
any accurate physical signs; these were bulging of the
precordiuni and increase in the area of iiercnssion dul-
ne.ss. Laennee, however, doidjted the possibility of diag-
nosing pericarditis with certaint)'.
The discovery of the pericardia! friction nd) by Collins
in lH-4 madecerlain the recognition of dry pericarditis.
Since this time our knowledge of the physical signs of
all varieties of jiericarditis have increased remarkably,
but none are so pathognomonic or of so miadi assistance
in diagnosis as this peculiar fi'iclion rub.
Anato.mv. — Before l.iunching n|ion a description of the
diseases of the pericardium, it will be wr'll to drvolc a
few lines to its normal anatomy. It is a filn'o serous sac,
,soincwhat conical in shajie, surrounding the heart and the
origin of tlu' great vessels. Its base is directed down-
ward, rests upon the diaphragm, and is firndy attached
to its central tendon. an(l more looselv lo its muscular
structure byarenlar tissue. Its narrower portion is di-
rected upward, and surrounds the great vessels. The
fibrous layer is contunu'd for some distance along the
coats of tile great vessels, in the form of prolongations,
wliich gradually become incorponitcd in their coats.
The inferior vena cava )ia.s.ses through the floor of the
pericardium to reach the heart. The serous membrane
lines the fibrous sac and is rellectcd over the surface of
the heart, thus constituting ils ])arictal and vi.sceral por-
tions. TIk y are continuous along the great vessels,
about an inch tcian inch and a half above the base of the
heart.
E.xternally . the perieardiuni is in contact anteriorly and
laterally with the jileura! <'overing the lungs, witii the
exception of a triangular sjiace, behind the lower ster-
num, which remains uncovered. It is attached by
fibrous bands I o the manubrium and ensiforni cartilage.
Behind it are the (esophagus, deseeiiding aorta, bifurca-
tion of the trachea and left bronclius. and the other
struclures wliich tVn'in tla; root of the left lung. The
phrenic nerves jiass down, one on cacli side of the peri-
cardium, on their way to the diaphragm.
In health the serous surfaces are kept moist by a secre-
tion inn-inal to serous membranes. Thcamount is always
small, but varies from u few cubic centimetres to an
ounce or two. It is common to find at aulopsy several
ounces of jicrieardial fiuid. In most cases, however, this
is a post-niorteni transudate. As aresull of ilie iiresence
of this fiuid the scnnis surfaces glide smoothly over eiich
other during the various phases of the heart's action
without producing audible or (lalpable signs.
The pericardium of an ailult man with a healthy heart
is capable of holding from fourteen to twent^v-lwo ounces
of fiuid ; that of a boy between six and nine years old.
about .six ounces when the sac is distended to the full by
injecting water into it, by means of a syringe, through
an opening made into the anterior part of the pericar-
dium (Silison).
Tlie following are the important diseases of the peri-
cardium :
1. Pericarditis: («) dry or plastic (pericarditis sicca);
(li) wet pericarditis, or pericarditis with elfirsion ; (c) sup-
purative pericarditis; (rt) chronic adhesive jiericarditis,
2. Ilydropericardium.
;i. Hamiopericardium.
4. Pneumopericardium.
."). New growths in the pericardium.
JIoRiiiD An.\to.\iy. — I. AhnoniHil Qinditionsof the Peri-
ami/ mil not of clinical interest, and which do not furnish
physical signs.
(ii) AliKciire of tJie Pcrii'tinti ii m .—Th\?, occurs in ectopia
cordis. It is usually only ]iartial, there being a slit in
the pericardium through which the heart jirotrudes,
Veiy rarely the heart and the left lung lie in the same
serous sac. The heart is covered by the visceral layer of
the pericardium; at the origin of the great ves.sels there
are usually found rudimentary portions of tlie parietal
layer in the form of fringe-like reduplications.
(/') Diirrticula. — Hernia-like pouclies are rarely found.
They are due to the jircssure outward of fiuid. This oe
curs in chronic conditions in which t he fibrous layer has be-
come weakened, and cither yields (jr separates and allows
the serous layer to be pushed through by the exudate.
Such pouches are usually small, but they have been
known to contain as much as from three to four ounces.
The opening into tin' pericardium may be wide or narrow.
These eonclitions are not recognized during life.
((') Jlit/c >Spots, also called soldier's spots and tendinous
spots.
By these tf'rms are meant those circumscribed, whit-
ish, slightly Ihickencd spots which arc so l're(|uciitly
found u]ion the pericardium. Some authorities look
upon them as evidences of an old jicricarditis. and as such
Ihey have iufiuenced the statistics of x'ericarditis.
Most writers now believe them to be areas of chronic
hyjierplasia of connective ti.ssue. Friedreich believed
that they resulted from a continual mechanical irritation
of the surface of the heart, and were found most fre-
f[uently on those jiarts of the heart which were contin-
ually brought into contact with the more resisting
portion of the chest wall. These spots are ncarl\- always
found on the visceral piericardiuin and on the anterior
surface of the right ventricle along the coronary arteries.
They are much iiKU-e conimou in advanced age than in
youth, and in men than in women. They are of no clini-
cal importance and cannot be recognized during life.
('/) T/u'iuHi/ Pi'ririiirliuni. — The wall of the sac may be
thinned as a result of distention from an enlarged heart
or from the pressure of fiuid.
(() J''<iir/r/ii. llodliK. — These have been found lying free
in the sac, and have been regarded as polypi detached
from the inner surface of the pericardium, or as results
of tibrous or calcareous deposits about fonngn substances.
( /') CiiIriiri'iiiiK Jliptm'tf:, — Incases of jirohinged pericar-
ditis there may be more or less calcareous deposit in the
liei-icardium.
II. Ai'iitc I'/iix/i'i- I'l liairi/itis. — In this variety Vnitli lay-
ers of the pericardium are covered with a yellowish,
sticky layer of inllammatory lymph of varying thick-
ness. .\s a result of the constant friction of these two
surfaces during the heart's action, this material is thrown
into ridges, and at times jiresents a ragged appearance
(so-called bread and-luitter adhesions of Eaeniicc). resem-
bling the appearance of two slices of bread and butler,
which have liecn stuck together and then drawn apart.
It has also been likened lo tri|)e. The involvement of
the peiicardium may be universal or only partial. If
only parti.al it is more common at the base of the heart
th.'in elsewhere.
The various changes occurring in pericarditis are sonie-
55S
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Peri<'ar<liiiiii,
Poricsirtliiiiii.
times described as following a definite order of succes-
sion: (1) Increased vascularity; (~) fibrinous exudation ;
(3) tluid elTusion; (4) absorption; (5) adhesion. It is
ver>- seldom, however, that these stages can lie recog-
nized, as there is likely to be a mixture of two or more —
as, for instance, the association of a plastic exudate with
Huid effusion, or even the combination of adhesions and
fluid.
It is possible for absorption to take place, followed by
resolution. Very often, however, especial!}' in the peri-
carditis sicca, the plastic material becomes organized into
firm adhesions which pass from parietal to visceral ])ei-i-
cardium. In the early stages of an intlammatiou the ad-
hesions may be very fine and delicate and easily broken
with the fingers. Later on, however, they become ex-
ceedingly strong, and the pericardium cannot be sepa-
rated from the heart without tearing the heart substance.
The presence of adhesions may be partial or imiversal.
If universal, there will be entire obliteration of the
pericardial cavit_y. Adhesions may also exist between
the pericardium and pleura, or between tlie iiericardium
and che.st wall, as a result of mediastino-pericarditis (peri-
carditis externa).
Effusion. — As previously stated, there is present nor-
mallj' in the pericardial sac enough fluid (a few cidiic
centimetres) to keep the surfaces well lubricated. In dis-
eased conditions this fluid ma_v be enormously increased
in quantity and greatly altered in character. Roberts
says that the average quantit}' of fluid in pericarditis
is "from eight to twelve ounces, but it may range from an
ounce or two to two or three pints or more. Balfour .says
several pints; Broadbent says that au}- large amount is
exceptional.
The statements of different authorities vary much as
regards the size of exudates. Sibson states that the cffu-
sicm is likely to be large in rheumatic pericarditis, while
John Broadbent says that it is the exception to find a large
effusion in this condition. The truth is, there is no defi-
nite rule. Roberts states that the quantity is likely to
be small in Bright's disease. However, Dr. Herman
Allyn {Americiin Meciicine, October 18th, 1902) reports a
case of pericarditis which occurred as a terminal infection
in Bright's disease, and in which he removed by jiara-
ceutesis, on the daj- previous to death, furty-fonr ounces
of bloody serum. At autopsy the pericardial sac was
foiHid to contain about two hundred and fifty ounces
of blood J' serous exudate.
It is generally stated that the exudate is large in cases
secondary to scurvy. In the Russian epidemic referred
to later, the quantity amounted to from four to five pints.
Character (if Fluid. — This varies much, depending on
the nature of the inflammation. In the typical case of
jiericarditis it is a clear yellow, in which shreds of fibrin
and leiicocytes may be present. In rheumatic jiericardi-
tis it is usually clear, but may be blood-tinged and may
occasionally become punUent. In new growths and tu-
berculosis the fluid is likely to be blood-tinged, but not
necessarily so. In scurvy the exudate is usually bloody ;
in fact, it may be almost clear blood.
The specific gravit}- of a pericardial exudate, like that
of other serous cavities, is usually above 1.015, though
there are rare exceptions to this rule.
Ahuorptioii. — The natural tendency in most cases of se-
rous or sero-fibrous effusion is toxvard absorption sooner
or later. This is especially true in rheumatic cases. In
fact, after leaching the acme, in a day or so-tliere may
beadistinct diminution inamount, and in from four to six
days the (piantity maj- fall to normal. In rare cases an
ordinary inflauunatory exudate does not undergo absorp-
tion, but remains as a chronic collection, or may become
hemorrhagic or pundent. Many authorities believe that
even a fibrinous exudation may be absorbed, up to a cer-
tain amount, after undergoing a fatty change.
The fibrous patches left from pericarditis are larger,
thicker, and have a more irregular distribution than tlie
so-called milk spots, and as a rule are associated with ad-
hesions.
A consideration of the mmbid anatomy of peiicardilis
would not be complete without reference to the changes
which are pioduced in the heart. Broa<lbent .says: "The
heart is usually found U> be dilated to a vaiying degree.
In thesidjacute or chidnicca.ses in which the jiericardium
has become adherent, the dilatation is often extiiine, and
the heart miLscle soft ami fiabtiy, showing evidence, on
microscopical examination, of well-marked, inflamniatorv
changes. Dr. Poyuton has shown by a series of sections
of the heart wall, in cases of rheumatic pericarditis, that,
the cardiac muscle, as well as the pericanlium. is almost
invariably attacked by the inflamniatoiy process, and
that there are foci of small round-cell infiltration between
the muscle fibres throughout the thickness of the heart
wall. The myocarditis which accompanies pericarditis
is therefore not simply an extension of the iuflamniaticm
from the pericardium to the myocardium. There is
granular and fatty degeneration of the cardiac muscle
due to the toxic effects of the rheumatic jioison, as well
as actual destruction of muscle fibres by inflammatory
exudation."
Eichhorst applies the name Ziirkergiissherz^frosted
heart — to cases in which the epicardiutn is thickened by
chronic pericarditis, so that itgives theorgan the appear-
ance of being covered by a sugar icing, as in the case of
a frosted cake.
Calcareous Pericarditis has been referred to above. In
chronic cases the heart may be completely invested by a
calcareous coat which may in places be 1-1.5 cm. thick
(Osier).
Etiology. — Pericarditis is almost always a secondary
infection. Its etiology resembles very closely that of en-
docarditis. The more careful our examinations and the
greater our bacteriological knowledge, the fewer will be
the cases of idiopathic pericarditis discovered.
Rheumatism is by far the most common cause of peri-
carditis. Roberts, in "Allbutt's System," states that
pericardial inflammation is to Ix' looked upon not as a
mere complication of rheumatism, but as an essential part
of the disease.
Sibson noted that in the large majority of cases of
rheumatic pericarditis endocai'ditis was also present.
Broadbent states that pericarditis must not be regarded
as a separate entity, but as part of a general inflamma-
tion of the heart, the myocardium being almost inva-
riably and the endocardium fr<'quently affected.
There is no definite relation, when a large number of
cases is considered, between the severity of the joint af-
fection and the severity of the pericarditis. It may de-
velop at any time during the attack, even preceding the
joint affection, or late in the disease.
Pneumonia, pleurisy, the various acute infectious dis-
eases, especiall.y scarlet fever — during the stage of des-
quamation or that of nephritis, — chorea, pyiemia, pur-
pura, scurvy, are all causes of pericarditis. Especial!}'
interesting is its association with IJright's disease. Taylor
found that pericarditis occurred in about ten per cent,
of his cases of Bright's disease. vSibson, in an analysis
of 1,691 cases of Briglit's disease collected from various
.sources, found that jiericarditis existed in 8.17 percent.
Tuberculosis, carcinoma, extension frotu contiguous tis-
sues, traumatism, are also causes of pericarditis.
Aneurism of the aorta causes '2.0 ])er cent, of all cases,
a very lugh figure when one recalls the comparative in-
frequency of aneurism (Preble).
Scurvy is frequently accomiianied by hemorrhagic
pericarditis. Seidlitz and Kyber report an epidemic oc-
curring in Rus.sia in 1840, in whicli 30 out of 00 fatal
cases showed hemorrhagic pericarditis. Tiie fluid was
dark, and amounted to four or five pints.
Sears, in a study of 100 casesat the Boston City Ho-iiii-
tal, assigns rheumatism as a cause in 51 ca.ses, jiiii-umo-
nia or infection with the pneinuococcus in 18 : in T chroiuc
nejihritis, and in 5 pleurisy was the primary disease.
It is now generally .accepted that the pericarditis of
Bright's disease is usually an infection, often a terminal
infection. (Banti believes in the ur.-emic theory.) Chronic
disease lessens the resisting power of the tissues and in-
vasion by micro-organisms becomes easier.
559
Perioardluiik,
Perltardiuni.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Bacteriology. — In acute pericarditis Flexner. in a
limited number of cases, found bacteria present in the fol-
lowing order of frequency. M. lanceolatus, 11; strepto-
coccus, 4; staphylococcus, 1; B. pyocyaneus, 1; B.
influenza", 1; M. lanceolatus and B. col'i communis, strep-
tococcus, staphylococcus aureus and B. eoli eomnuinis,
1 ; staphylococcus and B. coli communis, 3 ; unidenti-
fied, 1.
Infection ^Knuw.— Pneumonia, 8; bronchitis, 2;
erysipelas, 1 : leg ulcer. 1 : tonsils. 1 ; peritoneum, 1 ;
cancer of stomach. 1 ; sloughing myoma, 1 ; doubtful, 7.
Tubercle Iiaeilli have rarely been found in cases of
tuberculous pericarditis.
Stmptom,\toi.ogy. — It was early recognized that the
symptomatology of this condition was so iudetinite, ob-
scure, and inconstant, and resembled so closely that of
other cardiac conditions, that a diagnosis could not be
based upon it. This is only partly because the disease
comes on .secondarily to other conditions. The symptoms
are often so indefinite that pericarditis is entirely over-
looked, and may alter almost not at all the symptoma-
tology of the primary disease. Even in the so-called idio-
pathic cases the subjective phenomena are very indefinite.
The following imiiortaut sympt(jms may be mentioned ;
Pfiin is present in many cases of pericarditis, especially
early in their course, when friction sounds are heard, but
it is not ]:iathognomonie, and bears no special I'elation to
the severity of the attack. It may be extremely severe
in localized pericarditis and entirely absent in large effu-
sions or extensive adhesions. When present it is usually
in the precordial region. It varies much in its character,
from a dull aelie to a stabbing or tearing pain. It usu-
ally disappears with the advent of the effusion. There
may be pain or tenderness in the epigastric region, espe-
ciallj' when upward jiressure is made at one or other of
the costal angles. This pain usually comes on later than
the precordial pain. The patient may complain of oul_y
a sensation of distress, a ]3ressure or tightness about the
heart, especially if a large effusion is present. There
may be dyspna'a and palpitation.
The pulse has no special characteristics. The heart
action in the early stages is rapid and energetic. Subse-
quently, as a result of the mechanical embarrassment
superimposed by the presence of a large amount of
fluid, and the involvement of the myocardium and its
nerves, the lieart action becomes weak and rapid, possi-
bly irregular. In the early stages it may vary from 90
to 130; later, in rare ca.ses it may reach 160. In some
cases there is ver_y little alteration from the normal, and
rarely the pulse "rate is below normal. Dr. Ewart says
that in many cases of effusion the pulse is quick, resem-
bling the Corrigan type. Pulsus paradoxus is said to be
more marked in adherent pericardium than in any other
known condition.
Friedreich's sign of collapse of the cervical veins dur-
ing diastole is not considered important.
The respiratory symptoms vary much. Respirations
are usually somewhat increased in frequency. If the
effusion becomes large, dys|m(ea and even orthopno?a
may supervene. The patient usually prefers to lie on
his back or on the left side. In large effusions there is
often a short irritative cough, and in rare cases distress-
ing hiccough due to involvement of the phrenic nerve.
There may be pain or difficulty in swallowing as a re-
sult of pressure of an efl'usion upon the cesophagus, or
due to nerve irritation.
Inasmuch as pericarditis is a secondary affection, there
is usually present the fever of the primary disease. The
pericarditis may cause a slight extra elevation of temper-
ature. It may be practically normal throughout, or only
slightly elevated, to 100' or 101°; rarely to 103° F.
It must be remembered that the symptomatology of
pericarditis may be altered by the associated primary
disease. Thus, a case secondary to Bright's disease
would differ from a case secondary to rheumatism.
Enormous effusion, by interfering with the action of
the heart and aeration of the blood, may produce the most
grave symptoms of dyspnaa, cyanosis, very rapid and
weak heart action, which if not relieved may eventuate
in death.
The rapid heart action, the pulsus paradoxus, and the
asynuuetry in the size of the pulse of the radials, the ir-
regular tyi)e of temperature, the paralysis of the recur-
rent laryngeal nerve, the unequal pupils, the disturbed
mental state, may all be important signs, if present (Bil-
lings).
Physical Signs. — Acute Plastic or Dry Pericarditis. —
Fortunately the signs of this condition are very distinct ;
the danger is that they may disappear before the physi-
cian's attention is directed to the precordium. In some
cases they are very evanescent, disappearing in a lew
hours ; in others they persist for days.
Pericardial Friction Huh. — This is the pathognomonic
sign of dry pericarditis. It is a superflcial, dry, scraping
or rubbing sound, distinctly dependent upon the heart
movements. Freijuently it is a to-and-fro friction cor-
responding to systole and diastole. It does not corre-
spond exactly with the first and second sounds of the
heart, but may occupy a place between them. At times
it is only sj'stolic. It is said to be first heard in most
cases over the base of the heart, but may be heard first
as a single systolic scratch at the apex. It is usually
heard best just to the left of the sternum, between the
third and fifth ribs. As the inflammation progresses it
may be present over most of the ijrecordiiuu. even to the
right of the sternum, in children. It is due to the rub-
bing of the inflamed pericardial surfaces over each other.
Palpation. — In well-marked cases a friction fremitus
can be felt.
Clinical experience has proven that the most common
cause of the disappearance of the friction sound is the
advent of an ett'usion which separates the pericardial sur-
faces. Another f'airl}' common cause is the development
of adhesions, uniting the pericardial surfaces. Again,
there may be absorption with resolution. The friction
sound may reappear after the absorption of the fluid.
lUffercatial Diagnosis. — A pericardial friction rub is
usually so characteristic that little difficulty is experi-
enced in its detection. It must be distinguished from
organic and functional miu'murs and from pleuritic fric-
tion sounds. Cardiac murmurs almost never have this
superficial scraping, to-and-fro sound; they are likel}' to
be more distinctly syst<ilic or diastolic, and have special
lines of transmission. They are not .so much altered by
changes in the patient's position and are more perma-
nent.
Pleuritic friction sounds are very- similar in their char-
acter, but are depenilent on respiratory movements, aiid
can be eliminated by causing the breath to be held.
Plciiro-per/canlia'l Friction. — A friction sound resem-
bling very closely the true pericardial friction is heard
when there is inflammation of that part of the pleura
which overlaps the pericardium. With each contraction
of the heart the external surface of the pericardium is
forced along the under surface of the inflamed pleura,
and a friction sound is i>roduced. Forced expiration
might tend to eliminate this sound.
Signs of Effusion. — The fact that a friction sound has
been heard is of great assistance In diagnosing an effusion.
It is fair to supjiose that an increased area of cardiac dul
ness, which develops subsequently to the detection of a
pericardial friction rub, is due to an effusion. But one
always keejis in mind the fact that a cardiac dilatation
must be reckoned with.
Percussion. — It is usually stated that less than 100 c.c.
of fluid cannot be recognized by percussion.
In an effusion of moderate degree the outline of dulness
is quite characteristic, being of an irregular pear shape,
or that of a triangle with rounded angles, whose base
faces the diaphragm, and whose apex is above, to the
left of the sternum. (Cabot states that he has not been
able to make out this characteristically shaped area.)
More important is the fact that the dulness extends
much farther to the left, beyond the apex beat, than it
does in hypertrophy or dilatation.
Rotch iias drawn special attention to the blunting of
560
REFERENCE HANDBOOK OP THE JIEDICAL SCIENCES.
Porirardliini.
Pericardium.
the cardio-hepatic angle in the right tifth intercostal
space in pericardial effusion. In health this cardio-hepa-
tic angle is approximately a right angle. In pericardial
effusion it is more obtuse. Rotch lays great stress upon
the presence of absolute dulness in the lifth intercostal
space, extending one and one-eighth to one and a half
inches to the right of the sternum. However, this is
found in dilatation of the right heart: for instance, in a
case of advanced mitral insufficiency it is a common ex-
perience to obtain dulness in this area, and a consetjuent
blunting of the cardio-hepatic angle. In fact, Broadbent
speaks of two cases of dilated heart in which paracentesis
was resorted to, because the signs seemed to point con-
clusively to pericardial etTusiou.
It is also a difficult matter to decide where liver dul-
ness ends and heart dulness begins.
The explanation of tlie difference of opinion in regard
to the value of Retch's sign in the differential diagnosis
between pericardial effusion and dilatation of the heart
is due, I think, to the fact that one authority has in mind
absolute heart diUness, the other only relative duluess.
With a large effusion, signs of compression of the left
lun,g develop. Above the line of dulness is an area of
tympany or hyper-resonance, with increased vesicular
or broncho-vesicular breathing. Ewart has called atten-
tion to the presence, in large effusions, of a circumscribed
patch of dulness or impaired resonance just below the
angle of the left scapula, over which there are increased
vocal fremitus, bronchophony, and bronchial breathing.
Broadbent. I believe, is correct in saying that these signs
might also be present in any case of enormously enlarged
heart.
Position of the Apex. — It has been held by some of the
authorities (Sibson) that the apex is pushed upward and
outward by the fluid. Others state that it is tilted up-
ward and "inward, tliat is, is floated by the effusion.
Rotch believes from his investigation that this is an er-
roneous view. It seems impossible for a fluid of a lighter
specific gravity than the heurt to float it upward.
Ludwig and Bowditch have observed that the impulse
of the heart, as seen normally in the fifth left interspace,
need not be caused by the heart's apex, but may be
caused bj- a portion of the heart above the apex strikin.g
against the chest wall. This fact I liave observed many
times. It should also be remembered that in children the
apex beat is normally in the totirth interspace. The
presence of a high pulsation could be accounted for by
the tumultuous action of that portion of the right ven-
tricle.
A very important sign is the gradual weakening of the
apex beat with the increase of fluid. It may be entirely
oblitei'ated. In pericardial effusions the pidse may be
strong and the apex beat weak: in heart lesions the apex
beat may be heaving and the pidse weak. The effusions
may become enormous and thus hinder the heart's action.
"The presence of adhesions nuiy prevent a pericardial
effusion from assuming the typical shape. Rotch speaks
of a case in which dulness failed to appear in the fifth in-
tercostal space (right side), because of the presence of ad-
hesions binding the lung tightly to the right edge of the
sternum.
PrKULENT Pekicarditis. — This disease furnishes the
same physical signs as the serous effusion. It might lie
suspected from the etiology, i.r., if secondary to suppu-
ration in the other parts of the body, especially of the
lungs or pleura. The leucocyte count would very likely
be higher than in the simple serous jjericarditis. Para-
centesis is the only positive means of determining the na-
ture of the fluid. The temperature curve is of tlie septic
type, resembling that of empyema. The process may
come on insidiously. It is usually purulent from the
outset, though a serous effusion occasionally becomes
purulent.
Adherent Pericardictm. — The symptoms are not at
all characteristic, and cannot be distinguished from those
of organic heart lesions.
The physical sigi.s in marked cases ma}- be quite dis-
tinctive. They depend upon whether the adhesions exist
Vol.. VI.— 36
between only the parietal and visceral layers of the peri-
cardium, or whether they include also adhesions between
the external pericardium and the chest wall or pleura.
The following are the most important : (1) Fixation of
the apex beat. Under normal conditions the apex beat
moves a considerable distance with change of position of
the patient and forced inspiration. (2) Systolic retrac-
tion of one or more interspaces. This sign, however, is
unreliable, especially if the retraction is present in only
one interspace, and at the apex ; for it is occasionally seen
in greatly by pertrophied hearts, and it may also be due to
atmospheric pressure.
If there be distinct dragging in of the costal cartilages
at the lower end of the sternum, one can be almost cer-
tain of adhesions.
Broadbent' s Sign. — " Systolic retraction of the posterior
or lateral w"al!s of the thorax maj' indicate the presence
of a universally adherent pericardium. Such retraction
may, however, be seen even when the pericardium is not
adherent to the heart, but only to a larger extent than
normal to the central tendon of the diaphragm, to the
muscular substance on either side, and to the chest wall
as well. In such cases the heart is usually greatl}' en-
larged and hypertrophied from old valvular disease.
The explanation seems to be that the portion of the dia-
phragm to which the pericardium is adherent is dragged
U]iward at each systole of the heart, so that the points of
attachment of the digitations of the diaphragm to the
lower ribs and costal cartilages are dragged inward and
retracted."
If pericardial adhesions are present between the heart
and the diaphragm and the chest wall, the descent of the
diaphragm would be much diminished. Fluoroscopic
examination would be very uscfid in demonstrating this
point. Litten's phenomenon would be diminished or
absent.
Enlargement of the heart is common in adherent peri-
cardium. There are both hypertrophj' and dilatation.
The hy]iertro|ihy lesults from the obstruction offered to
the regular contraction of the heart.
Broadbent states that the heart becomes dilated dviring
the acute pericarditis, and before it regains its original
size, becomes anchored in this position bj' adhesions.
Friedreich's sign of diastolic collapse of the cervical
veins is not considered useful by the majority of mod-
ern writers.
The pulsus paradoxus has generally been held to be a
sign of pericarditis. It is characterized by the disap-
pearance of the radial pulse during inspiration. Kuss-
maid believes that it is of diagnostic importance in in-
durated mediastino-pericarditis; it is due to the fibrous
cord dra,gging on the aorta during inspiration.
Most of these signs are dependent upon the presence of
adhesions between the pericardium and the chest wall.
AVhen such adliesionsare absent signs are very indefinite.
Signs and symptoms of incompensation may come on
which cannot be distinguished from those of incompen-
sated organic lesions.
An important condition is that oi p.icvdo-cirrhosi.'i oi the
liver due to oblitei'ative pericarditis. In this condition
there is an enlarged liver, associated with ascites, but
without (edema or enlarged spleen. Autopsies have
shown, according to Becker, in all recorded cases, that
ascites is due to a passive congestion of the liver, causing
a connective-tissue formation with subsequent contrac-
tion and obstruction of the portal circulation, the result
of obliterative pericarditis.
Differential hiagnosis. — The chief difficulty lies in dis-
tinguishing between dilatation of the heart and pericar-
dial effusion, when, as occasionally hapjiens, neither fric-
tion soiuid nor murmur can be heard. This ma_y be better
appreciated when it is remembered that on se\eral occa-
sions the right ventricle has been punctured by the para-
centesis needle with fatal results, the diagnosis of effu-
sion having been made. In many cases in which the
effusion is only of moderate degree it is difficult to be
absolutely certain of a diagnosis.
Massive pericardial effusions, amounting to one and a
561
P<>i-i4-iirditilll.
I*<'riiitMiiii.
REFERENCE IIAXOBOOK OF THE MEDICAL SCIENCES.
half ur two litres, have bueu inistaki'ii for pleuritic
elVusioiis,
The following excellcut table is taken from Rotch's
"Pediatries," p. TGI:
Differential Diagnosis BETwf:KN a Dilatko Heart and a
Peiucariiiai. EFFI'SIOX.
Case I. — Endocarditis;
dilated heart.
Girl, eleven years. A t-
lack followed acute
articular rlieuina-
tism.
Ortbopnopa ; precor-
dial pain : heait'.s
impulse teelile, 1ml
perceptible a little
to left and lielow
left nipple, llfth in-
terspace.
Vertical alisolute dul-
ness lint increased.
Alisoliitc ilulness un-
dcrlheslcrnmn.and
to left, of slernum :
identical with cases
n. and III.
Alisolute dulness diil
not extend to right
of stcruuin.
Systolic miuinur
ajtex.
Recovery.
Case II.— Pericarilitis;
effusion.
Bov. si.\ years. At-
tack followed acute
articular rheuina-
tisin.
(irthopncea : precor-
dial pain ; heart's
iminilse feehle but
pcrcepliblealitlieto
left and liclow left
nipple, flflh inter-
space.
Vertical absolute dul-
ness not ini-reased.
Absiilutt! dulness un-
der the sternum and
to left of slerninn;
identical with cases
I. and III.
Absolute dulness in
fifth risrhtinterepace
2 or :i cm. from edge
of sternum.
Pericardial friction
rub at base.
Recovery.
('a.«e III.— Endocarditis;
enlarfxed heart ; peri-
cardial effusion.
Girl, eicht years, Au-
gust 3d. Attack fol-
lowed acute articular
rheumatism.
Ortliopucea ; precordial
pain; heart's impulse
feeble, but perceptible
all over cardiac area,
with apex beat a little
below and to left of left
nii»ple, Ilfib interspace.
Vertical absniute dul-
ness not increased.
.Absolute dulness under
the sternum and to left
of sternum ; identical
witticasesl. and II.
.^l)solute dulness in fifth
right interspace 3or4
cm. from edgesof ster-
num.
Soft systolic murmur at
apex, transmitted to
axilla : pericardial
friction rub at base.
August tith. Less dul-
ness in fifth right in-
terspace: apex mur-
mur much louder and
harsh.
August 11th. Dulness
only to right edge of
slernum.
.August ISth. Dulness
only to middle of ster-
num ; friction rub
ceased.
December 1st. Physical
examination the same
as on .\ugust Isth,
showing enlarged
heart and mitral sys-
tolic murmur.
The following points, mentioned by Osier, may assist
one in dillereiilialiiig between dilatation of the heart and
pericardial elltisioii :
lu dilatation the iinjiulse in tliin-ehcsted people is tisii-
all.v visible and nndulatory; the shock of the carditic
Bound is more distinct I3' palpable in dilatation; the pe-
cnliar area of dulness in effusion, es]iecially if the upper
limit shifts with change of position of the patient.
In dilatation the heart soiuids are clearer, often sharp,
valvular or IVetal in character ; galloii rhythm is common,
whereas in effusion the sounds are ilistant and mutHed.
Rarely, in dilatation, is the distenlion sutlicieut to com-
press the lung and produce the tympanitic note in the
a.xillary region.
Ftnonm'Djiic cratnimition is extremely useful for differ-
ential diagnosis. The opaque ;irea does not pulsate as it
does in enlarged Iie;irt or aneurism, Tlie miper level
eau be seen to move with changes of ]iosition.
Diseases of Vie, I'erienrdinin, in Cliililrcn. — Only a few
special observations need be meiitioneil under this Iiead-
iug, as the signs of pericardial disease arc ju^actically the
same at all ages, Rotch states that so far as Ik^ could de-
termine bv the dissection of si,\teen infanlsof diff<-rent
ages the Tclaliou of the infant's pericardium does not
differ from that of the adult. 'Hie amount of fluid nor-
mally ]uvsent is of variable (juantity, but is probably
tmder .5 e.c. When jiericaiilial friction sounds are ab-
sent, the dia.gnosis of ])eric:irditis in a young child is
attended with great dillicuUies. Some wrilcrs (Warthin)
state that an aceenlualed pulmonary second sound is
characteristic of pericarditis. In inrancy. however, the
pulmonary second sound is normally much ;iccentuatcd.
Owing to the greater flexibility of its thora.x tiie child is
much more likely than the adult to manifest a bulging of
the precordium as a result of the iiressure of the fluid.
It must be kept in mind that on account of the sinall-
ness of the child's thorax the heart and pericardium are
both brought nearer the surface than in the adult; and
as a result the heart's impulse can be felt, and the heart
sounds heard, iu much larger effusions than would be
possible in adults.
Pericarditis sicca is uncommon in childhood. Exuda-
tion takes place more freciuently than iu the adult, and
with greater rapidity, and is more likely to be purulent
(Rotch). Exudation tinged with blood is not uncommon
in early life, and is not so significant of tuberculosis as is
a pronounced hemorrhagic exudation.
Holt states that jiericarditisis rare in infancyaud early
childhood, only two cases liaviug been seen in seven hun-
dred and twenty-six consecutive autopsies at the New
York Infant Asjdum. In later childhood the disease is
more frequent. According to Jacobi, Holt, and other au-
thorities diseases of the lung and pleura, especiidly of the
left side, take first rank as etiological factors iu infancy
and early childhood. After the fourth year rheumatism
takes precedence and the pericarilitis is then usually as-
sociated with endocarditis. Pericarditis may develop in
the new-born as a result of infection of the cord. In
children pericarditis may develop and become very j^ro-
nounced, w hile the articular complaint is mild.
In young children pain seems to be generally absent.
Prognosis. — Pericarditis should always be looked iipon
as a serious di.sease, chiefly because of the myocardial de-
generation which accompanies it. Death may take place
iu a few days in the acute cases associated with rheuma-
tism and pneumonia, btit this seriuel is very uncommon.
The immediate prognosis in these cases is generally good.
The probability of repeated attacks, the likelihood that
adhesions will form, and the presence of myocarditis ren-
der the prognosis for a long life unfavorable. When as-
sociated with Plight's disease the prognosis is bad.
Patients occasionally die from .syncope as a result of
embarrassment to the action of the heart from pressure,
bv very large collections of fluid.
Su]q5urative pericarditis is nearly always fatal if asso-
ciated with a general septicaunia; if it is .secondary to an
empyema or other localized collection of pus, there may
occasionally be recovery, with the adoption of early and
proper surgical treatment. Of thirtj'-five cases of suj)-
purative pericarililis treated by incision, fifteen recovered
and twentv died (Roberts, .1/H. Jour. Med. Se., December,
1897).
In adherent pericardium the prognosis is serious if
there are adhesions to the chest wall, or if the heart is
enlaiged, or especially if these adhesions are associated
with valvular lesions. Universal adhesion of the pericar-
dium to the heart, provided the heart is not enlarged,
does not necessarily tend to shorten life.
Tredlmeiit. — Pericarditis must always be considered
a serious disease, even if the symptoms are slight. The
liaticnt should be put to bed. The diet should be chiefly
liquid, milk forming the major part. The stomach slionld
not be overloaded. In the milder cases soft articles of
food may be given. Pain should be relieved chiefly by
the aiqilication of the ice-bag. In children hot applica-
tions may be more satisfactory. Morphine may be re-
quired in some cases. Restlessness and sleeplessness
should be controlled liy suitable doses of bromide or trio-
nal. Tlie heart action, jmlse, res]urations, and color of
the iiatient should be closely watched, and heart tonics,
such as strychnine and digitalis and ammonia, given
when indicated. The time may come when th' heart is
overwhelmed by the obstacles presented bj- the ^-normous
eft'iision; the pulse becomes extremely weak and rapid,
marked dyspmea and cyanosis develop; then heart tonics
are useless, and one must resort to paracentesis to save
the patient.
Unless the symptoms arc lundcrately urgent a serous
effusion should not be evacuated, because many times the
absorption is very ra])id. If the effusion is large and has
existed for many days, and shows no signs of resorption,
it .should then be evacuated without hesittition.
5ti2
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
Pcrlrardiiiiu.
PrriiK'illll*
Paracentesis Pericardii.— The pericaniium is tapiK'fl
■with a Polain aspirating sot in tlic same way as is tlie
plfura. Tlie only dillVrence is in tlie scleetidn of Mut
points of puncture. An e.\cellent method is first to freeze
the i)art with an etli^'l chloride spray, make a very small
incision through the skin with a bistoury, then insert the
needle at riglit angles to the chest wall for a distance of
from one and a half to two inches. After consulting a
large numher of authorities upon the correct site for
puncture, and finding that each writer advises a different
location, I have come to the conclusion that if a fairly
large effusion is i)resent it is safe to puncture anywhere
from an inch to the right of the sternum to an inch or so
beyond the left nipple line, between the fourth and si.xth
ribs. One is cautioned to avoid wounding the internal
mammary artery. Little attention need be paid to the
intercostal arteries.
Rotch very strongly recommends the fifth right inter-
space 4 cm. "(H in.) outside the right border of tlie ster-
num. He states that an effusion of even as little as 100
c.c. can be found at this point, and that there is no danger
here of wounding tlie heart, or the right internal mam-
mary artery, or the pleui'a. Osier recommends the fourth
left "interspace, either at the sternal margin or 3.5 cm.
(1 in.) from it. He also speaks of the fifth left interspace
an inch and a half from tlie left sternal margin, and close
to the costal margin in the left costo-.xyphoid angle, as the
]ioint where the needle may be thrust u])ward and back-
ward.
Purulent effusions should be treated like any other ab-
scess, by early free incision and drainage. Irrigation of
the sac is not advisable except in selected cases.
The treatment of adherent pericardium is practically
that of organic heart lesions (myocardial and valvular).
It is necessary to keep up bodily nutrition by pro]ier
exercise and diet, and at the same time guanl against
overtaxing the weak heart. If symptoms of iiicompen-
sation develop they should be treated by rest, diet, and
cardiac medicines, as indicateil elsewhere.
H.EMOPEUiCAHDiUJr and Hydkopericardium have
been considered in detail in Vol. IV.
PNEUMOPEKiCAUDirxf, because of its extreme rarity
and hopeless prognosis, is of very little practical impor-
tance. By it is meant the presence of gas or air in the
pericardial sac. As a matter of fact, gas is never jires-
ent alone, but is in combination with Huid, usually pus,
i.e.. pyopneumopericardium. The fluid may be ichorous.
It is always secondary to some very serious destructive
di.sease in which a communication is established between
the pericardium and a cavity or tube containing air — as,
for instance, perforation from the oesophagus, especially
in connection with cancer; rupture into the pericardium
of a lung cavity, or pneumothorax, or perforation of a
gastric ulcer. It may occur as a result of penetrating
wounds, such as fractured ribs, concussion or crushing
of the chest, or injury from the side of the cesojihagus.
The gas in pneumopericardium varies in amount and in
composition, and is generally offensive. It may be un-
der so great pressure that when the pericardium is punc-
tured the gas escapes with a hissing noise.
Symptoms. — These are very indefinite, and dilhcult to
dissociate from the primary disease. If the gas is )iresent
in abundance there will be dyspnn?a, cyanosis, attacks of
syncope, collapse, a feeble and irregular pulse, and occa-
sionally dysphagia and precordial distress.
Physical Sign.i. — There may be bulging of the precor-
dial region. The apex beat is weak or absent. The
heart movements may produce a very peculiar crackling
sensation due to the bursting of bubbles.
Percussion signs are very striking. A metallic tym-
panitic note is lieard over the distended pericardium.
Because of the presence of fluid and air a freely movalile
area of duluess is detected in the dependent part, upon
change of position. The quality of tlie tympanitic note
may also vary "with the change of position.
Aiisciiltation. — The heart sounds are unusually loud and
may have a metallic ring. If murmurs are present they
take on the same (juality. The cardiac movements and
deep breathing agitate the fluid and gas present in such
a way as to jiroduce unusual adventitious sounds. Tlu'y
have a metallic ringing (|uality, and have been likened
to the sound of a water wheel.
Treatment is expectant and supjiortive. It may at
times be wise to allow the gas to escape through a' fine
trocar, or even to incise and treat surgically. Little can
be done in a medical way.
AVw Groicths and Parasites. — L'nder this heading are
included tuberculosis, carcinoma, and hydatids. Tuber-
culasis is much more common than the latter two. It is
very unusual to find the tubercles of acute miliary tuber-
culosis on the pericardium. In most cases tuberculosis
of the pericardium is chronic and secondary to tubercu-
losis in other parts of the body, especially of the lungs
and mediastinal lymph glands. In many cases of pul-
monary tuberculosis the complicating pericarditis is of
the simple serous type. The exudate in tuberculosis and
carcinoma of the pericardium is likely to be blood-tinged,
and may be purulent or ichorous.
Carcinoma of the pericardium is extremely rare and is
always secondary, the sac being involved by extension
from neighboring organs.
Hydatids of the pericardium are extremely rare. Clini-
cally we have no means of recognizing the presence of a
new growth in the pericardium, except as we infer its
presence from the detection of similar disease in neigh-
boring tissues. James liae Arneill.
PERINEORRHAPHY. See Ohst.iric Operations.
PERINEUM, SURGICAL ANATOMY OF THE.— I. The
M.\LE Pehineu.m. — In the skeleton the perineum corre-
sponds to the outlet of the pelvis. It is a diamond- or
lozenge-shaped space bounded in front by the pubis and
subpubic ligament, behind by the coccyx, and on each
side, from before backward, by the rami of the pubis and
ischium, the great tuberosity of the ischium, and the
great sacro-sciatic ligament.
The whole space measures about three inches and a
half from side to side, and four inches antero-posteriorly.
At the posterior part it is from two to three inches deep;
anteriorly it only
reaches the depth
of one inch. The
perineal space is
separated fro m
the pelvic cavity
above by the ree-
to-fascia and leva-
tores ani muscles.
A line d r a w u
across from one
ischial tuberosity
to the other, and
passing immedi-
ately in front of
the anus, would
divide the space
into two parts (see
Fig. 3794), the anterior of which is called the vret!iral
triangle or true perineum, and the posterior the anal
or rectal triangle. The anterior triangle contains the
liulb and urethra, with the muscles of the perineum
proper; the posterior triangle has in it the rectum and
the two ischio-rectal fossa-.
Surface An.^tomy. — In the undissected subject the
superficial area of the perineum is very limited, espe-
cially when the thighs are brought together; it then con-
sists of a narrow space or groove reaching from the
coccyx behind to the symphysis inibis in front. In the
ceiitie of this groove is an elevation of the skin, called the
median raphe, which runs from the fnmt of the anus,
over the scrotum, to the under surface of the penis. No
vessels cross this line, and in this situation incisions may
be made without any fear of hemorrhage. The osseous
boundaries of the i)erineum may be easily made out
tlirough the skin; the great ssicro-.sciatie ligaments, how-
ever, iieiug covered by the gluteal muscles, can be felt
Fro. 3704.— Outk'l of (lie Pelvis. Line divid-
ing outlet intii anterior or urelliral triangle,
and posterior or rectal triangle.
563
Periueuiu.
Perlueuni.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
only by pressing in a line drawn from the coccyx to the
ischial tuberosity. In thin subjects tliey can be more
easily felt. Tlie anus is
situated at the midpoint
between tlie tuberosities,
anil its centre is about
one incli and a half
from the end of the coc-
cy.\. Tlie central point
of tlie perineum is a lit-
tle more tlian au inch in
front of the anus; this
point corresponds to the
middle of the free bor-
der of the triangular
ligament. A knife in-
troduced here, anil given
a slightly upward direc-
tion, would reach the
membranous urethra.
Immediately in front of
the central jioint may be
felt, in all but very fat
persons and children,
the bulb of the luethra
and the corpus spongi-
uid urethnd fistulae are often
Fig. 37ai.— 1. Bladder; 2. pnistJite: 4,
bulb; .'i-ti. seminal vesirU-s and vas
deferens; 7. ureter; s, rectum ; 9,
sphincter ani. IRoser. i
osum. Alisce.sses point,
seen, in this region.
The menibrancjus portion of the urethra perforates the
triangular ligament one inch below the symphysis p\djis,
and one inch and a half in front of the anus. The skin
of the perineum is thin and covered with hairs; about the
anus it is of a brownish color and thrown into radiating
wrinkles b)' the contraction of the external sphinctei';
these folds are much enlarged when the hemorrhoidal
veins are swollen and iiitlamed. If the skin of the anus
be everted, ;i line whiti' line is seen which marks thr
junction of the .skin and mucous membrane, and corn'
sponds exactly to the lower margin of the intern;d
sphincter. Thei'e are a number of follicles about the
margin of the anus, and small subeutaneousabscesses fre-
quently occur in this situation. These must not be con-
founded with tistuhe. The usual incision in lateral lith-
otomy passes between the anus and ischial tuberosity, a
third nean-r the tuberosity than the anus.
If the linger be introduced through the anus into the
rectum, many important landmarks may be felt. The
finger for the tirst inch is grasped by the sphincter mus-
cles, principally the internal. Here the internal open-
ings of tistuhe maybe felt; these openings are rarely
much above the upper border of the sphincter ani. One
can easily feel ulcers and fissures in this situation, when
they are present. In the front wall of the bowel the
membranous portion of the urethr;i. Ciin be made out in
the middle line, and when ;i catheter is intrciduced into
the bladder it can be easily felt as it p;isses through the
membranous portion; with the finger in the rectum a
catheter can be guided into the bladder in cases of en-
larged prostate, and if the instrument enters a false p;is-
sage it can be detected and directed into the proper chan-
nel. The prostate gland can he IVlt one inch and a half
from the anus, and its condition ascertained if it be en-
larged or inflamed. Passing beyond the prostate the lin-
ger comes on the trigone of the bladder. AVheu the blad-
der is distended it may be made out through the rectum
as a soft fluctuating tumor. It is more Citsily felt when
the other hand, placed above the pubis, presses the ape.x
downward. The bladder, when distended, may be tapped
through the trigone with a curved trocar, wiihout there
being any danger of wounding the ])eritoneum, which
generally reaches only to within tour inches of the anus.
In rare cases the peritoneum passes down between the
gut and the trigone. In such cases, of course, in this
operation, it would inevitably be wounded.
The vesicula; semiuales can rarely be felt, unless af-
fected by disease.
Stone in the bladder in children can often be diagnosed
through the rectum. Above the trigone of the bladder
transverse folds of mucous membrane in the rectum can
be felt ; these are soft and velvety when healthy, but
when ulcerated or inflamed the}' feel thick and cause
great pain on defecation. ]\Iany diseases are diagnosed
by the linger in the rectum, viz., idcers, polypi, hemor-
rhoids, stricture of the gut, diseases of the prostate, deep-
seated abscess of the ischio-rectal fossa, pelvic tumors,
etc.
With the wdiole hand introduced into the rectum the
entire pelvis may be explored, as well as the lower part
of the abdomen.
IscHio-iiECT.\i. Fossa. — The ischio-rectal fossa is the
space which exists on each side between the rectum and
ischial tuberosity. It is of a pyramidal shape, with the
apex pointing upward to the pelvic cavity, and is from
two to three inches in dejith.
Boiiiiiliirun. — Internally, the levator ani covered by the
anal fascia; externally, the obturator internus muscle
covered by the parietal layer of pelvic fascia; in front,
the triangidar ligament and transversus perinei mu.scle;
behind, thr lower edge of the gluteus maxinnis, the great
sacro-sciatic ligament, and the coecygeus muscle.
The space is tilled with fat, and cro.ssing the fossa
obliquely are the inferior hemorrhoidal vesselsand nerves.
The anterior portion is crosseil by the perineal vessels and
nerves, and entering the fossa at its posterior part is the
perineal branch of the fourth sacral nerve.
The tuberosities of the iseliiahave also a cushion of fat
over theiu, and when this is removed several bin'.sa> are
seen. The apex of the space corresponds to the division
of the jiehie fascia into parietal and visceral la_Yers, or
rather to the junction of the anal with the obturator
fascia. When the anal fascia is removed the levator ani
muscle is expo.sed, and internal to the levator ani is the
visceral. layer id' pelvic fascia.
The lower end of the rectum is placed between the two
fossa', slung, as it were, by the meeting of the two leva-
tores ani muscles, and held in place by the external
sphincter and recto- vesical fascia. The fibres of the leva-
tores ani muscles at the lower end of the rectum are sep-
arated from one another, and in this situation the anal
fascia is also very thin, so that little resistance is offered
to the entrance of pus.
hchin-fectal Abscess and Fistula in Ano. — Abscess in
the ischio-rectal fo.ssa is not an uncommon affection, and
is often caused by the idceration of foreign bodies, such
as fish-bones, thiotigh the b(}wel into the fossii, and there
setting up inflammation. Sitting on cold, damp seats
after excrcisi' is another, and perhaps the most common,
cause of ischio-rectal abscess.
When pus forms in the fossa it presents at the points
of least resistance, viz., the internal wall of the fossa and
the skin at the b:isc. When the abscess breaks through
the skin it will be found that after a time a sinus re-
mains, which generally communicates with the bowel;
this sinus is called afistjihi iiinin). The internal opening
of the fistula is usii;i!ly within half an inch of the margin
of the anus, as at this point pus can more easily peue-
rate the rectum, because of the thinness of the fascia and
the scantiness of the muscular fibres. The external open-
ing may lie anywhere in the region of the posterior part
of the perineum. To prevent the formation of a fistula,
the ischio-rectal abscess shoidd be opened early and
freely.
PiiKiNEAL Fasci.e. — The superficial fascia of the peri-
neiun consists of two layers, between which, in the rectal
triangle, is a large amount of fat; in the urethral triangle
there is less, and as the fascia reaches the scrotum the fat
is replaced by the muscle or dartous tissue of that struct-
ure. The deep layer of fascia (fascia of Colics) is limited
to the urethral triangle; it is attached to the base of the
triangular ligament, to the anterior lips of the rami of
the pubes and ischia laterally, and anteriorly it is contin-
uous with the fascia of the scrotum. By its junction
with the triangular ligament posteriorly it forms a pouch,
which is divi(led into two portions by a median .septum.
This pouch has an imjiortant influence on the direction
which urine takes when extravasated, or pus when it
364
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Periiieiini*
Perliiouiii.
forms, in tliis region. Owing to the attachment of tlin
superficial fascia to the base of tlio triangular ligament
and to the rami of tlie piibcs anil iscliia. fluid cannot go
back toward the anus or down the thighs, but. as the
fascia is continuous anteriorly with the dartos of the
scrotum, no rcsi-stance is offered to its progress forward
and upward over the scrotum to the abdomen.
This is the course taken by urine when extravasated in
front of the triangular ligament. When an abscess forms
in the perineum, owing to the median septiun, it is usu-
ally confined to one side of this pouch, and the swelling
is triangular in shape. The pus, as it jiasscs forward, on
account of the deficiency of the septum in front, tills both
sides of the pouch.
The anterior perineal pouch contains the superficial
perineal muscles, vessels, nerves, and the root of the
penis, which latter is made uji of the two crura of the
cavernous portions and the btdb of tlie spongy portion.
Mundcs. — The muscles of the perineiun bound the peri-
neal triangle, in which the knife is entered in the opera-
tion of lateral lithotomy. The base of the triangle is
formed by the trauversus perinei muscle, tlie o\iter siile
by the ischio-cavernosus (erector penis) mu.scle. and tlie
inner side by the bulbo-caveruosus (accelerator uriute);
the triangular ligament forms the floor of the triangle.
The point of meeting of tlie two transver.se perineal
muscles, the sphincter ani, and bulbo-caveniosus muscles
is called the tendinous or central point of the perineum.
Along the lower border of tlie transverse muscles is seen
the transverse artery, a branch of the internal pudic.
Triangular Ligament. * — This ligament divides the
perineum into two portions — a deep and a superlicial.
It has very definite attachments to the subpubic ligament.
the rami of the pubis and ischia. and the superficial
fascia. It also blends with the central tendinous point
Fig. 3796.— Superflc'ial Dissection of the Muscles of the Perineum.
1, Bultm-cavernosus niusi-le: ~, isrliin-cjiviTnosus : 3, transversus
perinivi ; 4, triaui^ular li^^inient ; ."». s|i|iiii»irr ani : 0, coccyj^eus: 7.
preat gluteus nuiscle; s, rt-iiular fatty tissue of the is<'bio-rectal
fossa: 9, sacro-sciatic lif^ameut ; A^ ischio-pubic ramus; ii. ischium;
C, anus ; £>, coccyx ; E, cavernous body.
of the perineum. As suggested by Prof. I). J. Cunning-
ham, of Dublin, it is better to regard this ligament as a
*This structure is sometimes named the anterior layer of the Irian-
(Tular ligament, the posterior layer being the parietal layer of pelvic
fascia. "It is also called the deep layer of the deep perineal fascia aud
the subpubic fascia.
distinct membrane, and to class it in the same category
as the obturator membrane; for "it lies in the same mor-
phological plane as the bony and ligamentous wall of the
Fig. 3797.— The Muscles of the Perineum. Deep Dissection. A,
S.ymphysl3 pubis ; B, bladder : C. prostate; A seminal yesicle ; E,
urethra cut transversely; 1, triangular ligament; 3, deep trans-
verse perinei musi-le ; 5, Cowper's glands ; 6, subpubic plexus of
veins.
pelvis." and it completes the pelvic wall in front iu the
same manner as the thjroid membrane closes the thj'roid
foramen.
When the body is erect the lower surface of the trian-
gular ligament looks downward aud forward, and the deep
surface upward and backward.
Slnicttiree in Relation irith the Trianyvlar Ligament. —
In front are the structures named above as being con-
tained in the perineal pouch.
The ligament is pierced by the urethra, and also by the
dorsal vein and nerves of the penis and the internal pudic
arteries. The urethra pierces the ligament one inch be-
low the symphysis pubis, in the middle line. The parie-
tal layer of pelvic fascia (posterior layer of the triangtilar
ligament) is above and behind, and is attached to the lig-
anrcnt below, but as it proceeds upward the space be-
tween them widens. Between these two structures are
the membranous portion of the urethra, the pudic vessels
and nerves, with the artery of the bulb, the dorsal vein
of the penis, the compressor urethrte muscle, which sur-
rounds the membranous urethra, aud Cowper's glands.
These latter empty their secretion into the bulbous por-
tion of the urethra; in inflammatory conditions of the
urethra they ma_y become infiamcd and suppurate; they
are the homologues of Bartholin's glands in the female.
Tlie membranous piortion is the least dilatalile portion
of the urethra, and is frequently the seat of traumatic.
strictures; it measures three-fourths of an inch in length.
Behind and above the pelvic fascia (posterior layer of
the triangular ligament) is the ape.x of the prostate gland,
covered by the levator ani muscle and by its own capsule.
From this description it will be seen that the triangular
ligament divides the perineum into two compartments, a
superficial and a deep ; tlie superficial contains the peri-
neal muscles and root of the penis ; the deep the mem-
branous portion of the urethra, the pudic artery and
nerves, the dorsal vein of the penis, the compressor ure-
thne muscle, and Cowper's glands. The base of the tri-
angular ligament is the meeting-point of three fasciae,
5fi5
Periueiini.
PtTiiieuni.
REFERENCE HANDBOOK OF THE IVIEDICAL SCIENCES.
viz. ; (1) iicrineal fascia; (2) triansuUir lijriniient ; aud (3)
the pariflal layer of tht- pelvic fascia {pusleriur layer of
the triangular ligament).
The triangular ligament somelinicsolTers an obstacle to
the introduction of "a catheter: for if the instrument be
the two pudic veins; proceeding forward, it passes be-
tween tlie triangular ligament and the parietal layer of
pelvic fascia (posterior layer of the triangular ligament),
aud then, running under cover of the rami of the pubis
and ischium, pierces the triangular ligament from behind.
not kept against the upper wall of the urethra, it is apt
to sag in the lower wall, which is very distensible, aud
reach the triangular ligament below the opening of the
raemljranous urethra. After the triangular ligament has
been successfully pa.ssed. the point of tlie instrument may
be arrested in the membranous urethra by the sjiasmodic
contraction of the compressor urethriB muscle which en-
circles it; this obstruction may be overcome, without
exercising any force, by merely keeping the end of the
instruiueut jiressed gently against the olistructiug point;
after a short time the muscle relaxes aud the instrument
slips into the bladder.
Kicks in the perineum, or injuries from falling astrad-
dle of anything, may rupture the membranous jiortiou of
the urethra, and in tliesi: cases blood and urine will be
cxtravasate<l In'tween the triangular ligament and the
parietal layer of tln^ pelvic lascia (posterior layer of the
triangular ligament). Sbo\ild the injury tear the trian-
gular ligament, then the extrava.sated tiuid would take
the ordinary course upward over the scrotum aud abdo-
men. When extravasation has occ\n'red. free incisions
should be made in the perineum, and if the urethra be
completely torn across, the |ierineum should be opened
in the middle line and an instrument introduceil into the
bladder.
Professor Cunningham, of Dublin, has pointed out, in
his "Dissector's Guiile," that in removing the various
structures from tlie surface to the prostate gland, alter-
nate layers of fascia and muscle arc met with, viz.: (1)
Superlicial fa.scia; (2) superfeial pcriiintl mnxrlen ,• (li) tri-
angular ligament: (4) cnmjircKsor urctlinr nmnrJe : {.")) pari-
etal layer of pelvic fascia, or posterior layer of the tri-
angular ligament; {ft) lernUir <fiii iiiuxrlr : (7) capsule of
the prostate and pubo-prostatic ligament.
Tii.teriKil Piidt'i' Artir//. — The puilic artery is seen in the
rectal triangle, enclosecl within a sheath of ]ielvic fascia
formed 1)\- the sjilitting of the obturator fascia.- It lies
al)out one and a half inches above t.hi' level of the ischial
tuberosity and is ;iccompauied by tint pudic nerve and
5f!(;
half an inch below the symphysis and a little to one side
of the miildle line. It tiieu divides into its two terminal
branches, the artery to the corpus cavernosum. aud the
artery to the dorsum of the peuis. The pudic artery,
while in the i.schio-rectal fossa, gives off the licmor-
rhoidal. and a little fuither forward the superficial and
transverse perineal, arteries. While passing behind the
triangular ligament, it gives off the artery of the bulb,
the wotmding of which was formerly so much dreaded
by surgeons. The pudic artery itself is said to be iu
danger of being wouuded iu lateral lithotomy, but this
accident could occur only to the most careless operators,
when withdrawing the knife and sweeping it outward.
It is possible to wcuind it only after it has left the protec-
tion of the pubic arch.
Exi'I.oU.VTIO.N OK THE Bl.\dl>er thkough THE Peei-
SEU.M. — This operation is little more than a perinea! .sec-
tion. According to Sir Henry Thomp.son, after intro-
diunng a grooved stalT an incision sluuild be made in the
median line, commencing three-fourths of an inch in front
of the anus, and the jiarts should be divided till the staff
is reached in the membranous portion of the lu'cthra: the
finger is introduced into the bladder through this inci-
sion, the jirostatie urethra dilating easily; the stalf is
now removed and tlie exploration of the bladder is made.
Through this median incision tumors and stones of mod-
erate size can be remoxed. There is little hemorrhage,
even should the bulb be wounded, for this latter struct-
ure is not very vascular in the median line.
Partu Diriilrd in Litteval LHhotonnj. — The inci.sion is
commenced one inch and a half in front of the anus, and
is carried downward and outward to a jioint between the
anus arid great tuberosity, a little nearer the tuberosit}'
than the anus.* In order to reach the stall in the mem-
branous urethra the following structures must be cut:
In the first iiu'ision: Skin and .superficia! fascia; trans-
■* 'ftie incision ein]ilnyi'd in laler.il litliiitoniy falls aliout In a line
liaralii'I Willi the asreiuliug ramus of the pubis aud Ihe ischio-caverno-
sus uiusL-ie. tltoser.)
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Peri lieu in*
Perineum.
verse perineal musele and artery; base of the triangular
ligament; the heniorrhuidal vessels and nerves.
Second incision: The knife is now guided by the fore-
finger, passed up behind the triangular ligament, its
point placed in tlie groove of the stalf, and the blade is
lateralized and pushed along the groove into the bladder.
In this incision the following parts are divided, viz. :
Jlembranous portion of the urethra and compressor ure-
thra; musele; parietal layer of pelvic fascia (posterior
layer of the triangular ligament); anterior fibres of the
levator ani and left lobe of the prostate.
Piirtii tu be Aroided. — {I) Artery of the bulb, (2) rectum,
(3) pudic artery.
(1) The danger from a wound of the artery of the bulb
is not great, and is somewhat traditional: with the mod-
ern methods of arresting hemorrhages no one need fear
wounding the artery of the bulb. Very frequently it is
abnormal in its distribution, and its division cannot be
avoided.
(2) The rectum may be cut, especially in children, if
the bowel is not emptied previous to operation, or if the
incision be carried down too vertically.
(3) The pudic arter_y need never be wounded in a prop-
erly performed operation. It can be cut only by latenil-
izing the knife too much in withdrawing it. If wounded,
it may be secured with the modern artery forceps with-
out great difficult^-.
In the withdrawal of the knife a too vertical incision
mav cut through tlie prostate, and so divide the visceral
layer of pelvic fascia. Should this accident happen, no
ill" results will follow if the wound be kept sweet and be
thoroughly drained. Wcjundiug of the visceral layer of
the pelvic" fascia is a danger much dwelt on by the older
lithotomists, and surgeons of the present day still have a
when enlarged can be removed through a perineal inci-
sion either transverse or vertical. Also the seminal vesi-
cles can be reached through the same route. When af-
fected with tuberculous disease it is sometimes necessary
to remove them. Tlie ureter as it enters the bladder can
be reached through the perineum, and stones which have
become lodged there successfully extracted.
Testicle ix Pekixeu.m. — During the descent of the
testicle, and after it has passed through the external
abdominal ring, it may, instead of entering the scrotum,
pass down into the perineum (ectopia perinealis). In
these cases it mav be felt slightly movaljle under the skin,
about an inch and a half in front of the anus. The scro-
tum of the side in which the testicle is lodged in the peri-
neum is deficient if the alTeetion lie congenital; if the
case is of traumatic origin the scrotum of that side is
present. The displacement has no evil effect on the tes-
ticle, which is always of a good size. The abnormal
position of the testicle renders it liable to injuiy, and
patients applj- to the surgeon for relief. An operation
has been devLsed for restoring the misplaced testicle to
its proper position in the scrotum, but its success has been
onl}- moderate. Excision is sometimes demanded to rid
the patient of his trouble.
II. The Female Pekinevji. — The space occupied by
the female perineum, owing to the wider pubic arch, is
somewhat larger than that of the male. It differs from
the male perineum in being jierforated in the median line
by the vulvo-vaginal opening. This opening occupie.s
the place in the female w liich in the male is the situation
of the bulb. In the female this bull) is, as it were, di-
vided into two halves, as is also the muscle covering it.
The space between the divided bulb is the opening of the
vagina. The nigiiui extends upward and backward be-
I
\
/ \
V:
■ J
/
1 rtin out c»ntr9
' COCCYX.
FIG. 3799.
"■&sSw,at._
traditional fear of this accident happening. In children,
lateral lithotomy can scarcely be performed witho\it ciit-
ting through the prostate gland, and at tlie s:ini(' time
the visceral layer of (lel vie fascia ; yet no ill results follow ;
on the contrary, tlie operation is safer in cliildren than in
adults. The real danger in adults is not from wounding
the pelvic fascia, but from wounding the prostatic plexus
of veins and the ejaculatory ducts. The prostate gland
tween the bladder and rectum, its upper part being cov-
ered by peritoneum, and thus it is in (lose relation with
the peritoneal cavity.
The iniiugvUir lic/iniiciit isalsodividcd into two halves,
and on this divided ligament rests tlie divjdccl bull), the
vagina passing between. So we have a bulb wliich is
called the " vestibular bulb " on each side of the vagina,
and the.se bulbs are joined above by a small plexus of
567
P4'riiieiiiii,
Periosteum.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
vessels called the " pars intermedia. " The bulbs are cov-
ered by the sphincter vagina; nmscle (bidbo-cavernosus).
This is the homologue of the fused l>idbo-ein-crnmu>t mus-
cle in the male. We also see the anterior fil.ires of the
Fig. 3800.— Tbe Bulb r.f the Vagina with Hie Venous Svsteni of tbe Clitoris, Viewed fnim in
front. (After Kohelt.) 1, Bulb : Z, constrictor nuiscle ; B, glans of clitoris ; 9, communlca-
tion with the obturator veiiis ; l;i, cavernous body.
levator ani muscle embracing the vagina as they do the
prostate gland in the male.
The stiperficiul fuscin and C"Ues' fascia have the same
attachments as in tbe male, but diiier in being perforated
by the vagina.
Tbe glands of Bartholin and Duverney are situated on
each side of the commencement of the vagiua behiud the
triangular ligament, antl correspond to Cowper's glands
in the male. Their ducts open on each side between the
hj-men and labium minus. It is not uncommon to have
abscesses connected with these glands, to cure which
they have to be dissected out.
The clitoris and nymph;e cori'espond to the penis in the
male. Tbe clitoris is composed of two corpora cavernosa
and a rudimentary glans. It is much smaller than the
penis, and is not perforated by the urethra. The corpora
cavernosa are attached to tbe inner side of the pubic arch
in front of the triangular ligament, and, as in the male,
are covered by a muscle, the ischio-cavernosus (erector
clitoridis). The glans is surrounded by a membranous
fold, which is the homologue of the prepuce in the male.
The rii/rar cleft opens on the surface between the two
labia majora; anteriorly opening into this cleft is the
urethra, and posteiiorly is a recess called the fossa uavic-
ularis, and in the centre is the vagiua. The space ante-
riorly between tbe clitoris and the urethra is called the
vestibule, and this is bounded on each side by a labium
minus.
Tbe labia majora are two thick folds of skin covered
with hair and united in front to form the mons veneris.
In each labium are blood-vessels and dartous tissue as in
the scrotum of the male, of which they are the homo-
logue. The vestibule corresponds to the lower pros-
tatic and membranous portion of tbe urethra in the
male.
On separating the labia ma.iora tlie uymiiha' or labia
minora are seen. These arc fohls of skin which are con-
tinuous above with tlii' prepuce of the cbtoris and below
join the labia majora about the centre. As a rule they
do not project beyond the labia majora, but in the dark
races they are of larger size and project considerably be-
yond the vulvar cleft. In old age they are also more
prominent.
The hymen is a thin fold of mucous membrane of vari-
ous forms, which partiall_v occludes the vaginal orifice;
in some cases the vaginal orifice is
completely closed, and then we have
what is called an iuiperforate liyincii.
Occasionally the hymen is absent or
has been destroyed by inllammatory
action in childhood. Its presence is
not necessarily a proof of virginity
nor is its absence significant of the
loss of the same. When the hymen
has been ruptured, and in women
who have borne children, the rem-
nants are seen as small rounded ele-
vations called "carunculte myrtl-
formes. "
The vessels and nerves of the fe-
male perineum do not differ essen-
tially from those of the male; the
pudic arterj- is smaller, while the
superficial perineal artery going to
the labia is larger. Owing to the
small size of the clitoris as com-
p.ired with the penis, the nerves and
bloodvessels supplying it are much
smaller.
The Perineal Body, or the so-called
perineum of the obstetrician, fills in
the space between the vagiua and the
rectum; in section it is triangular in
shape, with the base of the triangle
downward, corresponding to the skin
between the posterior part of the
vagina and the anterior border of the
anus. Anteriorly is the fossa navicu-
laris, and posteriorly is the rectum. The perineal body
measures at its base about one and one-quarter inches
from before backward, and laterally extends from one tu-
berosity to the other; in this space is the tendinous point of
the perineum, to which are attached several muscles, such
as the levator ani, sphincter ani, transversus perinei, and
sphincter vagime. Laterally we have the ischio-caver-
-10
12 _
Fig. .3801.— Dissection of tbe VulTO-va^nal Oriflce with the Glands
of Bartholin. 1. Oritlce of vagina ; 2, hymen ; 3, meatus urinarius ;
4, navicular fossa ; .5, bulb <if vagina; 6, vulvo-vaginal or Bartho-
lin's glands ; 7. 8, duct with opening cut through oriflce of vagina :
10, constrictor vagin;e partly resected on left side to show the
glands of Bartholin ; 11, transversus perinei muscle.
nosi muscles. Running across the perineal body we have
a transverse septum which, in the female, is very strong
and consists of connective tissue, yellow elastic tissue,
568
REFERENCE HANDBOOK OF THE JVDiDICAL SCIENCES.
Perfuoiiiii.
Perlosloiini.
anil involuntary muscular tilires; it can be felt as a hard
boilj- wlien examined tlirou,i;h the posterior commissure
of the vagina. The "perineum" is a highly distensible
body, as is well seen in childbirth, when it is almost ob-
literated. Above the perineal body the vaginal and rec-
tiU walls are in apposition, loosely connected with areolar
tissue. This so-called perineum isfreqviently torn in first
labors, and if the rent be not sewed up immediately so
as to enable union by first intention to take place, the
vaginal orifice will be much enlarged and the sujiport of
the perineal body be lost. Occasionally these rents ex-
tend into the rectum, and a very miserable condition re-
sults, there being partial or complete incontinence of
fiBces. Operations undertaken for the repair of this con-
dition are most successful even when of old standing. It
is, however, much better to repair the rent as soon as
possible after its occurrence.
Tearing of the perineum with general relaxation of the
pelvic fl(ibr and increase in the intra-abdominal pressure
predispose to prolapse of the uterus. This condition Is
rarely seen in the nullipara or in well-to-do multipara.
It is "the hard-working woman, who gets up to work too
soon after childbirth, in whom this condition is most fre-
quently seen. Francis J. S/iep/urd.
PERIOSTEUM. ACTINOMYCOSIS OF.— Actinomy-
cosis is rarely primary in the iieriosteum; but the perios-
teum is not infrequently involved by direct extension
from actinomycotic processes in neighboring structures.
In primary actinomycosis of the mouth the periosteum of
the jawbone is first involved, later the bone; in actino-
mycosis of the lungs the process may extend to the pleura
and thence to the periosteum of tlie ribs and vertebrae.
In these cases of secondary extension there occurs first
an attinomyodic periostitis with formation of granulation
tissue. As a result of this a superficial caries is produced
and the interior of the bone becomes involved. Here the
process develops more rapidly, the bone becomes filled
with granulation tissue, and expands into a honeycombed
shell. (Jver this the periosteum may develop irregular
masses or spicules of bone or thick layers of fibrous tis-
sue. Tlie microscopical picture is that of a strong re-
active inflammation; numerous mast and plasma cells are
present. The clinical and diagnostic features are given
under the head of Actinomycosis.
Afdred Scott Warthin.
PERIOSTEUM, TUBERCULOSIS OF.— Primary tu
berculosis of the periosteum is regarded by most writers
as a very rare condition; but it probably is of not infre-
quent occurrence. Though the majority of cases of pri-
mary tuljerculosisof the bones are of myelogenous origin,
there can be little doubt that numerous cases begin as a
tuberculous periostitis (periostitis tubercnhisa). The proc-
ess begins with the formation of a granulation tissue be-
neath the inner layer of the periosteum. This shows lit-
tle tendency to caseate, but on the other hand becomes
ossified. Small tubercles are found in the early stages, but
the process shows a great tendency to self-healing through
the formation of bone (ossifying periostitis). As a result
of such healing, exostoses or hyperostoses are formed.
The writer believes that man)' of the so-called inflanuna-
tory local hyperplasias of bone are tuberculous in origin.
In "other cases the process may break through the peri-
osteum and a tuberculous sinus or a "cold abscess " may
be formed; or in some cases the bone becomes involved,
and the clinical picture becomes that of a bone tuberculo-
sis. Superficial caries may follow, either with or without
the formation of deep focil As in the case of gummati>us
periostitis, pseudo-C3-sts may be formed by the liquefac-
tion of encapsulated caseous areas. The cyst wall may
be bony. Secondary tuberculosis of the periosteum is
very common in connection with bone or joint tubercu-
losis. Aldrcd Scott Warthin.
PERIOSTEUM, TUMORS OF.— The primary tumors
of the periosteum belong wholly to the connective-tissue
growths. They are both benign and malignant; the
former, usually arising from the inner osteogenetic layer
of the periosteum, are covered by its oiiter fibrous layer;
the latter break through the fibrous layer and invade the
neighboring tissues. Occasionallj- both benign and ma-
lignant foniis maj- arise from the outer laj'er.
Benign Grotrths. — The osteomn is the most common be-
nign growth of the periosteum, occurring usually as a
circumscribed bony growth, termed an exostosis. The
periosteal osteoraata are classed by some writers under
the general term osteophyte ; but by others the latter term
is used to indicate a very small bony growth of the peri-
osteum. Larger, more diffuse periosteal osteomata are
known as hyperostoses. A circumscribed hyperostosis differs
from an exostosis in being less circumscribed and more
superficial. According to their structure the periosteal
osteomata may be classed as: exostosis eburnea, composed
of hard compact bone without marrow spaces ; exostosis
sporigiosn, composed of spongy bone about equally made
up of bone tissue and marrow spaces ; and exostosis ine-
dulhiris. containing very large marrow spaces. The mar-
row in the exostoses presents the same general appearance
as the bone marrow proper. According to histogenesis
the periosteal exostoses maj' be divided into two classes:
those arising from the connective-tissiu' of the periosteum
{exostosis fibrosa), and those of cartilaginous origin {exos-
tosis cartiloginen). The former may arise either from the
inner or from the outer layer of the periosteum ; in the first
case they are immovable \iiiim-oeable periosteal exostosis), in
the latter they are movable {movable periosteal exostosis).
The cartilaginous exostoses may arise from a proliferation
of the periost-]3erichondrium. usually from the epiplij'seal
cartilages. They occur most frequently in young chil-
dren and are usually multiple. In other cases cartilage
may first form from the periosteum, and this may later
develop into bone. Exostoses ace found most frequently
on the cranial Ijones. the bones of the trunk, and the long
bones of the lower extremities. Many of them are not
neoplasms strictly, but are hyperplasias of inflammatory
origin.
('hoiidroma of the periosteum is of less frequent occur-
rence. It may develop from the inner laj'cr (immorable
pieriosteal chondroma) or from the outer layer {nmcahle
periosteal chondroma). The cartilage may be formed
from pre-existing cartilage {epiphyseal), or from connec-
tive tissue, or from cmbr3'onal inclusions of cartilage
Aiilage. They occur most frequently upon the short bones
of the extremities, the shoulder blades, the ribs, and the fe-
mur. They are very likelv to undergo secondary changes :
myxomatous degeneration, calcification, etc. They show
a marked tendency toward malignancy. Osteochondroma
of the periosteum sometimes occurs ; and there is also a
peculiar growth, the osteoid chondroma, wliicli may reach
an enormous size. It is found chiefly on the long bones
of young individuals and shows a tendency to become ma-
lignant. The surface of the growth is usually smooth, the
cut surface partly hyaline and transparent, partly lamel-
lated and reticular.
Fibroii/a of the periosteum is rare. It occurs most fre-
quently in the periosteum of the bones of the mouth and
nose (fibroid epulis and fibroid polyps). Through exces-
sive development of blood-vessels the growth may as-
sume the character of a telangiectatic fibroma. It is also
very likely to become calcified {.piroma ossifimns) or to
undergo myxomatous change. Malignant changes may
develop.
Myxomata arise rarely from the periosteum. They are
seldom pure myxomata. but present the appearance of
myxochondroma, myxofiljroma, myxosarcoma, etc. They
form round or oval "masses covered on the outside by a
dense layer of fibrous tissue.
Lipomata of the periosteum are known as parosteal
lipomata. They are very rare, and are nearly always
congenital. They usually contain areas of striped muscle
fibres. The exact nature of these growths is not yet
known. They have been reported as occurring on the
anterior surface of the cervical vertebra-, body of the
pubis, frontal bone, scapula, etc.
Anyiomata of the periosteum are very rare. They
569
Perlostllls.
Perltont'uin.
HEFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
have been observed on the cranium and sternum. An ec-
tatic condition of the blood-vessels is very common in all
of the tumors arising from the jieriosteum.
Pseiidn-cyats may be formed beneath the periosteum as
the result of the liquefaction of the contents of subperi-
osteal hanuatomata or of subperiosteal tubercles or gum-
mata.
Siiiroma is the most important of the primary growths
of the periosteum, and — ne.xt to the periosteal exostosis—
of most frequent occurrence. It may occur at any age,
but is uiore frequent in the young. The ]ieriosteal sar-
comata ma\- occur in any jiart of the skeleton, Ijut are
more frequently seen near the ends of the long bones,
particularly of the lower extremities. They may be di-
vided into "the hunl and llie .■"'/( forms. The soft growths
show a variegated surface, and usually contain areas of
softening and extravasation; the firmer whitisli portions
of the growth may be homogeneous or fibrous. The
harder growths are usually whitish, and present a more
or less fibrous, radiating surface. As a rule, the growths
are more or less nodular. Originating in the majority
of cases from the inner layer of the periosteum, the
growth assumes a more or less spindle shape and tends to
surround the bone. Later, it breaks through the perios-
teum and invades the soft tissues adjacent.
!Microscoijically, the periosteal sarcomata represent
nearly every form of sarcoma: round cell, spindle cell,
polymorphous cell, giant cell, alveolar forms, fibro-sar-
coma, osteosarcoma, osteoid sarcoma, chondrosarcoma,
osteochondrosarcoma, myxosarcoma, angiosarcoma, and
numerous comliination forms. The most common vari-
ety is the spindle-cell form containing bone or osteoid
tissue. Tlie most cellular, and consequently the softest
forms, are the most malignant. Tlie malignancy of the
different varieties varies somewhat with the location.
The giant-cell epulis of the jaw is of relatively .slight
malignancy, but a growth of the same structure on the
long bones is much more malignant. The bard fibrosar-
coma, and the osteo-,chondro-, and osteoid .sarcoma, often
show relatively slow growth and but little tendency to
set up metastases: but under certain conditions any one
of these forms may take on au increased malignancy.
Metastases of periosteal sarcomata usually appear first in
the lungs, later in the lymph glands, and finally in any
part of the body. The metastases are frequently of a
softer and more cellular nature than the jirimar}', but
may develop bone or osteoid tissue or c\'eu cartilage.
As the result of the growth of the periosteal tumor the
bone may become infiltrated and rarefied, and in some
cases undergo spontaneotis fracture; or in other cases
there is set up, in the neighliorhood of the tumor, an ossi-
fying osteomyelitis which leads to tlie most marked scle-
rosis of the bone. New bone is very fre(iuently formed in
the sarcoma, particularly next to the old bone upon which
the tumor rests, so th.it the latter seems to spring from an
osseous base. In otlu'r cases trabeeida' or delicate spic-
ules of lione may be formed in a radiating manner through
the tumor mass, or irregular bony masses orspicides may
be .scattered tlirough it (ossifying sarcoma or osteosar-
coma). The degeneration of portions of the growtli, as
is commonly seen in the softer varieties, may lead to cyst
formation, or tf) ulceration, abscess formation, or gan-
grene, as the result of secondary infection. Large hwma-
tomata may result from hemorrhage into the tumor.
Witli the exception of the epulis and the hardest forms,
sarcoma of the periosteum usually runs a malignant
course. The growths show a great tenileney to recur
after operation, and as a rule they give rise to motas-
tasc!s.
Secondary tumors of the periosteum are not infrequent;
both sarcoma and carcinoma may invade the periosteum
from ijrimary gnjwths of neighboring structures. Second-
ar_y carcinoma is the more frequent. Caries and second-
ary involvement of the bone may residt. An ossifying
periostitis is almost always set up, so that the secondary
tumors come to he more or less surrounded by newly
formed bone, oreontain irregular bouy masses or s|iicules.
AldivdS-oH Wait hi II.
PERIOSTITIS. See Ost.ilis, etc.
PERISTALSIS. See Intestinal Mavements.
PERITONEUM. (ANATOMICAL.) See Abdomen.
PERITONEUM, NEW GROWTHS OF.— Primary tu-
mors of the peritoneum are relatively rare; secondary in-
volveiuent bj- malignant tumors, which are primar}- in
some one of the abdominal or pelvic organs, is on the
other hand of very frequent occurrence. Further, tu-
mors which are primary in the retroperitoneal tissues are
to be placed in a .separate class from those wliich are pri-
mar}' in the tissues of the peritoneum proper, that is,
which develop either from the endothelium or from its
basement meiubrane.
Priiiiary Peritoneal Groirths. — The most important of
the priiuary growths of the peritoneum is the endvt/ie-
liiima, often called endothelioma earci namatosum or endo-
tlielial cancer. By some writers it is spoken of as pri-
mary carcinoma of the peritoneum, but the latter usage
is confusing and should be avoided. The designation
primary carcinoma of the peritoneum should be applied
only to those rare carcinomata of the peritoneum wl]ich
ari.se from the columnar epithelial cells of embryonal in-
clusions of intestinal Anlar/e. The piimary endothelioma
of the peritoneum forms multiple flat plaques or flattened
nodules, which are more or less confluent or bound to-
gether bj- flattened cords or strands. Rarely the nodules
may be larger and more elevated. About the larger
plaques there are often seen numerous luinute flattened
nodules, solitary or becoming confluent into little groups.
The color is usually white and the consistency soft; in
some cases it is hard and firm (endothelioma fibrosuin).
The peritoneum about the plaques is more or less thick-
ened. In many of the nodules a j'cllowish caseous centre
is present, the appearances closely resembling small case-
ating tubercles, A serous or sero-fibrinous exudate, usu-
ally hemorrhagic, is often present in the early stages; in
the advanced stages it is invariably so. Microscopically
the flattened tumors are found to consist of a firm con-
nective-tissue stroma enclosing cords and strands of
cells, which are often low columnar, and arranged upon
a basement membrane after the manner of gland cells;
so that the tumor possesses a distinctly tubular character.
In many of the tubule-like cords an apparent lumen m.ay
be seen. The surface endothelium is usually absent over
the larger plaques and nodules, but over the small ones
it may be greatlj' thickened, forming a layer consisting
of many strata of cells. Simple necrosis and caseous
necrosis are found throughout the larger growths, and
occasionally there is a mucoid change. The vascular sup-
\\\y is usually rich. The cells of the tumor appear to rise
lioth from the surface endotbeliinn and from the endo-
thelium of the lymph spaces and vessels (endothelioma
lyiiiphnni/iomatoxu III). The anastomosing, cords and
strands follow the lymphatics. Metastasis into the solid
organs is rare ; secondaries when found occur in the jileura,
dura mater, or other serous membranes. The pleura may
be involved by direct extension. The growth is identical
in structure with the flat tubular endothelioma of the
other serous membranes; and it should be borne in mind
that the peritoneal growtlis may be the result of direct
extension from the pleura or they may be metastatic.
The writer has seen one case in which the peritoneum,
pleura, and dura seemed equally involved; and the only
apparent reason for assigning the primary origin to the
licritoueum was the greater area involved in the case of
this membrane.
Primary anr/iosarcoma of the peritoneum occurs very
rarely. It may develoji as a plexiform angiosarcoma,
consisting of newly formed blood-ve.ssels, whose walls
proliferate and form cylindrical masses of cells. Myx-
omatous cliangeisnot infre(pient in these growths {iiiy.ro-
angiomrcoma), and under such conditions the tumor
may bo mistaken for a colloid carcinoma. In other cases
the sarcoma may show the structure of a perithelioma.
Kaufmaun deseiibes a case in which the entire perito-
570
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
PerloDlltis.
Peritoneum.
neum was coveretl with small warty or tlattened nocUiles
of grayish-red color and very vascular. Ascites was
present, and the surface of the growths was covered with
a thick tibrinous exudate.
Primary carcinoma of the peritoneum is of very rare
occurrence. The cases observed have been of a cylin-
drical-cell variety, with mucoid change (colloid carci-
noma), and the growtli advanced diffusely over the perito-
neum. According to Birch-Hirschfeld the origin of these
growths is from the epithelium of embryonal "rests" of
intestinal Anhu/e.
Prima?-!/ benign tumors of the peritoneum are rare.
Lipoma, fibroma, myxoma, and chylanyioma have been ob-
served. The lipomata ari.se chiefly as tumor-like hyper-
plasias of the epiploic appendices or from the omentum.
The cases of fibromata and myxomata reported as arising
in the peritoneum are of somewhat doubtful nature. In-
flammatory liyperplasias of connective tissue ma^^ have
been mistaken for neoplasms. The majority of the be-
nign growths undoubtedly arise in the retroperitoneal
tissues. Polypoid lipomata of the peritoneum may be-
come freed through tearing of their pedicles; as free
bodies they are likely to become calcilicd.
Mesenterial cysts (chyle cysts, cystic lymphangioinata) are
of rare occurrence. They have been ob.served in chil-
dren. They form bladder-like, thin-walled cysts, wliich
often reach a large size, holding several litres of tluid.
The intestines may be adherent to the anterior surface of
the cyst, and thus give rise to percussion signs of an area
of tympanitic dulness passing over an area of absolute
dulne-ss.
Pecidnn-like proliferations of the peritoneum occur
during pregnane}'. Thev are usually confined to the
pelvis, but may spread over a larger part of the perito-
neum. After delivery they undergo resolution and be-
come calcified.
Secondary Growths.- — Secondary carcinoma of the peri-
toneum is of very frequent occurrence. The primary is
most often located in the stomach, pancreas, gall-bladder,
intestine, testis, ovary, or uterus. Tiie peritoneum maj'
be involved by cordiyiiity, by continuity, or by /nctastasis.
In the latter case a dissemination or implantation metas-
tasis ma,y occxu over the entire peritoneum; the deeper
parts, the pelvis, flanks, and root of mesentery, showing
the most extensive growth. The dissemination of the
growth is aided by the accompanying ascites, ^vhich is
often very great. This may be secondary to the develop-
ment of the carcinoma, or it ma}' occur before the latter.
It is usually heniorrliagic in character. In some cases the
development of the peritoneal secondaries is very rapid,
partaking of the nature of an inflammatory process, and
giving the clinical picture of a xie\Mo\i\i\s ( peritonitis car-
cinomatosa) ; or in other cases the secondaries may form
scattered or confluent nodules (carcinosis peritonei). In
the latter case ascites may or may not be present ; in the
former it is always present to a greater or less extent.
The nodular and the diffuse forms pass into each other
without sharply defining lines.
The general characteristics of secondarj' carcinoma of
the peritoneum depend upon the nature of the primary
growth. Adenocarcinoma forms usvially nodular perito-
neal metastases; they are chiefly located on the under
surface of the diaphragm, in the flanks, pelvis, and omen-
tum. The nodules are white, soft, often showing nuicoid
change. The arrangement along the lymphatics is often
very striking. Confluence of the nodules gives rise to
flattened warty masses. Medullary carcinoma, forms soft
nodules of large size, showing necrosis, lunbilication,
hemorrhage, etc. The metastases of this variety into the
peritoneum are less common than are those of the other
forms. Seirrhotis carcinoma forms a difl'use fibroid thick-
ening of the entire peritoneum, accompanied by perito-
nitis which often covers uji the appearances belonging
to the new growth. The small intestines may be con-
tracted into a liard mass not larger than the fist. The
appearances are those of a chronic fibroid peritonitis
rather than of a new growth, and the condition is often
mistaken for the same. On section the thickened serosa
is hyaline, hard, and tendon-like. In all cases in which
such fibroid change of the peritoneum is found, the
lymph glands should be carefully examined for metas-
tases, secondary scirrhus being more easilj- recognized
in the lymph glands than in other structures. The
pylorus, gall-bladder, and jirostate should be thoroughly
examined for the primary, which ma}' be of insig-
nificant size. The dilluse mucoid or colloid carcinoma,
which is usually primary in the stomach, gall-bladder,
or testis, produces very marked and characteristic ap-
pearances in the peritoneal cavity — particularly in the
omentum and in the neighborhood of the stomac'h. The
entire peritoneum may be infiltrated. The serosa, in
particular of the omentum, is greatly thickened, cov-
ered with glassy, translucent, yellowish or yellowish-
red masses containing mucin. The omentum may be
changed into a thick, homogeneous mass, through which
run strands and fibres of connective tissue enclosing
the colloid substance (honeycomb appearance). The
smaller, yoimger nodules :nay be white, opaque, and
firmer. The cystocarcinoma of the ovary or testis
may give rise to extensive peritoneal metastases, the
entire surface of tlie membrane being sometimes com-
po.sed of cysts filled with a nuicoid substance. The
peritoneal cavity may become entirely filU'd with a col-
loid-like mass. Psammocarcinoma of the ovary may
give rise to peritoneal metastases, containing calcareous
masses.
Secondary Sarco7na. of the peritoneum is more rare;
melanotic sai'coma, myxosarcoma, lymjihosarcoma, osteo-
sarcoma, chondrosarcoma, spindie-cell sarcoma, and
angiosarcoma have been reported.
Primary cysladenoma of the ovary may give rise to im-
plantation metastases or may involve the peritoneum by
continuity, spreading first over the broad ligament and
then over the peritoneum. In the case of the papilliferous
cystadenoma or surface papilloma of the ovary, portions
of papillK may be broken oH and transported by grav-
ity, peristalsis, or movement of ascitic fluid, and may de-
velop over the peritoneum, wherever they may lodge.
Rupture of an ovarian cystadenoma may lead to the cov-
ering of the peritoneum with mucoid or colloid nmterial,
which, becoming partially organized, gives rise to the
condition known as pseiidomyxonta peritonei. This is not
of the nature of a neoplasm, but represents a reaction on
the part of the peritoneum, tending to organize the for-
eign substance spread over its surface. If in the coUoid
or mucoid substance living epithelium or portions of
papilla' are transported, these may grow and foi'm benign
growths which later may become malignant. As a rule,
such transported epithelium usually dies or forms small
cysts which remain stationary after reaching a certain
size.
Transplantation Metastasis. — In puncture for the relief
of a.scites or in opeiations for the removal of malignant
tumors, al)dominal metastases may be set up in the
puncture or in the seat of surgical woimds (inoculation
nietaslases).
Dermoid cysts anA ieratomaia occur in the peritoneum
of the pelvis, in the mesentery, and in the omentum.
In the latter case a [jrimary tumor of the ovary may be-
come adherent to the omentum and later lose its connec-
tion with the former organ.
Pscndo-cysts arise from collections of exudate between
peritoneal adhesions.
Primary retroperitoneal tumors are much more frequent
than those primary in the peritoneum. Lipomata of large
size (sixty -three pound.s) have been reported. They may
be mistaken for ovarian C}'sts. It is imjiortant to note
that the retroperitoneal lipoma forms an elastic, fluctuat-
ing tumor, from which on aspiration no fluid can be
drawn (pseudo-fluctuation). My.rolij>un!a, fibroma, myx-
oma, fibrosarcoma, niy.rosarcoma. and anfiiosarcoma of the
retroperitoneal region have been describeti. The writer
hiis seen a round-cell sarcoma, apparently ])rimary in the
retroperitoneal tissue, weighing eighty pounds. The re-
troperitoneal organs were not directly involved and
showed only changes due to pressure. Secondary ma-
571
Peritoueuin.
I*erouluf .
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
lignant tumors in the retroperitoneal lynipli glands are
of fretiiient occurrence in carcinoma of the uterus, etc.
(See also Omentum.) Aid ml Sn At Wart/iin.
PERITONEUM, SURGICAL AFFECTIONS OF.— The
anutoiiiy ami iili\ siol.iuy "f the ]icrit<m(MHn are discu.ssed
under tiie heading-, 16(/'«Hf/(. (Aiiatnnili-uL). Tlie pathol-
ogy of acute and tuberculous iutlammatinn will he found
in "the article on JVritoiiitis, Septic ninl Tuhcirnloiis. in
The Ai'PiiNiii.v. Under the heading J)iiiphm(/>ii will be
found a description of subphrenic abscess and its treat-
ment, while additional information in regard to the peri-
toneum may be found in the ai'ticles entitled Abdomen.
(Siiiyienl. ) ; Abdominal Timum ; Appeiid/citix : and in the
article immediately preccrling this. In the present article
the surgical treatment of lesions of the peritoneum is
briefly given.
Acute traumatism of the peritoneum is of little sig-
nificance apart from traumatism of the organ which the
peritoneum covers. The effect of direct injury to the
peritoneum is often the formation of adhesions between
opposed peritoneal surfaces. A familiar illustration of
this is seen in umbilical and inguinal heruite. Such
adhesions will prfiiluce slight or serious symptoms, ac-
cording to their situation and extent. If the attachments
are between unimportant organs (for inst^mce. between
the omentum and the parietal peritoneum), occasional dis-
comfort may be the only result. If more sensitive organs
are involve<i (for example, the stomach or the intestine)
the pain suffered may be very great and the function of
the affected organ may be seriously interfered with.
Furthermore, such adhesions in the form of bands are a
not infrequent cause of intestinal obstruction.
Adhesions due to a single traumatism or to an acute
attack of inflammation tenil to atrophy, and in the course
of time they nia_v completely disappear. Thus the scar
of a laparotomy may for a time be attached to visceral
peritoneum, while at a second laparotomy performed
some mouths afterward it may be found entirely free.
Adhesions ar<' dvie to a loss of peritoneum resulting from
traumatism or inflanunation. If, therefore, raw surfaces
can lie avoided at operation, resulting adhesions will be
reduced to a minimum. This can be accomplished in
several ways. The peritoneum can be sutured over the
pedicles of tumors and over fresh wounds. Or, if the
peritonevuii in the vicinity is not sufficient for the piu'pose,
the omentum may be used to cover the raw surface by
stitching it in place; or grafts ma_y be cut from the
omentum and stitched over the raw surface: or, finally,
sterile peritoneum from the ox mav be stitched over the
raw surface. This method has been recentl}- advocated
by l\Iorris, who has given the name "cargile membrane"
to artificial peritoneum of this sort.
For clinical and therapeutic purposes acute inflamma-
tion of the peritoneum is !)est divided into circumscribed
and diffused, or general peritonitis. If the circumscribed
peritonitis is not pundent, it may be treated by rest, ex-
ternal eohl, etc., unless the organ from which it springs
requires more radical treatment — fiir example, circum-
scriljcd peritonitis due to threatened perforation of the
appendix. If the circumscribed peritonitis is purulent,
such symptomatic treatment is dangerous, since no one
can say how soon tbe inflammation may break througli
the fibrinous adhesions which circumscribe it and spread
to other parts of the peritoneum. Therefore it should
be relieved by incision and drainage.
The progno.sis aTid treatment of difl'useor general peri-
tonitis are in a most unsatisfactory state. ]iartly on ac-
count of the difference of opinion as to what constitutes
a diffuse peritonitis, and partly because of the difflculty
of determining, even when the abdomen is open, how
extensively tlie peritoneum is inflamed. Some surgeons
would limit the term general peritoiutis to those cases in
which every portion of the peritoneal cavity is involved
in the inflammation. Such a widespread inflammation
rarely occurs, and is perhaps never recovered from. It
.seems better, therefore, to use tlie term diffuse or gen-
eral peritonitis as indicating inflammation, not limited by
well-marked adhesions, having a tendency to extend and
sutficiently widespread to make the general sj'mptoms
much more prominent than the local ones. Such general
symptoms usually become prominent when the inflam-
mation extends to the peritoneum covering tbe small in-
testine. Thus peritonitis may exist for a long time in
the pelvis, or in the lesser peritoneal cavity without giv-
ing rise to the well-known symptoms of general peri-
tonitis. There are also many cases of appendicitis in
which, if operation is performed early, the appendix is
foimd not sliut away from the general peritoneal cavity.
To describe such a case as one of general peritonitis,
merely because the surrounding coils of intestine are
more or less covered with a fibrinous exudate which has
not had time to mat tliem firmly together, is entirely
misleading, and j'ct this is frequently done b}' writers
who have reported cures of geneiul peritonitis. It is
therefore impossible to state the prognosis in a given
case or a luuidred cases of true dllf use peritonitis other
than to say that the prognosis is bad. But it is by no
means hopeless.
Unfortunately, the ideas of treatment of diffuse peri-
tonitis are widely at variance, so that one can do no
more than to state the different methods by which
responsible surgeons believe that the}' have saved their
patients. If diffuse peritonitis is threatened, though not
well established, the action of tlie intestine can be stimu-
lated by the use of cathartics or stopped by opiates,
while the rectum and perhaps the cohm can be emptied
by injections of water, salt solution, soap-suds, oil, etc.
Some surgeons employ opiates to decrease peristaltic
action, on the groimd tliat peristalsis tends to spread the
inflammation: while others claim that the salvation of
the patient dejientls ujion increased peristalsis, which
will increase the resorptive power of tbe peritoneum.
To decide between these two plans of action is particu-
larly ditflcult, because no one can say whether a threat-
ened diffuse peritimitis would or would not have spread
and killed the patient had the treatment been of a differ-
ent character. When tlie inflammation has extended to
the peritoneum covering the small intestine, the intestine
is paralvzed, and cathartics have no effect, and there is
certainly no indication for the use of opium.
In considering the operative treatment of diffuse
peritonitis it will be well to take up the steps in the
operation one at a time, since there is no general agree-
ment in regard to any one of them. Some surgeons
advocate a single incision and some multiple incisions,
the latter in the hope of obtaining a more thorough
drainage. At any rate, the incision or incisions should
permit the surgeon to inspect and cleanse so much of
the peritoneal cavity as maj' be involved in the inflam-
mation.
The second step in the operation is the cleansing of
the affected peritoneum from pus. fibrin, and foreign
materials, faeces, etc., if such lie present. This may be
done by irrigation with sterile hot one-percent, salt
solution or by wiping the peritoneum with gauze com-
presses wnuig out of such S(jlution, or with dry com-
presses. If irrigation is employed, it should be abun-
dant, so that the abdominal cavity may be quickly
flushed. Some surgeons bring the small intestine out of
the abdominal wound and others omit this step, which is
spoken of as evisceration. The object of cleansing is to
remove in the sliorlest possible time and with the least
possible loss of beat the greater portion of the infectious
exudate. How best to accomplish this with the least
injury to the peritoneum is a question to be settled by
the individual surgeon. Probably moist gauze is less
irritating to the peritoneum than dry gauze.
If irrigation is employed the fluid which remains after
cleansing may be sponged out, or it may be left in place.
Some surgeons fill the abdomen with salt solution and
close the abdominal wound, claiming that the dilution of
the infectious material and the increased resorption from,
the peritoneum thereby pi-oduced are of the greatest bene-
fit to the patient.
If the intestine is greatly distended with gas, some^
OCi
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Peritoneum,
Peronlne.
surgeons empty it by puncture or by one or more sliort
incisions. Such openings are forthwith closed by Lem-
bert sutures. Others take advantage of the operation to
inject into the himen of the small intestine an ounce or
more of saturated solution of sulphate of magnesia, be-
lieving that the strong peristaltic action which often fol-
lows will markedly benefit the patient.
Those who leave fluid in the abdominal cavity suture
the wmuid without drainage. The patient is then placed
in bed with the hips elevated so that the iliaphragmatic
portion of the peritoneum in which the lymphatic circu-
lation is the most active shall be the most dependent
portion. Others pass gauze or glass or rubber drains in
various directions, either through the chief abdominal
wound or through other wounds made especially for
drainage in the lumbar and iliac regions, or into the
vagina, or even into the rectum in case of pelvic sup-
puration. Mikulicz's handkercliief drain may also be
used. [See Abdomen. (Surffioil.).] Rehn recommends
that a tube be passed through the mesentery of tlie small
intestine and allowed to emerge in either loin, so that ir-
rigation may frequently be made through it.
After-treatment consists in the apphcation of heat
externally and within the rectum, the subcutaneous in-
jection of cardiac stimulants if necessary, and the sub-
cutaneous or intra venoiis injection of salt solution ; the
object of all of these procedures being to combat shock.
If the patient is troubled with vomiting, the stomach
should be washed out. No opium should be given, and
only so much morphine subcutaneously as is absolutely
necessary to control pain.
Tuberculosis of the peritoneum may be accompanied
by an abundant serous exudate or it may give rise to a
fibrinous exudate with adhesions and contractions, or it
may assume an ulcerative form.
The pi'ognosis is in general an unfavorable one, al-
though many cures have been reported as the result of
both "internal and surgical treatment. Recovery is more
likely to follow operation when the disease is present in the
serous form ; but even in such cases one should be careful
not to mistake a temporary improvement after operation
for a iiermanent cure. As far as is known Spencer Wells
was the first to open the abdomen of a patient having
tuberculosis. He did so through a mistake in diagnosis.
The patient recovered. Since then many surgeons have
operated intentionally, and the good results have been
variously attributed to the entrance of light or air, to the
mechanical irritation of the peritoneum, or to a simple
escape of the serous exudate. A more careful examination
of the results of operation makes it doubtful whether such
an exploratory laparotomy has any great tlierapeiitic
effect. It seems more probable that most of the ])atieuts
who have recovered after such a laparotomy Wduld have
recovered without it, while operation has often a dis-
tinctl}' bad effect upon a patient whose tuberculous peri-
tonitis is associated with fever. The abdomen is usually
opened b}' a three- or four-inch incision in the median
line. The fluid which is present is allowed to escape and
is carefully sponged out and the various peritoneal
pouches may or may not be dusted with powdered iculo-
form. The" abdominal wound is clo.sed by suture, or a
drain may be left in its lower angle for a week or more.
The shock of such an operation Is naturally slight and
most patients rapidly recover. A certain amount of
fluid quickly appears, but may be resorbed. If it is not,
a second operation may be performed. Such a quick
recovery from operation may be looked for in the serous
and fibrinous forms of the "disease, while operation per-
formi'd upcjn a patient suffering from purulent or su])-
jMU-ative tuberculous peritonitis will ver\' likely be fol-
lowed bj- intestinal fistula and death. Of cour.se. if a
focus for the disease is fomid in some organ which cau
be safely sacrificed it should be removed. An accom-
panying disseminated serous tuberculosis will probably
be cured if its original focus is removed. But, as
stated above, many patients who appear cured at first
afterward suffer from a recurrence of the disease or die
from tuberculosis in some other organ. However, as the
risk of operation is so slight, it seems justifiable in these
cases even if it is a mere aid to the natural forces of the
body in their elfort to overcome the disease.
Benign tumors of the peritoneum, or. strictly speak-
ing, of the subserous tissue, are fibroma, lipoma, and
mj'xoma. Such tumors \isually develop in the root of
the mesentery, in the mesocolon, or in the omentum, and
are described under the headings OiiieKtmn and Retro-
peritoneal Tmiitjrs. In the mesentery are also found
serous, chylous, and hemorrhagic cysis as well as con-
genital dermoid and teratoid cn sts. Ecliinococcus cysts
are found in the peritoneal cavity, where they develop
after the rupture of some primary cyst of the liver or
other organ. Actinomycosis, starting usually from the
ciccum, may produce in the peritoneum inflammatory
swellings, some of which will contain the characteristic
pus of this disease.
The treatment for benign tumors is their radical
removal. This also applies to echinococcus cysts when
the3' are so situated as to make removal feasible. If
they are not removable, the_v should be drained exter-
nally. Actinomj-cosis should be treated by removal, if
possible, but, if this is not practicable, by curetting, cau-
terization and drainage, and by the internal administra-
tion of iodide of potassium.
JIalignant tumors of the peritoneum are secondary- to
malignant disease of some abdominal organ. Under such
circumstances hundreds of metastatic nodules may be
scattered over the peritoneum. There is generally a
sero-hemorrhagic ex\idate. Such a condition is of course
inoperable and the abdomen should be closed at once.
A metastatic nodide in the peritoneum may be excised
for microscopical diagnosis and the wound closed bj' one
or two stitches. Thus one avoids the risk of troublesome
hemorrhage which may follow excision of a portion of
the primary growth.
Plastic operations upon the peritoneum for the sake of
covering raw surfaces have been spoken of above and
are also described under the heading Omentum, for it is
the omental peritoneum which is usually employed for
grafting. Ethrurd Milton Foote.
PERITONITIS, SEPTIC AND TUBERCULOUS. See
The Api'ENDrx.
PERITYPHLITIS. See Appendicitis.
PERONINE — benzyl-moriihine hydrochloride, C«Hj-
CHj.o.OH.CnHi.Nb.HCI— is an o'dorless. bitter, white
p<iwder. composed of prismatic crystals and having the
nature of an alkaloid. It is solulile less than one per
cent, in cold water and in ten jiarts of boiling water, and
is nearly insoluble in alcoliol and chloroform. It is
closely related to codeine, dionine, heroin, and morphine.
For the treatment of the cough of tuberculosis,
Schroeder, who was the first to study this drug, consid-
ered it intermediate in value lietween coileine and mor-
phine. His report, however, covers only twelve cases,
in two of which it produced sweating and dilticult ex-
pectoration, and in two others of whieh it failed to
influence the cough. Nowak. in eighteen cases, found
the cough less frequent and inten.se. but dry, and expec-
toration more difficult. At times there were burning in
the bronchi and copious perspiration. jNIuuk reports
good effects on cough even after morphine and codeine
had proved inefficienf. He also found peronlne calma-
tive to an epileptic who suffered from frequent attacks
of frenzy. All the writers agree that there is no liabit
formation. JIayor found it to be three times as to.xic to
rabbits and guinea-pigs as is codeine, and believes its
eardio-deprcssant effects too pronounced to permit its
use in medicine. Other writers, however, reijort no
unpleasant effect on cardiac, respiratory, or digestive
functions.
Besides its antitussive action, peronine is slightly anal-
gesic and hypnotic. It is employed in tuberculosis,
whooping-coueh, emphysema, bronchitis, and similar
affections in doses of 0.03-O.Ou gm (gr. i-f). Schroeder
573
Perry Springs.
Pefrifurtioii.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
had uo untoward effect from 0.08 gm. (gr. 1^), though
nausea and constipation followed larger do.ses.
W. A. Bastedo.
PERRY SPRINGS. — Pike County, Illinois. Two
hotels, capaeity 'i't^K
Access.— Viii Wabash Railroad to Griggsville or Perry
station, thence bv hack nine and six miles, respectively ;
also from St. Louis via Illinois River to Naples, seven
miles distant, where steamers laud d.'iily.
This attractive health and pleasure" resort is located
among some hills on the west hank of the Illinois River.
The surrovmding country is coveied by luxuriant forests
and intersected' by numerous deep ravines, narrow val-
leys, and clear, winding streams. The extreme tempera-
ture ranges are 100' P^ in summer to —20" F. in winter.
The climate is moderately dry and clear most of the time.
The springs are three in numlier, and are located about
two hundred yards from one another. The temperatvire
of the water ranges from 50" F. in summer to 4S° F. in
winter. The waU-r from the iron spring is supplied, hot
or cold, to fourte<'n bath-rooms. Tlie following table
contains the analy.ses of the three springs, as furnished
by Dr. Englemaii. No. 1 being the iron, No. 3 the mag-
nesia, and No. 3 the sulphur springs:
ONE tJxiTED States Gallon Coxtaixs:
Solid.s.
No. 1.
Grains.
No. 2.
Grains.
No. 3.
Grains.
ir,.S9
IT.nt
..i.5
' 2.i-4
u.l:.'
.44
l..iS)
19.7.5
14.81
.40
.38
1.10
1.4.i
19.6K
10.49
.27
Potassiiini .ind .smipum silicate
3.4.5
.58
Sodium sulpliitte
1.49
1.46
Tcttal .
3.S.24
40.17
37 t)7
No offfaiiie matter.
Tlie waters are said to lie of i-onsiderable efBcacy in
stomach, liver, and kidney troubles.
Jnmes K. Crook.
PERSIMMON. — lh''is/i)/ivis. Under the name persim-
mon, both the bark and the inii'ii)e fruit (chiefly the lat-
tei) of Uiosjit/riis Virgiaidna L. (fani. E/iciiaccii] are con-
sideralily emjiloyed as astringents, partieulaih' in the
southern United States. The bark lo(jks not unlike oak
bark with the corky layer still upon it. The fruit in the
unripe condition is green, drying dark brown, of globose
form, and nearly an inch in diameter. It contains sev-
eral flattened oval or ovoid seeds. Before maturity the
persimmon is (me of the most astringent of substances,
but after tliorouglily maturing, and especially after being
attacked by fi'ost, this astiingency is mostly lost and it
becomes sweet and edilile. The only imjiortant constit-
uent of both drugs is the tannin, and their uses are
purely astringent, similar to those of geranium, sumac,
etc. The common method of employment iu the house-
hold is in the form of an infusion or decoction ; only the
fluid extract is employed by the medical profession.
Tlie dose of either the hark or the fruit should amount
to 2, 4, or even 8 gm. ( 3 ss. to 3 i. or ij. ).
llciinj II. Itiisbi/.
PERSODINE. See PcnulpliaUi>.
PERSPIRATION. See ,Sfa"«, Functions of.
PERSULPHATES.— The alkaline persulpliates liave
recently come into notice because of their exees.sive con-
tent of oxygen and the ease with which this is liboi-ated.
Theiraction maybe likened to that of hydrogen dioxide.
A five-per-ceut. sulution oi soilium persuliiluite kills most
bacteria, and a half-per-cent. solution will check their
development. The fatal dose for a rabbit (liuU. gen. dc
Therap.) is 0.4 gm. per kilogram of body weight, and for
a dog 0.T5-1.0 gm. per kilogi-am.
In thi-ee- to flve-per-cent. solution itconstitutes a good
wet dressing for lupus and ulcers (Kiouka). Internally,
it acts as an antipyretic in fever, and is said to impiove
the appetite and digestion in tuberculosis, anieiuia, neu-
rasthenia, etc. The dose of sodium persidphate is 0.1
gm. (gr. iss.), or from one to two teaspoon fu Is of /;cr.v'*-
diiie, which is a 12 to 1,000 acfueous solution of the
sodium salt.
Ammonium persnlphnte is useful as a test for albumin
or indicau in urine. In the presence of albumin a ten-
per-cent. aqueous solution forms a turbid, giayish zone
at the line of contact.
Iu testing for indican a crystal of ammonium persul-
phate is atlded to a mixtiu'e of equal parts of hydro-
chloric acid and urine. On shaking this with chloro-
form, the latter on settling forms a blue layer if indican
is present. W.' A. Bastedo.
PERUSCABIN, benzoic acid benzyl ester, is an artifi-
cial piiHluct lepresenting the active constituents of bal-
sam of Peru. It is odorless, non-staining, and non-iiii-
tating, and is highly recommended by R. Sachs for the
treatment of scabies. Diluted with three parts of castor
oil, it is applied over the whole surface every twelve
hours. The cure is absolute, and no irritation whatever
is pi-oduced, even in an area affected with eczema or
dermatitis. TT'. A. Bontcdo.
PES GIGAS. — Pes gigas, or macropodia, is the naiue
given to a condition of congenital hyperti'ophy allecting
Fig. 3802.— Pes Gigas. (From Joiinial of Tropical Mediiiiie. I'.Oii.)
either the foot alone (whence the name) or the leg and
the foot. It may he unilateral or bilateral, the former
being the more comuion : the left side is more often af-
fected than the right. Pes gigas is found in two forms:
574
REFERENCE HiVXDBOOK OF THE MEDICAL SCIEXCES.
Perry SprlngOo
Petrifaction.
(1) a form in which tlie hypertrophy is tnie or symmetri-
cal; here the whole foot, or leg and foot, suffer a general
hypertroph}', the symmetry and contour of the part being
observed, and the only abnormality being the enormous
size. (2) The false or asymmetrical form, in which onl_y
certain parts are affected; this is the more connnon va-
riety, and generally shows itself in the enormous devel-
opment of one or two toes, or in large fatty excrescences,
or in hypertrophy of some of the muscles of the calf of
the leg." (See Fig. 3802.) The cause of pes gigas is un-
known.
The skin is always Involved, and, in addition to the
hypertrophic condition, tlie cutaneous sensibility ma}' be
aii.seut or diminished ; it is never increased. In hy pertro-
]ihy of the toes the nails generally enlarge pari passu
wiih the other parts. The subcutaneous fat is increased
in amount and is apt to be irregularly disposed in lumps.
"When the toes are affected the metatarsal and phalangeal
bones are always enlarged: but this enlargement is gen-
eral, and the only deformity noted is an outgrowth at the
extremity of the bone, at the junction with the articular
cartilage. The condition of the joints involved is vari-
able; sometimes the motion is normal, sometimes it is
limited, and sometiiues there is complete ankylosis. Pas-
sive mobility may or may not be elicited ; the ligaments
are thickened.
The treatment is not satisfactory. (1) Pressure in vari-
ous forms has been recommended ; but, besides being
tedious in its application, uncertain in its effects, and
decidedl}' painful, it is not free from danger: and hem-
orrhage, ulceration, and erysipelas have ensued from
this method of treatment. (2) Ligature of the main artery
has also been suggested; but this method, too, has not
been characterized by brilliant results, (o) Amputation,
of colossal toes and judicious trimming of superfluous tis-
sue will give a presentable and serviceable extremity.
This is probably the best procedure. li. J. E. IScutt.
Literature.
Anderson : St. Thomas' Hosp. Rep.. N. S.. VfZ, vol. xl.
Jacobson : Article " Pes Gigas," in Heatli's Diet, of Practical Surgery.
PETECHl/E. — These are small, round, blue-red or pur-
ple s|iiits or points in the skin, or in the serous or mucous
membranes, that cannot be made to disappear by pressure.
They are usually not elevated above the surface. They
are "caused b}' minute extravasations of blood into the
subepithelial or subserous tissue. They arise for the
greater part through diapedesis, and occur chiefly, though
not exclusively, on the dependent portions of the body,
particularly over the legs. They are often localized in the
hair follicles. In the serous membranes they are found
most often in the posterior wall of the pleural cavity, and
on the posterior jjortion of the epicardiuin and pericar-
dium. In the mucous membranes they occur most fre-
quently in the conjunctivse and mouth, but may be found
in any part of the body. According to their etiology
peteciiiiE may be classed as traumatic, infectious, toxic, and
neu ropathic.
Petechise may he produced by the bites of fleas {pur-
para pulicoaa). These may be mistjiken for purpura or
other hemorrha.gic diseases. They may be distinguished
from the latter by the fact that the puncture caused by
the flea shows as a darker point in the centre of the spot,
and by their greater abundance over the trunk. Local-
ized petecliioe may occur also as the direct result of cer-
tain forms of trauma, and may be of medico-legal impur-
tance in the establishment of the occurrence of trauma.
Petechits occur also in the course of many of the acute
infections: sceirlet ferer, tariola, diphtheria, endocarditis,
plarjue, yellow ferer, elwlera, anthrax, septicmnia, measles,
typhus fever, rfieumatisjn, typhoid, acute yellow atropihy, etc.
The cases in which such hemorrhages occur are usually
more severe than the non-hemorrhagic ones. The differ-
ent forms of the primary purpuras are also characterized
by tlie occurrence of petechia; in the skin and mucous
niemljranes: purpura simjihx. purpura rhevmatica, mor-
bus maeulosus Werlhofii, and Barlow's disease. In the last-
named, innumerable minute hemorrhages maj' occur
throughout all of the internal organs. In sctiri'y pete-
chia; occur in the skin, in the mucous membranes, and in
the pleura, pericardium, endocardium, and peritoneum.
It isvery probable that tlie purpuras are infectious dis-
eases, in part caused by the streptococcus, in part by
bacteria not yet recognized.
Petechia may lesult also from a lowered nutrition of
the vessel walls, as in starvation, pernicious ancemia. leu-
kcemia, cachexia of malignancy, etc. It is ver_y probable
that in these conditions there is an intoxication which is
the chief factor in causing tlie changes in the capillary
walls. Petechiie occur also in icterus, nephritis, poison-
ing with bromine, iodine, pliosjihorus, arsenic, snake-venmn,
etc. PetechiiE have also been observed to follow the use
•of quinine.
In chronic passive congestion of marked degree pete-
chia; may be formed in the body surfaces and also in the
internal organs.
Petechias may arise as the result of excessive emotion,
or during the hysterical or hypnotic state (stigmatiza-
tion).
As diagnostic and prognostic aids petecliioe are of great
significance. The size, location, conditions of occurrence,
etc., are all very important factors.
Aldred Scott Warthin.
PETRIFACTION.— The deposition, in the tissues, of
solid, crystalline, amorphous, or granular salts of lime,
magnesium, or uric acid is kuownas petrifaction or putri-
fying infltration. AVhen tbe deposit consists of lime
"salts or of a combination of salts of lime and magnesium,
the process is usually spoken of as calcification or cal-
caremis infiltration. A physiological calcification takes
place during the process of" ossification of the skeleton;
in this ca.se the deposit of lime in osteoid tissue is an es-
sential step in tbe development of a new tissue. All
other deposits of lime salts within the body tissues must
be regarded as being of a patliological nature.
With the exception of the new formation of bone in
the repair of fractures and in tumors, calcification is es-
sentially a retrograde change, the precipitation of the
phosphates and carbonates of Ihne and magnesium occur-
ring onl}' in degenerating, dying, or dead tissues. In
old age a deposit of lime .salts occurs in the walls of the
arteritis, in the costal and laryngeal cartilages, in the
walls of the capillaries of the lungs, stomach wall, and
kidneys. This phenomenon is explained as due to an
excess of lime salts in the blood, resulting from an ex-
cessive absorption of lime salts from the bones. Preced-
ing the deposit of lime salts there occur certain retro-
grade changes characteristic of old age — hyaline change
of the blood-vessel walls, etc. This calcification of old
age is of such common occurrence as to warrant its being
regarded as physiological. The resorption of lime salts
from one tissue and their deposit in another is known as
metastatic calcification. Calcification of the mature pla-
centa is also of such frequent occurrence as to be re-
garded as physiological. The presence of brain sanil in
the choroid plexus and pineal gland is so universal that
this may also be included under the head of physiolog-
ical.
Calcification occurs most frequently as a sequel to
fatty degeneration, hyaline change, cloudy swelling, sim-
ple "or caseous necrosis. It is found in s"clerotic vessels,
endocardial thickenings, hyaline thickenings of dura,
peritoneum, pleura, and pericardium, in the interstitial
tissue of hyaline goitre, in corpora fibrosa of the ovary,
old tubercles, gumniata, old abscess cavities, inflamma-
tory exudates, and in thrombi (artcriolithsor phleboliths).
A deposit of lime salts may occur in ana;niic or hemor-
rhagic infarcts, focal necro'ses, in dead ganglion cells, in
encysted trichina, and in the necrotic areas of tumors.
It occurs also in osteoid and hyaline connective tissue of
tumors, and in psanimomata". The connective-tissue
stroma of both carcinoma t a and sarcomata not infre-
cpiently shows calcification (sarcoma and carcinoma jjctri-
ficans). Myofibromata of the uterus very frequently
5t5
Polrolnliiiii.
PlKt£;o«',vlo»is.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
show a greater or less degree of calcification. Lime
salts are also deposited in the dead fat cells in cases of
fat necrosis. Calciticatiun of the renal epithelium fol-
lows tlie cloudy swelling jiroduced by such jioisons as
mercuric chloride, carbolic acid, bismuth, aloin, etc.
Retained decidua or clioriou, or portions of tlie dead
I'c.'lus and its membranes, may become calcitied (litho-
celyphnpa'dion), or the sac may ru])ture and the l'a?tus
e.scape into the peritoneal cavity, later becoming calci-
tied (litiiopa'dion). In diseases o"f tlie bones cliaracterized
by a resorption of the lime salts, the latter may be de-
posited in other tissues of the body.
Calcified tissues are hard and wliite and sharply out-
lined; tlie area affected may lie largeor.small. Tlie lime
salts may be dissolved out by the action of acids, in the
case of carbonates with tlie formation of carbonic acid.
Microscopically, deposits of carbonates or phosphates
stain deep blue or violet with hiemato.xylin.
A deposit of uric-acid salts occurs particularly in gout.
The gouty deposits consist chiefly of sodium urate with
small amounts of carbonate and phosphate of lime. The
tendon sheaths, synovial membranes, ligaments, articu-
lar cartilages, kidneys, skin, and subcutaneous tissues are
cliietly affected, but the deixjsitsmay ultimately be found
in nearlj- every organ of the body. The larger deposits,
called tophi, form large rounded masses, of a white, plas-
ter-like substance, which are found particularly in the
joints and tendons.
The individuals exhibited in museums as " petrifying "
or "ossifying," are either cases of myositis o.ssificans or
of scleroderma.
Petrifaction of the tissues of the body after death may
occur under certain conditions, but is probably very rare.
The majority of cases reported as such are in reality ex-
amples of adipocere formation. Very little is known
with certainty regarding the jictrifaction of the cadaver.
Petrified or fo.ssili/ed bones of the human race are very
rare. Such have been reported to have been found in
caves and in bog deposits whose waters were impreg-
nated with iron and lime. In old bones there may some-
times occur a crystalline arrangement of phosphate of
lime, or the bony structure may become so impregnated
with mineral elements that its color and consistency be-
come greatly changed. It is very probable, however,
that a complete replacement of the elements of the bone
or of the body tissues with mineral constituents is of
verv rare occurrence. (See also Valfification.)
Aldied Scott Warthin.
PETROLATUM.— The word petrolatum stands, both in
Latin and in English, as the official title in the United
States Pbarmacopo'ia for an nuctuousderivate of petrole-
um, obtained by distilling olT the lighter and more vola-
tile constituents of the oil and imrilying the residue.
Three grades of petrolatum are official. thedilTeieuce being
in consistence only. They are entitled, severally, Pctrola-
turn Liquidum, Liquid Petrolatum ; I'ltrotntiiin'MoUe, Soft
Petrolatum; and Pit mint uni Spixxu/n, Hard Petrolatum.
The first of these grades is of the con.sistence of oil; the
second is soft, like lard, and corresponds to the well-
known ])roprietary substances m.v(7;';(< and rnsiiioline : and
the third is liard. like cerate. When the word "petrola-
tum," without modification, is used in prescription," soft "
petrolatum isdispen.sed. Petrolatum consists |irincipally
of a mixture of paraffins (hydrocarbons of tlie formula
C'„Hj„ -I- i), but prol)abh' also contains some olefins (hy-
drocarbons of the formula C„II.j|,), which, by their softer
consistence, tend to increase the nnctuousness of petro-
hituni. Petrolatum is a whitish or yellowish material,
more or less fluorescent, tasteless, and with no odor, ex-
cept when heated when a faint odor of ]ietn)lcum is jier-
ceptible. It is entirely amorphous, and, in fluid condi-
tion, makesa transparent liquid. It is neutral in reaction.
It is insoluble in water; scarcely soluble in alcohol, or in
cold absolute alcohol; but soluble in Ijoiling absolute
alcohol, and readily soluble in ether, chloroform, disul-
pliide of carbon, oil of turpentine, benzin, benzol, and
in fixed or volatile oils. When heated on platinum foil,
it is completely volatilized without emitting the acrid
vapors of burning fat or resin.
Petrolatum owes its medicinal value to its combining
with the physical attributes of the serai-solid fats the
chemical peculiarity of the paraffins, of being practically
unalterable and indifferent to chemical agents. Petrola-
tum neither hardens nor turns rancid b}' exposure, and
can be treated with any chemical likely to be prescribed
medicinally in an ointment without being itself attacked
thereby. The substance is therefore available, either by
itself as a simple unguent, perfectly bland and change-
less, or as the fatty basis for medicated ointments.
Edicard Curtis.
PETROSULFOL is a sulphur-containing bituminous
product closely resembling ichthj'ol, but with a less dis-
agreeable odor. It is miscible with water or oil, and is
used as a general succedaneum for ichthvol.
)V. A. Bdxlcdo.
PHAGOCYTOSIS.— Phagocytosis is the term applied
to the ingestion of solids by living cells. That leuco-
cytes were capable of taking up inert particles when in-
troduced into the animal body or even when mixed with
the freshly drawn blood of such animals as the newt had
long been known, when Haeckel pointed out the simi-
larity between such processes and the engulfing of food
]iarticles by unicellular organisms. Roser went further
in suggesting that resistance to infection by bacteria
and other living irritants was due to the phagocytic prop-
erties of the cells of immune animals.
It is to Jletchnikoli and his followers, however, that
we are indebted for much of our knowledge concerning
this particular physiological function of cells. In his
researches on the comparative pathology of inflammation
phagocytosis in many tjpes of organisms Avas studied
and the capacity of their cells for dealing with various
solid particles determined.
It does not lie within the scope of this article, however,
to give in e.rtemo the opinions held by Metchnikoff
and others relative to immunity excepting in so far as
they bear upon the mechanism of phagocytosis, the fac-
tors which influence it, the fate of the matters enclosed
by cells, and the value of the process as illustrated in the
life histories of organisms.
Tin .Virlomixiit of P/oo/uri/tosi^. — Before the ingestion
of solid particles by cells is possible the two must be
brought together. In the case both of the amu'boid uni-
cellular organisms and of the wandering cells of the
higher animals, this is brought about by the attraction of
the cell to the particles. (See the section on Leucocytes,
under Blood. ) The attraction exerted by particles upon
motile cells is ]irobal)ly operative only over a limited area,
and although there is some difl'erenceof opinion concern-
ing the matter, it would apjiear that a certain amount of
the solid particles being dissolved in the fluids containing
the cells may stimulate them to approach the particles or
under other conditions to repel them.
Amoeb* or other single-celled organisms are brought
into the sphere of influence of food particles and bacteria
by difTusion currents, and micro-organisms may by their
own motility come" into such a position as to be more
ea.sily engulfed. .leniiiugs and jloore have shown that
when paramecia anil other infusoria pa.ss by their own
movements from a less attractive into a more attractive
solution, they tend to remain there because tlieir move-
ment in the initial direction is arrested and reversed just
as they are about to leave the agreeable environment.
Bj' a series of reverses they are kept swimming backward
and forward acro.ss this attractive sphere and thus accu-
mulate, not liy initial attraction toward, but by inability
to go away from, the agreeable environment. It remains
to be proved whether any .such explanation can be
adapted to the accumulation of leucocytes in the neigh-
borhood of bacteria and their toxins.
In the higher organisms provided with Ij-inph or blood
channels or both, the transportation of wandering cells
to the vicinity of foreign particles is passive, although
571)
REFERENCE HANDBOOK OF THE 3LEDICAL SCIENCES.
Pcli-olntiiin.
Pliagocytosis.
their sirrcst at the margin of the vessel walls and their
later emigratidu is an active process in response to stim-
ulus. Fi.\ed cells like the endothelium ot tlie lymph- and
blood-vessels, serous cavities, and the spleen pulp may
throw out pseudopodia and entangle and ingest bacteria
which are bronght to them by tiie circidacion. They
may even bud oil' tlie large nionouuclear leucocytes which
are so markedly ania>boid and pliagocytic, but jiroof that
tliesc after engulting bacteria or other particles may again
become li.\ed is wanting. It is a connnon thing for a
wandering phagocytic cell to be later engulfed with its
contents by fi.\ed cells, especiall_v endothelial cells.
Phagocytosis is to be observed in a multitude of ways,
but perhaps as simple a demonstration as any is a luodi-
fication oi that used by Kanthack and Hardy. A drop
of fluid from the posterior lymph sac or peritoneum of a
frog is withdrawn by a capillary pipette, placed in the
centre of a clean cover-slip and lightl}' iuocidatcd witli
a fresh culture of hucilliis akihrucCs, hacillun Jilamcii-
ioms, or some other large nou-nn)tile orgaui.sm. The
drop is inverted o\ er a vaseliued hollow ground slide, or,
better still, a ring of filter pajier may be placed upon a
slide and the drop of inocidated lymph inverted over the
hole (Miss Green wood's method). The filter paper should
be thick enough to jirevent the drop from coming in
contact with the slide, and should be moistened with
water from time to time to prevent the desiccation of the
lymph. This metiiod provides plenty of o.xygen. Such
a preparation may be kept under observation for hotirs
at room temperature, and the leucocytes, of whicli in the
frog there are fewer varieties than in manmials, remain
active and may be seen to attack the bacteria according
to a definite plan. A better method, especially for dem-
onstration to large cla.sses, is to inoculate a cidture directly
into the jieritoneum of the frog and to withdraw dro]is
for micioscopic slu<ly froiu time to time. OUservatiou
may be made while the cells are living as outlined above,
or smears stained with eosiu and methylene blue may be
prepared at various stages.
It will be seen that the coarsely granidar o.xyphile
(eosinophile) and hyaline (large immonuelear) leucocytes
are actively attracted to the chains of bacilli, the former
being; generally the first to attach themselves. Their
granules e.\hil)it streaming movements before, and usu-
ally disappear immediately after contact. The lympho-
cytes (small monoiuiclears) .seem to take no active iiart,
although they become included in the Plasmodium
formed by the otlier two varieties of leucocytes and the
chains of bacilli which become bent into sliarji angles
and finally tightly compressed. The individual cells
seen to become a part of the Plasmodium, soon lose their
outline, and in unstained specimens eaimot be differen-
tiated. The pla.smodium later breaks up, and the com-
ponent cells again become free in from five to nine hours.
The coarsely granular o.xyphile cells which have hist
their granules and whose protoplasm has become ampho-
philic upon contact with the bacilli sometimes regain
their granules witli their o.xyphilic reaction. In the liya-
line (large mononuclear) cells, however, at this stage fre-
quently one or more vacuoles esm be seen which contain
chains of bacilli doubled ujion themselves so that from
two to five or more bacilli are included. The included
bacilli are undergoing degeneration as evidenced by their
swollen, granidar, or generally "wilted" ap|icaraiice.
Kanthack and Hardy after a very extended series of ob-
servations concluded that with fully virideni bacilli tiie
coarsely granular oxy]ihile cell is called into action first,
and through contact with the bacilli, by a process of
"e.xtra-cellular " digestion orueutralization, works them
harm, after which phagocytosis on tlie ]iart of the hya-
line cells becomes possible. They maintained that this is
true not only for frogs but for mammals, and were con-
vinced that phagocytosis as the initial movement is possi-
ble only where non-virulent bacteria or other relatively
inert particles aie employed.
The difference in the mndiis opernmli of these two
leticoeytes has been veiy graphically illu.strated in a more
recent juiblication by Hardy in which he was able to
Vol. VI.— 37
measure accurately imder the microscope the rate of
growth of chains of bacillus tilanientosus (non-virulent)
which had been introduced intoadrop of frog lymph and
observed under the microscojie for a number of hours.
He found that in those bacilli which had come into eon-
tact with coarsely granularo.xyphile cells no growthtook
place. Those in contact with hyaline cells or lymjiho-
cytes grew out into long filaments, as did also ihe free
bacilli. Wliere one end of a chain was enclosed within
a vacuole of a hyaline cell growth in that direction was
arrested, although division of the bacilli at the other end
of the chain went on. It will be seen that the material
("•slime") extruded or exuded by the coarsely granular
oxyphile cell at the time of the disappearance of its pro-
toplasmic granules, or iierhajis, more correctly speaking,
that contact of the bacilli with the changed protopUism
— true phagocytosis not diking place — had the same in-
hibitory effect upon the growth of bacilli as had the con-
tents of the digestive vacuole of the hj-aline cell. The
vacuoles of phagocj'tic cells iirobably all contain a fer-
ment. Such has been shown to exist in the food vacu-
oles of the amo'ba b_y Krukenberg, Reinke, and Green-
wood. Further, the ferment fluid has been shown to be
acid, althougli secreted by an aikaliue protoplasm. In
these vacuoles whatever is capable of digestion goes into
solution and serves as food for the cell, while the insolu-
ble remnants are extruded.
It is impossible to hazard any opinion concerning the
exact nature of such digestive tluiils or mechani>m, par-
ticularly when con.sidering the destruction by jihagoey-
tosis of bacteria against which animals have been ren-
dered imnume. It lias been suggested by Ritchie as
tpiite po.s.sible "that by virtue of one set of jiowers a
phagocyte may kill a bacterium, by virtue of another
set of powers it may digest it, and the latter process nray
be the same as ordinary proteolysis, as it occurs in con-
nection with the intestinal glands of an animal." It
must be remembered, however, that typhoid bacilli will
develop in solutions of pancreatic ferment posse.s.sing
sutlicient activity to digest fibrin, and it is well known
that in artificial digestions with all the common ferments
antiseptics must be employed in order to prevent over-
growth of putrefactive and other bacteria. Certain ob-
servers, including some of the Pasteur school, even go
so far its to suggest that nearly all kinds of ferment activ-
ity in the animal body are facilitated by, if not largely
dependent on, the ]ire.senee of bacteria.
One is therefore forced to ask whether the phagocytic
inclusion and digestion of bacillus typhosus by the cells
of an animal immunized against that micro-organism is
accomplished in exactly the same manner and by the
siune ferment actix'ity as would be the cholera vibrio had
the animal been rendered resistant against that organ-
ism. It does not seem possible that by repeated immu-
nizing doses of a given micro-organism the phagoc-ytic
cells can be so altered as comiiletely to change their di-
gestive mechanism. It is well known, however, that
bacteria are frequenfl}' englobed, and later during their
gl'owtli, or by tljeir production of stdistances which may
neutralize or destroy the digestive ferment, the jiliago-
cytes may be destroyed, although similar cells may hiter
by a process of immunization acquire the i.iroperty of
seizing and also digesting the same bacteria.
Further diseussitm ot these matters will be nccessiiry
in considering the questionsof what cellsare phagocytic,
the fate of enclosed bacteria and other masses, the eco-
nomic uses of phagocytosis, and the relation of phago-
cytosis to present-day theories of immunity,
AVii.vT Cells .\ue Pii.vgocytic?
In tuiicellular organisms phagocytosis affords a means
of securing food and tor defence. In more highly ilevel-
opcd organisms with the greater specialization in other
functions thatof iihagocytn.sis isassigned todefinili'ci-lis.
jiartieularly those of mesodermal firigin. When iiiicio-
organisms or particles obtain aceess to the body lluids
they may be carried to any part of the liudy unless (lis-
Piiauoiylosis.
UEFEREXCE HANDBOOK OF THE MEUICAL SCIENCES.
posed of or arrested. Similarly, when irritaut particles
or micro-orgauisms are localized iu the body, jiluigocytic
cells aud those with other defensive activities may be
hurried to the front by way of the lymph aud Ijlood
channels. It may be w'ell to consider first the free or
wandering cells which are phagocytic, and secondly
those which are fi.xed.
1. Pii.\GOCYTOsis IN FiiEK Cki.i.s (see also section on
Leucocytes under BIumI). If we luok upon phagocytosis
as an active process the red blood cells may be excluded.
Lymplwcytes (small) are not phagocytic. Their proto-
pla.sm is so scanty as to leave no room for inclusion of
particles uor have they been slifiwn to be actively motile.
Cddvsely griiiiuUn- oji/phile cill.^ (eosinophile), although
infrequeiit'in normal blond, are more plentiful in lymph,
and iu tissue spaces they are abundant. Kauthack and
Hardy consirlrr them to be never phagocytic. Mesnil, a
pupil of iletchnikolf, states that they may be phagocytic.
I have always looked upon them as never phagocytic until
two }'e;irs ago we encountered one uudoubtetl case of in-
clusion iu, aud partial digestion of, B. Jiliimentosnti by one
of these cells in an exudate resulting several hours after
an intrapleural injection of tlie organism into a guinea-
pig. The eosinophile granides were perfect, and the
bacilli \ver(! contained within a vacuole. Phagocytosis
on the part of tliese cells must be extremely I'are. They
appear to act rather by a process of extracellular paraly-
sis or digestion of bacteria.
The finely iiriiiiyjltir oxyphih' (pnlymoriihonnHeur) Uvm-
cytes, or " microphages " of Metchnikolf, are the chief
phagocytes of the blood. Where initants are applied to
vascular areas these cells very quickly appear in the foci,
emigrating rapidly from neighboring vessels. In pus
formation, in the tibrinocellular exudates of diphtheria
and pneumonia, and in exudates in serous cavities and
many other sites, these cells are present in vast numbers.
In pneumonia there may lie present iu the hepatized area
many times the total number of these cells normally pnes-
ent in the whole body. Where do they come from? In
certain infections the manufacture of these cells in the
marrow of the loug bones is tremeudousiv stimulated
(Muir, also Roger), so that following the initial temporary
diminution of leucoc^-tes in the blood the increased out-
put is sufficient to supply all demands. The subcutane-
ous injection of staphylococcus pyogenes aureus into
the tissues of rabbits, and serial observations on there-
suiting ab.scess formation (Hohnfeldt) allord an excellent
opportunity of studying cheniotaxis and phagocytosis
iu connection with these cells. Their i)hagocytic prop-
erties and modes of action ma.v be studied in smears of
gonorrlueal pus, in purulent fluid iu cases of cerebro-
spinal meningitis, and iu pus from abscesses. The se-
quence of changes in intlammation iu which finely granu-
lar oxyphile cells bear a part maj- be well observed when
fluid from the abdonieu is withdrawn from time to time
after intraperitoneal in jei I ions of various micro-organisms
(Pfeilfer, Durham, and others). These cells possess the
capacity for engidfiug carbon and other insoluble pig-
ments and of digesting pieces of tibrin, cell debris, bac-
teria, and other soluble materials. Vacuoles, evidently
digestive, may often be seen surrounding the particles,
although not always. This variety of leucocyte is. in
short, instnunental iu the removal of inhaled pigment
particles, hemorrhages into the tissues, fibrinous exu-
dates, anil otiii'r dilritiis, wliil<- in resisting the pyogenic
micro-orgauisms it is iirobably the chief factor.
The. hyaline {In rye ni(iiioniieleiir) hi/n/rytcf or "macro-
phages" of JletchuikotT are seemingly derived from the
eiidotheliiun of ves.sels and from the spleen and lym-
phatic glands. The phagocytic work iu those tissues
where the transportation f.-icilities of the blood stream
are not readily available is dejiendent to a great degree
upon these cells. Kanthuck and Ilanly believed that
only iu case of feebly vindent liacteria and non-irritant
particles are they capable of immediate action. That
they do o|ierate after other cells have been engaged is
evidenced by the fact that other cells, such as the finely
granular oxypbiles, are very frecjuently found iu vari-
ous stages of disintegration enclosed within them. The
intraperitoneal or intrapleural inoculation of non-viru-
lent bacilli into guinea-iiigs illustrates this well. Jlal-
lory believes that where an irritant of a low grade of
virulence is present, proliferation of the fixed cells aud
phagocytosis are prominent features. In tyjihoid infec-
tion this is true, and hyaline cells are especially active
phagoc.vtes, the finely granular oxyjihiles being incon-
spicuous. In tuberculosis and leprosy phagocytosis is
comiuon, and eudothelial cells are particularly active. In
purulent iufections the finely granular oxyphile aud uot
the hyaline cell is the chief phagoc_yte. In the liaigs in-
haled carbon pigment and broken-down blood pigment
— in pneumonia of heart disease — are contaiued in large
amoiuits iu large flat cells with roviuded or oval nuclei.
Whether these are hvaline leucocytes or desquamated
alveolar e]iithelium cannot alwaj-s be determined. Hya-
line cells are the comiecting link betweeu entlothelimn
and leucocytes, aud ^luir has pointed out that in infiaui-
matory leucocytosis increased activity in and production
of hyaline cells can be found evideuced in the h-mphatic
sinuses of lymph glands aud by the mitotic figures in free
hyaline cells.
Other Tfirieties of leneoeytes have not been recognized as
phagocytic, aud, in fact, little is known concerning their
activities.
2, Pii.\GocYTOsis IN Frxp:D Cells. — The endothelial
cells are markedly jihagocytic for bacteria and other jiar-
ticles which are brought to them iu the blood or lymph.
They engulf particles by throwiug out pseudopodia, and
within limits they are quite amceboid. It has been s\ig-
gested that iu extremely small vessels where the endothe-
lium composes a large part of the vessel wall, vasocon-
striction or dilatation may depend upon thickening or
thinning of these cells as a response to direct stimulation
by materials flowing in the blood or Ij'inph. This, if
true, has an important bearing uot only on inflammation,
but upon the vascular phenomena of fever. In consid-
ering the finding of pigment particles in fixed connective-
tissue cells as iu those of the sujiportiug tissue of the
luug, or iu glands, there is a question as to their exact
mode of entrance. It is among the possibilities that free
leucocytes act as phagocytes aud wander by way of
blood or lymjih channels or between or through other
cells until the particles ultimately reach the location in
which they are foimd. Or the original phagocytic leu-
cocytes may have died and set free the pigment to be
taken up by a second leucocyte, or b}- an eudothelial cell,
or by a connective-tissue cell. Or the original leucocyte
witli its contained particles ma}' have been bodilv en-
gulfed by a growing connective-tissue or other fixed cell.
Evidences of such a process are not wanting. In phago-
cytosis on the part of eiuthelium — superficial or in glauds
— the problems are just as complicated. When bacteria
enter the liver through the portal circulation aud are then
engulfed and killed or attenuated by the liver cells and
ultimately extruded or excreted into the bile capillaries,
it is likely that the eudothelial cells of the portal capil-
laries act first aud that these yield up their contents to
the liver cells. Whether epithelial cells such as tho.se
in the milk glauds can take up living bacilli aud excrete
or secrete them in a virulent condition so that thej' are
eliminated through the ducts, is a C|uestion. Adauii has
suggested that such is the case where tubercle bacilli are
found in the milkof cowswhose udders liear no evidence
of tuberculosis. !Mauy other matters bearing upon this
question might be discussed, such as the methods of ex-
cretion of bacteria and solid particles by wav* of the kid-
ney, tonsillar infcctiou in tuberculosis, etc., but they do
not lie within the scope of so limited au article as this.
The Fate of Encloseel Partieles. — When insoluble [lig-
ment particlesare found iu situatious to which they could
not have been swept by currents of lymph or blood,
ama^boid phagocytes have probably been the carriers,
and such cells may set free their contents either before
or after death.
Undoulitedly through phagocj'tosis many bacteria are
killed, but. as we have seen, not all of those which are
57S
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Phagocytosis.
PliagocytosiSo
taken into the interior of pliugocytcs are destro\-ed.
JletcliuiliotT has isolated .single leucocytes wbieh "con-
tained micro-organisms, and in a drop of broth under the
microscope he has watched the bacteria increase within
the cell until it was filled and tinally destroyed, the micro-
organisms escaping into the broth. In many cases of in-
fection observation would warrant the belief that bac-
teria may be engulfed and carried considerable distances
b.v phagocytes, which are then destroyed, the bacteria lib-
erated, and a new focus of infection is set up. In many
infectious phagocytosis is pronounced throughout the
whole course of the disease. This has constituted a diffi-
culty for those who advocate the phagocytic theory of
immunity. In such chronic diseases as leprosj', tuber-
culosis, and -glanders, bacilli, apparently many of them
living, are to be found enclosed in pliagocj'tes. In epi-
demic cerebro-spiual meningitis and gouorrha>a — diseases
of a more acute nature — one of the diagnostic points in
connection with microscopic examination is the demon-
stration of the diplococci within the cells (finely granular
oxyphile). It would therefore appear that while phago-
cytosis is uudoubtedl_v an important factor in resistance
to infection, there are distinct steps, namely, attraction
of leucocytes which then engulf bacteria and hiter digest
them. That di.gestion of bacteria does not alwa3's follow
their enclosure in phagocytes is ajiparent.
The Ftictors which Influence PlKi'jucytosis. — Anj-thing
which checks chemotaxis interferes with phagocytosis.
It has been conclusively sliown that highlj' virulent bac-
teria are less apt to attract wandering cells and induce
phagocytosis than are more attenuated microbes of the
same kind. For instance, if atteuuiited anthrax bacilli
be inoculated in one ear of a ralibit and virulent anthrax
bacilli be inoculated in the same manner and dose in the
other ear of the same raljbit the results are quite dilfer-
ent (Metchuikoff). In the one ear the attenuated bacilli
induce a tremendous accumulation of leucocytes, while
in the other ear fluid is poured out into the tissues with
little or no attraction of leucocj'tes.
The state of resistance of the animal is also important.
Immunization to anthrax renders an animal capable of
responding to a dose of virulent bacilli by an accumula-
tion of leucocytes, while a similar dose in an untreated
animal induces a huge outpouring of fluid.
The presence of soluble bacterial products in a definite
locality tends to favor the attraction of leucocytes from
the neighboring blood-ve.ssels, while the circidation simid-
taneoush' of the same materials in large quantities in the
blood stream tends to prevent it. This is illustrated
(Roger, Hulfer) by inoculating the bacillus of sympto-
matic anthrax into the subcutaneous tissues of a rabbit
when leucoc3'tes rapidly accumulate at the site of inocu-
lation and al)sces.ses result. If another rabbit be similarly
inoculated, while in adilition an intravenous iuocidation
is made, there is tremendous outpouring of fluid, but no
leucocytosis at the site of the subcutaneous injection,
and death results in a few hours. Hence phagocytosis is
apt to occur when the invading bacteria are not too viru-
lent, when the resistance of the host is .great, and when
the irritants and solulile products are present in much
greater abundance at a point or points outside the ves-
sels than in the circulating blood.
The economic vsck of phagocytosis have been dealt with
more or less fully in the preceding portions of the article,
and need be only mentioned here. As a factor in nutri-
tion evidences of the importance of phagocytosis decrease
as we ascend in the scale of development. For instance,
in the amoeba observation would tend to show the ex-
treme importance of phagocytosis in this connection,
while in the higher animals proof that it takes a great
.share tn the securing and assimilation of food is wanting,
although such may yet be forthcoming. As has been
stated, pigment and solid debris, such as exudates, hem-
orrhages into the tissues, dead cells, and tissues of all
kinds are largely removed by phagocytes. In the spleen
phagocytic inclusion of dead blood cells and animal and
vegetable parasites is always demonstrable. JIany more
examples could be quoted were it necessary. In their
attraction to, inclusion of, carrying away, and destruc-
tion of invading organisms the "phagocyt"ic cells may be
exhibiting characteristics largely acquired in exercising
their more physiological functions.
Phagocytosis in Belation to Present-day Theories of Im-
munity.— Ehrlich's brilliant experiments and deductions
(see article on Im)iiuhity)havc necessitated a remodelling
of many of our ideas, and Mctchnikoff in accepting Ehr-
lich's views has attempted to harmoni/.e phagocvtosis
with the activities of complements and inunune bodies,
Ehrlich believes that immunity against bacteria (or other
cells) depends upon the original possession or artificial
induction of a special substance, "inmiune body," which
firmly unites with the bacteria and thus enables auotlier
substance, "the complement," which is present normally
in the animal to kill the bacteria. The immune bodies
are more resistant to heat than are the complements. In
the serum obtained from an imnuinized animal Ijoth im-
mune body and complement may be foiuul. although
Metehnikoff believes tliat both are liberated from leuco-
cytes (microjihages and macrophages) by " phagolysis,"
and that in the body the final action of the complement
on the bacteria takes place only within the cell during
phagocytosis, even should the immune body have beeit
■ free in the fluids.
It has long Ijeen known that bactericidal substances are
more abundant in the leucocytes than in the fluids of the
body. More recent work of Denys and Leclef seems to
show that from rabbits innuimized against streptococcus
the serum when mixed with leucocytes from such an ani-
mal was no more destructive for streptococci than when
mixed with the leucocytes of a normal rabbit, while bj-
itself it was practically not bactericidal at all. Two anti-
bodies seemed essential for the destruction of the strepto-
cocci : one was to be found in the immune serum, and the
other was afforded eciuallj' well by the leucocytes of the
normal or treated rabbit.
Bulloch's work on ha'moly.sis tends to show that in the
rabbit an increase of finely granular oxyphile cells in the
blood accompanies the formation of complement and that
activity of mononuclear leucocytes is related to the forma-
tion of immune body.
There seems to be as yet no information available con-
cerning the exact source of complement and immune
body. We are not justified in assimiiug because a sub-
stance is bactericidal in test-tube experiments that it is
operative as such in the body. We have seen alreatly
that the coarsely granular oxyphile cell acts deleteriously
upon virulent bacteria, and that it is not markedly pha-
gocytic. There are doubtless other cells which are anti-
bacterial and non-phagocytic. In assuming that the
same cells produce both imnume body and complement,
Metehnikoff is not borne out by the' observed facts, al-
though lie admits that the former is more likely to be
liberated into the body fluids than the latter.
The digesticm of bacteria by phagocytes Jletclmikoff
apparently considers to be due to a ferment which seems
to be the same sort of thing as Ehrlich's complement.
It is not quite clear whether his "cytases" include
complement which remains fixed in the phagocytes, the
immune body which under some conditions escapes into
the fluids, and in addition special "stimuliues." which
acting on the phagocytes cause them to approach bac-
teria and engulf them. Ritchie, in his admirable critical
review of the subject, asks very ijcrtinently how the so-
called education of leucocytes is brought about. He
suggests that in the case of immunization by repeated
intraperitoneal injections of chok-ra vibrios it is perhaps
jiossible that in the later injections the especially active
phagocj'tes may have been the same individuals engaged
in the former encounters with the vibrios.
Although the life history of a leucocj'te is probably
short, he .suggests that such "sensitized" leucocytes
might even be attiacted from distant parts of the body.
It is easily seen tluit while admitting such possiliilities
he leans to the viuw that the active leucocytes in each
succceiiing injection are new ones probably derived from
the bone marrow or lymphatic sinuses.
5Y9
Pliuriiiaroptcin.
Piiariiiacu|>u.'ia.
KEFEREXCE HANDBOOK OF THE JUiDICAL SCIENCES.
To limit tlie formation of the active substanre.s of Elar-
lioli to tlie phagocytic cells of the b(«ly as .Metchuikolf
has dcme, further complicates au already complicated but
otherwise satisfactory theory of immuuily. There seems
to be ample evidence that there are many other active
factors in the protective mechanism than those afforded
by phagocytosis. Phagocytes are undoubtedly impor-
tant, but not all the phenomena of immunity can be ex-
pressed in terms of ijhagocytosis. /•'. F. Wisbmok.
PHARMACOPOEIA.* — (Greek (pnii/mvi-oiia, from
(firi/y/iii,(M, mrdirine, iemedy,and -ouh\ to make, to prepare ;
Latin, ;)/(!<j';«(/fu//«M or p/iiirmtux'pain ; German, P/kiihik-
kiijiite. ; French, j/htinnacopee ; Spanish, fa niiKcojica. etc.).
A phariiuicopa'iit, in the modein sense, may be ilelined
as a work published by .some recognized authority,
for the purpose of securing uniformity in the kind,
quality, strength, and composition of .simple and com-
pound remedies used in the practii'e of medicine. It
may eitlier be of a local character, or it may apply to a
whole country. During the early history of ]iliarmaco-
jiteias, the term was also often a|iplied to works written
or jiublished by individuals, without the official .sanction
of governmeutal or ]>rofessioiial authority. The Greek
word onitiiuKD-oila occurs in later Greek medical writings
uniler its proper meaning, " the preparation of medi-
cines," or "the art, or business, of preparing medicines."
As the title of a book treating of tliis subject, however,
it is probably not older than the beginning of the six-
teenth century.
Aiieiciit iitid Media'nil Pnriirmrs of Pliitrmacopaifis. —
'While the ancient nations did not possess any works
which could be full}' set side by side with our modern
pharmacopreias, j'et the gradually accumulating mass of
tacts relating to the preparation and practical use of
medicines resulted in the composition of numerous works
which treated at least incidentally of this subject. In
giving an account of the literature relating to the latter,
we shall confine our.selves to tho.se works the influence of
which has, in one way or another, extended to our times.
EijUjit has furnished ustheohlest existing documents
containing fornudas and directions for the preparation of
medicines. The (ddcst known is the Papi/rus Ehen, dat-
ing fnjm the year 15.52 B.C. (see.Vtd. lice, 11, pp. 247-251),
wiiich mentions a large nmnber of simple remedies, and
also contains numerous formulas of compounds, often in
the form of regular pharmacojiodal reci]ies, acct)mpaiued
by signs and terms expressing weights or measures, pre-
cisel\' as is customary at the present day.
The Meilk-id Pujiip'iis of Berlin (.see AVoenig, '" Die
PHauzen ini alten Aegyptcn," Leipsie, 1886), written
about 1350 B.C., contains a great number of foruuilas,
with exact statements as to ingredients, and weights and
measures. These formvdas are for both internal and ex-
ternal remedies, including enemata. The remedies are
niostl_v simples, plant jiarts, gums, resins, etc., with a few
metals, liijuors, and well-known li<piids, including urine,
bile, blood, and fa'ces of various animals.
In addition to these written documents, there existed
also formularies scul]itured in stone, one having been
found upon the walls of a regular pharmaceuticariabor-
atory or dsit (.see Woenig, lt>c. cit., 872) in the temple of
Edfu.
India. — Anexanniiationof the ol.h'st Indian literature,
that of the Vedas, Bralunins, and Sutias, reveals little but
superstition as to both disea.ses and remedies. The piin-
cijial medical works of the Hindoos, viz.. those of C'hara-
kaaiid Sueruta, cannot be tra<-ed back beyon<l the eighth
century -\.D. (.see AVw Rcmediex. 187(;, 22!)). the founda-
tions evidently having been <Ierivcd ixmw the Greek.s.
Jlost (jf these medical works are charaeteri/.ed. aixl their
meaning is obscured, by the poetic or m<'trical .style em-
ployed in them. Four or live centuries then elapse be-
*Tliis urticle is practically a rcpiint of ttiosc cmtrilmii-d iiv In*,
f'harlcs Hicc Id tlie iircceiiiiif; edition of this work and In tlic SuppU--
IlH'iil (Vol. I.\.) ; the records. 1 niijjlit add. Iia\c hccti luouszhl lip lo
date, and a few cliantrcs lia\'e been made in tbe intereslof ecounmy
cf .space.— ytijuri/ i/, liushu.
fore we meet with any other notable writings of this
kind. Am<iug the later medical treatises the most im-
portant are " Ashtangahridaya," by Yagbbata, and the
"Bhiivaprakaca," by Bhava, both of them only a few
centuries old. The.se contain likewise many formulas
interwoven in the text. Regular treatises on pharmacy,
or formularies, are not numerous (to the former belongs
the "Prayogamrita" of Vaidyachintamani. and others');
but treatises on materia medica or glossaries of simples
are much more common. The most extensive of these
is the "Nighautnraja, " by Narahari, of Cashmere, being
a dictionary of products of nature, etc., with synonyms.
Another smaller but useful work is the " JIadauavinoda"
of Jladauaiiala.
(jirece. — The writings of Hiiipocrates (about 460-377
ii.c.) were the first, as well as the most important, in the
early history of Greek medical literature. Although
none of his genuine writings is devoted exclusively "to
the preparation of specitic medicines, numerous .such
directions are contained in them, and the pharmaceutical
art liecame developed during the succeeding centuries in
]iroportion as the rational treatment of disease, upon the
fcnuidationlaid by Hippocrates, spread through the culti-
vated nations of Euroije and 'Western Asia.
Of those works which are known to have exerted a
permanent influence upon the formularies of later times,
that of Andromachus of Creta, Nero's court physician,
next requires mention, being a sort of poetic formulary.
He also wrote a poem on Theriae and its preparations,
which for centuries was highly influential in medical
practice. About 65 a.d., Servilius Damocrates com-
posed similar pharmacological poems, his Cdinpouud of
theiiac, thus treated, being subsequently known as " Con-
fectio Damocratis." In about 78 A.r>. , Dioscorides wrote
his famous r/^jcd ("Materialia"), a most valuable cyclo-
panlia of simples, which became one of the chief sovirces
of pharmacological writers down to the Middle Ages.
The next im]iortant Grecian medical writ<'r was Clau-
dius Gallinus (131 to about 210 .\.i).). His numerous
writings exerted an influence ecjual to that exerted by the
works of Dioscorides. Tw(j o( them treat especially "oq
the compo.sition of medicines according to the places " (of
application) "and according to classes. " His numerous
complex mixtures gave origin to the term "Galenical."
Of later wi'iters. the more important are: Aetius, of
Amida, in Mesopotamia (sixth century a.d.), who gives
numerous formulas for plasters, .salves, etc. ; Alexander,
of Trades, in Lydia (525-605 a.d. ), and Paulus, of ^Egina
(seventh century .\.I). I, both of whom likewise quote
mauy formulas in their writings. Passing now over
several centuries, we And no iiuthor worthy of mention
until we come to Nicolaus ilyrepsus, of Alexandria (sec-
ond half of thirteenth century A.D.), who compiled an
" Antidotarium " (I'lvvaiispov), or formulary, containing not
less than two thousimd six hundred and tiftysix formu-
las, in forty-eight chaliters. This work wtis written in
Greek, but only the Latin translation has been ]iublished
(tirst edition, Basle, 1549). It is also entitled "Antidota-
rium Magnum "(not to be confounded with the "Anti-
dotarium Parvum " of Kicolaus Pra;])Ositus). In spite
of its eucyclopa'dic cliaracter, this formulary did not ac-
(piire as much reputation as the less extensive woilcs of
Mesne or of Nicolaus Pnejiositus.
liDiiie. — Previous to C. Plinins Secuudus (23-79 A.D.)
only the writings of M. Porcius Cato (234-149 B.C.) in-
terwoven in agricultural treatises, need be mentioned.
In the great work on " Xtitural History " by the former,
many subjects relating to materia medica are treated.
The "CompositionesMedica'of Scribonius Largus" (tirst
centuiy \.v>.) is the tirst literaiy production, having
the nature of a foi'mulary, of Roman origin. It con-
tains the first correct description of the method of
obtaining oinum. A treati.se by Rufus of Ephesiis on
cathartics was for a long time influential. ^lauv- other
more or less important works by Romans were written
in Greek.
Afiihif C'oimlritn. — The Arabs were the first to develop
the art of the apothecary and to establish regulations re-
JfO
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pliariuacoiioeia.
Pharniacopwia*
gartling the quality and price of his medicines, and speci-
fying ^vhich of tliem were to bo kejit in stock for instant
use. Their advent infused new life into the torpid con-
dition of the medical and other sciences.
At the end of the ninth century. Shabur beu Sahl
wrote a sort of dispensatory under the title of "Ibdal"
(Haji Khalfa, ed. Fliigel, i.. 14"-!), and about the middle
of the twelfth century Abul Ilassau Hiliet-allali ibn Tal-
mid composed a similar work, entitled " Kraliadin " or
"Grabaddiu" (Arabic, qardhudin, or qrdhdiJin), which
was commonly followed hy Arabic apothecaries. The
most important of these works was that comjiosed by the
younger Mesne (Maswiyah el-^Iardiui. died lUlo .\.D.),
of Jilaridin, on the Eujjhrates, and of which only the
lialin translation ise.xtant, under the title " Autidoiarium,
.sen Graliaddin Jledieaminum compositorum." This
remained for a long time the chief canon of phannac.v.
It contains a large number of formulas arranged in
twelve chapters, each treating of a different form (for in-
stance, Pilula\ Cerata, etc.) under which medicines are
applied or administered. Not less than four Italian
translations of this work appeared previously to the year
ISOO, and the Latin text was often reprinted.
The writings of the most celel)rated of all Arabic phy-
sicians, viz., Avicenna (Abu 'Ali Ilussain ben Abdallah,
Ilni Sina, 9TS-1036 a.d.), also contain many formulas
which were incorporated in subsequent collections.
Other writers, whose works contributed in this direc-
tion, were Ibn AVatid el-Lachmi (about lUoO .\.D.), called
Albenguefit in medieval literature, whose work on sim-
ples has been published oul3' in Latin translation. Sera-
pion the younger (Ibn Serabi, about 1070 .\.D.) was the
author of a similar work, but this was much more es-
teemed and made use of than the former.
The most important Arabic writer on materia mcdica
is Ibn Baitar (about 1197-1248 a.d.). His work on sim-
ples and foods, based on his own observations and on the
works of Greek, Arabian, Persian, and Syrian writers, is
a perfect storehouse of information, and has e.xerted con-
siderable influence upon the development of therapeutics
and pharmacy among his countrymen.
P(i-»iic has little of interest to present in this direction.
If we except a treatise on materia medica. based upon
Greek, Arabian, and Indian sources, written by Alherwi
(ninth century A.». ), w-e meet nothing of interest until
the close of the seventeenth century, when Father Ange
de la Brosse, de St. Joseph, published at Paris (in 1681)
the ■" Pharmacopa>a Persiea, ex idiomate Persico in Lati-
mun con versa." That this is no translaliou of an origi-
nal Persian work has been recognized many years ago by
Dr. Hyde, who supposed it to be the work of Pere Jlat-
thieu. Leclerc ("Histoire de la Medecine Arabe." Paris,
187(5, ii., 481) reports that it is a translation of an Araliie
work existing in manuscript in the National Library at
Paris. It bears internal evidence of the intimate ac-
quaintance of the author with European medicines, some
of which were probably then unknown to Persians, while
others which were known (such as opium) are oniittrd.
In 1771 Mir Jlohammad Hu.s.sain, of Khorasiin. wrote a
Per.sian pliarmacopa-ia, and subsequently an encyclopa'-
dia of materia luedica ("Makhzan el-adwiya," "Treasury
of Medicines ") of considerable merit.
Medmv/il Europe. — Up to about the fifteenth century
the apothecaries in European countries situated to the
north of the Alps did not prepare many compounds
themselves, owing to the difficulty of importing the nu-
merous, often bulky, and perhaps scarce, crude mate-
rials. They were in the habit of obtaining the finished
preparations from Italy, where the art of pharmacy was
in a nourishing condition. Among the works written
during the Middle Ages, which either served themselves
as pharniacopa?ias or formularies or at least contributed
to their compilation, may be mentioned the following;
The " Antidotarium '' (also called " Antidotarium par-
vum." to disting\ush it from the "Antidotarium" of
Nicolaus Myrep.sus) of Nicolaus Pra?positus, of Salerno
(first half of the twelfth century), consisting of about one
hundred and fifty alphabetically arranged formulas for
compounds. This compilation, together with Mesue's
"Grabaddin" (see under Arabic countries), constituted
the most celebrated formulary of the ^Middle Ages (first
edition, Venice, 1471). Other important works of this
period are the following: "Compendium Aromatario-
rum" (1st edition, Bologna, 1488), bj- Salailiuns Ascula-
nus, a useful and much used work, in wiiieh mucli atten-
tion is devoted to the description of drugs and their mode
of preservation; "Luminare Majus," by Jhudius do
Boscho (1st edition, Venice. 1496), a highly esteemed dis-
pensatory. A counterpart of this is the "Luminare
Minus" (Venice, 1.517), of Quiricusde Augustis de Tor-
thona. The "Antidotarium Florentinum " (1st edition.
Florence, 1489: often reprinted) is the first pharniacopa-ia
or formulary published in Europe under governmental
authority.
HisTOiiY OF PHAR>t.\C0P(Ei.\s. — The literature of
pharmacopoeias is very extensive, and an exhaustive
account is beyond the limits of this work. Yet, since
a reliable list or sketch of at least the more important
pharmacopa'ias is often of great use to those who have
to consult medical works published in previous years, a
condensed account of them is here given, arranged by
countries; among the latter being included, for the sake
of completeness, most of those which possess no regular
pharmacopeia of tiieir own, but use some other work
either from choice or by command.
2\'<>te. — In quoting editions of the less important phar-
macopteias, only the date of the first one is usually given.
A plus sign (-|^) behind the date indicates that several
editions followed. In some cases the date of several or
of all editions is given. The word "pharmacopoeia" is
usually abbreviated to save space.
Atr/i'iifine lirpuhlic. — This countrj" possesses no phar-
maco)Keia, although commissions have long been main-
tained, at least nominally, for preparing one. The " Far-
macopea del Pais," although a mere fiction, has been
legallj- recognized, and the French, Spanish, and Italian
authorities are variovisly followed.
Ai/sf I ill-nil Hf/ini/. — In 1729, the Vienna Pharmaceuti-
cal Society published a dispensatory under the title of
" Dispensatorium Pharmaceuticum Austriaco-Vieu-
neuse." which was reiieatedly revised and rejiriuted. In
1739 appeared the "Dispensatorium Medico-Pharmaceu-
tieum Pragense," which also saw .several editions. An
otlicial pharmaeopfeia jirepared by order of Government
by Stoerek, .lacquin, and Well, was published in 1774
under the title "Ph. Austriaco-Provinciolis." This was
several times revised, and also translated into German as
well a.s into Dutch, the Netherlands at that time forming
a part of the Austrian empire. After the loss of the
Dutch provinces a ficsh start was made, and the first
liharmacopa'ia proper appeared in 1812, under the sim-
ple title, " Pharmacopo'ia Austriaca." The subsequent
editions appeared in— 1814 (ii.), 1820 (iii.), 1834 (iv. ; this
being full of misprints was republished in 183(5) ; 1855
(v.); 1869 (vi.).
A supplement to the Austrian Pharmacopo'ia was pub-
lished in 1879, and a new edition (Editio VI 1.) went into
efiect on the 1st of Januarj', 1890. The Avistriaii Phar-
macopa'ia is rather small, comjirising only five hundred
and sc'venty-eight titles. Its text is in Latin. From
the year 1795 a special military pharmacopceia was main-
tained, its last revision dating from 1872.
L'p to 1871 the Austrian Pliarmacopceia was valid for
the whole empire, but in that ye-M a separate volume
was supplied for Hungary, and this was rei.ublished in
1888 under the title " Magyar Gyogyszerkonvy ; JIasodik
Kiadas." This work compris(!sfive hundred and sixteen
articles, and possesses both Hungarian and Latin texts on
ojiposite pages.
The first Croatian pharmacopceia was published in
1888. under the title " Hrvatsko-Slavonska Farmako-
pc.ea," being practically a duplicate of the Hungarian in
Slavonic and Latin texts.
Belr/iniii. — Previous to 1823, there existed the Pliarma-
copreia Belgica of 1659. and various pliarmaeopaias rep-
resenting the different cities, as i liose of Brus.sels ( 1 039 + ),
5S1
Plianuacopcpia.
Pilar III ai-op4ieia.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Gand (1653 + ), Levdeu (1C38 + ), Lii-go (1T41), Lille
(1640 + ), Antwerp (ifj(n. Um. 1JS12). as well iis the Aus-
trian Pharmaeopd'iu wliieh was (iflicial from 1774 to 1805,
when it was su]ierseilc(l by tlie Pliannaenpceia Batava.
Owing to changed jiolitical eonditions these cannot be
considered to be Belgian national works in the present
sense. Such a one, however, apjieared in 1823, repub-
lished in 18.54 as the "Pharmaeo]Hi'ia Belgica Nova," of
which a "second," and the latest, edition ap]U'ared in
1885. This work clo.sely resend)les the French Pharma-
copeia, though without its conspicuously uiuuerous
blunders. The text is in Latin and French, the former
being .specified as the oflicial.
BiilitHii has no pharniacoiKvia. The French is that
mostly u.sed. though in I he western portion the Spanish
is couimon. Through the works of ('cruowicz, the Por-
tuguese Pharmacopieia has cousiilerable influence in the
eastern provinces.
Brazil also is Avithout a pharmacopieia, though many
attempts to compile one have been made. The Spanish,
Portuguese, and French works are largely used, and the
work of Cernowicz is highly influential.
British Eiitjiirc. — Up to the year 18(i4. England, Scot-
land, and Ireland possessed each its own pharmacopa'ia.
That for Englaml was tirst published in i(il8. under the
title "Ph. Londinensis," bv the Loudon College of Phy-
sicians. It was .several times reprinted with slight
alterations, until l(i.50, when its second revision was
publislied. The succeeding revisions appeared in 1677
(iii.): 1731 (iv. : in this edition vegetable drugs were
for the tirst time defined as to origin); 1746 (v. ; in this
edition a great advance was made: many of the old com-
plicated formulas were ciu'tailed and shorn of useless
material); 1788 (vi.); lsd!)(vii.); 1834 (viii.); 1836 (ix.);
and 1851 (.\.). Besides the oflicial editions, the text
was incorporated into many other works, such as
commentaries or dispensatories, either written for it
alone or for all the British Pharmacopieias together.
It was also translated into various other languages, even
into lliiidustain (Calcutta. 1824).
Th<'1irst ])harmaeo|)0'ia for Scotland was published by
tlic Edinburgh College of Pliysicians in Ui'JSl, under tile
title " Pharniaco|Keia Collegii Hegii ^Medicorum Edinbur-
gensis. " The subsequent editions or re-issues wt're very
numerous.
The tirst iiharmaco]ia>ia for Ireland appeared at Dublin
in 1807, under the title " Pliarmacopceia Collegii Medico-
rum Regis et Regina' in Ilibenua." Previously, how-
ever, a s]iecimen pharmacopo'ia had been jirepared and
circulated already in 1794. and again in 1805. The Dub-
lin Pliarmacopu'ia was revi.sed in 1820 and 1S50.
In 18(54 appeared the tirst "British Pliarmacopceia"
tinder the medical act of 1858. Many inconsistencies oc-
curred in that work, chietly due to the dithculty encoun-
tered in reconciling the differences between the three
countries. In 18(i7 a new edition was produced by the
general medical council, and to this a supiilenient, con-
taining thirty-four additions, was luiblislied in 1874. In
1885 a new edition was produced by Professors Attfield,
Redwood, and Bentley, under the direction of the Medi-
cal Council. Although showing a great advance over
its ]n-edeccssor, this work was far from satisfactory,
owing to the fact chietly that the editors were not ciil-
powered to avail them.selves of the assistance and exjieri-
ence of other experts. Some of the princi])al errors were
corrected in a sidjsequent suiiplcment. In 18S6 Attfield
was apiiointed '■ reporter on the British Pharniacopceia to
tli(^ ^IedicaI ('ouncll," his duty being to sulimit to the
Medical Council annually a synopsis of current publica-
tions bearing upon the contents of the Britisli Pharmaco-
])ii'ia, and making suggestions for its future iniprove-
iiient. The third reprint of the Biitish Pharmacopieia
appeared in 1888. and a su])pleinent thereto in 18!l(l, con-
taining forty-four new articles. In the preparation of
this supjilement the pharmaceutical ])rofession of Great
Britain was graciously invited to suggest desirable addi-
tions or ini|U'ovements. liut not yet to assist in the actual
work of revision. The fourth and last eilition of this
work was published in 1898, and is by far more satisfac-
tory than any of its ])redecessors. It shows not only a
much broailer relation with other modern pharmacopteias,
but its editors have evidently protited greatly by the sug-
gestions emanating from the British medical anil pharma-
ceutical professions. The metric and English equivalents
of weights and measures stand side by side in the text as
well as do the Fahrenheit and Centigrade equivalents of
temperature. The nomenclature of the titles is excellent,
the name of the special article jireceding that of its class.
as " Cardamomi Semina." In this practice it is at an
agreement witli the United States, but not with the Ger-
man Pharmacopieia. In the botanical nomenclature of
its definitions, no pirinciples, properly speaking, are fol-
lowed, curri'nt custom in Great Britain, even when erro-
neous, being taken as the guide and facts and principles
being twisted Avheu necessary to constitute a defence.
The descriptions are sulticiently full, and are given in
simjile and juilieious, yet not unscientitic style. The
tendency in this, as in other modern pharmacopoeias, is
toward the elimination of antiquated and worthless arti-
cles, as well as tho.se of complex composition.
The usefulness of tlie British Pharmacopada is re-
stricted bv a wholly selfish, unscientitic, and unprofes-
sional refusal to permit the quotation of any ]iortion of
its text, even for purposes of coinment or criticism.
One of the dependencies of Great Britain, viz., Inilin,
has a pharmacopieia of its own. In 1842. Dr. W. B.
O'Shaughnessy issued, by ortler of Government (under
the authority of the East India Company), "The Bengal
Dispensatory " (Calcutta), as a precursor to "The Bengal
Pharmacoiiieia and General Conspectus of Medicinal
Plants" which he published at Calcutta in 1.844. In
1868 a " Pharmacopieia of India" was ]Uiblislied at the
same place by Dr. Ed. .1. Waring, under authority of the
Secretaiy <d' State for India. This is now in force, along-
side of the uew British Pharmacopieia. The main oli-
ject of issuing a separate pharmacopieia for India was
ofBcially to encourage and authorize the employment of
East Indian drugs, among which are many posses.sing
very valuable properties. A most useful companion to
this work is tlie " Sup|dement to the Pharmacopieia of
India." by Moodeen Sheriff, published by order of the
Government of JIadras, in 1869. This work contains
synonyms of the ]diarmacopa'ial articles in fourteen lan-
guages. A revision of the pharmacopieia of India is in
contemplation.
In 1887 the British Pharmaceutical conference ]iroduced
the " UnolHcial Formulary." containing thirtv-seven arti-
cles, to wliicli nine were added liy a supplement jiul)-
lislied in 1889. The abbreviation of the title of this work
is"U. F. B. P. C."
Cenfnil Ai/irriani Stu/cs. — These states have no jdiar-
macopa^ias, and there is the greatest want of uniformity
in the authorities followed, the Mexican Pharmacopada
not wielding the influence which would naturally be ex-
pected of it.
C/iilr. — In 1886 appeared the " Farmacopea Chilena,"
prepared by Dr. Adolfo JIurillo, and published in Leip-
sic. Its text is Spanish, and it bears much resemblance
to the French Pharmacopieia, thougli containing far fewer
errors.
China. — This country has. of course, no olRcial phar-
macopieia, though there are numerous works of an un-
otlicial character treating of such subjects, the best
known and most extensive being " Pen tsao kung mu."
of Lis-hi-chin. |uiblislied about 1560 \.\i. While con-
taining niueli of value, its basis is of course largely su-
perstitious.
Diiiiiiarh-. — In 1658 the " Dispensatorium Ilafniense"
was published at Coi)enliagen, and this was several times
reprinted. The first olticial pharmacopoeia appeared in
1773. the second in 1805. and the third in 1830. The last
mentioned was, however, counted as the first work, the
others not being regarded subsequently as deserving of
the name. Hence the next edition, published in I8(i8,
was designated as " Eilitio .Seeunda." Sn]ipleiiients to it
appeareii in 1874, 1876, and 1886. On August 1st, 1893,
5S2
REFERENCE IIAXDI'.OUK OF THE MEDICAL SCIENCES.
PSiiiriiiacopceia*
Plisiriiiacopoeia^
a new edition went into effect. The text of the work is
in Danish, the titles are in Latin. Much similarity exists
between tiie Danish. Norweccian. and Swedish pharraaco-
pa'ias. which is the result of deliberate design, as these
countries are closely allicil in customs, traditions, and
language. A separate military pharmacopa'ia is in exist-
ence,
Ecuador. — The statements made concerning Bolivia ap-
ply also to Ecuador.
Franct. — In 1353 King John, "the good," commanded
the apothecaries to follow the " Antidotariuni " of Nico-
laus Propositus. Strict regulations regarding the prac-
tice of pharmacy were made in lyoO, and frequeuth'
afterward. As early as 154(5 a "Ph. Lugduneusis" was
publislied at Lyons, which was several times reprinted.
A French "Parajihrase sur la Pharmacopee " was issued
by Bri(,-on Bauderon, of Mascon, in 1588 -|-. In 1590
the Paris Faculty of iledicine was directed to prepare a
dispensatory ; but. as nothing was done. Parliament, in
1597, ordered twelve members of the facultj-, designated
by name, to prepare the work. The order was, how-
ever, not obeyed. Several French cities early jiossesscd
pharmacopeias of their own, thus: Burdigal ("Ph. Bur-
digalensis," 1643); Strasburg (Ph. Argentoratensis,"
1725-f-); Toulouse ("Codex Medicamentarius, sen Ph.
Tolosana," 1648, 1695): Valenciennes (" Ph. Valentianen-
sis," 1651). A new " Pliarmacopee de Lyon" was also
published hy Vitet in ITss. The last-named work, to a
slight extent, answered the purpose of a revised edition
of the last Paris Pharmacopa?ia in some localities. In
1637 the "Ph. Parisina" appeared as a precursor to the
first official Paris Pliannacopttia. which was issued in
1639 under the title "Codex iledieamentarius. seu Ph.
Parisicnsis, in lucem edita a Ph. Ilarduiuo." Revisions
of this appeared in 1645, 1732, 1748. 1758. No further
revision appeared then until, after an interval of sixty
j'ears, a national pharmacopir'ia was issued in ISls, un-
der the title: "Codex Jledicamentarius, seu Ph. Oallica,''
the text being in Latin. In the second and following
editions the French language was cho.sen for the text,
only the synouvms of tTie titles being given in Latin.
These editions "appeared in 1827 (ii. ), 1839 (iii.), 1866
(iv.). and 1884 (v.). The last revision was a very unsat-
isfactory one, as the revisers did not seem to liave pai<l
attention either to the other new pharmacoptcias (United
States and German) whieh had appeared a short time
previously, or to the copious literature relating to pliar-
macojireial improvements. Immediately after the work
had been issued very numerous errors were discovered iu
It, so that the Government was compelled to make a fresh
issue, in which one hundred and thirty-two alterations
were incorporated; and a speci;il pampldet entitled "Er-
ratum," was shortly afterward sent o>it. in whiili ciglity-
three additional changes were directed to be made. Bui
this list of errata is not only itself not free from errors,
but is far from being complete. In connection with the
French Pharmacopa»ia should be mentioned the ^^•ell■
known work of Dervault, "L'Officine," constituting an
exhaustive commentarj- and supplement to the pharma-
copa?ia. In some foreign countries, which do not possess
a pharmacopoeia of their own, this work is frequently
followed as the principal authority, being used either iu
the original French or in Spanish translation.
Germfiny. — The first official formulaiy published in
Germany was that of Valerius Cordus, published after
his death by the city of Nuremberg iu 1546, under the
title " Pharmacorum omnium qua; quidem in usa sunt
conticiendorum ratio; vulgo vocant Dispeusatorium
pharmacopolarum " (see Am. Drn<i.. 1887, 21). The
work contains formulas of Galenical preparations, taken
chiefly from ancient writings, with few simides. Sumc
of the titles continue to the present day. though in somk-
cases the composition has utterly ceased to corresjiond
therewith. The work was often reprinted at home and
abroad. There is a Paris edition of 1548, three of Lvons
(1552. 1559, 1599). two of Venice (1556. 15(53), etc." In
the Nuremberg edition of 1592, great advances were
made, several American drugs (.sassafras, sarsaparila.
and tobacco) being introduced, chemicals first appearing
(alum, borax, sjiltpetre, etc.), as well as some artificial
salts from ashes of plants and other substances. Ex-
tracts and distilled waters were also added. Equalh- im-
portant changes occurred in the next edition (1598),
white arsenic, corrosive sublimate, calomel, and oil of
vitri"bl being among the additions. The next edition
(1612) was little changed. The fifth and last edition ap-
peared in 1666. and showed great changes, many for the
worse, some for the better, such as the introduction of
cinchona, jalap, balsams of Peru and Tolu, tinctures and
many new chemical salts, under the then prevailing al-
chemistic nomenclature. This edition contained nearl}-
all classes of preparations of which we still make use,
organic proximate princijiles being of course unknown.
It certainly formed the basis upon which subsequent
European pharmacopieias were constructed.
In 1538 the physicians of Augsburg prepared a sort of
pharmacopa?ia under the title, "Conclusiones et Proposi-
tiones Universam Medieinam Complectentes," containing
formulas which were afterward generallj" followed.
Augsbuig was at that time the chief e)itrcpi'it of the Ger-
man trade with Italy and the Levant; hence many of the
imported medicines came hy way of Augsburg. In 1564
the first edition of the " Ph. Augustana " was published,
whieh was often revised, and Cologne followed the ex-
ample in 1565, bythe publictttion of a " Dispeusatorium,"
which was replaced by a " Pli. Coloniensis ■' in 1627.
The disunited condition of the countries inhabited b_y
the German nation up to within recent times has been
the means of bringing into the worUl a large number of
independent pharmacopadas, for separate cities or
principalities, of which a list follows here: Stralsuud
("Aetuarium Ph. Stralsundensis," 1645); Quedlinburg
(" Quedlinburgensis Ollicina Pharmaceutica," 1665);
Brandenburg (" Dispeusatorium Brandenbnrgicum,"
1(598, forming the startiDg-]ioiut of the later Prussian
pharmacopeias); IIanover(" Pb. Ilantiverana," 17(.I6: last
edition, 1861); Hamburg ("Dispeusatorium Hambur-
gense," 1716; "Codex Ilambnrgensis," 1835, 1845); Ra-
tisbon ("Disp. Pharm. Ratisboneuse." 1727); JIuuster
("Di.sp. Monasteriense," 1739); Wiirtemberg ("Ph. AVir-
tembergica," 1741; last edition, 1847); the Palatinate
("Disp. Med. -Pharm.." 1764); Brunswick (Disp. Pharm.
Brunsvicense." 1777); "Wi'irzhurg (" Pharm. Herbipolita-
na." 1778; last edition, 1796); Westphalia (" Disp. West-
phalieun:." being identical with Piderit's "Pharmacia
Hationalis" [see under Saxony], 1779); Fulda ("Disp,
Fuldense," 1787); Bremen ("Pharm. in usum . . . Bre-
meusis." 1792); Schaumburg-Lijipe ("Disp. Lippiaeum."
1792); Oldenburg (■• Ph. Ol'denbnrgensis." 1801); Hessen
("Disp. Electorale Hassiaeum." 1806; "Pharm. llassia',"
1827, 1860); Erfurt ("Neue Phannakopoe " . . . von
Trommsdorff, 1808, was introduced by order of the
French in place of the "Prussian Ph."); Saxony (iu 1806,
Piderit's "Pharmacia Racionalis," Cassel, 1779-81 was
prescribed as Ph. In 1820 appeared "Ph. Saxouica."
the last edition in 1837); Bavaria {"Ph. Bavariea." 1.822,
last edition in 1859); Schleswig-Holstein ("Ph. Slesvico-
Holsatica." 1831); Baden ("Ph. Badensis." 1841).
Man_y of these were revised and reiniblished a uumber
of times.
The most important of alj former German pbarmaco-
pa;ias has undoubtedly been the Prussian. This had its
beginning in the "Brandenburg Dispensatory" of 1698,
the last revision of which, or tlie sixth edition, appeared
in 1781. In 1799. the first "Ph. Borussica." was iiub-
lished. The next editions came out in 1801 (ii. i. 1.813
(iii.). 1827 (iv.), 1-829 (v.). 184() (vi. ; this is considered to
liave been the best pharmacopoia nf its time); 1862
(vii.). Four editions of !i sejiarate Military Pharmaco-
pceia were also published, the last one in 1868.
The problem of a united pharmacopceia for all German
states had often been agitated, but in vain. In 1861 Dr.
Walz proposed the publicatii)n of a German Pharmaco-
pa'ia b}' private enterprise. \\ Inch was to be recommended
for adoption, or at least as a pattern, to the different
German States. The work appeared in 1865, under the
583
Pliariiiaroixria.
Pliai'iiiao(»i><iL'i:i.
REFERENCE IIAXI)I)( loK OF THE MEDICAL SCIENCES.
title " Pharmacopnea Germania\" Amona- the compilers
were two Austriaus. as it, was at the time believed that
the work might be accepted liy all (ieni'aii-speakiug
peoples. But the war of l.S(i6 rendered the project, as
originally coiKT-ived, nugatory. A .sei-ond edition was
published iu 1S6T. in which tlie Austri[Ui members were
omitted. Yet even this failed of recognition. It was
oidy after the establishment of Die German em]iire that
the desired object was attained. In 1S72 was issued the
lirst "Ph. Germanica." superseding all the separate phar-
macopivia at that time in force in German eountiies.
Some amendments to this were luiblished in 18T3. AVhen
the time for a new revision arrived the Government in-
vited all medical and iiharmaceutical bodies and promi-
nent individuals in both professions to submit proposals
regarding the new revision. Coutriliutions were received
from a large number of sources, and these were printed
by Government in a large folio volun-.e of si.v hundred
and ninety-one pages. The Committee of Revision, con-
sisting of thirty -tln-ee members, luider the presidency of
Dr. .struck. hiM oidy a few personal meetings, but the
work of tlie commission was uuhjIi facilitated by the fact
tliat the Government from time to time issued printed
circulars among the members. The final draft of the
work having been lirst printed iu German (fob), the work
appeared in its ollicial Latin garb in 1S83. and went into
force on January 1st. 188:!. An ollicial German transla-
tion was likewise published: and an English translation,
by C. L. Lochman. apjieared at Xew York in 1884.
A standing committee, a|)pointed by the German
Pharmaceutical Association, almost immediat(dy under-
took a critical revi.sion of this work, and iu 1887 a per-
manent pharmaeopix^ia commission was created liy the
Government. In 1806 the third edition appeared imder
the title. '" Arzneibuch fur das Deutsche Reich. Dritte
Ausgabe. Pharmacopn/ia Germanica. Editio III."
The Latin language was abandoned and the text made
wholly German, with the exceptiim of the titles of the
articles. In the work of its revision the pharniacopoMa
con.mittee of the German Pharmaceutical Association
was of the greatest value.
The example set by the Uniteil States (188(5 to 1888)
and Great Britain (188T), in iiic]:iaring national formu-
laries of nuolticial preparations was f(dlowcd by the
pharmacists of Gernrany iu 18ill, when the Gerniau
Pharmaceutical Association ptiblished a similarwork un-
der the ratlH>r awkward title: " Arzneiuu'ttel welche in
dem Arzneibuch fiir das Deutsche Reich ( Dritte Ausgabe ;
Pliarmaeo]uria Germanica, Editio III.) nicht enthalten
sind " ( = "Remedies which are not contained in the Arz-
neiliuch." etc.). This contains eight hundred and eleven
arliclcs.
The fourth ami last edition of tlie German Pharmaco-
peia was published in I'.tutl. It exhibits the degree of
progress whieli might reasonably be expected at tlie close
of a decade so noted for research and criticism as tliat be-
tween b8fl(l and IflOO. An unfortunate departure, how-
ever, is tliat of the uniform omission of the authorities of
botanical names. In those eases in which there is but one
such aulhorship, hence but one interpretation of the
name, the omission is not serious; Init there are some in-
stanci'sin which actual doubt astowhat ]ilant is intended
may exist. Another unfortunate custom is that of plac-
ing the class name of a drug in advanc(> of its individual
name, in the title, as"Flores Malva»" insteail of "Malva?
Flores. "
The intluenee of tlie GiTman l'li;irm.iriipcri.i extends
far beyond the geogiaidiical liniils of the (icrmiin em-
pire. Outside of the United States Pliarmacn|iciMa there
is prob:ibly no other, even not exceiitini;- the livitisb,
which is so frequently drawn upon by prrscribcrs in this
country,
(irrii'i-. — The Irrst Greek Pharmaeopo ia was published
in Athens \inder Kin,"' Otto I,, in 18:;7, tinder tlie title,
" K///;i7/o/ (papftann—otia . . . —apa \tji'iri''>T IJor^jor, ^av^pinv
AnvihiKpnv. Iu(7/}r) 2(7/i7o/)/o)', " etc, ("'Greek Plmrmacopa>ia
. . . by Johannes Rouros. Xaverios Landcrcr. Jose|ili
Sartorius,'' etc). It was b;iscd on the Fn neh. jiavar-
ian, and vaiious other German pharmacopoeias existing
at that time. The text is in Latin and modern Greek,
side by side. Synonyms are given in Italian, French,
En.iflish, German, and Turkish, wherever ])0ssible, but
among them are many mistakes. In 18(58 Profes.?or
Landerer had the work reprinted, with a supplement
{-iiliapri/ua) of the tiewer preparations, an ctj'mological
glossary, and a table of antidotes. Thisrepiint was offi-
cially recognized by Government. In ,2-eneral it must be
.said that the work is very far behind tlie time.
Il<ii/fi has no pliarmacopivia of its own. The Frencll
Codex is mostly fojlowe'l.
Ilairiiiian Idiiiuh. — The United States Pharmacopceia
is generally followed.
Hiinijary. — See Austria.
Iti'ltl. — Italy was the first country in Europe in which
an ollicial pharmacopoua was juiblished. Tliis was the
" Antidotai'ium Florentinum," first pnlilishedat Florence
in 1-198. Other similar worUs ajuieared at !Mautua (" An-
tidotarium Mantuanum." Venice, l.").")!)); Bergamo ("Ph.
Bergomeusis." 1.580): Venice ("Ph. Veneta." 1017: "Co-
dice pharmaceutico." 1790); Messina (" Ph. Messanensis,"
1629); Naples (" Antidotarium Neapolitanum," 1649);
Turin ("Ph. Turinensis." 1736): Sardinia ("Ph. Sardoa,"
1773; the last edition, "Farmacopea per gli Stati Sai'di,"
of 18.53 is still in force) : Bologna (" Autklolarium Coll,
Med. Boloniensis." 1783): Genoa ("Formulario farm.,"
1791): Ferrara ("Farm. Ferrarese," by Campnna, 1799,
etc.); Parma ("Ph. Parmensis." 1828: another edition of
this appeared in 1839 for Piaccnza, Parma, and Modena
together). The Church States, Tuscany, Lucca, and
many other Italian |u'ovinces follow a dispensatory pub-
lished by Orosi, under the title " Farmacologia teorica c
prnetica ovv(>ro Farmacopea Italiana." Lombaidy and
Venice use the Austrian Ph;irmacoiia'ia; Naples uses,
besides other works, tlie " Ricettario farm. Napolitano."
ISoO, Throughout Italy a new work by Ruata, entitled
"Farmacopea Nazionale e Generale. Materia Medica e
Tei-apia " (Verona and Padova, 1883) is now frequently
emiiloyed.
Although a commission for the publication of a na-
tional pharmacopoeia was appointed years previously,
the draft, under the presidency of Professor Canizzaro,
was not reported until 1884. and the work was not
published until b'^92. ^Meanwhile, different portions of
the country used such works as were prescribed liy their
local authorities, the army using the Sardinian Piiarma^
copreia of lSo3. The present work is entitled, "Farma-
copea uffieiale del Regno d'ltalia" (Svo, Roma). This
work was one of the first to introduce statements regard-
ing the percentages of active constituents of drugs such
as belladonna, jalioraiidi, and eolchicum : j'et methods of
assay are not iirescribed. so that the utility of the proce-
dure is qiiestionablc.
Japan. — In 1880 a commission of twenty-one members,
several of them Europeans in the service of the Japanese
Government, under the presidency of Mr. Hosoakwa,
undertook the work of preparing a pharmacopo'ia, which
was published in August, 1886. as an octavo volume of
nearly four hundred pages, the text in Japanese, under
the title. "On yaku znUi Nippon y.aku kiyokii ho.'' It
consisted of an introduction, preface, and body, the lat-
ter comprising;- four hundred and seventy-live titles, fol-
lowed by general directions for keeping certain dru.iis and
preparations, lists of rea.gents and volumetric .solutions,
lists of articles always to be kept on hand, list of sepa-
randa. maximum doses, tables of specific ,e'ravily and of
elements, a J:i|ianese and Latin index, list of errata, table
of doses for adults and children, then another list of er-
rata. The official text was in Japanese, the scientific
chemical, botanical, and zoological terms iu Latin, in
Roman characters, with Japanese tran.sliteration. In the
treatment nf the subject, the I'nited States, British, and
German Pharniaeopieias were niostl\' followed, but the
text showed also indeiiendent and cai'eful work on the
part of the eoni|n'lers. The si.gn v, placed under an un-
usual quantity of a powerful remedy, is to be used by
prescribers for the same purpose as the exclamation
oS-i
■REFERE>XE IIANDBOOK OF THE ^[EDICAL SCIEXCES.
Pliariiiaoopflela*
Pharniacopwka,
point in European practice, viz., as an evidence that the
prescrilier intentionally ordered a large dose. The sec-
ond edition of this work appeared in 1891, under the title
'■ Pharniacopa?ia Japonica. Editio Altera. Tokyo, An-
no .x.viv. Meiji (1891)." It is wholly in Latin.' It re-
semliles its predecessor in general appearance and con-
struetiou. but in the nomenclature of clii-niical subst;inces,
the last German and Austrian pharmacopteias have been
followed as guides.
Liheria. — The United States and British pharmaco-
po'ias are usually followed.
Me.rici>. — ^The Pharmaceutical Society of Jlexico. in
1874, published a pharmacopoeia whieh was officially
recognized by Government. It was one of the best phar-
macopa-ias of its time. In 1884 a second edition was is-
sued by the same society, the text of which was already
completed at the close of 1881. Its title is "Nueva Far-
macopea Mexicana de la Sociedad Farmaceuti&a de M(!.x-
ico." It presents among other special features a veiy
copious materia medica, paying particular attention to
native products. The text is in Spanish in two columns.
In general the work rather corresponds to what we would
call a dispen.sntory, as it treats also of the mediral jirop-
erties and uses of the several drugs and preparations,
and covers a gooil deal more ground than is usual for a
pharmacopoeia. It is a very carefully prepared and
meritorious work.
yethrrlnndi'. — The frequent political changes in the
Low C'rymtries were not without influence npon the ex-
istence or validity of its pharmacopa>ias. Among the
earlier works of this kind which may he mentifjued here
are the following, in cities now belonging to the Nether-
lands: Amsterdam ("Ph. Amstelodamensis," l(i;i(i; last
edition, 1792, see below); The Hague ("Ph. Hagana."
1652; last edition, 1758); Utrecht (''Pli- Ultrajeclana,"
1650; last edition, 1749); Louvain ("Ph. Lovardensis,"
1687; last, 174.-,); Haarlem ("Ph. Ilarlemensis," 1693;
last, 1741); Dort C'Ph. Dordracena," 1708; last, 1766i;
Eotterdam ("Ph. Roterodamensis," 1709; last, 18:'!5i;
Alcniar ("Ph. Alcmariensis," 1723); Grouingen ("Ph.
Groningana." 1724, '30). At one time the Nether-
lands belonged to Austria, hence the "Ph. Austriaco-
Pi-ovincialis" was made otHcial and a Dutch tran.slation
of this was published in 1781. After the establishment
of the Batavian republic (1795-1806) a commission was
appointed to draft a pharmacopa'ia. This was com-
pleted and published in 1805 under the title "Ph. Bata-
va," and was a work of great merit, being by far the
best of its time. This work has been extended and com-
mented upon by Niemann (1811, second edition, 1824) in
an excellent manner. In 1851 appeared the tirst "Ph.
Neerlandica," the text being both in Latin and in Dutch.
It had much resemblance to the French Codex. A re-
vised edition, both in Latin and in Dutch, appeared in
1871. the Latin version being, as in the first edition, the
official text. It contained si.\ himdred and fifty-tive
titles. In 1884 a Government commis.sion was appointed
for revising this work, and a new edition appeared in
1889 under the title, " Nedcrlandsche Pharmacopee. Der-
de Utgave ( = third edition), 's Gravenhage, 1889." Ex-
cepting the titles of the articles, the text is entirely in
Dutch. A Latin edition soon appeared under the title
" Pharmacopoeia Neerlandica. Editio tenia. Hagir Co-
mitis, 1889." It was specially decreed, however, that
the Dutrh edition was to be considered the official one.
In 1891 the Rotterdam In'anch of the Netherlands
Pharmaceutical Society (Nederlandsehe JInalschappij
ter Bevordering der Pharniaeie) fciUowed the lead of
other countries, by issuing an unofficial formulary under
the title: "Supplemeutum op de derde Utgave der Ne-
derlandsehe Pharmacopee . . . 's Gravenhage, 1891."
It eontains five hundred and seventy-three articles.
Siirira)i(\v\ not possess a pharmacopoeia of its own vin-
til 1854, the Swedish Pharmacoprt'ia being used in the
coiuitrv up to that time. The "Ph. Norwegica " was re-
vised in 1870, and this second edition was reprinted with
additions in 1879. It coutainssome five hundred and ten
titles. The text is in Latin. It much resembles the
Swedish and Danish pharmacopa-ias, b>it the influence
of the German Pharmacopojia is clearly perceptible.
Pararjuay. — The French, Spanish, and occasionally
other pharmacoptt'ias are usuallv consulted.
Peru. — The French. Spanish, United States, and Brit-
ish pharmacoptt'ias are usually drawn upon.
Puliind. — See Russia.
Porturjal. — In 1704, CaJtano de Santo Antonio pub-
lished a "Pharmacopea Lusitana Galenica" at Coimbra.
This was republished at Lisbon (as "Ph. Lusitana," or,
"Ph. Ulis.sipouense") in 1716. and twice reprinted. In
1785 appeared de Poiva's "Farmacopea Lisbonense."
The first official pharmacopa^ia was published by Dr.
Tavaresin 1794, under the title "Farmaeopeia Cieral para
o Reino e Dominios de Portugal." In 1825 this was sup-
planted by the "Ph. Lusitana." and this was followed in
18;;J8 by the "Codigo Phannaceutico Lusitano" (revised
1858). Finall)' a new "Pharmacopi?a Portugueza " was
issued in 1876. This is a veiy good work, prepared with
care and judgment. The text is in Portuguese, except
the synonyms of titles, which are in Latin. It has been
shorn of the obsolete rubbish of the therapeutics of former
times.
Eoumr/iiia issued a pharmacopoeia in 1861, tinder the
title " Pharmacopo>a Romana." A second edition, re-
vised, appeared in 1874. The text throughout is in
Roumanian, without Latin synonyms. It bears some
resemblance to the Austrian Pharmacopoeia, but has some
di.stinctive features of its own.
Eussiii. — Up to the j-ear 1866 Russia had no official
national pharmacopttMa. except one for the army which
was first issued in 1705. In 1779 a revised and much im-
proved edition of the latter appeared, under the title
"Ph. Castrensis Rossica." This was followed in 1789 by
a special pharmacopoeia for the navy ("Ph. Navalis,"
last revised in 1869). Both of these were superseded in
1808 by the "Ph. Castrensis Ruthenica." edited by Wylie,
of Mo.scow. This was several times revised, last in 1866.
A civil pharniaeopaMa appeared as early as 1778 at St.
Petersburg (reprinted in 1782), under the title of
"Ph. Rossica," and a second edition in 1798 (reprinted
1803); but these were not otlicially recognized, the phar-
macists being compelled to consult almost every promi-
nent European phannacopa'ia when putting up prescrip-
tions. That which was most followed, generally, was
the "Pli. Borussica." In 18(iO the first ofticial civil phar-
macopoeia was issued. Tliis was followed by new edi-
tions in 1871, 1880, and 1891. The title is " Kossii.skaya
Pharmakopeya." edited by the >Iedical Council in the
Department of the Interior, by order of his Imperial Ma-
jesty, etc. Great care was bestowed upon the two last
editions, the best features of the German Pharmacopo-ia
being incorporated into it. The text is in Russian, the
main titles and synonyms, however, and the names of
the ingredients entering into the jireparation being in
Latin. A special pharniacopa>ia for the u.se of the im-
perial court was published in 1874. Hence there are
four Russian pharmacopo'ias iu existence — the military,
the naval, the civil, and the court phai'macopoeia. The
military work is in some respects a sort of dispensatory,
as it goes more into details.
A separate pharmacopoeia was published for Poland, in
Warsaw, in 1817, under the title, "Ph. Regni Poloni;B,"
but this does not seem to have long remained iu force.
On the other hand. Finland published a pharmacopu?ia
of its own ("Ph. Fennica") in 1819 (at Abo). Later edi-
tions of this aiipeared at Ilelsingfois iu 1850 (ii), 1863
(iii.), and 1885 (iv.). The text of this is in Latin. It is
closely allied to the several Scandinavian pharmacopoeias,
and in certain features still more closely to the last Ger-
man Pharmacopa>ia. In extent, it is one of the smallest,
comprising only abotit four hundred articles.
>§;/«(«.— -Previous to the appearance of a national work,
local pharmacopoeias lia<l bi'cn in existence in the follow-
ing cities: Salamanca "(Ph. Salamanca," bv J. Bravo,
1.588); Barcelona "(Ph. Catalana." 1686); AInieria ("Ph.
Almeriana," 1724); Saragossa and Valencia ("Oliicina
Medicamentorum," 1601, 1698, 1739); Madrid ("Ph. Ma-
685
pilar III ai'opiv la.
Pliariiiacopu'ia.
UEFERENCE ilANDUOOK OF THE MEDICAL SCIENCES.
tritf-nsis." 1T29 + I In l.i21 was priblislicd at Madrid
till' "Examcn Apotliccaridium." composed in 14!)7 by
Prdro Ik'Ufdicto .Mati-o, wliicli lias been found by 3Ial-
laina to be a verilaljlc pliarmacopiria. Tlie first, national
pharniacopceia ("Ph. Ilispana") appeared in 1794. This
and the ne.xt three cdition.s. viz., of 17<JS. 1S03, and 1817,
were written in Latin. The fifth (bsfiO) and si.\th edi-
tions (1884) are in Spanisli with Latin synonyms of the
titles. The " Farn.aeopea Otieial Espanola " appears to
have made the least progress of any. Even the last edi-
tion, liei'e and there, betraysau adherence to unscientific,
empirical, or obsolete remedies and methods. Besides,
it bears internal evidence of the influence of the new
French Code.x. In the number of articles, of which it
contains nearly one thousand .seven hundred, it is only
exceeded by the last-mentioned worli.
Attempts have been made to prejiare a separate jihar-
maeop(eia for Culia, but no tangible results have been
reached thus far.
Sirnhn. — A. " Ph. Ilolmiensis " was published at Stock-
holm in 1686. The first work, hearing tlie title " Ph. Sue-
cica," appeared in 170"), liut Avithout special authority.
The first official phannaeopa>ia appeared in 1775, and ilie
succeeding editions in 1779 (ii.): 1784 (iii.); 1790 (iv.);
1817 (v. ; in this eili lion tlie chemical portion was edited by
Berzelius, and the botanical and zoological by Swartz;
it was the most advanced and perfect phariuacopa?ia of
its time); 184.5 (vi.), and 1869 (vii., with supplement of
1879). The last edition has been several times reprinted
with amendments. It has much resemblance to the Da-
nish and Norwegian (see under Denmark). The text is in
Latin, and the number of titles is six hundred and sev-
enty-seven.
Sii-it'.erli(iiil. — A "Ph. Ilelveticorum " was published
at Geneva in 1677. In 1684 there apjieared in the same
city an edition of Cliaras' "Pharniacop(ea Jiegia Galeni-
ca ct Chyniica." which was followed as authority for a
long time. The Basle Medical Socii'ty, in 1771. pub-
lished a "Ph. Helvetica" (containing an introduction by
A. de llaller). A "Ph. Gencveusis" appeared in 1780,
and was reprinted several times afterward. In 1S,")2 an
elaborate draft of a pharmacopcria for the Canton of
Berne was ])ulilished at Berne under the title " Pharma-
co])a';e Bi'rnensis 'I'enlaiuen " This may be regarded as
the precursor of tlie "Ph. ifelvelica," juibli.shed in 1805
at Scliallhausen. )iy the Swiss Pluiruiaceutieal Society.
The latter work has been recognized by law in most of
the cantons, but not in all. A .second edition appeared
in 1872, and a large su|iplement in 1S76.
The text of tliis ]ilianuaeop(eia is in Latin, and has
much in common with the German Pharniaeop(eia. A
new work, "Pharniacopceia Helvetica, EditioIII.," was
issued in 1893.
The Canton of Tessin lias a pliarmacop(cia of its own,
published in 184H. Geneva uses tlie French Codex.
Turlciy. — The Imperial Jledical School at (lonstautino-
ple has directed the use of tlie French Coilex. Other
foreign pharmacopo'ias, however, are also in use.
I'nigiiiii/. — The Freneli and Spanish phaiiuacopcvias
arc chiefly in use.
Veiieziichi. — Tlie Fieneh and S])anish phannacopo>ias
are mosth' in use. Long since, the mcdi<'al faculty at
Caracas took initiatory steps td prepare a national phar-
niacopceia, without result so far.
CMirh'X I!i,-c.
Revi.sed by J/,iiri/ I!. Itnsliy.
PHARMACOPOEIA, UNITED STATES. -IIisionY.—
The liist |ili.irma(op(ria in llie I'liited Sliites was pub-
lished at Philadelphia, for the use of the ^lilitaiy Hos-
pital of the United States army, located al Lilitz. Lancas-
ter County, Pa., in 1778, uniler the title, " Pliarma,coiHeia
simplieiorum et cflicaciorum in usum nosoeomii militaris
ad exereitum fiederataruiu America' eivitatum ]iertiiien-
tis; hodienne nostra- iiio|iia' rerum(|ue august i is. feroci hos-
lium sa'vitia", liello(|Ueeru(leli ex inopinabi ixitria' nostra'
illato (lebitis, niaxime aecommodata '' (" Pliarmacopteia
of the more simjile and ellicacious [preparatiousj for the
use of the Militarj- Hospital of the Army of the United
States of America; specially adapteil to our present pov-
erty and distress, due to the ferocious cruelty of the
enemy and to the bloody war unexpectedly brought
upon our fatherland "). Only one copy of this edition is
known to exist, which is in the surgeon-general's office
at Washington. Of a second edition, there ajipears to
be likewise only one copj- known (see J//(. Jmir. Pltann.,
1884, 483). Tl'iis was issued iu 1781. Upon the title
page appears the name of Dr. William Brown, as author.
It is entirely iu Latin, in thirty -two pages. It contains
eighty-four internal and sixteen external remedies. Pre-
vious to the year 1820, various European pharmaco]5a'ias,
chiedy tho.se of Loudon, Edinliurgh, and Dublin, were
used in the United States, though tlie want of a national
l>h;irmacop(eia was, to some extent, filled by Coxe's
"American Dispensatory" (first edition, Philadelphia,
1806+ ), and Thaeher's "American New Dis|iensatorv "
(first eilition, Boston, 1810+ ). In 1808 the "Pharmaco-
po-ia of the Massachusetts Sledical Society " was pub-
lished at Boston, and in 1S16 the "Pharmacopoeia of the
New York Hospital " at New York. The first impetus
to a national jiharmaeopa'ia was given iu 1817, by Dr.
Lyman S|iauldiiig, in a plan laid before the Medical So-
ciety of the County of New York. (For details of the
history of the "Pluirmaco|iteia of the United States of
America," consult the latter work, sixth edition. New
York, 1882, pp. v.-xiii.). The first convention for the
formation of a national pharniacopceia assenjbled at
Washington on January 1st, 1820, at which time the sev-
eral drafts previously prepared by the several district
conventions were consolidated and revised. The finished
work was ]uiblislied at Boston, on December 15th, 1820,
both in Latin and iu English. A .second edition ajipearecl
in 1828. Before adjourning, the convention provided for
a future revision of the work, by arranging for the call
of a convention in 1830, Owing to a misunderstanding,
however, two separate conventions were held in this
year, one meeting at New Y'ork, and the other at Wash-
ington, and two separate pliarmacopceias resulted from
this, one being ]iublished at New York iu 1830, the other
at Philadelphia in 1831. Fortunately, the bodies who
had met at New York subsei|Uently abandoned the plan
of continuing a separate revision in the future, and iu
1840 the third general convention assembled again at
Washington. The Committee of Revision appointed at
this conveutiou Avas authorized to request the co-oper-
ation of the colleges of pharmacy, and this resulted iu
the coutriliiitiou of much valuable material. The uew
revisiou was published in 1S42, the text being for the
first time only iu English, the Laliu being restricted to
the titles and suionyms. At the next convention, in
1850, the incorporated colleges of pharmacy were for the
first time invited to participate iu the deliberations.
Previous to this, only incorporated medical societies had
been invited to send delegates. The fourth edition of
the wcu'k appeared in 1851, and a second edition of this
in 1855. The next two conventions met at the appointed
time, iu ISOO and 1870, and the fifth and sixth eilifions of
the pharuaicopceia were issued in 1863 and 1873, respec-
tively. Several years before the ne.xt succeeding con-
vention (in 18.S0), a very lively interest Avas awakened in
the proposed new revision of the work, and several plans
were advanced, looking toward a radical change in the
nianuer of revising and controlling the revision of the
]iliarmaeo|io'ia. .V large amount of preliminary work
was also bestowed, princiiially on the part of the Ameri-
can Pharmaceutical Association, upon the |ilan and cciu-
tents of the next editiou. The convention which assem-
bled at Washington, iu 1880, was the mcist reiirescntative
of any that had so far been held, and after a general plan
of revision had been ado]ited, a Committee of Revision
and Pulilication Avas appointed, consisting of tAvcnty-five
members, residing in various parts of the United States,
This committee has made a detailed report of its proceed-
ings in the preface to its work, Avhicli apjieared toAvard
the end of 1882 (see "United States PharmacopaMa,"
1882, pp. xxvii.-.xxxiii.). The title page designates this as
5SC
REFERENCE HANDBOOK OF Till: MEDICAL SCIENCES.
Pliarinacopoela.
Pliaruiacopoela.
the " Sixth Decennial Revision " ; consequently, this was
the serenth edition of the work. In this revision radical
changes were made, the intention being to render the
work as indepeutient of commentaries as was possible.
The arrangement was alphabetical tliroughout, all crude
drugs and chemicals being detined and accompanied by
disiriptions or by tests of identity and purity. Actual
weights and measures were replaced by a system of parts
by weight, except in the case of tluid extracts. Many
obsolete articles were dropjjed, and many new ones ad-
mitted, the total number of accepted titles being nine
hundred and ninety-seven. The general verdict of all
com])etent critics, both at home and abroad, was that
tliis was one of the best pharmacojja'ias ever issued, and
that it did not suffer by comparison with works that ap-
peared later.
It having been long felt that the pharmacopooia con-
tains a considerable number of prejiarations whicli are
not frcquentl}' prescriljed. and are retained only in order
that, if called for, their uniform composition may be in-
.sured, the American Pharmaceutical Association under-
took the compilation of a "National Formulary of Un-
otlicial Preparations," primarily designed to establish
uniform formulas for any compound used in legitimate
]iliarmacy or prescriljed by jiliysiciaus, and for which
there is no recognized official standard. It was believed
that this formulary might eventually be made the reposi-
tory of all such pharmacopceial articles as are no longer
deemed of sufficient importance to be included in the
official list. This work was published in 1888, under
the above title, and has proved ver_y useful. In May,
1890, the Decennial Conveuticju for Revising the Phar-
macopteia met at \Yashiugton, and resulted in the elec-
tion of a conunittee of revision, consisting of twenty-six
members, located in different sections of the counlr}', and
gave instructions for the "Seventh Decennial Revision,
or the "Eighth Edition," which was published by the
committee itself, and went into elfect on January 1st,
1894. The most important features introduced into this
work were the substitution of the metric system of
weights and measures for " parts b_v weight " ; "the refer-
ence of the standardizing of preparations by chemical
assay, and of such assay processes to the discretion of
the committee, the committee subse(|ueutl}- deciding
upon the ado]ition of such standards for only a few
di'ugs and preparations; volumetric methods were made
to replace, as far as possible, gravimetric methods; arti-
cles protected by proprietary rights were excluded ; im-
portant changes in chemical nomenclature and notation
were adopted, though radical measures were rejected; in
botanical nomenclature the Rochesler code was adopted
as authoritative ; ninety articles were dropped and eighty-
eight were added; tlic word ajfic in!, -was adopted to re-
place " officinal. " This work was received universally as
representing tlie most advanced, yet sufficiently conser-
vative standard among pharmacopceias, and the advances
in it have so far conunended themselves to tlie medical
and pharmaceutical i)rofessions during the decade since
its apiiearance, that further progress in Ihe same direc-
tions has been generally urged, particularly in that of
an extension of the list of assayed drugs and prepara-
tions. It may be safely said that tlie Pliarmacopceia of
1890 has done more tlian any of its predecessors for gen-
eral pharmaceutical education, and to only a lesser de-
gree for medical education. At the present time (.Janu-
ary 1st. 1903), tlie work of the Eighth Decennial Revision
is nearly completed. Soon after the meeting of the con-
vention of 190(1. death removed the beloved and highly
talented chairman of the revi.sion committee. Dr. Charles
Rice, and Prof. Jose])h P. Remington was elected as his
successor. The interest in this revision, throughout the
country, has been general and hearty, and the committee
has worked with tin: greatest enthusiasm. Of the many
important changes in the pending publication some are
fairly ratlical. The work of revision and that of publi-
cation have been assigned to distinct bodies ; the former
to a committee of twenty-live members, as before, the
latter to a board of trustees, a regular incorporation
having been effected for this purpose. Among the spe-
cial features of this revision the following are worthv of
note: Whenever po.ssible, articles are toTje standardized
on the basis of chemical assa}-; physiological standards
may also be represented in the requirements for anti-
toxin, notwithstanding the instructions of the conven-
tion to the contrary, the committee having decided that
the importance of the subject demands even so danger-
ous a precedent as this; although the descriptions of
crude drugs are to retain, so far as is consistent with
clearness and accuracy, the simple language of the pre-
ceding edition, yet simple descriptive terms are to be in-
troduced, wherever necessary, to facilitate the detection
of elements of adulteration entering into powdered drugs ;
a wonderful advanceover the instructions of 1880, which
forbade the introduction of any characters wliicii cmild
not be seen with a lens magnifying " about ten diameters" ;
doses are to be specified, and. tiually, the revolutionary
principle has been accepted that proprietary rights of
limited duration in a meritorious drug, providetl that the
conditions render it amenable to standardization and re-
sulting control, do not constitute an objection to its rec-
ognition by the Pliarmacopceia, and a sub-committee
has been ajipointed to determine what proprietary arti-
cles can propei'ly be admitted under this rule.
Autliority of tJii' Phai nuicopa-id. — The authority of a
phannacopaMa may lie legal or professional, and liiay be
established either before the existence of the work", by
the legal or professional appointment of its compilers, or
thereafter, through its adoption by a government or by
a representative professional bod}'. In either case it oc-
cupies a special otfice, and all matters pertaining to it are
therefore denominated ofiridl, or, according to older
usage, "officinal." Thus we have official and unofficial
drugs, medicines, reagents, and other substances, as well
as official titles, synonyms, definitions, descriptions, tests,
formulas, processes, doses, etc. The professiowil au-
tliorit_v of the Pharmacopo'ia is not compulsory, except
as a violation of such of its provisions as have profes-
sional sanction involves professional disrepute. Its legal
authority, estabUshed by statutes, with penalty attached,
is of course so. In this way the United States Pharma-
copo'ia has been made the legal authority in many States,
as well as wherever the jurisdiction of the national
Government extends.
Objects and Scope of the Pharmacopeia. — In the defini-
tion given under Piiarmacopa'ia, it is stated that the
standards named apply to the " medicines used in the
practice of medicine " ; not mere)}' to those whose merits
justly entitle them to such use. The object of the book
is to provide a means of assuring the user of a drug or
medicine that he shall receive that for which he calls.
The right of each individual to such assurance, regard-
less of whether his selection of the article is well advLsed,
is obvious, and constitutes the chief basis of procedure in
the preparation of the book. The selection of the articles
to be made official is thus based upon the fact of their
common use. Since very many worthless or very infe-
rior articles are in common use by physicians as well as
among the laity, the recognition of such in tlie Pharma-
copoeia is thus called for. On the oilier hand, many
valuable drugs are brought forward without ever at-
tracting much attention or coming into general use, so
that the mere fact that the compilers of a pharniacopa>ia
believe a new drug to possess merit does not justify
them in recognizing it. Such a drug must first establish
at least a probability of coming into general use before
it shall receive recognition. Frcmi the almve, it follows
that "the recognition of a drug liy the Pharmaeopa'ia is
not evidence, prima facie, that it possesses merit, nor the
absence of such recognition that it does not." It also
follows that the Pliarmaco]ia?ia is not to be regarded as
a guide to the [jraetitioner in the selection of his reme-
dies, but rather as an index to the general conditions of
practice in such respect and as an authority for testing
the genuineness of tlie articles treated by it. A knowl-
edge of the merits of the arlieles. .-ind an abilitv tci make
a judicious selection, are supposed to be gained from a
587
Pliarniaro|iapia.
PltariiiaoopoEias,
REFEHENCE HANDBOOK OF THE JIEDICAL tSCIEXC'ES.
study of text-l)ooks and otlier litpmture relatina: to fhera-
pcutics. It niav be added that ('.\ii<'ri<n!ce in the United
States lias repeatedly demonstrated tlie fact tliat the in-
triiihiction of an article to the Fliarmacopipia has very
little Aveijjht liy itself in extending its use.
In spite of tiiese general facts, however, the compilers
of our Pliarmacopo'ia do recognize a certain responsibil-
ity for favoring the wortliier articles: so that at their
periodical revisions they are disposed to employ a liberal
construction of the above guiding principles and to lean
toward the expurgation of tlie more worthless articles
and the introduction of meritorious ones whenever the
conditicms wnll possibly justify them.
There is another class of important articles which many
pby.sicians, even among the iTiore inli'lligent. see with
snrpri.se to be denied a recognition in the Pharmacopoeia,
notwithstanding tliat such denial is a natural nece.s.sity;
such articles, namely, as are, for one reason oranother, not
subject to any ofli'cial delinition. description, or stand-
ardization, (if this class tiie most consjiicuous examples
arc found among cop^Tighted articles. In these cases it
is the names alone which are copyrighted and which
have a fixed identity. Absolute ownership of these
names is conferred by the copyright, and there is n«
stipulation a,s to the u.se which is to be made of them,
except that they shall be arbitrary, that is. not descrip-
tive of the article to which they are apidied. The}' may
be meaningless, or they may be devised with the nbject
of misleading the public, as by naming the syrup of a
Well-known fruit, whereas, if such were the real origin
of the preparation, its name would be descriptive and
would at once lose the copyright protection. Further-
more, the substance to which the name is applied may
be changed or substituted at the will of the owner of the
name and as often as he desires. Manifestly, control and
standardization by a pharmacopo?ia of an article so
named is an impossibility. The case is rpiite ditTerent
with those articles which are protected by patents of
limited duration, either upon the product itself or upon
the process by which it is prejiared. Such protection
provides for publicity and freedom at the end of the pat-
ent period. Ethical views regarding such protection
have of late undergone a very great change. Here, as
in many other parts of the medical field, rationalism has
replaced blind and arbilrarv nding, and the oii bono
stand.ird has come to be apjilied, with the result, as
stated lielow, that certain important, not to say abso-
lutely necessary drugs which enjoy limited protection
are to he reeogni/ed in the forthcoming edition of our
Pliarmacop<eia,
Offiriii/ A(//;/c.v if nil T),fiiitioi,». — The official Latin and
English titles call for little discussion. They constitute,
like other names, a basis for S]>ecifying the respective
articles, and their use in jireferencc to that of any other
names by which the articles may be known, enables the
prescriber to secure the support of otlicial. and in inany
cases of legal authority, which he might find it dilticuft
to olitain if he used an unotlieial title, subject to different
apjilieations in dilTeient localities, and perhaps even in
prof(-ssi(inal literature. In special cases, when tlie latter
condilion exists so as to involve s|iecial danger of misun-
derstanding, the Pharniaeo]i(eia may also recognize one
or more synonyms.
The otlicial definition is intr-nded to be a full statement
of what constitutes the article named by tlie title, and at
the .same time limits it by the exclusion of all else. In
the case of ]iure chemicals or juire substances of natural
origin, as alkaloids and glneosides, the chemieal formula
usually constitutes a complete definition. If the article
is not required or expected to he absolutely liure. a state-
ment of the allowable amount, and perlia[)s of the nature,
of the impurity fre(|uently forms a part ipf the detiniliim.
In the case of animals or plants or their parts, the ih'fini-
tion states clearly what Jiart or parts shall be employed.
The terms used in naming such jilants and parts are those
authoriratively employed in zoology and hoianv. In
cases in whicli zoological orbolani<"il authority is divided,
as in tlie rules of botanical nomenclature, the couijiilers
decide which method and rules shall be employed, and a
statement to that elfect is incorporated into the introduc-
tion of the book. The family or natural group to which
the animal or plant pertains is also named in tlie defini-
tion. This is. strict!}- speaking, superlluous to a defini-
tion, but proves convenient and in.structive.
When the living part is to lie taken or eollected in
some particuhir stage or condition, as "in full bloom."
"in the second year of its growth," "when full grown,"
" fully ripe," etc., this fact also is stated in the definition,
as is any change which is to be made in it in preservation
or preparation, as "the dried root," "a prepared exuda-
tion," "an inspissated juice," a hark "kept one year
before being used." or "not kept longer than one year,"
etc. In special cases, a note may be appended to a deti-
nition specifying some danger to which the article is
peculiarly liable, and stating how the same may be
avoided. In a few cases, when the facts regarding the
origin of an article are unknown, as in the case of the
root of an unkn<nvn species of Smilax. or when the num-
ber of species yielding the article is indefinite or incon-
veniently lar.ge for specification, the definition cannot be
made fully to accomplish its purposes. The best possi-
ble mu.st then be done with it and the description must
be relied ujion, to accomplish the remainder.
Offii'iiil Stamhirch. — Tlie standards of the Pharmaco-
poeia are physical, chemical, and ph3'siological, and are
incorporated into the descriptions.
The olescription, in other cases than tho,se referred to
above, i.s not to be regarded as partaking of the same na-
ture as the definiticm. butasa statement of the tests which
are to be applied by one having the article in hand, for
the iiur]iose of empioyingthe specified standard. These
standards and tests may be qualitative or quantitative.
The ordinary physical test is included in the description
of the drug as regards color, surface, and other external
apjiearances, hardness, weight, fracture, structure, odor,
and taste. Chemical standards, qualitative or qiumtita-
five, do not differ from those ortiinaiily employed in
chemistry. Physiological tests are by manj' regarded as-
excluded b}' the general nature and uses of a pharmaco-
poeia. Nevertheless, many of the physical tests, such as
peculiar effects upon the nose or tongue, the pujiil and
other organs, may fairly be denominated as physiological
and the extension of this class of standards in the pliar-
macopd'ia in the future is to be anticipated.
Preparaiions. — Among the several preparations to
whicli drugs are subject the Pharmacopeia makes a se-
lection, in each individual case, based upon the nature
of the article, on both pharmaceutical ami therapeutical
grounds, and these preparations are enumerated just
after the description. In those cases in which a small
amount of the drug enters into some otherarticle or prep-
aration merely as an adjuvant, and not especially for
its own medicinal effect, such article or preparation is
not regarded as a preparation of that drng and is not
thus named. Proximate principles, such as alkaloids,
glucosides, fixed and volatile oils, also, are not treated as
]ireparations. There are a number of instances in which
neither pharmaceutical nor therapeutical considerations
can deterriiiiie a selection, and here no preparation is
specified, though opinions are not wanting to the effect
that at least one oHicial preparation ought to be supplied
for every official drug. Tlie preparations thus named
are then treated, in Uie regular alphabetical order of
their titles, as othcial articles, their formulas and meth-
ods of |u-eparatiou being given in full detail and. in some
cases definite stiUidaids being su[iiilied. similar to tho.se
above described for the drugs tlir>mselves. The question
has been much mooti^l as to whether a preparation can
be considered to be official if. made strictly in accordance
with the formula anil of a quality fully equal to that re-
sulting from tlieotticial process of manufacture, it difTers
merely in some variation from the latter. The question
is a delicate ami not unimportant one. It is urged upon
the one hand that the principal object of prescribing an
official process is to insure the quality of the preparation,
and that if departures from it be permitted, a tendency
588
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
l'liariiia<'opceGa,
PlEariiiaco^wias.
to laxity may be encouraged. Upon Uie other Iiaud, it
is clear that in large manufacturing operations the nieth-
otls of the retail pharmacist are imijracticable, and e\'en
that a better result niaj' be otherwise attained. The
view of this subject, which has always Ijeen taken, at
least in modern times by the revisers tJiemselves, is that
a deviation from the ]iroc.ess is permissible, provided that
a satisfactory jireparatiom is insured.
Dosen. — The United States Pharmacopcria has never
heretofore been willing to assume the responsibility in-
volved, or which might be involved in particular cases,
by the adoption of doses. The posisibility that the pre-
scribed dose might in individual cases act disastrously,
and that the compilers of the Pharmacopceia might be
held responsible for having authorized it, has always
acted deteiTCDtly. At length, however, a method has
been devised by which, according to the highest legal
advice, a system of otlicial dosage can be adopted which
will be free from this damger. Doses are therefore to be
introduced into the forthcoming edition, although their
exact limitations have not yet been made public.
T/ie Appcmlix. — The Appendix of the P]iarmaco]ioeia
containing lists, detinitions, desciiptions of reagents,
tables of atomic weight, thermometjlc equivalents, aleo-
liols, acids, and other important chejnicals, of saturation,
equivalents of the English and metric sy.sticms of weights
and measures, is of great importance, possessing an au-
thoritative value for accuracy and a facility tor i-eference
which, without any regard to the subject matter found
in the body of the work, entitles the latter to a conven-
ient position upon the shelf or table, not only of every
physician and jjharmacist, but of every person whose
work brings him into contact in any wa_v with pliysical
or chemical science.
U«e of the PJiarmacopmo.— The use of the Pharmaco-
poeia by i^harmticists is incomparaljly greater than that
by physicians, and to thfe fact is in great part due the
higher tlegree of accuracy and care and the more definite
knowledge of theformer profession regarding the materia
medicti. Kot only is this true, but it is tuideniable that
the most serious shortcomings of the mediiral profession
in matters therapeutical might be largely eliminated
•were they to rely more fully upon reference to this
work. While it is true that the Pharmacopa'ia j^rovides
no information directly concerning therapeutics, yet it
contains very full information, and of the most reliable
character, concerning materia medica, fundamental to
therapeutics and, in turn, the highest teachings of tliera-
peutics constitute its basis as to prepai'ations and dosage,
and as to a majority of the drugs treated.
Hen rp 11. Eudiy.
PHARMACOPCEIAS. GENERAL AND INTERNA-
TIONAL.— Many works have been pubhshed. which are
desigiK-il t(i roiuprise the text of all, or at least the most,
prominent pharmacopceias. Among the earlier authors of
such works are Lemery, Charas, Spielmann, Swediatn'.
Quincy, Brugnatelli, etc. Of more recent works tlie fol-
lowing deserve special mention; A. J. Jourdan, "Ph.
Universelle" (Paris, 1828, second, ed. 1840); P. L. Gei-
ger, "Ph. Universalis" (Heidelberg, 1835-45); B. Hirsch
"Universal-Pharmakopoe" (Leipsic, 1885, vol. i.).
JIany j'ears ago efforts began to be made to bring
about greater ham^ony in the different pharmacopieias.
and the proposition was finally made to inaugurate an
International Pluirmacopoeia. Opinions ditfered greatly
for a long time, not only as to whether the plan was
feasible at all. but also in regard to details. Steps were
tinallj' taken to liave a draft of the work prepared, but
national jealous}^ on several occasions rendered itsaccept-
auce impossible. It was not to be expected that each
civilized nation would abandon its own phannacupieia,
specially .adapted to the li;ibits of its own jieopk- and its
own domestic resources, for one elaborated without re-
gard to such considerations, and possibly introducing
unfamiliar preparations or changing the strength of such
as were in connnon use. The utmost thai coulil be ex-
pected was that the dillereut nations, whenever revising
their own phaj-macopoeias, would gradually approximate
such preparations as were regaided worthy of interna-
tional regulation to the pro|)<)sed standard. Another
hope which was expres.sed was this, that the Interna-
tional Pharmacopa'ia might be used and followed as an
iiKkpenderit work in different countries in this way, that
prescribers wotdd designate preparati(ms contained in it
in their prescriptions. A plan has been presented for the
establishment of a common pharmacopa'ia for tlie Ameri-
can continent. Tliis is too wide a scope to be feasible at
present. But it is feasible to prepare a pharmaeopaia
for all the Spanish -speaking countries in Central and
South America, jirovided all political differences are
waived for the sake of the beneiit which may accrue
from the result. After some uniformity has been reached
in Central anil South America, it remains to be seen how
much further it can be canled. At the International
Pharmaceutical Congress, held at Brussels in 1886, the
draft of an international pharmacopa'ia was preseiated
b_v the jn'esident of the International Commission, Baron
A. von Waldheim, of Vienna. Yet, in its preparation
tlie other members of the commission had not been suf-
ficiently consulted, and the draft was not accepted.
Other meetings of this Congress have been held since,
the seventh taking place at the close of the meeting of
the American Pharmaceutical Association in Chicag^ in
1893. At this tune what may be regarded as the first
practical step tow"ard reaching an international agree-
laeut was taken when the American Pharmaceutical As-
sociation appropriated 81,0(10 toward defraying the ex-
pense of preparing and publishing an international
pharmaeopceia. to be confined to the treatment of potent
remedies. In 1897 the Congress met again at Brussels,
but did not approve of this projirosition for a restricted
pharujacopoeia, and again indorsed the idea of a large
and comprehensive work. In the mean time, no steps
have been taken toward carrying out that plan, and the
less visionary representatives, led by the American and
British contingents, have gone ahead with the initial
steps in the direction of preparing a work treating of po-
tent remedies. A report on this subject has lieen sub-
mitted to representative bodies in the different countries,
and there seems to be some prospect that important re-
sults may follow.
Instead of attempting the almost impossible, the advo-
cates of uniformity in medicines appear to be willing to
bring about tlje desired end by natural means, that is, by
first causing the consolidation of the pharmacopa'ias of
contiguous countries, particularly tho.se in which the
same language is spoken. Thus, Germany has long ago
displaced the host of local pharmacopceias in existence
previous to the establishment of the empire bj' a single
natit>nal work. Italy has done the same. The Scandi-
uavi-au countries also contemplate doing this. It is easj'
to forest* that there never will be an international phar-
macopa'ia which will replace each individual national
one. The best that can be hoped fi>r is a work containing
the description, definition, requirements of purity and
strength of what may be called international remedies,
single or compound, and even this cannot be introduced
without risking danger from the administration of prepa-
rations the strength of which as contained in the inter-
national pharmacopojia differs from that prescribed in
the national pharmacoiiaia of the dispenser.
C/utrles Sice.
Revised by Henry II. Eunby.
Untversal Phaem.\cop<ei.\. — In this place should be
mentioned the work by Dr. Brimo Hirsch, of Berlin, en-
titled, " Universai-Pharmakopiie. Eine vergleichende
Zusammenstellung der zur Zeit in Europa und Xord-
amerika gl'ilti^en Pharmakopoeu " (Univer.sal Pharma-
cnpa'i-a. A Comparative Digest of the Pharmaco])o'ias
in force at the present time in Europe and in the Uinted
Slates). This work contains in-aetically the whole text
of the several pharmacopcvias (except that of Portugal;
in such a way that the similarities and differences of the
requirements of the several texts are shown at a glance
5S9
Pharynx.
Pliaryux,
REFKRENCE HANDBOOK OP THE JIEDRAL SCIENCES.
iu connection -with each subdivision of an article. It is
a Work of ivtVivnrc iinlispeiisalilc for ever_v ri'vision com-
mittee iu this and otlier countries for many years to
come. Clhtrks Rice.
PHARYNX, ANATOMY OF. See Toimh, etc.
PHARYNX, DISEASES OF: ACUTE INFLAMMA-
TIONS.—In tlietc\t-li(H>ks, i;cnenilly. the use dfllie term
pharyngitis is somewhat coufusinu;, as tonsillitis, uvuli-
tis, and palatal intiammation. as well as intlanunatiun of
the pliaryn.x projier, are loo.sely iucluded iu the term.
While in" nearly all intiammatious of the pharynx the
contiguous structures anteriorly are involved, yet, as dis-
eases of these structiu-es are considered elsewliere in this
work, the term pharyngitis, as here used, will be deti-
nitely limited to inflanunatious of the pharynx proper,
except in treating of tlie throat complications of the
acute fevers.
SiMi'LE AcfTK Pn.VRVNGiTis. — Acute intiammation of
the pharynx is usually accompanied by iiitiainmation of
other portions of the upper respiratory tract, aud there
is commonly more or less nasal occlusion. Acute inflam-
mation, not septic or traumatic, strictly limited to the
pharynx, is ver}- lare.
Eiiologi/. — As arule the acute disea.se is either the light-
iug up of a subacute intiammation or an extension of acute
nasopharyngitis. As etiological factors may be men-
tioned: bad air, poor food, sedentary habits, alcoholic in-
temperance, excessive use of tobacco, and iu general
anything that tends to lower the vitality. Digestive
disorders, nasal obstruction, sudden atmospheric changes,
influenza, and tonsillitis are frequent cau.ses. Heredity
plays an important part, and rheumatism aud gout are
sometimes factors. As traumatic causes maj- be noted,
irritant jioisons. tiame, hot water, steam, foreign bodies.
Pathology. — There are hypera?mia and congestion of
the blood-vessels in the submucosa, with pressure ou the
mucous glands and lessening mucous secretion dining
the flrst stage. In the second stage, congestion is some-
what relieved and the secretion is poured out, the tenac-
ity of the latter depending on the amount of fibrin pres-
ent. If the amount of flbrin be very great, there is
formed a false membrane which is uou-infectious.
Syiiijitnius. — The attack is usually sudden and is ushered
in by a feeling of malai.se and chilliness rather than a dis-
tinct chill. The temperature rarely goes beyond 101°-
102 F. The digestive system is usually derauged, the
appetite is lost, the bowels are constipated, the tongue is
furred, and the breath is foul. Pain iu the nuiscles of the
neck and back is common ; there is generally headache aud
often there is aching of the joints. At lirst there is dry-
ness of the throat and the surface of the mucous membrane
isshiuy aud smooth. Later, the secretion becomes abim-
daut and the membrane thickened and rough from hy-
pertroph.v of the lymphoid follicles. The voice becomes
thick and husky aud there is fatigue ou talking, even
when there is no apparent involvement of the larynx.
Iu the attempt to get rid (if tlie mucus the patient hawks
and hems rather than coughs, while the dryness, or later
the thickening, causes frequent efforts at swallowing.
The feeling at first is as though there was a hair iu the
throat; later, it is that of a larger foreign borly. Pain is
a constant symptom, being increased b_v the efforts at
swallowing. AVheu the group of follicles just back of
the posterior pillar is much involved, jiain referred to the
car is usual. l)eiiig convej'ed through Euslachiau involve-
ment or by means of the glossopharyngeal or .lacobson's
nerve. The .sense of taste may be decidedly obtunded.
especially if the lingual tonsil is involved: but this
symptom is rather an accompaniment of nasal obstruc-
tion. The color of the mucous membnine varies from
pink to dark red, and the superficial lilood-vessels show-
much enlargement. The attack may be limited to oue
side, but it is nearly always bilateral.
Pnir/iiDsis. — This is favorable, but at the .same time the
disease manifests a strong tendency to become chronic,
by rea.sou of the continuance of the exciting causes aud
the impossibility of putting the organ at rest. The dura-
tion varies from three or four ilays to two weeks, accord-
ing to the severity of the attack and the general health
of the patient.
Treatment. — This should begin with a saline cathartic,
preferabl}' preceded by one or two grains of calomel in
triturate, Tiucturc of aconite in one-minim doses hourly
seems to have a special action in pharyngeal inflamma-
tion: but, if the paiu is considerable, pheuacetin, five to
eight grains every three or four hours, or Dover's pow-
der, may be given. If there be a rheumatic diathesis, the
salicylate of strontium, Ave grains every three hours,
will prove of value, while iu tonsillar complications salol.
five grains every four hours, or salipyriu, teu grains at
like intervals, will be better.
Quinine is recommended, but it is most likely to be of
service when the tonsillar involvement suggests mild
sepsis. In the early stage cold externall_y by wet com-
presses or a cold coil will give relief; later, heat will be
more agreeable. A four- to six-per-cent. solution of ni-
trate of silver brushed lightly over the pharynx is useful,
but one of the newer albuminous silver compounds, as
protargol in ten-per-cent. spray, will be less irritating
and just as good. Lennox Browne pironounces guaiacol
— tift_y per cent, in sweet almonil oil, used with brush or
spray — to be the best of all local applications. This
burns sharjily, but is followed by an ana-sthetic effect.
While gargles do not reach much of the posterior wall of
the pharj-ux the_y do reach the contiguous jiarts, and any
oue who lias personally used a gargle knows the comfort
which follows its use. If a patient does not know how-
to gargle it is not well to rely on the method, as in such
cases it is nothing more than a mouth w-ash. The best
gargles are on the order of the Doliell solution, used hot.
If carbolic acid is disagreeable, it ma}- be omitted and the
solution made up w-ith equal parts of cinnamon w-ater
aud pepiiei'inint w-ater. In the early stage a spray of
mentholated benzoinol, from two to four grains of men-
thol to the ounce, may be more agreeable than a wati>i-j'
application. Later, a gargle or spraj' of tincture of chlo-
ride of iron w-ill hasten recovery.
Demulcents iu the form of lozenges are often grateful.
They may contain menthol in minute dose combined w-ith
guaiacum or euealyptol.
Shurly recommends, for the mitigation of local distress,
a tablet of biuiodide of mercury (gr. ^V t" .?■'• sir* t" '-"=
held in tlie mouth till dissolved, the dose being repeated
every two or three hours till five or six have been taken.
In the second stage, if the secretion continues profuse for
too long a period, atropine or aconitine, gr. y^jVir to gr.
-I^y every two or three hours, w-ill hasten recovery. Steam
iulialations are generally worse than useless, although
sometimes temporarily soothing iu the earliest stage.
G.\XGKEN-ous Acute 1n"fl.\mm.\tionop the Ph.\rvnx.
— This disease is ordinarily classed under infective or
phlegmonous pharyngitis, the .severer forms being ac-
companied by sloughing. Including all forms under this
title, one writer will give the prognosis in infective
pharyngitis as verj- grave, while another, limiting the
term to the milder cases, will state that the proguosis is
uniformly favorable. The gangrenous form of infective
pharyngitis is very likely to arise from localization of the
infecting germ iu typhoid, diphtheria, scarlet fever, and
other infectious diseases. In such cases the iufecting ma-
terial prol.iably reaches the point of localization through
the blooil instead of from absorption through the mucous
membrane, as seems to be the case iu the milder, more
superficial forms in which the streptococcus is the infect-
ing germ. The iimgnosis is very grave, both from the
severity of the local process aud from the development
of septicaemia. Treatment is directed chiefly to the sys-
temic infection, elimination being encouraged and stimu-
lants given. Locally, mild antiseptic solutions are of
most use.
Goi-TY Ph.\hyngitis. — This occurs as a manifestation
of the general disease, but may appear quite indepen-
dently of iuvolvement of other parts.
Lermoyez and Gasue give the foUowiug diagnostic
590
REFERENCE HANDBOOK OF THE JIEDKAL SCIENCES.
Pliai-} iix.
(lata: (1) Sudden onset, acute evolution, and sudden dis-
ajipearance. (2) Sharp febrile symptoms, depression.
(3) Very acute pain, out of proportion to the local ap-
pearances. (4) Tendency of iutiammation to diffuse itself
over the pliaryn.x and spread toward the larynx, ordi-
nary quinsy being more localized. (.")) Dark red and
cedeniatous appearance of pillars of fauces, uvula elon-
iiated. and posterior wall of pharynx swollen. (6) Ab-
sence of exudation. (7) The glands at the angle of the
jaw not involved. Colchicum is to be used in the treat-
ment of such cases. Locally, soothing gargles, or prefer-
ably sprays, are indicated.
Heispetic Pn.\RTN(inis. — (Synonyms; Common mem-
branous sore throat ; Aphthous sore throat ; Benign croup-
ous angina.) Herpes of the throat, which is a milder
disease than the skin affection, appears as a discrete erup-
tion, the individual spots measuring 6-(S mm. in diameter
and being located on the posterior wall of the pharynx
or anterior surface of the faucial pillar.s. Thu etiology \&
varied. The local manifestation is probably due to a
peripheral degeneration of the nerves of the affected area.
The general condition has a very considerable etiological
signiticance, disorders of the alimentar_v tract and many
fetirile diseases acting as causes.
The earliest si/niptoms are dryness of the throat and
pain of a burning or stinging character. The constitu-
tional sj'mjitoms are as a rule slight, fever if present
being of mild grade. The eruption may be unilateral or
bilateral. The vesicuhir stage is seldom observed, the
vesicles rupturing early and the excoriated mucous mem-
brane becoming covered with a thin, soft membrane
which is easily wiped off. Labial herpes is usually also
present. The disease lasts for from eight to sixteen
daj's, but has a very consideraljle tendency to recur.
Diufinnsis is made from other membranous anginas by
the mildness of the symptoms, the laliial herpes, and the
thinness and suiierticial character of the membrane.
Little local tnntmeiit is necessary; bland sprays or gar-
gles, and applications of silver nitrate (two or three
grains to the ounce), or of resorcin (ten grains to the
ounce of glycerin) will be found useful. If pain is con-
siderable orthoform may be used.
Membr.vnovs Pn.VKYNGiTis. — Non-diplitlieritic mem-
branous pharyngitis, the term being limited to eases in
which an actual pseudomembrane develops on the phar-
ynx.— whether or not tlie tonsils and palate be also in-
volved,— is a very rare disease. In nearlj- all individuals
there is a well-developed strip of glandular tissue lying
just back of the posterior faucial pillar. In ordinary lacu-
nar tonsillitis it is quite common to Und this follicular area
involved in the exudative process. The exudation fmm
the several follicles in the strip may coalesce and give the
appearance of a narrow membranous strip on either side
of the pharynx. This condition, which is frequently
spoken of as a membranous sore throat, is properly only
an acute exudative follictdar pharyngitis. Kyle de-
scribes a membranous pharyngitis; "An acute infectious
process in which there forms on the mucous membrane
surface a highly coagulable albuminoid material which
constitutes a false membrane and occurs along with des-
quamation of the superficial epithelium." Such a condi-
tion must be verv rare.
Emil Mayer in IflOO described a case due to Fried-
liinder's bacillus, and was able to collect thirteen of the
same kind from the literature. In measles there is some-
times developeil in the pharynx a strejitococcal membrane
which resembles very closely the membiane that is formed
in diphtheria; its presence constitutes a grave complica-
tion.
The (iiar/yuisisof membranous pharyngitis is not always
easy. Localized areas of epithelial necrosis, or herpetic
pharyngitis after the vesicles have ruptured, cannot be
distinguished by the naked eye from false membrane.
This frequently leads to mistakes in diagnosis, and the
terms herpetic pharyngitis and membranous pharyngitis
are freiiuentlv used synonymously. The greatest care is
needed in differentiating this condition from diphtheria,
and it is commonly accepted that any case of membranous
sore throat is to be treated as diphtheria until a diagnosis
is positively reached.
The prognoHs is generally favorable except in the strep-
tococcal variety, in which the outlook is more serious.
Treatment. — The systemic treatment should be the same
as for diijhtheria in the severer varieties. Locally, disin-
fectants and detergents are indicated. A spray of pyro-
zone, hydrozone, or any high-class hydrogen peroxide
solution is of value. The ordinary commercial solutions
of hydrogen peroxide are sometimes very irritating to the
throat and should never be used. Lotiier's toluol .solu-
tion is also effective. It shovild be applied with a swab,
and care should be taken to squeeze out the excess.
Pemphigus. — Cases of pemphigus of the pharynx are
occasionally reported. The bidla' are rarely seen before
rupture. The acute disease is attended by hi-adai he,
I)ain, and fever. The duration is from one tn three
weeks, but there is a strong tendency to recur ami be-
come chronic, especiall}' in the aged. The disease is dif-
ferentiated from diphtheria by the bacteriology, the easy
remova! of the exudate, the ai)senceof glandular enlarge-
ment, and the mildness of the constitutional symptoms.
Adhesions are very likely to form and should be carefully
guarded against. The ireatiiniit is about the same as for
herpes.
RHEr.M-\Tic Pii.\RVNGiTis. — Rheumatism of the phar-
ynx is occasionally observed, but perhaps not so often as
the descriptions would ordinarilv lead one to believe.
It is claimed that extensive ulceration of the pharynx
may result directl_v from rheumatism. The diagnosis is
made from the history of the patient; from the sharp
pain, especially on swallowing, which is out of propor-
tion to the redness of the mucous membrane, and vaiies
in severity as a rule several times in the twenty -four
hours; and from the prompt relief afforded by the salic}'-
lates. The local treatment should consist of hot gargles,
together with the external use of a chloral liniment or a
twenty-five-per-cent. ointment of ichthyol.
TR.\r-M-iTic Pii.\RYNGiTis. — This is an acute inflamma-
tion of the pliarvnx due to wounds, foreign bodies, caus-
tics, and the inhalation of dust or vapors. Children are
especially liable owing to their freipient mistakes in
swallowing hot or caustic fluids. Persons working in
dust or in caustic vapors are also liable to pharyngitis of
this type. Any foreign body that may become lodged
in the throat or may lacerate the mucous membrane as it
passes through the pharynx may give rise to inflamma-
tion with (edema and at times abscess formation. In any
traumatic jiharyngitis tliere is danger of the inflammation
and fl'dema extending to the glottis with fatal results.
In the aged or enfeebled the irritation caused l)y the
swallowing of a bit of crust or a small piece of eggshell,
or any such material, may give rise to fatal inflammation.
Treatment. — In the case of a foreign body, if it be still
present, prompt removal should be effected through the
natural pas.sages if possible; if not. by external pliaryn-
gotomy. Often, however, it is found that the otlending
body has been removed or swallowed, and that only the
effects are to be combated. Soothing applications should
be made — oily sjirays containing from three to six grain.s
of menthol to the ounce, Dobell's solution, and adrenalin
cldoride, 1 to 4,000, to be rejieated every two hours or
oftener. Bland fliuds only should be swallowed, all solid
foods being avoided. If (edema threaten, scarification
should be done to a suflicient extent to afford relief.
Urticaria of the Pu.iUYNX. — Urticaria may make its
appearance in the pharynx either after or before its oc-
currence on the skin, but always in conjtuiction there-
with. Those cases of supposed urticaria localizing them-
selves in the pharj'nxarc probably cases of angioneurotic
tedema (which see).
The causes of i>haryngeal urticaria are naturally those
of the affection in general, e.g.. shellfish, small fruits,
stings of insects, drugs (copaiba, cubebs. quinine, capsi-
cum, turpentine), the neurotic, rheumatic, and gouty
states, genital disorders. ]iregnaney, constipation, etc.
There is a form of acute febrile urticaria which develops
suddenly and usually appears at the Sitme time on the
591
Piiaryux.
Pharynx.
liEFEHEXfE HANDBOOK OF THE >tEI)I('AL SCIENCES.
cliost Hiid iu the mouth. Tlif fhiiractcristics of the affec-
tidti ill the phurvu.x ;ue tlic siiddrii iiivasiiiii with cougli,
dyspiKfa, aud local imtatiou. Locally the mucosa shows
acoudition fesembling that of iullatuiiiatory rodenia.
The pmff/iosis is nevef bad excei)t in those i-are cases in
■which the malady exteuds to the laiyn.v, wlieu we may
have a clangerousdyspua'a. At times the tongue is badly
swollen.
At the onset of the attack the system should lie cleared
out with emetics and pui-gatives, euemata. etc., so a,s to
iriiiove tlie exciting cause. Laige doses of the alkalies
shotilil then be given. Locally ice pellets, weak sprays
of cocaine, adrenalin, antipyriii, etc., will generally give
(piick relief. The occurrence of dyspucea must lead us
to prepare for either iutiiljatiou or tracheotomy. It must
be remembered that articles of food ordinarily harmless
mav at times i>recipitate an attack.
Intubation or tracheulomy may become necessary if
the swelling increases rapidly. lusutHations of morphine
sulphate, gr. i-gr. ss. iu an inert powder, may be re-
quired for pain, or. if there be much abrasion of the mu-
cous membrane, orthoform may be more etfectivc. In
the case of escharotics the indications are practically the
same: viz.. to use anodynes and emollients.
Ci,CEii.\TivE Septic 'Fit.\uvx(;iTis. — (Synonyms: In-
fective pharyngitis; hospital sore throat: suppiu-ative
pharyngitis.)" This is a form of infective ])liaryiigitis
which occiu's in jjersons reduced in health by harfl work
in unsanitary employments. Work in the dissecting
room, exposure to septic secretions from wounds, atten-
dance on diplitheria or scarlet-fever patients, are frequent
causes of the di-sease in medical students aud physicians.
The streptococcus is the usual infecting organism, but
the staphylococcus is generally associated with it.
I'atliiAiniji. — The ulceration is the result of the action of
the infecting bacteria on the epithelium: they first cause
necrosis of tlic superficial cells; then, entering the deeper
layers, they obstruct the lilood supply and cause furtlier
necrosis. "According to the virulence of the infecting
organism and the resistance of the tissues the ulceration
may remain superficial or may extend deepl}', in the latter
case resulting in the phlegmonous or gangrenous form.
.s'//m;(^«/is.— The attack usually begins with languor
and headache, quickly followed by a rigor, high tempera-
ture, rapid pulse, aud other accompaniments of fever.
If the deeper tissues are involved, all symptoms are
graver iuid delirium occurs early. The tongue is heavily
coated aud the breath is foul. Locally, the lirst symp-
tom will be dysphagia, the throat graduiilly becoming
dry and swollen, ami tilling u)i with foul mucus, requir-
ing constant clearing and causing the patient much suf-
fering. The pain may be felt in the ear and may extend
low down in the pharynx. Both tonsils are involved, the
intiatnmation being as a rule superticial, but the cervical
glands are frequently nnich Rwolleii aud painful. The
ulcers which are usually lenticular in shape and covered
with a grayish exudate are often seen on the tonsils and
palate as well as on tlie jiharynx. The local lesions are
often so slight as scarcely to .seem a sufficient cause for
the great systemic disturbance.
Iliiii/iiimis. — Any acute iiharyngitis may be accom-
panied by ulceration, but the local and systemic symp-
toms are not so severe ii>s in the seiJtic form. The rajiid
development aud the determination of the jirecise charac-
ter of the invading bacteria will aid in diagnosis.
1^-iir/nosi.s. — Iu the more superticial form this is favor-
able jirovided the sufferer be removed to more hygi('nic
surroundings. If the disease penetrate to the (lee]>cr lis
sues, the prognosis is exceedingly grave on account of
the liability to sloughing, to extension to the larynx, aud
to the ilevelopmeut of septicannia.
Trcfdiiieiit. — Constitutional treatment with active ton-
ics— iron, strychnine, quinine, etc. — is very necessary.
Alcoholic stimulants ari' often reijuired. The autistrep-
tococcus .serum should Ijc of especial value in these cases,
but ( liuical evidence of this is not yet ussui ini;. Locally,
i<-e internally and externally is indicated in the earliest
stage, but later, if tlie symptoms become more severe.
hot applications should be used. Alkaline sprays or gar-
gles should be u.sed frequently. If any astringent appli-
cations be made to the ulcers they should be of the mildest
character and very gently applied. A spray of four or
five grains of menthol to the ounce of benzoinol will
sometimes prove grateful. If the pain be very severe,
orthoform in powder should be used two or three times
daily. Careful attention to the cleansing of the throat
b}' the nurse, wlio thus largely relieves the patient of
the necessity tor voluntary muscular action of the parts,
will add greatly to his comfort.
Ph.\ry>'(;itis in the Ex.v^them.ww and ix Otiieu
Fevehs.' — Ei-ji-iipeUiis. — Erysipelas of the pharynx aud
contiguous structures may appear as an independent dis-
ease or as a complication of a cutaneousattack. It it oc-
curs consecutivelv to erysipelas of the skin the infection
may extend to the pharynx by way of the nose, mouth,
or ears, or by metastasis.
The attack begins with fever, and there are sharp ptiin
in the throat and difiiculty iu swallowing. Immediately,
or after one or more daj's, the pharyngeal mucous mem-
brane becomes swollen and gli-steuing and covered with
rojiy mucus or muco-pus. Vesicles, tilled with .serum,
blood, or pus, and varying iu size from one-sixteenth to
one-half of an inch in size may ajipear. In .severe cases
abscesses or gangrenous areas ma}' devcdop. Involve-
ment of the tonsils, accessor}' sinuses, and middle ear is
very likely to occur. The glands of the neck are swollen
and tender. 'E^-M\y (Uagnosiais. dillicnlt unless there have
been a previous eiysipelas of the skin. Later, the very
general involvement of the pharynx and the character-
istic appearance just described serve to make the diagno-
sis clear. The j'lw/nnsis is grave, as extension to the
larynx nia_v occur with fatal result.
Treatment. — The general treatment should be the same
as for erysipelas elsewhere; it should be of a supporting
character, with large doses (twenty to thirty minims) of
tincture of chloride of iron every three hours. Locally,
iehthyol is of value; from ten to thirty jier cent, in glyc-
erin should be painted on the inflamed mucous mem-
brane three times dail_v. Alkaline cleansing sprays shouKl
also be used. Ice internally aud externally may be sooth-
ing and useful early ; tit a later stage heat will be better.
liiflueiaa. — In nearly all ca.ses of influenza of the re-
spiratory tract the pharynx and fauces are involved. A
reddeneil area passing down on either side of the soft
palate is frequent enough to be of considerable value in
the diagncsisof the disease. The tendency to pass into a
chrouic inflammation is rather slrouger than it is in sim-
ple acute [ihaiyngitis. The inflammation may be very
intense, and superficial necrosis of the epithelium on the
anterior pillar of one .side, with whitish. exudation whidi
looks like a very thin membranous deposit, may be very
suggestive of diphtheria. The local treatment is that of
simple acute pharyngitis. The following formula, which
is to be used as a spray every two hours, has lieen found
by the writer to be veiy serviceable in this and other in-
fectious forms of Iiharyngitis: K Pyrozone, fl. ; i. ; boro-
lyptol, fl. 3 vi. ; water, q.s. ad fl. 3 iij.
When the iuHainnuifion is more intense, soothing alka-
line solutions will be found to answer better, while tinct-
ure of chloride of irou. two minims to the teaspoouful of
glycerin and water, swallowed every two hours, will
hasten resolution.
lutmiiittent Fen >: — It is well recognized that a pharyn-
gitis may be due to malarial ])oisoniiig. The fi/ziijituiits
are tho.se of sinijUe inflammation, except that pain may
be sharper and redness less marked. Trnitmeni is that
of the systemic disease with simple alkaline gargles or
sprays for the local condition.
Meadi'n. — Inflainination of the jiharynx and fauces is
generally so marked in measles that a diagnosis cau often
be made from the pharyngeal picture alone, before the
eruption apjiears on the skin. Tlie mucous membrane is
deeply injected, the eru]>tion appearing in blotches or
points, wiiili- ihe siirfice presents a distinctly rough ap-
pearance. A memlirauous exudation due to the strepto-
coccus somelinies forms on the pharynx aud tonsils aud
h'^l
REFERENCE HANDBOOK OF THE 3IKDICAL SCIENCES.
Pliaryux.
Pharynx.
constitutes a very serious complication. True diphtheria
mav appear as a complication, rendering the prognosis
nnich graver than in either disease alone. The treatment
of the visual throat condition should be by alkaline sprays,
such as Dobell's solution, followed by an oily spray of
one or two grains of menthol to the ounce of benzoinol.
Phcnmoiwi. — The pneuniococcus seems at times to enter
tlie blood through the pharynx and tonsils, determining
an attack which is characterized by the irregular range
of temperature, vaiying from 100" to 105° or 106' F. one
or more times in twenty -four hours. There is little or no
cough, the symptoms being purely those of a blood in-
fection. The disease may run a course of seven to ten
days without localizing in any organ, or it may after
thi-ee or more days localize as a lobar pneumonia, much
simplifying the attack: or it may localize in any of the
parts of the body now recoguizecl as suljject to the inva-
sion of the pueumococcus. Careful inspection of the
throat will detect redness of the pliarynx and fauces, the
redness of the anterior pillars being not so bright as in
influenza and following more closely the border of the
tonsil. A culture taken from the throat will reveal the
pueumococcus in almost pure culture and will render ex-
plicable some otherwise obscure fevers. The cases seen
by the writer have been in children, ranging in age from
fifteen mouths to five years. Local treatiuent is of doubt-
ful value, mild detergent sprays being indicated if any-
thing be used.
Seiir/et Fever. — The pharynx and tonsils furnish almost
the earliest manifestations of the disease. Before any
rash has appeared on the skin the vivid red of the
pharynx and fauces will suggest the onset of scarlet fe-
I ver. " A little later a bright rash will appear on the soft
palate, while the previously reddened pharynx and ton-
sils will become darker and covered with thick mucus.
The involvement of the tonsils and phaiynx is fairly
typical of the severity of the disease, the luilder cases
showing only slight redness and moderate tonsillar folli-
culitis, while in malignant cases there will be an intense
inflammation of all the tissues of the phaiyux with more
or less membrauousexudatiou and with great swelling of
the glands below the jaw. Between these two extremes
willbe seen all grades of inflammation. The inflanuna-
tion is very likely to extend to the pharyngeal tonsil and
through the Eustachian tube to the middle ear. Ulcer-
ation of the tonsils may appear early, while ulceration of
the ])luirvnx or pillars is a later manifestation of the dis-
ease, rarely occurring before the fifth day and often much
later. In the case of a membranous deposit the meiu-
brane may be diphtheritic, caused by the Klebs-Loeffler
bacillus, or it may result from the action of streptococci
<jr other micrococci.
Deep inflammatif)n and even sloughing are more likelj'
to result from streptococcal infection, and lymphatic in-
volvement is more pronounced in such infection. It has
been strongly urged recently that scarlet fever must be
recognized as an etiological factor in perforations of the
faucial pillars and tlii' soft palate. Generally such per-
forations are accepted as positive evidence of syphilitic
disease: and while in the vast niajorit}- of instances this
is undoubtedly the causative factor, yet it is well to re-
member that scarlet fever may cause the condition.
Treatment. — Attention to the throat early and sedu-
lously is essential in the management of this disease. In
{■ase of severe neck symptoms the ice-bag or a Leiter coil
may be used, to be followed later liy hot applications.
The use of an alkaline spray alternating with an antisep-
tic spray, such as the pyrozoue mixture previously men-
tioned, will prove very satisfactoiy. The tincture of
muriate of iron in glycerin, as ordinarily prescribed in
these cases, is very etficacious: two or three drops to the
drachm of glycerin is quite strong enough.
Sindllpox. — As in the other eruptive fevers the tliroat
manifestations are fjuite marked in siuallpox. Redness
with inflammation may appear several days before the
skin eruption, but the rash is usually apparent on the
skin before it is seen in the throat. In hemorrhagic
smallpox, however, ecchyinoses may be seen in the
Vol. VI.— 38
pharynx before tlie skin eruption appeals. In severe
cases there may be pseudomenibrane with much pain.
The treatment is that of any acute pharyngitis — deter-
gent and disinfectant sprays or gargles. Severe pain
mav require applications of orthoform, cocaine, or men-
thol.
Ti/phoid Fever. — Inflammation of the jiharynx is not
uncommon in typhoid. There is usually some injection
of the mucous membrane, with dryness and sometimes a
difficulty in swallowing. A faucial exudation is occa-
sionally seen during the third week. This pseudoniem-
brane is very thin, but is adherent and is characterized
by the presence of .staphylococci. As true diphtheria oc-
casionally complicates typhoid a bacteriological examina-
tion may be neces.sarv for diagnosis. In case of consider-
able involvement of the pharynx and fauces, detergent
washes will be beneticial. InvolveiTient of the larynx is
much more serious than that of the pharynx.
Varicella. — Some involvement of tlie jiharyux and pal-
ate is usual if the skin eruption be at all marked. The
vesical stage is short, the vesicles breaking early and
leaving excoriations. If there be much pharyngeal dis-
comfort a gargle, such as the following, is of value:
1} Sodii biborat., sodii bicarb., aii gr. 1.: acid, carbol.,
gr. xvi. : tr. m}-nii:e, fl. 3 iv. : glycerin;x>. fl. 3 ij. ; a(|.
cinnamom., q.s. ad fl. 3 viij. M. Sig. : Dilute with an
equal part of water and gargle every two hours.
CT)rslar!i.s P. Head.
PHARYNX. DISEASES OF: ACUTE PHLEGMON-
OUS PHARYNGITIS.— (/-"'/"■/'/-.s- Anyina.) Various
names have been applied to this affection. Among them
may be mentioned the following: erysipelas of the
liharvnx. diffuse cervical abscess or phlegmon, submax-
illary bubo, infectious submaxillary angina, sublingual
ab.scess or phlegmon, subhyoid phlegmon, gangrenous
induration of the neck, cynanche cellularis maligna, cy-
nanclie sublingualis rheumatiea. While early writers
asserted a speeilie individuality for this disease, later au-
thorities regard it as a se|itic sore throat with a peculiar
localization, not difl'ering etiologically from phlegmonous
pharyngitis, erysipelas of the pharynx, or acute a-dema
of the larynx, all of which seem to represent merely ilif-
fereut degrees of virulence of the same infecting agent.
The question of primary development and localization
depends probabi}' upon the seat of original infection, and
it is difficult to distinguish delinitely a line of demarca-
tion between the purely local and the less complicated,
as distinguished from the n>dematous and purulent forms.
The application, clinically, of general bacteriological
principles to this group of septic inflammations harmo-
nizes to a certain extent former conflicting views.
Ludwig's angina is a diffuse phlegmonous inflamma-
tion of the floor of the mouth and of the intermuscular
subcutaneous tissue of the submaxillary region. It may
end in resolution, abscess, or gangrene.
Gerster defines It as a phlegmonous destruction of the
submaxillary gland characterized by alarming and exten-
sive dense anlema, caused b_v the unyielding character of
the fascial envelope of the gland, which O'denia is most
manifest about the lattei- vicinity, namely, the floor of
the mouth.
Its possible epidemic character can be explained by the
simultaneous exposure of various patients to the same
septic influence. As a seijuei to or complication of in-
fectious maladies, it has been oliservcd more often in
typhus fever.
As yet no special iiathogenic germ ^if the disease has
been found, and where examinations liavc been made
only the ordinary microbes of suppuration have been
present. It is only in respect to the site of the disease
that it may claim sj.iecial ct)Usideration. The location iu
which the"]ius originates is a triangular pyramidal siiaee
with the following boumlaries; The apex (below) corre-
sponds to the point where the mylohyoid muscle borders
the genioglossus. The base (above) stretches along un-
der the tongue. The external wall (oblicpie) is made up
of the internal face of the inferior maxilla and the mylo-
593
Pliaryiix.
REFEREXC'E lIAXPnooK OF THE -MEDICAL SCIENCES.
liyciid musclf; tlio internal wall (vcrlical) liy tlic genio-
glossus and the liynglossns. Tliu nuicous nu'inbr.uu' of
tilt' lloor of the mouth and X\k yUdiihihv iiiil>liii;iiiiilis close
its cavity on top. It is through this channel, liowever,
tliat the infection gains entrance, so that the att'ection of
the submaxillary gland is in many, if not all. instances
seeonilary.
The si/iiiptiiDia are constitutional and local. The for-
mer ai'e in general those of pus furmation. but il is im-
portant to bear in mind that the pathological |irocess
may also give a distinctly astlicnic lyjie of symptoms,
with an overwhelming jn'ostraliou and low tempera-
ture.
Tlie local s\-m]itoms. in adciilion to the prominent
swelling of the neck, present the fullowing diagnostic
poiutsiFirst. and most diagnostic of all. there isa ]>i'cul-
iarly hard and wooden-like induratioTi of the alVected re-
gion, sharply detiued from the surrounding noinial tis-
sue: second, the thrusting forward and upward of the
tongue toward tlic palatal vault by the accumulating in-
Hauimatorj' products; third, severe dyspnrca, with the
possibility of laryngeal cedema: fourth, the sensation of
pressure as from a hard pad or button-like swelling at
the inner aspect of the dental arcade. With all of these
there are as.sociated the ordinary IValurcsof a phle.gmon.
Swallowing is painful, if not im|Missiblc, on account of
tlie muscular infiltration, and the jiatient may nut be
able to open the mouth.
The prnr/iin.sis is a]\\'ays grave and the rate of mortal-
ity high, one series of cases reporting over fifty per cent,
of deaths. Death most frcciuently results from sepsis,
or from suffocation due to laryngeal (cdcma.
The condition must be dillerentiated from osteomyelitis
of the lower .law, simple adenophlegmon of the submax-
illary gland, and the rare disease ktiown as Fleischman's
hygroma. In the first there is no limited focus of iuHam-
mation. The entire bone is affecteil, the iufianuuatory
process is more generalized, and the sulihyoid region is
rarely involved. In the second, adenophlegmon, the in-
flammation is superficial, the glantl and its capsule are
easily accessible, there is no wooden-like hardness, siiper-
licial incision gives exit to pus, and the process is local-
ized at the outset behind the internal face of the ma.\illa.
In the third the diagnostic points are suddenness of
onset, location in the median line, and lack of cither con-
stitiitioual or local evidi'uces of intlammation.
The tiriifiiiciif must be baseil u]ion three jirinciples:
First, early and free incision ; second, carefid subseciuent
antisepsis; and third, constilntl.mal sn]iport. The con-
dition is (me of ptomain poi.soning. The cause must be
removed, and the eticcts already pinilueed must be vigor-
ously counteracted.
Gerster demonstrates that the objiit of the incision is
not so much to evacuate jms as to relieve tension. He
supports the modern view that the submaxillary gland is
the focus of the disease, and atlaebcs much imjiortance
to the fact that jircssure over the o'llematous area rarely
causes |)ain exci'pt directly over thi' glauil. If such evi-
dences appear, di'lay in operating is not justitiable.
The operation must be done under general aiucsthesia,
for deeji tissues must be exjilored, in close pro.xiiuily to
important vessels and nerves.
Fluctuation may be ilelayed because of the pus being
confined within a tibrous capsule. Early incision may
cvataiate nothing more than an ichorous discharge, while
pus may form later, but tension is thus relieveil and the
consequent dangers of suflncation are nuicli lessened.
Deep lateral incision over the s\ibinaxillary gland,
operation throu.gh tlie mouth, and even external incision
in the median line are all to be condemneil.
The must effective method is that sugu'ested by Ger
ster, nanii'ly, to lay bare the entire subinaxillary region
by a careful dissection befoie making the incisi(ui for
evacuating the abscess
To be eff'ective the incision must ]ienetrate the niylo
hyoid muscle.
Following incision irrigalion with bichloride (1 to 1,00(1)
or boric acid (1 lo 100) must be carefully carried out, ami
stimulants and tonics administered according to indica-
tion. Tlie application of cold to the neck, if of any
value at all, can be of service only in the very earliest
stages.
Hydrogen peroxide may assist in the separation of tlie
sloughs.
A good resume of the literature of this subject is given
by J. E. Newcomb in the New York Medical Journal,
November 2:id. ls9."i. I). Biyson Delavan.
PHARYNX. DISEASES OF: CHRONIC AFFEC-
TIONS.— 1. Sniri.i., (-'lUioNic Infi,-\mm.\tiox. — In Uiis
form of inthunmation the morbid process usually localizes
itself on the iiharyngeal mucosa in'0]ier. the surrounding
structures cscajiing. Occasionally it localizes itself in
the faucial pillars and may then be properly called chronic
faueitis.
A frequent cause is the continuous action of irritants
such as excess in alcohol, tobacco, dusty occupations,
etc. JIany cases are associated with chronic nasopharyn-
gitis. In many cases also the malady is but one feature
ill a general catarrh affecting the entire food tract, for to-
the latterand not to the respiratory tract does the iiharyn.x
functionallv' belong. Acid fumes, over-use of the'voice,
abnormal humidity of the air, high temperatures, are all
to be reckoned as possible causes. It may be dillicult to
isolate the exciting factor, for many of the cases come on
so gradually that it is difficult to determine any special
reason for their occurrence. Undoubtedly the modern
method of living in overheated hou.ses is a powerful pre-
disposing agent.
The changes set uii in the mucosa are those of a pro-
liferative intlammation. The vessels may show ail initial
hyperjemia, but the essential change is the formation of
new connective tissue in the deeper layers of the mem-
bianc. jNIucous glands are here scanty, but seci'etion
from the membrane as a whole is increased, and in view
of the abnormal surroundings it soon becomes viscid.
Occasionally nodular veins may be seen coursing over-
the posterior wall of the pharynx.
The most prominent symptom is local irritation, but
actual ]iaiii in swallowing is rare. Owing to the co-in-
volvement of the stomach, there are more or less morning
retching, nausea, aii<l even vomiting. These conditions
may make examination of the throat extremely difficult.
The breath may be sour and offensive. Constipation and
tlatulency are frequent. Cough and huskiness of the
voice are not uncommon. Ilemonhage occasionally
takes ])lace from a ruptured caiiillarv. The muco.sa is
dark anil beef}' in appearance, luit this feature does not
extend farther forward than the posterior pillars. The
pharyngeal wall may be covered with tenacious secretion.
The grade of severity of the symptoms is generally condi-
tioned on the amount of acconipanving nasopharyn-
gitis.
lyedtiiicnt sliould be first directed toward tlie<'orrection
of any vicious habits in eating or drinking. Excesses in
tobacco and all alcohol must be cut off short. The
former are indicated by a dry glazed look, and tire latter
by a red, angry ajipearance of the mucosa. To facilitate
a thorough examination of the throat, we may use ice-
water gargles, liiomide sprays, bromides internally, and
even weak cocaine sprays. I have generally found it
necessary to interdict, during treatment, tea. coffee, and
all very hot or highly seasoned fatty and greasy foods.
All focid must be thoinughly masticati'd, and but little
lliiid should be taken at meals. Attention is now to be
given to the gastro-cnteric tract. Cholagogues. salines,
alkalies with bitters, etc.. here find a proper application.
Attention in detail to the foregoing malters will often
obviate the necessity for local treatment. For topical
use we may emjiloy solutions (twentv grains to the
ounce) of silver nitrate, the zinc salts (the chloride ex-
cepted), alunmol, or jirotargol. For such remedies as
are apjilied by cotton carriers, tlie oleostearate of zinc,
made of zinc stearate in mentholated albolene, forms an
agreeable viscid menstruum. Before any of these are ap-
plied, the mucosa should be thoroughly cleansed with a
y.n
REFERENCE HAXDBOOK OF THE JIEDICAL SCIENCES.
Pliaryux.
Pliaryux.
■n-arm, alkaline spiaj'. Gargles are of secondary value
here, as the puckering of the throat surfaces, incident to
their use, gives only a partial contact with the nuicosa.
2. Chronic Follicvlah In1''i>.vm>iation.^ — This vari-
ety practically limits itself to the pharyngeal wall proper,
the faucial structures not being involved. It is of clinical
importance because the S3'mptoms are out of all propor-
tion to the mild appearance of the lesion.
The brunt of the process falls on the lymphoid follicles
and is one expression of "lymphatisni " or the tendency
of all lymphatic structures to take on overgrowth during
the earlier periods of life. "While (hiring the very early
years this tendency is more noticeable in the uasophar-
yu.x, it maj' become localized, as time goes on, in the
"pharynx proper. Bad hygiene is an important causative
factor. The subvariety of the disease called "granular."
because the smallnessof the follicular enlargements gives
the mucosa a granular appearance, has been referred to a
systemic hyperacidity: but this view is objectionable, in
that it invokes the relation of the mucous glands to the
condition, thej^ becoming stopped up by the action of
the acidity which precipitates their mucin. Improper
vocal effort, both overuse of the voice and use luider im-
proper conditions, may lead to follicular enlargement;
hence the familiar name of "clergyman's sore throat."
As noted above, the follicular enlargement may be
granular or may occur in the form of large masses like
red beads on tlie pharyngeal wall. At times it may be
localized behind the posterior pillars, the appearance
presented being not unlike that of colunuis or bead-
chains. This is the "pharyngitis lateralis" of some
wiiters. These longitudinal deposits maj' fu.se with the
pillars, but are generally of a darker hue. The follicles
nearest the mouths of the muciparous glands are the
most involved. In all cases the process is essentially a
hyperplasia, an actual increase in the number of ly mplioid
elements, especially about the elTerent channels of the
nodes themselves. This hyperplasia may involve the
entire thickness of the mucosa or it may confine itself to
projections from the surface. At first the enlargements
are'soft, but they harden and become smaller with time.
The process seems to involve the tendrils nf the sensory
nerve fibres, though whether merely by compression or
in sfime other way not understood is luieertain. This
nerve involvement accoiuits for the relative severitj- of
symptoms.
The most prominent symptom is pharyngeal dysa-sthe-
sia increased by swallowing or vocal eiTorl. Secretion is
not as a rule increased. It ma_v be blood-streaked by the
rujrture of a superticial vessel. The tonsils often liecome
adherent to the faucial pillars, and from the frequent
efforts at hawking the uvula becomes elongated. The
voice is husky and a nervous, irritable cough is present.
The patients become very neurotic, and this fact in turn
aggravates pre-existing symptoms. The disease contin-
ues indefinitely unless treated, though it does not .seem
to predispose to lesions of the air tract below.
Trcdtiiiciit calls for the same general measures as for
simple chnmic pharyngitis, anil in aildilion for the de-
struction of the enlarged follicles. Any of the caustic
acids or the electro-cautery may be useil for this ijurpose.
A small iron wire, heated in the Hame of a spirit lamp,
will answer. A drop of a two-per-eent. solution of co-
caine injected into the area of punettu'c makes the latter
practically painless. Six or eight punctures may be
made at each sitting, an antiseptic siiray being used on
the intervening days. The minute sloughs should be
allowed to come away before tieatment is resumed. Cu-
retting of the entire area has been advised. Internally
we may give the iodides in small doses and the various
alkaline mineral waters freely. It is unlikel.y that the
latter are of real service tuiless they correct some under-
lying diathesis. Tobacco shoiild be cut oil. Aleolml
may be used sparingly. Nervous patients need arsenic,
strychnine, and phos])horus.
'A. CiiHONic AthoI'IIIc Inki..\m.m.\tiox. — In this vari-
ety there is an actual atrnphy of glandidar tissue and of
the other elements of the mucosa. Some authorities look
on the process as merely the teiminal stage of t'he ordi-
nary catarrh ; others as a separate affection. It may oc-
cur alone, but is more often associated with similar le-
sions in the nose and nasojiharynx. It may be a sequel
of severe local acute conditions such as occur in the exan-
themata and diphtheria, and is not infrequently a feature
of diabetes and chronic Blight's disease.
There may be a proliferation of new connective tissue,
so that in the earlier stages, before the follicles have atro-
phied extensively, they apjiear to lie on a whitish bed and
the whole membrane is very dry. This is the so-called
" phaiyngitis sicca. "
The main symptoms are an uncomfortable feeling of
dryness with more or less pharyngeal dysa-sthesia. The
mucosa may be covered with thick, dry, tenacious secre-
tion. Removal of this, ■which strings down from the
na.sopharynx, may uncover a rather red subaciitely in-
flamed area.
2'reiitiitent calls for restoration of the nose and naso-
pharj'nx to the normal and for the correction of any vi-
cious habits. Persistent dryness should always lead to
an examination of the urine, for the underlying cause may
thereby come to light. The dried mucus should be re-
moved by warm, alkaline sprays, and for home treatment
the patient mayinhale mentholated steam orthe vai)or of
menthol in association with eucalyplol and comjjound
tincture of benzoin. For topical application we maj'
use ichthyol in glycerin (ten to thirty per cent.) or the
familiar Mandl's solution — iodine gr. v., potassium iodiile
gr. X., carbolic acid mij., and glycerin 3 ss. The writer
has had much satisfaclion with solutions of mucin. This
conies in the form of tablets containing gr. v. each of
mucin and bicarbonate of soda, and gr. i. of menthol, the
latter giving an agreeable odor and Havor. and serving
to keep the solution in warm weather. For the latter
]5urpose thymol may also be used. Mucin seems to re-
store moisture to the mucosa and maintain it simply in
virtue of its hygroscopic properties. The above tablet,
which has the apjiearance and odor of pepsin, may be
added to half an ounce each of sterilized water and ster-
ilized lime water, shaken well, and ap]ilied either on a cot-
ton carrier or in spray. If the latter be used, the spray
tube should be flushed out with clean water at intervals
so as to prevent clogging. The tablets ma}' also be gi\'eu
to the patient for use as troches.
It must be remembered that treatment is at liest only
palliative, for advanced stages of the all'ection present a
condition practically irremediable.
4. RlIEr.MATIC AND CJoiTV Infi-am.matioxs. — ^1. 7?//< "-
■iiiiitir liitliiiiuiitition. — Rheumatic pharyngitis occurs in
two forms: (1) acute, and ('2) chronic.
In the acute form we find the same list of piredisposiug
and exciting causes as for rheumalism in general. The
local changes follow- the same seiiuenee as in acute ca-
tarrhal iutiaiiiniatiou, except that the grade of inflamma-
tion is less severe, is apt to be localized in patches, and
causes au amount of pain out of all proportion to its
apjiarent intensity. An inflaniin;ilion of the librous fas-
cia of the pharynx is |iossiblc.
The course of an attack is somewhat as follows: Local
symptoms — burning, dysphagia, and dryness — first ap-
pear, and are followed" by a mild attack of fe\'er and
constitutional depres.sion. After two or three days these
disappear, the pain suddenly shifting to the muscles of
the neck, back, or extremities, possibly to some joint.
The swallowing of the saliva continues to lie annoying.
Inspection ma.y show livid patches or streaks in the
throat. The pain is somewhat peculiar and stinging, so
that those affected leain to recognize it. The sudden
onset, the character of the iiaiii, the history of rheuma-
tism, and the sudden shifting of the local storm area
form a fairly definite clinical ]iiclure which lasts for four
or five days. In the writer's oiiinion, a diagnosis from
mere inspection of the fauces cannot be made. Some
writers have reported ]iharyngeal nlceralious which
proved to be resistant to every other mode of treatment,
but healed under ^ulti-l■heunlafic measures.
Treatment calls for the exhibition of the usual remedies
595
Plinr> iix.
Pliaryux.
KEFEKENCE IlAN'DBooK OF THE MEDICAL SCIENCES.
for rheumatism, togetUor with local iuiodyiu's aud seda-
tives.
Ill the chronic form we find the same list of causes as
for chronic niiiscidar and joint rhcinuatism. It is more
common in men tlian in women, and I lie jieriod from the
twentieth to the sixtieth year marks its age limits. The
on.set may he sudden, hut it is generally very gradual,
and patients come un<ler <il).servati(in only alter months or
even years of iiideliiiite pharyngeal jiain. Tliis is often
referred to the region of the hyoid hone. Ingals tinds
the lesion more conimcm on the right side. From this
site the pain may radiate to or he felt on one side of the
laryn.x, in the t"onsil.>;, trachea, side of the hase of the
tongue, etc. The parts witlun reach are ]iainful on press-
ure" and are genciidly so during swallowing or pliona-
tiou. Continuous siieech is especially tiresome. Curi-
ously enough the pain may disapjicar during eating. It
is very caiiricious as to character, localization, and in-
tensity. All combinations in tliese respects are possible.
The gastro-enteric tract is generally sluggish. Inspec-
tion reveals nothing constant. An area of congestion
may surround the painful spot. The alTeetion may be
confounded, as far as subiective symptoms go, with al-
most any eomnion iiiflanimatiou of the throat, and each
must beruled out by exclusion, special stress being laid,
for rheumatic pain, on the shifting of the area of annoy-
ance, a change of severity according to the weather, and
a history of the rheumatic diathesis.
The treatment is identical with that of the chronic
rheumatic state in general ]ilns the use of local sedatives.
To the areas of tenderness we may apply solutions of
aconite, morphine, metallic astringents, etc. Ingals ad-
vises the use of applications of the following mi.xture:
Morphine suliiliate, gr. iv. ; tannic acid, gr. xxx. ; car-
bolic acid, iilxxx. ; and glycerin and water, of each
fl. 3 s.s. This may be used as a spray by the physician
or applied in oue-half strength by the patient at home.
Internally he gives three grains each of salol and extract
of [ihytoiacca every few hours.
IS. (loiiti/ bifliimmdtioii. — As in rheumatism gouty
manifestations in the pharynx may be either acute or
chronic.
The acute form occurs in those of a llthfeniic diathesis,
in heavy eaters wdio indulge in hut little exercise, and in
those wiio have lead poisoning or renal changes. The
ontlireaks are more common in cold weather and follow
dietetic excesses, over-indulgence in wine, heavy mental
or emotional strain, etc. 3Iost of the patients are between
thirty and forty years of age.
So far as concerns ]iathology, nothing more than a ca-
tarrhal intlammatioii can be found. There is a patchy
hyiiera'iiiia with redness and (edema of the ])haryngeal
wall, possibly with swelling of the soft ]ialate and uvula.
The tonsils may be moderately enlarged and the larynx
congested.
The xjiiirptiiiiis are jiain, out of all proportion to the
apparent severity of tlie intlammation. irritable pharynx,
coated and flabby tongue, scanty and high-colored urine.
After a series of such attacks the teeth may ajipear large
from retraction of the gums and they have a yellowish ap-
pearance. Diagnosis must be made from rheumatism and
from simple neuralgia. Assistance is derived from the
presence of tophi or i itlier gouty manifestations elsewhere.
The pain may suddenly leave the throat and appear in
the joints, usually bearing the brunt of gouty out
breaks.
Treatment calls for the exhibition of colcliicum and the
use of local sedative washes, as for rheumatisiii.
In the chronic form of gouty pharyngitis we tind a
dark-red discoloration of the uvula, .soft iialate. faucial
pillars, and tonsils, the "angina uralica" of the older
writers. Occasionally an acute ledema of the parts is
added. At times the process localizes itself in the corner
between the iiosterim- and lateral pharyngeal walls, which
may be swollen and red. lu young patients the mucosa
may lie covered with mucus or muco-pus; in older pa-
tients it is more apt to be dry and glazed, with a network
of enlarged vessels or scattered livid spots. lu one case
there was a daily casting ofi: of lime salts from the mu-
cous follicles.
The syiniitoriis consist of attacks of sharp pain radiating
to the ears, irritable cough with the expectoration of
pellets of viscid mucus, intense throat irritabilit}', and
disordered gastro-enteric tract. Possible symptoms are
spasmodic obstruction of the nose (alone or "with coryza),
dysphagia, laryngeal spasm, modification of voice, and
rapid vocal fatigue. There is always a tendency to acute
exacerbations. The urine shows an excess of oxalates,
phosphates, and urates.
TrcatiiKiit comprises an antigont regimen and local
sedatives. The mineral waters are of esiiecial service.
One of the best local applications con.sists of menthol gr.
X., and terebene tti xv. in li(iuid paraffin.
5. SvPiiimTic IxFi,.\MM.\Tiox. — For information as to
present-day vii'ws of the nature of the syphilitic virus,
other articles in this II.\ndbooiv must be consulted. It
may be said in passing that acute and chronic inflamma-
tions of the jiharyngeal mucosa distini'tly jjredispose to
specilic infection.
The initial lesion may appear on cither the soft palate
or the tonsils. A chancre, more or less indurated, is pres-
ent with later erosions from irritation or ulceration.
There is invariably enlargement of the cervical glands,
and in due time eonsfitutional sym|itoms develop.
Erythema appears in from the sixth to the sixteenth
week or later. The mucosa on tlie lips, cheeks, tonsils,
uvula, soft palate, and posterior ])liar_yngeal wall has the
ap])earanee of passive congestion. The areas involved
vary in size from a pea to a penny. The erythema is
symmetrical ami shows a sliarp demarcation from the
surrounding tissue. This demarcation and symmetry are
strongly suggestive, for otherwise the mucosa appears
as if only (U'dinarily inflamed.
The mucous patch may occur at any time, though it is
generall}' one of the "secondary" manifestations. It
poisons the buccal secretions and is therefore especially
dangerous. The patches are ovoid and shallow, possibly
symmetrical, and represent areas with an exudate of se-
rum and a free supjily of im|ierfectl_y developed cells.
Without treatment these .areas and their surrounding
zones of tissue ulcerate and cicatrize, the cicatrix being
stellate.
The giunma ajipears in from five to fifteen years after
infection. Its favorite site is on the posterior surface of
the soft Jialate. This lesion rarely pas.ses over anatomi-
cal boundaries, that is. it does not extend directly in
front of the faucial ]iillars. above the pharyngeal tonsil,
or to the larynx. It appears as a ditfuse inliltration, may
form rajiidly. and may undeigo rapid destruction. It
may be nodular, in which case there is a bulging of the
superjacent nuicosa. There is an infiltration of the tis-
sues and vessel walls with small round embryonic cells
emliedded in a gelatinous basement substance. The mu-
tual crowding of these cells shuts off the blood supply,
and the whole mass breaks down into a cheesy consis-
tency surrounded by a zone of granulation tissue, which
later becomes fibrous. Abscess f(UTnation is rare. De-
struction does not pass beyond the confines of the origi-
nal deposit. Large areas may give way while bands of
fibrous tissue ]iass from one point to another, thus dis-
torting the parts. Fluids may therefore regtn-gitate into
the nose and the soft palate becomes adherent (rarely com-
pletely so) to the posterior ]iliaryugeal wall. The hard
palate may become involved and perforated and occa-
sionally a large vessel is eroded. Qumnrata are more
rarely alisorbed in the pharynx than elsewhere. Occa-
sionally the course is so acute that immense destruction
occurs in a very few days.
The sj/iiijitiinis of the initial lesion are painful swallow-
ing and enlarged glands, that is, nothing outside of what
may accomjiany an ordinary sore throat. The diagnosis
is often indecisive until cutaneous lesions appear. In
erythema we rind a jieculiar stiffness of the tliroat mus-
cles and painful swallowing. In the mucous patch there
is extreme sensitiveness increased liy all irritants and by
overuse of the voice. Nutrition may be interfered with.
596
REFERENCE HANDBOcMv OF THE JIEDICAL SCIENCES.
I'liaryux*
Pliaryux.
Frt'sli patches appear iu groups occupying, in order of
relative frequency, tlie soft palate and uvula, anterior
surface of auteiior pillars, tonsillar convexities, anil an-
terior surface of the posterior pillars. A patch on one
side ma3' bj' contact symmetrically reproduce itself on
the other side. A fresh patch is strougl}- suggestive of a
recent application of silver nitrate. A few cases have
been seen \vith a thick exudation suggestive of diphthe-
ria and attended with marked constitutional symptoms.
The nyiiijit'iiiiti of the gumma are mainly mechanical.
After ulceration has occurred pain maj' be severe. The
typical tertiar}- ulcer is deeply excavated with sharply
delined edges, surrountled by an angry red zone and cov-
ered with bright yellowish p>is.
The diagnosis of' the advanced lesions is not difficult :
but the same is not true of the earlier ones. At first
sight the patients may present nothing but the lesions of
an orilinary sore throat. A most careful examination
should be made, together with an investigation into the
po.ssibility of infecti(}n. All apparently simple catarrhal
cases not yielding to treatment must be regarded as sus-
picious, and also those cases presenting a persistent dys-
phagia without apparent cause.
Treatment must be prompt and energetic. Alcohol,
tobacco, condiments, and all irritants tnust be given up.
The tooth brush must be used regularly and foUoweil liy
rinsing with some w-eak antiseptic. If deglutition be ex-
tremely painful a weak cocaine solution may be used be-
fore eating. The patient must be told that lie is a poten-
tial source of danger to others, and strict hygiene in
every sense must be enforced. Local lesions should be
cleansed with an alkaline sjiray and dusted with ortho-
form, or argyrol (silver vitellin) may be applied in thirty-
per-cent. watery solution. For home use as a cleansing
agent we may order bichloride solution, 1 to 3,000, or black
wash. Each mucous patcli should be touched with sil-
ver-nitrate stick. Indurated areas may be painted with
a solution of bichloride, two grains, in sulphuric ether,
five drachms. On fissured ulcerations a ten-percent, so-
lution of iodoform in ether may be sprayed. Small pala-
tal perforations may heal under the combined effect of
constitutional treatment and the a]iplication to their edges,
thrice weekly, of mono- or trichloracetic acid fused on a
probe. Sometimes an obturator may be fitted, with ad-
vantage to the act of swallowing.
Constitutional treatment must be adapted to the ex-
isting stage of the disease (see article on Si/philis). De-
formities and stenoses must be treated according to the
requirements of each individual case.
6. Tuberculous I.\fi,.\mmation. — In the vast major-
ity of cases pharyngeal luberculosis is secondary to depos-
its in other parts of the body. The primary form is,
however, possilile, and forms about one per cent, of all
cases of acute tuberculous intlamuiations of the up]ier air
passages. As opposed to this rarity is the virulence of the
disease. Favorite seats of invasion are the uvula and soft
palate, especially the anterior surfaces of these structures ;
then come the tonsils, posterior pharyngeal wall, and hard
palate.
The general causes are those of tuberculosis in general.
The exposed position of the parts would seem to predis-
pose them to infection, but their constant movement in
normal function tends to clear away morliid material be
fore it has had time to iienetrate the tissues. Some au-
thorities believe that the saliva offers a distinct barrier to
the acclimatization of the tubercle bacillus, while other
forms of bacterial life, with which the oral cavity swarms.
are also inimical to bacillary growth. Infection may
come through the blood and lymph, through the inspired
air, and through foodstuffs.
The disease may manifest itself in two forms: (1) the
ordinary miliary tubercle; and (2) a papular lesion con-
fined to small areas, and especially apt to settle on the
anterior surface of the soft palate. In both the micro-
scopical picture is the same, viz., a small round-celled
infiltration of the connective tissue gradually extending
into the vessel walls. Then follow endarteritis, oblitera-
tion, cheesy softening, and ulceration. It is difficult to
find either bacilli or giant cells in scrapings from the sur-
face or in bits of tissue removed.
On insjiectiim we may note eithei- the miliary depo-sits
studding the mucosa and apjiarently sliining through it
as white points, or there may be the lai-ger jiapular
masses extending in the primary cases as a fringe of
small excrescences along the anterior pillars. After a
while these deposits break down into characteristic ulcers.
These may by their coalescence involve a large area. The
uvula becomes swollen, cedematous, and exquisitely
painful. Cases of perforation of both tlie soft and the
liard palate are on record. The general ajipearance of
other pharyngeal surfaces is one of anaemia due either to
the endarteritis or possibly to a toxic vaso-cou.striction.
The most constant sj/mptom is early and constant pain
in the affected areas. The palatal muscles are swollen and
stiff with resulting dysphagia. Food accumulates in the
pharyngeal recesses and may get into the nasopharynx.
Cough is present and the accunudation of saliva is exces-
sive. Speech is hesitating, but the voice is not changed
unless the larynx is involved. Later the cervical glands
are enlarged. If the process is coiifineil to the tonsils
the difficulty in swallowing is much less. Owing to the
latter symptom the patient is loath to take food, and the
emaciation incident to the constitutional malady is hast-
ened.
Diagnosis is based upon the characteristic appearance
of the parts and the coexistence of tuberculous lesions
in other parts of the body. Syphilis must Ije excluded
in doubtful cases by the results of treatment. The two
diseases may coexi.st. Tlie typical tuljcrculous ulcer is
shallow, with a surface flush with the surrounding mu-
cosa, with the same color, covered with ropy mucus and
possibly with a peria'dema; in cases complicated by
syphilis the ulceration is extremely sluggish, has a dirty-
looking secretion, and is but little painful.
The prognosis is as a rule bad, though a few recoveries
have been reported. The local condition is but one feat-
ure of a constitutional involvement. Healing of the
ulcerations will greatly conduce to the tolerance of liv-
ing, even though the constitutional deterioration goes
steadily on.
Every hj'gienic and tonic measure possible should be
instituted. Climate does not seem to be of much service
in pharyngeal tuberculosis. All sources of buccal irrita-
tion should be removed, the teeth placed in order, and
the food .should be pultaceous. The patient will often
find it easier to gulp food down than swallow it in the
conventional way. The jilan most in vogue at the pres-
ent time for treating the ulcers is to curette them thor-
oughly under cocaine and then rub in solutions of lactic
acid iu water, beginning with say ten per cent, and grad-
ually increasing up to eighty per cent., or even the pure
acid. The ulcerated surfaces shoidd be regularly
cleansed with hydrogen peroxide, then with a weak alka-
line .solution, and finally dusted with .some such powder as
aristol. Enzymol, a proteid ferment, may be substituted
for the peroxide. It is less irritating and just as eflicient.
Menthol in olive oil, twent_v per cent., has its advocates.
Jlorphine with cocaine or taimin may be cautiously ap-
plied, but the use of the first-named remedy .should be
avoided as long as possible. For the cough we may give
lieroin iu oue-twelftli grain iloses every three hours. Or-
Ihoform is here used as a local anodyne with great ad-
vantage. It may be dusted on with equal jiarts of stca-
rate of zinc or subcarbonate of bismuth. To insure its
contact as long as possible with the affected parts we
may use the excellent formula of Frendenthal, viz. : Men-
thol 10 gm., expressed oil of almonds 30 gm., j-olks of
two eggs, orthoform (13i gm.), and water to make 100
gm.
7. Actinomycosis op the Pii.\uynx. — This is an infec-
tious, parasitic, and inoculalile disease primarily attack-
ing domestic cattle, but comnumicable from them to man.
The original source of infection is grain. Bollinger says
that oats grown on uewlv ploughed laud are the main
carriers of contagion, but that rj'c and other grains are
at times similarly affected. In" man the infection may
597
Pharynx.
Pliarynx.
REFEREXCE HANDBOOK OF THE MEDICAL SCIENCES.
arise by iiKiculution Irdin animals, possibly from infected
cereal focidstntrs, iinil (Idublle.'iS often from the fnMjiient
habit of field workers of ehewing bits of hay, straw, etc.
Flies may carry the contagion. In one iustauce kissing
was the method of eonvej'ing the disease.
It is difficult to say just how often the pharynx is
affected, as reliable statistics (m this iioint arc lacking.
We may refer to the figures of J. Israel, who found that
out of five hundred cases the head and neck were involved
in fifty-five per cent, and the throat and lungs in twenty
percent. Figvires as to localization in the pharynx are
not given. In the latter site the disease may In' primary
or secondary.
The infcctin,g agent is an organism called the "ra}'
fundus." Its exact place in classification is still a matter
of dispute. By some it is called stveptothrix actiuomy-
cotica; by others, actinocladothrix. It appears in the
suppurative foci (hereinafter described) aggregated in
small masses of a yellowish color. It can be cultivated
in gelatin and more (pnckly in agar and beef serum. Its
favorite temperature is about 95' F. For examination a
bit of tlie suspected material should be smeared or teased
on a slide, carefully dried in a tlanie and then stained a
few minutes in a soluticm of iiicrocarminc. washed in wa-
ter or alcohol, and mounted in glycerin. Sections of tis-
sue arc handled in the same way and mounted in glycei in
or Canada balsam. The finigi ajipear yellow and the
remainder of the field led. Tlie actinomycotic lufts and
single nodes may be recognized, scattered about in the
field, and easily distingui.shable from the surrounding
red.
According to Leiiinanu ciuh of the yellowish masses
maybe subdivided into three zones: (I) An outer ziaie
made up of club-shai)ed, wedge-like rays with rouuded
bases appearing wlieii viewed in section to be set on star
fashion and surrounded by large cells or by cells seem-
ing to conuiiu fragments of the fungi in their substance:
<2) a middle zone made up of branching mycelial threads
(furcated) passing from the centre to tlie periiihery ; and
('■>) an inner zone maile u\t of cocci in chains. The
threads are the active portion <if the organism and the
])ortion ca|iable of artificial growth.
Certain observers have noted the presence of structures
known as Kainey's or Mie.schler's corpuscles. These are
cylindrical tube-like bodies and are supposed to be due
to the growth of the ray fungus inside muscniar tibrcs.
They are therefore r;it her a result than an essential ele-
ment of the process.
When once infection lias occurred extcusiou is probably
not through the lymphatics but by destruction of the
vi'ssel walls and the conseiiuent. easy access to the inner
organs by the blood stream. The accom])anyiiig glandu-
lar enlargement is due to the admixture, with the ray
fungi, of pus micro-organisms, notably the streptococcus
pyogenes aureus.
Undoubtedlj- the mouth is the most frc(iuent jiortal of
infection; especially the alveolar processes of Ihc lower
jaw. Israel has found the fungi in the lacuna' of healthy
tonsils, but they are harmless in the absence of solution
of tissue continuity.
The first manifestation of infection is generally a peri-
osteal abscess running the usual cour.se and leadiug in
about six weeks to true periostitis. The surrounding
ti.ssues are invaded, and suppuration aiipears between
the chin and the hyoid bone, produced, belt remembered,
noi by the fungi but b_y juis cocci. Other cases begin as
a gingivitis with spongy gums and alveolar stomatitis.
From the foregoing sites the lesion attacks localities far-
ther back, notably the pharyngeal wall. The tonsilsand
palatal arches are but rarely involved. Not infreciiicntly
the cheeks suffer. When once the pharynx becomes in-
vaded, either primarily or secondarily, we note small
reddish elevations looking not unlike a subacute pliaryn-
.gitis upon a mucosa previously the seat of chronic
changes. The adjacent tissues swell and then seem to
lose their appearance of acute inllammation. becoming
more like a zone of chronic infiltration, irregular in sur-
face and firm to the touch. Suppuration soon appears
with the development of angry-looking sinuses with un-
deriuined edges.
Aside from general pliaryngeal discomfort, there are
no li/nil xyiiijit'iiiix ; actual jiain is not constant. Later,
comes the general deterioration due to the suppuration,
but it is not accompanied by any special features. The
characteristics, therefore, of the disease are: (1) The re-
markable extension and induration of the parts; (3) the
slow dra.gging course of the inflammation ; (3) the exten-
sion of the process to the surface, after the lapse of sev-
eral inonlhs, by a .softening and final spontaneous evacu-
ation, the inis being sero-sanguiuolent ; and (4) tlie (|uick
healiii,g of the local focus with apparently a favorable
outlook, but the appearance of the infection in the neigh-
borhood, or at a distance, with fresh vigor. Fatal symp-
toms are always tardy in development.
/>(Vf,v»«*(s is called for from syphilis and from malig-
nant disease, especially sarcoma. Sections of the latter
may present apj^eaiances which strongly suggest actino-
mycotic tissue, but in the latter the microscope will re-
veal the raj' fungi.
Trriitiiient calls for radical excision if this is possible.
Inlernalh', large doses of the iodide of potassium have
been given, anil have ajipareutly cured some cases. The
internal use of silver nitrate has also been advised. Near-
ly every antiseptic has been used locally, but there is
no specific. Without doubt bichloride is as efficient
as anv.
8. "Gi,.\ndeks. — Glanders is a disease primarily affect-
ing horses, and may be communicated from them to man
and from one man to another. The exciting agent is the
Bacillus mallei, resembling morphologically the B. tuber-
culoses, though somewhat shorter and thicker. Infection
may be conveyed from an infected animal b.y the fine
spray of coughing <u' sneezing, or by the handling of ar-
ticles used about the animal.
In man the nasal structures are generally the jiortals
of infection, and the process extends to the pharynx.
It begins Avith evidences of a low-grade inflammation, and
changes with the formation of granulation tissue con-
taining the characteristic bacilli in swarms. Suppuration
soon follows along the avenues of lymphatic distribiilion.
Pus intoxication rapidly develops, the supiniration show-
ing a distinct tendency to burrow. Cartilage and Ijone
may be attacked.
The ttymptomx are those suggested by an area of local
infection. Following the latter we liave. within a few^
days, pain and swelling with degenerative changes.
When the pharynx liccomes affected we have inter-
ference with deglutition and phonation. There is a
breaking down of the cervical submaxillary and sub-
lingual glands, with occasional fistula' o]K'ning exter-
nally. Finally, the general picture of scptica'inia de-
velo])s.
In these days of early examination of all susjiicious
discharges there is not much danger of overlooking a
case of acute glanders, but there are cases in which the
only evident changes are those of a subacute pharyngeal
catarrh with variable p.-iin, slow glandular involvement,
and indefinite and remitting constitutional symptoms.
The pharynx shows reddened elevated areas, over whicli
are scattered small undermined ulcers from which dirty
pus exudes. At first the pharyngeal functions are not
greatly hanipi-red. but increase of the infected areas may
mechanically block the breathing and food channels so
that death follows from general exhaustion.
/)/((_»///.»/.< is called for especially from the destructive
lesions of syphilis. A history of possible glanders infec-
tion will of cour.se put us on our guard. This we sup-
plement by the dcteetion of the Bacillus mallei. Some
of the chronic cases have been mistaken for ulcerating
sarcomata; in such doubt inoculation tests should be
made.
The acute form of the disease is raiiidly fatal. The
use of mallein. an artificial ]irodiict from potato culture
of the Bacillus mallei, may be used for purposes of diag-
nosis, as it gives a reaction similar to that of tubercu-
lin. Its curative properties are slill sub judici, but in
598
refere:sce handbook of the medical sciences.
Pliaryux.
Fharjux.
Yicw of tlie gravity of the situation it slioukl aUvays be
trii/d. No positive nieaus of cure is at present l;no\vn.
Supporting treatment merely retarils llie inevilable end.
Some of llie clirouic cases are said to have ended in
recovery, but tlie vast majority have been fatal within
two years. In these cases treatment should consist of
thorough curetting of the infected area, the use of anti-
septic washes, and the administration of strychnine and
iron in full dosage. Some authorities recommend the
pushing of the iodides as in tertiary syphilis.
y. Retropharyngeal Aisscess. — ■ These cases arc
often overlooked, because no digital examination is made
of the pharynx, tlie observer contenting himself with
mere inspection. The affection should always lie sus-
pected in a child with difiiculty in breathing and swal-
lowing without apparent cause.
The jihlegmon forms in a tlat shallow cavity behind
the iihaiynx and tesophagus, limited posteriorly by the
spinal aponeurosis and anteriorly by a connective-tissue
sheath. Its lateral boundaries are sheaths which stretch
from the aponeurosis to the lamellar spinal sheaths.
Above is the basis cranii, and below, the mediastinum.
The contents are sympathetic ganglia and lymph nodes
receiving drainage from the neck, nasopharynx, and
jiharynx. Externally are important vessels and nerves.
'I'he above is the most frequent site of the abscess, but
lateral sites are pos.sible: many of the latter are doubtless
but •• pointings" from a central focus.
Tlie intlanunation begins in the lymph nodes and ex-
tends to the cellular tissue. It may, liowever, begin in
the latter from irritation, as from instruments or a foreign
body. In children in whom the disease is far more com-
mon than in adults, infection may come from such condi-
tions as otitis media, erysipelas, pharyngitis, etc. An
antral empyema is recorded as the cause of one ease. In
childri'ii of the tuberculous, .syphilitic, and lymphatic
(liatlieses, there is always a lessened resistance to infec-
tion, and it is in just such children that the malady is
most common.
In infimts the first symptom may be refusal of the nip-
ple ; then follow a metallic cry, dysphagia, and dy spna-a.
In older children there is the usual sore-throat symptom
complex, and inspection may at once reveal the nature
of the trouble, hui jjalpatinu s/n^iiM iicrcrbe oiiiitteil. This
:nay reveal a soft, boggy tumor, which pushes forward
the soft jjalate, and in whicli iierhajis fluctuation may
be felt. Lateral cervical swelling is also ])ossible.
The main danger (nevious to rupture lies in possible
laryngeal a?dema with bulging of the entire larynx for-
waid.and consequent asjihyxia. Burrowing may lead
to inliltration of the cervical tissues and death from sep-
sis. The most common danger is ru|pture during sleep,
escaiic of the pus into the lower air jiassages, anil speedy
asphyxia.
Pus accumulation may occur within twent_y-four hours
after initial symptoms: other cases may last several
weeks, or even several months if they are tuberculous in
origin. Diagnosis is called for from coryza, tonsillitis,
croup, and even diphtheria.
Immediate evacuation of the pus is necessary. The
child must be held in a good light with open mouth, a
gag being u.sed if necessary. With a protected lilade an
incision should be made from the middle of tlie fluctuat-
ing area to its bottom. Imineiluiltlji after iiicim'oii, tlie
eliild ir/iic/i has been held iriih its hc<id foncavcl should he
innrted.ia as to allow the pus to run out of the mouth.
Meanwhile tl:e finger which was in situ directing the
incision, should be passed into the sac so as thoroughly
to oiien it and thus prevent refilling. Lateral ])ressure
of the pus will direct the large vessels initward .so that
there is little practical danger of injuring tliem. In one
case sudden death occurred as the incision was made.
Q^lema of the glottis was not present, but the pneumo-
gastric nerves had been stretched by the pressure of the
pus. Death was ascribed' to reflex syncope. In cases
with much cervical swelling lateral incision from the
outside has been suggested. Some have even recom-
mended this procedure for central lluctuafion, the escape
of pus into the lower air passages being thereby pre-
vented.
10. Pharyngeal Mycosis. — Over one hundred organ-
isms are found in the healthy mouth. The most common
are the oidium albicans, actinomyccs, aspergillus fumi-
■gatus, bacillus fasciculatus, the fungus causing nigrities
lingu;ie or "black tongue," and various species of lepto-
thrix. By common usage the term pharyngeal mycosis,
when used without moditication. refers to the alfection
characterized by the growth of the leptothrix. It was
first described by Fraeukel in 1873, receiving the name
nnxosis tonsillaris benigna. It occurs on the tonsils,
tongue, pharyngeal wall, faucial pillars, epiglottis, and
rarely in the nose, nasopharynx, and larynx.
The fungus clings to the epithelia and often prefers a
healthy to a diseased surface, above which it appreciably
projects. It is of horny consistency and is removed with
ditticulty. Threads may connect the isolated deposits so
that the general appearance is that of roots Avith running
tendrils. If a portion be teased out and examined in
glycerin under the glass, we note a mass of epithelia sur-
rounded by irregular granules in which are embedded the
spores of various species of leptothrix. These spores are
arranged in link-like processes, their ends being rounded
or club-shaped. The processes vary in length, and may
be curled up at the ends in liair-like filaments. Besides
these bodies there are round or oval, highly refractive
bodies arranged in colonies or scattered among the
branching spores. The link-like processes are the myce-
lia of the fungus, and staining with methyl blue will
show alternating colored and uucolored segments. The
fungus has never been cultivated outside the human
body.
As clinically seen the afTection follows previous phar-
yngeal inflanunatiou, tleposits of tartar on the teeth,
altered reaction of the buccal fluids, disordered digestive
states, etc. There is no reason to believe that rheuma-
tism or gout has any direct causative relation. Inci-
dentally it may be said that the same fungi have been
found in fcetid bronchitis, ti'acheal ozscna, pulmonary
gangrene, rhinoliths, tonsilloliths, vesical calculi, the
tongue coating of low felirilc states, in the lachrymal duet,
intestines, vagina, and fa'ces. At any site they may pre-
cipitate lime salts from thuds holding the same in solu-
tion.
In 1895 Siebenmann advanced a different view as to the
nature of the familiar jjliaryiigeal mycosis, claiming that
it was essentially a hyperkeratosis of the mucosa. All
tonsils exhibit this in a varying degree, and this collec-
tion of hyperkeratosed epithelium is a constant menace
to the integrity of surrounding structures.
The s//mptoieis are pharyngeal dysa>sthesia, cough, difti-
culty in swallowing, sensation as of a foreign Ijody, and
occasionallj' reflex pain in the larynx. Possibilities are
fever, enlarged submaxillary glands, and congestion of
the palate and uvula. Periods of Improvement and re-
lapse succeed each other without an_y treatment whatever.
The affection is in no wise dangerous, and it alarms pa-
tients out of all proportion to its gravity.
Trefitiiient. — In treating a case the teeth must be placed
in proper condition, the digestion regulated, and for a
time at least all sweets must be cut oft. Climatic changes
may give surprisingly favorable results. Nearly e\'ery
caustic has been suggested for the destruction of the roots
of the fungi ; mere superticial clip ping off is useless. The
only reliable measure is the use of the galvauo-cautery
liluugcd into each crypt harboring a root of the fi'ngus.
If tlie cautery is unavailable, chromic acid fused on a
probe will answer. .lauies E. ^eireumb.
PHARYNX, DISEASES OF
Air I'assar/e^ ete.
FOREIGN BODIES. See
PHARYNX, DISEASES OF: MALFORMATIONS. DE-
FORMITIES. AND NEW GROWTHS.- ■nir,..nsi, Illation
of this subject luilurally reciuiics its division into two
parts: (1) Malformations and Deformities; and (i) New
Growths.
599
Pharynx.
Pliaryux.
REFEUEXCK HANDBdUK OF THE MEDICAL fSCIEXCES.
1. Malformations and I/KFOiiMiTiEs.
Tlioie are two kinds of iiialformiitions wliicli afl'cct flic
jiliarviix — stenoses and dilatations. \Vc will take up
these subjects in the order named.
Stenoses may be con.tienilal or iioslnalal. and tliey may
be incomplete or complete. Complete stenosis or atresia
is accompanied by pocket-like (lil.-itations or ])Ouches.
These nialfi^rmations are to Iieascribed to iiniialalanom-
FlG. 38o:i.— niapbnijjia of the Pliar.vnx. (Case of Dr. S. S. Blsbop.)
alies of development. Thi' constrictions are most often
found in that part of the ]iliaryn.\ which lies adjacent to
the cricoid cartilage of the larynx, hut they have been
met with also in the upper jiart of the idiaryn.x. at the
junction of the oral ami nasal |iortions of this cavity.
The lower constricliou apiiearsas a riu,i;-likeseptvMn of
mucous membrane, wliicli may reiliice the calibre of the
tube by one-half or more of its diameter, and cases of
complete atresia havi' lieen reporteil. Fortunately, these
stenoses may ccisl without bein.!;' prodiictiveof sulfering
soiling as they do not become the seat of an inllamma-
tory pidcess.
The palatal, or lii.yh, stenosis is I'nrmi'd by a meniliraiic
which stretches from the soft palate backward and out-
ward to join the post<'rior anil lateral walls of the
l)haryn.\. Cases of diaidira.ain of the jiliaryJi.x resulting
from scarlet fever, sucli as the writer has reported, and
syphilitic adhesions, may be mistaken for congenital ste-
no.ses, lint a close examination may revival scar tissta.',
wliich is indicative of a |ircviiius inllammation.
Postnatal malformationsare the res\dt of twoclasscsof
causes; intrinsic and extrinsic. Intrinsii' causes, or those
which have their origin in the pharynx, .arc such .as sc:n-
let fever, lupus, syphilis, di)ihtlieria, and traumatisms.
Extrinsic causes, or those wliich o|ierate rmm witliout
the pharynx, are in the nature of difcirniilirs of the
s]iine, tumors, anil abscesses.
Intrinsic stenoses are most often due 1o syiiliilitic ad-
hesions which spread out above the oral pharynx and
connect the posterior phar3-ngeal wall and posterior col-
umns of the fauces with the soft palate. Thediaiihragin
thus formed may be partial or complete. Tlie appearance
of this adventitious tissue, and the presence of suggestive
scar tissue, together with more or less inflammatory ile-
struction of the adjacent soft parts, will simplify the
diagnosis. The dilferentiatiou is still further facilitated
when |ierforations of the hard i)alate ;ue present, for
these seijuels are particularly characteristic of syphilis.
Sypliilitic membranous adhesions are sometimes found
connecting the pcsterior pharyngeal wall with the ba.se
of tlie tongue, or a syphilitic stenosis may be formed at
a iioint opposite to the cricoid cartilage of the larynx,
wiiiM'e the congenital stricture is most often located.
These membranous diaidiragms are perforated, and. like
the prenatal stenoses, the_v maj' cau.se little or no incon-
venience so long as tlicy are not involved in any inflam-
matory action, and they arc not jirone to such attacks.
Scarlet fever is sometimes responsible for these mem-
branous obstructions. Such a case was reported, with
an accompanying photographic illustration (Fig. 3803),
by till' writer in fsys.* The subject was a young lady
who had had an attack of scarlet fever when she was a
small child. The age at which she was sick could not be
ascertained. The nasal ]iharynx was found to be sepa-
rated from the oral portion by an adventitious membrane,
which extendeil from the posterior columns of the fauces
and the arch of the soft palate downward laterally and
backward to the lateral and posterior walls of the
pharynx opposite to the base of the tongue. Its general
direction from the palatal attachment, instead of being
nearly horizontal, closely approximated a vertical plane.
In the centre of this ilia]ihragm was an oval o])ening. the
long diameter of which was vertical. Thriaigh this per-
foration the iiosterior wall of the pharynx was visible,
and nasal respiration took pl-ace. The patient com|)laineJ
of no serious inconvenience resulting from this anomaly.
excc]it that food wotdd lodge behind the membrane and
demand her attention to wash it out so as to prevent de-
composition and its results.
Suppurative processes of the pharynx in the course of
other diseases may produce anomalies similar to the one
which 1 have just described. Such diseases are diphtheria,
smallpox, lujius, and erysipelas. lu such instances the
pharyngeal symijtoms become very prominent ami dis-
tressing during the inflammatory stage. The constitu-
tional disturbances arc pronounced, the cervical .glands
may be involved, the difliculty of swallowing is marked
ami becomes evident to the patient's friends. Inspec-
tion of the tliroal reveals the cliaracteristics of an intense
degree of inflammation: redness and tumefaction of all
the surfaces involved, (edema of the soft palate and uvu-
la, and, in the advanced stage, suppuration and ulcer-
ation. These characteristics of inflammatory affections
which eventuate in piharyngeal steno.ses should put the
practitioner on his guard a.sainst such results.
Traumatic causes of pharyn.geal stenoses are in the na-
ture of scalds, such as the a<-eidental drinking of hot
liquids liy children, and the chemical action of caustics,
such as carbolic acid, iiota.sh, etc.
TrenUiient. — The treatment of stenoses of the pharynx
may most conveniently be considered under twolieadiugs
— general and local. In the case of syiihilitic adhesiims
general treatment should tirsl be instituted, and should
consist of the exhibition of the iodides and mercury ac-
cording to the princi])les laid down in the article on
syphilis. The local treatment formerly consisted of sys-
tematic dilatations by means of graduated bougies, but
the tirm, tilirous character of the membrane does not lend
itself encouragingly to this method of treatment, for the
stenosis returns after the dilatations are discontinued.
The knife also was much in vogue in early days for the
eradication of these anomalies, but we now have, in the
electric cautery, a much safer and more certain means of
removing adventitious tissue.
*Si'e "Diseases of tbe EaY, Nosi', and Tliniat, and tlieir Accessory
Cavities," by S. S. Bisbop, ~d edition, p. JIG.
«j(-l()
liEFEKENCE HANDBOOK OF THE .MEDICAL SCIENCES.
I*liiir} nx.
Pharynx.
A ]iraetically bloodless and painless operation is possi-
ble hy means of the electne-cautery dissection after the
application of suprarenal extract and cocaine to the held
of operation, as follows: A fresh or preserved saturated
solution of the su])rarenal gland is applied to the per-
iphery of the membrane which is to be removed. The
writer reverses the method usuall_v employed in the ap-
plication of suprarenal solution and cocaine, and applies
the .suprarenal preparation first for the following reasons:
If the blood-vessels of the tissues to be operale(l upon are
first contracted, the blood current is so far diminished in
volume as to reduce toa minimum the amount of cocaine
that is taken into the circulation. Hence there is less
liabilit}' to the to.xic manifestations of cocaine, Jlore-
over, when it is possible to contract the tissues before
applying cocaine to them the ano'sthetic penetrates rela-
tively deeper and produces a more jjrofound degree of
ana'sthesia. By observing this rule of i^rocedure it is
possible to employ a stronger solution of cocaine tiian
would be safe if the order of ajjplication of the remedies
were reversed. I liave demonstrated the importance of
these facts in a long series of operations.
Cocaine shoidd be applied to the surfaces to be severed,
not by means of a spray, but by the cotton applicator,
care being taken that the siu'plus of the cocaine solution
is expressed from the cotton pledget on the carrier before
the application is matlc. This is necessary in order to
prevent any excess of cocaine from running down into
the larynx or the oesophagus. Strong solutions of this
very tiixic remedy must be either avoided, or employed
in the ])barynx with the greatest caution. For the sake
of emphasizing this statement it is excusable to cite a
case winch was brought to the attention of the writer by
a former clinical assistant. He was about to operate on
a patient's throat after having applied cocaine, but be-
fore lie began the operation alarming symptoms de-
veloped, and the patient suddeidy expired in Ins eliair.
It nuist be kept in mind that in lliese tlniiat ojierations
an extensive siu'face must be cocainized, and that, tliere-
fore. a large amoimt of the drug may be absorbed. The
writer has seen numerous cases of collap.se and acute
mania result from its employment in operations wlicre
the surfaces requiring auasthesia were of much smaller
area, but these unfortunate manifestations were probablj'
due to the use of sprays that medicated oilier p;irts, in
addition to those which were operated upon, I believe
that sucli accidents can be avoided by the use of weaker
ineparations than those commonly employed, since they
are often of twenty or thirty-three per cent, strengtli, and
by takhi.g the precautions alread_v advised. The writer
attributes to these reasons the fact that he has never had
any such distressing experiences as those mcntioni-d
above. It is better not to apply to the pharynx solu-
tions of cocaine stronger than from four to eight per
cent. I speak in detail of these matters here in order
to avoid repetition in treating of pharyngeal procedures
under local ana-sthesia later. The operation, after co-
cainization, consists of passing a bent electrode, at a
white heat, through the periplieiy of the ol)structing
tnenibrane, carrjing the electrode, as it burns its wa.v,
throughout the whole circumference of the diaphragm.
Care must be exercised not to encroach upon thi^ sur-
rounding tissues, which we do not wisli to attack. After
the membrane has been thus severed, if any hemorrliage
occurs, tlie suprarenal extract must again be ainilied;
but if the electrode is properly used and isiiot allowed lo
cool before being removed from the tissues, little or no
hemorrhage follows.
It is advisable lo keep the patient under observation
for a few hours after the operation in order to anticipate
any secondary bleeding that might occur. Should any
tendency to the formation of exuberant granulations a|i-
pear, they may be suppressed by the application of tlu'
silver-nitrate pencil. If a ten-percent, solution of this
remedy be painted over freshly operateil surfaces, then-
is far less danger of hemorrhages, and tiie desired efleets
of the operation are enlianeeil.
Little in addition need lie said regarding stenosis due
to lupus, but the present indications are that we are
justified in expecting beneficial elfeets from the J'-ray
treatment.
Extrinsic causes of pharyngeal stenosis may consist of
tumors, such as an aneurism or a goitre, or the cervical
portion of the vertebral column may be ileformed or dis-
eased, or a retropharj-ngeal abscess may encroach upon
the lumen of the cavity; but the treatment of these con-
ditions obviously does not lie within the limits of this
article.
Pilatatiou of tlie pharynx may affect the whole, or
only a part, of the cavity. It generally exists in the
form of a pouch, whieli is comparable to the aneurismal
distention of an artery. Tlie congenital variety is to be
attributed to an intra-uterine devekipmental anomaly.
The acqtiired, or postnatal, form iirobably oceui's in
consequence of an imperfectly developed, or weakened,
area of the tunic of the pharynx, whieli yields to undue
pressure. Contributtiry to these causes are the habits of
improperly masticating fooil, and a hasty manner of forc-
ing large and irregular boluses of food down the gullet.
It is eas}' to coneei\e tliat these repeated distentions of
the pharynx tend to carry tlie mucous membrane between
the surrounding muscuhir fibres, esiiecially where the
latter may be weak or defective, A pouch so formed
may continue developing until it becomes several inches
long. It is most likely to be found extending downward
and backward between tlie vertebra- ami the n-sophagus.
Generally this diverticulum consists of the mucous and
submucous coats of tlie pharynx, but it has been found
to be enclosed in the tesnpluigeal cellular membrane.
Gceasionallj- these pouches extend to one side, and are
suflicicntly prominent to appear as a tumor in the side of
the neck.
The most prominent and constant symptom is a diffi-
culty in swallowing. Food lodges in the pouch and
forms a temporaiT tumor, which obstructs the act of deg-
lutition, until tlie iioueh is eni|itied automatically or by
the patient. He generally learns, however, tliat by digi-
tal pressure and manipulatiou of the tumor he is able to
express the contents and enjoy relief. Unless this isdone
the imprisoned food ma.y de<'ompose and set up an in-
tlanimatory condition. Indeed, such an infianimatory
process has given rise to the formation of adhesions
which have resulted in a closure of tlie .sac and a conse-
(lueiit permanent cure. But a less fortunate terminatiou
of such an inllamniation may be the occurrence of slough-
ing of the surrounding tissues.
Other distressing symptoms arising from the ejection
of food retained in the poueli are in the nature of an irri-
tation of the lower respiratoiy tract. For example, the
emi)tying of food into the larynx occasions violent
spasms of coughing, and some jiarticles may even reach
the bronchial tubes and cause attacks of bronchitis or
pneumonia.
The diagnosis of this condition is made with compara-
tive facility. The obstruction to swallowing, the tumor
which disappears and recurs, or whieli can be dissipated
by pressing out its contents, the ejection of undigested
food in the absence of actual vomiling, the cnlrance of
particles of food into the larynx sub.se(|Ueiitly to, instead
of during, a meal, together with the results of an exami-
nation with the throat mirror and digital exploration,
atlord a mass of evidence that is of a palbogiKJiuonic
character,
"Vliv pronnosisisnoi a cheering one. Without o]ierative
interference the condition is rarely corrected. In an oc-
casional instance an iutlaniniatory process is instituted
which eventuates in a siiontaneous closure of the pocket
and a resulting cure. But tlierc- is always the danger of
retention and putrefaction of foml. In some cases pa-
tients must needs subsisl on a lluid diet in order to avert
such results; but in conditions lliat lend tlu-ni.selves fa-
voralily to operative measures the anomalies may be cor-
rected.
Tmitmcnt. — We may best consiiler this subjr-ct under
two division;? — ])alliative and curative. Palliative treat-
ment restsmainly with the patient. Byavoiding hurried
601
Tliai-yiix.
Pliaryiix,
HEFERENOE HANDBOOK OP THE MEDICAL SCIENCES.
fating audiniix'if Oct. mastication lie R-niovcs tlic piincijial
cause of acquiretl pliaryngeal jiouclics, for it is tlie forc-
ing of boluses of food tljrougli tlie cavity tliat distends
tlie mucous coat of the pharynx and puslics the mem-
brane between tlie fibres of ils muscular lunie. After a
meal during which ingesta enti'r the ])ouch lie sliotild
mani])ulate the distended sac with his tingers until it is
emptied, and he may even be able lo wash it out by
means of a pro]u'riy curved syringe. I3y Ibis means the
fermentation and decomposition of retained food may l)e
prevented.
When the diverticidum is situe.ted at the side of the
neck the patient may iie alile to iirevent it, from tilling if
he will press upon it with his lingers, or if a compress be
worn over it at meal time. If these means do not suHice,
and if the symptoms become urgent, it may become nec-
essary to resmt to an ojieration.
O/icriitiir Treiitiiifnt. — The simplest and most promising
measure of this nature consists in the aiiplication of the
■electric cautery to the periphery of the pharyngeal mouth
of the sac. Cocaine shoidd lirst be apidied to the field of
operation, the surgeon being careful to observe the pre-
cautions already mcntioneil. After this iireparation for
the adhesion of the adjacent borders of the pouch rectal
alimentation is resorted to for a few days. In certain
cases it may be necessary to operate after the methods
cinplo_yed in ]iharyngotomy or O'sophagotomy, suturing
the edges of the divided mucous membrane to hasten
recovery and insure the subsequent integrity of the
pharyngeal cavity.
II. New Growths.
NeopUi.sms of the ]iliaryux will bo considered under
the following classitieati(m:
1. Epihla.itie mid tnipohUialic,
Papilloma
Adenoma
Cystcima
Carcinoma
;.'. Mi-»>lilfisfic.
Filn-onia
Lipoma
Angioma
Sarcoma
Fortunately the pharynx is not so often the seat of neo-
plasms as are the nose and some other areas; but when
growt'is do o<eur in the pharynx they give rise to war-
ranted apprehension, even if they are of a benign nature,
since, as Viichow has observed, they may take on a ma-
lignant character. More particularly is this true of tu-
mors situated, as these are. in a passageway which ren-
ders thiMU subject to freipiently rejieated disturbances
and irritation. A still further important consideration is
the hindrance which they may cause to the acts of swal-
lowing and breathing, and theconse((nent imjiairment of
nutrition and deticient oxygenation of the blood. To
these genuine reasons of anxiety may be added the ten-
dency to recurring attacks of inflammation to which
these growths jnedispose the subject, and the proueness
■of the intlammatory process to invade the larynx and
lungs.
Papii,lom.\. — This is an epithelial tumor of a lienign
character, wdiich occurs less frequently in the idiaryux
than in the larynx and mouth. The structure consists of
■epithelial c<'lls, with a framework of connective tissue
beneath the epithelial ]iroliferatiou. AVithin this tissue,
and septirated from it by the mendirana propria, is the
vascular area. AVhat has bo-n said nlative to the trans-
formation of innocent tumors into malignant ones a]iplies
with especial appiropriateucss to liapillomata, since no
other growths are so likely as these to umlergo degenera-
tion. Add to this fact the cxiiosed situation in the
pharynx and the frequently repnited irritation to which
their location subjects them, and all of the conditi<ins
fa^'or their malignant transformation. Aside from the
jiillars of the fauces and the tonsils, the most common
location of iiapillomata in the pharynx is the posterior
wall. The_y vaiy in size from a hemp.seed to a cherry.
Tho (ling nosin itf ]iharyngeal iiapilloma ordinarily pre-
sents little or no dilllculty, jiartieularly when no intlam-
matory process is present, lint since they are often as-
sociated with an inflammatory condition, or follow it, iu
such cases there is room for doubt. Then a section
shoidd be taken from the base of the tumor, or tumors if
they are multiple, for a microscopical examination. The
growths have a warty or caulitlower shape, and are of a
pale jiink or gray color when not made red by irritation
or inflammation. Their glistening appearance is due to
tiic rcllectiou of light from the secretions which moisten
their surface.
Unless they attain to a considerable size they do not
]irovoke any symptoms sulliciently marked to call atten-
tion to their presence, such as a sense of a foreign body
in the throat, or impeded deglutition or respiration.
The y»w/«(«/s of papillomata of the pharynx is favor-
alile, provided that they ilo not undergo a transforma-
tion into carcinomata or sarcomata. They rarely become
larger than a small-sized .grape, and .so long as they remain
of an innocent nature no suli'eriug is experienced.
Trciitiiii'iil. — Treatment consists in extirpation and cau-
terization of the seat of attachment. This is best effected
by means of the electric cautery, which accomplishes both
purposes at the same time. Or the tumor may be severed
close to the surface from which it springs, by means of
the scissors, knife, or the cold snare; but the base shotdd
be well cauterized afterward either with the electrode,
or the silver nitrate, or one of the other chemical caustics,
in Older to lessen the likeliliood of a regeneration or de-
generation of any tumor tissue which may remain.
Adf.nom.x. — True adenoma does not occur in the
]iharynx proper. Adenoid vegetations in the ua.so-
phiuynx are discussed under the heading of Tcii-rili.
(.;vsTo.\i.\. — The true cystic tumor, or that in which the
wall of the cyst is ]iroduced from a matrix of embryonic
cells, and the products of tissue proliferation of the cells
lining the cyst wall constitute the contents of the sac, is
rarely, if ever, met with in the pharynx. Retention
cysts, however, occur as the result of an intlammatory
process, which causes a stenosis or closure of the duct
leading from a glanil, with the result of distending the
duct, as the glandular secretions accumulate liehiiid the
stricture until the consei-[Ueut tumefaction becomes ap-
parent. The continued accumulation of the contents of
the sac causes sullieient jiressure on its walls to account
for the degeneration of its epithelial lining and for the
atrophy which is present iu tlie attenuated memlirane.
These cysts are generally found in adult life, or in those
wdio liave passed the meridian of life.
Tnntmciit. — .V simple and cll'cctive method consists in
opening the sac an.l destroyii^g its walls. This may be
accouqilished by an electrode, which serves the doulile
jivu'pose of dividing the wall and destroying the cyst
after the contents escape. Or the opening may l)e made
with a knife, after which the walls of the sac are de-
stroyed by a curette. Then the parts had best lie treated
with tincture of iodine or a tcn-pei-ccnt. solution of silver
nitrate.
C'.\KClNo.\l.\. — When cancer exists iu the pharynx
]iro]icr it is generally either secontlary to the same affec-
tion of adjacent tissues, such as the tonsils, the soft palate,
the (esophagus, or the larynx, or it is associated with
such an affection: and as diseases of these structures are
considered in other sections, in order to avoid repetition
the reader is referred to their ])id|ier headings.
FiiiinntA. — Fibromata are found in various parts of
the ]iliarynx, but they are more common to the nasal por-
tion than to the oral division of the cavity; and they
more frequently spring from the basilar process of the
occipital bone. A fibroma is a reiiresentativc tumor of
the me.soblastic lyjie. Like the submucous ti.ssue from
wdiich it takes its origin it is a connective-tissue growth,
and is the offspring of a highly vascular area. It is
made up (jf mature tibrous tissue from a matrix of fibro-
blasts. The growth of tliis neoplasm is always slow, and
frequently there is a tendency toward a myxcuuatous de-
generation, or it may undergo transition into a sarcoma.
As it is most often .seen in the superior portion of the
pharynx it is pear-shaped (Fig. 3t<(i4), but it may be ses-
sile, and it is a product of youth rather tliau oi old age,
•602
liKFEREXCE HANDISUUK OF THE .MEDlL'AL SCIENCES.
Pliarj iir;.
I»Uarju.Y.
1
Fig. otiOl.— FiViroma of the Pharynx.
fur it is rarely eucountfred above tlic auc of tliirty or
forty years.
Tlie xi/iiiptoms rcfcraljle to iiharyiigcal libroniata are
(leteriiiiiied by tlie position aad size of tlic tumors. Lo-
cated ill I be upper or nasal jiortiou of the pliaryux they
interfere with nasal respiration and impair the resonance
of the voice. They some-
times attain to enormous
proportions, extending
forward into the nasal
fossa?, crowding forward
the nasal and orbital
Ijones, jirotnuling and
separating widely the
eyes so as to constitute
tlie tmsightly deformity
known as " frog face," and
giving rise to persistent
lieadache. Extension of
the growth upward causes
encroachment on the cra-
nial cavity, evoking cere-
bral symptoms. If the
direction of tlie tumor is
principally downward it
causes frequent efforts to swallow, and it ina\' pro-
duce sutlicient pressure on the soft palate to impede
its movements in speech and deglutition. When it
readies the aperture of tlie larynx it may even threaten
sutt'ocatioD. Moutli-breathing is a prominent symjitom,
and hemorrhages frequently occur as tlie tumors are ex-
ceedingly vascular, linjiaired respiration, mental torpor,
and ■' thick speech " characterize large growths ; and when
pressure is produced on the orilicts of the Eustacliian
tubes, the proper ventilation of the middle ears is inter-
fered with and the liearing becomes defective. Acopious
mueo-purulent discharge is sometimes present.
The diagnosis of fibromata is not attended witli serious
dilKeulties. Their occurrence in young pensons and their
slow growth are characteristic. From mucous polypi
they are recognized by their firm, dense substance.
They are distinguished from adenoid growtlis in the
vault of the pharynx by the soft, spongy, lobulated ap-
pearance of the latter and their occurrence in the very
young (}nly. Fibromata are dense, smootli, and of a
dark red color.
Proiinmtis. — It should not be forgotten that, as Virchow
says, "tibroma only needs an increase in the size of its
ceils and a diminuti(5n of the cement substance to change
it into a sarcoma." The location of a fibroma in the
pharynx sulijects it to a great amount of irritation:
hence it is thereby predisposed to a degenerative trans-
ition into a sarcoma and to attain to large dimensions.
Unless the growth can be removed, or unless its develop-
ment can be repressed until the patient has passed his
twenty-lifth year, llie prognosis is grave.
Trent mciit. — Curative results have been claimed by
numerous writers from injections of alcohol, caustic pot-
ash, cliloride of zinc, dilute acetic or hydrochloric acid,
etc., into new growths. It isas.serted that if alcohol will
produce contraction and atropliy of tissues, as occur in
the cirrhotic liver of tlie inebriate, it will have a similar
ett'ect on a neoplasm, into the parenchyma of which it
niiglit be injected. Wliile some ob.servers believe that
the curative effect is produced, wlien the alcoiiol is in-
jected into the interior of the tumor, by causing the for-
mation of new connective tissue, with the obliteration of
lilood-vessels, lymphatics, and the parenchyma, others
inject it into the circuinference, maintaining tliat the new
connective-tissue formation, girdling the iieriphery of
the growtli. will choke the aiferent and efferent blood-
vessels, cut off nutrition, and thus cause atroph.v.
Electrolysis is especially indicated for growtlis hav-
ing a sessile formation, wliich precludes tlic use of
torsion or the snare. For this purpose a strong cur-
rent is employed under general anaesthesia. Much has
been eiaiiiied for the method of introducing medica-
ments with the electric current, or cataphofesis; but
whenever it is jiractieable to rimcjve the tumor in its
entirety, tliis procedure .should be preferred.
OpcrdtiokS. — There are several methods of operating
from which to choo.se according to the size and situation
of any given tumor. However, before detacliiug tlie
growth it should be secured b.y passing a strong thread
through if, in order to prevent it from faliing into the
laryngeal region of tlie throat and producing siittocalion
when the attachment is severed. The old methoil of re-
moval by the cold wire snare is in quite general use, but
on account of the great vascularity of tiiese tumors and
the consequent operative hemorrhage the electric snare
recommends itself, since it sears over the tissues and
clo.ses the mouths of the blood-vessels with coagula as
the tissues are being severed. For the same reason, in
those cases in which the form and position of the attach-
ments of these neoplasms lend themselves to such a pro-
cedure, the use of the electric knife at a white heat is
advantageous. Torsion can be practised when the tu-
mor is distinctly ])ediinculated.
Certain cases of iiharyiigcal fibromata can be oiiertitcd
on through the natural oral or uasal passageways by the
method mentioned above. Others, eithcr"'on account of
peculiarities of attachment or by reason of excessive or
irregular development, must be removed tlirough the soft
or hard palate, or i.iy means of resecting the nasal bones
or the superior maxilla. Sufficient room for operating
may be obtained by dividing the nose along the side of
the septum, beginning at the uasal process and cutting
from within outward. If more room is required, the
nasal process is resected; still better access is afforded by
incising the upper lip in the middle line and separating
its attachments liberally. The tumor is then detached
by one of the methods already described, or by the ]jeii-
osteal elevator, or liy blunt-pointed scissors, when it is
drawn out with strong forccjis. These are very bloody
and dangerous operations, and may require a preliminary
tracheotomy and ligation of the common carotid artery.
However, since the details of these ojierations, as devised
and modified by Ki'inig. Diefl'enbach. Langenbeck, Kouge,
Oilier, Koclier, and others are given iu other article.sin
this lI.\NDi!OOK, they will be omitted here.
1). IJryson Delavan strongly favors tlie employment
of electricity Iiotli for the purpose of cutting off the
blood supjily of fibromata and shrinking them jirepara-
tory to their removal, and for their extirpation as well.
Electrolysis is recommended, either by the unipolar or
by the bipolar method. Either oneis attended with
pain. The first is the more painful and slower of the
two. The bipolar method is less painful and more rapid
and extensive in its destructive effect. Some operators
make use of so strong a current as from 80 to 34li niilli-
ain])eres. After reducing the volume of the tumor it Is
removed, preferabl}', by the incandescent wire snare, with
the eU-ctric current of suflicieut strength to burn its way
slowly, so as to destroy the tissues thoroughly at the
attachment, and to close the mouths of the severed
blood-vessels. Delavan givescredit to Lincoln for intro-
ducing this method into America after the su,i;\gestioiis
of Voltolini and 3Iichel, and he presents, in addition to
many cases collected by others, statistical data compiled
hy himself, which bear out the claims for the superiority
of operations by the electrolytic needles and the electric
snare through the natural [lassageways.
The statistical tables referred to cover the decade from
1801 to 1901, and include 30 ca.scs operated upon liy vari-
ous surgeons who performed preliminary o|ierations,
such as resections of the nose, the superior maxilla, and
the ])alate. There were lOG cases iu which the metliod
of operating was through the natural jiassa.ges. Of
these, -IS are classed as surgical and .JS as electrical pro-
cc<liires. Eliminating all of those ca.ses in which the
o])erators forgot to inform their readers regiirdin,g the
nature of the results of their work, we liave remainin.g
si) cases which are of actual vaiue in deterniiiiing the
relative merits of the various methods emidoyed. This
sliows 13 operations involving a preliminary interven-
tion, with .54 per cent, of cures. 53 per cent, of deaths,
603
Pliai*> i)\.
PliaryUA'.
REFEHEXCE IIANDP.OOK OF THE MKDKAL t>rlE.\(_'E.S.
28 per ceut. of grave liemorrliascs. ami 17 percent, of re-
currences of the tumors. There ^\t^n■ 2i) cases in ■\vliicli
various suri;ieal jiroeedures tlu-oush the natural passaf^es
were resorted to, anil tlie results were niaile known.
The cures amounted to 80 per cent., the failures about
7 per cent., the hemorrhages aliout 17 per cent., and
there were no deaths reported. There were 47 cases in
which electrical operations were ]ierformed and tlie le-
sulls recorded. The percentages were as follows: Cured.
81 percent. : improvi'd. 10 per cent. ; failures, 3 per cent.
No deaths were recorded. By combining all of those
operations which were performed by way of the natural
passages, for the purpose of comparing tlie results with
thoseobtained after |ireliTninary procedures, it will lie
foiuid that the percentages are as follows: Cured, 83 per
cent. : improved, 9 iier cent. A comparison of the vari-
ous methods is afforded by the following table-
ANALYSIS OF METHOD.S.
S
S
«
Mi"
2 »
— T.H
1
=1
'6
£
a
s
1
H
1
1
1
3
t
Reseotion of palate . .
KesHC-tiKn of sujierior
maxilla
Ri-sertiuu of nust?
!»
10
M
-3
-4
-11)
B
ii
1
3
4
1
3
-^
3
1
1
Tntal
-17
13
7
5
21
-9
-11)
IS
11
16
9
^^
- —
'2
3
3
2
5
Total
4,H
-19
39
a")
Electrolysis
Galvano-rautHry Innp.
(Jalvano-caiitery l<H>p
with elecimlysis ...
(ialvaiio-cautefy
Kalviino-caiiterv with
34
1!>
1
4
4
-M
-n
—II
31
1
4
4
7
1
3
4
1
1
1
Total
58
-11
4-
38
1
Lii'ii.MA. — .V lipoma is a tumor coinjiosed of fatty tis-
sue produced from a matrix of lipoblasts and may be
either circuinscrilied or diffuse. Its occurrence in the
]iharyu.\ is exceedingly rare, and tliesyinptoms to which
it gives rise are characteristic of a foreign body in the
throat. When the growth is soft, it may lie mistaUen for
an ab.scess: liut the .symptoms and history of jius forma-
tion are lacking, and an exploratory puncture is decisive
of this question.
If the tumor is pedunculated, it can lii' removed by one
of tlie metliods described for liliroiiia, vi/.. by the cold or
the hot snare or by tlie elnirie kiiil'r ; otiierwise electroly-
sis is to be preferred.
An'Giom.v. — This term is used in a broad .sense by
throat specialists to include all vascular tumors, in con-
formity witli the classitication of Virchow. Strictly
speaking, the growth consisis of new blood-vessels that
communicate witli the sunounding vessels, of intersti-
tial tissue like that from whicli the tumor springs, and
of the blood within the vascular spaces, In contradis-
tinction 111 tills detinition. tumors that are made up of
lymphatic vessels are designated as lym|>hangiomata.
The oval grou]) of veins Ijcncath the mucous membrane
at the hack of the pharynx, known as t'ruveilhier's sub-
mucous venous plexus, has been found so greatly en-
gorged and tumelied as lo cause a .sensation as if a for-
eign body were in the throat, and an annoying cough.
The surface jircsents a lianl. lobiilated. and |)urple
appearance. Varicose veins are not uncommonly met
with in the pharyn.x, and they may liecome so nunierous
and distended as to form groups that are comparable to
cluslersof currants or blacklierries. Ileniorrhages may
111- expected from these growths, jiarticularly following
arty irritation, such as a digital examination.
Treatment. — If angiomata attain to a con.siderable size
they may cause much discomfort and apprehension on
the part of the patient, and they may even so encroach
upon the surrounding parts as to impair their fuue-
tious. A constant desire to swallow, embarrassed res-
piration and deglutition are not the worst features to
consider, Init profuse hemorrhages may demand an
operation in order to insure the safety of the patient.
In such cases the tumor should be complete!}- extir-
pated. It is rarely sutiii-iently pedunculated to admit
of removal with the cold or the hot snare: hence electrol-
ysis is the most fcasilile method. Should thyrotomy lie
resorted to, it maybe necessary to perform a prepara-
tory traclieotora}^
S.\RCOM.\. — As a primary disease of the jiharyn.x sar-
coma is rarely seen. It springs from the submucous con-
nective tissue, and generally depends from the inferior
surface of the body of the sphenoid bone into the
pharynx. It is an atypical yiroliferation of connective-
tissue cells from a matri.x of tibroblasts of congenital or
postnatal origin. Owing to the rich supply of lym-
phatic structure in this locality and its invasion by the
sarcomatous cells the tumor may show a transition into
the variety termed lymphosarcoma.
Like fibroma, a sarcomatous growth produces symp-
toms referable to respiration, sAvallowing, and the voice
in degrees commensurate with the location, size, and
shape of the tumor. The nasoiiliaryngeal .secretions are
increased in quantity, to which is added, after ulceration
occurs, a viscid, foul, and liloody di.scliarge. If pain is
present, it is in proportion to the amount of pressure ex-
erted on adjacent structures. Although the discharge,
which ajipears after ulceration takes place, is of a .san-
guineous character, the history of the growth may not
present hemorrhages to a .serious extent. In order to
make a jiositive dilferential diagnosis, resort should be
had to the micro.scope. The prognosis is unfavorable;
the progress is toward a fatal termination.
Treiitmeiit.- — If all of the diseased tissue can be re-
moved, this should be done, provided that melaslasis has
not occurred. It is useless to operate if a jiart of the
growth be left, for ra])id reproduction w-ill occur; and if
metastatic tumors have formed in other situations noth-
ing will avail from oiierative procedures on the |irimary
tumor. But if the growth can be enucleated from a cir-
cumscribing pseiido cajisule. leaving no renuiant of dis-
eased ti.ssue. and if no metastasis has occurred to rendei-
nugatory the result of the 0]ieration, it should be ]ier-
formed. Otherwise there is little to be aecomiilished be-
yond making the conditions as tolerable as possible by
the use of c-leansing. disinfecting, and astringent appli-
cations. Scth Scott Bistw]).
PHARYNX. DISEASES OF: NEUROSES.— Neuroses
of ihe phtnyiix consisl nl disluibaiiees of sensibility, .se-
cretion, and niolii.in.
An.-kstiiksi.\ of the Pn.\uv\x. — This appears as a
complete loss of the seusiliilily of the pharyngeal mucous
memlirane, or as a diminulion of the same, and can be of
either central or peri|iheial origin. "When of central ori-
gin it is due to hemorrliage, tumors of the Inain which
(-ause compression of the vagus and glossopharyngeus
nerves, inflammation of the brain, bulliar ]iaralysis, talies,
or lateral sclerosis. It is seen in conned ion with epi-
Icpsv. after influenza, in anwmia and in hysteria, and i*
one of the sequela- of severe general diseases, as pneu-
monia and especially diiilitheria. Cocaine, eiicaine, mor-
phine, t-liloial. bromide of jiolassium. carbolic acid, and
menthol, when used locally and internally, iiring about
ana-sthesia of the pli.-irynx. The retle.xes usuall\- fail,
and there is occasionally a feeling of general pain, even
in the |iresence of local ana>sthesia.
The (//(/.f//('/.s(V is made by direct examination. In I In-
case of ana-sthesia of one side only, one-half will have the
natural sensibility, while the aflected portion will be in-
sensitive to mei-lianical, thermal, or chemical initalions.
When the ana-slhesia is complete, Ihe mucous membrane
is everywhere alfected. When the result of diiihthcria.
(iol
REFERENCE HANDBOOK OF THE iMEDICAL JSCIENCES.
Pliarj iix.
Pharynx.
ana'stliesiii is often accompaniiMl with p;ii-;ilysis of tlio
iniiscli'S of flic lurvux :iiiil pliurviix.
TIr' pr"!/ii"sis (k'|>L'inls entirely upon the cause, and is
souH'times good and sometimes bad.
The treiiti/ii'iil is based on the cause. Associated with
diphtheria, the treatment is that of the general paralysis
of iliiihtheria, and consists of measures to keep up'the
iiutiition of the iiarts; careful feeding to prevent the in-
troduction of panicles of food into the laiyn.x ; the tise of
Ihe constant and induced electrical cnrreni ; and strych-
nine internally.
IIvi"EU.kstih;sia of the Phai{VNX. — By this term is
\uiderstood an increased sensibility due to central or per-
ipheral irritations, whercbj- an extreme sen.sitiveness of
the ]iharyngeal nuu'ous membrane is brought about,
whicli is described as ]iain, or is evident in the forin of
coughing, choking, retching, vomiting, and explosive
liclching of gases irom the stomach,
Ilypera'sthesia of the pharynx is a common manifesta-
tion, daily seen when an attempt is made at a laryugo-
scopio or rhinoscopic examination. It is often extreme,
many persons retching, gagging, and almost vomiting
whenever anv instrument is brought near to the pharynx.
Even the opening of the mouth and the drawing out of
the tongue frequently elicits the strongest I'ctiexes before
the instrtuiient has touched any pait of the pharyngeal
wall. It is connnon in persons apparently abs(dutely
sound, but is more so in those who are very fat, in drink-
ers, smokers, and nervous persons. Local diseases, hy-
peremia, acute or chronic catarrh, general hyperiesthesia,
and increased general nervous sensibility- intensify all the
manifestations.
Wliile it is a condition diflicult to cure by any method
of tieatment, most jiersons after a Avhile become used to
mani]iulations in tliis region, and the treatment <if the
pathological condition present usually diminishes the
sensibility.
yVr'/iz/Jc//^ consists in the local use of cocaine, menthol,
chloral, bromide of jiotassium, various gargles, taunin.
alum, and adrenalin, and in tlie avoidance of alcoliol and
toliacco,
PAii.fiSTiiEsi.\. — L'ndei' Ibis term arc included various
alinormal sensations, whicli are described as burning,
liressure, itching, dryness, abra.sious, lumiis, or a Sensa-
tion as of the presence of a foreign body in the pharynx.
Among the foreign Viodies complained of are pieces of
bone, hairs, toothbrush bristles, needles, pieces of bread,
cotton, portions of feathers — in fact, any substance that,
could possibly stick in the throat. Originally something
11. a}' have lodged there, but as a rule it has been removed
by retching or coughing before the physician was called.
Hysterical and nervous jiersons of botii sexes fre(|ueutly
complain of a lump in Ihe throat (globus hystericus), lif
a burning pain, or of a feeling of icj- coldness during the
breathing.
Another one of the common forms of para^stliesia is
tlie belief that there is a carcinoma in the throat, the cir-
ciimvallate ])aiiilke having been felt liy the tinger; and
it is often extremely ditbciilt to rid the mind of the indi-
vidual of tlie idea tliat a new growth is present.
A feeling of extreme dryness, without material objec-
tive change, is frequent in mouth-breatlicrs; in chlorosis,
ana'inia, and diabetes; and in users of morphine, atro-
pine, or belladonna.
Para'sthesia is a more or less constant accompaniment
of the chronic jiharyngeal catarrhs. It is found in con-
nection with tonsillar affections and with the various
pathological changes of the nose ami nasopharynx. In-
flammations of the interarytcuoid region, neuralgia of the
superior laryngeal nerve,' and affections of tlie central
nervous system are also causative. It can occur as a re-
Hex condition accompanying auicmia, chlorosis, hysteria,
uterine and ovarian diseases, early phthisis, and" hypo-
chondriasis.
The diagnosis is dependent upon a careful examination
of the entire pharynx, which must include an examina-
tion of the nasopliarynx, tonsils and larynx as well, so
that no possible source of irritation, direct or remote,
shall be overlooked. The patient will usually tell when-
ever a painful area is touched with the probe. Some-
times there are several of these iioiiits, which disappear
upon painting the area witli ten per cent, cociiinc^ The
course is very chronic.
Treatment must dejx'nd entirely ui)on the cause. So
far as anything local can be found, appropriate' treatment
is to be given; while for general nervousness and hyste-
ria the treatment appropriate to this condition must be
ap]died.
Secisetory Neuroses, — Hypersecretion cd' the phar-
ynx is a condition which not infrequently occurs, espe-
cially in singers. Individuals with apparently com-
jdelely normal mucous membranes complain of an
increased secretion of slim\- mucus in the pharynx, naso-
])liarynx. or larynx, making it necessary to swiillow very
often, and to spit a great deal when talking, the swal-
lowed secretion being fre(iuently vomited early in the
morning. Examination shows more or less of this mucus
on the back of the phalangeal wall and around the velum
palati. This condition is sometimes observed in old [leo-
ple. Its cause seems to be some disturbance in the ucr-
\'ous control of tlie secretory glands.
Ti-eatment is only partially successful. Tlie condition
sometimes disappears of itself, but is liable to return.
Belladonna has been recommended. Small doses of iodide
(d' potassium or the syru]! of hydriodic acid frequently
do good by increasing somewhat the secretion of the
glands, so that the slimy mucus is less thick and there-
fore less complained of.
There is also a condition <if nervous lessening of secre-
tion, with a feeling of great dryness, seen in connection
with hysteria or the use of morphine or belladonna, and
found in sufferers from diabetes.
NEi'iiOSEs OF Monu.rrv.— Cramp-like spasm of the
constrictors occurs occasicjually, most frequently in per-
sons suffering from dyspepsia or .some stomach ali'ectiou;
in general functional neurosis; occasionally in granular
pharyngitis, hypertrophy of the side walls, and in con-
nection with inflanimatory jjroeesses at the base of the
tongue. Cramp-like constriction of the muscles, inter-
fering with swallowing, is found in connection with dis-
eases of the brain, and is an accom|ianiment of tabes. It
is most commonlv seen as a tonic cramp in hysterical dys-
phagia. The muscles of the (esophagus are affected at
the .same time. In cramp of the muscles of swallowing,
the passage dow'nward of the mass of food is more or less
interfered with. In hysterical dysphagia the swallowed
mass is temporarily arrested at some point, usually with
a sense of pressure and pain iu the neck and around the
sternum, then without further hindrance it passes into
tlic stomach, or else with a feeling of suft'ocation, chok-
ing, and ex]ilosion of gases from the stomach it is vmuited
out. The swallowing of solid substances may be impos-
sible for days or weeks.
Cramj.) of the muscles of the soft palate occurs com-
paratively seldom. When of a tonic nature the velum
is in close contact with X\w. jiosferior pharyngeal wall, re-
sulting in an altered tone and impossibility of breathing
thniiigh the nose. The cramp may be of a cloni<' n,-ifure,
affecting only single muscles of the velum, as the levator
or tensor or the azygos uvuhe. The causes are very va-
rious, consisting of true alterations in the nerve supply,
central and peripheral irritations, and pathological jiroc-
csscs in the immediate neighborhood.
The (liiKjinmsol the various forms of cramji-like action
of the muscles is not always easy, since hysterical dys-
phagia can simulate many affections. It can be differ-
cnlialcd from true paralysis of the muscles of the phar-
ynx by its interniittcnce, as tlie ])henomenon is not con-
stant. The u.se of the sound, careful observation of the
liatieiit, and the study of all the possible causes will
usually enable one to make a diagnosis.
/';w/«t/«'« depends entirely u] ion the pathology, as does
also tile treiitment.
I'ah.m.yses of the Piuuvnx. — These are mostly of
central origin. Acute and chronic inflammafion i>i the
brain ; tumors; hemorrhages which bring about eonipres-
605
Pli«-iia(-*-ti.:i,
Pll«-llo4-(>ll,
HEFEHEXflC ilANDBOOK OF THE MEDICAL SCIEX'CES.
sion of the vagus, accessorius, and i:lo>.sopliaryugeus
nerves aud their branches: as well as desciieialivc^ proc-
esses of the brain and medulla, such as bulbar paralysis,
tabes, progre.ssive niuseular atrophy, anil facial paralysis;
lead intoxication; phthisis; grippe; pressure of earciuo-
inalous glands >i])on llie vagus and its branches — all
these may have muscular disturbances of the jiharynx as
their seqliehv. Of the p.cripheral causes diphtheria and
scarlet feverare the most freijuent. i^yjihilis anil general
neuritis are also causative.
Paralyses of sensation and of nioiion often occur to-
gether. Paralysis of the soft palate is the most fre-
quent, and may be one-sided or doulile-sided. comidete
or ineiim]ilete. AVlien it is one-sided, the jialate is drawn
.sometimes toward the sound and sometimes toward the
diseased side. The aich of the jiaralyzeil side is deeper,
while on the sound side the arch is higher and narrower.
During phoiiation the velum comes toward the sound
side, "when the uvula alone is paralyzed, wliieh is a fre-
quent condition in pharynx or hirynx catarrli and in pa-
ralvsis of tlie vocal cords, it goes toward the sound side.
In doulile ]iaralysis of the velum, it hangs with the uvula
straisrht down and shows no sign of active movement ex-
cept in respiration, ivlien the uvula moves slightly back-
ward anil forward; during iihonafion there is a slight
attempt for it to reach the posterior wall. The voice has
a very nasal tone. There is sehlom difficulty in swallow-
ing.
Paralysis of the constrictors nf the ]iliarynx. witli or
without accompanying paralysis of the velum and of
the lesophagus, is most frequent in connection witli
diphtheria, Scarlet fever, and the other infectious dis-
eases and in bulbar paralysis. When the paralj'sis is lim-
ited to the constrictors, particles of food lodge at tlie
ba.se of the tongue aud in the adjacent sinu.ses, aud fluids
pass easily into the laiynx, jiroducing intense cough and
suffocation. If the superior conslrictur alone is para-
ly/.eil. the particles of food m:iy be thrown into the nose.
The ilidi/nijuis of paralysis of the mu.scles of the phar-
j'ux is very easy, but the condition is often overlooked,
especially when tlie jiaralysisis ineoiuplcte. TJie incom-
plete jiaralysis often suggests adenoid vegetations or
polypi in the nose. When brought about through in-
flammatory or mechanical causes there are redness, swell-
ing, cedema, idcers, and cicatrices. The cause of the
paralysis is often diflicult to And.
In central paralysis the electro-motor excitability is
normal and can reniidn so. In complete ]ieri)dieial pa-
ralysis the electro-motor excitability very raiiidly dimin-
ishes aud can be lost by the third week.
Hysterical paralysis begins suddenly. dis;ippears sud-
denly, and comes again witlmut apparent cause.
The prnrjiKixis and the treatment must depend entirely
tipon liie cause. Prognosis is not giiod when the ci'Udi-
tiiin is nf central origin, but gnml when of diphtheritic,
rheiuu-itic, infectious, or of local inflammatory origin.
Electricity is the best reiucdy. The faradie current
can be used to advantage, all hough the galvanic current
is ju'eferable. AVhen the jiaralysis lias lasted any length
of time both are indicated, as the faradie current heljis
maintain the nutriliou of the muscle w liile the galvanic
directly stimulates the uerve. When electricity is used
one I'lectrodc should be iilaced on the cervical vertebne
or the anterior svirface of the neck, the other on the
pharyngeal wall against the paralyzed muscle. The
jiharyngeal electrode should be one in which the current
can be turned olf and on. Strychnine internally, and
remedies which iirmuote the general nutritinu both of
the local jiarf and of the general cnnstituticin are to be
used in addition to the electricity.
Cf'injc I.. ni.-!„inh.
PHENACETIN.—(/'"m-rto'/-y-/»>», //<///,,) This well-
knnwn and ]ioinilar derivative of cnal tar was introduced
in ISn; bv Dr. O. Hiusberg and Pinf. A. Kast.' Its
chemical formula is C'fiH,Of.JI;,XIK'lI:,CO. In the last
revision nf the British Pharniaci>|iieia it was recognized
as an official drug. The cheinical iclatiou of pheuacctiu
to allied compounds will be readily understood by refer-
ence to the following formuUe:
Acetanilid, CeH^
/H
^\XIICTLCO.
T- 1 ■ r. ir /CTI3
E.xalg.n, CJI,^^.„(^j^CO.
Methacctin, (^'flli^xjic'n no
Pbenacetin , C.II , ( § j'fei=j^(-.Q
Pheuazone. or antipyrin, which is therapeutically al-
lied to the above, is related only so far as all are derived
from jihenyl compounds; its formula is
Phenacetin forms in white, glistening, scaly crystals,
without odor or taste. It is slightly soluble in cold
water, 1 part in 1..500; more soluble in hot water, t part
iu 70; and freely soluble in reetitied spirits, 1 part in l(i;
it is also soluble in glycerin. The cry.stals melt at 27.5"
F. A recognized test for pbenacetin is the production
of a deeji red color when chromic acid is added to a
cooled and tiltered solution of one grain in twenty min-
ims of hydrochloric acid diluted with ten times its vol-
ume of water. Sul]iliuric acid should dissolve it with-
out color, and burned with free access of air it should
leave no residue. The presence of paraphenetidiu mav
be detected by melting forty grains of chloral lu'ilrate in
a water-bath, aud adding eight grains of phenacetin aud
well shaking; a solution takes place which is colored
violet, reddish, or bluish in tint, according to the propor-
tion of the impurity present. Another test, though less
delicate, is to add eight grains of phenacetin to one and a
half drachms of iodinesolution, 1 to 20,001); when filtered
a pure salt yields a colorless liquid; a pink tiut indicates
the presence of paraphenetidin. Phenacetin does not
form a bromine comjiound as acetanilid does, and this re-
action furni.slies a test for the presence of the latter salt ;
the addition of bromine water to a saturated solution of
the suspected salt, imparts a yellow color; if acetanilid
is present the solution becomes turbid, if it is absent it
remains clear. The presence of acetanilid, exalgin, or
methacctin may be detected by adding two grains to
twenty luiiiiius of concentrated hydrochloric acid; phen-
acetin remains undissolved, the other salts enter into
.solution.
Phenacetin was introduced as an analgesic and anti-
pyretic much superior to the other similar compounds,
on account of its freedom from any toxic action. It
rapidly established a re|nitatinn as one of the most safe
of the numeriius new antipyretics, and has been very ex-
tensively employed in all febrile diseases, and for the re-
lief of pain in all its forms. Its action isuot accompanied
by the numerous unfavorable symptoms that are common
to the coal-tar derivatives. The most frequent undesir-
able effect that may be caused by its use is the onset of
sweating, more or less profuse. Although its composi-
tion is such that it may cause the alterations of the blood
that arc ]>roiluced by exalgin, acetanilid, etc., the in-
stances in which any such condition follows its use are
extremely rare. Some cases, however, are reported in
which there were paleness and coldness of the extremities,
free ]ierspiration, precordial pain, dj'spna^a, shallow rcs-
jiiration. feelile pul.se, cyanosis, and other evidences of
collap.se. Many of these cases of poisoning occurred in
females, and generally followed theemploj'raent of large
do.ses; lint in one case nnly three doses of seven grains
each were given. Tlii' |iresence of impurities, especially
parai)licnetidin, is luidoubtedly the cause of many of
the unfavoralile symptoms. Very large doses have been
given without any ill effects. A case is reported in which
sixty grains were given daily for two weeks, as an ano-
dyne; in another case one ounce and one drachm were
given during one week to a patient with neuritis, aud iu
Odfi
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pliciiaoetin*.
PIlL'llOCOll.
a case of tetanus one ounce and five drachms were given
ill niiK-teeu days. During e-xperimental rcsearcli upon
r.uinuds. it lias been given for a [iruloiiced period in
doS( s equal to one and two-tliirds grain ])er pound of
body weiglit without producing any derangement of the
system, or causing any irritation to the mucous mem-
brane of tlie stomach.
A series of experiments on animals by Drs. Ccriia and
Carter- have led them to the following conclusions: (1)
Phenacetin in moderate doses causes a ri.se of the arterial
pressure by acting upon the heart, and probably likewi.se
by exerting a stimulating inlluence on the vaso-motor
system. (2) In large amounts it causes a reduction in
the pressure, which is largely of cardiac origin. (3) In
small doses it increases the force of the heart by a direct
action. (4) It increases the pulse rate chietiy by cardiac
stinuilatiou, and possiblj' also by influencing Uie cardio-
acceleratiug apparatus. (5) In large quantiiies the drug
reduces the number of pulsations, primarily by stimulat-
ing the cardio-inhibitory centres, and later by a depres-
sant action on the heart. They also found that in large
amounts it caused a marked quickening of the res|iiratory
movements b_v a direct action on the medulla, ami Iha't
where sufficient quantities were given to produce death
it was due to resijiratory failure. (See also Plunoi'nll.)
As an antipyretic it is given in doses of from live to
ten grains, every hour or every two hours. It rc'duces
the temperature slowly and effectively; during the first
and seecjud hours there is not much intl uencc on the fever,
but in the third hour its greatest effect is manifested.
The continuation of the afebrile state varies, but usually
after the fourth or fifth hour the temperature begins to
ascend. The fall of the temperature results chiefiy from
a decrease in heat production, with a slight increase in
the heat di-ssipation. The slow aclion of the drug is
thought to depend on its insolubilit}'. In chronic febrile
troubles its action is not so marked, and a tolerance of
the drug appears to ensue upon its jirolonged adnu'nis-
tration. When there are pain, restlessness, and insomnia
accompanying the fever, the beneficial effects of the drug
are most marked. A sense of ease and comfort is pro-
duced, and a calm, refieshing sleep follows. By some
it has been supposetl to e.xert a decided hypnotic action,
but careful ob.servations in melancholia and mania have
not confirmed this view. In typhoid fever it has proved
of great service. From five to eight grains are generally
sutiicient to reduce the temperature to normal in about
three hours ; when it begins to rise again a second dose
will prevent an^- hyperpyrexia for twenty-four hours.
Many prefer to employ it in smaller doses frequenlly re-
peate<l — two grains every two or three hours and con-
tinued throughout the period of pyrexia; in this way it
maintains the temperature at a low point and the fever
runs a mild and uncomplicated course. In childieu it
proves beneficial in all febrile disorders; single doses of
two grains will produce a lowering of temperature, or it
may be given in fractional parts of a grain ever_v two
or "three hours; one-third of a grain having proved
sufficient to subdue the fever and allay restlessness.
For "?(« grippe^' it has proved very serviceable, and
has replaced the older antipyretics to a very great ex-
tent. In tills disease the small and frequently repeated
doses were of little avail, a single dose of ten or fifteen
grains being generally sufficient to relieve the fever and
the severe cephalalgia with which it was usually accom-
panied. One of its earliest applicalioiis was as an anti-
rheumatic. It has no influence in warding fiff the car-
diac and other visceral complications, but it reduces the
fever and lessens the pain and swelling in the joints: to
be of any benefit it must be employed in much larger
doses than in any other fel)rile aft'ectiou. At least fifteen
or twentj' grains must be given three times daily, and
some state that a better effect is produced by thirty
grains given twice in the day. In children five grains
three or four times a day may be required. In painful
affections unaccompanied by fever, and in the various
forms of neuralgia, it requires lo be given in the same
full doses to secure a relief from suffering. A single
dose of from fifteen to twenty grains will prove surtieient
when any benefit is to be derived, while small and fre-
quent doses exercise very little, if any, action in control-
ling the pain. Phenacetin has also acquired a reputation
as a remedy for whooping-cough. It is given in doses
of from half a grain up to two grains every four hours,
and affords rajiid relief to the severe jiaroxysins. It is
also supposed lo shorten the duration of the disease.
Compared with the allied drugs, phenacetin nia}- be
said to be more pleasant and Sitfe, Ijut less powerful' and
slower in its aclion : and perhaps less certain, as it fre-
quentlj' fails to pioduce the desired effect.
loclojjheiiacetin or iocloji/ieit in is a compound of iodine and
phenacetin introduced by Dr. Scholvein, at a meeting of
the Berlin Pharmaceutical Society. 1S91. It contains
fifty per cent, of iodine, and forms in steel-blue crystals,
with an odor of iodine and a burning taste. AYater de-
composes the salt, liberating the iodine in a free state. It
possesses the active germicidal and antiseptic ijroperties-
of iodine, and owing to the looseness of its combination it
was suggested as an intestinal antiseptic. The local irri-
tation proved a source of discomfort, and toxic symp-
toms frequently followed its employment. It is now
seldom employed. Baiumoitt Small.
^ Centmll). f. tresam. Tbprap.. April, lSi>7.
= Ttieru|>i-iitii:"iiazi-lli-. Maroli. lsn:j.
PHENACETIN, POISONING BY. See Synthetic Pri-
sons, Organic.
PHENALGIN — ammonio-idienylacetamid — is a fine
white iM,w(li-r nf ammouiacal odor and slightly alkaline
taste. With water it makes an alkaline solution. It is a
proprietary remedy of uncertain composition, stated tO'
be an efficient analgesic, antii\vretic. and antiperiodic.
The ammonia present is intended to prevent depressioa
of heart and respiration. Do.se 0.3-1.3 gm. (gr. v.-xx.).,
ir. A. Bastedo.
PHENAZONE. See Ant I pyrin.
PHENEGOL. Sl-c Egoh.
PHENOCOLL.— (Amido-acet-para-phenetidin.) During
the past few years our knowledge of the chemistry of
modern antipyretics has so far advanced that new syn-
thetical remediesare produced, the therapeutic properties,
of which have been carefull\- considered beforehand.
Such a one has been prejjared by German manufac-
turers and introduced under the name of pheuocoll. It
is said to be an antipyretic, po.ssessed of all the favorable
qualities of phenacetin, and devoid of any of its undesir-
able effects. It is obtained by rejilaciiig in phenacetin
one hydrogen atom of the acetyl grou|i liy the amido
group NH2. Its formida is
C6H,0C5H5NnC0CH.,NII, -f- 11,0.
Phenocoll, the base, f<n'ms in white acicular crystals
which have a tendency to mat themselves together. It
is readily soluble in alcohol and warm water, but only
slightly in chloroform, ether, and cold water. DikUe
caustic alkalies, or dilute acids when cold, have no power
to split up the compound, but by jirolonged boiling it is
resolved into its constituents. The most important char-
acteristic of this coinjiound is its ])ower of combining
with acids and forming soluble salts.
The /ii/droc/ihridc of plicnocjll 'lA the salt generally em-
ployed, but salts have also been I'ornied with other acids.
lihe Siilici/lfite occurs in long needles; it has a sweetish
and not di.sagreeable taste, and is supiHi.sed 10 add some
of tlie therapeutic jiropcrties of salicylic aci<l to i)lieno-
i-oll. It has been introduced to I lie ]u-ofession undei the
name salocoll.
VlicHiiC'iU hydrncldiiride is a while, minutely crystalline
powder, with a bitter, saline, but not disagreeable taste.
It is soluble in cold water, about oiu' jiart in sixteen,
fnrniing a neutral, stable solution. It is still more solu-
ble in hot water and in alcohol.
QOI
Plleui»l-Ki»lBilEl
Fklladelplila.
KKFKKENCK HANDBOOK OF THE MEDICAL SCIENCES.
Tho superiority claimed for it over oilier antipyreties
was bused not only oii its greater- solubility and more rapid
action, but also on its perfect liarmlessness. Tlie result
of experiments by Dr. Isaac Ott. however, shows that in
veiy large quantities it produces the same effects as
plienacetin and similar compounds. lie reports: (1)
that upon frogs it produces a general paralysis, due to an
action upon the cerebrospinal a.xis; ('.3) upon rabbits it
produces a cyanotic coiulitioTi of the cars, and reduces
the force and" frcciuency of the heart: (3i it kills through
an action upon the centre of respinition.
The investigations and clinical reports upon the action
of this new remedy have been chietiy made in Germany
and Italy, but Drs. Cerna and Carter, of Philadelpliia,
Iiavedone some very thorough experimental work, to de-
termine the com]iarative action of antipyrin, plienace-
tin, and plienoeoll. The following arc their conclirsiims
regarding its action on the heart and circulation:
1. PhenocoU. in ordinaiT amounts, has practically no
effect upon the circulation.
3. Large doses diminish the blood pressure by influenc-
ing the heart.
3. PhenocoU reduces the pulse rate bj' stimulating the
cardio-inhibitoiy centres. It then increases the rapidity
of the pulse by paralyzing said centres. The final dimi-
nution is of cardiac origin.
4, Upon the blood itself phenocoll has no action.
As to the relative action of the three antipyretics that
were experimented with, the_y sum all as follows:
1. Antipyrin, plienacetin, and phenocoll all fail to pro-
duce any eifect on the heat functions of the normal ani-
mal.
2. Antipyrin produces a decided fall of temperature in
the first hour after its administration in the fevered ani-
mal. This reduction is due to a great increase in heat
dissipaticm, together with a fall in the heat production.
3. Plienacetin,' lioth in septic and in albumose fevers,
produces a very slight fail of temperature during the first
and second hours after its ingestion by the stomach, but
the greatest reducti<in occurs iluring the third hour after
its ingestion. Tlie fall of temperature results chiefiy from
adecrea.se in lieat proiluction, with a slight increase in
the heat dissip;ition. Tlic increase in dissipation is not as
great as with antijiyrin. Probably the delayed action of
the drug depends on its insolubility.
4. PlienocoU causes in fever a very decided fall in tem-
perature, which occurs during the first hour after the ad-
ministration of thcilrug by the stomacli. This reduction
is the result of an enormous diminution of lieat produc-
tion, without any alteration of heat dissipation.
Phenocoll has been recommended as an antipyretic,
analgesic, antiriicumatic, and antiperiodie, but has not
proved itself of particular value. Its action resembles
that of plienacetin, but phenocoll requires to be given
in larger doses. In some instances ill ctTeets have fol-
lowed its eni]doymcnt. Excessive sweating, d_yspua?a,
marked depressiim, rashes, darkened urine, and many
other unfavorable symptoms have been reported,
/>' ini niiiiit Siiitdl.
PHENOL-BISMUTH — C,ll.().Bi(()H).— is a luacti
■cally odi'iios and tasteh'ss. wliite, non-irritant. an<l non-
toxic powder, containing nineteen per cent, of ])heuol.
Like other bismuth prejiarations, it is used as a mechani-
cal .sedative and antiseptic to the gastro-intestinal tract,
but in addition, as siiown b\' the urine, sets free some
of its phenol. Xo poisonous effects have been noticed
(Jasenski) from taking .5 gin. (gr. Ixxv.) a day for three
weeks. R. W. Wilcox says that it is superior to all other
forms of bismuth in fermentative (lys])e|isias and in
chronic gastritis marked by pyrosis, or boulimia. The
dose is 1-5 gm. (gr. xv.-lxxv.) daily. IT. .1 BustcOo.
PHENOLPHTHALEIN-C,H,.CO.C(C.,H.')H).,.0 — is
pre|iai'ed liy digesting ten parts of phenol, five ]iarts
phthalic anhydride, and four parts concentrated sulphuric
acid for several hours, boiling the residue with water to
remove soluble matter, and then boiling the remaining
resinous substance in benzol. Pheuolphthalein is a yel-
lowish brown powder, which, in 1 to 30 aleohi>lic solu-
tion, serves as an acid-alkali indicator in voluinetrie anal-
ysis. Colorless in acid solutions, it turns a brilliant pink
on neutralization with an alkali. It is not, however, a
safe indicator for the carbonated alkalies.
At the British ^Medical Association. 1902, Tunncliffe
reported over one thousand cascsof its use asacathartic.
It may safel_v be employed in renal disease as it is ex-
creted by the intestines and not by the kidneys. The
dose is 0. l.")-l gm. (gr. iiss.-xv.)in tablets. 0.3 gm. (gr.
V.) being usually sulflcicnt to purge an adult.
)('. .-1. Bastedo.
PHENOL. POISONING BY.— This substance, now a
very familiar aiitisiqitic, is known more generally as car-
bolic or pheuic acid, also as coal-tar creo.sote. True creo-
sote, the characleristic ingredient of wood-tar, especially
that from lieech-wood, is not identical with phenol.
Phenol, as the common name indicates, has some acid
properlies, but is, more strictly speaking, an alcohol.
Its formula is C,iH,-,HO. When pure it is a colorless,
crystalline, deliquescent mass, soluble in water, alcohol,
and glycerin, with a well-marked odor, and a burning
taste. The crude carbnUc arid of commerce is variable in
composition, and often consists of little else than neutral
tar oils, which are destitute of any antiseptic qualities.
Applied to the skin, phenol produces a white sujierfi-
cial eschar; on the mucous surface the effect is more se-
vere. A number of cases are recorded in which death has
resulted from external application, even to a limited sur-
face. The introduction, at a comparativelj' recent date,
of phenol in antistqitic surgery has been responsible for
several fatal cases.
AVlicn phenol is swallowed in moderate concentration
an intense burning sensation is immediately experienced
in the throat, ii'soiihagus, and stomach, the mucous mem-
brane becoming white and hardened. Vomiting of a
frothy mucus occurs. The skin becomes cold, the lips
and ears livi<l, jiupils contracted and insensitive, and
breathing diflieult: the pulse may be 120 and irregular.
The urine becomes dark-colored, and may be suppressed.
These syniptoms are soon followed by insensibility, with
stertorous breathing. The appearances after death are
largely those of local action of the poison, but the train
of s.vmptoms sliows that, as in the case of nearly all
other |Xiis(ms, there is a distinct action on the nervous
system to wliieh the fatal result is largely due.
The fatal quantity is somewhat difiicult to fi>;, owing
to the gri'al variation in strength of the commercial solu-
tions, in which form the acid is generally encountered in
cases of jioisoning. In one case noted li\' Taylor a woman
died in about half an hour after swallowing a wineglass-
ful of. probably, a weak aqueous solution of phenol.
The minimum fatal dose is given by some authorities as
one draclim. Iiut recovery from such an amount is possi-
ble. Half an ounce is almost invariably fatal. Fatal
results have several times occurred rather rapidly, that is,
in less than an hour.
The best antidote is alcohol — the strong commercial
spirit for external apiilication, common whiskey, or the
cominercial spirit diluted considerably, for internal use.
The alcohol not only stops the acti(m of the poison, but
if the damage be not very great, it restores the condition
of the tissues. Other chemical antidotes that have been
advised arc magnesium suljihate, sodium sulphate (these
are supposed to form less active sulphonates), syrup of
lime, and even vinegar. The manner in which the last-
named acts is not ex]ilained, Init it has been strongly rec-
ommende<l by some persons. After the severe symptoms
have abated, the stomach should be washed out with
tepid water. It is not advisable to attempt to produce
vomiting either by emetics or by hypodermic use of apo-
mor]iliine. Ihnri/ Leffinann.
PHENOL-SODIUM SULFORICINATE is a yellowish
liquid soluble in water ami alcohol, and recommended by
Von Tovolgyi for tuberculous laryngitis. Used like lac-
•608
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
PlirnoI-BiKniuth.
Philaaelplila.
tic acid without preparatoiy ana?sthetization of the tliroat,
it reduces tlie tuberculous infiltration and favorably in-
fluences the dysphagia. It has also been used for diph-
theritic throats and in skin diseases. W. A. Bastcdo.
PHENOLURIA. See Urine, etc.
PHENOSAL— Cc.H..OC.Hs.NH.CO.CH2.0.CoH,COOH
— is llie aceto-salicylate of pheuetidin. and occurs in
sparingly sohdjle needles or plates of acidulous taste. In
the alimentary tract it breaks up, yielding lifty-.seven per
cent, of phenetidin and thirty-four percent, of salicylic
acid. It is antipyretic, and is especially recommended in
rheumatism. The dose is 0.3-0.7 gm. (gr. v.-x.) three or
four times a day. 11'. A. Bnstedo.
PHENOSALYL. — This compound antiseptic is the residt
of a sciies of experiments upon various antisejitics b}'
Dr. de Christmas, in the Pasteur Institute, Paris. He
has shown that when certain antiseptics are associated
• together in one and the same solution, the microbicide
power is greater than that of the sum of the solutions of
each acting separately. The prei)aration to wljich he has
given the name phenosalji is considered by him to be a
most etticient antiseptic, its action on the various bac-
teria being exceeded only by sublimate. It lias the fol-
lowing composition: Carbolic acid, 90 parts; salicylic
acid. fO parts: lactic acid. 20 parts; menthol. 1 part.
The three acids are heated up to the point of liquefac-
tion, when the menthol is added. It is very soluble in
glycerin, and in water to the extent of four per cent.
Biauiiiont Small.
PHENOSUCCIN — pvrantiu. para-ethoxv-phenvl suc-
cininiide, C„lI..UC,H5.NiCOCH2)2— obtained by the ac-
tion of succinic acid on para-amido-pheuol, occurs in col-
orless needles which are insoluble in water and ether, but
.soluble in alcohol and acetic acid. It is antipyretic and
antineuralgic in dose of 1-3 gm. (gr. xv.-xlv.) daily,
clinical experience showing that it has no depressing
effect except in large quantities. The sodium salt forms
a sweetish solution with water. 11'. A. Bastedo.
PHENYL-ACETIC ACID— alpha-toluic acid, CeH,.-
CHa.COOH — is obtained by boiling benzyl cyanide with
potassium hydroxide solution. It occurs in white glassy
scales of burning aromatic taste and soluble in liot water
and alcohol. It is given in dose of 0.06-0. l.j gm. (gr. i.-
iiss.) with cod-liver oil for tuberculosis of the lungs.
ir. -1. Basted/).
PHENYLHYDRAZINE — CeH5.NH.NH,. —a colorless
oily liquid wlii( !i snii.lities into tabular crystals. It is
slightly soluble in water. An hydrochloride forms in col-
orless scales which are readily soluble in water. Plienyl-
hj'drazine is an intermediary product in the preparation
oi' many antipyretics, notably antipyrin and hydracetine,
but its toxic action is too marked to allow- of its employ-
ment as a therapeutic agent. Plienylliydrazine levulinic
acid, under the registered title of antithermin, was em-
ployed as an antipyretic in do.ses of five grains. It is now
but little used, as its action is uncertain, and is not so safe
as that of antipyrin and other similar preparations.
Phenyllmlrazine is best known as a test for the pres-
ence of sugar in urine, and is known as Fi.scher's test.
It was discovered by Prof. Enul Fischer, and depends
upon the property of the sugar forming, in the presence
of phenylhydrazine, crystals of phenylglucosazone.
Beaumont Small.
PHENYL-SALICYLIC ACID-ortho-oxy-diphenvl-car-
boxylic acid. t\,lL.OlI.C„II;,C00H— is a"\vhite powder,
slightly soluble in water and more so in alcohol and glyc-
erin, and is emploved as an antiseptic dusting powder.
W. A. Bastedo.
PHILADELPHIA, PA.— Philadelphia, founded by Wil-
liam Pcnn. was the first capital of the LTnited .States.
The pojiulation was estimated January 1st, 1903, at
Vol.. VI.— 39
1.347,712. The city, situated at the conllueuce of the
Delawareand Schuylkill Rivers, in latitude 30" .")7 north,
is nearly on a line with Madrid and Lislion, and is about
sixty miles from the sea in a direct line. The interven
ing portion of the State of New Jer-sey is almost a level
plain, abounding in pine, oak, and other timber of sec
ond growth. To the westward the land rises gradually
and the nearest mountain ridges are from fifty to one
hundred miles distant. The liighest elevation within the
limits of Philadelphia is 4.j0 feet. The mean annual tem-
perature is .53' F., with extremes of — -0 F. i1Sn9) to
103' F. (1901). The extremes in 1902 were 12' F., Feb-
ruary oth, and 95° F. July 9th. Precipitation. 49.76
inches. Days with precipitation of 0.01 inch or more,
128. Snowfall, 32.2 inches, distributed as follows:
January, 7.7 inches; February, 14.3 inches; March, 4,2
inches; December, 6 inches.
Clear days, 131; partly cloudy, 103; cloudy. 131.
Thunderstorms, February, 1; March, 3; April, 1; May,
3; June, 8; July, 13; August, 9; November, 1; total, 39.
The prevailing direction of the wind was northwest
and the maximum velocity was 52 miles an hour, from
the north, on December 5th. While the mean temper-
ature for the year is about 5.7° F. higher than at London,
the mean for Januar}- is 3' F. lower, and for July 15° P.
higher. The relative humidity at 8 a..m. and 8" p.m. is
75 percent, and 68 percent. The rainfall averages 43
inches, considerably greatei- than that of London"(24.84
inches). London, iiowever, exceeds Philadelphia, as
well as New York, Boston, Chicago, and all the princi-
l)al cities of the United States in the number of rainy
days. There are about 129 clear days each year in Phila-
delphia, which is less tlian at Baltimore (141), at Denver
(150), or at Phffinix, Arizona (2.39). The spring opens in
Philadelphia two or three weeks earlier than at Boston,
and autumn lasts longer. Roses may bloom through
November. The winters are not generally severe.
Comparatively little snow falls, yet there ma.v be days
or weeks of temperature below the freezing point. Pliila-
delphia has 86 parks, the largest, Fairmount Park, con-
taining over 3,300 acres, through which flows the Schuyl-
kill River, spanned by foiu- bridges. Within the limits
of the park the river reaches a width of about one-fourth
of a mile. At the northernmost boundary of the East
Park the romantic Wissahickon stream empties into the
Schuylkill, and the beautiful paths along its borders are
favorite resorts for driving, riding, cycling, and walking,
while the well-wooded hills that rise" just'beyond are at-
tractive places for picnics. There is excellent boating on
the Schuylkill and on the Wissahickon. Throughoutthe
park at convenient places are houses of rest, restaurants,
dairies, and playgrounds. The natural beauties of the
grounds are ju-eserved as far as possible. At the south-
western border of the jiark is the extensive Zoological
Garden.
Fairmount Park is of inestimable value to tlie citizens
of Philadelphia, and doubtless exerts a controlling influ-
ence on the death rate, particularly among children.
The general death rate of Philadelphia in 19(12 was
17.67 per 1,000 population. It was lower than that of
New York City ( 18. 74). and reflects credit on the energetic
measures adopted by the Bureau of Health. Carefufand
minute attention is paid to disinfection alter contagious
disease has been reported. Vaccination has been vigor-
ously carried out. During the past year (1902) the
deaths from smallpox numljcred 231 ; from scarlet fever,
143; from diphtheria. 435; from diseases of the heart,
1681 : from pulmonary tuberculosis, 2845. and from pneu-
monia, 2976. The deaths from consumjition have recently
fallen to second place, owing to a wider knowledge of the
principles governing the spread of the di,sease and to the
distribution of pamphlets showing how the di-sease may
be prevented. The Pennsylvania Society for the Pre-
vention of Tuberculosis has assisted in this way to limit
the spread of the disease.
Great good will accnu' from the recent gift of SI. 000,-
000 by jir. Henry Pliip|is for a systematic cflort in Phila-
delphia to eradicate tidierculosis by the establishment of
609
Flilllpplucs.
Plile^iiioii.
REFERENCE IIAXDBOOIC OF THE MEDICAL SCIENCES.
pulilic clinics, sanatoria, and tlic dissemination of infor-
mation as to till' means of previ-iition. Tliis will irreatly
aid the work of the Free Hospital for Poor Coiisnnip-
tives. Tile ri-eent fjift of Mr. Andrew Carneyie of
81,500.0(10 for I liiity branches of the Free Library of
Philadelphia, and the recent opening of the Boys' lliah
School, a building which cost wilh its eipiipment SLotlO.-
000, and which is probably the linest school buiklin;? in
the world, are notable steps toward the city's progress in
education.
Pliiladelphia is in a transition slate wilh reference to
great inuuici|i;il improvements. Chief of these is tlie
construction of enormous filtration beds at Torresdale, on
the Delaware front, in the northeastern portion of the
city, at lio.\liorou.gh in the northern jiortion, and at Bel-
mont in the northwestern portion. These are liarlially
completed and will cost over SI 7.000,000, anil they will
insure a satisfactory water supply,
Tlie Philadelphia Hospital, with its insane depaitnient
and almslii>use, is situated on the lower Schuylkill, aii<l
coiuprises within its walls a total po|)ulation of about
five thousand. Steps have recently been taken to re-
move the hos]iital for the insane and the almshouse to
a new location below Torresdale. and on the [iroperty
known as Blockley a new Philailelphia Oeneral Hos]iital
■will be erected. The original buildiu,a:s construcled in
1834 will lie torn down and new buildings erected in ac-
cordance with modern plans.
The Municipal Hos|jital for Contagious diseases will
shortly lie removed to a new site in the uortheasteni por-
tion of the city. There are over lifty hospitals in l^hila-
deli)hia. Chief of Iheseis the P<'nnsylvania lIos]iital, the
oldest institution of ihe kind in the United States,
The iMedical l)e|iartmeiit of the University of Pennsyl-
vania was established in 17(i.) by Dr. John Jlorgan, Dr,
William Shippen, Dr. Adam ICuhii, and Dr. Benjamin
Rush, Avho constituted the first medical factdty in Amer-
ica, The number of its graduates is l;.'.3lil. and with the
sister schools of Jefferson College, the Jledico-Chiniigi-
cal, and the Woman's Jledical Colle.ge, this school has
had a strong inlUnajce in maintaining the high standard
of medical education in the United Slates.
Philadelphia has long been famous for its teachers of
medicine and surgery, and their contributions to metlic«l
literature, issued by the well-known medical publishers
of the city, have carried the fame of American medicine
throughout the world. The names of Benjamin Hush,
Shippen, Physick, Wistar and Horner, Barton, Chap-
man. Pancoast. Gross, Stille, Hodge, Pepjier, Wood, Da
Costa, Agnew, and -iMitchell are hou,sehold names in the
medical hislory of our country, Uri;/ UinsdiiU'.
PHILIPPINES, THE. See J/,//,/?,/,
PHIMOSIS.
nt Si:.:'iiiil Oryiivx. Mule, Discnais of.
PHLEGMON.— Dkfinitio.n-.— To set exact limits to the
term phle.gmon is far from easy. Etyniologleally the
word signifies no more than intlatnniation (the idea of
"heat" or "burning " being equally present in both terms
— (f'/Jyi'iv — intlammare). Naturally, therefoie, ithasever
been loosely used. The concept lias been merged, on the
one side, into that of the .so-called cellulo-eutaneous eiy-
sipelas; on the other, into that of the localized .abscess,
French and German surgeons ti.se the word in its wid-
est sense. By phlegmon they mean any ])yogenic in-
flammation beginning in the subcutaneous cellular tis-
sue; even furumde and carbuncle are by some described
as varieties of the class phlegmon. In tiiis idea they usu-
ally classify phlegmons as(i') simple or circumscribed,
a localized inflainmation resulting in a localized abscess;
and {h) ditfuse or spreading.
English and American surgeons, however, have come
rather geni'rally to attach to the word almost exclusively
the latter siguitication, that of a dift'u.se process.
Inclining to the latter .view the writer would adopt
Ziegler's definition and restrict the term phlegmon to
that pathological process in which there occurs a more
or less extensive infianiniatory exudali' of sero-puruleut
or seid-tibriiio-)Hiruleiit nature (often called purulent
o'dema). spreading rapidly in the subcutaneous or in any
of the submucous ti.ssues over a somewhat large area.
The causative agent is. so far as we know, always bac-
terial. The process may spread deeply and involve mus-
cles, fascia, and even periosteum, and may lead to p.va'-
iiiia or septica'inia.
In this sense the term must include those cases which
are usually called "phlegmonous erysipelas," for Ihe
liatbologieal and even the clinical pictures are practically
identical, and the etiological factor is the same. Phleg-
monous erysipelas, however, will be found discussed un-
der Eri/fiipelus in this iI.\NDi!0()K,
On the other hand, we have those comparatively mild
cases of "cellulitis" which, after showing some tendency
to spread, subside easily under hot ajiplications, or spon-
taneously, without causing material anxiety, Tliese, too,
must be considered to be iihlegmonous. though of a mild
type, liecause their nature pathologically and bacterio-
logically is the same as that <if the more severe destruc-
tive process wilh which we usually associate the idea of
phlegmon. The essential — that of a spreading inflam-
matory exudate caused by pyogenic organisms — is the
same; and the difference, one only of degree.
While the process usually has its main seat in the sub-
epithelial structure, it may at times involve principally
deep areas of areolar tissue, such as the mediastinum, the
preverteliral, oi the deep perineal region. In such cases
the atrium of infeclion may not be evident,
Erioi.ouv. — Phlegmons are in all cases due to the in-
vasion of micro-organisms in a soil unable to resist their
growth. It is with reference to both our bacteriological
and our clinical knowledge that the writer would suggest
the following classification*:
I. Those cau.sed by streptococci, staphylococci, or both ;
also those ascribed to rarer organisms, ejj., pneuinococcus,
gonococcus, etc.
II. Tho.se in which the entrance of gas-forming bac-
teria, with (U' without (but most often w-itb) the above-
mentioned organisms, leads to the development of a sub-
cutaneous emphysema and gangrene in addition to the
inflammatory signs of the ordinary phlegmon. This
class is called "progressive gangrenous emphysema,"
•■gangrene foudroyante," or "gas jihlegmon ."
III. Those caused by the extra va.sation of urine.
Such a classiticatiou is naturally far from arbitrary.
The classes fre(piently overlap. For instance, a urinary
extravasation is no doubt often, in part, a streptococcus
phlegmon, and may be also in part a B. aerogenes cap-
sulalus infection. The last-named is mostly combined
with an infection of Class I. Class I. affords by far the
greatest number of phlegmons.
It is evident that the discussion of the etiology of
phlegmons must bf almost entirely bacteriological. It
will be in place, however, to say first a few words in re-
gard to the iiiodt; of riiiritnre of the organisms concerned.
In general the nlrinin is a wound of some sort — from the
most insigniticaut abrasion to the most complicated in-
jury. As a matter of fact we find that phlegmons de-
velop most frequently in connection wilh the more severe
injuries. The contusion of the tissues in such cases ren-
ders them less resistant, while the recesses of large
wounds offer greater opjiortunities, both for the entrance
of infective matter and for the development of anaerobic
bacteria, and also render cleansing less easy.
The classical descriptions of severe phlegmon, espe-
cially of the gaseous form, are those furnished us by mili-
tary surgeons of the two preceding generations. Gun-
shot wounds and open fractures are clinically the injuries
* in tilt* ffillowin? <liscus.sioii I hnve avoided tlie term "malignant
leilenia" bwiaisc of ii.s lack nf exartnes.s. It has evktenily liilheito
been useil in a louse -icnse. to <iHsiirniit<* rases both of jras-baciltus In-
fection (i.e.. iranffrene foiKiioyantp, piofiressive eiiiptivseniaions
pan^rene, etc) and of severe stivitto- or staphvlocoocus phlct-'iiion, as
well as of plilej_'liioii line lo tlie liai'illus of nialifjnant a'deiiia IKocli),
Kiirtlier, the term in liself siifxyii-sts that tlie bai-iiuis of nialisnaiit
lerteiiia is thi- laiiMiiive factor, xvliiTeas late iuvesiisation has shown
that this liacillus is tint rarely at fault.
CIO
KEFEUEXCE HANDBOOK OF THE MEDICAL SCIENCES.
Plillipplues.
PllloglllOII.
most frequt'iilly oom])licatcd by iilili'gniou. piiiKttiired
wounds Il'SS ficiiui'iuly. cleau cuts least often of all.
Two or three cases are on icconl of tlie developinent of
gas phlegmon following a hyjiodeimic injection, or the
subcutaneous injection of saline solution. In some cases
the wound of entrance may not be in the skin but in a
mucous membrane. Finally, in some oases, no point of
entrance can be found.
Going on to discuss more in detail the bacteriology of
phlegmon, we shall have to treat particularly of: (k) the
relative roles of the p\ ogenic cocci ; (/') the bacillus aero-
genes capsulatus and other gas-forming bacteria; and (c)
the nature of the phlegmon of uriuaiy extravasation.
(a) Since the work of (.)gston and Rosenbacb in the
early period of bacteriology ( bSisU-iH")), it has been taught,
and is still generally believed, that, while the staphylo-
coccus is nearly always the cause of circumscribed
abscesses, phlegmonous inflammation is due to the
streptococcus pyogenes. More extended knowledge,
however, has shown us that such a proposition, uliile
possibly true in many ca.ses, must suiter numerous ex-
ceptions. It would carry us beyond the proper limits of
this article to go fully into the question of the strepto-
coccus as a disease-producer. Nevertheless, inasmuch as
the phlegmon has hitherto been considereil a streptococ-
cus inflammation pKV e-irclk net: it may not be amiss to
consider here whether such a conclusion is quite justified
or not.
What is the relative etiological importance of these or-
ganisms in the causation of phlegmon? When we come
to examine the literature of the subject, we find reall_v a
very small number of phlegmons, conqxiratively speak-
ing, in which the streptococcus pyogenes has been found
as the causative agent, Janowski' in his monograjih
upon sup])uration, says: "Numerous ex])eriments have
shown that the streptococcus is not necessarily more viru-
lent than the staphylococcus; on the contrary, that it
produces decidedly less often than the stai)hylocoecus its
efl'ect upon the organism of the host. It has bei-n found
also that whereas the .streptococcus alone, or more fre-
quently combined with the staphylococcus, occurs in
many cases of small abscesses, it is discovered compara-
tively seldom in phlegmons, for which in particular it
was claimed (Ogston and Rosenbacb) to be ch;uaetcristic.
Thus Steinbaus,- examining 10 eases of phleiiinon, found
the streptococcus only once, and in that ca.se cond.iined
with staphylococci. In the other 9 cases the latter ahme
were present. Janowski,^ in 8 phlegmons foimd the
streptococcus only once alone, in 4 cases staphylococci
alone, and in 3 the two combined. Szczegolew' exam-
ined 21 cases and found the streptococcus alone onlv
in 7."
In 19 cases occurring during late years in the Royal
Victoria Hospital, Montreal, tlie bacteriological examina-
tions revealed the staphylococcus (mainly aureus, or al-
bus, or both) in 8; streptococcus pyogenes in 8; and in
3 a mixed growth.* It may thus be inferred that the
staphylococcus (aureus or albus) plays at least as great a
role in the causation of phlegmon as does thi^ streptococ-
cus pyogenes. I have been unable to find in the litera-
ture of the last few years any special discussion upon this
point.
(i) Oas Phleffmons. — That variety of acutc^ phlegmon
which produces gas in the subcutaneous tissues has ever
been greatly dreaded by the sin-geon. The term fmidro-
yante (gangrene foudroyante). given to it by Maison-
neuve. e.xprcssed its terrible character. It was" the "pro-
gressive gangrenous emphy.sema" of the older surgeons,
* The possibility of some degree of error in tipiires such as those
quoted must be admitted. The dlflletiitv of erowirifr the strepto-
roc<--us pyocenHS on ai-tifli-iiil media : Uie fart tliat, as Marnioicli has
sho\yn. tlu-y snim extlaust ttle mt-diuin and refuse to f:T(j\v fuilln-r ;
their liaiiility In lie oultrrown Ity Tlit' ItarduT sIapl)vlocor<-us ; tin- fre-
quent failure . in tia- part of harI*TioloLnsls ti> t'.xamine stained slides
of the original pus: and nnalh liie fact that some strt'iih.cncci ju'e
strict anai^ioin-s. winlst anaeruliic cnltinvs jui- rarcl\' set up as a
routine practice.— all these points tender an ntiunalilled accepiatice of
statistics itpon the point in question impo.ssi)tie. save in casi-s iti
which we linow that very careful woik has been done. Nevertheless
the Ogures are extremely suggestive.
and indeed still goes by that name. The Germans call it
" Gasphlegmon."
With the modern method of treating wounds it is be-
coming a much rarer disease th:in formerly. 'I'lie
chapter of its etiology is still far from being closed;
nevertheless, the researches of Welch anil Nuttall, Fle.x-
ner, and several others in this country, tind of Fraenkel
in Germany, have thrown a Hood of lii;lil upon the ques-
tion.
In 1891 Welch and Nuttall,'' of lialtimore, discovered
the organism to which they gave the name "bacillus
ac'rogeues capsulatus." In 1893 Fraenkel," ignorant of
Welch's work, discovered the Sitme organism indepen-
dently, and gave to it the name of " bacillus phlegmonis
emphysematosa." It is by Welch's name that it has
come to be most widely known. This organism is a strict
anaerobe; and it is po.ssible thiit the comparative paucity
of thorough anaOrobic work, botli before and since 1893,
may account for the fact of its not having been earlier
discovered, and also for the ftiet that there exists still,
after ten years, but a comparatively small literature upon
the question. Up to a late period the bacillus of itialig-
nant o'dcma was held to lie accountable for practically all
cases of "gangrene foudroyante." In the last few years,
owing to the publications of Welch and Fraenkel, the
pendulum has swung to the opposite extreme, and the
bacillus of malignant o'demtt is alloweii but slight if any
part in the causation of the gaseous jihlegmon. AVelch,'
in a thorough diseussimi of the; subject, in which he ?e-
vieAvs forty -.si.x cases of bacillus ayiogenes infection, re-
marks on the nei-d of a more accurate knowledge con-
cerning the malignant oedema bacillus. Neitherhe nor
Fraenkel could find it in their comparatively numerous
cases of emphysematous gangrene: and he believes that
older investigators woiked with insufficient methods.
Fraenkel " regards the ilisease caused by his bacillus
(which is identical witli Welch's) as one .■(»(' genen't). and
that dtie to the maligiiiint o'detiiit bacillus as quite a dif-
ferent clinical entity, because in animal experiments the
latter produced no gas.
Hitschmann and Lindcnthal,' on the contrary, believe
that gangrenous emphj-sema is an anatomico-ciinical en-
tity, but due to different infections. Of these the bacil-
lusof mtilignant (edema would betheonemost frequently
found; Welch's bacillus iiexl ; while finally the bacilltis
coli communis and the proteus might be responsible for
a few cases.
The most recent work upon this question is that of Sil-
berschmidt.'" His conclusions, ba.sed on extremely thor-
ough and straightforward w-ork, certainly carry weight.
In three cases of phlegmon accompanied by the develop-
ment of gas, he found in one the bacillus tedematis
maligni; in another, an organism belonging to the
"group of malignant (edeitia biieilli": jind in the third
an undetermined non-pathogenic anaerobe. In all cases
there was mixed infection ; iti the first with B. coli com-
munis, in the second with streptococcus jiyogenes, and
in the third with staithylocoeci and strejitococci. He
concludes that the B. irdematis maligni may certainly
cause the formation of gas iti "giingri-ne foudroyante.""
In a fourth case of infection iinil de;ith. following the
opening of a cold abscess of the feiiiiir. in which there
occurred a gradual formation of gas in the course of the
six days subsequent to the opertition. Silbef.schmidt found,
in addition to the ordinary staphylococci and strejitococ-
ci, a strictly anal'robic stre)iloeocctis which produced a
foul odor. He comes to the conclusion that gangrene
foudroyante may be caused by a number of different oi-
gani.sms. He is inclined to ascribe typical yas i;anni'ene
to anaerobes alone. He contests the strict ehissiliialiou
of Welch and Fraenkel, .-inil apices with Lindeiithal and
Hitschmann that the same clinical picture ;is is recog-
nized to be due to Welch's B. ;ii'ronenes ca)isulattis may
be produced by other anaeiolies and in es])eeial by the ba-
cillus of malignant o>dem;i.
There is some evidence in late lilcrattire 1o show that
other anaerobic bticteria besides Welch's liacilltis and the
bacillus of malignant o;dema may produce gas in the tis-
(ill
Pllle:;lii«>u.
Pllle;;'lllolB.
liKFEUEXCE IIANI)]!()C)K OF THE I\n:i)Ic;AL SCIEX'CES.
sues inim r/lnin. Eiiuk'iitliul " f(.iiii(l an aiiui'Toliicljiioil-
lus (in con junction witli the 15. coli communis) belonging
to the group of tlic (cdcma Ijacilli, wliicli liotli /n ritro
and in tlic tissues produced gas. He isolated it from
cases of colpoliypcrplasia cystica, characterized liy tlic
formation of gascysts in tlie vaginal wall with surround-
iug necrosis and cell iutiltration.
It has been claimed by various observers thai the B.
coli communis may cause gas formation in the ti.ssues, es-
pecially in cases of diabetes. Such statements, in tlie light
of our general Unowledge concerning 15. coli infectious
and concerning llie role <if anaerobes in gas production,
nuist be viewed with considerable .scepticism. The ob-
servations thus far have not been based upon sufficiently
thorough work. The same may be said of the proteus
Hauseri. for which similar claims have been made.
In this question of etiology we have been discussing
the seed only. ]5ut the soil has also a great importance.
These gas-inciducing anai'robic organisms are ubiquitous
in their nature; they aie I'otuid in jjiactically any speci-
naai of earth, or dung, or dust. J. ('. Friedman'- lias
foiuid seven dillerent anaerobes in the ca'cutn and appcn-
di-\ of man. of which the 15. ai-rogenes capsulatus was
till' most frei|uent. Why then are .gas phlegmons com-
paratively so rare? 'I'lie reason must be sought in the
unsuitability of the soil. The seed is constantly being
sown; but the soil nearly always destroys the seed, or at
least refuses iiouiishnient. Its resistance must be dimin-
ished befi >re 1 he .seed can grow. And thus as a matter of
fact we find that these infections nearly always compli-
cate severe injuries: in the majority of cases recorded it
is an open fracture. There is nearly always some chemi-
cal or meclianical lesion of the tissues. This was well
proved cx]ieriinentally by Berson.'^
!>jlit)hiii!<is is also, without doubt, an extremely impor-
tant factor. An old observation shows tliat the virulence
of the streptoeoeeus may be enormously increased by
growing it with the B. prodigiosus. The greater number
of the more severe septic processes are found bacterio-
logically to show ini.xed infections. In all si.\ cases of
severe infection reported by Silberschmidt there was
mixed aOrobic and anai'robic infection ; and it is es]iecially
in the case of these anai'roljic organisms that this (|uestioii
of symbiosis becomes of ini|iortance. F'or it has been de-
monstrated in the test tube that evenastiict anaerobe
will grow well enough in the presence of some oxygen,
provided a hardy ai-'robic organism is inoculated with it.
The latter probably uses up what oxygen is present, and
thus creates a partially anai'robic atmosphere.
Practically the conimoiiest germs found with the gas-
lu-odueing bacilli have been the pus cocci, B. coli com-
munis, B. typhosus, and imtrefailive bacilli. For the
B. al'iiigenes capsulatus, or the B. tedematis maligni to
be found as the sole organism in severe or fatal cases of
gas phlegmon is of rare occurrence.
It goes without saying that, apart from local injury
and the symbiosis of bacteria, all such general disea.ses as
reduce the vitality of the patient in'edis|iose to the de-
velopment of a soil favorable to the invasion of disease
germs. Thus, for instance, a |ililegnionous erysipelas
may be fatal in the advanced stages of tuberculosis or
cancer; and the urinary extravasation of the strictured
alcoholic is notcniously dingerous to life.
((■) In iifuiiirt/ (.vtrardxiitiiin the urine iiililtiiitis the
perineum, scrotum, iienis, and frc(iucntly also s]ireads
to the upper jiart of the thigh, the groin, and the lower
abdominal region. Ase]itic urine in the subcutaneous
tissue in small i|Uantities has been shown ex]ierinientally
to produce but slight intlammatory reaction, or none at
all. Nevertiieless. clinically, the iutiltration of urine
seems to produce almost in every case a most, decided in-
flammation. In many cases no doubt the urine isalready
infected. Even if not infected at the moment, as in cases
of wounds of the healtliy urinary tract, it is usually given
every chance to become so by tlie necessary catheteriza-
tion. Moreover, it is driven into the tissues not only
with great force, but also in great quantity, the bladder
muscle acting as a tis ii tenin. Some of the organisms
which most frequently infect the bladder decompose the
urine with the formation of ammonium carbonate and
often also of free ammonia. The B. coli communis, B.
lactis aSrogeiies, or other bacteria belonging to the same
group; the diplococcus ure:e liiiuefacicns, the proteus
Hauseri are those most often found. The staphylococcus
and streptococcus are also not seldom present, and would
render still more acute the intlammatory process set up.
When we con.sider what a powerful combination of factors
for ill we have in these cases, — the mechanical distending
action of the urine, the chemical action exerted by the
jiroducts of its decomposition, the special inllammatory
action of the bacteria present, and liually the rundown
condition of most of the subjects, — we can understand
how virulent the process often is, and how the patient so
rapidly succumbs to the sepsis engendered.
Clinically we usually find the extravasation taking
on a j)lilegmonous character very rapidly. A painful,
vividly red swelling a|ipears. and it needs no long time
for the decomposed, fre(|uently ammoniacal urine to
cause breaking down ami putrefaction of the tissues,
with the formation of foul-smelling pus and very fre-
quently gas. High fever soon sets in, and the general
condition becomes rajiidly bad. Frequently operation,
even early operation, comes too late, and death follows
with septic symptoms.
One point, that of the frequent presence of gas in these
lihlegmons, remains ratlier unsettled. Whetherthe colon
bacillus can be accused is very doubtful ; at the most it
might produce gas in diabetics. It is possible again that
the gas represents in ]iart at least free ammonia from the
decomposition fif the urea.
Anai-roliic bacteria, such as those concerned in gas
phlegmon elsewhere, may be at the bottou of it. biit I
liave been unable to find literature upon that point.
AVeleli. in Ids exhaustive article' upon cases of gas-bacil-
lus infection, shows that the 15. aerogenes capsulatus
may not only gain entrance to the body by way of the
urinary tract, but also set upi its own infection in the
tract itself. The .gas produced "may be either free in
the cavity of the bladder, ureters, or renal pelvis, or con-
tained within submucous blelis. or in both situations."
But though the presence of this bacillus in the urine is
well attested iimidc the urinary tract, I can tiud in a
somewhat careful search of the literature no record of its
having fjeen demonstrated in urine outside the tract — I
mean in extravasations. This is a point for future in-
vestigation.
MoHBiM Ax.xTOMV. — In discussing the morbid changes
which occur in this disease, we take as our ty ]ie the acute
phegmon of a limb which oecasionally complicates a se-
vere injury, and which is due to the ordinary pyogenic
cocci.
The gross and microscopic changes in the tissues are
practically the result of a very intense intlammatory
process, and involve principally the subcutaneous cellu-
lar tissne, but also the true skin and in some cases the
deeper structures. The skin becomes deeply red. and
there often occurs a decided lymphangitis, so "that clini-
cally we see the well-known red lines running toward the
neighboring glands. In the cellular tissue the organisms
advance ra]iidly along the lymphatics and connective-tis-
sue spaces, while the host reacts with a copious out|iour-
ing of intlammatory lymph. The parts become so infil-
trated that there is imparted to the examining linger the
hard sensation of brawn — a brawny u'dema. The skin
later assumes a dusky red tint, and exudation jiroceeds
to the point of threatening gangrene. Occasionally gan-
grene actually occurs, the skin becoming marbled with
pur|)lisli-red areas and being thrown oil tinally, either iu
patches or tiver larger areas.
If incisions are made iu the early stage, say within the
first day or two, there exudes nothing but a thin serum
which may or may not be slightly turbid from admixture
of leucocytes and flakes of flbrin. If the process has
gone on to the "brawny " stage the cut surface shows a
pork like aspect, or sometimes mine like orange inilp,
especially at the area of greatest intensity. A little later.
612
REFERENCE ILVNDBUOK UF THE MEDICAL SCIENCES.
Plilegiuon.
Pblegiuon.
vesicles filled with a turbid fluid may form in the skiu,
owing to localized exudation in the rete.
Jleauwhile iu the cellular tissues, if the case be severe,
the inflammatory process goes on from mere inflltralion
to a coagulation necrosis. The necrosis is due not only
to the mechanical distention of the exudate, with the
venous thrombosis and general circulat(ir_y stasis which
it produces, but also to the accuuuilation of bacterial
toxins. It seems to be a frequent pro])erty of the organ-
isms usually concerned (virulent streptococci or staphy-
lococci) to cause intense and rapid necrosis of tlie parts
infiltrated, while their peptonizing power remains in the
background. Nevertheless, after the necrosing process
has continued a variable time, there succeeds — if the jia-
tient have not succumbed to a fulminating septicieinia — a
certain amount of liquefaction or peptonization, so that
in the cotu-se of a few days we have in the subcutaneous
tissues what might be called a laUe of pus, iu which float
shredsand massesof sloughy tissue. After incision these
shreds often have to be pulled or cut off. -.ind resemble
strands of ■■ wet tow " or "wet chamois leather." If the
liquefying process has been less active, we get a series of
small ponds, or irregular bayous of pus, separated by
isthmuses or peniusulse of wholly or partl_y dead tissue."
If incision does not give vent to the pus, it re(iuires no
long time for the latter to find its way out through the
skin. In such cases sloughy ulcers jiersist. throULih
which shreds of necrotic tissue and pus are discharged,
and healing takes place slowly by granulation. In rare
instances it may burrow deeply and invade joints, de-
stroy muscles and tendons, or corrode arteries. If deejdy
situated and covered by strong fascia' — such as in the
pelvirectal sjiace. the retroperitoneal tissue, the medias-
tinum or under the fronto-occipital fascia — it may not
.seldom break through into hollow viscera, or attack the
serous membranes.
The miovscnpiriil -jiheiioiiicim are largely those (jf ordi-
nary inflammation — outpouring of inflamniatoiy serum,
diapedesis of leucoc_vtes, phagocytosis, the accumulation
of round cells in groups in the corium and in the .septa
between the fatty masses of the pauuiculus: the reaction-
ary proliferation on the part of the lymphoid and fixed
tissue cells; and the dilatation of the lymphatics, which
are filled with organisms.
Tlie microscopical appearances in detail will vary ac-
cording to the severity of the infection. In mild cases,
subsiding rapidly under incision, there is evidently com-
parative!}' slight reaction of the body cells: pus may not
be found; and the exudate is reabsorbed. In the typical
severe case the early extreme serous exudation liecomes
iu the course of a few days invaded by a large number
of leucocytes; the proteolytic ferments of the pyogenic
bacteria come into play; necrosed tissue is liquefied, and
pus is formed. Tliis pus is not localized, but is distrib-
uted over considerable areas as an infiltration. Finally,
in the fulminating cases we find again but slight evidence
of any cellular reaction. The bacterial toxins kill before
the individual defenders of the body can marshal to re-
sist. Welch' has found this last-mentioned state of
affairs to be especially true of pure infections with the
B. aSrogenes capsulatus. This bacillus, if pure, leads
mainly to necrosis, the nuclei disappearing by karyoly-
sis, while leucocytes and cellular reaction are remarkable
by their absence.
The characteristic points, however, in ordinary phleg-
mon are the excessive primary exudate of serum, tlu^
comparative!}' late proliferation and advance of the leu-
cocytes and other body cells, and the marked necrosing
power of the microbic toxins.
While the above would represent the changes in the
average severe case of phlegmon, many otiier less fre-
quent types might be set up. dependent upon the situ-
ation of the process and its degree of virulence. Thus
we have the deep phlegmon, situated underneath the
deep fascia, in which the pus accumulates in tlie inter-
muscular .septa, which it luay infiltrate in long strands.
The superficial structures meanwhile may show for many
hours or for manv days no sign of the underlviug infec-
tion ; yet sooner or later oedema develops. In mild cases
the exudate may never become purulent and may be
finally reabsorbed if incisions have not been made. At
the other extreme, we meet the very malignant tyjie iu
which the whole limb becomes, within twenty-four to
forty-eight hours, intensely a>dematous. while tlie patient
succumbs, or the limb is amputated, before pus has time
to form. Such cases are due probably to the extremest
degree of virulence of the pus cocci.
In cases of emphysematous gangrene the above picture
becomes more or less typically modified. The wound
secretion, hitherto comparatively healthy, becomes in-
creased and smells horrible; thin, fairly clear serum flows
from the drainage openings: the parts around the wound
become swollen; the neighboring skin begins to show, in
spots or in patches, a purplish or blue-black coloration ;
air collects in the interstices of the subcutaneous tissue,
giving to the examining finger a sensation of fine crack-
ling. This emphysema, accompanied by extreme cedema,
spreads rapidly up ti.e limb; tlie skin takes on a special
coloration, which was particularly noticed by the first
observers and was compared to that of a dead leaf, or to
that of Florentine bronze. Sometimes it looks like a
week-old ecchymosis. The distended veins stand out iu
blue against this dark-biown background: here and there
show up patches of a darker color, beginning gangrene,
which, in this form of phlegmon, tends greatly to be-
come extensive. Tlie emphysema may extend so rapidly
that its advance has been followed for inches during a
few minutes' observation.
C'LiMC.-iL CouusE. — This will vary to some extent ac-
cording to the nature and degree of virulence of the
causative factor. If we take, as liefore, an ordinary case
of rather severe wound infection, the .signs are somewhat
as follows. They may be considered as {a) local, and (A)
eousiitutional.
(ii) Local. — At a variable period following the infliction
of the wound, but usually within three or four days, in-
flammatory signs appear in its neighborhood. The edges
grow red and (edematous; the same condition spreads
rapidly up the limb, invading the subcutaneous cellular
tisfiue per milt inn tun ; at the same time pain of variable in-
tensity is usually felt in the parts. The lymphatics may
show as red lines in the skin leading up to the nearest
lymph glands. Tlie (edema may involve a whole ex-
tremity within thirty-six to forty-eight hours. Vesicles
frecjuently form and are filled with turbid serum.
If numerous incisions arc made at an early stage, the
process may frequently be arrested and subside with or
without the formation of pus. The converse of this pict-
ure is seen in those cases iu which, in the absence or fail-
ure of operation, the inflammation extends rajiidly be-
yond the limits of the extremity involved and attacks
"the trunk. Exit us litiiUs, within a very few days, is then
the most frequent ending.
('') C'linMitutiunal. — The .symptoms are usually grave.
Even the cases of slight or moderate severity are ushered
iu with chilliness, fever, general malaise, etc. In the
very severe cases the chill is marked, the fever high, the
pulse rapid ; the patient may become somewhat deliriou.s.
and after a variable lapse of time sink into a typhoid
condition and die of acute general sejisis. In other ca.ses,
especially iu those whose resistance has been weakeiK'd
greatly, the course may be of an astbenic type from the
beginning, and the patient shows neither locally nor con-
stitutionally any appreciable effort at throwing off the
no.m. Cases of this nature are to lie set down, in th«
present state of our knowledge, to infection with the
streptococcus pyogenes, the staphylococcus aureus or al-
bus, or to a combination of both; with the additional
liresence, in some cases, of still other bacteria, such as
those of the colon group and proteus.
The ordinary severe case, left lo itself or operated late,
is characterized in its later course by the results of the
extensive cellular necrosis. Through spontaneous or
operative perforations pus and shreds ol slough are dis-
charged for many days or many weeks. If finally the
wounds granulate up, the structures involved — skin,
613
Plllc^'IIIOU.
Plile;;iiion,
REFERENCE IIAXDCOOK OF THE MEDICAL SCIENCES.
nuisdes, tendons, fascitB, nerves, and arteries — are all in-
volved in the reparative sear; and the i)atient maybe
left with an impotent limb. In some eases liealinir <loes
notoecur; su|i|)iirative fever continues i pyaniia or sep-
tico-pya'niia develops and ultimately leails to the death
of the patient.
When Welch's B. afrogene.s eapsulatus or, less often,
the bacillus of malignant a-denia entei's tlu' field, either
alone or combined with the ])3-o.s;enic cocci, tlie clinical
picture is usually more grave, <.)ur classical clinical de-
scriptions arc given by .Maisonneuve and I'inigoll. In
their day, with the abvindance of military surgery, cases
were much more freciuent than now. Pirogolf divides
the cases into two clinical groups. As I am unable to
get access to llie original literature, I paraphrase from
Welch."
"(It) III tiie very virulent there is but slight local reac-
tion while the part goes on into crepitating gangrene. Tlie
emphysema and necrosis spread ra|iiilly and the patient
usually dii-s in a few days with symptoms extremely
to.\ic and asther.ic. (h) In the other group there is reac-
tion. The emphysema is preceded and accom]ianied by
local (cdemaor purulent intiltration. as well as by febrile
reaction: it appears later after the injury, and spreads
less rapidly. All grad;itions are. however, ob.served."
The cases in which phlegmon has lieen ascribed to the
invasion of bacteria other than those mentioned above
are very rare. Abnkvist '^ describes a case of extensive
intiltraling abscess of the foot in which gonococci alone
were found, lie refers to four similar ca.sesin the litera-
ture.
A cellulitis of tlie oibit has been described as due to
tlie influenza bacillus. '■'' Netter"' reports a case of
phlegmon due to Fraenkel's pneuinococcus.
Other than these I have been unable to find in the
literature.
In addition to the above general consideration of phleg-
mon the wiiter has thougjit it advisalile to make a few
remarks u|>on the cliaracteristics of iihlegmon. in its vari-
ous localizations, before .going on to the questions of
prognosis, diagnosis, and treatment.
PHi,ECiMONS OP THE ScAi.i". — The anatomical peculiar-
ities of this region give an especial interest to the ques-
tion of phlegmon. The parts are .so unyielding that
inflammatory processes lend to s[)read widely and to in-
filtrate. This is true of inflammations both aliove and
beneath the fronfo-occipital aponeurosis, but especial!}'
of the latter. The subaponeurotic connective tissue being
continuous with the cranial periosteum, plilegmnn, when
it attacks the former, is extremely apt to destrov the lat-
ter and so lay bare the bone. The dangers of tlie subja-
cent, more or less inevitable, bone intlanimation, or of
vein thrombosis, are evident. The internal periosteum
(/.('., the dura mater) may easily become involved. Von
liergmami refeis to eases of deep seated brain abscesses
arising solely by infection transmitted liy contiguity
along thrombosed veins. As eoniiiaird witii the su]ierti-
cial soft parts, the .a|inneurosis, together with the connec-
tive tissue binding it to the periosteum, necroses very
easily. This is due largely to the maiUK'r of its blood
sup|ily. AVliereas the main vessels of the sn|iertieial
parts run horizontally to the surface and thus frequently
escape injury in lacerated wounds, those su)iplying the
aponeurosis and iieriostetim run mainly vertiealiy to the
parts nourished, and are apt to be torn aeioss in wounds
of the scalp. Moreover, the tension which the tight
aponeurosis exercises upon any large exudate leads me-
chanically toward death of the tissue.
Diffuse phlegmon, therefore, of the scalji, especially
if deeply situated, is one of the most formidable compli-
cations of eont used and lacerati'd wounds. Kurtiuiately.
aseptic surgery has maile it rare. The accompanying
fever is high, and the resulting abscesses are numerous,
while the liability to inlracraiiial suppuration is not
small.
The erysipelas whicli attacks deep scalp wounds is
especially to be feared. The subaponeuroiic nnective
tissue is in such wounds the part must injured; and the
hirns minoris resistentkv thus created attracts, so to speak,
a superficial erysipelas into the deep parts, and thus gives
rise to a phlegmonous erysipelas.
Phlegmon occurs usually as a complication of wounds
of the head, but also follows osteomyelitis of the cra-
nium; or, again, it may be an extension from face phleg-
mons. Pain, swelling, high fever, and especially the
swellingof glands behind the ear are the early st/miitrnus.
Early diayiioxix is important, liecanse here, it anywhere,
is early and deep incision — down to the bone if the iihleg-
mon is deep — necessary, if both extensive necrosis and
also the danger of intracranial mischief are to be avoided.
The incisions must tie kept well open with gauze or drain-
age tubes.
Pitt.KGMONS OF TifE Neck. — Inflammatory processes in
the neck are usually circuinscribeil and end in abscess.
The diffuse ]ihlegnuin is comparatively infrequent: it
ma_y arise primarily as such, or may be secondary to a
localized inflammation.
It is caused by infeciiou of wounds by extension from
neighboring inflammations, either by contiguity or by
the lymphatics through an adenitis. Rarely can it be as-
cribed to a haniatogenic infection, as in pyaemia.
The clinical picture varies somewhat according to the
anatomical region involved. Uf these the most import-
ant is the litihiiKt.i-ilUin/ phkyiiKjii , for which the ordinary
term is Ludirirfs dhginn. It is Certain that Ludwig's
angina isalianie which has been too loosely used. ]\lo.st
frecjuently it has been confoundi-d with other inflamma-
torj' lu'ocesses which have as their most striking symp-
tom an aniema of the glottis, such as phlegmonous ery-
sipelas of the larynx, or acute perilaryngeal infection
dejiendent on other causes. As a matter of fact the dis-
ea.se described by Ludwig, in 183S, was an acute iufec-
tion of the connective ti.ssue of the submaxillary spaces
se<ondary to an adenitis of this region, the original lesion
being usually a carious tooth, a mucosal uh'cr. ora tonsil-
litis. The depth of the inflammation, the extreme press-
ure exerted on thi' exudate by the unyielding deep fascia
covering the space, and the liability therefore toward in-
volvement of neighboring (U'gans (in especial the larynx)
gave the disease a cliaracii-ristic picture — that of a severe
and frequently fatal infection. The term Ludwig's
angina sliould be reserved for cases showing the above
pathological condition.
Baeterwliiiiiedllii the streptococcus is found most fre-
quently. In four cases re|xined by Leterrier the strep-
tococcus was found twice, the staphylococcus aureus
once, and iu the fourth an tmdetermined bacillus. In
four examined by tJasser, the streiitococens, combined
with a very virulent 15. coli communis, was found in each
case (([noted by Jordan iu the " Ilandbuch der praktischen
Chirurgie '').
Pdtliiihifiieiilhj there are found a purulent infiltration of
the connective tissue of the space, and an extensive in-
flammatory (edema of the floor of the mouth, the larynx,
and the phaiyux.
The niinijitDiiix are in general those of the acute phleg-
mon iinywhere. But the local conditionsadd the charac-
teristic signs of difficult or impossible deglutition, great
dyspmea, impossibility of opening the nmuth. salivation,
i\m\ fiitiir t'.r '//■<. Death frequently follows in a few days
with sym])toius of general sepsis, or from laryngeal cede-
ma it tracheotomy be not tpiickly done. The infection
ma.y kill in from two to three days. Such fulminating
cases are <lue to an extremely virulent slivptococcus tox-
a'lnia. and the earliest surgic:d interference may be insuf-
ficient to prevent death. In some cases of a-milder de-
gree of infection a localized abscess results, and breaks
into the mouth or through the skin.
The p>-'i;/iHi.ii.s has certainly brightened of late years.
Delnrme in IS!):! was able to report a series of seven re-
coveries in cases operated early.
Trmliiii'iit. — Incision should be practised at the earliest
possible moment, even befiii-e pus can be diagnosed. It
is best made a finger's lireadlli below and parallel to the
alveolar border id' the jaw. Afti-r superlicial incision it
is best to proceed deeply with a blunt pointed instru-
G14
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Plilef^nion*
Phlcgiuon.
ment. Witli great d3'spnoea tracheotomy should bo done
without hesitiUion.
Phlegmons muy develop at the angle of the jaw and in
the submental region ; but in these situations they tend to
localization and heal easily upon incision. Phlegmons
may arise in the loo.se areolar tissue sunoumling the
large vessels of the neck, the vessel sheath. Thi-y come
in fre(juenc}' ue.xt to those of the subma.vilhiry region,
and originate most often from the deep cervical glands
following anginal affections, carious teerh, otitis, etc.
While infection in this region is frequently of the com-
paratively mild, circumscribed tj'pe, yet when the sevei-e
spreading type docs occur, it is one of the most danger-
ous conditions possible. The swelling is deep and hard
and may extend rapidly from the ear down to the clavi-
cle, and from the spine to tlie trachea. The skin becomes
reddened rather late, and wry -neck and trisnuis come ou.
Frequently death occurs from sepsis before pus forms.
AV'heu aljscess forms, the pus may sink into the niedias-
tinuiu or axilla, and may cause compression of the tra-
chea, ojsophagus, large vessels and nerves, and these
complications may be the immediate cause of death.
The prognosis is bad. Trci-tiiiuiit consists in very earlv
multiple incisions.
Complications. — Besides those already mentioned tliere
ma3' occur erosion and perforation of vessels. In the
case of a vein, bleeding maj' be absent, if the vein has
been occluded \iy a thrombophlebitis; in the case of an
artery, however, there follows not infre<pi<'ntly fatal
hemorrhage, although at times the bleeding is moderate
and repeats itself at intervals. The carotids have been
ligated in continuity in such cases with success.
Keclus-'' has described under the name of " phlegmon
ligneux du con," a rather chronic form of phlegmon, de-
veloping very slowly, of very liard consistence, and
involving a large area on one side of the neck. It may
simulate closely a new growth.
Pni,EGMONS OP THE Axii,i,.\. — These are either subcu-
taneous or subfascial. They have their origin usually in
a lymphangitis running from a primary infection in the
hand, arm, or breast. Freiiucntl}' the atrium of infec-
tion is scarcely to be found, and the first symptom i.s
pain and swelling in the axillary glands.
The s\d]cutaucous phlegmon is easy of diagnosis; more
difticult is it when the phlegmon begins dee|ily luider the
pectoralis and spreads toward the axilla. AVith the ordi-
nary constitutional disturbance we get a dull jiain and a
restriction of shoulder movements, especially of abduc-
tion. It is only after several days usually that a dilata-
tion of suiiertieial veins and a slight swelling over the
pectoral region are seen.
Incision should be made, as soon as the affection is diag-
nosed, at the posterior edge of the great pectoral Ihrougli
the deep fascia, and then blunt dissection shoidd be con-
tinued with the linger under the muscle, until the pus is
reached.
Phlegmons of the Upper Arm. — In this region
phlegmons of a comparatively mild nature and iii'-.idious
ou.set are not infnM|Ucnt on the inner side of tlie arm. anil
originate in inflammatory conditions of the lymphatics or
lymph glands in the bicipital sulcus or in a bursitis ole-
crani.
Apart from the ordinary suljcutaneous ]ihlegnions .la-
boulay -' distinguishes cases in which the process is sit u-
ated under the deep fascia running in tlie sheath of the
vessels, thus forming a band along the inner side of the
arm to the axilla, which upon abduction of the arm is
painful. Naturally the fascia must always be split in
order to lay open the focus.
Phlegmon of the Fixgers .\nd H.\nds. — Phlegmon-
ous processes in the hand require especially early diagnosis
and thorough treatment in view of the too frequent loss nf
function, sometimes of "earning power" (as the Germans
call it), following upon failure or neglect in this ]iarticular.
The panaritia. confined to the terminiil phalanx, are
hardly to be considered here. Nor do the infections br-
ginning in the periosteum and confined to one of the idia-
langes properly come into our classification of phleg-
mons. It is true that either of them may lead to
phlegmonous processes, but to discuss them would lead
beyond the limits of this article.
The important phlegmons of this region are those
which involve the tendon sheaths, either primarily or
secondarily. It is necessary to remember with regard to
jihlegmonous processes, whether in finger or hand, the
anatoiuieal ijeculiarities of the subcutaneous connective
tissue. On the dorsal surface the connective-tissue
bands, uniting skin to fascia, run at an acute angle, in
fact nearly parallel to the long axis of the limb, thus al-
lowing of a great deal of elasticity in the subcutaneous
tissue. On the palmar surface the reverse is true; the
connective-tissue bands run mainly vertical to the long
axis of the limb, and are characterized b_v thickness and
densit_v. The restdt is that any infiammatoiT exudate
occurring on the palmar aspect meets with great resis-
tance in its spreading toward the surface, but finds an
easy path toward the dorsum. Thus it happens that a
marked cellulitis, with great redness and a'dema, fre-
quently appears on the dorsum of the hand, while the
focus is really situated on the jialmar surface and may, if
beneath the palmar aponeurosis, have occasioned on that
aspect of the hand no sign at all suggestive of inflamma-
tion. No doubt the cyanotic cedema of the doisiim in
such cases is caused partly also b_y pressure on the deep
dorsal veins as they jiass forward between the metacar-
pals to join the palmar arch.
In such cases au exact examination is required, lest
dorsal incisions be cotmtcd suflicient. and the one really
necessary palmar inci.siou down to the focus lie over-
looked. The one ciiterion available is an exact localiza-
tion of the point of greatest tenderness. The whole hand
should be examined for this area with a blunt-pointed
probe. The point of greatest tenderness will always
correspond with the primary spot of infection; and as a
matter of clinical exiierience that focus is in the great
majority of cases on the jialmar side.
AVith regard to infectious of the tendon sheaths we
must remember their anatomical relationships to each
other. The tliumb sin alb runs u|i to a point under the
annular ligament, while that of the little finger extends
under the annular ligament, and in some cases a short
distance up the arm. Both couiniunicate with the large
Jialmar bursa. Infection of either of these two may lead
by continuity, even in the absence of direct communica-
tion, to involvement of any or all the others.
The course is frequently very acute. In a very few
days the sheath may lie filled with jius; and, being nor-
mally but poorly nourished, it necro.ses very readily. In
such cases the necessity lor the ]iioniptest surgical in-
terference is exceptionally evident; expectant treatment
is apt to leave a practically useless hand. If not opened
early the infection may spread to the deeji connective
tissue and cause an extensive phlegmon of the palm;
it mav extend from here up beneath the annular liga-
ment and cau.se a deep phlegmon between the muscles
and tendons of the forearm. The (lossible further dan-
ger of se])tic thrombophlebitis and pyu'inia is well known.
Even nowadays such progressive jjldcgmons, which
might have been arrested in the hand by jiroper interfer-
ence, lead occasionally to amputation of the arm. Fail-
ing this, convalescence extends over months, and at the
end the patient is left with an arm whose usefulness is
largely destroyed. The imiiortanee of early interference
in, for instance, the case of a workinginau is enormous.
Rather too long and too dee|i a cut than too small or too
late a one. It is scarce possible fur it to be too early. It
is wise in incising the palm foi a deep infection, to push
forward bluntly with a pair of forceps after getting
through the skin. A counter opening on the dorsum with
through-ancl-through drainage is of ten advi.sable. Gen-
eral aiuesthesia is probably the best for these extremely
painful phlegmons of the hand.
AVith regard to after fesulls a certain amount of fixity
of the tendon involved is scarcely to lie avoided. Yet if
massage, hot bathing, jiassive movement, and electriza-
tion of the corresponding muscles be instituted as soon
615
Plllt'l^lllOII.
J:*]ilc;i;lllull.
REFERENCE IIAXDBOOK OF THE MEDICAL SCIENCES.
as possil)li\ a satisfactory animint of fuiu'tion iua_y not
iiifriM|iieutly he recovcrpil. The ciiclothcliiim ololliing
tendons and tendon sheatlis (as inch'cd eveiywliere in tlie
hody) possesses a large oapaeity of regeneration, pro-
vided function he restored early; hnt if tihrous tissue he
allo\ve<l to contract into a sear and pro<lnce adhesions, it
can evidently never be replaced by endothelinni. Thus
orthopedic measures to be successful must lie instituted
as early as possible.
Phlegmons of the dorsal surface are much rarer and less
dangerous.
Phi.eg.moxs op the Foot. — Deep phlegmons, under-
neath the plantar aponeurosis, cause, as in the hand, in-
tlainmatory signs on the dorsum. lon.g before anything
appears on the sole, and nuiy lead, if care is not exer-
cised, to incision in the wrong place. If the process in-
vades the t<ai<lon sheaths in the neighborhood of tlie
ankle-joint there is apt to follow rapid extension up the
leg.
Incisions should be made when possible so that the
scar will not he e.\])o.se(l later to pressure.
Pekii'Hoct.vi, Piii.eo-Mons. — Theatrium of infection in
this important class of phlegmons is in the great majority
of cases in the rectum. Slight abrasions from the pas-
sage of fa'Ces, scratches produced by hard and pointed
hitsof food — sucli astish bones — small nlcerationscaused
by stagnation of fa'ces in the lacuna' of jMorgagni — all
these represent opportunities for the invasion of path-
ogenic germs. Moreover, it must ))e admitted that infec-
tion may occur with an intact mucosa, througli the lym-
jihoid tissue in the wall, in analogy with the same process
in the tonsils. Catanhal iullammation. ulcers of any
kind, inflamed hemorrhoids, may he the starting-point
of a phlegmon. Infection of the anal skin. e.g.. eczema;
extension of intlanunaticais of neighboring organs, such as
urethiitis, Cowperitis. prostatitis, and in the female Bar-
tholinitis— all these niaj' give rise to a phlegmonous peri-
proctii.is.
The intelligent treatment of Uiese phlegmons is insepa-
rable from a knowledge of the anatomy of the paits.
AVitl.i ut .noing too deei>ly into this (pjcstion, we must
remind the reader that the perirectal connective tissue —
that ti.-;.-ue niimely in which phlegmons mainly run their
courRc — is divided into an inferior or supertlcial, and a
superii^;' cu' deeji |iorti()n; the former called the ischiorec-
tal fo.s.si, the latter the ]ielvireetal space.
It is the levator ani muscle with its encdosing fascia', the
superior and inferiiu' diaphragniatit- fascia' (or. as it usu-
ally appears in lOuglish literature, the two layers of the
triangular ligament), which divides the two spaces.
Phlegmons, therefore, may be superficial (!<■., situated
in the ischiorectal fossa), or deep (i.e., in the iielvirectal
.space); or they may spread sometimes through both re-
gions. In the first ca.se they may extend to the peri-
aeimi, scrotum, groin, or thigh, while in the second case
tliey spread hy direct continuity into the pelvic and
thence into the aljilominul retrnperitoneal areolar tissue.
>uid so U]) to the kidneys or in front over the anterior
abdominal wall. These are naturally nuich the more
dangerous. Portions of the peritoneum, even of the
bowel, may become gangrenous, .-md septic i)eritouitis
develop. Death most often results in from two to ten
days. Such phlegmons are fuhninating in character,
lua-smnch as virulent anatrohie gas-iimdueing bacteria
are invariably to he found in the fa'ces. it becomes evi-
dent that iieriprocta! |ddegmons may at anytime assume
the fuhninating type of emphysematous gangrene, or
".gangrene foudroyante," The bacteriological aspect of
the [jucstion has already been discussed.
Another type, described especially by Kraske in connec-
tion with a wound, is characterized hy gas formation,
but Avith a much milder course. It is sai(i that the B.
coli is the etiological factor; hut svich a conclusion, in
view of recent work ujion the anaProhes in gas phleg-
mons, must appear at least duhio\is.
The onset is insidious; locally the wcnuid shows often
nothing but a breaking down of the granulations and
sli.ght (edema in the neighborhood. Fever is slight or
absent. Graduall}', however, there develops a tissue
emphysema and .small gas-containiflg abscesses, with ne-
crosis of the tissues near the wound surface. At times
metastases develop, even in the absence of fever or chill.
Ultimately the patient becomes both restless and sleepy
(if the apparent paradox be allowed), then somnolent,
and in the course of weeks usually succumbs. Recovery
is ((uite rare.
Some authors describe a third form, characterized by
gangrene, called the "diffuse, gangrenous phlegmon."
This is. however, merely a variety of the fulminating
type of phlegmon.
In the above we have been speaking especially of the
severe spreading forms of the disease. They "may be
complicated, or not, by gas formation, and their proyno-
Kis is an extremely had one. AVIien infection is less viru-
lent we get a more circumscribed intiammation. with early
formation of abscess. The acute ischiorectal abscess is
often styled a phlegmon, but within the limits of this
article it can hardl}' be considered such.
Infections of the pelvirectal space are much more fre-
<iuently spreading in type. Dlitgnimx is here diflicult on
accoimf of their deep situation. Still, careful digital ex-
amination will often discover an inflammatory mass caus-
ing the rectal wall b> bulge inward. Even before such
swelling occurs, the presence of rectal and vesical tenes-
mus with deep jielvic pain should lead to a probable diag-
nosis of pelvirectal phlegmon. If left alone, or diagnosed
late, tlie condition is apt to cause extensive ab.seesses and
break through into neighboring organs or the skin, when
it does not lead to a fatal issue.
I'lnitiiieiit. — This is of course early incisioji. This
should never be made through the rectal wall, no matter
how tempting a pointing abscess may he; for in such
case drainage is ]ioor and faces enter the abscess cavity.
The incision, both in ischiorectal and in pelvirectal infec-
tions, should be through the i.schiorectal fossa. When
the absce.ss is deep — /.c, pelvirectal — the levator ani
should be exposed, and then a blunt instrument shindd
he passed between the two heads of the muscle, where
they reunite beneath the jirostate. The opening should
he made secure by a large stiff drain.
Phlegmons ok tii?; Testicle. — Phlegmons in this
region ac(iuire a sp<'cial interest from their tendency to
gangrene. They originate mostly from phagedcenic'" ul-
cers or wounds of the penis, urethra, and perineum; or
from suppurative cavernitis of the corpus cavcrnosnm ; or
from urinary extravasation, or as a result of sup])urative
periproctitis. They are characterized by an extremely
tense swelling of the scrotum, with frecpient ending in
gangrene of the skin, the inliammation often s]ireading
rapidly on the abdomen and the thigh, and also deeply
to the tunica vaginalis anil the cord. In this last case it
leads on not infrequently to phlegmon of the pelvic cel-
lular ti.ssue and even to peritonitis.
In virulent infections, and especially with urinary in-
filtration, also when the phlegmon connects with para-
proctitic processes, there frequently develops gas in the
infiltrated tissue. p>iiecially in these cases is the gan-
grene apt to be deep and extensive. The bacteriohigy
of this condition has already been described.
It is a point of considerable practical interest and im-
portance tliat an ordinary infective phlegmon, arising
from some focus in the anal gut or the ischiorectal fossa,
may s]iread with great rapidity and severity over the
perineum, scrotum, and the neiglilxiriug parts, and thus
simuhite a urinary extravasation so elo.sely as to induce
surgeons of experience to do median perineal cystot-
omy.
Pni.EiiMoNS OF THE Tnoi{.\cic W.VLL. — These are for-
tunately rare, for the progiKisin is always grave. They
usually spread from a purulent axillary adenitis and in-
vade most often the anterior wall, lying U]ion the fascia
underneath the greater pectoral. They may arise pri-
marily in the dee]! fascia from penetrating wounds. Usu-
ally they break through the skin, rarely into the pleura.
Ki'immell.'-'' of Hamburg, describes one ca.se which, ex-
tending from an empyema, spread over the whole of the
616
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Plilrc:;inon.
PiiU-i'itiuu.
right side of the back and down over the gluteal region,
as far as the great trochanter.
Diiir/nosiii may be extremely difficult in the early stages.
The one symptom at that time is extreme pain over the
whole side of the chest, so severe as to make respiration
difficult. This, with the accompanying fever and chill,
causes the condition to be easily mistaken for pleurisy.
It may be several days before redness of the skin, or
tluctuation at some point, renders the diagnosis unmis-
takable. A careful consideration, however, of tlie nature
of the pain, and of the severe constitutional signs, ought
to permit fairly early diagnosis.
Kummell" reports that of ten cases in the E|)pendorf
Hospital only two recovered; the rest all died of general
sepsis. No doubt some of these belonged, however, to
the old days of "expectant" surgery. At the present
day earlierdiagnosis and radical incisions ought to save
a much greater proportion.
Phlegmons of the CEsopn.\Gcs. — Phlegmon in this
region is siniated in the submucous tissue and is very
rare, but may be extensive. Some cases described as
phlegmons are evidently small localized abscesses.
When pus has formed it tends to break through into the
a?sophagus or the trachea, rather than to spread through
the mediastinum or into the pleural cavity. It may fol-
low the arrest of a foreign body in the a'sophagus, or
represent the extension of a pihlegmouous gastritis. In
a few cases no cause can be ascertained.
The symptomD. apart from tho.se of constitutional dis-
turbance, are mainly of local origin— ditticnlly of deglu-
tition, with pain along the course of the (esophagus,
especially behind the sternum and radiating to the
back; nausea; cough; occasionally vomiting of purulent
material.
Diiignnsis is extremely difficult except in cases in which
the historj' of the stoppage of a foreign body is clear.
Traitmh't. — With the O'sophagoscope a prominent ab-
scess may be discovered and opened. In severe cases the
question of external incision must be considered, if the
symptoms indicate a lesion above the thoracic cavity.
Apart from these indications treatment must be expec-
tant.
G.\STRic Phlegmon. — Cases of this kind are usuallj'
diagnosed with certainty only post mortem. The phleg-
mon complicates carcinomatous disease not infrequently,
simple ulcer but rarely. Occasionally it is caused by
foreign bodies or traumatism. It involves mainly the
suljnuico^a. The stomach wall is usually immensely
thickened, inflamed, and (edematous. Perforation may
occur in either direction. Clinically the picture is tluit
of acute gastritis with peritoneal symptoms and fever.
Kinuicutt ■' has lately described a striking case.
PHLEG.MONS OF THE L.VKYNx. — lu perilaryngeal phleg-
mons the symptom which dominates the clinical picture
is naturally that of a dangerous ccdema of the larynx.
And yet, for the sake of an exact knowleilge of the sub-
ject, the writer feels inclined to offer a prefatory note of
protest against the loose, slipshod way in which the term
"ffidema'of the larynx " or "a?dema"of the glottis "has
been so generally used, as if it represented a disease en-
tity, instead of "being, as it is, merely a symptom. It
may be due to entirely non-inflammatory causes, such as
severe nephritic or cardiac disease, in which it appears as
part of a general anasarca : or to the pressure of a tumor
causing local stasis. When of inflammatory origin the
cedeina may be the result of a primary infection in the
submucosa, occurring in the course of infectious diseases
as a metastasis; or of a primary local erysipelas (if we
admit that such reall_y does occur). On the other hand,
it may be caused secondarily by extension of some in-
flammation of neighboring parts. It is under this head-
ing that the laryngeal phlegmon is rangeil ; such a
phlegmon may have ari.sen in the floor of the mouth, or
in an adenitis at the angle of the jaw ; or it may have de-
veloped from a peritonsillar or peripharyngeal infection,
or, from an infection located in the connective tissue of
the neck; or finally its starting point may have been in
the areolar tissue of the submaxillary triangle, this last
representing Ludwig's angina in the strict sense of the
term.
These phlegmons are accompanied by the usual local
and constitutional signs. In this jilace it is necessary to
speak only of the dominating sign of local laryngeal
cedema, when it is of an_v severity. The symptoms de-
pend mainly on the diminution of the laryngeal opening.
The obstruction occurs usually by swelling of the aryepi-
glottic folds. Thus we have inspiratory dyspucea and
hoarseness. Pain may be constant, but is increased by
swallowing.
The one point upon which emphasis must be laid is
that the submucous infiltration may develop with ex-
traordinary rapidity. While this is true of infective wde-
ma, it is especially so of the traumatic a-dema. The
breathing must be constantly watched. A tracheotomy
may become necessary at any moment, and indeed many
patients have died for lack of it. von Ziemssen's rule
was, ''never under any circumstances to leave a patient
suffering from oedema of the larynx, and rather to do a
tracheotomy with a penknife, if proper instruments are
not at hand, than to let him suffocate."
While the prognosis of phlegmons generally is never
especiall}' bright, it becomes decidedl\' darker when they
become complicated, as in this region, by laryngeal oede-
ma. Sestier (quoted by von Bruns in "Handbuch der
prakt. Chir. ") found in 213 cases of o'dema glottidis (no
doubt of various causation, not solely of phlegmonous
origin) 1.58 deaths. Of the total number 30 had had
a tracheotomy done. No doidit jiresent-day methods
would show much more favoralile results.
As regards trctttment, besides the matter-of-course in-
cision for the original phlegmon, the surgeon must be
constantly in readiness to do a tracheotomy for the sec-
ondary oedema laryngis. Where the necessity stops short
of a tracheotomy, ice shotdd be given, and the ice-bag
kept applied ext^ernally. Intubation is contraindicated.
Complications. — These are mainlv of the nature of
metastatic inflammations. Suppurative synovitis and
arthritis complicate phlegmonous ery.si]ielas not uncom-
monly. The same result may be brought about by direct
extension of the iurtammalion into the deep structures.
An infective pneumonia has been described as due to a
streptococcus metastasis from phlegmonous erysipelas.
Endocarditis and albuminuria are rare.
Septicfemia, pya?mia, or seiilico-pya-mia not infre-
quently develop from a phlegmonous focus. Septic in-
flammations of the various serous membranes may come
on, especially following streptococcus infectious — pleu-
risy, empyema, peritonitis, meningitis. The B. aGrogenes
capsulatus may also cause peritonitis or meningitis.
Di.\GNOsis. — There is really no other disease from
which it is necessary to dilferentiate phlegmon when
superficial, as it usually is. The question of diagnosis
comes in only as between its own various forms. It
is desirable, however, to distinguish these, both for
therapeusis and for prognosis. The rapid development
of gas and of gangrene and its fulminating character
distinguish easily cases of gangrene foudrot/niite from
those of ordinary phlegmon (Class I.); but less easily
from cases of urinary extravasation. A late case in
the Royal Victoria Hospital, Montreal, of a B. aBro-
genes capsulatus phlegmon, starting from the rectum
and involving scrotum, penis, and groins, simulated so
perfectly a lu'inary extravasation that it was only at
post-mortem that the ab.sence of the latter could be made
quite certain. Still, in most cases, a diagnosis should be
made from the previous history of urinary trouble, :ind
from an examination of the urinary tract.
The diagnosis of a deep, subfascial phh-gmon may oc-
casion considerable ditficulty. The decqi pain, the fever,
and other signs of constilutidiial distiu-baiice will point
plainlv enough to an infected conilit ion ; but to determine
the e.xact localization of the process, whether it is in the
soft tissues or in the bone, i.e.. an acute osteomyelitis,
may be far from easy. In acute osteomyelitis the pain
is apt to be more severe, more localized; while subcu-
taneous oedema develops to a less extent and rather later.
Plilcccnion.
Pliloridziu.
ItEFEHENCE HANDBOOK OF THE MEDICAL SCIENCES,
Moreover, acute osteomyelitis oecurs almost coustantly
during adolescence and develops at an epipbyseal end.
As a matter of fact it is really nothing more nor less
than a phlegmon of bone: and its treatment is the same
as for phlegmon of the soft jiarts.
In the case of phlegmons of Class II. — gas phlegmons
— a very early diagnosis is of great import;ince for suc-
cessful tlierapeusis. Bloodgood ■■" has reviewed these
cases from the surgical standpoint in a very tliorougli
manner, and I quote from him.
" Unquestionablv in gas-bacillus infections an early
diagnosis is always possible, and not at all difficult. In
any recent wound with symptoms of infection, one
slioidd at once make cover-slips from the tluid in the
wound. The presence of large bacilli, morphologically
like the gas bacillus, even with the absence of gas bub-
bles or emphysema, is practically, in the mujority of
cases, pathognomonic of a gas-bacillus infection. If one
finds in addition air bubbles in the Huid, or emphysema
in the tissues, plus the presence of bacilli in cover-slips,
there is practically no question about the diagnosis."
Under the licad of treatment I shall quote further re-
marks of Bloodgood. which are a corollary to the above.
I suppose we may assume that a phlegmonous erysip-
elas, (.('., a phlegmon of the deeper stj-uctures develop-
ing by e-\ tension from a true erj'sijielas of the skin, is a
pure streptococcus infection. If we have any faith in
antistreptococcus serum, we must be careful in such
cases not to overlook in the general jihlegmon the coex-
istence of the cutaneous erysipelas; for in such eases, if
in any, would Ihe serum have a chance to do good.
Prognosis. — The outlookin any of our three classes of
phlegmon is usuall,v grave: but by all odds gravest in
the phlegmon of gas gangrene. The fulminating cases
of ordinary phlegmon (Class I.), which kill in a few
hours, are rare. >tore often the initieiit dies of the infec-
tion during the first week or two after the onset. If he
escapes tlien. he may die later of chronic sujipiualive
fever and pyaemia. If he recovers, he may be leit with a
functional!}' inqiotent limb.
In cases of gas gangrene (Class II.) the prognosis,
without operation, is practically always toward a fatal
ending. With early and proper treatment it is bj' no
means so black as our predecessors have jiainted it : and
it is yearly becoming less grave. The earlier and more
thorough the operation is, tlie brighter becomes the
outlook.
AVeleh ■ says that results are better after amputation
than after incisions only. Of the cases collected b}' him
of emphysematous gangrene, atfecting primarily the ex-
tremities, the recoveries numbered fiS per cent, after am-
jiutation, and 83|- percent, after incision without ampu-
tation.
Ti!E.\T.MEXT. — The treatment of phlegmon may be
considered inuler the three headings — non-operative,
operative, and serum-therapy.
yun-Operative. — Naturally this can be thought of only
in the mildest cases. Take, for example, a cellulitis
orginating in an infection of the hand, and spreading
with greater or less rapidity u]) the forearm. The sur-
geon incises such cases almost invariably as soon as he
sees them, and counts the distiguring scars — so disfigur-
ing, especially on the back of the hand — as not to be
weighed for a moment in the balance. Let us admit,
upon the whole, that he is right. And 3'et, how often
does the general practitioner apply in these eases hot an-
tise]]tic formentations alone, and see his conservatism, or
the patient's disinclination to the knife, justified by the
event! There is room here for the cxerci.se of the nicest
surgical Judgment. The writer believes that in the early
stages of these sjireading cellulitis cases, mild types of
phlegmon as they are, hot antiseptic apiilications or the
hot continuous bath should be tried first; that, however,
both the local and the constitutional sym])toms should be
watched carefidly and almost continuously. If. after a
variable ninnberof hours, to be judged by the intensity
of the process, the infection is evidently advancing, nud-
tiple incisions should be practised.
Some surgeons prefer cold applications, especially in
phlegmons of the deeper regions, such as the perilaryn-
geal or peria'sophageal. Elevation of the part and ab-
solute rest are matters of course.
It may be mentioned at this point that Crede's oint-
ment'■ (a salve containing fifteen per cent, of soluble
metallic silver) has been strongly recommended by some
in the treatment of septic infection of wounds. It is
usuallj' rubbed into the skin after the fashion of the mer-
curial ointment in the treatment of s^vpbilis; and it is
claimed that the formation in the blood of powerfully bac-
tericidal silver salts effects a general antisepsis of the en-
tire organism (Werler'"). The writer is unable from per-
sonal experience to give any opinion upon the question;
but the method of treatment has not cimie into wide use.
Operiitive. — This will vary, according to the case, from
a few superficial incisions to the amputation of a whole
extremity. -Multiple incisions are the rule in moderate
cases. After incisions the parts should alwaj's be kept
enveloped in hot, wet antiseptic dressings or in the con-
tinuous bath. The value of the latter in severe local in-
fections has been particidarly demonstrated by the ex-
perience of the great Hamburg clinic, and more lately
by that of various hospitals elsewhere.
Incisions in the early stages must be numerous and they
must enter the subcutaneous tissue, so as to allow of
the escape of as much of the infected serous exudate as
possible. In the later stages, with a large amount of pus
present, they must be extensive enough to secure a free
opening for the |ius wherever it may happen to be; that
is, the pus must be followed relentlessly into all recesses,
and counter-openings must be freely made. Necrotic tis-
sue should be removed as thoroughly as possible. Rub-
ber drains of a good size should be inserted into the main
openings. Copious hot irrigation with bichloride solu-
tion should be u.sed. Care should be taken not to place
the inci.sions too near each other, for fear of gangrene of
the intervening skin from lack of blood supjily.
Verneuil prefers to incise with the thermocautery in
order to avoid the considerable bleeding which frequent-
h' occtu's. This is of doubtful advantage. A certain
amount of bleeding is more likely to do good than harm,
by relieving the congestion of the part, and also b\' re-
moving some part of the infective material.
The .serious (juestiou of amputation must often be
weighed. The tendencj' of the infiamination to spread
rapidly and deeply over the larger part of the limb must
l)e our main guide to the virulence of the infection and
the necessity foramiiutation. The constitutional disturb-
ance, in especial the height of the fever, has less signifi-
cance, for in the grave asthenic cases reaction may be
comparatively slight. In general it may be said that
when we have an intense unlema, steadily and rapidly
advancing, which has approached the proximal joint of
the lindj an<l Avhich shows the dusky hue of threatening
gangrene; and when the constitutional signs are severe,
or when the patient is in an asthenic typhoid condition —
in othei' words, when clinically we have before us the
excessively severe, fulminating, or almost fidniinating,
type of infection, then aminitation at the joint is urgently
called for. In most of such cases tlie indication for such
radical procedure will have been made absolute by the
failure of previous multiple incisions to arrest the ad-
vance of the (edema. It will be a questinn for iixlividual
judgment whether an earlier amputation through the
shaft of the humerus or the femur may not be advisable.
Even when the infection has spread beyond the limb
on to the trunk, anqHitation at the joint should still be
done: for recovery in such cases has been recorded, and
indeed not so very infrequently. Amputation through
the forearm or leg must be a rare thing. It might be
considered in cases of fulminating gangrene or s]u-eading
emphysematous gangrene; but the lesion in such cases
has usually spread lieyoud the knee or elbow by the time
it is accurately diagnosed, so ra|.)id is its advance.
The above remarks are applicable especially to cases of
Class I., those of ordinary phlegmon. Cases of Cla.ss II.,
gas gangrene, require, from their especial virulence, con-
618
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pliles^iiion*
Fhlorldzln.
sideratiou apart. Bloodgood in liis admirable article in
"Progressive Medicine." IHOO. has svnnnied up the indi-
cations so well that I need only ipiote tlieni;
■■ K the infection is recognized early and the destruc-
tion of the soft parts and bones is not e.xtensive, free in-
cisions with immediate continuous Ijath treatUK'nl .should
be tried. K the general synijilonis nf infection are not
immediately relieved, amputation should be done. If,
however, the infection is recognized late, one should take
no risk, but amputate at once. An early diagnosis will
often save life; and from many observations an amputa-
tion may not always be necessary."
The treatment of cases of Class IH., urinary extrava-
sation, is treated of elsewhere in the H.^ndbook. Here
it need only be said that multiple incisions and free
drainage, as" for any other kind of phlegmon, fulfil the
main indicatious.
Strum-thevapy. — The question of serum-therapy in
streptococcus affections is one which is yet far from set-
tled. It is well known that Marmorek prepared his origi-
nal antistreptococcal serum from a streptococcus obtained
from a case of pseudomembranous angina. Great ex-
jjectations were entertained of the new serum in all dis-
eases supposed to be caused by the streptococcus, and
Marmorek went so far as to request of accouclieurs that
it be used in puerperal sepsis to the exclusion of the tried
clinical methods of curetting and irrigation. These early
Iiopes were d.K)med to disappointment. Clinically it soon
became evident that the new serum had but little cura-
tive power, while experimentally it was shown that Mar-
moiek's serum w-as totally inellicacious against diseases
of streptococcus causation otiier than that of the origi-
nal one. Thus eases of phlegmon, erysipelas, and puer-
peral sepsis remained nearly always iinbenetited.
Since these early experiences, large numbers of isolated
cases of all kinds of supposedly streptococcus infection
have been reported. With the exception of a certain
number of favorable, oeca,sionally even of brilliant re-
sults, these reports tend to demonstrate the general in-
clliciency of the serum. Petruschky examined the ques-
tion espeei;dly in regard to phlegmon, and came lo a
conrhision entirely unfavorable to Marmorek 's serum.
The conclusion generally arrived at" was that the
streptococcus genus was composed of a number of s])e-
cies. which, however similar in morphology or cultural
characteristics, differed materially in the matter of their
immune sera. Of late years a close study of the strepto-
cocci has discovered a considerable nmnber of these more
or less differentiated species. Van de Velde,'' in Denys'
lalioratory at Louvain. has endeavored by imuiunizing
with a number of these different streptococci simidla-
neously. to overcome tliis difficulty, and to produce a se-
rum which he calls "polyvalent" — a sort of shotgun
serum which if it missed one streptococcus might hit an-
other. Tills " polyvalent " serum, it is said, has met with
slightly more success than the original, but lias not come
into general use.
On the other hand, within the last year <ir I wo, various
workers have tried to demonstrate the essential unity of
all the various streptococci with the exception of that
of Pferdednme (our Sirangles). Streptococci cultivated
from cases of tuberculosis, measles, erysipelas, scarlatinal
angina, abscesses, phlegmons, puerperal sepsis, angina
in acute rheumatism, ulcerative endocarditis, and jy'ii-di'-
driixc. were examined thoroughly by Jlcyer" in respect
to their morphology, virulence, h;cmolysis, growth in
filtrate of their own culture medium, and their si)eeilic
immuni/.ing sera. Similar investigations have been con-
ducted Iiy Widal and Besanfon,-" Menzer,'-' and Jlarmo-
rek.-- All tend to prove the " unity " of all the various
streptococcus families, except that of Pferdedruse. If
they are a unit, why then should any antistreptococcus
serum fail to do good? Much further investigation is
needed.
Tlie whole question is beset with difficulties. There
is the one already mentioned, that one variety of streiito-
coccus apparently will not immunize against another.
So long as it is impossible to say to which particular
streptococcus a given infection is due, the use of Mar-
morek's serum or of any other antistreptococcus serum
remains largely a matter of (dianee. Further, it is be-
coming more and more evident that the streptococcus
does not play such a dominating role in many infections
as has been believed. Certainly in the case of phlegmons
we have reason to believe that the stajihylococcus,
Welch's gas bacillus, the bacillus of malignant Q?denia,
and other less known organisms, may either singly or in
symbiosis with each other or with the streptococcus,
cause infections which it has hitherto been the custom to
ascribe, usually' without thorough bacteriological inves-
tigation, to the streptococcus alone.
Phlegmons, in which bacteriological examination care-
fully conducted both aOrobically and anadrobically has
shown infection witli but one organism, are rare; and it
is reasonable to believe that in many cases in which anti-
streptococcus serum has been given with negative results
the infection has been one, not of the streptococcus, but
of one of the other organisms mentioned ; or, at least, of a
symbiosis of the streptococcus with these others in which
file streptococcus played the minor part. In this con-
nection a case-^ reported from St. Petersburg is interest-
ing. It refers to a septica'uiia treated without the least
benefit with antistreptococcus serum. Following this In-
success, antistaphylococcus serum was administered, with
brilliant results. The writer refers to another case in St.
Petersburg, one of ulcerative endocarditis, in which anti-
staphylococcus serum gave a similar good result. Un-
fortunately cultures were not made; yet the facts are
suggestive. We have been in the habit of ascribing
Avithout careful investigation the causation of many dis-
eases to the streptococcus, and peihaps quite wrongly.
Another point which may e.\iilain the general insuccess
of the serum is this: that if we are to believe Aronson,''-*
the antistreptococcic sera on the market contain com-
paratively very small ciuantities of anti-bodies.
In view of all these dirficulties, all that can be said is
that the practitioner, in desperate cases, may use anti-
streiitococcus serum on the off-chance of its doing good;
lint he must await more certain Iiacteriological knowledge
liefore he can use it with judgment or with any sure
hope of itssuccess. His main reliance must be placed on
early diagnosis, and prompt and thorough surgical treat-
ment. - Kdirard Archibuld.
BiBLIOGRAPniC.VL IlKFKKEXCKS. *
1 Die Ureachen (ier Eiteruiig voni lieutiiren Staudpunkt der Wissen-
schatt. aus. Ziegler's Bellriiffc. I!<1. .w.. Heft 1.
^ Pie Ursachen der ariiTt'n EitcriiiiL', Leipsir. 1SS9.
3 Janowstii: Zlesrler's llcitiML''', Hd. vl., l.ssi).
* Szi'zesolew : ti'U-r dn- Aeiinlosrie acuter Eitening. Diss. St.
Petersliufe. ].SH3.
5 liuHi'tiii of tlie Jolins Hopliins Hospitjd, ]8!)2, iil.. p. 81.
^ UelitM- (iitsptilejrriionen, Hainliurg ii. Lelpsie, lstl3.
• Biilli'tm .)..l]ns Ucipliliis H.i>]ijtiU, SeptL'iiiber, I'JIK).
<■ Miin.-ll. IlM-d. Wu.li., IMIll, p. Iliim.
» .Milll.-li. iiip.t W..,-li., ISH!), p. Ilw").
>» Zeit. fiir llvgit-iii-, lid. 41, Hi'ft:i.
" Z.-lt. fur (,i-lHiit.^li. 11. Gynlilidl., Bd. 411. Heft 3.
■= Trans, riiicir^'o I':i!li. Sndetv. Ncivember 12lb, 1002.
" .\lin;ili-»<h' rinstitut PasUnir, IKin.
n .\lvlii\ f. IHTiii. u. Svpli., xlix.. 2-:i.
15 (iuuldV Mi-di<-al .\iiiiiial ut Surtrery. ISKIO, p. 411.
"• Comptes rendiis de la Soo. de Uiologie, I8SK), No. 28.
" Mery : La Seinaine medieale, 1897, p. UO.— Courmonl : Ihiih. 1.893,
p. 171.
>s ccntralWatt fi'ir BaktiTi(ilusrii-. Bd. x,\iv., p. 68.).
i» Bfilin.T kliii, Wn.'li.. (in,, her nth. l!Ki2.
=" .\ri-liivi's ill- Mi-ili'iuii- I'.vpiTiiiK-iitale. 1890.
"-' Berliner kliii. Woeli.. Wit;,
'"• Maniiiiivk : .iimale.sde I'liistitut I'a.steiir, 1902.
=' St. ivteislniii;. Med. Wocli., No. Ki, liRH). Reported in Progres-
sive Medicine. ItiOl.
" Prog. Med., 1900, vol, i., also Ari'liiv f. C'liir., Bd., Iviii., 3, 1899.
-^ von Brans, von Bergiiiann, von Mikulicz : Haiuilnicli der prak-
tischen riiiruiLne (prt.>w/H)l.
'-"Faun-: liaitc de Chinirgie. par le Dentu et Dclliet, article,
"Phli-fTiiioii IiilTiis," par, I. L. Faurc.
:■ B. Civclc: Klin, tlierap. Wocli., 1.898. Nos. 14 and !.">.
=s Iiciitschc uii-il. Woch., Ortolieri'.tti. 189,8.
-'■' Philudcliiliia Med. Jouni.. November 17tU, 1900.
311 pingressivi- Medicine, 19IK1.
PHLORIDZIN.— C2,H=.,0,„. 2II.;0. A glueoside ob-
tained from the root-bark of the ajiple. pear, cherry, and
other fruit trees. It forms in tine, colorless, silky needles.
019
PIluualioBl.
PllO!«i>Iloi-|is
KEFEKK>;C'K lIA.\i>i;ouK UF THE .MEDICAL SCIENCES.
sdlublc only in one thousand parts of colil water, but
freely solui)Ie in boiling water. It is only slightly solu-
bles in aleohol. It melts at a teniperalui'e'of 2'ii' F.. but
becomes .solid again at 226' F.. and melts a seeond time
at 3;!.")' F. Phloridziu is very similar to .salielu, and
lieated with potash it yields pliloretie acid, which is
homologous with salicylic and anisie acids.
It has been employed as an antijjyretie iti doses of fif-
teen to thirty grains, but is not now u.sed.
Phloridziii is utilized in pliysiological research, as it
has been found to induceai-titicial ilialietes. When given
to the extent of eight grains ])er jiound of body weiglit
it causes polyuria and an e.veretiou of sugar which con-
tinues for twenty-four or thirty hours, and is not influ-
enced by diet. It sometimes produces diarrhfea, but no
other ill" effect has been detected, unless the drug is ad-
nunistered for a prolonged peiiod. when marked eniacia-
tiou and debility supervene. Phloridziu acts directh"
upon the renal e|)itl]elium. permitting thcescapeot sugar
from the blood and lessening theamount of sugar held in
solution in the Idood. Bi'duiiiniit. i<itinll.
PHONATION. See Jjin/ii.i; P/ii/md<yy „j the.
PHOSOTE — creosote idiosphate — is a colm-less syrupy
li(|ui(l. (lauaining eighty jicrcent. of creosote, but witii
only .a slight I'dor and taste of this substance. It is em-
])l(jye(l in tuberculosis as an easily borne form of creo-
sote, and is given in doscof U.7-l.<Sgm. (gr. x.-.\x.) three
times a d;iy. 11". -l. Bastedo.
PHOSPHATOL is a thick, reddish-yellow li(|uid pre-
pared by the aclion of phosphorus trichloride on creo.sote
in alcoholic soda scjlution. It has a Inuning taste, is
slightly Eoluble in water, and is readily solulile in alcohol
and oil. It can be given in milk or wine or in capside
in the same dosage as creosote. 11'. .1. Buxtii/o.
PHOSPHORIC ACID.— By i.h.isphnr;,- a.-id is signilied.
in uiediciiie, a solution of conunou or ortho|dinsph(iric
acid (IlaPOj) in Avater. Two grades of strength id' sucli
.solution are ollicial in the Uiutiil States Pharmacopceia,
as follows:
Afiihitii. Plii>sjih<jj-ii-iiiii. Phosphoric Acid. Tliis [Uepa-
ration re|)resents eighty-live per cent., by weight, of
orthophosphoric acid and fifteen per cent, of water. It
is a colorless lluid, without odor, but with a strongly acid
taste. Its specific .gravity is l.Tlll. It nn.\es in all jjro-
portions with water or alcohol. It sliould be preserved
in glass-stoppered l)ottles.
Plios|ihoric acid is intensely acid and iriitant. but does
not innnediately corrode living tissues and coagulate albu-
min, as ilo the majority of the strong mineral acids. In
any considerable quantity, however, this graile of the
acid would prove a sharp, and very likely fatal, irritant
Iioisou if swalloweil without dilution. This strength of
acid is rarely prescribed in medicine, being official simply
as a convenient solution to be kept in stock by the drug-
gist for the making of the following, the commonly pre-
scribed pre|)aiation:
Acitbim Phiixphorietnii Diliitinn, Diluted Phosphoric
Acid. This grade of the acid is compounded by nii.\ing
one part, by weight, of the foregoing strong acid with
seven and a half parts of distilled water. The solution
thn.s contains ten per cent, of orthophosphoric acid, and
has the specific gravity 1.0.57. Tlus acid resembles in
general iiroperties the other diluted mineral acids (see
Suliihiirif Aciil). but is di.slinguislied by having a pleas-
anter flavor (its acidity resemliling that of the fruit
acids) and by being, as a rule, better bm-ue by the stom-
a<di than its congeners. It may, therefore, be used for
the common jiurposesof the mineral acids, to allay thirst,
improve digestion, repress teudeucies to .sour fermenta-
tion of the contents of stomach or l)owels, and to check
morbid sweating. By many it is further (laimed that
phosphoric acid, ingested, tends to revive an exhausted
nervous system, to excite the sexual function, and gen-
erally to enhance nervous activity and power. By such
claimants the acid is regarded as the therapeutic equiv-
alent of uneombineti phosphorus; but certainly it fails in
that most pronoiuiced therapeusisof free [ihosphorus, the
frequent cure of neuralgia. A special claim for phos-
phoric acid, of capability to lessen the excretion of sugar
in diabetes, is now probably pretty generally abandoned.
Diluted phos])horic acid may be given in doses of from
twenty drops to a teaspoonful or more, three times a day,
the dose to be largely diluted with water, or with syriip
and water. The precaution obtaining with the giving
of other mineral acids, of taking the draught through a
tube and rinsing the miiuth after the swallowing, need
not be insisted upon in the case of this acid.
Edirard Cu rtis.
PHOSPHORIDROSIS.— Luminous sweating is a decid-
edly raie affection. Cases have been reported in which
tills curious idienomenon was observed after the inges-
tion of phosi)horus and the eating of idiosphorescent
fish. It is probable that the phosphorescence is due to
bacilli; for several species of photobacferia have been
found, most of them being derived from fish.
V/iiir/ea 2'iiirns/ieiid Dude.
PHOSPHORUS.— Phosphorus isavadable for medicinal
purposes in llie form of tlie element itself, or as it occurs
in the special compouml ^inf jihunpliidc, a <'om|iounil that
readily yields free phosphorus upon swallowing, under
the conditions present in the stomach. Phnspliorus is
official in the United States Pharmacopa'ia under the title
Phospliorus. Phosphorus. It is a solid body, of thea[)-
pearance and consistence of white wax. It has a peculiar
and disagreeable odor. ()u cxjiosure to air, it gives off
white fumes, luminous in the dark and of a garlicky
odor. Phosphorus is insoluble in water, but dissolves in
3.J0 parts of absolute- alcohol at lo' C. (59' F. ), in 24i>
parts of boiling absolute alcohol, in 80 jiarts of absolute
ether, in about ~iO jiarts of any fatty oil. and very abim-
dantly in carbon disul]ihiile, the latter yielding a solution
which must be handU'd with the greatest care to jireveut
danger from tire. If left ex]iosed to the air, phosphorus
takes fire spontaneously. According]}' it must be kept
carefully under water, in a secure and moderately- cool
place, protected from light.
In its physiological relations, as in its chemical, phos-
phorus is unique. It is locally exceedingly irritant-
even corrosive, although, strangely enough, in some ex-
periments bits of solid phosphorus have lain embedded
iu the connective tissue of animals for weeks without
exciting any local reaction, (trdiuarily, however, upon
skiu or mucous membrane phosphorus in substance ex-
cites inflammation, possibly followed by ulceration and
gangrene of the area expo.sed to contact. Even the fumes
of phosphorus may inflame exposed mucous membranes,
such as the coujunctivaand the mucous na-mbraueof the
mouth and respiratory tract, and inflame even to consec-
utive necrosis any accessible ])eriosteum. Thus used to
arise iu match factories, in the days before the use of
allotropic phosphorus, cases of necrosis id' the .jaw, the
periosteum being generally reached by the poisonous
fumes through the avenue of some defective tooth.
Taken internally, even therapeutic doses are very apt to
irritate the stomach, as shown by loss of appetite, nau-
sea, uneasiness, and even pain and tenderness at the epi-
gastrium, or, in higher grade, by the additional symiitoms
of vomiting and diarrlio'a. Flatulence and eructations
of phosphoreted .iiasi's are further disagreeable local
eifects of the medicine upon the digestive apparatus.
Phosphorus when swallowed is readily absorbed, but
exactly in what cliemical status has not been definitely
proven. That it reaches the blood, in part at least, as
uucombined phosphorus dissolved by the alkalies of the
intestinal juices or by fats is, theoretically, certainly not
impossible, and is the obvious suggestion of nnuiv chem-
ical considerations. On the other hand, that some por-
tions undergo various grades of oxidation is again per-
fectly iiossible and likely.
The constitutional effects that follow the internal tak-
G20
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Plioilatiou.
Pllosplioriifi*.
ing of pliosphnnis are symptomatic of modifications of
nutrition. In tlicnipeutic dosage in licaltli tlii-rc is ordi-
narily little obvious derangement beyond wliat may bo a
retk'.x of the gastric irritation set up by the drug; and,
auatoniically.the most striking result of the medication
is a tendency, )iroveu by dissection of animals.' toward
increased activity of development of bone, ("artilagi-
nous epiphyses ossify "n-ith undue sjieed and completeness,
spongy bone tissues increase in thickness, and compact
bonein hardness. And a similar special tendency toward
nutritive activity in itcrro^is tissues, under the adminis-
tration of phosjihorus, is commonly, and probably rightly,
inferred from the two facts, first, that in nerve tissue, as
in that of bone, compounds of phosphorus are prominent
normal constituents, and, secondly, that many morbid
derangements of nerve function which are fairly refer-
rable to malnutrition or to exhaustion of nerve tissue, tend
to abate under a regime of phosphorus medication, A
special aphrodisiac action has been claimed for phos-
lihorus, but cases in which any etiect of this nature has
l)een ol)Served liave probably been cases of previous de-
bility or exhaustion of the sexual function, in which the
renewed sexual desire is .simply the natural consequence
of restoration of j)ower through improved nerve nutri-
tion. In originally vigorous subjects several series of
observations have shown that phosphorus does not pro-
duce any direct aphrodisiac effect. =
In over-doses, single or continued, phosphorus pro-
foundly deranges untrition, inducing fatty degeneration
of glaiidvdar and other tissues, and hemorrhages. Death
may result, or an impairment of health from which re-
covery is slow and difficult. For a detailed discussion of
this singular poisonous operation of phosphorus see arti-
cle P/ioKji/ionis, I'oisonitig by.
The therapeutic application of phosphorus is the inter-
nal administration of the drug for the bettering of de-
ranged conditions of the nervous and the bony structures.
Thus it is among the standard remedies to try in neural-
gia. Naturally enough, the more recent the case, the
greater the chance of relief and of cure, and unless relief
comes within forty-eight hours, the medicine will prob-
ably fail altogether (Ashburton Thom|ison). In other
nerve derangements it may be said, broadly, that in such
as belong to the category of the naturally curable ones,
recoverj- may ]ierhaps be hastened by the use of plios-
phorus ; but that in the incurable or difficultly curable
nervous diseases the agent generally does little or no
good. Thus the high hopes at one time formed of the
avail of phos])liorus in such maladies as epilepsy and
locomotor ataxia have utterly failed of realization ; but
in such conditions as so-called nervous prostration, or in-
cipient dementia, the drug is often of distinct benefit.
Similarly phosjihorus has been praised in osteomalacia
and in rickets.
In the important matter of the rf««c of ]ihosphorus,
there is much difference in the practice of different Jihy-
sicians. Some coutiue their dosage to 0.0006 gm. (gr.
j-^), thrice daily, while others begin at once with 0.003
gm, (gr. j^j), given with the same frequency, and aim to
increase to double the amount, under guidance of the
effects wrought— curative to the disease on the one hand,
or irritative to the stomach on the other. Certainly, the
larger of the doses cited are well borne in a very consid-
erable number of cases, and certainly, also, the same may
succeed, and speedily too, in curing a neuralgia, where
the minute dose of the timid prescriber utterly fails of all
impression upon the disease.
The mode of ailininistrntion is an all-important matter
in the case of phosphorus, since by faulty prescribing the
dose may be unduly irritant or nauseouson the one hand,
or inert on the other. In general, phosphorus must not
be given in substance, no matter how extreme the sub-
division, because of irritation ; and in prescription in sohi-
tion a solvent must be sought that will hold the phos-
phorus secure against oxidation, and at the same time not
furnish too disgu.sting a potion. The most generally ser-
viceable solvent, where the ])reparatiiin is to retain the
fluid condition, is a fixed oil, freed from contaminating
oxygen and water by a preliminary suiJerheating.
S(iuibb has strongly advocaleil cod-liver oil,^ fearing
vegetable oils because of an alleged tendency of phos-
phorus in solution in the same to "develop poisonous
properties," presumed to be "due to the formation of hy-
pophosphorous acid." Sweet almond oil is, however, the
most generally selected of fatty solvents, and has been
adopted by the United States Pharmacopcpia as the basis
of the official oily preparation. Chloioform and ether
are inconveniently volatile for the making of a permanent
fluid preparation, and carbon disulphide is too disgusting
and noxious. Absolute alcohol can be made the basis of
an efficient fluid mixture, as in the official spirit of phos-
phorus and its derivate, elixir of phosphorus. For pills
of phosphorus the plan should be followed of actually
dmohing the phosphonisin some fluid, which eitlier itself
hardens, by cooling, to a solid, or which, incorporated
with some indifferent powder, will form a pill mass. In
either case, the indispen,sable feature is secured that phos-
phorus is in true solution still, although the pill as such
is of course a solid. An obvious practice for the making
of such pills is to dissolve pliosphorus in melted resins,
which on cooling reacquire the solid conditinu with, now,
the phosphorus held in solution. But while these resin-
ous pills are easy to make and to take, there is strong
reason to fear that the contained jihosphorus may easily
be allowed and even helped to oxidize. The pharmaco-
paial procedure given below is probably as free from
objection as any.
in whatever form or dose phosjihorus be given, a car-
dinal rule, insisted upon by almost all who have had
much experience with the medicine, is that the adminis-
tration shoidd never be ujion an cni]it,y stomach, nor, on
the other liand. iiunuilintth/ after eating.
The phosiihorus pre|iaratious of the United States
Pharmacoptt'ia are as follows:
Oleum Pkofsphonitum , Phosphorated Oil. Pliosphorus
is dissolved by gentle heat in sweet almond oil which has
been ])reviously lieated for fifteen minutes to a tempera-
ture of '2~ii)° C. (482° F.), and then cooled and filtered.
After the phosphorus is fully dissolved and the solution
cooled, a small charge of ether is added thereto. The
finished jiroduct contains one per cent, of phosphorus and
nine of ether. By measure, one minim lejuesents about
gr. y^ of phosphorus (United States DispeiLsatory).
Phosjihorated oil should be clear and with a decided taste
and smell of phosphorus, and the few drops which will
constitute a dose (see remarks on dosage, above) may be
given in capsule or in emulsion, flavored by a trace of oil
of pejipermint, or of gaultheria, or of bitter almond.
The official emulsion of almoinl forms a convenient vehi-
cle for an emulsion, flavored as just described. Phos-
phorated oil must be kept in small, glass-stoppered vials
in a cool place, and the phosphorus keeps best when the
vials are completely full.
Pil'ila: Phoftphoii . Pills of Phosphorus. Phosphorus is
dissolved in chloroform by gentle heat and the solution
added to a mixture of acacia and altlura in a mortar. A
little glycerin and a little water are next poured on, and
the whole is rapidly beaten to a pill mass, which is imme-
diatelj' cut up into the proper number of pills. Each
pill is then coated with a solution of balsam of tolu in
ether, and when the coating is dry the pills are put up in
well-stoppered bottles. These pills contain, each. 0.0006
gm. (gr. Y^^) of phosphorus, and from one to five pills
will constitute a dose. (See remarks on dosage, above.)
Spiritus P/ioitpJion'. Spirit of Phosphorus. This is a
solution of phosphorus in absolute alcohol nf the strength
of 1.2 per cent, of phosphorus. It is oflicial for the mak-
ing of the elixir of phosphorus.
'Eli.n'r Pho^pliori. Elixir of Phosjihorus. This prep-
aration is a mixture of the spirit of pliosphoru.s, glyc-
erin, and aromatic elixir, with a flavoring of oil of anise.
It is a transparent liquid, containing about 0.00025 gm.
(jrr. ^;) in each cubic centimetre (Tiixvi.). Unoffi-
cial, but well known and niueli used, is an alcoholic solu-
liim of iiliosplioi'u?; devised by Asbburlon Thompson, of
England, and comniouly called 'J'/'uinpsoii's Solution of
621
PlioMpliorii^.
PiQOMpliorus.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
P/ii>f:i>?ionis. It is prepared as follows: One grain (0.065
gni.)of phosphorus is dissolved in H. 3 v. {Ui gm.)* of (/A-
ntdutc alcohol by the aid of heat, and the solution added to
a iritrmcd mi.xture of ti. ? iss. (56.25 gni.) of glycerin and
fl. 3 ij. (6.68 gill.) of alcohol. When the resulting mixt-
ure has cooled m xl. (2.13 gm.)of spirit of pejipenniut
is added. The preparation should be a bright, clear,
colorless solution, wliereiu the odor and taste of plios-
pliorus are almost completcl}' masked b_v the |iungency
of the aleoliol and peppernnnt. It is essential that the
alcohol used to dissolve llie jihosiilKirus be literally ahxo-
lull'; and in such ease tlie preparation, if kept in well-
tilled and well-stoppered bottles out of the light, will
keep unaltered long enough for the treatment of an aver-
age case. If all the phosphorus be and remain di.s.solved,
the solution contains 0.003 gm. (gr. ,V "early) in 4 c.c.
(H. 3 i.) — a.scaut teaspoonful. The dose, averaging from
one-third to one small teaspor>id'ul. is best taken clear,
but if too sharp in tliat condition, may be taken in water,
the mixture to be made only at the time of each adminis-
tration.
Under no circumstances should phosphorus be pre-
.scribed as an ingredient of extemporaneous composite
medicinal mixtures.
Ziiif P/iiisji/iidc : ZusP,. A peculiar compound of plios-
pliorus, which practically amounts to a medicinal pre]!-
aration of the element itself, is what is otlicial in the
United States Fharmacopa'ia under the title Zuiri P/ion-
phidinii. Zinc Phosphide. This compoun<l appears as a
finely crystalline powder, or as crystalline lumps. It is
gra3'-blaclv in color, with a metallic sheen on broken
pieces, and gives faintly the odor and taste of phos-
phorus. It is insoluble in water or alcohol, but dissolves
in siil]diuric or hydrociiloric acid, witli evolution of hy-
drogen phosphide. Zinc phosphide must be kept in
small glass-stoppered vials.
This compound is lacking in the vigorously irritant
action of phosphorus, yet even in therapeutic doses may
easily upset the stomach and even excite vomiting. From
its ready decomposition by aci<ls it yields, in the stomach,
some medicinally active condition of ]dios|ihorus, and its
admini.stration is therefore followed by therapeutic results
similar to those attained by the use of the uncombincd
clement. The phosphide is, liowever, not so certain as
preparations of phosphorus itself, and is probably most
commonly turned to as a last resort in cases in which
phosphorus persistently disagrees. Zinc phosphide con-
tains one-fourth of its weight of phosphorus, and the
dose therefore ranges from 0.003 gm. (gr. ;\|) to 0.016
gm. (gr. J). It ma.v be given in pill form, and, unlike
phosphorus, may be prescribed in condiination with other
medicines, avoiding only acids, which decompose it.
After swallowing, however, the certainty of medicinal
action will be enhanced by effecting this same decom-
position through the agency of an acid draught, such as
lemonade or a little vinegar. The most disagreeable feat-
ures of the drug are a tendency to eructations of phos-
plioreted hydrogen and to disttirbanc(> of the stomach.
With the larger of the doses mentioned above nausea is
not at all unlikely. Edward Curtis.
' Wegner: Vlrctiow's Archiv, June 23d, 1S72.
- See Phillips' Materia Medica and TtJerai)eutii\'?, Inorganic Sub-
stances, p. .')],
^ Nule on the .\duiinistratinn of Phosphorus, E. R. Squibb. M.D.,
Proceeding's of tlie Am. Pliannuceutioiit Assn. fur ISTtt, ami iiainphlet.
I'hlladetpliia, 1S77.
PHOSPHORUS, POISONING BY.— It is doubtful if
there is another substance among the many common poi-
sons which is of so much interest to the toxicologist as is
phosiihorus — an interest arising from sin historical vie\v-
point, and because of the desire to discover the invste-
rious causes of its insidious action on living organisms.
Jloreover, we meet with the anomaly that, uidikc most of
the other inorganic poisons, and especially arsenic, anti-
mony, and nitrogen, members of the same group in the
* In catrulatiufz the metrio equivalents regard has been paid to the
speL'ltlc gravities of the several fluids.
Periodic System, this element is toxic in its free or ele-
mental state, while its compounds (save the lij'dridcs)
are practically non-toxic'.
Phosphorus was unknown to the layman as a jioison
prior to 1840. Shortly after the popularization of
matches, abcmt the year 1883, the public became ac-
quainted with its deadly nature, and because of the ease
with which the material could be procured, poisonings
by phosphorus became alarmingly frequent. In no
country have the number of cases been so numerous as
in France, where from 1840 to 1880 there were 336 crimi-
nal cases of poisoning by this element. The maximum
number in a single yetir was 94 in 1860, or, if we con-
sider the period 1851-70, we find that out of a total of
793 deaths due to poisons 267. or 33.7 per cent., were
due to phosphorus, while during this same period 287
are charged to ar.senic, Fi-ancc still heads the list in the
number of cases of poisoning by this element, which
u.sually equal, or even exceed aunuallj', those due to ar-
senic. The substitution of "Parlor" and "Safety" or
"Swedish" matches (invented by Bottger in 1852) for
the yellow phosphorus match was immediately followed
by a decrease in the criminal use of phosphorus; the de-
crease was also due in part to the fact that it became
known to criminals that a process had been devised by
which the poison could be easily and surely detected (the
MitselK'ilicli method).
Homicidtil poisonings are now rai'e. The ma.ioiity of
ca.sesare due to attemiits at sincideor to accidents among
children.
Only "j'cUow" phosphorus, the hydrides of phos-
phorus, and the phosphides of certain elements, such as
calcium and zinc, are of toxicological interest.
TrUriir P/i<i,sjilMrii)i. — The general properties of this al-
most colorless, wax-like substance are too well known to
retiuire review. A word as to its solubility is, however,
necessary. In water pure phosphorus is practically in-
soluble; in fact, it has lieen asserted that what is thought
to be a solution represents merely exceediuglv tine parti-
cles in suspension, or else that it is a solution of the
vapor. According to Hartmann 1 litre (about 3 xxxiv.)
of water at 38" C. (100.4 F.) will take up 2 mgm. (gr.
Trns) "f pho.sphorus; while in oils its solubility varies
from 1 to 100, to 1 to 10,000 parts, according to the nature
of the oil and various conditions, such as temperature,
etc. In bile phosphorus is readily soluble, 100 parts of
this fluid dissolving 15 to 25 parts.
Because of the low solubility of phosphorus in most of
the fluids of the body, only slight action generally fol-
lows the ingestion of large fragments of this substance.
When taken, however, in a finely divided condition the
action is very violent.
Poisoning by phosphorus usually results from matches,
j)hosphorus pastes (vermin killers), or phosphorus oil
(Oleum phosphoi-atnm).
Miilc/ieti. — The moilern " parlor " and "safety " matches
are usually harmless, so far as poisoning by jihosphorus
is concernetl, ow ing to the fact that tliey are made of
non-toxic red iihosphorusand an oxidizing agent, such as
potassium chlorate. The matches of a decade ago, known
variously as "friction," "brimstone," "sulphur," "hici-
fer," "phosphorus," etc.. matches, are to be charged with
by far the majoiity of deaths. The heads of these
matches contain on an average about five per cent, phos-
phorus, the limits vaiying frinn three to seven per cent.
A single head usually contains from | to 1.5 mgm. (gr.
0.005 to 0.023). In these matches the sticks after being
dipped in suliihiir are tipped with a mixture of glue or
dextrin containing coloring matter, phosphorus, and an
oxidizing substance such as lead nitrate, lead peroxide,
nitre, potassium chlorate, or some similar conijiounii.
Dissolving these heads in water or a warm liquid yields
a liquid in which the phosphorus exists in an emulsion
in an exceedingly finely divided condition.
PJioKphDriia Piistis are now seldom employed, though
formerly they were in great demand for destroying rats
and other vermin. Here th<' iihosphorus exists very finely
divided with flour, lard, and sugar or molasses as a basis.
fi22
REFERENCE HANDBOOK OF THE 3IEDICAL SCIENCES.
Plio^pliorus»
PliospUorus*
These pastes vary greatly iu composition. Tliey con-
tain, on an average, about two per cent, of phosphorus,
but may contain as high as live per cent.
Phoiiphine. — The hydride HjPis the only one of impor-
tance. One-fourth to one-half per cent, in air causes
death in animalsintweut}' to thirty minutes, while 0.2 per
cent, will produce symptoms of asphy.xia in a few min-
utes. In man, when it is hreathed in very small amount
in air for any length of time, the symptoms closely re-
semble those prochiced by phosphorus vaiiois. Under
this head there is another possible source of i>hosphorus.
or rather phosphine, poisoning It has been suggested
that there ma.v be a reduction of phosphates in the- intes-
tines by bacteria (a form of auto-into.xication well known
in the "case of reduction of sulphates to hydrogen sul-
phide). Some have even gone so far as to claim that
acute yellow atrophy of the liver is duo to this cause.
This action of bacteria is well established for sulphur,
arsenic, and antimony compounds; b\it although it is to
be expected for compounds of phosphorus by analogy,
all investigations have given thus far negative results
with pure cultures of powerfully icducing bacteria, the
reduction being carried onlv to phosphites.
Fattd Bene. — The weight of phosphorus which consti-
tutes a fatal dose is quite uncertain. An examination of
the records shows such a variation that it is diliicult to
make an accurate statement. The fatal dose seems to
depend, more than is the case with most inorganic poisons,
upon the nature of the material containing the poison, the
state of division of the phospliorus. the nature of the
material in the alimentary canal, and the idiosyncrasy of
the individual. As regards matches, we find tlial a child
has died after sucking the heads of 3 matches. In an-
other ca.se 8 heads caused death. Si.xteen match heads
have caused the death of an adult ; and Tardieu cites a case
in which ItJl matches were immersed for seven or eight
minutes in a cup of hot coffee with a resulting solvent
action so low as to permit the matches when dry to be
ignited by rubbing in the usual manner, yet the poison-
ous draught caused very dangerous symptoms. Other
records sliow that where death has resulted from swallow-
ing match heads the number of these taken in each case
has variedfrom (50 to 3.000; and that, on the other hand,
recovery has followed prompt medical aid where from
3,000 to" 4,000 match heads have been taken.
In the case of Oleum phosphoratum it is jirobable that
a dose of 200-2.50 mgm. (gr. iij.-iv.) will produce dan-
gerous results, and that .500-600 mgm. (about gr. vij.-
i.x.) will almost invariably prove fatal.
Phosphorus itself, linely divided in hot water, has in a
few instances been employed for homicidal and suicidal
purposes. Although the smallest fatal dose recorded is
about 8 mgm. (gr. ^), this is abnormally low. It is be-
lieved that the toxic dose of well-dissolved or exceed-
ingly tinel.v divided phosphorus is probably about 15
mgm. (gr. "0.23), and that the fatal dose lies iu the neigh-
borhood of 1.50 nigra, (gr. ij.-iij.). Recovery has fol-
lowed a dose of over 300 mgni. Occasionally cases are
met with which seem to indicate that i)hosp'horus may
at times have a slight accumulative tendency. With
animals the doses may be safely set as follows:
Horses and cuttle
Sheep and swine.
Ooiis
^owls and cats . .
Fatal dose,
(j rains.
0.5 to 2.00
.10 to .30
.(F>to .10
.01 to .03
Therapeutic dose.
Grams.
0.010 to 0.050
.arz to .(KI5
.0005 to .(»rz
.0005 to .001
The most susceptible animals per kilogram weight are
fowls, the next swine, then dogs. According to Nannyn
parrots alone seem to be relatively immune.
Fiitiil Period. — This is quite variable, but there can be
no doubt that phosphorus should be classed as a slow
poison. The usual period lies between one and fot'.r or
five days, with most deaths falling on the second or the
third day ; yet life may sometimes be prolonged until the
seventh day, or very rarely until the seventeenth to the
twentieth day. Several cases of remarkably rapid death
are recorded. Caspar cites the case of a young woman
who took 194 mgm. (gr. iij.) of phosphorus in an electuary
and died in twelve hours, while Habershon is authority
for the statement that death has taken place in thirty
minutes.
Symptoms. — The dift'erences in the symptoms between
acute and chronic iioisouing are ehietly only of degi'ee. and
yet at the same time tlie_y are quite maikeil. Even in
acute cases it has been shown by Tardieu that it is pos-
sible to distinguish three distinct forms, which have been
tei'med common, nervous, and hemorrhagic, according
as certain symptoms predominate. The lack of space
forbids a consideration of these. Occasionally a patient
will show a combination of all these types, the one fol-
lowing tho other.
In what may be called for convenience a typical or
normal case of poisoning (generally the result of matches),
the victiiufirst complainsof pain in tlie throat. Usually,
but not always, this pain extends downward with increas-
ing severit}', and is most marked in the epigastrium and
abdoiuen. The tongue is enlarged and coated. Nausea
in its most acute form sets in. followed later by vomiting
of mateiial of a mucous and bilious character. Very
rarely at this stage is the vomit tinged with blood, but
the ejected material is generally phosphorescent in the
dark. There may be annoying eructations with an allia-
ceous odor and taste; the exhaled breath may even be
luminous iu the dark and give rise to a thin white vapor
upon striking the air. Colic and diarrha'a set in at this
stage, in about thirty per cent, of the cases. The pul.se
may for a short peiiod be accelerated with an accom-
panying slight rise in tempcratuie. but soon it becomes
small, weak, slow, and often irregular. The temperature
may fall as much as 3 or even 4° C. Respiration, which
also suilered a slight acceleration, becomes slow, op-
pressed, and sometimes stertorous. This train of symp-
toms continues for from twenty-four to forty-eight hours
W'hen a remission often takes place; nausea and vomiting
ceasing and the abdominal pain disappearing save for a
few vague twinges. A perioil of ajiparent convalescence
supervenes for two or three days; then suddenly, when
all seems to be going well, the victim is stricken down
with the most violeutsyniptoins. Icterus appears, accom-
jianied by hemorrhages, increasing in number and sever-
ity, in wiiich practically all channels are affected. Vom-
iting and purging having again set in, the ejected matters
aie bloody in character and may at times consist almost
wholly of blood ; there is bleeding at the nose and even at
the ears, and in women there is almost invariabl)' more or
less uterine hemorrhage. Up to the present time, in spite
of (he reputed aplirodisiac action of phosphorus, no vene-
real excitation has been observed in cither sex in acute
poisoning. The blood discharged is very thin and fluid.
Hemorrhages have been known to contintie for se\eial
months, the victim becoming weaker and weaker, and
sinking into deeper and deeper apathy, being roused
only by recurring nervous disturbances. Acconi]ianying
the hemorrhages is seen anaemic cachexia and urticaria,
and a blotched skin. The eyes are icteric, blood shot,
and prominent. Owing to paralysis of the sphincter
muscles there may be, in the last stages of the disease,
involuntary expulsion of urine and fa'ccs. Prior to this,
however, the urine is apt to be suppressed, and when
discharged or drawn will be found to contain albtuuin,
peptones. hjX'moglobin. bile pigments, biliary acids,
fibiiu and hyaline cylinders, fatty dro|iIets, often leucin
and t^-rosin, almost invariably Siirccilactic acid, subnor-
mal urea, and abnormal ammonium salts, phosphates,
and sulphates. It is quite safe to assert that icterus is
absent in exceedingly rapid death only. Death takes
place in coma or syncope, occasionally iu convulsions
preceded by delirium.
In addition to the above-mentioned S5'mptoms there is
often quite marked paralysis of the voluntary muscles,
especially those of the legs, preceded by coldness or
numbness and accompanied by formication and twinges
623
PllO<k|>llf>l*llf!i.
PUospliorus.
REFERENCE HANDHOOK OF THE MElHfAL SCIENCES.
of pain. Oceasioniilly there is an:rstlicsia of the lower
extremities, but otherwise there seems to he no loss of
sensation.
Recovery from severe acute phosphorus poisoning is
rare and takes place only after a loni; time.
The symptoms seldom ajipear in less than one to three
hours, more often in live to seven liours. There are ex-
ceptions, however; for example, Taylor cites a case of
a young girl who swallowed a ipiantity of phosphorus
jiastc, and who at first sulfered from .symptoms so slight
that it was tliought that Init little poison had been in-
gested. It was not until the following day that she was
taken ill, and on the second day had apparently recov-
ered; on the third day she was stricken willi symptoms
of poi.soniug, but these were not violent until the fifth
day. Deatii took place on tlic sixth day despite the elTorts
which were made during all this [lericid to save her life.
At one time or another practically all the secretions and
excretions have been observed to be liuninous in the dark
— the exhaled breath, vomited matter, stools, urine, per-
s]iiiation, etc.
Pliospliorus camiot lie classed, as is very evident from
tlie above, as a raiiid or even niodi'ialcly ra]iid poison;
and, on the other liand, eviilence is lacking wlucli wuuld
justify its being credited with any truly latent action.
Acute Poisoiuiig in Aniiiiiils. — Typical symptoms,
similar to those seen in man, are observed in dogs and
swine. Horned cattle behave somewhat similarly, but
horses and fowls are affected in an entirely liiffereut
manner. Fowls are exceedingly sensitive to this poison,
suffering cliiefiy from severe thirst, diarrho'a, iuid chorea.
They ilie witlmut liaving sliown any characteristic symp-
toms .save that they are ajit to move with a peculiar
hopping gait. Horses die suddenly in a few days, hav-
ing shown practically no symptonis of poisoning. In
cows a cessation of milk .secretion is almost invariably
observed. In animals, especiall.y ruminants, the first
symptoms appear after several hours. The shorU'St pe-
riod of illness can be set at about ten to fifteen hours.
Hlost animals die on the second or third day. or on the
tliird tn the tiftli day. Sometimes dciith comes on vciy
suildcidy through paralysis of the heart follnwing an ap-
parent im|n'ovemciit.
Chriinic Pvixiiniiiij is almost invariably tlic result of
breathing air containing vapors of jihosphorus, and is
therefore seen in workmen engaged in industries iising
jdiospborus, such as the manufacture of "sulpluu-"
matches, phosphor bronze, etc. In the manufacture of
]ihosphorus chronic poisoning is very rare. Uj) to 10011.
in the great C'oignet factory in Fiance, there had been
only one case of maxillary necrosis in fifteen years. In
the days of the extensive manufacture of sulphur
matches chronic poisoning was so alarmingly frequent,
especially among workmen in the '■drying rooms," that
several gcivernmcnt.s pa.ssed laws forbidding the maiui-
facture of this kind <if match. Sinc(^ the introduction of
parlor and safet}' matches chronic poisoning has become
very rare.
This remarkable disease is characterized by bronchial
catarrh, chronic gastroenteritis, loss of appetite, consti-
jialion often followed by diarrhipa, cxqui.site toothache,
chronic jieriostitis passing into necrosis of the maxillary
bones, cachexia, and fever. In general, we have all (he
symptoms of acute poisoning, but in much less violent
form and coming mi slowly and insiiliously.
The gums swell; there may be salivation; the teeth
ache, (leca}', loosen, their dentine becomes expo.sed;
there is per.sistent gingivitis; dental ab.scesscs increase in
lumdjcr and the fistula' discliarge se(|uestra and fetid
pus. The breath is horribly fetid. The victim suffers
from pains in the Joints and legs, rapidity weakens and
wastes away. Hectic fever sets in, and de.ith may occur
in convulsions, more often in coma or syncojic^
Usually it is thelowermaxillary whicli isfirst attacked;
less frequently and less .seriously, ul the outset, the up-
]ier jaw is affected. As the disease progresses both jaws
liecome diseased. Sometimes the necrosis extends to the
nasal bones and even to the base of the skull, when death
from meningitis results. In the case of severe necrosis
the mortality seems to range in the neighborhood of
forty-five ])er cent. This disease lias been incorrectly
termed by some European physicians progressive necrosic
osteoperiostitis. Following the necrosis there is marked
thickening of the affected bones, and the cartilage be-
comes o.ssified. AVorkmen having caTi(jus teeth sutler
most from ma.xillary necrosis. In fact, there is reason
to believe that, in the absence of penetrating caries,
necrosis of the jaw bones is rarely if ever met with.
It has, therefore, become an eslabli.shed custom in all
well-conducted phos|)horus industries to employ only
men and women having sound teeth. Necrosis "of the
jaw develops after about six months' exposure to the
vapors of ]iliosphorus. Occasional!}' it may appear in
a shorter period, or may fail to ajipear until aftrr several
years. This is only anolher instance of the remarkable
variation in the action of this element.
Contraiy to the facts observed with most other sub-
stances giving rise to chronic poisoning there are no rec-
ords showing that the domestic animals frequenting the
industries are attlicted with iihospboiism.
Aiilidotix. — The most satislactorv chemical antidotes
are copper suliiliate. and oxidizing substances such as
(ltd turpentine, hydrogen peroxide, potassium permanga-
nate, etc. In the case of acute poi.soning administer cop-
per stUphate, three grains every five minutes until the
stomach has been sulliciently cleared. Follow this by
one of the oxidizing agents, as, for example, old turpen-
tine in emulsion in mucilage, one drachm every half-hour
comliined with the inhalation of turiicntine vajior, or
wash out the stomach with O.'i- or 0.3-iier-cent. solution
of ]iotassium iiermanganate, or witli a one- to three-per-
cent, solution of peroxide of liydrogen. Magnesium sul-
phate may also lie given to clear the bowels. The etficacy
of copper sulphate depends upon its action as an emetic,
and upon its property of reacting with phosphorus to
form an iusohdile coiqicr ]ihosphide and in part to oxi-
dize the phosjihorus, metallic copper and phosphoric
acid resulting. With old (oxidized) turpentine a tur-
pentine-phos]ihoric acid of low toxicity results, while
with permanganate and peroxide the phosphorus is oxi-
dized to non-iioi.sonous phosphoric acid. Besides tlie ad-
ministration of antidotes the patient must receive such
treatment as the symptoms require. Administer ice and
cold demulcent drinks. The paralysis and the sinking
of blood pressure must be counteracted by excitants.
All substances and foods containing fats or oils must be
forbidden. Some iiractitioners bar the use of alkaline
drinks on the ground that there is danger of the forma-
tion of phospliine; others insist upon their use as essen-
tial to maintain the alkalinity of the blood.
Priiplnil(i.ri«. — In all industries using phosphorus, ex-
ceptionally good ventilation is imiierative. There should
be a constant circniatiou of fresh air in all the rooms.
Exceedingly great care should be exercised under the
sii]iervisioii of a competent and conscientious foreman.
Every workman shoukl be required to wash and bathe
frequently and thoroughly, and especially always to
wash the liands before eating. Medical examinations
should be made compulsory at stated intervals, and all
cases of sore mouth, toothache, etc., should be at once
excluded from the workrooms. Only men and women
with sound teeth should be eui]iloycd. A mouth wash
containing boric acid, beta-naiihthol, and eucalyptol has
been found useful as a preventive against necrosis.
Post-moiicin Appetiriuices. — In typical cases the appear-
ances after deatli are veiy striking and characteristic.
Acute yellow atrophy and cirrhosis of the liver are prac-
tically the only diseases which yield lesions that can be
confused with poisoning by phosphorus. The appear-
ances are almost identical in each of these diseases, yet
the symptomsaiid iirogress of the diseases are so different
that there is little danger of error when the practitioner
is in possession of tlie liistory of the case.
There is often corro.sion and ulceration of the stomach
and duodenum. The mucosa of the stomach is soft,
swollen, mammillated, and degenerated.
G2i
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Pliosplioriiy.
Pliospliorus.
Tlie most characteristic feature, however, is the re-
markable icteric condition anil Tatty degcucration of the
liver and kidneys in i>articular, but also of the hearl,
of the glands of the stomach and intestines, and even of
the muscles. The alimentary canal as a whole is iisu-
all.v contracted. Multiple hcmorrhajjes are found in the
lungs, heart, and throughout the alimentary canal. Oc-
casionally there is no corrosion uor vdccration of the mu-
cosa of the (esophagus and stomach, but in such cases a
liemorrhagic or ecehymosed condition is rarel)' absent.
A similar condition obtains in the mesentery and the
peritoneum.
The pleural and pericardial cavities contain hlood_v
serum and the serous membranes are ecehymosed.
The liver will generally be found enormously enlarged,
fatty, soft, pasty, and light or dark yellow in color, with
the acini enlarged and prominent, while here and there are
hemorrhagic spots. When the jieriod of illness has been
very prolonged, the liver may be found to be not only
no longer enlarged, but even subnormal in size. It may
be luminous in the dark.
Although slow poisoning by ammonia, alcohol, ar-
senic, antimony, cyanides, sulphocyauates, etc., also
gives rise to fatty degeneration, the steatosis is seldom so
extensive, so marked, nor of so rapid formation as in
poisoning b_v phosphorus. Cases are recorded in which
death from phosphorus took place in forty -eight hours,
yet in this short period there was marked steatosis of the
liver, kidneys, heart, and .glands of the stomach.
Rarely death may take place and the antojisy will fail
to reveal any noteworlh}- lesion or marked intlamniatiou
of the mucosa.
Mechiinixin. nf Action. — As regards this phase of the ac-
tion of ])hosphorus, it is to be stated that at the present
time no satisfactory theories have been formulated. Be-
cause of the lesions and remarkable elfects of phosphorus,
this substance has long been amcst interesting and fruit-
ful field of research for toxicologistsand pharmacologists,
yet in spite of the many investigations the mechanism of
its action is still an ignis fatuiis.
Phos])horus seems to be resorbed without change, and
is carried b}' the blood either in colloidal solution, in the
state of excessively tiue emulsion, or the element is va-
porized by the heat of the body and the vapor dissolved
by the blood. It suffers, because of the high partial
pressure of the oxj'gcn in the blood, little or no inunedi-
ate oxidation. The effects produced upon the tissues
cannot be due to the action of hypophosphorous, phos-
phorous, or phosphoric acids, nor to any alkaline salts of
theseacids. The hypothesis that hydridesof jihosphorus
are formed and carried by the blood and aie the ]irimary
cause of illness seems to be no more tenable than the oxi-
dation tluMjry.
It has been shown repeatedlv that while from a chemi-
cal viewpoint jihosphorus should not be able to exist as
such for an}' length of time in arterial blood, not only
is such the fact, but, as already stated, it suiters but lit-
tle change.
All experiments go to .show that phosphorus is to bi^
classed as one of a group of poisons chieflj' alTccting the
metabolism, of wdiich group hydrocyanic acid, oxalic
acid, and carbon monoxide are tlie other best-known
types. Bauer has pointed out that the oxygen taken up
and the carbon dioxide given off in acute poisoning is al-
ways abnormally low (eight to eleven per cent. CO.; in-
stead of twenty-four to twenty-seven per cent.), and that
the respiration curve indicates a powerful disturbance of
the metabolism. Moreover, this is further borne out by
the fact that peptone-like digestion products are usually
eliminated in the iirine, that the urea is subnormal, and
that the albumin of the food, and also to a certain extent
of the organism, is decomposed, and goes to form fat,
lencin, tyrosin, and probably sarcolactic acid. The de-
crease in the amount of urea has been explained on the
theory that owing to the formation of acids (lactic acidV)
a great part of the nitrogen, which would otherwi.se lie
converted into urea, goes to form ammonia lo neutralize
the acids. Beeau.se of this neutralizing action the alka-
VoL. VI.— 40
linity of the blood falls and probably countless blood
corpuscles are destroyed; for this la'tler rea.son phos-
phorus is also classed, by some aulhorities, in tlie group
of so-called "blood poisons." This wliole question of
action on the blood is very little understood. Cases are
reported in which no destruction of blood corpuscles has
been observed. In man there seems to be a transitory
increase of erythrocytes and a decrease of leucocytes. In
dogs the erythrocytes and ha'mogloliin are not affected,
but the leucocytes seem to lie increased. In fowls there
is luidoubted dissolution of red corpuscles and an in-
crease of leucocytes. Following the destruction of the
red blood corpuscles — which, it is assumed, takes place
at some stage in poisoning bj' phosphorus — an abnormal
secretion of bile pigments takes place; at the .same time
the bile becomes thick and viscid and moves through the
ducts slowly. To account for the direct cause of icterus
several theories have been advanced: one ascribing it to
catarrh of the duodenum and cutting off of the ductus
choledochus; another to the compression of the tiny bile
ducts by the swelling of the liver; still another that the
mucosa of the biliary passages becomes diseased, and that
there is finally a clogging of these passages through fatty
de,generation and rupture of the walls of the vessels. It
is likeh' that all these causes contribute to the retardation
of the flow of the bile, and that this fluid overflows into
the lymphatics. The cause of the iiolycholia is. how-
ever, not yet understood, but its results are apparent in
cerebral disturbances, as shown by coma, etc.
As to what happens to the phosjihorus in its long so-
journ in the blood we know but little. Only one point
is clear. Part unites with many as yet wholh- unknown
basic products Of the metabolism to form toxic com-
pounds. Selmi has succeeded in isolating some of these
compounds from the urine, and has given them the name
phosphoptomai'ns, while Van den Corput has called
them toxicomains. According to this latter investiga-
tor most of the ill-effects of phosphorus are due to the
formation of these retention toxicoses. Besides these
phosphorus bases in the urine and blood, Kunkel ad-
vances the hypothesis that part of the phosphorus is oxi-
dized by the blood, and that the phosphoric acid thus
produced is eliminated in the form of esters.
In the matter of the fatty degeneration of the liver the
weight of evidence seems to be that wc must regard it as
the result of two causes; one, the formation of fat in the
organ itself, and the other the transportation of preformed
fat to this organ. Experiments on animals have shown
that the microscope will demonstrate the beginning of
fattv degeneration in the liver in as short a time a.s six
to eight hours after the administration of the poi.son, and
in about twelve hours in the kidneys and heart (Kobert).
No satisfactory explanation of the cause of the corro-
sion and ulceration of the mucosa of the alimentary canal
has yet been found. It has been suggested that this may
be the result of the nascent action of oxygen acids of
phosphorus at the moment of their formation ; but since
the early formation of these acids is imcertain a better
explanation is wanted.
As to phospliorus necrosis, little can be saiil save that it
follows periostitis. It is not the mineral sti'oma which is
attacked, but the cells of osseous tissue. Necrosis often
follows an injury to the bones or periosteum, in illus-
tration of which an interesting ease, recorded by Wegner,
may be cited. A boy working in a malch faci ory rapidly
developed periostitis and necrosis of the bone following
the breaking of his leg. Wegner's in vest igal ions on the
action of phosphorus on the liones are of great interest,
although they shed liut little light upon the mechanism
of the action. He foiuid that tiie administration of very
small amounts of phosphorus daily, either internally by
the mouth or as vapor, to young animals, caused an ab-
normally rapid development of osseous tissue, that the
bones formed were more compact than usual, that the
medtdlary cavities were much reduced in size, and that
the almormally develo|ied bones did not differ in chemi-
cal composition from bones normally grown.
Investigations upon the action on the heart show that
025
Pliolonilcr«gra|»liy.
Fliotoniicrograpliy*
UEFERKXCK IIAXDliooK OF TIIK MIODKAL SCIENCES.
the beating is arrested in tliastoleiii botli wiirm- and coUl-
blooded auinials, that tlieaeticui i^ |irolial)ly direetly upon
the lieart museles. that tlie aiitoniatie cenlres arc lirst af-
fected and tlien the muscles are nival l_v weakened, al-
thougli they still respond ti) arlilicial stimuli.
Cliniml Tints fur Pliosjilifirus. — E.xpose to the vapors
given off from the warmed material to be tested two
strips of filter paper, one of which has lieeii moistened
with silver-nitrate solution, the other with lead-acelate
solution. If phos])horus is prcseiU. the silver jiaper
blackens while tlie lead paper sliould remain unehang<'d.
If both papers blacken, hydrogen sulphide is present and
mu.st lirst be removed before testing. In such an event
add to the material to lie tested sufticient leail acetate
solution to precipitate all the hydrogen sulphide as lead
sulphide, and test with the two jiapers as before. The
blackening of the silver-nitrate paper is due to the forma-
tion of silver phosphide and metallic silver.
A less satisfactory test consists in boiling the mateiial
to he tested with a small piece of roll sulphur. After a
few min\ites the piece of sulphur, which has taken up
most of the free phosphorus present, is removed, washed,
and examined in a darkene<l room. On being gently
warmed and rubbed with the linger the suljihur will
shine with the peculiar glow of phosphorus, if this latter
element is iire.sent.
If possilile the suspected material should always be
tested in the laboratory by the Jlitseherlich distillation
method.
There are reasons for believing that jihosphorus can
e.xist in the body in tlie free state for about eight weeks.
After twelve weeks it can still be detected in the form of
phosphorous acid, but after about fifteen weeks it is pmb-
able that all the elemental phosphorus has been elimi-
nated or oxidized to ]ilios|ih()ric acid. As regards the
detection of free ]ihos|ihor\is alter death, it is safe to say
that chemical tests usually fail after four weeks; but
there are instances in which it has been possible to obtain
undoubted proof tifteeu weeks after burial.
Kinile Mull in n Chaiiint.
PHOTOMICROGRAPHY— Definition.— The process
of (ibtainitig a m,uros(o])ic photograph of a microsco])ic
object. It is sometimes incorrectly termed micro]ihotog-
raphy. which is the reduction by photography of lanii-
seapes, portraits, or other gross jihotographs to collodi(m
positives of minute size, which are subsequently mounted
Ijeneath a small convex lens, in watch charms, paper
knives, pencil handles, and the like. It is to be noted
that this distinction is not universal on the continent of
Europe. The above title in German is Mikrophotogra-
phie; in French, Photianierographie.
IIiSTOUV. — The tirst photomicrographs and probably
also the first photographs were taken by Wedgewood
and Davy. The record of their experiments, publishe<l
in 1803, some time after the death of Wedgewood, show
that they used a solar microscope and oiitained images
upon paper and leather which had liei-n washed with a
silver solution. They were, however, unable to tix the
images so obtained and, when exposed to daylight, the
entire .siu'face became uniforndy dark.
The Kev. J. B. Ueade, of England, in 18:!7, with a so-
lar microscope photographed entomological specimens
and .sections of vegetable tissues upon jiaper coated with
nitrate of silver solution and fixed the images with an
infusion of galls. In 1S39. at a soiree given by the JIar-
Fig. 38()5.— InsliUhiiinii for l>li..t..iiii.n>(.'i:i|iliv uiih Heli.isiiit. The cilije<ts iuv Miniiis-'c
uiierusfope, acreens, sliuUer, aud uiarur; eulside the wiuduw, ua u levellini
I. frniii
; stuud :
eft to litrlit, ill tlie fiillou mff inder;
lieliostut and a second mirror.
626
REFERENCE IIA^'DBOOK OF THE JIEDICAL SCIENCES. J^»"'»»"''f'-"S'-ai>I'y-
Pliutuiuicrograpby.
Fig. 8806.— The Optioal Bench, Arninsred fur Pliulcunicrntri-aiiliy Willi the Electric Arc Liiiiip. The cibjects are iin-aiis;eii. from left to right, in
the fcillowin? order: end of camera, microscope, scivetis. .shutter, water-bath, condenser system, ai'c lamp: on the table: battery of
oculars and olijeriives, color screens and Indb of pneumatic release of shutter; under arc lamp— the adjustable shunt coil; at the ex-
treme right, against the wall: switches and rheostat.
In practice a i-li>th is thrown over the frame which encloses the microscope, for the purpose of shutting out the rays of light from the
eyes of the operator, while permitting at the same lime all necessary manipulation. The sci'eeus, watei'-bath, condensei'S, and arc lamp are
ail enclosed in such a manner as to reduce to a mininuiiu the es<:ape of light into the roora.
qiiis of Norllianipton. tlien president of the R(iy;il So-
ciety, Mr. Reade e-\liiliitcd more ]ierl'eet. results, and
some of his pliotomicrograplis ^veI■e on s;ile at a baz;iar in
Leeds the same year. It was not until after Dagiierre
had annoimeed his dLseoverv lieloie the Ae;idemy at
Paris on the 19th of August,' 1889, th;it attempts to u.se
photography to obtain pictures through the niieroseope
were generally undertaken. In 1840 Jlr. Dancer, of
England, photographed through a gas niieroseope upon
silvered plates: he also by means of the solar mieroscoiie
photograplied wood sections and fossils on paper and
glass plates. Dr. Donne, of Paris, in 1840, presented to
the Academy of Sciences pliotniuierogmiilis on daguerro-
typejilates; and inciillabi>rati(Ui with M. Leon Fcnicaiilt,
in 184.'), pulilished an atlas on tlie study of the tliiids of
the body, illustrated by cuts from dagtierrotypes. One
of the lirst publications in England to use photoniiero-
graplis as illustrations was the Qmirti rly Jdhi-hhI of the
Microiicopiml Siicieii/, whicli in 18.53 contained prints
from negatives by Mr. Joseph Delves. Since these e:irly
attempts tlie practice of pliotomicrography and its use
for illustration have steadily grown. The list of those
who have done notable work is a long one, and contains
many well-known names.
The Apparatiin. — The several parts comprising the ap-
paratus for making photomicrographs are collectively
called an installation. In its simplest form it may be a
long bellows camera with a photograidiic lens on the
front or on the front of a conical e-\tension, as ordinarilv
used by photograjihersfor making enhirged copies; such
an arrangement is useftd when the cn-iginal object is of
comparatively large size and tlie magnilication slight, ;ts
the limit of a few dianielers is very (|nickly reached by
this method. For most photomicrograpliic work a mi-
croscope is a necessity, as arc also the accessory ap]ia-
ratus on the optical bencli and, in the jiresent day of rapid
dry plates, the eatnera. Sometimes, in the days when the
slow, comiiaratively non-sensitive wet plates were in use,
the room in which the optical Iieneh and microscope were
placed formed the camera ; the source of illumination was
outside the room, and enough diU'nse liglit was admitted
through yellow glass to enable the operator to work.
Such an arrangement was use<l liy Surgeon-General J. J.
Woodward in making his now classical photomicrographs
of difficult test diatoms, etc. At the present time, how-
ever, the rapid color-sensitive plate demands much
greater care in the exclusion of all light not nseil in tak-
ing the picture, and many forms of photomicrograpliic
apparatus have been devised. Some operators, in Eu-
rope especiall.v, prefer to work with the vertical appa-
ratus, subsequently enlarging the pictures so obtained;
but most of the English and American photomicro-
graphersuse the horizontal apparatus, and with the long
camera bellows obtain the desired magnilication directly.
The installation, then, m.ay be described as consisting of
the .source of light, the optical Ijcnch with its accessories,
the microscope, and the c;imera.
The Source nf Light. — This may be an oil lamp of ona
tj27
PliotoiiiU-ro^rrajvIi) ,
Pliot<»iniero^raiiliy.
KEFEP.EXC'K ]lAM)i;()t)K OF THE MEDICAL SCIENCES.
or more burners, illumiiiatiug gas, a Wclsliacli buriu-r,
or an acetylene tianie. All of these may lie classilied
as illumiuauts of a low order, as when liiirh powers
are vised their illumiuation beeoine.s too feeble to enable
satisfactory focussing of the image. The lime light in
any of its moditications forms the ne.xt higher order of
illumiuaut; magnesium ribbon or llashlight the iKi.\t;
then may be put the arc light; and, most powerful of all,
the sun. AVhen the sun is the souice of light, it is nec-
essary to use au lieliostat to ccuitr<il the rays used for
illumination, as after centring the light it should re-
main centred without appreciable variation ; otherwise
much time is wasted and many vexatious failures are
inevitable. It is desirable that the helioslat be of com-
paratively .simple construction in order that it may not
easily get out of order. 1 have found that what is
known'as the PrazmowsUi lieliostat is a very efficient
form, lieing very easily adjusted ami quite simple in con-
struction. This iuslrument carries a single jnirror on its
a.xi.s which is caused to follow the sun by clockwork.
The rays, being thrown at a convenient angle by adjust-
ment when starting, arc maintained in the same direction.
A second mirror on an adjustable stand intercepts the
rays reflected from the lieliostat mirror ami, if tiie instal-
lation is rightly jdaeed, directs them through llie micro-
scope and camera. If, however, it is not convenient to
have the installation so ])laced, a third mirror on the
ojitical bench directs the rays in the desired direction (.see
Fig. 380.)). All photomicrographers who have v.-orked
with sunlight know, however, how few are the perfect
unclouded days when the work can be satisfactorily per-
formed, as even the thinnest cloud passing across the
sun's disc practically extinguishes the light with result-
ing delay and dithcully in making correct exjiosure; but
notwithstanding the annoyances and dillicullies attend-
ing the use of sunlight, until recent years those accus-
tomed to it generally returned to its use after trying
other methods of illumination. At the present time,
however, with the electric current almost everywhere
available, the use of tliearc light frees ])liotomicrograi)liy
from man_v of the ditliculties formerlv obtaining. Tlie
essentials for illumination by tlie arc light are, the con-
tinuous current, a simple form of focussing lamp, a
rheostat, and a shunt coil of simjile form used outside
the /one of heat radiated by the lamii, and capable of
delieale ailjustmeiit. Many of the failures to obtain .sat-
isfaction from the arc lamp, aside from too delicate con-
struction, have been due to the fact that the controlling
coils were within the lamp body. Now, while such a
laiuji may w-ork perfectly in the open where its heat is
radiated away quickly, when we enclose it so that its
light may not escajie into the room to the annoyance of
the o|ieralor, it soon begins to focus irregularly or not at
all. The reason is simple: the actuating nie<:hanisin of
the lamp is controlled by an cleetro-magnet ; temperature
has a decided intlueiiee on electro-magnets; with a givi'ii
strength of current, the higher the temperature of the
iron core the less will lie the amount of magnetism de-
veli)|ied therein. The remedy is also sinijile. A shunt
coil with its armature balanced over a contact ]ioiiit and
capable of close adjustment is inserted in the circuit any-
where between the lamp and its rheostat. It can thus fie
|)Ut whei-e it will be uu;ill'ected liy heat, and can be relied
U|ion to pcuform its functions at all limes. The normal
current goes as usual by the two main wires to the lamp
and liack. but when the arc has re;ielieil such a length,
determined by the adjustment at the shunt coil, that the
resistance becomes too grc;it, the current gnes from the
main wire by a small c(mneetiug wire through ilie shunt
coil, actuates its electro-magnet, juills down the arnia-
lure, and through the contact mentioned alio ve is shunted
throiigha third wire, which enters the lamj) byaseparate
biniliiig screw and actuates the controlling mechanism.
The lamp immediati'ly focuses, and so delicately can the
shunt coil be adjusted tli;it the laiuji will ;iiitoiiiatieally
adjust its locals every other second or two, each time
moving the carbons together only a fraction of au inch,
and keeping the crater of the positive carbon luaetically
in the optical axis without flickering or change in the
steadiness or intensity of the beam of light, the prime re-
quisite of any illumination for photomicrographj' (see
Fig. 3806).
The Optical Bench . — This consists of two parallel rails
or V's or a slotted board flxed between the microscope
anil the radiant (the mirror reflecting the sunbeam, tlie
crater of the i)Ositive carbon, or the flame of gas or
lamp), and holding the condensers, water-bath to absorb
the heat rays, diaphragm stands and screens for various
purposes, and sometimes the shutter lor the exposures.
These are all arranged ou stands so that tliey may be
moved to and from the radiant. They should also be
adjustable as to height as should the radiant itself.
The MicniarDpe. — The microscope niaj' be of the usual
pattern ; but for those using as low a power as a three-
inch or four-inch lens, a microscope with a body tube of
larger diameter and sliorter length will be found most
convenient. The long focus, low-power lenses can then
be used inside the body tube, being held by a cone fitted
to .screw in place of the draw tube; beside the usual sub-
stage condenser there should be an achromatic substage
condenser of about 1 N. A. adjustable for centring, a
ring with screw thread to hold lenses sometiiues used as
coiiden.sers. and a simjile low-power condenser for illumi-
nating large objects when slight magnification is desired.
There are also accessory pieces of apparatus, such as
prisms, black ground stops, devices for oblique illumi-
nation, monochromatic illumination by means of the raj's
of the spectrum, etc., all fitted to the ring of the cou-
dcuiser carrier so as to be interchangeable. These latter
are rarely used except for special lines of work. The
stage tif the micro.scope should be large anil of the type
known as mechanical, moving in any directiun in its own
plane. The aperture of the stage should be of such size
that the high-power condenser may lie brought close to
the object. The front of the stage lu.ay be fitted with a
sliding carrier for rouglily centring the object and a
tilting carrier for special occasions. The battery of ob-
jectives may consist of any number desired; it will be
found, Jiowcver, that a large number is by no means
necessary for widely differing magnifications, as by
lengthening or shortening the distance between the mi-
croscoiie and the sensitive jilafe, various magnifications
may be hail with the same olijective. An amplifier mav
be used for the same purpose, as also oculars of differing
powers.
'The Camera. — This may be of any usual make, the
size adapted to the wants of the o|ierator, or it may be a
specially maile long bellows camera. It may be "firmly
fixed to the same bench or jilaiik that carries the micro-
scope, optical bench, and radiant; or it may liave a sepa-
rate stand of its own and be capable of movement to and
from the microscoiie. It is quite necessary that the con-
nection between the microscope and camera, while ex-
cluding all light not used for illuminating the object,
should be of such a nature that no vibrations may be
transmitted to the niicrosco|ie when adjusting the plate
holderor withdrawing llie iliiik slide. Acone front with
cylindrical end is usually ]il;ieed on the camera, and this
may be connected with the luieroscope by a light-tight
sleeve of fabric, or it may fit in, without touching, a
double metal cylinder on the eye tube. When using a
long bellows camera, some means of focussing both the
coarse and the fine adjustments of the microscope from
back of the camera must lie added to the installation. Va-
rious methods of accomiilishing this have been described
by ]ihotomicrographers, each having its advantages.
The e.sseiilial iioinis are that whatever method is u.sed, it
must not convey any jar or vibration to the niicro.scope,
or bring a strain ujion the screws of either adjustment.
It must of necessity work smoothly.
I'l-ocedure. — It is necessary when first setting u|i and
adjusting the various parts of the ajijiarafus to consider
some one part as lixed and adjust all the other parts to
it. Generally it will be found best to consider the micro-
scope as the fixed part, and that imaginary line passing
through the centres of objective and ocular and indefi-
628
liKKKKENCE IlA.NDIiUOK OF THE MEDICAL SCIENCES.
Phoioiiiit-ro;
PUotoiiiiero;
irapliy.
;rapUy.
niti'lv prolouged. called tliu optical axis, as that line
with" which the centres of all the other parts from radiant
to ground glass of camera must coincide. Suppo.se we
have a long bellows camera, an arc lamp, an optical
bench (with a large condenser, a water-bath, and sup-
ports for diaphragms or screens), and a microscope, and
that we wish permanently to moimt them ujjon a long
narrow table or bench, two or three feet wide b_v about
twelve feet long. At one end of our table we would
place the lamp, ne-\t the optical bench, then the micro-
scope turned to the horizontal position, and finally the
camera. Upon the size of the ground-glass screen of the
camera would depend the heiglit above the table of the
tube of the microscope. This having been determined,
the base.of the microscope is clamiied lirruly to the table
in its proper position, so that the ojitical axis passes over
a line drawn through the centre of tlie tabk- in the direc-
tion of its length. The camera may now be placed be-
hind the microscope and adjusted roughly as to the cen-
tring of ground glass with tlie optical a.\is. The same
may be done with the optical bencli in front of the micro-
scope, and then with the lamp. A quick method of rough
centring, which I have fonncl jiractical, is to cross threads
diagonallj' from corner to corner of the camera back, the
ground-glass screen having been removed. This will
give the centre of the ground glass screen. From this
centre stretch a thread through the camera-tube of the
microscope, through a pinhole diapliragm in the stage,
and on through like diaphragms on the optical bench,
fastening the thread at last to one of the carbons of the
lamp. The various parts are now adjusted until the
thread, being stretched taut, passes througli the dia-
phragms without touching. The final centring is by
the light. Removing the thread, jnitting a low-power
objective in the microscope and starting tlie lamp, we
focus the condensers .so that the image of the crater,
taken up by the objective, is thrown upon the centre of
the ground-glass screen of the camera. After the cen-
tring is accomplished we are in readiness to take a picture.
The object is fastened to the microscope stage and the
low- or high-power substage condenser adjusted. Tlie
image ma}' now lie thrown upon white cardlioaid for ad-
justment, centring, etc.. or by interjiosing ground glass
and a color filter between the radiant and the substa.ge
condenser to render the light bearable to the eyes, the
operator may view the image directly through the micro-
scope in the ordinary way. The camera is then con-
nected as above to the microscope and the final focussing
done from back of the ground-glass screen, or, as some
prefer, by means of a magnifying glass adjusted to the
surface of a plate glass screen, which oi'cupies the
same position as the sensitive plate when the picture
is taken.
We must now wait a few moments and then reexamine
our image. If it is as sharp as we left it. we may proceed
to photograpii it; if, however, it is not so sharp as wlien
we had finished focussing it. it will be necessary to find tlie
cause and the remedy. The diange of adjustment may
be caused by jarring, by a worn tliread on the micro-
meter screw, bj' too strong a spring in the micrometer
movement, or by a change in the temperature of the
room or parts of the apparatus. The micro.scope sliould
be so mounted that no jar can be transmitted to it; worn
parts should be replaced: and the temperature of the
room should always be warm so that the starting of the
lamp will not cause a noticealile increase in that temjiera-
tin-e. It is always well to start the lamp a few minutes
before one is ready to take the picture, and allow the
dilTerent parts to adjust themselves to any changed con-
(liticms. The adjustment of focus, etc., being .satisfac-
tory, the exposing shutter is closed. The plate-holder
containing the sensitive plate is jilaced in position and the
exposure made. The subsequent operations of develop-
ing and printing are pureh' ]ihotograpliic, and are the
same as in ordinary photography.
Special Formii of Appunttnu. — Of special forms of ap-
paratus and adaptations to special purposes there are
many. Perhaps among the most useful to the laboratoiy
worker in bacteriology, wlier(! a limited range of magni-
fication {i.e., from two humired to one thousand diame-
ters) is desired, is that of the Mis.ses Foot and Strobell.
Any of the small vertical cameras may be used, and the
microscope may be the same one iis<'(l in ordinary re-
search. The novelt_v consists in obtaining the focus di-
rectly bj' the eye, ob.serving the image thnnigh the micro-
scope with any one of a scries of negative lenses ]ilaced
on top of the eyepiece. The negative lenses n.sed are
those test sets furnished by opticians, and number from
one to ten dioptrics and their fractions. The use of this
lens will of course cause the image to vanish and refo-
cussing will be necessary. If the right minus lens has
been c'hosen, upon its removal from over the eyepiece
the image will be found thrown upon the ground gla.ss
of the camera above as a sliarp picture. In each case the
minus lens, best adapted to the end in view, must be
found by trial. The method is faulty in that no provis-
ion is made for removing the negative lens from the eye-
piece without some risk of disturbing the focus obtained.
It has, however, the great advantage that any light can
be used that one would ordinarily view objects through
the microscope by, as ordinary did'used daylight. The
exposure will of course run into the minutes with its at-
tendant risk of change of focus or displacement. The
preliminary wait, after obtaiinng the focus by this method
to allow for change in focus, etc., is more important than
with the horizontal apparatus; for the microscope being
in the vertical we have the infiuer.ce of gravitj- acting
directly upon the focussing mechanism.
PJtotomicrogyitphy iij Vohirtd Otijtrls. — Informer J'ears.
when the wel collodion jirocess was in general use, and
when later the gelatin dry phites were introduced, the
pliotomicrographer was limited in the selection of sub-
jects to those lliat were nearly colorless, and was unable
correctly to render those objects that contained mixtures
of red. or yellow and blue. The chloride of silver of the
wet plate and bromide of silver of the dry plate were
alike sensitive to tlie light rays of short wave length (i.e.,
the blue and violet) and comparatively insensitive to the
ra3's of longer wave length (i.e., the green, yellow, and
red). The lilue portions of an object would be fully im-
pressed on the plate long before the green, yellow, or red
portions made any impression at all; and if an attempt
was made by prolonging the exposure to render the lat-
ter, the blue jjortion through over-exposure would be
lost. It was not until Vogel announced his discovery
that an ordinary gelatin dry jilate, when bathed in a
solution of an aniline dye, became more sensitive to the
rays of longer wave length, that it bei"ime possible to
represent by the light ami shade of the photograph the
brilliancy of the various colors as they afl'ected the eye.
It was not enough simply to dye the plate. The dj'e,
while rendering the plate more sensitive than before to
the yellow end of the spectrum, did not diminish its sen-
sitiveness to the blue which was still in excess. The
problem was solved h\ diminishing. (U' in some cases en-
tirely cutting out the blue and violet rays by the use of
fluids that absorbed them. Such flui<is, ti'rmcd color
filters, had previously been in use for just the opposite
purpose, i.e., to allow only the rays of highest refrangi-
bihty to pass through the object, for the purpose of in-
creasing the resolving power of the objective. It was
afterward found that films stained with the proper dyes
could be used in jilace of the fluids, a gain in convenience.
Since then the color or colors of theoliject donot present
much difficulty, provided, howevc'r, the object is not too
thick nor too deeply stained in parts; nor, on the other
hand, so lightly stained as not to alTord suflicient con-
trast, as in certain thin jiathological specimens where the
diseased tissue will not take a good stain. It may be al-
most impossible to obtain a .satisfactory photomicrograph
of such objects. It is possible at the present time to go
beyond the mere represeiit.iition of colored objects in
monochrome, as by the use of tlie proper color screens, as
first demonstrated" by the writer in IWo-DO. three sepa-
rate photomicrograiihs may be taken of a section stained
in three or more stains; and b}' means of the commercial
629
PQi<>l<»flicrapy.
Plchi.
RKFKRKNCF, IIAMir.ooK OF TIIK MKDUAl. t^('IE^•C■ES.
tliivecokir printing prorcsscs now in usr. il can In- i|uile
faitlifiiUy rcin'othiced iu its original colnrs.
Pnpurtitioii itf SpeciiKeim. — 'llic- sprrial prcparatiim "I
spefinicns for pliotoinic'iogruiihy is nol al prcsi-nl so nciis-
sarv as before the introiluelion of the color-sensiiivc plate
ami tlie eolor lilter. Tliere are. Innvever, certain rei|nire
meuts tliat liave to be complied with if the best results
are to be olitained, as, for instance, sections of tissue niusl,
be thin, evenly cut, and, above all, they should be Dal.
Many an otherwise good specimen cannot be used for jiho-
toinierography because siillicienl c.irr was noi taken to
get it perfectly flat ujion iis slide, and with its cover-glass
ilowu upon it. Xow it must be remcmliereil tliat the
objective has no depths of focus: that is, only those oli
jectsor portionsof tlie object in one plane at right angles
to the optical axis can lie in focus at one time. _ Any
other idane of the object reiiiiires a separate focussing of
the objective to render its image .sharp; and therefore a
section only slightly iiregnlar, and which to the eye,
(owing to its powi'rof accommodation, wliieli is invobin-
iarily'used) .seems quite thil, upon lieing pliolograiihed
willgive a negative for the most part sharply defined,
but containing spots or areas of various sliapes which are
quite blurred. The photomicrographer cannot by any
n.eans short of flattening such a specimen obtain from it
a good result: for if he shoidd, by stopjiing down the
substage condenser or when ]i(jssilile the objective, seek
to render more than one ]dane of the specimen sIku]), he
would inevitably intioduce errors of refraction which
in them.selves would spoil the result. Ridges or knib'
marks, due to the chattering of the knife bhide of the
microtome when cutting the section, will always show
iu the photograijh. Sjiccial staiinug, as mentioned
above, is not necessary, though it is always dilficult to
secure a good result from a section too deeply or too
,ightly stained: but in general any section stained so as
to show well to the eye ill the microscope will make a
good photograpb.
Limitdtionn. — To pliotomicrogra]iliy, as to all oilier
things, there are limitalions. These aiv more especially
evident when we seek very high magniticalions. As we
go beyond one thousand (iiameters, it becomes more dif-
ficult "to obtain satisfactory images: and while it is pos-
sible to obtain sharp images of certain selected objects,
such as a portion of the i'rustule of a diatom, up to five
thousand diameters, it will be found that only such ob-
jects as lend them.selves to the work can be so taken, and
that, except as a /"///' dc /"m-. the results are all out of
proportion to the labor and lime expended. AVhen much
Jiigber magnifications than one thousand arc desired, the
only practical way is liist to photograjili the object with
as high a power as will give a good, sharply defined
image (say up to three tlunisand diameters), and then to
enlarge the negative. In this way it is possible to attain
inaguitication of ten or twelve thousand diameters, lint
again we are limited in this method, aswdien we attempt
to enlarge a gelatin negative more than three or four
diameters, the^grain of the gelatin begins to become dis-
agrceablv app^rrent and to interfere with the sbar])ness
of outline of the image. It should always be remembered
that the magnification of the objective is the only mag-
nification that resolves the details of the object. "What
further enlargement we may get by oculars of high
power, by in<'re:ised leiigtb of camera bellows, or by en-
larging tile negative, does not add any detail to that re-
solved"' by the objective originally : it simidy spreads the
image as given liy the objective over a larger surface.
It follows "then that to magnify any object further than
to make its details clear to the unaided eye is useless and
to be coudemned. Edininl Lniiiiiii(j.
liim.ioiai.M'iiY.
Journal of the noyal Institution, ISie,
John Towler : The Silver Sunheiini.
Cinitain .^Imev: .\ '1 realise on I'liolotriaphy.
Meilieo-Chirurcical lieview. July, 1SI4.
MoiiHssii-r: La i'liotot'iaphle aiiiiliqiloe aii.s re.herilies iniiro-
j:rapliiques.
licale; How to Work with the MicriwoiH'.
Neuhass : MiUrophotuKniiihie.
^tprnhe^^; Pholomierograpbs and How to Malie Tliem.
fool anil strohell : Zeitsehr. fur wisseusohf. Mikruskopie, etc., Bd.
.vyiii,. lliOI. I'll. t-1. t-il.
I.eaiiiiiiL^ : stiiilii-s from the Pepartment of Pathology. Colletre of
I'lnsioiaiis ami Siir^'eons, Cohiinhia l'ni\ersity. Vol. y,. Part i.,
l.syil !IT.
PHOTOTHERAPY. See Roentr/en Puty, etc.
PHOTOXYLIN. — A nitrocellulose, similar to (lyro.xy-
lin. but prepared from wood pnlp iustead of cotton.
\ three- to live-percent, solution iu etjual jiarls of al-
cohol and ether is recommended to replace collodion iu
plastic snrgeiy and other conditious iu which such an ap-
plication issu.ggested. The solution forms a thick liquid,
which upon evaporation leaves a firm, dense film, which
is stronger than that of collodion. Beniniiont SimiU.
PHRENIC NERVE.— An.\tomy.— The phrenic nerve,
or llie Intel iial respiratory nerve of Bell, is the principal
motor nerve of the diaphragm. The spinal origin iu
dogs and rabfiits is located iu the auterior horn of the
spnialcord ;it the level of thefifth and sixth cervical ver-
tebra', and iu man in the centre of the interior horn, ex-
tending from the middle of the third to the sixth cervical
.segment. The superficial origin of the nerve is from the
third, fmirth. and fifth cerviclil nerves iu the following
liro portions:
N'umlnT
of CILSi s.
W.
Ill
ii't
Fourth
only.
Yi
4
9
Fourth
ami llfth.
21
Third.
fourth,
anil dflli-
■A
i:!
Third :iia
fourth.
I.iischka
Brook
Ort'on
(i
11
0
Total
100
:jt-;!T«
-!--»
I.Vl..:!
When there Is a sirit'le root, it is always from the foiinu u, r. e.
CoiiisK.— The course of the nerve is as described in
the standard text-liooks. there being but few variations.
I'a.ssing over the anterior surface of the scalenus auticus.
diagonally downward tind outward, it passes iu front of
thefirst "part of the subclavian artery and behind the
subclavian vein. In about four per cent, of ca.ses. how-
ever, the nerve passes iu front of the vein, and so lies
iinmeiliately behind the clavicle. Two cases are on rec-
ord in which the nerve |>assed through the vein. Passing
into ihe thorax it lies, on the light side, externttl to and
slightly liehind the right innomiuate vein and the supe-
rior vena cava: on the left side, iu froutof the arch of the
aorta. On both sides it passes between the pleura and
the pericardium, anteriorly to the roots of the lungs; on
the right side being iu close contact with tlie root. ai:d on
the left side passing out and to the left, in order to pass
around the heart. "The right nerve has an almost verti-
c;tl direction, and passes to the upper surface of the dia-
phragm, where it divides into from three to six branches,
whicii pierce the diaphragm externally to and iu front of
the opening for the inferior vena cava. Thi^ loft nerve
has a more circuitous route, uud generally divides in the
substance of the diaidiiagm.
Ilrnnches. — \. t'ommuuicatiug: (1) From the upper
ganglion of the cervical sympathetic gangliated cord.
(2) Occasionally, from the loop formed by the desccndens
andcommiinicanshypoglossi. (o) From the nerve to the
siibclavins. (4) Tile right nerve, at its termination, sends
blanches U> the right semilunar ganglion of the solar
jilexus. (•■>) The left communicates with the sympathe-
tic plexus to the o'sophagus above the diaiihragm.
i. Distribution: (1) On the right side, to the superior
vena cava, (i) Pleural branches, from one to three iu
number. {'■') Branches to the pericardium, usually three.
! (4) Lii.schka has described twigs to the right auricle.
(.")) Termintil branches to the diaphragm. This is the
' main distribution of the nerve. It supplies the entire
diaphragm excejil an aiea along the costal margin, about
;.i cm. in width, which is supiilied by the lower six inter-
; costal nerves, and an indeterminate area on the crura,
630
KEFEliEXt'E HANDBOOK OF THE MEDICAL SCIEKCES.
Fli
i>l<>tliorapy.
probably supplied by the vagus. The exact area, sup-
plied by tin; fibres from tlie various roots of origin, is
as yet undetrnniued. A single case of a dog. iu which
Sehroeder divided the iipjier roots of origin, and on post-
mortem found drgeneratioii of the anterior and middle
portions of tlie muscular imrlion of the diaphragm, with
the lateral and jiosterior portion intact, is tiie only case
of the kind on record.
Relations. — In the neck the nerve lies on the anterior
surface of the scalenus anticus muscle, beliind the great
vessels and the sterno-cleido-mastoid muscle, tlie omo-
hyoid muscle an<l tlie transversalis colli vein. In cross-
ing the subclavian artery the nerve generally lies external
to the origin of tlie internal mammary, but internal to the
course of the artery iu its course iu the thora.x. The other
relations have been noted.
The physiological function of the nerve is that of the
principal motor nerve supply to the dia]>liragin.
P.\tiioi.<i(;y. — 1. Paralysisof half of the diaiiliragm, as
a result of inflammation or degeneration of I he ]ihienic
nerve, on the corresponding side, as a result of exposure,
lead jioisoniug, or compressiou, may occasionally occur.
Thecimdition generally comes on slowly and is character-
ized by inversion of the type of respiration, w-hich reduces
intra-abdominal pressure, causing ditlicnlty in defecation,
etc. Respiration is usually affected only during exertion,
when dyspntea results.
3. Neuralgia. Someauthoritiesde.scriliea form of neu-
ralgia characterized by pain in the lower ami anteiior
jiart of the thorax, along tlie line of diaidiragmalic at-
tachment, extending uji into tlie neck and along the in-
side of the arm, with jiainfiil areas at the ])oints where
the nerve becomes superficial. This condition is said to
complicate angina pectoris. Graves' di.sease, and some
forms of cardiac disease.
3. Surgical Pathology. Injury to or division of the
nerve may occur iu gunshot wounds or slab wounds, or
in the course of surgical operations. This complication
has generally been regarded as fatal, and the statement
has been generally made in the surgical literature that it
was necessarily so. A careful review of the literature,
however, shows only six cases on record iu which the nerve
was injured. In all other cases, usually reported as in-
juries of the phrenic nerve, an examination of the origi-
nal article shows that some other adjacent structure had
been injured instead of the phrenic. <lf the six cases of
actual injurj' to the nerve, iu tlielirst four(lliose reported
by Schurmayer, Beck, Bardeleben, ami Erichseii) there
was also injury to some other important structure, which
■was alone sufficient to cause death. Of the two cases of
injury to the nerve alone, the first (reported by Macken-
zie) was instanlh" fatal. The .second (reported liy Sehroe-
der ill 1003) ended in recovery, with |iaralysis of the cor-
responding half of the tliaphragm. Mackenzie's case was
that of an Indian coolie, w lio suddenly fell dead, jind on
post-mortem examination the reporter was unable to find
any sulticieut cause of death, except a rupture of the
right phrenic nerve. It hardly follows, however, that
the rupture of the nerve was the cause of death.
Schroeder's ca.se, then, is the only one on record in which
the phrenic was injured without injury to surrounding
structures, and in which the exact ex tent of the injury was
known. In removing a fibroma, which was attached to
tlie borders of the foramen formed by the third and
fourth cervical vertebra', the ujiper root of the phrenic,
coming from the third cervical, was found traversing the
upper and outer part of the tumor, wlide the lower root
came from below. As the tumor was thought to be
malignant, an attempt was made to dissect the nerve
from the tumor; but in doing so, tlie roots of the nerve
were torn off. There was no material change in the pa-
tient except an iiicrea.se of respirations to 32. The nerve
was united by sutures, and on being iiinched below the
suture, the diaphragm responded. There was no cough
or hiccough nor any other symptom, either during the
operation or afterward, except that the resjiirations re-
mained at 24 to 32 for four or five days, and then came
down to 20. Examination after recoveiy showed the left
half of the diaphragm stationary and two and one-half
inches above ils normal position. The patient left the
hospital completely recovered, and resumed his former
occu])ation.
Exik-riinentid Reseitrches. — 1. On the Human Being. In
eighteen ca.ses of tuberculous glands of the neck, the
nerve was pinched during operation with the following
results; Contraction of the corresponding half of the dia-
jiliragm, with sudden rising of the anterior abdominal
surface below the costal arch. In ten cases the right
nerve W'as pinched and the left iu eight. In one case ou
each side there was some pain iu the region of the dia-
phragm, 'out it subsided in forty-eight hours. The
symptoms usually attributed to irritation of tlie dia-
iiliragm (i.e., sneezing, coughing, and hiccoughing) were
not observed in a single instance.
2. Experimental Researches on Dogs. In the course
of an extended series of experiments on dogs, the follow-
ing results were obtained ; After resecting as much as
possible of the cervical portion of the nerve, it was found
that after resection of one nerve onl}'. there was an in-
creased thoracic expansion and a slight abdominal retrac-
tion, changes which were more evident on the divided side
than on the normal side. In case of a double resection there
occurred an invert d type of respiration, i.e., decided re-
traction on inspiration and increased thoracic expansion,
due to I lie action of the accessory respirator}' muscles.
In uiiilati'ral resection kymographic tracings showed that
the normal iKilf of the diaphragm rose half an inch on in-
spiratinn and fell the same distance on ex])iiation, while
the half of tliediajiliiagin on the side on wdiicli the uerve
had been resected moved only an eighth of an inch, as
it was moved passively by the movements of the normal
side. After division of the nerve, tli<' diaphragm be-
comes relaxed and the muscle arches nj) into the thorax.
The type of respiration becomes increasingly costal when
one uerve is divided, and inverted when lioth nerves are
cut- The accessiny respiratory muscles become \ery ac-
tive. There is no sneezing or coughing. In one case of
double division the respiration became laliored, but re-
mained so for only a few days.
PtiKt-iiiDHeiii Findings. — Iu ca.ses in which the dogs
were killed iufroui seven to fourteen days after resectiou
of the nerve, the atrophy of the diaphragm was not great
and tlie coliir was reddish-yellow. When a longer time
had elapsed, the afi'dphy was marked, the paralyzed ]iart
being thin ami flabby, the color pale yellow, and in older
cases translucent. In all cases there remained a margin
from one-(piarter to three-eighths of an inch in width^at
the costal border, which retained its normal color and
thickness. Tliis margin is supplied by the intercostal
nerves.
Snninwrii. — 1. From clinical, experimental, and ana-
tomical data it would .sceiu that the diaphragm is not an
essential luuscle of respiralion, and that the im]iortaiice
of injury to its principal nerve, the phrenic, has been ex-
aggerated. Injury to the phrenic or division of one nerve
is not nece.s.sarily fatal. It may, however, predisiiose to
lung infection or be followed by diaphragmatic hernia.
2. While tliediaphragm issupplied wilh branches from
the lower six intercostal nerves, they are inferior to the
jihreiiic in importance and unable to take the place of the
phrenic afler division of the latter.
[A full bibli(igra]iliical list will be found in the Febru-
ary uumber, 1S)02, of the Anicriani JnurnnldJ the Medical
Srienees.^ William E. Sehroeder.
Frederick B. Oreen.
PHTHISIS PULMONALIS. See Lnngs. Titherculosisof.
PHYSICAL MEASUREMENTS. See N„cnl Ih/yicne,
and ii'Cniils, Kniinimdion of.
PICHI.— F.\Bi.\N.\. The dried leafy twigs of Fabiana
inihricatft R. et P. (fam. tyilrinncne).
This large evergreen, heather-like shrub is common
upon high dry hills in Chile. It is rather closely related
to the tobacco plant. Only the small twigs should be col-
631
Pifric Ai-i<U
Plodra.
KEFEHEXCE HAXDUOOK OF THE MEDICAL SCIENCES.
Icctffl. though much of the driis;; of ooiiuiutcp ineluclcs the
hii'ge woody branches, or even the tninks, several inches
in diameter. The branclilets are slender and crowded
with leaves. The bark is ushy ^ray and linely roughened
by minute, short, sharp, thickly set loniritudinal ridges
aiid minute gUmd-lilie protuberances, bolli of wliicli e.\-
hiliil, under tlie lens, a peculiar resinous structure. The
bark of the trunk and larger branches scales off iu ragged
strips. The bark is rich in the re.sinous constituent, which
exists also, to a much smaller extent, in tlie young wood,
but is practically wanting from the old wood. Tlie leaves
are broadly ovate and thick, about a line long, bluish or
whitish green by reason of the resinous exudation, which
is profusely deposited at their bases and edges. Toward
the ends of the branches are numerous very short branch-
lets, each terminating in a iiersistent white or bluish
tlower, which is funnel-sliai)ed and from a third to a half-
inch long. These flow'ers are rarely seen in the drug.
Five uneijual, included stamens are borne tipon the con-
stricted portion of the corolla. The style is slender, the
Stigma small and two-lobed. The fruit is a two-celled
capsule, about one fifth of an inch long, and contains
several brown seeds.
The important constituent of iiirhi is a large ami va-
riable amount of a bitter resin. Associated with this is a
little volatile oil, the imiiortant constituent of which is
fahianol, and to whicli tlie peculiar odor of the flrug is
due. A fractional amount of the alkaloid fnhidiiine and
a fluorescent glucoside. occurring in bitter crystals and
resembling ajsculin, also oc<-ur, together with gum. an
inert crystalline resin, and ordinary jdant constituents.
Pichi'is a highly valued drug, both with the laity and
with the profession, iu Chile and other South American
countries, and was introiluced into use in the rnited States
by the iircsent writer (7V/<;-. Gii:., l.sS.'i, p. 8101. Its sjie-
cial repute is for the treat iiieiit of vesical and renal troubles
arising from the uric-acid diathesis and for the expulsion
of gravel and small calculi. It also acts as a sedative to
the irritable mucous niembrane. modifying the secretion
and subduing the pain. The following account of its
action and uses, by Beaumont Small, in the preceding edi-
tion of this work, can scarcely be improved upon:
"Its use has been extended to all forms of acute and
chronic intlamniatiou of the urinary organs, and numer-
ous reijorts of eases iu which it has been emiili>yed tell of
its beneticial action, not only in cystitis and vesical irri-
tation due to simple causes, but also when these have
arisen from gonorrha'al and prostatic disease. A special
indication for its use is said to be the presence of pus iu
the urine. Dr. Reginald Harrison, after using the drug
for four years iu private aii<l liospital practice, stated
that he obtained considerable beiietit from it, particularly
under the following conditions; (1) In renal colic and the
passing of calculi through the kidneys and along the ure-
ters attended with luematnriai though not exercising
any solvent power, it seems by its action on tlie tissues in
some wa)' to favor the escape of the stone, and thus to
suppress the bleeding. {'I) In tlie hemorrhage which
frecjuently accompanies cancer of the bladder. (3) The
sedative action of the drug on the inucovis membrane of
the bladder has proved beneticial in many instances of ir-
ritability connected with an enlarged prostate.
"In addition to its emiiloyment iu urinary disorders, it
is recommended for the relief of the headachi', dyspepsia,
and other symptoms arising from a condition of lithiasis,
and has been used as an heinitic stimulant for jaundice
and dropsy due to hepatic disease. Given in small doses,
preceding the meal, it has beiMi found to be ;ui I'xccllcnt
stomachic,
"The drug is generally administered in the form of a
decoction or Huici extract. The decoction is prepared Iiy
adding one ounce to twenty ounces of water, tlu^ whole
to be given iu four portions during the day. The dose
of the fluid extract varies between ten minims and two
drachms. The average dose is from half a drachm to
one drachm. The effects of the drug are usually experi-
enced after a few doses have been given. The extract is
not miscible with water, and the appearance of the mixt-
ure is made more pleasant by rendering it alkaline. Glyc-
erin is recommended as tlie best vehicle for its adminis-
tration; it is a fairly good solvent, and maintains the
drug in suspension iu tine particles. Salines should not
be combined with it, as they cause the separation of the
resin in dense curds. Fluid extracts of hyoscyamus, hy-
drangea, buchu, and other remedies may be combined
when tlie_y are indicated, A solid extract allows of its
administration in powder iu capsules. The dose is from
two to ten grains." Ueiiry II. liiisby.
PICRIC ^C\D.^{Cl(rhflzotie Acid. Trinitrophenol), CeHj-
(X<)ji3.(->1I. Picric acid may be formed by adding car-
bolic acid to fuming nitric acid and heating. It crystal-
lizes in yellow, glistening, laminar or acicular scales. It
is soluble in 9.5 parts of water, and in 16 parts of alcohol.
It readily combines with alkalies to form salts, of which
ammonium jjicrate is preferred as a therapeutic ageut.
Picric acid and its salts form powerful explosives, and
many accidents have been due to their careless handling,
Amuioniiiiii picmtc forms in yellow crystals, soluble in
Avater and alcohol. It has a bitter taste, is odorless, and
imparts a yellow color to everything with which it comes
iu contact.
Picric acid and its salts may produce toxic effects when
administered internally, or when absorbed from the skin
or abraded surface. It has caused weakness and depres-
sion, diarrluea, colic, lilack urine, jaundice, convulsions,
collapse, and death. It stains the tissues yellow and
produces an alteration in the cliaracter of the blood.
Many cases are reported in whicli it has given rise to un-
favorable symptoms when applied externally in the treat
ment of burns and skin affections. It also discolors the
skin and lias produced a vesicular rash and an erythema-
tous conditi<in resembling scarlet fever.
Picric acid in the form of the ammoniatehas been sug-
gested as a substitute for quinine in the treatment of
malaria and malarial neuralgias. It is given in doses of
one-eighth to one and a half grains three or four times a
day. Althinigh it lias been of service in the hands of
some, it has not proved of sutlicient value to warrant its
continued use. On account of its property of .staining the
tissues it has also been suggested as a method of treating
trichiniasis.
Picric acid is employed locally in the treatment of in-
flammatory atfections of the skin, and for burns and
scalds. In erysipelas the application of a saturated solu-
tion, whicli has a strength of nearly one ]ier cent., has
proved of value. It is to be apidied from five to ten
times a day and the solution allowed to dry upon the
part. Its power of reducing the infiammation is sup-
posed to be due to the fact that it penetrates the corne-
ous cells of the skin, and by its astringent property acts
as a protective to tlie Malpighian layer of cells; it also
actsasa parisilicide upon the specific cause of the disease.
It is recommended in eczema wlien the infiammation is
acute and sujierticial and accompanied by mucli itching.
It is of less service in chronic forms accompanied by in-
duration of the skin. A compress of the saturated solu-
tion is kept applied to the part for several days. It les-
sens the weeping and pain and promotes healing.
Of late years it has been particularly recommended for
the treatment of burns and has been extensively em-
ployed for this purpose. It is most serviceable in burns
of the first and second degree, as its special elTcct is to
favor the growth of new epidermis. If there is a granu-
lating surface it is of little value. A layer of ab.sorlient
cottou, saturated with the solution, is kept applied to the
part. Under this treatment the heat and pains siibside
and the sujierficial lesions quickly heal. After which,
if there are deeper burns and granulating surfaces, they
may be treated by other means. Ointments of a strength
up to five per cent, have been used, but it has been
pointed out that where absorption and ill effects have
occurred, these stronger preparations have been em-
ployed. The discoloration of the skin may be removed
by washing with alcohol or witli a solution of carbonate
of lithium.
G?,-2
REFERENCE HANDBOOK OF THE JVffiDICAL SCIENCES.
PUrio Acid.
Plcdru,
Fig. 380'.— Fruit of Cocculus Indi-
cus. Whole aud in seetiou
(Baillon.)
Pici'ic acid has also been used in genito-urinary disor-
ders, urethritis, ear and eye diseases, and many other con-
ditions, but has not met "vvith mucli favor.
Bcaiiiiwnt Siiiidl.
PICROL — di-iodo-resorcin monosnlfonate of potassium,
CoUIt! (OH)2S03K — is a white, odorless, bitter crystal-
line powder which contains tifty-two per cent, of iodine,
and is soluble in water, glycerin, and ether. It is a sol-
uble substitute for iodoform. IT. .1. Bustcdo.
PICROTOXIN.— P2>)wtew)?;m (U. S. P.).— A neutral
principle obtained from the seed of Anamirta Cocculus
(L.) \V. ct A. {Meninpermum C, L. ; A. paniculuta Col-
ebr. Fam. Menisperrnacfce).
The origin of pici'otoxin from fish-berries lias been ex-
plained under Goccidus Indicvs. The seed alone contains
the active principle pic-
rotoxin. This is extracted
witb boiling alcohol, the
solution concentrated and
cooled, the fat removed,
and the residue treated
with boiling water. The
picrotoxin is crystallized
out from the slightly
acidulated decoction, and
is afterward purilied by
the use of alcohol. Sev-
eral associated alkaloids are liable to occur as impurities
of picrotoxin. The substance is thus descrilied liy the
Pharmacopoeia:
Colorless, flexible, shining, prismatic crystals, or a mi-
cro-crystalline powder, odorless, and having a very bit-
ter taste ; permanent in the air.
Soluble, at 15' C. (59' F.), in 240 parts of water, and
in 9 parts of alcohol ; in 25 parts of boiling water, aud
in 3 parts of boiling alcohol; also soluble in solutions
of the alkalies, and in acids. Very slightly .soluble in
ether or chloroform.
Picrotoxin is neutral to litmus paper.
When heated to 200' C. (392° P.) picrotoxin melts,
forming a yellow liquid, and upon ignition it is con-
sumed, leaving no residue.
Concentrated sulphuric acid dissolves picrotoxin witli
a .golden-yellow color, very gradually changing to red-
dish-brown, and showing a brown fluorescence.
On mixing about 0.2 gm. of powdered sodium nitrate
with three or four drops of sulphuric acid, in a small. Hat-
bottomed capsule, sprinkling a minute quantity of pi-
crotoxin over it, and then addin.e, from a pipeltc, cuncen-
trated solution (1 in 4) of sodium hydrate. (Iro)) l>y clrcjp,
until it is in excess, the particles of picrotoxin will ac-
quire a brick-red to deep red color which fades after
some hours.
On diluting 3 c.c. of alkaline cuprie tartrate V.S. with
10 c.c. of water, and adding a small portion of picro-
toxin, red cuprous oxide will be separated within half
an hour at ordinary temjjeraturcs, and much more rap-
idly upon the application of heat.
The aqueous solution of picrotoxin should remain im-
affected by mercuric or platinic chloride T.S., tannic
acid T.S., mercuric potassium iodide T.S., or other re-
agents for alkaloids (absence of alknloUh).
Action and Uses. — The most elaborate study of the
action of picrotoxin was that made by Chirone and Tes-
ta, whose conclusions were as follows (fjmdini Medicul
Record): (1) Picrotoxin is capable of causing a true iirti
ficial epilepsy. (2) The epilepsy so induced is indciien
dent of the ps3'ehomotor centres, inasmuch as it is most
intense after the removal of those centres. (3) Picrotoxin
acts primarily on the bulb and on the commissui'al fiVncs
between the cerebral and spinal centres, and secondarily
on the spinal centres themselves. (4) It demonstrates
the existence of a functional antagonism between the
psychomotor and motor centres of the bulb and spinal
cord. (5) The convulsive movements of the limbs in-
duced by picrotoxin depend primarily upon the action of
the drug on the bulb, which is thence propagated to the
spinal marrow, and secondarily upon its direct action on
the spinal centres. ((1) In fVogs llie intiuence on the
spinal functions is more marked than upon the cerebral,
while in dogs and the higher animals Ihe cerebral motor
centres are the most acted upon. (7) By ciuelionidiuean
epilepsy of cerebral, by picrotoxin an eiiilepsy of spinal
origin, can be induced.
From the foregoing it is evident that the action of ])i-
crotoxin closely resembles that of sfi-ychuine. Besides
the use of this substance for poisoning tish. it is said
to be a constituent of some arrow poisons and to be em-
ployed for the poi-soning of vermin. The flesh of fish
poisoned by it is said to be dangerous unless early steps
are taken to remove the poison from it.
The medicinal employment of jiierotoxin is exceed-
ingly limited. It has been recommended in jiaralysis,
epilepsy, chorea, hystero-epilepsy, etc., but has not "been
very successful. As a retarder of the pulse it might be
thought of, but we have already several safer remedies
for this purpose. It has been used considerably for the
prevention of the night sweats of phthisis; the hypoder-
mic use of gr. -rl^ to gr. -^ proving very serviceable in
many cases of this troublesome condit ion. It lias been used
locally in some cutaneous diseases, and as a parasiticide
(in the form of an ointment) ; but it has no advantage for
this purpose over less dangerous substances. "Convul-
sions and death have followed its ap|ilication to tlie
head " (Brunton); from one to two per cent, of picrotoxin
in, say, petrolatum is of suflicient strength lor pediculi,
etc., if it is desired to use it. Dose, from 1 to 10 nigni.
(gr. ^ to gr. J). Uciin/ II. Rushy.
PIEDMONT WHITE SULPHUR SPRINGS.-Alameda
County. California. 'i'hcsi- springs an- located three
miles from Oakland, aud have gained considerable local
;'eputation in the treatment of rheumatism, jaundice,
liver and kidne.y troubles, and disorders of the stomach.
There is a well-kept hotel with plea.sant giwunds at the
place, and its nearness to San Franci.sco makes it available
for residents of that city as a da,v resort. The situation
ou the western slope of the Berkeley Hills commands a
most picturesque view over San Francisco Bay and the
Golden Gate. The following analysis by Winslow Ander-
son shows the mineral ingredients of two of the springs:
O.VE UXITED STATFS (iAI.LOX C'ONT.VINS:
Solids.
The Iron
Sprinir.
Graiu.s.
The Sulphur
.Siiriurr.
Grains.
Sodium chloride
,i 10 1 7 91
11.70 1 fl.4()
Sodium carbonate
.52 0.20
;i V> 76
Mafrnesium carbonate
li 37 3 17
1 M 17.80
Calcium carbonate
2.13 3.33
1 .1)0 1 7.09
Ferrous carbonate
1.73 Trace.
.i'i 1 Trace.
."j.Si l.SO
4.11) .'i.OB
Urpauic matter
Trace. Trace.
Total solids ....
Vi 20 j (ii.iil
Gases.
Ciiilinnic acid aras
Siilphurctcd hyrirnjTen .
Temperature of water .
Cubic inches. Cubic inches.
Tiace.
.is-
4.«l
'.).a">
tiO°
These analyses show that the waters are valuable as a
tonic, antacid, diuietic. and aperieni ; they are useful in
dyspep.sia. constipation, antemia, rlieumatism, and liver
and kidney troubles. ./mucs K. Crouk.
PIEDRA. — (Synonym : Trichomycosis nodo.sa.)
This is a jiarasitic disease that occurs on Ihe long haiis.
especially those of the scalp. It may allcci the beard.
(333
l*i;^llli>llt.
PlgllU'lll.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
It. %vas first ck'scribi'd as occurring only in Cuuca, one of
tlic United States of Columbia. A few cases liave been
reported in Germany and one in tbis country. It is cliar-
aeterized by tlie appearance of from one to ten small,
dark-colored, very liard and srilty nodes along a hair.
When the hair a'tfeeted by the "disea.se is combed or
shaken, the nodes rattle tcjgethcr like .stcmes. This gave
the disease its name, which in tlie Spanish language
means stone. The hair itself is unaffected, the nodes
being simply attached to it. AVomen are most conunouly
alTeeted, men only exceptionally so, a.-id then it is their
beards.
Etiology. — It occurs in warm countries and is a fun-
gous growth. Microscopical examination shows that the
nodes are composed of a mass of ]iigmented spore-like
bodies arising from one cell that sends out colunuis ra-
dially in all directions.
Diagnosis. — It differs from the other diseases of the
hair in which nodes form, such as trichorrhexis nodosa,
in that the hair itself is unafl'ected. Its nodes differ from
the nits of pediculi in their dark color, and in tbeir not
being placed on one side of the hair.
Tiuo.\TMENT. — The nodes can be readily removed by
soaking them with a hot solution of bichloride of mer-
cury 1 to 1,000. They can be combed off or pulled off
when softened. Giorge T. Juekmn.
PIGMENT. (PATHOLOGICAL.)— The pigments found
in the human body, either under normal or under jiatho-
logical conditions, are formed either by the body cells
themselves (inlriimic or ((iiloi'litlioiamx ji/'(/)iie)it), or are
derived from the bile (/ic/«iti)f/ciii>iiii pi</weiif) or the blood
(JiiFiiiiittiyiiKiiis pif/iiiriit). or are foreign iiigments which
are deposited within the body from witliout {e.rtriiigir
plflhteiit). The last named may enter the body, through
the respiratory or the gastrointestinal tract, or through
wounds ; or, as in the case of malarial |iigment, they may
be formed inside the body liy the activity of the c(dls of
parasites.
Pigment.
1. Autochthonous,
~. Hepatogenous .
Ha'matogenous . -
Melanin.
Liiiochrome.
II;emofuscin.
Bilirubin.
lla'matoidin.
Ibemosiderin.
4. E.xtrin.sic
1.
2
3'
I r..
I 0.
Carbon.
Silver.
Lead.
Tattoo.
Malarial pigment.
Vario\is dusts.
1. ArTOCiiTiioNoi's Pigments. — Mihtniii is found nor-
mally in the cells of the refe and in the choroid. It is
believed liy the majority of writers to be a product of
specialized connective-tissue cells (cbromatophores),
which in tlie skin lie just beneath the cells of the rete, in
the upper layers of the tissue of the dermis. These cells
contain tine yeUow or brownisli granules of melanin, or
their protoplasm may be diffusely stained with the piig-
nient. Protoplasmic processes containing the pigment
extend from the cbromatophores into the epidermis, be-
tween the epithelial cells of the rete, and it is believed
that the pigment is transferred to the ciiithelium by
means of these processes. The chromatophores are most
numerous normally in the skin of the Hexor .surfaces,
about the nipples, external genitals, ami an\is. They are
moiv abundant in dark-skinneil individmds than in tho.se
having a light skin. The chemical nature of melanin is
not known; it is a nitrogenous body rich in sulphur, and
is believed to be a pi'oduct of the eondiination of certain
split products of albumin that contain sidphur. It does
not give a reaction for iron. It is not a derivative of
hamioglobin, luit is either built up by cell activity from
the end products of albumins circulating in the biood or
is formed by the cell from its own albumin.
A pliysiological increase of melanin occurs during
pregnancy, particularly about the nipples, external gen-
itals, and in the median line of the abdomen (linea fusta,
chloasma uterinum). This pigmentation is especially
pronounced in brunettes. In freckles, tan, lentigines,
pigmented moles and warts, etc., the pigmentation is due
to an increased formation of melanin by the chromato-
phores. In various cachexias, but particularly in Addi-
son's disea.se, there is a greatly increased production of
melanin, to such an extent that the individual may be-
come very dark, ilelanin may also be formed in excess
in or about scars of the skin caused by various skin lesions
or eruptions. From an abnormal proliferation of the
chromatophores a pigmented sarcoma (melanotic sarco-
ma) may arise. The cells of these growths produce mel-
anin in great excess, so that their color is usually brown
or black. Their metastases, wherever produced, likewise
form melanin. .Such metastases occiu- most frequently
in the liver; and they often overshadow the primary
tumor, which may be of iusigniticant size, often originat-
ing in a small pigmented mole The excessive produc-
tion of melanin by sarcoma c-ells is of the nature of a de-
generation; with the formation of the melanin the cells
die
lApoclimiiic is the coloring matter of fat tissue, corpora
lutea, ganglion cells, epithelium of the seminal vesicles,
and of the greenish-coloi'ed sarcomata known as cliloro-
mata. Its chenucal nature is not known. It does not
contain iron, and is colored black by osmic acid.
Jlii'iiiofiiscin is the yellow or brownish granular pig-
ment found in heart muscle, striped muscle, and in the
unstriped muscle of the gastro-intestinal tract, vas defer-
ens, seminal vesicles, etc. The pigment found in the
cells of the glands of the stomach 'and intestine as well
as in the cells of the lachrymal, mucous, and sweat
glands, is by some writers regarded as identical with
ha'inofuscin, by otiiers as belonging to the melanin group.
Its sulphur content favors the latter theory. Ha'inofus-
cin iloes not give the iron leaction. In atrophic condi-
tions of nuisele. particularly when following hypertro-
phy, the amovmt of ha^mofusciu is cither relatively or
absolutely inci'eased. The color of such muscle may be-
come a dee)) brown. This is not infrequently seen in the
case of atrophy of heart muscle in failure of compensa-
tion for valvular disease (brown atropliy of the heart).
Microscopically, the pigment is found to consist of line
yellow granules arranged at the poles of the nuclei, in
the form of a cone, the base of the cone toward the nu-
cleus. In all cases the jiresence of a notable amount of
ha'inofuscin in muscle cells is to be taken as an evidence
of degeneration (pigment atrophy).
Hepatogenois Pigment. — Bilirubin is found as a
pathological pigment in the tissues in icterus. As a re-
sult of the appear.mce of liile pigment in the blood, the
skin, conjunctiva', tlic internal organs, serous mem-
branes, subcutaneous tissue, blood plasma, urine, etc.,
are stained yellow in mild or recent cases; but in jaun-
dice of long standing the color may be an olive-green or
a deep bronze The bile pigment gains entrance to the
circulation as a result of obstruction to the outflow of
bile through the biliary vessels, or through changed con-
ditions of the liver cells brought about by intoxication,
infection, or through nerve influences, whereby the se-
cretion of the liver cell, instead of pas.sing into the bile
ca|iillaries, jxisses into the blood. Carried through the
body by the circulating lilood, the bilirubin gives to all
of the tissues a ditfuse yellow color. After a time gran-
ules of bilirubin collect in the lymph spaces and in the
tissue cells themselves, and particularly in the lymph
glands, spleen, and bone marrow. In the cells of the
connective tissue, liver, and kidney, rhombic plates and
needles of bilirubin may sometimes be found. In the
kidneys the cells of (lie convoluted tubules are stained
with bile pigment, and in the collecting tubules yellow,
brown, or greenish casts are foiuul. The presence of the
casts is due to (he degenerative processes set up in the
cells secreting the bile pigment. In icterus there con-
stantly occurs a de|iosit of lutmosiderin in connection
with the bilirubin, as a result of the destruction of red
blood cells by the bile acids.
034
REFERENfK IIAXDDOCJK OF THE MEDICAL SCIENCE;^.
Pi;£lll4'lll.
Pigment.
IL«MATOGENors PIGMENTS. — The pigments arising
fniin the destruction of the red blood cells may be classed
in two groups: one containing Iron, /iiniiosider/H. and one
not giving the iron reaction, ha iiKitnidin. The exact
<]ieniical nature of these pigments is not linown, and the
leriMS Ih\ iiiiitoidin and /mi/io.siihri/i lepresi nt groups of
related pigments ratlier tlian individual pigments. Tlie
<leposit of derivalives of blood pigment is known as
haiiiiii-hriiiiiittonis, that of luemosideriii alone, as /ni'mimde-
/■'/.»/.«. Ila-matoidin and luvmosiderin in all cases are de-
rived from the destruction of lutmoglobin, either in e.x-
travasates or in the circidating blood. lIiimuMdin is
regarded as identical with bilirubin. It is a ruby-red or
reddish-yellow granular or crystalline pigment, soluble
in absolute ether, chloroform and carbon disulphide. and
iiisiiluble in water and alcol.ol. AYith potassium feriocy-
aiii<le and hydrochloric acid it gives no reaction for iron.
Ihemosiderin occurs in yellowish or brownish grauides,
which when treated with potassium ferrocyanide and
hydriichloric acid give the Prussian blue reaction. With
annnoniiun sulphide it forms a black sulpliide of iron.
After a time luvmosiderin niav lose its iron reaction and
become changed to luematoidin.
Ma-matoidin is formed when tlie blood pigment is but;
little exposed to the action of living cells, as in the cen-
tral portions of throndn. or in large extravasates in the
tissues, or in extravasates lying in the body cavities. It
may be produced artificialiy by enclosing blood clots in
capsules which admit the tissue juices but not the wan-
dering cells, and by introducing such capsules into the
peritoneal cavity or beneath the skin.
Ilaunosiderin is formed in extravasates, in those por-
tions exposed to the action of living cells, and is usu-
ally found around the periphery of thrombi and extra-
vasates, in the area of organization. The pigment may
lie free in the tissue, or may be contained within cells.
The free pigment and that contained within phago-
cytes give rise to a pigmentation of the tissue about
tiie cxtravasate, varying from a liglit yellow to a deep
lirowu. After hemorrhage into the lung alveoli botli
luematoidin and li;emosiderin granules may be found
in the sputiun, either free or in phagocytes (pigment
cells).
Both h(ematoidin and licfinosiderin may be carried from
the seat of extravasation to the lymph glands and there
deposited. Soluble blood pigment in the circulation is
deposited partly as htematoidin anil partly as luvmoside-
rin, in the spleen, bone nuirrow, lymph glands, liver
cells, and kidney cells: and under certain c<jnditions in
the pareiichymatouscellsof various organs. The greater
jiart of the pigment thus deposited gives the iron reac-
tion, and therefore is to be classed with hremosideriu.
Such deposits of iron-containing pigment occur in per-
nicious ana;mia and pernicious malaria, in poisoning
with arsenic, toluyleudiamin, potassium chlorate, mush-
rooms, etc., in overheating of the body, etc. As a result
of the destruction of the red cells there occurs a luvmo-
globina'mia; an increased amount of bile is formed, and
there is an increased excretion of tu'inarv pigment. In
the kidneys the ha;mosiderin is found chiefly in the cells
of the convoluted tubules. In pernicious anaemia the
hsemosiderin is found in greatest abundance in the liver
cells of the peripheral portion of the liver lobules.
Arotuid the central vein the liver cells may contain
lia'tnatoidiu. The endothelial cells of the liver capilla-
ries also contain the pigment; in the early stages of the
])rocess the ])igment may be foimd only in these, later it
is transferred to the liver cells.
If hajmosiderin comes into contact with hydrogen sul-
phide it becomes changed into a black h:vmosiderin Iiy-
<lrogeu sulphide. This condition is known an j).viid<ii)ie-
lidiosis. It is usually seen after death in the intestinal
canal, peritoneum, and suppurating wounds, but its
production is dependent u]ion a formation of haMiio-
sideriii in the tissues before death. It may take jilace in
the living body as the residt of hydrogen sulphide pro-
duced by bacteria. Tlie green color .seen in the early
stages of the decomposition of the cadaver is due to a
sulphur compound of metha>moglobiu, produced by the
action of H-jS on oxyhaemoglobiu,
A peculiar brown or black pigmentation of cartilage,
tendons, and the capsules of the joints occurs in old peo-
ple, and occasionally in younger individuals. The con-
dition is known as (jr/iro/Kixix. By snme the pignsent is
regarded as allied to melanin, by others as a derivative
of blood pigment. Neither its chemical nature nor its
mode of formation is known. A similar pigmentation of
cartilage may be proiluced by foiinalin.
ExTRixsic Pio.MEXTS. — f<{/ver taken into the body as a
soluble salt (silver nitrate) is reduced by the cells of the
blood-vessels and deposited as free silver or a low oxide
in the connective ti-ssue of the kidneys, intestine, skin,
intima of large arteries, adventitia of the smaller ones,
choroid plexus, etc. The epithelial structures and ner-
vous tissue are alone spared. The pigment appears in
the tissues in the form of fine black granules, lying in or
between the connective-tissue cells. The condition is
known as ac(7.v;7'<i. (See Ai;r/>/riii.) Lead n\a.y be deposited
as a grayish-black discoloration of the gums, consisting
of granules of sulphide of lead. Iron nuiy lie taken into
the body in excess and deposited in the bone marrow,
spleen, and lymph glands (.«>/< /<;.«/.■<), but this is rarely of
a noticeable extent. In iron workers the lungs may ac-
quire a reddish tinge from the deposit of iron-oxide dust.
C'arhon is the most common of the extrinsic pigments.
It is usuall}' taken into the body through the respiratorj'
tract and deposited in the connective tissue of the lungs
and in the peribronchial lymph glands irnitltracosis). Un-
der certain conditions, such as softening or tuberculous
caseation of the bronchial glands, the carbon pigment
.acts into the general circulation and is deposited in the
spleen, bone marrow, lymph glands, liver, etc. It oc-
curs in the tissues as a dee]) grayish-black, coarsely
granular pigment. Colored diistx from pottery clays,
pigments, etc. , may be foiuid in the respiratory tract of
individuals following certain trades. Various pigments
ma}' be introduced into the body in tattooing. Cinnabar
and India ink are tnost coinmonl}' used. The pigment
occurs in the connective tissue of the dermis as coarse
black granules. The greater part of the pigment intro-
duced into the wound of the skin is carried to the lymph
glands, the remaining portion lies in the spaces of the
.scar tissue formed. As the pigment is constantly re-
moved by wandering cells the outlines of tattoo marks
slowly become indistinct. Carbon nuiy enter the body
through wounds of the skin: jiowder marks, cinders
rubbed into cuts, etc. Silver ]>articles may also enter
the body through the skin or respiratory tract. Malarial
liiiliiii'iit is a brownish-black pigment formed by the cell
activity of the malarial Plasmodium. It does not give
an iron reaction. By some writers it is incorrectly called
melanin. Its chemical nature is wholly ludiiiown. It
collects in the small capillaries of the body and is taken
out of the circulation b}' the endothelium and also by
wandering Cells, and transferred to the tissue cells, chiefly
in the sjileen and bone marrow.
P.\Tiioi,OGiCAi. AiisENCE OF PIGMENT. — A failure of
melanin production leads to the conditions known as nl-
binisin or vitiligo. The absence of jiigment may be con-
genital or acquired. A lack of pigment throughout the
skin of the entire body is known as al/n nismus tinirer-
tailis ; in certain regions oidy as albinisinvs partialis.
The hair may also be destitute of pigment (leucotrir/iia);
and in universal albinism the pigment of the choroid and
iris is also wanting. Acquired rililii/o is a condition
characterized by a loss of pigment over certain portions
of the skin, following scarlet fever, typhoid, or recurrent
fever; or occurring as an eiiidemic disease without known
cause. Idiopathic cases also occur. With the loss of the
skin pigment may be associated a leiicotrir/iia nrquimta.
Vitili.so appears to depend upon an atrophy of the chro-
nuitophores; its exact nature is unknown. It may de-
pend upon a disturbance of adrenal function, or of the
sympathetic system. .V third form of absence of pig-
ment follows infectious inflamnuvtions of the skin, lep-
ros}', syphilis, etc. ; and is known as leucoderma. The
635
Pilocarpus.
Pi Ilia.
REFERENCE IIAXDiiOoK OF THE MEDICAL SCIENCES.
skin covering tlie scars proilnced by these diseases loses
tiie power to produce piirineiit. This may be explained
hy a disappearance of llie chroniatophores, or by the in-
ability of tlie epithelium to take up llie pijrment. The
non-pigmented portions are not infrequently surrounded
b}' a heavy pigmented border. (See Coloiiiiy Matter,
Arr/i/na, Vitiligo, etc.) Aldred Scott Warthiii.
PILOCARPUS. See JahonimU.
PINEHURST AND SOUTHERN PINES, N. C— Pine
liiir.st, six luuidird and I hiil> tcrt alio\ !• s( a level, is situ-
ated in the "Pine Belt" of Nortli Carolina, not far from
the centre of the State, about seventy-tive miles south-
west of Raleigh. It is a comparatively recent creation,
an attempt by one jierson to establish a model healtli re-
sort in a favorable climate.
It einl)racesaliout hve thousand acres, privately owned,
and untlerthealisiilute control of the owner. Much labor
and expense have been bestowed upon this enterprise:
the grounds have been carefully lai<l out by landscape
architects, and every attenticjn has been paid to the sani-
tary conditions, sewerage, water supply, plumbing, etc..
so il^at one is assured of finding here most wholesome
hygienic siUTOundings and excellent accommodatinns.
Consumptives, howevei', are not received, the desire evi-
dently being to provide a winter resort for the large
number of persons who, tlumgli not ill, desire to spend
the winter in a comparatively mild and equable climate
where fhe_y can remain for the greater part of the time
out iif doors.
Invalids are also received here, according to the writ-
er's understanding, suffering from diseases other than
tuberculosis. The soil of all this u]ilanil region is sandy,
quite re.semliliug the dry sand on the edge of the seashore,
in whicli .soil the long-leafed pine nourishes. Pines and
sand comprise the scenery, but this lack of variety has
its compensation in the abundant simshiue and bracing
air. Moreover, the peacefulness of such surroundings
must be restful to tired nerves.
The average winter temperature ranges from about -14
to (i.'i' or 70 ' P., said to be about that of Southern France.
In January. 1902, the maximum tenqierature was 72 and
the minimum 20", while in Philadelphia it was 54' an<l
15° res]iectively, and in Bo.ston 54 and 4" F.
There is a large amount of sunshine, and one can gen-
erally spend most of the time out of doors. In the Pied-
mont Plateau which embraces this region, the annual
average rainfall is4!1.85 inches, and for the winter r2.2.S
inches. Snow is said to appi>ar about once in two years,
but remains only for a few hours. January is the cold-
est month ; there may then be frosts at night and thin ice
may coat the ponds. Sjiring begins by the niid<lle of Feb-
ruary. Profecliou is afforded from tlie cold northwest
winds \\y the Apalaeluan range and by the pine forests.
Naturally there is little to attract the visitor in this mo-
notony of sand and silent, dark pines, liut art lias done
much to make life attiaetive here. There are extensive
golf linksand a clul) house; shooting preserves for quail ;
horseback riding, tenuis, croquet, etc. There are several
hotels of varying prices, and furnished cottages for rent.
The water is obtained from artesian wells and is pure and
good. All the conditions of modem living are found
here, and every attention seems to have been'given to the
maintenance of a high standard of sarutary excellence.
Pinehurst has electric railroad connection with Southern
Pines, .six uules distant, which is on the Seabuanl Air l^ine
Railroad. It is a journey of eighteen hours Imm New-
York to Pinehurst.
Southern Pines, about six hundred feet above sea-level,
is six miles distant from Pinehvirst, and possesses sinnlar
conditions of climate, soil, and vegetation. It is situated
upon a large sand bank, and is surrounded by the char-
acteristic jiine.
It is a comparatively new town of about one thousand
inhabitants, and is essentially a winter health resort
largely made up of Northern inhabitants or visitors. It
has more of the features of a town than Pinehurst, there
being several churches, shops, a graded school, library,
electric lights, a trolley line, good water supply, and a
sewerage system. There are several hotels of' varying
acconunodations and prices, furnished cottages, apart-
ments, and boarding-houses. Tubercidous patients are
genei'ally received here, although at the largest and most
ju-etentious hotel, the "Piney Woods Inn," the statement
is made that "confirmed consumptives will not be cared
f(U-."
Opportunities are alTorded for various outdoor diver-
sions, such as golf, tenuis, driving, bicycling, and small-
game shooting.
It is saiil that several thousand visitors frequent this
resort during the winter season, and it can be recom-
mended, es])ecially bir those of moderate means and re-
(piirements who desint to live with their families in one
of the many .small cottages which can be obtained at a
moderate rental.
Several miles south of Southern Pines is Piueblulf,
which is lieing developed as a health resort.
The air in all this pine-belt region is pure and dry. and
impregnated with the balsamic emanations of the pines.
It affords favoral)le conditions for many cases of tubercu-
losis an<l bronchitis, for convalescents from acute dis-
eases, and for those suffering from chronic nephritis.
This region is also a convenient halting iilace for those
going to or returning from the lower South.
The season is from November to April.
Edirard 0. Otis.
PINE LAWN SPRING.— Bergen Couutv, New Jerse)-.
— P(.s'r-( )FFICK. — llnllokus.
Tlu^ Pine Lawn Spring water, recently introduced into
the markets, is obtained from an artesian spring at Hoho-
kus, twenty-three miles from New York City. The place
is not used as a resort, but we are informed that residents
of the neighborhood attach considerable medicinal value
to the water and use it in large quantities. The follow-
ing analysis was made in 18U7 by Jlessrs. Smith and De
Roode. chemists of New York:
One United States gallon contains: Potassium sulphate,
gr. O.Oti; sodium chloride, gr. 0.43; sodium sulphate, gr.
0.32; calciiun sulphate, gr. 0.49; calcium nitrate, gr.
0.60; calciumcarbonate.gr. 2.04; magnesium carbonate,
gr. 0.72; alumina, a trace; silica, gr, 0.57. Total, 5.29
grains.
The water is exce]itionally free fi'om organic matter,
and presents no evidence of surface pollution. It is
clear, palatable, and sparkling, and well adapted for the
table. James K. Crook.
PINGUECULA. See Cotij,incHra,ctc.
PmKHOOT. —i^pifielia (U. S. P.). The dried rhizome
and rocts df .^pii/cliii narilaiidica L. (f'am. Luiiaiiiacea).
This is a jierennial herli, witli a horizontal, twisted
rhizi>me, and several erect, simple, somewhat quad-
rangular sti'uis. Leaves op]iosite, sessile, ovate-lanceo-
late, smooth. Inflorescence terminal in aime-sided (scor-
pioid) spike, of half a dozen or more showy flowers.
Calyx small, ti ve-]iarted ; corolla tubular, trumpet-
shaped, with five acute, spreading lobes: bright scarlet
outside, bright yellow witliin. Stamens five, inserted on
theeorolla; jiistil single; ovary two-celled, several-seeded,
superior. Pinkroot is a native of the iliddle and South-
ern States, where large ipiantities are annually collected.
Its medicinal properties have been known for upward of
a century.
The descri|ition of the drug is as follows:
The rhizome is of oblique and sharply tortuous growth,
somewhat branched, mostly 2.5-5 cm. (1-2 in.) long and
3-4 nun. (^V"r. ■"•) thick, knotty from the approximate
stem bases of the upper surface, which bear cup-shaped
scars, dark brown or blackish, thickly clothed under-
neath and at the sides with long, rather coarse, tinel.v
branched, lighter brown roots, winch are usually broken
shortly, not leaving a long, bare, woody central portion;
brittle, showing a whitish wocxl and a dark or decayed
636
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pilot' arpns.
Pjuta.
pith: somewhat aromatic; taste sweetish, bitter, and
somewliat piintrfiit.
The larger, lighter-colored rhizome of liiirllin, sp.,
with fewer coarse roots, from which the bark readily
separates, is frequently substituted or admixed.
But little is known of the constituents of this drug.
Starch, resin, gum, tannin, fat, volatile oil, and other
ordinary plant substances exist, together with a small
Fig. 380S.— Pinkroot. a. Twig with blossom ■ /), grain centre ; c,
section of flower ; c/, section of grain : c, fruit. (Baillon.)
amount of the volatile alkaloid spigdine, which is soluble
in alcohol and water, and is probably the active constit-
uent.
Action -\nd Use. — In overdoses spigelia is a narcotic
poison. Quickening of the pulse, diyness of the throat,
flushing and heat of the skin, uneasiness and delirium
have followed its use. There is little doubt that in the
eases in wliich it is most employed, — cases of liniibn'ci or
round worms, — it is of considerable value. A fluid ex-
ti'act {Extrdctiiin Spigelid Ftiiidnm. U. S. P.) is a good
]irei5aiation, and the one genei'ally jirescribed. It is fre-
quently comljiued with senna or some other cathartic.
Dose of the fluid exti'act, for an adult, 2-8 c.c. (tl. 3 ss.-
ij.); for small childi-en, fi-oin I to 4 c.c. (fl. 3 i to i.).
Allied P/rt/i^f.— Another Spigelia. 5. antht'lmid L.,
growing in South Aniei'ica and the AYest Indies, has, as
its name implies, similar properties and uses. Altliough
used chiefly in its home, it has also been iiiti'oduced into
Eui'oiie. it is i-egai'ded, probably correctly, as moie ac-
tive than our own. Iknrij 11. Itiisby.
PINTA. — (Synonyms: Carat, Cai'ate, Carathc, ^^al dc
Ion pilltllK.)
Pinta is a parasitic disease chaiactei-ized by the ap-
jieaianee on the skin of spots and palchesof vai'ious sizes
anil colors.
Until recent times the di.sease had been observed only
in Central America, Mexico, and South America, but
lately reports have been published of its occuri-ence in
Afi'ica. It is s;iid to be most common in the Jlexican
States of Tabasco and Chiapas, but it is also (piite pi-eva-
lent in Peru, Bolivia, and Brazil. In Venezuela and Co-
loniliia. along the low-lying banks of the rivei's Zulia and
Magdaleiia. the afl'eetion is quite in evidence. The lialf-
bi-eeds. mulattocs, and mestizos tliat make u]) the bulk of
the laboreis and crews of vessels plying these waters
seem to have a peculiar susceptibility to tlie disease, or
perhaps their skins ofler less resistance to its inroads than
the skins of the pui'e whites or pure negroes. I have
often seen on these river boats as many its a half-dozen
cases on a single vessel. So common is the trouble that
it soon ceases to awaken interest in the average passen-
ger.
The dorsal surfaces of the hands and feet, the anterior
aspect of the legs, and the surface of the chest are the
])arts most often affected. The disease attacks both sexes
and all ages, although it is seldom seen in children under
six years of age. Like other diseases of a similar nature,
it seeius to have a preference for people of unclean habits,
tilth appareutl}' having a direct bearing not only on the
liersistence but perhaps on the very existence of the af-
fection. For this reason it is rare in the better class of
mestizos and native whites.
The color of the patches may be red, blue, black, or
white: hence the Spanish names rojo, aziil, negro, blanca,
etc. The size of the individual patches is quite variable.
The disease first appears in one or two small spots which
tend to increase along their periphery and merge into one
another: it also extends by auto-iuoculatiou in the act of
scratching.
Some observers claim that the victims of this disease
emit an offensive odor. One compares it to the odor ex-
haled by a mangy dog, another compares it to that of
dirty linen. Personally 1 have never been able to detect
this peculiar smell apart and distinct from the naturally
oflfensive emanations from a body and clothes that have
never been subjected to the action of soap and water.
Symptoms. — The gcnei'al health is not iiffected in this
disease. Dr. Freites, of Venezuela, states that he has
observed as prodi'omal .symptoms chills, headache, ano-
rexia, etc., but, so far as I know, no other ob.server has
had a similar experience. The eruption appears suddenly
as one or two small spots, at first slightl}' elevated above
the suri'oundiug surface. It progi-esses slowly and may
even remain stationary for a variable period — the quies-
cent stage. This may be followed by a period of activity
when the patches extend peripherally (u- appear on other
parts of the surface, being the result of auto-inoculation,
in the act of scratching. Pruritus may be excessive,
even to the point of interference with sleep, or it may
cause little or no annoyance. Desquamation is as a rule
of a furfui-aceous character, varying in quantity from
almost nil in the wliite to a relative rdiuudance in the red
and black forms of the disease: in some cases of the lat-
ter variety It occurs in thick crusts. Suppuration and
bleeding are due to the injuries inflicted b\' sci'atching.
After a period of vaiiable duration some of the spots
merge into one another, giving the patient the character-
istic piebald appearance.
The above symptoms are common to all forms of the
disease. A few additional woids I'egarding each variety
of the disease would perhaps make the matter clearer.
W/iilc Form. — This looks veiy much like an ordinary
leucodermic patch. The coloi- is like that of yellowish-
white wax, and the surface of the ]iatch is smooth and
shiny. When this form attacks the hairy portions of the
body the hairs become thin, like lanugo, and lose their
pigment.
Jied Form. — This at first looks as if the surface had
been scalded; later the affected portions become bright
red and smooth. As the prui'itus in this form is usually
more intense, it is the one most liable to suppuration and
other accidents due to tiaumatism.
Blue Form. — The eruption a|)pears first as a group of
small blue spots, like those made iu tattooing; sooner or
later these spots extend and merge into one another, the
Avhole patch then having a peculiar blue color, which I
would compare to the lilue shell of a duck's egg. These
patches are covered by a thin layer of dust-like grayish-
blue scales.
Bliick Form. — In this form the spots are at first of a
dirty gray color, which gradiially becomes darker as the
.spots "themselves grow older and larger. Eventually,
the area affected resembles nothing so much as a surface
C3T
PijK'ra/.iii,
Pituitary <;Iaud.
REFERENCE IIANOBOOK OF THE MEDICAL SCIENCES,
S])R'acl witli a \ayvr of bhu< oiiitiiKMit. Aimllier division
tliut has buen made recognizes a siiiieiliiiiil I'nrm. incliid-
\ng the blue aud the blaek forms, and a ileep form, em-
bracing tlie white and the red varieties, in whicli there is
destruction of the deeper underlying ti.ssues. Several of
these forms may and do occur logetlicr in the same indi-
vidual.
Pathology, — "The scales contain a wliite, highly re-
fracting niyeelium. aud black sjiores whicli are round or
oval in .shape. The; sjiores contain a yellow fluiil in
which abundant pigment is found. The mycelial fila-
ments are short, non-branching, and taper from a broad
ba,se to a blunt jioint. by which each tilanlent is attached
to a single spore " (Manson).
Diagnosis, — Piuta may be distinguished from ana's-
thetic leprosy by the facis that the sensil)ility of tlie
patches is not impaired, and that the mucous membranes
are not attacked; from iic(iuiied leueodermia or vitiligo
by the fact that in the latter there are no changes of
structure or of sensibility in the affected skin. From
chromoiihytosis. ringworm, and erythrasma pinta may
be distinguished by'the history of the disease aud the
color aud localization of the lesions,
PiifKiNOSis. — As to life the prognosis is very good, but
the disease is very rclicUious to ireatment ; aud in spile
of all treatment it'nsually lasts a long time.
TitKAT.MEN't. — Absolute cleanliness and the local ap-
plications of chry.sopham'e acid, suliihur, iodine, the salts
of mercury; in fact, all the stronger parasiticides are in-
dicated. " A'. ./. J'unre de Leon.
PIPERAZIN (l)ieih!ileiu--Diiniiin. Ethh-nimin). —A
synthetical eomiiound primarily intende<l to replace
spermin, but found to be a ditTcrent body, both in
eliemical and in physiological characters. It is now
utilized only as a solvent for uric-acid deposits in tlie
place of lithia salts.
It is formed from thc^ action of ammonia on ethylene
bromide, which ])roduccs a nii.\Mire of compounds from
which diethy lene-diamin is se]iarated liy fractional dis-
tillation at a temperature between 130' and ISIt C.
AVheu separated by a liatented ]irocess it is supplied to
the profession under the name of pijierazin. It is a
solid which niells at 1(14" to 107° C, and boils at 14.5'.
It forms in bright, lustrous tables. V,^hen exposed to the
air it absorbs water and carljonie acid gas, and becomes
liquetied. It is very soluble in wati'r, aud forms a taste-
less, alkaline solution without being in the least corro-
sive.
E.xperiments with solution of jiiperazin ujiou uric acid
and u])on calculi formed either of uric acid or of uric acid
with plios|ihate of lime, prove that it e.xerts a powerful
solvent action. When placed in a one-per-ecut, solution
at a temperature of !)0 ' F,, the stones are rapidly acte<l
upon, the sharp edges are removed, and the surface be-
comes smooth and slippery; within twenty-four hours
the mineral portion is dissolved and a soft mucoid skele-
ton only remains. All forms of urinary deposits are said
to be more or less acted upon. Compareii with carbon-
ate of lithium it dissolves twelve timesas much uric acid.
Tests have been made of the relative solubility of frag-
ments of a stone in one-per-cent, solutions of piperazin,
lithia carbonate, borax, and sodium carbonate. In the
piperazin solution the fragment was dissnlved in si.\
hours, the lithia solution did not di.ssolve the fragment
until after forty-eight hours, the borax dissolved only a
very small portion in forty-eight hours, and the sodium
solution had no effect whatever after the lapse of the
same period of time. In each ease the residue was placed
in the ]iiperazin solution, when it entirely disapjieared.
The action of the drug when ailministered to a jierson
in health is perfectly harmless. It does not disturb the
digestive, circulatory, or respiratory organs. After its
administration aud absor]ition it is not decomposed or
acted upon, but passes through the system and is excreted
by the kidneys unchanged. Piperazin may be detected
in the urine two hours after its administration, and it
continues to be excreted for a prolonged period. The
urine is not rendered alkaline, nor in any way altered by
its prolonged u.se,
Piperazin is theoretically a very valuable drug for the
treatment of all conditions in which uric, acid is formed
in excess. Numerous cases are reported in which it has
been used with very marked success — in gout in all its
forms, in lithiasis, renal calculi, and vesical calculi, and
in many forms of rheumatism of a .gouty character. In
these conditions it is supposed fir.st to siiturate the uric
acid that remains dissolved in the organism, aud then to
attack all deposits of uric acid. The soluble urate of
piperazin that is formed is readily excreted with the
urine. The piperazin that is not neutralized in thi' sys-
tem comes in cont;ict with calculi and dejiosits in the
kidney an<l bladder and there exerts its specific proper-
ties. On account of its freedom from any irritating ac-
tion on the mucous membrane, it may be made to act di-
rectly upon the deposits in the bladder, by injecting a
one-per-cent, solution, which assists in the deeomiiositiou
of the larger calculi that would otherwise require oper-
ative treatment.
The results of its use have not always Iieen so favor-
able. Prof, n. A, Hare reports having em|iloyed it in
some cases of well-marked gout aud in gouty rheumat-
ism without any beneficial elfects, lie administered it
inU'rnally and by hypodermic injectiouin the usual doses
without relief. Sir William Roberts, in the"Crooniau
Lectures for 1802." on the treatment of the uric-acid di-
athesis, states that piperazin in blood serum or synovia
had not the slightest effect in adding to the solvent ]iow-
ers of these media on sodium biiirate, nor the slightest
effect in retarding its ]irecipitation frmn serum and syno-
via artificially impregnated with uric acid. He concludes
that if piperazin has any beneficial action in gout it is
not due to its .solvent powers on the material of gouty
concretions.
On account of its hygroscopic ]iroperties it must never
be ]irescribed in powder or pill fnrm. It is sup])lied in
bottles containing T> gm., whicli issutlicient for live d:iys'
use. This is to be dissolved in a definite quantity of
water, aud one-fifth given each day in divided doses.
The rpiantity employed liy all observers has been 1 gm.
daily, in solution, well diluted. The effects of the drug
are rajiidly manifested. After the subsidence of the at-
tacks a smaller dnse of eight to fifteen grains may be
given every third tlay, and continued for mouths. When
administered hypoderniically, fifteen minims of a ten-per-
cent, solution may be used. The injectiiais are to be
made in the ueighborhood of the affected joints. The
drug is to bo given internally at the same time. The
effects of this method are reported to be very gratifying;
the swelling aud pain subside and the deposits are ab-
sorbed and greatly reduced in size. In some cases it is
reported that deposits of gouty material in the pinn.-e of
till.' ears and in the eyeliils were removed by two or three
injections. The following solution is also prepared for
local aiqilication to the affected joints: Piperazin, gr.
xv.-xxs. ; alcohol, 3 v, ; water, | iiss,
Bcfiiiinuiit SiiiiiU.
PIPERONAL — heliotropin, inethvlene ether, iirotoca-
tecliui.- aldehyde. C,.,Il3,COOH.(),CH,— occurs in small
while crystals with a strong odor of heliotrope, and is
.soluble in alcohol and ether and insoluble in water. In
dose of 0,.5-l gm. (gr. viij.-xv.) it is antiseptic and
antipvretic. It is also used in perfumery.
ir. A. Basiedo.
PIPSISSEWA. Ch;iii,i),hihi. Bitter or False ir/;//er-
gncii, Pn'iifi'x I'ihi. "The dried leaves of Vhii)iit)iiiil(i
umhellatit (L.) Nutt. {I'ljriila u. L. ; C. corymbosa Pursh.
— fam. Pi/ifd(ir,ir)."
This very tu'ctty little plant, native of dry woods
throughout the cooler regions of almost the entire Nortli
Temperate Zone, is an herb-like underslirub, having an
erect stem a few inches in height, arising from a sliort,
prostrate jiortion. The leaves are crowded near the
ground aud the scape bears several very pretty, five-
638
REFERENCE HANDBOOK OF THE 3IEDICAL SCIENCES.
Piporazin,
Fit Hilary bland.
merous. wax-like, white, subpendulous flowers, about a
half an inch broad. The leaves are from 2 5 to 5 cm. (1
to 2 in.) long and 1 to 1.5 cm. (5 to f iu.) broad, oblauce-
olate, tlie lower half cuneateaud entire, the upper coarsely
and .sliarply serrate, acute or obtusish, thick and rigid,
brittle, above dark-green or brownish-green, and slightly
shining, the veins strongly impressed, luiderneath paler,
the veins very prominent; odbr very slight, tea-like;
taste astringent and bitterish.
Their constituents are almost identical (as are the jirop-
erties and uses) with those of Uva Ursi. There is be-
tween four and five per cent, of tannin, arbutin, sugar,
gum, etc., and a small amount of the yellow, crystalline,
neutral substance, Chitnaphiliii, which is inodorous and
tasteless, soluble in alcohol, ether, and chloroform, but
only slightly soluble in water. For its mildly astringent
an(l diuretic properties and uses, see Vra I'fsi. The
PharmaeopQ?ia provides a fluid extract, the dose of which
is 2 to i c.c. (fl. 3 ss. to i.). Henry 11. linshy.
PITCH, BLACK. — Common pitch. See Turpentine.
PITCH, BURGUNDY.— Pi.j; Burgundica (U. S. P., B.
P.); I'oU de Boiu-ijiiyne, Poix d(S Vosges, Poix jaune {Co-
(le.v Med.). This opaque resin is nominally, and proper-
ly, obtained in Europe from the Norway spruce, Abies
Abies (L.) Rusby (Pinus A., L. ; P. Piceei Du Roi— fam.
PiiKiceie), a magnificent evergreen with a .jiyraniidal
head reaching 40 metres or more in height, anil having
branches even down to the very ground. Its cones are
large and pendent, its foliage is close, and of a brilliant
green color. It is an abundant forest tree of Northern
Europe and Asia, and a frequent ornamental one here.
Burgundy jiitch is not an empyreumatic product like
common black pitch, but a turpentine wliich has been
exposed to hot water or steam, and has in consequence
taken up enougli of it to become opaiiue. It is collected
by making rather deep incisions iu the trunks of the trees,
scraping off the resinous .sap that flows out, boiling
it in water, and straining it through cloth.s. The collec-
tion is carried on iu Austria and Switzerland, but not to
a very great extent, and is diminishing. In the place of
this genuine article, the turpentine of other European
Pinaeete, prepared in the same wa}", is frequently substi-
tuted, and is sanctioned in most countries ; and besides
this, an entirely spurious preparation of common Ameri-
can rosin, mixed with oil or fat and water, is the com-
mon (false) Burgundy pitch of the market. That sold
in this country is said to be almost never genuine. The
following is tiie official description:
Hard, yet gradually taking the form of the vessel in
which it is kept ; brittle, with a shining, conchoidal fract-
ure, opaque or translucent, reddish-brown or yellowish-
brown; odor agreeably terebinthinate ; taste aromatic,
sweetish, not bitter.
It is almost entirely soluble in glacial acetic acid, or
in boiling alcohol, and partly soluble in cold alcohol.
The principal portion of this substance — eighty i)cr
cent, or more — is resin, amorphous and opaque until the
water is evaporated off, then clear; from three to live
per cent, of essential oils is also present, and from five to
ten of irater.
It is a mildly stimulating substance when applied to
the skin; taketi internally it has the properties of com-
mon rosin, or, in a luild degree, those of turpentine;
stimulating in small doses, irritating in large ones; l)ut it
is milder in its taste and action than common turpentine.
Its very limited medicinal use is almost entirely confined
to its presence in a few plasters, of wdiich the following
are official here: Burgtuidy pitch plaster (Eniphistnim.
Pieis Bnrcpnulicep. U. S. P.). Burgundy pitch, 80 parts;
yellow wax, 15 parts; olive oil, 5 parts, melted together.
it ma_v be used as it is, or as the basis for other more ac-
tive medicaments. The pitch plaster with cantharides is
more stimulating; it consists of: Burgimdy pitch. 93
parts; cerate of cantharides (thirty-two per cent.). 8
parts, melted together after straining the cantharidal
cerate through a very tine strainer. W. P. Bulks.
PITCH, HEMLOCK.— ft> Cnnadeims(V. S.), Canada
Pitch. This is a ijroiluct of the Hemlock i^pmee, Tsiiga
Canadensis (h.) Carr. (Pinus C L. : Abies C. Mx. — fam.
Pinacea). collected and prepared in much the same way
as the preceding. It appears often to have been boiled
for a greater length of time, and is frequently very dark,
almost black in consequenci'. It is described as follows:
" Hard, j'et gradually taking the form of the vessel in
which it is kept ; brittle, with a shining conchoidal fract-
ure, opaque or translucent; dark reddish-brown: having
a weak, somewhat terebinthinate odor." Canada pitch
has essentially the saiue composition and properties as
the preceding, and is u.scd for the same purposes. A
]ilaster is made of it in exactly the same way as the Bur-
gundy ]iitch plaster (see above). IT. P. Bolles.
PITUITARY GLAND— {IlffpopJii/si.'i Cerebri ; Ger.,i?.y-
pophyse ; Fi., Gland or Corps Pituita ire : Ita.]., Gland iila
Pituitma ; Span., GJtiandola Pituitaria.) V'esalius
was the first to describe this organ, and in his "De Cor-
poris Humani Fabrica " (1553) he calls it the " glans pitui-
tam excipiens," due to the mistaken idea that this organ
secreted the nasal mucus (pituita). Soenuncring (1TT8)
described it more fully and called it "hypophysis cere-
bri." Both thought that the pituitary was a gland, but
as they could not find any duct, they considered it a
part of the nervous system. Rathka (1838) pointed out
the significant fact that the organ is developed from
two Anlar/en. one arising from that part of the fore-gi;t
which later forms the pharynx, the other arising from
the base of the third ventricle. These views were dis-
puted for some time, but Jlihalkovichs (1874) agreed
with Rathka, and his proofs were so conclusive that but
few have disputed them since that time. Pathological
changes were noticed by many of the early observeis.
Wepfer, Bonnet (1679), and "Jlorgagni found collovd
cysts; Greding (1771) and JFelcarne (cited by jMechel)
fovmd "enlargements of the jiituitary gland "; and Wen-
zel claimed that diseases of the pituitary caused epilepsy.
The physiology of this organ has been neglected much,
and it is only "recently that its physiological action has
been given much attention.
AxATOMT. — The pituitary body is an oval, glandular
organ, consisting of two lobes and a ccnnecting part. It
rests iu the sella turcica, and is cnveUiped by a layer of
dense connective tissue, which is a imilougation of the
basal dm-a. The average weight of the pituitary is 0.5
gm. Inase-'ies of one hinulred cases Schonemann found
that the average weight was 0.II3 gm. between the ages of
twenty and thirty, but that the weight diminished after
that time until the average at fifty was 0.0 gm. Boyce
and Beadles examiiied the pituitary glands from fifty
female insane and found that the weight varied from 0.384
to 0.896 gm., the average being 0.(1 gin. In fifty male in-
sane the"weight varied from 0.712 to l.:i02. with an aver-
age 010.453 gm. The ages of these cases varied from
twenty-two to seventy-eight, none having presented
symptoms referable to the pituitary. ^Aeconling to these
authors the weight of the |)ituitary has no definite rela-
tion to that of the brain or to tiie age of the patient.
The organ measures about 14 nun. in its lateral diameter.
7 mm. in its antero-posterior, and (i to 7 nun. in thickness.
The color of the pituitary is a dark brown or a bluish-
red. The consistency of the ovgan is about that of the
normal liver.
Histology. — The microscopical structures of the two
lobes differ markedly, the anterior being made up of
glandular elements, and the jtosterior of a tissue resem-
bling, with ordinary stains, a modified glia. From the
coniTective tissue siirrounding the gland, line trabeculsB
carrying the blood-vessels lun into tbe interior and sepa-
rate'the cords of epithelial cells. These epithelial cells
are rather hexagonal in shajieand :ire i>f twn kinds. (Jne
contains a round or oval, dee|)ly staining nucleus em-
bedded in a large amount of graiuiUir protoplasm which
stains deeply with eosin (" eosinopliilic cells "). The other
cells are somewhat smaller, more granular, and they do
not stain with the acid dyes ("cyanophilic cells").
639
Piliiifai'y l-laiKl.
Plluilary <;laiid.
REFERENCE HANDBOOK OF THE 3IEDICAL SCIENCES.
The posterior lobe is enveloped by a capsule of connec-
tive tissue from which the tine septa carrviiis; the blood-
vessels enter the lobe. Immediately beneath the capsule
are several layers of cells, which, aecordiuff to (ienielli,
react with certain stains like glio-epitheliuni. Beneath
these is an indefinite layer of secretory cells of the epi-
thelial type, which are often arranged into distinct alve-
oli separated liy tlie fine connective-tissue septa. The
central zone of tliis lobe contains small round, polygonal,
and few pear-shaped cells together with a small amount
of connective tissue. The pear-sha])ed or nerve cells
possess either one or two neuraxons. These cells are of
two types, the large and the small pear-shaped cells.
The large cells have many branching dendrites ending in
feathery tufts. Tlie neiira.xons of these cells come off
close tii the cell bodies, have few collateral branches, and
end by breaking up into line threads, some of which are
lost near the cell, while others end in networks among
the epithelial cells along the border of the lobe. The
otlier type of nerve cell or the small pear-shaped cell has
dendrites, all of which are short, except one which is
covered with hair-like processes. All tlie dendrites come
off close to the cell body and terminate as clubbed ends.
The cells which possess more than one neuraxon are
flask sliaped. Each cell hastlu'ceor four dendrites which
graduall.v grow finer and terminate free, and from two to
four neuraxons which apparently terminate aljout similar
cells. Most of the neuraxons run toward the infuudib-
lilum, but Berkley, who has worked much on this sub-
.iect, has been unable to trace them into the infundibu-
lum. Gemelli has described nerve til)res in the pedicle;
they enter the posterior lobe and branch in the shape
of a fan under the glio-cpithelium. From tliere he was
unal)le to trace them to any cell in tliis lolie which he
coidd call a nerve cell.
The infuudibulum or the pedicle consists of a loose
connective tissue which is composed of anastomosing
stellate and spindle-shaped cells, and wliicli holds in its
meslies blood-vessels and nerve fibres and encloses small
blind spaces lined by cubical epithelium, the remains of
the neural central canal.
E.mbryoIjOgy. — The pituitary gland is developed from
two Anliir/en, one coming from the midbrain ectoilerm and
the other from the entoderm of the posterior pharj-nx.
At the angle formed bj' the pharynx and mouth a solid
bud of cells is given off from the median area of the
upper wall of the posterior pharynx. Tliese cells grow
out into the thin layer of mesoblast separating the brain
from tlie pharynx, and the bud as a wliole becomes hol-
lowed out to form a duct-like comnumication with the
pharyngeal cavity. About the time wlien tlie pharyn-
geal l)uil begins to develoji the brain .sends another bud
downward until the two Anliirjen come to lie side by side.
About this time tlie me.solilastic cells surrotiuding the
Anliif/i' from the jiharynx grow into this hoUosv llask-
,sliaped mass, and tlie wall of the once smooth cavity be-
comes folded inward ujioii itself. Tliese paiiilla- become
divided and interlaced to form the mature gland. AVhile
this has been taking place the canal conuuunicating with
tlie pharynx has become occluded and absorlied, and the
base of the sella turcica has ossitied.
When the Anhir/c for the posterior part of the gland is
given olT, it contains few eniljryonic ganglion cells, which
are found as cells less develo]ied than their correspond-
ing cells in the base of the third ventricle. Along with
tliese cells glia cells are found, some of which disappear
and others remain as the cells described by Berkley,
Pathological An.atomy. — Because ot the location of
the pituitary body pathological conditions at the base
of the Ijraiii are apt to cause secondary changes in it.
These secondary changes may or may ni>t be marked
enough to pruduce symptoms. Usually before symp-
toms on the jiart of the pituitary appear, the ]irimary
condition at I he base of the brain has ]iroduced its effects,
which have either killed the patient or have masked the
symptoms caused liy the pituitary lesion.
Chriihilorji Disiurbaid-ex. — General co/tfloitioii of the
brain, either active or passive, produces a similar condi-
tion in the pituitary. Ana>mia of this organ occurs in
general cachectic conditions such as result from malig-
nant neoplasms, tuberculosis, general arteriosclerosis,
etc.
Two instances of hemorrhage into the organ have been
reported: one by Bailey, in which the lesion was due to
endarteritis, and a second one by Anders and Cattell,
which occurred in a case of pernicious anwmia.
Infarct of the pituitary has not been reported as yet.
Jiitrui/nifk' Chdnges. — Atrophy of the pituitary "body
results from the cachexias of malignant tumors, tubercu-
losis, syphilis, and pernicious aiuemia. Senile atrophy
occurs physiologically in ever_v individual over fifty.
Necrosis. Necrosis of any form involving the whole
organ has not been reported, but localized simple, li(iue-
factiim, and coagulation necrosis maj' be present under
certain conditions. General infection may produce a sim-
ple necrosis of the gland cells of the anterior lobe of the
pituitary bod_y. Liquefaction necrosis may follow infec-
tion of the organ by the pus-producing germs, and coag-
ulation necrosis may be present under similar conditions.
Derjeiirnitiiiiifi. — General cloudy swelling and fatty de-
generation may result from the general intoxications of
infections or from inflammations of the tissues surround-
ing the pituitary. By far the most conunon retrograde
cliange in the pituitaiy is colloid degeneration, wliich
is. up to a certain degree, a physiological condition, sim-
ilar to that of the thj'roid. Accompanying an over-
productiou of colloid, there are often formed cysts, which
are due to the inability of the organ to excrete the col-
loid. These cyst walls are lined by the cuboidal cells
wliich are the remains of the parenchymatous cells.
Prucinvsi'V Cliuinjis. — Hypertrojihy. The most com-
mon ]irogressive change, if not the most common change
of any form, is hypertrophy. This change is confined
usually to the glandular portion of tlie organ, and occurs
in a large number of cases of acromegaly. The paren-
chymatous cells of the anterior lobe are increased both in
size and in number, the connective tissue being relatively
increased also.
Inflammations. Inflammation of the pituitaiT gland
is usually secondary to a meningitis and, in pywmia, sec-
ondary aliscess ma_y develop in the organ. Secondary
inflammation may in rare cases result from an abscess of
the pharyngeal vault.
Chronic Inflammations (Granulomata) ; Tuberculo,sis.
In litOl Baldwin re|)orted tuberculosis of the pituitary
gland in a case of general miliary tuberculosis; that this
was a true case of tuberculosis cannot be doubted since
the germs were found in stained sections. A careful
sttKh' of the literature at that time failed to give another
ca.sc of true tuberculosis of the pituitary. Weigert had
reported a case of " tuberculous-like granuloma " of the
pituitary, but he was not positive as to its identitv since
he could find no germs in this grantiloraa, and he could
find no tubercles in any other part of the body. Boyce
and Beadles, and AVagner have reported cases similar to
that of Weigert, but were unable to demonstrate germs.
S3'philis. Lancereanx says that the hypophysis may
be enlarged in hereditary syphilis, such enlargement
being due to increase of the connective tissue, Weigert,
Barabacci, Birch-IIirschfeUl, Hunter, Sokoloff. Frasier,
and Hektoen have reported gummata of this organ wliich
resembled in structure gummata found elsewhere in the
brain.
Tumors. The only mature connective-tissue tumors
which have l.ieen reported are two cases of lipoma, and
one of fibroma. The lii)oma in both cases arose from
the fat tissue about the organ, and not from the gland
proper. Chiara published the case of a woman, aged
sixty-three, in whom a fibroma the size of a bean was
found in the pituit;irv.
Many of the tumors of the pituitarv gland which have
been reported have been called large, round-celled alveolar
sarcoma or endothelioma, other varieties of the sarcomata
being very uncommcm. However, when the structure
of the normal pituitary body is borne in mind, it is prob-
able that many of the so-called round-cell sarcomata
C-iO
REPEREXCE 1Ia:s-DB00K OF THE ilEDIL'AL SCIEXCES.
i*!! Hilary Gland.
Pllultary Gland,
were adenomata. One case of lympliosarcoma of the
pituitary, and another of spindle-cell sareoma have been
published, the foruoer by lleusser and I lie latter by Hoff-
mann. Of the mi.\ed sarcomata and those showing de-
generations or deposits some of the large round-cell sarco-
mata have been alveolar and consequently mixed. To
these way be added the angiosarcoma of Walton, the
niy-xosarcoma reported by Whitwell, and the gliosarconia
of the posterior lobe published by von Graefe.
Of the epithelial tumor.s various forms have been de-
scribed. As stated before, small retention cysts are com-
mon in the anterior lobe and in the infundibulum of the
pituitar}'. These may become veiy large and n-.ay replace
tlie .greater part of the organ. They ma_y be lined by a
single smooth layer of rather flattened cuboidal cells" or
the inner surface may be folded slightly. In every case
these cysts contain a substance verj' similar to the colloid
of thyroid, if not identical with it. Unless the retention
cysts are classed as tumors, adenomata of the pituitary
are the most common variety of epithelial tuuior. It is
]50ssible, however, that many of the so-called adenomata
have been examples of hypertrophy. In both hyper-
trophy of the pituitary and in adenomata the anterior
lobe is the only part of the organ which is affected, and
it becomes often a matter of personal opinion whether
a given case represents a condition of hyperti'ophy or
one of adenoma. In those cases which are gi'nuine in-
stances of adenoma all the elements of the anterior lolje
are increased in number and many of the epithelial cells
are enlarged. The lymph spaces between the cords of
cells are broader and in many the colloid secretion may
be slightlj- incrciised. These tumors are mahgnaut only
by position. Cases of carcinoma of the pituitary have
been described.
The possibilities of inclusions of foreign emlH-yonic
cells into the Anlage of the pituitar}' and tiie subsequent
formation of dermoid cysts from these cells are great.
Nevertheless, very few of these tumors have been re-
ported. Engel (1839), Pdppermann (1864), Arnold (18T.J),
Baart de la Faille (1875), Wasserthal (1875), Beck (1885),
White (1885), Sanisburg (1880), and Beadles have de-
scribed teratomata of the pituitary gland.
Most of these teratomata have been composed of small
cysts containing semi-solid pult.aceous imrterial. The
connective tissue surrounding these cj'sts contained small
pieces of bone. ALany of these tumors iiave been found
accidentally at autopsy and have produced no symptoms
during life. Others have been finmd in a fitus. and
these iiave shown a more comjilicafffl structure. Some
have contained cortex, ganglion cells, liver, parts of the
intestinal tract, hair, teeth, and bone, and they maj' have
represented a ]iarasite engrafted upon an autocyte;
others of these teratomata have ai isen from the remains
of the pharyngeal diverticulum.
Of the parasites found in man Sommeringhas reported
a case of echiuococcus cyst of the pituitary gland.
PnYsior.ooT.— The physiology of the pituitary is not
fully known. Before 1886 this organ was suiiji'osed to
repi-esent some evolutionary remains. In 1886 Marie
found that it showed marked changes in so many eases
of acromegaly that the old idea that it was non-functional
was reconsidered.
Oliver and Shitfer have injected into animals intraven-
ously a saline extract of the pituitary, and have found that
it: produced a rise in blood pressure. Howell confirmed
this work, and found further that a second dose did not
have so marked an effect as the first, imless considerable
time had elajised between the two injections. Shiifer
and Vincent were able to extract fi-om the pituitary one
sub.stance wliich depressed and one which increased the
blood pressure. The substance which jiossessed the power
of increasing the pressure was fomid to be soluble in salt
solution and insoluble in absolute alcohol and ether. The
other substance, however, was soluble in all three of these
reagents. The experimenters injected the salt-soluti(m
extract and found that the blood jiressure rose, l)Ut soon
fell. They explained this by the fad that the depressive
substance acted more slowly than the stimulating one.
Vol. VI.— 41
Osborne and Vincent extracted from the infundibular lobe
a depressive substance which resembled that obtained
from the cortex of the brain, and con.seciuc^nlly they are
not sure that the depression effects may not be due to
the nerve elements of the infundibular lobe.
That the pituitary gland is similar in structure to the
thyroid had been known for some time. jMichel (1800)
and Peremeschko (1806) were among the first if not the
first to note the similarity and, in describing the pituitary
.gland, they compared it to the thyroid. It nanained for
Ro.gowitsch, in 1886, to prove that this supposed simi-
larity was a fact. Since tliis time many workers have
observed in diseases such as myx<edema. cachexia thvreo-
priva. and cretini.smus, that the hypophysis is ineieased
in size. The cells of the glandular lobe are lar.^er thaa
normal, and the amount of colloid material found in the
organ is increased. Hence these writers have assmned
that when the thyroid is diseased, the hyijophysis at-
tempts to assume the function of the thyroid. On the
other hand, cases have been reported in which the liv-
pophj'sis has been abnormal either in structure or in func-
tion, the thyroids and in some cases the paratliyroids
have been increa.sed in size. In such cases it has- been
assumed that the tJiyroids and parathyroids attempt to
compeusat<' tor the diseased pituitary bodies.
The experimental evidence on this subject is not uni-
form at present. Casseli has been able to produce a con-
dition exactly analogous to cachexia thyrcopriva by re-
moval of the pituitary; and he states that arrest in
development of the pituitary retards the .growth of the
organism as a whole. Freed'mann and ilaas removed the
pituitar}' bodies from cats, and could not obtain the same
results. Nevertheless, the great weight of clinical evi-
dence and the larger part of the experimental study tend
to show that the relation is very close between thepitui-
tary body and the thyroid and the parathyroid glands.
Patliolugieid Aiialoiny (if Ai-nimerjidtj. — In all tlie cases
studied, Israel .says (19()l)Jhat Virch'ow was able to find
onljr five cases in which the pituitary was not enlarged.
In sixty-nine cases which the writer has liad the oppor-
tunity of analj-zing the pituitarj^ is formd " not enlarged "
in only one case. In all other cases thisorgan show.'f some
pathological change.
The following .shows tlie changes found as they were
diagnosed:
r\)Il()id des:eneratioii aud bemorrbage 2
Hyperrrophy (antei-ior tohe' 23
ItyperU'optiy {posrerior lube) 1
Vast'iilar hypei-tropby 2
Kibi-osis witb atrophy of follicles 1
'rumor i
Hypertrophy (?) or sarcoiua (?) 1
Glioma 1
Glioma (?) sarcoma (?) L
Neuroiiliomic sarcoma 1
Adenoma 10
Adeuoma (?) :J,
Sarcoma, round cell 19i
Sarcoma (?) or lymphadenoma (?) 1
Hi)
In 39 of these cases the thyroid w;us examine<l, and in
only 5 was this or.gan repoi'tcd normal.
The conditions found in this organ are as follows:
Normal 5
Atrophy 1
Airophy with interstitial librosis 2:
''Chalk-like "' dcpositj; 1
Colliiid desreneiiition 'A
Cystic degeneration 1
Hypertrophy 11
Hypertrophy with colloid cyst 3
Hypcrtropby with intersititial Ubrosi.s 3
Interstitial fibrosis 1
-"J
In this connection it niaj' be well to noie that in 18
cases in which the ihynius region was examined, the thy-
mus was repoi-ted absent in 7; persistent in 7; both loijes
were enlarged in .'!. and in 1 c;ise only the left lolie was
enlarged.
The relations of the pituitary to the tliymiil and tlij--
(i-tl
Plaoeuta.
reference: handbook of the jiedical sciences.
mus B:laii(ls iu iicromcgaly havi> iml been (iemonstrated.
That"palli(ilu<rical changes of tin.- pimitary dccvir in almost
evory case of afniincgaly is true, but palliological rliangos
are also found in tins body in cases in which there has
been no overgrowth of 1 lie" bones or any other symptom
or signs of acromegaly.
Frederick A. JlnUlirin.
PITYRIASIS.— Pityriasis is an affection of the skin iu
■which there is slight redness accompanied by a branny
desquamation. The term was formerly used to describe
many scaly conditions of the skin, but it is gradually
passing ou"t of use, as the condiiions are now described
under other headings.
Pityriasis of the" scalp is described in the article on
Eezemci; it is the dry form of dandruff in which the scales
do not adhere, but fall wheueycr the hair is bru.shed.
Pityriasis of the face and neck is usually found as ill-
defined slishtlv scaly patclu-s with very little redness.
This condition'is described by most authors under sebor-
rho?a or seborrlueic eczema. " (See article on Seborrhmi.)
Pityriasis rosea. Pityriasis rubra, Pityriasis rubra pi-
laris, "and Pityriasis v'ersicolor are described elsewhere.
(See the articles on PityriitKi's Roxea, P. Ruhra. anti P.
Biibnr Pilan'!:, in TiiE 'Appendix, and that on Tinea in
Vol. Vn.) Iloitiinl Mnrrmc
PIXOL is a cheap substitute for lysol made by mi.xiug
one jiound of green .soap with three pounds of liquid tar
(Pix liquida) and slowly adding a sohition <jf three and
one-halt ounces of potash iu three pints of water. The
resulting liquid is miscible with water, and is used, iu
live-per-cent. dilution, for disinfecting the hands, linen,
etc. It is claimed to be about as strong as carbolic acid.
ir. .1. BeiHtnh.
PLACENTA, ANATOMY OF.— The placenta (" ^}a-
Koi'f, a cake) is a discoid, spou'^y boily attached during
pregnancy to a portion of the*S'nncr wall of the uterus.
it is connected by means of the imibilical cord with the
ffEtus, and forms" for it the organ of resjiiratiou. uutri-
tiou, and excretion. After the expulsion of the child, it
y
becomes separated from its area of attachment, and to-
gether with the foetal membranes is cast off as the so-
' ' ' V
Fig,
58(19.— Maternal Surface of Mature Placenta, Showinir CiitvlPilons ; Membraui's Turned Bai-k.
X 73. (From J. \yiiiuidi:i- WilUauis.)
Flfi. 3S10.— Decidua Vera, Fourth Month. X 16. (From J. Wliit-
rldire Williams' "TesUlionk cit Olistetrlcs." Appleton & Co., New-
York, 1903.)
called eifter -birth (Xaclige-
\ hurt, rarriere-faix). The
portion of the placenta which
is attached to the uterine wall
is rough and irregular and is
known as the maternal sur-
face, while that facing the
fietus is smootli and covered
by the thin glistening am-
nion, %vhich overlies the
smooth surface of the chorion
and is closely applied to it.
The recently delivered i)la-
ccnta at term is smaller, but
at the same time somewliat
thicker than it is when in ute-
ro. ihe change resulting jiar-
tially from the compression
to Avhich the (u-gan has been
subjected during labor, and
partially from the escajie of
the greater part of the blood
<-ont^iiued in its interior.
The organ is spongy in con
sistence. and varies consid
erably in sha[)e, size, and
color. Iu single pregnancies,
612
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pil) I'inKiis.
as a rule, it is more or less rouudwl, tliougli it may be
ovoid or oval, reniform, crescentie or lobuhited. It
measures from 15 to 30 cm. in diameter, and from 2 to
4 cm. in thickness, generallv tliiuuiiiir graduallv toward
Fig. 3811.— Foetal Surfaced Mature Placenta. X %. (Fnmi J. Wliitrklge Williams.)
the edges, which fade away into the thin fa'tal mem-
branes. Sometimes, however, the thickness is fairly uni-
form up to the very margin. Its weight varies from .500
to 600 gm., being usually about one-sixth of that of the
child, though in syphilis, nephritis, and some other
conditions it may be relatively heavier.
The placenta presents two surfaces for examination,
the matenxil and the fatal {Figs. 3809 and 3811). The
former varies considerablj' in appearance, but is usually
dark red in color, varj-ing according to the amount of
blood contained in its substance and the density of its
structure. It Is divided into a number of irregularly
shaped areas, the cotykdons, which are sepaiated from
one another bj' shallow fissures. They vary consiiier-
ably in number, sometimes as many as thirty being ol)-
served, and may measure from 1 to 8 cm. in diameter.
The cotyledons are not primary divisions of the placenta,
but appear tirst at the fourth or fifth month(Minot). The
outer layer of the entire maternal surface consists of a
thin investment of deciclua, which dips down to form the
cotyledonary divisions, and. at the edges of the placenta
is continuous with the inner coating of the membranes.
The decidua is transformed uterine mucosa; while tlu'
placenta is in utero, it constitutes the boundary between
the chorionic villi of the placenta and the uterine mus-
cle, and separates in the iiual stage of labor, so that
its outer or compact portion is carried off as part of the
placenta and membranes, the spongy or glandular poi--
tion remaining attached to the muscle wall (Figs. 3810
and 3816). Scattered over tlie maternal surface are num-
bers of minute yellowish-white patches of varying size.
Some of these have undergone calcareous degeneration,
and impart to the palpating finger a sensation as of
coarse sand paper. Close inspection of this surface re-
veals the torn openings of many lilood -vessels. Tims
Klein was able to count one hundred and five of these
on a single specimen, fifty-one being arteries and fifty-
four veins.
As opposed to the rougher maternal surface, the foetal
side presents a smooth and glistening surface, and is
of a purplish-gray color,
mottled with minute yel-
lowish patches, and marked
by irregular yellowish-
wliite areas of varving size
(white infarcts) (Fig. 3811).
It is covered by the thin
glistening amniun which is
loosely attached to it, but
which may be separated as
far as the insertion of the
cord. Beneath the amnion
lies the smooth chorion,
from tlie lower surface of
which the villi extend,
giving rise to the mottled
apjjearance of the surface.
The umbilical cord termi-
nates upon the foetal sur-
face of the placenta, and
presents a dull white trans-
lucent appearance. It va-
ries from 1 to 2.5 cm. In
diameter, and averages 55
cm. in length, the extreme
variations being 0.5 and
198 cm. When unusually
short it ma,v give rise to
dystocia at the time of la-
bor. As the blood-vessels
are usually longer than the
cord, they grow in a spiral
manner, and are frequently
folded upon themselves,
giving rise to projections
which are termed false
knots. On the other hand,
true knots are sometimes
noted. These may be inost complicated in form, and
are believed to be due to foetal activity. Contrary to
the usual statements, tlie cord is not enclosed in an am-
niotic sheath, but is covered by stratified epithelium,
U.S.
Fig. 3813.— Umbilical Cord. Fa'tal End. X 5H. U.A., Tmliilical
artery: t'.S.. remnant uf umljilical stalk; U.V., umbilical vein.
(From j. Whitridge Williams.)
643
PIa<-otita*
Pljii-eiila^
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
which is continuous with tlmt of the abchmicn of the
fa^tus. Its interior is made up of mucoid connective
tissue — W/iiir/oiiian julli/. in Aviiicli ure emiieilded two
arteries, a vein, the iuul)i'.ieal stalk, and a rcnuiant of
the allantois (Fig. 3812), Tlie
latter is seen oiil\- at the fcrtal
end. The cord is larely in- ■,;'■'■ ■.i':-.^'."-''-'
serted centrally, beini; usu- •Vi-'-/''^':'.''^' ?-A
ally somewhat eccenti-ically [^■'•"^^■•■^■i-'''
placed, although occasionally .•■/'• .-.'^-'is.TV'v^;'
it may terminate at tlie mar- ' "'
gin of the ))lacenta— ia///«/'<;r
pldcdilit. Less freeiuenfly the
blood-vesseLs separate before,
reaching the fu'tal surface,
and make tlieir way to I lie jila-
centa in a fold of anmion —
Veliiiiieiitons i)iKcrtii)n. Tlie
arteries come down togcthi'r
from the cord, and are usually
but not always connected by a
transverse vessel, just before
reaching the jilaeenta. The
vessels then s]iread in all di-
rections in the superlicial part
of the chorion, each branch
producing a ridge upon its
surface, by wliieh ils course /\
can easily be followed. The ;■
veins lie beneath the level of C. J.L
the arteries, are larger in cal- :,
ibre, and distended with blood.
Both arteries and v<'iiis branch KA.-^
repeatedly, each set following
in a gen(;ral way tlie cour.se of
the other, but they do not an- i
astomose ui)ou the placental ' ,
surface. Gi'iierally I hey can
be traced in their rainitications *
until lliey disappear as line ''
branches, turning at right an- §:
gles into the placental tissue, •:
communicate with veins by means of capillaries, at the
free e.\trcniities of the clioriouic villi.
In nearly all ca.ses. as shown by Schultze. the luhhiliatl
vesicle and stalk may be. foun<l between the anmion and
Fig. •■i.^14.— Peters' Early Ovum. (Fiinn J. WliitrUlL-e WUliams.) r.E.. rterine cpitheliiim :
/?/.Zv., lakes of lilnoti ; ('ajf<., ileeidua relh',\a; '»./*.. *'e;e\v<*bspiiz " ; Dr., uterine glands;
/^Z., ileeuUia vera; 7V.. troptiolilasts: ('.. ^-a^iiilaries; K.A,, beginning embryo; BUG.,
lai-^'e blooti-vessels ; a-/», ponit of eurrauce of ovum.
Ku-
Ep
in order to supply
the choriiiuic villi.
Occasionally, how-
ever, a large vessel,
more often a vein.
I lips down abrui)t-
ly. The greatest
possible variation is
noted in the ar-
r.angeuient of the
placental vessels.
AN'lieu the cni'd is
inserted near the
margin they are ar-
ranged Tiineh more symmetrically than when the inser-
tion is nearer the centre. There are no signs of a dis-
tinct cotyledonarv circidation. but corrosion specimens
of injected jilacentiE show that the terminal arteries
Fic. :lsi:i. — Chorionic Villus from
'I'enii IMai-enta. Highly m;u;iiilleil.
t'T Knllitiajm.) Ep, Kpilheiial coverin;
.s", sIroMia of villus: 1', vascular loop.
Full-
(.\f-
the chorion, and near the placental margin, 'n'hcn the
membranes are sejiarateil it usually lies upon the inner
suifaie of the a;imion. The vesicle itself is a minute
roundeil sac, 0-1 mm. in diainetei-, which usually con-
tains in its int'iior a calcific iioint. It is attached to a
thi'ciui-like stalk which extends to the coi'd, and fre-
C|Uently can be traced thi'oughout its entire length.
These may rarely be aceom]iaiiied liy oinphalo-mcsenteric
vessels which have icmained persistent.
The decidual and choi'ioiiic layers of the placenta ar"
each le-x tlum a inilllmetre in thickness, save where the
hitler is thickened Ijy blood-vessels or infarcts. On sec-
tion the iilacenta pfesi'ut a spongc-Iike structure, whose
meshes are lilled with blood, while the imperfect partition
walls are formed by choiionic villi, which ociaipy the
space enclosed liefween the decidual and the chorionic
membranes. Some idea of the corui)le.\ity of the villi may
be obtained by tioating a small piece of placenta in deeiuor-
ea
REFERENCE HANDBOOK OF THE JEEDICAL SCIENCES.
Placenta.
Placenta,
mal salt solution, aiul washing it frw from Ijlood, wlicn
oiR' can distingiiisli a number of arliort'sccnt structures,
consisting of a iirimary stalk, whicli divides and sulxli-
vides like tlic liranclics of a tree. Tlie lai'ger stalks arise
fiom the maternal side of tlie chorionic
membrane and extend a varying dis-
tance through the ])laceuta, some eud-
ing freely, while others ai'e firmly at-
tached to the decidual portion. Under
the micro.scoiie. the arborescent branch-
ing is readil.v appreciated, and it will
be found that a great part of the in-
terior of the terminal blanches is occu-
pied by blood-vessels, which break up
into capillaries, just before reaching
their free ends (Fig. 3813).
Develojiment of the Placeiittt. — All early
human ova thus far described have pre-
sented, upon their outer or chorionic
surface, branching villi each of which
consists of a core of chorionic mesoderm
covered by two layers of epithelial cells.
For many years the origin of the latter
has been a source of dispute, due in great
part to the fact that much of our knowledge of human
embryology is jiiirely hypothetical, and is based upon
observations niadi^ upon the lower mammals. During
the last few j-eais, liowever, considerable light has been
thrown on this question by the study of the early huiuan
embryos of Peters, Leopold, and Spec, and by the work
of Selenka upon the anthropoid apes, and of Ilubrecht
upon hedgehogs. Peters' specimen is the earliest human
ovum thus far descril)ed, and was believed by him to be
from three to four days old (Fig. 3814). Jlany writers,
however, consider it to be somewhat older, probably at
FiK. 3815.— Relchert's Ovaui. Mag-
nided six times. (From J. Wtiit^
ridge Williams.)
the end of the first week. The ovum was embedded in
the depths of the endometrium, and was surroinided liv
a thin layer of mesodei-m, sui'mounted by a capside of
many layers of ftetal cctodeiin. To this latter Peters
applied the term trnji/i,il,liiK/.s: He ad-
vocated the view that the Irojdioblasls
proliferate rapidly, and invade theca|.iil-
lai'ies of the surrounding decidual tissue,
with tlie consequent formation of pools
of maternal blood of varying size. These
are situated in the trophoblastic cti])-
sule, but are bounded externally by de-
cidua, and represent the earliest stages
in the formation of the uitrrfiUcusupaces.
As a result of the ojiening of the mater-
nal vessels the trophoblasts soon present
a sieve-like appearance, and the ceUs be-
come compressed iuto masses of irregu-
lar form, some of which extend from the
ovum to the surrounding ti.ssue, while
the majority never reach it. Into these
the mesoderm soon makes its way, thus
giving rise to the primary villi. Those
reaching the decidua are known as fnnt-
etiiiig. or anchoring i)illi, a.nA become tirinly attached to
it by the proliferation of the ectodermal cells at their ex-
tremities, giving rise to masses of cells, which may be
seen throughout the first half of pregnancy and are des-
ignated as cell nodes.
During the tirst weeks of pregnanc_y branching villi
jiroject from the entire periphery of the ovum (Fig.
381."j), and come iu contact not only with the decidua
upon which it rests (serotina), but also with the layer
width separates it from the uterine cavity (rellexa).
During this period, the villi are devoid of blood-vessels.
Am E
P
:' A.C.
:cc.
. »»
if
X.-M^^Jv.
J' '«
» "ss
r
■"-IT)
Uec.
5 e t
Y
FIO. 3R1B.— .Seotinn thrnusli Fcetiil Membranes and Pecidiia at Term, (miside iif the I'lucental site. Magnilled 77 times. Am.cp.. epitlielium :
^.('..amniotic conneetive tissue; C.C.. cliuriouic couuecUve tissue; C.cp., clicriome enltlielium ; T, UegeuerateJ villi: nbrlu; Liie
decidua.
645
Placeula,
flareuta.
REFERENCE HANDBOOK OF THE JIEDKAL SCIENCES.
aud the ovum is nourished by osmosis Iroiii ihe niatcnial
blood. Probably as a result of contaet w il h the uiiitenuil
blood, the outermost cells of tropboblasts early nudergo
marked changes, becomiug converted into a layer of
Fig. :)S17. — Set'tiiin Ihroueh Cborionic Membrane and Villi of a TwivTVeeks (num. Ma<ruiflud -33 times.
'From J. "WlntridL't' Williams.) C.M., Chorionic membrane: Ei*. i-pithelium of chorionic- membrane; S.
connective-tissiie iNvor of chorionic membrane; K villi; .s. stroma of villus; ep., epithelium of villus; Ti\
decidual island (rcninunt of trophoblast).
coarsely gi'anular, vacuolated protoplasm, with no sign
of division into individual cells, and through it are scat-
tered irregularly shaped, dai-klj' staining nuclei. This
tissue is known as si/iirijt/iim. a term introduced in 1893
by Kossiuanu, although its characteristics had been rec-
ognized many years belnre by Knstschenko, who de-
scribed it as ])lasnioiliui]i. Beneatli the syncytium, and
in contact with the cliorionic connective tissue, develoiJS
a layer of sharply mitlined, jiolj-gonal cells, with clear
protoplasm and large vesicular nuclei, which is desig-
nated the rell Inner, or Xethchicht nf Ldinihani'.
With the advance of pi-egnancy, the blood supply of
the deeidua sei'otina becomes moi'e and moi'e ;ibundant,
while that of the ictle\a gradually disaiipeais; as a con-
sequence the villi in contact with the former are better
nourished, and grow more rapidly than elsewhere, thus
giving rise to the formation of the ehorion fmndimim.
At the .same time the villi covering the rest of the ovum
develop less rapidly, and eventually viuilergo atrophic
changes, so that this portion becomes known as the cho-
rion Ireve. As the ovum increases in size, the intervillous
sp;ices in the chorion heve diminish in size and gradually
become oblitciated, and by the fouith month, when the
retlexa has come in contact with the deeidua vera, the
villi become atrophied, lose their epithelium, and event-
ually appear as round or oblong h_yaline bodies. On the
other hand, the villi of tlie chorion frondosum proliferate,
and together with the deeidua serotina form the jilacenta,
which assmnes its distinctive characteiistics about the
third or fourth month. It is probable that the primary
villi do not increase in number with the advance of preg-
nancy, but their branches rapidly increase in complexity,
so that their growth has been aptly compared to the de-
velopment of a forest from a uumiier of young trees.
Cross sections of choricjuic villi differ markedly in
appearance at the vai'ious periods of pregnancy, and De
Loos has shown
that their age maj-
be roughly esti-
inaled aceordiug
to their structure.
Thus, in the early
weeks, they con-
sist of a more or
less mucoid stro-
ma with a few
blanching cells,
the ])roliferation
of which gives
rise to the fibrillar
structure ob-
served in older
villi. After the
first few weeks
tlie stroma is in-
vaded by blood-
vessels of fcetal
origin, which
come down liy
the cord, and
which follow the
villi in all their
r a ra i fi c a t i o n s.
The epithelial
structures also dif-
fer in appeai'ances
according to the
stage of develop-
ment. During the
tir.st few months
the distinction be-
tween the syncy-
tium and Lang-
hans' cell layer is
sharply m;irked.
As pregnancy ad-
vances, Langhans'
layer grailually
disappears, so that in the last months the villi aie cov-
eied only by a thin layer of Battened syncytium.
Projecting from the surface of the villi are occasional
buds of syncytium, which when cut across taugeiitially
appear as giitnt nils, lying fiee in the intervillous blood
spaces. They consist of a pi'otoplasmic mass, which
presents no distinct cellular divisi(jn, and contain a large
number of darkly staining nuclei. These represent the
lirst stage in the devehipment of new villous branches,
and, as might be expected, when one bears in mind the
development of villous processes, are seen less frequently
in more matui'e placeut;e.
Here and there, in the spaces between villi, may be
seen masses of small clear cells with vesicular nuclei —
decidval Mauds. These are usually surroumled by a
la.yer of syncytium, rarely, if ever, contain blood vessels,
and appear to consist of decidual tissue, which fie(|uently
presents areas of degeneiation. They are usually inter-
preted as cross sections through the so-called thcidnnl
septii, which ;ae supposed to extend toward the chorionic
menilu-iine. Formerlv thej' were regarded as being ma-
ternal in origin, hut in the liglit of more recent investiga-
tion, it seems better to consider that they arise from fa'-
tal tissue, and rejiresent areas of tropboblasts that were
not concerned in the formation of the chorionic villi.
The deciilua is uterine mucosa which under the influ-
ence of pregnancy Ijas been tiansformed to fit it for the
reception aud development of the ovum. It is composed
of large branching cells of an e]iitlielioid character, with
round vesicular nuclei, containing a i-atlicr scanty chroma-
tin network. In the ujiper portion of the d'cidua sero-
tina is a thin layer of homogeneous tissue, staiuing deeply
646
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
•*lafeula»
Placeuta.
with eosin, and containing many vacuolated areas. This,
tlic so-called layer of amalized fibrin, results from the de-
generation of the trophoblastic cells forming the cell
nudes. It was first described by Raisisa Nitabuch, who
showed distinctly that it marked the Iwinidury between
fu-tal and maternal tissue; the cells w'hieh lie above it,
in spite of their resemblance to decidual tissue, are of
fietal oiigin. and result from the proliferation of the tro-
plt)blasts, while tho.se below it are of maternal origin and
have developed from the stroma of the uterine mucosa.
Interspersed between the latter are giant cells of syncytial
origin, which invade the depths of the decidua serotiua,
and may even extend into the uterine muscle.
The intervillous spaces are lined throughout by syncy-
others. The portion of the intervillous sjjaces which lii^s
at the periphery of the placenta, between the edge of the
decidua serotina and chorion, has been termed the circu-
lar sinu.s. It is not a continuous channel, although the
villi here are less abumlant than elsi'where. The blood
gains access to the cavities by branches of the uterine
arteries, which pursue a convoluted cnurse through the
decidua serotina, and after their walls have been reduced
to a single layer of endothelium, open from the sides of
the decidual "septa. The blood escajies through wide-
mouth veins upon the detidual surface, and makes its
way to the large venous sinuses, underlying the placen-
tal site. It would consequently appear that the intervil-
lous circulation is uecessaril}' of a sluggish character,
G.C.
FIO. 3818.— Section through a Three-Months Placenta, Shovvins Structure of Chorionic Villi. Macnined 110 tiuies. (Fr.im J. Whitridge
Williams' -'Text-book of Obstetrics," Appleton k Co., New Y.irli, 190:3.) S, Stroma of villus; S\i, syncytmm; Z, Zellschiclit ; b.B.,
syucytial bud : G.C, so-called placental giant cells.
tium. save where it has undergone degeneration in the
decidua serotiua and forms part of Nitabuch's fibrin
layer. They contain maternal blood, as has been definitely
proven by the work of AValdeyer, Farre, Turner, and
thereby facilitating the interchange of substances with
the fce'tal blood in"the vessels of the chorionic villi.
The villi are bathed on all sides of their syncytial cover-
ing by the maternal blood in the intervillous spaces, and
647
Plareutn*
Plaicuta.
REFERENCE IIANDDOoK OP THE MEDICAL SCIENt'ES.
pontain liranclipsof tlie umbilical arteries wliicli breai< tip
iuto capillaries in the leriniiial raiiiilicatioDs. As direct
coiumuiiication between tbe t'a>tal and ni;iteriial circu-
j^ ,* '-^y^.
^
»,'^^ =«CBI1>Q,
"-ri- ■
'^ ?>'
^^/rj
Ui-
^ (^
■d::rr
- ^i > •?: J
— Chnrionlc
villi and
A ^ ^<^'5-'^-^ iiitcrvillous
vJ
— Docidua.
-^ — Chorionic
membrane,
— Amnion.
Fio. 3819. — Cross Section of Seven-Months PUicenta Showinjr Beirin-
ning Infarct Fonnation. (From J. WUilrntae Williams.)
lation has been disproven, it is eviileiil I hat the fietus
is nourished by sulistauees derived Irmii I he maternal
bliiod. by osmosis. an<l by the .selceiivi' powirnf llie syn-
eyliiim. These must traverse the layers of Ihe chcniouic
Tilli which separate the two circtdations. In the early
and midiUe months of pregnancy there are four such lay-
ers— syncytium, Laaghans' cell layer, the connective tis-
sue of the villi, and the endothelimu of the villous capil-
laiies. Later, this uuiuber is reduced to three by (he
disappearance of the Langhaus layer. These act as a
barrier to tlie passage of formed substances. While tbe
evidence coneerniug this question has been conflicting, it
seems probable, in the light of recent investigations, that
bacteria at least are not transmitted from the mother to
tbe child iniless tlie placenta presents definite lesions,
which may constitute portals of entry.
The full-terra placenta coutains many infarcts, which
if of moderate size cannot be regarded as a disease, but
rather as a sign of senility of the jilacenta, analogous to
the changes which are oliserved in Ihe villi of the chorion
heve at an earlier period of pieguauc}'. These begin as
a rule in an obliterating endarteritis. At tbe same time
changes may be seen in the portion of the villi which cor-
responds to the position occupied by Langhans' cell layer
in the earlv mouths. This j.'rogresses and the tissue be-
comes converted by coagulation necrosis into canalizetl
fibrin. If the process continues, numbers of villi become
fused together and are eventually converted into a fibroid
material, wliieli in its final stages is iudistinguisliable
from fibrin derived from the blood. Such structures are
laiown as white infarcts, and are constantly present in
varying size in every normal placenta, as has been shown
by Ackermann, Eden, and Williams. The primary
change in the production of infarcts occurs inost fre-
quenlly in the viUi, although it may be initiated in the
so-called decidual se]ita, which, as we have seen, are
prone to ilegcueration, owing to the absence of blood-
vessels. The frequency of infarcts has been enijihasized
b_y Williams, who found white surface infarcts of at
least 1 cm. diameter in 243 of 50(i placenta;, and marginal
infarcts which extended throughout at least one-third of
the placental peri]ihery in 1S4 cases of the same series.
AnimiiiUcs in Fvnii. — As already indicated, the placenta
may present many vai'ieties in size and form. We have
seen that it becomes discoid in shape by atrophj- of tbe
villi of the chorion heve. and develops from the chorion
frondosum, which is attached to the most liighlv' vascu-
larized portions of the decidua. Abnormalities in the
blood supply of the decidua cause most of the anomalies
of the placenta. If the vascuhirization, instead of being
limited to the single area of the chorion frondosum. de-
velops in several portions of the decidua, certain villi of
the chorion heve, corresponding to the seat of vaseulari-
zatiim, jiersist, and the resulting placenta may jircsent
one or more lobes, sejiarated from each other by normal
membranes. When it is incompletely divided iuto two
lolies and the vessels e.xteud from one to the other to
form the umbilical cord, we term it plfirciitn. dhnUlintu,
or Inpdrtitii. Aiilfeld noted this condition once in si.x
hundred cases. If it consist of two separate lobes, the
vessels of which are perfectly distinct, and do not unite
until just bc^fore entering the cord, it is known uii jiluirii'
tit i/iipU:i\ The insertion of the cord in such cases is gen-
erally marginal, and at the periphery between the two
lobes. (.)ceasionally the organ may ])e made up of three
distinct lobes— j</ii'rf»/(/. ttijilc.i; while in very rare in-
stances it may consist of a number of small lobes, Ilyrtl
having desciibed as many as .seven — placenta septiijile.r.
(_)ne or more accessory lolmles are frequently noted in
the membranes at some distance from tlie periphery of
the main placenta. Ordinarily they are united to the lat-
ter by vascular connections and constitute the placenta
aiircenturiata. When these are lacking and the accessory
lobules are functionless. they constitute the placenta
K/mcia.
Failure of the chorion hrve to atrophy results in the
formation of a thin placenta, which covers more or less
of the entire inner surface of the uterus with functioning
villi. This constitutes the /(/<(c/'H^( mcmbranacea. which
is frequently adherent, and may give rise to serious coni-
jilications in the third stage of labor. Atroiihy of the
central primary villi of the chorion frondosum gives rise
6-iS
KEFEREXCE HANDBOOK OF THE 3IEDICAL SCIENCES.
Pla(-eii(a«
to tlie so-called placctiia fenesirata iu which there is an
a|ici'tiire of var^iug size in the central portion of the
jiluceuta. covered oulj- by normal nieiubraues. Other
anomalies ma}' occur, and as repoited by Taurin the hu-
man placenta may be a broad annular organ \vhich en-
circles the uterine cavity like those of the carnivorous
animals.
The outlines of the placentas in the case of twins va-
ries accordingly as development occurs from tiie ova of
two Graatiau" follicles (double-ovum twins), or from one
ovum whose nucleus has undergone cell division (single-
ovum twins). In the former instance there are two dis-
tinct placentas. In the latter, ihere is but one placenta,
with a single chorion which contains two separate am-
nions, so that each child lies separated fiom the other by
two anmiotic walls. This septum ma}' be ruptured by
iinusual jjressure of the amniotic fluid or hy excessive
fa?tal activity- and atrophy of the partition may result.
The placenta in utero is generally attached either to
the upper portion of the anterior or posterior wall, and
extemls for some distance upward and upon the fundus.
If the insertion be low, it may cover the int*-rual os of
the cervix, which condition is known as phieinta prcn-ia
and constitutes a most dangerous complication of pre.g-
nancy. Schroeder has drawn attention to the fact that
the "direction of the round ligaments may indicate
whether the placenta is anteriorly or posteriorly placed.
If the jjlaeenta develops ujiou the anterior uterine wall,
the increased blood sujiply will cause a more rapid
growth in this region and the resulting increased breadth
of the uterus v\ ill cause the ligaments to run more oi- less
parallel. If the placenta be posteriorly situated the re-
verse will be true, and the ligaments will be found to
diverge in their course downward. The distance between
the internal os and the edge of the placenta maj- be esti-
mated by measuiing the length of the membranes of the
shed placenta from their ])oiut of ruijture to the placen-
tal margin. As rupture occurs over the internal os, we
can by this method frequently reconstruct the jxisitiou
of the' placenta in utero, having first determined by pal-
pation of the round ligaments as to whether the placenta
was anteriorlj' or posteriorly placed.
Frank Wortldngton Lynch.
LITEKATCRE.
Ackermann : Zur normaleai u. path. Auat. der menschl. Placenta.
Fe.stsclirift tiir Virchow. Bd. i., S. i'^S.
Atilf*-ld : I.elirlnu-h dpr (;e»>iirtsh., ;^veitp Autl.
Ballaut;'!!'- : 'J'lit- 1 iccinTeaoc of a Non-Allantoic or VlteUine Placenta
iu tlif Huiiiaji Sui'jfct. ( ibst, Traos., Edinl)., veil. x^ii.
Barbour; The Anat. and Relations of the Uterus, ete. Obst. Trans.,
Edinh.. 18S4.— The .4iiat. of Labour, Edin., ISS'J.
Buniiu ; Ueber die Entwickflunff d. menschl. Placenta. SitzuDgsl>e-
ricbt der pbysical.-medbimisctien (TCSfllschaft v.w Wiirztjur^. 1891.
—Zur Renntnissder rtero-placentar-Gefiisse. Arch. f. (jyn.. .v.\.\vii.,
1-1.5. ISIK).— Ueber die Entwiek. desiuutierl. Blutkivislaufes iu der
nieusch. Placenta. Archiv f. Gyn.. .\Uii_ 181-195. 189.).
Colucci ; Sulla vera natura gtaadolare delta porzionl matema della
placenta, etc. Mem. Accad. Sci., 1st Bologna, Ser. t, yli., ISSU, i:j3-
15S.
Duval : Le placenta des camasslers. Anna!, de Gvn. et d'Obst.. siv.,
IGT-l.si isaa.
Eden : A Study of the Human Placenta. Journ. of Path, and Bact.,
ISiifi.
Ercolani : Della stmtlura anat. della caduca uterina, etc. Bologna,
1S74. Quoted by Waldeyer.
Farre : Todd's Cyclop. Anat., 1S.")8.
Han and Gulland ; On the Structui'e of the Human Placenta. Lab.
Reports Royal College of Physicians, Ediuh., 1892.
Heukelom : Ueber die niensch. Placeutation. Aich. f. Auat. u,
Physiol., Anat. Al«h., It98.
Hulircclit: The Placentation of Erinaceus Europajus, etc. Quart.
Joiu-n. Micros. Science, xxx., 1.T89.— Die Holle des embryol. Tropho-
liliist*. etc. Cenu-alb. I. Gyn., 1897, 12il6.
Hvrtl : Quoted by Kollmann.
Kastschenko: Das menschl. Chorionepithel und dessen Rolle bei der
Histogenese der Placenta. Arch. f. Auat. u. PhysioL, Auat. Abth.,
18S5.
Elcin: Entnickelung und Euckbildung der Decidua. Zeitscbr. f.
GclHirt. u. Gvn., xxii., 1891.
Kollmann : Lehrbueh der Entwiek. des Menschen. Jena. 1898.
KosMnauu: Zur Histoloffie der ChorioiizotI*:n des Meuschen. Leuck-
liardt's Festschrift. 1892.
Kuu'li.-)! u. Engelmann : Untersuch. uber die Uterussehleimbaut.
Strieker's med. Jahrbuch, I.ST-I
LauvdiaTis : Untersuch. uberdif* men.schliche Placenta. Arch. f. Anat.
u. Entwickei., Leipsic, 1877, ias-'_>7ii.— Ueber die Zellschiclit des
mcusctiiichon chorions. Beiirage zur Anat. u. Embryologie (Henle's
resigab.--:, Bonn, 1882.
Leopold : Studien Ober die lUeruschleimhaut, etc.. Berlin, 1878. - Ueber
den Bau der Placenta. Verb. d. di-utscheu Gesell. f. Gvc, iiL,2.57,
1890.— Uterus u. Kind. Leipsic, VfH'.
LeoiMld, Marchesi u. Bolt : Zur Entwickclung und Bau der menscbU
Placenta. Archiv f. Gyn.. lix., olG-.'iM. ISii'J,
De Loos : Das Wachstum der menscblidieu Chorionzotten. D. I.,
Freiburg in B.. 1897.
Lj'ucb: Placental Transmission. Johns Hopkins Hospital Reports, x.,
190-2.
Marchand: Beitrage zur Kcnntniss der PlacentarbUdung. Marburg,
1898.
Merttens : Beitrdgezurnonuaienu. path. Anat. der nienschl. Placenta.
Zeilst'b. f. Gebuil. u. (iyu., ixx., 18it4.
Mlnot: Uterus and ErabiVo. Journal of Morph.. ii., Xo. 3, '889.
Nitabueh : Beitriige zur Kenntniss der uienscU. Placenta. D. 1., Bern,
1887.
Peters: Ueber die Einbettung des niensch. Eies. Wien. 1899.
Reicbert : Bescbreibuug einer frutizeiiigcn menscblichen Ttucht.
.Abhandl. d. k.'inig. Akad. d. Wissensclraften, Berlin, 1873.
Kohl': Die Beziehung der mutterlieben Gefasse zur den interv.
Riiumeu der reifeu Placeuta, etc. D. I., Bern, 1889.
Ruge : Ueber die menschliche Placenta. Zeits. f. Geb. u. Gyn., xxsix.,
1898.
Scbultze; Das Kabelbliischen ein constantes Gebilde, etc, Leipsic,
1861.
Selenka : Studien uber Entwickelungs. der Thlere. Heft 1, 3 and 5,
Wiesbaden. 18.s3, 1p84, n. 1891.
Sobatta: Die Befruchtung unil Furchung des Eies der Maus. Archiv
f. miliro. AmU., 189;"), xlv., Vy-%1,
Spee: Beobachtungen au eiucr menschl. Keimscheibe mit offener
Medullarrinue, etc. Archiv f. Anat. u. Pbys., .4nat. Alilh., 1899,
159-176.— Neue Beobachtungen Otjer sehr fdihe Entwickelungs-
stufen des niensch. Eies. Arch. i. Anat. u. Phvsiol.. Anal. Abth.,
1896, 1-.30.
Turner: Observations on the Structure of the Human Placenta.
Journ. Anat. and Physiol., vii., 120, 1873. also xi.. 1877.
Virchow : Ueber die Bildung der Placenta. Gesammelle Abband-
lungen. ii.
"SValdeyer : Bemerkun£:en utter den Bau der menschl. und Affen-
jilacenta. Archiv f. mikros. Anat.. xxxv., 1-02, 18t*u.
Weljsler; Human Placeutation. Chicago, Ibtil.
Williams: Obstetrics, New York, 1»8.
Young : Development and Structure of the Placenta. Med. Chron.,
November, 1896.
PLACENTA, PATHOLOGY OF.— The chief part of
the pathologj' of the placenta has Ix-en discussed under
the beads of Clwrimi, PaiUohgy cf the. and Dtcu/na.
Pathukigy of the. This article will treat only of the
general pathological conditions of the organ considered
as a whole; namely, anomalies of development, size,
and location, general disturbances of circulation, inflam-
mation, etc.
Anomalies of Dciyelopnmni. — These are of not infrequent
occurrence. Instead of the usual round or oval form, the
placenta may exhibit the greatest diversity of slnqie. such
as cresccntic, liorseshoe, elliptical, etc. {PI. bilobu. irihthi,
mriltihibti, I'einformlfi, fentMnitii, j.(Ui<liin'fornn'.i, etc.).
Besides the main organ there may be found completely
separated cotyledons ajipetiring as smaller accessory pla-
centas (PI. miee^nturiatce). The smaller accessory pla-
centas owe their origin to a localized failure of placental
development in certain areas corresponding to an eudo-
metritic thickening of the decidua with fibrin formation,
leading to au obliteration of the intervilkius sinuses at
the point of separation between the main mass and the
acce.s.sory cotyledons. Following the obliteration of the
intervillous spaces the villi of the intervening areas
undergo ati'ophy or fibroid cliange. Not infrequently
the accessory placentas may suffer a similar change from
obliteration of the intervillous spaces and appear in the
mature placenta as thickened, bloodless areas .separated
from the main organ (j.idctnia ■'<pnrui). If the placenta
becomes divided in similar manner by atrophy or non-
development of a portion of the chorion, into two portions
of approximately equal size, the phenomenon of au ap-
parently' double placenta with one child is |M'eseiited (PI.
duplex; dimidieitu, l/ipartitii). Smaller accessory jilacentas
may also be associ-ated with this condit ion. The cord may
be inserted marginally upon one half, or there may be a
velamentous insertion between the two halves. It is also
possible that a double placenta niiiy be formed by the
elmnges that occur in the placenta following the original
implantation of the ovum in one of the uterine burns.
Under such conditions the placenta finds jirojier nourish-
ment for its development upon the anterior and |)osteiior
walls of the uterus, but not in the horn it.self where the
decidua is develojied but slightly. As the result of the
non-developmeut of the chorion over the poorly developed
64&
Plat'ciila.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
decidua of the horn tlio jiortions of placenta developing
on the anterior and posterior walls liccome separated from
eaeh other and apjiear as a double orf;an. Aecordiug to
some writers a double placenta nia}' ln' formed through a
secondary implantation of a placenta retlexa iipon the
<i])posite uterine wall ; Imt liy the majority of authorities
this is considered doubtful. 'I'iie peculiarities in de-
velopment of the ]ilaceuta mentioned above have been
regarded as examples of an atavistic reversion to the pla-
cental type of some of the lower animals; but it is very
likely tiiat they represent the sequeUe of iiitlammatory
conditions of the endometrium, or are secondar}' to a lo-
calized obliteration of the intervillous spaces and atrophy
of the chorion analogous to infarct formation. Such
atrnpliy may be due to the fact that the affected portions
of the chorion do not lind a favoralile location for de-
velopment. The various anomalies of development may
have a practical importance, in that portions of the pla-
centa may be retained after delivcn-y ; this is particularly
likely to occur in the case of double jiiacenta or when
accessory placentas are present.
Phiceittu i/mrgi until. This term is applied to the; pla-
centa when the chorion Ueve is given off, not from the
edge of the ]ilacenta, but from its surface, .so that there
is produced beyonil the attachment of the fo»tal mem-
branes an edge or margin which does not stand in direct
connection with the main mass of the chorion. From
this margin the membranes are easily stripped: its sur-
face is covered with a thick, firm, yellowish fibrin layer
which is elevated 1-3 cm. above the general surface of
the chorion. On microscopical examination the fibrin
ring or margin is found U< cnnsist of atrophic and necro-
tic villi with obliterated blood spaces. Its structure is
therefore the same as that of the |ilacenta! infarct. If, on
the inner side of the fibrin ring, there is developed a ring-
formed elevation of the chorion, the variety known as the
phicetitn ciri'Kiiiriithitii is produced. Both of these anom-
alies develo]! as the result of an abnormal proliferation
of the refle.ni with a subse(|uent infarction of the .same
and of the encloseil villi. In this way there is formed on
the surface of the placenta a stift' and imdastic ring of
filirin at a time when the jilacenta has not yet attained its
full size. The fibrin ring hinders tlie peripheral growth
of the villi, but these are able to penetrate the decidua
outside of the ring, where they give ri.se to masses of villi
lying outside of the firm attachment of the membranes
to the placc'iita. .Vs the result of the formation of the
(ilaeenta marginal.a, ])orlions of the menibranesare likely
to be retained after delivery ; and in those cases in which
the condition develops very early the growth of the pla-
centa may be so limited that the ftetus will probably be
insufficiently nom'ished and abortion may oeeur.
The pliiciiitii meiiihrdiiKcea is a rare form in \\ hich the
organ is thin and tlat. and extends over a large surface,
either the whole or a large jiart of the chorion bearing
permanent villi. It has been variously explained, but
the most iilausible theoiy is that the jiersistence of the
villi over such a large jiart of the chorion is due to the
fact that the villi penetrating the original serotina did
not obtain sutflcient ncjurishmeut. The pliifefitn meiu-
bniiuirm may give rise to elinii-al symptoms of //^j/cc/i^;
pra'i-in, hemorrhages, retention, etc. Separation in the
case of this form of placenta is nnieh more serious than
that of the niirnial form of organ.
AliiKjriiiiiliti&f iif Site. — The jiliiceiitn privrin is the most
imjiortant form of abnormal location of the placenta.
The jdacenta may completely cover the os())laccnta pra3-
via centralis), or extend into the lower uleriue .segment
without reaching the inner os (placenta pnevia hiterali.s).
Tile etiology of the condition is obscure; and many
theories have been offered in exphmation. As a result
of previfius endometritis the cavity of the uterus may
beciinie so enlarged that its walls are no lunger in contact
with each other; so that when the ovum enters the ute-
rus it drops downward and becomes attached to the lower
portion of the uterus. In some cases the placenta prte-
via may be a normally .situated jdacenta, which is so large
that it extends into the lower uterine segment. It is also
probable that the placenta ]ira'via may owe its origin to
a development of a portion of the chorionic villi i^i the
decidua retlexa, instead of those implanted in the sero-
tina. The clinical importance of placenta pra-via lies in
the fact that in the later months of pregnancy the en-
largement of the lower pole of the uterus gives rise to
detachment of the placenta with conseipient hemorrhage.
Anomalies in the insertion of the cord arc not infre-
cfuent; the usual attachment is the centre of the organ;
not rarely it is eccentric, or even at tlie margin (Imtththire
placenta). When the cord is inserted into the membranes
some distance outside of the placental margin the con-
dition is known as nimiieiitoiis imertiuii. The vessels
bifurcate at the point of insertion, their divisions nm-
ning between the amnion and chorion to the placenta.
C'liraliitori/ ('/inni/is. — QCdema of the placenta occurs
rarely. It is usually associated with general u'dema of
the ftetus; more rarely with maternal drops}'. Disturb-
ances of fretal circulation, thrombosis of umbilical or
hypogastric arteries, antenatal closure of the foramen
ovale, etc., have been regarded as the exciting causes.
The placenta of acardiac monsters is usually u'llematous.
The number of leucocytes in the blood of the fu'tus may
show a great increase in these cases. The a'dematiuis
placenta is larger and heavier than normal, pale, fi iable,
and soft. Microscopically the villi are found to be
greatly enlarged and closely packed together; the inter-
villous spaces are reduced in size and contain but little
blood. The stroma of the villi is separated by fluid, the
cells being pushed far apart. The f(etus usually dies in
utero as the result of the conditions causing the o'denni.
Ilemon-lidije. — True apoph-xiesof the placenta are rare.
They may occur cither in the maternal or in the fo'fal
portion, an<l are usually the result of inflammatory
changes. In the fo'tal portion the mass of blood becomes
encapsulated by a dense layer of fibrin. The neighbor-
ing villi are compressed and become atrophic or necrotic.
The nutritiim of the fcetus may be impaired and abortion
result. Very rarely the hemorrhage may occur upon the
surface beneath the anmion, or the blood may bvirst
through the serotina and escape externally. In such
cases the fu'tus is usually born dead. In some of the re-
ported cases the hemorrhage was regarded as due to a
ruiiturc of a branch of the umbilical vein or artery fol-
lowing thrombosis, twi.sting, or laceration. The causes
of these hemorrhages are unknown and their iiathology is
doubtful. It is piob:dile that some of the cases described
were not true ]dacrntal apoplexies. The small dark red
areas frequently seen throughout the placenta, and re-
garded by many as interstitial hemorrhages, are not true
hemorrhages, but represent local congestions of the inter-
villous s|)aces. Inasmuch as the blood is contained within
the nornud blood spaces the condition cannot be consid-
ered to be hemorrliage.
Hemorrhage into or from the plac( nta as the restdt of
trauma oj- of allempfs at abortion are of frequent occur-
rence. Ilemorrhagi' from partial separation of the organ
occurs in placenta pra'via. In inflammatory conditions
of the maternal portion of the ]>lacenta, degenerative
changes in the serotina, etc., partial separations of the
ftetal placenta may occur. Such hemorrhages are of
frequent occurrence in the acute infections, .syphilis,
ne|dn'itis, Basedcjw's disea.se, chronic endometritis of
gonorrlKcal oliLiin. etc. tn all these cases the hemor-
rhage is from the maternal vessels and not from the fce-
tal. They represent decidual changes rather than pla-
cental. The cscajiecl lilood fills up the cavitj' caused by
the separation of the chorion or oviter layer of the de-
cidua, or may break thnuigh the fatal membranes or
escape externally. The serotina may be completely de-
stroyed and a large cavity formed between the muscle of
the uterine wall and the placenta. The chorionic villi
and f(etus may be compressed; the latter suffering from
disturljances of nutrition may die, or may present abnor-
malities of development.
Reti-iir/riide C/Hi/ii/ts. — As has been mentioned in the ar-
ticles treating of the pathology of the chorion and de-
cidua, the retrograde changes which are constantly found
■«50
REFERENCE IIANDHOUK OF THE MEDICAL SCIENCES.
Placenta.
Placeula.
in the inature placenta must be regarded as the expres-
siini of a j)hysiologieal decay of the oigan. The great
majority of the older observations on iutlanimatioii. fatty
Regeneration, amyloid change, etc., were most probably
nothing more at foundation than the various appearances
produced b_v the physiological processes of infarction
found constantly in the r:pe placenta.
Atriipliy of the placenta may follow extensive hemor-
rhages, or intlammation, or atrophy of the dceidua.
yernisin. — Simple necrosis of the chorionic villi occurs
in placental infarction. An abnormal degree of tliis
change may be caused by nephritis of the mother, by
syphili.s, tuberculosis, etc.
" riiirintal Infnrctiun (see Choi-ion, Patholoijy of).
Fiittif Dcjeiieration. — The cases described in the litera-
ture by Barnes and others were undoubtedly placental
infarcls. Fatty degeneration of the chorionic villi is
extremely rare except as a seijuela of other changes,
retained placenta, placental infarction, etc. A small
amount of fat is almost constantly present in the normal
ripe jilacenta, and is to be regarded as physiological.
Cclfiliriiticn within certain limits is almost constantly
found in the luature placenta, and is to be regarded as
physiological. Only in marked degree is it of pathologi-
cal .significance. In the latter case it follows exce.ssive
infarction, fatty degeneration, etc., in nephritis, syphilis,
acute infections, etc.
Aini/loid has been described as occurring in the ])lacen-
ta; but the appearances taken for amyloid were probably
those of infarcted areas.
Myxomatous degeneration of the stroma of the chorionic
villi occurs in retained placentas and in hydatid moles.
IHijnientation. — Deposits of blood pigment may >)e
found in both the normal and the diseased )ilaceuta, result-
ing from the disintegration of red blood cells contained in
the clots found between the villi. Rarely this jngmeut
may be taken up by the villi and be found de])osited in
the stroma of the latter.
Hyaline degeneration of the villi occurs to a certain ex-
tent in the ripe placenta as an evidence of physiological
atrophy. When it occurs prematurely, or to a marked
degree, it is to be regarded as of ])athological significance.
It may follow the changes proiiuced in the villi by the
acute infections and certain intoxications, but is most
often due to syphilis.
Hypertrophy. — An enlargement of the placenta may be
due to CTdema or degenerative conditions of the villi.
Fibrous hyperplasia occurs in syphilis, nephritis, etc. A
true h_ypertrophy — that is, an enlargement oi the organ
with preservation of normal structure — is of rare occur-
rence in as.sociation with abnormal development of the
fa?tus.
Jnflamination (see Chorion, Pathology oj).
Tuberculosis of the jilacenta has been described but a
few times (Lehniann, Schmorl, ami Kockel, Auche and
Chambrelente, Warthin). It is not improbable that the
disease is of more frequent occurrence tlian the few pub-
lished reports would indicate. Inasmuch as there are no
gross changes in the placenta by which the condition can
be recognized without microscopical examination, it is
probable that cases escape diagnosis. In all cases of :ua-
ternal tuberculosis of advanced degree, in miliary tuber-
culosis, and in all cases of maternal tuberculosis in which
the tubercle bacilli gain entrance to the blood, the bacilli
will undoubtedly be found in the blood contained within
the intervillous spaces. The conditions would tlierefore
favor the development of tubercles in this location. On
the other hand, it luay be argued that the syncytium and
fffital tissues possess a certain degree of immunity tow-
ard the tuliercle Ijacillus. This view is supported by the
fact that in placenta! tuberculosis large masses of filirin
containing great numbers of tubercle bacilli may be
found resting upon an apparentl)- normal syncytium;
and in a case seen by the writer the syncytium had even
grown around and enclosed such a fibrin mass containing
tubercle bacilli.
Syjihili.'i may afTect either the fo'tal or the maternal
portion of the placenta. In both cases the changes are
those of inflammation and premature degeneration. Oum-
matous proliferations hav<' lieen obse^'ved in the sero-
tina; but it is not improbable that some of the changes
described as such were in reality fibrin masses and not
gummata. The most characteristic and constant chauee
in tlie placenta due to syphilis is that which occurs
when the infection takes place at the time of conception
or during the early stages of pregnancy. In such cases
the chorionic villi not infrequently show a filiroblastic
proliferation (interstitial placentitis) of the villus stroma
with resulting obliteration of the chorionic vessels. If
the foetus survives, the affected villi undergo a fibroid
change. In the great majority of cases, however, the
condition results in abortion. Infection during the later
months may produce little change in the placenta; or the
physiological phenomena of obliteration of the chorionic
vessels and infarction may be nuich more extensive than
normally. The interstitial placentitis occurring in the
earh' months of pregnancy is characteristic of syphilitic
infection onh' in the involvement of large areas. A
similar change is also found in the neighborhood of pla-
cental tubercles.
Oonorrh(tal placentitis has been regarded clinically as
a cause of abortion. Two cases have been reported in
which the gonococcus was found; but neither the bac-
teriology nor the pathology was established beyond a
doubt. The etiological role of the gonococcus has, how-
ever, been clearly shown in cases of interstitial decidual
endometritis.
Placental adhesions with the uterine wall are of much
more rare occurrence than is usually believed. In rare
cases the serotina may fail of development and the chori-
onic villi ])enetrate directly into the uterine wall. In
cases of decidvial endometritis fibrous connective tissue
may develop in the serotina and give rise to firm connec-
tions between uterus and placenta. As a result of such
adhesions portions of the placenta luay be retained, and
this may lead to severe hemorrhages or to secondary in-
fection. Putrefactive processes may take place in "such
retained placental tissue, as well as in that retained after
abortion.
Detachments of the margin of the [ilacenta of slight de-
gree are relatively frequent, and possess no significance.
Their occurrence is revealed liy masses of fibrin or blood
clot lying between the decidua vera and the reflexa.
Jlore extensive detachments may endanger the life of
both mother and fcetus. Such detachments arc usually
associated with hemorrhage: the blood may collect in
tlie space formed by separation of the placenta from the
serotina or burrow between tlie layers of decidua and es-
cape externally. In rare cases the blood may rujiture
into the amniotic cavity. Only exceptionally, "when the
detachtnent occurs in the central part of the placenta
while the edges remain attached, is the hemorrhage un-
important. In such cases death of the fa?tus occurs,
however, as the result of disturbed nutrition. The
detachment of the placenta during birth is of rare occur-
rence. Such premature loosening of the organ is due to
sudden diminution in the volume of the uterus following
the loss of large amounts of amniotic fluid. The weight
of the placenta causes it to descend into the lower seg-
ment of the uterus, where it may present before the fo?-
tus, and may be expelled first. In such cases the child
is usually lost.
Changes in the Placenta after Intra-uterine Death of the
Fa'tus or Abortion. — After death of thefcetus in the early
weeks of pregnancy the retained chorion may continue
to grow. Heiuorrhages occur repeatedly, forming thick
layers of blood clot, which gradually loosen the jiTacenta
remains. These together with the blood clot are dis-
charged as a fbrin or fle.ihy mole. A deposit of calcium
salts in the fibrin mass gives rise to a stone mole ; niy.xo-
matous or liydropic degeneration of the stroma of the
villi ton hydatid or grape mole (see C/wrion, Pathology of ).
Through continued grt)wth of the villi with sucressive
dejiosits of fibrin, polypoid tumoTui placental polyps) may
l)(; formed. These may be discharged sjiontaneously or
may become gangienous or purulent as the result of in-
651
Placenta Pr;fiia,
Plaiilaiu.
REFEUE>'tE HANDBOOK OF TilE MEDICAL SCIENCES.
fectiiiii. A penetration of the uterine wall by proliferat-
ing villi gives rise to the condition known as innUynaht
or (lentriictire placenttil pili/ji (see Si/iiri/liin/iK).
Pdteental Ci/nts. — Cystic fornialious liave been fre-
quently described as occurring in the placenta. The
majority of these have undonlitedly been degeneration
cysts, arising either from a niyxonialous or hydropic de-
generation of the stroma of portions of the chorion, or
from the liquefaction of areas of infarction. Less fre-
quently small cysts maj- arise in the |ilacenta as the re-
sult of tlie liquefaction of small encapsulated hemor-
rhages. The cysts arising from the degeneration of
infarcted areas may reach a very large size, and in rare
cases may be mistaken for a second amniotic sac. They
are found usually on the ftetal side, beneath the connec-
tive tissue of the chorion. Their walls are lined b_y large
epithelioid cells, in jiart syncytial and in part decidual.
Small cj-sts lined with epithelial cells (so-called dermoids)
have been observed in the placenta. These have been
interpreted as representing remains of the allantois.
Tmiiovs, — Xew growths of the placenta belonging to
the connective-tissue group are e.Mremely rare. Alin
collected twenty-three cases from the literature, and
twenty additional cases have been reported up to 1902.
The diagnoses given were my.\otiliroma. tibroraa. angi-
oma, fibromyoma. and sarcoma. The majoiity of these
cases are very doubtful. T!ie so-called my.xonia libro-
sum is the most common form ; it is found usually on the
ftptal surface, and is rarely emliedded in the placental
mass; and still more rarely it reaches the maternal side.
These growths present a varied appearance, but are usu-
ally encapsulated, tirm. and homogeneous on section.
Microscopically they sliow an alveolar structure, the
tissue resembling that of the umbilical cord, sometimes
very rich in cells, at other times containing but few. It
is very doubtful indeed if these formations are to be re-
garded as true neoplasms.
Of much more frequent occurrence are the growths
ai'ising from the syncytium, the btnir/n chorio-epithdioiua
or hyiatid mole, and the malignant chorio-epithelioma
(.•s?/iiri//ioma intiliyniim). (See Si/nci/tioma, and Cliorion,
P,illii,l(i;iy of the.) Such growths arise from retained
chorion after abortion or delivery, usually after the for-
mer during the early weeks of pregnancy. From the
decidual cells a sarcoma may arise {surcoma ileciduocellu-
liin). Confusion, however, e.\ists with reganl to this va-
riety ; in many cases syncytioma has undoubtedly been
regarded as a sarcoma of decidual origin. (.See also
C/iorioii, I'idhology of, and Ikcidmi. Pnthohjrjxi of ; and
SyneytioiiKi.) Aldi-el Scoit Warthin.
PLACENTA PR/EVIA. (CLINICAL.)— When the phi-
cenla is atturhrd in wliole or in pari to that portion of
the uterus which is dilated during labor for the passage
of the child, it is call-'d "pra'via."
Di'. Robert Barnes, in a jiaper read liy Iiim in 1892 be-
fore the International Congress of Diseases of Women
and Obstetrics iu Bivissels, divided the uterus into three
zones — the fundal or superior zone, the equatorial zone,
and the inferior zone. The inferior zone is .separated from
the ciiuatorial by Barnes' boundary line, which lias also
been called the "'internal os of Brauue." the "ring of
B.indl." and "'.Schroeder's contraction ring." It is this
inferior zone which is dilated during labor for the pas-
sage of the child.
V.\hii;tii:s of Pi..vce>;t.\ Pit.KVi.\. — Some writers
make foiu' divisions of placenta pnevia:
1. Lat<'ral. in which the placenta is attaclied toward
the ujiper pari of the inferior zone.
2. .Marginal, in which the placental edge comes down
to, but does not cover, the internal os.
y. Partial, in which the internal os is partially covered
hy the edge of the ]dacenta. And
4. Complete, in which the internal os is completely
covered by the placenta.
The nomenclature of Schroeder, Budin. Parviu, and
others, who make liut two divisions, is more practical
and less contusing. Thev condense the first three varie-
ties under one head, lateral placenta pra-via, which in-
(!lndes all cases not complete. Lateral placenta pra'via
occurs more frequently than complete, probably iu the
ratio of two or three to one.
Frkquexcv.— Placenta pnevia occurs about once in
one thousand cases of labor, though the figures as lo its
relative frequencv are widelv divergent. Thus, Winckel
gives 1 to l,.500:"Kaltenbach, 1 to E.OOO or l,60ti: Jew-
ett, 1 to 1,00'.); while Townsend. at the Boston Lying-in
Ilosiiital, found 1 case in 230 labors, and White." atthe
New York Lying-in Hospital, reports a frequency of 1
to 322. These latter figures, however, are much higher
than is usually found, as a great many abnormal teases
are referred to lying-in hospitals by midwives and phy-
sicians.
Etiology. — The cause of the faulty attachment is still
unknown. Predisposing causes are endometritis, rela.xa-
tion of the uterine walls, anomalies of the uterus, as
uterus bieornis and unicornis. Ingleby reported two
eases in which there was a low opening of the oviducts.
Webster sjiys; "Three different sets of conditions ex-
plain the occuiTence of placenta prrevia: 1. Low implan
tation of the ovum 2. Development of chorionic villi
on the decidua reflexa, forming a reflexal placenta. 3.
Low implantation of the ovum with a retlexal pla-
centa."
Co\[PLic.\Tioxs. — Faulty presentations are common,
owing to the placenta filling the lower zone of the uterus
which is usually occupied Ijy the presenting part.
Anomalies of the placenta are frequently found in con-
junction with the faulty attachment. It is usually thin-
ner and spread out over a larger area than that occupied
by the normally attached placenta : it is apt to be irregular
in form, and " placenta succenturiata " is not uncommon.
There are fre(iuently abnormal adhesions between the
placenta and the uterine wall.
PiiOGXosis. — This is one of the gravest of the compli-
cations of pregnancy. The more nearly completely the
internal os is covered and the earlier the hemorrhage the
greater the danger to both mother and child. The prog-
nosis is atteeted by the time at which the case is first seen
and by the skill of the operator. The figures for mater-
nal mortality range from five or ten per cent. (Winckel)
to twenty-three per cent. From fifty to seventy per cent.
of the children are lost. Lateral placenta pra'via is less
dangerous than complete.
Sy-Mpto.ms. — The cardinal symptom of placenta pra?via
is hemorrhasre. This may occur at any time after the
formation of the placenta, but is rare before the twenty-
eighth week. In the coni]dete variety it occurs earlier
and is more ]irofuse than in the lateral. Winckel slates
that the first hemorrhage in lateral placenta pnevia oc-
curs usually after tlie thirty-second week; in complete,
between the twenty -eighth and the thirty-second. Hem-
orrhage occurring in the latter months of ])regnancy
without obvious cause is strong presumptive evidence of
the presence of a jiravial placenta. The diagnosis can
be made certain only liy feeling the placenta tliroughthe
OS with the examining linger. Before the os is suffi-
ciently dilated to ailmit the passage of the finger, the
failure to find the jilacenta by abdominal palpation, a
faulty presentation of the IVetus, and on vaginal exami-
nation inability to recognize the presenting part through
the vaginal vault and uterine wall, are suggestive symp-
toms.
The first hemoriliage. if it occurs before labor, comes
on without warning. It may be profuse, or there m.ay be
only a slight tlow which ceases spontaneously, to recur
after a few hours or days. Barely it is so profuse as to
cause death. Sometimes there is constant oozing.
Tre.^t.mknt. — The Irealment to be adopted depends
on the period of pregnancy at which hemorrhage occurs,
the extent of the lileeding, and the ability to control it by
simple measures.
When the first hemorrhage occurs before the child is
viable, when it is slight and controlled by rest in bed. if
there are no contractions of the uterus, we are justified
iu temporizing, in the hope of getting a living child.
652
REFERENCE HANDBOOK OF THE 3IEDICAL SCIENCES.
E>la<'<'iii:i JTavia.
Plautalu.
Such a couise beiug ilert'itiiined ujiou, the patient sliould
be kej l in bcii audas quiet as possible until labor comes
on sf oiitaueously or is induced with the expectation of
delivering a living child. She should be meanwhile on
a iHiuilious and non-stimulating diet, and should be
watched with unremitting care tor a. recurrence of the
bleeding.
Shoufd, now, the hemorrhage l)e profuse, whether labor
be ])resent or not. there is no condition of pregnancy in
which danger to life is more imniiueut or in which judi-
cious interference is more essential. We have t)efore us
then the problem of how best (1) to check the hemor-
rhage, (2) to expedite labor. No single method of treat-
ment can apply to all cases.
Should the hemorrhage occur first after the onset of
labor, w-ith lateral implantation of the placenta and a
normal ijresentation, if the os is fully dilated or easily
dilatable, simply ruptuiing the membranes and allowing
the presenting part to engage will often stop the hemor-
rhage. Should this fail to chock the bleeding, the head
may be brought down with the forceps, or, if the breech
present, a foot may be grasped and the os plugi^ed with
the thigh and buttocks. Should the ]5reseutatRm be a
transverse one, podalic version is indicated.
When, on the other hand, we have a brisk hemoi'rhage
coming on during pregnancy or labor, with a rigid os
barely admitting one linger, ru[)ture of the membranes
would be a verj' doubtful procedure. In such a case
most obstetricians advise the use of the tampon. To be
of use, it must be applied with thoroughness and care,
and, needless to say, with all aseptic jjrecautions. The
best material with which to tampon is gauze. It may
lie (tither sterile or medicated, and should be folded
in strips about one inch wide and two or three yards
long. A Sims speculum of large size facilitates its in-
troduction. The patient should be placed on her side or
in the hthotomy position. The cervi.v should first be
plugged if possible, and then the vagina should be firmly
packed throughout, the tighter the better. We accom-
plish two things by this procedure: check the hemor-
rhage and stimulate uterine contraction. The tampon
may be left in place, provided there is no oozing through
or alongside it, until the cervix is fully dilated or is eas-
ily dilatable. It shoidd be remembered that the tampon
is simply a preparatory measure. Its usefulness ceases
with dilatation of the os. Some physicians allow it to
remain until it is expelled by the advancing head. It is
better not to allow it to remain for a longer time than ten
or twelve hours, should no indication arise for its removal
sooner. When it is removed, if the cervix is found to
be dilated or nearly so, and the presenting part shows a
tendency to engage, the membranes should be ruptured
and the labor terminated by forceps or version. Shoidd
the cervix be partially dilated — two fingers or more — we
have to choose between the use of some of the rubber
dilators, such as Barnes' bags, the haUon of Charapetier
de Ribes, Branne's colpeurynler, etc., and ver,sion, either
external, or the combined external and internal or bipolar
version of Braxton Hicks.
Of the rubber dilators, the hallon of Champetier de
Ribes is probably the best. Its conical form and moderate
elasticity adapt it thoroughly to the purpose of a uterine
dilator, and acting from within it closely simulates the
action of the membranes in normal cases. It is urged
against it that it sometimes fails to stop hemorrhage, that
it adds to the danger of sepsis, and that it displaces the
presenting part. It is applicable to the same class of
cases as bipolar version, over which it has the advantages
that it can be applied without anaesthesia and that it
takes less time. But, like the tampon, its use is only a
preparatory measure, and its expulsion or extraction
must be followed in most cases by the use of the forceps
or version.
External version is practicable only before the present-
ing part sinks into the pelvis and before rupture of the
membranes occurs. As soon as it is accomplished the
membranes should be ruptured, a foot brought down,
and theos plugged with the thigh and buttocks. There
is little danger of concealed hemorrhage, as the pre-
senting breech makes firm pressure on the placental
site.
The conditions necessary for the performance of bipo-
lar version are: that the liquor amnii should be present,
that the cervix should admit two fingers, and that the
vagina should admit the rest of the hand if uec( ssaiv.
The operator should use, in the vagina, the hand eori'e-
sponding to the position, i.e.. the left hand in kit imsi-
tions, and the right hand in right. Two fingeis are
slipped up through the cervix and push the head to that
side upon which the dorsal plane lies, while with the other
hand the breech is pushed to the ojiposite side. As soon
as the head is pushed up out of the pelvis, the breech is
crowded down with the outside hand upon the fingers
inside the cervix, and a knee is grasped and brought
down. The version is completed by drawing down the
leg into the vagina, while the head goes up into the fun-
dus, and the breech engages. The advantages of bipo-
lar version over internal version are that it can be dime
earlier and that in bipolar version only two fingers enter
the uterine cavity, thus causing less shock and less dan-
ger of sepsis.
Internal version, oi' ordinary podalic version, is one of
the oldest and, when it is ajiplicable, one of the best of
the methods of treating placenta pravia. When there
has been little blood lost in tlie earlier pai t of hibor,
when the os is fidly dilated or is soft and sufficiently di-
lated to admit the hand, it is the most practical and di-
rect method of eSecting delivery. The hand and arm,
during their introduction into the uterus, make pressure
upon the bleeding surfaces, and thus check the hemor-
rhage, while, later on. the same ortice is performed by the
thigh and breech of the child.
Whatever the method of version, after the foot is
brought down and the os is plugged by the thigh, the
further delivery may be left to the natural forces, pro-
vided there is no imperative indication for rajiid extrac-
tion.
AThen the hemorrhage continues after the birth of the
child, the placenta should be extracted manually at once,
and the uterine cavity packed with sterile gauze, if nec-
essary.
There is another class of cases in which the cervix is
rigid and undilated, in which the tampon fails to stop
the hemorrhage, or in which if the hemorrhage is checked
the cervix fails to dilate and recurrence of the hemor-
rhags is imminent. In such a case, when the surround-
ings are not prohibitive, Ca'sarean section would seem to
offer much. With the improved technique of recent
years, the mortality after this operation has steadily
fallen, and as between it and ■"accouchement force " — by
which is meant forcible manual dilatation of a rigid and
oftentimes friable os, followed by internal version and
delivery — Cai'sarean section in competent hands should
give a lesser mortality. liicluii-d J-Cmll llivirii.
PLAGUE, THE. See Submnc Plague.
PLANTAIN— Codex Med. The flowering plant of
PUxnUiijo major L., P. media L., and P. l((i)rioliita. L..
three common European weeds, of which the first and
last have made themselves i)retty well at liome in our
fields and door-yards. They are very slightly acrid and
bitter, somewhat astringent, and quite mucilaginous;
containing a little of some sort of taimiii. soiue resiti,
some "hitter e.vtraftire.'' and considerable tiiiici/age. but
no more active substances. They are almost obsolete as
medicines, but were formerly esteemed as astringents,
ha-mostatics. and even antispasmodics, and were used
locally in leucorrhu'a, hemoiThoids, conjunctivitis, and
scroftdous eruptions.
The oixler Pla iitar/iiiacin is a large one. of severjrl hun-
<lred species, but none havina; active properties. The
s<'e(lsof one, P. P^jiHiiiin L.. have anabtiiidant n.ucilage,
like that of flaxseed, and are employed in the arts i'or
sizing cloths, etc., atid occasional!}' in medicine as col-
lyria or demulcent washes. 11'. P. Bolles.
653
Pla»iiio<ljiiiii .Tlal
REFEREXCE HANDBOOK OF TIIK MEDICAL 8C1EXCE^;.
PLASMA CELLS.-Iu 1891 riinn (li'scrilifirl the de-
iiK-nts which he called "plasma cells." believing tlicm
to eoiTespoiHi with certain .granular connective-tissue
cells til which Wahleyer had jireviously given the same
name, l^atc^r studies indicated that the two were not
identical, and Wahleyer advised thi> restriction of the
terra " plasma coll " to that of I'nna. linding that the
structures named by himself (Wahleyer) corresponded,
at least in large part, with the "mast cells" of Ehrlich.
Various papers on plasma cells have apjieared since
Unna's earlier publications, while their nature and prop-
erties have been the subject of numerous discussions,
often lengthy and occasionally acrimonious. From this
it appears that our knowledge of thi'ui is still far from
definite. There is even some dilTerence of opinion as to
what a plasma cell is in fact. It has received its name
on account of having jirntitpliisui that may be stained liy
basic aniline dyes. This property is by no means pecul-
iar to it, however, r.nd is shared liy several other varie-
ties of cells; for instance, ganglion cells, lymphocytes,
osteoblasts, certain .giant cells, and mast cells. (In the
case of mast cells, large granules contained in the Ijody
of the cell are the jiart stained, and tlicy assunn- a difl'er-
ent shadeof color fiom that of the pure stain itself — meta-
chromism.)
!Moi!iMioi,o(iv. — Witli Unna's polychrome methylene
blue (described hereafter) the proto)ilasm of the plasma
cells is stained blue-violet, while the nuclei become blue.
The outer i)art of the ])riitoplasm stains more deeidy
than the inner ]iart, leaving a pale zone around the nu-
cleus. The nucleus is round or oval, and is usually
placed eccentrically. Five to eight dei;ply stained
masses of chromatin occur in the nucleus, chietjy aroimd
its border. Some observers have ilescribed a nucleolus.
Two or more nuclei are occasionally present. In size
the plasma cells vary from being of the dimensions of a
leucocyte to objects of a much larger size — average di-
ameters. 6 to 7 /; by 8 to 10 //. In shape they are roinid.
oval, roughly cubical, or elongated, accnrding to whether
or not they are contiued liy connective-tissue filires or by
the pressure of other cells. Evidences of both mitotic
and amitotic divisicm have been Avitnessed in [dasma
cells.
The above account is, in all essential respects, in accord
with the views of von JIarschalkc'i. which have been
adopted by the majority of woikers. It ditfers some-
what from the one originally .given by L'luia. Accord-
ing to I'nna. the ]ilasma I'ells have jirotoplasm that con-
tains numerous granules ca]iable of being stained. Such
granules have not been seen by most other observers.
It is not uncommon, however, to find jilasma cells whose
])rotoi)lasm is not homogeneous, but which contain .small
clum|is an<l particles that stain unequally ami irregularly.
Cells having the metachromatic granules characterislic
of mast cells, but otherwise like ordinary ]ilasma cells,
have been seen — plasma mast cells. These are unusual.
Furthi'rmore. according to I'nna, the nuclei of plasma
cells give up their st;un much more easily than does the
protoplasm, and in a prejiaration iiroperlv made the nu-
clei appear as unslained spots. Some have even main-
tained that two kinds of plasma cells exist, those of Unna
and those of vou Marschalko. However, it is certain
that the staining of the mulcus dcjunds much on the
technique enqiloyed.
OccrnRENCE. — Although they were at lirst supjiosed
to belong only to pathological conilitinns, plasma cells
have been reported as occurring in lynqih nodes, in the
lymphoid tissues of the spleen, and in the bone marrow,
both in man and in the lower animals, in ligaments, in
the framework of mucous glands of the tongue, and in
the mucosa of the stomach aud intestine in man. Infor-
mation as to their distribution in normal tissues is not
very full or exact.
On the other hand, .so much has been written on their
occurrence in diseased conditions that a mere enumera-
tion of these conditions is impracticable. Unna's lirst
accounts of plasma cells were based on sections of lu|)us.
He directed attention to tumor-like collections of these
cells. Such a collection he called a " plasmoma." It has
since been learned that plasma cells are abundant in the
lesions of tuberculosis wherever situated, in those of
syphilis, leprosy, actinomycosis, and rhinoscleroma — i.e.,
the so-called "infectious granulomata." They are also
freciueuti}' seen in the stroma of carcinoma. In the main
they are characteristic of rather chronic processes,
where they constitute an important part of what is often
termed round-cell inliltration. They are .said to collect
especially around small arteries. Their relations with
the epithelioid cells of granulation tissue are in dispute.
In acute inllanunatory conditions, and especially in acute
suppuration, they ajqiear in smaller numbers. Plasma
cells have, however, been demonstrated in acute inflam-
matory lesions, bacterial or otherwise, in keratilis in the
rabbit, in recent granidating wounds in man and in the
dog, in the lesions of typhoid fever, in the cell intiltra-
tion of acute interstitial nephritis, and in the stroma of
the lung and even in the exudate late in lobar pneumo-
nia. Further work is needed on their relations to the
cells of sarcomata, and it may possibly yield information
of u.se in diagno.sis. The study of the plasma cells in
diseases of the skin has been carried on by Unna with
great energy; the results may be found in his"IIisto-
patholog}' nf the Skin."
Origin AND Functions. — Unna held that the plasma
cells were derived from connective-tissue cells, stating
that he was able to detect all the necessary transitional
forms between the two. This theory has obtained a few
adherents. Most observers, however, believe that jdas-
ma cells are derived from the lymphocytes, and chiefly
from the small lymphocytes. It is claimed by .some, fur-
thermore, that jilasma cells may become connective-tis-
sue cells and thus aid in the formation of fibrous tissue.
This latter hypothesis would make the production of
connective tissue from lymphocytes possible under cer-
tain circumstances, the plasma cells being an intermedi-
ate stage. It would modifj' existing ideas considerably
anil convincing proofs will be demanded before it Ciin be
accepted.
Some writers take a middle ground, believing that the
Jilasma cells come in part from lymphocytes and in part
from connective-tissue cells.
The functions of plasma cells in other respects are
equally uncertain. It is to be notetl that they are not
distinctive of auj' jiarticular disease or class of diseases.
Their relative absence in acute suppuration is remark-
able. According to Councilman and .Mallory. they have
the power of ama'boid movement, they may occur inside
the blood-vessels, and may be seen in the act of emigrat-
ing fro!n the bloofl-vessels. It is doubtful if they pos-
sess phagocytic projierties. afid if so these are jirobably
not energetic.
Other ideas that have been proposed as to tiuar func-
tions are purely spi'culative. It has been suggested
that their iiceuliar staining (irojicrt}' is the expression of
diminished activity or degenerative changes, that it in-
ilicaf es an increase of activity, that it is due to their hav-
ing taken up el in ■matin from other and de.generated cells,
that they lia\-e some protective function, and that they
.serve to eliminate some unknown substance.
Tec'Iiniqik. — Fixation of tissues may be secured with
alcohol, corrosive sublimate, Zenker's fluid, formalde-
hyde, or Midler formol. Either parafliu or celloidin em-
bedding may be used. Various methods for staining
plasma cells have been proposed. Unna's alkaline or
polychrome methylene blue gives satisfactory results;
thionin or toluidin blue serves equally well. The plas-
ma cells may sometimes be stained with hannatoxylin.
The following formula, which is one of many given by
Unna. will be found serviceable: Methylene blue. 1 part;
jiotassium carbiinate. 1 ]iart ; distilled water, 100 parts.
Till' solution must sUind for ]ieriods varying from weeks
to months before il is tit for use.
Stain in the methylene-lilue solution, which may or
maj- not be diluted, fifteen minutes or longer. The sec-
tions will be overstained.
Rinse in water.
654
REFERE>X'E HANDBOOK OF THE .MEDICAL SCIENCES.
Piasnia Cells.
Plasniodlum ITIalarlte..
Decolorize in water to which a few drops of "' glycerin-
ether" have been aihleil, for a (niurlrr of a minute or
several minutes, as required, till differentiation of the
structure begins to appear (one-per-cent. acetic acid, or
alcohol alone serves nearly as well).
Rinse in water.
Complete the decolorization with alcohol.
Clear in oil of bergamot or .xylol.
By this process the plasma cells are stained blue-violet,
their nuclei and other nuclei and bacteria blue, the gran-
ules of mast cells violet to red. Epithelial cells take the
blue stain, sometimes iutensel_y, especially the horny
layers of the epidermis; giant cells are frequently stained
as well ; also the products of certain degenerations, as
amyloid and mucoid, which maj' show varying degrees
of metachromism. IlcrbiH V. WiUiiims.
The literature of this subject up to June, 19(J0, will be found in an
article by tbe present writer in the American Journal of the Medical
Sciences of the same date. The most important articles that have
since ii[ii.eareil are the following :
Aliiiki 1st : Arch. f. Dennatol. and Svph.. Bd. Iviii., 1901.
Askanazy : Centralhl. f. all?. Path., etc., Bd. xiii., IHte.
Beattie : Journ. Pathol, and Bacleriol., vol. viii.. p. l^'y.
Bosellini : Soe. Med. Chir.. Bologna. December, 1!«)I, Abs. Centralhl.
f. allg. Path., etc., Bd. xlii., UW-', p, 331.
Enderlen and Jusli : Deutsch. Zeitschr. f. Chir., Bd. l.\ii., 1901.
Friedlander: Arch. f. klin. Chirurg., Bd. l.i;vii., 1902.
Harris: Journ. Amer. Med. Assn., vol. xxxviii., 1903, p. 634.
Herbert : Journ. Pathol, and Bacteriol., vol. vii., p. 91.
Mallorv : Journ. Exper. Med., vol. v., p. 1.
Pappeiiheim : Virchow's Arch., Bd. elxv., 1901, clxvl., 1901, clxix., 1902.
Schlesinger: Virchow's Arch., Bd. clxix., 1902.
PLASMODIUM MALARI/E.— The protozoan parasite
which Lavrnin discovered in 1880 was designated by
Maichiafava and Celli Plasmodium malariit. The or-
ganism which is classified with the sporozoa has little
resemblance to the multinucleated amoeboid bodies to
which the term Plasmodium has been given by zoolo-
gists ; but even though unsuitable the binomial name, in
virtue of its priority, is applicable to the species to which
it was originally given. Observations inaugurated by
Golgi have shown the existence of three readily distin-
guishable varieties of parasite, each of which is capable
of pi'oducing malarial fever. The organism discovered
by Laveran and later studied bv ilarchiafava and Celli is
the aistivo-autumnal parasite which causes the most se-
vere type of intermittent fever, characterized bj' irregu-
lar periodicity and occurring most commonly during the
lat« summer and fall. That type of malarial fever which
recurs at regular intervals of two days is caused by a
closely related parasite which, nevertheless, presents such
well-marked peculiarities that it is usually regarded as
a distinct species. A third parasite causes the quartan
type of malarial fever, distinguished by paroxysins re-
curring at intervals of three days. If. in accordance
with the opinion of a few observers, it should be shown
that the three parasites associated with these various
types of fever ai'e varieties of a single species, the name
Plasmodium malaritcisa])plicable to this variable organ-
ism. In the present article, however, the organisius its-
sociated with tertian, quartan, and testivoautumnal
malaria will be described as separate species.
The pai'asites of the malarial fevers multiply within
the red blood corpuscles of their human host.' Recent
research has demonstrated that they are capable of de-
velo])ment within the body of certain suctorial insects,
which have fed upon the blood of an individual sutTer-
iug with malarial fever. A second individual is infected
by the bite of such an insect, which thus acts as an inter-
mediary host.
Geographical Distribution of the irnlarinl Piirnmte. —
The general and local contlitions which favor the occur-
rence and spread of malaria are such as conduce to the
extracorporeal existence of the parasite. The presence
of mosquitos capable of transmitting the organism is es-
sential to the endemic occurrence of the disease, so that
the geographical distrilmtion of malaria is in gi'cat part
dependent upon factors which aid the multiplication of
certain species of mosquitos.
In Africa, malaria prevails in its most pernicious form
on the west coast, especially in the neighborhood of the
Congo and Niger rivers. South of tin- Congo malai'ial
fevers become infrequent and disappear iii the most
southern part of the continent. Upper Egypt is free
from the disease, which occurs with gretit severity else-
where upon the Mediterranean coast. "
In Asia lualaria is prevalent upon the coast of Asia
Minor, Arabia, and near the Per.sian Gulf. Endemic
malaria abounds not only in the basins of the Indus and
of the Ganges, liut ujion the tableland of the Deccau.
In many of the East India islands severe malaria pre-
vails, but in the Philippine Islands, though the disease is
widely distributed, it is not particularlysevere. Perni-
cious malaria occurs in places near the coast and along
the rivers of China, but in Japan the disease is mild and
infrequent. Of interest is the almost complete immu-
nity enjoyed by Australia, New Zealand, and the islands
of the Pacific.
In Europe malaria prevails in the southern part of Rus-
sia, pai'ticularly ujion the shores of the Black ami of the
Caspian seas, along the shores of the Danube, and upon
the peninsulas bordering the ^Mediterranean Sea. In Italj'
well-known seats of endemic infection aie the plains and
marshes of the western coast, including the Roman Cam- •
pagna and the Pontine marshes. Here the disease is so
prevalent that it has been designated Rfouan fever, and
its frequency and severity in Italy have stimulated luuch
of the investigation which, since the discovery of the
malarial parasites, has explained the complicated life
history of these organisms. Northern Europe, including
the British Isles, is in great part free fiom malaria,
though there is evidence that at an earlier peiiod, par-
ticularly in England and in Denmark, it has occurred
with severity in regions where it is now almost wholly
absent.
In the West Indies, along the northern and eastern
coasts of tropical South America, and in Central America
malaria exists in its worst form. The disease is common
in the southern part of the United States near the Gulf
of Mexico and along the Mississippi and its tributaries.
It occurs near the Atlantic coast with gradually dimin-
ished severity as far north as New YorkT Elsewhere are
a few scattered localities where the disease is of mild
tyi'e-
Malaria is pre-eiuinently a disease of tropical and sub-
tiripical countries, but prevails with diiuinished severity
in many parts of the temperate zone. It is endemic in
certain localities, particularly near the mouths and along
the banks of rivers. In such localities tire found the per-
nicious types of fever caused by the ;estivo-autumnal par-
asite, while where the disease is less prevalent milder
types, the regularly intermittent tertian and quartan fe-
vers, are more common.
Conditions vhieh Favor the Occurrence of Malaria. — The
influence of temperature upon the occurrence of the mal-
arial fevers is well illusti'atcd by the picceding account
of its distribution. In the endemic foci of the tropical
and subtropical countries where mtUaria occurs in its
severest form the disease prevails throughout the year.
In the temperate zone as the poles aie approached its
frequenc}" and severity progressively diminisli witli the
temperature, and, according to Hir.sch, malaiial fever
iloes not occur in localities where the lueau summer tem-
perature is below 15" or 16° C, Even in tiopical coun-
tries its prevalence increases during the summer and
reaches a maximum about the beginning of autumn. In
tem|)erate regions the disease may be limited to the
warmer months of the year. The incidence of the dis-
ease in Baltimore, as described b_v Thayer, illustrates this
CI mdition. During Januai y and February malaiial fevers
are almost absent, but the gradually increasing number
of cases which occur during the spring and early sum-
mer are of the luilder tertian and quartan type. Double
tertian and triple quartan infections occur later in the
sinnmer, and the a'stivo-autumnal parasite makes its ap-
pearance. Cases of testivo-autu'mnal infection now in-
creasing in nunil)er fonn a vei'v large jiroportion of those
which occur during September and October, and then,
655
T'lnjiiiiiiuliiiiii
UEFKRE^CE IIAADl-iUOK UF T'.IK MEDICAL SCIENCES.
irnulually diminishing in uumVicr. linully disappear t-oni-
pletfly duriiig the wiutcr.
Ciiiifdrniatiou of the siiil ;iih1 its satiiiMlinii witli nater
have an iinportailee little inferiof to that ol heal in detef-
miuiug the loeal ineidenee of malaria. Slandins water
associated with abiindaut vegetation is always sugges-
tive of a malarious region, and the name |iaUidal or
marsh fever ilUistrates fhe well-reeognized relationship
between the disease and marshy regions. The geologi-
cal character of the .soil does not influence directly the
occurrence of malaria, hut is of iniiiorianceonly in so far
as it determines the saturation of the ground. Hence a
clay soil is favoiable to the disea.se. while a more porous,
chalky, or sandy s<iil is less able to retain water; au im-
pervious subsoil is especially capable of fidljlling this
condition.
Since saturation of the soil has such an imiiortant in-
flui'Uce tilJon the existence of the disease, the most mala-
rious regions are tlie low lying coasts and the marshy
l)aid;s of rivers and lakes. Land wliich is submerged
during a part of the year is believed to be particularly
subject to endemic infection. The amount of rainfall
has an important influence, and in tropical regions the
. disease usually reachis a maximum about the end of the
rainy season.
Altitude, with its inllnence upon drainage and tipon
tempeialure, allects the local occurrence of malaria so
that the severity of the disease lends to diminish as one
ascends above the sea level. Nevertheless, severe mala-
ria may be endemic upon higli plateaus and even in
mountainous regions, but here, according to Ilirseh, it is
the basiu-like deprcs.sions that are most markedl}' in-
fecte<l.
Cultivation and drainage of malarial regions have in
numberless iustanei'S been followed by the disajipea ranee
of tlK' disease, but occasionally an op|)osite result is pro-
duced and endemics of severe malaria ha\e followed the
elearin.g of such lands, Jloreover, outhi-eaks or exacer-
bations of the disease have followed exlensivi; excavations
of soil in making canals, railroads, and foitilir-ations. but
carefi'l examination of the attendaiU circumstances have
not infreijuently shown that such disturbances have in
various ways interfered with surface drainage.
Kecent observations having shown that the malarial
parasites pass a part of their life within the body of the
mosquito, it has become obvious that the previously de-
scril)e<l conditions tinder which the di.sease occurs are
.such as favor the multi]dicalion of these insects. Since
the (U'Velopment of the larval mosquito occurs in stagnant
water, jioorlj' drained lowlands and marshes alTord most
suitable conditions, and heat and abundant almos[)heri(:
moisture are favoring circumstances. No malarious re-
gion has been found to be free from these insects, hut on
the other hand it is not sur]nising that malaria does not
always occur whi'ie mosquitos abound; for in the tlrst
place, as will lie ]iointcd out later, only mosipiitos of the
genus Anopheles have been found to transndl I he disease;
and in the second place, the malarial iiarasite may not
have found its way into a lo(ality win i-e mos(|iiitos of
this genus i)r<'vail. A correspondence exists betweeit
the habits of the mosquito and the seasonal incidence of
the di.sease in temperate climates. With the beginning
of winter many mos(|uitos are killed while a few hiber-
nate. In the spring tliosi' that survive lay their eggs
upon sta.gnant ponils and continue to nuiltiply during
the warm season. Marehiafava and Hignami stale that
duri:ig the fall mosqtiitos, many of which are iid'ected,
seek sludter within the liouses, thus explaining the fre-
(|uency of infection at thistime and thcoccasionaloecur-
reiice of house; epidemics.
Even slnnild mos(juitos of the genus Anopheles and
malarial jiarasites coexist in the srme locality, external
conditions will determine the pirevaience of tiie ilisease.
Investigations of the Italian observers have shown that
the parasites within the mosquito develo)i best at a tem-
perature between 2(1 anil HO C, but at I ( to 1.") C. de-
velo|jment does not occur. This fact accords with the
observation previously mentioned, that malarial fever
does not occur as one passes from the equator beyond an
isotherm at which the mean summer temperature is be-
low 1.') to 10° C, (W- to 00.8° Fahr.).
Metltiidbn which the Miiliin'iil I'lirnsi'te Enters the Bndy. —
Before Ihediscovery of the malarial parasite, two theories
explaining the mode of malarial infection were much dis-
cussed. It wss believed that the coutagium causing the
disease entered by one of two possible paths; either (i)
by the digestive tract, being ingested with water, in
which the infectious agent was thought to have its natu-
ral habitat; or (2) by the respiratory tract, being breatlied
in with the air.
Clinical evidence has been adduced to show tliat the
disea.se is a water-borne infection. Supporters of this
theory cited instances in which, of two neighboring com-
munities, each using a different water su])ply, one was
subject to malarial fever while the other escaped. It was
Ijclieved that boiling of drinking-water was an etlicient
prophjiaetic measure. Such claims are found to have
been based upon insutlicient evidence, and in individital
instances the dilliculties of diagnosis between typhoid
and malarial fevers were not clearly recognized. " In re-
cent years Italian observers have attempted to infect in-
dividuals with drinking-water obtained from localities
well known to be malarious. Celli failed to infect indi-
viduals in Rome by the repeated administration of water
brouglit from the Pontine marshes, and Zeri obtaineii
similar results in a considerable number of experiments in
which water from malarious regions was administered
in large quantitj- to healthy subjects.
Certain clinical facts favor the altemate theory of air
infection: for example, the well-known danger (if infec-
tion after exposure to the night air in a malariof.s di.s-
trict may be cited. The eontagiuiti was believed to Iiave
its home in the water and in the soil of marshy malaricnis
districts, whence it found its way into the air and was
inspirj'd by those exposed. Since the discovery of the
malarial parasites numerous efforts to discover some
phase of these micro-organisms in water or in the soil liave
proved futile, while tiie hypothetical means by which
such bodies might reach the overlying air was dilhcult
to conceive. 3Iorcover. certain well-known fads ai'e
incomiiatible with this theory; for example, prevailing
winds iiave little intiuence upon the spread of infection
from an endemic focus, and the fact is fi'equently cited
that uijon vessels anchored off a malarial coast only
tho.se individuals become infected whose duties carry
them ashore. This thc-ory of air infection, unsupported
by any convincing evidence, is now abandoned, since ac-
cumulating evidence has demonstrated that the malarial
parasite is transfericd from one individual to another by
a sin-torial insect, within which the micro-organi.sm passes
one .stage in its life history.
!Manson, in 18TS, showi'd that Filaria hanerofti is car-
ried friiin one human host to a sec<md Ity the mosquito;
Tlieobald Smith has shown that Texas fever of cattle is
inoculated by a species of lie. These important discov-
eries have pointed the way to a clear recognition of the
method by which the malarial parasites enter the human
body and ba\e helped to explain its life history outside.
The solution of these diflicult problems has received
much aid from the studies of parasites which, occurring
within the re<l blood corpuscles of liirds. are so closely
related to the malarial parasites that by some observers
tliey have been regarded, doubt less erroneously, as identi-
cal species.
The possibility that malaria might be transmitted by
tlu' mos(|uilo had been suggesteil long before the mala-
rial parasites were discovered and the fact had been recog-
nized that localitic's and conditions favorable to the dis-
ease are such as I'nrther the multiplication of this insect,
^lanson, in 1S|)(1, lironght this theorv into prominence.
Bignami subsei|uenlly published a considerable amount
of evidence to show th.it malarial infection occurs under
conditions which favor the attack of mosquitos. When
the wind blows on the Roiiian Campagna, he say.'', mos-
(piitos liiih- elosi' to the giMi'ud or beneath the trees and
are transportc<l little if at all from the locality in which
656
UEFERENCE IlAXDli(JOK OF THE .^rEDlCAL SCIENCES.
PlaKtixKliiini
ITIalarUf.
tlieiv '.arviv (Icvelop. Wlicn tlio ■wind goes down at sun-
set, tli(! insects rise; in great nunibcrsiind iittack nun ;uid
beasts. Tlie well-fecognized danger of inl'ection during
the night is (hie to tile nocturnal habits of tlic niosiiuitn
and is increased by sleeitiug iu tlie open air. Jhiiiy of
the precautions whicli are talien by tlie iuliabitants of
malarious districts to ward olf the fever are such as pro-
tect them fi'oin the attacks of insects. Ou the Pontine
marshes relative protection is afforded by cievating
dwellings on platforms six or eight feet high, for the
insect tends to fly close to the ground.
Ro.ss, working in India, lias shown that the parasite of
birds which is closely related to the malarial organism
undergoes a series of developmental changes within the ^ insect,
Irody of the mos-
quito, and subse-
quently fouud
that mosquitos
which had bitten
infected birds
were capable of
transmitting the
parasite to others
wliicli repeated
examination had
proved to be
healthy.
Grassi, in 1808,
undertook a la-
borious investiga-
tion of the species
o f m OS q 11 i t o s
found in malari-
ous regions of
Ital.y. and came
to the conclusion
that certain spe-
cies are constantly
present in districts of endemic infection. Where mal-
aria prevails Anopheles elaviger and other species of the
genus Anopheles are abundant, while in uon-raalarial
regions, though species of the genus Culex abound, he
found the genus Anopheles unrepresented.
Direct proof of the agency of suctorial insects was
finally brought by experiments of other Italian observers.
Bignami brouglit to liome mosquitos belonging to the
genera Culex and Anopheles, obtained from a mai'shy
region characterized by the severity of its malarial fever.
An individual who had never suffered with malaria slept
in the room in which these insects were liberated, and
was exposed to their at taels. during more tlian a monlh.
At the end of this time he became ill, sulTered with chills
and fever, and in his blood was found the parasite of
ajstivo-autumnal fever. In three subse(iueiit experiments
performed upon individuals who had never suffered with
malaria, fever caused by the tertian or a'Stivo-auttimnal
parasite was produced by the sting of Anopheles elaviger
obtained from malarious localities; in every case recov-
ery followed the administration of qttinine.
In one of these experiments, insects, obtained, to lie
sure, from a malarious region, were allowed to sting a
patient suffering with a'stivo-auliinuial fever. Subse-
quent examination of some of these mosquitos showed
those developmental phases of the panisilc which will be
described later. Three such mosiiuitos, of which two
were later fouud to be infected, were allowed to sting a
health}- man. After an incubation period of from nine
to twelve days, uncertainty being due to repeated expos
lire, fever of an irregular type ensued and the a'Stivo-
autumnal parasite was demonstrated in the blood of the
infected individual. It has lieen urged that these exjieri-
ments were conducted in Rome, where malarial fevers
are not uncommon. In order to meet this objection, Big-
nami sent to England where malaria rarely occurs, mos-
quitos infected with the ]iarasite of tertian fevrr. P.
Manson, Jr. , who expo.sed himself to the sting of these
insects, suffered a mild attack of tertian fever.
Demonstration that the parasites of malarial fever and
Vol.. VI.— 13
the related organisms of birds undergo a iieculiar process
of development within the body of f la^ mosquito, lunpli-
lies and contirms the experimental results just cited.
I'(in(f:ik's if the Miilariid F(ren<. — The micro-organisms
which cau.se nialaii.il feveis belong to the group of spo-
rozoa known as Ha-mosporidia. Recent observers have
sliowii that they undergo two cycles of development:
(1) One occurs within the human body where the organ-
ism, developing within the red blood corpuscles and
muliiplying by an asexual process, causes malarial fe-
ver; (2) parasites ingested by the mosquito when it
attacks an individual suffering with the disease under-
go a second cycle of development in the body of the
This second stage in the life history of the organ-
FiG. 3s;i0.— Parasite of Tertian Fever. (After Maretiiafuva aud Biguauii.)
ism is jireceded by a process of fertilization which occurs
ill the stomach of the in.sectand terminates by division of
the parasite into a great number of reproductive bodies
Golgi showed that the parasite which causes regularly
intermittent fever of the quartan type differs nioriiliologi-
cally from that associated with tertian fever. Both the
tc'i'tian and the quartan organism within the human body
develops in great groups, all members of which are at
any given time in the same jdiase of development. The
jiarasite of quartan fever completes its cycle in seventy-
two liours, while the parasite of. tertian fever repeals
its cycle every forty -eight houi's. It was subse(iiiently
shown that the organism present in those severer forms
of malarial fever which prevail in the late summer and
in the autumn months have distinctive peculiarities. In
harmony with the irregularly intermittent course of the
fever the parasite does not present the regular jieriodic-
ity which characterizes thcflevclopmcnt of the other two
varieties. Some observers have claimed that even among
the parasites producing the-irrcgular or a'Stivo-autumnal
type of fever two varieties may be distinguished, but
tile distinctions which they em])Iiasize arc not sullicieiitly
marked lo establish the existence of more than one a'sti-
vo-autumnal parasite. Jlost oViservers recognize the
existence of three distinct species of parasite: not only
are dilierences observable within flic human body, but
during their development within the nios(|uito as well,
niorpliological characteristics serve to identify the three
varieties.
For the purpose of clinical diagnosis tlie malarial yiara-
site is best observed in thin lilnis of freshly drawn blood.
.Aliich atteutitm has liecu given to the study or the ]iara-
.sitfc fixed and stained by a variety of met hods, in great
part modifications of that used by Komanowsky. who
employed .a mixture of eosin and methylene blue. The
body of the organism stains blue, while its cliromalin
substance takes a lilac color. 'Wright has recently so
modilied this method that it may be used for the purpose
of clinical diagnosis.
The Puranite of lei-tiiin Ferer. — The earliest phase of
(15 T
PlasiiKtdliini
lllnlariir.
refehencp: handbook of the medical sciences.
tin- pniasitc. Fig. 3ti2lt (1 'Uid 2), found witliin (lie red
blor.d rc'll is rt'presi'Uti'd by u iiiinulc clear body, oftcu
circular in outline, with a diameter about oue-fourlh that
of tlic corpuscle. Active anui'boid movemeuts are reaii-
Fin. :i.S21.— I'iiiiisili' (if (.uiartan Fever. (After Marcbiat;na ami Bignami.;
ilv observed, and the pnicesses which are jirotruded often
give the body a very irregular oulline. The li\'aliue or-
ganism may temjiorarily assnme the appearance of a ring.
This phenomenon is ajiparently due to the fact that the
centre of tlie <Iis(Nshaped body, becoming for a time thin-
ner than tlie ])eriphery, is lost to view.
As the organism becomes larger one or more particles
of yellowish-brown pigment formed from the h.'vmoglo-
bin" of the containing corpuscle appear witliin its sub-
stance, Fig. 3S3(1 (3 to 10). These granules, which have
an active dancing movement, increase in number and
size as the organism grows. At the end of twenty-four
hours the parasite (ills from one-third to one-half the red
coriniscle. the latter showing certain changes as the re-
sult of its presence, being larger and paler than the
neighljoring nnall'ected corpuscles. The young forms
exhibit active amceboid movements, which with further
growth become less conspicuous. At the end of about
forty-eight hours the organism has reached its full size,
about that of a normal red corpuscle, and is ready to
undergo the process of segmentation. The parasite.
Fig. 3820 (13 and 13), having assumed a circular out-
line, the pigment granules collect into a clump, often
a solid block, wlncli usually lies in the centre of the
bod_y. The organism acquires a ileuse opaque appear-
ance not observable in the amctboid stage. Refractive
dots may be seen near the periiihery, occasionally in the
more central portion, and radial striations extending
inward from corresjionding indentations at the margin
appear lietween the refracti\-e )i(jints. The striations
represent lines of sejiaratiou which divide the body into
segments corresponding in number with the refractive
dots; very frequently thrre is formed a ]ieripheral circle
of segments, within wliicli. nearer to I he central jiigment,
is a second group. These bodies, numbering twelve to
twenty '»' even thirty, assume a circular outline, the
aggregation being still surrounded by a pale, very incon-
spicuous yellowish rim, the remains of the much-en-
larged anil decolorized corpuscle. Fig. 3820 (11). Fi-
uallv, this ruptures and sets the bodies free in the plasma.
Fig.' 3820 (14 to Hi).
As previousl_v mentioned, all the members of a group
si'gment at ap]U'oximately the same time. During a pe-
riod of about three hours before the chill, the tempera-
ture rises gradually and .segmenting bodies can be found
in the blood. During the chill and with the beginning
of the hot stage, tlicy aie lueseiit in greatest number.
It seems probaljle that a toxic niatciial is set free when
tae parasite segmeiiis and that this toxin causes a febrile
rcactiim. Occasionally twogroujis of parasites arc pres-
ent in the same blood and dotiblc tertian fever results.
The two groups undergo segmentation on alternate days,
and at any given time parasites in two phases of devel-
opment are discoverable in the blood,
lu addition to the full-grown jiarasites which undergo
segmentation are even larger bodies situated within en-
larged pale corpuscles. Since they do not dividi' to form
reproductive segments, they were at one time regarded,
in part at least, as degenerate forms. Some of them ex-
hibit the remarkalile phenomenon known as llagellation.
Fig. 3820(1!)), and 1 heir signiticance will be subsequently
explained in describing this process.
Certain details of internal structure not observable iu
the liviug organism
6 6 may be stutlied in
stained specimens. In
preparations treated
with eosiu and methy-
leue blue according "to
the method of Roma-
uow.sky, the existence
of nuclear material
ma\- be demonstrated.
In such specimetis
young hyaline forms
exiiibit an external
zone of blue color, the
central part remaining
unstained. Situated near the periphery of the body, at
times encroaching upon the unstained area, moi'e rarely
wholly surrounded by it, is a compact round or oval
body which takes a deep lilac stain. As the parasite
grows the chromatin becomes less compact and, accord-
ing to Ziemann. takes on the appearance of a collection
of fine tilaments. When the organism has attained its
full growth, this mass of material divides to form a
variable number of irregular chromatin bodies, and when
division is complete each mass assumes a round com-
pact outline and is surrounded by an achromatic zone.
Changes now take place in the cell protoplasm and re-
sult iu the separation of the body into a corresponding
nuiuber of segments.
17ti' Punisiie of Quartan Ferer. — The quartan, like the
tertian inirasite. pursuing its development in great
groups, all members of which are in the same phase at
any given time, repeats its cycle iu seventy-two hours.
As with the tertian organism, the malarial paroxj'sm is
simultaneous with the process of segmentation, and,
when the result of an infection with a single group, oc-
curs every fourth day. When more than one grouji are
present, they reach maturity on diflfereut days, the mem-
bers of two groups uever undergoing segmentation on
the same day. When the blood is infected with three
grovips paroxysius occur daily.
The quartau parasite resembles closely the organism
of tertian fever; nevertheless, certain dilferential pecul-
iarities can be noted. The ama-boid liyaline bodies Fig.
3821 (1 and 2) are indistinguishalile from tho,se of the ter-
tian parasite, liut with increase of size and the acquisition
of pigment Fig. 3821 (3 to 9) the characteristic features
become evident. The pigment of the quartan organism
occurs in coarser granules having a deeper luown color.
The body of the para"site has a more refractive appear-
ance and its out line within the corpuscle is much more dis-
tinct: theamieboid movements are much less active, and
as early as the second day they almost or completely cease.
The changes ju'oduced in the containing red corpuscle
differ from those caused by the tertian organism; the
corpuscle is not swollen and decoloiized, but becomes
somewhat shrivelled and assumes a deeper color of a
greenish copjier-like hue. As the parasite increases in size
the surrounding rim of the corpuscle becomes smaller, and
at the beginnin,g of segmentation, about ten hours before
the paroxysm, though present, it is almost imperceptible.
The pigment F'ig. 3821 (10) collects toward the centre of
the body, and in doing so usually assumes a radial ar-
rangement not seen in the tertian organism. The seg-
ments are fewer in number, often not more than from six
to ten, and are arranged regularly in a single row about the
central pigment tnass. In stained specimens the details
of structure i)reviously described for the tertian jiarasite
are ol;served and the same division of the chromatin sub-
stance is found to precede segmentation.
T/ii' Parasite iif ^f'stini-diittniniiil Firer. — The severer
forms of malarial infection, including those presenting
pernicious symptoms, are caused by an .irganisin which
differs in sexeral important particulars from those pre-
658
REFERENCE HANDBOOK OF THE IVIEDICAL SCIENCES.
Plasniodfiini
Malaria-.
viou.sly (Icsciilx'd. Since, as already mentioned, its de-
velii|)ment, unlike that of the tertian and quartan para-
sites, does not take place in great groups, of which the
menihers mature at approximately the same time, its
cycle cannot be followed witli the same readiness. And
in accordance with this irregularity of development the
symptoms of the disease do not present the same period-
ically paroxysmal character observed in tiie other two
types. .Moreover, the parasite of the irregular fever does
not undergo its whole development within tlie circulat-
ing blood, and all stages of growth cannot be observed in
specimens obtained in the onlinary way. lu the blood
from the peripheral circulation only the yoimgest forms
are fonnd, the subsequent development taking place in
the internal organs. The more mature organisms tend
to accumidate in the spleen and bone marrow, possibly
becaiise. as suggested by Bastianelli and Bignami, the
red corpuscles being profoundly injured by the contained
parasite act as foreign bodies and are taken up by the
cells of these organs. The alweuce of definite groups
and the dilliculty of following in the peripheral circula-
tion the process of maturation through all its stages
have made it impossible to determine as yet the duration
of the cycle of development. Certain ob.servers believe
that it lasts two or three days, or even longer.
The youngest intracorpuscular form of the parasite,
Fig. 3833(1 to 7), is represented by an ama'lioid organ-
ism resembling the hyaline bodies of tertian and quartan
fever; it is, however," somewhat smaller and has a greater
tendency to assume a ring-like form. Such a parasite may
be seen to assume alternately a ring shape and an amre-
boid form. With further
growth pigment granides
are acquired, and occa-
sionally one sees in the
blood from the peripheral
circulation a small body,
one-tifth tlie diameter of
the red corpuscle, con-
taining one or two minute
granules of dark brown
pigment. Larger pig-
mented forms are only
very rarely fcninil in the
peripheral circulation, so
that the later stages have
been studied mainly in
specimens of blood aspi-
rated from the spleen. As
the parasite groAvs the
pigment increases in
amovmt, but does not be-
come so abundant as in
the tertian and quartan
o r g a n i s m s. I n d e e d,
Marchiafava and Celli
have described instances
in which the parasite at-
taine<l its full growth
and underwent segmenta-
tion withovit any forma-
tion of pigment. The in-
vaded corpuscle takes on
a greenish brassy color,
and wrinkling and crena-
tion may be observed in
corpuscles containing
even the smallest hyaline
boilics. The full-grown
forms. Fig. 3833(17 to 19),
vary considerably in size,
often exceeding i'n diameter one-half that of the contain-
ing red cell. The pigment collects into a clump. Fig.
3832 (Fig. 21 to 33), "and is finally caked into a soliil
block, us'ually situated near the centre of the body. The
organism acquires a refractive waxy appearance and di-
vides, in a manner similar to that exhibited by the tertian
organism, into from eight to sixteen segments, Fig. 3833
(34), which are finally set free in the plasma by the rupt-
ure of the containing rim of the corpuscle. In stained
specimens the existence of chromatin resembling that
of a tertian parasite can be demonstrated; it undergoes
the same division and arrangement previous to segmen-
tation.
In the blood of patients suffering with a?stivo-autum-
nal malaria are foimd bodies not present with the regu-
larly intermittent types — the crescents and ovoid bodies
described by Laveran. The crescentic bodies. Fig. 3832
(36 to 38), present in the blood after the fever has lasted a
week or more are longer than the red blood corpuscles,
somewhat more than half their diameter across, and with
very refractive protoplasm. A pale yellow rim project-
ing in bib-like form (38) from the concave side of the
crescent surrounds the organism ; this represents the re-
mains of the corpuscle in which the body develoiied.
Pigment, usually present in considerable quantity, is
cither distributed throtighout or collected into a mass
situated near the centre. The ovoid bodies, Fig. 3822
(34 and 35), differ from the crescents oulj' in shape. Early-
stages, Fig. 3823 (28), in the formation of these bodies are
found, and they reju'eseut transitions from the youngest
forms of the ordinary cycle. Becoming fusiform, they
develop in the red cells, and, as thej' exceed in length
the diameter of the corpuscle, become bowed iu oider to
accommodate themselves to its shape. Their signiticance
has been much disputed, but, now understood, will be ex-
plained iu describing the proccFf of flagellation.
FlagdlaHon. — The very remarkable phenomenon of
flagellation is observable in fretluv drawn bloocl. With
Fig. 3823.— Parasite of ^Estivo-Autumnal Fever. (After Man-liiatava and Bisnaml.)
tertian infection, within a week after onset of the disease,
large spherical bodies, which do not ,segment, are pres-
ent°iu the blood. The periphery of such a body in a
specimen of fresh blood now nnsurrounded by a rim of
corpuscle is seen to undergo violent undulation, when
suddenly there appear one or more thread-like filaments
which lash about so actively that their outline is distin-
659
PlafoiiKMliiiiii llalarlir.
Plasiiiorrlicxis.
REFERENCE HA>iI)BOOK OF THE MEDICAL SCIENCES.
guislu'd with difficulty. Fig. 3830 (19). A tlagellum
willi H (•lub-like cnUirgfrnciit at one (/nd not infix-qvicutly
sepunites from tlie puront body iind tlonts away in tlie
jila-snia witli an active undidalory motion. It lias lu-cn
sliown that tlie tlagella contain paitof theclifomalin sub-
stance. All the c-Xtraccllular boilies observulilein freshly
drawn blood do not undergo flagellation.
With the ((uartan iid'eclion a sinu'lar process is ob-
servalile. Flagellate bodies, however, are encountered
■with much less freipiency than in eases of tertian fever.
In cases of a'stivo-aiitiimnal fever it is the crescents
Fig. ^S2.3.— Diajrniiu Slunvin^ tlie t.ife History of ttie Aviau Parasite.
Proteosoma. 1 to -l. I)evelopmt'nt of tlie imrasire within the lilooil
of the ItU'il ; 4. ]!u*ro;;oitt*s ; .'> and (i. Kiael'niraiUHte ; .')(( and Of(. ini-
ciog.'iiiic'toeyte ; 7. ferntizalioii ; s lo 111. toiinaiinn and luatiuatioii
of ooevsts ; 11, spoi'oiioiu;. (After Grass! from Ltihe, C'cxt. /. Bakt.y
1903. .\xvli.)
which undergo fliigelhition. In a sjtecimeu of fresh
blood some of these liodies retiiain unchanged or merelj-
assiiiiiea I'ouiid oi- oval f(jrni; but others, after becoming
spherical, e.xtnide actively motile tilaments which may
become detaclied from the parent body.
The signiticauce of tliis iihenomcnou has been ex-
plained by the study of a closely related parasite, Ilal-
teridiuin dauilewsUy. wiiieli occurs in the blood of many
birds. This organism, wliich develops within the red
blood corpuscles as a semilunar or halter-shaped body
curved alongsidi' the nucleus of the containing corpuscle,
like the malarial parasites forms pigment granules from
the luemogloliin. Opie showed that the parasite may
assume two distinct forms, either of which when fully
grown becomes free in the ]ilasma after the blood is
drawn. With one form the protoplasm is gi'auular and
stains deei) blue by the method of Roiuanowsky ; the
nucleus is small. The other form, somewhat larger thiiu
the liist, is characterized by the |iossession of a very
large nucleus and scant protoplasm which stains with
dilTiculty. The supposition that this form alone under-
goes flagellation has been confirmed by MacCallum, wiio
has demonstrated the occurrence of a remarkable phe-
nomenon. Flagella break from the parent body and
make their Wiiy to the granular boihes which have be-
coiue extracelluhir. Several flagella may collect about
sruh a bod_v and bciit against it with active lashing move-
luents. One llagellum Anally projects itself into the
substance of the body, with wliich it becomes merged.
The process is to be regarded as one of fertilization;
the granular body with small nucleus is the female ele-
ment, or, according to zoological noiuenclature, the ma-
crogamete: the flagellum is the male element, nr micro-
gameti', its parent body being designated by ihi' term
microgametocyle. The fertilized body lemains quies-
cent for from lifteeu to twenty minutes, when it assumes
an elongated form and becomes capable of verv active
jirogressive movement, constituting the pseudo-vermic-
ulus described by Dauilewsky.
Flagella-formatiou observable with the three varieties
of malarial parasite doubtless represents a similar proc-
ess of fertilization, though onl_v in the case of the
iestivo-autumnal piirasite has the i)heuoineiiou been act-
ually observed. With both the tertian and the a'stivo-
autumnal forms morphological diflercuces have been
established between the microgametocyte from which
arise flagella or microgametes and the macrogamete
which undergoes fertilization. With the a-stivo-iuitum-
ual parasite those crescents which do not flagellate, like
the analogous macrogamete of the halteridiiun, .stain
more deeply and are granular. The fm-mation of a body
similar to the pseiido-vermiculus of birds has not been
ob.served.
Life I/ixtiin/ tif the Malarial Pdrasiies in the Bodi/ of
till- Miisf/iiito. — Stud}' of the parasites in birds has liere
again pointed the way to an understanding of the life
history of the malarial orgauisms outside the human
body. Koss. working in India, directed his attention to
the extracorporeal development of the aviau jiarasite,
Proteosoma grassi, because at tlie time cases of malarial
fever were not available. Observations of jMau.sou upon
the develc>|>meiit of filaria in the body of the mosquito
suggested the agenc}' of these insects. Ross proved that
the mosquito can act as an intermediary host in trans-
ferring infection from one bird to another, ;ind showed
that llie piartisile develops within the body of the insect.
The jiroeess of flagellation occurs with much activity in
the middle intestine of an insect which has fed upon the
blood of an infected bird. The flagellum or macro-
gamete unites with the microgamete, and the so-called
p.seudo-vermieulus wdiich results, endowed with active
motility, makes its way into the wall of the mosquito's
intestine, wdiere it becomes encapsulated and dividesinto
ii great number of minute bodies designated sporozoites.
The latter, after rupture of the containing capsule,
Anally reach the .salivary glands of the insect and hence
may be injected into a second bird, there to undergo
asexual multiplication.
In mosquitos which had fed upon tlie blood of indi-
viduals infected with tertian and a'Stivo-autumnal mala-
ria, Ross found lugmented bodies similar to those which
he had di.seov<-reil in mosquitos. Bignami, Bastianelli,
and Grassi have extended these observations iind have
shown that the tertian, quartan, and a'stivo-autumual
jiarasites pass through similar changes within the body
of moscpiitos of the genus Anopheles.
An insect of this genus confined in glass test tubes is
allowed to feed uiioii the blood of patients infected with
malarial fever. The mo.squito is .so voracious that it
stings when the mouth of the tube is applied to the skin
of the jiiiticnt. It is then kept couflned in a larger ves-
.sel at a temperature of 20'-o0' C, and is supplied with
abundant moisture and vegetable matter for food. The
parasite in the insect is studied after varying pieriods, in
the intestinal wall and in the .salivary glands, prepared
by delicate teasing and examined in salt solution. Sec-
tions of the insect hardened and stained for micro.seopic
examination give additional information.
With the tertian ])arasite fertilization of a macroga-
mete by a flagellum (microgamete) doubtless occurs,
though the process has not beeu actuall}' observed. Dur-
ing the second day after the insect has fed on malarial
blood pigmented liodies can be found in the muscular
walls of the intestine. Grown to twice the size of a red
blood corpuscle, they are sharply outlined and jjosse.ss
homogeneous or vacuolated protoplasm. In stained
specimens the chromatiu substance is found to have in-
creased in aiuount and may have undergone division
into severiil small ma.s.ses. Increasing in size, the jiara-
site acquires a refractive capsule, and on the third day
its eonleuts have divided into a varying number of small
bodies, each containing a jiart of the chromatin sub-
stiince: between these lie the pigment and a small
amount of undivided cytoplasm. This cyst-like body
6(50
REFERENCE IIAXDBOOK OF THE 5IEDICAL SCIENCES.
Plasntodlnm Malartse.
PIasuiorrliex2s.
increases in size and witliiu it is formed an increasing
number of small bodies. Finally, on the si.xth day, the
])arasitc, \vliich has grown lo such size that it projects
into the body cavity of the insect (compare Fig. 38'2.")
showing Proteosoma of birds), contains a great number
of slender bodies with pointed e.xtreraities, sporozoites.
Fig, 382.5 {C) each containing a particle of nuclear sub-
stance demonstrable only in stained specimens; they are
arranged in groups side "b.y side. The containing capsule
ruiitiu-es aud the sporozoites are set free in the body
cavity, whence the}' make their way to the salivary
glands of the insect. Should a mosqinto so infected
sting a human being, parasites are iniccted with the irri-
tant Huid secreted by the gland. Develojnng within the
red blood corpuscles, the organism now Ix-gins in its new
liuman host the asexual c_ycle of development with which
is associated tertian malarial fever.
A few observations have shown that the quartan para-
site passes through a series of phases corresponding to
those just described, but when mosqintos are allowed to
sting patients suffering with quartan fever, in onl}' a
smaTl proportion of the experiments are develo|)mental
stages of the parasite obtained. The small luimber of
flagellate forms observable in the blood of jiatieiits suf-
fering with quartan infection may explain this fact as
■well as the relative infrequencj' of tin's type of malarial
fever.
The development of the ncstivo-autumnal parasite in
tlie mosquito may be readily observed. On tlie seventh
day after the mosquito has stung a patient infected with
the disease, cyst-like bodies project into the body cav-
ity of the insect and are filled with sporozoites, which,
though more numerous, resemble those of the tertian
par.isite. Even before sporozoites are
formed, tlie a;stivo-autumnal parasite • ; .■ . i .
is recognizable b}' the cliaractcr of its
pigment and by the high refraction
of its cytoplasm.
Terms in general use bj' zoologists
liave been introduced to designate
various phases of the asexual genera-
tion of the malaiial parasite in man
and of its sexual generation in the
intermediate host, the mosquito.
Some of these have been mentioned.
The microgamete or flagellum, de-
rived from the microgametocyte or
flagellate bod\', unites with tlie more
grantdar macrogamete, and as the
result an oocyst is formed within the
stomach wall of the mos-
quito. Division of cyto-
plasm preceded by nuclear
division gives rise to a
great number of nucleated
bodies known as sporo-
zoites. The latter, inject-
ed by the mosquito, are
capable of transmitting ma-
larial infection, since they
are capable of development
within the red blood cor-
puscles of their human host.
Reaching a certain size, the
intracorpuscular parasites
divide without preceding
fertilization into a variable
number of bodies, which
may be termed merozoites,
each capable of re-entering
a red blood corpuscle and
undergoing tbe same proc-
ess of multiplication. A
certain numlier of merozoites. however, are not destined
to multiply by such asexual division, but give rise to
macrogamete or microgametocyte as alreadj' described.
By union of the male and female elements within the
Stomach of the mosquito is formetl a body which is
capable of development in the intermediary host. An
analogous alternation of asexual and sexual generation
occurs with other protozoan nucro organisms, notably
those belonging to the order Coccidia. Asexual repro-
duction is the means by which a few parasites which
t
.it*'
IS;:'-..'*,, '"r-"^V '^
'-*!^S:^,
Fig. 383.0.— Oocysts ct Proteosoma In the Wall of the Middle Intpstine
of the Mosquito. (After Ros.s from Liihe.)
have gained entrance multiply in the new liost. In tiie
case of the malarial parasite, relatively few organisms
injected by the mosquito multiply to form the great
number characteristic of the malarial fevers.
Eiifjeiie L. Opie.
PLASMOLYSIS is tbe term used in a general sense to
denote tlie disorganization of the achromatic part of the
cell, in opposition to l-ini/nli/ftia, which is applied to the
complete disorganization of the nucleus. Achrinniitolyf-is
is, accordingly, used as a synonym for plasniolysis. 'J'he
word plasmolysis, having been introduced by a number
of investigators working along special lines, is frequently
used in a more narrow sense to indicate the destruction or
degeneration of the protoplasm of
. .,^ : -;- " ■ certain forms of cells. Thus, for ex-
ample, plasmolysis is by a large num-
ber of writers applied only to such
changes in the red blood cells, and
is fised interchangeably with erythni-
(•//tnh/isis. In this condition the solu-
ble substances of tlie red cell escape
into the plasma so that the red cells
become smaller (microcytes) or come
to consist only of the outer envelojie
(red cell shadows). Through the im-
bibition of fluids such cells may be-
come swollen, Gi'awitz uses the
term to indicate solution of the n>d
blood cells and the production of
ha'moglobin.Tmia. In the case of
nerve cells, pla.smolysis is applied to the
simplest disorganizing changes in the achro-
matic part of the cell. In the case of bac-
teria, plasmolysis is used to indicate the
formation of clear sjiaces beneath the cap-
sule, due to the shrinking of the plasma, as
may be observed in bacteria held in a salt
solution, Altlrtd Sci'tt \V:irthin.
-yd..^^
\
* Si
;y
y
Fic. 3S24.— .4, Parasite of .■Estivi
Middle Intestine of Anopheles;
the oocyst; C, ripe sporozoites.
PLASMORRHEXIS is the tciin applied to
processes of disorganizatipu
in the protoplasiu of the
cell, in opposition to Imrynr-
rhe.ru. which is used to de-
note similar processes in
the nucleus. By the ma-
jority of writers jilasmor-
riiexis is applied to th<>se
changes as occurring in the
red blood cells alone, and
the word is used as a syno-
nym for (rythrorytiirylu'iia.
The jirocess is characterized
by the formation of small granules or globules in the jiroto-
piasm of the red cell, and the escape of these from the
cell ; or the formation of minute jiricklesor globules over
the surfaceof the cell, giving it anapjiearanceof a goose-
berry or mulberry ; or th<: formation of variously shaped
-autumnal Fever in the Wall of the
Ji, formation of sporozoites within
(After Gnuisi from LiUie.)
661
PlasMioschlsls.
Pleurisy.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
jirocossps. Plasniori'hexis may be regarded as the stage
immediately precoiliua; iilasmoschisis.
AldredScoU Warthin.
PLASMOSCHISIS.— Tlie partial or total disorganization
of the cell through fragmentation or splitting of its pro-
toiilasm. It is characteiized by the snaring off of the
processes developed through plasmorrhexis, and the
formation of round, oval, disc-like, angular, or thready
bodies, which may be homogeneous or granular; or bj'
tlie separation of the protoplasm from the nucleus. The
term is used, particularly with reference to the disinte-
gration of the red blood cells, as a synonym for cryf/iro-
eytoschids. It is believed b.v many investigators that the
blood plates are nothing more than speciidly formed prod-
ucts of the plasmorrhe.xis and plasmoschisis of the red
blood cells. Ahlrcd ,Scvtt WaHhin.
PLASTIC SURGERY. See Reparative Surgery.
PLETHORA. See Cireiilation. Pathology of .
PLEURISY.— The pleura may be the seat of various
forms of inflammation, some of wliich are only a part of
a general inflammation involving the tissue of the lung,
as in pneumonia, tuberculosis of the lung, and emphyse-
ma of the lungs, and some of which involve the pleura
without di.sease of the lung.
A pleurisj' may be primary, or it may be secondary to
disease of the lung, or to soun' general disease, as chronic
nephritis or rheumatism.
The different forms of pleurisy may be conveniently
classified as follows:
1. Pleurisy with the production of fibrin, or acute
pleurisy, or dry pleurisy.
2. Pleurisy with the production of fibrin and serum,
or sero-fibriuous pleurisy, or pleurisy with effusion, or
suliacute pleurisy.
3. Pleurisy with an excessive production of fibrin.
4. Pleurisy' with the production of fibrin, serum, and
pus, or empyema, or sujipurative pleuris}'.
5. Chronic pleurisy with adhesions.
6. Tuberculous pleurisy'.
7. Cancerous pleurisy.
8. Traumatic pleurisy.
Etiology. — Pleurisy occvu's at all ages and in both
sexes. Pleurisy may ba priiitary or secondary, but there
is at the present time considerable difference in opinion
as to the relative frequency of true iiriniary pleurisy, as
well as to the frequency of tuberculous infection as the
essential factor in the jiroduction of so-called priraarj'
pleurisies. Thus Striinipell states that we know posi-
tively of but two forms wbicli ma_v lie regariled as pri-
mary, viz., the traumatic and the rheumatic; while others
regard exposure to cold and wet and iudividual predis-
position as frequent exciting causes. Of late years, un-
der the lead of the French and German writers, the ten-
dency of a large numlier of the ]irotVssion has lieen to
regard the majority, if not all, of acute and subacute
pleurisies as tuberculous. Tliere seems, however, good
reason to reject so sweeping an assumiitiou. That the
tubercle bacillus is a frequent cau.se of pleurisy is, of
course, well known, but many cases of pleurisy with
effusion have been observed in which no tubercle bacilli
have been found in the exudate, and in which tubercu-
losis has not subsequently develo|5ed. Moreover, an ex-
actly similar pleurisy with elTusion has been prodticed
experimentally in the lower animals by chemical agents,
as is shown by Delafield. By injecting a saturated .solu-
tion of chloride of zinc with a hy]ioilcrmic syringe into
the pleural cavity of the dog he was enabled to excite a
pleurisy exactly resembling that whicli is seen in the
human subject. By varying the amount of fluid in-
jected h(! was able to obtain pleurisies of dilTerent degrees
of intensity, and with different amounts of products of
inflanmiation.
Pleurisy may be secondary to changes in the lungs,
notably tuberculosis of the lungs and lobar i)neumonia.
or to the infectious diseases, especially la grippe, to rheu-
matism, to peritonitis, to abscess of the liver, to carcino-
ma of the stomacli, liver, or chest wall, or to nephritis.
I5.vcTEiiioi.oGV. — Cultivations from the exudate give
in the larger proportion of cases negative results, but, as
stated by Netter, we may recognize three groups of acute
or subacute pleurisy, caused by the tubercle bacillus, the
pneumococcns, and the streptococcus respectively.
The tubercle bacillus is very difficult to find in the exu-
date. It has been demonstrated that a large amount of
the exudate must be taken to make the test complete,
either in cultures or in the inoculation of animals.
The pneumococcns pleurisy is almost always secondary
to a focus of inflammation in the lung. It may, howevei",
be primary. The exudate is usually purulent, but the
prognosis of this form is very favorable. The strepto-
coccus pleurisy is the typical septic form which may oc-
cur either from direct infection of the pleura through the
lung in bronchopneumonia or in cases of streptococcus
pneumonia; in other instances it follows infection of
more distant parts. Tliis is the most serious and fatal of
all forms. The exudate is usuall\' purulent.
These, then, are the important groups, but other bac-
teria have bcenfoiuid, as the staphylococcus, the typhoid
bacillus, the bacillus coli communis, the gonoeoceus, the
pncumobacillus of Friedliluder, and the influenza ba-
cillus.
Pleuuisv with Till'; Pkoduction ok Fihrin (Dey
Plei'KIsv). — Morbid Anatomy. — The inflammation may
begin on the pulmonary, costal, or diaphragmatic pleura
according to the cause which produces it. That begin-
ning in the pulmouaiy pleura is always secon<lary to
changes in the lungs. That which begins in the costal
pleura is often independent of any inflammation of the
lung. Usually only a circumseribe<l portion of the pul-
monary, costal, mediastinal, or diaphragmatic pleura is
involved, liut the entire pleura of one side of the chest
may be inflamed. The inflammation always extends to
the poition of the pleura oppo.site to it. The inflamed
pleura is coated with a more or less thick layer of fibrin,
and bands of fibrin extend between the opposite pleural
surfaces. As most jiersons recover from dry pleurisy,
but little is known of its bacteriology.
This form of ]ileurisy is regularly seen with loliar
pneumonia, less freciuently with bronchopneumonia.
It is very frequently associated with tuberculosis of the
lungs, and may be the first or only sign of such tuber-
culosis. It is frequenth' found in connection with la
grippe, and it may develop at any time in the course of
this disease. It may develop simply from exposure to
cold.
Syiiijitom.i. — The rational symptoms are usually few
and not well marked. There may be more or less jiain
over the affected side, a slight dry cough, a little fever,
and some malaise. Often these symptoms are absent.
Though the pain is usually referred to the seat of inflam-
mation, it must be remembered that this pain may be
referred to a distant point, and thus the error may be
made of regarding the case as one of lumbago or of ap-
pendicitis, of renal colic, or, in cases of diaphragmatic
pleurisy, of ]ieritonitis.
The physical signs are characteristic. Over the in-
flamed area are heard crepitant or subcrepitant rales.
With these there may be a little dulness on percussion
and some little diminution in the intensity of the breath-
ing, but the essential sign is the presence of fine pleuritic
riiles. These rales may be scanty or very abundant.
Sometimes they may be so faint as to be heard with the
greatest difficulty. They are usually brought out best
by causing the patient to cough. It must be remembered
that these nlles — contrary to the usual impression — are
not necessarily constant; they may come and go in the
same manner as a bronchial rale. If the pleurisy be dia-
phragmatic or mediastinal, no rales may be heard.
With acute or subacute miliary tuberculosis of the lung
a dry jilcurisy may either mark the invasion of the tuber-
culous'inflammation of the lungs or it may be repeated
from time to time as the tuberculosis i;oes on. Recent
662
REFERENCE HANDBOOK OF THE :MEDICAL SCIENCES.
Plasmosrhlsls,
Pleurisy.
pleuritic rales, pain in the chest, and a rise of tempera-
ture regularly accompany these attacks.
So well is ft recognized that fine pleuritic rales maj' be
the only symptom of a beginning tuberculosis that such
evidence of localized dry pleurisy, especially if primarily
at the apex of the lung and attended with afternoon
fever, is always a source of great anxiety to tlie phy-
sician, unless "he can be sure that he has to do with an
acute pleurisy due to other cause than tuberculosis, as,
for example, "one occurring in the course of an attacli of
influenza. In primary dry pleurisies involving the costal
pleura there is a great variation in the extent of pleura
involved. Tiie inflammation may involve only a small
area of the pleura; tliere are rales heard over a circum-
scribed area only, tlie patient has but little fever, and the
pleuris}' runs its course in a week. In other cases the
pleuritic rales are heard all over the front or back of the
chest, the pain is quite severe, there is considerable fever,
and the patient may be confined to bed or to the hotise
for two weeks.
Tlie prognosis is good. Most cases end in recovery after
a short time, but the patient is often left with permanent
thickenings and adhesions of the pleura. Such adhesions
may give no further trouble, or they may form the start-
ing-point for a chronic pleurisj- with adhesions, or the
process may go further and cause chronic interstitial
pneumonia and chronic bronchitis.
Rarely, dry pleurisy is succeeded after several days by
a pleurisy with effusion.
In a moderate number of cases one or more attacks of
dry pleurisy are followed by pulmonary tuberculosis.
'Treatment.— '}ili\ny of the "milder cases are never seen by
the physician and need no treatment, although it would
seem wise to keep them in the house till the pleuritic
riiles have disappeared. The more severe cases should
stay in the house or go to bed till the attack has run its
course. There is no"especial drug treatment. The pain
in the chest may be relieved by [loultices, strapping the
chest, opium, p'henacetin, or the like. Most physicians
either paint the affected chest with iodine or employ wet
or dry cups, but it is doubtful if anything is gained by
these counter-irritants.
Pleikisy with the PRODrcTioN OF Fibrin and
Seru-m (Pleurisy with Effcsiox). — This is a much
more serious form of pleurisy, and is the type which is
most commonly seen by the general practitioner, since
many jiersons "with acute dry pleurisy never consult a
phvsician.
Morbid Anatomy. — The essential lesion is the inflamma-
tion of the greater part of the costal and pidmonary
pleurse on one side, and the accumulation of a consider-
able or large amount of serous fluid in the ]>leural cavity.
Sometimes, however, the extent of the inflamed pleura
is small, and the serum is shut in by adhesions (saccu-
lated pleurisy).
Rarely, the jjleura" of both sides of the chest are in-
flamed, and when this is the case there is apt to be peri-
carditis also.
The surface of the inflamed pleura is coated with fibrin,
and bands of fibrin join together its opposed surfaces.
In the pleural cavity is found clear or turbid serum of a
straw or amber color, containing a few leucoc^ytes. Red
blf>od cells are so rarely found that a bloody effusion is
usually regarded as a sign of a tuberculous or a cancer-
ous pleurisy. The blood, however, may be due to an in-
jury. There are, moreover, a few cases which do not
differ from ordinary cases except that the fluid is bloody.
Thus liloody fluid may be found in pleurisy in connec-
tion with cirrhosis of the liver and with infectious dis-
eases. The quantity of fluid varies from a few ounces
to a quantity suflicient completely to fill and distend the
pleural cavity. The fluid is, of course, found in the
most dependent part of the pleural cavity, unless shut in
by adhesions, in which case it may be found anywhere,
but most commonly at the base oif the lung and in the
neighborhood of the axillary region. If the effusion be
of any considerable quantity the lung is compressed up-
ward" and backward against the vertebra^, the degree of
compression of the lung depending upon the amount of
fluid. In extreme and long-continued cases the lung is
almost uuagrated. If the amount of fluid be great the
adjacent viscera ma)' be displaced. After the inflam-
mation has sulisided the serum and fibrin are absorbed
and the pleura is left thickened by connective tissue and
with connective-tissue bauds between the two layers.
The compressed lung expands again either conipletelj- or
partially; if the latter, more or less retraction of the af-
fected side of the chest is left.
The causes of pleurisy with effusion have been alreadj'
stated.
The behavior of the acute cases is such as to make it
probable that infection by the pneumococcus is the cause
of the inflammation : and'this belief has been confirmed in
a considerable number of cases, but, as before stated, in
a large number of cases the fluid is found to be sterile.
The diagnosis is made by the symptoms and physical
signs.
The essential symptoms are pain in the chest, coiig?!,
with little or no expectoration, dyspnaa, wadfcrer.
The essential physical signs are absent, or greatly di-
minished, vocal fremitus, fleitness on percussion, feeMe or
absent breathing, feeble or absent roicc.
With this combination of symptoms and physical signs
the diagnosis is one of the simplest problems in medicine,
but there are so many variations from these conditions of
the problem that a more extensive discussion of the sub-
ject is advisable.
First, as regards the symptoms and course of the dis-
ease. We may conveniently divide the symptoms of
pleurisy with effusion into three groups:
1. Pleurisy with an acute invasion.
2. Pleurisy with an insidious invasion.
3. Pleurisy with a subacute invasion.
In the first group the symptoms may very closely re-
semble the invasion of lobar pneumonia.
In the second group the pletu'isy inaj' be entirely over-
looked by the unwary, and " malaria" or some eijually
indefinite diagnosis may be made.
In the third group the conditions are more regular and
the diagnosis more simple.
First Group. — In pleurisy with an acute invasion the
patient is suddenly taken ill with the .symptoms of an
acute infection. Sometimes there is an initial chill, as in
pneumonia : more often there are chilly feelings, and then
the patient is taken with a sudden pain in the chest, with
a high fever, 103'-10-t' F., a dry cough and immediate
prostration. The pulse is full, "lOU-120. and the face is
flushed. In a few hours dyspnrea appears, and this may
increase so greatly that tlie patient cannot lie down in
bed. The breathing is from 28 to 35. The pain is apt
to be very great and referred to the affected side, but it
may be also felt throughout the muscles of the body.
The pain, on the other hand, may be very slight over tlie
inflamed pleura, but is referred to the opposite side of
the chest, or to the abdomen. In the latter case, if it be
on the right side, the rigidity of the abdominal muscles
and the situation of the^iain may lead to the erroneous
diagnosis of appendicitis, an error which of course would
be corrected by a jjroper physical examination of the
chest. As the"fluid accumufates in the pleural cavity
this pain becomes much less.
While the constitutional symptoms are going on the
fluid accumulates rapidly, and within two days it may
fill the pleural cavity ; biit the (|uantity of fluid varies
greatly in different cases.
The patient continues to have a high temperature and
all the appearances of a severe illness for about two
weeks; then the temperature subsides, leaving only a
moderate afternoon fever, which continues as long as the
fluid remains in the chest. These cases make us think
of an infection of the pleura by the pneumococcus.
The prognosis is usually good, but sometimes death
occurs, and some of these patients die suddenl.y.
In the second group, that of insidious invasion, we
have a picture wiiicli is just the opposite. The disease
begins so gradually that the jiatient hardly knows when
663
Pleurisy,
Pleurisy.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
ho bpgau to be ill. He has a little fever, he feels weak,
lias but little apjielite, ami he iiiny feel short of
breath ou exertion, hut the dyspurea i.s not urgent. He
may liave no eougli and no jiain in the side, and he ma}'
go about his busine.ssfor weeks sullering from fever and
loss of llesli before the di.sease i.s leeogni/.ed. For exani-
])le, a gentleman coming from the South told me tliat he
had suii'ered for th tee months from "malaiia and an en-
larged spleen:" Hisdyspua^a was obvious tome at ouee,
but he had hardly noticed it. His left chest was com-
pletely tilled with lluid. The term "sih'iit pleuri.sy " has
been aiijdied to this grou|i of cases, and they are not in-
frcciuently tuberculous in tlieir origin.
Tlie ilnration dc|iends entirely iijion the length of time
the fluid is left in the chest. If tlu' lluid is removed re-
• covery, as a rule, ensues at once — Imt tuberculosis of the
lungs sometimes f(dlo\vs later; the interval may be weeks
or months or years.
The third griniji i.s perhaps llie ninst ennuuon. The
invasion is of moderate severity; tlic temjierature is
about lOr F. in tlie morning and not, usually above ld3°
F. in the afternoon ; tlie respiration is aboiu iiO and the
])nlse about 100; pain in the side, dry cough, and dysp-
noea are prominent sym])toms. The patients usually
feel ill enough to go to bed, though they do not always
do so. The lluid accumulates in tlie eliest fairly quickly
at first; tlien it continues to increase slowly, and if treat-
ment is not instituted it will go ou slowly increasing for
several weelis.
The progno.sis is good; tliese patients rarely die, and
they usually make a perfect recovery.
The duration depends upon the treatment. Twenty
years ago. wlieu I -.vas a liospital interne, the regular
treatment was rest iu bed. blistei-s to the ( best and diu-
retics, and the regular duration was six weelis in bed and
two months iu ho.spital. Now the dnriition is often not
more than two or three d;iys iu bed, and perhaps two
weeks in hospital.
After recovery from this ]deurisy changes in the cliest
may be left l)eliind. which elianges are iu proportion to
the quantity of lluid and tlie leugtli of time it remains in
the pleural cavity. The expansion of the lung may be
complete, and no evidence of the former pleurisy remains.
Ml >re often liands of eonnective-ti.«sue adhesions are left
between tlie opposing surfaces of the pleura, and the ex-
pansion of the lung is not complete. As a result there re-
mains more or less i-etraction of the affected side of the
chest, and tlic adliesions of the pleura may catise pain in
the eliest for several mouths; or, less frequently, these
adhesions may be the starting-point of a chronic pleuri.sy
with adhesions, of an int+a'stitial pneumonia, or of "a
chronic lironchitis.
The phiisirnl nir/iix of ]ileurisy with effusion depend
largely upon the amount of the elVusion and tipon its
situation. The rule is tliat we find the fluid iu the lower
part of the pleural cavity, and tlie lung inori" or less
compressed upward and backward against the verte-
bral column. It is eu.stomary to describe the physical
.signs as in three groups, those aliove the level of the
fluid, at tlie level of the tluid, and lielow the level of the
lluid. but for the purposes of thisarliele it will be sulli-
cient to give the piiysical signs found abdve tlie level of
the fluid and lielow the level of the lluid. as these are
suflicient for all practical purposes.
/».i/Jrt7/w» uiay or may not show a fulness nf the chest
upon the affected side, and Hierc is usiudly limitation of
motion on the affected side. In children tliere may be
bulging of the intercostal spaces below the level of" the
fluid. If the effusion be large there may be displace-
ment of ilie heart or of the liver. ))ut this displacement
is not seen iu cases of moderate etfusion. Tliere may be
evident dyspuaa, and the patient usually lies upon the
affected side.
Thi< t-nfiit fivmilii.i is usually absent below the level of
the fluid, but it may be only diminished evin in large
elTusicins.
Pcri-'ission. above the level of the lluid. luiiy give ex-
aggerated resonance, or skodaie resonance, or normal res-
onance. Tlie percussion note over the opposite chest
may be exaggerated or tympanitic. Below the level of
the fluid the percussion note is usually absolutely flat,
and this flatness together with the feeling of marked re-
sistance to the linger used as a plexinieter is so constant
a .sign of fluid in the pleural cavity as to suggest at once
the diagnosis without further physical signs, though it is
not, of coui'Se, pathognomonic. In many cases, however,
wo do not get absolutel}' flatness, but only more or less
marked dulliess, oven when the amount of fluid is con-
siderable; this is notably the case in children. If the
amount of fluid be small we get dulne.ss ou percussion
of varying degrees of intensity.
Upon iiiiKniltiit/'iii of the breathing, almre the level of
the lluid, the breathing is usually normal ; it may be of
a blowing character (cavernous or broncho-cavernous), or
it may be feeble; below the level of the fluid it is gener-
ally stated that the breathing is tiliseiit. but this has not
seemed t« In', the case to me, I should prefer to s;iy that
below the level of the lluid the Iireathiiig is quite "feeble
iu most eases; oxceptionallj'' it is absent. There is an-
other and most important exception to the character of
the breathing heard all the way down the chest, below
the level of tlie fluid, viz., distinctly bronr/iuil brmf/iiiig.
This characteristic of the breathing in many cases of
pleural effusiini is now quite genei-allj' recognized, but it
is necessary to emphasize it on account of the danger of
mistaking this breathing for that of consolidation of the
lung. It is usually mited iu cases of large pleural effu-
sion; but this ciinriition is by no means essential.
If the etfusion be slight, the breathing is only slightly
diminished in intensity or is normal.
The Ktiee above the level of the fluid isusually normal;
it may be exaggerated or it may be sli.ghf ly diminished
in infensifj'. Below the level of the fluid the voice is
very greatly diminished or absent. If there be bronchial
breathing there is usually bronchial voice also: and this
firoucliial voice often seems distant from the ear. If the
effusion be moderate in amount, there may be only slightly
diminished voice or there may be a^gophonj'.
Iiiiksmay be heard over the affected side if one see the
case before the efl'usion of serum has taken place. After
the two liij'ers of the pleura are separated by the elTusiim
it i.s only rarel_v that one hears rales below the level of
the fluid. The important exception must, however, be
noted that tine rales may be heard lielow the level of the
fluid. This is not the place to speculate as to the ex-
planation of this phemonenon, but it must be borne in
miuel that rfiles may be heard below the levid of the
fluid, or else the error of excluiling pleuri.sy with effu-
sion will inevitably be made.
R;tles may, of course, be heard above the level of the
fluid if there be fibrin on the pleura, or bands of adhe-
sions at that point.
If the fluid be shut iu by adhesions (Sii.cculated), we
get irregular idiysical signis, dulness or flatness, changes
in the breathing and voice, and rales, corresponding to
the situation of the fluid and the compression of the lung.
In many eases there may be doubt as to the presence of
fluid in the pleural cavity, and this applies to fluid ft'ee
in the pleiir.al cavity as well as to sacculated pleurisy.
Here the diagnosis may be made by the introduction of
an exploring needle attached t<i a hypodermic syringe.
This little procedure is .attended with such slight" riskto
the patient that its use is to be recommended in all cases
of uncertainty of diagnosis. It must be I'eraembered that
a " dry lap " does nut exclude the presence of fluid, wdiich
may be shut into numerous compartments by adhesions,
aud'therefore introductions of the needle at several differ-
ent points may be reipiired before Ihe fluid is found.
Cases of .sudden death Juire followed exploratory
puncture, but fortunately these cases are rare.
As recovery takes ]ilace and the lluid is absorlied, the
breathing and voice can be heard more and more dis-
tinctly, and lower and lower down, until recovery is com-
plete. The flatness changes slowly into marked dulness,
and this dulness persists for sometime after .all the fluid
is removed. When there is doubt as to the exact height
6»U
REFERENCE HANDBOOK OP THE 3IEDICAL SCIENCES.
PIciirl'Kji.
Plpupisj,
of the fluid which reinaius, the [joiut at. which the voice
becomes distinctly nnitfled is the most reliable test.
The treatirumt of pleurisy with effusion is a matter of
great importance both as regards the duration of the ill-
ness and as affectini; the future of the patient. Person-
ally I believe that there should be but one recognized
form of treatment, and that is the mechanical removal of
the tluid bj' aspiration of the chest, and that tlie sooner
the fluid is removed the shorter the duration of tJie dis-
ease and the less the risk of the formation of permanent
pleui'itic adliesions. Aspiration, which was first advo-
cated b.y Bowditch and Wyman many years ago, is now
extensively adopted by physicians, but many still adhere
to the practice of depending upon the lymphatics for the
removal of the exudate, and wait. tAvo or more weeks be-
fore resorting to aspiration. There are many who seek
to restrain the exudation by the use of the dry diet, and
wlio give sodium chloride in considerable doses. If the
effusion be at all considerable it has been an almost tmi-
versal custom to administer diuretics, even though aspi-
ration were resorted to quite early. After aspiration the
use of diuretics is really unnecessary, and its use before
aspiration is of doubtful value.
The method I would advocate is that in the cases with
high temperature and other symptoms of acute and severe
invasion the patient be put to bed and on a fluid diet.
His restlessness should be quieted by the use of some of
the coal-tar antipyretics; and if the pain in the chest be
severe, relief may be obtained by the apjilication of poul-
tices to the chesl, or by the administration of morpliine.
After two or three days of this treatment, if the Ihiid has
accumulated it should be removed at once by aspiration.
The temperature usually falls on the day following as-
piration, and the acute symptoms subside also, and in a
few days the patient feels well enough to sit up. In the
cases of insidious and of subacute invasion the removal
of the fluid seems to be all the treatment necessary. The
patient may be put on a normal diet at once, and may be
gotten out of bed as soon as the fluid is removed. Before
a.spiration the skin of the chest should be disinfected, just
as for a major surgical operation, and the aspirating
needle and the operator's hands also rendererl aseptic.
With these precautions purulent infection of the pleura
does not ensue.
The amount of fluid removed at one sitting varies. If
the amount be not very great, it may be all removed at
once; but if the chest be entirely filled, it is not safe to
remove it all till t)ie following day. In ordinary cases it
is a good rule to remove all one can get, but to stop if
the patient feels faint or if he begins to cough. If a lit-
tle fluid be left it will usualh' take care of itself. In
cases in which the fluid re-accmmulates two or more aspi-
rations may be required to effect a cure. The subacute
ca.ses in which removal of the fluid is not attended by a
fall of temperature are apt to prove to be tuberculous.
Sudden death has followed aspiration of the chest, but
this is a very rare accident. It must be also borne in
mind that when a chest is completel}' filled with fluid
sudden death may occur if a.spiratioii is delayed, and that
it is imperative to i-emove a portion of the fluid as soon as
possible.
The differential diagnosis of pleurisy with effiu.sion
must be made from empyema, pneumonia, pleurisy with
excessive production of fibrin, pericarditis, abscessof the
liver, or other enlargements of the liver, and new growths
of the pleura. Of course the question of the fluid in the
pleura being an hydrothorax, or of the pleurisy being a
part of a tuberculous process in the lung, or of a loiiar
pneumonia, must also be considered. A due consideration
of the associated symptoms will usually lead to a correct
diagnosis, but where there is doubt the introduction of
the exploring needle is the most important aid to diagno-
sis. It must also lie remembered that the leucocytosis in
all cases of inflammation of the pleura, except empyema,
is usually moderate in amount, abotil ten to foiarteen
thousand per culiic millimetre, but the leucocytosis may
be low in pneumonia or high in a pleurisy, so that the
Wood count is not a certain means of differentiation be-
tween these two diseases. Where tljcre is the slightest
element of doubt the impoi-tance of the introduction of
the exploring needle cannot be too forcibly emphasized.
Preiiuently pus will be found by the exploring needle
when the physical signs would suggest consolidated lung
or onl}' a thickened pleura.
Among the infants which we see at Bellevue Hospital,
many of whom are half starved or badly nourished, it is
not so uncommon to find pus in the pleural cavity when
the only reason for the introduction of the needle is a
febrile condition and a little dulness over one chest.
Pleuhist with ax ExcEssr\-E PRODrcTioiv of Fibrin-
is a much more uncommon condition. AVe lind the pleura
on one side, both co.stal and pidmonarj-, greatU' thickened
by a deposit of fibrin, which may be even an inch or
more in thickness; there ma\' be a little fluid in the pleu-
ral cavity or there may be none.
This jjleurisy may be seen in connection with an acute
articular rheumatism, or with tuberculosis of the lung,
or with epidemic influenza, or without known cause.
The symptoms are very similar to those of pleurisy
with eft'usion with acute invasion, or to those of lobar
pneumonia.
The physical sign,s are usually diminished or absent
vocal fremitus, flatness on percussion, distant bronchial
breathing, distant bronchial voice, or, more commonly,
ajgophony, and abundant fine and coarse pleuritic rales.
The physical signs may resemble those of a pneumonia
or of pleurisy with effu.sion.
Exploration of the chest shows that little or no fluid is
present, and the absence of the rusty sputum, of the high
leucocytosis, and of the flushed cheeks, which are so char-
acteristic of pneumonia, may point to the correct diag-
nosis.
Fnless the inflammation is tuberculous the prognosis is
good.
The treatment is symptomatic on!}'.
EwPVEjr.i. — The inflammation usually involve.s the
whole of the pleura on one side of the chest; occasionally
it involves a cfrcumscrilied portion of the pleura only.
When we examine the pleura we find two different
conditions:
(1) We see that it is coated with fibrin and pus, and that
the pleural cavity contains pnrulent serum. This form
is most common in children.
(2) In other cases we find the conditions as above, and
in addition the pleura itself is much changed. It is split
up by a great number of new cells, so tliat it resembles
granulation tissue. In old cases the pleura becomes
much thickened and may be infiltrated with the salts of
lime.
As in pleurisy with effusion the fluid usually accumu-
lates in the lower part of the pleural cavity, or it may be
sacculated in any part of the pleural cavity; or it may be
sacculated between the lobes (interlobular empyema), "and
this is said to occur most commonly between the middle
and the upper lobe of the right lung. The suppurative
process may cxteud from the pulmonary pleura to the
lung, and the jius will then eseape at intef. als from the
bronchi, or the pus may escape through the chest wall,
or the pus may travel down and simulate a jisoas abscess.
In a few eases the inflammatory products and the super-
ficial layers of the pleura become gangrenous. The
purulent fluid is either thin and consi.sts of a considerable
number of i>us cells in an ordinary sero-librinous effusion,
or it is thicker and contains a large number of pus cells,
or it is a thick and creamy fluid, nearly all pus cells.
This latter is usually pneumococcus empyema.
The micro-organisms foimd are either streptococci or
pneumococci in the great ma.jority of cases. In 109 cases
of empyema examined by Xetter, he found the strepto-
coccus alone in 48 cases, the pneumococcus alone in 29'
cases, the pneumococcus with streptococcus in 3 cases.
Staphylococci were found in 2 cases. Of 13 tuberculous
cases ihe tubercle bacillus was found in 6.
Of 15 cases of foitid effusion sapropbj'tic organisms
were found in all.
Xetter points out the much gi'eater benignit}" of the
665
Pleurisy,
Pleurisy.
REFEHEXCE HANDBOOK OF THE MEDICAL SCIEXCEa
pneumococcus, and explains by tliis fact tlie more fre-
quent recovery of cliildren; for of 28 cases in children
the pneumococcus was jiresent alone or with the other
two cocci in 1")— a ratio of 53 per cent,, which is exactly
that of the streptococcus in adults.
The micro-organisms of less frequent occurrence are
the typhoid bac'illus. the colon bacillus, the gonococcus,
and the influenza bacillus.
The intiammation may lie primary or secondary. If
primary it may follow exposuie to cold or to heat, or be
without discoverable cause, or it may be only a part of a
general streptococcus or pneumococcus poisoning.
It may be secondary to an abscess in the wall of the
thorax, "in the liver, in the abdominal cavity, or in the
lung, anv of which may rupture into the pleural cav-
ily. " ' . .
Emp}-ema not uncommonly follow s a lobar pneumonia
or a griiqie pneumonia. It may follow a sinqde pleurisj'
wilh etfu.sion, but it is a (|uestion if this does not depend
upou the imperfect jirecautious taken in aspiration. In
the primary cases the rational symptoms are the same as
those of the first group of pleurisy with effusion, only
they art? much more severe. The temperature is higher
ami may be of the pus type: there are chills and sweating
and marked prostration. The synqjtoms may continue
acutely and the patient die in a short time, or they may
subside and the inflammation jiass into a chronic course.
^Vheu empyema follows a pneumonia it regularly de-
velops as the iinenmonia is sidjsiding, or a few days
after defervescence. The temperature rises agaiu and
the patient feels ill agaiu. In the secondary cases the
larger number ptnsiie a subacute course, with afternoon
exaeerbatious of fever, dyspuo'a, cough, and gradual loss
of tlesh and strength.
Kecovery with absor])tion or with perforation is very
rare. But in some patients there is a partial recovery,
most of the pus is ab.sorbed. but there is set up an inter-
stitial pneumonia, with more or less bronchitis, which
goes on indefinitely.
Tlie physical signs are essentiallj' the same as tlio.se of
pleurisy with effusion, and subject to the same modifica-
tions, the only exception being that sacculation and ir-
regular and indefinite physical signsare more common in
empyema. In many ca.ses the diagnosis can be made
only by the exploring needle.
The diseases from which differential diagnosis must be
made are pleurisy with effusion, pneumonia, abscess of
the liver, subphrenic abscess, tuberculosis of the lungs,
and malignant endocarditis; the last two being thought
of only where the physical signs in the lungs are unsatis-
factory.
The duration of emiiyema, when no operation is per-
formed, may be from a few days to mauy years, the pa-
tients in the latter case finally dying, emaciated and with
waxy degeneration of liver, spleen, and kidneys.
The p;w//(<w(> without operation is bad : with a proper
surgical operation it is very good. Kecovery is almost
the rule.
Treatment. — The essential jioint in the treatment is to
remember that we have to do with an aljscess, and that
we must follow the ordinary surgical rule, viz., to open
the abscess and evacuate the pus. This should be done
just as soon as the presence of the pus is shown by the
exploring needle, and nothing but the removal of the pus
should be thought of. No matter how weak the patient
may be he will gain by the evacuation of the pus.
The method of procedure varies according as we have
to do with children or with adults.
In chililren aspiration should first be resorted to, and
in a majority of cases this will effect a cure. If thi' tem
pei-ature does not fall, and the pus reaceumidates, then
the chest iua_y be opened and a drainage lulie inserted.
In a<lults it is a wa.ste of time to aspirate. The chest
wall shoidd be opened at once, under the strictest anti-
septic precautious, and a drainage tube inserted.
There is some diti'erence of opinion as to whether it is
better to incise an intercostal space or to remove a portion
of one or more ribs. Personally, I [irefer to remove a
large piece of one rib, as the indications are twofold: to
make au opening large enough to permit of the insertion
of the hand aud the breaking up of pleuritic adhesions,
so as to periuit of thorough drainage, and to favor tlie
closure of the abscess cavity by the collapse of the chest
wall. It is not necessary to wash out the pleural cavity
unless the contents be fa'tid. A good-sized drainage tube
is inserted, absorbent dressings are applied, and the whole
chest is wrapped in bandages. The wound is dressed only
when the discharge comes through the dressing. The
patient is gotten out of bed as soon as possible, and at
the end of a month, at the latest, the drainage tidje
should be removed. The principal danger after oper-
ation is that of reinfection of the pleura, and the success
of the operation depends upon the antiseptic precau-
tious taken during the operation and in the sul)sequent
dressings.
If one can be sure that there is only a small sacculated
collection of pus, as may be the ease in an empyema fol-
lowing pneumouia, aspiration is all that is necessary to
effect a cure.
CuROKic Plecrisy with ADrrEsioxs is a condition
which is of interest chiefly because of its resemblance
to chronic miliary tuberculosis of the lungs, and of
the importance of discriminating between the two dis-
eases.
By chronic pleurisy with adhesions we mean a chronic
productive inflammation of the pleura, and not the old
adhesions which are found at so many autopsies.
It is au iuflanimatiou which is chronic from the begin-
ning and results in the production of new connective tis-
sue only. We find thickenings of the pleura and adhe-
sions between the costal and pulmonary pleura. One
pleura may be involved, or both, or only part of one
pleura. The natural tendency is for the inflammation to
extend, until finally both lungs are completely adherent
to the Walls of the chest. There develops more or less
inflammation of the larger bronchi, and the heart be-
comes smaller.
The disease usually originates in the adhesions which
have been left by previous attacks of dry or of subacute
pleurisy, but .sometimes no history of previous pleurisy
can be obtained. It may be associated with emphysema
or chronic phthisis.
The si/iiipti'iii.s are slight or well marked, according to
the extent of the lesion. There may be only some pain
over the chest and a slight dry cough, or there may be
considerable pain, cough with expectoration, dj'spna'a,
and loss of flesh aud strength.
The physical signs depend upon the extent of the le-
sion If this be slight there are only a little dulness
over the affected chest and pleuritic tales. If the lesion
be extensive, we have more marked physical signs. The
chest is flattened or retracted, expansion is diminished
over the affected area, vocal fremitus is sometimes nor-
mal, sometimes increased, and sometimes diminished.
The latter is perhaps the most common condition. There
is more or less well-marked dulness on percussion ; the
breathing is diminished, or it may be clian.tred in charac-
ter, lesembling bronchial breathing or broncho-vesicular
breathing ; the voice is usually diminished, but it may be
increased in intensity. Over t'heaffected area are usually
beard numerous ]ileuritic rales, some the creaking sounds
of old adhesions, others the crepitant and subcrcpitant
sounds of more reeeut adhesions. It must he romeni
bered that if the jileuiu' are tightly adherent there will be
no rales at all. These jiaticnts usually die from .some in-
tercurrent disease, but occasionally the pleurisy is the
only discoverable cause of death.
The tiriitini lit is to expand the lungs as much as possi-
ble, and to live an outdoor life as much as possible. I
am in the habit of advising svich a patient to take the
deepest possible breaths at each street crossing, and to
practise mild chest gymnastics night and morning. The
pneumatic cabinet is of service in these cases. Cod-liver
oil and general toines also help.
Ti'BEia iLOfs Pi.Eriiisv is usually secondar\' to tuber-
culous inflammation elsewhere in the body: most com-
666
REFERENCE HAXDBOOK OF THE MEDICAL SCIENCES.
Pleurisy.
Pleurisy.
monly, for example, in the luugs, next in the broueliial
lympli nudes, then in tlie peritoneum, bones, ete. ; or tlie
tuljereulous pleurisy forms simply a part of a general
miliary tubcreulosis. lu some cases, however, no tuber-
culous focus can be found elsewhere in the body, and these
must be regarded as cases of prinuuy tuberculosis of the
pleura.
The inflammation regularly involves the whole of the
pleura on one side. It may be coutined to the costal
pleura or may involve also the diaphragmatic or pulmo-
nary pleura.
There may bo localized, or widely disseminated, miliary
tubercles upon or beneath the pleural surfaces, either
in direct association with lesions beneath the pulmonary
pleura, or apart from them, or upon the costal pleura.
According to Delafield the gross appearance varies as
follows:
1. The pleurals thickened, its surface is bare of tibrin,
it is of a bright red color from the congestion of the blood-
vessels, and this red surface is mottled with white dots —
the miliary tubercles. In the pleural cavity is bloody
serum.
2. The pleura is thickened, it is thickly coated with
fibrin, no tubercles are visible to the naked eye; the
pleural cavity contains clear serum.
3. The pleuia is thickened and the pleural cavity con-
tains purulent serum.
In all these cases the changes in the pleura itself are
essentially the same — the thickened pleura is inlillrated
with new connective-tissue cells. Scattered through its
entire thickness are tubercle granula, either singly or
joined together by diffuse tubercle tissue. The smaller
blood-vessels show a growth of their endothelial cells.
In the serum of tuberculous pleurisy the tubercle bacil-
lus may be occasionally demonstrated Ijy staining, espe-
cially if the centrifugal machine is used, but it requires
long and careful search, and often all one's efforts are
unrewarded. The tubercle bacillus may be associated
with other bacteria, most often with the staphylococcus
pyogenes in the purulent exudate.
Many cases of pleurisy with sero-flbrinous exudate,
giving no growth of bacteiia on the ordinary culture
media, are found to be tuberculous by the inoculation of
guinea-pigs with the tluid.
The sytiiptoms and physical signs are the same as those
of pleurisy with effusion, or of empyema, or of pleuris}'
with an excessive production of librin. Of course the
only positive diagnosis lies in the finding of the tubercle
bacilli in tluid withdrawn from the pleura, but this is a
procedure which is rarely successful. A fairly positive
diagno.sis can, however, be made in a majority of the
cases by the consideration of associated conditions.
Thus a bloody serum is more likelj' to indicate tubercu-
lous pleurisj' than anything else. A "silent pleurisy " is
very apt to prove to be tuberculous. When the tem-
perature remains high after the serum has been removed,
and when the serum reaccumulates rajiidly after each
aspiration, the case is usually tuberculous. When the
family history and the patient's history point to tuber-
culosis, the diagnosis can usually be correctly made.
AVhen there is empyema and the opening of the chest is
followed by little or no improvement, the case is iisuall)'
tuberculous. When the empyema is sterile it is usually
tuberculous.
The treiiiment is unsatisfactory. We remove the fluid
or we open the chest for the empyema; and then, if the
diagnosis is certain and the patients are well enough, we
treat them as we woidd any case of tuberculosis by out-
of-door life, change of air, creosote and cod-liver oil, and
good food.
C'ANCEROtJS PLEriusT is rare: it may be primary or
sccondarj-. Fibroma, sarcoma, and endothelioma may
occur as primary tumors of the pleura. Fibroma and
lipoma formed in the subpleural tissue may eucroach
upon the pleural cavity.
Endothelioma usually occurs in the form of larger or
smaller, flat oi- projecting, irregidar nodular masses fre-
quently most marked and extensive upon the costal pleu-
ra. Carcinoma may invade the pleura by extension, or
sarcoma or carcinoma ma}' be secondary to distant
growths of the same nature. Small white, slightlv pro-
jecting, often pigmented elevations of the jjleura, "either
single or multiple, are common. These were formerly
regarded as mostly miliary fibromata, but Hodenpyl has
shown that tliev are mostly fibrous masses which replace
or enclose miliary tubercles.
The tumors may be a.ssociated with an exudative pleu-
ritis, and with either primary or secondary cancer of the
pleura tlie exudate is frequently bloody. It nuist be re-
membered that though bloody fluid suggests either tu-
berculous pleurisy or cancerous jileurisy, and is due to
one of these causes in the great majority of cases, it is
possible to have a hemorrhagic pleurisy from other
causes :
1. A perfectly simple pleurisy niaj' be hemorrhagic.
2. A bloody fluid is met with in the pleuris_v of the
asthenic states, such as cancer, nephritis, and cirrhosis,
in the malignant fevers, and in severe infections.
3. There may be a hsematothorax due to the rupture
of an aneurism, or to the pressure of a tumor on the
thoracic veins.
4. The chest wall or the lung may be wounded by the
aspirating needle, and blood in this waj' may .get mixed
with the sero-flbrinous exudate.
5. Wounds of the walls of the chest, fractures of the
ribs, and blows on the chest may cause hemorrhagic
pleurisy.
The symptoms of a cancerous pleurisy are those of the
original new growth plus the signs of a pleuritis. If it
be a primary new growth of the pleura, the diagnosis
ma}' present verj- great difticulties.
The subject of TR.'i.UM.'VTic Pleurisy need not de-
tain us. If there be perforation of the costal or pul-
monary pleura there will usually be a sero-fibrinous pleu-
risj', which may become piuulent. Fracture of the ribs
or blows upon the chest may cause a dry pleurisy or a
sero-flbrinous jUeurisy.
PxEU.MOTUoii-W. — By this we mean air iit the pleu-
ral carity, and also pyopneumothorax, air tind pus in the
pleural cavity, and hydropneumothorax, air and serum
in the pleural cavity.
Air alone in the pleural cavity, a pure pneumothorax,
is an extremely rare condition, for a pneumothorax usu-
ally becomes a pyopneumothorax, or, more rarel\', an
hydropneumothorax. We. therefore, speak of these three
conditions under the term pneumothorax.
Pneumothorax occurs chiefly in adults, although we
see it occasionally in very young children. It is more
frequently met with in males than in females, and most
commonly on the left side. It is caused by anything that
perforates the pleura and allows air to enter the jileural
cavity; but in ninety per cent, of the cases this cause is
the rupture into the pleural cavity of a softened tuber-
culous nodule, or of a tuberculous cavity.
Other causes are: Perforating wounds of the chest;
perforation of the diaphragmatic pleura from malignant
disease of the stomach or colon, or idcer of the stomach:
perforation of the pleura by cancer of tlie (esophagus;
jierforation of the pleura, in the normal lung, from rupt-
ure of the air vesicles during straining; septic broncho-
pneumonia; gangrene of the lung; abscess of the lung;
jierforation of the lung from the pleural cavity by an
empyema; the development, in a pleural exudate, of the
gas bacillus (B. atrogeues capsulatus).
Osier has seen pneumothorax caused by the ru])ture
into the pleura of an hemorrhagic infarct in chronic heart
disease.
Pneumothorax has occasionally followed the intro-
duction of an exploring needle into the lung. The
number of cases of pneumothorax due to these excep-
tional causes is so small that practically pneumothorax
is regarded as of tuberculous origin until it is proved
that it is not,
Pathiihujy. — If it be a pure pneumothorax we find
the air in one (jf the i)leural cavities under considerable
pressure. The lung is compressed against the \'ertebral
667
l"l**iirl<ty Root,
Pneiiiiialio rabiiiet.
REFEREXCE IIAXDDOOK OF THE MEDICAL SCIENCES.
rnluniii, and it may be small, dense, and iinaCrated. If
tlicre l)c^ old pleuritic adliesions the liuij; may not be
comjiressed against tlie vertebral culnmn, but irregularly
com])ressed, being held against the chest wall by the
adhesions. Tlie mediastinum and tlie ]iericardium are
displaced, l)eing drawn over to the opposite .side, and the
liver or spleen may be displaced downward. It' there
lie a pyoimeumotli'ora.N, or an hyilropneumothorax, there
is iu addition tluid in tlie pleural cavity, purulent or
serous, and the jileura is intlanied.
S;/)i>ptiims. — In the tuberculous ca.ses we have first the
ordinary liistory of tuberculosis of the lungs, then dur-
ing .sonic severe muscular exertion, or during a paroxysm
of coughing, tlie rupture of the pleura suddenly takes
place and the patient experiences a. severe pain in the chest
accompanied by intense dyspniva and a feeling of weak-
ness or faiutiiess. He may even become completely un-
conscious, and he may die without recovering conscious-
ness. If he does not ilie at once he rallies from tiie sliock
caused by the rupture of the lung. Init he is much sicker
tliau he was before. lie has constant and very severe
dyspno'a. and lie is usually confined to his bed. He may
remain iu this condition for two (.r tliree weeks and then
die. either with or witliout, tliough more conunonly with,
tile develoiiment of pyojineumotiiorax, or he may grow
slruiigcrand be able to get out of bed and go about a
liltle. but if pyopneumotliorax has not already developed
it usually supervenes. Then tlie symploms of pyo-
]uieiiinothorax are developed, whicli are, of course, sim-
])ly ail inteusitication of the symptoms of tuberculosis of
the lung witli mixeil infection. The patient loses flesh
rapidly, he lias a high fever at niglit, he sweats pro-
fusely, and he may expectorate a great deal of foul-
smelling material — the pus from the ]ileural cavity. He
tiiially dies of exhaustion. It must be reinemliered, liow-
evcr, that tliere may lie no urgent syni|itoms of ])iieumo-
tliorax in cases of long-standing tuberculosis of the lungs.
There has been found post mortem a pneumothorax
which was unsusiiected during life. West states that
even in liealtliy adults this latent pneumothorax may oc-
casionally occur.
The iliarjiiiixis of pneumothorax is usually made with
ease by the physical signs. 'I'he rule is that the affected
side is larger than the other, and it moves but little with
respiration. The heart is dis|ilaceil, and the liver lU'
spleen, or both, may be displaced downward. The vocal
fremitus is usually ab.sent.
Percussion gives tympanitic resonance or exaggerated
resonance, or amphoric resonance. Auscultation gives
amphoric breathing or absence of Ijrcathiug. Ausciilta-
tion id' the voice gives amphoric wliisper or very feeble
voice.
If the lung be adiicieiit to the chest wall, there ma}'
be ]ileuritic adhesion rales. There may be the metallic
tinkle, even though no rtnid be ]u'esent.
TIk' coin sound. Trousseau's "bruit d'airain." is char-
acteristic. To obtain this sound the auscultator should
put one ear on the back of the chest while an as.sistaut
taps one coin cm another jdaced on the front of the chest.
The metallic-echoing sound whic-h is jiroduced in this
way is one of the most constant and characteristic signs
of pneumothorax.
Certain exceptions to these physical signs must be
noted :
1. Thc^re may be but liltle displacement of the viscera.
'i. Voc-al fremitus may persist.
9. Percussion may give nearly normal resonance, or
JliitniKs, or ilHliicts. signs which may very well deceive
us greatly.
4. The breathing may be normal over most of the
chest, m- it may be bronchial.
Tlie physical signs of pyopneumothorax or hydro-
imeumothorax are usually tlio.se of pneumothorax above
the level of the fluid, and of pleurisy with eliusiou below
file level of the- fluid, to which is added the characteristic
sign id' .air and tluid in the ]ileural cavity, viz., the Ilip-
pii'mtlr xiirriixnioii. This sign is obtained by |ilacing
the auscultator's car upon the clicst. and then shaking
the patient's body. Asplasliingsonnd is produced whiidi
may be audible even at a distance. The patient can often
feed and hear this tluid splashing iu his chest.
Pneumothorax must beilifTcrenfiated from large phthis-
ical cavities; from total excavation of one lung; from
diaphragmatic hernia following a crush or other accident ;
from pleurisy with elTusion. In most cases the difTereii-
tial diagnosis docs not present serious difficulties. The
total excavation of one lung in which only a thin shred
of lung tissue remains attached to the chest wall presents
the pliysical condition which exactly resembles a jueu-
mothorax and therefore ijresenls unusual dilhculties in
diaguo.sis. This is, however, a very rare condition, ami
the patient does not develop a pyopneumothorax.
The priirinnsin is usually bad. According to "\^'est,
the mortality is seventy per cent. The tuberculous c;f.es
usually end fatally within a few weeks. According li>
West, of thirty-nine patients, twenty-nine died within
a fortnight, ten died on the first day, and two of the.se
williin twentv and thirt}^ minutes, respectivelv, of the
attack.
Pneumothorax developing in a healthy individual, it
is said, often ends iu recovery. There are tuberculous
cases in which the pneumothorax, if occurring early,
seems to arrest the progress of the tuberculosis.
The question of trcdlment is a difficult one to decide.
As a rule, little cati be doni^ for the unfortunate victim.
An oiieratiou for empyema does little good, since we
have in the advanced tuberculosis of the lung the main
cause of the inllammation of the pleura. In cases which
develop early the fluid mav, of course, be removed by
aspiration, if serous, or a rib may be excised and pei'-
mauent drainage obtained if the fluid be purtUent. If
the patient suffers from dyspnoea due to the pressure of
the air, this may be relieved by the insertion of a tine
trocar and allowing the air to escape. The asjiirator
shouM not be used. Frtiiik IC. Jacksun.
PLEURISY ROOT.— .l»V^;)/i'.? (U. S. V). Buttcrfy
TT'crt/. "The root of AscUjiiiix liiberosn/L. (fani. .{.vicpia-
dacea)" (V. S. P.).
Afi)'h-piiix L. is a genus of some sixty species, occurring
chiefly in North America, a few in Central and South
America, and in the tropics of the Old World. A number
of these have been found to possess the composition and
properties of the official one, and it is probable that the
same jiropcrties are general in tlie genus.
The species in question is very abundant in sandy soil
from New England southward and soutliwestwanl. It
is a perennial, hairy herb, sending up a cluster of erect
or ascending steins a foot or two long, as tliick as a
goose-quill, densely leafy, and bearing at the summit
.several branches terminating in hand.sorae large umbels
of orange-colored flowers. It is the only species of the
northeastern United States with orange-colored flowers.
The commercial root is irregularly or interruptedly fusi-
form, 10-"20 cm. (4-8 in.) long, 1-.5 cm. (1-3 in.),Vareh'
more, in thickness, usually cut transversely or longitudi-
nally into irregular pieces; externally light orange-
brown, becoming gray on keeping, coarsely annular at
the crown, bearing numerous fine longitudinal am! trans-
verse furrows, imparting a finely fubereulate appearance
and feeling; fracture tough, uneven, granular, whitish,
tlie thin bark yellowish in the outer layer, the wood
bundles pale yellow; almost inodorous, taste bitterish,
slightly acrid and nauseous.
Besides two resins, gum. and a large amount of starch,
pleurisy root contains the bitter glucoside asclepiadin, to
whicli its ]u-opi'rties are chielly due. Asclepiadin is a
j'ellow aini'r|ilii>iis substance, soluble iu alcohol, ether,
and hot water, becoming of a deeper yellow, then green,
with concentrated sulphuric acid.
Pleurisy root is diaiihorcfic and expectorant, and in
domestic and country practice it has been used exfen-
.sively iu lung alfecfions and catarrh of the air passages.
In large doses it is emetico-cathartic. If desired, it can
be given in decoction. Dose from 1-3 gm. (gr. xv. to
xlv.). The fluid extract is official. Ilenri/ H. Runhy.
66.S
REFEREXCE HAXDBOUK OP THE MEDICAL SCIE:S'CES.
Pleurisy Koot.
Pueuiuatic Cabinet.
PLOMBIERES.— Plombifeips has been called, not with-
out reason. " tlie QuufU of Watering-places of the Vos-
ges." It is charmingly situuteil, and its surroundings
are so attractive that it is a favorite summer resort with
many who have not been ordered there for a course of
the waters. The little town has only about two thou-
sand inhabitants. It is situated in a narrow valley, with
mountains rising steeply up on either side. The climate
is invigorating, and, while the days in summer are often
hot, the nights are invariably cool.
Analysis. — One thousand parts of the water contain
in parts:
Temperature
CartKinic acid (free)
Silicic acid
Sulphate of soda
Sulphate of ammonia i
Arseniale of soda 1
Silicate of soda
Silicate of lithia /
Silicate of alumina \
Bicarbonate of soda
Bicarbonate of potasli
Bicarbonate of lime
Bicarbonate of magnesia
Chloride of sodium
Fluoride of calcium '.
Oxide of iron and nian.^nese \
Organic and a^otyzed products
Total .
1.5.S° F.
I).lill«38
.IKbw
.iaT()4
traces.
.12862
traces.
.02288
.01(;73
.IKTTS
traces.
.01044
traces.
indica-
tions.
0.. 370.5.3
la
i3r» F.
n.ias79
.07.539
.07.534
traces.
.07343
traces.
.01426
.00125
.049155
notable
traces.
.00794
traces.
indica-
tions.
124° F.
0.12S7
.02731
.«I274
traces.
.05788
traces.
.01133
.OOIIS
.0286.S
.00670
.0092;
traces.
indica-
tions.
0.(r2295 0.25821
I
3
o «
11.5° F.: 68° F.
0.IWS25
.007.39
.10070
traces.
.10(311
traces.
.02092
Man
.mm
traces.
.01005
traces.
indica-
tions
o.ooaio
.0»:')89
.046S5
traces.
.04209
traces.
.00818
traces.
.0)451
.01253
.00651
0.29823 0.1!««V5
A special feature at Plombi(^'res is the long time (from
half an hour to an hour and a half) during which patients
remain in the water. Mr. Wolff ("The Watering-Places
of the Vosges ") says that only four springs out of the
twenty-seven which are now in use at Plombieres are
drunk at all. The first is the chalybeate, which is very
mild, and is employed mainly as a table water and as an
adjunct to bathing in cases of anaemia and chlorosis.
Another spring used for drinking, and also for bathing,
the "Source Savonneuse," is mildly laxative. Besides
these, the "Source des Dames" and the "Source du Cru-
citi.x " are emplo^'cd for what little drinking there is.
Apart from the chalybeate and the Savonneuse. the
Plombieres waters all belong to one category. Dr. Cou-
stantin James calls them alkaline; Dr. Bottentuit, "c/;--
seniatet'S sodiques, siilfatees ct silieiitees sodigues" ; M.
Jacquot, " bicarbonaiees sodifjnes siHcati'es'' ; and Dr. Jlac-
phei-son, "indifferent." The latter designation is most
in keeping with their slight degree of mineralization.
The s.ame author states that, "in addition to the baths,
a verj' effective remed}- in some cases a]iplied at Plom-
bieres are the etnres, also called etinfs dc I'Ki/fei: These
are hot vapor baths, for which the heat and vapor are
supplied by the running springs. There are two such es-
tablishments, both of course underground, and both, at
their hottest points, very hot indeed. But for people
who cannot stand excessive heat, there is the convenient
institution of etuvcs en hoite, which are taken in a closed
box, with a hole left in the top for the head." Ener-
getic massiige is also much (■mploy(_'d at this spa; so that
the patient's time, what with drinking, bathing, walk-
ing, douching, massaging, and dieting, is quite fully oc-
cupied. Most of the visitors are women, although it is
by no means an exclusively " female watering-place."
The place is rich in mineral spiings, but the propor-
tion of solids in the waters is rather insignificant. Over
tvventy-tivesprings are used at Plombieres, and the water
of most of them is collected into a single conduit and con-
veyed to the dilferent thermal establishments. Only three
of the latter are perfectly modern and satisfactory, viz.,
the J^outcaue Therines, the Bain liumaiii, and the Bain
SUmislas. Although so slightly mineralized, the varviivg
temperature of the baths (65' t(j KiU F.) admits of a cer-
tain amount of variety in treatment. The waters ai'e
easih' borne when taken internally, and do not jiroduce
any constitutional disturbance.
A course of Plombieres is useful in many nervous
states, especially those associated with hypera'sthosia. as
well as in those depending upon litha'mia. 3iaiiy symp-
tomatic neuralgias and paretic conditions derive benefit
from a course of treatment at Plombieres. Still joints
ma}' be limbered up, lumbago cured, gouty manifesta-
tions alleviated, diseases of women improved. 'I'he place
also has quite a reputation for the cure of sterility,
though on what grounds does not specifically iipp(.'ar.
The waters are also applicable to cases of gastralgia,
dyspepsia, catarrhal conditions of the bowels, especially
when accompanied by chronic diarrha'a. Some skin dis-
eases, such as eczema and psoriasis, are likewise said to
be greatly' benefited by these waters. The chalybetite
springs are, of course, useful in anaemia and chlorosis.
In phthisis the place is said to be contraindicated.
Plombieres is a dccidedlv international watering-place,
although English and Americans form but a small con-
tingent of the six thousand annual visitors of the spa.
With reference to accommodation, Sir. Woltf is authority
for the following: "The better hotels and villa-pensions
seem intended for people altogether of the better classes.
The3' are good, but dear. Of course, there are less pre-
tentious ones, down to the lowest point of the .scale; for
the spa is much visited. The following are among the
best: The Grands Hotels, Hotel de la Paix. H<*)t(l Stanis-
las, Villa Jlocquard, Le Chalet Rose, and Maison Kossig-
nol. There are as many as about a hundred piivate
hotels, many of them with a regular table-d'htite. " Al-
together,'it is quite true that Plombieres should be bet-
ter known in our country than is now the case, especially
as it is more convenient of access than Wildbad Gastein,
Teplitz, and the other spas of that order, which Ameri-
cans are w-ont to visit. Edmund C. M'endt.
PLYMOUTH ROCK MINERAL WELL. — Wayne
County, Michigan. PosT-t)i-FiCE. — Plymouth.
Plymouth isa handsome village of ab(mt eighteen hun-
dred inhabitants, twenty-three miles west of Detroit,
fi'om whence it is reached by both the Flint and Peie
Marquette and the Grand Rapids and Western railroads.
The well is situated in a picturesque spot on the farm of
Dr. M. V. B. Saunders. It was bored several years
since, and the following analysis was made bv Prof.
John E. Clark, of Detroit, in 1893;
One United States .gallon contains; Sodium chloride,
gr. 14.38; sodiinu sulphate, gr. 0.37; sodium bicarbo-
nate, gr. 5.37; potassium bicarbonate, gr. 1.73; calcium
bicarbonate, gr. 5.47; magnesium carbonate, gr. 2.1)0;
alumina and iron carbonate, gr. 1.73; silica, gr. 0..50;
organic and volatile matter, gr. 1.29. Totiil, 33.64
grains. Lithium carbonate and carbonic-acid gas not
estimated.
No accommodations have so far been prepared for visi-
toi'S. but the water is widely sold. It is a good example
of the alkaline-saline carbonated vai'iety of water, auci is
useful in conditions to which thiscl;iss is applicable. Its
best effects have been observed in disordeieil states of the
stomach, especially when accompanied by hyperacidity.
It is also highly recommended in irritable states of the
bladder and kidneys as a diuretic and diluent of the
urine. It is said to have produced excellent results in
gout, rheumatism, gravel, and other aifect ions.
Jtnin.Hji. Croi'k.
PNEUMATIC CABINET, THE.— The pn(M!matic cabi-
net, as distinguished frcjm the pneumatic chamber of Eu-
ro]iean countries, is an air-tight box of sufficient size to
contain only a single patient.
Bv me;insof an attached liellows the contained air may
be rarefied or compressed, and by means of a tube and
stopcock in one wall of the cabinet the patient's lungs
may be instantly connected with, or cut oil from, the out-
(>C9
Pueiiinatlc Cabluei.
Piieuiuonia,
UEFKKEXt'E HANDBOOK OF THE MEDICAL SCIENCES.
side ;iii'. The caljinet is designed for the aiililicutiim of
ditii.Tciit.iid atiiio.s|ili(.-iic ])ressiin'S, the dilTcrciitiatioii be-
ing lietween the eutaneous ami |)ulnionaiy circulations.
Coiiiciilentl\- it may be advautagei)iisly employed iu tlic
administration of the various inhalations. It has no re-
lation to, and is iu no way conijiaralile with altitude, but
is properly classed with apparatus for the rise of com-
pressed and rarefied air. It dillcrs, however, from all
other apparatus of this class in that tlie differential press-
ure is apjilied to t!ie sj'stemic as well as the pulmonary
circulation. As this dift'ei-eutiation is always negative,
the effects upon vascular tension and blood flow arc di-
rectly the opposite of those from compressed and rarefied
air.
Pliydcs. — Theavailablc variations of atmospheric press-
lire to which the patient may be sulijected and under
which respiration may take place are:
1. Diminished jiressure on both cutaneous and pul-
monary surfaces, the patient being in and breathing the
rarefied air of the cabinet, called negative pressure.
2. Increased pressure (in both surfaces, called positive
pressure (rarely if ever used).
3. Barometric pressure on the inilinonarv, with dimin-
ished pressure on the cutaneous surface, the patient being
in rarefied air while breathing fi-om without, called nega-
tive differentiation.
4. Barometric pressure on the pulmonarj', with in-
creased ]iressure on the cutaneous surface, called posi-
tive differentiation.
Kespiration may be continuous under either of the
above conditions or the differentiatiou ma^v be shifted be-
tween inspiration and expiration, giving the following
combinations:
Combinations.
iDspiration.
Combined
with expiration.
Called.
Under No. 1
Under No. 4
Under No. 4
Forced inspiration.
Foroed rf"ipiiution.
For \ »'xi«ii;itin!i.
ObstructL-d respiration.
Under No. 3
Under No. 2
Clinical experience has shown that negative differen-
liation, and its combination with negative pressure in the
form of forced inspiration, are the most effective and, es-
sentiallj', the only desirable methods of application. The
physical demonstration is, therefore, limited to these two
motions.
Negative Differenlintinn. — In this motion respiration is
carried on under a constant differential pressure, that
upon the pulmonary circulation being barometric, and
that upon the cutaneous and abdominal circulations
being less by Ihe amount of rarefaction iu the cabinet.
The mechanical effects are identical with those from com-
pressed air aside from the circulation: but as they can
be obtained iu larger degree b_y f(.>rced inspiration with
an increased instead of retarded circulation, this motion
is never employed for tlie purpose of expanding and
clearing the lung. Because the respiratory effort is
shifted from inspiration to expiration, respiration under
tliese conditions has been thought to be of benefit as a
form of pulmonary gymnastics, and iu developing the
expiratory muscles. I5ut the results are of little clinical
value as it is the voluntary muscles which are increased,
not the normal expiratnry forces of pulmonary and tho,
racic elasticity.
The value of this form of pneumatic differentiation de-
pends solely upon its action on the eireulation. Respi-
ration under negative differentiatiou results iu:
1. Reduction of vascular tension iu both the systemic
and the pulmonary circulatious.
2. Depletion of Ihe pulmonary vessels with venous
hypera'iiiia of the sy.stemic circulation.
3. Slowing of the entire circulation, both systemic
and ]Milnionarv.
4. Mild an.-emia of the cerebrospinal vessels.
The manner in which these conditions are developed is
obvious. While the barometric pressure of the respired
air offers no increased resistance to the pulmonary circu-
lation, and hence no impediment to right heart action,
the lower pressure on the cutaneous surface becomes
essentially a suction force influencing all the .systemic
circulation, save that of the brain and cord, which are
protected by their bony envelope. As the result all the
systemic vessels, and particularly the capillaries, are di-
lated, vascular tension is lowered, and for a moment the
circulation is hastened as the blood is drawn from the
lung, lint with the continuance of the differentiation
the contracting arteries gradually force a rehitive excess
of blood into the veins, from whence it passes more
slowly to the pulmonic vessels which are under the
higher barometric pressure. The coincident slowing of
circulation and pulmonary ana-mia are such that a strong
man can hardly lireathe five minutes under a negative
differentiation of one inch of mercury without marked
dyspuaia. C'linieall}', therefore, this motion must be al-
ternated with negative pressure, which increases the pul-
monary circulation.
The pathic conditions to wliich negative differentiation
is applicable are: ('0 pulmonary hemorrhage There is
no measure at our command which so quickly arrests
bronchial hemorrhages. It is an almost universal im-
pression that pneumatic dilfereutiation of necessity
causes abnormal exiiansion of the lung, and is therefore
dangerous in all cases of hemorrhage, or where there is
softening of pulmonary ti.ssue Such is not the case, and
negative differentiatiou may be applied with even less
than normal expansion of the chest. It is, therefore, of
value (/') iu all forms of acute iullammatory hyperannia
of the lung or pleura. It affords immediate relief in
((■) pulmonary congestion from any form of cardiac dis-
ease, except mitral obstruction, and is the proper motion
with which to begin the treatment of any organic cardiac
or arterial disease, with the above excei^tion. In all of
the above conditions after the acute processes have been
relieved, negative differentiation should be supplemented
or replaced by forced ins])iration.
Forced Iiinp/nitinii. — The etTects of this motion are of
two distinct forms, mecliauical and circulatory. The
]Hilmouarv expansiou, the opening and clearing of col-
lap.sed and plugged alveoli, and the sirefehing of pul-
monary and pleuritic fibroses attained by means of the
pneumatic cabinet do not differ in themselves from the
corresponding effects of compressed air. The clinical re-
sults, however, are verj' greatly superior by reason of
the coincident effect of the cabinet upon the attendant
pathic processes through its control of the circulation.
In this motion, during inspiration, which takes place un-
der negative differentiation, the action upon the circula-
tion is the same as with negati%-e differentiation alone.
It is greater in degree since a higher differentiation can
be employed when the patient is to expire into rarefied
air. With the decrease iu cutaneous pressure the vessels
are dilated and the blood is drawn from the lungs through
the heart and arteries into the veins with a quickened
flow and lowered tension. Before tliis action reaches the
point of slowed circulation inspiration is ended and the
differentiation instantly changed to negative pressure,
under which, although the absolute pressure on the cu-
taneous and pulmonary circulations is the same, there is,
nevertheless, a relative negative difTerentiation in favor
of the iiulnionary vessels due to their weaker anatomical
protection :uh1 siijiport. A pulmonary suction is thus
developeil which tlraws tfie blood from the hypera?mic
veins into the depleted pulmonary vessels, again with
quickened flow and under lowered tension. Thus dur-
ing each res|)iraforv C3'cle a double negative differentia-
tion is developed alternately iu favor of the systemic and
the pulmonary circulations.
Continuance of this process results in increase of both
circulations with all which that implies of increased ab-
sorption and improved nutrition, and this, too, under de-
creaseil vascular strain.
It is Ibis jiowcr of the cabinet to liasten circulation and
diminish arterial strain which distiuguishes it from all
67U
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pnpiiiuatic Cabinet.
Pneutuouia.
Other forms of apparatus for the use of pneumatic differ-
entiation, and which renders it tlie most potential meas-
ure for tlie relief of very varied conditions. All the me-
clianical effects of compressed air may be attained by
forced inspiration, with the addition of improved tissue
nutrition. This motion is valuable in all forms of iiillam-
matory ijidmouary disease after the acute stage. All
pulmonary and pleuritic fibroses are loosened and ab-
sorbed much more quickly than by any other means.
The effect of forced inspiration upon all forms of organic
heart disease, with the exception noted under negative
differentiation, is more immediate, satisfactory, anil pro-
longed than that from any other method of treatment.
Cardiac angina and dyspna>a are speedily relieved, often
within a few minutes, and in young subjects this relief
often becomes permanent after a few treatments. Cases
of aortic regurgitation give especially brilliant residts.
In all conditions producing high arterial tension also,
this measure affords very marked relief, the extent and
duration of which depend, of course, upon the nature
and continuance of the primar}' cause. The treatment
does not cure Bright's disease, but it does relieve and de-
lay the secondary arterial and tissue changes.
C/iiirlcs E. Qnimhy.
PNEUMOGASTRIC NERVE, RESPIRATORY FUNC-
TION OF. See Itespiratiou. ^
PNEUMONIA, BRONCHIAL— (Synonyms: Broncho-
piii-uiiiiiniu, catanlial imeumonia. lobular pneumonia,
capillar}' linmchitis, etc.) The name bronchopneumonia
is growing in favor, especially in this countrv. and is
preferable. The condition is marked b}' the presence of
bronchitis with areas of pneumonia. The latter are as a
rule peribronchial, being confined to the immediate vicin-
ity of the small bronchi, the bronchioles and their atria,
tlie cells adjacent to which are filled with exudate.
Etiology. — The disease is most common in the ex-
tremes of life, that is, in the aged and in children under
five years old. Of the cases occurring in children, about
one-third are primary, the others being secondary most
often to the diseases of childhood. Of these, measles is
most frequentlj' complicated by bronchopneumonia, and
after this come pertussis, diphtheria, scarlet fever, influ-
enza, and chickenpox. It will be noticed that these are
diseases in which bronchitis is regularly present, or in
which the upper air jjassages are involved in the morbid
process. In older children and adults the disease maj'
occur as a complication of anj- long-continued, severe ill-
ness, especialh' in those cases in which the mucous mem-
brane of the mouth and pharynx becomes foul and the
laryngeal reflexes are less effective than normally.
The predisposing causes in primary cases are old age
or infanc}', bad hygienic surroundings, the impure air of
overcrowded, poorly ventilated rooms, bad feeding, and
institutional life. We must also include among the pre-
disposing causes the frequent presence of the diiilocorcus
pneiunonia^ and other pathogenic micro-organisms in the
healthy air passages.
The exciting causes are sometimes difficult to discover.
Exposure to cold and wet is one cause, and this accounts
for the greater frequency of the disease in the cold
months. The predisposing causes of secondary broncho-
pneumonia are the same as those of the primarj- form of
the disease, plus dorsal decubitus and the weakened con-
dition due to the original disease. The exciting cau.ses
are again hard to determine. Exposure is one. but there
is a something in addition which favors the growth and
multiplication of the micro-organisms usually present,
even in health. In cases of deglutition pneumonia the
exciting cause is manifest.
The development of l)ronchopneumonia in old penple
is favored by the diminished powers of resistance and the
le.ss jierfect expectoration.
B.^CTERiOLOGY. — In Studying the flora of bronchopneu-
monia we have again to distinguish between primary and
secondary cases. The micro-organisius most commonly
found are the diplococcus pneumoniae, streptococcus,
ius.
staphylococcus aureus and alhus, Friedliinder's baci
and Loeffler's bacillus.
In neariy all of the primary cases the diplococcus
pneumonise is present, and in about half of the.se it exists
alone. When not alone, it is most often associated with
the streptococcus and much less frequently with the
staphylococcus and the other organisms just mentioned.
Infrequently the streptococcus is found alone.
In secondary cases it is the rule to find a mixed infec-
tion. The diplococcus pneumoni;e appears in about
seventy -five per cent, of the cases, but seems less potent
in giving character to the disease than the .streptococ-
cus. The diplococcus pneumonia', the streptococcus, the
staphylococcus, and Friedliinder's bacillus may each be
present alone, unassociateil with other bacteria, l)ut in
the case of Friedliinder's bacillus, at least, this hajipcns
only rarely. Although, generally speaking, the strepto-
coccus plays the most important part in bronchopneu-
monia complicating measles, it is precisely in this form
that the diplococcus pneumonia' is more often found in
pure cidture than in other secondary cases.
Holt reports six tiiberctdous cases which were sttidied
by Wollstein, and in all of which the diplococcus pneu-
monia; was also found; indeed, this organism gave the
character to the disea.se in these cases, as clinically they
were indistinguishable from tho.se of an ordinary broncho-
pneumonia, the post-mortem examination alone" revealing
their tuberculous nature.
Bronchopneumoina has in rare instances been found to
be due to forms of streptothrix, and I'reucli investigators
have reported the finding of the colon bacillus.
Indeglutitiou-pneunKinia the streptococcus and stapli}'-
lococcus are most commonly found, and then, as a ride,
in virulent form.
P.\THOi,OGic.\i, An.\tomv. — In about eighty percent,
of the cases coming to autopsy, lesions have been found
in lioth lungs. These lesions consist essentially of those
of bronchitis and of jmeumonia.
AVhen the chest is opened the pleural cavities are seen
usually to contain little or no excess of fluid. The pa-
rietal and pulmonary ])leuial surfaces may be normal or
the seat of a fibrinous pleurisy. The lesions of the latter
consist of patches of fibrin which vary considerably both
in extent and in character. At timesthey are almost in-
visible lustreless spots, and then again they may be quite
large and thick (as nuich as half a centimetre thick) and
more or less discolored. Such patches correspond closely
to areas of superficial pulmonary consolidation.
The lungs do not collapse as completely as they nor-
mally should, though crepitation is found quite generally
when the lungs are handled in the search for nodules of
consolidation. The latter are most often found in the
lower lobes posteriorly. There may be found collapsed
areas, bluLsh or
bluish-brown in
color, set in a
lighter back-
ground. These
are areas of sim-
ple atelectasis,
and will yield to
gentle inflation
through a tube in-
serted in a bron-
chus. The bron-
chial nodes are
invariably con-
gested and en-
larged. The heart
— the right side
more commonly —
may be dilated.
On section, the
pneumonic areas
stand out a little,
are of a dark mahogany color, or more or less marbled
with gray, smooth or finely granular, and moderately
wet; only a small amount of dark blood escapes from the-
Fig. :t82ti.- liroucln 'pneumonia. Kxiulale in
an air ceil, ronsistini? of exfoliated cptitie-
liuiii. a few pus eells, and a tittle flljrin.
(From DelaBeld and Prudden.)
6YI
]*llelllli<>lliH«
I'lii'iiiuouiat.
REFERENfE HANDBOOK OF THE JIEDICAL SCIENCES.
vessels. Such ai'cus vary greatly in size, aiid may be close
tnn'etlier or widely separated. Near the centre of each
-a bronchus is seen, white or sray. because of the exudate
which it contains. The unconsolidated lung tissue may
ric. ;is2r.— iiiwN. i.^ri.i,. di,,..i.i., ,,, .1 1 ..i,..
iiionii^ Area, wiili lirunrbus m its ( *'n
latter merges into tin- sunniiiuUni^ zom- <
the acouuipauyinii: eiiipliysi'ma is slauuu.
.--li^/.. iiitr siriirle Lolmlar Pii<-u-
n: Till' tiai'kenca wall of tlie
li pni'uinnnja. Near the (■lh-ium's
I From Delalleld ami I'nuli ten. )
r
be normal, but more often it is congested and cedematous,
particularly beliiud. An (;mpliysema, usually vesietdar,
isoften present, being most ]u-onounceil anteriorly. Upon
section of the areas of atelectasis, dark tluid blood escapes ;
tlie cut stirface is seeu to be smooth, with occasional
lobules pi'ojec-ting aliovc it. Creamy pus can be pressed
from the smallest lu'onchi : portious carefull\' removed are
found to contain 110 air aiid they sink in water.
With the aid of the uiicr'^seope we see that the exu-
date williin the bronchi of the consolidated areas is com-
po.sed of leucocytes, mucus, desquamated epithelium in
various stages of disintegration, a few red blood cells, and
the inicrii-organisms responsible for the condition. The
walls of the bronchioles and brcnchi are swollen and in-
filtrated with new small round
cells with more or less indis-
tinct contours and hax'ing huge
nuclei. (See Plate XLIX.)
Northrup menlions a me-
chanical dilatation of the small-
er bronchi. These dilatations,
which are for the most ]iart
fusiform in shaiie, are found
with especial fre(|ueucy in tlie
lower lobes. They are asso-
ciated, according to this au-
thority, with three conditions:
(1) Weakened bronchial walls;
(3) abundant secretion within
the bronchi; and (3) im]ierme-
able tissue surroumling them.
The dilatation is due to the
^^eretion being forced by eacli
inspiratory impulse from larger
to smaller bronchi. The proc-
ess, which is observed in chil-
dren l)(t,weeu three and live
years of age, occurs more often
after the'tifth day of the dis-
ease. The dilatations disap-
pear entirely on tlie recovery
of the |)atient.
As the walls of the bronchi-
oles an; swollen and infiltrated
with new cells, so also are those of the atria and of the
air sacs, including the partitions between the air cells.
The caiiillaries are engorged with blood and small hemor-
rhages may be noted here and there. The air cells, air
sacs, and atria are filled with leucocytes, swollen desi|iia-
mated e|iitheliuin, occasionally a IV'W red bliwjd cells, and
sometimes also a little fibrin.
In deglutition- or aspiration-bronclioimeumonia the
process is more intense, the infiltration with leuco-
cytes often resulting in supptiraiion and gangrene.
In the areas of atelectasis tlie bronchi are seen to
be tilled with pus and swollen and detached epi-
tlielia, and the walls of the bronchioles are intillrat-
eil; the air cells and sacs are partially collapsed,
the diminished lumen being filled with swollen and
proliferating cpitliclia and pus ceils. The blood-
vessels are tortuous and gorged with blood. Heie
and there are hepatized lobules. In some cases the
emjihysema is very marked (.see Fig. ;-!828).
The bronchial l\'mpli nodes may or maj' not show
a cellular infiltration. They are always congested.
Symptoms. — The symptoms may be most ob-
scure, even misleading, making it almost impiossible,
for a period of several days, to reach a correct di-
agnosis.
I'viid fomal SympiomH. — In primary cases, as in
acute bronchitis, the oaify signs are a general mal-
aise with more or less anorexia, slight elevation of
tein]ierature, acceleratiou of juilse and resjiiration,
and cough, dry or with mucous exjiectoratifin in
patients old enough to perforin that important act.
The invasion ni.ay resemble that of lobar pneu-
monia, being marked by a chill or convulsion and
by ra|ud rise of temperature to 103' or 104' F. or
over; or the inx'asion may ]iresent no characteristic ft-at-
urcs, the symptoms resembling those of typhoid fever
or meningitis. In the cereln-al cases there may be re-
]ieated convulsions, apathy, photophobia, retraction of
the head with rigidity f)f the neck, and an absence of
physical signs of consolidation.
Ill seroiuliiry cases, the jirodromal symptoms and the
invasion are masked by the symptoms of the primary
disease. The invasion is gradual, seldom marked tiy a
chill or convulsion, the child becomes restless, the fem-
perature rises, and the pulse-respiration ratio diminishes,
if there was a cough before, it becomes worse, ot one de-
velops if there was none previously. If there is any
expectoration it is mncn-punilent in character. An early
%X::^^:f
•^-.-.''^
Is
i
ss;is. — Bronrliopneiiinonia in an ,\tiult, simwiii*^ Several .\reas of ConsolidatioTi, witli the
'tiiral nniiiiliiis I'MIIed Willi F.xiidaie. Marked emphvseiua uiav also be seeu lu parts of the
■rlioii. iFloiu lielaUeld and I'ruddeli.)
symptom may be the cough. — painful, frequent, and
hacking, — and it often continues after resolution has
taken placi'.
The temperature varies according to the extent of the
672
REFERENCE HANDBOOK
OF THE
MEDICAL SCIENCES
PLATE XLIX.
<SiHi3-*
'1 mmf^^^^-'^-^y'MK r
^J'»_J <^°-*-
'-S.ljJ
t^-
</
- kB
X,
%^^^F#ys If
5
J
IJ'
3"
c1'
.^
^m
'j^
^Q
kJ^-?^«~x-4* an
/
"•rA^-V ^^
?>T
.i-
/'
V '
-^^
^^,
k^
'f^^~^-^^\^^^
-s,"^
ACUTE BRONCHO-PNEUMONIA
D^^lCCll~^^l trDf~nji riCi Ariiri ric c-riinnrc ihi ci*ti_u-m /-m
(COPIED, BY PERMISSION, FROM DELAFIELD S STUDIES IN PATHOLOGICAL ANATOMY.)
REFERENCE HANDBOOK OF THE 3IEDICAL SCIENCES.
Pneumonia.
Piicuiiiouia*
lesions, tin- virulence of the iufection, and the general
coudiliou of the patient ; upparently also it is inllueueed
by tlie variety of micro-organism iiresent. It may rise
slowly or very siuUlenly, as a rule to lOo' or 104 F., and
it averages moderately high, with sharp elevations, most
often in the afternoon, hut at times in the early morniug.
The variations in the temperature curve gradually be-
come less and less; in favorable cases the general trend
i-i dowuwaril, restoration to the normal being by lysis.
In unfavorable cases the trend of the cur\-e is constantly
upward, the temperature sometimes going as high as
107" F, The temperature may be of a high, continued
type, this usually portending a fatal issue. On the other
hand, in greatly debilitated subjects the temperature
may rise little if at all above 100' F. The usual termi-
nation of such cases also is death.
Pain is not a constant symptom, and as a rule it occa-
sions little trouble.
Cyauo.sis is quite common, but there is little or no
dys])n(ea. When it is caused by atelectasis the temper-
ature remains unaffected or falls a little. The skin is
often cold and clammy. These sjinptoms disappear
upon the removal of the cause of the atelectasis, and the
patient is then about as w-ell as before the attack. If the
cyanosis persists for more than a day or two, however,
tiie result is a fatal one.
In well-marked cases, the respiratory rhythm is
changed. Instead of the inspiratory murmiu- being
nearlv continuous with the expiratory, the pause whicli
in health was after e.vpiratiou and before inspiration, is
now transferred and is after iusidraticm and before ex-
piration. The child tiuickly draws its breath, holds it,
then with an explo.sive .grunting sound expires and with-
out pause inspires. The expiration is iirolonged and
loud. There may be Cheyne-Stokes respiration.
Gastro-enterie s_vmptoms, such as loose green stools
without vonnting, are frequent in infanc_v. The urine
may become scanty, high colored, and with a trace of
albumin, but casts are rare.
In cases ending in recovery amelioration of all symp-
toms may occur at an}- time from the fourth day to the
third or fourth week. In mild cases it is looked for from
the fourth to the eighth day.
Resolirtiou takes from seven to fourteen daj-s in favor-
able cases. Relapses are common.
Phj/aical Signs. — It may be that for days no signs at
ail can be discovered within the chest, and it frequently
happens that no signs of consolidation are found at any
time during the course of the disease. In i^rimury cases
the tirst signs are due to congestion and bronchitis; thej'
are either localized in one or more areas, or are generally
distributed. The results of percussion may be negative,
or there may be slight dulness. On auscultation we de-
tect feelile breathing, which later has a higher pilch over
the affected areas, and is associated with tine sibilant
and coarse sonorous rales of the same or of wider distri-
bution. These rales may di.sappear when the patient
coughs. A little later, very fine moist rales are heard,
as a rule, only over one or more areas, usually in the
lower lobes behind. The vocal fremitus is luialtered.
In such cases the pneumonic areas are deeply seated,
small, and scattered.
The signs of consolidation, when present, vary accord-
ing to the degree of consolidation, the area involved, and
its proximity to the chest wall. In well-marke<l cases
percussion reveals the existence of dulness in varying
degree, associated at times with a sense of resistance.
The vocal fremitus is increased only over areas of fairly
complete consolidation. Auscultation reveals the pres-
ence of the rales above mentioned, only they arc more
marked and ajiparentlv closer to the examining ear; the
breathing is bronchovesicular or diminished ; the voice
soiuuls ajiproach the bronchial in character. In the cases
in which there is a consideralile area of complete consoli-
dation, the signs mere nearly approach those of lobar
pneumonia, a disease which occiu'S in yotmg children
more often than was formerly believed. Tlie dulness
and vocal fremitus, however, are less than one would
Vol. VI.— 43
expect to tind with voice and breathing of such a bron-
chial character. The signs of bronchitis are rarel}' gen-
eral, and are most numerous in and near the edges of
the consolidated areas. Friction sounds are infrequently
present, usually oidy in cases of complete consolidation
extending to the pleura.
It may be necessary to make the patient cough in order
to develop the sounds of bronchitis, or crying may bring
out, in an area of dinuinshed voice and breallung, a
marked bronchial quality. In extreme cases the breath-
ing becomes shallow and very rapid, 80 or more to the
minute, with retraction of the xiphoid and ribs and play-
ing of the alaj nasi. The right ventricle of the heart
may be fotnid increased in size.
When resolution begins the signs of consolidation,
which were the last to come, are the first to go. They
may disappear very rapidly or they may persist for days
or weeks. The signs of bronchitis subside less rapidly,
often being found as late as from two to four weeks after
resolution has begun. The blood count, as a rule, reveals
a decided leucoej'tosis ; in influenza pneumonia, however,
it is only in exceptional cases high.
Complications. — ^ We- rarely find any pleurisv, except
when there is marked pulmonary consolidation that
reaches to the pleura. The simple fibrinous pleurisy is
the most common.
The possibility of empyema must always be borne in
mind. Abscess of the lung complicating bronchopneu-
monia is found in about seven per cent, of the cases that
come to autopsy ; these abscesses are usualh' minute and
multiple, and not clinicall_v discoverable. Gangrene is
less frequent. Tubercidosis may complicate any bron-
chopneumonia, and in fatal cases cannot be diagnosed be-
fore death.
As in lobar pneumonia, so in bronchopneumonia, a
purulent meningitis maj' occur, and may mask the symp-
toms of the i>rimary disease.
Pericarditis is foimd at times, almost always in cases
in which there is marked consolidation in the left lung.
The rarity of endocarditis makes it hardly worth men-
tioning.
It is common to find functional derangement of the
.gastro-intestinal tract, as shown by vomiting and diar-
rhea, which are serious, not in themselves, but in that
they reduce the patient's chances of recovery in the
other fight.
Nephritis is not a common complication, and when it
does occur it is usually of an acute exudative type and
does not much affect tlie course of the original disease.
Di.iGNOsis. — Tlie diagnosis of primary bronchopneu-
monia from lobar pneumonia is at times very dilficult.
It mu.st be made on the age, history, and mode of inva-
sion, on the character of the temperature, on the sputum
(when there is any), and on the physical signs; the latter
alone furnish positive evidence.
The diagnosis from pleurisy with effusion or from
empyema must be settled by an exploratory puncture,
several dry taps ■with a large-calibre needle being neces-
sary to establish the absence of fluid.
As an aid to diagnosis in uncertain cases, in children
two years of age or under, Northrup gi\-es the three
following points:
1. The pulse-respiration ratio tends to depart from the
normal, which is as four is to one, and aiiproxinial^s or
exceeds tliree to one. For instance, instead of being
80 to 20, it approximates the ratio of 120 to 40.
3. Fever; persistent elevated temperature, whether
remittent, intermittent, or uniform.
3. Rtiles; subcrepitant and crepitant over a circum-
scribed area or areas, and especiall}' if these ri'iles are
found on one side only.
Malaria is excluded by the absence of malarial organ-
isms, by normul .spleen, and by no history of exposure in
malarious regions; the presence of leucocytosis also ar-
gues against malaria.
TuEATMENT. — No treatment directly influences the
pneumonic process. jMuch, however, can be done to
prevent the development of the disease and to help
G73
Put'iiiiionia.
Piii'iiititfuia.
REFERENCE HANDBOOK OF THE IMEDICAL SCIENCES.
the patient pass safely through it, when once it is estab-
lished.
1 would outline the treatment under the following
heads: (1) Prophylaxis. (3) (Jcneral management of
the disease. (3) t)iet and feeding. (4) Sjieeial treat-
ment: (rt) by drugs; (4) by serum therapy. (5) Sympto-
matic treatment: (o) to relieve paiu ; (b) to lower the tem-
peratiu-e and moderate the nervous symptoms; (f) to
stinuilate the heart, in order to prevent cardiac failure
or to overcome it- if present; ((/) to stimulate respiration.
Prnphylactic treat iiniil is very important. Care must
be taken to see that children are sufficiently cicithed yet
not overclothed ; that they are much out of iloors, and
that while indoors they are in well-ventilated rooms, with
a temperature not over 08 or 70 F. during the day and
a few degrees lower at night. Children ill with any dis-
eases, particularh- those that are most likely to be com-
plicated by bronchopneumonia, should be turned often
in lied, now on one side, then on the other, now on the
back and then on the abdomen. Bronchitis in an infant
should Ije mnst carefully treated, as such cases, es|ieeially
if neglected, are very' prone to develop bronchopneu
moniii. Inall casesthe mouth should be carefully washed
at least once daily, preferidily witli some alkaline anti-
septic solution; and antiseptic nasal sprays are advisable
as ]u-eventive measures.
Udiinil. Treatment. — Infants are better for lieing much
held in the nurse's arms; older jiatients are to be put to
bed at once and the bowels moved by calomel, in doses
of one-tenth of a grain every half-liour or every hour for
ten doses, or until the desued eliect is obtained. The
sick-room should be large, light, and well aired; there
shoidd be a steady renewal of the sujiply of fresh air.
and — if it is deemed advisable — additional moisture
slioidd be imparted to it. A change of rooms several
times in the twentj'-four hours is the liest arrangement.
provi(hd all of the windows of tlie one which the ]ia-
ticnt leaves be opened wide so that it may be in the best
condition upon his return. An open fireplace is an
excellent ventilator. AVlien the patient's temperature is
Idgh the temperature of the room may be at from 6.5' to
68° F. ; when the patient's temperature is normal, the
room temperature shoidd be 70 F. The chest had better
be protected by an oiled-silk jacket throughout the at-
tack, and the skin of tiie chest may advantageously l)e
kept red by some light aiiidicatiou of mustard. Tliick
hot pcniltices should not be \ised.
It is well to establish a luore or less strict isolation, and
to disinfect the patient's rooms and their contents before
they are used by another person. Especially sliould tliis
be done in secondary cases.
Great care should be exercised in the management of
the diet, as the turning of the tide one way or the other
often depends upon it. Plenty of cool water, noticed,
should lie at hand, and the patient sho\dd In- encouraged
to drink it.
Sjieeial Treatment. — Drugs can often be given to ad-
vantage by inhalation. Tlie child should be placed im-
der a tent and some kind of a vaporizer employed. A
variety of drugs may be added to the water or it may be
used by itself. The addition of creo.sote gives particu-
larly good results. Turpentine, com|)ouuil tincture of
benzoin, and terebene may also do good service when
exhibited in this way. The iidiaiations should be given
for from eight to fifteen nunules at a time, every two to
six hours. " The cough is often greatly relieved by such
inhakdions. The adnunistration of drugs which, it is
believed, can make the blood a less favorable medium
for bacterial life, is not to be considered in the case of in-
fants and young children.
For aec'omplislnng this purpose we must look to the
better iireparation and tisc^ of serum thera)iy, which is
now oidy in its incipiency.
Si/mptomatic Treatment. — Pain severe enough t<i de-
mand the administration of some form of opium is un-
usual. When such a condition does e.\ist, small doses of
Dover's powd<'r are quite ellieient. Ordinary tempera-
tures, sav those under 104 F. rect;il, do not in tlient-
selves call for special treatment. However, it may be
advisable to apply cold, when this degree of temperature
is reached, in order to control the nervous symptoms,
such as sleeplessness, restlessness, or delirium. In some
cases Holt gives for this purpose one .grain of phenacetin
every two hours to an infant of six mouths.
The cold is best applied by cool or tejiid sponging, or
by packs. The spongings are to be frecpiently repeated
until the symjitoms for which they are given are con-
trolled. Both cardiac and respiratory stiiuulants may be
needed. Of the lirst class we will mention alcohol in the
form of lirandy or whiskey, stryclmine. nitroglycerin,
and caffeine. None of these is to be administered as a
routine treatment. As a matter of fact, however, veiy
many, indeed nearlj' all, patients with secondary broncho-
pneumonia need cardiac stimidation, the chief indication
for such being a weak, rapid, irregular pulse. The
physician sliould determine how much alcohol it is de-
sirable to give in the twenty-four hours and have it ad-
ministered in small divided doses, well diluted with at
least from six to eight times its bulk of water. A child
one year old may need only half an ounce of brandy dur-
ing the day, or he may need as much as two ounces. The
dose, whatever it is, should be reduced as soon as possi-
ble, and the alcohol should not be continued for too long
a time. Nitroglycerin may be used to lielp the heart
over a partieulaily hanl strain. To a child of the age
mentioned above, gr. -i-^ji-TBtt <^'»> be given eveiy hour for
several (hises, say five or six. Str3'elmine is not to lie
given so frc.'cjuently as alcohol or nitroglycerin. To a
child of the age mentioned gr. ^-J^ to gr. -j-i^ of strychnine
maybe given every three or four hours. It is often best
to u.se two of these drugs, giving them alternately. The
effect of calfeine is less certain and the drug is not so
much used as the others for its etfects upon the heart ;
as a res|iiratory stimulant it is better.
The seat of the disease being in the Itings, it is very
natural that respiratcpiy stimulants should be called for.
Strychnine helps here iust as it does in cases of cardiac
failure, and in addition to it we can use atropine, caf-
feine, and oxygen, all of which may be necessary in cases
of respiratory failure. We should not wait until the jia-
tient is in e.it re mix before giving oxygen; when adminis-
tered it should be considerably diluted with air.*
After an attack of bronchopneumonia general tonics
are indicated, and it is especially advisable for the ]ia-
tient to have a change of air, preferabl}- to a warm, tiry
climate, where he should remain for several weeks.
PKOf4Nosis. — This must always lie guarded, for bron-
chopneumonia is a dangerous disease. The mortality of
all cases, considered together, is between sixty and sev-
enty per cent.
The mortality of primary cases varies greatly, viz. , from
ten to fift_y jiercent., depending iqion the previous condi-
tion of the jiatient. upon the virulence of the infection, and
upon whether the child is an inmate of an institution or
not. In private jiractice the maximum mortality is
about thirty per cent.
In .secondary institutional casesthe mortality of infants
under one year of age is appalling. In certain diseases
it reaches and stays at fine hundred per ci'iit. for months
at a time.
The progno,sis depends ui>on the child's age. surround-
ings, and previous condition, and upon the nature of tlie
infection. Rachitic children developing lironchopneu-
monia are almost sure to succumb. lironchopneumonia
is most fatal when associated with iierlussis, next with
measles, and then with diphtheria. This order, liow-
ever, is a matter about whieli statistics differ.
Holt says the shortest cases are the most fatal; that the
only termination under ninety-six hours is a fatal one,
and' he says further tliat, in cases of over two weeks'
duration, the prognosis grows worse with each day of
continued temperature.
Patients havini; a low temperature, little or not at all
above 100' F., are usually in a condition of low vitality,
and consequently about seventy five jier cent, of them
die. The niort;dity of cases in' which the temperature
oi 4-
REFERENCE HANDBOOK OP THE :\IEr)I(AL .SCIENCES.
Piioiiiiioiiisi.
Pucuiiioiila.
reaches 106° P. or over is about eighty-five per cent.
The most favorable prognosis is in cases with a fairly
even temperature curve, one that does not run to either
extreme, and does not vary much one way or the other
from 103° or 104° P., during the period of activity of the
infection.
A steeple chart with great ri.ses and correspondingly
great drops of temperature, simulating;- a pus tempera-
ture, usually indicates a mixed or a streptococcus infec-
tion, and the prognosis is worse than in the cases with
a more even curve.
A convulsion or two at the onset of bronchopneumonia
does not affect the prognosis unfavorably, but when con-
vulsions come later in the course of tlie disease they do
aifect it. and that decidedl_v for the worse.
Bronchopneumonia may terminate in resolution, sup-
puration, gangrene, chronic brouchopneimionia, or death.
Henry E. Hale.
BlBLIOGRAPHT.
Among the works consulteil the following deserve specially to be
mentioned :
Strtimpell : Text-book of Medicine.
Rot<'h : Pediatrics.
Lockwood : Practice of Medicine.
Delatirld and Prudden ; I*athol'it^ira! .Anatomy and Histology.
Nortbiup: Transactions of Med. Soc-. state of Xew York. 1S99.
Miller: .\rticle on " Lnntrs, .\natornv r,f." in Vol. V. of Reference
H.lXriBOOK OF THE MEDICAL SCIE.N'CES.
Grancbfr, Comby, and Morfii : Traite des Maladies de I'Enfance, tome
quatiieme.
Boncbard et Prissand : Traite de Medecine.
Holt: Diseases ■ if Infancy and Cblldbood.
Andrew H. Siuitli : .\rticle on "Lobar Pneumonia," Twentieth Cen-
tury Practice of Medicine.
Loomis and Thompson : American System of Practical Medicine.
PNEUMONIA, CHRONIC — (Synonyms: Interstitial
Cirrliosis of the Lungs, Cliroiiic Interstitial Pneumonia,
Pulmonarj' Fibi'osis. Fibroid Phthisis.)
Chionic pneiunouia is not an indejieudent morbid en-
tity, but occurs as a setpiel of one or more previous or
coexisting pathological conditiousof the lungs or pleui'a.
It is a chi'ouic productive inflammation which may occur
wherever connective tissue is found. It is eucountei'ed
in two chief forms, circiunscribed and diffuse. The cir-
cumscribed form is associated with tuberculosis, gum-
mata. tumors, infarctions, hemorrhages, abscesses, and
every morbid growth, and really is the attempt of the
part to wall oft' the pathological condilicui.
The dilfuse variety is secondary to incompletely re-
solved lobar pneumonia or to acute or subacute broncho-
pneumonia and chronic bronchitis, spreading mostly from
the bronchial walls. It may also be a result of pleurisj',
and is then called by Chai'cot pleurogenous.
Interstitial pneumonia may invade the lung in great
bands, wJiich develop in the normal septa. A potent
cause of intei'stiiial pneumonia is the inhalation, for a
considerable length of time, of dust, as necessitated by
certain occupations; for example, coal-mining, stone-
cutting, and some kimls of work in iron. Zenker calls
this form pneumonokoniosis.
In general arteriosclerosis inflammation of the connec-
tive tissue of the arterial walls extenils to thtttof the lung
itself and results in a diffuse intei'stitial inieumonia.
Chronic pneumonia is, as a rule, unilateral, but in
pneumonokoniosis it is always bilateral. The circum-
scribed variety is, as a matter of coui'sc, distributed ac-
cording to the distribution of the lesions with which it is
associated. When these lesions are close to the pleura
this membrane becomes involved, its two layers being
thickened and adherent. The zones of new connective
tissue about the original lesion contain blood-vessels at
first, but later these become moi-e or less obliterated,
although there is not the same tendency to death of
tissue as is found in tuberculous lesions. About these
zones there is usually pi'eseut a certain amount of em-
physema.
In well-marked cases of the diffuse variety more or less
of the pleura is adherent and greatly thickened, and the
affected lung is smaller than normal and cannot he sepa-
rated from the chest wall without tearing. The lung
feels fli'iu and leatheiy. The heart may be di'awn to the
affected side, and its right half may be hyperti'ophied.
On section the pleura is seen to be tough, filirons, and
of a grayish color. There is often a creaking sound as
the lung is cut. The cut surface is tirm. .shiny, and of
a dirll red or bluish color or marliled. Jlucli pigment is
often present throughout the lung tissue and in the bi'ou-
chial nodes. The walls of the small hrunehi are increased
in thickness and in many places dilab'd. Some of the
dilatations are lai'ge and often contain varying amountsof
pus. The microsco]5e shows the new tissue to be connec-
tive tissue of the small-celled varietj* ; most of the cells
are round, but some are fusiform. There are at first
blood-vessels in this new tissue, but they tend to disap-
pear later; there is, however, as before mentioned, but
little teudenc}' to tissue necrosis. The walls of the atria,
air sacs, and air cells are infiltrated with the new con-
nective-tissue cells, and the air cells may contain organ-
ized exudate.
In the unilateral cases the unaffected lung is enlai'ged
because of the compensatory emphysema in-esent.
Symptoms. — In looking for the symptoms of chronic
pneumonia we first get a history of one or more of the
tliseases which it follows, especially chronic bronchitis or
protracted bronchopneumonia. In the early stages the
patient may feel fairly well, complaining only of cough
with sero- or nnico-piu'uleut expectoration. The cough
is worse in the morning, and is paroxysmal when there
is an accumulation of seci'etion in the lower lobes. As
the process advances there is dyspnoea on exertion. Lv-
ing on the unafl'ected side may cause dyspncea, as it re-
stricts the action of the functioning lung; consequently '
patients with unilateral chronic pneumonia lie on the af-
fected side. With the onset of ulceration a new order of
symptoms is noted, all of them being v.-orse during the
winter seas<m. The sputum changes its character and
becomes a thin muco-purulent fluid, of a gi'a}- or black
color and is often fetid. On standing it separates into
layers; the lowest contains solid particles and is yellow-
ish in color; the next above is a greenish tluiil; and the
top layer is thin and fiothv and contains mucus and fat.
Cavities are formed, allowing of accumulations of pus,
and these in some instances are emjitied by change of
po.sition. Fever, of a hectic type, and night sweats may
be looked for early, and small, frequent h:emoptyses are
common occurrences. With the conditions present giv-
ing such symptoms. It is no wonder that the patient's
geuei-al condition becomes rapidly wor,se. The whole
aspect of the case is that of chronic pulmonaiy tubercu-
losis, excepting that no tuliercle bacilli can be found.
Tliere is no elevation of temperature except during
exacerbations of the bronchitis and after ulceration lias
begun, as noted above. Pain is by no means a constant
symptom. It is present only when the pleui-a is involved,
anil then the diminution of respiratory movement on that
side usuall3' keeps it from being very severe.
For months we may be able to discover only the phys-
ical signs of previous or coexisting disease. Gradually
tliei'e develop signs due to diminution of aUrating sur-
face, thickening of pleui-a, contraction of the new tissue
giving lessened m- absent respiratory movement, deform-
ity of the chest, spinal curvature, and displacement of
the heart. The canliac pulsations are sometimes abnor-
m:illy visible. The dilatations of the bronchi, with or
without contained fluid, also give rise to special sj-mp-
toins. In unilatend cases the imafl'ected side is increased
in size, has increased respiratory nuivements, and shows
the signs of coiupensatoi'y emphysema.
TuKAT.MEXT. — In the management of these cases jm'o-
phylaxis is of the utmost impoitance. All patients with
jiersistent bronchitis, or with protracted or unresolved
pneumonias, and those who have had several attacks of
bronchopneumonia, should receive the very best tonic
trcalment with respiratoiy exercises; and above all, they
should find the climate in which they do best and should,
if possible, live there. When the trouble is due to the
occupation, this must be abandoned. No treatment di-
rectly affects chionic pneumonia when once it is estab-
675
Pneumonia.
Pnciiuionia.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
lislic'd. The tlicrapeutie ciirleavor is IIkm to control the
cough, overcome the fetor of tlie siuitiiiii. .-uul keep up
the general tone of the individual. Tiie patients must
avoid exposure to cold and v.-et. 'I'hey must spend tlieir
winters, at least, in the South, and are belter for living
the j'car around in a dry, warm, ei|ual)Ie clinuite. Mod-
erate daily outdoor exercise and the l)esl of food are very
important.
Diagnosis. — In aiming at a diagnosis of chronic pneu-
monia, we have to consider the possibility of pleurisy,
cancer of the lung, pneiuuothorax, and pulmonary tuber-
culosis.
PiiOfiNOsis. — The outlook for the future comfort and
happiness of these patients depends largely upon their
dispositions and tlieir ability to get to a suitable climate.
No hope of cure can be lield out to them. The disease,
however, is seldom in itself a cause of death. Some in-
tercurrent malady usually terminates the scene.
Uihi-y E. Hale.
PNEUMONIA, LOBAR.— (Synonyms : Croupous Pneu-
monia. Fibrinous Pueumouia, Pneumonitis, Lung Fever.)
The lung dilfers from all other structures in having two
separate eirciilation.s — the nutrient, supplied from the left
side of the heart through the bronchial arteries, and the
functional, supiilied from the right side of the heart
through the pidmonary artery. This doidjle eirculaliou
underlies all the phenomena of pneumonia, and must be
recognized in any dctinition of tlie di.sease, as without it
the disease itself could not e.xist.
Definitiox. — Lobar pneumonia is an acute disease in
which a specitic parasite invades the air cells of one or
more pulmonary lolies, where it grows in a libriuous me-
dium exuded from the functional cajiillaries, and gener-
ates a toxin that infects the system at large.
The local ])rocess causes consolidation of the affected
area Ijy tilling the air cells with the efl'used material,
which material is afterward removed, leaving the struct-
ure of the lung intact. The general infection is marked
by fever, which in a typical ca.se begins with a chill,
and after a duration of from four to nine days ends
abruiilly hy crisis.
In most cases a local dry pleurisy is excited, the phe-
nomena ot which are added to those of the pneumonia
proper.
Di^ath maj- take place from the viri:Ience of the infec-
tion, from loss of respiratory surface, from exhaustion of
the right heart, from consecutive asthenia, or from a
combination of two or more of these causes.
Symi'to.ms and Ci.tNK ai, C'oi'itsE. — The attack may
be preceded by pirodronies,' such as malaise, lieadaehe,
anorexia, pain in the limljs and back, eti-.- But, as a
rule, the first com]ilaint of the patient is of pain in the
chest, usually in the manunary region. This is sudden
in its onset and often very severe, and by restricting the
movements of the ribs renders the respiraljon superticial
and rapid. In most cases a chill follows, or, it may be,
precedes the jiain. The chill varies fioni a mere creep-
ing sensation to a heavy and prolotiged rigor, as severe
as in a case of intermittent fever. With the chill there is
a rise of temperature. The thermometer shows from 3'
to 4" F. of fever during the first twelve hours. ra|iidly
rising until the temperature reaches from 10;j to W'l' F.
or even more. Then there is a [leriod during which the
temjierature is maintained with slight variations until
from the fifth to the eighth day, when a crisis occurs
and the temperature becomes normal, or (iften subnormal.
Cough is an early sym]itom, but it is reiiressed as much
as possible to avoid the severe pain which it causes. The
expectoration is apt to \w frothy at first and mixed with
fiorid blood ; later it becomes viscid and very tenacious,
so that it is spat oitt with dilliculty and adheres like
thick mucilage to the vessel containing it. Its color at
this stage varies in dilTerent cases. It may be a light
yellow, a pale green, or a chocolate-brown, or a mixture
of these colors. It is often likened to prune juice.
Sputa of this kind may be considered pathognomonic.
As resolution progresses the expectoration becomes less
coloreil, less sticky in consistence, and more catarrhal cr
purulent in its character, and the quantity gradually
diminishes until it cea.ses altogether.
Tlie respirations are early increased in frequency,
and this quite out of proportion to the pulse rate aiid
temperature. In nearly every severe case the respira-
tions will go up to 40 or .50 or more to the minute, and
they not infreciuently reach 60 or more when the consol-
idation is extensive, or pulmonaiy oedema takes place.
This disjiropfirtionate frequency of respiration is very
significant. The pulse is full and strong in the early
stages, running from 90 to 100 when the temperature is
103° to 104" F., and becoming weaker and more frequent
as the disea.sc advances. When the respiration is greatly
embarrassed the pulse is apt to be small and creeping.
The skin is hot and dry at first, later there is a ten-
dency to iierspiration, which may be profuse. The face
is pale, with often a dusky red patch on each cheek.
The lips are inclined to a bluish hue in propiortion to the
degree of pnlmonarj' implication. They are often the
seat of an herpetic eruption.
After the first forty-eight hours the chlorides in the
urine are greatly diminished, or entirelj- absent. In
severe cases a moderate degree of albuminuria is common
during the height of the disease.
The physical signs begin to be appreciable, as a rule,
within from twelve to twenty-four hours after the initial
chill. Usually the first to be noticed is a fine crepitant
rille, heard only with inspiration, though in some cases
this is preceded hy a diminished clearness of the respira-
tory murmur. Dulness on percussion succeeds, increasing
iu intensity as the consolidation becomes more complete.
Ultimatel}' the respiratory murmur is wholly replaced by
a peculiar whiffing sound heard most distinctly to-\\'ar"d
the close of expiration, the so-called tubular breathing.
If the pdeura is involved there may be a nibbing or creak-
ing sound in addition. There are increased vocal reso-
nance and vocal fremitus. At the crisis, while the tem-
perature falls and the jjulse and respiration become less
frequent, there is no immediate change in the physical
signs, showing that the condition of the affected area
remains the .same.
In a large ]u-oportion of cases of pneumonia there is
decided leueocytosis, the white cells numbering 20,000,
30,000, 40,000 or more to the cubic millimetre.
Variations from the above course are common. The
pain may be entirely absent, or it may be felt at a point
outside the chest, as for instance in the abdomen. The
chill is absent in about one-third of all ca.ses. The sub-
sequent severity of the attack seems to be in some degree
proportioned to that of the chill, but this rule has many
exceptions, especiallv in advanced age. The tempera-
ture begins to rise from the moment of tlie attack, and
increases witli slight fluctuations until the maximum is
reached. In cases that pass the crisis tlie highest point
is usually a few hours before the decided fall takes place.
When death takes place before the crisis, the higliest
point often immediately precedes dissolution, wlu-n it
may reach 107 \ 108 , or even 109' F.
When defervescence occurs by crisis, which is usually
from the fifth to the eighth day, the temperature falls
within a few hours almost or quite to normal. This is
;ipt to occur during the night, and it often happens tliat
the patient is left at the evening visit with no sign of an
approaching decline of temperature, yet the next morn-
ing is found in an almost afebrile condition.
Within a day or two after the crisis the temperature
very often becomes subnormal.
In a considerable proportion of cases instead of crisis
there is a gradual fall of temperature until the normal
line is reached. This defervescence by lysis may be eom-
jdete at any time between the third and the fifteenth or
twentieth day.
DiUriinn. — As the pyrexia increases, delirium is pretty
frequently observed. "Occurring early, and in persons
having a tendency to cerebral disturbance in the presence
of fever, it may have but little significance, but in other
cases it is due directly to the infection, and it then points
G76
REFERENCE HANDBOOK OF THE ]\rEDICAL SCIENCES.
Piieiiiiiouia.
Pueuiiionia.
to a condition of considerable frnivit}-. Old persons are
especially liable to a quiet delirium resembliug that of
typhoid fever.
Sleeplessness is not at all uncommon, and should al-
ways suggest an inquiry into the haliils of the patient.
In children often, and very rarely in adults, convul-
sious take the place of the initial chill.
Cause.s of Deat/i.—DijiiUi may occur in a variety of
■ways. The patient may be overwhelmed by the intense
virulence of the infection, death occurring within from
thirty-six to forty -eight hours after the chill. iVjipar-
eutly all the vitarfunctions are overpowered by the tox-
a'lni'a. There is extreme muscular and nervous prostra-
DAY OF
DISEASE
S
1
1
u
HOUR
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a
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i3
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tion, the heart'sactiou becomes rapid and feeble, digestion
TEMP.
C. F.
41.1° 106°
40.5° 105°
40.0° 104°
39.4° 103°
38.8° 102°
38.3° 101
37.7° 100°
37.2° 99°
.36.6° 98°
36.1° 97°
90°
1
1 t
is suspended, the kidneys act imperfectly, delirium and
-
1 i
coma supervene, and death occurs from acute asthenia.
1
Iu other cases death is caused by cxliaustiou of the
right heart. The muscle, already enfeebled by the action
of the poison, tires out from overwork, dilatation aud
over-distention follow, and finally, failure to contract.
Still another cause of death is loss of respiratory sur-
face. Tliis is rarely the result of simple pneumonic con-
solidation, but there are added to this, congestion and
"J
^ , . J
i ^
oedema of other portions of tlie lung. The lung fills up
~^
/
'""T^-^
more and more, and death by asphyxia takes place.
\
Not infrequently death comes from exhaustion of the
X
vital ])0wers after a prot.ractcd struggle which the sys-
:
tem is no longer able to endure. This is common in
feeble and aged persons, aud occurs usually after the
febrile period.
Lastly, death may be caused by oue or more of the
complications of the disease.
In addition to the foregoing, sudden death inav occur
n
-^ -^n
1 1
I 1
1
1 '
at auv stage of the disease in a manner which, with our
, . . .
present knowledge, cannot be accounted for, aud for
which there is no anatomical explanation.
PATnoLOGY. — Aiitopxiciil Fuiihiiys. — These correspond
to a process extending from simple hyiier^mia through
extreme engorgement, fibrinous and cellular exudation
into the air cells, complete consolidation, fatt}' degenera-
tion of the exudate, and removal of the latter by al)sorp-
tion and expectoration. All of these stages may be rep-
resented at the same time in different portions of the
lung.
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The earliest lesiou is simple congestion. When the
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chest is opened a portion of the lung may be found in
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PULSE
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rounding normal lung, and to the touch it is slightly
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and exude a bloody frothy scrum. The physical sign
corresponding to this condition is a slight localized feeble-
ness of respiration, with more or less abundant moist
rales. A few hours later the hyperasmia has passed into
an extreme degree of vascular engorgement. The dis-
eased part shrinks but little when the chest is opened.
The pleural surface is of a deep red color, veiled by more
or less of tibrinous exudate, which peels off readily in
tliikes. The resistance to touch is markedly increased.
DAY
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C. F.
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Fig. 3830.— Defervescence by Lysis.
677
Pnoiiiiii»ikia.
Pneuiiiouia.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
aud on set-tion tli(> tissue is nion' ivadilN- divided tliaii in
liealtliy luni>'. Tlie out surfaces are darlc red. and darli
blood niiujxled with air Inllows tlie l.nil'e. The appear-
ance resembles elo.sely that of an incised spli'cu. and the
term splenization is apjilied to this stage of the local dis-
ease. Mieroseopieally, the ])ulnionary capillaries are
found distended with hlood. more or less fluid occupying
the air cells. But the lung still crepitates between the
thumb and finger, and can be squeezed dry without break-
ing down. A piece of it. thrown into water floats.
The corresponding physical signs are diminished reso-
nance on percussion, broncho-vesicidar resjiiration. crepi-
tant rales, and slightly increased vocal resonance. A
pleural friction sound also is often ]ireseut.
In the next stage the air cells are filled w ith a fibrinous
exudate, by which the parenchyma is completely solidi-
fied. If a considerable area is involveil, the lung is in-
creased in volume, and pushes out into the intercostal
spaces, so that furrows are imprinted on its surface by
the ribs. The lung is usually covered by a den.se layer
of fibrin, which, if removed, shows a deep mottled red or
purple color beneath. This layer is adherent to the cos-
tal pleuia also, and the separation leaves l>oth surfaces
rough and irrcgidar. When cut into, the solidified mass
has m\ich tin- consistence of liver, and is dark red or
brownish-red in color, and for this reason the condition is
known as red Jicpntixatioii. A piece of lung in this con-
dition will sink in water. The infiltrated ti.ssue does not
crepitate on pri-ssure. is friable, and can be torn nuich
more readily than normal lung structure. During this
stage the weight, of the lung may reach 2.500 or 3,000
gm.. instead of (JOO gm. which is the normal average.
Microscopically the contents of the alveoli consist
Fig. SSil.— Air Celt Filled with Pneumnnic Exiiflnte. (Drawn by
Dr. Louise Cordes from a specimen in the lalioniloiy of tlie l>i-es-
byterian Hospital, New Yuri;.)
chiefly of fibrin in the form of a delicate mesh, red blood
corpuscles, leucocytes, epithelial cells, and numerous
diplococci pneumonia;. Other organisms, such as strep-
tococci, staphylococci, etc., are often found associated
with the s].)ecific microbe.
In this stage the capillaries derived from the pulmo-
nary artery are occluded, and the resulting thrombosis
extends back into the larger vessels. The septa between
the air cells are but little clianged. The nutrient vessels
remain pervious.
The physical signs of hepatization are dulness ap-
proaching to flatness, and increased resistance on percus-
sion, with t\ibular breathing, or perhaps entire absence
of respiratory sound and increase of vocal resonance and
of vocal fremitus.
Succeeding the stage of red is that of ffirii/ lieptitiza-
timi. Jliu'h of the red coloring matter has been removed
by absorption, white corpuscles have been added in great
numbers, and the formed elements in the contents of the
air cells have degenerated into a fatty, granular material.
Hence the change in color. The tissue is softer than in
the previous stages, so that the finger can be thrust into
it, and the pit thus made fills with a dirty puriform fluid.
As resolution progresses, the infiltrated material is
gradually removed, partly by absorjjtion, partly by ex-
liectoration, and little by little the air regains access to
the alveoli. It is several days, however, before the physi-
cal signs get to be entirely normal.
Often, besides the specific pneiunonic le.sion liinited to
a certain area, there is congestion in other parts of the
same lung, and perhaps in its fellow. This may be so
intense, and the resulting seci'ction so abimdant, as to
leave iusufiieient bi'eathiug siu'face, and thus be the im-
mediate cause of death. The congestion may be hvpo-
static, when it will be limited to tlie <lependeiit portion
of the lung, or it may be due to cardiac weakness and
affect all parts. Very frequently more or less pulmonary
irdema is present.
Abscess of the lung as an event of pneumonia occurs
in between one and two per cent, of all cases. The ab-
cesses vary in size from that of a pea to the dimensions
of the entire lobe.
Vfter death from pneumonia the left cavities of the
h lit ai'c usu;dly fmind nearly or quite empty, while the
light are distended by firm coagula Ihatoften extend into
the branches of the pulmonary artery. The spleen is
often enlarged and the liver congested. The
cells of the renal tubes may be in the condi-
tion of cloudy swelling, and in a small pro-
]iortion of cases there is fully develojied
"nephritis."
P-\tiioIjOgt. — It is now very generally con-
ceded that the essential phenomena of jnieu-
nionia are due to the action of one or more
forms of bacilli. In nearly every case the
diplococeus of Friinkel is found in the exu-
date. With this are sometimes associated
other micro-organisms in such number as to
suggest that they may fday an important
though subsidiary part in both the local proc-
ess and the general infection.
As to the relation of the specific organism to
the disease as a whole, we may note:
First, that no amount of traumatism inflicted upon the
1 tug be the methods ever so varied, produces pneu-
m mn. We may cut, bnii.se, burn, or scald the lung;
wt may introduce mechanical or chemical irritants into
th( iir jiassages, and while we get a certain kind of re-
icti n as the result, we do not get pneumonia.
■^ cond, we may have pneumococcic infection in sev
eral serous and synovial cavities at the same time, result-
ing in suppuration in each, and not have pneumonia.
Third, we may inti'oduce the pneumococcus into any
portion of the body save the lungs, and even into the
blood itself, an<l not get inieumonia.
Fourth, but if we introduce active ]ineuniococci into the
liarenchyma of the lung we get pneumonia as the result.
Fifth, in iiioliably every case of pneumonia coming to
autopsy tluring the active stage, if the .seai'ch is properly
conducted, the presence of pneumococci in the lung can
be demonstrated.
678
REFERENCE UANDIidoK UF THE MEDICAL SCIENCES.
Piioiiii&4>iiia,
Puoiiiiiouia.
The iiiferuuce from those facts is tliat tlio one thing
necessary for the development of jiueumonia is the pres-
ence in the alveoli of pneiimococei in a condition of active
niullipliciition.
It is known that jineumococci exist in llie upper air
passages of a considerable projiorlion of i)ersons in abso-
lute health. It is necessary only that favoring conditions
should result in the translation of souu^ of these iiit-o the
nlveoli in order that pneumonia occur. Once in the air
cell tlic s|iecitic organism produces its specilic irritation,
causing effusion of the specific exudate. In this exudate
as in a culture medium the coccus gi'ows and separates
its specific toxin, which in turn is absorbed into the
blood, and gives rise to the fever and other manifesta-
tions of toxtemia.
So long as fresh supplies of toxin arc being formed,
or in otlicr words, so long as the consolidation is spread-
ing, so long the toxremia will be maintained. But here
again, as in artificial cultures, there is a limit beyond
which tlic process cannot extend. A given cpiantity of
culture medium can maintain the life of a given number
of germs only for a certain time, Ijcyond wliich tlie changes
produced init unfit it as a soil for the further growth of
the organisms, and the death of the latter jnits an end to
the process. With the supply of toxin cut oil, tlie tem-
perature falls.
This does not exclude the theory of an antitoxin. In-
deed, numerous observations, and especiall.y those of the
Klemperer biothers, go to show that a transient immu-
nity is created by an attack of pneumonia, and that this
immunity may be transferred to another suliject by serum
Inoculation. This could scarcely be explained exce])t on
the theory of an antitoxin, and I can see no obstacle to
accepting both theories in explanation of the phenomena
in question.
The specific organism of lobar pneumonia is the piieii-
moeoeciis luiiceolatus. Discovered in 18S0 by Sternlierg,
its causal relation to pneumonia was demonstrated by
him a few years later. It is generally seen in pairs of
oval or lancet-shaped elements surrounded by a capsule.
In cultures, short chains of three or four members are
common. Like other micrococci, it is non-motile. It
grows in faintly alkaline media, and by transplanting
every third or fourth day the growth may be continued
indefinitely.
This organism is found, in all but a verj' small i)ercent-
age of cases, in the expectorated material. Failure to find
it is probably due to defective teclmique. When a iiure
culture is injected into the substance of the lung typical
croujious pneumonia results.
When in a dry state the pneumococcus retains its viru-
lence for long periods, especially when protected by being
mixed with dried sput\un. The disease has been coni-
mmiicated to newcomers in bouses that had been closed
for months.
Recent researches show that in fatal cases of pneu-
monia the specific iliplococcns is (|uite commonly present
in the lilood, while in cases ending in recovery it is only
excel! tionally iMicouiitered.
Diagnosis. — A typical case of pneumonia seen from
the begiiuiing can scarcely be mistaken for any other dis-
ease, The abrupt onset, the pain, the chill, the fever,
the respiration accelerated out of proportion to the tem-
perature, pulse, and respiration, and, finally, the peculiar
expectoration, will suffice to establish the ditignosis even
without the aid of the physical signs. P>uf when the
latter are added, and we have fine crepitation with in-
spiration and a little later a blowing sound with ex])ira-
tion, while I he vocal resonance and the vocal fremitus arc
exaggeraleil. and the percussion note becomes constantly
duller until it a|iproaches Hatness, there is presented a
picture which lor vividness and individuality can hardly
be surjjassed.
But not all cases of juieinnonia run a typical course.
There is scarcely one of the classical synq)toms or signs
that may not sometimes be wanting. In about twenty
per cent, of all cases the chill is absent. Pain is not a
marked feature unless the pleura is involved, and in cen-
3
%^
\:/
^
t
I'
^»
'->.
fe\
ffiC
t
m"
tral pneumonia it is often not severe enough to excite
complaint. In feeble or elderly persons the fever may be
slight; indeed, even apart from these conditions, some of
the worst cases
that we meet
show but a mod-
erate tempera-
ture through-
out. The pulse
may not corre-
spond with the
temperature;
and the respi-
ration, usually
the most char-
acteristic of
the symptoms,
is sometimes not
strikingly fre-
quent. Cough
and expectora-
tion may be en-
tirely absent, or
the cough may
bring up only
a little frothy
mucus from the
lironchial tubes.
Apart from the
above, the diag-
nosis involves differentiation from quite a range of affec-
tions, such as bronchopneumonia, pulmonary cedema,
pleurisy with effusion, i)ulmonary phthisis, cancer of the
lung, atelectasis, engorgement in fever, typhoid fever,
for "which the reader is referred to the articles in which
these affections are discussed.
CoMPLiC-\TioKS. — There are several affections that so
often appear with iineumonia as to make it reasonably
certain that there is a connnon influence at work, and this
infl\ience can often be found in the presence of the pneu-
mococcus in the h)cality in question. The following
tables show the complications observed at the Presby-
terian Hospital, New York:
Complications of Pneumonia.
Out of 4S8 Cases.
^_j^^-*^-S
FIG. 38.32.— The Micrococcus Lanceolatus In
Pneumonia Sputuui. .4 .4, Leucocytes ; J3B,
red l)Ioo(t cells : C, epillielial cell ; D. ciliated
epithelium ; E E, pneumococci, >, I'M).
Number
of cases.
Re-
covered.
Died.
Pleurisy with ellusion
Pcricariliti'f (acute)
20
fi
li
;i
1.3
17
1
6
H
il
1
3
4
1
Out of 304 Cases.
(iangrene of leg ...
Delayed resolution.
Relapse .
Delirium tremens.
Pyieiiiia
.Vliscess of lungr . . .
I.arynpfitis .
I
Erysipelas
Persistent bronchopneumonia
.\cute nephritis
liMleina of lungs
Kmpyema
H
I'l
10
Prognosis. — This is modified by a number of pre-
existing conditions, the principal of which are sex, age,
season of the year, habit as to the use of alcohol, and
the |iresence or absence of certain chronic diseases.
While pneumonia is more frequent in men. it is more
fatal ill women. Of 'i'i'S patients in the Presbyterian
Hospital 170 were males, with a mortality of 38.8 per
cent., and 53 were females, with a mortality of 31.2 per
cent. The mortality in reference to age is shown by the
679
PiieiiiiKtiiia.
Pueuiiiouia.
REFERENfE HANDBOOK OF THE MEDICAL SCIENCES.
following table taken
byterian Hospital:
also from the lecorils of the Pres-
PxECMONiA^tat Oases.
Relation to age.
Died.
Per-
centajre
dying.
Ile-
covered.
Per-
ceutage
re-
covered.
0
0
37
31
IB
111
.5
0
0
!)
23 +
47 +
la-j-
13
IK
11
95
62
42
IS
,s
3
IIKI
Between r. anillii veare.. .
Between 111 and I.'i yi-ai^. . ,
Between 1.5 and ™(l years. . .
Between -'Hand :!ll veal's.. .
Between ItO and t'l vcai-s. . .
Between 4ii and ■■>() years. , .
Between 50 and 110 years. . .
Between liO and TO years. . .
Over 70 years
11 M)
id
711 +
77 +-
112"
It
J4t
32+-
2113
ti7 -f
As to seasons of the year, the spring months give the
lowest mortality, tlie summer sliows a slight increase,
■while in the autumn and winter the percentage of deaths
is .greatest.
Theliabittial abu.se of alcohol tmfits tlie systetn to bear
up against pneumonia, as is .shown by the foUowiug
table :
PXEfMoxiA— t2s Cases.
Relation to aleoholism.
Per-
centage
dying.
Re-
eovered.
centage
re-
covered.
Markedly alcoholic 3*1
Moderately alct)b«)lic .52
Noli-alcuholie 45
15
1 09
171
:;9
(')7
79
Among pre-e.xisting coiulitioiis a rlunimatic habit, dia-
betes, and clironic renal insullieieney, especially if asso-
ciated with cardio-vaseular changes, rendc'r the progiuisis
much nuire serious. Tlie pi'esenee of advanced valvular
disease leaves but little chance forreeoverv. Of the con-
ditions arising in the course of tlie di.sease and all'ccting
the pro,gnosis, the tirst is the initial cliill. This occurred
in 14-1 out of a .series of 223 cases, with a mortality of
thirty-four per cent., Avhile the remaining 7!) cases in
which the chill was absent gave a mortality of only nine-
teen per cent,
Tlie prognosis depends largely uiion the extent of the
pneumonia. AVhen botli lun.gs are involved not half of
the patients recover. Pneumonia occupying the whoU'
of a lung is more dan,£;erous tlian wlien only a part is in-
volved. The right lun.t; is more freiiuenliy implicated,
and also gives a higher mortality.
A feeble pulse that is freciuciit in v<'latinn to the respi-
ration and temperature isa disquieting clement, as is also
a very frei[uent respiration, especially when it occurs
with a moderate temperature.
Up to 105" P. the danger does not seem to increase ma-
terially with the ri.se of fhe thermonii'ter. A hi.sher tem-
perature, iiowever, tells imniediately upon the (leatli
rate.
A physical si.gn that has an important prognostic sig-
niticanee is accentuation of the pulmonary second sound.
Tills is the result of increased tension in the pulmonary
arteiy. and is a measure of the obstruction in the lung
on the one hand, and of the power of the right ventricle
on the other. If this accentuation becomes less marked
it is either because the obstruction is diminished, which
is a favoralile sign, or because the riiilit ventricle is lie
coming weaker, with all that this implies. AVIiicli of these
two conditions is iirescnt is (easily determined by the gen-
eral symptoms,
A considerable increase in the number of the white
blood cells is, as a rule, a favorable indication, while a
low count is unfavoi-able. In anything like asevere case
the prognosis is alarmin"' if tlie leucocytosis remains be-
low 12,bw or 14,U00. On the other hand, a high leuco-
cytosis persisting after the temperature falls indicates
further trouble in store, probably some complication.
It is generally believed that the presence of herpes labi-
alis is of good augury. If there is an absence of expec-
toration in the second and third stages, or if the c-xpec-
toraliou becomes scanty and difficult, the oullook is
gnive, A sudden cessation of expectoration, if accom-
panied by tracheal riiles, indicates the near ajiproach of
death. Late delirium is an unfavorable sign, as are also
apathy and .sonuiolence.
The mortality in pneumonia dilTcrs enormously under
dilTerent conditions. It is mtich .greater in hospitals than
in private practice, and in civil than in military hospitals.
In civil hospitals it runs from twenty-live to thirty per
cent., while in private practice it is scarcely half so
great. The death rate is much liigher in some years and
in some localities than in other years and in other places.
ETioLociV. — While the essential cause of pneumonia is
the development of a specilic germ in the pulnionaiy
alveoli, there must be a contributing cause that in some
way opens the system to attack. Among the predis-
posing causes are the following:
Se.x. Males are more liable to attack than females.
Age. If the total number of persons living at any
given age be considered, it is probable that the ratio (if
cases in successive decades is fairly uniform except during
the mo.st active; period of life when exposure is greatest.
Race. In America, the ne.gro race is decidedly more
liable to pneumonia than the white.
Former Attacks. A jierson who has jiassed through
one attack is more liable to another.
Unsanitary Living. Pneumonia occurs more frequentlv
in dark, crowded, and ill- ventilated dwellings than where
tin; supply of light and air is ample.
The principal exciting causes include exposure to cold,
exhaustion, the presence of some other infectious disease,
and o])erations under the use of an anaesthetic.
Altlniugh not readily communicable, pneumonia may
undoubtedly be transmitted from jierson to person. In-
deed, it quite fre(|uently assumes the form of a veritable
epidemic. In addition to this, certain houses have been
observed to furui.sh, year after year, an undue proportion
of cases, vvliieb .seems to indicate that the infecting prin-
ciple lurkeil in the a|)artments.
As to the etiology of pneumonia in general, we are
obliged to admit that in a large proportion of cases the
attack appears to come on siiontaneousl}".
Tiii';.\T.Mi".NT. — A correct treatment of pneumonia must
recognize that the disease is essentially a germ culture
.goiu.g im in the air cells of the affected jiart. The causal
indication, therefore, is to inhibit this culture. The de-
liatable iiuestion is whether such inhibition is practicable
by any safe means withhi our reach. The writer is tirinl,v
convinced that it is; and observations sustaining this
view are rapidl.v accumulating from man.v sources. The
problem requires that vvc rid ourselves of the conception
of an "inflammatory" jtrocess carryin,!; on an independ-
ent work of its own, over and above the response of tis-
sue to the irritation of the micro-organism. This irrita-
tion dep<'nds upon a S|)ecitic vital iiropertv' of the
pneumococcus, as is shown by the fact that no other
irritant whatsoever will produce a like result. If, tliere-
fore, we can so modify the bacterium that it loses its
specific irritant property, the essentiall.v ]U)eumonic
changes in the lung will be arrested. This then is the
tirst indication for treatment, and it is as unwise to defer
action uiiiin it until the ca.se becomes severe, as it would
be to defer o]iening an abscess until the si.gns of pya?niia
slioidd appear.
It is clear that the material exuded into llie air cells
must conliiin its share of anysubstance circulatin.g in the
blood from which the exudate is derived. This makes it
(lossiblc lo impregnate the exudate with anv desired
iiiedi<ameiit, includingone inimical to the pneumococcus.
It is not necessaiy lo kill the .germ: it is enou.»h to in-
hibit ils growth, a very much easier thing to do.
A considerable number of dru.sis seem to be capable of
producing this eflect. The salicylate of sodium or am-
680
REFERE^-CE HANDBOOK OF THE MEDICAL SCIENCES.
Pnenmonfa
Pnenmoula.
monium lias, up to tbe present time, been the most effi-
cacious. It is given in doses of ten or lil'teeu grains every
two liours. In a large pro])ortion of cases, especially if
giveu early, it will aJfect the temperature at the end of
tioned above have been employed with more or less suc-
cess for their antibacterial effect, but have nothing
especially to recommend them.
Aside "from specitic measures, the treatment of pneu-
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tbe drug were administered every four bours. Temiierature readied the nnrmal on Ihi- fmiitu day.
twenty -four hours, and bring about a defervescence liy
lysis in the course of tbe two or three days following.
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doses of fifteen grains four times a day. Of twelve cases
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case defervescence was by lysis.
Creosote and its carbonate have also been emjiloyed
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hours, either in emulsion or in capsules.
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raonia will be in accordance with the following indica-
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poison as it forms; sustaining the vital powers and par-
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compensation for loss of respiratory surface by the in-
halation of o.xygen ; reduction of excessive temperature :
relief of incidental symploms.
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well as calomel. Its operation is often followed by a
considerable fall of teiiipeialiire wliich may be perma-
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^ , 1 n
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1
1
1
\
n-
1.
i,-
c
1
\
/
MM
1-
^
"
2
H
1
^
/
\
A
U/
- -■■■ 1 <
-?-?
^ S£
1
1
1
^
V !
\,
/""
V
) ' r ■ 1 1 ° ^
™,^
0 , <
-
C
I
h
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j
'
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hi
< ' 5
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1. i:s
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RESP.
«! M
■:> -0, rjl -i •.; y. ;j — —\
21 S
" 2
3
s
f!iS!S! S
2:?!
fi « 2 3
?,<ii -'?. S;j;l
PULSE
S;=|S'§,S|g|?i2|32|§|
= '2
~ '^^T.
= 2.
I 1
tiiiS:
-\ =0, i-| ao r. =,
gig|S,5|S|gj
Fig. asil.— Patient having Double Pneumonia wlio was Treated with Sudium Salicylate. Entered hospital on the third day of the dispense with
pneiimi.nia of the lower right lobe. On the 5i.Kth day the left Inwer lolie hecame involved. Cold applied to tin' chest for lenipeiatute
above 103.5° F., aud twenty grains of sodium salicylate admiuisteivd every four bours. Defervescence by lysis. Normal lemiieniture on the
tenth day.
of cases is a very remarkable result of remedies of this
class, and demonstrates the i)ower they possess to modify
the usual course of ihe disease.
Specific medication of this kind is more efficient tlie
earlier it is resorted to, Init it is not without value at any
stage of the disease. Mauv remedies besides those men-
neiit. If the urine is scanty a diuretic is called for, aud
the best of all is an abundance of cold soft water.
The vital powers must be sustained, and at the first
evidence of flagging stryclinine, stroiibauthus, caffeine,
or other heart tonic is eailed for. Much liarni is done by
a routine use of digitalis. This drug iucieases the periph-
6S1
Pii*'iiiiioiiia of
Iiifauts.
KEFKKENCE IIANDBCXJK OF THE MEDICAL SCIENCES.
enil resistance and thus atkls tn the lal.ior of the liearf.
while at lh(^ same time it favors veiums congestion by
lessening tlii' capacity of the aitciial system. Its use is
admissilile when cardiac arrhyllimia is present, but it
should always be guarded by an artiM-ial dilator. Alco-
holic stimulation inay be re(iuired almost from the first,
particularly in those patients who are addicted to its use.
It is indicated when the pulse is small and thready, or
when there is persistent deliriiuu in an alcoholic subject.
When under its use the temiierature shows a reduction,
anil the (udse loses in frcqui'iicy and gains in volume, we
may be sure that the ali'cihol is doing good. It should
not. however, be given in sucli ([uaiuity that its odor re-
mains persistently in the breath.
The pulmonary circulation may require to be relieved
by dividiiiK' the blood more ecpially lictween the arteries
and the veins. This is accomplished by the use of arte-
rial dilators. Of these sodium intrite in doses ui two
grains every two hours gives the most satisfactory aiid
even result. It can be suiiplcmentcil by nitroglycerin
as occasion demands. Tlie indication for arterial dila-
tors is found in a small anil creeping pulse wdth failing
pulmonary second sound and a tendency to cyanosis. In
cases presenting these conilitions in an extreme degree
venesection followed Ijy saline infusion will sometimes
prove .singularlv beneficial.
Compensation for loss of rcsiiiratory surface may be
secured to some extent by udialations of oxygen. These
shouhi be resorted to whenever the respiratioiis exceed
forty per minute, and they may be made continuous if
the condition persists.
For the reduction of excessive temperature cold s|iong-
inff and an ice-cap to the head are the most available
means. When the fever produces extreme jactitation,
tending to nervous exhaustion, the coal-tar preparations
may be emiilnyed very cautiously and for brief p<'riods.
For the relief of pain hyiiodcrmic injections of luor-
phiiie ai-e Ijy far the best means at our command. They
are ellicient" ami at the same time, by slowing and deep-
ening the respiration, they improve the circulation in the
affeeled part. They are to be used with care, however,
and their fre(|Ucnt repetition is tdbeavciided. Hot poul-
tices on the one hanil, and i<-e-bags on the other, are pre-
ferred by many, and aic fairly ellicient. In mild cases
dry cu|is or sinapisms m.-iy sufliee.
The feeding of the iia'tient requires close attiaition.
The tendency Is to feed too highly. The conditions pres-
ent arc very unfavorable to digestion, and undigested
food in the alimentary canal gives rise to llatulent dis-
tention and greater eiubarrassmeut of respiration, besides
being a burden rather than a help to the \ital ]>iiwcr
already overtaxed.
A concentrated fluid food that will not rc-adily ferment
is to be given, but in no greater (inaulity than can be
ea.sily digested and assimilated.
All abundance of fresh air from first to last is indis-
pensable, and anxiety lest this sboidd cause the ]iatieut
to take cold should'be ilismissed. "Antiseptic jirecau-
tions" should lie adopted.
Serum Iherajiy has not yet established its claim to be
adopted, though" the prosjiect for the future is somewhat
encourauin". Aiti^i't ir Iltirmdiire S/iiiih.
Books Axi> Autici.ks Co.\sri.TEr>.
Ijiriiiiis : I'eppf'r's System of Jteil.. vel. iii.
Stursrisanil CoMpUind: PiifUiimni:!.
El'^ner- MeiUcai News. .lanuarv stti. I.sas.
(i M. StiTriliei!.' : Text-beok '<( liaiti.nnlejrv.
Iln-lilirius .larkson : Tlie I.am-et, Deeeii.her 22cl, l.stH
(Isler: .Miieri.-aii Journal of the Meilical spieuoes. .lamiary, 1898.—
I'raelice of Medicine, tliird edilion. Isns.
Potiiln: Deliriuiu In Pneumonia. Med. Week, Paris, l.sOi, vol. v.,
Kdward I'" Wells- Pneuinonii- Fever ; Its Mortality, wltli ,i f'onsidera-
tion ..f SoMic of the Elements of Protrno.sis. Journ. .Uu. Med. .\sso-
eialion, .laiuiarv lltll, 18iC
Flint ; liiseases of the liespiratorv nrffans. 1861!.
Andrew li. Smith: Some Considerations upim Aeute (ihstruelive Dis-
eases of the l.unj-'s. Aul. .lourn. Med. Seieiiees. Octolier. ]!<',»>.
Deiinv : stieplo.-eoeie Pneuiuoiiia. lioslou Med. aiul Sury. .Iiairn.,
April 7th, IS'.IS, p. 341.
Eyre and Washhourn : Varieties and Virulence of the Pneumococcus.
Till' Eaiieel, I,(jiidon, January 7th, 1S1«).
Delafleld and Prudden : Handbook of Pathological Anawmy and His-
tolopry. New Vork. 18!)7.
James and Tattle : Bacteriology of the Blood in Disease. Medical and
Surgical liepoit of the Presbyterian Hospital, New York. vol. lit.,
LS9S.
Ewing: New York Medical Journal. December Ifitli. 189:3.
R. C. Cabot: Boston Med. and Surg. Journ., August ;)d, 189.5, and
March 22d, WM.
Dvce Duckworth ; Prognosis of Pneumonia. London Lancet, August
Ist, 189B.
Tallman : La Medecine Jlodrmc, Paris, Marcli ~'f)th, 189.5.
Kronlg: Berliner klinisclie Woilieiischrift, No. 11, March Uth, 1898.
Silk : The London Lancet, Marcli :;iitli. 1897.
Schultze : Presbyterian Hospital Medical and Surgical Report, 1898,
p. 311.
Emmerich : Fort.schritte der Medicin. 1884.
SmorvosliV : La Snuaiiie Mediiale. I.sill, p. 384.
Hare: TherapeLiiic i^azette. isii:,. p. :.'^':i.
Robinson: Suggestions as to Piophvlaxis. Contagion and Treatment
of Pneumonia. Mcdi.al Ite.crd. Febninry Ult.h, 1898.
Robert Liegel : Wieiu-i imd. Wo.liens.hnft. May 7th, 1898.
Oertel: Respiratorisrhi- Theinpie, Lelpsic, lH8:i,
Baruch : The Management of Pneumonia Patients. Medical News,
January 'M, 1897.
Peabodv : Medical Record. February 19tli, 1898, and July 12th, 1902.
Klemperer Urothers ; Berliner klinische Wochenschrift, August 24tli
and :!ls-t. iwil.
R. van Sainvoord : The State of the Vasomot^jrs in Acute Lobar Pneu-
monia, and its Bearing on Treatment. New York Med. Journ., vol.
Ixviii., p. .521, 1898.
Smith, Andrew H. : Lobar Pneumonia. Twentieth Century Practice
of Medicine, v.d. xvi.. New Y'ork, 1.899.
The Treatment of Pneumonia as Based upon Recent Views of its
Patliologv. The New York Medical News. December 16th, 1.899.
Specillc Medication. Medical Record, March Ifith, 1902.
PNEUMONIA OF INFANTS.— The acute pneumonia
of infaiils may assume one of two distinct types— either
that of tin iicute lobtir pneumonia or that of au tictite
bronchoimeumonia or lobular pneumonia. The former
t\'pe, which is less ciimraon tluiu the other, is caused by
the pneumococcus, develops as a priiuary disease, has an
acute onset, runs a short course, is characterized by a
continuous high temperature, ends by crisis, and allows
a good prognosis. The other tyjie of luieumonia is the
most coiumon tlisease of intancy, is usually secondary,
maybe caused by one of several micro-organisms, is var-
iable in onset, runs an iudeliuite course with irregular
temperature, ends by lysis, and allows a less favoiable
prognosis — that is, one which depends largely on the dis-
ease to which it is secondary.
Lobar Pneu.monia.
Infantile lobar pneumonia— croupous pneumonia; Fr.,
La Jini'iimonic frit Ill-he ; tier., I'rimiire r/eniiine I'lien-
'iiionii- — corresponds in some mettsiire to the lobar pneu-
monia of adults, but it allows a more favorable prognosis.
Lobar pneumonia is au acute disease of short duration,
characterized by inliammation and hcptitization of a cer-
tain iirca of lung tissue, and is caused by the pneumo-
coccus.
Etioloiiy. — The disease is almost alwtiysprimaiy. Al-
though it is less comiuon before the third year, it m;iy oc-
CASES SUtvlMER
AUTUMN
WINTER
SPRING
80
70
60
50
40
30
20
10
—v^
^^^/
'-^^
y/
-^
"C"-
^ -^
^
^>-^
'^'^^^^^ 1
Fir.. 3.8:)5.— Chart Sliowing the Frequency of Lobar Pneumonia in
Infants and Children at Different Seasons. , Cases reported
tiy Dr. Comhy: ■ . « «, cases reported by Dr. Holt: . cases
reiiorted liy brs. Northrup and Freeman.
cur in early iuf;incy . In fact, ctrses have been reported in
which the disease developed before the birth of the child.
6S2
REFERENCE IIAXDBUOK OF THE MEDICAL SCIENCES.
Pnoiiiiioiiin ot
Infaiils.
Fahr.
105'
All statistics seem to agree that boys are more fre-
tjueutly atfected with the disease than girls, the general
ratio being 60 per cent, boys and 40 per cent, girls.
Comby reports tliat in 172 cases seen by him 105 were in
boys and 07 in
girls. Of 44 cases
reported by Hen-
ocli 24 were in
boys and 20 in
girls. Holt re-
ports 60 per cent.
of his cases as oe -
curriug in boys.
Rilliet and Bar-
thez, OTit of 408
cases, report 221
in boys and 187 in
girls." Of 43 cases
at the Foundling
and Nurserj- and
Child's hospitals
in New York 2.5
were in Ijoys and
a toxaemia from the absorption of the poisons wliic}i are
produced in the lungs. The lesions are not usually in
the same state of development in all parts of the involved
lung tissue at the same time, for while one area is in the
na
Zo
17 in girls, or 60
per cent, in boys
and 40 per cent.
in girls.
Season. ■ — This
disease is seen
most often in the
spring. Tlie ac-
c o m p a n y i n g
chart (Fig. 3835), constructed from data by Combj- and
Holt and tlie authors of this ]iaper, shows the freiiueney
of lobar pneumonia, in children, in New York and Paris
at different seasons. E.xposure to cold, traumatism, con-
tagion, and previous poor health have been mentioned as
occasional etiological factors; but if they do i)lay any
part in the production of this disease, except by lowering
the resistance, this m\ist be true only in rare instances.
The micro-organism regularly found in the sputum
and in the lesion, and occasionally in the blood, is the
micrococcus lanceolatus or pneumococcus of FrSnkel.
Various other bacteria may be associated with the pneu-
mococcus.
Patholoot. — The focus of tlie disease may be located
in various parts of the lung, but certain lolies art- more
often affected than others. Holt finds that the left lower
lobe is the one most often affected, the next in order being
the right upper and the right lower. Comby, on the
other liand, finds that the riglit upper lobe is much more
frequently affected, the next in order being the left upper
and the left lower. IMonti, who has had a large expe-
rience with the disease in Vienna, considers that the right
upper lobe is much more often involved than the left,
and the left lower much more often than the right. The
cases collected by the present writei's show that the right
upper, tlie right lower, and the left lower lobes are about
equality often affected, while the left upper lf)be is the
least apt to be involved. The exact figures of relative
frequency are as follows:
^
I
I
*
i%
11
^5 =
2:
Holt
Comby
Ashby
Norttirup and Freeman
So far as its general characters are concerned, the lesion
of lobar pneumonia in children corresponds to that in
adults. It will therefore not be necessary to deserilje
them here in detail (see article on Pneumonia, Lobar, by
Dr. A. H. Smith). The disease is an acute exudative in-
flammation of the lung, in the course of which the air
spaces become filled with red and white blood cells,
serum, anil fibrin. At the same time there is developed
Fig. 3tNS(i.— Temperature Chan of a Case of Lobar Pneumonia in a Baby of Nine Months.
condition of red hepatization, a neighboring area may
sIkiw gray hepatization.
Resolution does not always take place. The products
may pei'sist and become organized, or they may break
down and form an abscess, or, finally, a necrotic process
may ensue and gangrene manifest itself. In the lobar
pneumonia of infants, however, these terminations are
less often observed than they are in adults.
Pleuris}", with the development of fibrin only, or with
a plastic exudate, or with pus, may accompany the pneu-
monia. A lirouehitis is usually present. Pericarditis,
endocarditis, and meningitis occasionally occur.
No sputum is, as a rule, expectorated by infants, all that
is coughed up is swallowed. We have found that the
sputum may best be obtained for microscopic examina-
tion by washing out the stomach half an hour after the
child awakes and before food is given. AVhere this fails
sometimes titillating the pliarynx causes cough and ejec-
tion of small masses of mueo-pus.
A leucocytosis appears at the beginning of the disease,
and increases in intensity, disappearing as the tempera-
ture drops.
Symptoms. — There is no incubation stage in the lobar
pneumonia of infancy. The baby becomes suddenly
very severely ill. It usually vomits and has a rapid rise
of temperature. Convulsions may occur with the onset,
especially in infants that luive rachitis. Chills are rarely
seen with the onset of the pneumonia of infancy. The
child becomes dull and apathetic. AVith the rise of tem-
]ierature the pulse rate is increased, while tlie respira-
tion is increased out of proportion to the pulse rate.
Thus the ratio of respiration to pulse, which normally
should be one to four, approximates that of one to three.
Tlie cliild develops a short dry cough, and is apt to have
an expiratoiy grunt. The a\-x nasi expand with each
inspiration. The child's face is usually flushed and the
skin dry. The severity of the attack may usually be
judged from the degree of elevation of the temperature.
Cereltral symptoms often accompany the disease. Con-
vulsions are occasionally seen, \vhile stiffness of the back
of the neck, stupor, and delirium are often present.
The typical temperature chart of the lobar pneumonia
of infancy sliows a rapid rise of temperature to about
104° F., .slight morning remissions and evening exacerba-
tions continuing for less than a week, and the disease end-
ing by crisis. Such a chart is shown in Fig. 3836; it
Right
Right
Left
upper.
loyrer.
upper.
»
3
1
2
~
3
"
Left
lower.
1
3
1
1
683
Pueiiiiioiil:i or
lul'auls.
UEFERE^sCE HANUBUUK OF THE -MEDICAL SCIENCES.
ri'])irsc-iits the variations in temperature dljserved in a
cliikl nine nicmths old uiiile jiassinj; thniu!;li an attaek of
loltar pneumonia. In otlier eases tlie remissions are more
pronounced, the eiiarts resemhlinn' more nearly those of
bronchopneumonia, liul dill'erinj;' in the taci tliat the dis-
ease now umh'r consideration runs a sliorl course and ends
by crisis. The temperature continues to be elevated for
about a weeli, and tlien usually fails somewhere between
the tifth and the tenth days. It may fall on the .second
day or may ])ersist for fully two weeks.
The puise, which is at lirst full and strong, varying
from I'JO to IGU beats iier nnnule, later lieeomes weaker,
more ra|iid, and sometimes irre.i:\dar or intermitteut.
The respirations are also increased in rapidity, even more
so than the juilse; they may reach as hii,'h a rate as 40or
60 or even 80 per minuie. Usually, however, they bear to
the pulse a ratio of one to three or at times one of even
one to two anil onedialf. The inspirations are short and
the e.\pirations lonj; and accompanied often by a charac-
teristic urunt or irroan.
Piivsit'.u. Sie;NS. — The physical signs of lobar pneu-
monia in iufancy differ so malerially from Ihose usually
found in adults thai, they shoidd i;e especially enijiha-
sized. These physical signsare usually late in appearing
and are less regular and well detiued. winle in some cases
no physical signs at all can be elicited until afler tlie
temperature has droiijied.
Many eases show, at the beginning of the attack, evi-
dences" of congestion ; these being recognizable in the
form of sliglit dnine.ssou percussion and dimini.slied re-
spiratory murmur, at times quite pronounced. In many
of the cases neither of these signs is preseni, but on care-
fullv going over the chest there will be found a small
area where subcrepitant or crepitant rales will appear at
the end of a dee)! inspiration. In other eases the first
sign will beasmall areaeif high-iiilched breathing, which
may or may not have the true bronchial character. In
whichever of these manners the signs tirst appear, other
of the usual signs of lobar jjiieumonia in the adult ai'e
gradually added, so that in most cases, before the end of
the week, the chest will present, in some particular area,
a group of char.-ieterislic signs, the most important of
which aredtdness on jiercussion, bronchial breathing and
bronchial voice sounds, and increased vocal fremitus.
In some cases the disciise manifests the characteristic
onset and range of temperature, the ratio of the respira-
tion to the pulse is asone to three, the ahe nasi are dilated,
and the exjiiration groan is present, and yet no signs of
consolidation can be made out in the ciiest. However,
the signs in tlie c'hest are not essential for the establi.sh-
ment of the diagnosis in any given case jirovided there
be present the group of symptoms just enumerated. In
some cases the chest signs will lirst make their appear-
ance at the time wh<-n the temperature falls. Again, in
other eases, while there may be no delinite signs of con-
solidation, iiercussion over file area situated lielow the
clavicle may elicit an e.'iaggerated or tympanitic percus-
sion note, a sign which is believed by Comby to be of
great value as indicating an involvement of the pleura or
lung on that side.
Co.Mi'i.icATioxs. — The most frequent comi)licaliou is a
general bronchitis, which may lie tlu; result of an infec-
tion with other micro-organisms than the iineumococcus.
This complication may cause a greater daily variation in
the temperature than is usually .seen.
^e.xt in point of frcqiu-ncy are the pleural lesions. At
autO|.isies of these cases a dry ])leurisy over the consoli-
dated area — indicated liy a lack of lustre in the iileural
surface — is usually st^en. In six or eight ].ier cent, of
these cases some exudate of a lluid or jilastic character
may form in the jileural cavity. When this is marked it
forms a thick layer of libro-|uirulenl exudate of a yellow-
ish color and shaggy appearance, accompanied by more
or less iiurulent fluid. The character of this exudate in
children is iinport.-mt. for in some cases it is thrown init
inconsiderable amount, and yel only a small poition of
it is frci' lluid. This small (|uantity, however, is sulii-
cient to yield the pliysical signs of the presence of lluid
in the i)Ieural cavity and consequently to justify punc-
turing the chest wall with a nee<lle. But the ojieration,
umler these circumstances, is very apt to prove tmsuc-
cessful. owing to the fact that the needle becomes oc-
cluded by the thick exudate.
Jleningitis caused Ijy the ]uieumococcus may occur as
a complication, as may also pericarditis.
Di.\Gxosis. — The diagno.sis should be based on the
history of an acute onset in the midst of good health, on
the ratio which the resjiii-alions bear to the pulse rate, on
the prolongi'd expii'ation. on the expiratory grunt, and
on the dilatation of the ahe nasi. If the diagnosis can
be continued by physical signs on examination so much
the better, but the absence of these signs need not invali-
date the diagnosis.
PnoGXOSis. — The prognosis in primary uncomplicated
lobar pneumonia in previously healthy infants is good,
the mortality vaiying from three to live per rent. The
prognosis is graver in children that have not been robust.
The jircsence of only a slight leucocytosis is believed by
Monti to render the prognosis worse.
Ti!i5.\T.MENT. — On acco\iut of the possibilitj' of com-
municating pneumonia to others, and for the good of the
patient as well, a large, well-lighted and ventilated and
quiet room should be obtaini.d. But one person should
be alloweil in the roonr at a time. The uundier of cases
which have jiresented at the onset the symjitoms and
phv.sical signs of lobar pneinnonia, but which have
liromjitly recovered, is sufficiently large to w-arrant the
lielief that it is .sometimes possible to abort the disease pro-
vided the efforts directed to the attainment of this object
are made sullieiently early. Such treatment should con-
sist in the administration of a single fairly large dose of
calomel, the use of active counter-irritation by mustard
paste, applied either over the whole thorax or simply
over the suspected area, and the stimulation of the pa-
tient with strychnine. If no amelioration occurs within
twenty-four hours after this treatnu.'ut is begun, one may
assume that the disease will run its course.
The medication, after the disease has once become es-
tablished, should, as a rule, be directed either to the gas-
tro-enteric ti'act or to the heart. Expectorants are rarely
indicated. The tendency to constipation and tympanites,
which is apt to embarrass the patient by interfering with
the descent of the diaphragm, may usually behest treated
by rhubarb or by a comliination of rhubarb and soda.
Heart slinuilants are usually indicated early, and of these
strychnine is the most valuable; it should be given iu
rather large doses, gr. yjj; to gr, ^'j every three or four
hours. "When the extremities are cold uitro.glycerin is
useftd. Alcoholic stimulants shoidd be reserved as a
later resource. Among the antipyretics the use of water
will be found to be most effective. Sponging with eiiual
parts of alcohol and water has a moderate antipyretic
action, and later, if it should be found necessary, a cold
piack or a cool bath ma}' be given. Of the antipyretic
drugs only plienacetiu should be given. In order to .se-
cure a seilati\(^ effect a very small dose (0.15 gm or gr. i)
of codeine or from live to ten drojjs of paregoric may be
administereil. Oxygen (b.v inhalation) is one of the most
valuable stimulants, especially in the treatment of very
j-ouug babies who take meilieine badly by the stomach.
Bl!ONCIIOI'XEV.MOXI.\.
lironeliopneumonia — Eobular pneumonia: Capillary
bronchitis: Fr., Jir<'HrIii>-piu:untonu'; Ger., /lronr/fo/>n( '/-
iiiiiiiir — is an acute disea.se of indefinite duration, which
is characteri/.i'd by a capillary bnmehitis and by peri-
bronchia I. -u'cas of consolidation, and which may be caused
by one or mure <if several micro-organisms.
Erioi.ooY. — This disease is the form of primary pneu-
monia most cummonly found during the lirst two years
of life, and at the same time' it is the ordinary ioxm of
seeondarv liiieuinonia encountered throughouf childhood.
It is very conunun in infancy and early childhood ; and
at the auliqisie:- in the New York Foundling IIospit;d it
is a rare event not to find the evidences of mure ur less
il^^
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
PneiiiiKMiia of
SitfuiiCs,
broiK'linpiR'iiiiu)i]in. The (lisciisc occurs most frequently
during the first year of life iuid miicli U'ss fre(|ueully
witli each stieceetliiig yeur tij) to the tiftli. After tliis
ago it is not a comniou disease. lu tiie majority of cases
tlie disease develops dtirinf;' tlie winter season ; but this
statement is more true of broiiehopucumonia than of the
lobar variety, for cases of the former disease in infants
are seen also at other sea.sons of the year. Another im-
portant fact is, that bron(ho]ineuinonia rarely attacks in-
fants who have previously been in "ood health. It often
occurs in those who have had a preceding acute attack
of chronic gastric or iuteslinal disorder. Rickets and
hereditary sypliilis predispose to the disease. The fol-
lowing acute diseases which are apt to precede broncho-
pneumonia are arranged in the order of frciiueucy:
measles, whooping-cough, diphtheria, influenza, ileoco-
litis, and scarlet fever. Furthermore, the environment
has a good deal to do with the freiiuency of this disease.
Thus, for example, it occurs witli special frequency
among the occupants of the tenements and hospitals, and
among those who live in the crowded and poor sections
of the cities, as has been well shown, so far as Boston is
concerned, by Morrill.* Finally, exposure to cold, which
is by the laity considered all-important, is inidoubtedly
occasionally an active factor, but the history of a suffi-
cient exposure of this sort is rarely elicited. Experi-
mental researches in the lower animals have shown that
cooling of the body does preilispose to infection with the
pueumococcus.'
So far as the bacteriology of the disease is concerned,
it has been distinctly determined that there ere several
varieties of micro-organisms which may be actively con-
cerned in the production of bronchopneumonia. These
bacteria are also often found in the upper air passages of
healthy persons, and become active agents in tlie ju'o-
duction of bronchfipneumonia when the organism has
become depressed by a previous disorder or by a severe
exposure to cold or fatigue. One or .several varieties of
these bacteria may be present. The pneumococcusis the
organism most frequently found, while the streptococcus
and the staphylococcus are often present. Darrier,^ in
188.5, found in four cases of bronchopneumonia compli-
cating diphtheria the streptococcus either alone cir associ-
ated with the Loettler bacillus. Pruddcnand Northrup,''
in 1889, after an extensive .study of the bronchopneu-
monia of diphtheria in infants, also found that the strep-
tococcus was the usual cause. Netter ' studied bacterio-
logically 43 cases of bronchopneumonia. In 2.5 only one
organism was found, and in 17 more than one. As
regards the 25 with only one variety of micro-organism,
it was found that the pneumococcus was present in 10
cases, the streptococcus in 8 cases, the staiihylococcus
in 5 cases, and Friedliinder's bacillus in 3 cases. As
regards the 17 with more than one variety, it was found
that the pneumococcus and the staphylococcus were pres-
ent in 1 case ; the pneumococcus and strcjitococctis in 3
cases; the pneumococcus, streptococcus, and staphylo-
coccus in 2 cases ; the streptococcus and staphylococcus
in 5 cases: the streptococcus and Friedlander's bacillus in
3 cases: the pneumococcus, streptococcus, and staphy-
lococcus in 2 cases; and the pneumococcus and Fried-
liinder's bacillus in one case. Munier* in 10 cases, with-
out any diagnostic signs of influenza, found the PfeilTer
bacillus alone or associated with other organisms. In 5
cases he found Pfeilfer's bacillus alone; iu 2 cases with
the pneumococcus; and in 3 ca.ses with other undeter-
mined organisms. Wollstein.' quoted by Holt, studied
33 cases, 19 of whicli were primary and 14 secondary.
She found the |Mieumococcus alone in 17 of the primary
cases, with the streptococcus in 7, and with the staphy-
lococcus in 1. Holt found the streptococcus alone in 1.
and the staphylococcus alone in 1. He found that the
pneumococcus was present in 11 out of the 14 secondaiy
cases. It was alone in two cases; it was associated with
the streptococcus in 1 case; with the staphylococcus iu
3 cases; with the tubercle bacillus in 2 cases; witli the
tubercle bacillus and the streptococcus in 3 cases; and
with the tubercle bacillus and the staphylococcus in 2
cases. The streptococcus was alone in 1 case ; it was as-
sociated witli the staphylococcus in 1 case, and with the
tubercle bacillus in 1 case.
Anatomical Ciiak.acti-.ristics of the Liinr in In-
fancy.— Before we consider the pathology of the bron-
chopneumonia of infancy, it may be well to speak briefly
of the anatomy of the lung in infancy, fur this is ini-
doubtedly a determining factor in the preponderance of
the bronchial form of pneunioiiia at this age.
In infants the brouchi are larger and more numerous
and thus form a much larger proportion of the lung tis-
sue than is the case in adults. In infants, therefore, the
alveoli represent a much smaller proportion of the lung
as a whole. This is particularly marked during the first
two years of life. The connective tissue is present in
greater abundance and binds the different elements to-
gether very loosel_y. As a result the lilooil-vessels are
loosely held and easily become distended and encroach
on the alveoli. These characteristics of t\w. lung of in-
fancy persist to some extent until the fifth year, after
which period it may be considered to have a.ssuined the
adult type.
Pathology. — The lesions of the bronchopneumonia of
infancy are to be found most often in the jiosterior por-
tions of both lungs, generally of the lower lobes, but ex-
tending frequently to the posterior portions of the upper
lobes. In bronchopneumonia we have usually a trache-
itis, a Ijronehitis, a capillary bronchitis, and a iJueumo-
nitis, the inflammation starting in the upper air passages
and travelling downward until theliingtissue isinvolved.
TIk! intlainniation may extend downward slowly, several
da.ys elapsing before the pnei;monia is developed ; or, in
.severe infections in subjects with little resistance, the
disease may extend so rapidly that signs of pneumonia
are noticed simultaneously with the indications of inflam-
matiou of the upper air passages. Upon examining, at
the autopsy, the lungs of an infant who has had broncho-
pneumonia, one often finds evidence of some pleurisy
over the pneumonic area; perhaps onl_y a dull, lustreless
apjjcarance, or a little exudate on the s^rfacl^ and, in
rarer cases, a fibro-purulent exudate. On section of the
lung, if it be an early case, the involved area will be
found, usually in both lungs, to be dark red in color and
resistant to the touch. Other areas of congestion will
show the dark red color, but will olTer little resistance.
Tlie cut surfaces will also have for the most ]iart a dark
red color. Small wdiite areas, of the size of a pin's head,
are due to the tilling of small bronchi with muco-|iurulent
material which may be pressed out. The larger white
areas which are found at a later period of the disease,
are due to lobules undergoing gray hepatization. In a
section of a lung of a child where the broncho]ineumonia
has ailvauced still farther in its course, one often finds
all stages of the process in different adjacent lobules, so
that instead of having a general condition of red or gray
lieptization one notices a mottled appearance. The ex-
uilale which forms the con.solidation con.sists of serum,
epithelial cells, red blood cells, rtbrin, and polymorpho-
nuclear leucocytes. There is, however, as a rule, less
(ibrin, and the leucocytes are fewer than in lobar pneu-
monia.
Among the other lesions which are sometimes observed
in these cases may be mentioned the following; atelec-
tasis, hemorrhages, emphysema, and g.angrene. Atelec-
tasis may occur in areas supplied by bronchi which have
become plugged with mucus that forms a valve, allow-
ing the uir to pass out but not to enter. Hemorrhages
may occur in other areas, ,so that, on examination with
the microscope, the air passages are found filled with red
blood corpuscles. A vesicular emphy.sema may al.so oc-
cur, especially in the anterior portions of the lungs.
Both vesiculfl"' and interstitial pneumonia are frequently
found as.sociated with the bronchopneumonia of whoop-
ing-cough. Finally, gangrene of a portion of the in-
volved lung is occasionally found at autopsy.
In addition to the iiulmonary lesions already described,
the bronchial lymph nodes are eummouly fouud to be
enlarged from cellular hyperplasia. Occasionally, on
685
Pnoiinioiiia ul
liil'aiits.
REFERENCE HANDB(JOK OF THE MEDICAL SCIENCES.
cutliiiij such nndes. tulieiculdus lulnilt's arc discovered,
altliougli 111) tulicrculosis is loiiiid elsewhere.
Tkkmtn.\ti()Ns (IK Tin-; I)ise.\se. — Resdlution may take
place by cell di'Keiieratidii and aliscirptidii at any stage in
tlic process. 'I'his, however, lakes jjlace irrrgidarlj', and,
while certain lobides are iindergoing resolution, others
may show au advancing lesion. In the place of complete
resolution, chronic bronchopneumonia may establish
it.seU', especially in feeble liabics. wlio will thus be left
with ]>atclies of marked broncli(i|ineumiinia which may
persist for weeks or months. These areas undergo inter-
stitial changes Avilh dilatation of the bronchi, .and some-
times witli the formation of eavitii's which are filled w ith
muco-purulent mtiterial. At limes these cavities repre-
sent veritable abscesses. Finally, death may occur at any
sta,ge of the Ijrouchopueumoiiia.
Symi'To.ms. — In the bronchopneumonia of infants both
the symptoms and the course vary greatly, as might be
expected when the conditions are considered ; for the term
broncho]ineumouia is aiijdied to a disease tliat maybe
caused bj- any one or more of several micro-organisms,
and that may develop eitlicr as a primary affection or as
a secondiiry phenomenon in the course of some other
severe disease. If. in addition, we take into considera-
tion the varying resistance of the stibjects. the extreme
irregularity of the course of this disease will ap|iear per-
fectly natural.
Of the dilfereut symptoms which accomjiany a broncho-
pneumonia/<'«'r is one of tile earliest noticed, itnd it is
very rarely preceded by a chill. This fever usually ri.ses
to 103' and sometimes to 10-1' F. and then falls, rising
again as high as or higher than the highest point previ-
ously reached. Thus it continues with exacerbations,
followed by marked remissions usually of from two to
four degrees. The exacerbation of temperature nsually
occurs in the afternoon or evening. The temperature
lasts one, two, or three weeks, or longer. Only twenty-
five per cent, of the cases defervesce within the tirst
week. When the disease runs a long coiu'se. there are
often observed intervals during which the temperature,
for a day or two, will run much lower, rising a.gain with
the invasion of new lung tissue. The fever usually ends
Ly lysis.
A mtifjli is commonly present from the tirst. It isordi-
narily a <lry. short, hacking ecnigh. but at times it is par-
oxysmal ill character and may be almost incessant. Later
in the disease the cough may disa[ipear. owing to a loss
of rcHex activity in the air passages. Tlu' cough often
persists after theolher syni)itonis of the pueuuionia have
clisaii]ieared. Inasmuch as babies swallow all the mate-
rial which they cough np, we cannot examine the s]>utum
unless we take S|ieeial measures for olitaining it.
As the disease advances the respi i-dtiunx become rapid,
rising usually to from 40 to SO a minute, and sometimes
higher. Respirations above 30 should make one suspi-
cious of imlmonary com|)licalion, but usually they are
over 40. They vary from 40 to GO ordinarily, but may
reach 100 or more in severe cases. The rhythm of the
respiration is also distiirbeil. The pause, which normally
takes place after ex]iiralion is comidetcd. is done away
with and a jituise takes ])lace after ius]iiration. The
child quickly draws its breath, holds it. and then with au
exidosive grunting sound, expires, and without pause
agtdn inspires. The expiration is prolonged and loud.
The expiratory grunt is a very characteri.stie sym]>tora
of pneumonia in infancy. Another disturbance of rhythm
is that known as Chej'ue-Stokes respiration; this disturb-
ance occurs in .severe cases. Temjiorary suspension of
respiration also occurs in the very sick. It may last as
long as two minutes and be spontaneously resumed.
Evidence of respiratory embarrassment is also found in
the sinking in of the intercostal spaces and the dilatation
of the ahe nasi with each inspiration, in severe capillary
bronchitis. Cyanosis is another .symptom which often
develops in severe eases of capillary bronchitis.
The jiiilxi: is accelerated witli the onset of the disease,
and in an ordinary case will soon reach the rate of 1.50 a
minute. It is usually full at tirst, but later, and espe-
cially in the severe cases, it becomes more rapid and
weak.
A most important diagnostic sign of broncbopnen-
monia is to be found in the i-ntio irhieh the nspirutidim
hear to the pulse. This is usiially altered fi'om the nor-
mal ratio of one to four to a ratio approximating one to
three; that is, in an ordinary case the lespirations will
number about 40 or .'50 and the pulse beats from 120 to
1.50 to the minute. Such a respiration-pul.se ratio should
at once direct attention to the thorax, which should be
very carefully examined for evidence of pulmonary
disease.
Pain is not a symjitom of any im]5ortance in the bron-
chopneumonia of infancy. There is usually some sore-
ness in the chest, but these little jiaticnts do not, com-
monly, sulfer from acute pain.
So far as renhnd ki/ih/iIhudi are concerned, the onset of
bronchopneumonia in infancy is usually characterized by
a condition of apathy. The patients are said to be
"dopey"; they are markedly prostrated, indifferent to
their surroundings, and want only to be left undisturbed.
Convulsions at the onset are rare; they occur only in
very severe cases, in children with marked rachitis, and
in thoseof poor previous condition. Delirimnand stupor
often develop. The tric/ic cerebvale and Ivernig's sign
may sometimes be elicited.
Various e/iixtm-euteric syiiijitniiin are commonly associ-
ated with a broncho]incumonia. Thus, for example, an-
orexia usually occurs at the onset of the attack, while
thirst may supervene at a later sta.gc. The tongue is
sure to become coated, and in a certain numlier of cases
the disease begins with marked gastro-enteric symptoms,
vomiting, abdominal pain, diarrha-a, and tympanites —
symptoms which may lead to a false diagnosis, or at least
to overlooking the pulmonary condition.
PiiYSK Ai, SioNS. — Tile physical siunis vary as much as
do the sym]itoms. Some cases, which in other respects
are following a typical course, ma}' at no time give phys-
ical signs; that is. the disease fails to produce marked
changes in any part of the lungs adjacent to the thoracic
wall. In other cases local jdiysical signs will be elicited
only when the temperature falls, while in still otlier cases
one gets marked signs of consolidation from the begin-
ning of the disease.
Innjurtitni reveals the fact that the respiration is rapid,
irregular, and variable in its rhythm ; it also perhaps
shows the existence of a certain degree of cyanosis.
Pill jHtl ion is of less value in infants than it is in adults,
owing in part to the fact that the lesion ustially is bilat-
eral and in part to the fiict that it often fails to yield
good evidence of tlie existence of consolidation.
I'cn-iixxion also gives valuable infonnation less often
in infants than it does in adults. It must be practised
with care and with the em]iloyment of very little force;
one finger will suffice for the actual percussing, and the
examiner should make a li.aht, sharp stroke by quickly
withdrawing the finger. The revelation, by means of
percussion, of a very slight dulncss. especially if it is
associated with a sense of resistance, points to congestion
and consolidation, while a marked degree of dulncss
should raise a susiiieion that fluid is jircscnt. and this
conjecture should lead to the employment of auscultation
as a means of differentiating between these conditions.
It is by aiianiltiitioii that the first evidence of local pul-
monary involvement is usually elicited, and it is upon
auscultation that one must especially rely for locating
the brouehopneumouia in infancy. In these little sub-
jects the ear should not be relied on alone, but a .stetho-
scope with a small o]iening should also be used. If the
baby is emacialed, a Hexiblc rubber chest-piece may be
necessary. Auscultation gives information as to the
presence of rales, the duration of the expiration as com-
pared with the ins]iiration. and the pitch of the breath-
ing. Since in lironclio]nieumonia tliere is an inllamnia-
tion of both large and small bronchi, and often a pleuritic
inflamniation as well, all varieties of r;"iles may be heard.
The coarse, low-pitched, sonorous n'lles. which have-
their origin in the large lironchi. are usually present.
fiSO
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pitoiiiiiouia of
Infants.
Areas of subcrepitant or crepitant rales, audible at the
end of ail inspirator}- effort, are carefully to be looked for.
since they are usually the first physical sit;-n found by
which one can locate the bronchopneumonia in in fancy.
It is not sufficient to listen carefully over the chest of a
sleeping or quiet child for this sign, but effort must be
made to secure deep inspiration. If the child cough, the
cougliing will be followed by satisfactory inspiration, but
often it is necessary to make the baby cry. It is liuring
crying that the most safisfactorj' examination of the
baby's chest may be made, for it elicits botli deep inspi-
ration and voice sounds which may lie diHicult to gel i.)\-
other means. It the pneumonia is sufficiently devchiped
one may get a prolongation of expiration, and high-
pitched or bronchial breatliing.
In some cases tfie first local pli_ysical sign will be di-
minished breathing, which may be associated with did-
ness over the same area. Dulness and diminished brealh-
iug, although often due to congestion, should always
suggest the possibility of tluid being present. If tliese
signs are due to congestion, they should soon change to
bigli-pitched breathing with riiles; if they are due to
fluid, they should persist and become more marked.
The location of the heart apex should always be defi-
nitely made out. as a displaced apex often determines the
presence of fluid in cases in which other signs would
seem to point to consolidation of the lungs.
CouESE OF THE DISEASE. — The bronchopneumonia of
infanc}' usually begins with an abrupt onset, character-
ized by considerable fever and a couilition of apathy.
The child is evidently seriously ill. It coughs, breathes
rapidl_v, ami with each expiration is apt to groan or
grunt. Dj'spucca develops, and sometimes cyanosis.
The aloe nasi dilate with inspiration. The fever persists
for from one to three weeks, finafly ending liy lysis. As
the disease progresses, the prostration becomes more
marked, the pulse more rapid, and the extremities, nose,
and eais often become coid. The respirations become
very rajiid, and delirium or stupor may develop; gastric
or intestinal sj'mptimis also often occur.
The disease may manifest itself under one or the other
of three different types: the acute congestive type (or
capillary bronchitis), the latent type, and the persistent
type. The first of these, llie acute rorifjistin' ti/pe. may
be primary or secondary, and occurs most often in young
Infants. The}' become suddenl}' severely ill, and lircat he
with great difficulty and very rapidly (70 to 8l)) ; there is
high fever (104° to"l06° F.);"and the" pulse is rapid (ISO
to 2(K)). Death often occurs in from twelve hovirs to
three days. Some of these cases will end in recovery in
the course of a few days. By the expression latent type
is meant a bronchopneiunonia which is found in cachec-
tic and marasmic infants, who may have neither fever,
nor cough, nor dyspntea. It is a hypostatic pneumonia,
which gives little evidence of its presence during fife,
and is often first discovered at autop.sy. T\ig pergistent
type of bronchopneumonia is seen in children who are in
poor condition at the time when they are taken ill; it
also often develops after whooping-cough. In these
cases the disease usually runs a moderately severe course
for from two to three weeks, and then, instead of defer-
vescing and undergoing resolution, it continues for some
time to manifest a moderate degree of feveiishness and
the physical signs of persisting consolidation. These
patients are apt gradually to become weaker and die. al-
though some of them may recover after a long period.
In addition to the three types briefly outlined above, it
is permissible to establish — in accordance with {'ertain
characteristics that belong to tlie secon<lary bronebo-
pne\imonias following the dift'erent acute infectious dis-
eases— other less important groups. For examide, one
group may comprise those cases in which a bruncho-
pneumoniii deirlnps in the course of an attack of nienslcK or
scarlet ferer. In this group the pneumonia begins either
when the eruption is at its height or not until after the
temperature has fallen to normal. In the latter event
the temperature docs not remain at this low point but
soon rises several degrees, and evidences of the pneu-
monia begin to manifest themselves. But whether the
pulmonary complication develops at this later stage of
the original disease or whellier it develops at the time
when the eruption is at its height, the prevailing charac-
ter of the pneumonia is in eitlier case likely to be severe;
indeed, the disease often assumes a congestive character.
T/ie hronchopneuntonia of wlmoping-conijli constitutes an-
other group. This develops usually during or at the end
of the paroxysmal period. The onset is more gradual
and less severe than it is in the preceding group, and the
fever usually is moderate. The disease develops in chil-
dren who are much depleted by the whooping-eoxigh.
and it rims a long, subacute course. Penally, in the third
group maybe placed tlie bronchopncninnnia if diplalwria.
In this group of cases the disease again manifests itself
conunouly in a severe f(jrm like that which characterizes
the broncfiopueumonia of measfes and scarlet fever. It
usually develops early in the attack of diphtheria.
Bronchopneumonia also develops in connection with
other diseases. Thus, for example, it sometimes occurs
in a fairly severe form in the course of an inflnenza.
When it occurs in connection with xm ileo-colitis it usu-
ally develops at a time when the baby has been much
weakened by the primary disease, and it tlieu assumes
a type similar to that seen in whooping-cough.
C'oMPi.iCATioxs. — The one very conmion complication
of broneho]meumonia — the one for which diligent search
should be made daily, in order tliat it may not be over-
looked— is empyema. This occurs in a considerable num-
ber of cases, and requires a promjit evacuation of the
fluid whenever the bafiy suffers severely from its pres-
ence. Evidence of fluid is usually first found liehind or
in the post-axillary line; less fre(|ueutly it is found in
front. Diminished breathing soundsand marked dulness
on percussion are usually the first local signs. Another
occasional complication is p'lriilent meningitis, which is
caused by the same micro-organism that produces the
lung consolidation. Pericarditis is also sometimes en-
countered, but usually in connection with empyema. On
the other hand, in all the cases of bronchojineumonia
which have been seen by the writers in the New York
Foundling Hosjjital, the complication of an endeiearditis,
except when associated with pericarditis, has not once
been observed. Finally, in a certain number of cases,
tiiherciihisis may constitute acom|i]icatiiin of the lu'oncho-
pneumouia. In these cases the trouble may sometimes
be attributed to the breaking down of an old cheesy
bronchial lymph node.
Di.\GNOSis. — The early diagno.stic signs are the abrupt
onset, the presence of fever and of a certain degree of
apathy, the disturbed res]iiration-pulse ratio, and the dis-
covery, by auscultation, of the existence of rales in the
chest. To these signs may be added, at least for some
of the cases, the following: some didness on percussion,
a high-]Mtched respiratory murmur, and bronclio-\'esicular
respiration. Many of these signs may be absent, espe-
cially in the subacute form of the disease as it occurs in
weak infants or as a coinjilicafion of whooping-cougli.
The differential diagnosis from lobar pneumonia is
based on the following points: j\Iost of the cases of
bronchopneumonia are secondary, and when the disease
is primary in its nature it occurs usually in infants under
two years of age. The signs develop more gradually in
this disease than in lobar pneiunonia. Furthermore, the
remissions of temperature are more marked than theyare
in the latter disease, and the return to normal takes place
by lysis rather than b}' crisis. Finally, the course of the
disease, unlike tliat of loliar [meiunonia. is very irregular.
In order to distinguisli the disease from fluid in the chest,
wlieii there are signs Jioinling to the latter condition, it
often becomes necessary to resort to an exploratory
puncture in order to determine the truth. In making
such a puncture it must be remembered that the lluid is
often thick, so that a negative rcsidt from the use of a
small needle means nothing. A large needle should al-
ways be introduced in an aseptic manner.
PHOCiNOsi.s. — The prognosis in the lobular form of
pneumonia in infancy is always ver}- serious. It is mod-
OS^
l»ucii iiiopericard i ii in,
Podopliylluni*
KEFEREXCE IIAN'DBOOK OF THE MEDICAL SCIENCES.
ificd by several factors. In tlie first [ilaec. the younger
tlie child tile more serious the o\nlook. I'lieuiuonia in
an infant under one year justilies a vt-ry serious progno-
sis. The coniiition of tlic chihl's health before the uttacli
is another iniporlant factor. Tlie belter the health of
the baby when taken ill with tlu^ broiiehopneunionia the
better the prognosis. The environment of the child also
modifies the prognosis. Us\ially cases do nuich better
under good surroundings, with isolation, quiet, and
ideiity of air — i.e., under such conditions as may be fomid
auKJiig the wealthy classes — than they do in the tenements
an<l liospitals.
Primary bronchopneinnonia usually allows a much
better prognosis than does that which develojis in the
course of some severe disease; for tlie outlook in second-
ary pneumonia varies with the disease which it compli-
cales. Thus, in many of the eases of pneumonia com-
plicating diplitheria tlie ])atients die, and the mortality
of the disease, when it develops in the course of whooji-
ing-cough, is always very bigli (lifly to one hundred per
cent.). Tlic bronchopneumonia of mea.sles is usually of
a .severe form, but, notwithstanding this fact, Ihe mor-
tality is somewhat lower than it is in the secondary pneu-
monias of di])htheria and whooping-cough (thirty-three
to one hundred per cent.). In the influenza cases the
mortality is m<ire favorable.
Tr,K.\TMt;NT. — A study of this disease emphasizes the
imporlance of watching very carefully all eliildren who
are affected with colds, influenza, bronchitis, and the
other |irimaiy diseases whicli lirouclio])neunionia is apt
to complicate. Of still more importance is the careful
watching of the digestion of babies and tiie |iroini)t n;od-
ification of tlie diet when necessary.
The direct treatnu'iif is entirely .symptomatic, and the
general hygiene, nursing, and feeding are usually of far
more impoitauce tlian tlie medicinal treatment. A baby
with bronchojineviinoniasliould be placed ina large quiet
room with plenty of liglit and a soulhern exposure. The
room sliould be ventilated from out of doors and not from
other rooms in the bouse. Sonic moisture in llieroom
will make the iiatieiit more comfortable, and this may be
obtained by boiling Avater in a kettle. Bui one person
slK)uld be allowed in the room at a time, and the same
care should be observed to avoid distiiibing the patient
that is e.\ercised in the case of a nervous adult.
The diet should consist of milk or modified milk, or
milk with barley water, or oatmeal gruel. If the milk is
not well digested, it may be given only after it lias first
been ])eplonized. If but little is taken at a time, the
feeding may be done at intervals of one or two hours.
With the onset three modes of treatment should be ac-
tively tried iu an ell'ort to abort the disease. These are:
purgation, counter-irritation, and stimulation. For the
attainment of the first of tliese objects, calomel is alto-
gether the most satisfactory drug. For a liaby under
one year of age one-tenth of a grain may be given every
half-hour until from four to ten doses shall have been
given. If tliis medication fails to move the bowels, cas-
tor oil. in doses of one or two drachms, should lie admin-
istered. Counter-irritation over the aflectcd area, or. if
Ibis cannot be determined, over the whole chest in front
and behind, may be made with mustard paste. The
operation should be repeated at interv.'ils until a marked
redness of the skin is produced. Stimulation with
.strychnine in fairly large doses (from gr. ^j'.j, to gi-. ^)
every four to eight hours, according to the age of the
child, may be resorted to tempor.-irily. This treatment,
wliicli may be kept up until the physiological i-ITecfs
of the drug are obtained, will aid the organism in its
elfort to overcome the disease. Afterward tlie icmedy
may be admini.stered with advantages in smaller doses
throughout the entire course of tlie disease. The coun-
ter-irritation may also be repeated with benefit from
time to timi'. Stimulation should be used when nredcd.
Nitroglycerin is of especial value when the extremities
become cold, and it should be given in a dose of gr. ji^
every four hours. At the same time hot-water bags
should be apjilied to the feet. The administration of
alcohol internally may usually be reserved for severe
eases, since it is a drug that is often badly borne by
babies. It may be given in the form of whiskey diluted
with from eight to ten parts of w'ater and sweetened;
champagne and sweet wine may also be administered.
Oxygen is a most valuable aid iu the treatment of this
disease, and it may be given at frequent intervals or con-
stantly, and should be delivered from the pipe held close
to the child's mouth.
The gastroenteric tract must be carefully watched, as
marked tympanites, which interferes with respiration by
restricting flie descent of the diaphragm, is a freejuent
and very serious complication iu many cases, A mixture
of rhubarb and soila, or of rhubarb and soda with bis-
muth, or an occasional dose of castor oil, will often relieve
this symptom, but at times the introduction of a stomach
tube or rectal tube is needed for evacuating the gas.
Counter-irritation and hot fomentations applied to the
abdomen are also useful The employment of pneu-
monia jackets and of poultices, as a routine treatment of
the bronchopneumonia of children, has been given up.
Both of these tend to increase the temperature of a child
already suffering from fever, and they limit the expan-
si(ni of the chest, A woollen shirt provides a sufficient
protection to tlie chest.
Antipyretic treatment is needed in the severe cases,
and should be resorted to if the child is bearing the fever
badly, even if the latter is not very high. Stupor, de-
lirium, or great restlessness calls for antipyretic treat-
ment. A temperature of over 103° F. is usually an indi-
cation for antipyretic treatment. There is no disease in
which the thermometer is of .so little service as a guide
as it is in infantile bronelio]ineumonia. It is the child's
general <'ondition that furnishes the best indications for
treatment.
Bathing furnishes the best means at our disposal for
reducing temperatun!. Sponging with equal parts of
warm water and alcohol may be used for slight feverand
restlessness, but the most elficieut and simplest method
is to place the infant in a bath. The bath may have a
temperature of from 80' to 90 F. , and the baby may be
kept ill it for five or ten minutes. It is usually well to
stimulate the baby before putting it in the bath. The
bath nia.y be repeated as often as indicated by the tem-
perature.
The coal-tar derivatives slioidd never lie used as anti-
pyretics forinfants. Expectorants are very rarely neeiied
in the treatment of this disea.se. Ipecac is probably the
most ellicient. but, if used, it should be given in small
doses. Of sedatives, a warm bath is usually the only
one needed. If the cough is constant and interfeies with
rest, and if it is not relieved by a bath, five-drop doses
of paregoric may be given every three or four hours.
In protracted eases and during convalescence, the inter-
nal administration of creosote, or guaiacol and cod-liver
oil, or of some iron preparation may be of advantage,
while counter-irritation may be made by jiaiuting the
chest with Churchill's tincture of iodine, or by the use
of the Paqueliu cauter)-. WiUinm P. JS'orl/irtiji.
Riiirhind Godfrey Freeman.
LlTKK.lTrRE.
' Monti : Kiiulerlieilliiintle, Vienna. f902.
■ fteiueliolli iiml Koblanit : Deut. Arch. f. kl. Med., Ixv., p. 192, 19(10.
2 Darier; Sue. de i'.iulnirie. 188').
' I'nutilen and Nertlinip; Am. Jeiir. Med. Sciences. June, 1889.
' NeUer : Arch, do Med. exp.. January, f.sse.
" Meunier: Arcli. (it'll, de M(''d., Feliriiarv and Marcli. 1897.
' Holt : Diseases of fnfani.'V and Cliildlinod, p. isi.
" Mi.trrill : Cyclopedia of llie Diseases of ( tiiidren.
PNEUMOPERICARDIUM. See Perictrdium. Diseases
".!'■
_ PODOPHYLLUM. -r. S. P., .V.iudrah: M,n/-(,pple.
Tlic dried rhizome of i'lnluji/iy/liiDi jicitiitiiiii L. (lam. Jjir-
heridtici n ).
This stiiking and lieautifiil jilant isfound in the great-
est abundance in rii'h soil llinnighout tlie easleni and
central poiiions of North America, except the far north.
68S
REFEREXCE HANDBOOK OF THE JEEDICAL SCIENCES.
Paoiiiiioporfeardium*
Podopliylliiiii,
The dniff is innstly roHectcd in the Ohio valley nud the
Dioiintaiiis sdiilliwanl. The very long tiiul much
brauched liiizoiiies form a network a few inches beneath
the surface of the soil, and produce large beds of the
very peculiar foli-
age of the plant,
which is licrbace-
oiis, about a foot
hi^li. and of the
appearance shown
in theacconii>any-
ing illustration.
The leases are
thin and some-
what shining,
about a foot
broad, the flower
beautifully white
and waxy, and about two inches br
sterile stems terminate in a circular
attaclied leaf, which is similarly lobe
presents the appearance of an
wlK'nce the plant is often called
plant, whereas the form of those of tb
ing stems have given it the name
foot. The fruit is a yellow, sweet, and
berry, about as large as a pigeon's egg,
known as Jlay, hog. Devil's, or Indian appl
also as w'ild or ground lemon.
The _younger jiortions of the rhizome, after
being dried, are dark-colored, thin, and shriv-
elled, and are deficient in medicinal property.
The drug is thus described :
Of horizontal growth and indetiuite length, occurring
in irregular pieces: cylindraceous, liattencd from above,
consisting of joints about 5-10 cm. (2-4 in.) long, the in-
ternodes 2-8 mm. (^.j-J- in.) thick, the nodes al)out twice
as broad; yellowish-brown to dark brown, the darker
pieces usually longitudinally wrinkled, the lighter ones
nearly smooth, the nodes marked above by liroad cup-
shaped .sears and underneath hy wliitish, short stum]is
of the brittle roots; fracture short and sharp, whitish to
pale brown, resinous in the best drug, marked by a loose
circle of very short yellow wood wedges surnuuuling a
large pith; nearly inodorous; taste sweetish and Ijitter,
becoming acrid.
Tlie active portion of the drug resides in its three to
five per cent, of resinous matter, which is associated with
much starch, a very little gallic acid, and small amounts
of fixed oil, gum, etc. The resin is asomewhat complex
mi.xture, but is an ofticial substance and is verv largel_y
employed luider the name Pmhijilnillin. It is highly sub-
ject to adulteration, more than tilt)' per cent, of adulter-
ant having been reported in it; hence, theoliicial descrip-
tion should receive close attention. It is prejiared Ijy
exhausting the powdered drug with alcohol, concentrat-
ing the liltrate by evaporation, and ])ouring it into water
acidulated with a little hydrochloric acid, wdien the resin
is precijiitated. It is afterward dried and powdered.
The resin is de-
scribed as follows
in the pharmaco-
poeia :
" An amorphous
powder, varying
in color fro m
grayish - white to
pale greenish-yel-
low or yellowish-
green, turniiig
darker when ex-
posed to a heat over 35° C. (95° F.); having a slight,
peculiar odor, and a peculiar, faintly bitter taste. Per-
manent in the air."
Its alcoholic solution has a faintly acid reaction.
Soluble in alcohol in all proportions: ether dissolves
fifteen to twenty i)er cent, of it; boiling water dissolves
about eighty per cent., and deposits most of it again on
Vol. VI.— 44
Fir.. .3?37.— Podopliyl-
lum : Flowering
Flant. (Bullion.)
FIG. 3S38.
cooling, the remaining, clear aqueous solnlion having a
bluer taste, and turning brown on the addition of ferric
chloride T.S.
Resin of podophyllum is also solubk; in potassium
or sodium hydrate
T.S., forming a
<leep yellow liq-
uid, winch gradu-
a I I y bee o m e s
darker, and from
which Ihe resin is
reprecipiUited by
acids.
It should yield
not more than
0.5 per cent, of
ash.
Resin of podo-
ph3ilum ha.s the following composition:
The most of it is i-esinous PudoplniUic Acid,
which is brown, and soluble in alcohol and
chloroform, not in water, ether, or pietroleum
ether, anti is inert. Of I'lidojiln/llutuxin (C'js-
HjjOs -|- 2H2O) there is apparently a very small
amount (about one-fourth of on-:; per cent, of
the weight of the rhizome), the larger amounts
reported by various observers being probaljly
impure. It is best obtained by extracting the
drug with pure chloroform, and this extract
with pure ether, then iirecipitating with pe-
troleum benzin. Pure podophyllotoxin usu-
ally occurs as a white, amorphous, bitter,
slightly acid powder, oi- in crystals soluble in
ether, chloroform, hot water, and diluted alcohol. This
pure substance is very dillicult to obtain, being usually
contaminated with the isomeric Pirn>podoj)/ii//li», which
is readil}' formed from podoi>liyllotoxin by the action of
alkalies, and is much less active than the latter Pi-
cropodophylliu occurs in bitter crystals, soluble in alco-
hol, not in water. Podophyllotoxin is also very ajit to
be contaminated with podopliyllic acid, with the yellow
coloring matter podop/ii/l/nrjiKni tin, and with fat.
Action axd Use. — Podophyllum or its resin is locally
irritant, the dust occasioned by powdeiiug the drug
causing redness and smarting of the skin and inflamma-
tion of the conjunctiva;. It has also been known to
produce, upon the perspiring skin, ulcers which have
been mistaken for chancroids. It is an irritant cathartic,
whether introduced into the bowels or stomach, given
subeutaneously, or absorbed from a raw surface. It is a
very slow-acting medicine, requiring from twelve to fif-
teen hours before its effects begin, but it is also rather
jiersistent and thorough, and in full doses is followed by
numerous watery stools. Griping pains are frequent ac-
companiments, and vomiting and persistent diarrhiea
may follow if the dose is very large. After ])oisonous
amounts the above symptoms are exaggerated, and in-
flammation and ulceration of the intestines, bloody stools,
great prostration, stupor, and death may follow. The
action upnn man
and Ihe lower ani-
mals is essentially
the same. It is
supposed to stini-
ul.ite the liver,
and is very exten-
sively given with
a view to this ef-
fect, in the diges-
tive disturbances
called popularl}'
"biliousness," but probably, as w-e now know of nearly
all .so-called cholagogues. it does not increase the ])ro-
ilurtion of bile, hut merely favois its dejection.
JModerale doses of podophyllotoxin given toman pro-
duce the sameeiTecls as ]iodophyllum iiself, with perhaps
less pain and less tendency to vomiling. PicroiX)do]ihyl-
lin acts like the above, but less violently, in consequence,
689
J il ^^"^^tm^^^^M t
%.
-Rbizome and liusi'S of Roots ct PodopliTlUim.
Poisouiug.
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
as is supposed, of its complete iusolubility in water.
Podopliylhim aud its preparations are, then, useful
catharties where action upon the whole intestine, or at
least tlie small one. is desired, and when the expulsion of
bile is desirable. They are frequent ingredients of "' anti-
bilious" pills, both of regular and irregular iiractice. and
are frequently given, too, in small doses in "after-din-
ner" and other mildly la.xative pills.
Admixisth.\tiox.— The ])owdered crude drug may be
given: dose fi-oni O.o to l.ogm. (gr. x. ad x.\.). But, in
view of the great compactness of the ])reci]iitated " resin "
(Besiiin PtMhphyUi. U. S. P., etc.), this is to be preferred.
The following preparations are in the Pharmacojia^ia:
Extract (Erfnif/u/n /',«/<7i/( //'?'')■ strength about, -V ; Htnd
extract {/■lilnirlniii Pii(lophi///i Flin'dn//,), strength j, and
the before-mentioned resin, strength about "/', dose from
1 to B cgm. (gr. J ad i). Of these preparations only the
latter need be remeitibereil or used. P"duj,/,>//!i,t„.viii can
be had in the larger cities, aud shotdd be more uniform
than either of the above, though ver\' commonly it is not.
The dose of the ordinary commercial artiide is about
one-third that of the resin, Imt of the pure substance this
would be about live times too much.
"Mandrake" of the ancients was Minidnir/inYi nJUcimi-
rmn L., a solanaceous plant, containing mydriatic alka-
loids of the atropine type. It is now obsolete as a medi-
cine. Henry n. Riixby.
POISONING, LEGAL ASPECTS OF. -This paper
does not discuss the general priuei[)les of toxicology.
The reader's knowledge of these is taken for granted.
The nature of poisons, the distinguishing characteristics
of the various kinds, the different modes in which they
may be administered and will operate, the appropriate
methods of detection — these and other Ijranches of the
subject are elsewhere treated. The present purpose is to
state very briefly those peculiar duties of the practitioner
which are connected with the use or misuse of poisons.
Legal Dkfi.nitiox. — For the purpose of what may be
called legal toxicology, there is little need of establishing
a precise detinition of the term "poison." Medical au-
thorities on tlie subject agree that the word is one very
diffieidt (some saj' iinpo.ssible) of iirecise detinition. Tlie
law, in general, either leaves the question "What is a
poison? " to be determined by judges or juries, under the
counsel of medical men and experts, in view of the par-
ticular case which brings it furwaril for decision; or re-
lieves the doubtsand obscurity which hangoverthe word
by associating others with it which may enlarge its scope.
Thus an English statute passed early in Queen Victoria's
reign (1 Vic. c. 85, ^ 2), says that whoever shall admini.s-
ter, etc., to any person "any poison or other destructive
thing" with intent to connnit nuirder, shall be guilty of
felony. A trial tuider sucli a statute as this would not
call for any lengthy discussion of the meaning of "poi-
son"; testimony of experts, that the thing administered
was adapted, when administered in the way proved, to de-
stroy life, woidd be sulHcient on that ]ioint to sustain a
conviction. On the other hand, if the experts doubted
or disagreed, tlie judge would instruct the jury to give
the accused the benefit of the doulit. Early American
.statutes use the simple word " poison." leaving the courts
and juries to lix the meaning on the princiiiles above
stated. Thus in New York there are laws of long stand-
ing, punishing every person convicted of having "ad-
ministered any pois<ra to any human being;" and every
person who sliall "wilfully poison any spring"; and
every person who shall "wilfully administer any poi.son
to cattU'," etc., or shall "wilfully expose any ])(iisonous
substance to be taken by cattle"; etc. The actual ad-
ministration of even such laws as these does not tvirii on
chemical or medical discussions of the precise meaning
of "poison," nor vary mateiially with changes in the
exact idea attached to it by men of science. .Statutes
pa.ssed in recent }-ears specify what ar<' (leeme<l jioisons;
thus the Act of Omgress regulating sales of poisons in
the District of C'ohnnbia names in two schedules the
particular drugs intended; and of course, to sustain a
conviction under such laws, there must be proof that one
of the designated drugs was sold. Or, to put the idea in
other words, the vital question in a trial at common law,
as it is called, is not poisoning, liut murder; did the ac-
cused kill the deceased bv the drugs, etc., described in
the indictment'/ In a prosecution under a statute pun-
ishing a particular form i)f poisoning the question is.
Did the accused do the act prohibited Ijy the language of
the statute, in the manner alleged in the intlictmenf?
Experts called in cases involving poisoning are some-
times pressed to state by way of general detinition,
" What is a poison ? " Such questions are unreasonable,
except perhaps when put to test the witness' general
knowledge and qualitications as an expert. The legiti-
mate inquiry involved in the issue is this; Is the particu-
lar article or drug administered one within the class
prohibited by the statute or rule of law on which the
accusation is founded, as that is commonly imderstood'?'
A physician may not be able to give an exact definition,
or to enumerate all known poisons, 3'et be perfectly
qualified to give an opinion on a question of jioisoning
by arsenic, by strychniric. b_v laudanum, etc., and such
are the questions involved in all ordinary cases. Again,
there is no important legal difference between the mean-
ing of "poison" and that of "deadly poison." Drugs
winch prove speedily fatal when taken in small doses
are characterized as deadly, but this is a mere matter of
convenient cla.ssification. There is, however, a class of
cases in which a general definition of " poison " may be
important ; they are such as arise under a statute which
u.ses only "poison" to define the crime, without adding
" destructive thing " or any similar term of enlargement ;
b>it the thing administered is not a poison in any correct
sense, such as pins or needles, bits of sponge or wood,
tufts of hair, orange seeds or peel, chenw stones, raw
rice, poimded glass, boiling water, all of which have
been effectively u.sed with suicidal or murderous intent.
In these cases, the objection that the accused had not ad-
ministered a "jioison" would jirevail; at least the ijues-
tion of the extension of that term would be legitimately
involved. And generally, in inquiries as to criminal
jioisoning, the intent with which the noxious substance
was adnuuistered is quite as important an element as is
the tiature of the substance.
Anvi.;nTisEMEN-T -\nd S-\le of Poisons. — The dis-
seminati(in of advertisements of .so-called remedies for
proc\irenu'nt of abortion, framed in obscure, deceiUive
phraseology, has grown during the present generation to
be a serious evil, and deserves to be mentioned as con-
nected with the general subject of poisons. The regu-
lation of the issuing of advertisements and circulars
announcing such things rests wholly with the State legis-
latures and police. Congress has no power over that
branch of the subject. Several of the States have en-
acted laws which, however, are not, as a general thing,
very stringent or very eflieiently enforced. The rejires-
sion of the circulation of either the advertisements an<I
the circulars, or the remedies themselves, devolves on
Congress. The postal law, as in force at the beginning
of September, 1887. and wliicli operates, of course, over
the whole country, excludes from the mails all poisons
and every article or thing intended for the prevention of
conception or procuring of aborticm, or for any indecent
or immoral use, and every written or printed card, circu-
lar, etc., advertisement or notice of any kind, giving in-
formation when or how such things can be obtained or
made ; and jiunishes by tine and imprisonment any per-
son who shall deposit such things in the mails, or take
them from the mails for the purpo.se of giving them cir-
culalion (Rev. Stat., g 3878. g 3893, as amended July
lith, 1S70, HI Stat., 9U). The duty laws forbid and pun-
ish the im]Mirtation from abroad (a matter wholly within
the |iower of C(pngress) of all kinds of abortives, and ad-
vertisi-nieuts of them (Rev. Stat, t; 2491, as amended
iMarch :!(!. iss:!. 22 Stat., 489).
The srlliug of poisons, as distinguished from the mere
advertisement of them as being for sale, does not belong
to Congress (except as respects the Territories and the
(',(•( I
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Poisoning.
Pofsoiiliio;,
District of Columbia), but to the States. The laws are
quite numerous and are varied in their provisions, but
the general cbai'acter of them is that they do not forbid,
uor indeed restrain, the sale of poisons (in ordinary
course of business of dealers), but prescribe a manner in
which the vial or package containing a poisonous sub-
stance shall be labelled, and record made of the date of
sale, name, residence, etc., of the purchaser. Indepen-
dently of restrictions or penalties imposed by sjiecial stat-
utes, the courts throughout tlie comitry hold dealers in
drugs to a strict responsibility for sales of poisons made
by mistake. A druggist who negligently sells a poison
labelled as a harmless drug, and thereby causes the pur-
chaser's death, is chargeable with manslaughter. That
the error was merely carelessness is no j ustification ; deal-
ers in deadly drugs are held to a strict accountability for
their sales. They must take the highest degree of care
known among practical men, and are held to responsibil-
ity in dealing with poisons corresponding to the degree
of knowledge required in the business. They are under
a general inqjlied obligation that what they sell is gen-
uine, commercially pure, and fit for the use designed.
A Kentucky druggist kept a mill for grinding drugs,
and one day had need to grind some Spanish tlies in it
for a blister, and did so, uot cleansing the mill properly
afterward. Next day a customer brnught a iirescriptiim
calling for Peruvian liark, and tlie careless apotheearj'
passed the bark through the same mill. It thus became
mixed with a modicum of the dust of Spanish tlies, and
the unfortunate patient was made very sick. He recov-
ered damages for the suffering and peril to which he had
been exposed. The court .saidau aiiotbecary is bound to
know what he .sells; and if Peruvian bark alone is called
for, he must not sell bark mixed with cantharides (13 B.
Mon., 219). More recently, another Kentucky druggist
sold croton oil instead of linseed oil for a patient, who
died in consequence of the mistake, whereupou his widow
was adjudged to have a right to full damages (11 Bush,
380). And there is a memorable case in New York State in
■which some manufacturing druggists put up belladonua
in jars labelled, throiigh mistake, "extract of dande-
lion." These jars were sold to retailers at random, anil
one of them, a druggist in Cazenovia, filled a jirescri])-
tion calling for extract of dandelion from this belladonna
jar. The patient, a married lady, was nearl\' killed. As
the Cazenovia apothecary acted innocently he was not
prosecuted; but the husband sued the manufacturers,
and recovered (6 N. Y., 397).
POISOKIXG FN" ReFEUENCE TO THE DISTINCTION OP
Degrees in Muhuer. — In the legislation of many of
the leading States during recent years murder has been
divided into two degrees, the general purpose being to
class the more aggravated, deliberate forms of homicide,
in the first degree, and make them punishable with death ;
while those exhibiting an instantaneous intent onl.v shall
incur imprisonment for life. Murder by jioisoning is
eminently deliberate; in the statutes of several of tlie
States — of Pennsylvania and New Hanijishire, for in-
stance— killing by poisoning is expressly declared mur-
der in the first degree; under other statutes it falls into
that class by force of general terms employed to define
the class, such as " wilful, deliberate, and premeditated
killing." Under such statutes there have been one or
two convictions for the second degree, where poison was
unquestionably the means used for the homicide ; but
such convictions do not imply that poisoning is not in
the view of the law deliberate; they rather show a com-
promise amon.g the jurors; tho.se who hesitated to join
in a conviction which would be capital induced the
others to unite in a verdict of the second degree rather
than have a disa.grecment. The intent to kill is. how-
ever, essential under all accusations of murder by poison-
ing. In an Indiana case the accused administered a dose
of cantharides to a woman, not meaning to kill her. but
to excite her passions, so as to induce her to consent In
sexual intercourse ; but the dose was excessive, and
caused her death. The decision was that, for lack of in-
tent to kill, the crime was not murder.
The I.mportance and Difficulty of the Physi
cian's Duties in cases involving poisoning can scarcely
be overstated. His task involves intimate knowledge of
chemistry, and often of law, as well as of practical medi-
cine. The recovery of the patient if alive, the honor of
the dead in cases of .suicide, the reputation of the living
in cases of suspected murder, may dejiend on the acute-
ness and energy, or on the prudence and reserve, of his
measures. He must work, not only with friends and
nurses, but often with persons shuddering or smarting
under .suspicion, and witli jealous detectives, and with
suspicious police. If he is called while the sufferer is
yet living, his duties are complicated bj' the primaiy
effort to effect a cure. If death has taken place, he may
probably be the first person to detect any fleeting indica-
tions that crime has been committed, and is above all
others best fitted to register and preserve the evanescent
evidences. Moreover, with the progress of chemical
science, the list of means at the command of the well-
instructed poisoner is constantly extending, while the
rapidit_y with which the methods of detection at the com-
mand of the practitioner are increased in number and
complexity renders his task steadily more difficult and
responsible. Moreover, the nimiber and variety of
symptoms which poisons produce, many of which close-
ly reseiidjle those characteristic of natural disease and
are easily mistaken for them, complicate and embar-
rass the examination. There are several diseases whose
course and termination resemble the action of certain
poisons. In short, of all crimes that of poisoning re-
quires the most learning, acuteness. skill, and prompt-
itude for its detection. The imjiortnnce of the physi-
cian's part in the work is equalled only bj- its ditliciilty.
In the capacity of medical jurist he needs a thorough
knowledge of the pli}'siological, therapeutical, and toxi-
cal actions of poisons and of the lesions which they
may cause. As legal chemist he needs that wide
knowledge of the kinds of poisons and of their distin-
guishing characteristics, and that practical experience
and skill in chemical analysis and manipulation, which
will enable him not only to detect a jioi.son with cer-
tainty if it exists, but also to avoid all risk of obtain-
ing evidence of it, or of confounding things similar but
innocent.
Classification of Poisons for Legal Uses.— Dr
Pugnet suggests ("Med. -Leg. Papers," 2d ser., rev. ed.)
that the division of poisons into the organic and the inor-
ganic, though acceptable to the chemist, is insufficient
for the needs of the medical jurist. He suggests the fol-
lowing:
I. Corrosives.
I Sulpliurio aolii.
Strong Mineral Acids \ Nitric acid.
f Muriatic acid.
VrrH'tablc Aciil ■{ Oxalic acid.
j Strong alkiillH
Alhalics..
II. Simple Irrita.nts.
III. Specific Ieritaxts.
IV. Necrotics. •
Narcotics...
t(Uttivcs.
I Alkalim
r Tlic iiliovc d
Lime.
Zinc.
L Silver, etc.
I Ar.'<('nic.
I Mcrciii'.y.
-! ATititiiimy.
Ptu'spliorus.
I. Iodine.
.Opium anil its adiv
Hy
lioiiati's, etc
iluteil.
V. ASPHYXIANTS.
VI. .\BORTIVES
principles,
iscvaliiils.
ltcllad<iniia.
Slianionniln.
Calabar liean.
Disitalis.
Aconite.
Pi'iKssic acid.
Toliacco.
1. Hemlock.
Vat^ti'ttiutin' ..... -1 Hellebores.
f Uliloroform,
I Cliloral.
Bichloride of
iiicthylenc.
F.tlier.
Niirnuso.\ide.
. Amylene.
I ('iii(rii/,sirc.'i..N"ux Vomica, Brucinc, strychnine.
.Noxious sasps.
. EriTot. Sayiue, etc.
Cirehro-fiJinat .
S[tinaL
Aua'stliitics ■
691
Poisoiiliisc,
PoisoiioiiM Plants.
reperenc;e haxdbook op the medical sciences
The corrosives destroy the tissues with wliieli they
come in contact by chemical action, and are cliaraetcrized
by causing intense pain witli a burning. Tlic simjile
irritants cause primarily' iri'itation; secondarily, intlam-
malion, wjiieli may |irove fatal. The s])eeitic irritants
act primarily as local irritants, tiut have a secondar}'
speeitie action. These are the iiuisons with which the
physician is most fn^iuently called to deal in this coun-
try. In acute eases tliey cause lesions ol' the alimentary
canal ; liut in cases of slow poisonin:;' these arc wantint;'.
Of the neurotics, Dr. Pufjuct says tlial they have not as
yet occupied a prominent place in toxicology, hut the
day is not distant when the jiractitioner may be called
upon to investigate cases of criminal poisoning hy means
of them.
Tile abov(! elassifh-ation is the most complete which
the writer lias seen. (_)l hers which have received wid(^
approval aie those of Ortila, Taylor, and Tardicu (the
leading features of which arc given in 2 Wharton and
Stille's "Med. Jnr.," 4th ed.). What reeonnneuils it to
the toxicologist is that the various ])nisons are cla.ssilied
according to their distinctive physiological action niiou
the living organism, and not npnn their clienueal organ-
ization anddilferenees. C^lassificationsliy Christison and
Fodcre are also widely quoted.
Counsels and C.m'tions Rei,attve to a Legal In-
quiry.— The various works that discuss to.xicology in
its chemical and medical aspects contain numerous coun-
sels and cautions to the practitioner as to the manner of
carrying forward the scientilic investigation necessary in
cases of suppo.sed poisoning. This jiaper will select and
mention siu'h as arc ]iarticularly applicable where a sus-
picion of crime arises.
Remember that poisons may eiilcr the system with
fatal effect, not only by swallowing, but also by inhala-
tion, by absorption through the skin, inchuling the ac
ce.ssible muccnis mendir.-mcs, and by injection, subcuta-
neous or peranum. Swallowing is the mode bestadapted
for adnnnistcring them with murderous intent, but in
cases in which the symptoms are obscure and not ex
plainable b^-a siispicionof a jioison swallowed, the medi-
cal jurisprudent will do well to consider the jiossibility
that one or the other modes may have been employed.
Ill |iarti<Mdar persons, subslauces ordinarily poisonous
may be rendered inert, or those not ordiuariiy unwhole-
soiiic may be rendered ])oisonous, by some idio.syucrasy
of the individual, by a habit of taking them, or by a con
dition of disease.
A poisoncnis comiKUind may. by pnssibility, be formed
within the body by two niediiinrs iiiiKPCriitly jireserilied
or taken, cither of whiih alone would have been innoc-
uous.
An organ may, by possibility, become impregnated
with a poison after death, either accidentally, as where
it has been laid in a soil in which an^ poisonous elements,
or wheresneh elements are introduced in the process of
embalming; or feloniously, as where an attempt is nuuie
to introduce a ])oisou in ortler lo give ground for charg-
ing an innocent pers(ni with murder. The ]iresciice of
substances introduced after death is sci<'ntilie.-illy distin-
guishable, no doubt, frmn those taken in life; but the
two ma}' be confounded if the distinction is forgotten.
The narrative of the symptoms attending the last ill-
ness is of less service than is usually supposed in deter-
mining the criminal chai'aclerof the case. Jlodern ex-
peiieiice is, that death cannot be safely atliil.iuted to
poisoning from the symptoms alone; too m.-iiiy disea.ses
rcMiulile the action of poi.sons to allow of dispensing
with an autopsy and a cliemical examinal ion, when ]ioi-
siining is susjiected. And still less light is thrown by
the mere symptoms upon the question fundamental in
the legal aspects of the subject — whether the ]iois(m was
taken accidentall}' or ignorantly, or was taken with sui-
cidal purpose, or was administered with rehaiious intent
this (|Uestion must be decided from tlie general attendant
circumslanees of the ea.se.
The ]iliysician should never allow morai cireumstauces
to ]irejudiee his iniiiil, neither should he neglect them.
Inileed, he is the best judge concerning them. Let him
ascertain whether an enmity e.\ists between the sick
person and any one who attends or visits him; whether
any poisonous substances have lately been purchased ;
wdietherthe.se are still in the house; whether the alarm
ing circumstances came on immediately after taking a
drink or any other substance of an innocent nature: and
liarticularly, in case of a sick person, let him ascertain
whether anything has ))een given without the orders of
the pliysiciau or by a person ignorant of drugs; and then
he should draw a comparison between the symptoms
present and tlio.se that ordinarilj- accompany the sup-
posed disease.
He sliovdd carefidly examine and jirescrve samples of
every article of a suspicious nature, such as vials, boxes
or papers containing powders, remains of food or drink,
linen, sponges, cooking utensils, etc., in use about the
pidient ; and he may (if assured of the support of the
persons interested to promote justice) safely exercise a
good deal of assumed authoritj' in taking such precau-
tions as against anybody who may object or oppose.
Often a careful search of the premises and of the dead
body will bring to light some article wliieli, coupled
with peculiar circnnistauces, warrants suspicion.
To decide between the relative probability of suicide
and murder is a ditlicuit ciuestion. The following facts
are considered to indicate suicide: that the deceased had
recently met Avilh great losses or disajipointments, or
was suffering under disgrace, or under some f(n-ni of in-
sanity or delirium; that the mode of pois(miiig was cun-
ningly devised to avoid a suspicion of suicide wdiile yet
the deceased lield a life insurance polic_y: that lie left
any recent writing expressing his last wishes. If death
has not occurred, the circumstance that the jiaticnt docs
not complain, but declines medical aid and remedies,
confirms a suspicion of suicide. On the other hand, such
suspicion is partially excluded when the circumstances
favor the iiresumption that the fleceased was in the en-
joyment of a prosperous and happy life; when the drug
employed is rare and procurable only with great dilii-
culty, or is one which needs the co-operation of a second
person for its ailmiiiistration, or is known to be produc-
tive of long and severe sulTering. Considerations like
these, and the results of a skilful toxicological investiga-
tion, in which the means afforded by anatomical and mi-
crosccqiic science, chemistiy, and spectral analysis are
useful to be employed, are more inqiortant in determin-
ing that the death is attributable to pofson, and that this
may in'obably have been criminally administered, than
are the mere symptoms.
The examiners sliould observe perfect cleanliness at
every steit of their worl<; the organs removed from the
cadaver for chemical examination slioidd not be placed,
for exam]ile, upon boards <u- in rcceiitaeles whieli liave
been cleaned with disinfecting solutions which may have
had poisonous constituents, but should be placed in
gla.ss or porcelain-lined dishes previously cleansed. The
prudent and judicious advice given by Wharton and
Slillc (2 "Jled. Jur.,'' § 11) is tliat whenever, in a case
involving a suspicion of murder, "a chemical analysis
for poison is to be made of any of the organs, these or-
gans should be placed by the phy.sieian himself in per-
fectly clean glass jars ; glass preserve jars with a glass or
porcelain-lined cover are suitable for the purpose, and
can always be obtained in the ccmntry or city. Each or-
gan .should be ]ilaced in a jar b_y itself — for instance, the
stomach in one jar, its con'eiits in another, the intestines
in another, contents of intestines in a fourth, the liver in
a tilth, the kidneys in a ,sixth, the brain in a seventh, etc.
Tlie organs which should be saved for chemical analysis
are. in order of their importance, as follows: .stomach,
ciaitenls of stomach, liver, intestines, contents of intes
tines, kidneys, brain, heart, spleen, and urine if there be
any; in some cases, it is important to save portionsof the
muscular tissue, and in oliiers a part of the lungs. lu
some cases it is wise for the physician making the exami-
nation to divide each of these substances into a]iproxi-
mately two equal parts, each part to be kept in separate
f)92
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
Poisoning.
IPoisonous I'laiits,
jars, oue to be given lo one chemist for preliminary
analysis, and the other to be retained by the physician
himself, in case it may be necessary to have the anal_ysis
confirmed by another chemist, as is usually the case in
trials for murder by poison. These jars containing the
organs should be closed and sealed by the pliysician him-
self, the seal to be sianipi'd with a private stamp. They
should then be locUed u|.) until they are to be delivered
to the chemist. It is better that the organs be placed
under double lock, one key to be taken by oue person
and the other by another, so that neither one alone has
access to the organs ; this is. of course, not ncce,s.sary if
one person possesses the key and another has possession
of the stamp with which the .seals have been stamped.
When the jars are to be sent to a chemist, they .should be
sent b}' messenger, preferably by two messengers, since,
in the event of the investigation residtiug in a trial for
murder, the identity of the organs cannot be lost by the
death of the messenger. The organs should never be
sent by express since it is In that case impossible to
preserve with absolute certainty the identity of the or-
gans."
Sending the organs or their contents to the chemist is
often not enough, especially when crime is suspected.
Thus, the reason why no poisonous substance is fotmd in
the stomach may be that all which was not absorbed was
vomited; therefore all vomited matter which can be
procured, including clothing, or carpet, or surface of
floor which has received it. should have chemical exami-
nation. The vessel in which vomited matter has been
contained will often furnish valuable evidence, since
heavy mineral poisons fall to the bottom, adhere to the
sides, or leave a sediment. The offender m-dy have had
the intelligence and opportunity to empty the basin, etc.,
but not have thought, or not have been able, to attend to
the dress or the floor.
Formerly it was the practice to confine the analysis to
the stomach and its contents. Experience has, however,
shown that most if not all the viscera, including the
bladder and urine, are required before anything like a
satisfactory conclusion can be drawn as to the existence
of poison.
The stomach, with its contents, should always be re-
ceived by the analyst in its entire state, and not, as was
formerly usual, sent to him slit, and the contents mixed
in a jar with other fluids and organs — a practice which
is highly objectionable, as it may lead to the ends of jus-
tice being defeated by the complication involved. A
slight incision may sulliee to inform those who jierform
the autopsy of the state of the organ and tlie uatun- of
its contents, when it should be tied and handed to the
analyst. If, in case of accident or dispiite, a necessity
arises to preserve a portion of the stomach and other or-
gans, together with any fluids or solids, in bottles or
otherwise, for further i-efereuce and confirmation, this
may be done, but the_y should all be properly labelled
and dated and kept in a cool place.
Besides receiving the matter to be analyzed or exam-
ined, the analyst should be thoroughly informed upon
the history of the case, and the symptoms anil effects, as
a knowledge of these will aid his examination, enable
him to avoid useless searches, and prevent his overlook-
ing suspicious facts. Me should even be informed of the
exact time of the death, which is important in reference
to the length of time usually taken for a fatal operation
of the poison suspected: of the attitude of the body,
etc., especially if there were any dying struggle; as
certain poisons cause characteristic ^yrithings or con-
yidsions.
The analyst should never leave the vessel containing
the suspected flvnd in an exposed .situation. He should
keep it under lock and key. and, if interrupted in the
course of the experiments, should restore it to such a
place that he can positively affirm that no one could have
meddled with it.
The notes of an autopsy or chemical examination
shotdd be promptly reduced to an orderly report; and
greater care than is usually taken is desirable to avoid
the use of medical or chemical terms, such as are not
easily understood by judges and jurors.
AVhen the chemist has completed his analysis, if ho
finds that the poisoning has been committed with an in-
organic poison, such as ar.senic, antimony, etc, he should
bring the metal into coiut aud present it to the jury;
and there should be a sullicient quantity of it in order to
submit it to all the tests necessaiy for its identilicatiou.
With the organic poisons, the legal chemist would find
this almost an impossibility, as the organic poisons are
much more active, and are fatal in smaller doses. Their
presence can be proved by various tests which are relia-
ble; but their very nature would tend to prevent their
complete isolation in sufficient quantities for presentation
to the jury. lliiijuniiii Viiinjliiin A/i/uitt.
POISONOUS PLANTS. — It is generally agreed in
toxicology that the term "' poison " should not be applied
to any substance which produces its injury through me-
chanical means. Following this terminology-, we exclude
from consideration in this article all such substances as
cowhage, which produces intestinal injury chiefiy by the
piercing quality of its hairs, the sliarp awns of the niany
grasses so fatal to grazing animal.s, the prickles and
thorns of thistles, brambles, cactuses, aud similar plants,
which act mechanically, at least chiefiy, notwithstanding
that their presence often produces abscesses from which
blood poisoning may result. From this article are exclud-
ed also all the ordinary disease germs. Although, st rictly
speaking, such diseases are the results of poisoning by
these minute plants, growing within the s_ystem, their
proper treatment pertains to bacteriology and pathology.
Since most of the more important poisonous plants
are, by virtue of their activity, available for medicinal
purposes, they are discussed elscAvhere in that connec-
tion. Not only are their jjoisonous effects and the treat-
ment there considered, but descriptions ample for their
identification, in the condition of drugs, are provided.
In many cases such drug descriptions have been stipple-
mented by others, pertaining to the plants themselves,
often witli illustrations, in order to provide for their
identification in cases of poisoning by the fresh material.
The present article is intended to supplement the above
by considering important poisonous plants not used as
drugs. At the same time manj- of the latter will be re-
ferred to at the proper points in this system, and the
other articles upon them will be duly cited.
Gexek.^i. Ri:coi;mtion. — The question is frequently
propounded. " Is there any general rule by whiclt a poi-
sonous plant can be recognized at sight ? " To this ques-
tion an emphatic negative must be rettirned. There are
certain characteristics which frequently accorapanj^ poi-
sonous properties, but this is not true in all cases; and,
on the other hand, these characters may exist in the ab-
sence of such poisonous properties. Of such characters
are the peculiar lurid luirjile color seen upon the stems of
the castor oil, cicuta, eoiuum, pokeberr_y, dogbane, aud
mauy other plants, though shown also "b_y the harmless
angelica. A narcotic odor isconunon to man}' of the most
poi.sonous plants, but is waiuing in many others. An
acrid taste is probably the nuxst common characteristic,
and constitutes the best safeguard which we possess,
since it is likely, especially in the fresh article, to furnish
a warning before a dangerous quantity h.as been cou-
sumed. Thus the potato, though ordinarily quite bland,
inqiarts. when poisonous, a pecidiar bitter, nauseous,
and slightly acrid taste. Even this taste-guide, however,
fails in many notal)ly poisonous substances. It may be
added that milkj- -juiced plants are usually to be regarded
with suspicion.
Principal Poisonous Families.
Of the two hundred and eighty or more families of
plants, a number are recognized as being specially rich
in poisonous species; but not all of the species of any
family are poi.sonous. and important food plants are usu-
ally found closely related, in the same family, to violent
C93
Poisonous Plaiil!^.
Poisonous PlanlM,
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
pnisous. Thus the family Solanncea: contains the deadl_v
nitrlitshade, stramonium, and henbane, yet yields the
potato, tlie egg plant, and the tomato, and even the po-
tato itself may at times be poisonous. In the Enjihor-
biiicci^ we find the mauchiueel, cvoton. and eiiphorbium,
together with the cassava; and we have indeed poisonous
varieties of the latter. JIany similar ilhistrations might
be cited. It is, tlierefore, not deemed feasible to essay a
classification based upon botanical or an_y other general
relationship, although, as a matter of convenience, the
characteristics of several highly poisonous families are
given below. While only a practical botanist can be ex-
pected to utilize tills method of recognition to the fullest
extent, 3'et surgeons in the army and navy and other
travellers may gain great assistance by recognizing sus-
pected plants as pertaining to the following families:
Apocynacea; (the Dogbane Family). — This large family,
of more than a thousand species, chiefly tropical, is prob-
ably, all things considered, the most cotnmonly and
powerfully inoisouous. Its memlicrs are mostly heart
poisons, well illustrated by aiioc}"num, strophanthus,
and oleander. Its poisonous constitueuts are bitter and
chiefly glucosidal. though many alkaloids are contained,
and a number of them, or the extracts containing them,
enter into the manufacture of arrow jioisons, especially
in the Old-AVorld tropics. Poisoning accidents by mem-
bers of this family are rather common in tropical regions,
sometimes occurring through the tise of the stems for
spitting meat, stirring food, or in similar culinary oper-
ations. The Ixitanical characters are as follows: Juice
usually milky: leaves {in the poisonous sjiecies) opposite,
simple, exstipulate. Flowers regular, pierfect, o-nu'rous-
calyx inferior, jiersistent. imbricated; corolla tubular, the
limb usually rotate, convolute; stamens five, borne upon
the corolla and alternating with its lobes, the anthers two-
celled; pistil dicarpellary, the carpels distinct or united;
the ovary 2-celled or with two parietal placenta'; styles
united or divided up to the simple stigma; fruit usually
of two follicles, oceasioually drupaceous; S(!eds frequently
plumose.
Ariifi'n- (the Arum Famil}'). — Tliis monocotyledonous
family is well illustrated by the calla and calamus. Its
members are chiefly tropical, and produce thick, some-
what succulent stems, frequently climbing tree trunks,
and usually large, somewhat succulent, cordate leaves
similar to those of the calla. A great many species pro-
duce bulbous or tubeious.stem bases, commonly regarded
as roots. Some of these, as the taio (Ciihirntiii iscnlentd),
are important foods. Others would be so but for their
poisonous constituents. In a few cases, where these poi-
sonous ]U'operties are mild, they are destroyed by thor-
ough cooking, '\vliile in others tliis method fails and
attempts thus to use them may result di.^astrously. The
injurious princi|>les fall into three classes: First, as in
the seeds of jieltaudra and skunk's cabbage, needle-
shaped raphides of <-alcium oxalate, occurring in great
alnnidance. and irritating mechanically ; second, asinour
common wild turnip, acrid juices which are partly de-
stroyed by drying; third, powerful alkaloids, some of
them, or the extracts containing them, used in the manu-
facture of arrow poisons. The flowers of the ai'oids oc-
cur densely massed u]jon a cylindrical (as in calla) or a
'globular (as in skunk's cabbage) spadix, enclosed or sub-
tended by a spatlie (the white imrtiou of the calla), though
this is .sometimes obscure. Tlie plants are diacious, or
the staminate flowers are on the upper, the pistillate on
the lower portion of the spadix. Rarely the flowers are
peifect. There is usually no pierigone, though some-
times this exists in the form of a number of scales. The
filaments are very short, their anthers two celled, the
cells sejiarated by a liroad connective and ojieiu'ng dor-
sally. The ovary is variable in structure, the stigma
terminal, small, sessile, or on a very short style. Fruit
usually a berry, occasionall\' inflated.
(Uiftaaiv (the Cactus Family). — Beyonil remarking that
many leafless and spiny or succulent plants wliich do not
pertain to this family are frequently mistaken forcactuses,
little need be said of its characters. The juice is bland
and never milky, the flowers are showy, polypctulous
and polyandrous, and the inferior fruit is a many -seeded
berry. In desert regions, in the absence of food, and
more especially of drink, the flesh and juice of cactuses
are often utilized. In such cases it should be borne in
mind that while the spiny species are usually innocent,
tlio.se which are unarmeil. or nearly so, like the night-
blooming cereus and the anhaloniums, are often narcotic
or cardiac poisons.
Campatndacem (the Harebell Family), including Lohe-
lifKfm (the Lobelia Family). — The two divisions of this
family here named have been regarded by many bota-
nists as distinct families. Certainly there is a marked
distinction between their properties, the former yielding
roots rich in iuulin and sometimes edible, whereas the
Lobeliacea; contend with the Apoc_vnace;e for first rank
among poisonous families. The nature of the constitu-
ents and the character of tlie poisoning are pretty uni-
form and have been sufficiently detailed under Lobelia.
Since the poisonous species are very widely distributed
throughout both temperate and tropical regions and are
quite showy and attractive, their recognition is unusually
important; fortunately it is also quite easy. The juice
is acrid and almost always milky; leaves" alternate, ex-
stipulate, simple, and commonly abundant ; flowers per-
fect, mostly showy, usually 5-merous; calyx tube adher-
ent, the limb mostly regular and persistent; corolla
tubular, epigynous, irregular and oblique or two-lipped,
its tube fissured on the ujiper side; stamens five, inserted
upon or with the base of the corolla and alternate w'ith its
lobes, the filaments coherent for the most of their length,
as well as the anthers.
Cuoirhitiii-eiv (the Cucumber Family). — Notwithstand-
ing that this family is rich in edible fruits, like the
pumpkins, melons, and cucumbers, yet it contains also a
very large number of poisonous species. The poi.souous
properties pertain usually to the roots or the fruits. The
former class is typified in bryonia, and has been suffi-
ciently considered under that title. The latter is illus-
trated in our accounts of colocynth and elaterium. and
need not be further considered. No difficulty need be
experienced in the identification of the Ciicurhitacci',
which are tendril-bearing vines, usually iierbaceous. and
the flowersof which are invariably constructed like those
of the plants named above, though they are occasiou;dly
small or even minute.
EnjihorhiiicciT (the Sjiurge Family). ^ — The general and
poisonous properties of this family have been considered
in Vol. IV. The plants are readily recognized by their
milky juices, in couuection with the unisexual flowers,
which are themselves inconspicuous, though often sur-
rounded by showy modified leaves resembling a flower
circle. The perigone and andrceeium are so extremely
vaiiable as to be difficult of any brief characterization.
The ovaiy and fruit are almost uniformly three-celled
and the latter few-seeded.
Iriihiciir (the Iris Family). — This monocotyledonous
family almost uniformly contains irritant poisonous oleo-
resins, well illustrated by that of the ofiicial Irix. Owing
to their acrid properties they are not very likel_y to cause
poisoning, except through their medicinal employment.
Nevertheless, owing to the fleshy and obviously nutritive
character of their rhizomes or tubers, they are' not infre-
quently resorted to as famine foods in some countries,
and disastrous results have sometimes thus occurred.
These plants are [lerennial herbs with narrow, disti-
chous, often succulent leaves. The flowers are perfect,
with an adherent six-parted convolute and niarcesceul
)ierigone. The stamens are three and adhei-ent to the
outer fierigone segments. The ovary and seed pod are
commonly Uiree-celled, with a three-parted style, and the
ovules and anatropous albuminous seeds are numerous.
Ler/umiitasir (the Bean Family). — This family has al-
ready been briefly considered in Vol. V. as to the general
nature and proi)erties of its jioisonous constituents. As
poisons, its members present peculiar dangers, which,
upon the whole, are not equalled by those of any other
family. These dangers lie in the fact that, while the poi-
694
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Polsiouous Plants.
Poisonous Plants.
sonous constituents are very widely and irregularly dis-
tributed, and extremely subtle and uncertain, the faniih'
is at the same time the most highly nutritious as to ai-
buminiiid constituents iu the vegetable kingdom. Even
such edible articles as peas and beans are not entirely
free from poisonous properties, which become apparent
when they are fed in large quantities as stock foods.
Although the poisonous properties pertain to all three of
the sub-families, they are most common and conspicuous
in the PapilionacciE. The members of this family are
rather easily recognized by their almost uniform habit
of producing a legume for a fruit, and by their highly
developed exalbuminous seeds. In the Papilionace* the
leaves are alternate, stipulate, and usually compound,
the flowers papilionaceous and nearly always perfect, the
calyx more or less gamosepalous, the five or ten stamens
almost always more or less coherent. In the two other
sub-families the flowers, though often irregular, are not
papilionaceous, and the stamens ai'e commonly wholly
or nearly distinct.
Liliacem (the Lily Family). — This very large monoco-
tyledonous group is now, with good reason, divided into
tile Smilaceae, Melanthacefe, and Convallariacea? as dis-
tinct families. Nevertheless, since they agree, excepting
the Srailacea^, as to their poisonous properties, tlie entire
group is here considered. The plants are mostl_y herbs,
growing from bulbs or fleshy rhizomes. The juices are
usuallybland, though sometimes, as in the onions, acrid.
Indeed, the poisonous species have mostly acrid juices.
The leaves are parallel-veined and usually sheathing at
the base. The flowers are regular and possess a six-
parted perigone in two circles. The famih' is distin-
guished from the Iridacea' by its six stamens, which are
usually free, or nearly so, and distinct. The ovary is
three-celU'd and usually superior, the styles distinct or
united. The pod is three-celled, the seeds are numerous
and highly albiuninous. This family, like the Iridacea',
is very liable to cause poisoning accidents, owing to the
succulent and nutritious properties of its underground
portions and even of its herbage. The nature of its poi-
sonous constituents, both chemically and physiologically,
is too varied for au,v general description.
Loganiacece {the Nux Vomica Family). — This is here
referred to as being a small familv, closely related to
Apocynacem and almost equally poisonous. It is closely
similar to that family iu its structural characters, but
lacks the milky juice and the annular stigma. Acciden-
tal poisoning is scarcely likely to occur from its members,
except through their medicinal emploj'ment, and those
sidjjects are fully treated elsewhere.
Oxididarea' (the Oxalis Family). — This small family,
for a long time regarded as part of the Gerfinincav, is
readily recognized by the close similarity of all its mem-
bers in foliage and flower structure to the genus Oxalis,
represented by the wood sorrel, the sheep or lady's sor-
rels, common garden weeds, and by man}' species
cultivated in the conservatory. The herbage of these
plants contains oxalic acid and, like the meadow, field,
or kitchen sorrel (Evinex Acetosclla L.)has, when eaten in
excess, caused serious or even fatal restdts, both to chil-
dren and to adults.
PitpnveraceiP (the Opium Famih). — This .small family
is almost uniformly narcotic-poisonous, very many of its
species being also irritant. Its constituents are pre-emi-
nently alkaloidal, and these alkaloids are very numerous
and varied in their mode of action. Owing to their com-
monly irritant properties these plants are not likely to
cause poisoning, except through their medicinal use.
They have commonly milky or colored juices, mostly
compound or lobed leaves, perfect flowers (usually regu-
lai). their parts free and, except as to the carpels, dis-
tinct. The seeds are numerous and small.
rinaceie or Conifcrm (the Pine Family). — The large
family of cone-bearing evergreens is too well known to
reiiuire description. Itsconstituents and properties have
been sutiiciently indicated in our accounts of Juniper,
Sarin. Turpentine, etc. Similar constituents exist gener-
ally throughout the family. Poisoning is not likely to
occur, owing to the acrid and excessively- disagreeable
character of the tissues.
lianunculaeece (the Buttercup Family). — This large
family is distinguished by its alternate, exstipulate
leaves, flowers which show neither adhesion nor cohesion
in any of their parts, innate anthers, anatropous ovules,
and the small embryo in fleshy albumen, taken in con-
nection with the acrid juices. Tlir.se acrid juices are
commonl)' cutaneous and internal irritant poisons. At-
tempts to utilize them for blistering purposes have been
made, but the blister is not readily controlled. A great
number of the species contain, in addition, principles
which, upon absorption, act as cardiac paralyzants, of
which aconitine may be taken as the type.
Simarubacfce (the Quassia Family). — The constituents
and properties of these plants have been sufiicientl_y dis-
cussed in connection with quassia and simaruba. Their
consumption so as to cause poisoning is almost impossi-
ble, owing to their very bitter taste. A cui'ious case of
poisoning by Ailanthus is recorded below under " Poison-
ous Leaves."
Holanacem (the Potato Family). — A description of the
characters of this highly narcotic family is not called for,
since pretty much all of the species likely to cause poi-
soning have been already considered in connection with
the drug.s, Belladonna, Henbane, Stramonium, etc., or
below in connection with Solanum.
Uinhelliferw (the Parsley Family. ) — This very large fam-
ily, although it yields many important edible products
(carrot, parsnip, parsley, celery, angelica, etc.), contrib-
utes also such violent poisons as couium, cicuta, and
fenanthe. Its species are very readily identified. They
usuall}' possess, especially as to the poisonous species,
hollow stems, petioles wliich are dilated and sheathing
at the base, leaves pinnately compoimd. usually decom-
pound, as seen in celery and parsely, flowers in (usually
compound) umbels, these flowers "usually minute, with
five superior calyx teeth, five epigyuous petals and sta-
mens and fruits having the general structure of the well-
known conium, anise, coriander, fennel, etc.
Yiolncen (the Violet Family). — Although not at all
likely to be consumed in poisonous quantities, except as
overdoses of medicine, the violets should be remembered
as containing one or more emetico-cathartic poisonous con-
stituents, very similar to emetine, and long mistaken for
it. The violets are so well known that no description of
them appears called for.
Local Cutaneotis Poisons.
Poisonous plants can be conveniently divided into those
locally poisonous to the skin and those internally poison-
ous. The first-mentioned class w-ill be first considered.
They represent all grades of irritation, from a mild
and brief itching to a severe corrosion or a dangerous or
even fatal inflammation. The milder of these groups can
be accorded but the briefest mention. A large munber
of them produce no effect upon most persons, but have
been at times recorded as irritating to certain iudivid\ials
with a highly sensitive skin, or who are subjects of idio-
syncrasy. Illustrations of this class are seen in the fresh
herbage of Teratrum, in various species of Cypripedium,
Catalpa, Bliododendrvn, and Kalntia, and in Vnnilht. In
a number of cases the nature of the [loison has not been
ascertained, and it is possible that it is due to the presence
of animal or vegetable parasites, or other foreign boilies.
Others, like the various nettles ( I'rtirn. Vvtieastnim [La-
purtea] Urera, etc.) are regularlj' irritating, but the irrita-
tion is temporary, though often very painful, and unless
comphcated does not call for treatment. In the last-
mentioned genus of tropical American shrubs the stinging
hairs of the ordinary nettle are magnified into needle-like
lirickles, several inches in length, intensely poisonous,
and cau.siug severe inflammation when contact with
them is extensive and violent. The nature of this poison
and its treatment have not been investigated, though
doubtless much the same as in the nettles. Very similar
to the nettles are the stinging hairs upon the various
685
Poisonous Plants.
Poisonous Plants.
REFERENCE IIAXD1500iC OF THE MEDICAL SCIENX'ES.
species of Jatropha, Trayin. anil iitliers of the Enplwr-
biaceir. ,Siei/os in the Cncurbitaiyn', Kcliiniii, uml oUiera iu
the B'TiKjiiiiicnv. Tlinse of tlic Kup/inr/iiiirKr h-avv also
t,ro]iical relatives {Iliirii, etc.), in wliieli tlie haifs are
inai;iiili''il into spines, tlie elVeets of wliieli are severe.
The iin|iortant eiitaneous poisons, tlmse reqni ring our
attention, pertain eliielly to tlie families AiiKciirdiacem
ami Eiipliorhiaeni'.
The poisonous meniliers of tlir .iHie'iov/A/rvYrareuinner-
ous, anil their effeets are of eMreindy eonunon oeeur-
renec and very severe. Tlie |)oisiinous constituents, their
moile of action, syniptoms, and treatment are in all cases
either iilentical or so closely similar tiiat tliey can lie
readily considered unih/r the one sulijcct of Klius pioison-
ing, tlie furtlier consideration of the respective individ-
uals being conliued chielly to their description and recog-
nition.
Slnis Puisoiu'ii;/. — Tlie ])riiicipal agent conecrned in tliis
accident is tlie herbage of Ulitis rddicdn.i L., the coinnion
Poison ivy or oak. Climbing or Three leaved ivy or su-
mach, Mercury, or Black mercury. There is considerable
difference of opinion as to wlietlier Liuni's 11. to.rifiiden-
droti is identical witli his li. rmlicniix, but the title, as
hero used, includes lioth. Tlie plant is a slender North
American shrub, and occurs wild to some extent iu Eu-
rope, where it has been introduced. It may lie jirostrate
upon the ground, tliongh it jireters to climb shrubbery or
trees, iu sunny locations, or uiion fences or walls, to
which it clings by false or non-absorbing roots. Some-
times, especially southward, it grows with an erect, self-
supporting stem. Having thus attained a support, its
branches spread or droop outwaid to a eonsideralile dis-
tance, being thus very apt to brush against the faces
of tho.se walkin,g alon,g country roailsides. Flower and
fruit lialiit are well displayed in the accompanying cut
(Fig. :!So!)). The trib>liolate, or occasionally (|uini(Ue-
foliolate leaves sometinies reach a foot and a half or even
two feet, including tlie petiole, in length. The leallcts
are very thin and present a peculiar satiny lustrous ap-
pearance. Although usually apparently smooth (some-
times conspicuously hairy on the lower surface), tliey iu
reality bear an intinite number of extremely line and short
hairs. The tiowers are of a greenish-vellmv and are fol-
Flfi. :!s:!!l.- lilnis niilif:ins. (Twd-nillis niitiinil si:!c
lowed liy small driipaerous. pale green, smontli fruits. -
borne in loose bunelies. ipiile unliku those of the ordi-
nary red sumac.
.Sonic of llie conditions liy which poisoning can oenir
from tliis plant are iu dispute. t)n theorelieal grounds, 1
if what is known of the nature of the poisonous con- |
stituent lie taken into consideration, actual contact iu
some form appears to be requisite; yet innumerable and
Well-authenticated experiences render this view quite
untenable. There is the widest dill'erence in the snscep-
tibilit}- of diflerent individuals, some being apparently
incapable of being poisoned by it under any circum-
stances. Others, who have been exposed to it frequently
for many years witliout result may suddenly become
severely jioisoned. Others again are extremely sensitive
to its action, the most serious, or eveu fatal, results en-
suing from even a moderate contact. Finally, cases are
of common occurrence in which iioisoning occurs ap-
parently without any contact wdiatevrr, a strong wind
blowing over the plant from a short distance constituting
a sutHcient occasion. It has been suggested that in such
cases the pollen grains constitute a medium of transpor-
tation, but such occurrences take jilace when no pollen
.grains are present. It seems hardly credible that the al-
most microscopical hairs can be active in these cases,
notwithstanding that experiment has demonstrated their
power, iu very small nunibrr, to ell'eet slight jioisoning
when directly api)lied to the skin of sensitive persons,
under specially favorable condiiions.
JIuch speculation has existed, and many conllicting
statements have been published, as to the nature of the
active constituent, but the laborious researelies of Pfaff
have gone far toward clearing up this subject. lie has
located the poi.son iu the fat or fixed oil which exists in
fractional ]icrceuta,ge. and which has been called taxico-
ihiidivl. This is an alcohol-soluble fat, iu which charac-
ter it resembles croton oil and its relatives. Its chemi-
cal nature is very incompletely known. Reasoning by
analogy, we should assume that the oil is not poisonous
in its own form, but only through its freed fat acid. If,
as originally claimed h_v 3Iaiseh, who called iu to.ria/deii-
drie acid, this decomiiosition product be volatile and
active, all of the inconsistencies regarding its action
would be removed. The same or similar fat existing
underneath the bark acts siniilarly, and here again it is
notable that many cases of poisoning liave been recorded
as occurring by contact with the smoke emanating from
a smothered lire of the wood of the plant. It is also
stated that certain very sensitive persons cannot remaia
iu or near a room where the tincture of the fresh drug
' without the certainty of being poisoned,
■s of other sjiecies of Rlius, especially the
■r tree, act .similarly, and a case is on rec-
emanations from a bottle of this lacquer
poisoned the faces of those smelling
it, though there was no contact.
Poisoning did not result where the
substance came into contact with the
mucous membranes of the mouth and
nose.
There exist in the leaves, besides
to.xicodendrol, a small amount of re.s-
in, .some tannin, wax, and other un
important constituents.
Poison ivy has been highly recom-
mended by the homa-opatiis as a
medicinal agent, purely upon the
dogmatic assertimi .s/niih'd s/m/libus
cum III II r. and it has even founil its
way into the United States Phar-
niacoiKi'ia, though it is to be drop-
ped from the forthcoming edition.
Making the most lilieral .allowance,
we tile obliged to conclude from the
evidence at our command that its
medicinal activity is practically nil.
Ivy poisoning tirst aiijiears as mi-
nute, clustered, itching paimlcs,
ion brcome surrounded by a bright erythemii, in
purl pioduicd by the inevitable scratching. The pajiules
have by the next day become minute, deep seated, ec-
/cmalons blislers. For .several days this appearance is
not much changed, nor are the burning and itching di-
minished. Then the surface of the blisters gets rubbed
w liieh
G!»fi
REFERENCE HANDBOOK OF THE 3IEDICAL SCIENCES.
Poisonous Plants.
PoisonouB Plants.
off. the watery exudation moistens tlie smface affected,
and often spreads llie disease to otlier parts. The blis-
ters tiuall}' become pustvdar. and then crusts and scabs
cover the surface. The first appearance is always lo-
ne. 3840.— Rhus verni.x. (THo-flflUs natural size.)
cal, and if contracted in any of the usual ways is on
either the hands or wrists or the face. lu the latter situ-
ation the swelling is always great, tlie e^'elids generally'
becoming completely closed by it. From the liands it
easily extends to the breasts or male genitals, on the lat-
ter of which the burning is exceedingly hard to bear;
occasionally it becomes general. The course of the af-
fection in a single spot covers usually live or six days,
but it may often spread over twice that time when differ-
ent parts of the body are successively invaded. It heals
without a scar, but is a little apt to return on successive
summeis.
There is rarely any difficulty in establishing a diag-
nosis. The symptoms present some superficial resem-
blances to those of erj-sipelas, but in the latter disease
the underlying tissues are swollen and hard, whereas in
ivy poisoning the effects are superficial and the surface
is soft and somewhat fluctuating.
Numerous remedies and specifics are in use against
Rhus poisoning: still its course, when fairly begun, is
not often really aborted. The measures for its treatment
maybe divided into the following classes: (1) The de-
struction of the poisonous constituent; (2) the preven-
tion of friction due to scratching the affected surface, and
the prevention of the spreading of the poisonous matter;
(3) the relief or prevention of itching and pain from al-
mospheric irritation.
The first of these results can be fairly well accom-
plished if measures are taken very promptly after expo-
sure and before the symptoms of poisoning have fairly
presented themselves. Ordinary washing is inade(|uate,
unless very thorough in<l('eil : and it is, in fact, lialile to
spread the poisonous substance over a wider surface.
Washing with a great abundance of common cheap laun-
dry soap, or even the application of a thick layer of this
soap to the surface, has yieliled good results. " Washing
with a strong solution of sugar of lead is a favorite
method with some, and lime water, black wash, and
other alkaline applications are tiseful. The discovery of
the fatty nature of the poison serves to explain lo some
extent the principles of this line of treatment, the alkali
probably saponifying the fat and destroying its activity.
The second-named oliject is attained by the use of vase-
line or some similar application, and this also accom-
plishes part of the third object, protection against the
effects of the atmosphere. These applications should be
made as lightly as possilile, though thickly, antl not by
means of plasters or similar coverings. Excellent results
have been attained by applying the fiuid extracts of Grin-
delia, Eriodict_yon, and similar resinous substances, as
well as collodion. In these cases the effect is probably
due to the deposit upon the surface of a thin juotectivo
coating resulting from the evaporation of the alcohol.
Relief of the irritation is to he obtained by the application
of carbolic acid. An excellent method is the use of the
official lime liniment to wliich from one to five percent, of
carbolic acid has been added. To any small areas which
exhibit a specially irritable condition, a solution contain-
ing ten per cent, of the acid may be api'lied. Great care
should be taken, however, that no large area, and espe-
cially that no extremity, be covered up by even the
weaker solution. A saturated solution of oxalic acid is
highly recommended b}' some practitioners. As the ecze-
ma dries away, zinc ointment may profitably be applied to
take the place of the other applications. The Chcj-enne
Indians are said to employ with great success an infusion
or decoction made from the herbage of Ai^tnigdbis nitidus
Pursh., a near relative of the famous loco weed (.4. mol-
h'ssiiiius Pwsl.). This infusion is appilied just when the
eruption takes on its " watery " character. Since the
constituents of this plant are entirely tnikiuiwn, the prin-
ciple involved in its employment cannot be stated. The
fresh juice of the wild or great celandine, or jewel weed
(Iiiijiiitieiisfuha) is said to have been used with excellent
results.
Almost precisely similar in action to poison ivj' is the
Poison dogwood or elder or Swamp or Poison sumac (M.
remix L.T R- venenata D.C.) (see Fig. 3840). This spe-
cies is an erect-branch-
ing shrub or small tree
with a smooth ashy-
gray bark, of swamp
lands, throughout
Eastern and Central
North America. The
habit of the leaves and
inflorescence is indi-
cated in the accom-
panying cut. The
leaves are very
characteristic,
on account of
their deep red
petioles. The
leaves some-
times reach a
length of one
and a half to two feet,
are ncarlj- smooth, and
green on botli surfaces.
Flowers ami fruit are
verj- similar to those of
the poison iv_v.
The two species of
Rhus above described
pertain to the section
Yeiieniita. characterized by smooth fruits, and most, if
not all. of the species of which are poisonous. The
Jap:uiese lacquer tree {11. rei-nieifera DC. or ]\. reniix
Thunb.) has been already referred to. The lac(itier
is prepared from its milk juice, which frequently pro-
FlG.
a?4I. — Itlius diversiloba.
half natural size.)
(One-
69T
Poisoiioii#4 PlaiilN,
Poisouuiit* Plaut8»
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
duces severe poisoning, as does the lierbagc. The tree
■closely resembles our II. vcniix L. Species which quite
closely resemble li. radiains are R. uiicrocwrpa (Mx.)
Fig. yftl2, — Metopium. <(me-li;ilf njitural size.)
Steud. (It. To.rico(lendron niirrnnirjin'Mx.) of our North
Central States, i?. Mirhtm.rii Sargent (R. pumila Mx.) of
the Eastern United States, and, in the West, B. Ri/ilbcrr/n
Small and i?. d/ca-.^ihljii T. et G. (/.'. lohata Hook.), the
to this genus as R. metopium L. or R. n.ri/nic/njiiiim
Griseb., but is now called Metopium Linnmt. Engl, (see
Fig. 3842). Its close relative in Cuba, M. rcnomim
(Griseb.) Engl, has similar poisonous properties. These
are .small trees or large shrubs, and their fruits are red-
dish instead of greenish-white like the others named.
Fig. 384.3.— Comodacliii. ( Keduoeil one-half.1 ,1, Leaflet of C. glubra: 7!, has.
duster of C.dentata; C. upper portion of leal of C. ilicifolia ; /», leaf nt (
C'lili.foniini or Parijic PinKon Onh (see Fig. 3841). The
celeliiatcd Cinutl Siimnr. Moinitiiiii. iliinrhincel or Bmii-
wuod of Florida and troiiieal America, has been referred
Fig. 3844. — Lithra-a eaustica. (Two-thirds natural size.)
The genus Comodadia P. Browne {Dodoncea Plum.)
represents shrubs and trees of the central portion of
tropical America, including the West Indies, which are
violently poisonous. Several species are known as Onao,
and a number are here illustrated (see Fig. 3843). Poi-
soning by these species has been successfully treated
with an application of collodion. The follow'ing possess,
in their respective localities, his-
tories of poisoning similar to
those of the Vciieinitir. and Como-
tiiidia described above: in Chili
tlie LUtlii (Litlircra caustien Jliers
(Rhus c. Hook.) (see Fig. 3844); in
ilexico, the Copoljiote, Cuajiote or
C. Blanco, Guajilote or Stinking
Wood { Pseiidosmodi ngivm peniici-
osum (II. B. K.) Engl. (Rhus p. H.
B. K.); in Eastern Asia, Melanor-
rhoe laeciferii Pierre ; in the East
Indies, Iloltgarna femir/tnea
March. ; in Southeastern Asia,
Gluta Ren ff /ills L.
The iixed oil of the cashew or
caju nut, the ripened ovary of
Anacardiumoecidentidc L.. a small
tree, native of tropical America
and largely cultivated and natural-
ized in other tropical countries,
yields the vesicating principle euv-
dol. evidently very similar to the
poisonous element of Rhus. This
substance exists in specially large
amount in the middle layer of the
])eriearp, and the fatty substance
thence exuding frequently causes
l)oisoniiig. Cardol (C-jiHsoO-;) is soluble in alcohol and
etlier. In the crude condition it varies from yellow to
reddish or brownish, but can be decolorized. Poisoning
of leaf and fruit
Iilatvphylla.
69S
REFERENCE IIANDBOOIC oP TlIK MEDICAL SCIENCES.
PoiK4>iioii54 Plants*
I'oiMoiioiiM Plauls.
by it, and its treatment, are practically identical with
those pertaining to Rhus,
The only other cutaneous poisons important enough to
require consideration here are certain acrid j\iices of the
EuphorbiaceiB. Types of this class are Alvclos and Ea-
plivrbium (which seej. Others are referred to in our arti-
cle on Euphurhiacca'. In most of these cases tlie poison-
ing agent appears to be resinous. Incroton oil and some
others they are apparently fat acids. In the former class
the saponification treatment offers little promise. In
both cases protective and soothing applications are
equally efficacious as in Rhus poi.soning. ilaucliineel is
the large tropical American (chiefly NVcst Indian) tree
Hippomane Mancinclla L. It bears large, tliici';, ovate,
acute, finely serrate leaves and an apple-like fruit con-
taining several silvery seeds. Its milky juice is abun-
dant and is the poisoning agent, its active constituent
being apparently volatile. Treatment is much like that
applicable to Rhus jjoisoniug.
Internal Poisons.
In considering the poisonous plants which act through
the entrance of^their constituents into the circulation or
into the alimentary canal, the primary requirement ap-
pears to be their identification. This, in a majority of
cases, is most readily effected by reference to the objects
themselves, rather than to the symptoms as in cases of
poisoning by chemical substances. This fact has deter-
mined the following classification of these objects as
plant parts.
To discuss all poisonous plants would require a large
volume, and it has been deemed wise to treat tlie subject
from the standpoint of a North American work, consider-
ing all plants of importance, or likely to become so, as
poisoning agents in our own region, and including, from
outside of this region, only such as are of primary im-
portance. Moreover, no attcmiit is made to enumerate
all those known to possess poisonous [iroperties, since it
is clear that many of them are not at all likely to be
eaten. A still further restriction of the subject is made
by omitting, except by mere mention, those poisonous
plants or plant parts which become effective only
through their medicinal employment, these having been
sufficiently treated in the materia medica portion of our
work.
Fruits and Seeds.
These products are placed first because of their greater
liability to being eaten. Contrary to popular ideas, the
£
Fig. 3,S45.— Belladoniiii. Briinoh reduced one-lialf ; fruit natural size.
number of poisonous fruits and seeds in North America
is small. Even in country districts, where correct
knowledge of this subject should be found, many per-
fectly innocent substances are commonly regarded as
poisons.
IkUitdonnn (fam. SuliindrKi). — I'nduuliti'dly this is our
most important poisonous fruit, its seeds conlaining the
active constituents lUTtaining to the roots and leaves.
The plant is rare in a wilil state in tliis ccnuitry, though
very common in .Southern and Central Europe, Its
scarcity, however, renders it on some accounts the more
dangerous, since it is thus not well known. It is a
highly attractive, purple-black, shining, juicy berry, as
indicated by one of its common names, "black cherry,"
and has been often eaten by children in the regions where
it abounds. The accompanying illustration (see Fig.
3845) is ample for identilication. The plant is a tall,
widely sju'eadiug, smooth perennial herb, s<uncwliat re-
sembling the pokeberry plant, though not so large and
wanting the strong purple stem coloration of the latter.
All matters pertaining to the symptoms and treatment of
poisoning by it will be found under Delhidniind.
Bittersweet, True and Fahe. — Rather closely related to
belladonna is the true Bittersweet (Snlnnum Dvleamara
L., fam. Solanacea). Leaf, flower, and fruit forms are
shown on page 703, Vol. I., and tlie plant is tliere de-
scribed. It is'found both in Europe and in America, and
grows commonly in the edges of swamps and along
streams, especially where the water is stagnant, or where
the ground is subject to overflow. Occasionally also it
grows in other localities, as about shaded stone walls and
fence rows. The branches are long, slender, sprawling,
and widely spreading over bushes, and the fruits are
pendulous. Nothing more attractive than these fruits
can be imagined. They are of a ruby-red color, smooth,
shining, and .somewhat translucent, and children are very
apt indeed to cat them. Their poisonous properties are
rather mild unless large numbers are eaten. The seeds
appear to be the poisonous portion. The properties are
partly those of the drug Dulcamara, but more intense,
and the poisonous constituent appears to be solanine.
False Bittersireet (Celastnis scaitdens L,, fam, Celas-
tract'a) has been considered in the same connection. Its
fruits are also attractive, but possess an acrid taste ; hence
they are not likely to be eaten in quantity. Their poi-
sonous properties, due probably to a small amount of
saponin, are comparatively slight.
Potato Fruits. — The small berries which develop upon
]iotato plants are mildly poisonous, especially when un-
ripe, in the same way as are the berries of true bitter-
sweet. They have a" nauseous, acrid, and disagreeable
taste, and are not at all likely to be consumed.
Black A'if/hts/iade. — The fruits of black nightshade
{S'llaiiaai ni/jnini L,, fam. Solanacca-) may be dismissed
with the same remarks which have been applied to po-
tato fruits. This plant grows like a tall, slender, and erect
potato plant, in similar situations to those of bittersweet,
though usuall}^ in dryer ground and more in the vicinity
of l)arns anil waste" places. It is not very abundant,
Ihougli somewhat common in the United States, as in-
deed in almost all other parts of the world. Its fruits are
a little larger than large peas, and are of a greenish-black
color. The fruits of many tmpical species of Solanum
are similarly, some violentlj', poisonous.
Other North American berry-like or fleshy fruits re-
quiring consideration in this connection are the baneber-
ries, or cohoshes, red and white, pertaining to the genus
Artaii and the fruit of tlu! J'ew,
Aclaa {{am. Baniniciilacea') is a genus of several spe-
cies, probably more mimerous than generally admitted
bv systematic botanists, distributed from .Japan across
Asiaand the most of Eurojie, and in North America from
ix'can to ocean. According to ancient, and to one very
reeenl authority, the half-score species of f'imicifuga are
also included;'but to most botanists familiar with the
|i!anls in a state of nature, an absurdity is involved in
this association. The red and white berries have been
ri'eorded as poisonous, the medical laitanist Lindley say
inn of them that thev produce death with violent delir-
um, emesis, and catharsis (see Fig, 384G), The active
constituents of the baneberries have not been invest!-
699
Poi«ouoii!!i Plaiit».
REFEREXCE lIAXDI'.oOK OF THE MEDICAL SCIE^'CES.
gated, but are in all probability similar to those "f lark-
spur seeds audstavesacre. NoteiKuisli iskiiownof their
action to suggest anythiug more than ralimial treatment,
consisting of prompt evacuation, followed by alleviation
Fio. SMi'..— Aptn?ri. .1, A. rulira : U.
Mze. J
rrwo-tbirils u.Ttiinil
of the painful symptoms, and su)ipi>rt to the circulation,
which is depressed as in poisoning b\- hellebore.
Tew Jurriex (fain. Taxacea). — Jt was for a long time
supposed that the American creeping yew was a mere
vari<'ty of the European, which latter is recorded as hav-
ing produced various poi.soning accidents. >,'ow, how-
ever, it is recognized tliat they rejjresent distinct species.
The foliage and fruits are here illustrated. The plant is
an evergreen and the fruit is of a beautifid bright scarlet,
frequently with a somewhat glaucous surface (see Fig.
384T), The poisonous constituent, present in the seed
and foliage, is the alkaloid i'l.riue (C'l,tII.,.jX(.)|i, l. whieli is
bitter, ri-adily soluble, in its free state, in alcohol and
ether, but not in water, and is precipitated by silver ni-
trate. Its action is very imperfectly understood, tluuigli
it is compared in a general way with that of digilalis.
The following symptoms have Iieen recorded: nausea
and retching without much vomiting, dilaled ]iu)iil, <-on-
vulsions intenupting a scini-coniatose condition, a cold
and chunmy skin, and dillicult respiration. No cases of
poisoning iiy the American plant liave been recorikd,
though it doubtless acts similarly.
Plnjliiliiccii or juil.-fh, rrii has already been considered as a
drug'. The so-calleil Ijcrries are ill reality stone-fruits.
They are of a beautiful and tempting apiiearance, being
of a dark purple-black, shining and juicy, and are not
rarely eaten by children (see Fig. 384iH). After a little
time the taste becomes acrid, so tliat large quantities are
not usually consumed. The seed, which is the poison-
ous portion, is enclo.sed in a crustaceous endocarp, which
is usually not crushed in eating, so that the seed is pro-
tected for some time against the digestive juices, ^lean-
time the pulp itself is somewhat la.xative, so that the
dejection of the pyrenes in an entire condition is to be
anticipated. Treatment should consist in prompt emesis
and catharsis, followed, if irritant s_yraptoms should ap-
pear, by that applicable to jjoisoning by pokeroot.
Otlii'}' fleshy fruits. — In this connection brief reference
may be made to the fact that although the common >Iay
apple or mandrake berry is commonly and freely eaten,
j'et two cases are recorded of poisoning by it. one result-
ing fatally. The symptoms were those of poisoning by
podophyllin, although narcosis came on very early.
Such .seeds as those of the cherry, plum, and peach are
in all respects similar to bitter almond, and are capable,
when eaten in excess, of causing prussic-acid poisoning.
Two cases are reported in which intestinal inqiaetion of
wild cherry stones, followed by the freeing of the seeds
by maceration, resulted in poisoning, one of the cases
proving fatal. Excessive indulgence in eating the
sweetish fruits of any species of juniper may result in
poisoning similar to that by the ordinary medicinal juni-
per.
The fruit of Trinnis eomrrnnns L., the Black biyony
(fam. Didsc'trinceiv) grows upon a tendril-bearing vine ox
Northern Africa, Southern Asia, and Southern and Cen-
tral Europe. It (see Fig. 3S-t!t) is an active emetico-
cathartic poison, producing powerful diuresis, and ap-
parently acting much after the manner of squill.
In Southern and Central Europe, as well as in culti-
vation for lawn ornament, occur the ijcculiar fruits of
Daiihiie inczerenm L., which are (piite actively emetico-
cathartic and diuretic ; they are used fi>r tisli poisoning, and
sometimes poiscm children. The}' contain the glucoside
(hijiliiitn (Ci.,IIio09.2IlJ)) which is neutral, soluble in hot
Vl>.. 3.S4T.— Tiixiis
Branch slisrliil.v redueed ; ament ami fruit X 2.
(After Brillou ;md Brown.)
i water and hot alcohol ; also the amaroid daphnetin. which
i is a !(•( Illy acid and astringent principle, similarly solu-
ble. ^Vc her<' ligure also the fruits of llakrii kclir, the
eoiniuon ivy. which are discussed under the title /«/, and
those of Liijustnim vul//are, or privet, considered under
, the title Oloiren:
700
REFERENCE lIA^iDBOUK UF THE :\IEI)ICAL SCIENCES.
Poisouoiis Plants.
Polsouons Plants.
Finally, reference may be made to tlu^ fact that mild
nureolii' properties pertain to tlie eimimon elderberry,
notwithstanding the freedom with wbii-h this fruit is
eaten. Small animals, like barnyard fowls, have been
Fig. 3848.— riiytolacca. (Oue-balf natural size.)
recorded as suffering from intoxication from eating them.
Cooking or fermentation appears to destroy these proper-
ties.
Stramonium. — Among the non-fleshy fruits and seeds,
probably the most important poisoning agent is Datuia
or stramonium, the common thorn apple. An examina-
tion of our illustration (see Stramonium) will show that
the fruit is large and conspicuous, and very likely to at-
tract the attention of the curious or Inmgry. Growing
as it does in Tvaste places in cities, whose inhabitants are
not accustomed to observing vegetation, it not infre-
quently happens that its sec'ds, which are contained in
abundance, are eaten, especially by young people. It
is also stated that in India and other Oriental countries
where this plant abounds its seeds are often eaten by
starving people in times of famine, with widespread fatal
effects. The Thugs were said to use them freely for the
purpo.se of stupefying their intended victims. Such
assassins w-ere cahvd Dhaturicis. The symptoms are iden-
tical with those described tinder iStramoninni, as is the
treatment.
Henbane. — Closely related in everyway to stramonium
is henbane. The plant is similarly a large, coarse,
widely spreading herb, with clammy foliage and heavy
narcotic disagreeable odor. Its cap.sules are not more
than half so large as those of stramonium, and they dis-
charge by the separation of a terminal lid. Poisoning by
these seeds is not common.
Oiciiia. — Small fruits, usuallj' spoken of as seeds, are
those of conium and cicuta. The former has been sulli-
eiently considered under that title. Poisoning by the
latter, except as part of the plant itself, which subject
will be considered under roots, is not at all likely to
occur. The same may be said of the seed-like fruits of
our wild ]iarsnip, wljich are said to be somewhat poison-
ous, the action being partly acrid-irritant and jiartly
narcotic. IS'o authenticated cases of poisoning are re-
corded. The fresh juice is said to blister and tlie root is
regarded with suspicion.
To be classed with ergot, as poisonous constituents of
grain, are the darnel, the cockle, and perhaps the seeds
of other species of plants in the pink family.
Lolium, Deirnel, Bearded Darnel, Irraie (Fr.), ].olcU,
Tainnelkom (Ger.), is the fruit (grain or caryopnis, com-
monly mi.scalled seed) of X. teiniilentum L. (fam. Gra-
miiiea'), an Asiatic grass, growing commonlv in grain
tields there and in Europe, and so introdiued in this
country. The general structure of this seed is that of a
grain of wheat or rye. It is about a fourth of an inch
long, and comes away with the palets attached and en-
closing it, is convex on one side, groove<l on the other,
of a light brown color, smooth, starchy in structure, and
gradually develops a bitter taste after chewing. Its
presence in flour, if in large <iuantity, can be detected
by the appearance of the starch grains, which are much
smaller than those of wheat starch, nearly circular,
white-margined, the rest of the body without markings,
and having a peculiar brightly shining surface. The poi-
sonous constituent is the alkaloid tramline (CtHicX^O),
existing with temidcntic arid. There is a good deal
of obscurity regarding the mode of action of this poison,
but the substance is in general classed as a narcotic of the
delirifacient type, producing much nausea, dizziness, and
headache, with drowsiness. There is also at inrst con-
siderable irritation of the .stomach and intestines. Dar-
nel-contaminated flour is not dangerous unless the sub-
stance is present in very large amount, from which
condition a nutnber of fatal cases have resulted.
Cockle or corn coclie, tlie seed of Agrostemmei Githigo
L. (LycJinis O. Scop., fam. Cari/op/ii/llaceep), is very com-
mon in grain fields, more so in Europe, where it is native,
than in this country. The plant is a slender herb, two
or three feet liigh, the branches terminating in handsome
purplish flowers about an inch broad, and having the
general appearance of a common single-flowered pink.
The seeds are produced in a one-celled capsule and are
numerous, black, and about as large as morning-glory
seeds. Their active constituent appears to be a kind of
saponin which is exceedingly common and abundant in
this, the pink family. The properties of the poison are
those of saponin, and a percentage of the seeds in the
flour sutflciently large to produce fatal results is scarcely
to be expected.
The closely related plant Tacearia Vaccaria L. Britton
(Saponaria V. L. ; T". rulgerris Host.), the cow cockle,
cow herb, or field soapwort, produces seeds which are
apparently identical in action with the corn cockle.
This plant is at present spreading widely through the
grain fields of the Western United States, and the seeds
are becoming increasinglj' abundant as a constituent of
grain. Although they are rather easily screened out, yet
their possible presence in flour is to be recognized as a
distinct source of danger.
liicinvs or cnMor oil seeds have been rather fully con-
sidered under Castor Oil, so far as constituents and activ-
ity are concerned. These
.shining, reddish, and jmr-
p 1 e - s p o 1 1 e d, bean-like
seeds are very pretty and
attractive to children.
Their tendency' to be eaten
to excess is the greater be-
cause they have a bland
and nutty flavor, quite
free from the nauseous
odor and taste of castor
oil, unless they have be-
come old and rancid. The
common cultivation of
the plant for lawn de-
coration conduces to acci-
dents. In one case, a city
resident, moving to the
suburbs where a quantitj'
of these seeds were strewn
upon the lawn, fed them
to his horses with the re-
mark that it was a pity to see all those licans going to
waste. The effect ujioii the horses was fatal.
Several other Euphorliiaceous seeds were formerly much
701
FKi. HSin. — .1, Dai)line Meze-
riMim; li. Tamils I'liimnunis; C,
Limisinim vulirare: D, Hedera
liclj.N. (.\fU'r Hulnies.)
PoKoillKIM Plj|ll(«.
Poisonous Plants.
REFERENCE HAXDBOOK (JF THE MEDICAL SCIENCES.
cultivated iu guideus for use as cathartics, umier tlie
name of spurj^c or spurge seeds, and tliis lialiit has not
entirely died out. They produce, in overdoses, poison-
ous results similar to those of riciuus.
Coral 11(1111. — Acting by a toxalbumiu similar to riciu,
or even more like abrin (see J(r/iiiiiti/). the seeds of several
species of Siij'horii, especially N. cnmllintles Benth, (fam.
Legumiiumtr). have produced fatal jioisoningiu Texas and
the regions to the southwest. These coral beans resem-
ble a ^'onunon beau in form, some being larger, souie
smaller, and are of a bright scarlet color. They grow in
a brown or brownish cvlindraceous pod, which is con-
stricted between the si.'eds, so as to resemlile beads upon
a stick, and separating readily into its one-seeded joints.
TreatmenI of this poisoning has proved ditbcult and un-
certain.
LiqniifH (fam. Le;iiniun<»ia).—'Sla.uy species of the
genus Lnpiiiiis (wild bean or blue bean) are employed,
in both Europe and America, either as fresh fodder or
for the production of a hay very similar to clover l-.ay.
Although these fodders are used iipon a great .scale, with
only the best results in most cases, yet wholesiile and
fatal jjoisoidng has at times resulted". Many observa-
tions, together with some careful experimentation, have
apparently d<'termined tlie fact that the poisoning is due
to the seeds, wlucli resendile small beans and are pro-
duced in bean-like or jjea-bke pods, "When the herbage is
eaten previous to the formation of these seeds, or after
thev have lieen discharged from the pods, no bad results
folfow; liut if the seed's are eaten, especially when ripe,
either acute or chronic poisoning may follow. The
symptoms indicate a poison similar in its general na-
ture to digitalis or, still more so, to sparteine or ononis.
There is cerebral congestion, with frenzied and very ac-
tive lielirium. The heart is slow and strong, the blood
pressure high. Convulsions, with extreme alternations
of strengthand weakness, and finally prostration occur.
There is )iowerful diuresis, the urine being often bloody,
as in digitalis iioisoning. Death usually occurs in acute
cases within two hours of the appearance of the first
sj'mptonis.
JEsodu!!. — The common hor.se chestnut (seed of JE.
EippociiHUinutii L., fam. Jlijijiuciistiuificai') is regarded as
slightly poisonous, and certainlj- contains acrid saponin-
like piinciples (iirr/i/r<rnciti. and (ipldvihvttciii) which, con-
svuned in large amount, would prove disastrous. De-
prived of tins principle by powdering and maceration
in alcohol, tlie residue of the kernel is'highly nutritious
(protein eight percent., fat seven per cent., non-nitro-
genous extract conlaiiung among other constituents
fourteen per cent, of sugar), and it is now being so man-
ufactured in Gernuuiy. It is readily conceivable that, as
this industry extends, insuliicient purification may lead
to the distribution of a poisonous pnjduct. A western
and southwestern species (.E. Parln L.), the buckeye,
is apparently much more active, various fatal cases of
poisoning by it being on record. Its poisonous constit-
uent is similar to. but distinct from, argyrtescin. The
symptoms are violent emesis and catharsis, convulsions,
and other conunon accompanimints of poisoning by the
saponin group. It would appear from the accounts tliat
narcosis comes on rather more ((uickly than in cases of
poisoning by other saponin-eontaining drugs.
PoisoNors B.vKKS.
In the nature of the case poisoning of luunan beings by-
barks is not at all likely to occiu', except in medical cases
where a poisonous bark has been taken by mistake, or
overdo.ses of the bark have otherwise been given. It is
true that many barks are employed bv savages as arrow
poi.sons (see Ciinirc), but this suiiject scarcely pertains to
the present article. The jioisoning of stock by the eat-
ing of nutritive barks is in general prevented through
the natural instinct of the animal. In times of scarcity of
food, however, grazing animals sometimes eat the bark
of the eonunon locust tree illnbinia jm'iiiliinin'ii L.) with
poisonous results. This tree pertains to the family Le-
guminosa', or bean family, so noted for its production of
albununoid n\itrients. Its poisonous constituent has
been determined by Power as a toxalbumin, very subtle
andilillicult of isolation. Nothing is known of the treat-
ment, except what is derived from a knowledge that the
chief .symptom is extreme nausea with violent retching,
jicrsisting for daj's, accompanied by dizziness and great
depression. In animals marked salivation has been no-
ticed. The barks of wild cherry and of several Eri-
caccous plants are poisonous to stock in the same way as
their foliage, and the latter will be considered luider
Ilerbiigc. Tlie barks of various sjiecies of elder (Smnhi/-
ciix) are more or less poisonous, though it does not appear
that they produce accidents. This subject will be con-
sidered under Uoots.
Poisonous Roots.
Besides tin; true roots, that name is generally applied
b.y the public to all underground parts, such as man-
drake, lily of the valle\', Solomon's seal and other rhi-
zomes, the potato and the artichoke, which are tubers,
and the onion and garlic which are bidbs. All these are
therefore here considered together.
The two imjiortant poisonous roots of our region are
pokeroot and Cicuta. Probably no year passes without
some fatal cases of poisoning by those, and it occasion-
ally happens that quite a number of them occur at about
the same time.
Pokeroot has alreadj' been considered at length as a
drug, under that title, and its fruits have been elsewhere
discussed in this article. The root has been quite often
eaten by mistake for horseradish, which it rather closely
resembles, and for other edible roots. The strong acrid-
ity of hor.seradish tenils to avert the suspicion which
would otherwise be excited by that of the |iokeroi)t.
When freshly dug it is cpiite attractive, being large,
whitish, fleshy, and succulent, and containing large
amounts of starch and sugar, so that it is readily mis-
taken for a wholesome and nutritious article. Suspicion
once aroused, pokeroot is easily recognized. The base
of the stem, which is usually present in a broken condi-
tion, is seen to be divided by thin transverse partitions.
The surface is finely paiiillose, and usually ])resents a
spiral apiiearance, and the cross section exhibits a con-
spicuous coiu-eiitric arrangement of the tissues. Since
the young shoots are often cut and eaten as a substitute
for asjjaragus, portions of the root are apt to be thus
taken by too deep cutting. Thorough cooking amelio-
rates, but does not destroy its activity.
Cicuta. (Water Hemlock, Cowbanc, Brook Tongue,
Children's Death, Spotted Parsley, Beaver Poison, Jlusk-
uash Poison, etc.; Ger., ^Vaafierchkrlimj, G(fliriittli< rich;
Fr. . Cii/iie vi)'eii»e) is the root of various species of the
genus ' Cicuta L.,"fam. UmbeHifertr, a genus closely re-
lated and very similar to conium, some of the sjiecics
even having gone by that name (see Figs. 38.i0 and Ss.-)!).
These plants grow in swamps or other wet locations, along
lakes, streams, and ditches throughout almost the entire
North Temperate Z(nie, and are particular!}- common and
abundant iu Eastern and Central North America. Our
illustrations give an excellent idea of the roots, foliage,
inflorescence, and fruits. The plant grows to a height of
from three to five feet, and branches and spreads ratlier
widely. The stems and leaf bases are thick, hollow,
crisp.aiul juicy, and the former are usually more or less
purplish and glaucous. The base of the petiole cl.-isps
the stem. The leaf blade as a w-liole, though successively
much divided into small segments, is very large, often
two feet or more broad and long, and is thin and quite
green. The entire plant is smooth, and exhales a not un-
l)leas;uit odor when bruised. The fine white flowers are
in decompound umbels, terminating the branches. The
base of the stem, when Icuigitudinally cut, exhibits thin
fransvei.se |iarlilions, though these are obscure in some
species. The roots, in fascicles like dahlia roots, are usu-
ally from three to ten in number. They have about the
consistency of a raw ]jotato, are starchy, crisp, and juicy.
702
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
Poi)^4»ii(>iiM ll>laiit»».
Poi!»ouou»> Plauls,-
somewliat arnmatic, and not unplcnsant to the taste.
Tlicx- ail' I'.xterually of a biowiiish color, iiilerually wliite.
Tliry are about the size of Jerusalem artiehoUes, which
thev somewhat resemble, and for which they have been
mi.^taken. Boys visiting swamps for calamus often get
hold of them. Frequently also they are turned out in
Flo. 3.S.50. — Clcuta raaculata. (One-halt natural size.)
ditching operations, and they have then been experimen-
tally eaten by workmen with fatal consequences. The
aromatic steiii and the fruits have also been mistaken for
angelica. The constituents are believed to include co-
niine (see C'onium). Cicutoxin is also a verj' active con-
stituent. Although the nature of the i^oisou partakes of
and exuding from the mouth, cold, contracted, pale sur-
face and some diarrhu'a have been noted. Prompt eraesis
Fig. 3852.— <Enanthe crooata. Reduced. (After Holmes.)
by the aid of zinc sulphate has been found effective-
The further treatment is indicated by the symptoms.
Fig. 3S.51.— Cicuta maculata. (One-fourtli natural size.)
that of coniuin, yet there is far more of a teudenc}- tow-
ard irritation and convulsions. Tremors, violent contrac-
tions and relaxations of the muscles, astonishing mobil-
ity of the eyeball and eyelashes, widely dilated [Uipil.
frothing, often bloody, of the mouth and nose, epilepsy,
and after death a peculiar greenish fluid in the .stomaeli
Fig. 3853. — Sambuous Canadensis, (one-iliird natural size.)
CEnanihe CrncaUi. — In Europe this species, closel^y re-
lated and rather similar to cicuta, is regarded as taking
703
Poi*!iolli>ii*i Plniit!^,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Fio. 3S.>4,
li:ilf natunil
first rank iuiimii;- poisonous planl.s. Lilie cicuta, it
grows in damp soil and produfcs a fascicle of Hesln' roots
(sec Fig. 38.")2). Its leaves bear a slronj; ijeneral resem-
blance to those of celer_v, and it is free from disagreeable
or warning taste. The symptoms of poi.son-
iug are onl>' iu a minor ilcgi
those resulting from ciciita,
of the ]ioison is ])roliably qi
The .syniploms develop very i
freiiuently occurring within
two. Dryness of the iiioull
thirst, vondtiiig. then dizzii
weak pulse, pale and cold
blood pressure, pupils great]
failing resiiiration, inducing
result. Death
oc<'urs a]>par-
enlly from heart
failure. Judg-
ing from these
s y m ].) t o m s, i t
would ajipear
that the admin-
istration of digi-
talis Avould con-
stitute a rational
line of treat-
ment.
Siiiiibiii'i/s or
Elder {him. Cap-
r/fiiliiii'iir). (See
Fig. 3S.-):j.)— Ap-
parently clo.sely !i\yA\)
related to cicuta
as a poison, is the root of tlie common elder, and prob-
ably of other species of the genus. These roots (or more
properly rluzonies) are elongated, cylindrical, crooked,
somewliat branched, whitish, and possessed of a rather
thick, juicy bark. C!ommonly, some small shoots can be
seen upon "them, and these arc usually of a liluish-purplo
color at the place where the young leaves are forming.
When bruised, these roots exhale a rather disagreeable
odor, and the after-taste is acrid, (ioniine is said to have
been extrai'ted from some of the eldeis. The symp-
toms of poisoning are much like those from cicuta, and
jiromptly fatal results have been recorded.
Irisov nine Finn rhizome (fam. Irklaced), growing
commonly in swamps or low ground, along with calanuis
or sweet flag, is liable to be mistaken for the latter. The
distinctions between the two, once known, are sufficiently
easy for recognition. Iris grows in small or only modi'-
rately large clumps, while calamus covers Large patches,
almost to the exclusion of other growth, and usually in
wetter situations. Its leaves are longer, narrower, le.ss
thick and tleshy, and are greener, lacking the bluish-
green tinge of iris. Tlie plant is also taller. The rhi-
zome of calamus is long and rather uniform in thickness
for a consi<leral)le distance. That of iris is much thick-
ened at short intervals. Calamus is bitter and somewhat
acrid, so that tlie acridity of iris, though greater, is
apt to be endured by the heroic calannis chewer,
thinking that he has the rhizome of the latter. The
properties of iris have already been considered (see Fig.
3.S.")4). The fresh rhizome is Tnuch more initaut and vio-
lently emetic and cathartic than tlie dry drug.
Veritriiiii (fam. ^fellnlllllll■cll). — Growing in the same
swamps with iris, thougli usually iu more wooded or
sliade<l .situations, veratrum is often found. Although a
mistake is here not easy, such a possibility should not be
ovcrliioked, as the rhizome is tleshy and sue<'ulent. 15e-
yond refcriing to our illustnation and to our account of
the drug (see Fig. 38.50) this subject requires no discus-
sion.
('(Hints. — Various western species <if the genus Zygaile-
nus M.\.. of the same family with Veratrum, are known,
by this name, and several of them are recognized poi-
sons, especially /. rciieno.iiis Watson, or Death camas, a
uame which has been applied to a polymorphous species,
or a group of very similar species, accoi'ding to the vary-,
iug views of difl'erent botanists. In all probability most,
if not all, of tlie species of this genus are poisonous, but
only the death camas has produced serious results. The
genus is characterized as follows: Plants smooth, peren-
nial, from rhizomes or bulbous bases, the stem bearing
linear, somewhat succulent leaves, and terminating iu a
laceme or panicle of yellowish-white or greenish-white
niarcescent flowers, the perigone six-parted, its segments
gland-bearing near the base. Stamens six, borne at the
base of the perigone but free from it. the anthers cordate
or reniform. Ovary three-celled with three styles. Pod
completely dehiscent and containing narrow, angular
seeds. The genus is closely related to veratrum. Z. n-ne-
iwsiis is here figured (see Fig. 3S5.5). It is extremely
common and almndant in Jlontana and otiier Norllnvcst-
ern grazing regions, and is very destructive to stock.
All parts of the plant appear to be poLsonous. The bulb,
which is especially so, is recognized among the Indians as
dangerous to man because of its close resemblance to sev-
eral edible species. It appears to be bitter at times, quite
free from bitterness at other times. It is cousideretl fatal
to about twenty per cent, of the sheep poisoned by it.
The symptoms are said to be uneasiness followed b\' in-
coordination, then mu.scular parah'sis, especially of the
posterior limbs. There are dizziness, disordered vision,
regurgitation of frothy matter, salivation and weak res-
piration, with little cerebral disorder. The nature of the
poisoning may thus be re.garded as paralysis of the mo-
tor centres, jirogressing from below upward. The nature
of the ]K:iisons is unknown, though the indications are
those of one or more
glucosides. They are ...-C'~^
extracted both by
alcohol and by water.
Potassium perman-
ganate a]ipears lo be
a very efficient anti-
dote. ■
C'losely related to
Zygadenus, and by
some botanists re-
garded as pertaining
to it, is CJtrof.]ienii(t
III Ksi'iplimcii m {W idt.)
Kn nt ze (Melnn tli iu in,
HI. Walt, ; Aiiiiniit/ii-
II III III. Gray) the Fly
poison. Crow poison,
or Fall poison, a com-
mon buUiif-
erous percn
nial of sandy
soil of the East
ern United States
especially near the
coast, and in parts
of the Southern Cen-
tral States. It reaches
a height of two to
three feet, bears long,
linear grass-like
leaves, nearly an inch
in breadth at the
base, and large,
much-branched ]ian-
icles of greenish-
white llowers, about
a half inch broad.
The perigone con-
sists oi six distinct
]) a r t s. w i t h o u t
glands, and is niar-
cescent. The sta-
mens are six in number, and borne upon the base of the
lierigone si'gnicnts. Ovary and pod are three-celled,
the latter siilitting only at its upper portion, the styles
persistent upon the valves. The ovoid brown seeds are
Fin. as,-M.-^
Ililtlinil si:
pardiu'iit
Death Camas. (One-foiirtb
v.) (-After United Stales De-
jf Agriculture.)
ri)4:
REFERE^'CE HANDBOOK OP THE ilEDICAL SCIENCES.
Poisonous Plauls.
Poisonous Plants.
few and are apparently more poisonous than any other
part of tlie plant. As its names indicate, this plant, es-
pecially the seeds, is in use as an insecticide, and it is
poisonous to birds. Little is known al)out the nature
and treatment of the poisoning, but it appears to be in a
general way quite closely related to veratrum.
More or less closely allied to the above-named bulbs,
as well as to colchicum, are those of various species of
yaivissvs, Hippenstr itm . and AtnnrylUft, which are se-
verely poisonous. A uutnber of species of agave, per-
taining to this family (the Ainnri/Uidneea), as well as of
Liliacea?, yield so-called soap roots, used for their de-
tergent properties on account of their large content of
saponin, and for the .same reason actively poisonous.
Other similar articles, poisonous if eaten, but not likely
to be eaten e.xcept through mistake, are podophyllum,
sanguinaria, leptandra, arum, and actiea, all elsewhere
considered, and all so strongly acrid and disagreeal)le, or
even painful, that no considerable amount could be con-
sumed by a sane individual.
With couvallaria, aconite, Solomon's seal, and apocy-
num the case is somewhat different.
Oiinudlaria (see Lihi of tlic Valley) rhizome is sweetish
and not unpleasant except in the after-taste; and it is so
highly poisonous that it would not be improbalile for a
child to eat enough to produce poisonous symptoms. So
common an ornamental plant requires no description.
AcDinte. — The fresh tuber of this highly ornamental
garden flower is said not infrequently to have been mis-
taken for horseradish, incredible as this may seem. Its
biting taste is even exceeded by that of the horseradish,
so is not apt to excite suspicion, but it even more closely
resembles other roots which might grow in the garden
beside it. It is to be regarded as an exceptionally dan-
gerous article. Its toxicology has been sufficiently de-
scribed under the title of the drug.
Apucynnin or Doghane possesses a long cylindrical rhi-
zome, running horizontally at a sluut distance below the
surface, and fleshy and milky-juiced. It has an amyla-
ceous taste, only slightlv acrid, and might lie eaten. Its
properties have already been discussed.
Violet. — The roots of pansies and all other violets,
though not likely to be eatc'n, should be remembered as
possessing emelico-cathartic poisonous properties, almost
identical with these of ipecac.
Eupliarhiii. — The large, tleshy. and milky-juiced roots
of E. corolldta, K. ipecacuanha, and other euphorbias,
have been well-known and much used cathartics.
E. cnmllata is known as the Blooming. White, Purs-
lane, or Large-flowered spurge, Apple root or Wild liippo,
and is abundant in Eastern and Central North America.
It reaches a height of about three feet, is slender, widely
branched and smooth, and the flower clusters which
terminate its branches are subtended by showy and
petallike white involucres, each bract of which bears
a green gland at its base. The root is cylindrical, an
inch or more in thickness, and one and a half or two
feet long, of a very dark or blackish-brown externally
when dried, much lighter brown when fresh. It has a
thick white bark in cross section and a radiate sjiongy
central cylinder. Its taste is at flrst sweetish and pleas-
ant, though the after-taste is a little acrid. Its active
constituent is a resin. Overdoses are very powerfully
emetico-cathartic. the action being much like that of
ipecac.
E. ipecac'ianha is known as the White, Wild, North
American. Jlilk, or Spurge ipecac or Ijiecac spurge, and
is very abimdant in sandy soil along tlie Atlantic coast.
Its very slender, much-branched stems are numerous and
prostrate, so a? to form a sort of a mat-like grciwth. The
leaves are of most diverse forms on different plants, rang-
ing from narrowly linear to broadly oval. The herbage
and inflorescence ma.y be light green or more or less pur-
ple. The root itself is vertical, much longer and more
slender than that of the last, rather lighter in color, but
the woody centre inore yellowish. Its properties, as well
as its uses, are identical witli those of the last.
Potato. — Our consideration of poisonous roots may well
Vol. YI.— 45
close with a few words concerning the poisonous proper-
ties of the tuber, and more especially of the sprouts, of
the common potato. The potato at all times contains
traces of the highly poisonous alkaloid solauine. and
probabh* others, but ordinarily the percentage is too
slight to produce perceptible elfects. Since the greater
portion of this poison exists in the external layer, the
peeling of potatoes which contain it in excess, may eas-
ilj' prevent trouble. The substance appears to exist in
greatest amount in the rhizome of the potato, upon the
end of which the tuber develops. It is therefore uuicli
more likely to be present in the young (" unripe ") potato
than when it is fully developed. Similarly, when the
sprouts (young rhizomes) develop upon potatoes in stor-
age, the solanine becomes present in them in considerable
quantity. When the sprouts are lirst forming and of a
lurid purple color, the percenta.ie of poison is large,
gradually decreasing as they elongate, thiclien. and
whiten, and especially as they put forth green leaves.
Wholesale poisoning has resulted when, in times of scarc-
ity, an attempt has been made to eke out the potato sup-
ply by consuming tlie young sprouts. Potato tubers
which form above ground or at its surface, so that they
are exposed to the atmosphere and develop a purplisli-
green color, also contain larger amounts of solanine. Fi-
nally, it may be mentioned that very serious results have
followed the eating of potatoes containing black fungus
spots, the solanine percentage being greatly increased in
and just abmit the spots themselves.
Similar to the potato, in that it is perfectly wholesome
under some conditions and highly poisonous under others,
is the cassava, manihot, or tapioca root (fam. Eupltorbi-
aceii'), so largely used as a food in tropical America. Of
this root there are two varieties — the one sweet, the other,
bitter. The former is in general not poisonous, or not so
much so but that thorough cooking renders it whole-
some. Nevertheless, a small percentage of hydrocyanic
acid is almost always contained in or to be yielded by
its bark or the tissues near it. In the bitter variety an
important amount of this deadh" poison is always found,
so that it is not .safe to employ it, even for the manufacture
of tapioca, without a thorough preliminary maceration
and perfect cleansing. There are certain species of yams
eaten in the East Indies which also have to be treated by
thorough washing in order to remove a poisonous bitter
constituent, although not in this case hydrocyanic acid.
The poisonous nature of the roots of belladonna, bry-
onia, spigelia, caulopliyllum. colchicum. squill, and hel-
lel)ore, will be found discussed under those respective
titles, as drugs.
Poisonous Hekb.\6e.
In the nature of the case poisonous herbage is far less
likely to be eaten by human beings than are fruits, seeds,
or roots, and similar organs. Nevertheless, the use of
leaves as salads and potherbs, especially in times of scarc-
ity of food, as during famines or in the course of explor-
ations, renders necessary a careful attention to some of
them. Furthermore, the frequency of stock poisoning
through their use is greater than that resulting from any
other portion of the plant ; and a reference to the more
serious stock-poisoning agents is not out of place in an
article of this kind.
As human poisons, tansy, aconite, chelidoniuui, lobelia,
henbane, conium, belladonna, and viola, may be dismissed
with the statement that they are scarcely likely to become
elTeetive except through accidents atteniling their use as
drugs, which subject will be found discussed under their
respective titles in that connection. Tobacco may poi-
son, partly in this way and partly throtigh its use as a
popular narcotic, or during its application for parasites
infesting plants and domestic animals, under which cir-
cumstances it has frequently caused poisoning by its en-
trance to the system through wounds or other openings
in the skin. The sj'mptoms and treatment of tobacco
poisoning are elsewhere fully described. Absinthium is
a well-known poiscm, either acute, through overdosage,
705
Poisoiiuiis Piantiii.
Poisonous Plants.
REFERENCE HANDBOOK OP THE IIEDICAL SCIENCES.
or clircinir, througli the use of beverages containing it.
Botli forms of poisoning are deseribed under its title.
A sulbeieiit referenee to poisoning Iiy tlie foliage of the
cedars, pines, lieniloek, and other CJouifera' of the savin
Fig. .3.^.'t6.— Vfr:itruiii Viridt-. (oni--fnurtti ii:itin-a! size.)
or arbor vilte tyjie will be found under the poisonous
family I'iliaera . Krialed to these, but a<'tiug through its
poisonotis alkaloid, is the yew or taxus, whieh subject
has been ju'e.seuted in speaking of its fruit. Poisoning
by any of these is extremely unlikely to oeeur. The
same is true of pioisoning by the butteietips, clematis,
etc., of the Pulsaiilla type, in the poisonous family
Ranunculaceie. The foliage of the elder has already
been stated as open to the same suspieionsasthose alTeet-
iug its bark and root, and it neeil not be further consid-
ered. The folia.ffe and llowers of lily of the valley, or
C(mvallaria. eontaiu the .same poisonous con.-;tiluents as
those of its rhizome, and there is the same slight ]iossi-
bility of poisoning aeeideuts being caused by it. Th<'
occasional use of the stem and herbage of eieuta, mis-
taken for angelica, has already been mentioned. It eon-
tains the same constituents as the roots, anil the r.ynip-
toiusand treatment are identical. Poisnning by the lurb-
age of the black nightshade (see the sc'ction on Fi nits and
Seeds) is said lo have occurred, although it is claimid
that this herlia.ae has been used as a potherb, after cook-
ing, without injury. It is certainly open to grave sus-
lucion. Should poisoning by it occur, it uoiild doubt-
less be found identical with that of solanine from other
sources. Another plant whose herbage has not been
recorded as eaiisiug poisoiung. but which, for oliviijus
reasons, is to be re.garded with caution, is the poki-berry,
or Phytolacca. A\ atercresses. though comninidy re-
garded as (piite innocent, are capable, when eaten in large
excess, of producing dangerous and extremely painfid
symptoms. In one case seen by the writer, a painful,
severe cvstitis was established in this way. The jiossi-
bility of an abortion being produced by this article, as
well as by lior.'^eradish, is worthy of consideration.
Probalily the two most dangerous leaf poisons in exist-
ence, all things considered, are stramonium and veratruin.
The former has been fully discussed as a drug, and under
poi.sonous seeds. It possesses the peculiarity of tlnurish-
ing in periods of drought, resulting in famine conditions.
The wboleaspect of the plant is luxuriant anil succulent,
and a temptation to consume it under such circumstances
may often be great. As a matter of histoiy, ntimer-
ous poisoning cases have occurred in this way. especially
in India. Other cases are recorded in which travel-
lers destitute of food have ignorant ly eaten it. Vera-
trum (fam. }Minitliiir(ii) is a plant which grows in
swamps in the vicinity of callha. or American cowslip,
X\\i: herbage of which is eagerlj- sought in many sections
for cooking purposes, appearing as it does in early spring
when fresh vegettililes are scarce. Various cases are on
record in which the foliage of veratrvim has thus been
mistaken and eaten with serious eonseiiuenccs Vera-
trum poisoning has already been f idly discussed (see Fig.
3856).
The young shoots of Tamus communis (see the section
on Fruits) have been eaten like asparagus in the Old
World with serious results.
Sorrel. — This uaiue has been applied to two groups
of plants, very dilTercnt froiu a botanical standpoint,
but agreeing in their .sensible properties, constituents,
and toxicology. The name M'ood Si/rrd has been ap-
plied to the conunon O.ni/is iiceUi.iilhi L. (fain. O.ralid-
acne), which is veiy common in cool woodlands in both
the Old and the New World, and bearing white or jiink-
ish tinged and veini^d Howers. The trifoliolate leaves
clo.sely resemble a small idover leaf, but are .somewhat
fleshy, and the whole lierba.ge is strongly acid. O.xalic
acid, free andeombined. is the poisonous constituent, and
is said to have been first derived from this source. A
number of very slender, branching species, with smaller
and yellow flowers and smaller leaves, grow commonly
as gaiiirn and roadside weeds and are known as ladies'
sorrel or ladies' soui-grass. In tropical regions hundreds
of species occur, some of them very large. JIany species
are favorites among household llowers. All hnve the
same coiuiiosition and properties.
The other group represents thi' sheep sorrels or field
sorrels, ntunely, limiu.r arelimi L. and R. ifat'i.scHn L.
(fam. Piili/iioniireif). pernicious weeds growing in poor,
giavelly, or sandy soil throughout the northern hemi-
sphere. They are used to somi' extent as ingredients of
salads. These idso contain oxalic .acid and have, like
oxalis, caused fatal poisoningof both children and adults.
The trciitment and symptoms may be inferred from the
above statement that oxalic acid is the active agent.
It may be added that very large quantities of either arc
required to ])roduce dangerous efl'ects.
Aihiiiihitx or Tree nf Ilearen (fam. Siiinirnhneeir). —
These nasty-smelling leaves are not at all likely to be
eaten either by human beings or by domestic animals. It
is said even that tlies will not visit decayed meat when
hung in the branches of these trees. The leaves have
been utilized for the maiuifiicture of substances both
odious iind toxic to tlies. They have also, like the
liaik. been somewhat utilized in medicine; they contain a
liccidiar nauseous green oil. as well as tin amaroid. This
oil has been indelinitely stated as possessing poisonous
projierties. The bitter substance, though stomachic in
medicinal doses, is a gastiic irritant in larger doses.
Chronic gastritis of a rather serious type is reported tis
having occurred in till members of a family, as the result
of having drunk the wtiter of a well in the vicinity of
these trees. The roots extended into the water in great
numbers and probably the leaves also had lilowu into and
aecumulaled in the water.
hiiliniii. — The members of this genus, the American
laurels (fam. ICricucea). are distinctly poisonous, being
fici|Uenlly fatal to shei'p, though not at all likely to be
c.-iten by man, since the foliage is very bitter and di.s-
tigrceable. The large species(A'. Iiitifntiii L. ) is the well
Too
REFERE>'CE HANDBOOK OF TIIE MEDICAL SCIEXCKS.
Poi!^onoiiK Plants.
Poij^onoiis Plants.
known iiiiiuiitiiiri laurel or calico busli, sjioon wood, or
ivy bush, so coiunion throughout Eastern North Anit-r-
icii. The smaller species of common occurrence is K.
aiinUHtiffiliit L.. the small, dwarf, or sheep laurel, lamb-
kill, calf kill, or Uidkill. It glows in more open situa-
tions, on dry hillsides, and rarely exceeds three feet in
heijrht. Its leaves are mostly in whorls of three, its
flowers less than half as large as those of the other, and
of a deep rose color. Other small species are more rare.
The poisonous constituent of the laurels is the aniaroid
aii(lromedotij.nn (CjiHsjOjo). a neutral crystallizable sub-
stance, rather soluble in both alcohol and water. Jliu-
eral acids color its solution bright red. It is an ex-
tremely poisonous substance, and has been said to be. in
the pure state, more emetic than either emetine or apo-
morphine, and more toxic than aconitine. Animals are
not fond of laurel,
eating it only
when other food
is scarce. The
common symptom
of poisoning b_v
laurel is narcosis
w i t h muscular
weakness. Ani-
mals become cjui-
cscenl and stupid.
In the early stages
a staring glassy
eye is notable,
with great disor-
der of vision,
objects being ap-
parently distort-
ed. A staggering
gait ]irogressively
d e v e 1 o p s, a n d
finally the animal
lies down and goes
into a condition of
stupor. There is
no disposition
either to eat or to
driuii, the reap-
pearance of such
desire being a
pretty sure indi-
cation of recov-
ery. A thin licj-
u i (1 frequently
flows from the
(Two-thircis mouth. Stomach
digestion is ap-
p a r e n 1 1 y com-
pletely paralyzed. There are faint convulsive move-
mentsof the limbs, and death finally ensues from general
weakness, speciall,v of the respiration.
The poisonous constituent described above occurs com-
monly i?i tills family, oilier members of whieli have poi-
sonous records by reason thereof. The most impoi'tant
of these is I'ieris Mariana (L.) B. et H. (Andm/iwda M.
L.), which bears the suggestive name of stagger bush
(see Fig. 3.sr)7). It grows throughout the Atlantic re-
gion as far north as New England, preferring shrubbery
along the salt marshes. It is a shrub, from three to five
or six feet high, and its ]irofuse flowers are whitish or
purplish and of a waxy appearance. A flowering biaiieh
is here figured. The svniptoms of poisoning by stagger
bush are identical with those resulting from laurel. In
this connection the Ehododendmns may be mentioned as
having precisely similar poisonous properties.
Ledum or Lalnidnr Tea, Marsh. .S/rai/ip, (_'i>n/i'/if'jital or
James ten, and Marsli ronemary, are names ajiplied to the
two species (fam. Eriracea/) Ledum Groenlaiidifiim ( )eder.
(L. latifolium \it.), the broad-leaved auiX Ij. paliisireh..
the narrow leaved (see Fig. 3858). They are marsh
shrubs, the former ranging from Greenland through
Norlheru North America, the latter extending also
FIG. 38.57.-
-Pleris Mariana,
natural size.)
through Norlheru Europe and .\sia. The broad-leaved
species has been a much used substitute for tea among
IJritish - Ameri-
can voyagers,
and is only
moderately nar-
cotic. The nar-
row-leaved spe-
cies is much
more active.
Both are some-
what used me-
dicinally in do-
mestic practice.
The n a r r o w-
leaved species is
distinctly nar-
cotic, the symp-
toms closely re-
sembling those
of laurel poison-
i n g. If, as
claimed, andro-
medotoxiu is not
a constituent,
.some very simi-
lar body must be
present. A flow-
ering branch of
ledum is here
figured. The
leaves are well
distinguished by
their somewhat
thick and leath-
ery texture and
their smooth upjier and brown wool!}' lower surfaces.
The flowers are white.
The leaves of .such plants as the cherry, peach, plum,
etc. (fam Drupacece or liosacea) yield appreciable amounts
of hydrocj'anic acid. Although the consiunption of in-
jurious quantities by liuman beings is not at all likely to
occur, yet the leaves of the common wild cherry con-
stitute a well-known and much-dreaded stock poison.
The branches, trimmed out for fence rows or broken
down by boys in search of the fruit, have very frequently
been recorded as poisoning cattle, often fatally (see Fig.
ys.jO). An unexplained but well-established fact is that
FIG. 3858.
- Ledum latifolium.
natural size.)
(Two-tliirds
Fig. .3.^59. — Prunus serotina. (Oue-lialf natural .-iize.)
cattle will eat them from the living trees without ill
effects, but will be poisoned ujion eating them in a wilted
condition. That the effects are due to the hydrocyanic
acid liberated is fully evidenced by the efliects.
TOT
PoKoiloilK Krplilos.
Poi»«ouous ICeptiles.
REFERENCE HANDBOOK OF THE 3IKDICAL SCIENCES.
Delphinium or Liu-Il.i[iii r (fuin. lifiiiiinciddcea). — Tbe
getn'ral subject of lurksiiiir, as to coiistitui'iits and activ-
ity, lias lieeu considei-ed uucUt t lie titli' of Stavesacre Seed.
So well knowu a garden llower scarcely requires descrip-
tion. The accompanying illustration of ]). g/uiirnni, the
tall larkspur, often miscalled aconite, gives a sufficiently
good idea of the genus in general (see Fig. 38(iO). Some
of the species are larger, many much smaller. The flow-
ers are usuallj' of some shade of blue, sometimes pur-
FKi. 3860.— Delphinium glauomii. foiic-tliinl imtiinil size.) (After
t'niieil States Department uf .\rrrii-iilture.)
plish. Many sjiecies aliound in the grazing regions of
Western North America, and they are niueli dreaded as
stock poisons by herders, though the poisoning of liuman
beings is not recorded, and is not likely to occur. These
poisons are to bi^ classed partly with aconite, to a lesser
extent with stavesacre. as to the nature of their effects.
The symptoms are muscular incoonlination, motor pa-
ralysis, beginning at the posterior extremities, great car-
diac and arterial weakness, and hy|iersensitive skin, with
the special senses not affected. Convulsive Ireinors, espe-
cially of the posterior limlis, come on early and are fol-
lowed by convulsions which iucretise in violence, and in
one of which tlie animal usually dies. Death a|iiiciirs to
lie due chietly to failure of the circulation. Atri>]iiue has
been found a fairly good antidote, and potassinni ]ier-
manganate has also been found useful.
Lon/ Wiei!i< (fam. Lfj'/niiiHiniv). — Altliough jioisoning
by this ftimous group is contined practically t<i stock,
especially horses and sheep, yet no article on |ioisouous
plants coulil be considered complete without r<'ference to
it, particularly as it represents a very large and varied
class of leguminous poisons which more or less affect the
human system as well. The loco weeds pertain to the
two genera Astmr/iilns and Aranohm {(>.i\//triipix). and
knowledge as to their specific identity is in ;i number of
cases indefinite and uncertain. They are pereuuial herbs,
growing mostly in tufts or hummocks, with a dense ro-
sette of radical leaves and papilionaceous, mostly purple
or purplish flowers in sjiikes or racemes. The leaves are
elongated and pinnate, the leaflets mostly numerous and
more or less oblong or varying from ovate to obovate.
The fruits are coustruetcd like small pea pods, the seeds
mostly resembling small peas and often rattling loosely
in the dry pod. The herbage is without disagreeable
taste. Animals are not naturally disposed to eat it ; but
having once done so, in case of scarcity of otlierfood,
they become ravenously' fond of it and forsake all else iu
order to eat it. The poisonous constituents are not
known, though great efforts have been made to isolate
them. All indications point to their being of the nature
of toxalbumins. Whatever they are they are excreted
in the milk of the iiKitlier, since suckling lambs are fre-
quently fatally poisoucd together with the mother. Poi-
soning mav be either acute or chronic, the latter being
much more conimou. The symptoms are chiefly cere-
bral. There are incoiirdination and remarkable disorders
of vision, though nirely hliudiiess, and this usually in
acute poisoning. The effect upou the visiou seems to be
that of causing objects to appear distorted. A similar
effect upon hearing is observed. There are great and
progressive disorders of nutrition, and these are especially
referable to the skin and its appendages, sheep frequently
losing the whole or part of their fleece and the teeth
becoming loosened. Death, iu cases of long duration, is
usually from malnutrition. Very often the animal ilies
as a result of accidents, incurred either through frenzy
or through weakness incident to the poisoning, such as
falling into the water while drinking, and being unable
to rise again. There is no known treatment for this form
of poisoning other than to remove the cause and apply
general restorative treatment.
Henry II . Rushy.
POISONOUS REPTILES.— All poisonous reptiles, with
the single cxrcptinu of the liztird Ileloderma, belong to
the order Ophidia — snakes. It is a ]iopular eiior that
snakes ar<' easily divided into harmless and poisonous
ones by readily recognized characteristics. Such divi-
sion, however, is by no means a simple affair. The usual
classitication into Colubridte — comprising all harmless
snakes, — Coliibrida' veiieuosa?. and Viperidse indicates the
clo.se anatomical relationsliiji between harmless and veuo-
mous snakes, and in external appearance mimicry is so
frequently disiilayed that no one at a hasty glance is
able to distinguish a harmless snake from its venomous
relation. Thus, even experts have been subject to fatal
uiisiakes. Indeed, nothing but a close ins])ection of the
dentition can determine the nature of a specimen in ques-
tion.
Dif^trihuliim nf Sna/.-es. — It is but ntitural that the popu-
lar mind and imagination should have been occujiied
since time immemoiial with poisonous snakes. The fre-
quent tiuil almost niystcriousdeathsafter snake-bite have
surrounded tlie whole class w illi a halo of fetir and rever-
ence w hich has not been coutineii to a few localities, but,
in fact, liass]uead tliKHighoiit the whole inhabited world,
for poisonous snakes are found in all countries of the
temiierate. and more so, of the tropical zone. Numerous
genera of the lIy<lioi)hids, elegant swimmers with a later-
ally compressed tail, swarm throughout the whole inter-
tropical part of tlie Pacific Ocean. Their bite is justly
dreaded. The tropical islands, however, and the tropi-
cal countiies of the old continent are haunted by the
worst kind of snakes, the Elaiiidip. A large number of
genera and innumeralile ty]ics of every genus render
jiarts of those countiies, and especitilly of the islands,
almost uninhahitabk'. The chief representatives of this
genus are the Cobra di capello (Naja tripudians) and the
somewhat snialler. though not lessilangerous Krait (Buu-
garns fascial us), both Jiving throughout the whole of
East India. The most forinidaVile is the King-Cobra or
Ihimadryas (Ophioidiagus ela|is), the largest of all poi-
sonous snakes; it attains the length of fourteen feet and
it alone enjoys the reputation of attacking and even pur-
ro8
REFERENCE HANDBOOK OF THE IVHiDICAL SCIENCES.
Poisonous Keptilos.
Poisonous Reptiles.
sainj; man. Its uwirest rclativp, the AspLs of Cleopatra
(Naja liaje), the symbol of the Egyptian kings, lives
throughout almost the whole of Africa. In the Western
•n-orlti this genus is represented by the beautiful coral
snakes alone; one of them, Elaps fulvius. lives in our
Southern States, where it is littk- feared on account of
its alleged goodnature, or rather its lack of irritability;
its poison is, however, as active as that of its East Indian
congener. Snakes are ver}' numerous in Australia.
Two-thirds of these are poisonou.s, an<l they belong ex-
clusively to the faniih' Elapida' ; the Tiger snake (Hop-
locephalus curtus) and the black snake (Psctidechis
porphyriacus) iiave a fearful reputation. Europe has
none but various species of vipers; the well-known com-
mon viper (Pelias bcrus) lives in England, Germany, and
chii'tly in Fiance. In the departments of Vendee and
Loire Inferieure alone were reported 321 cases of bites
with G3 deaths in si.v years, in Auvergne 14 cases with 6
deaths: in the South around the Jiediterranean the more
dreaded sand viper (Vipera ammodytes) is found. East
India again has one of the most formidable vipers, the
chain viper (I)aboia Russelii). and in Africa there is the
sluggish but very poisonous puff-adder (Clothoarietans).
The greatest number of species of vipers are found in
America, all of them belonging to the sub-family of the
Crotalidii; or pit-vipers, .so called from a deep pit lyiu,g
between the nostril and the eye.*
The chief representatives of the pit vipers in the United
States are the rattlesnakes. The bandetl rattlesnake
(Crotalushorriclus) is present throughout the whole terri-
tory from the Atlantic to the Rocky Mountains and far
into Canada. Of the remaining si.K species of rattle-
snakes we have to note the largest of all North American
snakes — the diamond back (Crotalus adamanteus) of
Florida and the South, and the swift prairie rattler (Cro-
talus coulluentus) in the Mississippi Valley, and in the
great Western basin; finally tlie smallest of all, the mas-
sasauga or ground-rattler. To the same sub-familv be-
long the Southern water-snakes, the moccasin (Ankistro-
donpiscivorus) — animals so sluggish that the\' do not trv
to escape from an approaching man, and hence are not a
little dreaded by the negroes working in the rice-tields;
and finall.v, the beautiful copper liead (Aukistrodon con-
tortri.x), which is not. at all rare in the whole East — in
fact, lives almost in the same expanse as the bandeil rat-
tlesnake. In the Tropics almost all species grow to a
larger size; thus the copper head is repeated in the larger
fer de lance (Bothrops lanceolatus) of the West Indies;
the rattlesnakes' of Central America grow larger, as does
Fifi. 38H1,— Head of Rattlesnake.
the Crotalus durissus; and in the Orinoco Vallej' there
lives the bushmaster of tlie Dutch settlers (Lachesis mu-
tus), about as large as the Hamadrj'as of India,
* Tlie otjject of tliR pit. which sinks into a cavitj- of the maxilla— .'is
it were, a reversed ma.xillary sinus— is unknown. Leyditr calls it the
seat of a sixth sense, whii-h iiieaus nothing else but that he has no ex-
planation. At closer inspection I found the bottom of the pit not
lined, but overspread by a thin membrane, the continuation of tlu?
external inleirumenT. Under this membrane, showing abundant
ramillcatioiis of nerves, we find a cavilv which opens by a duct, at the
anterior marL'-in of the rirhit. .\ccording to the careful investiirations
of I)r. I'ollitzer, who followed it up by serial sections, the nerve con-
nects with the auditory nerve. Pricking or any other irrit^ition did
not produce any reaction, nor did the destruction of one or both mem-
branes have aiiy elTect upon the movements or the heaiin.g of the
snake. The hearing capacity of snakes is still a mooted subject with
authorities in natural history.
FIG. 3862.— Skull of Harmless Snake.
Poison Apparalun. — Snakes are ijrovided with numer-
ous teeth — solid, pointed, recurved liooks, which serve
rather to drag the prey down into the oesophagus than
for purposes of at-
tack and defence.
While the teeth
stiind in a single
row along either
liranch of the man-
dibula, they seem
to be almost indis-
criminately scat-
teredall over the
ma.xilla and palate;
nevenhelcss. two
rows of larger maxillary with two nearly parallel rows
of palatine teeth are readily distinguished. These are the
functionary teeth which, after being shed. — a frequent
occurrence, — are replaced by the numerous suceedaiieous
teeth scattered t'n-oughout the mucous inemljrane of the
palate. A poisonous snake exhibits the s;»me arrange-
ment of palatine teeth. Almost the entire row of maxil-
larj- teeth, however, is wanting, and its strengtli, as it
were, is concentrated
into one jjowerful
tooth, the poison fang,
which projects at the
anterior end of the
maxilla. It is true, we
often liud two or three
teeth at this point;
these are the functional
fangs with one or two
succedaneous ones which replace the primary functionary
whenever lost by accident or shedding. Only the Elapidai
exhibit one or two ordinary conical teeth which are situ-
ated directly behind the grooved fang. The fangs ai'e in
all cases tii'mly inserted in the maxilla, immovable, al-
most erect, in one family, the Colubrida^ vencnos* (com-
prising the cobras and liydrophids); in the Viperida',
however (including the true vipers and pit- vipers), the
FIG. 3863.— Skull of Cobra (Flaps).
Fig. 38t54.— Skull of Rattlesnake.
movable fangs are only erected for biting, and otherwise
in the resting they are folded back toward the jialate like
the blade of a pocket-knife in a plicti of mucous mem-
brane. The maxilla of theColubridte venenoste is rather
elongated and horizontal like that of the harmless snakes,
but it is considerably shortened and placed almost verti-
cally in the vipers. This short jaw bone, beaiing at its
lower end the tirmly socketed fang, articulates at its up-
per end with
the Itichrymal
bone, around
which it ro-
tates by the
action of the
p t (■ r y g o i d
muscle.
Some writers
are of the ojiin-
ioii that, by
looking at a wound infiicteil by a snake, the species of
the iinimal ctin be ascertained, tmd from the foregoing
description it c;ui readily 1m- understood how from the
Xnzr^
Fic. 38C.5.— Head of Cobra.
709
Poi6ou<»lis Kfptlles,
Polsuuoiis Reptiles.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
acfDiiipaiiyiug lisui-es tlic bite of a harmless or poisonous
snaUe could be ileleriiiiiied. A\'e nuist, however, bear in
mind that a snake, while biting, very seldom implanis
ffi
O
®
■F>
7;.
c.
Fifi. .3808.— Impression of the Teeth of -1. harmless snalie ; B. colira :
C, viper. /, fanff; m, raa.xiilary; j), palatiue; pt, pterygoid teeth.
all its teeth, and a wound seratclied .sideways liy a glid-
ing fang may lie more dangerous than the iniinession of
tlie whole tlentition.
Another clas.silication is sometimes made by dividing
tlie venomous snakes aceording to the sliajie of tlieir
fangs, whether they carry short, cone-shaiied, furrowed
fangs or long, pointed, tubular ones. This condition is
brought about develo]imentall_y in the first instance by
the folding of tlie dentine which leaves a longitudinal
fuirow witli an indication of a iierforation at tlie upper
and lower end along the anterior surface; and in the sec-
ond by a coniidete aiiiiro.ximation which produces a per-
fect tnlie. The Jiulp cavity is entirely separated from
the poison canal. To the fir.st cla.ss. the I'roteroglypha.
ticlong the Hydrophids and Elapida>. or cobras: the lat-
ter class, the tSolenoglyplia, comjirises the vi]iers and jiit-
vi])ers. The intensity of a poisonous bite is not dependent
n|ion the sliape of the fangs, except that a longer tooth,
such as that of the viperine snakes, is cajiable of inject-
ing the poi.son to a greater depth; imleeil, the viperine
poison a]iparatus is the most perfect of any in the veiio-
inous snakes.
There is a third cla.ss of poisiaious seqients. the so-
called (Jpisthogly])lia. the furrowed fangs cd' which, as
the name indicates, are situated toward the rear of the
mouth. It has long been doubted whether they should
be classed among the poi.soners. ami foi- this reason they
were grouped under th(^ name of " suspect i. " Recent in-
vestigations, however, have jirovcn to a certainty that
tlie_y also poison their prey, which mostly consists of
small, cold blooded animals. Catching them tirst with
the innocuous front
teeth, they push them
gradually backward
into the reach of the
jKiison in the liack
li'eth. III the action of
^\ hieli they soon suc-
cumb.
Tlie poison gland
completes the poison
apparatus; the former
is closely ill contact
with eii her side of the
skull, directly below
and lieliind the eye.
and is under I he in-
llnence of the dill'ercnt
]iortions of the tempo-
ral muscle. The but-
ton-, tube , or almond-shaped glands taper to a narrow
anterior iluet, wdiicli carries the secretion of the gland
to the base of the fang and is provided with a s|)hinc-
ter muscle, so that the snake is able to retain the poison
at will. and. indeeil. mav do so for months. The extra
;
,/
./"
Fir. :SS(;7.-ProtiMoir]viilia. J. f:inpiila\
(X, Fantr of kinir i-ulira. eleven feet
InlliX (natural size. S iiiin. In lellL'lh) :
?>, ttie same enlaiyeil (;J iliani.i: r.
cross section. /?. IlviliopliiiUe. </.
Faii!^ of pelaniys inalnral size. ;i inni.
in lenfxth) ; ( , the same enlar^eil (3
diam.); /, front view: i/,ei'oss seel ion.
ordinary development of the glands, as in th(^ Ci'ota-
lids, gives to the head that triangular shape which was
erroneously considered the characteristic of all jioLsonous
snakes, and which gave to some species the name Tri-
gonocephalns. The elongated glands of the Ethiopian
snake Causus rhombeatus extend under the skin on both
sides of the spine to the extent of one-sixth of the boily 's
length, while in the East Indian Calloiihis they reach
from the head into the abdominal cavity about one-
third of the total length of the body. In spite of these
abnormities the pioison gland must be ccaisidered physi-
ologically as the homologue of tlie mammalian parotid;
the latter is the only one of the salivary glands wliicli
produces an allmminons secretion. It is anatomically of
great uiterest that even in harmless snakes the beginning
of a poison gland can lie traced. It washing known that
a part of the siipralaliial gland — the yellow portion (l)u-
verno_y, Sehlegel. Leydig) — is easily separable from the
rest; it has not only a duct of its own which in the "sus-
piecti " leads to the posterior grooved tooth, but it also
possesses a histological structure diirering from that of
the supralabial gland. I'ndoiilitedly. this yellow ]ior-
tion of the innocuous snakes is Iheaualogueof the |ioisoQ
gland; even its ai|Ucous extract has been shown to be
poisonous to small animals (Blanchard). The structure
of the poison gland is that of acompound racemose gland
with elongated acini ; the glandular substance has colum-
nar, the duct pavement epitjielium.
Dcmriptiiiii of Vcin'iii. — Tlie secretion of the other sal-
ivary glands and of the mouth is alkaline, while the
</
Fig. .ascs.-solenoglypha : Viperiiia", a. Fansr of hamleil ratllesnake,
three feet Ioiil' uialural size): h, fanir of diamond-back rattlesnake,
si.\ feet lon^ 'natural sizet; c. tin' same eulari:red Ci diam.); (/. front
vii'W of tlie latter : r, cro.ss .section.
poison is always ;icitl. The color of tlie latter varies
i'l'om a light straw or greenish-yellow to a deep orange.
The viscous lluid, either clear or turbid (bitter in Naja)
is not odorless as often as.serted : ii has a specitic smell
for evciy siiecies. which is not easy to describe, Imt Ciisy
to recognize. Thus the odor of crotalus poison may be
called '■mousy"; thtit of thc/cr (//■ liiiiivi^ said to resem-
ble the oilor of fresh salt water. Its specific grtivity va-
ries from 1.030 to 1.077; the solids are variously stilted
as from twelve tosixty-seven pier cent. ; my own samples
tire mostly dried down to twenty-five or twenty pier cent,
of the original weight. The dry poison cracks on scaly
transiucent chips of a light yellow or deep lirown color
tuid also has a characteristie odor. Fresh ])oison under
the microsco|ie shows nothing but a few scaly c|iilhelia
and a niimlier of liiiely gi'anulatcd. amorphous, alliu-
minoid masses, which unilergo no change in a hanging
drop, cvi'ii after ti. long while. It was often, and even is
to-ihiy, asserted thai bacteriii or cocci exist in the poison,
.Vfter thoroughly sterilizing the collecting apjiaratus I
was not alile to see the least sign of bacterial life in broth
or gelatin cultures of the fresh poison; also in acid media
ill which the experiments were repeated no trace of life
Wiis to be found. In order to determine whether the
poison, which itself destroys life, might for I hat reason be
free fidiu microbes, 1 mixed fresh poi.son with B. siibtilis
anil 1!. coli for one-half hour and then inoculated it on
gelatin. The growth was lively, even more so than in
the control plates, proliably because the gelatin was liijue-
■](»
REFERENCE IIAXDliOOK OP THE MEDICAL SCIENCES,
o Poisonous It('|illIos.
Poisouoiis Ueptlles.
flcti at the points of contact with tlie poison.* A bac-
terial aclion, tlierefore. cannot be assuni(>d : llic rapidity
alone with which the poison acts iu the system would ex-
clude bacterial influence.
(Jhciiiistiii I'f tJic \'iiiiiiii. — The tii'st chemical anal.ysis
was made iu IS-i;! by Prince Lucieu I5ouaparte. who es-
tablished the iiroteid nature of viper poison and called
the poison "viperiu." Almost twenty years later (18(U
Weir .Mitchell found a similar proteid' in crolalus poison,
which he named "'crotaliu." Other iuvestitrators claimed
to have found alkaloids or ptomains. when Weir Mitchell,
associated with Heichert, published in iss:i the re-
sults of their studies, tljat the active principle of
snaUe poison was of an albuminoid nature; but
instead of one ingredient they liad discovered
two. One of them, easily diahzable and not
coagulable by heat, was called venom peplone;
the"^other, not dialyzable but coagulable b_y heat,
venom globulin. The proportions of botli were
not alike in cobra and crotalus poison ; even
among the Crotalidai they found wide difTereuees.
Thus cobra poison had 98 per cent, of peptone
and 2 per cent, of globulin ; but moccasin venom
had 92 per cent, of peptone and 8 per cent, of
globulin, diamond-back only 75 per cent, of pep- Fic. 3870,
tone and 2.5 jier cent, of globulin. Besides the umsele;
proteid there are a coloring substance, several
sails, and some fat. Mitchell's report was mainly cor-
roborated in 1886 by Wfilfenden. who discovered globu-
lin and several albumins in varialile pro|iortion in the
poison of cobra and daboia; one of the latter lie desig-
nated serum albumin: the other, corrcsiionding to Jlit-
chcU's peptone, syntonin, or albumose. Kanthaek's an-
alyses likewise demonstrated the presence of a proto-and
heteroalbumose in cobra poison. Martin and McGar-
vcy Smith found a harmless albumin and two very toxic
albumoses iu the pr>i.sou of the Australian snakes. It
may be asserted that iu no instance, up to the present
time, has a delinitive analysis of any jioison been v, orked
out; but all investigations centre in this one fael. that
the active iirinciple in all snake poisons is some furm of
albumose. f
Although probably both of Weir Mitchell's bodies are
alliunioscs, we may still, in default of aec\u'ate analy.ses,
use the convenient terms venom peptone and veni)m
globulin in our further discussion. Not onl_v do tlie vari-
ous poisons differ in the percentage of peptone and glohu-
lin. but also in the toxicity of the constituents themselves.
The venoms retain their "efficacy for long ]ieii(ids of time
under suitable conditions. Poison, when dried or mixed
with glycerin, has proved itself as active as fresh poison,
even after a lapse of twenty -two and twenty years re-
spectively. Putretaction de-
stroys it after a long time;
freezing, continued through
weeks, does not alter it, but it
is soon changed by healing
when the temperature is raised
to different heights, according
asi!9. - l.i«ation^nf jtie to the different'clK.'mical coni-
po.sition. The globulins are
rendered innocuous at 80° ('.
after tifteen minutes, whili' the
peptones are destroyed only by
applying higher temperatures for hours. The coagulal ed
proteids are inert in this state, but they regain their
toxicity when redissolved.* It is the more or less evi-
dent capability of chemicals to coagulate proteids which
determines their relative jiower of destroying the effi-
cacy of venoms, when the}' are mixe<l with the poison
Fir,.
Poison (ilam^ in Tnifiops
tielonyinir to the Dpisttio-
plyiiliii. o. I'nisoa glaud ;
/'. jiuiirahitiial ^larui.
* n.xiHTiiiu'nts with sterile snalce poison liave doinonstrated tliat it
litjui'lli's (.'fiatin lilce some (iiirestive ferments, f.i.u, tryp.sin. Welir-
inann lliids Iliat it poptonizi'S llliiiu \\valvly and does not i larify aniy-
lum. Fle.xtii'r stairs Ihal in aL'ar cultiiK* of II. antlu'aris. P. coli. and
B. typhi Ihe liar-lc-rja undi-rwt-nt rapid inyohition. Myouii nuiui'l'ons
oliseryalioiis. ivi-otded !ilio\i\ do net conthin this yie\y.
tit is \yoU linowii that alliuinosos, llie iiiddansot the hydralion of
albnniin, foi-rncriy called ptopoptonos and accurately defined l)y
Kiihne ami rhiltendon in lss4. dillcr widely as to Ihcii' toxicity.
Wliile our modern mi'ans do nol allow yet a c-Iieiiiical dillei-enlialioii
of those allnimoses whicli are ijreneiated Iiy superheated steam. I>\ L'as-
tric difiesiion. hy bacilli, or — as in oiir ease— by the iiarenchvma cell of
apland. the yaryinii reaction of tlie more sensiiiye li\'injjc orttuulsiii
toward thoui demoiLstriUos det'isiyely then' dillcreut nature.
—Head of Crotalus. a. Poison eland ; n\ poison duct with sphincter
; /j, d, portions of temporal muscle : /, plica of mucous meiiibruue.
in a test tube for experimental purposes. Aleiilml ren-
ders it inert for a tiineonly. Absolute alcohol seems to
coagtilate all poisonous ingredients, but the presence of
an intinitesimal part of water is sullieieut to retain the
toxicity of the su]iernatant fluid. Poisonous .serpents,
when ]>reserved in alcohol, have to be handled, even af-
ter yeai's, with the greatest care, as has been demon-
strated by a fatal accident to an assistant iu the St.
Petersburg Museum.
Pliyaiologkid Effects. — AI)sor|iti(in of venom from con-
nective tissue, whether introduced by hypodermic in-
jecliou or by the bite of a snake, takes place through
the blood-vessels, more rapidly whcu the blood-ves.sel is
wounded directly. Serous membranes absorb it very
readily. Its resorption througli uuicous membranes va-
ries; rattlesnake venom seems not to be absorbed in this
way ; cobra venom, however, passes through the ileum
ami conjunctiva, but nut through the stoniiich and rec-
tum. Gastric juice and bile do not affect it, but the pan-
creatic secretion destroys it. The resulting complex of
symiitoms varies partly on account of the varying ra-
|iiility of absorption, but more so because of the difl'erence
in the nature of the several venoms.
The phy.siological effects of both ingredients named,
Avhenever they are tested separately iu animals, are
widel.v different. The pept^me, though causing some
local o'dema, is more ])roductive of general nervous
symptoms, which, commencing as irritation, twitching,
and convulsions, finally end iu ]iaralysis; jiaralysis of
the respiratory centre is especially characteristic. The
globulin, on the contrary, incites a violent local reaction
with hemorrhages around the point of injection, hemor-
rhages of the mucous membranes, and deslruetion of the
coagulability of the blood. The latter ]ihenomennu re-
calls to us the results of experiments perfonned oil ani-
mals with pure peptones and alliumoses of digestion;
these excite not only characteristic lieinot rliages and
ni'croses, but also jiaralyses, the intensity of which is iu
correspondence with the higher hydrolysis of the albu-
moses. And thus, to go one ste]! farther: all the symp-
tnnis produced by snake venoms classify them distinctly
among the toxins, especially those of bacterial oiigin.
SvMl'TOM.\TOi,oiiY. — From the foregoing remarks it
will be jierceived that different cases of snake poisoning
cannot have an identical course, and that the numerous
contradictions of the mostly incomiihdi' records of snake-
bites are to be explained" only Avhen we consider each
* Recent adrices of researches ftoinff on in (iermany assure me that
the loxie principle does not belong to the albumoses, iu fad, thai it
IS uot at all ut a proteid nature.
711
Poif^oiioiiN Rr|>liles.
Poi»uiiou!) Koptilos.
REFERENCE IIANDliOOK OF THE IIEDICAL SCIENCES.
type of piiisoning separately. Lcuviiiy; usiiU' llic cases
of almost iustanlaneous death wliieli ale due to general
tliroiiiliosis. espetiidly wlien the venom lias lie<'ii aeeiden-
tally iiijecled into a large blood-vessel, we have lirsl to
make a distinction between tlie two gfcat clas.ses of
snakes, the eobdirines and the viiiefs.
To illustrate tlie first class, lei us brielly describe tlie
effects of a cobra bite: two small, scarcely visible iiunet-
ures in the skin are foiuid, wlience radiates a liurniuL;'
and stinging [lain witli .gradually extending moderale
O'dema. Within an hour, on an avenig<', the lirst con-
stitutional .syniptomsappear — a ]n-onouneed vertigo, like
that of drunkenness, (juickly followed by wc'akness of
the legs, \vhi<'h is increaseed to ]iara|ilegia, iitosis. falling
of the lower jaw with paralysis of the toii.gue and epi-
glottis, inability to sjieak and swallow, -with fully pre-
served sensorium, A mass of vi.scons, froth}' .saliva is
constantly dribbling from tlie ojien nmulh: nausea and
vomiting set in: the paralysis becomes general, the pa-
tient lies motionless. The pulse, a little accelerated, is
somewdiat weaker in the beginning, but keejis a moder-
ate .strength until even a few minr.les after the cessation
of res])iration. The latter, also acceleraled in the begin-
ning, soon becomes slower, labored, and more and more
su|iertieial, until it dies out almost imperceptibly. The
pu|iils, somewhat conlraeied, react up to the last mo-
ment. Slight convulsions, which we are accustomed to
see in aspliyxia. sometimes occur shortly before death.
Absor|)tion is exceedingly rapid; already after thirty
seconds a distinct areola is visible around the bite.
Death occurs at tlie latest within liflien hours, in thirty-
two per cent, in the first three hours. When the pa-
tients do not die of jiaralysis, they recover remarkably
quickly and wilhout later consequences. The atitopsy
reveals no (diangcs in the skin at the jioint of injection:
the subcutaneous tissue, however, is thickly intiltrated
with reddish serum; the surrounding blood-vessels are
congeslcil. All the internal organs are congested, and
the bronchi are tilled with frothy mucus and perhaps
with tluids which have been forced into the patient's
throat. The blood is mostly li(iuiil and dark.
r///(V. — After the bile of a viper, ej/.. a rattlesnake,
the local disturljance is most pronounced; violent pains
at tlu^ bleeding wound, hemorrhagic discoloration of its
surroundings, and later also of more distant ])arts;
bloody exudations on all the mucous membranes (nose,
mouth, conjunctiva), and hiemaluria or rather ha'inoglo-
binuria. Usually, somewhat later than after cobra
poisoning, but possibly within lifteen minutes, constitu-
tional symptoms develop, vi/., great prostration with
nausea and vomiting. A continuous fallofl)lood pressure
is nolieed. Respiration, iu the beginning accelerated,
grows slow and stertorous. After a temporary increase
of retle.xes, which in sii.seeptible animals and after large
doses may rise to convulsions, npislhntoiio^. and tetaiuis,
paresis siiiiervenes, with para|ilegia of tlie lower ex-
tremities, which progresses iu an upward direction, end-
ing iu complete paralysis. Albuminuria aiijiears after
about six hours. In such a condition death may result
in.side of twelve hours. If the patient recovers from the
paralysis, a septic fever may develop in con.sequcnce of
the enormous and multi|de hemorrliages, to wdiich he
nia\' succumb after a lapse of time. Eventual recovery
sets in very suddenly, even in the most desperate cases.
Not rarely, however, there remain sup]iuniling gan.gren-
ous wounds wliicli granulate poorly, break ojien repeat-
edly, and may lead later on to a deep necrosis, even of
the bones.
The elTccI (if the bite of thelropical \ ipers. especially
the E:ist Indian Dabciia Husselii, is iindonlitedly more
pronounced and violent. Sanious discli;ugis from all
mucous membranes are prominent fi-alures: such hemor-
rha.gie extravasations from lungs and bowels may persist
even during recovery. Albuminuria is never missed;
even hamiaturia is ob.served as a rule. The autopsy
shows a deep bloody intillration at the bite, down into
the ne<'rotic muscles, hemorrhages of distant niuseles,
particularly of the iutercostals; all serous membranes,
chielly the endocardium and the peritoneum, are com-
pletely covered b_y countless ecchynio.ses of all sizes; the
lungs show subpleural ecchymoses and infarctions; the
kidneys are hemorrhagic in the glomeruli and pelvis, and
there is cloudy swelling of the epithelium of the caaa-
liculi. Hemorrhages have been observed also iu the .se-
rosa and in the substance of the central nervous system.
The blood is lluid and does not clot, even after'a long
time.
A dispiojiortionate swelling is to be noted in poisoning
by the European viper; it sometimes extends over the
whole body. The poison of the African viper, the puff-
adder, acts iu a stupefyin,g manner from th(^ very begin-
ning; the animal stricken stands without motion" or
reaction as if the wdiole cerebral cortex were eliminated;
complete sensory and motor paraplegia ascends gradually
witli sharply detined limits.
The Australian snakes occupy an intermediate position
between the two types just described, for, besides a
prominent cobra effect, they produce moderate hemor-
rhage and always Iiannoglobinuria.
Wall relates a peculiar variation after the bite of the
East Indi:ui Bungarus fasciatus. Some cases cannot be
distinguished from the acute cobra poisoning, yet in
others a certain chrouicity of symptoms is .seen Which
can be compared only to the incubation period of infec-
tious disc'ases. From two to six days may have elapsed
after the bite without any sj'inptoms, wdien unexpectedlj'
a general debility sets in with albuminuria and a sanious
discharge from the eyes, no.se, and rectum. The patient
invariably suecuiabs w itliin a short lime.
An interesting incident is the |ieriodical relapse of
iniiammatiou and supinuation which is said to occur
mostly annually, almost to the day of the first injury.
The cases reported are too numerous, and have been ob-
served by too good authorities, to admit of a doubt.
While iu some instances there appeared only a scaly or
vesicular eruption of the skin, in others a sujipura'ting
intlamination set in. (..r/.. with regular loss of a nail. All
the cases on n'cord are from the United States and in-
clude all species of snakes — copperhead, rattlesnakes,
and Elaps. They have been watched for six, ten, twelve,
and even eighteen successive years. Perhaps the best
authenticated ease is tliat of a draughtsman of the Smith-
.souian Institution, wdio, according t<i Yarrow ami Stej-
neger. for ten years had the same inflammation of tlie
linger, bitten I'ly an Elaps. almost to tlie date of the
accident. A cure was finally efl'eeted by the use of the
South American herb, Jlicania guacho.
To n.se for comjiarison a well-known and familiar com-
plex of symptoms, we might call the sequeUe of a cobra
bite an ncnte bulbar prinili/n/s of the most furious and
vehement type. Likewise, for the second type, that of
viper poisoning, an analogy is found in aniW itsniKh'ii;;
spiiiid juir:i///sis. the last stage of wdiich exhibits alike
bulbar symptoms and inhibition of respiration It
should be remembered that the common ascending spinal
paralysis is also ascribed to an infection. Yet. whereas
iu the two disi'ases named, the development of the ner-
vous symptoms is very slow and gradual, and they may
take years or at least weeks to ad\'ance to a fatal exitus,
in snake poisoning the efleet is almost instantaneous. It
may, thereiore, be considered firmly established that
snake venoms affect the molor ganglia of the anterior
horns and idiiefly the medulla oblon.gata, exercising a se-
lective inlluence upon the adjacent centres of respiration
and deglutition. There exist records of a few accurate
microscopic examinations of all organs after snake poi-
soning (Nowak). In general they resemble the changes
which we are wont to find in all kinds of poisoning (if
whatever origin, esiiecially by the toxins of /.ymofie dis-
eases— e.;/. , fat ly degeneration of the liver with inflamma-
tion of the bile ducts, be.srinning as early as thirty-five
minutes after jioisuning; in chronic cases focal necrotic
destruction of liver celjs, acute parenchymatous nephri-
tis, disseminated imeumonic iiatclies, slight beginning
of fatly degeneral ion of the heart muscle, etc. Of the
pathological changes iu the central nervous organs, we
712
REFERENCE HANDBOOK OP THE JIEDICAL SCIENCES.
Poisonous Reptiles.
Poisonous Reptiles.
also have some accurate records (Evving, Bailey). As
we may expect, they demonstrate a ]ininoimced acute
degeueratiou of the ganglion cells throughout the central
nervous sj-stem. Tlie chromatic bodies generally disin-
tegrate with some loss of the chromatic substance, the
outlines of the Nissl bodies being completel}' obscureil;
the micleus and nucleolus may be normal or swollen and
opaque; the dendrites irregular, shrunUen, or detached.
These changes are to be found in the cells of the cortex,
the cerebellum, olfactory lobe, basal ganglia, medullary
nuclei, anterior horns, and spinal ganglia, most marked,
however, in the anterior horn and in the Purkinje cells
and the mitral cells of the olfactorj' lobe. These changes
were exhibited only in their beginning in those animals
which had been killed in a short time by a large dose of
venom, but were more advanced and involved a much
greater number of cells in the cases of more chronic poi-
soning. Alt, after poisoning with puff-adder venom,
liuds the changes in the posterior columns so marked
that they are perceivable to the naked eye.
The old question whether snake venom is a nerve or a
blood poison, therefore, must receive the answer that it
is both a neurotoxic and a hoemol_\tic substance. Nay,
recent investigations have shown that both principles are
ph3"siologically distinct, for Flexner has demonstrated in
miro that in a mixture of venom with an enuilsion of
brain substance, the chief (neuro) toxic constituent
unites with nerve cells while the agglutinating and lue-
molytic element combines with blood corpuscles. It is
of considerable interest to analyze more accuiately its
influence upon the circulatory system, which is such a
prominent feature in viperine poisoning, but is neverthe-
less of paramount influence in cobra poisoning as w<'ll.
The assumption that the action on nervous tissue is but
a secondary sequela of its primary action upon the circu-
lation must be positively denied, inasnuuh as extremi-
ties whose circulation is entirely obstructed by constric-
tion respond readily to the action of the venom upon the
nervous centres; neither do we nii.ss any of the chai-ac-
teristic nervous symptoms in frogs, in which the blood
has been entirely replaced by decinormal .saline .solution.
Notwithstanding the facts just related, some of the
phenomena might be referred to a disturbance of the
vasomotor centres. Some investigators ascribe them to
an enormously increased diapedesis, as is seen after the
local application of poison to a capillary area ; while
others consider it to be a rupture of the capillary walls.
The blood cells escape after a hypodermic injection of
venom, and are destroyed to such an extent that a few
hours later but one-half of the normal blood corpuscles
may be counted.
The point which has been creating the greatest divers-
ity of opinions is the poison's inlluence upon the coag-
ulability of the blood. Formerly it was an accepted
dogma that cobra venom increased and viper venom
inhibited clotting, until recent investigations of Heiden-
schild and the more accurate experiments of Martin, of
Sydney, have cleared up the matter. The doses as well
as the mode and rapidity of introduction are matteis of
the greatest importance. As a rule coagulalion is inhib-
ited for a long period. A small dose injected intrave-
nously causes a positive phase of coagulabililj' of two or
three minutes, which is followed by a negative |ihase of
longer duration. A second larger mjection brings on the
same positive and a much longernegative phase. A third
still larger injection, which is borne remarkably well, de-
stroys coagulability for a long period and. as it were, im-
munizes the blood against fiu'ther coagulative intluence
of the poison. At the same time the leucocytes disap-
pear almost entirely from the circulating blood ; tlu'V are
massed in the liver, lungs, and lione marrow, and reajipear
only when the blood regains its coagulability (or perhajis
inversely). Auehe found the bone marrow much con-
gested soon after poisoning, and regards il as evidence of
a reaction of the blood-forming organs, — a reaction which,
within a few hours. Hoods the circulation with an rtb\in-
dance of leucocytes. A hy]iodermic injection, and there
fore the majority of all snake bites, acts in the same way
as a small intravenous injection. Immediate introduc-
tion of a larger quantity of jioison into a blood-vessel
ma_v cause a sudden complete clotting of the whole mass
of blood, with the exception of that in the pulmonary
veins and the left heart. 3Iany conti'adictory reports of
the blood pressure, sudden .stoppage of respiration, etc.,
are explained by the sudden massive thrombo.sis. The
immediate cause of coagulation is prol)ably a nucleo-
albumin. analogous to the lilirinogenic substance of Wool-
dridge, also a uucleo-albumin. It is not preformed in the
venom, but, as Martin has it, is liberated instantaneously
by the action of the poison, from the stroma of the de-
stro3"ed erythrocytes and from the endothelium of the
blood-vessels; it brings on extensive thrombosis at one
stroke. Or, according to the theorj-of Delezenne, which
would explain the different phases of coagulability and
fluidity, nuclco-histon is formed which splits into leuco-
nuclein and hist on ; the former, which is retained by the
liver, accelerates coagulation ; the latter, which remains,
retards it.
Man}' of the symptoms noted in former experiments
are now explained b}' the recent interesting methods of
study in hfemolysis. The first etTect of snake venom
upon blood in ritro is agglutination, speedily followed
by ha-molj-sis; the escaping hamoglobin is not changed,
the spectrum remaining normal. A great variation in
susceptibility to this latter reaction is distinguished in
the dillerent animals, but most noticeable is the differ-
ence of hiemolytic power in the several varieties of
venom. Contrary to what we should expect from the
prominent symptoms, cobra venom is most actively ha'-
molytic; those of moccasin, copperhead, and rattlesnake
are hemolytic in less degree, in the order named. The
action upon leucocytes is similar to that upon erythro-
cytes, although the several varieties of white cells show
different susceptibility.
Arlother important effect of snake venom is the loss of
the germicidal propertj' of the blood plasma. It is well
known that normal blood serum destroys micro-organ-
isms, or at least retards their gniwth. Ewiug, of Wash-
ington, was the first to show, in 1S94, that this faculty
was annihilated in the blood of animals killed by crota-
lus poison, and Martin has confirmed it for the venom
of the Australian black snake. This explains both the
well-known rapid putrefaction of the poisoned organs
and the danger of subsequent decon\position of the ex-
travas;ited blood, and the resulting sepsis during con-
valescence. The recent luvmolyiic studies mentioned
above have shown that the germicidal power of serum
is rendered inactive through the fixation of the serum
complements by the venom.
A closer similarity in the two types of poison can be
created in an artificial way by heating. The aggluti-
nating power is- destroyed by a temperature of from 75"
to 80° C, a temperature which leaves the hemolytic
power undisturbed. The latter is somewhat reduced in
crotalus poison by 90° to 96° C, while it requires 100' C.
for at least fifteen minutes to make an impression on
cobra, copperhead, and moccasin venom. A prolonged
heating, however, of viperine jioisou destroys the in-
tense influence upon the circulation to be .ascribed to the
globulin; after such heating it approaches cobia venom
in character.
In briefly summarizing the mode of dying from snake
poison, we might say that d<'ath occurring within a few
minutes is due to general thrombosis; a patient who dies
within twenty-four hours may succundj in the first hours
to jinralysis of the resjiiratory centre, later to general
paraly.sis: lethal exit us. after such a period, days or even
weeks after the bite, may be the result of sepsis or of
general prostration following prolonged supinn'aiion.
From what has been said, it will be seen that lli<> dan-
ger, of a snake-bile must vary considerably. Statistics
cannot give us an adequate idea as regards this jioint.
Not all cases are rcporleil, and not all bites rejiorled are
those of venomous snakes. Moreover, chance is an im-
|i(>rtaut factor as regards the seqvieUe; c.r/.. in what con-
dition was the snake when biting? Were one or both
713
Foisouous ICcptllcs.
KEFERENCE IIANDCooK OF THE MEDK'AL SCIEXCES.
faiiirsdi'i'ply iniiiluiitfd, or was! he skin inrri'ly scratclicd?
Hciw nid ami in what, coiidilioii of liiallli was tlie biitcii
individual'/ India, as is gciicndly know n. iias the largest
liKirtality fromsnakcbiles— a fact easily explained by llie
(^nonumis number of snakes, and these the nin.it deadly
of all. the cobras. Nevcrtbeh'ss, iiidolenee and supersti-
tion of the population may increase the nuinI]erof fatal
accidents considerabh-. Those may be right who con-
sider the smaller ntimber of il-illis in America and
Australia as due to the greaterintelligence of the people,
becau.se a rational treatment, especially the early aiipli-
■cation of a ligature, is instituted in time.* In default of
reliable analyses, the only way to decide this ]>oint has
been shown "by Calmette'to be that cif comparative ex-
periments. After eai'efully grailed hypodermic injec-
tions, to determine bow much poison may kill a kilogram
of aiumals (mostly rabbilsi, the t'oUowiug table has been
worked out :
1 em. of rolira ami ;isi>is kills 4.i«w)ksm. of rahhit.
1 ^'in. of ll(.|.l(icepli;illls kills 3,4."i(l kjIITl (.f nil. I. It.
1 gill, offer lie liiiire anil |isi'iKlecliis kills. ''IH) ksnn. of raMiii.
1 Km. of C'rotalus lioniilus kills liHl ktnii. of raliiiit.
1 (fill, of I'elias berus kills -.")!) kiriii. of rabbit.
But even this method has not yet yielded undisputed
results, for ^Martin claims for hoploeephiilus 4.000 and
for pseudecbis 2.000 kgm. At any rate the to-\icity of
.snake venom is exceedingly high. A comparison with
the toxins of infectious diseases shows that only that of
diphtheria comes up to 4.000 kgm., tii.xopeptone to 3
kgm., and the albumose of anthrax to not more than SO
gm. Besides the hiirli toxicity it is akso the exti'emely
rapid absoiption and consetiuent early appearance of
grave symptoms wliieii tlistiuguisli snake venom from
other toxins.
If the most serious eases {i-.f/. , when both fangs, and espe-
cially those of a large tropical snake, have thrown their
full dose of poison into the tissues) are left out of consid-
eration the ]ii'ognosis is not so bad as is generally believed.
AVeir .Mitchell gives the mortality of crolalus bites in one
place as i.'i per cent., in another as not more than 12 per
cent. ; that of the Australian snakes is said to be only 7
per cent. ; but for India Fayrer sliites it at fiimi 2.5 to '.i'y
per cent. It has been meiitioiicd how quickly an ameli-
oration may set in, even after the most seiious n"rvous
symptoms have preceded. This is undoubtedly a reason
why so many remedies have gained the undeserved rejiu-
tation of being a sure cure. Jlost of the patients would
have I'ecovered without them. Comparing these condi-
tions with the results obtaiiiLil in experimental bacteriol-
ogy, we should say that in must eases of snake-bite the
minimum lethal dose of toxin is seldom injected, so that
the body cells are still able to combine Avitli and tix the
toxin, in consequence of which they not only speedily
recover, but also, as we shall see later on. develop a cer-
tain iiumunity by casting olf antitoxin.
Ti!i;.\TMi-:XT. — The pioof of the utter hel])lcssness of
flii'ra]ieutics of ]iast j-earsisihe long array of remedies
recommended iuid used at all limes for snaki'-bite. The
object of treatment is threefold : first, to ])iexent absorp-
tion of the poison; second, to accelel'ate its elimination;
third, to destroy or neutralize it, and to treat symptoms
of imminent danger. If the wounded linib,<-f/., atiiigcr,
cannot be am|iulated iiiiiekly. at least the circulation
should be checked or retaidcd by a ligati.i-c. iis ]iiaclised
since time immemorial. A lig;ilure is;i|ipliedas lightly as
possible, not only at one, but tit two or three places — e.g.,
when a finger has been bitten, round the linger itself, at
the wrist and tit the elbow. The expeiieneed W.dl is so
convinced of the advantages of Esiuarch's lublier band
that he not only recommends eveiy physician in India to
li;ive one in readiness, but wants to see it in every well-
reirulated household. The ligature is I'eiaxed at inter-
*Tlie stafistii-s of tlio Inilian (iovernnieiit liavp qiven for yenis'.'iii
averatre annual niortalitv of 2ii,(HHi pi'i-sons. Itei-ent ail\ ices. Iiow ■•ver,
llave i-alli'il Iliis iiimilicr airain into liowbt, as lia.s been ilon • I efoiv.
If si-i'ins to lie the prartice of onicials m renioie. isolated ilislncis to
aserilie in their reports any ea.se of ileatli to siiakc-liite. wli.-n.'Ver it
is tlioiiL''lit ilesii-.iiite to cover a t'lime or oveu a nej^lect of iiut,v on ilie
[lart of Uie ollleial.
vals of some hours to prevent gangrene, but is applied
again as soon as practicable.
It has been an often recommended custom to suck the
wound with the lips or to apply cups. The result of
such a measure is at least doubtful, because of the linely
punctured bites; the sucking ought to be preceded by a
long scarilication into the deeper ti.ssues. It is still safer
to excise a hir.ge area of these tissues or to destiny them
V ith the actual cautery. Wall, taught by long experi-
ence, recommends proceeding in the most ruthless man-
ner. By these means the tibsorption of poison can be
limited to a possible minimum, so that the s\-stem shall
gain time to overcome the whole quiintity at Intervals.
IIow can we hasten the elimination of the injurious
substance? The kidneys are attacked to a greater or
lesser de.gree by the poison, especially that of viiiers;
lieiice it is doubtful whether we should be permitted to
inci'ease their activity. The vicarious excretion In- per-
spiration, stimulated by diaphoretics (<;.,'/., jaborandi) has
had dubious results. It has been demonstrated, how-ever,
that part of the poison is excreted by the stomach, Alt
found that alktiloids, chiefly morphine, after i y].iodcrmic
use were excreted by the stomach almost to one-half of
theiramouut. When be tried the aame method for snake
venom, it was discovei'ed that the animals who.se stom-
achs were washed out were saved, whereas the controls
died; at the same time, the washed-out lluid was again
poisonous to other animals. Hence it is probable that
the use of the stomach pump may be of good service.
Tho.se who have read ti minute description of, or have
personally witnessed, the sntike dance of the J\Ioki and
Zuili Indians of Ari/oiia will remember that after the
performance the dancers, who are sometimes bitten by
the snakes, recei\e a potion prepared by the priests
which contains an emetic. The whole crowd stand
around a certain part of the ptirapet to empty their
stomachs freely. This custom has undoubtedly beea
justified by long experience.
The question then remains. Are we able to riaider in-
nocuous the ]ioison in the tissues surrounding the bite?
This efficacy has been claimed for a whole series of spe-
cifics, Avhicb owe their reiMitation jiartly to old traditions,
partly to experiments in the lest tube. The majority of
these s;>ecilics, which it is true neutralize the poison in
r/i'r« after a shorter or longer jieriod (carbolic acid, e.(/.,
only after twenty-tour hours), destroj- all ti.ssues to such
an exti'Ut that it seems juc rcrable to apply the cautery.
Eviai the much-praised permangantite of potassium, lee-
ommended especially by Eacerda, of liio, Brazil, has not
ful:illed the high expectations, b>r neither locally applied
in ii one-per-eeut. solution nor injected intravenously has
it the elective faculty to single out snake venom for oxi-
dation in presence of other proteids. One per cent, of
chromic acid has gained somewhat of a reputiitiou; it
does not destroy the tissues sinniltaneously with the poi-
son, but it merely makes them shrink. Calmctte has fre-
quently tested hypochlorite of lime in a solution of 1 to
GO.* lie found both its local and repeated liypodei'inic
applictition netir the bite as well as its internal adminis-
tration of good elTect ; not l':ss so a onc-per-cent. solution
of chloride of gold as ;i local remedy.
Ammonia, extensively used internally and externiilly,
is nothing but ji stimulant, Feoktistow actually advises
against it. because he thinks he has seen after its use in-
creasing licmorihages, causctl by higher blood pi'essuie.
Wall also cautions against exciting the circulation by
stimulants; he advises to keep the victim as quiet its
possible and to husband bisstrengtb. Neitherliasalcohol
any local clfect as a coagulating medium; it is to be
rated tilso as a meie stimulant. It has always met with
tipiireciation on the part of the real or, more so, of the
alleged victim. Indeed, the use of this infallible S]ieeitic
has often been eariied to such an extent that it was
iiiqiossible In decide whether the [latient succumbed to
snake venom or lo tin acute alcoholism. In one ease,
* He advises against the employment of more concentrated solutions
whiili are less active ami proiUice eschars.
714-
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pi>£*»oiif>rN Rrptiles.
PoisouollK Reptiles.
t.g.. tlie vise of five qiuirts of whiskej' is recorded. It is,
moreover, a fact that iiiloxiealed persons, wlicii liittenin
tliis state, have not proved to lie lietler protected against
snalce-bites than .sober people; aud the enormous doses
whieh we often hear of as liaviug been administered de-
serve nothing but condemnation.
As to a rational treatment, it is necessary to inquire
first as to the prominent morbid changes \vhieh threaten
life. Are tliey irremedialUe or aie they transient? Tliat
they are transient is proved b\' the many individuals who
survive a snake-bite in spite of llie gravest symptoms.
We liave seen that the jioison exerts, first, a luemolytic
action; second, a destructive influence upon the cells of
the medulla. We know at jiresent of no pharmaceutical
remedy which will arrest either the escape of the lia^mo-
globiu into the plasma or the rupture of the capillaries,
Dor is any drug known that will check the influence of
to.xin upon the nerve cells. The changes in the ganglion
cells, the dissemination and disitppearance of the Nissl
granules, whatever this may mean, must be fully repara-
ble, since, as we have seen, rehabilitation takes place
rather suddenly without leaving any sequeUe. If we are
not able, e.(j., to re-establish the function of the respira-
tory centre immediately, enuld we not at least tide over
the" dangerous period of deep depre.ssion ? One method
suggests itself to a medical mind, i.e., artificial res|iiia-
tioii" The heart beat ceases several minutes later than
respiration, and in one experiment Fayrer succeeded in
keeping up the circulation for eight liouis longer by arti-
ficial respiration. Fayrer and Lauder Brunfon strenu-
ously recommend that it be continued not only for hours
but "for days, with or without a traclieal cannula. This
advice seems to have fallen somewhat into disuse, espe-
cially since Martin claims that in poisoning by Australian
snakes he saw no good results from artiticial rcsjiiration,
death occurring in spite of it in fifteen minutes after
the heart stopped. Notwithstanding some faikues, we
are justified in trying it for an extended time, always
keeping in mind that an abrupt cliange may set in in the
most desperate cases.
In this connection we have to consider a remedy which
even recently has been praised with a certain persistency
as a specific, i.e.. strychnine. First vised liy Piinglc iu
Australia, it was tested in India, and in spite of the little
encouraging reports was enthusiastically eliamiiioned
by Dr. Muller, of Sydney. He declared that tlie failures
were due to insuffleient doses, and lie began with a dos(,>
of at least 0.01 gm., re])eated several times until slight
tetanic symptoms a|>peared.*
Many "cases in Australia have been tn'ab-d with stiyeh-
nine, and upon the advice of the Government Indian sur-
geons liave also vised it (piite extensively. Nevertheless,
llie results are not so convincing tliat we could rely upon
this drug as a specific. The experiments of ICanthack
and Feoktistow were negative. Interesting, however,
is the hitter's positive experiment tlial artificial tetanus,
brought on by strychnine, was arrested by snake venom.
Rou.x stales that tetanus antitoxin has a certain influence
upon snake poison, but not inversely. Atropine has
been recommended as a stimulant for the respiratory
centre. Not man}' instances of its use are recorded, but
there is no reason why it should not be resorted to as
well as strychnine.
It may be approiiriate to relate the few instances in
which snake poison has been used tlierajieuticall.v. Dr.
Amaden, of Glens Falls, near Lake George, a country
abounding iu rattlers, cured a man, aged twenty-five
j'eais, with unmistakable tetanus b}' two injections of
one drop of fresh rattlesnake poison. It should be men-
tioned that snake venom has been used in an uns_yste-
matie way for several other diseases (e.<j , yell.iw fever), of
course without success. Recently it has been asserted
that during the plague in India sonve successful ino<-iila-
* The tolerance toward stryctinine seems to be quite extraorilinary
in tlicsc fnses : thus li.ltiT) (,'m. wn-s used in tlip oasR of a lioy tliirii'fli
years cf :il''' williiu thrci- and tliree-quarter hours. d.O") frm. in live and
one-halt hours, n.ii.'> rrni. in four aud one-half hours, U.tXiti ijiu. in seven
hours, 0.:.';) \i\i\. in six days.
tions of cobra poison (gtt. ;,',; and -.',) v, ire made, and that
some similar experiments iu monkeys gave ecpially good
results. Later corres|Oiideiice, however, is silenl regard-
ing these experiments. The trealment of le]ira with
snake venom has been without any result.
Aniirenommis ,'>ennti. — The Iherapeulies of snake-bite
were in this state of hojielessness when in INi.T) Calmetle,
and almost simultaneously Fraser. surprised both the
scientific and the lay world with an antivcnunions serum.
It is to serum therapy and inimuni/.ation, as we sliall
presently see, that we have to look for the successful
treatment of snake-bites.
Regarding this topic the qviestion first arises: Are there
animals, as often asserti'd, which are immune to snake
jioison? In East India the mongoose, a kind of weasel,
the deadly enemy of tlie cobra, has the re]iutatioii of im-
munity; and iu Europe the droll, bristled hedgehog
(Erinaeeus europanis) is considered as the natural de-
stroj'cr of vipers because of its reputed invulnerability.
More accurate observers have shown that the mongoose
owes its apparent safety to a lowsvisceptibility (from ten
to twentj'-tive times le.ss than rabbits, Elliot) against
both cobra and viper venom, but more to its agility, and
that the hedgehog is partly protected bj'its spinous coat.
It possesses, however, a higher resistance to snake poison
than other animals, and fnmv nvy own investigations I
might figure a resistance of about four times that of a
ralvtiit of equal weight. A relative immunity toward
various toxins is well known toexist indiirerent animals.
The poisonous snakes them.selves possess a perfect im-
munity against their own poison, the species wilh weaker
poison a relative immunity toward those with stronger
venom, and even the non-pdisonous snakes enjoy a cer-
tain secvirity against the bites of the poisonous ones.
The king-snakes of our Southern States, which are the
enemies and destroyers of our poisonous serpents, seem
to enjoy a perfect immunity.* Although Weir Mitchell
tiuds that, at least in some case.s, crotalus is not immune
against its own poison, it is a common oecvirrence among
venomous .snakes in captivity that they bite each other
fiiriou.sly without any evil eifect. One of Cunningham's
cobras resisted inoculation with an amount of cnbra ven-
om suflicitnt to kill one thousand fowls. This faculty
is ascribed to inner secretion, to the incessant influx of
toxin into the circulation. The discovery of Blanehard,
that the extract of the yellow part of the supralabial
gland of Tropidonotus nalrix, and even its lilood serum,
kills small animals with distinct .syniptoms of poisoning,
seems to corroborate this theory, ('unniugham, how-
ever, finding after many experiments with cobras that
their scrum has no antitoxic action, comes to the conclu-
sion "that the natural immunity of cobras is perfectly
distinct in its nature fi'oni the artilicial iumninity, which
is established iu other animals as the result of confiuued
treatment with cobra venom, and that it is unconnected
with anv material of the nature of an antitoxin in the
blood." "
The iilea of immunization is by no means a modern
one. Even in antiquily wo hear of it, and among savage
tribes of ancient and modern times, wherever poisonous
snakes abound, attempts al protection against snake ven-
om aie made vinder various forms, sometimes associated
with mystic eeremonies, The iioi.son is rubbed into the
skin, as is done in Bengal, or it is taken internally in the
fresh state, or parts of the dried poison glands are eaten
(as practised by the savages of Sniiih Africa). A shep-
herd, immunized in this way, aduiiited that the dried
gland of the cobra had an inioxicating elTect, wliich he
compared to that of Indian hemp, exce]it that, whereas
the latter lost its elTect gradually, the action of the fir-st
was not impaired by lialiit. Or it is irsed as an iuocula-
»I have iniected a kins-snake <()p]iih<iUis (jrlnhis) of Florida, of
TOM LOM. weiirht. with 1 trui. of fresti inocoasin poison, a <iuaiuiiy whii-li
I'.in ui'ViT he injecled hv a sintrle hiii' of the tiri-'osl vcno us snake.
With the exirption of a liroiiiuiniTd loral swdlinp and smuio iipparent
.silk fooMne for a few days, the snake survived Uiis oxpiTiinem well.
.\ .nitalns of three feet in lenptli and ahout Sou (;ui. weiL'ht received
fi. Ml- drops of cohra Venom: ii siekeued within half an hour and was
found dead the next uiorning.
715
Poisonous ICt>|>tilrs.
Polsouoiis Ki'ptiU'K.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
tion ill the interior of Afriea (Serpu I'iiilo). Sometimes
one of the reputed antidotes is emplovcd lor sin extended
time, as, t-.f/. . the ciirutlox tie ciilihi-iix of Mrxico use a com-
posite plant. Mieania gnaelio.*
Sewall, of Anil Arbor. iMieh.. was tlie lirst to intro-
duc<! metliodieal inoenlation of siial<e venom Avitli the
idea of immuni/ation. His ex]ieriments. in wliieli, by
gradually inereasi'ii do.ses, iie made his pitreons si'cure
ajiainst seven times theletlud dose of niassasaui;a poison,
were pulilished in ISST. Calmette, direetor of the Pas-
teur Institute of Lille, Franee. after a number of failures
succeeded in .seeuriiiK immunity, and at the same time in
elaborating a protective untiveiiomous serum which, in
spite of some 'weighty o])])ositiou. must be considered to-
day the only reliable antidote to the deadly action of
snake poison. Eraser, who worked independently of
Calniett.e for six years on the .same subject, has produced
a similar serum, called by liiin antivenene. It is dried,
in which state it is .said to keep indelinitely. Calmette
mauufactuieshis serum by inoculating with cobra venom
or with a mixture of colira, crotalus, viper, and hoplo-
cephalus venoms, in both of wliicii the lia'molylic agent
liastirst been eliminated by healing to 81)' C. The inocu-
lation of horses has been carried on in some instances for
three successive years, so that these animals, which suc-
cumb to a dose of 15 mgin. of cobra imison. linally toler-
ate a dose of 3 gin. A prolonged feeding also imparts
iniimmity. but reciuircs larger doses and Induces less jiro-
teetivi' power. Antiveuomous serum is put up and sold
in vialsof 10 c.c. each. Its protective valueiscalculated
by Calmette in the following wa_v : If 1 c.c., injected inln
the ear vein, is found to jirolect a rabbit of 'J.IKIO gm. (3
kgm. ) ag.ainst a dose of venom, fatal williin tifteen to
twenty minutes, it is .said to contain -'.OlKl ;nitiveiiomous
units, anda vial of lOc.c. consequently 30,II(M) units. No
serum is sent out without ]iosse.ssiiig a strength of at
least 10.000 units; and for the tropical countries serum
of as high as 40.000 units is inanul'aetured.
It has been shown liy experiment (Myers. IMartin,
Semple, Flexner) that 0.1 cgm. of Calmette's serum neu-
tralizes 0.1 mgiu. of dried colira ]ioison, both in (vV/v/and
■i)t corpiire. This ))ro|iortion holds good for the ha'ino-
lytic and antibaeteriolytic and the inhibitory action of
venom upon clottingof the blood. Of rattlesnake venom
even 8 nigm. are neutralized by 1 c.v. of the serum. For
the counteraction of the neurotoxic |iriiiciple of the ven-
om, somewhat largi'r doses of antiveuomous serum are
recpiired. For jiractieal purpo.ses it maybe stated that
it acts as a full prote<'tive in a dose of from .5 to 30 c.c. ;
and the 10 c.c. conlainetl in Calmette's vial are therefore
amjdy sullicieiit for the avenige case of snake-bite wdien
injected even one and a half hours after the introduction
of venom. If more time has elapseil. or graver symp-
toms have si't in — as may occur aftir the bite of a large
trojiical snake— -it is advistible to inject 20 or even 80
c.c. shnullaneoiisly. Fraser recommends injections into
the injured liml) rather than into distant p.-irts, and the
administration of repeated smaller doses instead of one
large dose; but Calmette' thinks they are best made into
the lax skin of the hypocliondiiiim. Although antiveuo-
mous .serum is absorbed laiiidly from the subcutaneous
tissue, it may not be quick enough in .severe and belated
cases; then it is advisable to resort to direct intravenous
injection, linniimity thus conferred by antiveuomous
serum acts very rapidly and energetically, but disap-
pears very soon again, inside (d' from luo to four days,
wliile inimuiiify, created by gradually increased inocula-
tionsof veiumi, lasts for months i five tociiihtl. the longer
the larger doses were finally employed (active imniunily ).
Even the young guinea-]iigs of a inolher thus iminunizeil
ac(|uire immnnily for .several niniiths.
Calmette's stateanents have not bei'ii acce)iteil wit limit
contradiction. Eraser does not agree with him on all
points, nor did the ex])eriiiieuts and pr.aetieal experieiici^
of the Indian surgeons and of Martin thoroughly conlirm
♦From fjii'ts te tK' repelled Inter Dll. It .seems net lit all iiniiroliuble
that cerijijn Ileitis may eeniaiii siilislauees wliieli are capable of re-
iluelng the to.'iiclty of venom.
his premises and predictions. Not only lias controversy
arisen as Id the curative value of antivenoinous serum,
but also other (|uestions have been stirred u]i in relation
to the chemical and physiological action of toxin and an-
titoxin, iiuestions wliich promise to be of the greatest
importance in settling this vital probleiu of therapeutics.
The interest of the subject warrants us going into some
details as regards the coutr.jversy.
First, it was objected tliat Caliuette asserted his anti-
veuomous serum to be equally effective against all kinds
of venom, in direct opposition to Behring's law that
every to.xin requires a specilic antitoxin. It should be
borne in mind that Calmette's horses are immunized with
a venom in which the ha^molytic element has been de-
stroyed. Hence while he may work out an antitoxin to
the more im|iorlaut constituent, the nerve poi.son, he
neglects the other agent entirely. And indeed (Uinning-
hani declares an antivenoinous serum wdiicli is elllcient
a.gainst cobra venom entirely valueless against Daboia
venom and inversely, wliile Martin claims that Cal-
mette's .serum has a slight but distinct protective effect
againstoneof the constituents of Australian snake venom;
but, on account of its present slight antitoxic strength,
it is ]iractically valueless in Australia. Calmette. after
having elucidated experimentally all these jioints of
objection, comes to the conclusion "that his aiitivcno-
nious serum acts as a perfect preventive against the ven-
om of any species of .snake. " He admits that in a case of
viper poisoning some local disturbances may persist, even
with consecpient suppuration, but that fatal exitus is at
all events prevented. Other experiments seem to ]u'ove
that also the ha-molytic agent in venom as well is de-
cidedly inllueiiced by antiveuomous .serum (Steiihen and
.Myers). Fiirtheriuore. we must consider that a dose of
venom may not be sullicient to kill, even though only
one of its constituents has been ueutridized. And as a
most decisive proof, a number of reports from different
jiarts of the globe leave no doubt of the curative value
of Calmette's seriiui. It has been used with benelieial
ell'ect in East India, in Egypt. Africa, and the West In-
dies, against the different serpents of those countries.
Some of the failures reported by the Indian surgeons may
be accounted for by the deterioration and consequent dini-
inution of power, to which antivenoinous serum is sub-
ject in a hot climate. Notwithstanding this imiiairment,
however, there are even reports of the effective apidica-
tion of such weakened samples of antivenene.
Another objection was made that the curative power
was entirely overrated, since Calmette used as a test for
estimating its value onlv one minimum lethal dose of
poison. Eraser thus calculates that for a man weighing
(iO kgiii. a dose of 330 c.c. of antivenene would be re-
iiuired.* an amount which becatise of its bulk and juice
would preclude its practical employment. Statistics
and calculations do not, however, bear out this objection,
for, with rare exceptions, not much more than the lethal
do.se is injected by the snake in the average instance.
Mori' theoretical, but not less interesting, is the ques-
tion of action of the antivenene, whether it is chemical or
physiological. Whereas C'almette with Roux and Biiih-
ner insists that antitoxin elicits or stimulates the resist-
ance of tissues. Fraser and Martin assert with Behring
that the action can be only chemical. The exiieriments
with snake poison and its antidote conducted by Martin
and others point positively to a chemical iiction.
Observations of great interest were reported by Pliisa-
* The liiirie of this artrunientation is not quite otivimis. .\.ssuiiiiiip
thiit mole or less jinwer of natllial Immtinity is dormant in every
annmil whieh eiuiViIes It to o\ercome a siihiiiinimal lethal dose of
poison, we ouylit to exiiect that this power increases in the same ratio
as the size of llie animal, no matter whether the power is aserihed to
the whele svstem er to one or several separate orjrans. 'riie avenif^o
dose of piiiseii HI a snake-hite will i-emaiii tliesaine in the larire as in
the small victim: part ef it is iimniinized by the iiijiiivd organism
itself, and t. Illy the siirphis remains for the aelioii of the antivenene.
Consequenth . ihe lar.LM'r animal slands a hetlei chaiiee and requires
eomt)ai-aIi\elv less antivenene. Callnetle and others lia\e already
e.vpre.ssed Ihisiipinion by fermnlillinjr a law that the ipiaiitllvof an-
tiveuomous srM imi reipiired is not oiilv in inverse ratio to the snseep-
tibilitv of an aniimil. but also to its weij.'lit. iMan shows more power
of resistance than the aniuials e.xperimeuted upon.
Y16
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. ^'■'I"""""" "'''••!|"'*
Pi>iw<>ii<>ii<« lEcplilc's,
lix. While ex periraeuting with viper venom exclusively
he found many substances which exhibited apparently a
elecidcd antitiixic ellect — c.f/., cholesteriu, separated from
biliary calculi and from carrots, or tyrosiu, obtained frcjm
the bulbs of tlie wcll-Unown flower Dahlia, and from
mushrooms.* All these bodies, some of vej;etable ori-
.ein and the hij;li(st tinal products of ]iroteid metabolism,
had a ilccideil immunizing effect against viper venom, as
had also the senun of the animals treated with these sub-
stances. Tliey were capable, however, of raising the re-
sisting jiower of the organism but little above the mini-
mum lethal dose of venom : and, moreover, to be at all
etlicaeious. they had to be injected at least twenty-four
hours previous to tlie administration of the venom. f A
similar antitoxic intiuence is exerted by the cortical sub-
stance of the suprarenal glands.
Cahnelte, after repeating tlie above experiments, has
extended them by using bouillon, bile, normal and anti-
tetanic serum, etc.. with the same apparent antitoxic
effect, which is little pronounced and transient. He
claiius that all these substances act only as cell stimu-
lants, to counteract the deleterious influence of the ven-
om. Advocates of Ehrlich's theory would as well say
that they stimtdate the cell to the overproduction of a
toxophil side chain, which as antito.xin is received and
kept ready for use by the blood plasma. It is immaterial
which theory we may ap])ly. The observations of Phisa-
li.x are still in an experimental stage, and, though they
may result in very practical conclusions, they may in the
mean time serve to unravel the mysteries of the relation
between toxins and antitoxins. And to investigations of
this nature snake poisons, as ^Martin has pointed out, are
paiticularly well adapted. They have the advantage of
being less sensitive than other toxins to light and heat,
and of being comparatively easy to obtain in a form
which preserves a remarkably constant composition.
To sum up, the most commendable treatment Mould
be:
One or several tight ligatures should be made above
the wound, followed perhaps by deep scaritieations ;
then injection of antivenomous servim, if at hand. If
the latter cannot be hail, injections shoukl be made of 20
to 50 c.c. of a solution of hypochlorite of lime, 1 to GO,
at several points near the bite and elsewhere. Stimula-
tion, if necessaiy, by either stiychnine or atropine (or
alcohol?) ; lavage of the stomach : artificial respiration for
hours; and, not least of all, continuous encouragement
of the victim, for a deepiuental prostration goes together
with the physical dejiression of the nervous centres.
Helodekm.\.— It remains now to consider the only
poisonous reptile not belonging to the snake group, the
lizard heloderma. which is represented by two species.
Fig. asTl.— Head of Heloderma. Sideriew.
The habitat of one of them. Heloderma suspectimi Cope,
is in the .southwest of the United States, in New Mexico
* Tttere are. no d<tutit. inanv other substances of similar action, and
it is noi iiiiproliaiilt'thaf ^onieof Hit- popular anti'iorcsto snake vcnoni,
lilie llic plant, nifiiiiotii-d hHfi.re, Micania. owe their parliv dcsiTved
reputation tJ.> an intiuence similar to that stated alRn-e as exerted by
choiesterin, etc.
+ Possibly in these cases the presence of a larjre amount of choies-
terin in the blood serum acts in the same way as it does with other
proiopiasina puisnns. . .r;.. saponin ; it conihines directly witb the toxic
sulisian-c. thus pri-ventint: the cln..lesterin of the blood cells them-
selves from dom^? su, and from bein^ destroyed. (Ransom.)
t>
Fio. 3872.— Teeth of Helo-
derma. a. Natural size
(3 mm. in length): h.
enlarged <:3 diam.): c,
cross section.
and Arizona, around the Gila Rivei-, while its somewhat
laiger congener, Heloderma horridum, lives in Central
America. Its popular name, "Gihi monster." denotes
the awe and fear with which the anim;il is legarded hv
the native population, but the same is hardly justified
by its exterior nor by its habits. The length attained by
the adult animal varies fiom eigh-
teen to twenty-two inches. Its
skin, which i.s studded with in-
numerable horny elevations, like
small, round nail-heads, exhibits a
salmon or orange color, iuteritipt-
ed by black rings and iifegular
figures; the slow and sluggish,
dragging gait does not entibie it
to make an attack or onslaught.
The breath is said to be ollensive
and to issue from the mouth in
pufts of black vapor; but only the black tongue is some-
times thrust out, and the exhalations and saliva have
the plea.sant odor of fresh calamus or sweetfiag. Its
reputation as a monster seems to be founded upon the
fact that the natives have ficcasional ly observed grave con-
sequences following its bite. It undonbiedU' bites veiy
rarely, and then only when it is teased or coiiiered.
When pursued it throws itself tijion its back and bites in
this position, holding on as tightly as a bulldog.
The fact that but occasional!}- grave seijueUp follow
the bite of a Gila monster accounts tor the many discrep-
ancies that have prevailed as to its toxicity until very
recently, not only aiuong the natives, but also among
the best scientific observers. The first confirmation of
its poisonous nature seemed to be establishetl by the tlis-
covery of grooved teeth, about :?— 4 mm. long, four on
either branch of both maxilla and mandibula, in shape
similar to those in the snakes Opisthoglypha or "suspec-
ti."* The mandibula appears somewhat swollen, owing
to the projection of its disjiroportionately large, elon
gated submaxillary ghiuds, whose f(mr separate ducts
lead to the base of the above-described grooved teeth.
The buccal secretion is whitish, transparent, slightly
tui'bid. somewhat viscid, alkaline, mostlj* contaminated
with traces of blood; it has the fragrant odor of calamus
and shows some scaly epithelia, salivary corpuscles, and
some amorphous granules. A hanging drop soon swarms
with bticteria. Gelatin is liquefied with lemon-colored
colonies. When bitingon a rubbercord ananimal yields
on the average five to six drops; a large animal once
gave twenty-two drops. The saliva dries in grayish-
white scales to one-eighth or one-tenth of its original
weight.
The arrangement of the teeth and of the glands makes
us understand why opinions as to the poisonous natuie
of heloderma have differed so widely. When an animal
seizes its victim only with the front teeth, or does not lie
on its back while biting, none or very little of the buccal
secretion may enter the wound. When, however, a
vigorous bite has been inflicted, the consequent phenom-
ena have proven the venomous character beyond any
doubt, and the hj'podermic application of the pui'c saliva
in sufficient doses has invariably proved fatal to the ani-
m;ds experimented upon — rabbits, mice, and frogs.
The first effect of the injection — an inability to sit or
stand — is manifested after a short time, about ten to fif-
teen minutes in frogs, thirty minutes iu rabbits. A cer-
tain drowsiness, similar to a narcosis, overpowers the
animal; paralysis and in.^eusibility seem to |iroceed from
behind forward. The lespiiation is not Itibored. but be-
comes giadually slower and sujierficial until the animal
exinres after a few hours with some hai'dly noticeable
twitchings. The heart has first a perioil of increased
activity, which is followed liy gniduiil iiai;ilysis and a
great fall of arterial pressure, due to vascular dilatation.
While these symptoms prevail after a small dose of ven-
• There is possibly another poisonous lizard in East India, Lantha-
notus lloriH'cnsis. wiiich dilTei-s considerat)ly from Heloderma. but
which is provided wiih shallow grooved teeth. As to its toxicity
nothmg is iiuowu tSteindachner).
7i:
Poisons.
Pofsous*
REFERENCE UANUBOUK OF THE JIEDKAL SCIEXCES.
om. l;ii-y:o diiscs seem to ar-t directly uiinii the lieiirt mus-
cle, Ihc auimuls dyiiijr within leu to luciity minutes with
<lysi>im'a and convulsions. Home investigatofs e.\i)lain
these symptoms us the couscciucnce of ijeneral muscular
paralysis (Santcsson ) : ot hers, as a pai'aly sis of the cent ral
nervous organs (Van Dcnburgh). A faint lia'inolysis is
noticed in ritm. liul in the l)ody no cfl'cc I upon the lilood
is visilile, noexudation ovliemorrhagea(ipcars. The lix'al
symptoms, with raie e.\e<'ptions, are entirely wanting';
it is even dillicult to tind the spot where the venom has
been injected. Yet it ouglit not to he forgotten that a
few ea.ses of persons bitten hy a heloderma are on record
in which extensive and )iaiTiful local swelling is noted.
Tlie ant()])sy shows nothing but a very much dilated
heart and an enormous vencjus congestion of all internal
organs. The mieroscoitical examination of the sijinal
cord, however, reveals extensive changes in the ganglion
cells of tlie anterior horns; in fact, Bailey found the
changes almost identical with those described as due to
the action of snake venom. It is not hard to believe,
therefore, that snake venom and the saliva of heloderma
are almost identical iu chemical composition. Santesson
has demonstrated that tliis saliva contains albnmosesas
well as sonic niiclein bodies, tlie latter pcrhtips responsi-
ble for the sliglit action upon the blood.
Tretitiiifiit. — It is to beexpecti d that tlie peisousbitteu
by a lieloderma will seldom exhibit grave .symptoms, ex-
cept when accidental!}- a blooil-vcs.sel has been struck
directly. A treatment after general surgical iirineiplcs
■will siifiice to subdue the local ]ihenomena, wliile the oi--
ganism has time to overcome the effects of tlie injected
toxin. Yet a ligature ought not to be omitted, and
otherwi.se the use of antivenonunis serum should be re-
sorted to as well. The similarity of the toxins of snake
venom and the saliva of heloderma justifies the adminis-
tration of the same antidote, (.'almetti' even claims for
his antivenoinous serum the same success in stings of
scorpions as for suake-liite. Hii.ttnr Jjiiiyiinniii.
BlIU.IOUR.lI'llV.
Alt : Miinrli. inert. Woeli., Isie.
AliiJiden: UiM, News. 1.SS3.
Aiifhe; .loiiiTi. de ,\ted. ilt- lionlcjiiix. 1002.
Buil'-v, in Lanirnisiun's "'t'oisDU Siuilics," Merliciil Rerord, lOOi), it.
ist;inc'liiir(l : I'mnpt. reml. de la Soe. ilc liiulie., l,sin.
CnliiicUc-: Annal. de I'lnstii. Piisteur, l.silt, l.s'.i;. ls9s.— L.' venin des
serpents. I'ari.'^. Istt.'i.
Cnnnlnirliani: Ifepiirt, ralcntta, IsiC-tii), in .Naiiiiv, ]s'm;, Iiecciiilier lutli.
DelcZHimi' : Arch, di' IMiv.'^in!., x.
Elict: Hrit, Med. .Inuni.. I'.nin, Itioii. i., ij.
E«ins: Medicat Ilword, 1.S!I4, i.
Ewintr. .7. in LnnmiiannV, "t'nisnn Sn:il<es," Mi-diral Kfinrd. HKKI, ii.
Fayivr: 'I'lianatupliidia "f India. I.nndon. ]ST2.
Favivr and I.andi'r Jiriiiilcin : I'mc tiiiv. Sue, l.ST:;, 1ST:!, IST.j.
Fi-olillstuw: Inall!.'. DisM-rt.. D.jrpat, l.ws.
Flexnt-r and .\(rj?iictii : .tuurn. of I>;xpcr. ,Med., vl.
Fraser: l!i1t. Med. Jonrn., l.sii.5. i., yii, i.
KaiiUiai'k : .loiiru. of l^Ii.vsiol.. -\iil.
Levdiir: Arch. f. niikr. Anat., ix.
Martin, f. J. : I'loe. Roy. Soe. .\. S. W.. 189.5.— Also in Alllmtt's System
of iMcuic-ino, iii.
Milcliell, W. : Siiiitlisonian fontrili.. xii.
Mlteht-Il, W., and Reiclierl : Slililll.scmiall Cnmnh., .\x\ i.
Mliller: Snalii- I'oison, Sydney, isii:!.
Mmms: Tr.TLs. Patbol. Sot-., .51; Lam-et, Ilinii, i.; Jmirn. of PalboL,
liHil.
Nfiwak : Ann. de I'tnst. I'aslenr. Istts.
rili.salix: Coiiipt. ivnd. di' la Sor I'.iol., l.stlii. hsnr, l,«;is.
Ransom : Dents, mod. Worli.. lilOl.
Seiiiple: ISrit. .Mori. .loiirn., ISIM, i.
Sewali : Jonrn. of IMiysioI., ylii.
Stephen and Myers: Jonrn. of Pathol.. 10(1(1.
Steinoi!Cr: 't'lic I'oison Snaiios of iN'orlli ,\iiier.. Washington, 1S05.
Wall : tnilian Snake I'olsons, Issii.
Wehriiiann: Annat do i'lust. I'a.sienr. IstiS.
Wolft-ndcn ; .loiirn. of I'leslol., \ ti.
Yai'row : Aiiier. Jonrn. ot Mod. Sciences. ]ss4, i.
llihiil, nun.
Bailey, in I.anirniann's "Poison Snakes" Medical Record. liHIl), ii.
Milclicll, W.: Medical .\i'\ys, ls,s;i, i.
Saillessoll: Nold. Med. ArU., Key lestliand, ISflr.
Shii!r-ldi : .Valine, London, l.s'.)l.- N. V. Med. Jonrn.. Is'.il. i.
Sleindaclmer: Doiiks. it. U. Akad., Wieii, t.sTS.
Van IienhiirLdi and Wie-iit : Amor. Joiirii. of Physiol., iw
yari'iu. I oii'sl and Stream, l.s,ss.
POISONS.-— A concise detiiiiti(in of the term poison,
wdiieli will satisfy the medical, the legal, and the popu-
lar acceptations, is a practical impossibility. To the
layman a poison is any substance wiiicli. when ailminis-
tered in hiiiall do.ses, causes disturbance to health or de-
struction of life; in a legal sense it is any substance of a
desirnetive or noxious character, wh.-itsoever its uature
or mode of oiicratioii, which, taken into the system, piro-
duces injurious or fatal cll'ecds. The popular deliniiioii
excludes many well-recognized poisons which aid injnii
ously only iu large do.ses; the legal includes, or may be
made to include, many substances not strictly ])oisonons,
such as powdered glass, iron tilings, and other tilings of a
similar character, which are merely mechanical irritants.
To the physician and toxicologist the term means any
substance of inheient deleterious cliaraetei', either organic
or inorganic, and incapable of self-re|uoduction. wiiich,
acting chemically upon the ti.ssucs or tiuids of the liody,
may, by causing alteration or destruction of the same, or
disturbance of function, seriously affect the health <ir
destroy life. This delinition excludes mechanical agen-
cies, direct thermal changes, electricity, bacteiia, and
the low forms of animal life.
The published statistics of poisoning are very meagre,
but the few tables which we have are interesting in sev-
eral ways, indicating the classes of substances and s])e-
cial substances most freiiuently selected or aecich-ntally
administered, atdill'erent times and in ditfereut countries,
and showing the proportion of accidental, suicidal, and
criminal deaths due to poisoning.
The returns made by the English coroners of the in-
rpiests held during 1837 and 1838 showed the whole
number of deaths by poisoning to be .541. Of this num-
ber opium was the cause iu 19(i ea.ses. the majority of
which Avere accidental or sm'cidal. Ar.seuic stood next
in order, with 185 cases, the majority of which were
criminal. Thirty-two cases were due to sul])liuric acid,
37 to prussic acid, 19 to oxalic acid, and 15 to corrosive
sublimate and other preparations of mercuiy.
During the years 1803 to 1867 there occurred in Eng-
land and "Wales 2,097 deaths from poison. Of this num-
ber no less than 638 were due to opium and its prepara-
tions. 151 to prussic acid and potassic cyanide. 83 to
arsenic. 77 to mineral acids, 66 to oxalic acid, 61 to
strychnine. 58 to compounds of mercury, 15 to plios-
pliorus. and 11 to ammonia.
In France, during the years 1851 to 1871. out of 873
cases. 387 were due to arsenic, 367 to phosphorus, 1.59
to copper. 36 to sulphuric acid. 35 to cantharides. while
opium and its preparations were responsible for but 6.
In Finland, of 30 fatal cases occurring between 18(50
and 1866. ar.senic caused 7. jihosphorus 5. and .strych-
nine -1.
Out fif -15 cases re|iorted in Jrassachu.setts during the
lieriiid 1S78 to 1881, opium was responsilile for 18,
arsenic for 13, and all others for 14.
Although |ioisoiiing is ii fre((Uent means of suicide, the
]icrcentage of these cases is not nearly so high as is gen-
erally supposed; but yet, judging from what tigures wc
have l.iecn able to obtain, this method of terminating an
unsatisfactory existence is graduall}" becoming more
IHijiular. In Prussia, for instance, while there was a
great increase in the number of suicides from all causes
during the jicriod 1871 to 187li, the relative frequency of
.self-poisoning was very much greater. The increase from
all cau.ses over preceding years was 43.60 per cent., but
suicide from poisoning alone had ni(n'e than doubled in
fre(|Uenev, the increase being 136.10 per cent.; but,
even then, poisoning was the means en)|)loycd by but a
fi'action over three per cent, of the whole number of
suicides. Puriiig the eight years ending with 1876, the
whole number <jf these cases was 34,918. and of this
number 786 were by poisoning (3.15 percent.). Solid
or li(|uid [loisons were elected by 707 persons, and gase-
ous by 79. It is interesting to note further that, wliile
by far the greater number of suicides were men, the pro-
portion being 80.50 against 19.50, or more than 4 to 1,
tlu^ 7s;6 suicides by poisons were nearly evenly divided
between tlii' two sexes, the proportion being 53.9 men to
47. 1 w(diiin.
(Jf the whole nuuiber of suicides reported iu Ravaiia
718
REFEREXCE HANDBOOK OF THE MEDICAL SCIENCES.
Poisons.
during the fourteen years ending with 1870, 2 per cent,
were due to poisouine. In 1871 the jiercentage increased
lo 3.2; during 1 873 ''it was ii. 00; in 1873 il fell 1o2.20;
increased again in 1874 to 2.70, and fell oil again sliglilly
in 1875 to 2.50. The popularity of iioisoning as a means
of suicide varies great!}' in dilferenl countiies. In Swe-
den, from 1843 to 18,55, nearly a fourth of the suicides
chose this means (21.7 per cent.); in England, in 1858
and 1859, 9.10 per cent.; and iu other countries as fol-
lows: France, 1835-44, 2.48 percent.; 1848-57. 1.80 per
cent.; Belgium, 1840-49, 1.80 per cent.; Deumaik,
1840-56, 1.50 percent; Wiirlemhcrg, 1857-70, 1.20 pea-
cent. ; Geneva, 1838-.55, 4.90 per cent.
Of the accidental deaths occurring in Prussia during
the years 1869-70, 54,303 in nuniher. 2,448, or 4.50 pe~r
cent., were due to poison. This number includes 1,873
men and 575 women; 348 of the victims were under and
3,100 over fifteen years of age. During the fifteen
years ending with 1877 there were 77 cases of criminal
poisoning in Prussia, or 0.056 per cent, of all crimes.
In France, during 1826-29, out of 2,663 capital offences.
150. or 5.63 per cent., were for poisoning. In England
and Wales, during 1840, there occurred 349 deaths from
poisoning (181 men, 168 women); 101 eases were suicidal
(74 men, 87 women); and 188 were accidental and homi-
cidal (107 men. 81 women). Among the latter, oiiium
caused the death in 43 children imder five years of age.
Classification. — Various methods of classification of
poisons have from time to time been recommended ; hut
no system has as j'et proved wholly satisfactoiy. The
old classifications, according to source or chemical prop-
erties, such as: (1) animal; C-) miueral ; (3) vegetable; or,
(1) organic; (2) inorganic; or (1) acids; (2) alkalies; (3)
salts, are of no value, since they convey no idea regarding
the iiroperties of a poison or its mode of acliou. Orfila's
division into (1) irritants; (2) narcotics, and (3) narcotico-
irritants; Tardieu's into (1) irritants and corrosives; (2)
hypostheniants; (3) stupefacieuts; (4) narcotics, and (5)
tetanies: and Taylor's into (1) irritants, and (2) neurotics,
are all good ; but each has its defective prints. Taylor's
is. perhaps, the best. The irritants are derived fnan the
animal, vegetable, and mineral kingdoms; those from
the latter source may be further subdivided into acid,
alkaline, non-metallic, and metallic. The neurotics are
subdivided into (1) cerebral; (2) spinal; (3) ceiebro-
spinal, and (4) cerebro-cardiac.
The irritant poisons include manj' which arc also cor-
rosive in their action, causing disintegration of the parts
with which they come in contact. The pure irritants
e.xert no such chemical action, and are much slower in
the development of symptoms. They cause irritation
and inflanuTialion of the ])arts to which they are apidied,
with violent vomiting and purging, intense pain, and
well-marked effects on the nervous sy.stem. These
S3-m])t(jms occurafter a greater or lesser interval, accord-
ing to the nature of the particular poison. The pain,
winch is usually of an intense burning character, is.
unlike tiiat due to colic, miu;h increased by pressure.
Septic irritants produce additional symptoms of a char-
acter formerly known as typlioidal.
The neurotic poisors act chiellj' on the brain, cord, and
nerves; occasionally, the symptoms manifesteil partake
more or less of the character of irritant poisoning.
Those acting chiefly on the brain, producing stupor and
insensibility, |n'eeeded by fulness in tlie head, vertigo,
impaired vision, delirium, etc., belong to the cerebral;
those affecting chiefly the cord, producing tetanic or
clonic convulsions, to the spinal; those producing sym[i-
toms referable to the brain and cord, to the cerebro-
spinal; and tliose affecting the brain ami hi'art, to the
cerebro-cardiac class.
Action. — The action of poisons may be local, remote,
or both. Local action is physical and chemical, and is
mainfested by inflammation, corrosicm, and direct effect
upnn the nerves, wherel)y the functions of organs arc
impaired or destroj'cd. It the chemical afliiuty of the
poison for the tissues at the point of apjilicalion be not
great, the result is irritation ami iuflanmiatiou ; if, how-
ever, the affinity be great, the action is most intense, and
we have actual corrosion. Kemote adieu depi nds upon
absorption into, and transportation by, the blood to the
various organs which may be allected. Thus, for in-
stance, digitalis afi'ects the heart, strychnine the cord,
and o)iium the brain. Iu any case of acute fatal poison-
ing, death is the result of the n'Uiote action of tie poison,
which may or may not have a local action.
The ordinary action of poisons may be modifitd by the
size of the do.se, by the chemical c( mbination of the
substance, by the state of aggregation or admi.xtuie, by
the condition or absorptive power of the part or inom-
braue to which it is applied, by tlu; condition of the
patient, by habit, and by idiosyncrasy. The young and
old are more susceptible, as a rule, than tlie middle-
aged; women more than men; and fasting more than
well-fed persons. Disea.se also may rei:der the subject
less susceptible, or, on the other hand, may facilitate the
action of the poison. Habit diminishes the effect of
many poisons, so that a much larger dose is required for
the manifestation of symptoms than would be for per-
sons not so habituated. Idiosyncia.sy is a peculiar con-
dition of the system which enables harmless substances-
to produce violent synijitoms similar to these of iiTitant
poisons. Thus manj- persons aii' unalile to eat certain
articles of food, even unknowingly — such as shell-fish,
fish, strawberries, some kinds of meat, butter, honey,
and other things. In the same way, manj' persons aie
seriously aifectetl by small medicinal doses of opium,
strychnine, arsenic, and other pharmaceutical prepara-
tions. A second fonu of idiosj'mrasy is a tolerance for
ex'ceptionally large doses of jioison by persoDs in no way
protected by the influence of habit.
Absorption. — In order to produce poisonous symp-
toms, the presence of a certain amount of poison in the
l>lood is usualh' necessary, and the amount required de-
pends upon rapidity of absorption and of elimination.
A certain amount of any poison in the blood is incapable
of producing any symjitoms. Beyond thisis that amount
which is capable of prod'. eing characteristic symptoms
— the jioisonous dose; then that amount capable of
destroying life — tlie minimum fatal do.se; and beyond
this up to a certain point, the acliou is increased in vio-
lence and ra]ndity. The poisonous and minimum fatal
doses are relatively large if absorption is slow and eliuii-
nat.ion rapid, and small if the latter conditions are le-
versed. 'The rapidity of al)sorption depends greatly
upon the physical proiierties of tl'e]ioison; liquids aie
more raiiidly absorbabU' than solids, soluble solids more!-
than insoluble, and gases more than liquids nr solids.
Some insoluble solids may be rendered solulile, and
hence more absorbable, b\- the action of the juices of the
stomach and intestines.
Poisons maybe taken into the system directly through
flic blood, as in absorption from wounds or injeciion into
l)lood-vessels; they may be ab.sorbed through the skin or
from the cellular meivibrane, from inflamed serous sur-
faces, and from all nuicous nnunbranes. Absoiption
directly into the blood from wounds occurs with great
raiiidity. Tlu'ongh healthy skin covered with <-uticle,
absorption is very ,slow and in small amount. It is in-
creased by rubbing and by thi' addition of tatty sub-
stances or solvents of the poisons. Gaseous substances
are more absorbable than watery solutions, particuhnly
if the latter are warm or hot. O'l the other hand, ab-
.siirptiou from a diseased skin is very raiiid, aiul many
fatal cases have been noted from the aiiiilieation of
washes, ointments, and dressings to discasc<l surfaces.
INIucous surfaces ab.sorb i)oisous in the following ordrr
of raiiidity: (1) lungs; (2) stomach; (3) intestines; (4)
UKUith; (5)' nose; (6) eyes; (7) tear passages; (S) rectum ; (9)
vagina: (lO)uterus; (ll)bladder: (12) lu-cjiuee. Theiiiu-
cous surfaces of the lungs and the air jiassages absorl)
poisons with great raiiidity, and particadarly tliose in the
form ol gas or dust. Thi' lining nn>mbrane of the stom-
ach and intestines is usually the absorbent surface in
ordinary cases of poisoning. Fulness of these organs
letards, and emptiness favors, absorption. Certain poi-
^m
Poisous*
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
sons whioli are rapidly fatal wlicn inlrodufcd iiitii tlii?
circ'ulaticiM (suakc poisons, cunire, etc.) are liarmless iu
a lull stDinacli. and, indeed, are absorbed only iu small
amount wlien that organ is emjity.
Concerning the absorbent power of other mucous mem-
branes, it is necessary only to remark that all areellicient,
though in a somewhat varying degree. On account of
the absorption of poLsous by the nuicous membranes of
the intestines and bladder, it is sometimes necessary in
treatment to administer ealhartics, or to eathelerize, in
order to prevent the reabsorption of substances which
are undergoing elimination frojn the .system by the .saliva,
the juices of "the stomach, pancreas, and intestines, the
bile, or the urine.
Eu.Mix.VTiux. — As soon as absorption begins, the sub-
stance is dilTused through the wholi> body by the circula-
tion, and at the same time the )iroce.ss of elimination is
begun. Coincident xvitli this is still a third process, that
of deposition in the various tissues of the liody, from
which, however, the poison is eventually eliminated, mi-
less death intervenes. Deposition goes ou chieliy iu the
liver, kidneys, spleen, brain, and heart. The effect of a
poison depends upon the relative rayiidity of absorption
and elimination, and these jiiocesses go on with greater
or lesser rapidity according to the nature of the sub-
stance. If elimination proceedsasrapiilly as absorption,
fatal results do not occur; but with a slower elimination
the poison accumulates in the system, and, provided a
sulHcieutly large amount has been administered, destroys
life. Elimination is influenced by the chenn<>al aflinity
of the poison for the constituents of the blood or of the
tissues of the affected organs. If this allinily is great,
the ])rocess is slow ; if weak, the jiroci'ss is very rapid.
Gaseous and volatile poisons are excreted chietly by
the lungs; others chietly by the kidneys, though all
secretions of the body play a more or less inijiortaut part
in the process. Certain poisons appear to el<'et particu-
lar secretions, though the kidneys act iu most cases as
the most iniportaut organ of elimination. Thus mercury
elects the salivary glands, arsenic and antimony the mu-
cous and serous raemlu'anes, and many metallic poisons
the liver.
Di.\«.Nosis OF P()isoNi.\(;. — The diagnosis of the ad-
ministration of .'i ])oison is based on the symptoms and
their course, the detection of poi.son in articles of food
and drink or in the e.jecta and e.xcreta, on the post-mor-
tem appearances, and ou the detection of the suspected
substance in the organs of tlu' decea.sed. The symptoms
are usually of sudden onset, in a person iireviously in
good health, soon after eating or ilrinking. If several
persons are affectid at the same time, there is commonly
a marked similarity iu the symptoms. 'Where the poison
is administered to a sick person, the diagnosis is rendered
more ditlicult on account of synnitoms already present,
which may appear to lie modilled or exaggerated, and
the |ihenomena of poisoning may seem to be only the
natural course of the disease. Too much importauce
should not be attached to the fact of recent eating or
drinking, since a poison may be inhaled, injected, or ap-
]ilied e.xleriially. The diagnosis of the |iarticular kind
of |)oisou involved is of great imponauee for the deter-
mination of the treatment to lie puisued, ami it is there-
fore essential that the medical attendant should know, if
possible, the exact eour.se of the symptnms from their
tirst appearance, the previous history of the patient, and
the e-xaet nature of any medicines wliii-h may have been
administered. Owing to the siniihirity ol' symptoms of
jiarticular diseases lo those ]iroduced by certain poisons,
one must often exercise great care in making a dilferen-
ti.-il diagnosis. The physician is often aided in forming
an opinioti liy the moral as|iect of the case.
Acute irritant )iiiisoniug may be suspected when vio-
lent purgiiii; and vomiting, accomjianied by jiaiu in the
region of llie stomach or complete prostration, occur in a
person without some assignable natural cause. Acute
neurotic )ioisoning manifests itself by more or less sud-
den symptoms referalile to the nervous .'system, such as
Stupor, insensibility, delirium, or convulsions. Chronic
poisoning is more difficult of diagnosis than ae\ite or
subacute, ou account of the less marked character of the
s\'mptoms. which are often, or indeed usually, ascrib-
able to natural causes.
In making a diagnosis in a case of suspected poisou-
in,g, it is to be borne in mind that symptoms may be
delayed by fulness of the stomach, sleep, or iuto.xicatiou,
or may be moditied or intensitied by disease or debility.
Among the diseases which may be confounded with irii-
tant poisoning may lie mentioned cholera asiatica, cholera
morbus, gastritis, enteritis, gastro-euteritis, colic, peri-
tonitis, intussusception, and dysentery; among those
which may simulate neurotic poisoning are apoplexy,
sunstroke, uramiia, septicemia, epilepsy, tetanus, dis-
eases of the brain and of the heart, pulmonary embolism,
eerebro-s]pinal meningitis, rupture of the stomach or
gall-liladder, typhoid fever, and coma of various oriirin.
Of very great importauce in the diagno.sis and sulise-
(juent treatment of poisoning is the detection of the
substance in the remains of food or .drink, or iu the
vomitus; but as it is possible, in any case of criminal
poisoning, that these substances may have been removed
and others .substituted, or in cases of feigned poisoning
that a poison may be introduced into the food remains or
vomited matters, reliance cannot always be placed upon
this evidence. But the detection of the poison in the
tirine of the patient establishes the diagnosis beyond any
doubt. Yet, at the same time, it should be remembered
that the non-detection in that tluid does not bj- any
means prove its non-e.xistence in the body.
The TnE.\TMENT in cases of poi.soning depends alto-
gether upon the nature of the particular substance in-
volved. The first indication, except when corrosives or
poisons administered otherwise than by the mouth are in-
volved, is evacuation of the stomach and administratiou
of antidotes, stimulants, etc. (See special poisons under
their appropriate heads. See also article ou Aiitkhitis.)
PosT-MoiiTE-M Indkwtio.ns. — It frecjuently happens, in
cases of suspected poisoning, that an autopsy is all that
is necessary clearly to establish the cause of death, jiar-
tiinilarly in cases of sudden death, which to the miedu-
(;ated mind are associat<'d usually with susjjicious cir-
cumstances. The jiopular belief iu poison as an agent
of sudden death is doubtless, iu great part, <lue to works
of fiction and the stage, where the interval occurring be-
tween the swallowing of the poison and the termination
of life is so short that the two events are almost simul-
taneous. As a matter of fact, sudden death is much
more likely to be due to disease than to poison, and,
indeed, the only poison which apjiroaches heart disease
and apoplexy in rapidity of fatal effect is anhydrous
jirussic acid, a jioison not easily obtainable. But, in
consequence of the popular tendency to as.sociate the
two ideas, innocent persons freqiu'utly are suspected or
acctised of a heinous crime, which may be easily dis-
proved by the appearances on section. On the other
hand, with perhaps equal or greater freciuency. the
autop.sy serves to direct suspicion or to strengthen it in
cases of ])oisoning which have resi'inbled disease. But
it not seldom fails to throw any light whatc\er upon the
iiuestion of the cause of death, and then a chemical
examination may be reqviired.
The external appearances indicative of poison are very
few. and of no great value. Evidence of corro.sive action
is sometimes furnished by the skin and clothing. The
jiresence of certain ]ioisons mav be betrayed by their
odors, and of others by stains. There is nothing char-
acteristic to be observed from the attitude of the body,
rate of cooling or of decomposition, or expression of the
ciiiinleii.'uiee. Rigidity is usually more marked and
longer cnntinued in death from strychnine, and is often
diiiguostic of this poison; in other cases, no great dilfer-
enee is to be oliserved. Internal appearances vary ac-
cording to the poison ; they may be absent, or so slight
as not lo attract attention in cases of death by neurotics,
or they may be very marked and characteristic where irri-
tants, and particularly corro.sives. liave been employed.
The ehenucal and physical propeities of the blood
rso
REFERENCE HANDBOOK oF THE ME[>I('AL SCIENCES.
Poisons.
Poif«ous.
sometimes undergo marked changes ; it is darkened I13'
cliloroform, ether, carbonic acid, siilphurcted lij'drogen,
and oilier gases, and by prussic acid and cj'anides. oxalic
acid. etc. ; by morphine, strychnine, and some others, it
is both darkened and rendered mure thiid. TIjc greater
number of mineral poisons have no ell'ect on the blood.
The blood-vessels of the brain are sometimes observed to
be engorged in narcotic poisoning, but this appearance
maj- be very slight or entirel)' wanting. The principal
post-mortem appearances due to poison are to be fovind
in the alimentary canal and abdominal viscera. Corro-
sion of an J- part of the alimentary canal, .softening of the
mucons membrane, which is changed in color and easily
detached, and evidence of intense inflammation or per-
foration, are diagnostic of corrosive acids or alkalies, etc.
In irritant poisoning, the stomach and intestines show-
signs of inflammation of a more or less intense character,
and sometimes ulceration and perforation, thickening of
the walls, or even thickening and softening. The changes
produced in other organs are chiefly engorgement and
fatty degeneration ; the latter occurs sometimes with
surprising rapidity in the liver in poisoning by arsenic
and phosphorus.
The post-mortem appearances in an3' case of suspected
poisoning will be but imperfect evidence of the presence
or results of poison, unless it is possible to distinguish
them without doubt from analogous appearances which
may be the I'esult of disease. Otherwise the proof of
poisoning must rest on the detection of the iioison in the
body, or on outside evidence. The changes which may
be referable to disease or to the action of irritant poisons
as well, are softening, thickening, reddening, ulceration,
and perforation. Softening of the walls of the stomach
may be due to poison, to disease, or to post-mortem
change. Ifitisdueto poi.son, similar changes are usually
to be found in the mouth and icsophagus: if to disease
or post-mortem digestion, these additional changes are
wanting.. Reddening may be due to poisoning or to
gastritis, gastro-enteritis, gravitation, or to contact with
the liver or spleen. But these appearances are not likely
to be mistaken by one accustomed to post-mortem exami-
nations ; the redness of poisoning is usually accompanied
by some peculiaritj- of appearance which renders it
readily distinguishable. Ulceration is more commonly
referable to disease than to poison. "When it is due to the
former, the accompanying redness is confined to the im-
mediate locality, whereas in poisoning it is more or less
widely diffused. There is also a considerable dilTerence
in the symptoms. Care should be taken not to confound
ulceration, which is a vital process, with corrosion,
which is chemical. Perforation of any part of the ali-
mentary canal is. like idceration. of more common ficcur-
rence in disease than in poisoning. When due to disease
perforation of the stomach is accomijanied by little if
anj- vomiting and no purging, and death is due to jieri-
tonitis. The aperture, if due to ulceration and not to
corrosion, is usuall_v small in size, and with smooth,
regular edges, instead of large, rough, and irregular.
Perforation from post-mortem digestion is very rare;
it may be suspected from the fact that there has been no
peritonitis, nor any symptom before death, to indicate
such a severe process. Perforations of the (esophagus
and intestines are commonly due to ulceration from the
presence of a foreign body, and in such cases the latl<'i'
is usually discoverable. The intestinal wall is ]ierforated
frequently in disease, as, for instance, in typhoid fever.
Chemical Examination. — When a chemical analysis
of the bod}' is deemed necessary, the greatest precautions
should be observed in performing the autopsy, and in
, the i)reservation of organs and fluids. The stomach
should be ligatured at both ends before removal. On
its being opened tlie contents should lie received in a
clean glass or porcelain vessel, and their (juantity, color,
odor, reaction, and consistency, and the presence of any
unusual substances should be noted ; the intestines should
be treated in like manner. Each organ, on removal,
should be jilaced in a clean vessel by itself, sealed with a
private seal, and labelled. Any suspicious vials or pow-
Voi.. VI.— 46
ders, and all remnants of food, vomitus, urine, or other
substances connected witli the case should be sealed at
the same time and delivered to the chemist. In ca.sc of
exhumed bodies, where decomposition has iiioceeded so
far that the coffin is no longer entire, it is often advisa-
ble to take, in addition, a sample of earth from ab(jve
and below the receptacle. On the delivery of the
organs, ei cclern. to the chemist, it is well to give also a
more or less complete history of the case, in order that
he ma.v have an idea as to the nature of the poison for
which he has to search. From the symptoms and post-
mortem appearances, it is freciuently possible to cut the
work of chemical analysis down to a minimum. Failure
to detect a poison in the body is by no means conclusive
that death has been caused naturally', for there are many
poisons which cannot be isolated. The fatal dose of
many is so very small that, even if not eliminated in
great part before death, its distribution over the system
renders it impossible, with our as yet imperfect means, to
be isolated. In such cases the proof depends on symp-
toms and other attendant circumstances. Nor is the
presence of pioison in the dead body proof that it has
caused death, for it is conceivable that poisonous sub-
stances may be introduced into the body after death has
alreadv occurred, or may have been used in the process
of embalming. But the discover}' of the poison in the
liver and other viscera, and particularly in the urine,
usually indicates ante-mortem administration. In many
cases in which death is the result of chronic poisoning, it
may be impossible to detect any of the substance, which,
having performed its work, has been eliminated from
the system. Volatile poisons also may be lost within a
very short interval after death, and others may lie de-
composed or oxidized in the living body. In most cases,
the ability to detect the jioison depends upon the length
of time which has elap.sed after death, upon the interval
lietween the first manifestation of s.vmptomsand dissolu-
tion, upon the amount taken, and upon the amount
remaining in the stomach and other organs when death
occurs, for reasons which have been given.
Before proceeding to a chemical analysis, a careful
examination of the stomach with the aid of a magnify-
ing glass should be made. Such inspection may reveal
cr.vstals or powders admitting of read.v examination, or
Ijarticles of vegetable matter ma.y be detected which
may be identified from their botanical characteristics
with the aid of the microscope. The organs subjected
to analysis should be a<'curatel.v weighed, anil an.v pecul-
iarities observed should be noted. It is best to divide
the organs into several portions: one for preservation;
one for volatile substances; one for alkaloids, etc.; one
for metallic substances; and one for special poisons.
The reagents and chemical apparatus used in an investi-
gation must be free from anv impurities. The work
should be carried on with great precautions, and with-
out assistance except such as is absolulel.y necessarv;
for the chemist must be prepared to swear to the identity
of the organs, and to the impossibilit}' of any tampering
with liis work on the part of others.
The methods of analj'sis to be pursued varv with the
nature of the poison. JIany substances require special
processes for themselves alone, while others may be
grouped together under a single process. It is best to
look first for volatile substances which are easily lost
with keeping, such as chloroform, ammonia, volatile
acids, alcohol, ethereal oils. etc. The substance sius-
])eeted of containing a volatile poison is rubbed up with
sulHcient distilled water, made acid or alkaline accord-
ing to the substance sought for, and distilled ; the dis-
tillate is then further examined b.v special tests.
The anal.vsis for metallic compounds requires that the
organic matter of the examined substances shall be de-
stroyed, since otlu-rwise it interferes with the character-
istic reactions. For this piirjiose the substance is heated
in an open dish, or glass llask, with chemicallv pure hy-
drochloric acid and jiotassic chlorate, the latter being
adiled a little at a time until the color of the resulting
liijuid remains straw-yellow for half an hour after the last
721
Poisons.
Polsous.
REFERENCE llAXDliOUK UF THE ilEDlCAL SCIEXCES.
addition. Tlie excess of chlorine; is tlicii driven off by
prolonjjed lieating over the water Imlh, oi- by tlic pas-
sage of a stream of carbonic aeid throiiirli tlie liiiiiid.
wliicli is llien liUereil and subjected lo the rejiular i)roc-
ess of ijnalitative analysis.
The analysis for alkaloids, ghicosides, etc., is one
which requires great care and delicacy «( manipulation.
The amount present in any one case is usually very small
and widely <listributed, and it is, therefore, not at all
surprising that an analysis for this class of poisons ofti'U
yields negative results even in the best of hands, when
the administration of the poi.son may be proved abso-
lutely. The method of DragendorIT lor this class is the
one most favoral)ly regarded. This process is bricH}-
as follows: The tissues are cut up small and extracted
with acidulated water Uw several hours at 40' to 50' C,
strained through cloth, and filtered. The filtrate is
evaporated to beginning syrupy consistence, mixed with
three or four volumes of alcohol, and allowed to stand
twenty four hcnirs. It is then tillered, the alcohol is
driveii oil' by evaporation, and tlie residue is transferreil
to a stoppered tiask after being cooled an<l filtered.
The fiuid is next shaken in the llask with freshly rectified
naphtha, ami then allowed to stanii until the two tluids
separate into two layers. The naphtha is then decanted,
and the process is repeated as long as a jiortion of the
naphtha ih'canted each time leaves any residue on evap-
oration. The naphtha removes ]iipi'rine, picric acid,
camphor, and similar substances, a constituent of the
black hellebore, ethi'real oils, capsicin, carbolic acid, and
decomposition products of aconite. The fluid is uext
shaken with benzol, which removes calTcine, cautharidin,
.santonin, caryophvllin, cubcbine. aloetin, digitaline, col-
chicine, chry.sammic aciil, picric aeid, and colocynthin.
It is next shaken with ehlorol'orm, wliieh removes cln-
chonine, theobrounne, iiapaverine, narceine, pierotoxiu,
helleborein, digitalein, sa|ionin, and j<-rvine. It is then
shaken with naphtha, which removes theexcess of chloro-
form, and next is made alkaline with ammonia, and
shaken again with naiihtha, which removes strychnine,
quinine, sabadilline, conhydrine, brncine, veratrine, eme-
tine, coniine, lobeliiie, nicotine, aniline, and trimethyla-
miue. From the alkaline fluid benzol removes atropine,
hyosc3'amin<', strychniu<', luncinc, pliysostigmine. qui-
nine, cinchonine, narcotine, codeine, thebaiue, veratrine,
sabadilline, del|)hinine, nepaline, aconitinc, uapelline, and
emetine. Chloroform is then used to remove nioriihine,
papaverine, and narceine, and amy 1 alcohol for morphine
and solanine. The fluid is then evaiiorated with gla.-^s
powder and extracted with chloroform, which removes
curarine. These si'paratc extracts are eva|iorati'd each
in several watch-glasses, and the resiilncs subjected lii
chemical and physiological tests.
ChdiliS Ihirriiiijloii.
POISONS, ABSORPTION AND DISTRIBUTION OF,
IN BOTH ACUTE AND CHRONIC CASES.— .VII p.ii-
sons arc absorbed. Tlii',v may enli r the body by various
channels, but sooner or later they find their wa}' into the
circulating blood and lymi)h, and are then distributed in
greater or less quantity throughout the lioily. Toxic
actiim is directly dependent on the absorption of the
poi.son, and the extent of acticm is in direii lu-oportion
to the rate of absorption. A substamc in itself insolu-
ble and indillusible, or incapable of being rendered solu-
ble and dilTusilih." b.y the jinccs of thi' body, is incapable
of being absorbed, and hence cannot be a iioisnn.
The fact of aljsorption ciinnot now be c|ueslioned. All
poisons cajjable of detection by chemical or other meth-
ods are found after death in the blood itself, and in parts
of the bod}' remote fi'om the ])oint of intindiu'tion ; anil
this is true whether the poison has been iDioiduccd into
the body through the mouth or reetuni. through ihe
lungs liy inhalation in the form of vajior. by hyjioderinic
injec'lion, by contact with an abraded surface, or even
through the sound skin.
ClKCfMSTAXCKS WHICH jroFlllV Till. .\ llSOlir't'loN OF
Poison's. — Obviously, one of the most important circum-
stances modifying the absorption of a poison is its solu-
bility and dilfusibilily. Everything else being equal,
the greater till' solubilily and dilfusibilit,y of a poison, the
more rapid its absorption, and hence the more rapid its
manifestation of toxic aclion. As a rule, the .salts of the
alkaloids are more .soluble than the alkaloids themselves,
and hence the toxic action of the former is more rapid
than that of the latter, Arsenite of potash is more rapid
• in its action than arsenious acid: and this is due in great
measure to the rapid absorption of the incu-e soluble com-
liound. The action of many chemical antiilotes is confined
wholly to the conversion of the rapidly soluble form of
the poison into a compound either wholly insoluble, or
insoluble to such an extent as to delay its absorption, and
thus admit of its removal from the body before it has been
absorbeil in sufficient amount to lead to a fatal result.
Thus, in poisoning with oxalic acid the exhibition of lime
water in large quantities leads to the formation of calcium
oxalate, a conqiound ccunparatively insoluble and hence
limited in its toxic action.
A.gain. the abscu'plion of a jioison naturally soluble is
increased b.v introducing it in the form of a solution.
Thus arsenious oxi<le introduced into the stomach dis-
solved in water, is more rapitlly absorbed than when
introduced in the form of powder. Further, when dis-
solved in dilute alkalies, thereby bein.g converted into a
new body, it is still more rajiidly abscu-bed, thus inlro-
diicing another feature into the problem, viz., that of
diffusibility. It is here much the same as it is with cer-
tain foods: in order to have absorption we must have
not only solubility, but also diffusibility. Thus raw
egg albumen, while readily soluble, is of little u.se as
food until by the action of the digestive .juices it is con-
vened into (Jiffii.sihic jiroducts. Arsenious oxide, then,
when dissolved in a given volume of water, is rapidly
absorbed ; liut the same equivalent of arsenic introduced
in a similar manner, in the form of an alkali arsenite,
is still more rajiidly absorbed bj' virtue of its greater
ditfu-siliility. Ilence, everything else being equal, the
more soluble and ililTusible the form of the jioison, the
more rapid is its alisorption, and consequently the more
vigorous its toxic action.
Again, the nature of the surfaie to which the poison is
applieil modifies materially the rate of absorption. This
depends mainly on vasiidarity ; the .greater the sup])ly
of blood, the more rapidly does absorption go on. Hence
the introduction of a poison in the form of vapor into
the lungs leads to more rapid absorjition than does injec-
tion into the intestine : and siniihirly, the injection of a
soluble poison into the intestines or vagina is ordinarily
b)llowcd by more rapid absorption than when it is intro-
duced into the stomach. While, then, tlx' natural vas-
cularity of an organ or tissue li:is some modifying influ-
ence on the alisorption of a poison, the condition of tiio
blood vessels also exerts some influence. Fulness of the
blood-vessels opposes a mechanical obstacle to absorption
and thisnodotdit explains, in part, why itisthat poi.sons
taken on retiring at night are sometimes delayed in their
action until the uiorning, since during sleei) tli<' with-
drawal of blood from the brain leads to an accumulation
in the abdominal organs, ami hence retards absoriilion
from the alimi'iitar.v canal. For a similar reason, jioisons
taken on a full slomach are much less raiiidly absorlied
than when Ihe stomach is in a comparatively empty con-
dition. The delayed absorption incident to the former
state is, of course, due in jiart als<i to the mechanical
obstacle atTordeil by the food itself, the latter keejiing
till' jioLsou for a time aAvay from the stomach walls.
Hence absorption, and eonseipiently toxic action, is most
ra|iid when the poison is taken into an enqity stomach,
less rapid when taken with food, and still less nipid
when taken after a hearty meal.
Ill rnnsiiliring absorption fioni the alimentary canal,
we have to notice, further, the modifying action of the
digestive juices. Insoluble substances are not directly
absorbed, but many comjiounds. by the action of the
iligeslive juices, are so altered that their solubility is
either increased or diminished, thus modifying their ab-
roo
REFEKENCE HANDBOOK OF THE MEDICAL SCIENCES.
PoiNonm*
PoImoiin,
sorption, and hence their toxic action. As examples of
the former there are many metallic carbonates, as lead,
copper, zinc, and maniianese wliicli, wlien talien into
the stomaeli, may be cliangcd by the acid of the gastric
iuice into soluble chlorides, so tliat wliat was in itself an
insoluble anil non-i)oisonous substante may be converted
into a vigorous poison.
DisrosiTioN OF THE Poison after Absorption.—
Once entered into the circulation, there is a twofold dis-
position of the poison possible. Either it is deposited
for a time in the various tissues and organs of the body.
or else it is at once eliminated through some one or more
of the various emunctorics. Ordinarily, if sufficient
time intervenes between the taking of tlie poison and
death, there is a tem]iorary deposition of the poison
throughout the bodv— after "which, however, the depos-
ited poison is grailuallv redissolved and eliminated.
Careful study of'collectc'd facts further shows that, as a
rule, the poison is deposited in the largest amounts in
tlii^ liver, kidneys, spleen, heart, lungs, muscles, brain,
and bones. In otlier words, these organs and tissues
have the power of absorbing and retaining poisons, and
fvnthermore. this absorliing' power is not tlie same for
the different organs. Chemical analysis in poison eases,
and in experiments on animals where the conditions are
known witn much more detiniteness, clearly tcstilies to
the accuracy of this statement. Further, variation in
the conditions under which the poison is taken modities
not only absorption as a wliole. as already indicated,
but also" the absorption by individual organs and tissues.
The form of the poison'; the character of the dosage,
whether small and oft-repeated, or a single large one;
the mode of administration, etc., all are liable to exert
tlieir own modifving intluenee on the absorjition of the
pois(ra by the ditfereut organs. A knowledge of such
modifying intluenee must then necessarily he of great
value." esjiecially in medico-legal cases; for in time the
accumulated facts will serve as data on which to found
dctiniie conclusions concerning the form of the poison,
the mod(! of administration, the length of time interven-
ing before death, and many other points of a similar na-
ture, so important in criminal cases.
In this connection, therefore, the results of the quanti-
tative analysis of the various organs and tissues of the
body in jioison cases are of great importance, for. as they
show the distriljvition of ihe poison under known condi-
tions, the time may come when it will be possible to
draw deductions in "unknown cases from the analytical
results.
During the past few years many data have been col-
lected in this direction, a few of which may be ailvan-
tageously mentioned.
X'arholie Acid.— A man swallowed 1.5 c.c. of an olhcial
preparation of carbolic acid (1(10 parts phenol -f 10 jiarts
of water), and died in fifteen minutes. AVith the internal
organs Dr. Bischolf ' obtained the following results;
ll" gxn of liloDil conlalnetl O.naw gm. phenol = n.(i231 per cent.
1,4S() •■ liver •• .KtTIi " " = M'M "
332 " kiflnev " .-1)10 " ;; = M2() ;_'
.5(is •' lieart imiscle " .IsiiH " = Mbi
l.ur-. " Drain " .:114( = .O-'l,
12.5 " urine '■ smi " " = .IM^
This case is particularly intei'esting as showing how
rapidly a readilv soluble and dilfusible substance may be
absorbed, and how quickly it may be distribtded through-
<iut the body. Further, it is to be seen that the jioistm
was. at the "time of death, in position to lie eliniiii;iled,
having entered into the urine.
Oxalic. Acid. — An unknown dose of oxafic acid, fol-
lowed bv death in tiftecii minutes. The amounts of
oxalic acid found bv Dr. Bischolf were as follows:
In 2.240 (rni. stomaeli. intestines.
isi)
;«n
2'.«l
w
730
liver,
heart blontl ,
heart
kidney
urine
brain
.. 2.280 t;m. o.xalie acid.
.. .28.-) ••
.. .04:! ••
.. .ceo '■
.. .014 "
.. .007 "
Potamum Cyanide. — An unknown case of potassium
cyanide. The analysis made three days after death. -
•ii> gill, stomach and contents contained O.lKl'.ci gm. HCN.
r>'.i.") " intestines *' .Oisii
K2 " intestines " .iKlil
rm " liver " .0170
1;'X " heart " .00:a
ItW ■• hruiu " .0144
Arsenic. — The case of an adult female who lived two
days after tjiking a fatal dose, fm-nishes the following
res"ults reported by Dr. E. S. Wo<id.=
17fl gni
stomach
contained 0.0443 gin. arsenic
0 "
stomach contents
■• .01197
490 "
intestines
" .0638
62 "
intestines contents
" .ttio.".
237 "
liver
.11497
149 "
left kidnev
" .0043
12.T "
right kidney
" .nm
31H "
uterus
531 "
brain
" .oots ••
In all these casesof poisoning the order of distribution
of the poison is much the same as that previously stated,
the liver standing first, then the kidneys, heart, lungs,
etc. In experimenting on animals, howevei-, where the
poison can be variously introduced, it has been noticed
that the distribution of the absorbed poison is not always
the same. It is easy to see how there might be a decided
difference in an acute and chronic case of poisoning, for
if elimination of the poison commences at once, it fol-
lows that the relative amount of poison contained in the
liver and kidneys must necessarily be different in a
chronic case tliaii where a single large dose of the poison
is taken. Again, it is not difticult to see how the/ocm
of the poison might modify the rate of absorption and
the oi-derof distribution. This latter fact has been clearly
indicated by results obtained with arsenic, both in ex-
periments on animals and in poison cases. Thus Scolos-
siiboff,' under the impression that the muscular paraly-
sis noticed in the extremities of animals poisoned with
arsenic was accompanied by a localization of the poison
in the muscles, subjected his hypothesis to the test of ex-
periment, feeding the animals experimented on with a
solution of sodium arsenite. The results obtained in this
manner were all of a like nature, and in several respects
different from all preconceived ideas. Thus, in one ex-
periment with a bulldog, whicli hiid been fed for thirty-
lour days with the ar.senitc, the following amounts of
absorbed arsenic were found;
.contained 0.25 uigiii
3.71
S.85
a.33
"f .Tvsenlc (As).
100 gin. of muscle
Kill " liver
Kill " liraln
KK) " spinal c.ird ....
It is to be noticed in this experiment that the amount
of arsenic in the lirain is three times as great as in the
liver. In another experiment, with a griffin dog, the
brain contained, per 100 gm. of tissue, dotdile the
amount of arsenic contained in the muscles. In every
experiment, comparatively large amounts of arsenic were
found in the brain, thus giving evidence of a special
localization of arsenic in nerve tissue; but this result
was contrary to the experience of all toxicologists in
arsenic cases. Scolossuboff gave liis results to the world
as characteristic of arsenic poisoning in general, without
apparently considering that he was exiierimenting with
a fniiu of iirsenic seldom used as a jioison. and with
which toxicologists ha:i had little practical experience.
In the white oxide of arsenic (As-jOa). the .ii-.senic of
commerce, and the form most commonly used as a
puison, we have to deal with a substance but slowly
soluble, while in sodium arsenite we have one of the
most readily soluble and one of llie most easily dilfusible
of the .soli'd compounds of ai-seiiie. If the amoiuit of
arsenic in the brain could be taken as iin index of the
form in which the poison was taken, whether as a solu-
'ble or as a comparatively insoluble compound, it would in
many cases of poisoning be a point of great importance.
But ill order to have the point in (piestion of any practi-
cal value, we must be certain, on the one hand, that
723
Poisons.
Poisons.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
under no circumstances can the taking nf tlie wliite oxide
of arsenic, eitiier in tlie form of powder or dissolved in
water or otlier neutral lluids, be attended witli accumu-
lation of arsenic in the Ijrain otlier than in the merest
trace; whih', on the oilier hand, the takiiii; rit a soluble
arsenite should be attended with u propoiiionally large
amount in the brain. It might he argued that in elironic
cases of poisoning with arseuious o.xide, where the person
has for weeks or months been taking small or gradu-
ally increasing doses of the oxide. \\/v jioison might then
aceuinulate iu the brain. Such arguments have been
maile, but the facts at our disposal tend to show the in-
correctness of such a theory. On the otlier hand, the
use of the more .soluble arsenite (and doubtless all of the
other .solulile salts of arseuious and arsenic acids) should
be attended with a noticeable deposition of arsenic in the
brain. The literature of the subject contains but little
definite, the amount of arsenic iu the brain being gener-
ally ex]u-essed as a mere trace or in other eiiually am-
biguous terms; imjilying. however, in the generality of
cases, that when present it was only in very smidl ipian-
tity. But recent data on this point arc quite decided.
E. Ludwig.'' of Vienna, writing from a large experience
on the distribution of arsenic iu the organs and tissues
of suicides poisoned with arsenioiis oxide, and likewise
in tlie organs of dogs poisoned with the same form of
arsenic, liolh in acute ami in eiironie ca.ses, says; "In all
experiments it was inv.u'iably found that most arsenic
was collected iu the liver, that in acute cases the kidneys
also contained cousideralih^ arsenic, while the bones and
brain showed hut very small i|Uantilies of the poison."
Ludwig, moreover, states that "iu chronic poisoning with
arsenic, where deatli docs not result, the poison remains
longest in the liver, while from the other organs it is
excreted much earlier." Quoting one of his cases, that
of a suicide, an acute case of poisoning with ar;.:euious
oxide, the following results are worthy of notice;
l,4sOgm. (if liver...
144 " kiilney.
lino " iiiuscie.
1,4111 '■ liiain ..
linues ..
.(■(intained .'il.tK) iiifjin. of arsenic (A.s
7.09
.."lii
niily 11. trace.
In 1880, the writer,' in conjunction with Professor
Johnson, reported on two cases of poisoning with arseui-
ous oxide, in wdiich the poison was detected and deter-
mined in all jiarts of the body. In one case there was no
question whatever as to the form in which the ]ioisim was
taken, for a mass of the while oxide was found undis-
solved iu the stomach itself. Here there was present in
the stomach, liver, and other internal organs, f<3." grains
of the poison, while the brain contained a hardly per-
ceptible trace of arsenic. It wonlil thus ajijiear that
the (iintiinit of the poison taken has little inlluencc on
the amount absorbed by the brain. In this jiartieular
instance there was as large an amount to draw upon as
is often found in cases of poisoning, yet the quantity
contained in the brain could not have been much smaller
aud been recognizable. The length of time, however,
intervening between the taking of the poison and death
was prohalily not long, although there had been time for
decided absorption by the liver and other organs. In
the second case referred to, wliere there was decided evi-
dence of chronic poisoning, a somewhat similar result
was obtained. In this case there was lucseiil in the en-
tire body Tt.'Z'i giainsof ars<'nious <i\ide, most tlii>roughly
aud evenly distributed, even to the hones, and yet the
brain contained only an unweighable trace of the jioison.
Again, ex])erinients carried on in the w Titer's hilioratoiy,
on animals have led to the same result; whenever the
animals have been fed with arseuious oxide, the amount
of .-insenic found iu the brain lias been extremely minute,
while in ]ioisoning with a .soluble ar.seiiile a niiieli larger
aiiiciiint has been found in the brain. At one time it was
considered that the ju'eseiice of ar.senic in the br.iin was
proof |)ositive of the ante-mortem character of the jioi-
son; that in no case would the poison, inlnidiii-ed into
the stomach or rectum after death, lind its way liy ns-
nio.sis to so remote a part as the brain. iSuttnn," iiow-
cver, by experiments conducted on dead animals, finds
that arsenic may pass by diffusion quite raiudly even to
the brain. Such being "the case, the only way 'to distin-
guish between ante- and post-mortem "introduction of
arsenic would be to determine the amount of puison con-
tained, for example, in tlie outer portions of the liver, as
coiuiiared with the percentage amount in the centre of
theorgau. Guare.schi'* has also reported on the distri-
bution of arsenic in a case of poi.souing with arseuious
oxide, and he likewise found only traces of the poison in
the brain. Mauy other cases of poisoning witli the more
insoluble forms of arsenic, in which the distribution of
the Jioison has been studied, lend favor to this view, that
arsenic is to be found in the brain in any quantitv only
when the poison has been taken iu afeadily soluble
form. One case which came under the writer's obser-
vation is particularly important iu this connection. A
laboring man ate for his dinner a quantity of bean soup;
almost immediately after he was seized with the fu-di-
naiy symptoms of acute arsenic poisoning, and died iu
nine hours. The autopsy showed a marked condition of
inflammation of the alimentary tract, aud a chemical
analysir showed 76.0 mgm. ofar.senic iu the liver, 0.6
mgm. in the kidney, wiiile one-half of the entire brain
contained only a recognizable trace of the poison. A
portion of the soup (13,5 c.c.) yicldeil 314.6 mgm. of
arseuious sulphide, while the fact that the arsenic was
introduced in the form of arseuious oxide was proved by
finding in the sediment from the soup an abundance of
the octahedral crystals of the oxide. Such a case as
this must necessarily carry considerable weight with it.
Kverytliing favored the ab.sorption of the arsenic, yet
the brain contained only the merest trace. Again, the
writer has obtained like results in an acute case of poi-
soning with Paris green, or accto-arsenite of copper, iu
which the liver ('3.il84 gm.) was found to coulain 12.7
mgm. of ar.senic; the kidneys (.515 gm.), 8.4 mgm. ; 78.5
gm. of muscle, 0.9 mgm., aiid the brain (1,179 gm.)only
a slight trace. Tliese results certainly indicate that the
relative distribution of the poison may offer some sugges-
tion as to the form in which the poison was administered,
and that, with arsenic at least, a comparatively large
amount iu the brain may be indicative of a readily",soluble
form of the poison. In this connection, however, there
are always other facts to be learned in the distribution of
the poison, wdiich may substantiate the indications ob-
tained liy analysis of the brain, and at the same time,
jierhaps, enable us to distinguish between an acute and
a chronic case of poisoning.
It is a favorite defence' in poison cases, particularly
with arsenic, morphine, and some other poisons, to claim
that the jioison found in the bod}' of the deceased came
from some hypothetical medicine containing the poison,
and which the deceased had long taken, or tJhat the per
sou was habituated tn the daily use of the toxic agent.
A study of the distribution of arsenic in acute and
chronic cases of jioisoning shows jilainly that many times,
with this poison at least, it is quite jiossible to" decide
tlefinitely Avhether the jioison has been for a long lime in
the body, taken in oft-rejiea ted doses, or whether it has
been introduced iu one or two large do.ses.
As jireliminary to a discussion of this jxiint 1 will
quote two results of my own experience.
(fi) In this case there was every reason to suppose a
case of chronic poisoning with arseuious oxide. The
following results were obtained by analysis of the jiarts
a year aud a half after burial :
Weit'lit of
orKiuis.
liriiiiis.
Stoaiai^h and spleen .'ilt
Kiiliievs SO
liver I ri'.io
one lunKaliil lle:irl I 441
liilesMni's unci iiteiiis i iiTS
(Ine liiiiK anil Ij>|iiiil fimn llinra.x 4112
Bliiililer 73
lirain i 477
Weight of
arsenic,
Ctrauis,
.(KKilKl
.I147SR
.I114.i4
.itt'isa
.iio."is:i
Trace.
Trace.
Per cent.
lUlKitii
.iin.si-,
.1 ins II
.oieai
.110140
24
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Polsous.
Polsous.
I'piier arm (left)
Forearm "
Hand "
Lower leg (right )
ThiKh •■
Foot
Thighbone "
Transverse section of body above pel
vis.
Muscle an<i ribs from left breast
Abdominal muscle, right side
Weight of
organs.
Grams.
2«8
l.iO
1.323
3MS0
615
1.920
4()6
615
Weight of
arsenic.
Grams.
.(XWS
.(Kll.")t<
.0(H)19
.(»)S(;4
.Ol(;:io
.CKIKI5
.(KJU40
.ttirni
.(HBri
.00358
.1X1081
.(HHBn
.0(W12
.000S5
.(H«l.")l
.taea
.0(XX)6
.00156
.IXKMl
.00058
(b) III this case tbe evidence pointed to acute poisoning
with some readily soluble torm of arsenic. Following
are the results obtained by analysis :
.\rsenic as
AsjOs. lirain.
Stomach ard oesophagus * 0.138
Large and small intestmes ;iU
Liver (one-half) 109
Kidnevs 029
Heart Inne-fourth) 038
Lungs und splien (two-thirds) 114
Brain ' ■ tne-Uiird i 025
Diaphragm 010
Trachea, larynx, and tongue 081
*The internal organs were preserved separately in alcohol, hence
the weights of tissue analyzed are not given.
Left arm
Right leg
Thigh bone
Transverse section of body at pelvis
Muscle from breast (right)
Muscle from back (left)
Weight of
tissue.
Grams.
1,2.30
4,630
216
4,(K10
510
620
Weight of
arsenic.
Grams.
0.006119
.00764
' '.lii26,V
.00(>i5
.(r2:jll6
0.1X10495
.1K10164
' '.('166296
.00124
.00371
In (ii) the total amount of arsenic was 5.26 grains, in
(b) 3.119 grains; yet it is to be noticed in (i) that the
brain contained a comparatively large amount of ar-
senic, while in (a) there was found only a ti'ace. This
fact, if our theories concerning absorption by the bi'ain
are correct, would imply the administration of a soluble
form of the poison. Further comparison of the two
series of analyses shows other noticeable points of diller-
ence which point to the same eouclusiou, and also throw
some light on the character (acute or chronic) of the
poisoning.
When there has been time for even distribution of the
poison, as in chronic cases, there would seem to be no
reason why one set of muscles should contain more aiseuic
than another, aside from such differences as might arise
from differences in vascularity, etc. On the olher hand,
tliei'e is every reason for supposing that when death
ensues only a few hours or less after llie poison has been
taken, the distribution might be quite irregular.
The following table shows the distribution of the
arsenic through .the muscle ti.ssue in the two cases, cal-
culated to grains of As^Os }ier pound of tissue :
<(i) (h)
Thighbone 0.(X)4
Leg (nti .011
Transverse section I(i9 .021
Arm OK) xm
Muscle from breast 0(3 .()S7
Muscle from back .260
Muscle from abdomen 040
In (rt) the results, with the e.Kception of I he ti-ansvei-se
section, show a fairh- close agreement. There is not that
gradual increase from nothing in the bone up to a fourth
of a grain per pound as seen in (^). The irregular ilis-
tiilmtion of tbe poison in tissue of tbe same kind, noticed
in (4), is certainl}- indicative of the arsenic having been
taken but a short time before death, particularly as there
was none whatevei' found in the bones, which fact would
certainl}' exclude the possibility of chronic poisoning.
Again, in (h) the two kidnc;,s yielded only 1..5 mgm.
of metallic arsenic, while the tongue and adjacent parts
(175 gm.) gave 4 mgm., and a ponion of the inuscles (200
gm.) gave 5.65 mgm. of metallic arsenic.
A.ssuming the usual order of distribution, the amount
of arsenic in the kidneys in (//) would suggest only a
proportionally smaller amount in the muscles; and vet
in this particular iiistaiiee the amount of arsenic con-
tained in 620 gm. of nui.scle tissue is greater than the
amount contained in theentire liverand kidneystogether.
The kidneys, however, are the organs above all others
concerned in the elimination of arsenic. Elimination
usually commences almost immediately, and yet in this
particular case there is but ().()29 of a grain of" arsenic in
the kidneys, while in less than three pounds of mu.scle
tissue there is contained half a grain of the poison. This
fact would neces.sarily imply that elimination had but
just commenced, and that cimseciuently the poison hati
not been long taken. It might, perhaps, be argued that
the proportionally large amoimt of poison contained in
the muscles, as compared with the liver and kidnevs,
might imply chronic poisoning, but coupled with the
peculiar distribution is the entireabsence of arsenic from
the bones. Ludwig. moreover, states that in "both
acute and chronic poisoning with arsenious oxide, most
arsenic is invariably found collected in the liver." and
that "in chi'onic poisoning with arsenic, where death
does not result, the poison remains longest in the liver,
while from the other organs it is excreted much earlier."
It is impo.ssible, therefore, to make the results obtained in
{h) accord witli a case of chronic poisoning with arsenious
oxide; and further, the amount of poison found in the
brain, and the proportionally large amount in certain
muscles, would apparently indicate an extremelj' soluble
and diffusible form of arsenic as the toxic agent.
Such results as these certainly favor the belief that
it is cjuite po.ssible to draw definite conclusions as to
whether we are dealing with an acute or a chronic case
of poisoning. Further than that, it is possible, in some
cases, to decide even more detinitely regarding the time
at which the poison was taken prior to death. In this
connection, the fact to be considered most closely is the
amount of poison contained in the liver, as compared
with the amount present in the alimentary canal and in
the ditferent organs of the body. When arsenic, for
example, is taken into the stomach, absorption by the
liver through the portal circulation commences almost
immediately : and, as Dr. Geoghegan ' has plainly de-
monstraled. deposition of arsenic in tbe liver continues
to incicase up to about fifteen lioiu's after the poLson
has been taken, after which it commences to diminish.
Dogiel, '" who has confirmed Geoghegan's I'esults as to the
time required for maximum saturation of the liver, says,
"a maximum of ar.senic in the liver kills the animal."
The absolute amount of arsenic involved in maximum
saturation of the liver must neces.sarily vary somewhat
in different cases. Barker," from his analysis of portions
of the liver of Horatio Sherman, coneluil'ed that the en-
tire liver containeil nearly live gi'ains of ar.seuic. In the
case of Dennis Hulburt, also anal_yzed by Professor
Barker, the liver contained over seven giains of arsenic,
and it would seem as if these amounts must approach
near to the maximum. When such large amounts of the
poison are found in the liver, it is safe to assume that the
poison must have been taken at least fifteen hours before
death.
In recent cases of administration of arsenic, it has
been claimed by Taylor'-' that the poison may be found
in the stomach and intestines, and not in the liver or
other organs. This can liardly be correct under ordinary
ciicumslances, since death seldom results so quickly
from arsenical poisoning as to prevent the alxsorption of
at least a small trace of the poison by the liver. Dogiel,'"
who has experimented scDuewliat on tlie rajuditv of ab-
sorption b}' the live)', found that on forcing 500 mgm. of
ai'senious oxide dissolved in water, into the stomach of a
dog, death resulted in one hour and live minutes. In a
second experiment, conducted in the same manner, death
725
Poisous.
Poke Root.
REFERENCE HANDBOOK OF THE 3IED1CAL SCIENCES.
resulted iu one hour and thirty-cii,'lil miniilcs. In tlie
Aim ca.se the liver was found lo contain 1)4..") mgni. of
ar.scnious oxide; in tlie .second case, i;i7.!S insni. Tims,
judging from tlie amovmt in the liver at the cud of an
hour, certainly l)ut a few miiiulcs would have been re-
quired for the ali.sorptioi> of a dcteclalile (|uantity of ar-
senic.
Arsenic having hecn deposited in the liver or el.se-
whcre, gradually diminishes, and if the person should
survive, entirely disappeais iu from two to three weeks.
A case bearing directly on this point came under the
writer's notice some time ago. An entire family were
taken sick, directly after eating, vvitli all the sym])toms
of arsenic poisoning; all of them recovered except one,
a middle-aged man, who died just two weeks after ])ar-
taking of the poisoned food. An autopsy was made,
the internal organs wei'e delivered to the writer for
analysis, together with the various art ieles of food par-
taken of by the family at the time of Iheir sickness. A
portion of the bread (TyO gm.) contained 32.7 grains of ar-
senious oxide, while a piece of cake (KJO gm. i was found
to contain 55.5 grains of arseuious oxide, thus proving
the character of the poisun.
Analysis of the internal organs gave the following re-
sults, showing that at the time of death elimination was
nearly, but not (juite, complete;
Stotii:icli Cffi jjni.) continued O.KI lugm. .irsenic (As).
(.)iip-tliiril liver (42S jriii.) " .20
(Ine lililnev las:! (.Mil.) " J^
Ciue-lialf iiitcsiine (4;i7 t'lii.l " -20
Tliisili Mjii>cii- cwi (fiii.i " .2"i
One-liiiU brain onto (T'li. I " trace
Conci.se experiments on animals, carried nut ipiantita-
tively, are etipalile of yielding many instructive results
iu reference to the relative distriliutiun of a poison under
dilfcrent eonditiims. The writer has recently conducted
a .series of experiments witli antimony,'^ a few of the
results of which may be advantageously given, as con-
linnatory of .some of the preceding statements.
((() Ili/podermic liijei-t/"ii of it Snlntioaof Turtur F.iu.ti:-.
■ — (1.120 gni. of tartar emetic was introdm'e(l under the
skin (right thigh) of a eat weighing 1.2(i2 gm. The
animal (lie(l in two hours. FollowinL' is the distribution
of the piiisnn:
■total
weiplit.
(irains.
Liver
Brain
He;ut :mil tlin.L's
Kidney
Stoiiiitcti aiiil intfstines,
Musi'lefioni t)acli
:i2
12
74
i:i8
Wcislit
of SO.
MiltiKraliis.
SO. l>.-r too
KMi.ot
tls.sue.
Milliyi-atus.
6.a">
.tiO
.70
.1.5
.SO
1.2")
2.21
2.1.S
2.1.S
1.2.-)
1.08
.till
9.S.")
In a .second expeiiment a smaller amount of tartar
emetic ((l.(IS2 gm.) was injected hyiiodeiinatically, and
instead of being introduced in a single d"se. it was
divided into three, and injected se]iai'ately, seveial hours
apart. As a result, the animal lived twenty-two hours
after the first dose. The following results show the dis-
tribution of the poison;
Total
weight,
(jrauis.
Weiftht
of SI,.
Milti^nalus.
Sli. iier IIXI
^nii. of
tissue.
Millitiiaius.
11.5
63
9
ftS
17
1(j6
0.(10
l.->n
.20
2.00
i70
0.21
Liver
Biiiin .
2.:iS
•7 -!.»
Stomach ami intestines
Heart atKl Iniiirs
2.04
1.47
Muscle from liar-l;
.till
;i()4.,5
.5.2.')
The only difference of importance between these two
cases is the element of lime. As might naturally be ex-
pected, therefore, there is a more even distribution of
the poison in the second ease than in the first. Further,
in the second case the kiilneys stand first in tlieii- cnntent
of antimony, the liver contains a proiiortionttlly smaller
amount — much smaller proportionally than was found
in the fii'st case. This is. of course, due to the fact that
in the second case the animal had lived long enough to
iidmit of extensive elimination, and, consequently, those
parts which had originally contained the most, particu-
larly the liver, had been drawn on to the greatest extent;
so that at the time of death the excretoiy organs, nota-
bly the kitlneys. were the richest in poison. Quite no-
ticeable in both of these cases is the comparatively large
amount of antimony in the brain — which fact would
agree with the previous statements regarding absorption
by the brain when a readily soluble and ditfusible form
of poi.son is u.sed.
(/)) Iiijictiiin iif II Sill lit inn iif Tiiiinr Eiiidic per EiHiim.
— IJ.24 gin. of tartar emetic, dissolved in a little water,
was injected into the rectum of a rabbit, in two doses.
Death resulted in about twelve hours. Following was
the ilistribution of the iioison:
stomaiii aiKl small intestines
Brain
Rectiitu and adjoininfr intestines
I.iier
Kidneys
Muscle
I'riue
Heart and luuits
Total
weight.
Grams.
18
.54
13
KK)
403
Weight
of Sb,
Milligrams.
8.S9
.40
1.10
.20
Trace.
12.99
Sb. per 100
Km. of
tissue.
Milligrams.
1.5.:io
4.40
3.0,5
2.i)8
1.92
1.11
1.10
Perhaps the most noticeable feature of these results is
the eoinparatively large amount of antimony contained
in the stomach and small intestines; a result which,
taken iu conjunction with other similar ones, would ap-
pear to indicate special absorptive action on the part of
the eiiithelial cells of these parts. The amount of anti-
mony in the kidnevs, and particularly the amount in the
urine, indicates plainly" that at the tiitie of death elimi-
nation was going on raiiidly ; but the fact that the per-
centtige content of antimony in the liver was greater
than iu the kidneys, might itcrhtijjs be taken as an in-
dic;tlion that absorption was not completed.
((•) Experiment on a Diy irit/i Antiniurnons O.riile. — A
dog weighing 14.2 kgm. received, with his food, 2.073
gm. of antimonious oxide, during a period of seventeen
days, in doses of from U. 032 to 0.125 ,gm. per day. The
dog was then killed by chloroform eighteen hours after
the last dose of antimony had been given. The follow-
ing 1 (Stilts show the distribiuiou of tlie poison;
Total
weilfbt.
ti rains.
Weight
of Sb.
Milligrams.
Sb. per 100
gm. of
tissue.
Milligrams.
I ■ ■
452
140
1.57
79
200
S2
117
440
23.7
1.8
1.2
.4
.9
.1
Trace.
Trace.
.5.24
1.28
Muscle (forc-li'sri
.76
Brain .. ...
..50
.4.5
Kidneys
.12
Heart
Blood
1,(»17
28,10 1
In this experiment, which may be termed a chronic
case of poisoning with an insoluble form of antimoii}-,
the relative distiibution of the jioison is .seen to be .some-
what dilTerent from what it Wiis in the preceding cases.
First, the brain eonttiins relatively less antimony than in
r26
REFERENCE ILVNDBOOK OF THE JIEDICAL SCIEN'CES.
Poisons.
Poke Root.
the pivcediug; secondly, the livur contains a noticeably
large amount of the iiciison. while the kidneys conlain
only a tiacc. This latter result would seem to indicate
that elimination was going on ([uitc slowly ; but analysis
of the twenty-four hours urine showed that the amount
eliminated by the kidneys in au entire day was consid-
erable. Thus on one day, the entire twenty-four hours'
urine contained 13..~) mgm. of metallic antimony; on an-
other day, 22. .5 mgm
With cop))er. Ellcuburgcr and Ilofmcisterhave found,
b\' e.xperimenis on sheep, '^ tliat the liver contains the
niost copper when small doses have been regularly ad-
ministereci. and, further, that this organ retains the
metal with the greatest tenacity, they having found it
there forty-one days after the last dose. The pancreas
was also found to retain the copjier with nearly equal
tenacity; the kidneys do not contain so much of the
poison. Elimination is mainly by the bile or through the
intestine. Deposition of coiipcr iu the nerve tissue is
quite small, but still smaller in the muscles, though
copper is to lie found in the muscles after administration
of copper .salts. Ellen burger and Hofmeister also state
that the depo.sition of copper is proportionally much
greater it it is administered in numerous small doses, the
cells then having time to absorb it.
With lead, Victor Lehmaun '' has obtained some inter-
esting results. In his experiments the lead was intro-
duced by hypodermic injection in the form of nitrate,
the animals iised being rabbits. Two of his series of re-
sults are given in full.
(a) 0..5 gm. of lead nitrate introduced at one dose.
(b) 0.01 gm. of lead nitrate introduced daily, until
finally a total of 0.21 gm. of the lead salt had "been in-
jected.
DlSTRIBCTIOX OF LEAD IN (a)
Liver . . .
Kidneys.
Heart ...
LuntK...
Inle.stlue
Muscle..
Bones.. .
Brain ...
Bile
Weight ol
the organ.
Grams.
40
13
3
6
ir>
30
Content of
lead.
Milligram.
0.2.50
.im
.125
.123
.312
.1H7
.187
.083
.12.5
Lead per 100
gm. of
ti.'vsue.
Jlilligrams.
0.62.-)
4.807
4.115(3
2.0,S3
1.9,53
.02:5
2.U7S
.7S1
t.lliS
DiSTRIRUTIO.N' OF LEAD IN U>i
Weight of
the organ.
Grams.
Content of
lead.
Milligram.
Lead iwr 100
gm. of
tissue.
Milligrams.
25
4
.5
2
10
3
3
0.(1(12
.123
.1S7
.062
.123
.031
.12,5
.li)
.125
n.250
Kidne.vs
Hear'
3.120
3.T.50
3.123
1.785
.312
4.1UU
4.1('.B
Bile
6.250
Very noticeable iu both series is the small content of
lead in the liver, an organ which, as a rule, contains the
largest amount of absorbed poison. The relatively large
amount of lead in the bile naturally suggests that t lie
elimination of the metal takes plate mainly througli tais
channel, which would account for the small content of
metal iu the liver. Further, experiments conducted on
rabbits show plainly that more lead is excreted in the
f*ces than in the urine, the lead iu the former doubtless
coming from the tiile poured into the intestines. Quite
noticeable also is the large amount of lead in the bones,
wliich amount probably grows larger the longer the lead
has time to act.
Katurally, such systematic work as has been done iu
studying the relative distribution of ]ioisons has been
(ontined mainly to minend substances, but it is to be
hoped that the time will come w hen there will be a col-
lection of data embracing all poi.sons capable of detec-
tion by chemical means. When such a time does come,
it will doubtless be found that we cannot establish any
general laws regarding the relative absorption and dis-
tribution of poisons as a class, but rather that each indi-
vidual poison or group of jioisons will show some pecul-
iarity characteristic of itself — which possibility, or rather
probability, makes it all the more needful for us to ac-
quire, as speedily as possible, accurate knowle(ige of the
relative absorption and distribution of the individual
poisons.
Post-mortem Imbibition of Poisons. — Ante-mortem dis-
tribution of poisons i.s, as we have seen, due to the carry-
ing power of the blood and lymph. Poisons are ab-
sorbed, distributed, and tein]ioiarily <leiiosiled. Peiisons
may, however, travel through the f/<(«/body, after cir-
culation has ceased, b^'a process of imbibition or diffusion,
by the same method as tliat by which s;ilt works its way
gradually through a barrel of fresh jjork when placed on
the upper layers. The rate of imbition of poisons depends
in large measure upon the interval ela].ising between the
death of the bodj- and the introduction of the poison.
Arsenic, for example, introduced into the rectum shortly
after death, liefore the tissues have become rigid, travels
with a fair degree of rapidity and in time may be found
iu distinct traces even in the brain and spinal cord, while
in the abdominal organsthe amount present may be (luite
large. Where a long interval elapses after death, the
poison introduced post mortem travels more slowly, but
even in this case it gradually penetrates to remote parts.
In view of these facts, it is olivious that in ca.ses of poi-
soning where a surjilus of the jioison remains iu the gas-
tro-intestinal tract after death, and the body is buried for
some time prior to the auto|isy, the apparent ante-mor-
tem distribution of the poison is liable to mcK'itication
by post-mortem imbibitiou. This is an important fact to
be kept iu mind in drawing conclusions from the analyti-
cal data, especially in cases in which a large surplus of the
poison is uuabsorijed. Wilh metallic jioisous. however,
]iutrefaction may (]uiclvly put a stop to posl-moriem dis-
tribution, since the formation of hydrogen sulphide from
the decomposing proteid material is very lialile to trans-
form the metallic salts into insoluble sulphides, thereby
preventing further migration. li. Li. Chittenden.
Rkfkkences.
' Berichte d. Deutsch. chem. Gesellsch.ift, 16. 1337. -Iliiil.. 13,5,5.
3 Wharton and Stille's Medical Jurisprudence, vol. ii., Poisons, p. 1.51.
' Bulletin de la Society fhimii|ue de Pans, 24. 126.
^ Auzeiger der k. Akad. d. Wissensiii., Wien, xviii., 18.
' Amer. Chem. Journal, vol. ii.. p. -".L". ' Ihid.. vii., p. 75,
' Abstract in Journal ot the i hem. Soc. of London, 18,84, 19il.
•' Tavlor's Treatise on Poisons. American edition, 1875, p. 4(1.
'" Pfliisrer's Archivfiir Phvsiologii>, 24. 34-i.
' ' Reiwrt lit the Sherman I'oisoning Case, American ChemLst. 2, 443.
1= Treatise nn Poisons, p. 42.
" Chittenden and Blake: Distritniti<m of Antimony in the Organs
and Tissues : Studies from the Laboratory of Physiological Chemistry,
Yale Cnlversitv, vol. ii.. p. 69.
" Abstract in Journal (hero. Soc. of London, p. 474, l.s.S4.
'=• Zeitschrift fur physiologische Cliemie, vi., pp. 12 and .'i2S.
POKE ROOT AND BEKR\. —P/i;/i<>l<iccn' rmllr. and
p?)i/toli(cea> ffKcl'is (U. S. P.), Scoke, Garget. These
two drugs are defined respectively as "the dried root"
and " the fruit " of Phytolacca deca'ndra L. (fam. Phytolac-
cacnv).
This plant is a very large perennial herb with a thick,
lleshy root and bearing cylindrical racemes of dark-pur-
ple "juicy berries. The" root, at the crown, attains a
diameter" of several inches and divides into two or three
large branches. It is brownish-wiiite externally and
faintly yellowish-white internally. It bears quite aclo.se
geuerarresemblance to horseradish, a fad which has led
To numerous fatal poisoning accidents. The stems, when
young, are bland and juicy and are used by country
"(leople in some localities as a pot-herb. They at length
attain a height of 1 to 2, iu the Southern States 3 or 4
metres, are at first green, afterward red or purple,
727
Polaiitl sprii
Polarlnii'irj.
REFERENCE ilAXDIloOK OF THE MEDICAL SCIE^'CES.
Fig. 3S7;>.— Poke Weed Flower.
branched ■wiilply, arc smooth and cylindrical and hollow
when old, though with thin tiansvcisc jiartitions. Tlie
leaves are larije, alternate, pcliolcd, ovate or oblong, en-
tire and smooth. The llower.s are in terminal racemes,
becoming lateral and e.\tra-a\illary by the growth of the
stem." They are regular
and perfect, having five
sepals, ten stamens, and
a ten-celled ovary. The
fr\iit contains ten thin
|)utainina, enveloped in
a pnrple liesh, and each
containing a single .seed.
The fruit, when fresh,
is about 1 cm. (? in.)
broad.
For medicinal pur-
poses the root is ga.tii-
ered in the autumn, sliced lengthwise or crcsswise, and
dried. The berries are gathered when ripe and dried hi
the sun, in masses.
Jjiaerijiliiiii of llic Rout. — Consisting mostly of trans-
verse or longitudinal slices of sparingly brauclu'd, cylin-
drical, somewhat tapering, usually twisted roots, rarely
exceeding 7 cm. (3 in.) iu diameter, externally of a rich
or yellowish-brown, tinely wrinkled (longitudinally or
spirally) and thickly annulate with lighter-colored, low
ridges; transverse slices exhibiting several concentric
rings of interrupte<l wood wedges, the intervening zones
much retracted; longitudin;d slices exhiliiting the wood
bundles as bands, with the intervening medullary tissue
greatly retracted; fracture fibrous: internally yellowish-
gray ; inodorous, the powder highly sternutatory ; taste
sweetish, afterward highly acrid.
The Fruit. — The dried fruit forms a close and heavy, ag-
glutinated, purple black mass, the stcnn-s conspicuous as
brightly shining jiarticles, the odor slight, the taste fruity,
but peculiar, acidulous and sweetish, somewhat acrid.
The structure of an individual fruit is given above.
Poke root contains an activelj' poiscnious, bitter and
acrid, amorphous glucoside. which is believed to be
saponin, a sm.all amount of the white crystalline alkaloid
pJii/tiilam'iie, large amounts of .sugar and starch, gum, a
little fat, resin, etc. The tannin has been called ;)A(/^.'-
lacrin. P/it/tidaccir iii'/'d occurs in the root and is, next
to the coloring matter, the most important constituent of
the fruit.
Action and Usk. — All ]iarfs of the adult plant are
active, and cause iu sufficient doses vomiting and ])urg-
ing. It has also some narcotic or stupefying power,
and in poisonous doses causes, in addition to the intes-
tinal symptoms, convulsions and coma. Death fre-
quently follows. Its action is slow and protracted. Poke
root has been administered as an emetic, but the prac-
tice is exceedingly bad. It is also recommended iu
rheumatism, scrofula, inflamed breasts and testicles, and
as a dressing for cancers and indolent rdcers, but is in
very little favor in regular practice, probably not nearly
so nuich as its properties warrant. Enough may be ab-
sorbed from washes and ointments to produce its consti-
tutional elTects. It is said to be useful as a jiarasiticide
in sycosis, tinea cajiitis, the itch, clc, but there are
doubtless many better drugs for this purpose.
The PharmacojHcia, Avith very poor reason. lUMvides a
fluid extract of the fruit but no prejiaration of the root,
of which latter the best form of administration is the
fluid extract. The root has been given iu 1 gin. (gr.
XV.) doses as an emetic, as an alterati\-e in doses of OJJO
to 0,3 gm. (gr. i. to v.). and the dose of the fluid extract
should correspond. The fruit and its fluid extract are
given in doses Ave or six times as large. The juice of
the fresh fruit is often administered in c(nintiy practice
in doses of 2 to 4 c.c. ifl. 3 ss.-i.), but its acliim is very
weak indeed. JJairi/ JJ. RiLihy.
POLAND SPRINGS.— Androscoggin Countv. Maine.
—Post-Dffick. — South Poland. Springs Morel.
This resort is located iu the town ol Poland, twentv-
five miles north of Portland and ten miles west of Lewis-
ton, at an elevation of about 800 feet above the sea-level.
Poland is reached from Boston by the Boston and Maine
Railroad. The spring boils up from a fissure near the
crest of a magniticent mound of the oldest rocks at the
rate of about eight gallons of water per minute. The
bed of the spring is composi'd of gneiss, scarcely distiu-
gui.shable from the original granite, this gneiss being,
as the geologists inform us, the oldest of the sedimentaiy
rocks. The unvarying temperature of the water through-
out the year, as well as its Ireedoni from organic matter,
would indicate a very deep origin. The surroundings
of the spring have been extensively improved .since 18.59,
iu which year, it is said, the water was first describeil by
a physician. The Poland Spring House was erected iu
1870, and afler various alterations and additions reached
iis present proportions in 1889. It is situated upon an
elevated plateau, and commands a beautiful and diversi-
fied view of the surrounding hunlscaiie. The analysis of
the water made in 1879 by Prof. P. L. Bartlevt,' State
Assayer and Chemist, resulted as follows: One United
States gallon contains: Silica, gr. 1.07; calcium carbo-
nate, gr. 1.36: calcium fluoride, a trace; lithia, a trace;
organic matter, gr. 0.28; potassium sulphate, gr. 0.18;
sodium chloride, gr. 0.47; alumina, a trace; magnesium
carbonate, gr. 0.31; iron carbonate, a trace; sodium car-
bonate, gr. 0.09. Total, 3.7(5 grains.
This may be classed as a mild alkaline-calcic water,
with very slight ferruginous ]iro]ierties. It has long
had an exten.sive reputation iu the treatment of rheuma-
tism, gout, and dyspepsia, and in rena! and hepatic dis-
orders. It is best known, however, as a table water, for
which purpose it has au extensive .sale throughout the
United States. James K Crook.
POLARIMETRY.— Polarimetry is the measurement of
the angle of rotation of a ray of polarized light, and in-
struments adapted to the purpose are termed polarime-
ters. Polarized light is light which (as explained by
the accepted theory) has been changed so that vibrations
transverse to the path of propagation have been reduced
to a single plane. By this change the rays become much
more susce]itible to interference and may lie used for
detecting dillercnce of structure not appreciable to or-
dinary light. Polarization may be brought about by
reflexion or refractiiui of ordinary light, and also by
direct transmission through some substances, such as
tonrm.'diue, Iceland sjiar, and quinine iodosulphate. Of
these, Iceland spar is the only practicable material, and
all laboratory instruments employ it. The crystal in its
natural state, composed of pure calcium carbonate, is
rhoinbohedral and double-refracting, that is, a ray pass-
ing into the crystal is split into two rays, both of which
are polarized. For the best results in jiolaiimeters the
crystal is cut in an oblique direction and th<' pieces are
re-cemented in their original jiosition with Canada bal-
sam. By this means one of the tuilarized rays is pre-
vented from passing through, while the other is trans-
mitted. A crystal so prepared is called a Nicol's prism.
When a ray of light, wliite or of any ccdor, pa.sses through
this prism, it will not be completely transmitted through
a second similar prism unless the latter is placed in the
same relative jiosition, or 180' of arc from it. At any
intermediate position, more or less of the polarized ray
will be intercepted, and at a 90° position — technically
termed " crossed nicols " — only traces of the light pass.
JIauy substances possess power to affect the ray in such
a way that when they are placed between the nicols, these
must be turned slightly from the above angles to get
the maximum effect of transmission or obstruclion, and
such an elTect is believed to be due to the fact that the in-
tervening body twists the plane of vibration of the jiolar-
ized ray, and the sci'ond nicol has to lie twisted to com-
pensate for this. Any substance which possesses this
twisting (rotating) power is termed "optically active."
The degree of rotation is fairly constant for any given
substance under definite conditions, and hence the
amount of au optically active substance may be meas-
728
REFERENCE IIANDBOUK OP THE MEDICAL SCIENCES.
Poland Spring
Polarlutelry.
iiri'il by mcasuriuff the extent to wliich the nicols have to
be iiilj'ust.ed in order to eorreet tlie rotation produeed.
Ill iii(' actual construction of polarimeters many details
have to be regarded in order to secure delicacy and accu-
racy. Jlauy'forms have been devised, but only a few
are" now emploved. In all these a beam of light passes
through a Nicol's prism, called the "polarizer," then
throuah the substance to be testeil. then through another
Nicol's prism, called the "analy/.er," and then to the eye.
As the mind cannot carry a recollection of the exact
brightness of a field of light, some comparison is pro-
vicied as a zero point, and the degree of alteration of the
analyzer required to bring the whole field to uniformity
is the measure of rotation. Substances dilVer as to the
direction in which the light is rotated. When this rota-
tion is such that the analyzer has to be moved to the
right in order to compensate, the substance is termed
dextrorotatory and designated --f-; when the opposite
effect is produced the suljstance is termed lijevorotatory
and designated — .
The adjustment of the analyzer to restore the zero may
be made l)y the direct rotation of it. and the extent meas-
ured in degrees of arc; but in the instruments now usu-
ally employed the compensation is made by means of
sujjerposed wedges of quartz, which are shifted horizon-
tally to the right or left as re((uirrd and the amount
of shifting indicated on an arliitrary scale termed the
"sugar scale." This is graduated and adjusted so that
if a solution containing 26 gm. of pure cane sugar dis-
solved in sufficient water to make a volume of 100 c.c.
at 20° C, is examined in the instrument, the rotation will
correspond to 100. This scale has been introduced be-
cause the principal use of the polarimeter is the deter-
is the best. This gives a pure strong yellow light. The
conunon polarimeters aie now constructed to use white
light from any ordinary source.
Fig. 3874 sliows a form that is now extensively used,
the Landolt-Lippieh polarimeter, as made by Schmidt &
Haeusch, of Berlin. K is a lens and mirror for illumina-
tion and reading the scale. J II is the analyzer with the
compensating quartz wedges. The details of the opti-
cal train are also shown in outline. At the polarizing
end, also shown in detail, a large Nicol's prism, which
receives and polarizes the light from the lamp, t^ears in
front two small similar prisms, so arranged that the
central rays are unalTected by them. By tliis means is
obtained a field uniformly illuminated when the adjust-
ment is at zero: but when any rotating body is intro-
duced, the central segment becomes darker or lighter
than the side segments. In a cheaper form of the instru-
ment only one accessory prism is u.scd. and a "double
field" instead of "triple field" isobtained. Thematerial
to be examined is dissolved in a suitable solvent, clari-
fied if necessary, and a portion placed in a tub(iof known
length closed by glass caps. On now viewing the field,
any rotation of the ray will be markerl by a contrast in
illumination, and to restore the uniformity the quartz
wedges must be .shifted more or less, A given sub-
stance has usually constant rotating power under given
conditions, but temperature, density of solution, nature
of solvent, and many other fact(jrs produce variations.
Fig. 387-t.— Triple Field Polarimeter with Details of Polarizing aiirl Analyzing Apparatus.
Ami'iul, New York.)
(With permission of F.imer 4
mination of the amount of cane sugar in raw sugar ami
syrups. It enables the analyst to read directly the per-
centage, but this applies to cane sugar only. For some
purposes, monochromatic light must be used, for which
a non-luminous gas flame charged with some sodium salt
Some bodies have a high rotation when freshly dissolved,
liut fall off much when allowed to stand or when heated
to boiling. This abnormal etTeet is termed " liirotation "
Milk sug'ar shows it to a high degree. In order to make
comparisons between dilTereut bodies, a factor termed
729
Pol) rliroliialo|»Iiilin.
Polyuria.
REFEREXC'E HANDBOOK OF THE JIEDICAL SCIENCES.
specific rotatory power, iiidicatcil by ["], is calculated
by tlie formula — j-, in \vlii( h ,; is tlic augular deviation
observed : c the numl)cr of grams of tlie substance in 100
c.c. of solution; and I tlie leugtli, in decimetres, of col-
umn of liquid examined. As the rotation differs some-
what with liglit of tiiffereut colors, the s])ecific rotatory
power is now usually given for yellow light correspond-
ing to the D line of the solar spectrum (.see Siicctmxcope),
and the symbol is written [i/J". In practice certain
weights, termed "normal weights," of material are em-
ployed. At the International Commission for Uniform
Methods of Sugar Analysis held at Paris, 111(10. it was
agreed that the normal wei.aht '■shall be 26 gm. of pure
sugar wciglied in air with brass weights," and dissolved
in 100 true cubic centimetres. Thougli the principle of
•the operation of tlieso instruments is simple, yet accurate
results are olitained only by niucli care and experience.
The expense of the standard form of ]iolarinieter has
led Id eifnrts lo e(iiistrnct clie:iper forms tor clinical use.
The instrument of vonFleischl has met with most favor.
It employs wliite light and is so constructed that two
spectra are sliown at once with a dark band in each, the
two being coincident when tliere is no rotating body ; but
one of the bands is disiilaced when a rotating body is
introducr<l. and the analyzer can be revolved mitil the
coincidence is restored. The instrument is graduated
so tliat the percenta.ge of rotating Imdy can be read olf
directly. It is constructed for estimation of sugar.
CUiiiciil Ai>i>lieiitiuiix. — Polarimeters are of but limited
application in clinical diagnosis. Apart from tlie ex-
pense, the cimdilions interfering with accuracy are nu-
merous. Practically, tlie estimation of sugar in diabetic
urine is the only medical use made of them. Albumi-
nous substances rotate i)olaii/.ed liglit, but the fact has
no diagnostic value. Diabetic urine is ajit to contain sev-
eral oiitically active bodies, not all of which are dextro-
rotatory; hence the oliserved reading will be a resultant
of all the actions. The polarinieter may bo of u.se in
making routine tests in a given case todetermine the
effects of treatment ; but even then it will be necessary
to check occasionally by the chemical tests which can
now be ])erfoniied with ease anil celerity, and with suffi-
cient accuracy for clinical purposes.
L'line, as a ruli', will require clarification and decolori-
zation for examination in the polaiiineter. A solution of
lead subacelate is commonly employed; 50 c.c. of the
sample are added to 5 c.c. of the oilicial solution, the
lii|uidswell mixed and filtered through a dry filter. The
first iO c.c. are rejei'ted and the examination is made
on the next jiorlions. The dilution mu.st of course be
allowed iuY by increasing the reading ten per cent.
llcnry l.effnuinn.
POLYCHROMATOPHiLiA. — (l'o/,/r/,rom,/.v;,.) The
term applied by Ehrlieh lo that condiliou of the red cells
in which they take, not only the diffuse stain, but also
the nuclear, .so that they exiiibit a bluish-red or violet
tinge, or may even take a deep lilue stain when stained
witii luematoxylin and eosin, or mcthyleneblue and
eosin. By Ehrlieh and others this pheiiomenon is re-
garded as essentially degenerative, a progressive "coagu-
lation necrosis," whereliy the cell loses its allinity for acid
stains. They are siiiiported in this view by the" lU'esenee
of such cells shortly after hemorrhage and in starving ani-
mals, and by the polychromato]ihi!ie chanicler of inega-
lobli.sls. Further, cells showing this characteristic are
usually ragged in contour or show vacuoles. (_)n the
other hand. .\skana/.y and others hold that the' jioly-
chiiimatojihilic cells are ihv t/omif/rsf cells of the lilood.
and aie not degenerating forms. This view is based
chielly upon the fact that a large portion of the red
cells of llie fietus are polychroinatophilic. According to
Sherrington, the brownish color frequently seen in red
cells is to be regarded as due to an inconi|)lele oxidatfon
of h.'eiuoglobin. Ewing would regard this as a form of
polychromalopliilia and would limit the term polychro-
masia to this diffuse brownish color of the cell, which
occurs in anaemias and is also seen in the normal marrow.
On the other hand, lie would class the bluish-staining
granules and areas in red cells, originidly ilesignated as
polychromatophilia, with C4rawitz's untniihti-^dcyenem-
Hon of red cells. Even though the phenomeiion be
proved to be identical in significance with the last-named,
it would appear best to use the term polvchroniato]ihilia
in its original application by Ehrlieh, and not to transfer
it, according to Ewing's suggestion, to an entirely differ-
ent process. " Ahlnd Scolt WaHhin.
POLYCYTH/EMIA.— The increase in numberof the red
blood cells, due either to an absolute increase in the
number of the red cells or lo a decrease in the volume of
the plasma. An ab.solute increase in tlie number of red
cells above the normal has not yet been demonstrated to
occur. Theoretically, such an increase could be brought
about by an increased formation of red celLs, or through
a longer life of the individual cells. A relative polycy-
th:emia is of frequent occurrence. It occurs in the new-
born, and is Usually highest before nursing begins, and
gradually disappears during the first few weeks. Its
cause is doubtless to be found in the temporary concen-
tration of the blood due to various factors. E-iving finds
that the polycytluemia bears a rather close relation to
the degree of cyanosis exhibited by the exjiressed droji,
and believes that theconeentration of blood is princinally
referable to a state of relative stasis which is established
in the perijilieral capillaries in the first hours after birth.
The average count of red cells in the new-born ranges
from o,36S,000 to G,rjOO,000. Too early ligation of the
cord may cause a reduction of 500"000"to 1,000,000
(Hayem and Helot). After nursing begins, the red cells
fall about 2.")0,000 a week, until "the usual average is
reached.
According to many observers there occurs a polycy-
tlaemia in individuals residing at high altitudes. The
change may take place within twenty-four hours, the
iucrcasi! amounting to a million or niore, reaching the
limit in two weeks and then remaining permanently
high. On return to low altitudes the polycvthaania dis-
apiiears very rapidly. The percentage of'liaunoglobin
is less affected, and the volume of the red cells'uot at all.
The phenomeiKMi has been variously explained ; by some
writers as a comiiensatory increased lu-oductiou "of red
cells, by others as due to concentration of the blood, by
still others as an error in estimation, due to the fact tluit
the results obtaiuc'd by the blood-counter are dependent
upon temperal lire and barometric pressure.
Polycytluemia occurs also in the diarrha-al diseases,
particuhirly in cholera, as a result of the concentration
of the blood. In chronic dysentery it may be offset
by the aiaeniia produced. Similarly, in typhoid fever
the progress of the ana-mia may be obscured by the con-
centration of the blocd. A reliitiveiiolycythau'iiiaoccurs
also in chronic valvular disease of the heart with pa.ssive
congestion, incndocanlitis, in excessive sweating, in phos-
phorus poisoning, after cold baths or the ajipiication (if
drug.s causing contraction of the vessels (alcohol, etc.),
and in cases of jioisoning with illuminating gas. In
phosiihorus ]ioisoning an increase to over S.dOfi.OOO has
been observed; it is probably due to the de|iletion of the
blood from vomiting. An iiicrease of 2,000,000 to 3,000,-
000 may be observed after large doses of salts.
Ahlred Scatt Wartliin.
POLYDACTYLISM.— See Ibiuilsand Fiiu/eis, etc.
POLYFORMIN, INSOLUBLE, is prejiared by dissolv-
ing resorcin in iin aqueous solution of formaldehyde, and
adding an excess of ammonia. It is an odorless, taste-
less, 3-ellowish-brown, amorphous powder, insolublein all
oi'dinary solvents and rich in formaldehyde. It is usej
asan aniiscptic. ir. A. Ri-ilcfh.
POLYFORMIN, SOLUBLE — di-resorcin-hexa-methyl-
ene-tetr,iniine — occurs in while crystals which are very
soluble in water or alcohol, but insoluble in ether or oils.
730
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
PuI)-cIii-oniatoi>liUla.
Polyuria.
It is decomposed bv heatiiis in solution, setting free
foinialdelivde. E.xterualiy. it is employed in parasitic
skiu diseases, and internally lias been used as an antisep-
tic in the alimentary and urinary tracts and as a diuretic.
It is said to appear as formaldehyde in the urine.
Ti'. A. Bastedo.
POLYSOLVOL — Solvin, sodium .sulplioricinate — is
prepared by acting on castor oil with strong sul])huiic
acid, adding a solution of sodium chloride, then neutral-
izing the iree acid with soda. It is a thick, clear,
light-yellowish oily liquid, insoluble in water, but form-
ing with it a good emulsion, Polysolvol possesses the
property of dissolving thirty per cent, of phenol, twenty-
five per cent, of menthol, ten per cent, of salicylic acid,
and other subsfciuces in like proportion.
W. A. Basledo.
POLYURIA. — (Synonyms: Hyperuresis, Diabetes In-
sipidus. Diuresis, Essential Polyuria.)
Polyuria means an excessive flow of virino. There
■ are numerous cases in which this occurs temporarily,
and is due to dietetic or nervous changes, and a few in
which it occurs persistently. The latter are best named
esmntiiil jjolyxiria or diabetes insipidus. I shall at the
present time describe the latter cases. Instances of per-
sistent or chronic hyperuresis were recoginzetl and
described at an early period of medical history, but no
attempt was made to classify them. In 1G70, however,
Thomas Willis discovered the existence of sugar in the
urine of some of them, and nearly a century later Sau-
vages described anew the excretion of sweet urine, as
a distinct form of disease, under the name of diabetes
anglicus. But it was not until near the end of the
eighteenth century that Cullen and P. Frank placed all
causes of persistent poh'tu-ia in two classes, the one hav-
ing sugar in the urine and the other none, the first being
called diabetes mellitus and the second diabetes insipi-
dus. This distinction has been maintained by all sub-
sequent observers. Diabetes mellitus is now classed
with the morbid conditions of assimilation and nutrition.
Therefore only the non-saccharine cases, or those of dia-
betes insipidus, are still thought of as es.sentially poly-
urias.
Etiology. — Cases of temporary polyuria are due to a
variety of conditions such as the drinking of large quan-
tities of fluid or the eating of excessively large amounts
of sugar. It is also caused by such nervous diseases
as hysteria and epilepsj'. Chronic polyuria has been
ascribed to exposure to cold, and to a residence con-
stantly in damp and dark rooms. However, the causative
influence of these conditions lias not been proved. In-
juries affecting the brain and spinal cord, more especially
penetrating wounds in the region of the fourth ventricle
and medulla oblongata; violent mental emotions and
persistent f unctionar diseases of the nervous system are
known causes in certain instances. But manj' cases are
on record which can be traced to no special cause. Age
evidently exerts a predisposing influence, as shown by
the following statistics; Of 24a recorded cases 18 were
under five j'cars, 33 between five and ten years, TiO be-
tween ten and twenty 3'ears, 59 Ijetween twenty and
thirt.v years, 43 between thirty ami forty years, 20 be-
tween forty and fifty years, 13 between fifty and sixty
years, and 8 between sixty and seventy years, which is
equivalent to 7,"> per cent, between the ages of five and
forty years. Observations iu regard to sc.x .show more
than twice as many cases in the male as in the female.
There are not a sutflcient number of relialjle observa-
tions on record to justify the conclusion that the disease
is hereditary. It seems probable that either a functional
or structural disease of the centre in the medulla which
controls the blood supply to the kidneys and excretion
by tliem exists in all cases of diabetes insipidus.
Symi'TO.ms .\xd Clixicvi, History. — When not the
result of direct injuries to the central portions of the
nervoussystem, or of sudden mental emotions, the symp-
toms of polj'uria generally develop slowly and without
marlted clianges, except the gradually increasing quan-
tity of urine which is voided au<l the corrcspondiuglv in-
creased thir.st.
When the urine is greatly in excess, the skin ajipears
dry and somewhat shrunken, but much less than in dia-
betes mellitus. There are .some paleness of the features,
mental despondency, disturbed sleep, unusual weariness
from moderate exerci.se, excessive appeiip' for food as
well as constant thirst, and frequent eructations and
flatulence, with cousiipation of the bowels. As much
as twenty -five to fifty pintsof urine may be voided daily.
In most ca.ses the specific gravity of the urine is dimin-
ished in proportion to the Increase of its quantity, vary-
ing from 1.001 to 1.008. The fluid is nearly colorless.
Its reaction is often neutral or feebly alkaline. There-
fore it readily undergoes decomposition. Although the
amount of solids iu the urine is small, the proportion of
urea is often great. A considerable thirst is felt and the
mouth and lips rapidly become parched. Apjietite is
variable. A moderate loss of flesh is the rule, but such
patients do not become emaciated. In spite of an appear-
ance of average plumpness these patients lack endurance
and ambition. When the di.sease is not aiused by, or
associated with, injuries or structural diseases of the
brain or spinal cord, it may continue man}' years, and
rarel.v proves fatal unless from the nature and extent of
complications. Some cases have been observed to pre-
sent great variations in their progress, the quantity of
urine sometimes dimiuisliing to tlie normal, with corre-
sponding improvement in other symptoms, and then
increasing again. In some cases exacerbations are trace-
able to unusual mental or nervous excitement, in others
to exposure to cold and damji air, and in still others to
excesses in eating and drinking.
During the active progress of essential polyuria the
increased quantit}' of urine consists entirely of water,
while the quantity of the other natural constituents
voided in the twenty-four hours remains nearly the same
as in health.
This explainswhy the waste of tissues and impairment
of health is so much less in this form of disease than in
diabetes mellitus, even when the actual quantit_vof urine
discharged in the twenty -four liours is greater in the
former than in the latter. The contlition of the diges-
tive organs varies much ; sometimes food is imiierfect-
ly digested, causing acid and gasecnis eructations, flat-
ulency, and constipation, alternating with diarrlKca.
These .symptoms, however, appear to depend more di-
rectly on the morbid conditions that have caused the
polyuria or have existed as complications, than upon the
excessive flow of urine.
Pkogxosis. — The duration of the disease depends al-
most entirely upou the nature of the causes ami compli-
cations. Those cases which are associated with diseases
or injuries of the cerebral and sifinal centres usually
either recover or prove fatal at an carlj- period, while
those which are dependent upon chronic functional dis-
orders may continue for manj- years. K. Willis has left
on record a case that continued for fifty years, and Neuf-
fcr one that ended fatally in four months. It is gener-
ally conceded that permanent recovery from this disease
is rare, but it does occur sometimes sjioiitaneously. Com-
plications or intercurrent diseases cause death in much the
larger number of instances.
Di.\G>'OSis. — The most reliable and characteristic symp-
toms of diabetes insipidus, or essential polyuria, are per-
sistent daily excretion of tpiantilies of urine above the
ordinary maximum of health, or of low specific gravity
(between l.UOl and 1.008), and destitute of sugar and al-
bumin; unnatural thirst, increased in direct latio to the
increase in the qtiantity of tn-ine voided; and a loss of
endurance. At first, cases in which polyuria is caused
by habitually drinking very large quantities of fluids,
may be mistaken, for example, for cases of diabetes in-
sipidus. In the early stage chronic interstitial nephritis
may be mistaken for it. This can happen only when
albumin does not occur in the urine or occurs only occa-
sionally. In this stage of interstitial nephritis the in-
i31
Polll<':rrauatc.
Poinpliolyx.
REFEREXC'E HANDBOOK OF THE MEDICAL SCIENCES.
creased flow of urine is moderate ratlier lluui excessive,
and llie s|)ecitic gravity is almost uniformly above 1.008.
A careful study of tlie eirculalory disturbances, wliieli
ari' a part of interstitial neplirilis and do not e.xist in es-
sential ijolyuria. makes a ditiguosis easy.
P.\TiioLO<:ic.\L An.\to.my. — An es.sential polyuria gen-
erally continues for many years, and rarely terminates
fatally e.vcept through the iiilerventiou of other diseases:
few opportunities, therefore, are alTi>rded for careful
post-mortem examination. Howi-ver. in some cases tlie
Iddneys have been fovuid slightly enlargeil and more
vaseu'lar than natural, but often they appearecl unaltered.
Much the most numerous iuiil impoi tant changes have
been found in the brain and cord. These consist of in-
tianunatory and degenerative changes in the region <if
the fourth' ventricle, and less frc<iuently in the menin-
ges; of gunuriata and exoslo.ses; and of tumors. Sueli
changes witlun the cranium are evidently the residts of
jirior constitutional disorders, and arein no sense deiieud-
ent on the polyuria. Chemical aiialy.scsof the blood have
shown a moderate increase of the solid constituents in
proportion to the water. It may lie safely assumed tliat
uncomplicated p<dyuria does not involve uniform struct-
ural changes either in the kidneys or in other parts of
the body, but rather such a moditication of the renal
vaso-motor nervous mechanism as to induce and maintain
an increa.scd blood pressure, and consequent increased
elimination of urine.
TnK.\r.ME,NT.— In the treatment of this affection, it is
of the highest importance to ascertain from the history of
the patient what accidents, injuries, coincident diseases,
or constitutional morbid conditions, hereditary or ac-
quired, may have been influential in developing or jier-
petuating the disease. In all cases in which such causa-
tive conditions can be found, the removal when jxissible,
or alleviation when removal cannot be accomiilisbcd,
should demand careftd tuid [lersistent attiaition.
For permanently conlrolling the diuresis no remedies
have been found to be relialile or uuiformlj' successful.
Those who suffer from this disease shoidd live in well-
ventilated, well-lighted, warm and dry rooms; should
wear warm flannel undeiclothes. take a warm-water
bath, followed by rajiid light friction with dry flaimel.
daily or at least two or three times a week ; and take as
m\u-h exercise in the open air daily as is possible with-
out fatigue. Such quantity and quality of food may be
eaten as the digestive organs of the patient will tolerate
without developing ga.stric distress or luucli flatulenc.y;
but sugar should be eaten sparingly, for an excess of the
latterin the blood will aggravate the polyuria. Very cold
beverages should be iivoided, and es|)eeially such as are
diuretic, like beer, cider, and milk, ilelons and grapes
among fruit increase diuresis iuid must be eschewed.
Rest and sleep should be had at regidar intervals and
in sulflcieut amounts. Emoti<inal excitement and fatigue
must be avoided. To promote vicarious elindnafion by
skin and lungs, the hot baths and friction of the skin,
already advised, are important. Breathing exercise, slow
climbing of hills, ami a residence in a high altitude and
dry climates are usefid.
Among the numerous drugs which have beiai em-
ployed are pilocarpine and cathartics as luians of pro-
voking elimination by ollu'r channels than the kidneys.
Their utility is transitory and slight.
For their effect upon thetoneof the renal lilood-vessels
such drugs as strychnine, ergot, and astringents liave
been tried. They all lend to increase blood ])ressure,
which we would" expect to aggravate, not to relieve,
the important symptoms of the disease. Although in
indiviilual cases they have seemed usefid. they cannot
be said to have a specitic aclion.
Valerian, castor, musk, asafetida, cainidior, belladoiuia,
opium, and potassivun bromide are other drugs which
have occasionally seemed beneficial.
Drugs, however, are not to be relied n|ion. They may
be used to meet indications in individual patients, and
hygienic and dietetic treatment is important.
3'. *S. Davis, Jr.
Fio. as:;
-Pume^r.inate Bark.
POMEGRANATE.— *■.;?•«««/(»«. GrtUKiti Cortex, or
Ciiiii.r a III i.iili . Urenndier. "The dried bark of the
stem and loot of Punica (tnuiatinit L. (fam. Pniii-
caceivy v. S. P.
This is a very beautiful shrub or small Xv("\ producing
a dense crown of glossy dark-green foliage, handsome
deep-.scarlet or crimson (in one form white) flowers, and
the delicious fruit well
known under this
name. It is a native
of Southwestern Asia
and is now everywhere
cultivated in tropical
and subtropical coun-
tries. Some pharma-
copa'ias require the
root bark only, a ju-
dicious restriction (see
(.'o ii,^t i 1 1I e nts). The
French Codex recog-
nizes also the flowers
and fruit, and the rind
of the latter, but all
these are very inferior.
The bark occurs in
quills several inches in
length, and (1.5 t(.i "3
cm. (I to i in.) in di-
ameter, or in broken
pieces of the same, the
bark 1 to 3 nun. (jijlo J in.) thick; outer surface consist-
ing of broad, shallow, rough, coiumonly short and re-
ticulated, yellow fissures, alternating with less rough-
ened, gray or slighth- purplish-gray bands having
sliarp, lightly elevated" margins, and usually more or
less marked with small blackish spots of lichen; root
bark, especially the thicker pieces, browner, less fissured,
and more or less scaly and roughened ; inner surface finely
striate, with some longitudinally elongated, blister-like
elevations, and varying in color from pale greenish-
yellow to cinnamon-brown; fracture short, granular,
greenish-yellow, and showing a somewliat laminated
structure: taste astringent, very slightly bitter.
Ciiiintitiienls. — The important constilm/nts of pome-
granate bark ara four alkaloids, together aggregating
from one per cent, to three per cent, of the weight of the
drug. Although evidence ou this point is contradictory,
it ajipears pretty well established that the root bark con-
tains about a half more alkaloid than the stem bark and
that the barks of the white-flowered variety are richer
than those of the red-flowered. There is a large amount
of tannin (twenty percent, or more), some manuit (" puni-
cin " or "granatin"), much yellow cidoring matter, and
a very large amount (ten to fifteen per cent, or more) of
ash. The taiuuc acid is interesting, being partly gallo-
tannic and partly a form peculiar to this drug. The al-
kaloids exist for the most part as tannates. The most im-
portant is jidhiiii-ine or "ininicine" (CjHisNO), which
is a vohdile liquid, soluble in water, alcohol, etlier, and
chloroform, and rapidly oxidizing. vqion exposure, into a
resin-like body. Its salts are crystalline. MiUnil-peUitie-
riiie (CjHiiNO) is similar, but somewh,at less soluble in
water. This tilkaloid is more abundant in the root bark,
the former more in the stem bark. The other alkaloids
are i.io-pillitieriiiea\v\ p.f'H/dii-pi'lhtiirinc or " granatonine"
(C3HisNO.-H...(-)). the latter occurring in prismatic crys-
tals, soluble in water, alcohol, and chloroform, and in
nine parts of ether.
Pomegranate bark deteriorates rajiidly on keeping.
The alkaloids undergo a change, rendering them less
soluble, soon after which they become decomposed. It
is to be jiarticidarly noted that the commercial substances
passinu' as pelletierine and its salts are in reality mixt-
ures of all the idkaloids named above.
Action .vno Usics. — The important use of pomegran-
ate bark is as a ta-nicide. its alkaloids lieiug active.
Ojiinions differ as to whether the parasite is killed or
merely paralyzed b}' the drug. In any case, a brisk
r3-2
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Poinoeranate.
Poiiipliolyx.
cathartic is required after its adininistratiou, owiDg to
tlie strongly astringent eiTect of its tannin. Its astring-
ent properties are often utilized for gargling and similar
purposes and have been used internally, though the
large doses thus used have frequently been followed by
unpleasant emetic, and to some extent narcotic, elfects.
There is no official preparation, thotigh an unofficial fluid
extract is often employed, in doses of 3 to 6 c.c. (H "
ss.-iss.), and the powdered bark is given in correspond-
ing doses. A very good method is to suspend the latter
in mucilage. The ten-percent, decoction is the form
probably most used, in winegla.ss doses. The tannate of
the alkaloids (so-called " pelletierine-tannate ") is now
very largelj- emplo_yed in doses of 0.3 to 0.4 gm. (gr. iij.
to vi.). This is after all the best form of administration,
since the inhibiting action of the free tannin of the bark
is thus avoided.
The rind of the fruit {Granati Fructus Cortex ; Cortex
Maliairii) is largely utilized for Its astringent properties.
It contains rather more tannin than the bark, together
with a still larger amount of gum, and is free from
the alkaloids which, as stated above, often render the
use of the bark as an astringent undesirable. This rind
occurs in irregular, curved, chip-like fragments, about 3
mm. (^'jin.) thick, externally brown, with a yellowish or
sometimes reddish tint, tinely tuberculate roughened, in-
ternall)' of a lighter or whitish color, marked with con-
choidal depression indicating the position of the masses
of seeds. The terminal pieces bear the tliick. tubular,
cup-shaped remains of the calyx tube. The fracture is
short, sharp, and granular. The drug is nearly odorless
and strongly astringent.
Henry H. Rimhy.
POMPHOLYX.— (Synonyms: Cheiro-Pomphulyx ; Fr.,
Ui/si(lnisis : lli/sidrose.)
Definitiox. — An acute exudative eruption character-
ized Viy the foi'mation of vesicles and blebs, nsuall3- of
moderate size, and occurring for the nifist jiart on the
hands and feet: in some instances it maybe limited to
the palms and soles. It is a disease ,seldom encountered,
and is liable to be confounded with other eruptions of
the bullous type.
Symptoms. — The clinical features of pompholyx are
well-defined and distinctive, and in most works on der-
matology the disease is recognized as a distinct affection.
It was first described by Jonathan Hutchinson and Til-
berry Fox. of London. The former gave it the name of
cheiro-poinpholyx, while the latter in reporting the same
case gave it the name of d}'.sidrosis. During a period of
twenty years the present writer, in encountering manj-
thousand cases of skin diseases, has seen but one or two
instances of this affection ; nor could these be reganied as
typical examples of the disease, for the eruption during
its whole course was not confineil to the regions most
frequenth' involved — namely, the hands and feet — but ex-
tended to the forearms as well. While a student in the
Black Friars Skin Hospital in London I had the oppor-
tunity of studying several cases that were regariled by
Mr. Ilutcliinson as typical examples of the affection. In
some of these, if I remember correctly, the disease like-
wise extended to the forearms, and frequently the feet
were exempted. The disease usually begins in the sum-
mer, especially during excessively hot weather. The
first syiuptorns complained of are burning and tingling,
with the development of deeply seated vesicles which are
single and later be<'ome grouped by the development of
new lesions; tlie most characteristic position at first
being the sides of the fingers, and the eruption gradually
extending to the palms. When the lesions are confimd
to the thick skin of the palms of the hands and the soles
of the feet the}' have been very aptly compared to boiled
sago grains emliedded in the skin. This ap])earance is
due to the thickened epidermis, as ijoiiiled out liy
Crocker, rather than to any special variation in the le-
.sions themselves. The eruption is usually synmictri-
cally distributed. As the lesions develop the groups of
vesicles not infrei|Uently coalesce, forming large, irregu-
larly outlined bulUe filled with a serous fluid, and pro-
jecting above the level of the skin. At first the contents
are translucent, but later they become opaque. In reac-
tion the fluid is neutral or slightly alk.-iline. At no time
is there much inflammation in the surrounding skin, in
which respect the disease differs from certain affections
with which it maybe confounded. In the course of two
or three weeks the lesions begin to subside, althousih
new imes appear from time to time. The contents be-
come absorbed and finally the outer epidermic wall ex-
foliates, exposing a reddish area of delicate new skin,
which marks the site of the former lesion. The disease
often runs its course in a few weeks, or at most in one or
two months, although it is liable to recur the following
year. At times, in debilitated subjects, the lesions may
assume a red color and the surrounding derma become
slightl}' Q?dematous. The epidevmis not inf rcciuenl Iv be-
comes undermined and then soon ruptures, exposing to
view a red, exudative surface. Gradually, however, this
process subsides, and recovery may take place as before
stated. The subjective symptoms are usually slight.
Aside from the burning and tingling previously men-
tioned, there may be marked impairment of the general
health, in which case exces.sive sweating is sometimes,
complained of. Itching is never a prominent symptom.
Pathology. — As the name given to the disease b}- Til-
berry Fox ' indicates, this writer regarded the affection
as in some way associated with the sudoriparous glands.
Later investigators, and especially Robiu.son,- have de-
monstrated that the lesions show no especial connection
with these structures. On the other hand, it has been
shown that the pathological condition is one of inflam-
mation which takes its origin in the rete, gives rise to a
serous exudate from the capillary blood-vessels, and then,
collecting between the rete cells, forms variously sized
vesicles or bullw. As this effusion takes place there fol-
lows a gradual degeneration of the cells of the rete mu-
cosum. While .some of the vesicles, especiall_y those
situated on the outer surface, may rupture when the in-
flammatory process is more extensive, there may be a
general extension of the fluid at the periphery, thus caus-
ing the undermining previou.sly mentioned. Later, the
entrance of pus corpuscles changes the translucent fluid
to one of an opaque or even yellow color,
ETioLociY. — The disease, is nearly ahvays associated
with general debility, or it occurs in those whose nerve
tone is below par. It is especially liable to occur in
women who have been subjected to excessive mental
strain or worry ; and yet, while it is more frequently luet
with in women, men are by no means exempted. Jtiddle
age seems to be the period of life in which the disease is
most frequently encountered ; only a few cases have been
reported in children and the di.sea.se is extremel_v rare in
old age. Crocker has not seen it under twelve years,
and the oldest patient was thirty -eight, while Hyde- re-
cords a case at sixty. The disease is supposed to be due
to some abnormity in the innervation of the skin, although
its exact nature has not been determined. On tJie nther
hand. Unna has found a bacillus resembling the tubercle
bacillus, although slightly thicker, and he is disposed to
regard it as an essential pathological factor in the di.sease.
Di.\G.Nosis. — The limitation of the disease to the palms
of the hands and the soles of the feet — a characteristic
which is considered by some authoritii'S to be essential —
renders the affection less liable to be confounded with
other affections to which it bears some similarity : namely,
with eczema, pemphigus, and derm;ititis heiiietifurmis.
In my own experience the line of deniarcalion is not so
sharph' drawn, and the affection gradually merges in
type with other well-recognized diseases. When limited
to the palms and plantar surfaces the only condition to
which it bears a clo.se resemblance would be blisters from
slight traumatism, eczema, and an accinnidation of sweat
under the thickened epidermis. Eczema is seldom limited
to these stn'faces, and is always accompanied l)y inflam-
mation and marked itching ; while inflammation and itch-
ing are usuall_y insigniflcant features in jiomidiolyx. The
persistence of the eruption, together with the formation
of new lesions extending over a period of a week or more,
•33
Poiii'O de L.4'oii Sp'g
PortkkeratoMis*
REFEREXCE IIAXDBOOlC (iF THE MEDICAL SCIENCES.
wdiikl enable one to exehule blisters arising from sliglit
injuries. >l(iriMliliieiilty. liowever, would heeueountereil
in differentiating the affection when seen on the lateral
surfaces of the tingei's and on the backs of the hands.
Here the affection bears a close resemblance to eczema:
but in eczema there are more extensive intlammation and
less tendency lo the formation of liullre. and in eczema
the outer wall of the lesions easily rujitures, giving rise
to excoriated itching surfaces of irregular outline. lu
pompholyx, on the other iiand. the epidermic wall sel-
dom ruptures and the lesions remain circumscribed, (n-
coalesce in such a manner as to form bull:e. Further-
more, it sliould be borne in mind that pompholyx is
most liable to occur in adults, ami especially in women
who are deliilitated or who have been overwrought, and
that the disease tends to a spontaneous recovery, and at
the san.e time is likely to recur upon the reciuTence of
conditions favorable to its development. Ivy poisoning
must likewise be excludeil in making a diagnosis, but
the acute inflammatory character of this disease and the
tendency of the er\iption to appear on other parts, render
it, as a rule, easy to distinguish it from ponijiholyx. The
Uist doubts, however, would be removed if the history
of an exposure to the jjoisouous plant could be obtained
in addition.
PnoGNOsis. — The prognosis in pompholyx is good so
far as the individual attack i.s concerned, although there
is a tendency for the disease to return with successive
years. In some instances the irritation to which ]ioni-
pholyx gives rise lias engendered an eczema which may
persist indetinitely. On tlie other hand, the disease
may not return for several j'ears, although, upon thi^
return of ill health, it will be very likely to appear
again.
TiiE.\T>rENT. — The treatment should be partly consti-
tutional or general and partl_y local. The former seems
to be of the more importance, as the individual attack is
self-limited. First, all debilitating influences slioidd be
removed, and as far as iiossible the patient should be
urged to avoid worrv, ovi'r-<'Xcitemcnt. or intense men-
tal labor. General hygienic tneasures should lie ad-
vocated, namely, exercise in the open air, cold bathing
with vigorous friction inmiediately thereafter, and diver-
sions of a relaxing nature. Change of location from in-
land to the seashore, or from the seashore to tlie moun-
tains, is in some cases highly beneticial. In addition to
this the jiatient should be given a generous diet and in
some instances tiaiics, and the room which he occupies
shindd liavc a sunny exposine and should be well venti-
lated. Aside from these general measures individual
cases shoidd be treated according to the indications pres-
ent. Strychnine is a drug which must fre(|ueutly be
called into requisition. Iron, especially in its mcne as-
similable forms, ([uinine, cod-liver oil, and in some in-
stances arsenic, are valuable drugs.
The local treatment consists |iartly in .soothing ap])li-
cations and pan ly in such as protect I he surface from the
air and from the irritation of clothing and other extra-
neous substances. It is best foi-cibly to ruptiu'e the le-
sions, especially when large, and Hush out the cavity
with a satin-ated solution of boric acid and water. In
some cases, when the lesions rtijimre. black wash may be
used, I can also reconnnend the following a|)plicati(ni:
Salicylic acid 2 jier ivnt., and diachylon ointment (|. s.
100 per cent. This should be spread on some lirni wliile
cloth and kept constantly applied to the diseased area.
Every twenty-four hours the surface of the skin shouhl
be cleansed with a saturated solution of Ijoric jcid, or
with Wider to w hich a small fpiantity of carbolic acid has
been added, and a fresh application of the ointment
should be made. This ointment is es]iecially valualile
when the soles of the feet are involved. .Sli'lwagon ■'
recommends the following: Menthol, gr. ij. : acidi sali-
cylici, gr. x. : emplastri plnnilii, emplastri sa|.onis. a;"i
5 iss. : pelrolati, ; v. M. The prevention of ]iu-,d in
fection is one of the main objects in treatmiiit, and, to
accomplish this, we nniy with benetit ajiply a solution of
corrosive sublimate (1 to 2.000) or white precipitate oint-
ment (five per cent.), the latter serving as a jiarasiticide
as well as a protective agent.
Williiiin T/wnias Coiiett.
REKEBENCES.
' Piitluilogical Society's Transiicti'ins, London, vol. xxis., p. 264.
- .\rrliives of t^ennaifilnjry. \.)|. iii.. Xu. 4. p. 2.s9,
» Hvfle, J, N. : Diseases of tlic Skin, I'liilailelpllia, 19(10. p. 279.
< Sti'Uvagon, H. \V. : Diseasps or llu' Skin, I'biladelpllla, 19(12, p. 344.
PONCE DE LEON SPRINGS.— Crawford County,
Pennsylvania. Post-Okkice — Jleadville.
Access. — Viil Erie Railroad or by Pittsburg, She-
uango and Lake Erie Railroad to H'leadville (.separate
depots), thence about two miles to springs.
The Ponce de Leon Springs may be said to be in a
process of development. An electric line of railway from
jleadville is now being constructed, and a modern first-
class hotel will soon be built. The location is very
favorable for a pleasant summer resort, being twelve
hinidred feet above the .sea-level and surrounded by ])icl-
uresque hills. There are six mineral springs, only one
of wliicii has been submitted to a (pialitative exannna-
lion. An analysis by Prof. Henry Letlmann, of Philadil-
jihia, resulted as follows: (Jue United States gallon con-
laius:" Sodium sulphate, gr. 0.17; sodium chloride, gr.
0. 00; calcium bicarbonate, gr. l.yO; magnesium bic:u--
bonate, gr. 0.47; .sodium bicarbonate, gr. 1(5.73; silica,
gr. 0.70. Total, 20.y(j grains.
A second analysis by .1. Siugley, Ph.D., professor of
chemistry in the Western Pennsylvania ^Medical College
of Pittsbiu'g, resulted sidistantially as above. The fol-
lowing gases Were also found: Carbonic acid, 1.38 cidiic
inches jier gallon; oxygenand nitrogen, 7. 23cubic inches
per gallon; hydrogen sulphide, abundant traces.
The water is a bland antacid and diuretic. It will be
found of vahn: in certain stages of Bright 's disea.se. espe-
cially when the urine is scanty, liigh-colored, and irri-
tating. It is also useful in assisting the diminution of
calcareous dejiosits and of uric acid in gout .and gravel.
The water will sjieedily relieve acidity of the stomach
and heartbiu'n. It is used conunercially, and also for the
manufacture of a ntunber of teiniierauce beverages.
Joints K. Crook.
PONS AND MEDULLA. See various articles under
Brat II.
PONTRESINA. See EinjaJihc.
POPLAR. See Willoir.
POPPY, — The prineijial products of the poppy plant
will be foiunl ilescribed under the titles of opium and its
more important alkaloids. Some minor products are
here considered.
l'"l'l'!l ^-'iipsvles (Pnprireris cnpsnlm ; Fruciiis or Capita
PiipiirirU iiiiiiHitvni) are more or less employed in medi-
cine for the opium which they contain. Their botanical
origin has been fully stated under Opium. For the pur-
poses here considered, they are gathered when nearly
ripe and are dried in the sun. They are more or less sjjhe-
roidal, but vary in the different varieries, from strongly
oblate to strongly jirolate, and they avinge from one and.
one-half to three inches in diameter. The larger ones,
and those of ju-olatc foi'm, known as the " black " vari-
ety, are generally regarded as sniierior. Tlie color is
pale brown, and the surface nearly smooth. At the sum-
mit there are from eight to six teen, or occasionally twenty
short, ni'arly .sessile, recurved stigmas, indicating an
equal number of placenta', the latter projecting as sliarp
ridges upon the inside of the capsule. Partly concealed
uiidi'r the stigmas are a circle of small pores through
which the miiture seeds escape. The seeds are not a part
of the capsule considered as a drug. Numerous constit-
uents have been reported as occurring in these capsules,
but from a medicinal point of view they may be regarded
as identical with those of opium. The morphine content
* Ilftluced from grains per imperial 'gallon.
734
REFERE>'CE HANDBOOK OP THE 5IEDICAL SCIE.XCES
Ponce <le Ijoou Si»'gs»
Porokcra(u»$is.
rarclj- c-xcecds a foiirtli of one per cent., notwithstanding
that "claims for a much larger yield have been made.
The younger the i)ods the less morphine do they con-
tain.
Poppy capsules were official in the United States Phar-
macojja'ia of 1870, and are still so in the British Pharma-
copieia, but their use in the United Stales has almost en-
tirely given place to that of otlier and more definite forms
and jireparations of opium. In Great Britain the syrup
is probably tae most largely used preparation, ami is
mostly administered to children, though the extract is
also coiisiderabl_v employed. The dose of any prepara-
tion should represent from one to two drachins of the
capsvde.
Po]ijiy sietU possess no narcotic properties whatever,
though it is said that traces of morphine can be found in
them. They are used purely
for their fixed oil. which is
an important article of com-
merce. The oil is quite
bland and possesses only
the nutritive and demul-
cent properties of vegetable
fixed oils in general.
Pnppt/ Pitiilx, or Rid Pop-
py Pdiils (R/iivKilas Pe.tnla)
are the petals of Pitpaver
Rha'aK L., the common red
or field poppj' of Europe.
They resemble rose petals,
but are larger. The color
of the fresh petals is a bril-
liant scarlet red, with a
large black spot at the base,
but the color becomes pale
and didl in drying. They
are used entirely for their
coloring matter, for the tint-
ing of pharmaceutical
preparations, and hence are
greatly preferred in the
fresh condition. The col-
oring matter is divisible
into two portions: rhandic
arid, which is dark red, sol-
uble in both water and al-
cohol ; and pfipiireiic acid,
which is of a brilliant red, soluble in water but not in
alcoliol. An alkaloid {rheadine) exists in very small
amount, but is unimportant. It is said that a trace of
morphine has been extracted, but the article can scarce-
ly' be regarded as medicinal. Henry II. Rushy.
POROKERATOSIS.— (Synonyms: Ilyperkeratosis ee-
ceiitiii ;i. K. ratciiliiiiiia eccentrica. Hyperkeratosis ligu-
rata centrifuga atrophicans, Porokerat(.ise.)
Defixition. — A unique form of hyperkeratosis, begin-
ning as a small papule. This ]iapide having slowly en-
larged becijines dejiressed at the centre, and its margin
usually develops into a lidge involving a ril't and de-
fining an area of varying extent.
In 1S87 Maiocchi reported a case, marked by a singular
appearance of the skin, which be diagnosed as a form of
ichthyosis hystrix. After a lapse of six years the same
case was brought to the notice of Mibelli. who pro-
nounced the lesion exceptional and peculiar, claimed that
the pathological jirocess was distinctive, and finally cliar-
acieri/.e<l tlie afleclion by the name of porokeratosis.
Simultaneously with the observation by Mibelli, an
article was published by Respighi describing a num-
ber of similar cases under the name of hyperkeratosis
eccentrica. The disease has been especially observed
in Italy, particularly in the district of Parma. Cases
occurring in the Uuiteil States have been reported by
Hutcliins, Gilchrist, and Wende. A few cases liave been
noted in Germany, France and, very recently, in Eng-
land.
SY>rPTO.MS. — The disease is of slow development, first
appearing as a papule of varying size, dirty brown, dry,
and invariably surrounded at the base by a collarette of
scales. As the papule increases it takes on a decided
change. The lesion, the periphery of w hicli is subject to
a gradual development, extends centrilugally ; the cen-
tral jiortion becomes slightly depivssed. and the margin
resolves itself into a unique border which re|iresents a
non-inllammatory hypertrophy, sharply delined against
the outlying soiuid skin, and forming a continuous or
broken ridge. In the ndddle of this ridge is found a rift
somewhat irregularly dividing the same into two lateral
halves, all of which constitutes a lesion nidike any other
known, and which has been characterized as a "scam,"
"dike," or "wall." It is dirty gray or blackish in color
and usually qtiite pronounced, though iuill-iletined Ciises
it may appear simply' as a loose rim of epidermis. The
Fig. '.'>-~'.i\. L ,...i ,,; i'urol;enito&is of Five Teai> M.,i.,. .:..:. i:.^ ..iTL^:Ld aiv-u is luaaiiled by the i-har-
aeleiisui; nUed ridjre. Tlie iesiim sliuwn here was ihe uuly uue iireseul in this case. (From Grover
■\V. Wende's collection of photographs of skin diseases.)
centre, so long as the lesion is small, consists of a homy,
t hickened. epidermic patch. After the lesion has attained
a certain size the centre ma}' become normal in appear-
ance. Sometimes the natural furrows of the skin are
erased ; again, there is clear evidence of atrophy. The
functions of rhe sweat and sebaceous glands are inter-
rupted. In some areas absence of hair is observed. Epi-
dermic concretions, the size of a millet-seeil, are some-
times present, now divided b^'lhe furrow, again attached
to tlie inner siile of the seam; or they may appear at any
lioint within the affected area.
The areas alTected by hyperkeratosis vary in size —
many do not measuie over one-eighth of an inch in di-
ameter, while some become much larger and may even
cover the gi'cater ])ortion of an extremity. As a rule,
they do not exceed an inch in diau'.cter. and in the ma-
jority of cases they are much smaller.
The lesion is always slow in development : at times the
condition remains stationary. The shapes assumed are
round, oval, or elliptic; they may become polycyelic
by eoullnence or may all run together, especially when
their dimensions are greatly increased.
The lesions often affect tlie mucous membranes lining
the mouth. All orany jiart of the skin may be attackeil.
The. favorite regions, however, are the face — especially
the nnse. forehead, and cheek.s — the ears and neck, the
dorsal surftrces of the hands and feet, and the extensor
surface of the forearms.
The lesions of the mouth are generally not very nu-
merous, although present in a large number of cases.
They consist of small asymmeti'ical spots varying from
733.
Porro OpiTiitioii.
I'orllaild.
REFERENCE HAXOnooK OF THE MEDICAL SCIENCES.
tlie size of a pin to that of a lentil. Like tlie lesions of
the sliin, tlicy may be oval, polycyclie, or iire.uulur.
Tlie suhjeclive symptoms are witliout siieeial impor-
tance; only oceasionally does the patient coniplaiu of
pruritus, either slight or intense. \Vlien the feet are af-
ieeted the shoes sometimes cause pain liy ]iressure.
The evolution of the lesions is essentially slow ; some-
times a single focus continues durina; many years. Sub-
frfsxrfrf^
"?^
j.'i'^v''-""''
'.•riSsV:"' ■
l§»'^
I
■♦.'■
l.Jt>^.. - . ^-\^- -: -•
Fig. 3877.— Criiss Seetion nf the ('li:ini(ti'ri^tii- i;iilL'e ill a Case of PorokiTatnsis. In'aiiditlou
to the conduieii >A tmirkcd liviMTktM;iinM^. whirh Is revealed in the piciiii'i'. tliere may lie
seen a s\vt*at pMie wliirU is uhsiiiKtrd liv Un- pri'senee of a blaek liurny plu^j; tliat e.vteiids
down to tlie levid ot Itiu acini. ((tru\ er \V. Wt- ndc. \
sequently the disea.se extends by the development of new
lesions, and, in the end, the lesions are disti'ibuted bilat-
erally.
ErreiiAioY. — The eaiisi- of the disra'-e is larirely a mat-
ter of conjecture. It may show liereditary teiideucies,
though often it does uid. The ]iossiliility of liei-editary
transmission is shown in theciises published by Gilchrist,
in which eleven members of one family were discovei'i^d
to be affected in the eouise of four generations. Res-
pigbi also reports an instance of the malady which re-
curred in seveial geneialions. ^lost of the cases occur
in laborei's. jNIales suiter more often than females; some-
times the affection is developed in childi'en between the
ages of two and eight; generally, iiowevei-, it iipjiears in
adolescents or adults.
The jiroof that the alTeclion is iiiU'asitic in its natiue is
wanting, although in a series of four inoculations made
uiion as many dill'ei'eut imlividuals by AVende. one was
suceessfid, undoubtedly owing to local irritation U]ion a
susceptible skin. lies]iiglii made e,\]ieriments in tians
lilantation, but they jiidved to be negative. All e.xam-
inati(nis for micro-oi-ganisms have been without lesult.
P.\'riioi,ooY. — The main feature of this disoi-iler is a
special form of liy])erkei'atosis. The elevated and cii--
cinate mai'gin is compo.sed of a mass of cornilied cells,
whiel however, still retain their nuclei. The lesion
forms a conical plug corresponding to the intcrpapillary
depression into which the enlarged glandular oriticcs com-
bine, but are obliterated b.y horny masses — a cotidition
which strongly resembles lichen spinulosus. All parts
of the epidermis are involved, especialh" the lower horny
and ujiiier icte layers. A small amount of cellulai' iiilil-
tration with (edema is seen in the papillary layer of the
cutis immediately underlying the affected epithelium.
The derma undergoes a sclerotic degeneration in the
upper layeis. At lirst it is hyper-
trophied, but in the advanced stage
atrophied. The sweat glands are
dihiled and reveal epithelial pro-
lifenition and liyiierkeratinization.
J'^Iiillielial accuiniihuions in the
sweat ducts and sebaceous glands,
as well as in the hair follicles, have
been ob.served I)}' ]Mibelli. Respighi,
and Gilclii'ist.
Di.voxosis. — The clinical chai'ac-
teristics of poi-okeiatosis ai'c so
unique that a mistake in diagnosis
is not likely to occur. In the early
stage the lesions may be mistaken
for lichen jilanus, but this is gener-
all_v accomjianied liy itching, is not
continuous, and does not attack
several members of the .same fam-
ily. The essential lesions are the
characteristic jiapules. striated on
the surface, and of a dark led color.
Tliere are instances of lichen planus
essentially annular, but in that case
the rings are limited by a red jirom-
inence, and one does not see either
the furrow or the edge of the poro-
keratosic circles so characteristic of
the disease.
PR0G^■osIS. — The disease does not
affect the general health, and, be-
yond the possible dLstiguremeut,
need not create any anxiety. Some-
times the lesions disappear spon-
taneously. When located about the
joints, especiallj' of the fingers or
feet, the alfection may cause some
pain from ]iressure and the inter-
ruption of functional operations.
TiiE.^TMiOiNT. — The same treat-
ment is required as that given to
some forms of ichthyosis. The
lesions, in the early stages of the
disease, are to be removed by sidicylic iicid plasters or
the iise of the curette. Joseph has obtained good results
by excision. Gilchrist recommends electrolysis. Both
<if these modes (if treatment wei'e employed in the case
illustrating this ;irticle, but without favorable results.
Undoulitedly this peculiar treatment is applicable, only
to smidl lesions. Gruur 11'. Wende.
BlBLIOGRArilY. •
Milielli: (iiorii. Ital.. 189^, p. StH; Mnnatsliefte, Nnvemlier 1st. 1S93;
Inteniatidiial .\Uas of liare Skin Piseases. vol. i.\., lSii.3; .\rchiv,
ISilil. vol. .\lvii., p]i. 1 and at.
Respijrlii : tiioi'n. ital., l.sifi. p. 356; Mdnat.stiefte. 1,SS14, vol. xviii.. p. 70
(Iian.slation of lli-st, paper); Gioini. ital., IS'.)-"), p. (59; Monatshefte,
I'.HKI, vol. x.\.\., |i. :!1S.
Ris|iis-'lii and Iilicrev : Aunales. 189S. pp. 1, 609, and 7:34.
Iliiti'liin.'*: .loiirn. Ciitan. Dis.. 1S9I), p. ;)73.
Ri'isiier : Inauir.-DissiTtnlion. stra.s,slniriT. t89(>.
M..Jos('pll: Arctiiv, IS97. vol. xx-xix.. p. ;Ui.
(iilclirist: P.ull. Joliiis tlopkins llosp., 1S97, p. 107; Jouru. Cutan. Dis.,
P<9S, II. 149.
fi. \y. \ycnde : Joiini. Cutan. Dis.. 189S, p. .50.').
lia.srli: IVstcr iii'-d.-chirnrsr. I'rcsse, 1898, p. (Hfi.
(iallouMv : liiit. .loiirn. of Derm., pp. -G-, vol. xiii., 1901.
PORRO OPERATION. See Ovhtrcnn Section.
PORTER SPRINGS.— Lumpkin County, Georgia.
Post-Offick. — Pol tcr Springs. Hotel.
Access. — Via tri-weekly hack line from Gainesville,
'"''i' ^ ■ ■ «■•
■ -^^fcS^li:,; -;s,
fair*' '*^- ■M^^'-''y-,.-'i
r:',()
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Porro Operation.
Portlaud.
the springs being twenty-eiglit miles north of that city,
and ten miles nortli of Dahlonegu. Tliey were discov-
ered only a few years ago in a lieautiful cove on tlie
soutliem slope of the Blue Ridge Jloiintains. Tlie waters
have acquired an extensive reputation onaccoiut of their
valuable chalybeate properties. The hotel has a capac-
ity for about one hundred and fifty guests, and is kept
open from June l.")th to October 15th.
The situation is very high for this region, being more
than three thou.sand feet above the sea-level, an elevation
greater than the top of Lookout Mountain. Some of the
peaks in tne vicinity reach an altitude of almost five
thousand feet. Although located in a semi-tropical lati-
tude, the high elevation of Porter Springs gives the cli-
mate an invigorating, bracing character not subject to
exhausting heated sprlls. Tlie waters are .said to con-
tain, besides irou, liydi-ogen sulphide gas with sulphates
of magnesia, jiotassa, and soda. Some of the springs
contain also small ijuantitics of iodine, lithia, and man-
ganese. It is unknown by whom these determinations
were made. A proper quantitative analysis is needed.
Jtiijten K. Cruol,-.
PORTLAND, MAINE.— The largest city and coniuier-
cial nirtrnpi)lisof Maine, with a population of about ufty
thousand, one hundred and fifteen miles northeast of
Boston, is beautifully situated at the head of Casco Bay,
Portlaud is the centre of a number of attractive seaside
resorts which are easily reached from this city by sea or
land. Such are Old Orchard Beach, Scarborough Beach,
Prout's Neck. Keunebunkport, Pine Point, Saco Pool,
and Wells Beach to the south ; and Boothbay, Harpswell,
Islesboro, Isle Au Haut, Vinal Haven, Deer Isle, Camden,
and Castiue to the northeast. Indeed, the whole coast
of Jlaiue with its innumerable indentations and many
islands affords a great variety of attractive summer re-
sorts with a cool, delightful climate. It is visited at this
season by thousands of people from the inland cities of
the North, South, and West, Portland itself and its
picturesque surroundings offer very many attractions,
and possess a cool summer climate and a steady sea
breeze.
There are many fine buildings and churches in tlie city,
a number of parks, notably the Eastern Promenade with
a fine view of the city and harbor, and many points of
historical interest. The drives are delightful, and excur-
sions liy water throunh the harbor and Casco Bay with
its man}' islands, are numerous and pleasing. Diamond,
Peak's, and Cushing Islands are favorite resorts near the
city, easily and quickly reached by water. The accom-
modations, both in Portland and the various other resorts
mentioned above, are abundant, good, and of varying
jirices. The following table represents the climat'e of
Portland and will also convey an idea of the climate of
the resorts lying to the north and south. In general.
the summer climate is seen to be a cool marine one, with
frequent sea breezes, a majority of pleasant davs, and
a humidity of about seventy per cent. There are often
quite sudden and marked changes in tcmperatvue, and
fogs are not infrequent. Such a climate is a stimulating
one and well suited for the overworked, for neurasthenics,
and for those suffering from anaimia. scrofula, and bone
and joint tuberculosis. Convalescents from chronic dis-
eases also do well in this climate. It is too damp and
variable for laryngeal and pulmonary cases and those sub-
ject to neuralgic atfectious, Esiiecial mention sliould be
made of the exceptionally fine beach at Old Orchard, the
finest in New England, extending for a distance of ten
miles and affording most excellent surf bathing. This is
a very much freiiuented resort, antl offers accommoda-
tions of everv kind and description, Hinsdale (vol. iv,.
Book II,, "Health Resorts," "Physiological Therapeu-
tics") says that the climate of Kennebunk|iort is not ex-
celled on the New England coast, "Tlie s<iutU and
southwest breezes," lie says, "are from the water; a hot
land breeze is a rarity, and fogs are not of frequent oc-
currence," He recommends the climate for neurasthenics
and those suffering from insomnia and melancholia.
Portland, as well as the various resorts about it, can
be easily reached from Boston either by rail or by watei.
'Edirard 0. Otis.
PORTLAND, OREGON.— This is the largest city in
the State of Oregon, with a population of 90,438, and is
situated at the head of ship navigation on the Willamette
River which flows into the Columbia, It is in no sense
a health resort, but it is mentioned here, and a climatic
chart is given, for the sake of contrasting the climate of
the eastern and western sides of the North American con-
tinent. By comparing the charts of Portland, Jle,, and
Portland, Ore., the contrast will be seen. "Portland,
Ore,, lies nearly two degrees farther north than Portland,
Me,, yet its mean winter temperature is no less than fif-
teen and one-half degrees warmer than that of its name-
sake on the Atlantic coast. It is within one degree of
being as warm as that of Norfolk, Va., and is about ten
degrees warmer than that of New York City, On the
other hand, the summer at Portland, Ore., is slightly
cooler than at Portlaud, Me., and is about seven degrees
cooler than that of New York City and almost exactly
the same as that of Montreal," "The range of tempera-
ture is decidedly less at Portland, Ore,, than it is at Port-
land, Me, The rainfall is much greater, and the relative
humidity is higher (especially in winter), and the number
of cloudy days is much greater. The great cloudiness of
the Oregon winter weather is a feature of the climate not
clianicterisfic of any other part of the United States ex-
cept the Lake region and St. Lawrence Valley distiict"
(Richards). Richards (previous edition of tlie H.\nd-
HOOK) calls attention to the close resemblance between
CLIiM.\TE OF PoUTl,AND, Mb., LATITUDE, 43" 'M' . T.ONlilTUDE, TO' 1.5'. PeIIIOD OF OnSERVATIOX TWEI.VE YeAKS.
TeinpeiHlnre. ftp^pt^es Fain-.—
A vei:iiii- ineiin leinperature
Aveni!.'e daily range
Mean nf warmest
Meaji ..r rulilest
Hii:h'*st or nia.xjnmiri
L<i\\ est ur miuimuiti
HuHiidity—
Average mean relative
Precipitation-
Average in inches
Wind—
Prevailing direction
.\veniffe hourly velocity in nilles . . . ,
Wfiither—
.\vei-age number clear day,s
Average number fair days
Avenige number clear and fair day,s.
Vol, VI,
2,1 "°
T.i!s
31,9
IK, I
.W.O
-11..")
1-2.6i
3.22
S1.7
12.0
21.7
32.6°
14.2
41.2
27.(1
(K.O
- 7.0
ns.is
3.2.1
N. W.
ai
11.6
18.8
.51.8°
1B.2
64.1
47.9
94.0
;}4.0
f>1.7:«
R.3
n.s
20.1
6'.1.7"
16,6
79,
62.4
97.0
31,11
70, ir
3,."i2
S. W.
6.1,
8, 6
60.6°
14,4
69,5
55,1
94.5
37.0
73.6-!
6.7
ln.2
11,1
21.3
.50.4°
14.2
58.8
44.(1
83 0
28.6
TO.S-J
3.06
s. W,
7,3
8.9
U.5
20.4
,38.11"
13.1
46.7
33.K
68.0
- B.O
70.8«
3.8.-J
N. \V.
8.3
9.1
10.6
19.7
65.3?
R.95
N. W.
K.5
23.2
34.8
58.0
70. W
10.40
27.8
40.2
68.1)
71.7?
10.67
S. W.
7.4
28.2
33.2
614
71.8?
9.02
.\. W.
8.0
28.5
a">.9
64,4
«;),7S
:'.9.l«
.\. W.
7.6
107.7
144.1
:K1.8
PorlMiiioiitli.
Porlsinoiitli.
REFERENCE HAXOBOOK OF THE MEDICAL SCIENCES.
Climate ok Poktland, Ouegon. Latitide, 4r)°32'; LoNonxDE, 123' 43'. Period op Observation, Twelve
Years.
Tfmperalure, Degrees Fahr.—
Mean averaire teniperatuic
Averafje daiiv range
Mean nf wannest
Mean of ii.ldest
Highest (ir nia.xinnnn
Lowest or miniuuim
Hninkiity—
Mean average relative
Prei-ipitation—
Average in inches
Wind-
Prevailing direction
Average hourly velocity in miles .
Weather-
Average number clear days
Average number fair days
Average number clear and fair da
:!9.i)»
10..S
4.5.2
MA
W.fl
3.0
7SAf
7.34
3.4
7.0
10.4
^
is
c*
>.
o
1
Z3
s
Si
S
<
47.3°
.5fi.0°
68.2°
60.9°
53.0°
45.1°
51.5°
64.2°
53.0°
41.0°
l(i.2
20.5
21.9
2(1.0
14.2
12.3
.5.i.S
(17.4
70.8
70.7
59.2
51.4
39.1)
4(1.9
.54.9
.50.7
45-0
39.1
7ti..i
Wi.O
95.5
90.0
79.0
HS.O
2.1.5
33.0
46.0
39.0
31.0
;.'2.5
175.9?
64.a«
&3.7^
69.2*
77.6^
78.4?
70.3!!
65.1?
75.1?
78.7?
7.27
2.44
.71
1.62
4.95
7.37
13.19
3.34
13.94
23.72
s.
N.W.
N.W.
N.W.
s
s.
S.
N. W.
S.
,'i.
.5.1
4.S
4.7
4.2
4.1
4.5
4.9
4.5
4.3
5.3
4.4
.5.1
15.3
ViA
7.1
4.7
14.7
37.0
24.2
9.6
7.1)
9.9
7.4
9.5
9.9
8.8
26.1
26.4
:».2
21.1
11.4
15.U
21.9
17.0
13.5
40.8
6;j.4
.52.4
30.7
.52.4°
72.3*
54.18
S.
4.7
85.5
111.8
187.3
tlie climatic conditions clmi'acteristic of PortlaiKi. Oi'c,
and tliose prevailing aloni; the west/n'n coast uf the Euro-
pean continent. The teinpcratiii-es of the Oregdn coast,
he says, are sti'ongly siiggcslive of tliose found tlii'ough-
oilt liorthwesteni Europe; further, the aliiKist rainless
summer witli heavy winterrainfall is a feature of climate
in which tile Oregon coast i-esemliles the MediteiTaucan
basin i-ather than the more northerly parts of Europe.
l-:,t Irani 0. Dt/.s.
PORTSMOUTH, N. H., AND ADJACENT RESORTS.
— This "old town liy the sea" is mdieed here nut only on
account of its own attraetions, hut because in its vicinity
are a number of well known summer maiine health re-
sorts; the Islesof Shoals; Kyeand Ham|itiin Beachcsand
Little Boar's Head; York llarborand Beach; Ogunquit,
Passaconaway, Kittery, and Newcastle.
Portsmouth, lifty -seven miles from Boston, is situated
a few miles above the mouth of the Piscataqua River,
and pos.sesses an excellent liarhor. It is the only seaport
(if New Hampshire, and in the days of wooden sliip-
liiiiMiug was a very prosperous tiiwn, as is evident from
the stately maiisiims still remaining there.
The pi'cscnt popidatiou is about ten thousand, and the
tiiwn presents a quiet, tranquil aspect rpiite in contrast
til its bj'-gone activity when ships wei'e launched from ils
y.-irds and were entering and departing fi'om its spacious
liai'bor. The streets are beautifully shaded, and the old
resiliences of the ai'chilectui'e of seventy-five era liun-
di'cd vears ago, with their atti'active gardens, together
with the water views from the decaying wharves, all
combine to give this old city a most )iietui'es(iue appear-
ance. There are al.so many points of historic interest in
;ind about the city, for it was tiist settled in l(i23. On
an island opposite, in the town of Kittery, is the United
.States navy yard. There ai'e no meteorological obser-
vations to lie had in i-egai'd to Purlsmouth, but a fairly
accurate idea nf the climate may be obtained by striking
an average of the climatic data of Boston and Portland,
wdiich aie on the coast fifty miles east and west of Ports-
mouth,and which dilfcrbut liltle fi'oni each oilier. Esti-
mating in this manner we have the following figures;
Mean average yearly temperature, 47. 3 F. j\iean aver-
age temperature for the four seasons: sjiring 4-1. 1', sum-
mer 68.1°, autumn .')0.3°, winter 26. S'.
The annual mean rclalive humidity of Pnrtlai^d and that
of Boston are almost identical, and that at I'oitsmouth is,
therefore, probably the same, which is (i'.l.lj per cent.,
varying but little (luring the year. The average number
of clear and fair da vs is; spring .'58.3, summer ().5.(j. autumn
(il, winter 59.0: year, 244.7. The yearly rainfall is 43.6
inches. The prevailing wind is from the southwest and
west. All along this coast there may be a few very liot
days during the summer, but generally the air is cool and
deiighlfiil, and the sea liteeze is almost a ihiilv occur-
rence. The accommodations are good, among them one
very excellent first-class hotel. Although Portsmouth
is a city, yet it is such a mild and quiet one that it offers
many advantages for even a wdiole summer's .sojourn.
Tlic society is exceptionally good, to which the adjacent
navyyai'd makes valuable contributions; the air piu-e and
cool; the scenery in the vicinity vei-y attractive, and there
are many excursions both by lantl and water. There are
various churches, one the historic old St. John's, a good
library, a well-equipped hospital, and excellent physi-
cians. Frequently some of the vessels of the North At-
lantic Squadron visit Portsmouth during the summer,
and there are always one or more wai'ships at the navy
yai'd.
The water suppl}' of Poit.smouth is fi'om springs and
driven wells a few miles from the cily, and is regarded
as of excellent (piality. Sewei-s emptying into tide water
are being slowly introduced, although many of the old-
time vaults still remain.
The average yearly mortality for the last eight years
(1S94-1'J01) is lil2.-) JUT thou.saud.
An old I'esideiit and iiractitioner of Portsmouth assures
the writer that the sanitary condition is giiod. and that
there aie very few cases of sickness which can be atti'ib-
uted to unsanitary conditions.
One is I'cferred to the writings of T. B. Aldrich,
Lowell, and Mrs. Celia Thaxter for chai'iniug accounts of
Portsmouth and the Isles of Shoals.
Neircdxtlr. — This small island at the mouth of the Pis-
cataqua River, about two miles from Portsmouth, is a
popular summer resort, with a large hotel, boarding-
houses, and cottages. The situation of Newcastle is very
picturesque, and it has a beautiful and extensive ocean
exposure. It is connected with the mainland by liridges.
and has fretpient connnunication with Portsmoulh by
land and water. There arc op|iortunities for golf, tennis,
lioating, and bathing. There is a military gairison at
Fort Constitution. The climate is the same as at Ports-
mouth, with the exee|ition that being directly on the
ocean, it Is more iieculiarly marine.
Kittci-ii Point, at the mouth of the Piscataqua River,
o]iposite Newcastle, is very attractively situated and is a
popular summer resort, affording good accommodations,
both in hotels and cottages. It has frequent communi-
cation with Purlsmouth both by trolley and by boat.
I,\I('H "f Sh'iiils. — This group of small, rocky islands lies
about nine miles ofT the coast, and has <'ommunieation in
the summer with Poitsmouth several times a day by a
comfoi-table steamer, the voyage occupying about an
hour. Ap|ilcdore is the largest of the group, which con-
sists of eight islands, and contains two liuuilred and fifty
acres. The formation of these islands is granitic, and
they present a rugged pictui'esque appearance, barren,
and with very sparse vegclation. Huge. irre,gular reefs
jut out into the ocean, and after a storm the play of the
rss
REFERENCE IIANDBUUK OF THE JIEDICAL SCIENCES.
Portftiiioutli.
Portsmouth.
surf is vt'i-y imposing. Only two of tlic islands provide
ucconnnodations for suninu'r nsidcnls, Appli'dori' und
Star Island, there being extensive hotels un both islands.
The accommodations are rather more elaborate and e.x-
])ensive on the former (Appledore), and tliere are several
cottage annexes. These islands have been a popular
summer resort for many j'ears, owing to the cool, equa-
ble marine climate found there, with an absence of dust
and flies. Here one can e.xpcrience all the climatic intlu-
<'nees of a sea voyage without the discomforts incident to
ship life. They are far enough removed from tlie main-
land to be free from all contaminating influences, and
from whatever quarter the wind blows it brings pure air.
From a " weather record " for the summers of 1897-98
(June 25th to September l.'ith) kindly furnished the writ-
er by Dr. J. W. Warren, who has been a summer resident
of Appledore for over twenty years, the following data
are condensed :
Mean temperature (Fahrenheit scale) from two daily
observations at nine and four o'clock. .]une(2.'jtli toiiOth)
03.3°, July 65.7°, August 67°, September (l.st to 1,5th)
64.8°. The maximum temperature for this period was;
June (25th to 30th) 70°, July 81°, August 78°, September
can be reached from the latter place by steam railroad,
or l)y feriT, and a most atlra<liv(> trolley ride. York
Harbor is the principal resoit, and enjoys a wide popu-
larity. Cottage life predominates, although tliere are
several good hotels. The coast is bold aiid rocky, and
the York River winds inland for some nine miles, and
has a large flow of tide water. The residential portion
of the town is built ujion ledges with little or no subsoil,
so that there is good surface drainage, aided by the nat-
iiral declivity of the land toward the sea. Further in-
lanil are wooded districts- and tillage lands. The climate
is a particularly stimulating one, favorable for convales-
cents, for wiiom a marine climate of this nature, com-
bined with sea bathing, is desired. The air is generally
cool and the temperature equalile, an exticmely hot or
cold day in the summer lieing rare. Fogs are unusual.
'I'he following climatic chart was obtained through the
kinilness of Dr. Seabury \V. Allen, a summer resident of
York Harbor, as also nuich i>f the information contained
in this account. The |irevailing wind is southwest to
southeast during the sununer months, and is only e.xcep-
tionally of suflicient velocity to interfere with canoeing
or sailing.
Cli.mate of Y'omc IIauhok — PitEP.^nED by Dk. Seabikv AV. Allen.
Temperature, Degrees Fahr. —
Average or normal
Highest or maximum
Lowest or luiuimum
Precipitation-
Mean annual precipitation for Iwenty-flve years, 40 to .5tl in.
Mean ni'intiily average rainfall (April to Septembei')
tweiny-Uve yeais, 3.4 in.
Average number of days iu wtiich rain fell (for three years).
Average daily temperature (for nine years) -[
June.
63.3°
92.3
4o.U
11
A.M.-
I'. M.-
July.
69.9°
fto.a
51.6
9
8 A.M.- 6"
8 P.M.- 67
.\ugust.
6.5.8°
87.3
48.3
8 A.M.-6.')
8 P.M.— 70
September.
58.4° i For three
79.3 V years,
39.6 ) 1892-1894
8 A.M.-.i6
8 P.M.— 57
8 A.M.— 4.5
8p.M.-4^;
(1st to 15th) 80°. Minimum, Jime (25th to 30th) 56°, July
56°, August 53°, September (1st to 15tb) 56°. The sum-
mer temperature is said to be several degrees cooler than
it is on the coast. Cold, raw days are infrequent, and
the difference iu teinperatui-e between day and night is
slight, so that one can generally sit out in the evening.
In general, the variations in the temperature are never as
pronounced as on the mainland.
The average number of fair days for the two years
was: June (25th to SOlh) 4, July 15, August 17, Septem-
ber (1st to 15th) 9. Number of parti v cloudy, misty, or
foggy days: June (25th to 30th) 2, j'uly 13, August 10,
Sepltember (1st to 15tli) 2. Partlv rainy or rainy days:
June (25th to 30t.h) 1, July l.o, August 1.5, September
(1st to 15th) 1..5.
The prevailing summer winds are southwest and
south-southwest, and are not generally high. Fogs are
not so prevalent as farther east, although they occasion-
ally occur. The average number of rainy days is .said to
be much less than at Portland or Boston.
Therapeutically this climate has been found to be of
great benefit to convalescents and to certain cases of
neurasthenia. It is peculiarly valuable for those who,
for one reason or another, wish to be much in the
open air and at rest, for there are few inducements
or opportunities to take exercise. Many years ago the
late Dr. H. I. Bowditch considered the summer climate
of these islands favorable for early ca.ses of pulmon-
ary tuberculosis, and they surel.y possess the recpiisite
of pure air. Many cases of hay fever find innnunity
here. On White Island is a lighthouse, a prominent ob-
ject from the mainland. There is good sea fishing and
sailing about the islands. A steam launch alfords fie-
(pient communication between Appledore and Star Isl-
and.
For much of the above information the writer is in-
debted to Dr. J. W. Wan-en.
Tork Harluii- iiiuJ Benrh. — These resorts, on the Maine
coast, are about nine miles distant from Portsmouth, and
Thunder storms are frequent in summer, but a contin-
uously rainy day is the exce])tiou. The water supply is
excellent : it is obtained fi'oiu an inland lake some five miles
distant. The ice. milk, and faiin produce are also of
good quality. The larger hou.ses and Imtels have sewers
running into the sea, the smaller ones either connect with
one of these sewers or have cesspools of their own.
So far as known there have been no cases of illness at-
tributable to imperfect drainage. Indeed, this resort en-
joys almost complete immunily fiom zymotic and infec-
tious diseases. Gastrointestinal disorders, especially in
childi-CH, are rare. Such a climate, or indeed any cool
marine one, is obviously not suitable for iiatientssutfering
from rheumatism, bronchial and pulmonary afl'ections.
Ycrk Beach, situated a few miles to the eastw-ard of
York Harbor, possesses essentially the same chai-acteris-
tics as the latter, -with the exception of the drainage.
Heie, on account of an extended swamp, lying behind
the lieacli shingle, and whii-h is imperfectly drained,
there is always more or less stagnant surface water, and
for this reason this locality is not so desirable as a place
of summer residence.
Several miles beyond York Beach and to the northward
is the Passaconoway Inn, on a rocky promontoi-y, afford-
ing good accommodations, and still farther along the coast
is the extensive Ogunquit Beach, reaching toward Wells.
Rye Bench. — This well-known anil favoiite sununer re-
sort is eight miles distant from Portsmoulh by electric
i-oad, and is also easily reached fmni Boston by rail to
North Hampton and thence b}- trolley. The air is
warmer than on the Jlaine coast, but is fresh and cool,
with an almost daily sea breeze. Moreover, the humid-
ity (about, seventy per cent.) is considerably less than at
many other marine resorts. The majority of summer
ilays are clear or fair, and the rainfall at that season is
moderate. The genei-al healtbfulness of this resort is
noteworthy, and children especially thrive here. The
i-a|)idity with which tlelicnte and sickly children improve
in this climate is often ipiite remai-kable. It is also fa-
739
I'orto Uico*
KKFEUE.NCE llAMJliUOK OF THE MEDICAL SCIENCES.
voniblc for the agcil ami delicate jiersoiis and con vales-
cents from various diseases. Tlie surf bathing is good,
although the wateris cold, averaging about 00 to 65 F.
during July and August.
The drives are very delightful, over gciod country
roads, and through pleasant pastoral scenery. An ocean
Iioulevard extending along the whole coast of New
Hampshire is in process of construetiou at Kye Beach,
and when completed will afford an exceedingly attrac-
sage separates the island from Hayti, and on the east lie
the Virgin Islands and Saint Thomas. Porto Uico is
about 1,000 miles southeast of Florida, and about 1,,")00
miles from New York City. The shape of the island is
that of an elongated quadrangle, its long axis running
cast and west. The greatest length of the island is 108
miles and its average breadth is 'SI miles. The estimated
area is H.GOD square miles, or about 1,000 sipiare miles
greater than that of the State of Delaware and 1,300 square
I'm. ;isT,s. — Islami uf Purto Itico. (Fi^'ures uear u:uiii\s uf places indicate alrltiute in fet-t.)
tive drive of about eighteen miles from the Piscataqua
River, on the north, to Hampton River on the south.
There are well-keiit golf grounds with an attractive
cluli-bouse, and a picturesque stone E|)iscopal church
near the water, "St. Andrew's by the Sea." The sani-
tary conditions are generally .sooti. and all the li(}tels and
large boarding-houses have sewers running to the sea.
The water supph' is from springs, artesian and surf.ace
wells. The accommodations are excellent, though rather
expeu.sive, and there are many social attiactions. Cottage
life here as well as at the iicighljoring Little Boar's Head
has become quite an important feature.
Little Boar's Ucdd. situated about a mile south of R_ye
Beach, iiossesses the same chariictcristics as the latter.
The name is derived from the bluff upon which it is situ-
ated. The views over tlie marshes and towai'd the sea
are particularly charming. Th- accommodations and
class of visitois are quite like those at Rye Beach. In-
deed, both from its contiguity and identity <if interests.
Little Boar's Head can be rcgardeil as a ])ortion of Rye
Beach. It is reached by trolley fiom Portsmouth or
from Boston by railroad and trolle}'.
ILimpton Beiirli. — Although not so fashionable as Rve
Beach, this is a mucli-fiequented resort, with several
liotels of moilerate price and fair accommodations, ami
many small cottages stfelching along the bi'acb. There
isa long, hard, sandy beach extending for some miles, and
aft'ording excellent surf bathing. In the rear of the beach
are extensive marshes. There are many attractive drives
in the vicinity, although the wooded and cultivated land
does not approach the water so closely as at Rye Beach.
This is a favorite resort for excursions, and coiise-
qtiently might not be so attractive to the iiermaiicnt
guest. It is reached by electric road from Portsmouth
and Exeter, and is within three miles of tlie steam rail-
way. Ediriinl O. Otis.
PORTO RICO.— Porto Rico (,s>/h;'.v/(. Puerto Rico),
aboriginal name Borinquen, in size the fourth island of
the West Indies, is situated between latitudes 17' .")0'
and IS' 30' north, and longitudes (i.")° 30' and (57° 1.")'
west, Oreenwicli. (.)n the north is the Atlantic Ocean,
on llie south the Caribbean Sea. on the west ilona pas-
miles less than that of Connecticut. In appearance Por-
to Rico is an agglomeration of hills and mountains chan-
nelled witii innumerable steep and narrow valleys. The
hills and mountains abut more or less abruptly on the
ocean, with but here and there an intervening strip of
flat or gently sloping shore. Notwithstanding the strik-
ing unevenue.ss of the island, there is a definite orogra-
phic system traced as a sinuous crest from near the
southwestern corner eastwardly. and about one-third
nearerthe southern coast than the northern. In the east-
ern part of the island this crest bends sharply an<l tei'mi-
nates near the northeast extremity of the island in the
peak, El Yunque. 3.609 feet above sea-level, the highest
point in Porto Rico. The .general elevation of this crest
ranges from 3,0U0 to 3,000 feet above .sea-level, with
here and there a jiass somewhat lower or a peak some-
what higher. From this general crest the mountains
and hills decline coastwaiil. Thecoastward fall is much
greater toward the south as aconsequenc<-pf the proxim-
ity of the mountain crest to the southern coast. This
crest divides the island into practically two watersheds,
the larger one draining north and west, the smaller
di'aining south and east. Flowing down these two
sheds, rapidly and often precipitously, are more than
thirteen huntlrcd named sti'eams. But few are naviga-
ble, and then only for a few miles. The coast, unlike
that of Cuba, has but few fringing reefs to interfere with
the close approach of vessels to the shore. There are a
number of good natural harbors. San Juan, on the
north, is the most important commercially. It now has
a depth of twenty-nine feet in the roadstead and twenty-
two feet at the wharves. Other ports that may be entered
by the average ocean-going vessels are Ai-ecibo. Aguadil-
la. Mayaguez. Gu.-inica. Arrayo. and Fajardo. When it
is considered that the total coast line is not much more
than three hundreil miles, Porto Rico ajipears well pro-
vided with harbors. Viquez. a small inlet off the east
coast, has two excellent harbors.
Geoliifiy. — ^Though one of the earliest colonized islands
of the New Worlil, practically nothing is known of the
geology and mineral i-csources of Porto Rico. The early
Spanish settlers worked some placer gold, and some is
still to be fotmd in the rivers of the northeast part of the
740
REFERENCE HANDBOOK OF TilK MEDICAL SCIENCES.
Porlo Kico.
Porto Rico.
island. INIercury, maguetic iron ore, copper, eoal, salt,
and several other minerals are found, but till a sj-stema-
tic survej' is made no estimate of the actual importance
of these minerals and of others not mentioned can be
given. Several thermal and mineral spriiig.s, and one
or two caves of interesting formation and beauty are
known.
Fauna. — The indigeuous mammalian fauna have prac-
tically disappeared with the exception of a few species
of rodents, of which the only peculiar one is the some-
what squirrel-like agouti (common also to all the other
West Indies). A number of bats are foiuid. The cur-
ious marine mammal, the manatee, frequents the shoal
waters of the coast. Fish, both fresh- and salt-water va-
rieties, are plentifid. Noxious reptiles are .said not to
exist, and insect pests are not over-plentiful. The usual
domestic animals thrive well, and good beef is to be had
thrciughout the island.
Flora. — Vegetable life flourishes even to the tops of
the highest peaks. However, it is uow only on the more
inaccessible mountain slopes aud tops that considerable
remnants of the once large indigenous forests are found.
Some of the native woods possess properties that are pe-
culiarly suitable for certain purposes, but their scarcity
precludes their general use. Intelligent reforestation
would seem to offer returns of commercial value.
Among the many native trees. Baron Eggers dcscriljes a
beautiful talauma with immense white odonius flowers
and silvery leaves, a hertella with crimson flowers, an
unknown tree with orange-like foliage and large purple
flowers, and most conspicucms of all. the Cocoloba macro-
phylla, with its great purple spikes of more than a yard
long. Of woods common to other of the West Indies,
there are found hard and soft Spanish cedar, sandalwood,
and ebony. Tree ferns are niunerous and of large size.
The ab.sence of epiph_vtes is in .striking contrast to their
abimdance in the forests of the neighboring islands.
Coffee, of excellent quality, sugar cane, yams, oranges,
cocoanuts, and many of tiie other tropical fruits are cul-
tivated and yield well. A species of rice, requiring no
irrigation, is found growing upon the highlands, and
forms one of the staple foods of the laboring class. An
excellent grass, Ilymenachne striatum, covers the low-
land pastui'cs, and on it is fattened the beef for which
Porto Rico is esteemed by its neighboring islands.
Climate. — Though somewhat nearer the equator than
Cuba, Porto Rico is not correspondingly warmer. On
the contrary its temperature, taken as a wliole, is slightly
more comfortaljle. This is due to the situation of the
island farther out in the ocean, and at the windward
angle of the Antillcan system. This position, combined
with its slight!}- more southern latitude, gives it the un-
obstructed flow of the northeast trades at all seasons of
the year. Porto Rico, again compared with Cuba, owes
somewhat of its more agreeable temperature to its smaller
size, giving it a nearer approximation to the true marine
air temperature of its latitude. The only statistical data
of value in determining the climate of Porto Rico are the
observations made by the United States Weather Bureau
station at San Juan. This station was established late in
1898. At the same time a number of what are now known
as voluntary stations were established, but the data fur-
nished by them are not yet accurate enough to be of much
use, climatologically. The table given below shows the
principal climatic values for San Juan, as determined
from four years' observations.
Temperature. — A recoril of temperature was kept by
the Jefuliu-a de Obras Publicas, prior to American occu-
pation of the island, but it does nfit present on its face
that evidence of accuracy that well-kept meteorological
records exhibit. However, the results are given that
they may be compared with those of the annexed table.
The average annual temperature for twelve years was
78.9' ; the highest recorded temperature 100,8"' and the
lowest 06.1° F.
The hottest season of the year is from July to October,
inclusive, with an average temperature of 80' to 81°.
The coolest season is from December to March, inclusive,
with an average temperature of 75° to 77°. It appears
probable that this regimen holds for the island generally.
Local differences in altitude aud exposure should betaken
into consideration as affecting the nuiuerical size of the
values given. If we take two interior stations, Cayey,
1,205 feet elevation, and Adjuntas, 1,970 feet elevation,
the records of which, thougli brciUen, may still give an
approximation of the inland temperature, we shall find
that the average seasonal temperatures are from two to six
degrees lower thau those of San Juan. The highest tem-
perature iu three years at Cayey was 97°, and at Adj untas
in the same years 93°. The lowest recorded was 53' at
both places. At San Juan the average diurnal range of
temperature is about 10 to 11°, and at the two other sta-
tions it appears to be about 20°. Cayey is in the ea.st cen-
tral part and Adjuntas in the west central part of the
island.
Itainfall. — The average yearly rainfall at San Juan
for four years was 75.52 inches. From the records of
the Spanish authorities before referred to it appears to
have been 61.2 inches. Fair records of the rainfall in
other parts of the island are not yet to be had. However,
there is no doubt that the rainfall varies greatly, even in
localities but few miles ajiart. The raiufail is much
greater on the northern waterslieil than on the southern,
and much greater on the ucirtheastern part of the first-
named shed. Generally speaking, the rainfall is every-
where greater on northeast cxjiosures. On the southern
watershed there are many localities where the rainfall is
insufficient for the tropical vegetation and bari'en tracts
are not uncommon. Irrigation is necessary in many lo-
calities on this shed.
Tlie greatest aniotmt of rain falls from May to October.
The months of February and March are comparatively
dr}', February noticealil.v so at San Juan. In Porto
Rico, as in other tropical regions, the greater part of the
rain falls as an accompaniment of the almost daily thun-
der storm. The usual cloud regimen is clear skies in the
Showing Certain Climatic Factors for San Juan, Porto Rico; AvER.iGE of Four Years' Orservations.
stations.
Tpnit>Hratnre. Depress Falir.
.\\4T;it:e niiinlhly
.^\»-i;ijrH inaximiiin
.AVHnttrt' miiiiinuin
Hit'lii'st (absolute)
Lowest (absolute)
HuuiUlity—
Aventpe relative
Rainfall (inches) —
Average nionthlv
(ireatPst fall in 34 linurs
Avpnipe number rainy days.
Sunshine-
Percentage of possiltlo
Wind-
Prevailing direction
Averaee hourly velocity
(miles per bourt '
Jan.
81
7()
86
e*>
8K
.5.92
3.07
20
64
E.
Feb.
76°
83
70
89
66
76:5
0.88
.70
F,.
9
76°
82
70
89
66
74«
3.14
2.08
1.5
(i8
K.
II
.April.
93
liK
-6%
4.80
4.34
13
65
E.
10
79°
73
93
(^
li.3I
4. SI
17
m
8. E.
9
June.
80°
83
74
91
TO
82«
8.. 51
2.46
22
.56
8. E.
10
July.
80°
85
.S9
70
7.3(>
4.05
57
E.
Ausnst.
Sept.
Oct.
Nov.
Dec.
81°
86
75
91
70
81°
87
75
93
71
80°
SO
74
90
68
78°
84
73
.89
65
82
71
88
65
80!8
80?
82«
83?
81 S
7.66
6.26
18
8. a?
3.76
17
8.87
3.. 35
21
9.48
2.93
18
4..5r,
3.02
17
66
61
.58
61
(« :
E.
S. E.
S. E.
E.
E.
11
9
7
8
9
Annual.
78°
84
73
<Kt
65
S(«
75.. 52
63
E.
10
7-H
I»a8l-Mor«eiii E.xaiM,
Potassiuiu,
REFERENCE HAXDBUOK OF THE JLEDICAL SCIENCES.
moruing, cloudy iu tlie afternoon, and clcarins and clear
at night.
Wi'iitl. — The prevailing winds arc remarkably constant
from the east or between northeast and southeast. The
velocity is steady and averages ten miles an hour. It is
subject to a regular diurnal range, rising gradually to a
maximum at the hottest part of the day and subsiding
from that time to a minimum at the cocilest part of the
day, just about sunrise. This regularity and steadiness
of the Avind camiot lie over-estimated in its relation to the
comfortabk' habitability of Porto Kico.
.S'/<(;-(H.'i. —Though visited August 8th, 1899. by one of
the most ilestructive storms of ree<'nt years, the island is
well to the east of the usual tracks of West Indian hurri-
canes. Thunder storms, thotigh of almost daily occiu'-
rence and accompanied by great electrical display, are
not destructive, and one soon becomes used to their ap-
parent violence.
Hisliirii. — Porto Rico was discovered by Columbus in
1493. The first settlement was made by a party of
Spaniards under the leadership of Ponce de Leon, at Ca-
parra, a.d. 1.510, but it was shortly afterward abandoned.
San Juan was founiled by the same leader in loll. The
town was sacked by the English tuider Drake iu 159.5,
and again under the Earl of Cundx'rland in 1598. Since
then it has successfully withstoud the assaidts of the
Dutch in 1615, the Engli.sh in H!78 and in 1797, and the
United States iu 1898. On July 2.5th, 1898, the island
was invaded by the United States forces, who lauded
without opposition at Guanica on the southern coast.
Only a feeble resistance was subsequently encountered.
The Spanish formallv evacuated tlie island October 18th,
1898. By the treaty of Paris. December 11th, 1898, Por-
to Rico was ceded to the United States. A census taken
by direction of tlu' War Department, 1899, gave a total
poptdation of 953,343 inhabitants. Unlike most, if not
all, the other West Indian i.slands, Porto Rico has a
larger white than black population. In 1899 there were
RSg.^r) whites and 303,817 blacks The density of popu-
lation is also great, averaging 21)4 persons to the square
mile, a density equal to that of New Jersey and twice
that of Pennsylvania. The greater part of the popiila
tion is rural. The poptdation of the largest cities in 1899
was: San Juan 32.1)48. Ponce and its port 27.952, ilaya-
guez 15,187, and Arecibo 8,008. The ratio of illiterac_y
is high, but twenty-three per cent, of the population
over ten years of age being able to read. Agriculture,
such as it is. is the chief occupation, employing about
si.\t_v-three per cent, of the working population. The
most important products are eolTee, sugar, and tobacco.
The total value of exports from July, 1S98, to December,
1899, was 811, (321, 049. The imports during the same
period amoiuited to .512.054.542. Transportation facili-
ties before American occupatiim were poor. There ex-
isted btit one hundred and thirty seven miles of railroad,
and with the excejition of the excellent military road
from San .Tuan to Ponce, and a few connecting branches,
there were no common roads at all. .Much has been done
since to improve matters in this respect. The sanitary
conditions were equally iu kee|iing with the general in-
-difference shown iu other improvements. Few, very
few, houses had any efficient sewage disposal systems.
In many the systems were even worse than none, being
in their ultimate workings actually pernicious. The
average «lealh rate, calculated from reported deaths for
eleven years, is 30 ]ier thousand. Thereis reason to think
that this is considerably less than the actual. The chief
catises apiieartobe- Ana-mia, 22.,50 per c<'nt. ; tubercu-
losis. 6.78; diarrha'al diseases. 3.83; cerebri >si>inal men-
ingitis. 1 12; typhoid fever, 1.43: tetanus, 3.57. Small-
pox was, prior to 1899, one of the chief causes of
mortality, averaging annually 623 deaths. It is now,
happih". no longer a factor of importance, owing to the
thorough vaccination of the entire population carried out
hy the United States military authorities. Yellowfever
epidemics have oc<'urred occasionally. The large mor-
tality from anieniia ap]iears to be due to the general
infection of the drinking-water by the intestinal para-
site, ankylostomum duodenale. Ordinary care exer-
cised in liltering or otlierwise purifying the water used
for culinary and drinking purposes should be followed
by a great reduction in this disease.
ir. F. R. Phillips.
POST-MORTEM EXAMINATIONS. See Autopsies,
and Stir-JJiifii, I'litlwliiiji/ i)j.
POTASSIUM. — I. General MEDicraAi, Piioperties
OP Co.\rpou.NDS OF PoTASsir.u. — In its phy.siological re-
lations potassium is the most individual of the alkali met-
als, producing effects sufficiently ].ironounced to be seen
characteristically in the case of all its compotmds that
are capable of absorption. Such effects are as follows:
Locally, potassic comjiounds are irritant — less so than
the avcra.se of soluble comiiounds of the heavy metals,
but j-et sufficiently so to make a large portion of a strong
solution of a potassic salt dangerous on the score of irri-
tation alone. In the intestines, potassic salts tend to in-
crease the secretion of fluid, so that salts of this base that
are of low diffusion power ]jrove watery purges. Con-
stitutionally, the prominent effects are certain derange-
ments of function and certain effects that find their sim-
plest explanfitiou in the assumption that potassium
quickens the rate of oxidation within the organism as it
does in laboratory experiments. The derangements of
function are, first, an enfeeblement of the heart's action,
passing, iu poisonous dosage, to permanent arrest iu dias-
tole. The effect seems to be due, as results of all ex-
perimentation agree, to a directly paralyzing influence
upon the musculature of the organ it.self. Secondly, but
reqin'ring relatively larger dosage, there follows general
motor paralysis, voluntary and rellex. This effect is
proportionately much more strongly marked in cold-
blooded than in warm-blooded animals, and, in therapeu-
tic do.sage in man, is practically not seen at all. It is
probably accomplished by an action on nerve centres,
nerve trunks, and luuscles conjointly, but an action
which is most intense upon the nerve centres and least
so u|)on the muscles.' Tlie effects commonly assigned to
a (puckening of oxidation iire. in the healthy, an increase
in the solid excreta of the kidneys, with a ]u-n|iiirtionate
increase in the volume of the urine, and, in the litluenuc
individual, a diminution in the amount of uric acid ex-
creted, with a sinuiltaneous increase of urea and appear-
ance of calcium oxalate. These effects in litluemia are
translated to mean an oxidation of much of the uric acid
into oxaluric acid, which luoduct then splits into tirea
and oxalic acid.' In large doses, long continued, potas-
sic compounds prove noxious to nutrition, the blood be-
coming thin and unduly fluid, newly formed and lowly
vitalized tissues, such as cheesy deposits, tending to
liquefy, and health and strength generally to suffer.
Therapeutically, the effects of applications of potassic
compounds, determined by the potassium element of
their composition, are to depress the heart in stheinc fe-
ver, to oppose the lit hie diathesis, and to jirovoke cathar-
sis or diuresis. Otlier uses are derived from individual
peculiarities of the different compounds.
II. The Compounds of Potassif.m Used in JlEDt-
riNE. — The compounds of potassium official in the
United States Pharmacopa'ia divide, for purposes of
study, into two grrpiiiis^the one embracing compounds
whose effects are cither derived from the potassium or
are S'li geniris to the salt, and theother such as owe their
effects inaiidy to the acid radical of their composition.
The members of tlie former group, which alone will be
discussed in tliis place, are tlie /ii/ilro.iidc, curbohiittn (nor-
mal and acid), citrnte, acetate, tartrates {ncid and potas-
siosodic), sulphate, vitrate, and chlorate. The second
category comprises the hi/paphosphite, hromide, iodide,
sulphide (in tlie preparation. p</ta.isii siilphiirata), acid
chroinate, ei/anide. fern/ei/anide, pen/iaitf/aiiate, arienite,
(iu the preparation, liym/r potassii arsenitin). pntassin-
nhiminiiin si/lphate (alum), and pota.'mio-frrric tartrate.
For discussion of these compounds see, .severally, Hi/po-
j^hospldtes, Bruinides, Iodides, Sulphides, Chromium, Cya-
742
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Post-Mortciii Exam.
Potassium.
niihu. Fcrrocyanidcs, Manr/anese, Arsenic, Aluminum,
aud Iron.
I'litiMsitim Hydroxide (Potassium Hydrate): KOH.
This is tlio compound wliicli is liotli commonlj' and ofti-
cially IciKiwn asiVCi/sw;, j\)tassa. called also n; //.<//-• y»/^^v/(.
It is ol)taiiicd tii-sl iu aqueous solution by precipitating
with lime a solution of acid potassium carbonate. Such
aqueous solution, when rapidly boiled down, yields a
fluid of oily consisteuce — simply the hydro.xide melted
by the heat — which, poured into cylindrical paper
moulds, hardens on cooling info the cylindrical sticks in
which form potassa is commonly met with. Potassa
thus obtained is a white, hard substance, having a faint
alkaline odor, an<l a very harsh, caustic taste. It is ex-
ceedingly deliquescent, and readily soluble in water aud
alcohol.
Beside the stick form, potassa is ollicial in five percent,
aqueous solution under the title lAqmir poUtssir, Solution
of Potassa. This solution is made as just described, and
is a clear, colorless liijuid, odorless, but with the acrid,
caustic taste of potassa. It should lie kept in green
glass bottles, glass stoppered, and the stoppers should
be coated with vaseline or a thin layer of melted paraffin.
Specific gravity about 1.036.
Potassa produces phj'siological effects which spring in
part from an intense affinity for water, in part from its
powerful alkalinity, and in part from its operation as a
compoimd of potassium. Locally, in concentrated ap-
plication, potassa Is intensely caustic. A moistened stick
swept even lightly over a tender surface produces speedy
corrosion, which extends finally beyond the area of origi-
nal application, the tissues breaking down widel}' into a
brownish, slimy, pultaceous material. Taken internally,
therefore, in strong solution, potassa is a corrosive poison.
In such poisoning, the acrid, alkaline taste of the potion
is followed immediately by severe pain in the pharynx,
oesophagus, and ei>igasfric region. These symptoms are
in turn speedilj' succeeded by violent vomiting, where
the ejecta have the greasy aspect aud pultaceous consis-
tency of tissues corroded by potassa, and piove strongly
alkaline to test paper. The mucous membrane of the
lips, mouth, and throat may be bright red from irritation,
if the solution swallowed were not overstrong, or ma)",
in the case of strong potions, show direct corrosion, being
covered by a brownish film having a greasy or soapy feel.
Loss of voice and extreme dillieulty <if swallowing are
exceedingly common, but intestinal .symptoms are gener-
ally wanting. Constitutionally, the symptoms are those
of shock, from the suddenness and severity of the corro-
sion. In survival from serious grades of tlie poisoning,
stricture of the a'sophagus is a very common sequel. In
the treatment, the only peculiar feature is to give harm-
less acids to neutralize the alkali, but since the damage
is generally alread\' fully done before the phvsieian ar-
rives, this chemical neutralization rarely avails for much.
Vinegar or lemon juice are the acids most available, from
their being strong but non-corrosive themselves, and at
the same time readily procurable. Locally applied, in
nou-corrosive strength, potassa operates as a powerful
and harsh alkali. Acids are neutralized, grea.se becomes
saponified, epithelial tissues swell and soften, and acid
secretions, such as the gastric juice and the sweat, tend
to be called forth. Upon the skin, potassa lotions cleanse
from dirt or the crusts of dried secretion and e|iithelium
resulting from .skin disease. Taken internally, the rem-
edy excites appetite aud increases the flow of "the gastric
digestive fluid, or in cases of fermentation of the food
neutralizes acidit_y and so relieves the heartburn aud nau-
sea which such acidity excites. Constitutionally, medi-
cinal doses of pota.ssa produce, of course, (he e'fi'ects of
all potassium compminds as already set forth, and also,
because of free alkalinity, tend to neutralize morliidly
developed acid in the blood or tissues, to diminish the
acidity of the urine, or even to reverse the reaction of
that secretion to the alkaline. Probably in part becau.se
of the peculiar action of potassium as' such, and partly
because of the alkalinity of jiotassa, this compound is
of special efficacy iu the diatheses leading, severally, to
rheumatism, gout, and lithajmia, and in the skin diseases
urticaria, psoriasis, eczema, lepra, acne, and recurring
boils.
The medical uses of potassa are for the purposes above
detailed, yet, excejit as a caustic, it is not so much used
as its acknowledged potency would seem to suggest,
simply because it is rough aiid harsh, while at the same
time other and milder potassic compounds are equally
etlicient. Thus for direct local alkaline action the car-
bonates, and for constitutional alkalizing, the citrates and
tartrates, are respectively preferable.
To cuuterize with potassa, the adjacent parts should be
protected by adhesive plaster, ami the doomed area, if
covered bj' skin, should then be rubbed with a moistened
stick of the caustic uutil discoloration appears. If the
part bo a mucous membrane or raw tissue, a single light
sweep of the caustic is sufficient for even a profound
cauterization. In no case should the agent be used
where an exact limitation of the caustic effect is essen-
tial, as where the part to be destroyed is in close conti-
guity to important, or large, blood-vessels or organs. To
render the corrosion of potassa less spreading, a mixture
of equal parts of potassa and quicklime has been de-
vised, and is official iu the United States Pharmacopoeia,
under the title I'oti(«m cnia Cake. Potassa with Lime.
This mixture, commonlj' known as Vienna caustic, is a
grayish-white, deliquescent powder, .solulile in hydro-
chloric acid. It is less diffusive in its action than potas-
sa, by reason of the peculiar actiou of the lime of its con-
stitution. For use the powder is made into a paste with
a little alcohol.
For a potassa lotion, the solutiou of the Pharmaeopceia
is to be prescribed, diluted with several volumes of
water. For internal giving, the same solution is employ-
able, in doses ranging from 0.6.5 to 4 gm. ( ni x. to fl. 3 i.)
greatly diluted with some svrupy or mucilaginous fluid.
But potassa, as an iuternal remedy, is very objectionable
for any but a very temporary medication.
2ii>rwal I'litiLiKtnni Carbtiiuite : (K-jC()3)2.3H20. The
salt is official iu the United States Pharmacopa'ia under
the title Pataxsii Carbonas, Potassium C'arbouate. It is
a white, granular powder, very deliquescent, odorless,
having a strongly alkaline taste, and an alkaline reaction.
It is readily soluble iu water, but is insoluble in alcohol.
Potassium carbonate is so deliquescent that unless care-
fully ]iut up in well-stoppered bottles it will eventually
transform itself into an oily fluid, by dissolving in moist-
ure attracted from the atmosphere.
Phy.siologically, potassium carbonate is simply a weak-
ened potassa, yet not so weak but that, in strong solutiou,
it may prove a corrosive poison. Its use is mainly in
ointment or iu aqueous solution as a strong alkaline" po-
tassic application in skin diseases. Ointments of the car-
lionate are made with lard, the strength ranging from two
to ten percent. Solutions of the salt for service as lo-
tions range iu strength from one-half to one per cent.
Acid I'otansiiim ('arhonatc : KHCO3. The .salt is offi-
cial in the United State? Pharmacopoeia under the title,
J'ota.'<sii liica rbonas. Potassium Bicarbonate. It occurs in
colorless, transparent, prismatic crystals, and differs from
the normal carlionate in being permanent in the air. It
is odorless, and of a slightly alkaline taste ami reaction.
It is soluble iu 3.3 parts of cold water and is decomposed
by boiling wafer. It is pracficall\' insoluble in alcohol.
It should be kept in well-stoppered bottles.
Physiologically, this carbonate is .similar to the normal
salt, but weaker. The taster is mild, though mawkish;
the alkalinity feeble, and the salt is hardly capable of
being corrosive. The uses are, locally, as an alkaline
aiiplieation in skin disease, in ]ireparations such as are
dcsiribcd above iu speaking of the normal caibonate,
anil, internally, as a stomachic or constitutional alkali.
But for stouiachic purposes sodic salts are more agree-
able, and for constitutional alkalies the potassic citrates
and tartrates. If given internally, the do.sc ranges from
1 to 4 gm. (from gr. xv. to 3 i.).
^^ormal Potamiim Citrate: K^CVIIsO^.H.T). This
salt, formerly known as Salt vf Bicerius, is official in the
lis
P<»taf^Niiini.
PolaM>iiiiiii.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
United States Pliarmiieiip(eiu iiixicr the title Patamii Ci-
trus, Potassium Citrate. It is a ilelicjue.sccat salt occur-
ring in transparent prismatic crystals or as a granular
jiowiler. It is odorless with a slightly alkaline and cool-
ing taste. It dissolves readily in water, Inil slightly only
in alcohol. Potassium citrate is a not disagri'eal)!e tast-
ing, cooling salt, which is devoiil of all local harsh elTect,
and 3'et after ahsorjition seems to undergo ih'Composition
as regards its acid radical, becoming converteil into a car-
bonate. Such secondarily formed carbonate thereupon
exerts the usual aclion of an alkaline potassic compound,
as detailed under Polassa above. Potassium citrate is
thus available as a gentle diuretic, dia]ihorctic, and car-
diac sedative in fevers, and also as an agreeable and yet
eflicient agent for conslilutional alkalizing. It may be
given freely in doses of from 1 to 'i gm. (gr. xv. to xxx.)
in water or in elYervescing water, sweetened or aroma-
tized to taste. In order to obtain the .salt in efTervcscing
solution, in which condition it is more gratefid to a fe-
vered stomach, the following prcjiarations are official in
the United States Pharmacopceia: Pvtussii Oitnix Jiffer-
veseenx. Effervescent Potassium Citrate. This prepara-
tion is a |Hi\vder consisting of a dry mixture of citric
acid, jiotassium bicarlioualc, and sugar. When added to
w'ater, reaction instantly takes phice between the citric
acid and the potassium bicarbonate, with the formation
of potassium citrate and carbon dio.\ide. One or two
teaspooufuls make a dose, to be taken in water and
drunk <luring effervescence. Such efl'ervescent solution
takes the place of the old. so-called "neutral mixture,"
or "mixture of citrate of potassium," formerly but now
no longer otlicial. .Such mixture was siin|ily fiesh lemon
juice, strained, and neutralized with potassium bicaibon-
ate. lAqiuir PnUtssii Citnilix. Solution of Potassium Cit-
rate: This is a simple aijueous solution of the salt effected
by lu'inging together in water six ]ier cent, of citric acid
an<l eight per cent, of aciil potassium carbonate. It con-
tains nine per cent. <if jiotassium citrate, and shoidd be
made fresh when wanted. But the effervescing draught
made from the "effervescent citrate" is a better way of
getting the same solution.
Piiliixsiiiin Arcliiic : KCjIIjO.., The salt is official as
Piitiinxii Acetds; Potassiiun Acetate. This is an exceed-
ingly deli([uesceut salt, having a warming, nnldly pun-
gent, salty taste. Very soluble in water and in alcohol.
It must be kept in well stoppered bottles. Potas.sium
acetate is generally similar in properties to tlie citrate,
un<lcrgoiiig. like that sail, conversion into a carbonate
after absorption, and so operating con.stitutionally as a
potassic alkali. It is not so agreeable to the taste nor .so
grateful to the stomach as the citrate, but has a consider-
able reputation as a diuretic, as evidenced by its old cant
name of Sal il in re/ if inn. As a matter of fact, however,
it, — often, at least— does not prove more diuretic than the
citrate or other potassic salts. Potassium acetate may be
used for the same |>iu'posc and in the same doses as the
citrate.
Pol(mio-sridiiim Tmini/r : KNaC, II ,(),.. 4IU0, This
well-known salt, comnionl_v <-alled Uochelh' or Seig-
nette's Salt, is official in the United States Pliarniaco])a'ia
uniler the title Potiisxii et Svtiii Tiirt i-iix, I'otassiiun and
Sodium Tartrate. This salt occurs in colorless, rhombic
crystals, or as a white powder. It is odoiless. with a
cooling, saline taste, an<l effloresces slightly in dry air.
It dissolves readily in water, liut is almost insoluble in
alcohol. This .salt is decomposed by acids, with the pro-
duction of a ci\ystalline precipitate of acid pcjtassium tar-
tiate ("bitartrate"), and also by sohilile pluuiliic. calcic,
and liiisic salts.
Hochelle salt is mild in flavor and local action, tigrees
well with even a sensitive stomach, and differs from the
citrate anil acetate in being of low. rathei- than high dif-
fusion ]iower. Hence in full do.se it is jiurgativi', but as
compared with the average of .saline juuges ranks among
the milih'r. In non-purgative dose, especially if given
well diluted, it is absorlied, changes to carbonate after
the manner of the citrate and acetate, and then exerts, as
efficiently as other salts, the specific action of alkaline
potassic compounds. From its mildness it is preferred
by many to other potassium invparations as a constitu
tional alkali in rheumatism, lithaunia, etc. For constitu-
tional action as an alkali or as a diuretic the salt is to be
given in comparatively small but frequently repeated
doses, not to exceed, as a rule, 4 gm, ( 3 i ) at a time.
As a purge, the dose will range, according to the inten-
sity of the effect desired, from S gm. to 30 gm. ( 5 ij. to
3 i.) in water, plain or aromatized. A favorite mode of
administration is in elTervescent solution, as obtained by
use of the official Piili-is Eficrce.vens Coinjxisiliis. Coni-
pound Effervescing Powder. This is the well known
l^eidlit: jmiri!c>; and consists of two |iarts, one a powder
in blue paper, made up of about 2.(>0 gm. (gr. xl. ) of
acid sodium carbonate ("bicarbonate ") and about 8 gm.
( 3 ij.) of Hochelle .salt, and the other a smaller powder
in white paper, consisting of aliout 2.2.5 gm. (gr. .xxxv.)
of tartaric acid. Each portion is to be dissolved sepa-
rately in about 60 gm. (ff. 3 ij.) of iced water, sweetened
and aromatized if so desired, and the solution of the aciil
then to be added, half at a time, to that of the salts, and
the potion drunk during the eff'ervescence which imme-
diately occurs. The reaction upon mixing the solu-
tions is, of course, the decomposition of the sodium
carbonate by the tartaric acid, with the formation of a
sodium tartrate and the evolution of carbon-dioxide gas.
A single " powder " is a medium purgative dose.
Acid Potasmim Tai-tnite: KHC.ILOs.— This well-
known .salt, the civmof tartari or rraua <if tartar of com-
mon jiarlance, is olhcial in the United States Pharma-
copieia under the title Pi/tassii Bitartrax, Potassium
Bitartrate. It is ju'epared by a process of jniritication
from the impure salt occurring as an incrustation de-
veloping in casks of w-ine, especially of acid wines.
Such incrustation is called (/cr/^/?, or crude tartar, the lat-
ter name being derived from tlie tart quality of the wines
that furnish the greatest yield of the substance. The
purified salt maybe in crystals, but as furnished to phar-
macists it is in tine jiowder, towhiih condition especially
the cant nan'.e of "cream of tartar" applies. Tlie salt is
permanent in the air, and has an agreeal)le, subacid taste,
it is ]ieculiar in being comjiaratively insoluble in cold
water (201 parts), although much more soluble in boiling
water (16.7 jiarts). It dissolves sparingly only in alco-
hol. The solubility in water can be increased till the
salt dissolves in one part, by the addition of borax, two
parts to five of the tartrate. Commercial cream of tar-
tar always contains more or less calcium tartrate, whicli
salt is a normal constituent of crude tartar, but, accord
ing to the pharmaeopaMal standard, the proportion
should not rise above six jier cent. Besides this natural
impurity adulterations are often found, such as chalk,
gypsum, clay, sand, or ffour. Purchase of the article in
crystals ait'oids the surest wa}' to avoid these sophistica-
tions.
Cream of tartar is a cooling, acidulous salt, agreeing
well with ilelieate stomachs. Like Hochelle salt, it is of
low diffusion jiower and is therefore cathartic, aiul in its
)iurgative action is characterized by the copiousness of
the watery dejections it determines. For this reason it
is a favorite ingredient of cathartic mixtures intended for
caiTying off' a diopsical effusion, such as the compound
jiowder of jalap of the United States Pharmacopceia. In
non purgative dosage the salt is refrigerant and diuretic
— perhaps more gi'iierally <liuretic than any other polas-
.sic c'ompound, but, imlike the other potassic sails of or-
ganic acids, it does iir4 appear to suffer the usual con-
version in the lihuid into a ciirbonate. Such, at least, is
the inference from the clinical ob.servalion that cream of
tartar is not of the same value for constitutional alkaliz-
ing as are, respectively, the other tartrates, the citrate,
and the acetate. The uses of the presi'iit salt are there-
fore restricted to its application asa purge, a diuretic, of
a grateful, cooling .saline in feverishne.ss. The doses are
substantially the .same as those of Hochelle ssilt for the
same several juirposes. The powdered cream of tartar
may be suspended in water or mixed with molasses for
giving as a purgative, or, for use as a fever draught,
744
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pofa^Nf II III,
PutaNNiiiiiiv
may be dissolved in boiling water, and the solution,
when cold, given sweetened with sugar. The old-fash-
ioned, so-called iiiiiierinl draught is made by dissolving
one jier cent, of cream of tartar in boiling water, adding
one percent, of sliced lemon and eight of wliite sugar.
Crenia <if tdrtnr whey, so called, consists of one and a half
per cent, of the salt in milU.
Aoniiiil Piilnssiiim Suljilnite : K0SO4. Tlie salt is nfli-
cial in the United States I'harniocopoeia under the title
I'vliissii 8nlplutx, Pota.ssium Sulphate. It is a permanent
salt, occurring either in transparent, colorless rhombic
crystals, or as a white powder. It dissolves in abont 9.5
parts of cold water, and in 4 ]iarts of hoiling water. It
is insiiluble in alcohol. Potassium sulphate is, like all
sulphates, comparatively liarsh, and in large concentrated
dose has caused fatal irritant poisoning. It is of low
lliffu.sion power, therefore purgative, and its medical u.se
lias been as a saline cathartic. It is, however, little used,
because of its occasional harshness. The dose will range
from 8 to ]() gm. (3ij. to iv.), to be given in solution,
well diluted. This is the salt formerly called viln'olaled
tiirtiir and mil <!c diiohiis.
Pit/iisKiimi. A'itnite : KNO.1. This salt, tlie well-known
substance tu'tir, ur siiltjx trr. is official in the United States
Pliarmacopieia under the title Potami Nitras, Potassium
Nitrate. This is a permanent salt, occurring in color-
less, transparent, six-sided rliombic crj'stals, or in a crys-
talline powder. It is odorless, with a cooling, pungent
taste. It dissolves in about four parts of cold water and
in less than one part of hoibng wafer. It is almost in-
soluble in alcohol. It deflagrates when thrown upon red
hot coals. Under the- name of sitl prunelle or crystal miii-
end, nitre is also to be found in the shops in small circu
lar cakes, moidded from the salt, fused. Conuuercial
refined saltpetre is the quality of the salt to be employed
in medicine, and an article in small crystals is preferable
to one in large, since large crystals are apt to contain
some water, mechanically entangled in the process of
crystallization.
"Potassium nitrate, like the sulphate, is a powerful salt
in local operation, but, unlike the sulphate, is of high
diffusion power, so that even a large dose will be com-
paratively' quickly absorbed. Taken internally it is
therefore doubly potent, and even poisonous, a large
dose exciting severe irritant poisoning, and consecutively
producing in the highest degree the dangerous constitu-
tional ett'ects of the potassic compounds generally. The
.salt undergoes no deeomi>osition in the system, and is
therefore incapable of exerting any al/iidi'iu etrects, either
local or constitutional. In medicinal doses nitre produces
the antifebrile effects of the potassium salts generally,
being cooling and grateful to the stomach, and tending,
after absorption, to quiet a bounding heart and at the
same tini<^ to prove gently diuretic and diaiihoretic.
Being of high diffusion ])ower. it does not luu'ge except
in consi<leral)le dose. A iieeuliar jiroijcrty of nitre is
that, mixed with flesh venous blood, it turns the blood
bright red and impairs its coagulability; but in spite of
much theorizing, the fact does not lead to any special
therapeusis. Medicinally nitre is nowadays rarely used
internally, except as an ingredient of fever draughts or
of diuretic mixtures. Formerly it had considerable reiui-
tation in the treatment of acute rhi'umatism, Ijcing pushed
in full do.ses, but alkalies and salicylates have now sup-
planted the salt for this ap|ilieatiou. The single dose
of nitre should not exceeil 2 gm. (gr. xxx.), and the .salt
is best given in dilute solution. Considerable single
amounts, especially if in concentrated condition, are dan-
gerovis, but so rapid are flic absorption and elimination
of the nitrate that, by means of small and fretpient doses,
proiierly diluted for the taking, a very large (|Uantity —
from 30 to 03 gm. ( 5 i. or ij.) — can be jKissed tlinmgh the
system in the course of a single day without injury. A
special therapeutic application of saltpetre is the iidiala-
tion, for the relief of spasmodic asthma, of the fumes
arising from its combustioir As usual in antispasmodic
medication, some cases find relief from the agent and
others do not, or even suffer aggravation thereby. For
the applicatioD, white unsized jiaper, free from wool,
is steeped in a twenty-tive-per-eent. aqueous solution
of nitre and allowed to dry. A piece is then burned,
and the patient, with the face as near as can b<' borne
without undue irritation, inhales the white fumes that
ar(' given off. Such luepared jiaper is official in the
United States Pharmacopada under the title CliKi-tn Po-
Umnii Nitratis, Nitrate of Potassium Paper. It is some-
times called aiithma puper. Toxicologically nitre is of
.some importance, eases of poisoning by the .salt not
infrequently occurring. An ounce, swallowed at a
draught, has proved fatal in a number of instances.
Taken, as it eonunonly is in such cases, in pretty strong
solution in mistake for ]iurgative salts, it produces synqi-
toms of severe gastro-intestinal irritation — burning pain
in the stomach, violent vomiting and purging, the de-
jecta being sometimes bloody, and general collapse.
Whether the constitutional synqitoms are merely symp-
tomatic of shoitk from the irritation, as occurs so com-
monly with powerful irritant poisons like the nnneral
acids, or whether they are in part the expression of the
specific potassium poisoning fif nerve and muscle, is not
always easy to determine, and is of no practical bearing
on the treatment of the poisoning. Special symptoms
are urinary suppression, with strangury, tenesmus, and
bloody urine, and aphonia. These may or may not oc-
cur. Death may take place in two hours after the swal-
lowing of the poLson. There is no chemical antidote to
nitre, so that the treatment of a case of poisoning must
be conducted simjily on general medical principles.
Poiitssiiiiii CJihirnte : KCIO3. The .salt is ofticial in the
United States Pha,rmaeop{eia iimler tlie title Potiissii
C'/ilornn, Potassium (Chlorate. This is a permanent .silt.
occurring in colorless, shining, prismatic crystals or
plates, odorless, and having a cooling, saline taste. It
dissolves in 16.7 parts of cold water, but in 1.7 parts of
boiling water. It is slightly soluble only in alcoliol. If
heated or triturated with organic substances, such as
sugar, tannic acid, or cork, or with easily oxidi/alile
chemicals, such as sulphur or phosphorus, a tlangerous
explosion is likely to occur. The salt should, therefore,
be kept in glass-stoppered bottles and handled with care.
The chemical relationship bet\i'eeu chlorates and ni-
trates is paralleled, as usual in such cases, by resemblance
in physiological action. The present .salt thus closely
resembles nitre in its effects, the jnineipal difference
being in intensity of power, the chlorate being the
weaker — a fact jn'obably in part due to the less ready
solubility of the .salt. Yet the chlorate is strong enough,
in full concentrated dose, to be fatally poLsonous, with
symjjfoms of inten.se gastro-intestinal irritation, ajid. in
too lavish medicinal use, as has been the fashion in diph-
theria, to be the likely cause of much of the ne|iluilic
disonler thoughtlessly assigned, in etiology, to tlie dis-
ease instea<l of to the luedicine.''' For, like the nitrate,
the chlorate of potassium has a distinct tendency to irri
tate the kidneys, which, in the choked condition of the
organs common in diphtheria, may easily lead to dan-
gerous congestion. Potassium chlorate was forced into
medicinal notoriety largely by the theoretical consider-
ation that, since chlorates readily |iart with some of their
oxygen, thus proving active oxidizing agents, the salt
ought to serve as a consfifutiofial source of oxygen with-
in the animal system, and so )iidve of benefit in diseases
that tax the nutritive powers of the organism. Clinical
experience, however, does not liear out the jirognostica-
tions of theory, and physiological chemistry accounts for
the failure by finding "that, under the conditions of the
animal circulatiini, potassiiuu chlorate suffers no decom-
position, but is eliminated by the kidneys and other or-
gans unchanged. The only rational place of this salt in
medicine hinges on t!ie following fai'f : The chlonite is
largely eliminated by the salivary glands, and probalily
also by the mucous follicles of the mouth and ]iharynx,
and in inffammatory conditions of the surface textures of
these parts distinctly tends to healing. Sore mouth or
sore throat, catarrhal or ulcerative, is therefore treated
with advantage with potassic chlorate in the form of
T45
P4»la«»silliii.
Pr(>iiiiiliirt' liil'aiilh.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
wasli or gargle, or, better still, for the sake of rontinuous
applicatiou to the parts through the avenue of the saliva
and buccal mucus, given inteinally. A convenient prac-
tice is to prcscrilie a Hve-jier-cent. aqueous solution of
the salt, which is upon the vcrg<' of a saturated solution,
and direct this to lie used as a nioulh wash or gargle
every two hours, and at the same time a couple of tea-
spooufuls to be taken iuterually. Such quantity will
represent about 0..50 gm. (gr. viij.) of the salt — a moder-
ate single internal dose. Among tlu' varieties of buccal
disorders amenable to potassium chlonilc may be men-
tioned mercurial stomatitis; and some praclilioners even
condjine the pc.tassinm salt wilh their mercurials in con-
stitutional mercurialization, willi the view of lessening
the risk of salivation. In diphtheria, also, tlie chlorate
is a good deal used, the good effects beiug iirobably the
local ones otdy, and the risk to kidneys or heart from too
free dosage being genuine and considcralilc. Of prepa-
rations, the United States Pharmacoineia makes official
T/'ocA (>(■;' Potii.inii Clihiratis, Troches of Potassium Chlor-
ate, the ingredients being the salt, sugar, and Iragacauth.
and a little of spirit of lemon for flavoring. Kacli troche
contains 0.80 gm. (about gr. v.) of chlorate. In onlinary
sore throats or sore mouths, for the tiTatment of which
affections the preparatiim is es])ecially intended, these
lozenges, if allowed to dissolve naturally without chew-
ing, may be taken continuously through the da.y.
Kditiird Curtis.
' liinsreraml Murrell: Joiirhal of I*liysi»)lit)^'y, i., p. 88.
■^ Bashani : Prarlitieiier. vtil. v.. ji. ;i')Vt-
2 Ja.ul)i: Mi-ilK-al liecnnl, vul. xv.. p. 241.
POTASSIUM. TOXICOLOGY OF. -Independently of
the corrosive action which characterizes the o.xid. liy-
droxid, and carbonates of potassium, those compounds of
potassium with acids, which have little or no to.vic quali-
ties, such as the chlorid, sulfate, or tartrate, e.xert a
distinctly poisonous action. In this respect the potas-
sium compounds differ notably from tho.se of sodium.
E.xperiments on dogs demonstrate that the injection of
from 1 to 3 gm. of potjissiiun chlorid. nitrate, sulfate,
etc., directly into the circulation, produces death very
quickly from cessation of the heart's action. Smaller
quantities jiroduce a slowing of the iiul.se, more or less
gastritis, dyspncea, convulsions, and sometimes deatli.
Diluted doses seem to have a less serious effect than the
same weight of the salt in a concentrated form.
All fatal eases of poLsoning iu the human subject by
the potassium salts of non-toxic acids have been due to
ignorance or accident.
Ptiliissiuiii Broiiiid — KBr. — Two cases have been re-
ported in which deatli followed the administration of
verv larire quantities of imtassium bromid, Duncan
(Brithh'~ M,'d. .fniuiuil. l»s-..>. Part I.. ]i. UUi) relates a
case of a child three years old, who died in less than half
an hour after taking between o and (i gm. of the drug.
The other ctise was tiiat of an adult female, to whom was
administered by her jihysician 4.2 gm. every four hoiu's
for four days. The jiatient died five days after taking
the last dose (Hamer, Cnlnihhiis Med. Jovnui/, vol. ill.,
p. 2,19).
Aside from bromism several non-fatal cases are on rec-
ord, in some of which the jiatient exhibited a peculiar
idiosyncrasy as regards the tolerance of this substance.
Ptiliig.^iiiiii Vhhtrid — KCl. — The poisonous action of
this com]inund upon animals has been to some extent in-
vestigated. When injected into the blood sui^jdy of a
nerve, the latter loses its cx<atabilily. The sail is'elimi-
nated with the urine, but iiuich more slowly than so-
dium chlorid. I tiuil no fatal cases rejiorted asarcsidt
of the poisonous action of this salt upon human beings.
j'ljtiiagiinn jXttnitc — KNOj. — This substance is com-
monly known liy the naitie of nitre or saltpetre. Its use
as a jireservative of meat and other articles, and am<ing
agrii'ulturisis iu the treatment of diseases of domestic
aiuinals. makes it one of the common household drugs.
In pciisoning by potassium nitrate it is iinite certain
that tile acidulous constituent plays no small part in the
toxic action. This conclusion follows from observations
upon man and lower animals, when subjected to the ac-
tion of sodium nitrate (see two cases of poisoning by so-
dium nitrate, CoUischorm, DenUche med. Warhenschrip,
vol. XV,, p. 844). Large doses (3-.5 gm.) cause uneasi-
ness in the stomach and intestines, followed b_v vomiting,
diarrlia?a, and generally a frequent desire to urinate.
Fifteen to twenty grams produce an acute gastro-enteri-
tis, the voiuit tinged with blood, pronounced weakness,
cold sweats, and cramps, especially in the calves of the
legs.
Woodman and Tidy ("Forensic Medicine and Toxicol-
ogy") report six fatal cases in which the dose varied
from 1.5 to 45 gm., and the duration from two to sixty
hours. AVormley ("Jlicro-Chemistry of Poisons," p.
69) luentions an instance of an aged luan who died in
half an hour after taking a quantity of potassium nitrate
in mistake for sodium sulfate. Size of dose not given.
Bailey (Phihi. Med. and 'Sure/. Repnrter, June, 1873, p.
7.5) records a recovery after taking 125 gm.
Lesser (T7ir/f {;>//( r. /. ga: Mrd., 1898.3. F., xvi., 93)
reports the case of a woman aged forty-six, who died
twelve hours after taking about 70 gm.
Most of the cases of poisoning by potassium nitrate
have been due to mistaking the substance for magnesium
or sodiuiu sulfate or sodium chlorid. In several instances
overdoses produced serious results.
The .symijtoms consist of a severe burning pain in the
abdominal region, nausea, vomiting, purging, vomit and
stocils containing blcioil, coldness of the extremities, fa-
cial tremors, weak and irregular pulse, and collapse.
Dilhcult respiration was observed iu some cases.
No chemical antidote is known. The treatment shotdd
be to remove the poison from the stomach, give muci-
laginous drinks, and treat the symptoms.
I'ost-moiii III Ajipi'iinnire/t. — The stomach is usually
highly intlamed, with dark-colored patches, and the mu-
cous membrane partially detached. .Similar appearances
have been observed iu the duodenum and intestines.
Sometimes the indications of asphyxia are present; the
lungs are congested, and the right heart is tilleil with
thick, verj- dark blood.
Potnusiiim Siilfule — K»SOi. — This substance was for-
merly employed to produce abortion, several fatal results
having occurred from such use. Bayard reports a case
(Anil, d' Ili/i/iiiie, April, 1842) iu which 33 gm. of potas-
sium sulfate were administered as a laxative after
delivciy. Death followed in two hours. A case is
recorded in the Medicnl Times and Gazette, 1856, p. 420,
in which 8 gm., administered to produce abortion, caused
death.
The symiitoms noted were pain in the stomach, nausea,
vomiting, purging, and cramps iu the limbs. A post-
mortem examination showed the stomach to contain a
reddish liciuid. and the muc(nis membrane to be of a pur-
ple color.
Pijtassium hitartrate — KHCjH^Ob. — Although this sub-
stance, commonly called cream of tartar, may be foimd
in eveiy household. I hud recorded but two fatal cases of
poisoning by its use. In Tyson's case {Lancet, vol. 1..
18o7-38, p. 102) death followed in four days the taking
of 12.5 gm. Roger reports a case (Friedreich's L'/dtterj.
yer. Med., xxviii., 1887, p. 190) in which 200 gm. caused
death in twelve hours.
The prominent symptoms were severe abdominal jiain,
persistent vomiting and diarrhea, thirst, feeble pulse,
and |)aralysis of the legs. A post-mortem examination
showed the inteiior surface of the stomach covered with
red streaks and patches, and the intestines somewhat in-
flamed.
Ax.M.ysis. — Since potassimn compounds are normally
present iu the body lluids and tissues, the analyst can-
not report them as having been introduced into the
system, unless he can prove them present in abnormal
(|uantity, or iu unusual combination. Cream of tartar,
on account of its sparing solubility, may be found in
the stomach in tlie solid form.
Jj'iiis ir<;/-«(';- Pig;/.''.
74i;
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
P(»|jlMMilllll.
Frt'inallii-t' InlanlH.
POTT'S DISEASE, ^va tipine, Diseases of.
POWDER SPRINGS.— Cobb County, Georgia. PosT-
OkfH K. — Powder Spiiiigs.
Access. — Tiiko Western and Atlantic Railroad to Ma-
rietta, and from thence private con veyuuce to the springs,
ten miles distant.
These sjirings were discovered about fifty years ago,
but for want of improvements theii' reputation has been
confined to the suirounding country. There are four
springs, one of which has been approximately analyzed
as follows :
One United Stales gallon contains: Iron sulphate, gr.
2; calcium sulphate, gr. 1; iron o.xide. gr. 1.50. Total
solids, 4.50 grains. The contained gases are: Carbonic
acid. 1 cubic inch; hydrogen sulphiile, 1.5 cubic inches.
The other springs contain aliout the same ingredients.
The flow of water is about two and a half gallons per
minute. The waters are evidently chalybeate, and we
are informed that they have been founil highly useful in
depressed and debilitated states of the systein where a
fairlv potent ferruginous tonic is indicated.
■I.IIIHS K. ClYMlk.
POWHATAN LITHIA AND ALUM SPRINGS.— Pow-
hatan County, Virginia. Post-Offici;. — Toliaccoville.
Access.— From Richmond via Farmville and Powha-
tan Railroad to Tobaccoville station, forty-eight miles
west, thence three-quarters of a mile by private convey-
ance to sjirings.
The.se springs are two in number, one known as the
Lithia. the other as the Alum Spring. They yield about
live hundred gallons of water per'day. A (pialitative
analysis of the lithia water by Dr. W.H. Taylor. State
chemist at Riclimond, showed the presence of lime, mag-
nesia, soda, lithia, potash, iron, silica, sulphuric acid,
carbonic acid, ami chlorine. The alum water was ana-
lyzed at the Smithsonian Institution and found to contain
about the same ingredients, except that the lithia was re-
placed by alum. The water is sold to some extent, but
the property has never been much develoiied and no
hotel accommodations have been provided.
JiiDies K. Criiok.
POWNAL SPRING.— Cumberland County, Maine.—
Post-Offkk. — West Pownal. Hotel.
LocATio.N, — Eighteen miles from Portland and ten
miles from Poland Spring.
Access. — Via Grand Trunk Railroad to West Hanover
Station, or Maine Central Railroad to Pownal Spring
Station.
The surroundings of the spring are very pleasing
to the eye. The White ^Mountains, in the distant north-
western horizon, form an impressive background, while
to the southward a wide panorama is unfolded to the
view of the beholiler, even Portland harbor being easily
seen by tlie aid of a small glass. The locatiimof the
spring is upon land higher than any other in the im-
mediate vicinity, thus giving no opiKirtuuity for surface
pollution. The water comes apparently from the solid
rock, and is clear and sparkling. The avera.ge tempera-
ture of the water as it emerges is 43' F. This is subject
to a variation of only one degree in either direction during
the entire year. The following analysis was made by
State Assayer Franklin C. Robinson, professor of chemis-
try at Bowdoin College in 1898:
Reaction neutral. One United States gallon contains:
Silica, gr. 0.41; iron carbonate, gr. 0.04; calcium carbon-
ate, gr. 0.33; magnesium carbonate, gr. 0.02; sodium
carbonate, gr, 0,09; .sodium sulphate, gr. 0,08; sodium
chloride, gr, 0,1(); potassium carbonate, gr, 0,03, Total
solids, 1, 15 grains.
Organic and volatile matter, 0,01 grain. The water is
bottled and solil. It is recommeniled for the table, and is
said to be useful in dyspeptic and urinary comjilainls,
but the remarkable attenuation of the water would ap-
pear to reipiire the ingestion of large quantities in order
to secure ap|ireciable therapeutic effects,
Jiumx K. CriitiJ,-.
PREMATURE INFANTS.— By premature infants we
mean those babies which are born before the two huu-
<lred and eighty days, considered the normal length of
intra-uterine gestation, have elapsed, and after the period
of viability of the child. This iieriod, houever, is only
arbitrary, and varies wilhin relatively wide limits. In
this resjject much depends ujjon the nouiishnient of the
foetus ])rior to birth, the health of the mollier during preg-
nancy, the conditions deman<lingor leading up to the in-
terruption of pregnancy, the character and duration of
labor, the difliculty attending its birlh, as well as the care
of the infant after its advent into the world. Conse-
quently, in a syphilitic, tuberculous, or albuminous
mother, in a case of placenta pr;evia or <if accidental
hemori'hage oreclampsia, in a dry, jn'otracted labor, after
a breech, forceps, or version delivery — in all these con-
<litions, on account of the immature development of the
vital organs, the chance of survival of the baby is very
much reduced.
There are cases on record in which it is claimed that
the child in ulero reached only the twenty-fourth week
and yet lived. Perhaps, in the future, advances in our
knowledge of their care will enatile such infants, born
before the date supposed to be compatible witli life, to
survive. It is more likely, however, that such cases are
reported with mistaken calculations.
There are no characteristic appearances, no exact de-
velopment upon which we can definitely state the age of
the infant when it is born. The weight, the length, and
development all vary for a given length of gestation and
statistics given are tmly approximate, but yet of sutK-
cient value to guide us .somewhat in the management of
such infants. It is therefore generally the rule that if
the infant is born alive, we must endeavor, without re-
gard to size and characteristics, by the best caie and latest
knowledge, to preserve its existence.
The general characteristics in the clinical picture of a
jiremafure child are as follows: The head is very large
in proportion to the body, the abdomen is promini'Ut, the
movements are very weak, the body is limp, and the
child has a senile, emaciated, and wizened-up appear-
ance.
At the iiTenty-foiirth week- of intra-uterine life a fcetus,
when born, usually breathes feebly. Some cannot cry,
although others will give a faint mewl. The infant is
covered by lanugo. Its eyelids have separated, though
it is so feeble that it cannot often open and shut them.
There is very little subcutaneous adipose tissue. It
measures about 38-34 cm, (11^-13* in,) in length and
weighs 676 gm, ( | .xxiii.). The testicles are only at the
inguinal rings. This fcetus may live from a few hours to
fifteen days, Imt would in all probability die from insuf-
cient assimilation after a weak digestion of food, from
rapid loss of heat or from imperfect respiration. At the
tireittji-eifilith week the f(etus measures in length from 35
to 38 cm, (13,75 to 15 in,) and weighs 1,170 gm, (41j- oz, ),
The soles of the feet and jiahns of the hands are not cov-
ered by lanugo. The pupillary membrane, which liad
hitherto obscured the pu])il, has now disappeared. The
skin is still wrinkled, covered b.v vernix caseosa. The
child still has an emaciated appearance. Such an infant
with good care can live, but most of them die. There per-
sists, however, in the minds of .some of the old juactition-
ers and among the laily, the idea lh:it a child born at the
seventh month is more apt to survive than one boi'n at
the eighth month. Of course this is nonsense, for the
devehipment and functions of the vital organs are by far
less advanced at the earlier than at the later date, and it
stands to reason that the elder fietus will be stronger
thereafter. Professor Parvin, in his "Science and Art of
Obstetrics," tells how this superstition has descended
through more than two thousand years from Hippoc-
rates, The Greek explained it in this manner, that the
fietus is placed with its head at the fundus in the uterus
until the seventh month when the increasing weight of
the liead causes it to descend to the lower zone. As soon
as this occurs, the fa?tus attempts to escape, and if it is
strong it succeeds; but if the attempt fails, it tries again
747
Frcliial II i'4' liilaiilM.
Pri'iualiii-f lulaiil!k.
liEKKHENCE IIANDlioOK OF THE JIEDU'AL SCIENCES.
at the eiglilli month, and if tlio infant now siicfccds in
escaping from the utprus, l)cing exliansled by lis previ-
ous effort, it is more ajit to siieciimb.
At tlie tliii-iii-fiti-miil week the fietiis measures 311-41 em.
(151-16 in.) in' k-ngth, and weiglisl,.-.?! gm. (8niis.). The
hair on the sealp is h)nger and more abundant; the (low n
on (he face is di-sajipeariug. One of tlie testicles, nsually
tlie left, has descended into the scrotum. Tlie nails are
firmer, liut do not <iuile reaeii the linger tips. There is
ossification beginning in tlie lower epiphysis of the fe-
mur. The cliikl has lost .some of its senile iippearanee
and emaciation due to the increased deposition id' subeii-
taneous fat. At this jieriod, with proiier care, tlie eliild
ought to live. At the t!iirti/-si.ii/i week tlie infant meas
ures 42-44 cm. (IGi-lTJ in.') in Icugtii. and weighs 1.943
gm. (4J- lbs.). There is a decided increase in sulicutane-
ous fat. The nails are not j'ct perfectly developed. The
lanugo has disappeared and the bones of the head are still
soft and ver\' compressible. The infant is nincli stronger.
but is still in a condition to die ea.silv unless well eared
for.
A detailc'd description of a premature child is as fol-
lows: The /irad is iwcessively developeil and conse-
quently its contents (the brain) are excessively dcvelo]ied
ill comparison with tlie diminutive characteristics of the
rest of the body. Yet the head is very .soft and compres-
sible, for the bones themselves are very poorly ossitied,
thin, and parcliineiit like, crackling under pressure, and
the sutures and the fontanels are wide open. C'on.sc-
quently the .symmetry of the head is easily destroyed,
considerably so in the moulding of delivery, not only by
the bony pelvis, but also even by a rigid cervi.x or peri-
neum, yet more so in prolonged positions of the head
after birth. The moulding is usually temporary and the
bones ordinarily quickly resume their ju-oper relations.
However, if the cliild continuously lies on one side of its
head, even though the pillow is vi^ry sid't, from its mere
"Weight a marked deformity develops. This can be
avoided by letting the child lie on alternate days tirst on
cue side and then on the other.
Abdoiiwn. — The alidomen is almost always relatively
distended, due in a great measure to the huge .size of the
liver and the accumulation of gas in the intestines wdiose
peristaltic movements are very weak. This ilistentiou
may last for many weeks, and the .gradual return of the
abdomen to a normal size is a good sign in the gradual
development of the infant to the status of a cliilil liorn
at term.
tSkiii. — The skin is of a dull, brownish-red. more mark-
ed I v so at first than at a later period; when the child
cries this color changes to a brighter and healthier red.
A.side from this, the color is ajit to vary eonsideralily
at different times, for premature infantsare prone to ery-
thematous rashes, and are almost regularly icteric after
the second or third day. If the child is doing |iooily the
skin is pale, transparent, dry, scaly, and wa.xy white,
sometimes anlematous. It is soft and delicati', so thin in
some spots, especially over the forehead and skull, tliat
the superficial veins shine through. In other jilaces it is
very wrinkled, due to lack of adipose tissue; a coiKliiion
which gives to the body and extremities an einaciate<l
appearance and to the face a senile expression. There is
liresent a varying amount of lanugo, dejiending on the
degree of prematurity. The nails are soft and short,
they do not reach the ends of the digits; this is more
noticeable on the toes. The sweat glands are suii|io.scd
to lie undeveloped, but certainly many ]irematuie liabies
[leispire profusely if the temiierature of the iiicubati>rs
is too high. On the other hand, the sebaceous glaudsare
moderately active, yet more so liel'ore biiili llian after-
ward.
Tlie(.(7/r;/(i7/i.v are thinand emaeiati cl. with apjiarently
atrophied muscles. According to Dane the instep is as
Well devidoped as is that of an adult.
The nit/reiiieiitx are few and slow, but at times sp.as-
modic.
The venpii'ittidiis are shallow, irregular, and su])erficial.
and often suspended for a time. The little one sucks
slowly and weakly, and swallows with difficulty, and the
mere effort is followed liy more or less exhaustion.
The tinsiies of the infant are not yet sufficiently devel-
oped to meet the demands of extra-uterine life ; this is es-
pecially true of the (lastm-iiitfrii- tnict. The capacity of
the stomach is small, varying with the weight and size
of the child. The walls are weak and thin, and an organ
holding at lirst two or three drachms will easily dilate
until it has a capacity of an ounce or even an ounce and
a half, much to the infant's lo.ss. Even absorption is
slow and inetlicient, and the digestive juices are lacking
in ferments. The aniylolylie tunction is practically sns-
|iended. and should not be dei)eiided upon at all for the
digestion of stanhes. Sugar, on the other hand, is a
foodstulT most easily taken care of by sim|ile absorption.
It is needed to keep up the animal heat, wliicb is so easily
lowered in the premature cliild, and conscquentlj' is of
great importance. At first it should be given in lower
percentages till the gastro-cuterie tract is accustomed to
the new work which it is reijuired to perform. The func-
tion of digesting fats and alliuminoids is far interior to
that of a full-term child; and all forinuhe should conse-
f|ucntly at the lieginning be very low in such ingredients;
even breast milk must be well diluted in the more pre-
mature children for a number of days after birth.
The uiti's/iiiex of a piemature child contain meconium,
and after a few days, if the digestion is good, the f;Bces
assume the normal golden-yellow color. These infants,
however, arc jnone to constipation on account of weak
peristalsis, and often the stools contain curds, and too
easily become frequent, green, acid, and slimy.
The liein-t is relatively large, but its action is weak.
The foramen ovale often remains patulous for a longer
period than if the infant were born at term. Inasmuchas
the air cells of the lungs are by no means all in use for
oxygenation, and inasmuch as the blood soon becomes im-
poverished from insutliceiit nutrition, large demands for
increased work are niadi.' ujiou this vital organ. Conse-
quently the infant should be kept ([iiiet and no u.ieless
extra work should be put ou the circulation, which is in
such a precarious condition, not only on account of the
many changes which occur with the tirst respirations in
different structures of the body, but also for the reasons
mentioned above. The pulse is more rapid than that of
a normal infant, but it is not ]iermissible to base a prog-
nosis u]ion this fact.
The lil'it/d at birth contains an excessive amount of lue-
moglobin, but it is loosely held in the red corpuscle, and
the infant readily lo.scs it and becomes an;i;mic. De-
struction of ha-mogloliin is going on rapidlj' and its
manufacture progresses but slowly and for many days
does not make u|) the lo.ss. The blood itself, especially
in those cases which are doing poorly, soon becomes thin,
watery, and deficient in all its solid and vital ingredients.
The child conseipieutly often becomes waxj'-white and
u'dematous.
The animiil lient of the infant is easily affected. De-
privi'd of its source of eombusliou and insulation (tin'
sulicutaneous fat), variations occur quickly and readily
Thrust at birth suddenly into an atmosphere twenty-
eiulit degrees lower than that to which it had been aceus-
toiued hilherlo. no wonder the tempeniture falls simjdy
from radiation. The nietabolisiu is too slow to manufac-
ture enough beat to maintain aconstant tenqierature. and
the strain upon an uneducateil beat centre is not borne.
Again, another reason why the temperature is subnor-
mal is that the premature infant with all its vital organs
undeveloped is called upon tofurni.sh more heat than the
child at term, for we all know that the smaller the ani-
mal the greater is the surface exposed for radiation.
Conse(|uently the temperature is lowered both by an iii-
sutlieient heat production and by an excessive loss of
heat, which the heat centre is powerless to control and
therefore to s<'t in eiiuilibrium. So spasmodically does
this centre act that the temperature of the child will for
trivial causes run very high. This is especially the ca.se
during the first few days of life, and it is often very ditti-
cult, even in a well-regulated incubator, to keep this
748
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Prcliiaf lire lliraiitH.
Prffkialiire lufauts.
temperature normal. Besides, slight gastro-intestinal
troubles, as vomitiug. coustipalioii. or diarrliani. will
eause sudden rises which do not occur so readily iu the
full term baby.
The lungs are also in a very undeveloped state, and al-
though they are sufficiently "developed to carry on their
functions in extrauterine life, the tissues of tlie re-
spiratory tract are very sensitive and easily become in-
tlaraed. Especially is this tr\ie of the nose, nasopha-
ryn.x. and mouth, for here infection readily occurs
from inhalations of dirt and dust. Besides, even though
the baby has cried very well at birth, the respira-
tory elTorts do not at once aerate more than the an-
terior lobules of the lungs. Some of the children re-
main blue, breathing and crying weakly, and die in a
few days. Others gradually make a greater use of their
lungs, but from slight causes they acciuire a secondary
atelectasis in addition to the fa^tal condition posteriorly.
The irregularities of the respiration are very marked.
Adriauce ex plains this condition on the basis of his studies
of the embryology and patholog.y of the lung. Before
the fourth month of fu'tal life there are no alveoli, and
the bronchioles are far apart iu the niesenchyma. In the
development tlie tubes ramify rapidly. From this we
see that, if a child is born prematurely, the bronchi pre-
dominate and the few alveoli are enclosed in connective
tissue. The blood-vessels of the lungs are composed of
a rich, unsupported capillary network, whose elastic
walls are readily stretched and so encroach upon the air
vesicles. The feeble respiratory movements permit of
collapse of the air vesicles and engorgement of the ves-
sels— conditions which result iu hypostasis and atelec-
tasis, posteriori)' and inferiorly . Besides, the bony frame-
work is poorly adapted foraOfatiou. Being cartilaginous
and very elastic, even with a strong muscular eliort at
respiration, the lower part of the chest is drawn in. es-
pecially over the sternum, and only a very little air really
enters the alveoli. Cyanotic attacks consequently are
very frequent and often fatal. The respiratory centre,
like that of heat control, is spasmodic and weak in action.
These respirations are often delayed, feelde, and even
Chevne-Slokes in character, and this undeveloped centre
is often responsible for the cyanosis which ensues. Every
autopsy on premature children who have died within a
week or so after death shows atelectasis, and the weak
pulmonary organs are responsible for most of these
deaths.
The lirer is very large and fills over one-half the space
in the abdominal cavity. Bile is secreted in great quanti-
ties, and it is jirobably to over-production by tlie liver
cells and to engorgements of the ducts that we must at-
tribute the reg^ilar and early occurrence of icterus neo-
natorum.
The kidneys also perform their functions irregularly.
For a day or two no nrine is voided. Uric acid is secreted
in abundance, for the napkins of the child are often
stained with the characteristic pink color, and the pyra-
mids almost always on autopsy are found to be plugged
with uric-acid infarctions.
Phooxosis. — The weight of a premature child varies,
for the same duration of intra-uterine life, for many rea-
sons : consequently we must base our jirognosis less upon
the weight at birth than upon the general condition of
the child. Yet it goes without saying that, other things
being equal, the more premature the child the less is the
probability of its survival. The daily progressive gain,
on the other hand, furnishes by far "the best indication
that matters are progres.sing satisfactorily ; yet one has
to wait a long time" before this is manifest. Prema-
ture children, even though weighing less at birth, have
a greater initial loss, and a loss which extends over
a longer period, than the full-term child. It is not un-
comnKin for a child weighing three and three-quarters
pounds or therealionts to lose from ten to fourteen ounces
and to continue to lose for from ten to seventeen days.
This is due to the inunaturity of the digestive tract, and
to the fact that the babies are invariably intensely jaun-
diced. On account of tlie latter condifiou they lie iu a
stupor, are with difficulty aroused, and take their nour-
ishment very pooily ; then besides, they gain moreslowlj\
If the infant has, at the end of three or four weeks, re-
gained the weight which it had at birth, it will have
done very well. If. on the other hand, the loss is pro-
gressive, sooner or later there will be a fatal outcome.
The prognosis then depends on the general conditional
birth, on" the degree of prematurity, and most of all on
the subsequent care. Extremes of temperature nuist be
guarded against. Attacks of cyanosis are not necessarily
fatal, but they render the chance of survival very doubt-
ful. If the child lives for four or five days, and the
attacks are decreasing in number, the outlook is more
hopeful.
TnE.\T.MENT. — There are four distinct objects which
must be kept iu view iu the care and management of
premature children.
1. The maintenance of a iiroi.)er temperature.
3. The prevention of exliaustion.
o. The administration of the proper amount and kind
of nourishment.
4. The avoidance of infection.
Premature children can be divided into three classes:
(1) Those treated as babies at term. (3) Those wrapped
in cotton. (3) Those placed in the incubator.
The weight, length, appearance of the baby, and even
the assiuned period of gestation, calculated from the
mother's last menstruation, are simjily relative in esti-
mating the exact duration of ftetal life. It is by far a
better procedure to consider the general condition of the
infant, together with the above, before we put it into
one class or the other. The majority of the babies woukl
do better if they were to be placed in the last class from
the beginning. Without a couveuse the best plan is to
put a bab.v in cotton and surround it by hot bottles.
S<mie babies will thrive in this way, but most of the
very premature will not.
There are many kinds of incubators iu use. notably
those of Denuce, of Bordeaux, who in IS.j? produced the
first one which gave satisfactory results. Iu 1880 Tar-
nier constructed one which was afterward improved b)'
Auvard. Crede also invented one which was success-
fully nsed. The brooder of Dr. Rotch, of Boston, is a
very intricate and elaborate affair, in which the baby can
be weighed without removal. The best one is probably
that ot" JI. Lion, of Nice, first used in 1891. It is com-
posed of a jiarallelopiped of metal, standing on iron sup-
liorts. It can be disinfected without deterioration by
means of a steam stove luider pressure or b_v cleansing
with a solution of carbolic acid or with formalin gas
(Fig. 3870). Ventilation is obtained by means of a tube,
of about three iuches in diameter, which enters the com-
partment low down on the left side. The exit is thiough
a chimne)' in which is a fan, indicating b_y its rotation the
strength of the current of air. The air on entrance is
filtered by a gauze and cotton diajihragm. The front is
fitted with glass doors, through which the infant can be
seen, while at the side is a glass window by means of
which the nurse can attend to the infant's wants without
removing it. The baby is placed iu the middle on a soft
pillow, the warm, fresh air circulating about it. The air
is kept moist by a large jian of water jilaced in the bot
tom. A thermometer is hung close to the door, and a
hvgrometer is fastened to the posterior wall of the cham
bef. The heating is effected by means of a sifibon
through wluch hot water circulates, and which commu
uicates with a reservoir at the side. The temperature is
automatically regidated by a metallic thermostat, which
lifts or lowers a" cap over a flame. This apparatus is
very expensive, and therefore adapted for use only in
hospitals or in wealthy families. Besides the Lion iiicu
bator, there isavailable a cheap modification of tlieTarnier
or Auvard couveuse, which any carpenter can make at .-i
small expense. The main point iu its construction is
that there should be plenly of inlets and outlets for free
ventilation. The disadvantages of this apparatus are,
first, the lack of filtration of the air, and, second, there is
no thermostatic regulation of the temperature. To ob-
r49
Pmiinliii-i> Infants.
Prciuature liil'auts.
HEFEREXCE IlAXnnooK OF THE MEDICAL SCIENCES.
viiitf tlio latter rlilfloulty. tlicrcforc. ("ucl'iil atlciitidii will
lie necessary. A teniperatui'e as near cdnslant as ]iossi-
ble is to be obtained by varyinir the size of tlie tlanie and
its distance from tlie tube coiniecling with the main tank
of water (Fig. 3879).
In order to secure the ma.ximiim amonnt of fresh air
the incubator — whatever kind is used — should be placed
in the hall or in a large cool room. The direct rays of
tlie sun oiii:l.t never to sliiUc it, because their heat would
quickly unbalance n constant leni|HTature. Bi'fore jiiit-
tiug a baby into the chandler the apparatu-i slioulil be
Fici. llsTiC— hii-iibatur ol .M. Lmn. uf Nice, France.
chives o/ I'idiati-ics.)
I, Fiom llii- -ir-
thonmghly disinfected, as these infants are very suscep-
tible to infection. The liaby slinuld lie on a very soft
pillow.
The t<'mperature should vary with the infant. It
shimld be one which will keep 'the baliy's temperature
normal without exciting perspiration. I have found that
a temperature of from 86^ to 92' F. is about right. A
variation of a degree or two makes but little difference.
If a premature baby is e.xpected, an incubator, the air of
whicli is at a proper temperature, should be in readiness,
at the time of its birth. The baby itself is first made to
cry histilj' (not with liarsh methods of resuscitation, but
mainl_y by tlie employment of iiot baths and light titilla-
tion, and perhaps by easy swinging), and tlien the cord is
quickly tied off and suitable dressings are a|iplicd. After
the child has been weighed and anointed with albolene,
but not bathed, it is dressed. A mistake is made in en-
veloping these infants in cotton. So wrapped up they
will be too warm and will perspire too freely. The best
clothing is a small light shirt and a napkin from the waist
down, pinned over the feet and legs (Fig. 3881). When
the baby is placed in the incubator it should not be re-
moved, except to be weighed or nursed. The latter is
not permitted until it is thriving. The weight is taken
every tive. seven, or ten days, and about once a week the-
infant is ligbtlj- sponged.
The napkins should be changed three or four times a
day, only often enough for cleanliness, iind in such a
manner as to disturb the baby as little as |iossible. Before
feeding, however, especially when the baby is stupid or
sleepy, a light tap on the hand will make it take the bottle
with much less coa.xing and more rapidly.
The infant should' be kept in the incubator until it has
reached the development of full term, or longer if it is
not improving. Some of the babies, nevertheless, will
do well in cotton after having been given a good start in
the couveuse. If possible, the temperature of the incu-
bator should be graduallv lowered almost to that of the
nursery, before the baby is permanently subjected to the
variation in the temperature of the air of an ordinary-
room.
In the administration of nourishment the amount and
quality should depend on the age and digestive powers of
the infant. Oidinarilj-, si.x hours after birth, the child
should be given a warm sugar .solution (tive to si.x percent,
lactose in distilled water), about onedialf to one drachm
every hour. After from twenty-four to thirty-six hours
an equal part of breast milk should be added. This is ob-
tained by mas.sage and expression, b_v the breast pump,
orbv spontaneous expression while a baliy is nursing the
other breast. If the best results are to be obtained, this
milk should not be taken from the mother, but fnom a
wet-nurse at least seven or eight days post partum — i.e.,
at a time when the quality of her milk is about estab-
lished, or at any rate when it is comparatively free from
colostrum.
The amount of fluid nourishment administered is to be
gradually increased, a drachm at a lime, so that by the
end of a week the child will be taking from six drachms
to an ounce every hour. If the stools are normal, the
breast milk can be gradually increased and the sugar so-
lution gradually diminished; or. by the addition of a little
lime water, tlie infant can often be jiut on jiiire breast
milk at the end of two weeks. On this plan tlierc sho-dd
be little or no vomiting, and the stools should be normal,
or nearly so, from the beginning.
The method of feeding can in almost all cases be car-
ried on by means of sucking through a small nipple, es-
pecially if a little coaxing is resorted to. In some cases
a medicine dropper or a feeder, such as is recommended
by Rotch. can be tried if the baby refuses to suck. In
others wlio are extremely weak and who will not swallow,
gavage is necessary. In the experience of most men
these cases do not do well: one likes, therefore, to get
back to the bottle as soon as possible. The infants arc
apt to regurgitate, the milk fi lis the narcs or nasopharynx,
and when the baby takes its next iuspirati<m some of
the fluid is drawn into the larynx and even into the bron-
chi. This may cause an immediate asphyxia, an atelec-
tatic area in the lung, a bronchitis, or a bronchopneu-
monia, which will soon end in death.
As soon as the baby is strong enough and is percepti-
bly gaining, it can be tried at the mother's breast. At
first, two or three times a day is sufficient. If the child
■U
REFERENCE HAXnP.onK OF THE MEDICAL SCIENCES.
Proiiiatiiro liirauts.
Premature lurauls.
Fiu. 38K0.— Cbeap Incubator iu Use at the hHiiiiiie Maternity Hospital.
Pedial rka. )
does -n-ell, the number of nursings is graiUially increased
to every two liours. At tlie same time it is generally
necessary to give tlie child the breast between these
stated periods, and also to supplement the nursing by
the bottle.
Dr. Rotch says that the Ijest method of feediiiL' jireina-
turo infants isto give them the food which is carefully
prepared at tlie milk laboratories ; this food being, as he
believes, far superior to mother's milk. In the experi-
ence of others, although weak modilications of cow's
milk — as fat one per cent., sugar si.x per cent., and al-
buminoids 0.33 per cent., or even lower percentages —
have been used, the results have not proved satisfac-
tory, except in a very few cases. Mother's milk is the
ideiil food, and when it is possible to obtain it, every pre-
mature child should have it. Yet the variation in the
composition of this breast milk in the first few days must
be thoroughly understood if good results are to be ob-
tained, for it' often acts as a rank poison to the child.
The colostrum is already well known as a highly al-
buminous laxative secretion, and in many cases it purges
the new-born infant to an extreme. For a more emu-
plete and positive chemical analysis of human milk \vc
are indebted to .John S. Adriance." He has demonstrated
the peculiarities iu its composition during certain periods
of lactation. His results are as follows; During the
first few days the irregularities are most marked. Tin-
colostrum in tlie breast of a woman delivered at term
shows a wide variation in amount (it fat; the sugar is low
at first, but increases rapidly, and by the end of the tirst
two weeks makes a marked increase; the proteids, on tin
other hand, fail rapidly during the first few days from
a maximum amount on the second day, but less raiiiiUy
thereafter. This colostrum then is rich in proteids, due
to the sudden assumption of the mammary function and
to the transudation of serum from blood-vessels into the
breast secretion.
Even toa greater degree are these characteristics shown
in the colostrum after a premature labor, aud the high
percentage of proteids exists for a much longer time.
Consequently, the premature child should not at liist
nurse its mother, but a wet-nurse secured at least tem-
porarily.
In the mean time the mother's breasts should be ptmiped
and massaged or nur.sed by a baby
at term, so that they will not dry
up. After a time tlie mother's
milk can lie given diluted with a
sugar solution, and this should
be kept up until the mother's
milk becomes normal, the change
from wet-nurse to mother being
made gradually. In this way gas-
tro-enteric symptoms may be
avoided.
In some babies the color is
poor from the beginning, and at
any time they are especially liable
to attacks of cyanosis. Fen- these
conditions a little slapping to
cause a good cry or tlie adminis-
tration of oxygen will dissipate
theblueness. Often the adminis-
tration of a few drops of brandy
In liot water every two or three
hours will prevent further trouble.
One must be very sure, however,
that nothing has been aspirated
into the larynx.
A great danger in the care of
these babies is their susceptibility
to infectious. The incubator it-
self is a great germ carrier and
should lie regularly disinfected.
The weakness of the lungs and
gastro-euteric tract makes Ibe in-
fants especiallj' vulnerable. Un-
less the air is filtered, dirt is car-
; consequently the streptococcus,
pneumococciis are always present.
(from tbe Ai chives of
ried in continuously
staplniococcus, and
Fig. 38»1.— Clotbiug for
fniMibator liaby. tfrom Itie Archives nf
I'ijdialrics.)
761
i'miialiirr liitaiilK.
Hrrsbyopia,
UEFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
seeking an aveuue of entraufo. Tliroiigli the sl<in iu
<;'Czematous spots or in areas of irritation, at tlie navel,
tlirougli the eyes, nose, nioutli, larynx, lungs, stomach,
and rectum, the bacteria can ,gain admission. To pre-
vent infection, then, the most careful cleansing is ncces-
siiry. both of the iiicubalor and of the lialiy ilsclf. L'n-
^ioul)lcdly many of the later deaths can lie traced to
lliis source.
Finally, in the carrying ont of the above essentials in
the proper management of the jiremature infant, the
most patient and painstaking attention on' the part of the
nurse is necessary, and ujion her conscientiousness de-
jiends the chance of ils survival.
l!i.\iilt«. — The statistics furnished liere are taken from
2.o\i births which occurred at the Sloane Maternity Hos-
pital in the two years from Oetoljcr 22d, 1897, to October
■Jid, 1899. before which time there liad been no incubator
in use.
Four luuidred and ten nf these babies were premature,
but of these 74 were still-birlhs, which included macer-
ated fffitus and the still-born Ijabies of cases of placenta
pra'via. accidental hemorrhage, eclampsia, and the like.
Tliere remained, therefore, 33(5 which were suitable for
treatment.
Among these cases was a set of triplets and there were
18 pairs of twins; 85 wei'e treated as infants at term, and
of these -1 died — a mortality of 4f per cent. ; 14.") were put
in cotton, and of these 12 died — a mortality of 8 per cent.
Some of this class should have been placed in the incu-
liator. Ijut for lack of room it was impossible to do this;
UiO were incubator babies. These are divided into twn
classes: I. Those that died within four days of liirth;
II. Those that lived longer tlian four days.
I. Twenty-nine of the incubator babies died within
four days. All of these but 3 were more or less asjihyx-
iated at birth ; 9 were breecli cases, and of these .5 were
ilitlicult extractions: 3 were delivered after an accouclu'
meat force in placenta pra'via. The rest were vertex
Ijresentatious: but, of these, 2 were forceps deliveries: 0
were imder seven months of uterine gestation; 22 liad
reached a period of between seven and eight mouths, and
1 a period of eight and a quarter months.
The causesof the premature labor were as follows: an
endometritis in 14, sy])hilis in 2, albtmiinuria in 1, jila-
eenta pr:eviain 3. accidental hemorrhage in 1, persistent
vomiting in 1, twin in 1, violence in 1, and in 4 the labor
was induced. The lar.gest baby weighed 5-^\ lbs. ; the
smallest. 2fj lbs. Only 5 infants lived over twenty-four
liours; 24 were iu such poor condition at birth that they
survived onlj' a few hour,s. In 16 of these cases autopsies
were held, and in all of the.se there was marked atelec-
tasis; in 7 liemorrhages of some degree, either into the
brain or into the serotis membranes; in 2 tlie foramen
ovale was still patent.
II. Seventy-seven incubator infants survived the lirst
four days; .51 were children of primiparae, 27 of whom
were out of wedlock: 3 infants were under seven months
of gestation; 8 were over eight months, and the rest be-
tween seven and eight months along; 9 were breech pres-
entations; 1 a transverse and the rest vertices : 2 were of
triplets associated with albuminuria; 18 were in twin de-
liveries, associated with albuminuria or hydramnios. The
catises of the prematuic lal)(ii' were: endometritis in 27;
sypliilis in 4: phthisis in 2; albuminuria iu 7: acci<lental
hemorrhage in 1; placenta pravia in 1; in 2 the labor
was induced for albuminuria and eclampsia: 1 was a
Civsareau section: another an ectopic gestation; the
cause, in the remainder, was unknown. Seven were
delivered by forceps, 2 by version. 1 by accouchement
force, 1 by Cffi'sarean section, and the ectopic gestation by
a laparotomy; 12 wei-e slightly as]ihyxiated at biith. !l
moderately so, and ."i dci'lily ;isphy xiated ; 2 after one and
a half hours' work or resuscitation were put in the incti-
bator, head downward, and their condition was so poor
that they were expected soon to die, but they left the
hospital gaining in weight: .^ weighed less than 3 lbs.,
38 between 3 and 4 lbs., 33 between 4 and .5 lbs.. 1 over
.') lbs. ; the average weight was 3|f lbs. During their in-
cubator life 28 had one or more attacks of atelectasis.
All but 10 were more or less jaundiced. Tlie initial loss
of the infants was from 1 to 17+ oz. ; tlie average was 7
oz. These figiu'es are not (piite correct, as the babies
were weighed at different intervals, .some on the tilth
day, some on the seventh day, and others not till the
fourteenth tlay.
The perioil of loss lasted for from live to twenty-two
days, the average, eleven days ; 10 lost steadily till death ;
1 baby was iu the incubator only three dajs, while an-
other lived there eighty-two days. The average lime
was nineteen days. Some were removed early to make
room for others who needed the place more urgently.
Only 3 of the 77 cases vomited. The stools were nor-
mal in 32.
One ^vas discharged from the hospital as early as the
eleventh day, and others also too soon, at their mothers'
demand. One was eightj'-nine days old, the average
was twenty-four days.
In 16 diluted. breast milk was supplemented, at times,
with a mixtiue of cow's milk and water with Russian
gelatin and lactose. In 10 a If? proteid, 6"; sugar, and
0.33<; albuminoid modification of cow's milk was used.
In all the rest diluted breast milk was relied upon.
Twenty -seven never nursed at the breast; of these 12
died. A few nursed as early as the third or fourth day,
two or three times a day; others not for three weeks,
and one not till the sixty-eighth day. Of the 77, 13 died
in the hosi)ital, a mortality of nearly 17 per cent. The
cause of death was atelectasis and bronchitis in 7, acute
as]>liyxia from a curd in the larynx in 1, syphilitic pneu-
monia in 1, cerebral hemorrhage in 1, gastro-enteritis iu
3, and a patent foramen ovale and ductus arteriosus in 1.
The condition of 3 was poor at time of discliarge. fair in
24, and very good in 37 ; 32 were above their birth weights
and 'u were gaining iu weight. To letters written about
January 1st, 1900, no answer was olitained from 28.
Thirteen were reported as having died; 1 of these lived
fourteen months, 1 nine months, 1 four and a half
months, 3 lived two months, 6 lived six weeks, 1 only a
month. Five of these children died at the Nursery and
Child's Hospital and 3 died at Bellevue Hosi)ital. They
were bottle-fed, and the probable cause of death was
gastro-enteiitis. Twenty-one were foiuid to be dlii-e and
doing well. .Some had nursed and the others were bot-
tle-fed. The oklest liaby was twenty-two months and
almost all were good speciniensof healthy children. One
baby at seven months weighed 16 pounds. It weighed
■^tV pounds at birth and uur.sed its mother after leaving
the hospital. The ectopic and the Ciesarean babies were
in fine condition.
Statistics.
Inoubat<irs.
Tanner.
Charles.
Sloane
Hospital.
Savf't at ti ^ll,llUl^. W, percetit.
10 percent.
■■ (it., ■■ m
.. - .. ^,|
•• Tw •• r:
■■ s " •■ ,-s
tm per cent.
41
7."j **
Tl)
Ijti per cent.
S',1
Ul
From this table it appears that the statistics* at the
Sloane M.ilcrnity Hospital arc not so good as Taruier's,
ludess those baliies wlio were in very poor condition at
birth and who died in a few hours, are omitted.
Jmncs D. Vooi'ho'K.
LlTERATCRE.
Infections du iiouvcan-nc dans les convenses, Berlin.
Freds d'olisielriiiue. p. .S41.
Lancet, lS9r. vol. i.. p. ItilU.
* Tattles containinir inoi'c extensive data relating to these seventv-
seveii uases uiUlic found in llie .Archives ol Pediatrics for May Is't,
19011.
REFERENCE HANDBOOK OF THE JMEDICAL SCIENCES.
Pmiialiiro lurants.
Presbyopia.
ne la couveiise pour enfants, Auvard.
L'nion m^d., Paris, ISSi, vdl. xxxvi.. pp. 1035-1029.
New York Med. Recnni. INM.
Bull. ir™. de tlierap., Paris, 1S.S1.
Jour, d'accouch., Lli'Ee, 1S84,
Amor. ,luiim, Obstet., l.'iH", .Nx.\vi., pp. 6i)6-7()2.
Trans. Am. Assn. Olis. and Gyn., 1897, pp. 4;«-438.
Lvon, 18a«, p. .56. No. lot).
Anii-r. Mi-d. and Surr. Bulletin. 1696, ix., 311-313.
DiUree : .N. M"ntpelier nied., 1896, 3T5-3TT. Les eouveuses d'enfants.
Adriame: Amer. Juurn. of tlie Med. Sciences, April, 1901. Prema-
ture Infants.
RoK-li : Text-Booli of Pediatrics.
Holt : Diseases of Children.
AU]. Text-Book of Obstetrics.
PRESBYOPIA— Pr— from TrptajSuc, old, and ut/', eye;
Ff. , /irest/i/tic, from -luaiii-ri/c, an old-siglilfd person — is
"the condition in wliicli, as tlie resnlt of tlie increase of
3'ears, tlie range of accommodation is diminished, and
the vision of near objects interfered with '' (Donders').
The range of accommodation diminishes year by year,
from about 1.5 dioptrics, at the earliest age (ten years) at
which accurate ob.servations have been ]na<le, to about
1 tliiiptrie, at the age of si.xty-live or seventy ; at forty it
amounts to something less than 5 dioptrics, and at forty-
live to about 3.5 diojitries.'
Of the 1.5 dioptrics of aecommodatica which the child
of teu\'earsis able to bring iutoe.vercise. from two-thirds
to three-fourths (10 to 11 dioptrics) may be lost without
greatly incommoding an enimetrope in oi'diuary near
vision. In emmetropia tlie distance (P;)of the Ijiuocular
near-point (;)2) is the reciprocal of the nuniberof diojitries
representing the binocular range of accommodation;
hence, w-ith a binocular range of accommodation of .5
dioptrics. Pa = I metre (20 cm.), at which distance the
smallest print in ordinary use is easily deciphered by eyes
of average visual acuteness; when the binocular range of
accommodation is reduced to 4 dioptrics, Fi = } metre
(2.5 cm.), at whicli distance ordinary newspajier print
may still be read easily ; with the loss of another dioptric
of "accommodation (leaving but H dioptrics available).
P2 = J metre (33.3 cm.), and the reading of fine ])riut be-
comes ditticult, except under the conditiims of good illu-
mination and perfect acuteness of vision. These several
values of P» correspond, in emmetropia, to ages ranging
from aboiit thirty -eight to about forty-seven years, and
comparatively few eminetropes attain Ihi? latter age with-
out seeking aid fi-om convex glasses in reading or other
fine work; the adoption of convex glasses by an enime-
trope under forty is generally determined cither by the
exceptionally exacting nature of the work in Avhich he
habitually employs his eyes, or by the fact that his acute-
ness of vision is somewhat below the normal. When at
the age of from fifty to fifty-five years the range of ac-
commodation has become reduced to 2 dioptrics, P™ = 4
metre (.50 cm.1, and the book must then be held at arm's
length, at wjiieh distance only tlie larger sizes of print
can be read : but, even with this range of accommoda-
tion, a public speaker may be able to read fluently from
a plainly written manuscript lying before him upon a
reading-desk or table.
The diminution of the range of accoinmodatiou with
advancing years is a strictly physiological change, and
is ilirectly related to the progressive hardening of the
crystalline lens, in consequence of wliich it becomes less
and less capable of undergoing the change in curvature
requiri-d for the iidjustinent of the eye for near vision.
As this hardening of the crystalhne occurs in all eyes alike,
irrespective of their refractive condition as determined
by the relation of the curvature of the refractive surfaces
to the length of the axis of the eyeball, it would seem to
be scientifically correct to define presbyopia as the less
of accommodative power incident to advancing years.
Immemorial usage has. however, associated the name
with the particular conriition in whicli, as a result of in-
creasing age, near vision Ix-eomes indistinct while distant
vision remains either absolutely or relatively unimpaired.
As thus definetl. presbyopia is an incident in the life-
history of all emmetropes and hypermetropes. and also
of myopes whenever the myopia is of low grade — 3 diop-
trics or less. In niyoijia of higher grades, 4 dioptrics or
Vol.. VI.— 48
more, the distance of the far-point remains within J metre
(2.5 em.) of the eyes; so that, even with total loss of ac-
commodation, it may still be possible to read fine print
without the aid of glasses.
The striking contrast between the vision of mj-opes,
who see only near objects distinctlj-, and that of pres-
byope.s, who see distant objects clearly, while near objects
ai)pcar confused, was very early recognized," and. in the
absence of any definite theory of accommodation, presby-
opia was, for more than two thousand years, regarded as
the opposite condition to mj'opia. Hyiiermetropia, the
true opposite of ni3'0]iia, remained confoimded with
presbyopia tintil after the middle of the nineteenth cen-
tury, "when the demonstration of a change in the form
of the crystalline lens in accommodation by Cramer,''
and, independently, by Ilelmholtz,^ and the masterly
analysis of the phenomena of accommodation in its re-
lation to the several anomalies of refraction, by Don-
ders.* dispelled the cloud of obscurity in whicli the whole
subject had been so long enveloped, and through which
oidy occasional glimpses of the truth had been pre-
viously eujoj'ed by a few excejitionally acute investi-
gators. '
Premonitory signs of presbyojiia may often be detected
in emmetropes as early as the thirty-sixth year; excep-
tionally fine print, such as No. 1 of "jaeger's scale, being
no longer read with the same perfect fluency as in 3'onth,
especially if the illumination is defective. Within the
next five years newspaper print loses a little in sharpness
of definition, and the finest needlework becomes difficult
and perhaps deteriorates somewhat in quality. If the
acuteness of vision (V — see Optnmeiry) is normal, and the
print not too fine, relief from the increasing strain in ac-
commodation is obtained by holding the book or work a
little farther from the eyes; but if vision is subnormal,
or if the print is bad or very fine, a stronger illumination
may be demanded, without increasing the reading dis-
tance. By the age of forty-five the disabilit}' has gener-
ally increased to she point that only fairly large |uint
can be read with ease by ordinary artificial light, and a
more powerful lamp is procured or the book is held nearer
to the light; about this time the need of help from
glasses commonly suggests itself.
A hypermetrope habitually wearing neutralizing (con-
vex) glasses, or a myope wearing neutralizing (concave)
glasses, experiences the disaliilities of iirest)yopic vision
at about the same age, and in about the .same: degree, as
the enimetrope; thus, between the ages of forty and
forty-five, the hypermetrope discovers that his convex
glasses are no longer quite sufficient in reading, and sim-
ilarh', the myope discovers that his concave glasses
have become something of a hindrance in near vision,
although in both cases the neutralizing (convex or con-
cave) glasses continue to serve perfectly for distant
vision. A change to stronger convex glasses by the hy-
permetrope. or to weaker concave glasses (or, perhaps,
the temporary removal of his glasses) liy the myope, is
the remedy whicli now suggests itself, and whicli is,
sooner or later, adopted. With a change of glasses read-
ing again becomes easy, but with a corrcsiioiuling falling
oil in the distinctness of distant vision. For this reason,
an clderlj- emmctroiie either removes his glasses or looks
over them when not engaged in near work, and a presby-
opic ametrope ordinarily requires two pairs of glasses,
the one pair (neutralizing) for distance, the other pair
(stronger convex or weaker concave) for reading and
other near work ; the inconvenience attending the use of
two pairs of glasses nisiy be obviated, in many cases, by
wearing so-called bifocal glasses, in wliich both correc-
tions are mounted in a single setting before each eye (.see
Sjicrtiideis).
A hypermetrope, not wearing convex glasses, expe-
riences the disabilities of presbyopia at an earlier age
than the emmctropc. after having, perhaps, passed
tlirougli a more or less protracted stage of sullcring
from asthenopia (see Asthenopi(i). In myopia, on llie
other hand, if of low grade, the reading power with the
unaided eyes is retained to a more advanced age than in
753
Proaiiiuioii.
REFERENCE IIAXDBOOK OF THE MEDICAL SCIEN'CES.
emmetroiiia; iu tlic liiglier grades of myoiiiait is vetained
iuilfliiiitcly.
As a rcsull of tlii.' veiy giiulual increase in tlie resist-
ance wliicli must 1)0 overcome in order to elTecl siicli de-
gree of aeconi modal ive adjustment as is slill possilile in
presb\'opia, tlie relation of tlie aceommodation to tlie
convergence under.<;'oes a notalile cliange; tlie binocular
acconuiiodalion (A.) associated with lujuvergcnee for the
habitual reading distance becmning at Icnglh nearly
equal to the absolute aeconimodalion (A). In other
words, the binocular ucar-point (j»o) comes more and
more nearly to coincide with Ihc absolute near-iioint {]>).
Following closely upon the aeee])t;uiee of convex glasses
in near work, the distance (!'.;) of the binocular near-
point (p-i) undergoes a rapid increase, so that such read-
ing power as may have been retained up 1o the time of
tlie adoption of th(^ glasses is speedily lost, ami reading
without glasses becomes impossiljle. Hence the common
experience of presbyopes, that having once formed the
habit of u.sing convex glasses, their continued use be-
comes imperative; and tliis wdiethcr the glasses have
been adopted somewhat prematurely, or only after the
need of them has liecome lirgent. The tiio early use of
convex glasses is. therefoj-e. to lie deprecated, as entailing
tlie disabilities of pvesliyo])ic visiein several years, per-
haps, before the normal a.ge; ou the oilier hand, as there
is a positive limit to the range of aceommodation at any
given a.ge, the use of convex glasses cannot, as a rule, be
deferred liy an emraetrope much beyond the forty-tifth
year, unless lie be content to forego tlic> use of the eyes iu
reading ordinarv jirint or iu other line worU.
The total disuse of the aceommodalinn for a consider-
able period, as iu the case of protracted and exhausting
illness, may lead to the ]U'cmaturc development of jjrcs-
byopic symptoms, which are a]it to be interpreted as an
indication for the immediate adoption of convex glasses.
If glasses are used in such a case, they should be of the
least power compatible with the use of the eyes under
favorable conditions of illumination, and the patient
should be eueouraged in the ho|ie that, as the accommo-
dative power increases with use, the glas.ses may be laid
a,side. In cases of this kind it is often ])ossible to bring
the accominodation again into elTective use by the instil-
lation, once or twice dail.v for a few weeks, of a weak
solution of pilocarpine, and thus to put off the use of
glasses for perhajis several years.
In addition to the imiiairmeut of the accommodation,
which is the essential characteristic of presbyopia, the
refraction undergoes, iu the course of time, a slight but
positive diniinutiou, so that ultimately an emmetrope
becomes slightly hypermetropiic (H ncqiihitu — see lli/pcr-
inetropi(t), a hypermetrope ,somewliat more hyiicrmetro-
pic. and a myope somewhat less myopic; a very low
grade of myopia ina_y thus give place to emnietro]iia, or
may even pass through emmetro|iia to hypermetropia of
low grade. A low grade of hypermetropia, which late
in life neeessarilj' beciimes absolute (11 <i/js<ilnt<i), is, in
fact, the ultimate ncn'uial cemdilion of all emmetroiies. so
that in ailvanced age weak convex glasses come to l;a
required for perfect vision at a distance; liypermctropes
similarly require a moderate increase iu the power of
their convex glasses, and myopes require a corresponding
diminution in the power of their concave glasses. This
falling olf in the refraction is ordinarily scarcely to be
detected at the ageof forty-tive; at sixty it may amount
to perhaps 0..T dioiitrie, at seventy or seventy-live to 1
dioptric, and at eight)' to 2 dioptrics or more.
The /iriiliiieiit of presbyopia consists essentially in the
palliation of the disability by the use of such convex
glasses as are needed to supplement the failing accommo-
dation. A person originally emmetropic may, at the a.se
of seventy, require convex glass<'s of as much as ~y diop-
tries, in order to read fairly good jirint at a distance of
from 2') lo"*)cm. ; and if thcaimteness of vision is below
tire norma-1. it may be necessary to use glasses of 0 or 7,
or even s diopliies. in order to admit of reading at some
shorter distance. In the cas(^ of a jierson originally liy-
pcrmetropic, the measure of the required glasses will be
increased li.v a quantity equal to the grade of the hyper-
metropia; in myopia the measure of the glasses will be
similarly diminished.
The convex glasses first given to a presbyopic eiume-
trope of from forty to forty-tive years of age, should
ordinarily not much exceed 1 dioptric, and iu some cases
even weaker glasses may be more iicceptable to tlie i)a-
tient. These glasses should be used at first for only such
work as is performed with ditficulty without glasses, in
order that the habit of using the accommodation ma_y not
be needlessly or jMcmaturely abandoned, and they should
not be exchanged for stronger glasses so long as they
continue to attord the needed assistance. Subsequent
changes should always be made with reference to the
glasses already iu use. adding perhaps 0.5 dioptric at
each change, and it is often advisable to retain the old
glasses for a time for reading by daylight, reserving the
stronger gla.sses for more exacting work. It follows that
a presbyope should always preserve a record of the power
of the .glasses which he is using, in order that, in replac-
ing a lost pair, be may not be reduced to the necessity of
selecting new glasses at random, or after hasty and gen-
erally imperfect tests made by a shopman whose knowl-
edge, very probalih', may be limited to the trick of sell-
ing his wares.
A presbyope, using glasses perfectly suited to his con-
ditiou, is able to use his eyes in near work freely and
without fatigue; glassesof insuflicient strength fall short
of afl'ording the full measure of relief, and glasses of ex-
cessive strength compel the holding of the book at too
short a distance, thus imjiosing needless work upon the
recti interni muscles and so pos.sibly giving rise to mus-
cular asthenopia (sec Anlhiiioiu'd).
The clinical investigation of any ca.se of presbyopia in-
volves, first of all. the careful testing of the eyes iu re-
spect of the acuity of vision and for the estimation of
any hypernie;ro])ia, myopia, or astigmatism that may be
present (sec these titles). Aslias been already explained,
the measure of any hypermetropia that may be detected
nuist be added to, and the measure of any mvopia sub-
tracted from, the value of the glasses ordinarily required
by an emmetrope of corresponding age, in order to ar-
rive at an approximation to the glasses to be given for
reading. These tests are best conducted at a range of at
least f) metres, and only after the satisfactory deternnna-
tiou of the refraction should a trial of reading glasses,
chosen with reference to this determination, be made.
The tiual tests are made in reading line Jirint. If astig-
matism is present, it should, as a rule, be accurately cor-
rected by having one surface of tli(^ glass ground to the
appropriati' cylindrical curvature (see Antiymntism).
A rapid falling olf iu near vision, necessitating fre-
quent and considenible additions to the power of the
reading-glasses u.sed by a presbyope, sliould be regardcil
with especial solicitude as indicating the possible begin-
ning of glaucoma. In view" of the recognized danger of
lU'ecipitating an acute glaucomatous outbreak, the rou-
tine employment of mydriatics iu the investigation of
the refraetinn of presbyopes is to be especialTy depre-
cated.
Repeated changes from weaker to stronger glasses, at-
tended with a shortening of the reading distance after
e;ich change, point to a falling olf in the acuteness of
vision, ofleiicst from failure in the perceptive power of
the retina, or of the conductivity of the optic nerve.
A marked dimiiiiilion in the apjiarent grade of presby-
opia is occasionally observed late in life as a result of
Ihc development of a myopic state of the refraction; this
change, wliicli is jiopnlarly known as "second .sight," is
a not infrequent .symptom of incipient cataract.
Jiilni Green.
^ DoiKlors: On Ilie Anomalies of .Acrommodation and Refraction of
tlie Eye. 11. :nn. Thc! New syileiihaiii Society, I>oudon, isia.
- Iioiiilers: dp. cil.. p. aiir.
3 .\ii>t 'ifli:iii Trcjilise, J^po^A^/flaTa, .\.\,\i., ^'5; Oribasiiis; Aetius;
I'iiUllls .1':i:lllct:i ; (7 <ll.
^ rraiiier: 'rydschrifi (ter iM.iatsch. vonr Oeneeskunde. ls.")l.
' Heliiilioliz: Monatshericbtu der Akademie der WissenscUarien,
Berlin, Ketiniarv, ISTto.
754
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCKS.
Presbyopia,
Proaniiiioii.
'• Domicis : Airliiv fiir Ophthalmologie, vi., ISSO; On tlie Auoma-
liest'f Acnmiiiioihiljnri :in(l Uefractiou. IStil.
' rii/( liciliilcTs: Oy. I'lY., p. 325, uote.
» IhiiL, p. -M^.
PRESERVATIVES.— Food pivservatiou has been em-
ployed IVom a Very early period. Mauy methods are
available: drying, salting, pickling, smoking, the use of
heat and cold, and addition of sugar, saltpetre, and vari-
ous aromatic and astringent substances. Tiie exigencies
of modern food supply have greally extended both the
number of preservatives and tlieir applications. Low
tempeialure is probably the least objectionable method of
preventing decay, but its application is limited and
cosily. It is unsuitable for some articles. In food pres-
ervation reliance is now largely on chemical substances
that have decided antiseptic or germicide eirect.
All preservation, even that by cold alone, affects to
some extent the digestibility and nutritive value of food,
but tliese changes are lessobjectionable tlian those cau.sed
by decompositiou. Sterilization liy luat limls wide ap-
plication and has the advantage of producing a conditi<m
■which iK-rmits of some exposure to the air without decay
occurring. The medical questions which arise in this
connectiou are mostly^ those concerning the newer preser-
vatives. These are salicylic acid, benzoic acid, sodium
benzoate, boric acid, borax, formaldehyde, sulpliites,
fluorides, beta-naphthol, .saccharin, and a few .synthetic
products of complex composition and limited use. Each
sidjstance is found to be adapted to s|iecial uses. Thus,
boric acid and borax are uscil largely for meats, milk,
and butter; sulphitesand fluorides are used in fermented
beverages; salicylic acid, saccharin, benzoic acid, and
sodium benzoates are used in jams, jellies, mince-meat,
and preserved fruits and fruit juices. Formaldehyde is
largely used in milk, and is the most common preserva-
tive in market milk and cream in the summer .season.
For the preservation of many vegetable products, steril-
ization in hermetically sealed cans is emploj'cd and no
preservative material is needed.
The iih_vsiological effects and methods of detecting the
different preservatives have been subjects of extended
stutl}'. The latter problem has been solved in itiost cases,
but the former is still under active discussion. At pres-
ent, the weight of information seems to be that salicylic
acid, fornitddcliyde, tlie suljihites, and the fluorides are
objectionable either from inherent toxic qualities or by
reason of interferences with digestive functions. Nu-
merous investigations into the elfccts of boric acid aud
borax have failed to show that in moderate amount it
lias any injurious action, and the tendency is to permit
its use iu meats and butter, in which it satisfactorily re-
places common salt. Sodium benzoate seems to be .safe
lor use in fermentable foods, such as jams and jellies.
]?etana]ilithol is but little used, but it and saccharin are
probably ol)jectionable except iu special cases and under
supervision.
Most of the substances above enumerated are not ac-
tively germicidal nor capable of coagulating proteids,
but are rather inhiliitory of bacterial growth and enzy-
mic action, and thus prevent decomposition.
A dangerous [ihase of the modern use of preservalives
is that many of them are sold under misleading names
and their nature arul effects misrepre.sented by manufac-
turers. Foriuahlehyde, for exainple, is soUl in forty-per-
cent, solution as " formalin," which is not an objectionable
title, but weaker solutions are sold to nnlk purveyors
under such fanciful names as "freezene," "icene," an<l
the sellers' agents assert that the material is harmless aud
permissible. It has been found that a mixture of boric,
acid and borax is ustially more eihcient than either alone.
This mixture is often sold under the title "l)oron preser-
vative. " Another danger is that chemical stibstances may
be used to make up for deficiency iu quality or steriliza-
tion of foods.
The regulation by law of the use of preservatives has
so far been unsatisfaclory. Wholesale prohibition of any
but the old-established forms, such as smoking or jiick-
ling or salting, has been attempted iu some places, but
has resulted in nuich litigation and (|uarielliug. The
question must be approached in a sclent ilic way, and the
regulations must regard the exigencies of trade as well
as the interest of the consumer. For a comprehensive
study of the main questions tln^ re]iort of the British
Commission (Blue-Book, Cd. H3;i) will Ik- tVmnd valuable.
llninj Lr^niiiiin.
PRIMROSE, EVENING.--The leaves and tops of Ona-
gra bleniiia (L.) Scop. {(Kiiol/wni hinminh. — fam. Oiin-
f/racca). This plant is an exceedingly common weed iu
waste fields aud along road.sides throughout the United
States, especially in the northeastern and central parts.
It is hairy, the stem stout, erect, and branching, and is
readily recognized by the large yellow flowers, with four
obcorclate petals, eight long versatile anthers, four linear
stigmas, forming a cross, and the quadrangular ovary at
the base of a long filiform calyx tube. It contains much
tannin, with considerable gum, thus making it astringent
and at the same time emollient to the intestine. It has
consequently a considerable empIo_yment in the house-
hold iu the "treatment of diariinea. The dose is 2-8 gra.
( I .ss.-ij.), and the infusion is the best form of adminis-
tration. A number of species of the related genera CEno-
thera, Epilobium, etc, have a similar composition and
use. Ilennj 11. Rushy.
PROAMNION. — This convenient term was introduced
by Ed. vau Beneden to designate that part of the arm
(•/«i;7/(/«((/(« at the sides and iu front of the head of the
developing embryo which remains without mesoderm
for a considerable period, so that the ectoderm and ento-
derm are brought, in the region of the proamnion, iuto
immediate contact. As found in one stage of the rabl)it,
it has already been figured in this work (Fig. 267. Vol.
I.). A later stage in the rabbit, as seen in longitudinal
section, is figured by Kollikcr iu his " Grundriss d. Ent-
wickelungsges.," 2te Aufi., p. KIT. We find that it had
been observed in the chick by Kemak, His, and Kolliker.
Strahl was the first to direct special attention to it. It
has since been observed by various writers; van Beneden
and Julin have described it iu the rabbit, Heape in the
mole, Selenka in the opossum, and recently its exact
history has been admirably worked out in the chick by
Ravn, and in many birds and reptiles by Schauinsland.
The proamnion, then, has been observed in rejiresenta-
tives of the classes Reptilia, Aves, and Jlammalia: hence
we may conclude that it is commou to all Amuiota.
It will be remembered that the mesoderm grows out in
all directions from the blastopore, or hinder end of the
primitive streak. In a chick of twenty-seven hours,
the front edge of the mesoderm is a somewdiat irregular
transverse line, which crosses the germinal area aliout at
the front border of the iiead. This line is well shown in
His' drawings, loc. cit., PI. xii., F"ig. 14. As the meso-
derm expands, it does not grow forward iu the median
line, but does grow forward at the sides of the area pel-
hivuhi in front of the head of the embryo, A space is
thus enclosed between the mesoderm on each side; this
space later becomes the ju'oamidon; it contaius no meso-
derm. Later on, the lateral iiorlious of the mesoderm
ajiproach the median line again, some distance iu front
of the head, so that now the proamniotic area is com-
pletely surroimded by mesoderm. We see, as the next
]>ha.se of development, the head amniotic fold arising in
such a position that the proamnion is embraced between,
the arc of this fold and the head of the embryo; the pro-
amnion, therefore, constitutes the fiocu' of the pit formed
liy the upgrowth of the head anmion. In the chick the
proamnion never acquires an_v considerable development,
but gradually disappears by encroachments of the meso-
derm upon all sides, as has been well described by Ravn,
whose Fig. 3, he. cit., PI. xxi., will serve to give a
clear general notion of the relation of the proamnion to
the head, and to the true anmion in the cliick. The dis-
appearance of the proamnion in the chick involves some
curious appearances in sections of embryos, which liavn
has correctly aud fully elucidated.
Proaiiiiiiou*
Proslalt'.
REFERENCE HANDBOOK OF THE iMEDICAL SCIENCES.
In tlie rabbit, according to van Bcnedcn and Julin,
wliosc iibscrvalioiis have liccn conlinncd tn a certain ex-
tent liy KiJlliker and Hcapc, tlie role of ilu- lu'oanmion
is more considerable. Tlie hi.story of the proamnion, as
given by van Beuedeu, may be followed ea.sily by the
aid of tlie accompanying diagrams (Fig. :!^<S3), copied
lost. It is to be noted especially that the amnion de-
velops princi|.)ally over tlie posterior end of the embryo,
and grows forward. To this fact reference will be made
again directly.
We possess no observations, at present, as to the exist-
ence of a proamnion in man, and it is probable, owing
Fig. aiss.— Diagram of ilie Dcvclopuipnt of the Kietiil AilnH.i;a in the Rabliit, (After van Beneden and Julin.) A, H. C. D. Successive
stJiges; JIII1..-1, ijniaiimlon; jli\ area vasculosa; ( '"C, i.'u'lom ; Cipi', Cut", extra-emlirvoiiic poition of tbe cceloni ; £'», entndermii' cavity
of the embryo; K»/, extra-eiiihryonii' entoiU-riii ; /•>, ectoderm ; ,1/c.s. mesoderm ; -l;!). area placeutalls; ^4/, allautois ; T, tenoinal sinus
of tLe area vasculosa ; 1", yolk sac ; am, uuimoii ; itiii', poitloii of the amnion united witli the wall of the allaatois ; C/i, choriipu.
from van Beneden. In A, the ]n-oamnion. jim.A. is
ver_y small, and the allautois, Al, is just growing out.
In B, the embryo, which for greater elearncs.s lias been
shaded with stippling, has grown verj' much, and the
anterior half of its body is bent down at a sharp angle
into the J'olk sac. The embryo, liowever, remains sepa-
rated from the cavity }', of the .yolk sac, by the pro-
amnion, which forms as it were a hood, pro.A, over the
atiterior extremity of the embryo. The amnion ]iro]K'r
is as yet developed only over the posterior end of the
embryo. For the further hi.story of the amnion see
Am/dim, Vol. I. of this Handbook. The jjroainnion,
as can be seen in C and D, retains its iniixntance .as a
fivtal covering for ,a eon.siderable period, during which
the amnion nm. and allantois Al, are rai)i<lly pursuing
their development. After the stage shown in Fig. 38.S2,
D, liy the expansion of the cavity marked ('nr'. the amnion
proper, itm. encroaches more and more upmi tlie pro-
amnion, /im.A, until at last the emlirvo is entirely cov-
ered by the true amnion, and the proamnion is altogetlier
to the precocious development of the luiman amnion and
of the extra embryonic mesoderm, that no proamnion
occurs in the ccuu'se of human development.
Chillies IScchjiHck Minui.
LiTERATtTRE.
Beneden, E. v. : Recherclies sur la formation des annexes foetales
Chez les niaminitcres (Lapin et Chelropteres). Arch, blol., y., ^19-
4:M, ,') pis., isst.
Beapc, Walter: Quart. .Tourn. Micr. Sci.. xxvii.. 133-li;.X
His. \VillieIni : riiiersuclmui.'eu iiber die erste Anlasre des Wirbel-
Ihieti's. Die erste l-'.ntwickeluu^ des Iliihncheus im Ei, 4to, pp.
■i',M, Tafn. l;!. LeipziK. l.sils,
KiHliker. Albert : lirumli'iss der Entwickelunprsgeschichte des Men-
si'hen und der holiereii Tiere, zweite Aullage. Syo, pp. viii., 4.')4,
Leipiiiir. 1.SS4. For proamnion, see p. 107.
Stialil, H.: Ueber EplwickelunsrsyorKiinge am Vorderende des Em-
bryo voii Lacerta iifrilis. Arch. f. aiiat. Physiol., Ariat. Abth., pp.
41-.SS. Tafn., ill. iy.. IS,S4.
Selciika, E.: stiulicu iibiT EntwickeUingsKeschlchte der Tliiere.
Heft iv. Das (ipnssinii. 4to. \»W>. 9 plate.s.
Rayn. Edward: I'l'lier die luesodermfreie stelle in der Keimscheibe
des Hiihnereiuliryo. Arch. f. anat. Physiol., Anat. Abth., 1SS6,
412-iai.
75G
REFERENCE HANDBOOK OF THE MEDICAL SCIEXCES.
Pronniiiioii,
Proslalr.
PROFESSIONAL NEUROSES.
ffiis. I)isi:i.\, s ,uiil JJtJiiniiitiex of.
See Hands and Fin-
PROPYLAIVllN-Cna.Cn,.CHg.NHc,— forms colorless
crystals of ainmouiacal odor, and for the treatment of
chorea is administered in daily dosajre of 2-4 gm.
( 3 ss.-i.) in spirit of peppermint. IT. .1. Bastedo.
PROSECRETIN. H&e Secretin.
PROSTATE, THE.— The prostate gland (Gr. TvpncTarnu
from ~()" and laTinin, to set, or inr!//ii, 1 stand) derives its
name from its [losition at the entrance to the bladder.
Ax.^TOMY. — The )MosUUe is a body largely glandular
in character, and in sliape much like a Spanish chestnut.
In the upright position of the bud}' it lies just below the
bladder and behind the symphysis pubis. The ba.se of
this heart-sha])ed gland is in contact with the bladder and
vesicuUe seminales, -ivhile the apex rests upon the poste-
rior layer of the deep jjerineal fascia; the anterior surface
looks toward the pubis, and the posterior surface rests
upon the anterior rectal wall.
The urethra, as it leaves the bladder (pars prostatiea
urethra), traverses the prostate from near the middle of
its base to its ape.x, and rather more than one-half of the
gland lies behind the canal.
The prostate weighs from five to six drachms, and
measures approximtitely one inch and a half in length,
one and a half to two inches in breadth, and one inch
in thickness (antero-posterior diameter). Slight longitu-
dinal furrows along its anterior and posterior surfaces
show an indistinct tendency toward a divi.sion into two
lateral lobes, although the two halves are structurally
continuous with each other. In this connection it is
worthy of note that in some animals the prostate consists
of twt) separate lobes.
That portion of the gland which lies between the ejacu-
latory ductsand the urethra(pars supramontana, Jlercier)
is usually known as the middle lobe (Home). Situated
upon the floor of the urethra, yast at the entrance to the
bladder, it often forms a little prominence continuous
with an elevation of the vesical floor (uvula vesicic).
The portions of the gland behind and in front of the
urethra, connecting the lateral lobes, are known as the
posterior and anterior commissures.
The substance of tlie prostate is made up mainly of
three tissues: (1) Glands; (2) unstriped muscular fibres;
and (o) fibrous tissue.
The glands are of the acinous variety, and are most
abundant in the lateral portions of the organ, their ducts
coalescing and opening along the floor of the tirethra.
The muscular fibres are disposed in circular bands which
are continuous at the junction of the bladder with the
circular fibres of that viscus. Hyrtl also describes a
system of these fibres radiating from the caput gallina-
ginis. The fibrous tissue forms a firm enveloping cap-
sule which sends oLt-shoots through the substance of the
gland.
Just below the point of entry of the urethra the two
ejaculatory ducts enter the prostate, one on each side,
and, running forward through its substance and converg-
ing, they enter the floor of the urethra.
Tlic prostalic vrethra (pars prostatiea urethra) is slight-
ly narrower where it enters and leaves the gland than it
is within it. The hollowed floor of this portion of the
canal is called the sinus prostaticus, and is divided into
two equal furrows by a longitudinal ridgi! (verumonta-
num), the end of which farthest from the bladder is com-
posed of erectile tissue, and is capable of considerable
dilatation into a little round prominence which, with the
verumontanuiu running back from it. presents a fancied
resemblance to the head of a snipe — hence its name caput
gallimujinis.
On the top of this little eminence is the opening of a
minute sac — the utricle or sinus poeularis — which is
thought to be the analogue of the uterine cavity in the
female. Clo.se to the edge of this sinus, and sometimes
■within it, are the orifices of the ejaeulatory ducts.
Along the sides of the verumontannm open the prostatic
glands proper, to the number of from twenty to thirty.
The prostate is enclosed in a tough fibrous caps'ule
which is a part of the pelvic fascia. Besides its attaeli-
ments to the bladder and deej) perineal fascia, it is
further held anteriorlj' by the pidm-prostatic ligaments,
and posteriorly by the recto- vesical fascia. Its slight mo-
bility is provided for by the levatores prostata — muscu-
lar bundles, really partsof the levatorani — which, arising
from the posterior surface of the pubis, are inserted along
the lateral borders of the gland.
Its blood supply is derived from the internal pudic,
the vesical and hemorrhoidal arteries, and the veins
which form a plexus around the gland enqity through
the hypogastric vein. Tlie nerves are branches of the
hypogastric plexus of the sympathetic.
PiiYsioi.OGV. — The prostate is a sexual gland. After
birth it remains in a quiescent state up to puberty, w-hen
it begins to increase in size and development. It attains
its full growth at about the twenty-fifth year.
The secretion of the glands, which are especially active
during sexual excitement, is a slightly turbid fluid of
feebly alkaline reaction, with a specific gravity of 1.010.
It is especially rich in chloride of sodium (one per cent. ),
and, as solutions of this salt are known to excite the sper-
matozoa to movement, its presence in the prostatic fluid
is thought by some to perpetuate their activity. Prob-
ably the most important function of this secretion is in
producing coagulation of the secretion of the seminal
vesicles.
The prostate, further, in its character as a imiscular
organ, acts as an involuntary sphincter of the bladder.
As the urine accumulates a point is finally reached at
which the tension of the detrusor urina muscle pulls
open the rings of involuntary fibres around the neck of
the bladder and allows the urine to enter the ]>ars pros-
tatiea urethra'. Its presence tliere causesan urgentdesire
to urinate, and the escape of the water is then prevented
only by the eomjiressor urethra^, muscle, which is the
voluntary urinary sphincter. If this muscle does not
relax and allow urination to be completed, the prostate
closes down and forces the contained urine back into the
bladder, where it st:iys until the further increased tension
brings on another " besoin d'uriner. "
M.\LFORM.\Tioxs.— The prostate may he wholly want-
ing, in connection with a general lack "of developnient of
the urinary organs.
In exstrophv of the bladder there is no roof to the pros-
tatic urethra, and the gland ducts may be seen opening
through the nuicous membrane over the site of the orgaii.
In.il'Hies and Wouxds. — The deep-seated position of
the prostate makes it little liable to injury from without.
In severe crushes of the pelvis with fracture about the
pubis, it may be wounded. In perineal lithotomy it is
alwa_ys incised, and often somewhat contused by (\w ex-
traction of the stone. If the crushing and laceration of
the parts have not been serious, healing usually takes
place kiudly.
Injury of the prostate occasionally results from the
passage of instruments through the "urethra. This oc-
curs most commonly in cases of hypertrophy, in which
the irregular enlargement of parts of the gland has made
the canal tortuou.s.
A specimen in the museum of the Harvard JFedical
School shows a very nuicli enlarged middle lobe which
so obstructed the entrance of the catheter that the in-
strument had been forced directly through it and had en-
tered the bladder beyond.
The knowledge that such injuries are possible should
lead to their avoidance. Jlucli force is never needed in
the passage of an instrument, which is properly gui<led,
but a thorough understanding of the nature of the pos-
sible obstacles, an<l considerable patience and care in
overcoming them, are necessary to success in these cases.
Infi..\mm.\tion of Till'; Pi;ost.\te — Prost.vtitis — may
be either acute or chronic.
Arntf pnixtiititix is commonly the result of the exten-
sion of an iuflammatiou from adjacent parts.
0(
Prostate,
Prostate*
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
A gonorrlioeal urethritis is hy far the most usiial excit-
ing Ciiiisc. In tliiscase the iufliinnnutioii nuisliatk along
tlie uretiira to the prostate. That this is nut tiie usual
course of a gonorrhcra is due to the protection alToriled
by the eonslrietor urethr.-e musele. This sphincter, sur-
rounding tlie membranous urethra, prevents the dis-
charge from penetrating to the jjrostate and l)ladder. and
usually protects these deeper parts from partici|)ation in
anterior intlaMuuations. Occasionally the passage of an
instrument, or the forcing of an injection through the
constrictor, may convey iutectivc discharges past this
natural harrier.
A n<in-speeilic urethritis or an inflammation of the blad-
der may. in similar manner, e.\t<'nd to the prostate. The
passage of instruments, the api'licatiou of caustics, the
use of strong injections, the presence of calculi in the
bladder or prostate, accidental injuries, or operations
may be the exciting cause of an acute prostatitis.
Among other causes cited as occasionally giving rise to
prostatitis may be mentioned se.xual abuses, acrid irri-
tating conditions of the urine, the use of stinnilating diu-
retics such as cantharides and turpentine, the abuse of
stimulants, and the presence of intiammation in the rec-
tum. Proliably these conditions are rarely, if ever, com-
petent to c.xcite an acute prostatitis in a hcaltliy state of
the gland, hut only act to aggravate an already existing
intiammation.
A stri<tuic of the urethra greatly aggravates any deep
intiammation nf tliat canal, and makes its extension to
tile prostate much more lialile to occur.
Pathology. In acute inllamination the prostate is
much congested, with great swelling and O'dema, which
extend to the siu-rotmding parts. The jirostate itself
may be enlarged to three or four times its natural size,
and even with this degree of inflammation, resolution
and a return to a comparatively normal condition are
possible.
If, however, the inflammation runs a more acute course,
it may lead to the formation of abscesses, which, starting
as minute points of pus, may gradually enlarge and co-
alesce until, in an extreme case, the whole organ may be
reduced to one abscess cavity.
Spontaneous opeinng may take place backward into the
rectum, into the urethra, or into the bladder, and the pns
may even occasionally find its waj' down through the
ischiorectal fossa, or ijito the perineum, and point exter-
nally. Rarely, the abscess may open into the peritoneal
cavity, or into an adherent coil of intestine.
Symptomatology. The jiromiuent sym])toms are pain
deep in the perineum and in the reeluin, with tenesmus
of the bladder and the rectum. Urination is very fre
quent, and is accompanied liy great pain, especially dur-
ing the jiassage of the last few drops of water, which are
freijuently colored with blood.
Aceomiiauying these local symptoms there is usually
considerabk; fever, which may or may not be ushered
in by a chill. There is also often severe pain in the
back, loins, and thighs.
As the iuflammalion increases the pains become even
more severe, the urine in its passage scalds intensely, the
pressure and throbbing |)ain in the reettim become very
distressing, and defecation, which is constantly desired,
is, when it happens, a new source of suffering.
The stream of urine becomes small and hard to start,
owing both to the swelling of the prostate and to the
s|iasinoilic contraction of the constrictor urethrte muscle,
and finally complete retention ina_y result.
If a gonorrlueal discharge ]>revionsly existed, it may
disajiiH-ar at the onset of prostatic intiammation, or it
may lie clianged into a slight mucous ilischarge.
There is usually a good deal of tenderness in the peri-
neum, and sometimes also close above the symphysis
pubis. ,\ rectal examination is ilillicult on accotint of the
extreme sensitivenc^ssof the parts, accompanied b.y spasm
of the s|ihincter muscle.
If the intiammation gives rise to an alisccss. its forma-
tion is often heralded liy rigors with high fever. If the
abscess breaks into the urethra or bladder, there may be
a sudden escape of ptis in the urine, with an improve-
ment of the general symptoms.
If the pus cavity attains any considerable size, its
character may be made out through the rectum, where it
is to be felt hrst as a hard, boggy swelling, which later
softens and gives evidence of fluctuation.
If the abscess extends into the loose cellular tissue
along the rectum pya?mic symptoms may develop, and
in case of rujiture into the peritoneal cavity the charac-
teristic .symptoms of peritonitis will come on abruptly,
with a speedil\' fatal issue.
Treat meiit. Aljsolute rest is the first and most impor-
tant measure when acute inflammation of the prostate
makes its appearance.
The patient should keep in a horizontal position with
th(^ hips somewliat raised.
If severe pain is present — especially if frecpient spasms
of the bladder are aggravating the inflamed glaiul — opi-
ates should be given; and it is to be borne in mind that
tlii^se, by inducing rest from spasm, exert a really cura-
tive elVect. Jlorpbine and atropine subcutaneously. or
opium and belladonna suppositories, may be adminis-
tered under these circumstances.
All irritations from instrumentation, injections, or
stimulating diuretics should be avoided.
The bowels should be kept gently open b_v aiierients,
if necessary, and tliis point should be carefully looked
after when opiates are being used.
The urine should be rendered as unirritating as possi-
ble by the use of diluents and alkaline diuretics, and
nourishment should be giveu in a bland, unstimulating
form. Farinaceous gruels, milk, and light broths may
form the bulk of the diet. Alcohol should be entirely
avoideil in the acute stage of the disease.
If at the outset the fever runs high, it may be some-
wliat mitigated bj' the use of (|uininc or some more tem-
porary febrifuge, such as aconite or phenacetin. Late in
the disease, when it lias run a severe cour.se — especially
in case of exhausting suppuration — strong concentrated
foods and alcoholic stimulants may be re(|uired.
Locally, all jiossible measures for limiting the severity
of the intiammation should be employed. In an early
stage of the disease, leeches applied to the perineum may
be of considerable service. From six to eight should be
jiut on along the ra]>he and close to the anus. The
l)leeding may be encouraged, especiall}' in plethoric jier-
sons, until from fourteen to sixteen ounces have been
withdrawn.
Hot applic;itions. either by fomentations or by hot-
water bottles, to the perineum and over the luibes, arc
u.seful in diminishing yiain and spasm, and prol)ably as-
sist somewliat in limiting the inflammation. Hot Iiiii
baths are recommended for this same purjiose: but the
exertion and the unfavorable position required for these
add so much to the pelvic congestion as greatly to dimin
isli tlii^ otherwise favorable etlect of the heat. If used,
they should not be prolonged for more than Ave m- eight
minutes, as the maximum effect on the surface is pro-
duced in that time.
If retention of urine occurs, it must be relieved by the
careful introduction of a small, soft catheter (Nos. 12-14
Fri'iich scale).
Sometimes, when there is a spasmodic stricture at the
compressor urethra', a soft catheter will not ]iass. and a
slilT instrument must be used, requiring, of course, the
greatest gentleness of manipulation.*
When the retention persists and requires repeated cath-
eterization, an instrument tied into the bladder (mtnile
a di'iiii'iin) will often cause less irritation than would it3
frequent inlroducticni.
The jHissibility of ab.sce.ss formation is always to be
kept in mind, and the condition of the gland should be
watched by rectal examinations. If fluctuation is made
out, the abscess should be opened at once. This may
tisuallv be done throuirh the rectal wall with a curved
* Km- till' (lisi-ussiiin of i-atlieterization see uuiler Hypertroptiy of ih©
prusluti;.
7r;8
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Prostate.
Prostate.
bisioui-i Cliche, and the opening should be rather a punc-
ture than a long incision. This is for the purpose of
avoiding hcmorrliagc: and it is a good plan, with this
.same oliject in view, to make a careful examination be-
sore llie pinieture, to .see lliat no vessel of any size in the
rectal wall stands in danger of injur}' by the knife. In
case of bleeding, ice pellets should be inlroduced into the
rectum, and if these fail, pressure should be applied by
a tliorough plugging of the lower part of the bowel. If
the abscess is a laige one a draiuage tube may be intro-
duced into it through the rectal opening.
If examination shows that the abscess is working tow-
ard the perineum, it may be opened by an incision from
that direction, and thus a uretbro-rectal fistula with pro-
longed suppuration may be avoided.
When the abscess conunuuicates with the rectum thor-
ough irrigation of the bowel should be earrie<l out. and
an antiseptic, free from poisonous properties, should be
selected, on account of the absorptive power of the rec-
tal mucous membrane.
If the disease ends in resolution, care .shoidd be taken
that the recovery is complete, for an acute inflammation
may, if neglected, leave a chronic condition which is
sometimes extremely haitl to relieve.
Chronic Prostatitis. — Chronic inflammation of the pros-
tate may, as has been said, follow an acute attack. It
may. liowever, on the other hand, originate as a chronic
or subacute affection.
What has been said in regard to the etiology of acute,
will for the most part apply to clu-ouic. ]irostntitis; but
while the former is seldom the result of sexual errors
alone, these are not infrequently almost wholly respon-
sible for a chronic inflannnation of the gland: and it is to
be noticed that the imperfect se.xual indulgence of mas-
turbation, or partial intercourse, is much more produc-
tive of prostatic trouble than is the normal excitement
of proper coition. This is |irobably due to tlie unrelieved
congestion of the gland, left after these unnatural prac-
tices.
Pathology. A chronically inflamed prostate is usually
somewhat enlarged, but may be natural or diminished in
size. The gland is less firm than in liealth, and its text-
ure is more open and spongy. Upon section the cut
surface is red or dusky in hue. and moister tlian normal.
Little points of suppuration may exist, but are usually
few and small.
The mucous membrane has an increased vascularity
and may be thinned, particularly if the prostatic urethra
is dilated in consequence of an anterior stricture It
may, on the other hand, be thick and spongy, denuded
partly of epithelium, or much roughened with spots of
ulceration : sometimes, in cases of long standing, it is
pigmented. The sinus pocularis and dilated gland ducts
about it maj' contain i)us. Sometimes an abscess cavity
exists in communication with the urethra.
Synqitomatology. Patients with chronic prostatic in-
flammation are troubled with increased fre<|uency of mic-
turition, which in a mild case may be scarcely noticeable,
but is often very troublesome — occurring sometimes with
intervals of less than an hour.
There is sometimes pain of a dull, heavy character, re-
ferred to the periueum and lower rectum. There may
also be considerable ]iain low down in the back, with
twinges shooting into the thighs and testicles. A slight,
persistent urethral discharge, often most marked in the
morning, may be the only symptom. In some cases the
symptoms may be almost entirely of a sexual character,
such as are often spoken of as sexual neurasthenia.
The blailder, when full, may make its condition known
by a feeling of discomfort or actual pain, with intensely
urgent call to urinate
The passage of urine may be accompanied by slight
scalding sensations, and there may be a twingeat the end
of micturition, when the bladder shuts down upon the
sensitive prostate Occasionally tenderness in the peri-
neum may be felt upon deep pressure
The urine may be cloudy and contain, more or less
abundantly, clumps of muco-pus mixed with epitheliai
cells. These are little accumulations of secretion washed
out of the dilated gland duels, and dilfer from the loose
threads of mucus so common in chronic urelhiitis in being
smaller, more coherent, and rounded in form. When the
urine is passed in two portions, the first part is apt to be
more cloudy and to contain these clum|is of mucus more
abuudantlj' than the second part. Not infrequently,
however, even when the inflammation is confined to the
prostate, the pus is distributed througliout the urine and
both portions are cloudy. The reason for this has been
very clearly stated by Ultzmann,*and is as follows: The
internal sphincter of involuntary fibres sunouiiding the
vesical orifice of the urethra is compaiatively feeble,
wliil(! the compressor urethrie muscle, ju.st in front of the
jirostate aud surrounding the membranous urethra, ia
strong and competent, and, being under the control of the
will, it forms the voluntary sphincter of the blad<ler.
As discharges collect in the prostate they caimot force
their way forward jiast the constrictor, but readily escape
backward into the bladder, where they diffuse themselves
tlH'(nigh the urine. Even in these cases, however, when
the urine is universally cloudy, the first portion will still
be somewhat more cloudy than that which follows, and
will contain many more of the mucous jirostatic clumps.
The urine in mild cases may be cleai' with a modei'ate
number of "prostatic plugs" which settle rapidly to the
bottom of the urine glass.
The urine, when examined microscopically, will often
be found to eonlain, besides the pus, a considerable num-
ber of blood cells, and occasionally also a few spei'mato-
zoa. The blood may not infrequently be jjerceived to
come at the cud of micturition, when the bladder closes
down upou and squeezes the congested prostate.
A chemical examination frequeutlj' shows the presence
of a little albumin, often in larger quantity than the pus
aud blood would account for. In other resjiects the urine
is usually normal.
If the character of the stream is noticed, it will often
be found that its force is decidedly diminished, and that
after the completion of urination a few drops dribble
awa}^. Sometimes partial or total retention may occur.
This interference with urination is to be partly ac-
counted for by the swelling of the judstatic mucous
membrane, but is often largely dependent on a spasmodic
contraction of the constrictor urethra' nniscle; and if un-
der these circumstances a sound is passed, it will meet
with decideil resistance when it reaches the voluntary
siibincter. This spasmodic stricture may be so close as
greatly to aggravate the difficult}" and paiu of micturition,
for, as the bladder foi'ces the urine into the prostatic ure-
thra, if its further escape is prevented, the undue pressure
in this sensitive part is productive of very great suffering.
L'sually the spasm of the constrictor is finally overcome
by the accumulating intravesical iircssure. and urination,
beginning first by drops, presently comes with more or
less freedom.
As we have said, the constrictor muscle hinders pros-
tatic secretions from escaping anteriorly and appearing
as a urethral discharge. A very slight gleet in the morn-
ing is not infrequently observed. Sometimes also in these
cases a glairy discharge of prostatic mucus is iiressed out
and escapes w Idle tbe patient is at stool ; es|iecially is this
the ease when the bowels are constipated and mueb stiain-
ing is required. This is couunonly interjireted liy the
patient as an escape; of .semen, and he becomes convinced
that he is a victim of spermatorrhu'a.
Usually the microscope fails to find spermatozoa in
this discharge, which consfsts mainly of mucus, with
sonii'times a little admixlure of pus and blood.
Besides the local symptoms aud manifestations that
have been described, we see in these prosl.-ilie cases often
marked changes in flat general condition of our patients.
They are nei'vous and hysterical, or may be depressed
and despondent, with often a hypochondriacal over-esti-
mate of the gravity' of I heir trouble. Sometimes a true
neurasthenic condition may be induced in a case of long
■* " I'yuria," p. 2(i.
iOi
Proslalc.
Proslalc,
REFERENCE HANDBOOK OF THE JIEDK'AL SCIENCES.
standing. Digestive disturbances and palpitation of tlie
heart may occ-vir.
Physical Signs. An examination of the prostate
throiigli the rectum sliows it soinetimes sliglitly enlarged,
l)ut often normal or diminislied in size. In consistency it
is usually somewhat .softer than in liealtli.
If the urethra is explored wilh :in inslruuieiit it is com
monly very sensitive, but may be aiiasthetic; the latter
condition Iieing noticed usually in old cases. The ure-
thra should be carefully examined for a jiossible stricture,
audit is to be remembered that the constrictor muscle
will often bo fo\ind to make a spasmodic contraction just
behind the triangular ligament. The passage of the
sound througli the prostatic urethra is almost always
pahiful, and may excite an intense tlcsirc to urinate, or
an eiaculatiou of semen.
Diagnosis. The di>ease which we are considering is
peculiar to 3"ouug and middle-aged men, and is to be
kept <listinctly separate from by])ertrophy of the pros-
tate, which occurs only in the old. Intlammatory symji-
toms, it is true, are not uncommon in thislatterailection,
and will be discussed later.
Tuberculosis of the prostate olTcos many I'oints of ri'-
semblance to chronic proslatiti.s, and a differential diag-
nosis is often dillicull. and may be for a time impossible.
The detection of small nodules in the jn'ostate and a
marked teudency of the disordi'r to become worse as a
result of local treatment are suggi-stive of tuberculo.sis.
The constitutional tendmcies of the patient should be
taken into consideiaiion, and a careful search should be
made for evidem-es of tuberculosis in other organs. An
examinaticjn of the urine for tid.iercle bacilli may hel|i to
a solution, but a f.aihu-e to finil tlicm even after careful
search leaves the question where it was before, for they
are often sought in vain in imdoubted cases of geuito-
urinarv tuberculosis.
The discrimination lielwecn prostatitis and deep ure-
thritis after gonorrhoea is sometimes almost imjiossiblc.
Fig. •3.S.S.'?.— Sediment from Prostatic Discliarfe, Omtainiiiff Piis and
Epillu'lial Colls, Granules, .\uiyloid Budit-s. aud ISiitu-hfr's Crystals,
The rectal examination of tlie prostate may help to a
decision, lint n(]t infrequently it gives negative results.
A microseo])ieal examination of the dischai-ge obtained
by pressure on the prostate through llic^ rectum may giv(t
valual)le information, but this, too, is often misleading.
Tlie discharge in cither case contain^; pus and large and
small round epithelial cells. Amyloid bodies and cylinder
or caudate epithelium may be fotuid in considerable abun-
dance wlien the discharge is prostatic.
The formation of Bottcher's crystals upon the addition
of a drop of a one-per-cent. solution of phosphate of am-
monia to a <lrop of the secretion shows beyond question
that it contains prostatic fluid.
This reaction should be conducted on a microscope .slide,
under a cover-glass, and within an hour, usuall_v, crystals
such as are shown in F'ig. 3883 make their ajipearance.
They are composed of a phosphate formed from a base
which exists in prostatic fluid, and which is supposed to
impart to it its peculiar odor. Unfortunately, the mix-
ture of urine with the secretion prevents the formation of
these crystals, and so limits very much their diagnostic
usefulness.
It is always to be borne in mind that a comliinatiou of
urethritis and prostatitis is not uiicoiumon.
Treatment should be addressed to both the general and
the local condition.
The general treatment should be tonic, especially in
the cases in which much nervous depression exists.
A generous, unstimulating diet, with moderate exercise
in the open air, and with cold sponge baths in the morn-
ing, when the patient's strength will admit of them, are
to iie advised.
Tlie laws of sexual hygiene should be carefully ex-
])lained to the patient, and the importance of their ob-
servance made plain to him.
Preparations of strychnine and iron are often of bene-
fit, and they may be advantageously combined with
(|uinine or ergot, both of which seem to exert a .soothing
inlluence upon the prostate. Iodide of potassium may be
of assistaiua' when the intiammation affects the glandular
jiortions of the organ, and the addition of bromide of po-
tassium is sometimes distinctly useful in (piietiug sexual
excitement.
If the urine is highly acid or otherwise irritating, its
character should be modified by demulcent drinks and by
alkaline diuretics.
For a more direct local effect, cantliarides, turpentine,
sandal-wood oil, or copailui may sometimes be admiuis-
tered with advantage, especially when the infiammatiou
is mostly confined to the prostatic urethral mucous mem-
brane.
Various local measures of treatment ma_v be expected
to contribute to the cure.
Counter-irritation to the perineum, either with tincture
of iodine or with fly blisters, is often of great use. Cau-
tharidal collodion is a convenient blistering medium, and
should be applied to a small surface close to the raphe.
AVhatever counter-irritant is used, care should be taken
that it does not come in contact with the scrotum or anus.
After the application is dry, it is a good plan to fix a pad
of absorbent cotton in the perineum with a T-baudage.
This takes up the perspiration and prevents the blister
from spreading to the side ojiposite to that where it was
applied.
A\ hen there is much pain in the prostate and rectum,
liot injections into the bowel may lielii to iialliale it. anil
to reiluce the congestion in the same manner that hot
douches act upon the female iielvic organs.
Tlie most important local treatment, however, is that
applied directly to the prostate itself, and consists in the
p;issage of sounds, massage of the prostate through the
rectum, and in ajiplications and injections into the pros-
tatic urethra.
The use of sounds in chronic inflammation of the pros-
tate has long been recognized as of advantage, and the
benelit from them has been variousl_v explained.
Some surgeons think that they should be used cold,
anil ascribe their elliciency to the astringent action of the
cold. Others consider that tln'ir pressure within thi> pros-
tates exerts some beneficial influence by forcing the blood
out of the gland.
"While some good may perliaps be attained in eitlier or
both of these ways, it is ju-obable that the stretching of
the constrictor urethr.'C muscle, and the consequent relief
from spasnicidjc contraction of the same, will account, in
a large measure, for the good results that follow their
use. As has been said above, this sphincter is not iufre-
reo
REFERENCE HANDBOOK OF THE ]\IEDICAL SCIENCES.
Pro.*$fato«
Prostate,
qufutly iHit in a spasmodic state of contraction by the
proximity of llie prostatic inflammation, and in this state
of stricture it lias a tendency to aggra
vale, the deep inflammation, just as an
organic stricture tends to increase and
perpetuate a urethritis posterior to it.
U can be readily understood, therefore,
that the relief of this spasmodic contrac-
tion would act favorably upon the in-
flammation behind it.
As large a sound as will pass comfort-
ably through the urethra should be used,
aud it should be introduced with the
greatest gentleness. A sound passed
roughly down through the anterior ure-
thra will sometimes find the constrictor
tightly closed against it, when, had more
care been exercised, the urethra would
not have resented its introduction, and
it would have readil_y passed the mode-
rately contracted sphincter.
If the spasmodic stricture is a tight
one, it will sometimes be foimd necessary
to precede the introduction of the sound
by the passage of a French, olive-point-
ed, conical bougie; which, in.sinuating
its point through the obstruction, readily
dilates it and prepares the way for the
larger instrument.
When excessive irritabilit_v or an ac-
cess of inflammation make the applica-
tion of cold to the prostate desirable, it
may best be accomplished by the use of
the" cold sound. This is a hollow in-
strument, which after its introduction
can be chilled down b}' passing a stream
of water through it. It should usually
be kept in place for about five minutes.
We now come to speak of local ap-
plications to the prostatic urethra, and
in these we recognize the most ellicient
means at our command for subduing
chronic inflammation of this part.
The cases which are particularly
suited to this form of treatment are
^^ -„„,- tliose in which prostatic chunps are
' mannTprostatic present in the uriue, with or w ithout a
Syringe. A cap- purulent secretion : in short, in which
Kradua'ied*' fw- *'"' '""cous membrane is distinctly ,
Inge for the'in- affected. Medication may be con-
troductlon ot veyed to the pars prostatica urethra'
¥£e°ur?e"onbls either by the injection of a few drops
and ot the irri- of a strong solu-
tion, or by irriga-
tion with consiiier-
able cjuantities of a
weak solution.
The application
of soluble drugs to the prostatic
urethra is probably best accom-
plished by the injection of solu-
tions.
The constrictor muscle, situated
just in front of the prostate, pre-
vents the penetration of an ordi-
nary urethral injection, and special
instruments are therefore needed
for medication in the urethra pos-
terior to it. Figs. 3884 and 3886
represent such catheters for pros-
tatic medication.
The curve shown in these instru-
ments has advantages both in the
ease of introduction, and in the
readiness with w'hich the location
of the point can be determined from
the position of the handle.
When the instrument is verti-
FiG. 3884. -Ultz-
gaUng catheter
is modified from
Ultzmann's
struments. See
text.
Fig. 3885.— niagniiii .slmu mi; th.it it a -hra t-beaked
in.stninient i.s held with the handle vciiii'al, the
point rests just at the triangular ligament. The
dotted figure shows how the point slips through
theconstiictor muscle when the handle is brought
to an angle of forty-five degrees with the axis of
the body.
Ciil* the point necessarily rests just in front of the trian-
gular ligament; now, upon bringing it down to an angle
of forty -five degrees, and at the same time advancing It
slightly, the point slips on through the constrictor mus-
cle, but never passes beyond the prostate unless a spe-
cial effort is made to push it on toward the bladder.
Fluid injected through the catheter, when in this posi-
tion, cannot pass forward through the constrictor, but
washes out the prostate and escapes backward into the
bladder.
Of the various drugs used for prostatic application,
nitrate of silver is pei'haps the most valuable.
Two or three minims of a one- to two-per-cent. solu-
tion should be thrown into the prostatic uretlira thiough
the capillary catheter (Fig. 3884).
Some pain of a burning charac-
ter, with often considerable tenes-
mus, follows the application ; but
this usually passes off in the
course -of an hour or two. The
injection should be repeated
every four or five days, and its
effect may sometimes be lieight-
ened by the previous passage of
a sound. As convalescence is es-
tablished, the intervals in the
treatment should be gradually
lengthened.
Irrigation of the prostatic ure-
thra may often be practised with
great benefit. In c;ise there is
inucli irritability of the neck of
the bladder, with considerable
muco-purulent secretion, a sooth-
ing antiseptic wash is of use. A
two-per-cent. solution of bora.x
or boracic acid, with the addition
of a little glycerin, is a good in-
jection for this purpose.
If the use of an astringent wash
seems indicated, any of the mixt-
ures u.seful in gonorrha^a may be
tried. Perhaps a one-per-
cent, solution of acetate of
zinc is as good as an_v. The
irrigating fluid, after wash-
ing out the prostate, flows
back into the bladder, as
has been said, and from there it maj' either be
withdrawn by slightly advancing the catheter, or
it may be passed by the natural efforts.
While the above-mentioned procedures are ad-
dressed to the urethral aspect of
the prostate, further relief may be
_,-;'--' afforded b}' niiissage of the rectal
,.-%'-'' face of the prostate. This is done
by the fm-etinger introduced into
the rectum, aud should aim at ex-
pressing the contents of the pros-
tate. The amount of pressure
which may be safely used will
depend on the acuteness of the
inflammation, of wliich the ten-
derness will prove a safe guide.
Massage should not be given at
too short intervals, and is often
wisely made to alternate with the
other local measures above out-
lined.
After any manipulation or treat-
ment of the prostate the patient
should keep tjuiet, if possible re-
cunilii'iit, until till serious dis-
coiufoit passes away, and should
FIG. 3886.— Irrigating Ca-
theter. (After Ultz-
mann.)
* Throughout this article, when the ma-
nipulation of instruments is described, it is
supposc'd that the patient is in a lioi-izontal
position.
(61
ProMalo.
Prostate,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
avoid any exposure to ehill or fatig\ie for several
hours.
HvPERTROPItY OF THE PnosTATE, EM,.\Ii(iKD PROS-
TATE.— EtiiAogy. — The eau.ses of enlargement of the
|i rost ate are
<li(lieuU. to es-
liililish by any
a (I e (( 11 a t c
proof.
T h e o n e
thing whieli
seems to be es-
sential to the
e.xistenee of
the disease is
the advanced
age of the pa-
tients. Hyper-
ti'oi.ihy of tlie
prostate is
of tiftv, whereas
Fig. •'J^.st. — Dinsrram to Slum- tlie Shiipp of the
I'retlira in ;i VeTtiruI Sectinn Tlirough :i Pros-
tate Hilh au ICiilarscil Jliilcile Lolie.
practieally unknown before the age
after tliat it is e.xtivmely common.
Stone in the bladder, stricture of the nrelhia. irritation
by the frequent use of instrumcnls. se<ienlary lialiits.
gouty or rheinnalie diathesis, and e.\posiire to colil and
damp, have all been cited by surgical writers as ]iredis-
posing circumstances; but none of these conditions has
ever been positively shown to stand in a causative rela-
tion to the disease.
On the other hand, there is no doubt tliat. when pros-
tatic hypertrophy exists, any of these eoiuiitions may
greatly aggravate its symptoms; and besides those al-
ready named we may mention excesses in driulc or in
vener_y. prolonged voluntary retention, and the recum-
bent posture as familiar causes of increased prostatic
congestion.
I'atltiihKiii. — Hypertropljy of the jirostate may occur
through liy]ierplasia of the glandular ]iortions of the or-
gan, of the interstitial tissue, or of botli.
As the normal size of a particular ]irostatecan never
be known, it may lie hard to say, even on post-mortem
examination, wliether a given sjieeimen is enlaiged or
not. For approximate determination, however, a pros-
tate weighing six draclnus may be regarded as normal in
size, and anything over that is to lie considered hyiier-
trojihied.
Upon section of a prostate which is hypcrtroijhied, the
cut surface bulges irregtdarly above the ea|isule. It may
be grayish-yellow in color or motrled with blotches of
red, yellow, and gray, with
occasional dark pigmented
spots.
If the glandular element
predominates the surface is
soft, and exudes a tlind rich
it} cells. In interstitial hy-
))erplasla the surlare is diyrr
and lirmer.
Sometimes little projecting
bunches announce the for-
mation of lihrous or glandu-
lar tiunors within the organ.
Usually the liy)icrtrophy
afTects all pans of the gland
simultaneously, but not all
in the same degree.
The shape of the jirostatie
urethra — a matter of the lirst
cliincal and surgical impor-
tance— depends largely upon
the partial or general char-
acter of the hypertro]ihy.
either side of tbe middle lobe. If the enlargement is pretiy
evenly distributed through-
out the organ, the urethra is in the first place consider-
ably lengthened, sometimes measuring even 7 cm.
When the hypertrophy is partial the elongation is less,
though it is still marked.
"\
Fig. :»S.«.— Diagram of a Hori-
zontal Section ilirout^b the.
same ( irj^an. sliowins^ how tlie
urethra divides and Koes on
Furthermore, in cases of general hypertrophy, as the
latei'al lobes enlarge they compress the urethra from the
sides, until it becomes a slit-like canal with tolerably
firm walls in close apposition. As the lateral diameter
is thus diminished, the anteroposterior diameter is cor-
respondingly increased.
It will be readily seen that, as long as the enlargement
is symnietrical, the direction of the urethra is not mate-
rially altered ; but, on the other hand, it is equally evi-
dent that, if the liyperlrophj' is partial, and not evenly
distributed, the unequal pressure from one side or the
other of the canal will cause lateral deviations, and that,
if the middle lobe is unduly enlarged, the posterior por-
tion of the urethral floor will be raised, causing a devia-
tion upward or toward the pubis (see Fig. 38H7).
The ])iojection uijward of this lobe maj' make the in-
ternal urethral opening crescentic in shape, and if the
middle coalesces with either of the lateral lobes, this ori-
Ijce is ]nislied over toward the opposite side.
Sometimes the middle lobe grows out into the bladder
as a distinct tumor, which may be attached by a broad
base, or may stand off in a pedunculated polypoid form.
Besides the changes in the prostate itself, there are
other alterations in associated organs which we must
consider in connection with _
this disease, as they are in-
strumental in producing
many <if the symjitoms which
we shall have to study.
As the prostate enlarges
the internal meatus is raised
and a )iocket is formed in the
bladder just behind the en-
larged gland. The bladder
wall silso becomes tliickeiied,
partly in consequence of hy-
pertrophy of the muscular
coat, owing to the increased
resistance against which it
has to work, and partly ow-
ing to a sclerosis of the inter-
stitial tibrous tissue, like that
wliieh has occurred in the
prostate.
Interlacing muscular bands
often stancl out from the
vesical wall under these cir-
cumstances, forniing trabec-
uUe lietween which tliere are,
not infrequently, consider-
able iiouches of mucous
membrane.
Tlie walls of I he uri'ters
and pelves of the kiilneys
may also be somewhat thickened, and the interstitial renal
tissue undergoes frequently a hyperplasia.
As a later result of the luostatie obstruction the bladder,
ureters, and pelves of the kidneys may become greatly
distended.
Guycn and Lannois have laid particular stress upon
the fact, already hinted at and partly understood by
earlier writers, that coincident with these changes in the
urinary tract a general sclerosis, affecting specially the
walls of the blood-vessels, is going on throughout the
bo<ly.
Wlien from any ctiuse intlammation of the bladder, ure-
ters, or kidneys has associated itself with hypertrophy
of the prostate, we liave thefamiliar pathological apjiear-
anees of cystitis, ]iyelitis, and pyelo-nephritis engrafted
upon the organs already seriously altered by the prostatic
obstruction.
For a full consideration of these complications see the
articles on lllnihl, r of tli,: JLih and on Kidneys, Disen.vs of.
Nnliiml Hixfiirii. — The progress of the disease is slow.
The organs alVecled are not of vital importance, and the
changes in them may reach a very advanced .state before
tlu^y seriously threafeii life.
Guyon has divided the history of the disease into three
Fig. 3.S89,— Diagram of a Hori-
zontal Section through a Pros-
tale in which the right lobe,
A. Ls moderately enlarged,
the left lobe, iJ, somewhat
less so, while the middle lobe.
C. is mnoh enlarged and is
.joined to the left lobe, causing
a deviation of the vesical end
of the urellira to the right.
T«2
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Proslalo.
Prostate.
perindK: First, that of congestion, affecting mainly the
prostate, but also in less degree the bladder and kidneys.
JSecoiiilly, thai of partial reteutiou of urine. And, thirdly,
that of distciilion of the bladder with usually secondary
■changes in tlic kidneys.
This somewhat empirical division gives us perhaps
as gcKid a framework as any for the classification of the
clinical phenomena.
In the tii'st stage, that of congestion, we have some en-
largement of the prostate and functional disturbances,
especially iu the matter of urination. This condition
may persist for a long time, and in cei'tain eases, in
which for any reason the calibre of the urethra is not
greatly interfered with, it may exist almost indeliiiitely
without showing any tendency to pass on to the second
stage, that of retention.
Usually, however, sooner or later the obstruction to the
passage of the urine becomes greater than the force of
the bladder can overcome, and a slate of habitual partial
retention is the result.
AVhen this condition comes on slowly, the accumula-
tion of residual urine may be very insidious, and esca|)e
the observation of patieut and physician alike; on llie
other hand, an increase iu the prostatic obstruction may
occur suddenly, and the unexpected complete stoppage
of the urine may be the first auuoiuiceinent of trouble.
AVhen the retention of the second stage of the disease
•develops gradually, and is not discovered and treated,
the point may be finally reached where the bladder has
completely lost its tone and is so distended that tlie
urine escapes almost constantly by an overflow (retention
with incontinence). This same condition of things may
follow also an acute retention which has not been relieved
by catheterization and iu which nature has finall.y estab-
lished a leakage.
The third stage of the disease is now entered upon, and
if nothing is done for such a case the distention of the
bladder becomes extreme, and a secondary dilatation of
the ureter and of the pelves of the kidneys takes place.
This is soon followed by atrophy of the secreting piu'tion
of the kidney, and an increase of its interstitial tissue (in-
terstitial nephritis).
The secondary changes iu the heart and blood-vessels,
usuall_v a.ssociatcd with chronic ne])liritis, are likely to
make them.selves noticed at this time, if they have not
already done so, and the disease becomes a constant and
serious menace to life.
It is in this advanced stage of the disease tliat iuflam-
iiiatorj' processes, starting iu the bladder, rajiidly extend
backward to the kidneys, and uremic S3'mptoms jires-
eutly usher in the closing scene.
iSt/mjitoiniitolor/i/. — From what has been said in regard
to the historj' and jirogrcss of the disease, it will be seen
that the symptoms of the first stage are mainly dependent
upon the condition of eonge.stion in the prostate, bhidder,
and kidneys. And as tliis congestion is most considerable
iu the iirostate, the most noticeable symptoms eause<l liy
it are disturbances of micturition and of sensation, due to
the irritated state of the neck of the bladder.
In the second and tliird stages we have, in adililion, a
series of symptoms due to the mechanical obstruction to
micturition, and to the changes in the bladder and other
organs consequent U|)i)ii this obstruction.
We shall have finally to consider the symptoms arising
from various morbid conditions likely to appear as com-
plieatiiins in the cour.se of prostatic disease.
The first appearance of S3'mi)toms usually announces a
morbid condition which has already been coming on for
some time. When the enlargement takes j^lace in such
direction as not to encroach seriously on the calibre of
the urethra, it may reach very considerable prcjportions
before it causes any inconvenience to the patient.
One of the first symptoms to be noticed is an increased
frequency of micturition, which is specially marked at
night or early in the morning. Guyou regards this as
evidence of congestion, which is aggravated during re-
•cumbency and sleep. He calls attention also to the fre-
quent existence of erections iu these patients, on waking,
as further evidence of an increased congestion of the pros-
tate during sleep.
Pain is ordinarily not very noliceablc in the early stages
of the disease, altliough a dull aching (ir heavy dragging
sensation in tlie perineum, rectum, and behind the pidiis
is not uncommon.
If attention is paid to the manner in which urination is
accomplished, it will be found that early in the disease
the stream is slow to .start and diminished in force. This
is due largely to a loss of power in the bladder, but is to
be partly ex]ilaiued b}' the swelling in the pro.state, and
by a spasmodic contraction and slaunncring action of the
constrictor muscle.
The diminution in the force of the stream in a prostatic
patient differs from that seen iu eases of stricture, in that,
while a stricturcd patient can, by voluutary effort, in-
crease the force of his stream, a man with enlarged pros-
tate cannot do so.
Secoud Period. The symptoms which have their origin
in congestion continue during this period, and are, indeed,
intensified. Added to them we have other s3'mptoms due
to the retention, which is the characteristic condition of
this stage of the disease.
The retention may be complete or incomplete.
(Jomplete retention maybe acute and appear suddenly,
or it may be preceded by a peiiod of partial retention
which alwaj'S develops slowly.
The symptoms which accompan)' a complete retention
are easy of recognition, and a physical examination re-
veals the bladder distended above the pubis. Incom-
plete retention, on the other hand, comes on very insid-
iously, and is often overlonked for a long perind, at just
the time when recoguition and treatment of the condition
are of great importance.
Although, as has been said, partial retention comes on
quietly, still a careful examination of the symptoms will
usually elicit evidence of a changed condition of things,
at or soon after the time when the bladder begins to fail
of emptying itself. The feeling of weight behind the
]uibis is "likely to be increased, and tlie frequency of mic-
turition, which duiiug the first stage was decidedly more
pronounced at night, begins to be almost equally noticed
iu the daytime. The intervals between the acts of uri-
nation become short, and the call is imperative. In short,
the l)ladder being always partly full, it takes but a .small
additional quantity to distend it to its full capacity.
The only positive means of determining the conditions
of the bladder is bv a physical examination, and this
should be made in every tloubtful case.
Sometimes the bladder shows extraordinary tolerance,
and the disteutiou becomes so extreme as to cause incon-
tinence from overflow, before the patient feels obliged
to call upon a pln'siciau; and sometimes also, unfortu-
natel_y, before the medical attendant recognizes the na-
ture of the difficulty.
This incontinence is evidence of a verj' great degree of
distention, and shows that the di-scase has entered upon
its third stage. Usuall^y, before it appears, the disease
has already extended backward and has begiui to affect
the kiduej'S.
There is one symptom which may appear and give evi-
dence that the disease has reached the third stage, before
incontinence begins. This is i)olyuria. If the quantity
of mine in the twenty-four hours is measured, it will be
found considerably to exceed the normal.
Pain, which was an insignilieaut symptom in the first
stage, ma3' assume cousideral)le importance iu the secoud
and third stages.
Besides the discomfort in the |ierini'um and back due
to the congested and irritated |irostal<'. there is also con-
siderable pain before and during micturition, caused by
the distention of the bladder and its unavailing or jiar-
tiallv successful attenqits to enqity itself. Tlic passage
of the urine through the jirostate is also sometimes pain-
ful, and tliis is especially the case when the occurrence
of inflammation has rendered the urine pungently alka-
line and has made the parts particularly sensitive.
The cxaridiiatioii of the urine may give negative results
7G3
l»l-oslal.\
Hroslal*'.
REFERENCE IIANDHOOK OF THE .AIEDIl'AL SCIENCES.
(lurins I he early stages of prostatic dispasc; butwiiPii tlie
congestion of tlie liicliicys is considcralile tlicre are usually
albumin and a few casts. During ll:e last, stage of llie
disease, when iiolyuria has <'Stalilished ilself. Ilie speeitio
gravity islo\v(l (Hi;j-l.(KXi) and there is generally a small
amount of albumin, although this may not l)e (ireseut.
A few easts will generally be fouinl at this time. too. but
they may be ab.sent even when lli<' Uidneys are e.\leu-
sively diseased.
In the presence of iulliimmalorv eoni|ilieations llie
character of tlie urine is greallj' changed, as we shall see
later.
lu addition to the nion^ local symploms which we liave
been considering, there are also certain gi'ueial disturb-
ances which are likely ti> apiiear in advanced i)rostalic
disea.se. These are of two Uinds, digestive and febrile.
Obstinate indigestion in an old man, es])eeially if ac-
companied by nausea, siiould always lead us to take tlio
condition of the prostate into consideration. These jia-
tients are also very liable to a low feverish condition,
with extremely dry mouth and tongue, and this may an-
nounce the extension of inllanuii;Uion from the liladder
back into the kid)ieys.
We now come to the consideralion of llie eomplicalions
which are likely lo aris<' in proslatic cases, and of the
symptoms, or variation in .symptians, to which they give
rise.
They are cyslilis. ]ivi'lilis (pyeloni'iihritis), liaaiiaturia,
and slone in the bladder.
Cystitis is so common in ]iiost.-ilie hy|iertrophy Ihat it
may be looked upon almost as a necessary lesult. It
sometimes appears without apparent cause, sometimes in
con.se(|Uence of excesses in drink, or from exposure to
cold, and in this case the infection iirobably comes from
the reel urn or through the blood. Far more commonly,
however, it follows as a conseipience of the use of the
catheter or other instrument, and when it is once estab-
lished it is rarely got rirl ol' — but may, as we shall see,
by apiu'opriate treatnicni. be ki-|it within very reason-
able hounds.
When the inilammation of the liladder is at all acute,
the jiain and frequency of miclurition are ureal ly in-
creased. If the prostate shares in the inilammation, a
great weight and bearing-down jiain in I he rectum may
be felt, with a frc ipient urgent desire P.r del'ecati<in.
The urine lie(-omes thick from the adinixlure of ]ius
and mucus, which often si'ttles at the bottom of the ves-
sel in a thick, rojiy mass. Presently, in the majority of
cases, it undi'igoes alkaline fermentation, becomes am-
mouiacal, and has a strong pungent, often fetid odor.
The sediment now contains, besiiles the |nis. prostatic
cells and abundant crystals of trijile phosphates, often
associated with linely granular amorphous iihos]ihates.
If the intiammation extends from tlic> liladder back
tbroiin'li the ureters to the kidneys, the ri'sulting iiyelitis
or iiyeloneplirilisniakes itself known by pain in the liiiek,
high fever, more or less diminution or e\ en suppression
of urine, and unemie syinploms.
Tills course of things is cs]iecially liable t<i occur late
in the disease, when neglect of catlieieii/.ation has allowed
the uri'ters to become greatly disp'uded. Under these
circumstances, any exposure to cold or inslruinentalion
may be sulbcient tostart Hiefalal access of intlamnialion.
Occasionally, when the use of the calheler has been
neglected after the time when it should have been begun,
the final entrance ujion the catheter life, instead of being
a couservalive measure, gives the linal push towaid a
fatal issue. The existence of iiolyuria. with tirine of a
low speeitic gravity, should alwavs lead us to fear this
result.
Slmie ill tlie hl.iiililer not iiifreipieiil ly oceiiis in pros-
tatic patients as a conseiiueuce of cyslilis, in which ea.se
the stone is of the soft phosphatic variety ; or a stone com-
posed of uric acid, oxalate of lime, or cystin may form,
and owe ils origin primarily to a constitutional condition.
In either ease th(! prostatic hypertrophy may be re-
garded as partly responsible for the formation of the
caUadus.
In the tir.st case, that of the phosphatic stone, tlu' ob-
struction, by causing the cystitis and fermentation of tlie
urine, stamls in a pretty close causative relation to the
calculus. In the second case, in which the deposit of
crystals from the urine is due to a constitutional ten-
dency, the obstruction at the ]irostate may be the Condi-
tion which decides whether a stone shall form or not.
For, when the bladder is completely emiiticd at each
urination, the crystals as they form arc thrown out and
<lo no harm, whereas when there has been formed behind
the prostate a pocket in which there is always residual
urine, the sand collects there and soon agglomerates it-
self into a c<incretion.
When a slone forms lieliiiid an enlarged prostate the
liain is usually much increased, and is less amenable lo
treatment. It is referred often to the glans penis, and is
greatly tiggravatcd by motion, especially by riding in a
jolting vehicle. It is commonly less marked at night or
during rest.
lla'inattiria incase of stone is very likely to appear
after exercise or riding, wdiile prostatic hemorrhage from
congestion seems to be independent of any jarring of the
bkidder — in fact, is rather more likely to come at night,
when reeumbency favors prostatic congestion.
The sudden stojipage of the stream in the midst of
urination, by the rolling of the stone against the opening
of the urethra, is less likely to occur in case of an en-
larged prostate than iu a healthy bladder, owing to the
lodgment of the stone behind the prostate, below the
urelhral orifice.
If the presence of the stone affects the freipiency of
micturition, it tends to increase it rather iu the daytime,
when motion causes the stone to move abcnit, than at
night, when it is at rest.
llii'iiuitiiiiii, as has been sai<l. may result from the con-
gestion of the prostate with <ir without ulceration, or
from the presence of a stone. We may also have hemor-
rhage of considerable amount and duration, following
the use of iiislruments; and, lastly, the too sudden emp-
tying of an over-distendcil bladder may lead to an at-
tack of lia'inaturia, from the capillary oozing from the
vesical wall.
Sometimes clots of large size may form in the bladder,
and cause much pain and discomfort before they are
liroken up and expelled.
Pln/xii-iil E-viiiiiiiiiitioii. — .\fterit has been decided from
the syuiploms that there is a probability thai prosialic
liypertiophy exists, a thorough examination should be
made of llie prostate and bladder.
The objects of this investigation are to ascertain the
slage at which the disease has arrived, to learu the
amount of obslrucliou and the contiguration of the pros-
tatic urethra, and to discover any complicating conditions
which may exist.
The patient should first empty the bladder, so far as
possilile by the natural ciTorls, and the hypogastrium
should then be explored 113' palpation and percussion, to
see whether enough distention <if the bladiler remains to
be detecled in this region. The normal variations in tlie
position of the bladiler and intestines render this exami-
iialion (■flen unsatisfactory, especially when the abdomi-
nal wail is thick or rigid.
The- examiner should then explore with llie foreliTiger
the rectum. This is best done wit h I lie patient on the
back.
If the prostate is enlarged it will be felt pressing down
the anterior rectal wall. Its size, shape, and consistency
should be noticed.
The relative enlargement of the lateral lobes can usu-
ally be well made out, and nodular projections are some-
limes fell, caused by irregularities in thi' hypertrophy
of dilfc-reiil, p.-irls of "the gland. Keetal examination, un-
forluiialely, gives liltle or no information in regard totlic
condition of the third lobe, which is .so often Hie cause of
a serious obslrucliou to the flow of mine.
Incidenlally. the degree of tenderness to palpation will
be discoveii'ii.
The condition df ihe jirostate itseJf having been deter-
rei
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
I'lOSlillO.
mined, the examining finger should be curried up along
the jxisterior vesical wall, if that be possible, and the
condition of the bladder should be learned. In this in-
vestigation the bimanual manipulation between the fin-
ger in the rectum and the hand aliove the pubes, so com-
monly practised in examinations of the female pelvic
organs, is useful, and by it tlie amount of distention of
the bladder can often be most accurately made out.
Lastly, the urethra and bladder should }n- explored.
The existence of a stricture will probably be detected
in the passage of instruments for deeper exploration.
But in case of doubt the canal may be thorou,ffhly exam-
iued with large bulbs. A short-ljcaked sound should he
passed, and as it rims through the prostate deviations of
the urethra will often be shown, by the feeling of resis-
tance on one side or the other and by the turning of the
handle.
The sound iu entering the bladder may sometimes be
felt to slip up over a bar,- or may turn to one side around
a prominent third lobe.
After a projier search has been made for a possible
stone, the sound should be depressed until it lies in the
axis of the body, and then withdrawn until the concave
side of the beak comes against the neck of the bladder;
it inay then be rotated, and, as the beak sweeps the vesi-
cal face of the prostate, any irregular outgrowths or pro-
jections will be felt to arrest its movements.
If the sound has been felt to ride over an obstruction
at the neck of the bladder and if, after it is in, it rotates
freely, this points to a bar rather than to a globular en-
largement of the third lobe, which last would arrest the
beak of the sound iu rotation.
As the instrument is withdrawn slowly through the
prostate, the deviations dui- to jirojections inlothe ure-
thra are often felt even more phiinly than during intro-
duction.
Finalljs the urine may be withdrawn with a catheter
and the exact amount of residuum thus discovered. This
will be found to vary much at different times, and de-
pends somewhat upon the amount of urine which the
liladder contained before the last ui-ination.
When the bladder is full and the urine consequently
rushes out with some force in a considerable stream, it
will often be found that there is much less water left in
the bladder than is the case when urination is attempted
before complete distention has been reached.
Diiigiiox/s. — The conditions with which enlarged pros-
tate is likely to be confounded are stricture of the ure-
thra, stone in the bladder, atony of the bladder, cystitis,
cancer or other tumor of the prostate, tuberculosis of the
prostate, and tumor of the bladder.
The idiysical examination, if thoroughly made, usually
enables us to eliminate the first two of these conditions,
and if enlargement of the prostate with residual urine is
found w-e may, in the absence of other discoverable
cause, decide that an existing cystitis is dependent upon
the prostatic trouble. It may, however, be imijossible
to demonstrate the absence of stone behind an enlarged
prostate except by a thorough examination under ether
with the lithotrite.
The decision between a tumcu- of the prostate and sim-
ple enlargement is extremely difficult, unless the tumor
has assumed considerable proportions or has begun to
invade .surrounding parts. The phj'sical examination by
way of the rectum gives us our best help in diagnosis,
but the irregular growth of a tumor may at first simulate
the irregularities soiuctimes seen in hypertrophy.
The pain attendant upon the growth of a tumor is
more severe than that appearing early in hypertrophy,
though this is by no means constant.
In ca.se of a cancer the enlargement of neighboring
glands maj' help us to the right solution of the question,
and oecasionall}' the microscopic examination of the uri-
nary sediment will show the presence of cells character-
istic of a new growth. Not infrequently, however, it
will be necessary to wait until the progressive growth of
the tumor declares its character.
Tuberculosis of the prostate usually occurs earlier in
life than we could look for hypertrophy. In case of
doubt, tubercidous deposits must be sought for in other
organs (epididymis, seminal vesicles, lungs, etc.).
A tumor of the bladder may give rise to hemorrhages
and ditliculties of micturition which simulate those caused
by enlargeiuent of the prostate. Also a tumor may be
present in the bladder behind an enlarged jn-ostate, and
so complicate the symptoms.
The hemfurhagc from a tumor is ordinarily very much
greater than that from a congested prostate. But this is
not always the case, and whenever there is persistent or
intermittent hematuria, however slight, a careful search
should be made for villi or other bits of the tumor which
may be detached and passed in the urine, and which may
be recognized under the microscope.
Examination of the bladder with the sound may. when
a tumor is there, reveal a projection somewhere from its
wall. But sensations of this sort are very misleading,
and it is well, after a thorough sounding, to wash out
the bladder with the litholapaxy evacuator, with the ob-
ject of obtaining bits of the tumor, if one is there.
After definitely settling the diagnosis of prostatic hy-
pertrophy, it is always important to go further and to
decide in what stage the disea.se is, as we shall see that
treatment should vary according to the vaiying condi-
tions.
The steps to this decision have been sufiiciently indi-
cated above.
Tredtmeid. — As has been descriljcd, the disease under
consideration consists essentially in a tendency to con-
gestion of the prostate, bladder, and kidneys, with an ac-
companying hypertrophy and sclerosis.
For convenience we have divided it into three stages:
First, of congestion, with functional disturbances; sec-
ond, of simple retention; and, third, of retention with
distention, often incontinence, and perhaps involvement
of the kidne3'S.
First we will consider those measiu'es of treatment,
hygienic and medical, which are applicable to all stages
of the disease.
An_vthiug which has a tendency to increase the conges-
tion should be carefully avoided. A chill of the surface
should be especially guarded against. The i)atient
should wear Hannels next the skin, antl should carefull\-
avoid draughts or long exposure to chilly and damp
air.
The feet should be kept dry and wariu, and if the pa-
tient gets up at night to pass water, u.se the catheter, or
for other purpose, he shoidd cover his feet and legs
warmly. Neglect of these precautions may at any time
bring on an attack of retention, of cystitis, or even of
pyelonephritis.
Excesses in eating and driid<ing are to be avoided.
Large quantities of rich or highly seasoned food must
not be indulged in, and wine and beer are for the most
part better left alone. This caution should be under-
stood to apply only to overeating, as a sufiicient quan-
tity of nourishing food is of importance. If the patient
has been in the iiabit of taking a stimulant, a little light
claret, or some whiskey and water, may be alloweil with
meals.
Especial warning should be given against holding the
water over the ordinary time, parlietdarly if any call to
pass it is felt. An attack of coini)lete retention or of
cystitis may result from disregard of this rule.
Venereal excesses are, of course, to be avoided.
The effect of sedentary habits and of horizontal decu-
bitus in increasing the passive congestion in>ist lie borne
iu mind, and moderate gentle exercise is to lie advised.
The patient will do well, when engaged in any occupa-
tion that keeps him long in one position, to take an oc-
casional turn through the room; and at night or in the
morning, when he gets up for the purpose of emptying
his bladder, a short walk about his chamber will often
materially assist him in making liis urination thorough
and satisfactory.
Constipation" should be carefidly guarded against. In
prescribing for this condition, the violently acting drugs.
765
Prostate.
Pro»«tate,
REFERENCE HANDBOOK OP THE :MEDICAL SCIENCES.
which produce more or less congestion of tlic pelvic or-
gans, should not lie used.
The greatest assistance will often be iililained from rec-
tal injections. These are esiiecially useful when the me-
chanical obstruction of the prostate, pressing as it does
upon the rectum, is largely responsible for the failure of
the bo\V(!ls to act.
Cold injections are usually to be avnidid, though they
may sometimes render good service in hrl|iing to restore
the" functions of an atonic bladder. Hot injeclions (112 -
115' F,) will sometimes assist in reilueing congestion.
The functionsnf the skin sliould be stimulated as far as
possible. Rubbing and massage are to be employed to
this end, and baths also serve a'u.seful purpose if care is
taken against a sub.sequeut chill. A hot bath ending
with a sjiongc olT in cold water, and vigorous friction
with a rough towel, may be of real benefit, by bringing
the blood totheskin and so relievinginiernal congestion.
In selecting a climate fora jirostatic patient, preference
should be given to dry inland localities, wliere .sudden
changes of temperature are less likely to occur tlian on
the seacoast. Sometimes, however, wlien the general con-
dition is depressed and a stimulating cjini.ite is desir-
able, the seaside may be tried, special precautious being
taken against surface chills.
General medication directed against the disease itself
has but little to offer.
The iodides inaj- have a trial, in virtue of tlieir reputa-
tion in the treatment of sclerotic conditions of the blood-
vessels and other organs. If used they shindd be per-
sisted in for a long time, with occasional intermissions.
They have the disadvantage of sometimes disagreeing
witli the stomach, and it may be neces.sary to discontinue
them on this account.
Of the medication refjuired in the various morbid con-
ditions wliich may from time to time need correction, we
shall speak in considering the treatment of the various
periods.
Local treatment may be dividcil into palliative and
operative.
P(illiiilii-e Trentment. — Treatment in the first jierind is
almost wholly hygienic and medical.
In the absence of contplicalions. and before there is
any retention, the less instrumentation the better, as it
only aggravates the congestion, and introduces the dan.
ger of infection from dirty instruments.
If the urine is irritating from toogie.at acidity, an alka
line diuretic, such as citrate or acetate of potasli, is in.
dicated.
In case of pain, belladonna or hyjscyamus shmdd be
adininistered either by the mouth or by tlie rectum.
Opiates should be avoided, if possible, as they derange
the stomach and constipate the bowels. When urgently
required, however, tliey may occasionally Ije re-
sorted to.
Ergot, strychnine, or nu.\ vomica in some form
and quinine are sometimes useful, and act ap-
When
/
pareutly by diminishing
the congestion, and per-
)iaps also by stimidating
the contractions of the
bladder. If the circula-
tion is not good, cardial
stinudants may be of a>
sistance.
Second Period,
the stage of ])ar-
tial retention has
set in and the pa-
tient passes wa-
ter, but is notable
completely to
empty the blad-
iler, it is neces.sary to resort to the use of the catheter.
So important is this that every patient who is seen in
the tirst stage and put upon general treatment, slKmld
be warned that the time will almost certainly come
when catheterizatiou will be required, and that as there
FIG. asm
Callli'ter.
ULl.ILi:!!, LOSTo:;
-F.li'oweii c,^Uleter
dee of Jlercierj .
is no sure means by which he can tell when he reaches
this state, he should occasionally present himself for ex-
amination to decide this point.
Sometimes the partial retention is due to some acciden-
tal increase of congestion, whicii may disappear under
the use of antiphlo-
gistics. In such a
case the jiatient
may be put to bed
with leeches to the
perinetun, followed
by hot ajiplications fig. 3801
as.sisted by opiates,
if necessary.
If these measures fail, it will be necessary to draw the
water, and it will sometimes be found that, after a short
systematic use of the catheter, the bladder will recover
itself and again become able fully to e.xpel its contents.
Thus the disease may occasionally be moved back from
the second period into tlie first.
When complete retention comes on suddenly the cathe-
ter is indispensable, but in this case again its use may
perhaps later be given up.
When entering upon the use of the catheter, we may
often learn whether it is really needed by noticing the
effect upon the symptoms. If these are relieved or ame-
liorated, we are evidently on the right track.
It is to be remembered, however, that not infrecpiently,
on commencing catheterization, a cystitis develops itself,
owing either to the too sudden evacuation of a distended
bladder, to the iutroduction of dirt upon the catheter, or
CODMAN ecSHURTLEFF
Fig. 3892.— Double-Elbowed Catbeier (Sonde Bicoudee).
.simply to the irritation from the constant use of instru-
ments". It is important that the aggravation of .symp-
toms caused by this inflammatory onset shall not lead the
patient or doctor to infer that the catheter is doing harm
and should be given up, for it is by continuing its use
that the attack of cystitis may be most" quickly and surely
relieved.
Let us now consider bow and with what instruments
the catheterization is to be carried out.
As has been described, the walls of the urethra arc
pressed together and may be somewhat deviated by the
inequalities of the lateral lobes. The posterior ])art of the
urethral floor is also often raised by the projection of the
third lobe.
Our object is to reach tin- bladder through this sinuous
passage with the least possible amount of irritation.
If a soft, red rulilier catheter will tiiid its way into the
bladder, it is, by all odds, the best instrument to use. It
recpiires no skill for its direction, and can do no damage
to the urethral walls — a point of great importance, as it
enables us to entrust its use to an unskilful patient.
When, owing to the narrowness or tortuousne.ss of the
uretlira, the rubber catheter will not pass, we must re-
.sort to a stiffer instrument, and must adapt its form in
reference to tlie dilticulties which it has to overcome.
The obsi ructions which it will meet project from the
lateral walls and floor of the canal, and our effort must
be to carry the point of the instrument along the upper
or anterior wall.
!Mi-rcier devised for this purpose u flexible webbing
catlieter with theiioint sharjjly turned up(sonde coudee),
so lliat it might ride over the obstructions on the floor.
For those cases in which the hypertrophy of the third
lobe was very pronounced, he used a catheter with a sec-
ond bend, designed to lift its point still higher.
In inlrocliiciug these instruments, care should be taken
thai the |iiiint lie kept turned toward the roof of the ca-
nal, ami after it has passed the triangular ligament the
T66
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Prostate,
Prostate.
peuis should be depressed as much as possible between
the thighs, so that the tathcier may bo pushed straight
upward iu the axis of the body.
The English guiu-iilaslle callietcr may often l)e u.sed
with advantage, citlier with or without its wire stylet. U
it is introduced witliout a stylet it is a good plan to e.\ag-
gerate the curve of the instrument, as has been suggested
by Thompson. When used thus it .should he. introduced
cold and carried as rapidly as po.ssible through the ante-
rior urethra, for as it waims it becomes flexible and loses
its form. By passing it rapidly but carefully, its curve
often carries it over the obstructing third lobe.
If it meets an obstruction and, warming in the urethra,
becomes tlexible, the forefinger in the rectum shoidd be
used to lift the i)oiat of the catheter into the prostate,
while at the same time the handle should be brought
down to the axis of the bod}-, and the instrument, which
is then practically straight, should be pushed steadily
into the bladder. This should be done without the exer
cise of much force, as the point, when properly guided,
slips along quite easily and when it catches there is dan-
ger of its making a false pas.sage if pushed.
If the gum-elastic catheter is introduced w-ith a stylet
it should be curved into the form of a prostatic silver
c-ithcter. Sometimes, when the point catches it may be
lifted over the obstruction by the simple mauosuvi-e of
slowly withdrawing the wire while slightly advancing
the instrument. This curls the point upward and often
enables it to ride over the obstacle
Occasionally, when other flexible instruments fail, the
French conical bougie catheter will succeed iu worming
its way through the canal. It should be used with great
caution, as its comparatively sharp point may catcli in
and perforate the mueotis membrane.
Failing with other instruments, we may have recourse
to a metallic catheter of large curve.
The beak of this instrument should be long enough to
reach easily through the enlarged prostate, which may
be one inch and a half longer than iu the normal state.
If the curve is too short the point does not reach the blad-
der, but being engaged in the prostate, runs considerable
risk of making a false passage when the handle of the
instrument is depressed.
The forefinger in the rectum may give great
assistance in guiding the passage of this cath-
eter.
In using any instrument in a urethra with
false passages it is a good plan always to with-
draw for a considerable distance when the point
is caught, and then to try to pass the pocket
by cari-ying the beak down first one wall and
then another luitil the right passage is found.
Ordinarily the false passages exist in the floor
of the urethra; but this rule has many excep-
tions.
If, in a case of complete retention, after care-
ful and thorough
attempts we do not
succeed in reaching
the bladder, re-
course must be had
to puncture with
trocar or aspirating
needle.
This w a s f o r
merly done through
the rectum with
curved trocar, but
as this method can-
not be used autisep-
tically the suprapu-
bic puncture is to
be prefened. This
may be done with
a fine needle introduced close above the p\ibis. and. if
necessary, may be repeated two or three times daily for
a cousideralile time. Usually, however, drawing off the
urine in this way is followed by such a subsidence of
Fig. 389.3,— Englisti Gum-elastic Catheter
Willi E-taggerated Curve on Stvlet,
(After Thompson.)
the swelling as presently to allow the introduction of
the catheter. Leeching the perineum and the ailminis-
tration of ergot may also be of service in reducing the
congestiou.
The evacuation of a distended bladder, -whether by
catheter or by aspiration, should be performed slowly
and carefully. When
the distention is ex-
treme, the bladder
should not be wholly
emptied at one time
for if the internal press-
ure is too suddenly re-
lieved we are likely to
have a great congestiou ot
the vesical mucous mem
brane, with the escape i
blood into the urine, followcil
often by considerable inflam-
mation.
The greatest care sliould like-
wise be taken in the matter of
thorough antiseptic cleanliness, as
tlie introduction of germs into tli
bladder may st;irt a fermentation
the mine with cystitis. It is
course important, wheuever a cathi
is entrusted to a patient, that ca
instructions should be given to h
regard to this.
Catheterization having been
meuced, how often should it be n
In the cases of partial retent
moderate residuiun, the use of tli
each night before retiring is usu
cieut. As the dfsease prog
a point is presently reached \i
der habitually holds from
ounces of residual urine, am.
to urinate are conseciuen
frequent. Under these eit
stances the regular use
of the catheter is ic-
quired
If now the iiatient can
get along comfortably
while using the catheter
four times a day, he is
fortunate, and may live
for twenty or more years with his artificial urination.
Not infrequently catheterization will be recjuired six,
seven, or even more times in the twenty-four hours.
Especially is this the case when cystitis is present. The
water should always be drawn when the desire to mic-
turate is ing(/nt and persists-nt.
When catlielerization is recptired so often as to become
a decided soui-ce of irritation, and if the bladder is so
irritable as to be constantly liable to painful conti-actiou.s,
it will be found best to tieiu the catheter for a time (sonde
a demcurc). Usually iu a few days, after the bladder
has had a re.st, the catheter cau be again left out raid the
jialirMi can resume regular cathelrrizatiou.
During the tin.e wliile the patient is becoming accus-
tomed to the use of the catheter and llie bladder is
acquiring a tolerance of instrumentation, it is wise to
give some urinaiy antiseptic almost as a routine measure.
Of the antiseptics now at our command urotropin and
sandal oil are the most useful. Urotro])in may be given
in doses of five to eight grains two or three times a day,
and is a most useful drug, but it will occasicuially act as
an irritant, especially iu the iiresenceof ulceration of the
prostate, and in tliese cases .sandal oil is to be preferred.
Sandal oil Ls a more soothing drug, and is especially use-
ful where the tendency to irritability of the bladder ex-
ists.
Third Period. In this stage of the disease, systematic
emptying of the bladder is as urgently called for as at
any earlier time. The serious changes, however, which
Fk;, 3Sfl4,— Silver Catheters of Curve
Appropriate for Use through au En-
larged Prostate.
167-
Proslalo,
Proslatc,
REFERENCE HANDBOOK OF THE MEDU'AI. SCIENCES.
are likelj' to liave occuitihI in tlie iirctois ami kidneys,
with tile condition of passive eonirestinn wliieli exists
tliroui^liout the urinary Iraet, make llie use ot tiie eathe-
ter ii matter of considerable dani^cr, wliicli in some cases
may lie sosfreatthat it will be belter i)racti('e lo leave the
bladder undist\irbed.
In these eases the patient's eondilion of eom|iarative
health — troubled, it is true, by frecjuent and often partly
inv(dniitary micturition, but not debarred from ordinary
occujiations — makes a strikini; conliast with the state of
thin.us which may rapidly develop npou entering on the
"catheter life." For aslisjh' a<lded irritation to the blad-
der may be suddenly followed by a pyelonephritis, or
even more tibnipfly by renal congestion with suppres-
sion, ura'tuia, and death.
These dangers are alarming and imnunent enough to
make us hesitate, but what is to be ho|ied fnnu allowing
the disease to take its course? Nothing but a certainly
fatal issue, which is likely to come in a few weeks or
months, and w-liich may be prcci)iitaled at any time by
an e.\])osure to cold, by fatigue, or by a slight indiscre-
tion in diet.
On the other hand, Avhen catheterization is successfullj-
€stalilishe<l, the disease may be moved back from the
thii<l to the second stage, and the patient who was in
such danger may be put in a state of comparative se-
curity.
It "is, then, of the first im|iortance to distinguish the
cases in which catheterization is so dangerous that the
patient had better be left tol'ollowout the natural course
of the di.sease; and in all exce])t these most advanced cases
the catheter should lie used.
Each case must be decided on its luerits, and so nmch
dejienils on attention to detail tl^at we should .sometimes
bedeterred from comnienciiigcatlicterization with a care-
less and slovenly patient, wlicn we slnndd have resorted
to it could we have counted on Ins intelligent co-oper-
ation.
Guyon has laid down, for these advanced jn'ostatic
cases, a good rule of ]iraclice. lie puts the ]iaticnt U)ion
general tonic treatment, and if he finds that he is want-
ing in strength suflicicnt to beuetit by it, be does not
regard bim as in a state likely to be helped by inter-
ference with his bladder. If, howevei', he imiuoves de-
cidedly in bis general conditi<in, then Guyon regards it
as wise to lesort to the catheter.
The jueeautions to be observed in accustoming the ]ia-
tient to the catlieter are the .same that are required in the
second stage ot the disease, but they are now even much
more important.
Especially should the stnhhai eiu]>tying of a distended
bladder be guarded against. It may often rcipure two
or three weeks of catheterization before the bladder ac-
quires such tolerauce that it may safely be left empty.
During the ]ireliininary |)eriod the catheter slioidd al-
ways be pas.sed with the patient horizontal, to guard
against tlic too rajiid How of water; afterward, whin the
coiu|)letc emptying of the bladder is ilesircd. the veitical
position is the best for this operation.
ilperadi'e IVentmeiit. — It is inijiossible in the s|iace at
our command liere to do mme than suggest llie outlines
of operative treatment and oi the more iui])i)rtant pro-
eedines.
Kadieal operations aim at a cure; that is, at the com-
plete restoration of the function of urination. While
they often fall far short of this ideal, yet many cases are
practically cured. Perhaps the main reason why o])er
ative treatment has not been more .generally successful is
to he fouitd in the age of the patients, for in the majority
of eases we have to deal with men between fifty and
■ eighty years of age, and it is obvious that severe oper-
ations become more dangerous with adv.incing j'ears.
The willingness of the surgeon to operate in any indi
vidual case will also often be iidluenced by the social
condition of the iiatient, for a man of tli" lower classes
whocannot aft'ord the lime, trouble, and careful attention
to detail necessary to make catlieter life tolerable, may
wi.sely be advised to have some operutiou done, wlicreas
a man in easy circumstances may be kept comfortable by
less radical and safer measures.
Operation during First Stage. — As the symptoms of
the first sta,gc are lar.gely those of engorgement and irri-
tability, comparatively few patients will be seen at this
time, and as it is obviously impossible to decide detiuitely
how long a time may elapse before a patient reaches the
second stage, or whether this stage will be reached at all,
it is seldom that patients in the first stage arc to be ad-
vised that an operation should be done. Of cour.se, it
must be admitted that the earlier such operations are
done, the better, if they are to be done at all, but the
progress of this disease is .so variable that sound conser-
vatism will rarely be found in favor of operation at this
time.
Operation in the Second Stage. — The second stage of
prostatic enlargement is, as will be remembered, that of
beginning obstruction. At this time, the bladder will
iisuall_v be in good, or, at least, fair condition, and com-
paratively little damage will have lieeu done to other
parts of the urinary tract. This time is, therefore, in
most cases the time of election for radical operative
procedures. The patient is usually not too advanced in
a.ge, his blood-vessels are probably in good condition,
and the bladder and kidneys have not been irreparably
damaged. If. liowever, a patient, though in the second
stage, be found to have evidences of a chronic nephritis,
a damaged heart, or sclerotic arteries, the outlook will
be corresiiondingly less favorable.
Operation during the Third Stage. — The third .stage
being that of complete obstruction accomjianied as a rule
by more or less damage to the kidney will be an unfavor-
able time fill- radical operation. The mortality at this
time is almost |irohibitory. and there is little liope of re-
storing completely, or even in great measure, the func-
tion of the bladder. These patients may sometiiucs,
liowever. by careful catheterization or drainage of the
bladder, be so improved that an operation can later be re-
sorted to with reasonable hope of success. Hitherto the
rule has been to resort to radical ojierations only in the
more difficult and desperate cases. As a result of this
practice the mortality of such operations has been high.
The ideal time to choose for interference is when the
obstruction has become considerable, but before it has led
to .serious changes in the bladder, kidneys, and heart.
Could most of the operations be done at this early date,
the mortality would doubtless be much lower.
Unfortiuiately, iiatients at this stage of the disease are
usually too comfortable to be willing to face the risks of
o]ieration.
TiiK V.Mnons Operative Procedures. — The radical
operations may be divided into two general groups: the
internal ones, or those done through the urethra or
through a small perineal opening, and the external, oi
those which involve suprapubic cystotom}- or a large
perineal opening.
Inlrniiil ()/ii'r((tiiiii.t. — Of these the so-called Bottini
operation is the most iiromineiit. This is done with an
electro-cautery, somewhat resembling alithotrite, though
much smaller and more delicately made.
The male blade is connected with an electric battery
and acts as the cautery knife. The instrument is intro-
duced into the bkadder, and the beak hooked over the
prostate, the contour of which is mapjied out as accu-
rately as i»)ssihle. A furrow is then cut with the cautery
blade through the prostate in the middle line, the length
of the furrow lii-ing regulated accurately b_v a scale in
the handle of the instrument. Two lateral "furrows are
then also cut each at an angle of about forty-five degrees
from the median furrow. "When the sloughs caused by
the cautery have come away, the urethral obstruction is
often consideralily lessened.
This o|ieration is applicable to some cases which would
not stand more radical procedures. The relief is often
far from complete, and total failures are not uncoinmou.
The o|)eration may be done imdcr local or under general
an.Tsthesia.
Some operators prefer to introduce the instrument
T<;s
REFERENCE HANDBOOK OF THE AIEDICAL SCIENCES.
Prostate.
Prostate,
tlirougli a small incision in tlie mumbranous urethra. In
this wa}' shorter instruments are required, and they are
more easily guided liy tlie hand. The o|ieration does
not, however, e.'isentiall}' diller in its results from the
regular Boltiui operation.
A'-itef/iid (tperittiiiiis. — Of the external operations there
are three general tyjies: suprapubic, perineal, and com-
bined.
Siipnijinhir Operutioii.s. — All of the suprapubic oper-
ations begin with an ordinary suprainibie cystotomj'.
The bladder having been opened, two tyi)es of operation
are at onr conunand. First, tlie partial operation in which
portions of the prostate, such as a projecting third lobe
or a prominent bar, are renioveil, and no attempt is made
to remove the bulk of the prostate. This method may
be carried further and the prostate may be nibbled away
with cutting forceps, until the greater part of the ob-
struction has been removed. Operations of this type
have been practised for a considerable length of time, and
while sometimes giving almost or quite perfect functional
results, the}' very frequently fail completelj' to remove
the obstruction. In cases in which only a polypoid third
lobe, or a small projecting bar is removed, tlie operation
is of less severity, and carries with it a correspondingly
lower mortality than in the cases in which complete re-
moval is attempted, and it may, therefore, occasionally
be applicable to ca.ses in which the patient cannot stand
a more extensive operation.
(>f late years complete enucleation of the prostate by
the suprapubic route has been frequently jfractised, and
in selected cases it is an operation giving brilliantly suc-
eessfui results. The jirostate is surroimdcd by a very
distinct capsule, formed largely from the layers of the
pelvic fascia'. It is, therefore, possible to shell the gland
out from this capsule without excessive hemorrhage,
and in these cases the operation can be done rapidly and
bleeding readih' controlled by packing the cavity with
gauze. When the enlargement is very great, and espe-
cially when the glandular type of hypertrophy exists,
the hemorrhage may lie alai'ming and the raw surface
left behind is a great menace on account of absorption of
sejitic materials and extensive sloughing of torn and
bruised tissues. The cases likely to prove most favor-
able under the employment of this method are those in
which the prostatic tumor projects chietly into the blad-
der, is not of excessive size, and is of the tilirous rather
than the glandular type. To avoid the obvious dangers
of leaving a large wound upon the floor of the bladder the
pf'iinml openitions have been devised. The underlying
principle of all perineal operations is to bring the prostate
into view by a free perineal incision, which may be verti-
cal or crescentic; then to separate the prostate fi'ora the
lower segment of the rcetuni, and, after inci.sing the pros-
tatic capsule, to proceed to enucleate the glanil with the
finger much as in the suprapubic operation. In favora-
ble*^ cases this m.ay be ilone without tlamagc to the floor
of the bladder, and is at times also a very successful pro-
ceilure. The obvious dangers, however, are those result-
ing from extensive tears of the floor of the bladder and
jirostatic urethra, and from the not very infrequent acci-
dent of tearing the anterior rectal wall in the course of
the ojieration. The cases most suitable for operations of
this type are those in which the prostate is well within
reach of the finger, and in which the outgrowth has been
toward I he rectal aspect of the prostate, and in which
ulceration of the bladder does not exist. In order more
accurately to study the requirements of each case Alex-
ander has devised a coi/iljincd operation in which the blad-
der is lirst opened above the pubis, and then if the case
^ be favorable for perineal enucleation, a perineal incision
is niaile and the fingers of one hand in the suprapubic
wound iiush the prostate down while enucleation is done
wilh the other hand through the perineal incision. Some
operators do not o])en the bladder above tlu' pubis, but
carry the suprapubic incision down to the bladder wall,
and then with the fingers above press down the prostate
and make it aceessilile from the perineum.
It is important to renienilier tliat the careful selection
Vol.. VI.— i9
of the operation best suited to each case is of the first
importance, and it is, therefore, often wise to examine
the l)ladder carefully with thecystoscope before deciding
which operation should be undertaken, or whether any
operation is likely to give permanent relief.
(Jir/iiihclom!/ and Vasedomi/. — Thesubjectof oiwrative
treatment of prostatic hypertro]diy can hardly be dis-
missed without making mention of two operations which
have been advocated for the relief of the condition, and
which may still be done from time to time.
The operation of double orchidectomy, which was ably
advocated by White, had many advocates at the time of
its introduction. In some cases it appears to give very
marked relief in cases of congested prostates, liut this
relief is likely to prove but tcmporar_v, and in the most
favorable cases does not result in radical cure. It has
been followed in a fcv instances by very marked mental
symptoms, amounting in certain cases to insanity, and
this, togetlx'r with the frequency of total faihu-e to relieve
the symptoms, has ma<le it an operation which is very
rarely to be advised, and the interest in it at present is
largely historical.
\'asccton>p. — This operation, which consists of the liga-
tion and division of both vasa etierentia in the region of
the external inguinal ring, was strongly advocated by
Air. Harrison. It was hoped that it would have a result
equally favorable with tliat of orchidectomy, but with-
out its' unfortunate results. This hope has hardly been
justified, and the operation seems to be valuable largely
for the relief of those cases in which recurrent attacks of
acute epididymitis are a serious cause of discomfort to
the patient. It can be done if desired under local anaes-
thesia, and its technical details present no dilficidty.
Treatment of VonniJications. — Cystitis, which is the
most common complication of prostatic hypertrophy, is
to be treated according to the rules laid down luider Blad-
der. Diseases of The. on jiages 79,^ and 796, in Vol. I. of
this Handbook. When it occurs in the first stage of the
disease, general treatment is first to be thoroughly tried,
and local treatment thnnigh a catheter is to be resorted
to only when simpler measures fail. In the second and
third stages, when partial retention exists, the systematic
evacualion and irrigation of the bladder is the most effi-
cient means of treatment at our command.
Nephritis, or pyeloue]ihritis, must be treated on general
princi])les. Mustard poultices over the lower dorsal and
lumbar regions are indicated during the acute stage, with,
afterward, careful rubbing and friction to keep up the
action of the skin; a bland, non-stimulating, but nutri-
tious diet in abundant quantity ; and reguhition of the
bowels. If ura>mia threatens, pilocarpine and hot-air
baths may be used to promote elimination, and to relieve
the congestion of the kidneys.
A stone in the bladder can usually be removed readily
by lilholapaxy through an enlarged prostate, unless it is
of great size and hardness, or unless the careless use of
instruments has produced false passages. The pocket
behind the prostate often holds a small stone concealed,
and makes it hard to seize, in which case the hijis ma.v
be raised so that the stone rolls back toward the fundus,
where it is easily found and crushed.
When micturition is very difficult, it may sometimes
be thought wise to remove small stones by perineal inci-
sion, in the hope of at the same time relieving the ob-
struction.
When litholapaxy is impossible on account of the size
and hardness of the stone, it is usually necessary to re-
sort to the suprapubic incision. By this operation, too,
a iirominent middle lobe, or other cause of obstruction,
may sometimes be removed.
Athophy of the prostate may occur as the result of
mechanical pressure, or of destruction of portions of the
organ by inflammation. It may also appear in the
course of an exhausting disease, or as a consequence of
old age. It gives rise to no symptoms and calls for no
treatment.
Ti'MoKS OP THE PiiosT.VTE. — These may be classified
as follows;
r69
ProMale.
Hritriliifi*.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
^, , ( Retention cysts.
'^■^•'^^^ i Hydatids.
^/■T'"™ '. Ad.n.Mnvoma.
■Vdciioiua . . \
H(]UIld crll.
Sarcoma ■ Sj.indlr cell.
( Lyiiiplici-.
r, ■ \ Scirilnis.
( arcmonia ' f ' ,11 lid
Rett'iitinii cysts formed from diliitrd inland acini occur
iu many old prostates. Tlicy arc always small, and give
ri.sc to no inconvenience. Tlieir coiilcnls are .sometimes
inspissated, forming little concretions.
Hydatid cysts of tlie prostate are so rare thai Thomp-
son coidd, in fS83, learn of but one; and even in that
case it i.s doubtfid whether tlie cyst started in llii' pros-
tate or near it. "When discovered tiny should he at once
emptied.
Pure myoma is veryiare; aileuoma is somi'what less
so, but adeuomyoma is the most common of i>iostutie
growths. Paul thinks ordinary hypertrophy should be
ranked under this Iiead.
Tlie universal, .syuunetrical cnlargemeni can hardly, as
it seems, be cla.s.si(ied as a tumor, and yet the ]iathologi-
cal process is the same in it and in the circumscribed
masses which we recognize as new growths. These may
project iuto tlie urethra, the bladder, and iu other diree-
tion.s, or they may bo buried iu the midst of tlie gland
ti.ssue, from which they can be easily shelled out.
These tumors have sometimes been removed during
section of the gland iu lithotcmi}' or other operations, and
the removal of projections iuto the urethra has been con-
sidered above.
Sarcoma is occasionally observed in the prostate, where
it may start primarily, or to w hieh it may transplant it-
self from the testicli^ or elsewlieie. It usually appears
early, but may develop late iu life.
Carcinoma is more common than sarcoma, and ajipears
ordinarily after middle life. It may assume a scirrhus
or a colloid type.
In either of these last two malignant forms of growth
there may be a good deal of pain and considerable hemor-
rhages, especially after instrumentation.
In carcinoma the neighboring lymphatic glands are
likely to bi^ early involved.
Any cyst or tumor of the prostate may give rise to
symiitoms of obstruction. The ditlieulty of micturition
may reach a point at which some ojieralion for its relief
will be required. In opening the bladder for drainage
under these circumstances, eitlier the perineal or the su-
prapubic incision may be used, and the .selection woidd
dejiend soiuesvhat upon the size of the tumor.
If this is large and of a malignant character, which
makes its removal evidently impossible, su|irapiibic
drainage would be preferalile.
On the other hand, iu the case of a smaller or non-
nialiguani tumor the perineal incision should be used, as
by it the exact condition of things can be ascertained and
possibly beueliled. Harrison reports a case in which he
removed a cancerous growtli as large as the last iilialanx
of the thumb from the pmstalie urethra. The operation
was followed by great relief from distress iu micturition,
and the patient lived for fourteen mouths.
Triu-:itcfLosis of Tiir: Phost.vte occurs often second-
arily to tubercvilous conditions in other parts of the gen-
ito-urinary tnict. Jt probably also sometimes appears
primaiily in the prostate.
As ]iatients with genito-urinary tuberculosis usually
die when the disease is far advanced, it is rarely po.ssilile
to decide at autopsy where the di.sease originated ; and as
the organs are many of them deep-seated and beyond the
reach of physical examination, it is likewise im]iossilile
during life "to be sure that the prostate was primarily
alTecled.
On the other hand, this gland is situated at the junc-
ticm of the genital and urinary passages, is as it were at
the crossroatls through wdiicli any tuberculous material
from the kidneys or testicles must go in its passage from
the body. This situation makes it peculiarly liable to
secondary infection, and, as a fact, it is almost always
sooner or later involved.
The tu!iei(des may ajipear as little isolated gray gran-
ul(!s, scattered throughout the tissue of the organ, or
they may be agglomerated into masses which, if tliey
reach a moderate size, ordinarily become cheesy in the
centre and finally break down iuto abscesses.
Sometimes almost thewliole prostate is thus destroyed,
and its place is occupied by an abscess which usually
eommunicates with the urethra and bladder. It may
break through iuto the rectum, forming a recto-vesical or
a urethral listula directly through the prostate.
The siimptoiiis are those of a chronic pudstatitis (si^e
above) witli a special tendency to hemorrhage. They
may be as.jociated with evidences of tuberculosis elsc-
w here.
Phi/sicdl c.Tiimiiiiitioa by the rectum may reveal little
or no alteration iu the gland. Ordinarily, however, in-
equalities are felt which may give it a distinctly nodular
( liaracter. Tliis may be associated with enlargement, or
the ]irostate may preserve almost its normal size.
Tlie ejaculatory ducts and the vesicula> scminalcs
should be felt for, and if the disease has alfected them,
they may be found as thickened, resistant, cord-like
bodies. This is especially to be observed when the dis-
ease started iu the testicle and worked its way up to the
prostate.
Not infrequently a little shot-like mass is felt between
the rectum and the prostate, or it may be a little behind
and to one side of the gland. It is not attached to the
prostate, rectal wall, or .seminal vesicles, but is loose in
the tissues between thcni.
Dr. Bryson, of St. Louis, thought that in one case, in
which he hail an autopsy, he made it out to be a cheesy
mass within a vein. Possibly it is sometimes an infected
lymphatic gland.
The testicles, epididymides, and vasa defcrentia should
also be examined, and the urine sliould be investigated
for evidences of kidney complication and for tubercle
bacilli.
These last are very difficult of detection in the urine,
and their apparent absence does not argue against tuber-
culosis. When unmistakaljly present tJiey are conclusive
contirmatory evidence. In all cases of doubt the urinary
sediment should be inoctdated into a guinea-pig.
The phj-sical investigation should also incbnle the ex-
amination of the lungs, which may share in the tulier-
culous luocess.
IJiiiiliiiixix. — The di.sease may be confounded with
chrnnic prostatitis or cystitis, with stone or tumor in the
bhidder, or with pyelitis when accompanied by frequent
micturition.
While a careful con.sideratiou of the symptoms and in-
herited tendencies of the patient niaj^ enable us to form
a probably correct idea of the condition, it is only by a
careful jihysical examination that we can reach a positive
diagnosis.
I'csides the examination described above, an explora-
tion fif the bladder, under ether if necessary, will be
ncedeil for the detection or elimination of stone and of
tumor of the bladder.
There will be a certain number of cases in which a
diagnosis is at first impossible, and in which the true in-
terpr<4atiou of the condition can be reached only when
linu! has develoiieil characteristic .symptoms.
Tri'dtiiiiiit. — Jlost im]iortant is the constitutional treat-
ment with cod -liver oil, hypophosphites. and iodides.
A healthy out-of-door life, with moderate exercise and
good food, is to be enjoined.
TlKimpson advi.ses against local treatment, and it is
certainly important to avoid rough manipulation.
In the early stages of the disease, however, gentle local
measures may serve rather to allay than to excite irrita-
tion, and should be tried.
Irrigation of the prostate and bladder and the intro-
duction of iodoform pencils may he of service. Occa-
ro
REFERENCE HANDBOOK OF TITE MEDICAL SCrENCES.
Prostate.
I»riii-itus,
gionally tlie passage of a sound is useful 137 removing the
contraction of the constrictor muscle. The pain and fre-
quency of micturition may sometimes be much relieved
by these means.
While the jirognosis is necessarily grave, and the per-
manence of iniprovenient is always doubtful, still these
cases are not uhvays hopeless if seen early.
Prost.\tic C.\Lcn.i. — In the duets and dilated tubules
of the prostatic glands are found not infrequently little
yellowi.sh or brownish bodies, composed of an organic
substance allied to protein.
These, if they increase beyond a moderate size, begin
to have earthy salts deposited in and around them, and
tinally become prostatic calculi, which may reach the size
of a walnut or even of a larger object.
These calculi are usually multiple, and are facetted
from mutual attrition. They are hard, take a high pol-
ish like porcelain, and are white or light blown in coloi'.
Chemically, tliej- are composed almost wholly of phos-
phate, with a slight admixture of carbonate of Hnie, and
are to be distinguished from urinary calculi by tlie fact
that they do not contain any of the triple phosphate of
magnesia and lime, which is so large a constituent of
vesical calculi.
When prostatic calculi are made out they may be re-
moved by a median or lateral peiineal incision. The
operation is usually one of no serious danger, us the blad-
der is not opened. Arthtir T. Cabot.
Hugh Cabot.
PROSTITUTION,
Diseases.
REGULATION OF. See Camp
PROTAN is a tannin nucleo-proteid employed in dose
of 1-2 gui. (sr. XV. -XXX.) as an intestinal astrincent in
dian-bo-a. " H'. .1. UiMcdo.
PROTEINOCHROMOGEN, PROTEINOCHROME. See
Tryi,l„i,h.u,.
PROTHROMBIN. See Cwiyulatiun.
PROTOGEN. See Forinaldehyde.
PROTOPLASM. See Cell.
PROTOZOA, PARASITIC. See The Appendix.
PRUNE.— P;'««»m, U. S., Br. The partially dried ripe
fruit of Pruuus clomi.ttica L., or, according to the Briti.sli
and some other pharmacopadas, P. domestica Jitliana De
C. (fam. Iiu.<<acea'). The fresh fruit of the latter variety
is oblong, that of others subspherical.
The prune, coming originally from southwestern Asia,
is now everywhere cultivated in temperate regions.
Probably the best prunes for medicinal uses are those
grown in .southern Europe, since they are more acid. The
prune requires no description. It should not be over-
dried, should possess a very slight odor and a pleasanth'
sweet and acid taste. It owes its slightly laxative prop-
erties to the presence of acids, chietl_y malic, free, and
combined witli potassiumand otherbases. There is pres-
ent also sugar, to the extent of about one-third of the
■weight. The seed contninsamygdalin and yields prussic
acid, and should, of course, be removed.
Prunes have no other medicinal value than that of a
very mild laxative, sinular to nuiny otlier fruits, but the
concentrated juice is useful for administration to small
children, because of its pleasant taste. The only ollicial
preparation is the confection of senna (see Senna).
Prunes are very largely consumed upon the table for
their laxative effects, as well as for their food properties.
As served ujion ocean steamers, they usually liave some
senna boiled with them. Ilenry H. Rushy.
PRURIGO. — Prurigo is a malad}' tui r/encris. The con-
dition usually appears about the end of the first j-ear,
but may appear as late as the thirtieth year. The affec-
tion usually starts as a lichen urticatus, the characteris-
tic lesions of prurigo appearing later. There are two
forms: prurigo ferox or Hebra's prurigo, and prurigo
mitis, but a distinct line cannot be drawn between the
two. In piurigo ferox there are repeated eruptions of
pale red or skin-colored miliary papules, which itch vio-
lently. This eruption is generalized, but it is thickest
on the extensor surfaces of the lower extremities. The
papules are so small and project so slightly that they
often cannot beseen, although the\- can be felt. Scratch-
ing prod\ices excoriated ti]is, and these become covered
wUli blood crusts. Other lesions appear as the re.s^dt of
scratehinir, such as excoriations, pustules, crusts, pig-
mented areas, and a dry, scaly, and thickened skin
During the first few years wheals are frequently
found, but they disappear as the papules increase. A
secondarv eczema in all forms may also be seen. In
nearly all cases there is enlargement of the superticial
lymphatic glands, the femoral being most marked. The
tiexures are usually free from eruption. As a rule, the
eruption diminishes upira the advent of summer. This
form is incurable, but the patient can be relieved to such
an extent as to be free from the eruption at times. In
prurigo mitis the papules are fewer and the itching is le.ss ;
consequently the secondary lesions are much milder.
Most of the cases met within this country are of this type.
In some of these cases a perfect cure may be obtained by
careful ai'.d persistent treatment. When untreated, pru-
rigo has a marked effect on the ].iatient both mentally and
physically.
Etiology. — In discussing the causation of this affec-
tion we can do no more than mention certain conditions
with which it frequently occurs. It is usually found in
])oorly nourished and scrofidous children. Occasionally
there seems to be an hereditary predisposition, several
children in one family lieing affected. It is jiossible that
there is some congenital anatomical malformation of the
skin as is seen in ichthyosis.
P.M'noLOGV. — The alfection ]irobably starts as a vaso-
motor neurosis. Jlicroscopically the ]iapules are com-
posed of a round-cell infiltration, with oedema of the
papillie. Swelling of rete cells occurs and later there is
a hyperkeratosis.
Di.\GN0Sis. — The diagnosis is difficult at first, as in the
beginning the eruption consists mostly of wheals. The
condition is also misleading when large eczematous areas
cover the lesions of prurigo. The following points are
ciiaractcristic, and when they are present the disease can-
not be mistaken for any other condition ; A constantly
recurring eniption of miliary papides, resembling in
color the normal skin, ayipearing in early childhood, and
most luarked on tlie extensor surfaces; the enlarged
glands; and secondaiy lesions from scratching.
TuEATMEXT. — Very little can be expected from inter-
nal medication, tudess the patients are scrofulous or
poorly nourished ; in "which case cod-liver oil and general
hygienic measures will be beneficial.
Crocker speaks bigld}' of cannabis indiea as an effective
remedy for controlling the ilcliing. as in pruritus. The
dose should be gradually ineicased to thirty minims of
the tincture, well diluted, after each meal. Phenacetin
and antipyrin are among the most valuable remedies lor
the itching. Rest, an even teniiierature, and alkaline or
sulphur baths will make the patient more comfortable.
For the local treatment, naphtol, sulplnir, and tar are
the remedies most likely to relieve the itching and de-
crease the papular erujition. The usual way of using
sulphur is by the ajqilication of the ofiicial ointment or
Wilkinson's ointment. Tar can be used ]iure or diluted
with oil or lanolin. Naphtol should be used as an oint-
ment iu the strengtli of two to five per cent. AYhalever
local treatment is u.<ed. it should be vigorously continued
until there are no fresh papules and the skin is smooth
and tlexible. Occasionally it will be found necessary to
use first some liland ointment to cure the secondarv ec-
zema which so frequently acconipain<-s this condition.
Ihuriird Mornnr.
PRURITUS.— Pruritus is an affection of the skin char-
acterized by itching without any external cause. It is
an independent disease, and must be distinguished from
771
FMaiiiiiioiiia.
I>»o iKlolo iikii-iii ia.
REFERENCE IIANDBUOK OF THE MEDICAL SCIENX'ES.
tlie syiJiptoraatic itching common in sucli pruritic condi-
tious as eczema, scabies, etc. It is a sensory neurosis
due to a functional disorder of tlie nerves independent of
any source of irritation on tlie skin. The syui|itoms may
be so mild as to i)roduce but temporary discomfort, or so
severe as to cause profound misery or even sueli a decree
of nervous depression as may result in insanity. Scratch-
ing is the patient's method of relief, and llie excoriations
produced are ofteu preferable to the ilcliing. Although
scratching frequently relieves tlie itching in a certain
place, it usually e.xcites it in other parts. F'roni the scratch-
ing we may get excoriations, pustules, wheals, and pig-
mented areas. A rare result of such chronic scratching
is the condition called lichenilication, in which the sUin
is thickened and the natural lines are deepened, leading
to the formation of irregularly shiny papules. This con-
dition is usually found in the tie.xures, and is often mis-
taken for eczema and liclicu planus.
Pruritus is either general or confined to certain areas.
The former is frequently spoken of as pruiitus univer-
salis, and although the itching is general, it is seldom felt
all over at the same moment, and there are frequent re-
mi.ssions from any ilching. The most frequent causes of
this aifection are disorders of the alimentary tract, func-
tional derangement of the liver, cancer of the stomach or
liver, uterine disorders, malaria, gout, rheumatism, and
Bright's disease. Pruritus is always worse when the suf-
ferer is in bed, and is excited by exercise, forced rest,
and sudden changes of temperature.
The itching which accompanies jaundice is not a true
pruritus, for it is produced by the mechanical jiressure
of the Ijiliary coloring matter which is deposited in the
skin. Senile pruritus is an accompaniment of senile de-
generation of the skin. Although it is general, it is usu-
ally most marked on the lower extremities. It is very
Jiersistent.
Pruritus hiemalisand inuritusa'stivalis are terms given
to varieties of generalized pruritus which occur during
the cold and hot seasons respectively. Some authors
consider these forms distinct atl'ections. Pruritus hie-
inalis is duo to the dryness and britlleness of the epider-
mis which is can.sed by tlie cold of winter. Pruritus
a'Stivalis is occasionally found Muring the warm weather
of summer.
In the lijc<il forirm, although we can have itching in
any part of the body, the following varieties are most
common; iiruritus ani, pruritus vulva\ pruritus scroli,
pruritus palnue ct planta'. Pruritus ani may be due to
tissures, lieiuorrhoids, asearides, or pelvic tumors pro-
ducing local congestion. Pruritus of the vulva may be
caused by ovarian or uterine disease, diabetes, or "ure-
thritis. Pruritus of the scrotum is usually associated
with eczema. Pruritus of the hands and feet is mostly
found in the gouty, and fre(iuently is as.sociated with
liyperidrosis.
In the different forms of local in'uritus it is occasion-
ally impossible to discover the cause. The prognosis of
senile pruritus is unfavoralile. In the other I'ornis the
lu'uritus will usually cease if the cause is found and re-
moved.
I)r.\ONOsis. — All chronic diseases which are associated
with itching, such as ]irurigo, urticaria, scabies, and the
irritation from lleas, bedbugs, and lice must lirst be ex-
eluded. It is often iiiipossible to (lill'eicntiate clirouic
urticaria, as these two alfections fre(iui'ntly occur nnder
the same etiological conditions. Careful investigation
must b(^ ma<le as to the presence of any renal, liejiatic,
or digestive disorders.
Tlie diagnosis of senile pruritus must be made by ex-
clusion. In cases of pcr.sislent itching aroiunl the anus
and vulva, careful examination may show a dctinile jioiiit
from which the patient saysthe ilching starts. The skin
at this point may aiqiear to be perfi'ctly normal, but it
must be treated before the ilidiing will cease.
Tkf,.\tmknt. — A great deal dejiends upon the cause,
and the .sooner this is foniul out the sooner the palient
may be put on appropriale trealment. The internal
treatment is dietetic as well as medicinal. The food
should be easily digestible and all stimulating liijuidi
should be avoided. The bowels must be carefully regu-
lated. Calomel followed by saline aperients is often nec-
essary at the start. From now on, the internal treatment
must be in accordance with tlie general principles of
medicine, and the condition of each internal organ should
be investigated. Of the various internal remedies which
are used as nerve sedatives, cannabis indica is the best.
Ten to twenty tniuims of the tincture should be given,
Avell diluted, after each meal. Carbolic acid, gr. ij. in
each ])ill, one after each meal, is recommended by Brocq.
Antijiyrin ads well at times.
External treatment is necessary even if it is not cura-
tive, because it enables the patient to abstain from scratch-
ing, and this temporarily relieves the irritated nerves.
In the mean time other remedies can be directed to the
origin of the trouble.
For general pruritus lotions are preferable to oint-
ments. One of the best is compo.sed of liquor carbonis
detergcns, 3 iij. ; liquor plumbi subacetatis, 3 iv. ; glyce-
rin., 3 iv. ; di.stilled water, q.s. ad 3 viij. Another is car-
bolic acid, two per cent., in campihor water. Bichloride
of mercury, gr. ij. to an ounce of tifty-|ier-cent. alcohol,
is a good odorless lotion. A mixture of aromatic spirit
of ammonia and water, equal parts, is frequently used.
Five or six ounces of bicarbonate of sodium to an ordi-
nary bathtubful of hot water may be used with advan-
tage. Bran baths are soothing. They should be made
by adding from four to six pounds of bran to a tuliful of
water. Altera bath the surface should not be rubbed drv,
but should be |iattcd gently with a soft clolh and dusted
with some southing powder.
For pruritus liiemalis alkaline baths and emollient
11 reparations have proved most serviceable. A two-per-
cent, solution of salicylic acid in almond oil is an excel-
lent remedy. Similar applicationsare indicated iu senile
prurilus.
For local pruritus, dozens of remedies have been rec-
ommended, but until the cause is ascertained most of
them will give but temporal-}' results. If the patient can
locale a definite jioint from which the itcliing starts, the
destruction of this jioint by the actual cautery gives im-
mediate relief. Simider methods, as a matter of course,
should be used at lir.st.
For ju-uritus ani, mercurial applications give the most
.satisfaction; sucliare: ammoniated mercury, gr. xx., in
zinc ointment, ? i. ; calomel, 3 i., in lard, 5 i. These two
a re frequently combined. Hot compresses are very agree-
able. Carbolicacid in two-pcr-cent. solution can be used
in a compress or in an ointment. A supjiository of ex-
tract of belladonna, gr. ss. at bedtime, often gives relief;
inor]ihine may be added to this. Cocaine, gr. ss. in a
sup])ository, gives temporary relief. On the surface co-
caine is fre(iuently used in a boric-acid ointment, or in
combination with menthol, two per cent, of eacli. Cam-
jihor-chloral is commonly used. Ilydrocj'anic acid,
naphtol, and irhthyol are u.seful at times.
For pruritus vulva', hot (■oui presses of asaturated solu-
tion of boric acid sometimes give relief. Tincture of
benzoin painted on the jiarts daily with a camel's hair
brush is also an excellent remedy. Iloirtd-d Morroir.
PSAMMOMA. See Samwui.
PSEUDOLEUK/EMIA. See norh/kius Disease.
PSEUDOLEUK/EMIA INFANTUM.— (Synonyms; Au-
a'liiia infantum iiseuiloleuka'inica: Amvniia splenica in-
f'etliva dei bambini; Ana-mia sjileniea [Splenomegalie
primitive] ; von Jaksch's ana'inia. )
DF.FTNrrioN. — A di.sease occurring in infants, usually
in the tirst two years of life, characterized by great jial-
lor, considerable enlargement of the s)ileen, moderate
enlargement of the liver, a low erythrocyte count, a mod-
erate Icueoeytosis, consisting chietly of an increase of the
lymphocytes, numerous erythroblasts, low ha'moglobin,
the absence of especial enlargement of the lymph nodes,
and at times accompanied by hemorrhages (liiBmateme-
Trs
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Psaiiiiiioina.
Pseu(Iuleuka3iuia.
sis. hijemati'.na, purpura) witliout any known cause. The
cour.se of the disease is usually subacute or chronic.
Historical Notick. — The term "ana'mia infantum
pseudoleukiBmica " * was originally adopted on the
ground that the disease was one form of pseudoleuka;-
mia (Hodgkin's disease). Of late j-ears it has been so
clearly shown to be different from Hodgkiu"s disease, in
that the condition of the spleen is not the same, that the
name "pseudoleuka'iuia " is evidently a misnomer and,
strictly speaking, should nyt be used in couuectiou with
the class of cases under consideration. On the other
hand, there are as yet so much dispute and such varying
opinions among those wlio have carefully studied the
group of symptoms which are supposed to represent the
disease, that there is no other name which at present had
better be applied to it, since the evidence is very strong
' that no such di.sease exists apart from severe ca.ses of sec-
ondary ana'inia with enlarged spleen. It is supposed at
present to correspond to the so-called cases of splenic
ana?mia in adults. The same dift'ereuce of opinion exists
as to the recognition of a splenic ananuia in adults as
separate from severe cases of secondary ana?mia with en-
larged spleen. It is thought better, therefore, to describe
the symptoms of what has been stijiposed to be a sepa-
rate disease by the name under which it was first spoken
of, always wishing it to be fully understood that this
description merely represents what is known about tlie
subject up to the present time, and does not intend to
give the impression that the author necessarily believes
that it is a separate disease because he describes a set of
symptoms under the term "aniemia infantum pseudo-
leukremica." The subject is still si/b jiidicc. and nuich
further investigation must be carried out before a liual
decision can be made to give up the idea that there is
such a disease separate from severe cases of secondary
an;euiia.
We wish, however, to have it understood that it is the
so-called ''splenic antvmia" of adults with which the dis-
ease, if such disease exists, is associated rather than with
pseudoleuka?mia.
Formerly, anannia infantum pseudoleuka?raica was
considered a primary disease of the blood, but it was .soon
differentiated from the dill'erent forms of leukaemia, and
later from pseudoleukitmia (Hodgkin's di.sease). It is,
however, stiil believed by some writers to be a primary
disease of the spleen.
As far back as 1866 a case of a child suffering from a
severe form of an.Tiiiia accompanieti by an enlarged
spleen was reported by Gretsel. Cases liave since been
described, but in a somewhat indefinite manner, and the
next important work which appeared on the subject
was that of Bauti in 1883. Bauti, however, although
believing that anaunia splenica was a primary disease of
the spleen, considers it also a splenic form of pseudo-
leuka'iuia, and it is from Banti's descripticm that the
characteristic symptoms of tlie disease are taken as well
as the pathology. Following Banti a number of writers
have recorded cases which they considered to represent
the disease splenic ana?mia ; but their cases, in the light of
more modern investigation, are so closely allied in their
description to those of pseudoieukannia that they would
at the present time scarcely be accepted.
In 1891 Bndil published an article on splenic auamia,
and suggested the name "splenomegalie primitive."
Bruhl's work, however, was very much in the same line as
Banti's, and therefore need not be further referred to.
AVilliamsou in 1893 reported a case of a boy nine years old
who died, and a description of the lesions found in this
case will be given under pathology. Later writers, such
as Hawthorne in 1895, in the case of a child eleven years
old who recovered, and Taylor in 1896, in the case of a
girl thirteen years old in whom the symptoms were very
similar to those of pseudolcukicmia, have added nothing
new' to our knowledge of the subject. In like manner
* The title whicli is plarpd at the head of this paper was chosen
merely for rea.sons of cinnfiiieufe, i.e., simply because the time liad
pone by when the ariicln nii^ht have been placed under the title
which I consider to be preferable.
Goepel reported the case of a boy eleven years old on
whom sj.ilenectomy had been performed with recovery,
btit no histological report was made as to the condition
of the spleen, and although he stated that the operation
was performed for pseudoleukemia, no enlargement of
the superficial lymphatics was present at the time the
ijperation was performed, and the blood was stated to
have been normal.
In 1900 Osier reported fifteen cases which he consid-
ered to be cases of "primitive splenomegalie," but his
cases occurred in adults. He also reported some addi-
tional cases of splenic ana?mia at the annual meeting of
the Association of American Physicians in Washington,
April 29th and 30th, 1902. The opinion of those who
di.scus.sed Osier's paper gives the impression that splenic
ana'mia as a primary disease is not univei-siilly a<'cepted,
and, in fact, most authors consider it to be a form of
Secondary ana-mia.
In 188iSomma, under the title of "ana-mia splenica in-
fantilis," reported thirteen cases in infants and young
children. Fedde in 1889 and in 1890 spoke of this disease
under the title of "aniemia splenica infettiva." believing
it to be an infectious disease of infants. No details of his
cases, however, were given.
In 1890 at the Pediatric Congress in Rome, Somma and
Fedde presented papers on "Ansemia Splenica Infettiva
dei Baiubini." Somma's conclusions are tliat "anamia
splenica infantilis " is a disea.se which occurs in infancy
as a rule, but that adults are not exempt.
It is significant that a number of the cases, reported
by various authors, of the disease in early life show a
condition of rhachitis.
Cases have also been reported by Senator. Luzet,
Baginski, Alt, Weiss, Hock, tfchlesinger, Koplik. Monti,
Berggrun, Audioud, Glockner, and otheis, but in all
these cases rhachitis or some other condition of uuiluutri-
tion was present which could produce changes in the
blood identical witli those which occiu' in the secondary
auannias of early life.
P.\THOLOGY. — The pathology of splenic anamiia has
mostly rested on the findings in the autopsies described
by Bauti previous to 1883. The pathological lesions in
lliese cases were not those of leukamia or pseudoleuka'-
mia, and on this fact Banti laid much stress in his argu-
ment that tlie condition is due to a primai'y disease of the
spleen. In Williamson's case, that of a boy nine v'cars of
age, the patient was under observation for four months,
and finally died. The pathological lesions as described b}^
Bauti were marked fibious changes in the ti-abecula> and
the follicles of the spleen, and a great diminution of the
ci'lls. There were many large phagocv'tic cells contain-
ing red corpuscles, the bone marrow was red and showed
a lymphoid condition, but the lymph nodes were not en-
larged. The spleen weighed two pounds seven ounces,
the liver weighed two pounds twelve and one-half ounces.
The blood sliowed a diminution of leucocvtes, and the
red corpuscles were between 2,000,001) and 3.000,000
))er cubic millimetre. The temperature varied for four
months, sometimes as much as fotir degrees between
morning and evening. There was no history of rhachitis,
sy]ihilis, or malai'ia.
In the reports of tlie autopsies of Somma's cases of
ana'inia splenica infettiva dei bambini nothing very defi-
nite is added to our linowledge of the disease, nor are
the reports satisfactory or conclusive. The spleen is
firm and large, sometimes congested, sometimes with a
tliickened capsule. Vai'ious conditions, such as anaemia
of the organs, pulmonary congestion, serum in the ven-
tricles of the brain, and enterocolitis, and in one case
imeumouia of both lungs, are recorded. Lorenzo reports
the autopsy of one case in which there was an increase
of the connective tissue of the sjjleen and sclerosis of
the follicles.
Fedde states that the onlj- characteristic lesions are
found in the spleen, liver, and blood, that the glands are
normal or slightly enlarged, the liveroften enlarged from
congestion and from a slight increase of the connective
tissue, with fattj- degeneration and atrophy of the liver
773
Psciidoiuyxoiua
Peritonei.
REFERENCE HANDBOOK OF THE IVIEDICAL SCIENCES.
cells; the spleen large and firm. ■vvilU hypertrophy of the
(■onuective tissue, and the JHilp rich in lymph cells and
with the follicles hyperi)lastie.
Giauturco and Pianese report the pathological findings
ill a case of Fedde's as a spleen showing no increase in
interstitial tissue and with tlie follicles little developed.
Mya and Trainhusti reviewed the lesions found in the
spleen and liver. an<l came to the conclusion that tliey
were more or less di\erse. In one of the-ir cases tlie
lesions in the spleen were similar to those found by Banti
in cases of adult splenic ana'iiiia. there heing marked in-
crease in tlie fibrous tissue, together with atrcjplued folli-
cles and thickened trabecule.
Von Jaksch. in his description of amemia infantum
pseudolcukaiuiica, gives very few and very unsatisfac-
tory reports as to the pathological apiieaiances of the
disease; he considers them to l)e a chronic liyperidasia
of the spleen alleeting in diU'ereiit degrees p;uts of the
organ, with the liver sliowiug slight increase in the con-
nective tissue.
Hayem and Luzet report in their examination of llie
blood in amemia infantum pseiidoleuka-mica large num-
bers of nucleated red corpuscles, iu some of which there
was evidence of karvokinesis of some of the nuclei, and
they con.sider this to be of great diagnostic value. Fowler
also lays great stress upon the presence of large numbers
of nucleated red cells out of proportion to the diminu-
tion of the erythrocytes.
It is very evident that there does not seem to be satis-
factory post-mortem evidence to warrant a definite patho-
logical condition representing the S|)lenic an;i;mia of in-
fants. There seems to be present in most cases a chronic
hyperi)lasia of the spleen, w'hile in other doulitful eases
the spleen is not altered.
Etiology. — In regard to the etiology of anannia infan-
tum pseudoleuktemica uothiug definite has been proved.
Although pathological micro-organisms, finding condi-
tions favorable for their growth in the spleen, may, accord-
ing to Somma, find their way into the circulation and thus
produce changes which are represented by certain clinical
symptoms, yet there is no doubt that the true nature of
the disease, if such exists, has not yet been discovered.
Nothing has ever been found bacteriological ly to show
a direct relation between the micro-organisms present
and the production of tlie disease.
Sv.Mi'To.MS. — It is difficult to describe l\w symptoma-
tology of a disease which is so closely identified with
cases of seeondaiy ana'iuia with enlarged spleen, and in
which the group of symptoms that are sujiiiosed to repre-
sent an.'cniia infantum pseudoleuk.emica, are somewhat
diverse. Both sexes are eiiually liable to ]iresent these
symptoms, and tlu? patients are usually between the ages
of ten and eighteen months; one has been reported of
seven and one-half mouths, and one' at three and one-half
years. The onset of the disease is gradual, the nutrition is
poor; thereareeonsiilerable emaciation, a waxy fintof the
skin, at limes hemorrhages from llje mucous memluaiies
and the skin, a spleen much enlarged, and the liver mod-
erately eidargi'd. There is no tenderness over the bones,
and there are often a venous bruit in the neck and func-
tional cardiac murmurs. The blood shows the character-
istics of a secondary aua'uiia of varying intensity, that is,
a diminished number of erythrocytes, low ha'inoglobin,
variations in the size and slui.pe of tlie erythroeytes and
in the number of erythroblasts jiresent. The leucocytes
are not characteristic, being markedly increased in some
cases and in normal propoition in others. The lympho-
cytosis, reported by many writers, may occur umler any
condition, giving rise to an increased number of white
cells.
DiAG.Nosis. — There seems to be no doubt that anaiuia
iiifantum iiseudoleuka'iniea and ana'iiiia s|ilenica inlet -
tiva are the same condition, and, as there does not seem
to be reason for believing that the spleen is iirimarily
affected in either of them, they lU'cd not be dilVerentiated
one from the other. The ditferential diagnosis should
first be made from leuka'iuia and pseudoleukiemia. The
proportionately low leucocytosisaiid the absence of either
a general lymphatic enlargement or an excess of mye-
locytes in the blood would difl'erentiate it fi'om the
former, while the absence of enlarged lymph nodes
would exclude pseudoleukamiia. As there are so few
cases in which a thorough and reliable examination of the
organs has lieen made in which rhachitis was not luvsent.
the diagnosis between rhachitis with enlarged spleen and
secondary auipinia. and this supposed especial group of
symptoms, would be very difficult and seemingly impos-
sible.
We know that in infants the same blood changes
Avliich have been mentioned above often occur in con-
nection with an enlarged spleen in the course of or follow-
ing any disease of nutrition. We are therefore in the
position of attempting to make a diagnosis between two
conditions which may in the future be proved to be
practically the same. In making a diagnosis we should
limit the term anaemia infantum jisi'iidoleukiemica to
those cases in which no cause for secondar}' ana-mia can
be found, and in which the clinical symptoms and
changes in tlie blood already described are present.
PROCiNOsis. — The prognosis varies according to the ex-
tent and serious nature of the cause which produces the
condition. The symptoms run an essentially subacute
or chronic course; the large size of the spleen does not
neeessai'ily imply a fatal ending. When, however, sec-
ondary changes in the blood have occurred to such an
extent as to warrant the diagnosis of a severe form of
an.-emia. and when a spleen of considerable size is de-
tected iu connection with these blood changes, the prog-
nosis is very bad, as the infants u.sually die.
Tiu-:-\TMKN'T. — What has just been s;ud of the progno-
sis in this classof cases niayalso besaiil of thetreatraent,
which is. in fact, that of a case of secondary anaiuia. and
depends upon what is most reasonably supposed to be
causing the condition that is present. This may be ma-
laria, rhachitis, gastro-enteric disease, or some unknown
cau.se which, simply representing the conditions of ana'-
raia, calls for the usual treatment of arsenic, iron, proper
food, and hygiene.
An extensive bibliography of the subject will be found
in an article liy Dr. A. H. Wentworth in the " Medical
Communications of the Massachusetts Medical Society,"
vol. xviii., No. 3. 1901. Thonins ^orijun. liotclt.
PSEUDOMYXOMA PERITONEI.— The occurrence of
free mucoid or colloid-like material within the jieritoneal
cavity, as the result of the rupture of an ovarian cyst or
cystadeuoma, or of the direct secretion of a neoplasm into
tlie cavity, gives rise to a reactive proliferation of the
peritoneal surfaces covered by such substance and the
more or less complete organization of the latter. Asa
result of such partial organization the peritoneal surface
is found to be covered with a jelh'-like layer containing
blood-vessels and strands of connective tissue, closelj- re-
.sembling myxomatous tissue. To this condition the term
pseudomyxoma peritonei is ap)died.
The gross appearances vary with the amount of colloid
or mucoid material l,ying on the peritoneal surfaces, and
Avith the degree of organization. In the very early
stages the surfaces of the peritoneum are coverecl witli a
jelly-like substaiic(^ of varying thickness, ■svhicli is easily
scraped off, or may even be scoojjed out of the jieritoneal
cavity owing to the fact that it lies free therein. If organ-
ization has begun, the ])ortion of the colloid material lying
next to the peritoneum is not so easily scraped away, a])-
oears nuire opa<pu', and conlains minute vessels, as shown
by file fine reil lines running through it. Tin; ]ieritoneal
surface has there fori' a reddish, roughened a|ipeai'ance. and
is covered with line whitish or I'eddish strands enclosing
jelly-like collnid substance. As organization progresses
there is developed above the |ieritoneal surface a zone of
tibroblaslie tissue which in time becomes changed into
librons connretive tissue, sn that the peritoneum becomes
greatly thickened, the couditinn resembling that of a
chronic fibroid peritonitis. 11' the amount of colloid m:\-
terial scattered over the peiitoneum is sm:ill. it may be
comi>letely organized and tlie peritoneum become more or
REFERENCE HAN'DBOOK OF THE MEDICAL SCIENCES.
Pseiicloiii3'xonia
Pc-rltonei.
less thiokenccl. On the other hand, a thick layer of col-
loid (several inches I is but slowly absorbed and organized,
and may remain in the al)domcn for a lotig time with but
little change except where it comes into contact with the
peritoneal "surfaces. The reaction on the part of the
pti itoiieuni appears to vary greatly ; in some cases it
occurs iinmeciiately, in others it may be delayed for a
long time.
Microscopically, sections cut through the peritoneum
and the overlying mass of colloid show a tibroblastic
proliferation of the subendothelial layer of the jierito-
neum, a wandering of fibroblasts into the colloid, and the
formation of new blood-vessels which run out into the
colloid substance. As organization progresses interlacing
strands of connective tissue supporting blood-vessels are
formed throughout the colloid substance, enclosing be-
tween them masses of the ,ielly material which have not
yet been absorbed. These give the tissue an aiipearance
le-sembling myxomatous tissue, even under the micro-
scope. It is easily seen, however, that the structure is
not that of a true myxomatous tissue, but represents an
organization of a jelly-like foreign substance. All stages
of organization may sometimes be seen in the same case.
The writer has seen a number of cases representing dif-
ferent stages: in one of two years' duration the organiza-
tion of the colloid was almost complete, the peritoneum
being converted into a thick hyaline layer of connective
tissue, enclosing here and there bits of unabsorbed col-
loid. Contraction of the mesentery and matting of the
intestinal coils occur in this stage, and the appearance
resembles very much the condition of the peritoneum in
diffuse scirrhous carcinoma. The surfaces of the liver
and spleen are similarly involved, and in the late sta.tres
present a picture of marked perihepatitis and peri-
splenitis.
Localized pseudomyxoma occurs when, from the rupt-
ure of a small ovarian cyst or cystoma, a small mass of
mucoid substance is distiiliuted" in small jiortions over
the peritoneal surface. These show the same stages of
organization, hjaline change, etc., and finally come to
represent localized thickenings of the peritoneum. This
condition occurs most frequently in the ]ielvis.
If portions of living e]iithelium or of jiapilla' are set
free into the peritoneal cavity with the mucoid material,
after the rupture of an ovarian cystoma, these may pro-
liferate and set up implantation metastases. These may
become malignant; if the primary tumor has already un-
dergone carcinomatous change, these imiilantations are
likewise carcinomatous. In the case of the ordinary cys-
toma the implanted epithelium forms small cysts which
become stationary after a while and do not form large
growths. When the primary is a papilliferous cystade-
noma the implantation metastases are unieh more likely
to develop into larger tumors. It isconceivable that the
implantation metastases of epithelium arising from a be-
nign growth may later liecome malignant.
Small cysts lined with hypertrophic endothelium may
also be found iu the pseudomyxomatous tissue of the
peritoneal covering. These are probably derived from
the remains of the surface endothelium. It is also within
the range of possibiliiy that these may form centres for
the formation of a new growth of malignant character.
Pseudomyxoma of the peritoneum is not in all cases
formed by the rupture and discharge into the peritoneal
cavity of an ovarian tumor containing mucoid or colloid
material. Surface papillomata of the ovary tnay secrete
such material directly into the peritoneal cavity ; fui'ther.
cystic carcinomata of the stomach, intestines, or testicles
may give rise to the ju'esence of mucoid or colloid suli-
stance iu the peritoneal cavity, either from r\iptiue of the
piimai'V or from sec<indaries located in the ])eritoneum.
In the great majority of cases, however, the mucoid or
colloid substailce comes from the rupture of a large ovar-
ian mnltilocular cystoma, in which one chamber has been
developed at the expense of the others; or from a pri-
mary unilocular cystoma. If the cyst contents are
of a thin serous character they may be absorbed by the
peritoneum without the production of peritoneal prolif-
eration. The more jelly-like or colloid the contents the
more likely the occurience of pseudomyxoma. In order
to excite peritoneal proliferation the substance must be
of a fairly firm consistency and not easily absorbed.
Pseudomucin may or may not be present in the cyst con-
tents, but in the majority of cases it is a pseudomucin
cyst that ruptures. The jelly-like inatc! ial of the pseudo-
myxomatous tissue may give both mucin and ]iseudo-
nuicin reactions. Pseudomucin is, however, not neces-
sary to the production of pseudomyxoma. This term
should be taken as signifying the formation of a tissue
resembling myxomatous ti.ssue. Though s]ioken of as
colloid, the cyst contents in all cases are mucoid, but
when lirm and jelly-like they may be appropriately desig-
nated as colloid or colloid-like.
The cyst contents wlieu poured over the peritoneum
act as a foreign body and set up a reactive proliferation
which is of tlie nature of an iutiammatoiy process. The
presence of fibrin throughout the pseudomyxomatous tis-
sue may often be shown by Weigeit's fibrin stain. Lo-
calized collections of leucocytes may also occur through-
out the organizing zone. In case of an infected cyst, or
following infection as a result of operation, the picture
of pseudomyxoma and that of a fibrinous peritonitis may
be combined. The writer has seen one case of pseudo-
myxoma in which the cyst contents were scattered over
a peritoneum showing a marked subacute fibrinous peri-
tonitis. The colloid material was deposited on top of a
thick fibrinous exudate which was undergoing organiza-
tion. Organization of the colloid from the new fibro-
blastic tissue had begun in some areas.
To recapitulate, the writer holds that pseudomyxoma
peritonei is a condition of the peritoneum due to a partial
organization of a nuicoid or colloid material, which has
been deposited over the peritoneum as the result of the
rupture of an ovarian cystoma or of other cystic tumor
containing such material, or from the secretion of certain
tumors directly into the peritoneal cavity. This view,
however, is not held by all authors. Netzel, AVendeler,
and others regard the condition as due. at least in part,
to a chronic productive infiammation of the peritoneum
associated with myxomatous degencralion. This view
may be explained by the presence of pse;idomucin in the
lymph spaces of the peritoneum, following an absorption
from the ]ieiitoneal cavity. Westermark and Annell re-
gard the jell}' masses on the peritoneum as tlie product
of a specific form of peritoneal disease. Alshauser,
Strassmann, Pfannenstiel, and others regard the process
as due essentially to an implantation metastasis of tumor
cells over the peritoneum. On the other baud, AVerth (to
whom we owe the designation pse/idwii/JviiHi), Veit,
Kret.scbmar, and others hold practicall}' the .same view as
the writer, namely, that the colli. id masses are not metas-
tases but are to be explained as the non-absorbable mucoid
contentsof a ruptured cyst, which, scattered over tlie peri-
toneum, act upon it as a foreign body, become enclosed in
inllamnuitory adhesion.s, and undergo organization after
the manner of a thrombus, finally being replaced by bya
line connective tissue.
The prognosis in ]iseudomyxoma is not necessarily bad.
Large masses of colloid material may be kept within the
]ieriton(-.al cavitv for a long time without especial symp-
toms. Small amounts may be conii)leteIy aljsorbed and
organized, and the resultiug condition of the peritoneum
may give rise to the same sequela; as those which follow
clu-onic adhesive peritonitis. In o]ierations for the relief
of pseudomyxoma afler the rupttire of ovarian cysts, it
should be borne in mind that the ]>eritoiieum, after the
removal of the overlying colloid material, represents a
more or less denuded, hyperamic surface, Ihrougli which
infection may easily take place, ,eivin,s rise to a fibrino-
purulent peritonitis. The general resistance of tlie peri-
toneum appears to be lowered as the result of the pres-
ence of the foreign svibstance in Ihe cavity. The danger
that a malignant growth will arise from liie implantation
metastases is not veiy great in the case of a simple multi-
locular cystoma, but in the case of a papuliferous cys-
toma the danger of such au occurrence is much greater.
775
Pseiidopepsin,
FseadotuberciiIoslB.
REFERENCE IIANUBOOK OP THE MEDICAL SCIENCES.
Such metastases may occur in the operation -woimd. On
the whole, tlie safest procedure is to o])erate as soon as
possible after tlie rupture of the cyst, before organization
Las begun. A more or less marked ascites, which com-
plicates the iliaguosis, is often associated witli pseudo-
my.\onia : tliis is particidarly true in the case of associated
infection. It may occur, however, as tlie result of tl.'e
irritation produced by the presence of tlie foreign body.
Recurrence takes place when the primary tumor or the
metastases which produce the niucciid or colloid are not
removed: or when the implanlalion metastases become
active, and either burst or secrete intii the cavity. Re-
currence is much more likely to take place in the case of
papilliferous growths. Ahlred Srnlt, Wart/iin.
PSEUDOPEPSIN.— When the gastric mucosa is al-
lowed to digest for some time in a slightly alkaline me-
dium and in the presence of an antiseptic like toluol,
some of the proteids euler into solution and the trypto-
phan reaction (see Tri/ptop/)iii>)i:ai\ be demonstrated witli
the latter. According to Glaessner this self-digestion is
due to a specific proteolytic enzyme, to which he has a])-
plied the name psendoptjisiii. and which in some respects
resembles the tr\-psin of the pancreas and the autoiylic
enzyme of the liver. Pseudopepsiu is eliaraclcrized: (1)
By acting in alkaline solutions, in whieii ]iepsin is de-
stroyed : (i) by forming tryptophan as a ]ir(;duct of its ac-
tivity ; (3) by acting in the presence of free acid even to
thee.Ntent of 0.3 percent. HCl, and in the presence of pep-
sin which destroys .some enzymes. This behavior toward
acids distinguishes it from trypsin. Pseudopepsin occurs
in both the fundus and the pyloric portions of the .gastric
mendjrane, and in about efjually small amounts. Accord-
ingto Glaessner the proteolytic action of the iiylorus mu-
cosa is probably entirely due to ]iseudopepsiu. It is also
apparently the characteristic proteolytic enzyme of the
glands of Brunner — an observation which is of interest in
view of the a.ssumed hislological resemblance between
these glands and those of the pyloric portion of the stom-
ach. It is not unlikely that pseudopep.sin, or a similar
enzyiue, occurs in the ijylorie appendages of many tishe.s.
Pepsin can be obtained free fmm |iwudopepsin by appro-
priate chemical methods. In ordinary commercial prepa-
rations the writer has found evidences ol try])loiihan-
forming enzymes in very few instances. The existence
of pseudopepsin as a specific enzyme of the stomach has
been denied by Klug. J,<ifiii/i'ttc B. Meiidd.
Glaessuer: Hofmeisler's Beilriige zur ctiemiSL'lien Plivsiolosie. 101J2,
1.. pp. 26. as, 31, 111.
Klujr : I^fltitrer's Arcbiv f. die ^'osammte rti.vsiol., l^n-J, ,\rli.. p. 2s0.
PSEUDOTUBERCULOSIS.— It seems that the word
pseudotubi'i'culDsis w.is lirst used by Eberth in 1885 as a
name for a disease in rabbits, which, although it resem-
bled ordinary tuberculosis of these animals somewhat,
was not caused by the bacillus tuberculosis Kochii.
Later, the term has been n.sed in a broader .sense for all
conditions which resemble .senuine tuberculo.sis. but
which are produced by organisms other than the tubercle
bacillus. Baunigarten and others have oli,jected tr) the
use of the term, and it certainly is not a very good one.
If we use the word tubercuUisis in an etiological sense,
meaning a disease produced by the tubercle bacillus,
pseudotuberculosis might be inlirpreted as meaning a
disease caused by pseiidotubercle bacilli, lli,it is, by those
bacilli which resemble I he tubercle bacillus more or less
closely: which, at least according to the common acce|)-
talion of the term, it does not, altho pseudo-tubercle
bacilli sometimes may produce iiseudotidierculosis. If.
on the other hand, we ]uefer to use tuberculosis in its
anatomical sense, meaning a disease in which there is a
production of tubercles, that is. nodules in the tissues,
even then the term " pseudotviberculosis" is not very
fortunate. The nodules in this disease also are certainly
prcsetit and not in any way spurious, coinciding, in some
instances at least, with true tuberelis in all respects, even
down to the least histological detail. Nevertheless, de-
spite all these objections, the word will have to be re-
tained for the want of a better one tnitil, perhaps, medical
nomenclature is revised and put on a scientific basis, a
revision of which it certainly is very much in need.
Taking the word in its broadest sense as meainng a
disease with the production of tubercles, that is, nodules
of some .sort, but not caused by the tubercle bacillus, we
find tliat such a condition may be produced by many
dilVerent etiological factors.
There is first the pseudotuberculosis of the rodents (the
tubeiculiise zoogleique of the French authors). Tins
form of iisenilotuberctdosis occurs chiefly among rodents
(guinea-pigs, labbits, hares, mice), but also among birds,
particularly chickens, in the form of ejiizootics. Occa-
sionall.v it has been produced bj- the inoculation of the
most varying materials — e.g., tissue from a hypertro|ihied
ton.sil (Bettencourt), cotton through which the air of the
rooms of phthisical ])atients had been filtered (Chante-
messe). material from a case of suspected tuberculosis of
the elbow, aiul also from a nodule from a cow with
pearl disease (Courmont), material from a caseous nodule
from a child (Malasscz and Vignal), pus from a cow sus-
pected of suffering from tuberculosis (Nocard and Mas-
selin), and milk ( Parietti). The disease runsa more rapid
course than ordinary tuberculosis. At the post-morleui
e.xaunnation one finds small caseous nodules in the spleen,
liver, often in the kidneys, more rarely in the lungs, heart,
brain, peritoneum. Quite frequently the Peyer's patches
in the intestines are diseased and the mesenteric l\ mph
nodes show hirge irregular areas of caseation and sup-
puration. On microscopical examination the nodules
show more the appearance of chronic abscesses than that
of typical tubercles, but at times nodules with large
giant cells and typical caseation have been found.
AVoronolT and Siueff report that giant cells are very nu-
merous in the lesions in chickens, wdiereas in rodents they
found them occasionally only. Apostoponlos found
nodules w ith all the characteristics of ,gcnuine tubercles
in the liver of rabbits whicli he had inoculated by way
of the anterior chamber of the eye. The disea.se is pro-
duced by a short, rather coarse, non-motile or very
slightly motile bacillus, which doesnot stain with Grain's
method, does not form any spores, and does not liquefy
the gelatin. It .grows lu.xuriantly except on potato. It
does not ferment sugar, does not coagulate milk, does
not pro<luce any indol. Some authors describe irregular
polar staining. At times the bacilli are arranged in short
chains. It is dillicult to stain them in the tissues. Tar-
takowsky has announced recently that in beef tea they
form growths resemblin.a' stalactites, like those of the
bacillus of bubonic plague. The cultures have an un-
pleasant oilor, which is variously describe<l by dill'erent
authors. 'I'he organism seems to belong to the grou|) of
bacteria called by Ixruse in Flilgge's text-book '" bacteria
of hemorrhagic septica'inia." although Kruse himself
cla.ssities it with the bacillus mallei, to which it certainly
does not show nuu'h similarity. Lehmann and Neumann
[Uit it with the bacilli of hemorrha,i;ic septicaunia.
There are I wo cases on record pur))orting to be cases
of infection with the bacillus ]iseudotuliercidosis roden-
tium in the Inunan being. One of these was published in
l.sDl by Ilayem and Lesage. The patient suffered from
Addison's disease. At the necropsy the left adrenal was
found ilcstroyed by caseation. Tubercle bacilli could
not be di'Uionstrated, nor were there any typical tuber-
cles or giant cells in the sections. From the blood and
the caseous areas tlie bacillus ]iseudotuberculosis roden-
tium was olit:iined. The other case is that of a child
sulTering from bronchopneumonia and empyema. In
the |>us from the empyema. Alassa and Mensi (1895)
claim to have found the bacilli. We mi.ght also cite a
case of Courmont. who inoculated a guir'ea-pi,g with
material from a case of what was suspected to be tulier-
culosis of the I'lbow. The guinea-jii.gdevefoped a ty))ical
pseudniulieiculosis. In view of the small number of
cases recnnled, and the possibility of error in the bac-
teriological diagnosis of the organism, and also in view
of the fact that the bacillus pseudntubcrculosis roden-
tium .seems to be quite common, and therefore frequently
776
REFERENCE HANDBOUK OF THE MEDICAL SCIENCES.
P!S<-|l4lt»p<-|l|h,i||.
Pseudotuberculosis,
found as iicontiiniination in allsortsof material. 1 believe
we are jiistitieii in being a little sceptical about the na-
ture an<i ini]iortaiiee of the bacteria found in these cases,
tintil niiuc abundant and absolutely conclusive evidence
shall have been furnished.
Then, Ix'sides, we tind reported in literature isolated
cases in which a similar disease was caused by other bac-
teria. Some of them are more or less closely related to
the bacillus pseudotuberculosis rodentium. In I)u Ca-
zal's two cases, for instance (both in man, one with case-
ous nodides on the surface of the peritoneum and similar
nodtdes of the size of a nut in pancreas and liver; the
other witli large caseous nodules in brain, in pleura, along
spinal column and in both kidneys), he found a bacte-
rium which dilTered from the bacillus pseudotuberculosis
rodentium largel.v only by the fact that it liquefied gela-
tin, Legrain found a similar organism in the pseudo-
tuberculous lesions of a rabbit that had been inoculated
with sputum from a case of pulmonarv phthisis.*
In other cases the bacteria encountered were quite dif-
ferent. Preisz, for instance, and also tvutscher found
organisms which resembled diphtheria bacilli. Still other
and even more uncommon bacterial forms of pseudotu-
berculosis in animals have been reported by Cherry and
Bull. Galli-Valcrio, Vallee, and others but we cannot very
well enter here into a fuller consideration of these forms.
Again other forms of pseudotuberculosis are caused by
certain filamentous bacteria. In Eppinger's case of this
kind there were a cerebral abscess, a very chronic tuber-
culosis with calcification of lungsaod peribroncliial lymph
nodes, and tuberculosis of the pleura. The disease was
caused by a form of cladothrix (asteroides), which when
inoculated into rabbits and guinea-pigs produced pseudo-
tuberculosis. Fle.xner reports a case which clinically had
all the symptoms of pulmonary phthisis. At the nec-
ropsy he found pulmonary cavities and tubercle-like
nodules in the hmgs, omentum, peritoneum, liver, and
spleen. Although histologically the nodtdes were iden-
tical with tubercles, no tubercle bacilli were found, but
instead branching threads which stained well with Gram's
method. Cultures couUl not be ol)tained. An inocu-
lated guinea-pig died, but not of tuberculosis.
Infection with certain mould fungi is also one of the
many causes of pseudotuberculosis. By intravenous in-
jection of the spores of certain moulds in rabbits, for in-
stance, one can produce a most beautiful disseminated
pseudotuberculosis, as Grawitz has demonstrated long
ago. An interesting form of pseudotuberculosis, pro-
duced l.i_y mould infection, is described by Chantemesse
and others as occurring in i)igeons. The disease starts
with a caseous ulcer in the mouth, which is later followed
by the formation of nodules in lungs, liver, more rarely
oesophagus, intestines, kidne_ys. Histologically the le-
sions resemble tubercles very closely. The cause of the
disease is the aspergillus furaigatus. The disease seems
to be communicated at times to breeders of pigeons, who
stuff young pigeons by introducing food into the mouth
of the animals directly from their own mouths, in imita-
tion of the parent birds.
Nodules which resemble tubercles very closely are pro-
duced in the skin in certain forms of blastomycetic der-
matitis, and even more regularly are they found in an-
other rarer form of fungus disease, which has been first
described by Wernicke in Buenos Ayres, and has since
then been oliserved several times in California. The dis-
ease generally begins as a chronic cutaneous trouble re-
sembling hypertrophic lupus; later, a disseminated pseu
dotuberculosis of nearly all tlie internal organs except
the heart and gastro-intestinal canal develops. I have
seen cases, however, which did not show any cutaneous
lesions, but in which the primary infection seems to have
taken [ilace by inspiration into the lungs. The fungus
* In tlie Inst issue of Zie,!?Ier's Beitrjipe (1V102, xxxii., .52fj) Wrede
reports an interesiine: case of pseudutuliercuiosis in an infant.
Pharvn,x, cesoptiapus, intestines, liver, and adrenats were full of Cray
subiniliary nodules. Tlie con<iiIion was caused t»y a ttacilliis wliich
closely resemtiled the t'acillus psi'udoliitierculosis rodentium, but
whicti differed from it in staining witli Gram's method.
which causes the disease in the ti.ssues multiplies by en-
dogenous sporulation, only without formation of mj'celia
or budding, and was on that account first described as a
protozoan by Wernicke and Rix ford and Gilchrist, who
studied the earliest cases in California. I succeeded,
however, in cultivating the organism in artificial culture
media, and in these it grows out into long spore-bearing
hypha. The classification of the fungus is as yet doubt-
ful, and until our know ledge of it is more complete I have
propo.sed the name fungus coccidioides. I can only con-
firm the reports of earlier investigators that the similarity
in the histological structure of the lesions produced by
this fungus to typical tubercles at times is truly remark-
able. A histological diftereuyal diagnosis between thetn,
apart from the difference in the causative factor, is in
these instances absolutely impossible. With such typical
tubercles one finds simultaneously in the lesions numer-
ous submiliary chronic abscesses, very much like those
which commonly occur iu glanders.
With this long list of vegetable parasites our list of
producers of pseudotuberculosis is by no means ex-
hausted. Among the aninud parasites we find iiuite a
few of the smaller parasites or their eggs, which when
accidentally disseminated in the tissues can cause the
formation of tubcrcle-like nodules around them. I)e
.long, for instance, describes cases of pseudotuberculosis
in slieep and goats produced b}- intestinal worms (strongy-
lus rufescens), and claims that to the naked eye the dif-
ferential diagnosis from ordinary tuberculosis is difficult.
JIarsden also reports cases of large, more or less ttibercle-
like nodules in lungs, liver, and kidneys of sheep, hogs,
and goats, due to the eggs of filaria strongvius. In
IHSi Laulanie entertained the Societe Biologique in Pari.4
with the account of pseudotuberculosis of dogs piodtieed
b}' deniodex folliculorum, and in 1^99 Helbing read a
paper at a meeting of the Freie Vereinigung der Ciiirur-
geu Berlins, iu which he describes a case of pseudotu-
berculosis of the peritoneuiu in man cau.sed by the dis-
semination of the eggs of a tapeworm. The nodules had
the typical histological structure of tubercles; the eggs
or fragments of them were enclosed iu giant cells, but
there was no caseation.
Even small dead foreign bodies, particularly when
they are of a somewhat irritating nature, will cause the
formatii'U of nodules in the tissues. As early as 1869
Waldenburg piroved this by experiments, which he re-
lates in his monograph on "Tuberculosis, Pulmonary
Phthisis, and Scrofulosis" (Berlin. 1S69), a piece of work
which is not so well known as it deserves to be; and even
before him Cruveilhier (" Traite d'Anatomie pathologiciue
geiierale." iv., l.S02)had attempted to pioduce, and to his
own satisfaction succeeded in producing, tubercles in the
lungs by injection of small droplets of metallic mercury
into the trachea of dogs. Only recently Jleyer described
a case, observed in Hanau's laboratory, of pseudotidjer-
culosis produced by foreign bodies. In this instance a
gastric idcer had perforated and small particles of food
had licen scattered through the peritoneal cavity. Around
these small paiticles of food a development of tubercles
had taken place. A similar observation was made in an-
other case in which an ovarian cyst had ruptureil and a
large number of cholestcrin masses were disseminated
through the peritoneum.
When we consider the great variety of causes which
have just been cntmierated, the question seems natural.
Are we really justified in calling all these conditions,
which are so manifold etiolof/icnUi/. by the (jne name
pseudotuberculosis';' We shall be all the more inclined
to ask this question when we learn that in many in-
stances the lesions histologically do not resemble one an-
other entirely. In the pseudotuberculosisof the rodent.?,
for instance, tlie nodules on micro.scopical examina-
tion usually present the appearance of chronic miliary
abscesses, such as they are observed, fcu' instance, in
glanders, and not that of typical tubercles. The same
is true of the lesions caused by infection with cert;iin
pathogenic moulds. In these lesions giant cells and
caseation which are considered to be the more important
T77
Pseiidotuuior.
Psoas Abscess.
RErERENCE HANDBOOK OF THE MEDiaVL SCIENCES.
charat-terisius of true tubercles, are often aliseut. Yet
under otlier c<in(lilicjns tfie same parasite.s may produce
nodules wlikli in histological structure resemble ordinarj-
tubercles very closely. In cliickens. for instance, we learn
from WorouolT and Sinetf that the nodules produced by
the bacillus pseudotuberculosis rodentium contain many
giant cells. One must also not forget that in ordinary
tuberculosis the nodules show remarkable dilVerences in
histological structure aecordin.ir to the age of the nodule
and the number and virulence of the t\ibercle baiilli pres-
ent. Tubercle bacilli also at times may produce chronic
miliary abscesses. Since luy attention has been called to
this occurrence by s;)me observations made while study-
ing the ependyma of the ventricles of the brain in tuber-
(^ulous meningitis ("' Ueber ICpeudyniveranderungen tjei
tnberculoser Meningitis," Virrli. Airh.. cl., 1897, 305),
I have seen chronic miliary abscesses produced by tubercle
bacilli — and by tubercle bacilli alone without as.sociated
infections — quite frequently in other parts of the body in
man and animals. In infections with the fungus cocci-
dioides the simuUaneous occurrence of "typical" tu-
bercles and chronic miliary abscesses in the same organ,
produced by the same parasite, is very bewildering; in-
deed one is linally forced to recognize that the difference
between these two conditions is not a fimdanieutal one
— as a matter of fact, I have seen tiansitional forms of
otherwise typical tubercles with central aljscess cavity
Itlled with pus cells, — and that whether the tissues re-
spond in one way or the other depends only on the
amount of irritation to which they are subjected. If the
irritation is less marked, a "typical" tubercle develops;
if it is more intense, a chronic miliary abscess is pro-
duced. It seems, therefore, that in spite of the variety
of causes, and in spite of the varying appearance of the
nodules under the microscope, it is advisable to grouj)
all these conditions which are closely akin to one an-
other under one name, "pseudotuberculosis," provided
we keep in mind that in so doing we use the word
"tubercle " in its broadest sense for a nodule, without as-
suming anything too definite about its exact histological
structure. WiUiam Ophiih.
RKFEl'.ENCES.
BaciUus i^<^udi)tidit'ici(Iosi^ rocUittiuin.
Apostolopoulos : ArtKMten aus deni patb. lustitut Tubingen, it. 19S.
Rev. Centrulbl. f. patb. Auatouiie, viii.. 1;S97. ^itj".
Betti^ncourt : Arcblvos de Medicma, 1SS7. Rev. Centralbl. t. Baeieri-
olu^rie, xxiv., 98.
Bonome ; Arcli. per le Scienze medli'be, xsi., 1897. Rev. Lubarsch
anil ((stertag Ergehiiisse, v. 1.S9S. XIS.
Chantemesse : Ann. de I'Insrttut l^asteur, lt<S7, 97.
Cbarriu et Roger : Comples rend. Acad, des Sciences. IS.s.'i, cvl., 86S.
Cipolliui : Anu. d'Igiene, 1900. Rev. Centralbl. f. Baci., .'cxvill.. 1900,
44i;.
Coiirmont: Compt. rend. soc. Biol.. No. 35, O'.O.—lhkL, 1889.
lielbanco : Ziegler's Beitrage, xx., 477.
Dor : CorainesVcnd. A<-!id. dcs sciences, 1888, cvi.. 10"..*7.
Eberth : Vircbo\v"s .\rcliiv. ciii., 4.S8.
Granclier et Leiloux-Lebard : Airli. de m^d. exp., lS.s9, i., -03.— J?>i(L,
ls<iil. 589.
Huveni et I.e.^age; Butt. Soc. med. des Hop., 1891, No. 21. Rev. Cen-
tralbl. 1. Patbologie. iv.. 1893.
Malassez et Vignal : Airli. d. pbys. norm, et path., iss'i, 3iJ9.
Manfred! : Fortschr. d. Mcdicin, 1S.S!;. •*2.
Maii.sa and Mciisi : Rev Bantng. .lalircsh.. 1.s9.").
Mednm and Mosny: liev. Centralbl. f. Bact., x., ISfll.
Nucard : Sue do tjiol. Palis, 1889, liOK.
Nocard et Ma.sseliQ : Soc. de biol. Paris, 9 ser., 1,. 177.
Nuvoletti: Rev. Luliar-scb and Ostcrtag F.ipcbn.. i.. 3, 228.
Paiietii : Centralbl. f. Bjicteriologie. viii., 189(1, .')77.
PfeilTer: .Monograph, Leipsic. iss9.
Tartakowsky : llev. Lutiarscb and (istertag, v., 189.8, 6.85.
Viccn/i: Itcv. Baiiragarten Jatnvslicr., l.sVK), 3i;7.
Woronoft' una Sineff : Centralbl. f. Patliot.. viii., 1897, 023.
Zagari: Rev. Centralbl. t. Bact., viii., 189(1. 208.
Bacilli irscmhliiiij BaeiUuf psciulntiiliejriihixis r'idintium.
Du Cazal : Rev. Centralbl. f. Patbologie, ix., 189.s. 277.
Du Cazal et Vaillard: Ann. de i'lnstitul Past.. 1,S91, '.ViS.
Legi-ain: Rev. Centralbl. t. Bact., xii.. 1892, ,873.
Wrede : Ziegler's Beitriige, xxxii.. 1902, 5211.
Other Batteria.
Cherrv and Bull : Rev. Centralbl. t. Bact., xxviil.. 19(1(1. 447.
(ialli-Valeno; Ucv. Centralbl. t. Bact.. XX.. 189(5, 199.
Kni<cti>'r: Zcitscbritt f. Hyg., .xvUi., 1894, 32T.— Centralbl. f. Bact.,
xvii., 1895, 835.
Preisz : Ann. de I'lnst. Pasteur, 1894, 234.— Lubarsch and Ostertaff
Erg,, 1896, 1., 1,733.
Terni : LTIIlciale .sanitario, 1896, 159.
VaMe, mentioned by Jong,
FHamentmis Bacteria.
Eppinger: Ziegler's Beitriige, 1S90, ix., 287.
Flexner: Jobiis Uopklns Hospital Bull.. 1897.— Joum. of Exp. Medi-
ciue, iii., 435.
M'liihl Fungi.
Bovce: Rev. Lubarscb and Ostertag Ergebn., i. 3, 196.
Chanteiues.se: Rev. Ceutraibi. f. I'atbol., i., 1.S90, 581.
Eppinger: Lulntrsch and osteplag Ergebu., i., 3.
(laucherand Sargent: Rev. Centralbl. f. Patbologie, vi., 9.5, 1020.
Kotliar: Ann. de I'ln-stitut Pasteur, viii,. 479.
Laulanie, mentioned by chantemesse,
Blat^tomyectic Dtrmatifis.
Gilchrist : Johns Hopkins Bull., 1896.
Rickptts : Journ. of Med. Researches, vi.. IW., 375.
Montgomery : Repr. Rush Med. College Publ., 1902.
Fungus coccidioidc^
Wernicke: Centralbl. I. Bact., xii„ 1.S92.
RLxford and Cilchrist: J<»hns Hopkins Hosp. Rep., 1.
Ophiils and Moflitt: Philadelphia Med. Journ., 1900.
Animal Parasites.
De Jong : Rev. Miinch. med. Wochcnschr.. 1898, 1192.
Helbing: Berl. klin. Wocbenschr., 1899, 714.
Laulanie: Coinptes rend. Soc. biol. Paris. 1.8S4.
Marsden : Miinch. med. Wocbenschr., xxxv., 1898, 1100.
PSEUDOTUMOR. — The term pseudotumor is applied
to certain eulargemeuLs or swellings of non-ueoplastic
character which clinically present features by which
they may be mistaken for true neoplasms. In the ma-
jority of cases such false tumors are found in the abdom-
inal region. The}- may be produced by a great variety
of causes. When the swelling cannot be constantly felt,
but comes and goes, it may be designated asa ji/uintom
tuiiiiir. Such enlargements have no organic pathological
foundation, and are dependent ujion temporary condi-
tions. On the other hand, enlargements or swellings of
the abdominal orgtins due to organic disease may also
siintdate neoplasuis; these conditions should be included
under the designation of pse>i(lotumor or apparent tumor
proper. When caused by inflammatory masses of gran-
ulation tissue which later contract and dis;tppear, the
condition may be spoken of as vuiiishiiig or (.limppcaring
tumor.
Pi'iautnm tumors may lie caused by a cxinti^ction of the
abdominal muscles or by meteorism. Those caustxi by
muscle contiactioiis are found usualh' in the upper part
of the abdomen. The right rectus near its costal margin
is most frequently the pai't contracted, but the contraction
m;iy affect any segment or portion of the abdomintil mus-
cles. The contractions are often s|iasmodic. The entire
rectus may be rigid. Usually, however, but a single
segment is affected, the conti'action being almost always
unilateral. The patients are usually hysterical females
who present marked stigmata of hysteria; there are usu-
ally coexisting consti]iation and enteroptosis. The con-
traction may sometimes be made to disappear in a hot
bath; but in cases of marked hysteria ana;sthesia or hyp-
notic suggestion may be necessary for the differential
diagnosis. The superficial character of the tumor, its
flat, horizontal shape, slightly rounded and indistinct
edges, etc., in connection witli the stigmata of hysteria,
make the diagnosis easy.
Phantom tumors, due to meteorism or localized disten-
tion of the intestines with gas, are of fte(|Uent occurrence
in the same class of patients as described above, and are
ot'ten found in connection with the muscle contntction.
The character of the swelling, the percussion .signs, etc.,
make the diagnosis easy. The swellings occur usually
in the lower portion of the abdomen, particularly in the
appendix iegi(ni, anil above tlie pubis. They are found
freijuently in Avoinen who either pi-etend or i)elie\e that
they are pregnant (|iseudocyesis). The associated stig-
mata of hysteria, and the characteristic physical signs
render the diagnosis of slight ditliculty.
^78
REFEKENCE HAJSODBOOK OF THE MEDICAL SCIENCES.
Pseudotumor,
Psoas Abseess.
Apparent tumors of the epigastriura are, acrnrding- to
EinlJorn, of infre(|iu-nt occiirrenoe. lie reports forty-two
<:ises. eight occurring in men and thirty-lour in women,
'i'iie tumors presented in the epigastrium or in the left or
right lij'pochoudrium, and formed in theiuajortty of cases
smooth masses of the size of a hen's egg or a m-an's fist.
They were frequently puls;iting. could not always be
distinctly felt, and on light percussion yielded a dull
sound. They ran a long course, and there was usually
a history of a long-continued malnutrition. The tumors
remained unchanged or iliminLshed in size. They were
caused by prolapse of the left lobe of the liver, exposure
and thickening of the abdominal aorta, hypertrophic con-
ditions of the muscles of the alidominal walls, and prob-
abl_y adhesions around the lesser curvature of the stom-
ach. If the tumor is caused by the prolapse of the left
lobe of the liver, it is found usually in the median line
belowthe ensiform ; it is of large size and givesa dull tone
on percussion. Between the dulness of the tumor and
the ensiform there may be an area of tympanitic tone.
If the tumor is the aorta, it is deep, usually about two
inches long, and one to two thumljs in breadth, and pul-
sates. Hypertrophic conditions of the alidominal mus-
cles are superficial, usually horizontal, and not globular,
and arc located at one side fif the median line.
In very thin individuals the head of ihe pancreas may
be felt and mistaken for a tumor. Likewise floating
kidney, liver or spleen, rolled-up omentum, excessively
fat mesentery, f^cal impaction, distended urinary or gall
bladder, tuberculous thickenings of omentum or mesen-
tery, hydro- or pyosalpin.x, cystic dilatation of the ap-
pendi-X, etc., may sometimes be I'cgarded as presenting
the clinical appearances of malignant tumors of these
re,gions.
Inflammatory thickenings, tuberculous and syphilitic
nodules, encapsulated hiematomata, encysted parasites,
infective graiuilomata of unknown origin, localized hy-
pertrophy of muscle, local oedema, etc., are also often
mistaken clinically for malignant tumors.
The temi pseudotumor is also applied to the nodules
of a chronic inHamniatory nature caused by the experi-
mental injection of blastomycetes and other fungi.
Similar nodules may be produced l\v the introduction
of foreign bodies or the injection of certain chemical sub-
stances into the ti.ssues.
Disappearing tumors of the abdomen are usually the
result of acute inflammatory tumors of the omentum,
following appendicitis or salpingitis. The absorption of
exudates and the contraction of the granulation tissue
lead to the diminutiou in .size or total disappearance of
the tumor. Similar disappearing tiunors occur in the
skin, subcutaneous tissues, periosteum, and internuiscn-
lar connective tissue as tlie result of the formation cf
granulation tissue following trauma or hemorrhagic
extravasation. These may sometimes be mistaken for
sarcomata, both clinically and micro.scopically. The
presence of numerous plasma cells, the character of the
blood-vessels, and the general appearance of the granu-
lation tissue are points upon which the dillercntial diag-
nosis should be based. (See also Omentmn and Ahihnninal
Tuviors.) Aldn'd Scutt Warthin.
PSITTACOSIS. — An infectious disease occurring iu
birds, particularly in parrots, and transmis.sible io man.
The disease in parrots is of the nature of a chronic en-
teritis, characterized by diarrhcsa, wasting, loss of appe-
tite, and falling of feathers. In man the .symptoms are
those of a grave typhoid, with diarrha-a and a malignant
atypical pneimionia. The disease may be transmitted
directly from parrots to man or through intermediate
objects, and, according to some observers, from man to
man. The period of incubation is from seven to twelve
days: the s\'mptoms begin with malaise, epistaxis, and
digestive disturbances, followed by bronchitis and pneu-
monia. The urine contains a sinall aiuount of albumin.
There is lii.gh fever lasting for from three to four ihiys.
and falling by ciisis. These symptoms then recur in this
order several times, defervescence finally taking place by
lysis. During the attack the spleen is enlarged. Some-
times there may be seen a roscolar or petechial eruption.
The <lisease lasts about thirty days. The mortality is
about thirty-seven per cent. " The" prognosis is good if
complications do not occur. In the majority of fatal
cases, death is due to pneumonia.
Eberth iu 1S80, and Woltl' in 1883, observed the occur-
rence of a fatal mycosis in jiarrots which had been im-
fiorted in great number from the west coast of Africa
during is.so. Transmission to man was not observed.
In 18T',» Ritter saw a hou.se epidemic of severe pneumonia
whicii he thought was referable to a contagion from par-
rots, or rather froui the cages in whicli the birds had
been transported. The clinical and anatomical picture
of the disease was that of an atypical pneumonia. Simi-
lar cases were observed in 1882 by (.)st. and b}- Wagner
iu 1883 and 1886. The disease was introduced into Paris
in 1891 by some paiTots from South America. In 1892
there was an epidemic of the disease in this city, in whicli
fifty persons were affected. Cases of the disease were
also observed in Paris during the next four years, and
advantage was taken of the opportunity to study the
disease closely. The relation of the disease in man to the
affection of the parrot was clearly proved. Cases have
been observed also in Italy and Germany.
According to Nocard, the cause of the disease is a spe-
cific bacillus resembling that of typhoid fever. The
organism is short, luther thick, with rounded poles, is
motile, and is a facultative aerobe. It does not stain
with Gram's method, does not ferment sugar, does not
coagulate milk, and does not form indol. The tacillus
is very virulent; subcutaneous injections in rabbits, mice,
and pigeons kill within from fourteen to forty-eight hours.
In the Paris eiiidemic this liacillus was not found in the
human body; but, three years later, Gilbert and Fournier
founil it in onecase, iu the lieart blood of a woman dying
from the disease. Palamidessi observed an infectious
disease transmitted from parrots whicli he regarded as
resembling chicken cholera. The organism obtained by
him was regarded as identical with that observed by
Nocard. Other observers have failed to find the ]Nocard
bacillus; and Leichtenstern and others believe that the
disease of the parrots known as psittacosis may be cau.sed
by various bacteria (staphylncoccus. streptococcus, pneu-
mococcus, colon bacillus, and proteus), and tliat house
epidemics of atypical pneumonia iu man may occur with-
out such diseases of the parrot playing any etiological
role therein. These writers, however, admit the jiroba-
bilitv of such a relation iu certain cases, as in the Paris
epidemic of 1892.
On the other hand, ?Cicolle reports an epidemic attack-
ing eight persons (four dying), in Avliich the Nocard
bacillus could uot be found; but the serum from these
cases produced a typical agglutination of a ctdture of
the bacillus furnished by jS'ocard, in dilutions of 1 to 50
and 1 to 60. The blood of one of the cases also aggluti-
nated typhoid bacilli, although the piatient had never had
the di.sease.
Widal and Sicard claim that typhoid and psittacosis
can be differentiated by the Widal reaction. In dilutions
of 1 to 10 the reaction occurs with both; but the masses
of psittacosis bacilli are smaller and more crowded. In
dilutions of 1 to 40 there arrives a moment when the
bacilli of jisittacosis no longer react.
The bacteriology of psittacosis and the true relations of
the parrot disease to the atyjiical pneinnonia in man re-
main yet to be determined definite!}'. Further, it should
be observed that in the popidar mind psittacosis is re-
g;irdi-d as a form of avian tuberculosis, and tliat cases
have been reported of a supposed transmission of tuber-
culiisis from the parrot to man, wlience the origin of the
error. - Aldred Scott Warlhin.
PSOAS ABSCESS is a enid aim-ess located in the psoas
musilc. Tlie purulent material gains entrance into the
muscle after destroying the vitality of a portion of the
sheath by pii'ssure and infilti-ation.
The iliac fascia whicli ensheaths the whole muscle con-
19
PKorlasls.
Psoriasis.
REFERENCE IIAXDBUUK OF THE MEDICAL SCIENCES.
tines the pus and directs its course tliroiisli Hie siilistance
(if Hie iniiscle. the result of sueli liurrnwiii^' lieinij: exten-
sive drstruction of tissue. Tlie iuliltralion may involve
tlie muscle on either or both sides of tlie liody. The pur-
ulent material may accumulate until tlie sheath becomes
a mere pus sac with the lumbar )ile.\us of nerves crossing
its cavity, the muscular tissue being destroyed.
The cavity is irrrcgular in shape, bulging laterally,
and constricted, sometimes closed at the diaphragm and
beneath Pou part's ligami'nt.
An abscess resulting from tuberculosis of the bodies
of the lower dorsal or upper lumbar vertebr.i;- will, as a
rule, perforate the psoas sheath.
The pyriform pus sac so formed lies along the sides of
the dor.sal vertebra\ this lateral jiosition being determined
by the presence of the anterior and posterior common
ligamenls.
AVlien the source of the pus is situated above the dia-
phragm, its entrance into tlie psoas is facilitated l\v the
intimate connection of the iliac fascia with the ligamen-
turn arcuaium iuternum.
In the lumbar region the entrance of pus into the psoas
is aided by the formation of pouches between the heads of
origin of the muscle (body of the vertebra and interver-
tebral substance and front of the transvi^rse process of
the vertebra). These pus iiouches rujiture into the body
of the muscle.
Abscesses resulting from tuberculosis of the sacrum,
from sacro-iliac disease or from tuberculosis of the lum-
bar glaiuls, may also jierforate the sheath of the psoas
muscle.
Rigidity or contraction of the affected jisoas muscle
and perhaps neuralgia of the anterior crural nerve are
the most frequent symptoms. The contraction of the
muscle may lead to great deformity, demanding weight-
and-pulley extension, or even tenotomy for its correction.
Frequently the distended jisoas sheath can be detected
by palpation, and if the pus has reached Scarpa's trian-
gle it can be pressed up and down under Poujiart's liga-
ment, following the course of the jisoas muscle.
This is the usual cour.se taken by the ])us, which is
directed bj' the sheath toward the insertiini of the p.soas
and iliaeiismuscles; but it ma}' liurrow farther, pointing
lower down on the limli.
The puis on reaching Poupart's ligament may enter the
iliaeus muscle, or may leave the psoas sheatli along its
external border and burrow to the surface in the loin ; or
it may invade the gluteal or the ischiorectal region.
The direction taken by the abscess is iletermined by the
usual position of the bod\'. If the dorsal jiosition is
most constant, the pus may point in the loin or may even
sink upward into the pleural cavity. Other organs and
ti.ssues are occasionally invaded, and the pus may ojien
into the lungs, bladder, intestines, blood-vessels, or jieii-
toneum.
An early diagnosis will often allow of a successful
operation tlirough an incision in the loin. The abscess
cavit}' should be made aseptic and any diseased bone
scraped away. Tlie diaii'.age must lie lice and into an
antiseptic and elastic dressing.
Curetting the sac wall should not be attempted unless
the whole cavity is accessible.
Altliough a large collection of pus may become cheesy
or eneaiisulated, yet its presence is a possible focus
for the development of miliary tuberculosis or cerebro-
spinal meningitis. Then, besides, it is a well-known
fact that amyloid changes are likely to take place
in the viscera when suppuration continues for a pio-
longcd perioil. Conseipiently. early operative in-
terference is to be recommended in the linpi' that it
may prevent the development of such changes in the
viscera.
When the jius ajiproaches the surface, especially in the
groin whi'iv antiseptic treatment, is dillicult, and when
the sac is known to be large, aspiration is to lie preferred
to incision and drainage. The trocar should Im; passeil
in a slanting direction, piercing the tissues about an inch
before entering the pus sac. The lumen of the trocar
.should be frequently cleaned with a plunger or wire
hook, as the pus contains much semi-solid necrotic gran-
ulation tissue, cheesy matter, and often small particles of
bone.
After the sac has been washed out with a weak boracic-
acid or tincture-of-iodiue solution, it should be injected
with twenty or thirty grains of iodoform dissolved in
ether or suspended in glycerin.
The trocar should then be withdrawn, its retiring point
being followed by the linger from the sac to the exit so
as to prevent the entrance of any ]iurulent material into
its track. The wound should then be sealed with collo-
dion.
During the process of aspiration and flushing of the
abscess cavity the entrance of air must be prevented by
pressure upon the sac. The quantity of flushing liuid
should not exceed that of the pus withdrawn. Com-
presses should be applied in such a way as to insure the
apjiosition of the walls of the sac, in order to piromote
healing and to lessen the oozing of serum or blood be-
cau.se of the diminished pressure within the cavity.
Aspiration aseptically performed gives good results,
although it may require to be repeated several times.
The pus becomes more viscid, and the semi-solid masses
of necrased tissue and fibrin disappear as the healing
progresses.
If the abscess has opened spontaneously it should be
protected with dressings which promote drainage by
capillarity, such as jute or lambs' wool. At each daily
dressing two grains of carbolic acid in about fifty parts
of water should be injected into the sinus.
The treatment may extend over weeks or months, but
the danger from infection becomes less as healthy granu-
lations form in the cavity. Sometimes a counter open-
ing becomes necessary in order to allow of better drainage
and more thorough disinfection of the sac.
Pus from an inflamed ap|iendix, a periuephritic abscess,
or an empyema may invade the psoas muscle, but a
study of the con.stitutional disturbances will facililate
the differential diagnosis in such cases. The ditTerential
diagnosis of diffuse abdominal aneurism niaj' be made by
its impulse and perhaps bruit.
The diagnosis from iliac abscess rests chiefly on the
age of the patient, for jisoas abscess occurs generally in
the young with tuberculous history, and iliac abscess in
the adult.
The impidse transmitted to the swelling by coughing
must be carefully distinguished from that present in
hernia; a diagnosis may be made by observing the man-
ner in which the tumor can be reduced and in which it
reappears after reduction, and also by the fulness of the
iliac fossa, apparent on palpation.
Varicose veins, cysis, undescended testicle, and glan-
duliir swellings in Scarpia's triangle must also be differ-
entiated. Jasper J. Oarmany.
PSORIASIS. — Psoriasis is a disease of the skin which
jiossesses three characteristics that should render its
diagno.sis easy. These are: 1. The formation of dry,
papery, thin, silvery-gray scales, mica-like in their ar-
rangenu'iit. and as a rule easily detached, is a constant
pbenomi'iion. 3. Dryness is an absolute characteristic
of the disease at all stages and in every situation. There
is never, in a pure type of the affection, the slightest
moisture, greasiness, or tendency to ulceration. 3. The
development of points or discs of a color varj'ing from
)iale red toa red of a brighter hue, and showing a certain
degree of intlanimatory thickening — sometimes cpiite
marked, but usually only moderate or slight — is another
characteristic of tlie disease. These lesions are always
well deiined at their borders and tend to enlarge periph-
erally, sometimes wilh evidence of greater activity at
the border than in the centre. Contiguous lesions often
meet, birrning irregular, map-like figures, the points of
confluence becoming like the centre of theoriginal patch
or di.sc.
At the onset of the disease there is noticed, commonly
at some part of the surface of the body where the skin is
780
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Psoriastls.
Pf>ioria!»i<!i,
thicker than elsewliere, a well-defined spot or patch of
a pale red color (but of a somewhat brighter red in an
acute outbreak of the disease) and of variable size (from
the head of a pin to a lialf-dinic silver piece). At the
affected spot the skin is a little thickened, and its surface
consists of one or two layers of thin, dry, easily remov-
able scales which are quite small in proportion to the size
of the lesion. This lesion gradually enlarges — as a rule,
symmetrically — and in the part ueuly involved the char-
acteristic slight thickening of the skin and the formation
of loosely attached scales may be observed. When the
loose scales are removed it will be seen that the natural
lines of the skin, which
under normal conditions
are quite faint, are now
accentuated by the up-
raising of the intermedi-
ate areas through the
products of intiamma-
tion. AVhen the lesion
attains the full limit
of its growth, it may
be as large as a silver
half-dollar and of about
the same thickness.
Through coalescence
two or three adjacent
lesions may eventually
form quite a large area,
of irregular shape. I
have known an appar-
cntl_v single lesion, on
the extensor surface of
the forearm, to attain
an area of about four
b_y si.x inches. At no
time in the course of its
development did this
patch fail to .show the
pathological alterations
which are so character-
istic of the affection and
which have already been
enumerated.
If the scales are al-
lowed to accumulate
they form dry, mortar-
like masses. In some
cases the central parts
of the large lesions will
remain relatively quies-
cent for a considerable
period of time; the thickening process and tlie forma-
tion of scales being confined to a narrow border (from
one-twelfth to one-fourth of an inch wide).
"Punctate hemorrhage" constitutes another and thor-
oughly characteristic distinguishing feature of the dis-
ease. " If. in the younger or thinner lesi<ins, the scales are
removed down to and including the basal layer, lilecding
will take place from a number of isolated spots, not 1,-uger
than the point of a pin and corresponding to inflamed
papilla?, the blood-vessels of which have been torn.
L'jion the scalp, when covered with tlie natural growth
of hair, the disease presents an appearance somewhat dif-
ferent from that which it generally does on other |iarts of
the body. There is less infiltration, as a rule, although
quite characteristic discs and patches, like Ihoseoliservcil
on other parts of the body, may occur. The scaling is
often excessive, forming ]iiled-up masses of the dry, sil-
very, i)apery, and quite easily removable scales. Along
the" margin of the hairy region, especially on the fore-
head, there often appears a gyrate Ijand of the disease,
one-half of it being located oii the hairy surface and the
other half on the natural skin surface. Then again, in
other cases, the disease develops in the skin of the fore-
head and extends to a greater or less extent upon the
hairy surface of the scalp. In this extended area of
the disease the afiected skin is red and slightly thick-
FIG. 3bU5.— Psoriasis. (Frniiitlieo.
eases befonging to Dr. Jolin
ened, and upon it are seated the irrepressible dry, gray
scales.
Wherever the disease assumes a somewhat acute char-
acter there we may be sure of finding more marked red-
nessand a more rapid formation of scales of varying size,
but always of marked thinness.
Although itching is not a characteristic symptom of
psoriasis, my records show that it was present in some
degree in nearly all m_v cases. In some of these cases the
symptom appeared in connection with an acute outbreak
of the disease — either simultaneously with or just pre-
ceding the outbreak, — but in others it appeared to be due
simply to the accumula-
tion of scales.
While it is generally
held that the disease
shows a predilection for
the regions of the knees
and elbows, ni}- own ex-
perience does not give
any very strong support
to this belief. It cer-
t.-iinly has a ]ireference
for the scalp and for the
extensor or thick-skin
surfaces, but in a gen-
eral outbreak the dis-
ease respects no limits.
In one case, for exam-
ple, its manifestations
were to be seen on prac-
tically every part of the
surface of the body
save the scrotum and
feet.
Exfoliative dermatitis
may occur as the result
of an acute outbreak of
psoriasis, the entire skin
being involved in the
attack. Such an attack
is characterized by gen-
eral redness of the skin
(although there may be
free or partially free
areas) and by the rapid
and constant formation
and throwing off of pa-
per-like, thin, dry scales;
oft<'ii surprising quan-
tities being exfoliated in
a day. The skin is not
much thickened, the redness varies from a bright red to
a red of a dull lustre, and the inflammatory action is of
moderate degree. Itching in some measure may be ].ires-
ent. These extensive outbreaks usually subside, thus
differing from pityriasis rubra, which ends onl\' with
loss of hair and nails, wasting away, involvement of
vital organs, and, finally, death.
Psoriasis has been called a disease of the healthy.
While this is to some exteut true, my observation leads
me to amend this statement by saying that the people
who have it are in as good average health as their less
afflicted fellows, while some of them even deserve the
appellation of robust.
I have been unable to trace this disease to heredity,
and have seen but slight evidence in favor of the belief
that it affects the niembers of certain families. It de-
velops, according to my experience, in the more vigor-
ous years of life— that "is, from infancy to middle age;
my cases being mostly adults and undc^r the middle de-
cennitun of life. Tlie duration of the disease in these
cases has varied from a short time to a jieriod of a few
years. Furthermore, males have prejiouderated over
females in the proportion of two to one. On the other
hand, it must be remembered that psoriasis is quite a
rare disease in this latitude, and that there have been
too few cases to justify us in formulating any statistics.
Ilet'fiiiii iif ii|ioTML^r:i]>Ms nf sRl
A. Fordyce, .-f New York. )
rsi
I*MOrlaKis.
Ptomaine*
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Progperity and poverty, sobriety and iiitciiipermice.
cleunliuess and tilth, seem to exert no a|i|>reci:ilile inllu-
ence in warding olV tlic disease or in favorino: its devel-
opment. These intiueuces. however, when onre the dis-
ease has become established, may turn its further coiir.se
toward the lietter or toward the worse.
Tiie disease does not appear to have any depressing
inthieiice upon the general health. Otten it constitutes
simply a bodily discomfort, with pcihajis, in addition,
a certaiu amount of mental worry consequent upon its
presence.
Ktioi,oc;t. — As to the cause of psoriasis, we know
notMng positively. There arc many theories. In sonic
respects the disease behaves as if it were due to germ in-
tluence. tlic manifesUitions resemblingsomewhat those of
an exaggerated action of the ringworm fungi— as, for
example, the peripheral extension, the frequent clear-
ing up at tlie centre, and the persistent activity at the
border. Psoriasis presents a further resemblance to a
parasitic disease in tiie character of its relapses ; it being
an easy matter to asciibe them to re-infection from small
uucured points, such as can always be found on some
part of the body.
CortJSE OF THE Disease. — Recurrences are the rule:
often the central jjarts of the pale jiatches left after the
subsitleuceof an outbreak ,-irc the sites of a new eruption.
These relapses often occur immediately or very soon after
the subsidence of an acute outbreak. It is probable that
a person affected with psoriasis is never absolutely free
from the disease after the lirst onset. I have been able
to follow one such case for a period of over ten years —
that is. from the time when the patient was only three
and a half years of age to that when he was fourteen
ye<u's old. It is interesting to note that this patient has
always been strong and robust and that he has been in
no way retarded in his development.
Di.vGxosis. — The diagnosis of psoriasis should offer
little difficulty, if the features already descrilied are kept
in mind. In the following paragraphs I will mention
briefly the cliaracteristics wliich should enable the physi-
ciiin to distinguish it trom the various affections with
which it is most likely to be confounded.
Dry seborrlia?a of the scalp shows little if any inflam-
mation or thickening. The scales in this att'cctiou are
smaller th:ui those observed in p.soriasis. and if they are
present in a mass the latter is usually more fiiable : often,
too, these scales form slieatlis arouiul the hairs at their
insertion in the follicJes. Removal of the masses of scales
may show a reddening beneath and a slight moisture.
Scboriiin'ic eczema of the scalp usually sliows fewer
scales: if there arc patches they are thinner and slightly
moist, add the scales are greasy. When the disease ex-
tends from the scalp upon the forehead it may resemble
psoriasis, but there is little intiltration. the scales are not
diy and paj.iery, and the inflamed surface jireseuts a
somewhat more moist aiipi-arauce.
Syphilis of the scalp may show the so-callid corona
or frontal exten.sion. The color is. however, of a dcej)cr
shade, the intiltration more marked, and the scales are
smaller, more adherent, less papery looking, and less
abundant. Syphilitic patches on the seal]) lack the feat-
ures which have already been descrilied as characteristic
of psoriasis.
Riugworin of tin' scalji is rlrv. scaly, not iiililtrated in
any marked degree, has fewer, finer scales, and shows a
Well-marked, not greatly elevated lionhr which bears
evidenceof slight exudation. The hairs in the paicli are
broken or lustreless from the growth of the micro-
organism.
Eczema of the .s('al|i does not occur in the form of
sharply limited jiatclies: then, besides, there is a iiecul-
iar stiifcniug and thickening of the jians a(Tc;.-led, .-uid
there is either a frank, .sticky exudation iqion the sur-
face or there are points and lines of broken epidermis
where the exudation is just beginning to break forth.
Upon drying, the exudatiim assumes the form of gummy,
brownish, or yellowish crusts.
Seborrha'ic eczema on the bodv shows scarcelv anv
infiltration, the scales are few and often greasy, and the
affected surface has not tin; alttolute clryuessof psoriasis.
Syphilitic patches of the dryest form, when located
elsewhere than on the scalp, often show a tint of lividity.
and they iiavc a less regular .shape than the patches of
psoriasis: the scales also are smaller and less plentiful,
and tliey are formed at a less rapid rate than in the latter
disease.
Iti none of the diseases enumerated above can the
punctate hemorrhage be produced.
When compared with psoria.sis even the dryest eczema
of the body shows less symmetry of lesions, more thick-
ening, a less well-detiiied border, fewer scales, and these
not like tlie scales of psoriasis. Furthermore, the patches
have a stitt'er look and feel, and itching is more marked.
Ringworm of the liody shows fewer scales, and less,
if any, thickening of the part affected. On the other
hand, the lesion has a sharply defined border, which
appears to be the seat of an exudative inflammation. At
the centre of the lesion the skin is generally found to be
nearly free from inflammatory action.
AVhen psoriasis is associated with other morbid condi-
tions of the skin the physician will have to base his diag-
nosis upon the presence of certain features which are
cliaracteristic of this disease.
Prognosis. — The prognosis of psoriasis is unfavorable
as regards a cure, and doubtful as regards the removal
of the eruption. In all my experience I have .seen but
one case of psoriasis — at least so diagnosed — in which re-
covery was perfect ; but even in this case it is not perfectly
clear that an error in diagnosis may not have been made,
for upon reading my notes of the case again at the pres-
ent time I find that it may possibly have been one of a
slightly atypicid seborrhcfic eczema. Recovery followed
the use of treatment administered on the supposition that
the case was one of psoriasis. This patient was a woman
in good circumstances who died of alcoholism.
it is best to promise a patient with psoriasis nothing-
more than a certain amount of relief.
Ti!EAT.\iEN"T. — The ti'eatmeut of psoriasis is both ex-
tern-.il and internal, the former being the more etlicacious
of the two. Arsenic has been for years the chief reliance
in the internal treatment of the disease, it being often
pushed to large dosage and continued for long periods of
time. Its effects show such a mixture of good and evil
that I seriously question whether the benefits of the rem-
edj'are not more than offset by its disadvantages. Some
people reach the limit of tolerance (conjunctival irrita-
tion, pufliness of lid.s, gastric irritation) very early. If
they escape these, they may. under a long-continued use
of the drug, acquire other dermatoses scarcely preferable
to p.soriasis. However, it is well to give arsenic a trial,
but only in cases in which there is but a small degree of
cutaneous irritation. It is usually employed in the form
of Fowler's solution (liquor potass, arsenit. ): the dose
being, for an adult, five drops after each meal. This
dose should be gradually increased (an additional drop
at the end of every twenty-four hours) until the limit of
tolerance is reached.
Another aisenic;il preparation iswhat is called "Asiatic
pills," the formula for which is as follows: R Acid, ar
senilis, gr. i. : piper, nigiis. gr. xx. : pil. mas. q.s. M.
ft. pill. XX. Sig. : Begin with one after each meal: in-
crease by one everv day. As a result of taking these
pills, some patients have comphiined of stomachic irrita-
tion which they, quite reasonalily, attributed to the black
pep]ier, this irritation preventing in itself the object
sought — viz., to obviate irritation by the arsenic.
Iodide of iiolassium administered in large doses has
acquired considiTable renown as a means of relief for
jisoriasis. but mv experience with this drug has been of
such a discouraging character that I have given it up in
till' treatment of this disease.
Thyroid extrait. in the form of tablets (gr. ij.-x. t. i.
d.), has seemed, by actual comparison with other reme-
dies, to be decidedly beneficial : it constitutes, perhaps,
our best remedy for use internally in the treatment of
psoriiusis. TJiis opinion is at variance with that of excel-
782
REFERENCE HANDBOOK OF THE JfEDICAL SCIENCES.
Psoriasis,
Pioiiiains.
lent authorities, but is entirely sustained by my observa-
tion. All depends upon obtaining tlie pure, and there-
fore not inert, sul)stance. As tliyroid extract is capable
of inducing depression of the liearfs action and possibly
dizziness, the dose must be small at first, the elTect
watched, and it may even be necessary to attempt to
neutralize these effects by the administration of strych-
nine.
As is self-evident, the patient's general condition must
be kept at its best by such iuternal treatment as the
symptoms may require, just as if there were no psoriasis.
Faithful following of directions as to external treat-
ment, while onerous, must be required. The first re-
quisite is the removal of scales to permit the action of
remedies. Naturally, the treatment geuer.ally outlined
below is to lie much modified if the skin is found to be
abnormall_v irritable.
Hot batiis at night, in combination with the liberal use
of soap, greatly assist in removing the scales. Sapo
viridis may be used in full strength for removing scales,
or an alcoholic .solution (sap. vir., ? ij. : alcohol, Ji.)
may be employed ; but any strong soap will do quite as
well. As alkalies exert a special effect uixra epidermic
scales it is easy to understand the beneficial action of
soaps in removing them in psoriasis. Hot t;ir baths or
tar well rubbed into the patclies before an ordinary hot
bath is taken will often be foiuid hel|iful.
To aid in the removal of accumulated scales frrm the
scalp, it is advisable to apply freely a mixture eoitfaiuing
salicylic acid and olive oi 1 in the proportion of one part of
the former to eii;ht of tlie latter. After the mixture has
been well rubbed in, it sliould be allowed tosnak into tlie
parts for some time before it is finally' washed away. The
addition of formalin to this mixture (two and a half min-
ims to each ounce) seems to heighten its beneficial effect.
If a milder application is desired, the addition of twenty
grains of salicylic acid to one ounce of simple ointment
W'ill be found to answer satisfactoiily.
In my own experience with the treatment of psoriasis
of the scalp, the ammoniale of mercury, preferably in
salve form, has proven the most useful remedy. The
following are some of the formula' used: (1) R Hg. am-
mouiat., " ss.-i.; Ung. simp. (sen. Ung. aq. ros.), §1. M.
Rub well in at night. (2) I^ Ung. hg. amnion., ol. oliv.,
aa 3 ss. 31. Sig. : Vse at night. If there is not much
irritation, Ung. hg. ammon. (U. S. P.) may also be used.
These mercurial preparations can be employed only on
a limited portion of the general cutaneous surface, as
there is always some risk of inducing salivation if the
drug is too extensively applied.
I have used the following, but it produced slight ptya-
lism: if Hg. amnion., gr. xl. ; acid, salicyl., l\.; Ung. zn.
ox.,|i. 51. Sig. : Ajiply well morning and night. This
ointment may be considered perfectly safe if it is applied
over a limited area.
When there is a more general involvement of the skin,
chrysarobin in salve form is the best local remedy. Chry-
sophanic acid is much weaker in its action, and I have
abandoned its use. Chrysarobin usually exerts its best
action when its characteristic dermatitis is produced.
Under its action the skin becomes deep red, almost lilac
in color, hot, and itches. The subsiding, clearing patches
stand out as gray-white and unintlamed upon this red-
dened surface. The proneness of chrysaroljin to cause
irritation precludes its use on the scalp or face, for fear
that this irritation may involve the eyes.
The mo.st useful salve is the following: i{ Chrysarobin,
3 ss.-ij. : Ung. zu. ox., 3 i. M. Sig.: Knb well in
patches freed of scales at night — leave some on. To this
may be added acid, salicylic, 3 ss.-i., which often in-
creases its effect.
The varnishes so frequently employed in affections of
the skin seem to interfere with tlie action of the drugs
contained, but occasionally a varnish containing chryso-
phanic acid has proved somewhat beneficial in the treat-
ment of psoriasis.
The following formuI.T have been found useful: (1) I^
Chrysarobin., gr. xv.-3i. ; liq. gutt. perchoe, 3 i. M.
Sig. : Shake. Paint on patdies freed of scales. (3) I^
Acid, chrysophanic, 3 i. ; coUodii fiex., ? i. M. Sig.:
Paint on. (3) I^ Chrysarobin., 3 i. ; coUodii, 5 i. M.
Lanolin, when used as the base, makes a more adhesive
ointment, but the zinc oxide salve seems to prevent severe
irritation. It is customary to susiieud the chrysarobin
treatment upon the appearance of marked dermatitis,
but if this is not severe the use of the drug may be con-
tinued. To relieve this dermatitis, one of the follow-
ing preparations may be employed after suspending the
chrysarobin: (1) iJ Zn. ox. pulv., 3 iv. : phenol, (ninety-
five per cent.), 3 i. ; amyli pulv., 3i.i.; ai|., 3 iv. ]il.
Sig.: Shake; applj' often. (2) R Zn. ox. pulv,, 3i).;
amyli pulv., 3 i.; ol. oliv., Jij. M. Sig. : Sliake: apply.
Pyrogallic acid at one time was considered a good
second to chrysarobin as regards its elfiea( y in the treat-
ment of psoriasis; and it may still be found an efticient
remedy. The following is a suitable form in which it
maybe employed: R Acid, pyrogallic, 3 ss.-ij,; Ung.
zn. ox., § i, M. Sig.: Use in the same manner as the
chrysjirobin ointment, and in those cases in which the
chrysarobin ointment proves too irritating.
The tar preiiarations have proven useful in some cases,
especially where the skin will not bear stronger treat-
ment. The following are convenient formula?: (1) R Ol.
cadeuii, 3ij.; acid, pyrogallic, 3 i. ; ether, sulidiuiic.,
alcohol, aa J i. M. Sig.: Apply night and morning.
(3) R Picis liq., 3i.-ij.; Ung. zn. ox., Ung. diachyli.,
aa 3 ss. (or omit the diachylon). M. Sig. : Rub we'll in
once or twice a day. Leave on. (.3) R Picis liquid.,
3 iij.-iv. ; acid, salicyl., 3 i. ; Ung. zn. ox.. 3 iv. M.
Sig. : Apply in the usual manner.
In the em]iloyment of these different remedial pro-
cedures it is well to rcmenilier tliat a lotiim must be re-
applied so often that the parts will be kept constantly cov-
ered with the fluid: that a varnish must be re-applied as
soon as it peels off'; that a salve must be well rubbed in,
and a sufficient quantity must always be left on to keep
the drugs in continuous action upon the skin ; and. finally,
that .soap and baths and other scale-removing measures
must be employed often enough I'or the attainment of the
object de-sired. Then, when all this has been ilone. the
patient will probably still have some psoriasis, or a new
attack will supersede tlie old one, and tiie only certain
hope of an end to the disease is such as is offered by his
decease. M. 1}. HuUhins.
PTERYGIUM. See Conjnnctirn, Diseases of.
PTOMAINS. — Ptoniainsare basic, nitrogenous organic
snlistaiices pmduced by bacteria.
The first writer to suggest the probability of the forma-
tion of a poison coming within the above definition dur-
ing putrefaction seems to have been Kastner (Aidi. f.
r/isam. KaUirhhre, 1824, Bd. i., 448, 488: Bd. ii.. 499),
who advanced the hypothesis that poisonous sausages
contained an "alkaloid of decay" (Muderall'aluid) com-
bined with an organic acid.
In l^'o'i Schlossberger, in an extended paper upon the
sausage poison („l7-(7(. /. pliyswl. Eeilk., Ergiinzhft.,
1852) supposed "the poisonous substances occurring in
sausages and cheese to be organic b;ises, which have
their origin in the decomposition of the protein materials
rich in nitrogen, under certain conditions." lie sup-
]iorted this hypothesis by the following observations: (1)
When ammonia is jn'odnci'd in considenilile amo\int by
the decomposition of animal or vegetable substances, it
is accompanied by volatile bases; (2) by the action of
dilute potash upon poisonous sausages, much ammonia,
accompanied by a peculiar repulsive odor, is given off;
(3) tile physiological action of the putriil poison is very
similar to those of the known volatile alkaloids nicotin,
conii'n. spanein, ami to those of the artificial aniid, imid,
and nitril bases of Ilofmann; (4) one of these bases,
trimethylamin, is contained in herring pickle.
Four years later (IS.id) Panuni w,as probably the first
to obtain a ptomain, although in an impure condition,
and to demonstrate that the putrid poison is a chemical
78&
Ptoinains.
I'loiiia'ius.
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
substance ami not a li%'incr orajanism ("Bibl. fnr Ijaeger.,"
1856; Schmi(lf« ././/(;*., "l 8.59, ci.. 213; Arc/i. /. jHttli.
Aiiiit., 1874, l.\,, 328-35:i). Tliis substance was ilescril)e(l
hy Panuin as being soluble in water, from wliicU it was
precipitalile liy alcohol; c«pable of extraction from pu-
trid meat, and not identical with any of I lie known odor-
ousproductsof putrefaction. It iscapalileof withstand-
ing a boiling temiicrature, evaporation, and the intluence
of absolulealeohol, conditions inconsistent with the pres-
ence of organized life.
In ISGi; Bencc Jones and Dupre obtained from animal
matters a substance which they called "animal chi-
noidine." whicii gave preci|)itates with the general re-
agents for the alkaloids then known, and whose solution
exhibited a bluelluoresceuce (Med. Tuius uml (Jtiz.. 1806,
163). In 1808 Bergmann and Schniiedeberg obtained
from putrid blood a small (luantity of a crystalline sub-
stance, which was poisonous to dogs ami to frogs, and to
■which the name "sepsine"was applied (.1/n/. Cnitrdlld.,
1869, 497). In 1869 Zuelzer and Sounenschein obtained
from cadavers a crystalline sulistance having physiologi-
cal actions resembling those of atropiu (Ucti. kiln.
Wochensehi:, 1869, vi.,l21).
Between 1872 and 1878 Selnii published an extended
series of observations upon the reactions and juoperties
of putiid products, without, however, having deter-
mined their chemical com]>osilion ; and in 1875 proposed
the name "'ptomain," written by some recent German
avithors, ''ptomatine." derived from the Greek, nrufia,
i.i.. that which is fallen: a corpse. The contributions
of Selmi and his Italian followers — Morrigia and Baltis-
tiiii, Trottarelli, Rallaele, Ziino, Albertoni and Lussana,
Paterno, Spica. Brugnatelli and Zenoui, Hocci, Guareschi
and Mosso, and .Monari — have been numerous and impor-
tant. It remained, however, for Nencki and his pupil
Brieger to determine the chemical character of these com-
pounds. The former was the first to establish the com-
position of a ptomain by the analysis of a base having
the fornuila CMImN, probably n-phenyl-ethylamin, in
1876. The latter, in the most important researches upon
the chemistry of the ptomains ("Ueber Ptomaine," i.,
1885; ii., 1885; ill., 1886; J?eii. Min. Woehcnxrhi:, 1890,
xxvii., 241, 2C7, 11^3). established the constitution of a
mimber of the ]uitrid bases.
The ptomains have been, and still are, frerpicntly re-
ferred to as "animal alkaloids," a designation which is
misleading and imiiroper for two reasons: They are not
necessarih' jiroduced from animal substances, but many
are formed by putrefaction of vegetable proteins; nor
are they usually the products of animal metabolism, as
are their relatives, the leucomains. Only a few of them
are known to be alkaloids in the present acce])tation of
the term, i.e.. basic substances derived from heterocyclic
nuclei containiug but one nitrogen atom in any nucleus.
The great majority, and those best known, are of much
simpler molecular structure, and are moiiamins, diamins,
guanidins, hydramius, betains, or ami<lo-aci(ls. It will
be observed, therefore, that the designation " ptomain "
applies, not to the individuals of a distinct class of chemi-
•cal compounds, but rather to the bacterial origin of mem-
bers of several diiTerent chemical fuiu'tions. which may
also be produced liy synthetic methods, having in com-
mon only the two ipialities that they contiun nitrogen
and are basic. Strict regard for the derivation of the
name would limit its applicability to ])tomains ]iroduced
by saprophytic bacteria, either outside of the living bod\'
or within it, ;is in intestinal |nitrefaction m- in gangrene:
but it is now applied also to the basic products of jiara-
sific bacteria, the " toxins " of Brieger.
Some of the ptomains, as the diamins and the lower
terms of the monamin series, are either iion jioisonous or
poisonous only in very large doses. Others, and notably
those formed by pathogenic bacteria, are actively poison
ous. Wlien it had been found that pathogenic bacteria
produced in culture media and in the living body definitR
basic substances, such as Brieger's tetanin, which, when
injected into animals, produced symi)toms .similar t-o
those caused by the bacteria themselves, it was inf<Tred
that the manifestations of the disease were caused by
these ]3tomains. It has been shown, however, that the
basic substances obtained from cultures of the tetanus
bacilli, for e.xamide, are vastly inferior in toxic potency
to the bacteria-free cultures themselves. The inference
is plain that the bacteria produce other substances more
actively toxic than the ptomains, and it is now considered
as proven that the basic bacterial products play but a sec-
ondary part in the production of the manifestations of
disease caused by bacteria, while these other substances,
the "toxins, " conceruiug whose chemistry but little is
known. be3'ond the facts that they are non-basic, and
t hat some are possibly proteins, while others are certainly
not, are the essential bacterial jioisons.
\Vhil(> the toxins are in all probability synthetic prod-
ucts, the [jtomaius are undoulitedl.y decomposition prod-
ucts derived from the proteins or from complex phos-
phorus-containing organic substances, either by simple
cleavage m by hydrolysis, and many of thera are thus
produced from the parent sulistances by agencies other
than bacterial life. C'hi>lin is thus produced from the
lecithins by hydrolysis by barium hydroxid: the ainido
acids ami indole and skatole are similarly formed from
the proteins; the pyridin bases are found in oil of Dip-
pel, produced bj^ the dry distillation of bones; and
argiuin, the most abundant of the hexon bases, formed
by the action of Ijydrochloric acid and tin chlorid upon
the iiroteins, yields putrescin on further decomposition.
As the processor putrefaction is a gradual and pro-
gressive one, different basic lu-oducts are produced at
different stages, and b;ises obtainable in considerable
amount during the first days of putrefaction will have
more or less completely disajipeared at a later stage,
when other bases, not previous!}' present, will have made
their appearance. The nature of the bases (as well as of
other products) produced varies also with those condi-
tions which modify the ju'ogress anil nature of putrefac-
tive changes, viz. : (1) The kind of bacteria, particularly
whether aerobic or auaOrobic, and, consequently, the ac-
cess or non-access of air; (2) the nature of the protein
undergoing decomposition; (3) the temperature; (4) the
degree of moisture. It is also probable that in caiiaveric
putrefaction the nature of the ptomains produced is
influenced by the results of the simultaneous changes
which the carbohydrate and fatty constituents undergo;
as, for examiile. in the forniation of adipoccre.
As I he iilomains represent several dillereut classes of
chemical comjiounds, no general characters other than
those aliove indicated can be ascribetl to them. Nor can
it be expected that they should exhibit any cpialities or
reactions which could serve to distinguish them as a class
from other compounds.
j Although the chemical constitution of many of the
ptomains remains to be determined, tlait of quite a num-
ber has been established, suflicieiit to warrant their classi-
fication, so far as possible, according to chemical function.
Such a classification is here attempted.
;Mox.\mixs. — Met/ij/liiiiiiii. CHj. Nil:, and d/mctl/i/lami'n,
(CH;.).; ; NH, gases, and trhiiit/ii/liin/iu (CH3)3:.N, a liquid,
boiling point 9% have huig been known to exist in li-r-
riug brine, and together constitute the greater part of the
commercial " trimethylamiu," ]iiepai'ed by distillation of
beet sugar vinasse. They are al~o formed iluring the de-
composition of fish and of a number of other animal and
vegetable substances. Trimethylamin occurs naturally
in, or is easily lilieiated from, cod-liver oil, ergot, clieno-
podiiim, yeast, guano, human urine, the blood of the
calf, and many llouers. It probalily originates from the
decomposition of cholin (see below), from which it ma)'
lie obtained, aloiiy with glycol, by the action of caustic
potash: (•II.,()11.C1I,.N : : (Oil) (Cll;,);.- CII...O[I.CII.,OH
+ NtCIIa);,. All three of these bases have the odor of stale
fi.sh. are very soluble in water, forming strongl}- alkaline
solutions of hydroxiils, and soluble, deliquescent liydro-
chloriils. Each forms a platiuochlorid, easily soluble in
hot but s]iuringly soluble in cold water, and a readily
soluble auroehloiid. They are practically uon-ixiisou-
ous.
7S4
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Ptoiuains.
Ptoma'liM.
A7////A'WN(. CHs.NHj. dietfii/liniu'ii {C\Ui).,: NIT, and
triith'iiliiiiiiii (C-jHsilsN, are stmngly alkaline, oily liquids,
biiilinj'- jioints, 18% 56°, 89", wliicii "accompany the inetliyl-
amins in herring pickle, beet-sugar vinasse, and the
products of putrid tish, yeast, and gluten. Their hydro-
chlorids and platinochlorids are easily soluble in water.
Tliev are practically non poisonous.
I'l-Djii/liiiiiin, probably the iso-compound (CH3)2:CH.-
NH;, boiling point 32 , huttilamin (isoV), (CHs)^:
CH.CHi.NHj, boiling point 68\ iso-mnylamin. (CH3).., :
CH.CH2.CH..NH2, boiling point 9.5", and a /lext/lnmin
(('H3i2-.'CII.('CH.j)3.NH., are colorless, strongly alkaline
liquids occurring in cod-liver oil, beet-sugar vinasse, and
decomposing yeast. The amyl compound is actively
poisonous.
yenrki's base, CpHnN, obtained from a mixture of
pancreas and gelatin after five daj's' putrefaction at 40",
seems to have been ,3-phenyl-ethylamin, C6H5.CH....CH2.-
NHj. boiling point 197'. The free base is oily, has a pe-
cnliiir, not disagreeable odor, absorbs carbon dioxid from
the air to form a crystalline carbonate, and forms ii spar-
ingly soluble platinochlorid, crystallizing in long flat
prisms. Its aurochlorid is a yellow oil, which is rapidly
decomposed by reduction. A base, probably identical
with this, is formed by decomposition of ,3-plienyl-a-
amido propionic acid, or phenyl alanin, C6H5.CH2.-
CH(NH.;). COOH, itself a product of putrefaction (see
below). "
Ml/din, CfHiiNO, is a base obtained by Brieger from
human cadaveric matter which had been in putrefac-
tion four months at a temperature from + 5 to — 9°
in closed vessels. The free base is strongly alkaline,
lias an ammoniacal odor, and is a strong reducing agent,
and therefore forms no stable aurochlorid. Its platino-
chlorid is verv soluble. This base is believed to be
/?-oxyphenylethylamin, HO. C6H..CH2.CH2.NH2, derived
from" the "decomposition of tvrosin, which is p-oxv-
phenvl-alanin, H0.C6H,.CHs.CH(NH,).C00H, by loss
of C62.
Di -\ MiNs. — Tetrameihylenediainin, HaN.CH.j.CH-.-
CHi.CHo.NHj; putrescin — is one of several diamins
which were found by Brieger to be products of putrefac-
tion. It is formed, along with penta- and bexamethy-
Icncdiamin, during the putrefaction of fish, muscular tis-
sue, gelatin, and other animal tissues, appearing about
the third day and increasing in quantitj' for two to three
weeks. It is found in the urine and fseces in cystinuria,
in amounts proportionate to the quantity of cystin elim-
inated (diaminuria), and also in cholera stools. Putrescin
has been shown to be a diamin, and to be identical with
the tetramethylenediamin s.ynthetically prepared liy La-
denburg's method, although with methyl iodid it yields
only a tetramethylated detiYative, but no hexamethy-
lated derivative. The origin of putrescin from the pro-
teins occurs through the hexon base arginin ((S-guanidin-
fi-amido valerianic acid: UN: (NHj): .C.NH.CH2.CH..-
CHJ.CH(NH.,).C00H, which is formed from the proteins
by tryptic digestion. Arginin is split by hydrolysis into
urea and ornithin (iS-a-diamido valerianic acid), and or-
nithin has in turn been converted into putrescin, by loss
of carbon dioxid, by bacterial action: CH.2(NH.j).('H». -
CH.:.CH(Nll,).COOl"l = H,N.CH,.CH.,.CH5.CHo.NH,+
QO-2. Putrescin and other diamins may be separated
from most other substances by taking advantage of the
formation of the insoluble dibenzoyl compounds which
they form with benzoyl chlorid in presence of alkalies; a
property which they share with polyatomic alcohols and
aldo- and keto-alcohols. Its dibenzoyl compound crystal-
lizes in jdates or needles, diffieultl}' soluble in alcohol, iu-
solidjle in water.
The free base is a clear, rather thin liquid, boiling point
15G -157', having a disagreeable, seminal odor, strongly
alkaline, and absorbing carbon dioxid from the air. Its
hydrochlorid cr3'stallizes in colorless needles, soluble in
water, insoluble in absolute alcohol, not hygroscopic.
Its platinochlorid and aurochlorid both form hexagonal
plates, ilillicultly soluble in cold, more soluble in hot
water. Its jiicrate crystallizes in needles, sparingly
Vol. VI.— 50 '
soluble in water or in cold alcohol, soluble in hot alcohol.
It is practically non-poisonous.
Peiitamethylenediamin, H.2N.(C'H2)5.NH2, cadaverin, is
another diamin found b.v Brieger to accompany putrescin
as a product of putrefaction of muscular tissue, heart,
lung, liver, and other animal protein material, from the
third day to four months. It also accompanies putrescin
in the urine and f;vces in cystinuria. and in cholera stools.
It has been found in the intestinal contents in a case of
intestinal fistula, and is probably a normal product of
tryptic digestion, although it is not found in normal hv-
ces. It has been shown to be identical with tlie normal
peutamethylenediamin (formula above) prepared by La-
denburg's" method. Cadaverin originates through the
hexon base, lysin (]irobablv a-f-diamido eaproic acid,
CH~(XH:).(CH;)s.CH(NH5)."C00H, from which it is pro-
duced by putrefaction, as putrescin is formed from
arginin. " Cadaverin is a thick, transparent liquid, liav-
ing a very disagreeable odor, somewhat resembling that
of coniin ; boils at 175" ; fumes, and absorbs carbon di-
oxid rapidly when exposed to air, being converted into a
crystalline "compound. With methyriodid it forms a
dimethylated derivative. Its hydrochlorid is crystalline,
deliquescent, readily soluble in water and in dilute alco-
hol, but insoluble in absolute alcohol and in ether. On
dry distillation it spjits olT hydrochloric acid and ammo-
nium chlorid and forms jiiperidin: C;HnN;.2HCl = IlCi
-l-NHjCl + CsHiiN, an instance of the pyrogenic origin
of a cyclic from an acyclic compound, of an alkaloid
from an amin. Its platinochlorid forms needles or short
rhombic prisms, soluble in alcohol, difficultly soluble in
water. Its aurochlorid crystallizes in cubes, needles, or
plates, easily soluble in water. Its picrate forms plates,
soluble in liot water, sparingly soluble in cold water or
in alcohol. Its dibenzoyl compound crystallizes in
needles, soluble in alcohol, insoluble in water. With
potassium chromate and sulfuric acid it gives a reddish-
brown, evanescent precipitate. It is practically non-
poisonous.
Ncuiidin, H2N.(C5H,o).NH2. another of Brieger's dia-
mins, is isomeric with cadaverin, but of unknown con-
stitution. When heated with caustic potash it yields
dimethylamin and trimethylamin. a decomposition which
shows it to be not identical with amylamin, with which
it is also isomeric. Indeed, there are twelve possible
isomeres of this amin. Neuridin is produced, along with
cholin, during the first stages of putrefaction, particu-
larly of gelatlnoid substances, and increases in quantity
as putrefaction advances, wliile the quantity of cholin
diminishes. It is no longer present after fourteen days-
The free base is gelatinous, and decomjioses even during
evaporation of its solution. It has a disagreeable, sper-
matic odor, and is in.soluble in absolute alcohol and in
ether, difficultly soluble in aniylic alcohol, readily solu-
ble in water. It forms white precipitates with mercuric
chlorid and with neutral and basic lead acetate. Its
hydrochlorid crystallizes in long needles, and is veiy
soluble in water, insoluble in alcohol, ether, chloroform,
petroleum-ether, benzene, or amylic alcohol, except in
presence of other animal sulistances, when it dissolves in
the immiscible solvents mentioned. Its platinochlorid
forms fiat needles, soluble in water, insoluble in alcohol
Its aurochlorid crystallizes in short needles, difficultly
soluble in cold water. Its picrate forms needles, almost
insoluble in water, sparingly soluble in alcohol. Wlien
pure it is non-poisonous.
Siijin'n. is another diamin, formed along with putresiin.
cad;iverin, and mydaleiu, during the [lutrefaction of glan-
dular tissues. Brieger assigned to it the formula CjH,,-
N», but it is now believed to be isomeric with cadaverin
and neuridin, CsHnNj. It is distinguished from cada-
verin bj- the greater solubility and different crystalline
form of its platinochlorid, by the absence of an auro
chlorid, by the permanence of"its hydrochlorid in air, and
by its failure to give the reaction with potassium cliro-
niate and sulfuric acid. It is non poisonous.
HexamethyhvKdiftmiii. l\.'^.(Cll~)r..^B-,. is formed
during putrefaction of muscular tissue and pancreas. It
785
Ptoniaiiis.
Ptoiiiaius.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
is a crystalline solid, fiisiiiir at 40° and bnilinj; at 10.j°.
Its jilatiniichloiid t'oiins rlinniliio needles, sdluble in wa-
ter, sparingly solulile in alrolml.
Briei/er'x Ijiise, C-HsNn. i.someric but nut identical with
etliylenedianiin, ltjN,(CH..,)g.NH2, and siiiiposcd to be
ethi/lideiiediiimiii, CIIa.CHlNHr)^. was obtained from pu-
trefying tisli. Its liydrochlorid crystallizes in lung, bril-
liant needles, easily soluble in water, insoluble in abso-
lute alcohol. It does nut furm an aunichlmid. Its
platinocUlorid crystallizes in small .scales, sparingly solu-
lile in water. This base, adnnuistered hypodermically
iu small quantity to mice and guinea-pigs, produces in a
shiirt time increased secretion of the nasal mucus, saliva,
and tears, which are subsequently temjiorarily arrested,
to begin again later. The pupils are dilated and the
globes protruded. There is marked dyspmea. which
continues until the death of the animal, within twenty-
four hours.
Another base was obtained by Brieger in very small
quantity from cultures of the comma bacillus, which
may possibly be triiiit'thyleiieiliamin. H.jN.(CH2)3.NH2.
ilydalein was obtained by Brieger in small quantity
after seven days' exposure to air of putrefying viscera,
and increased in amount up to three weeks. The
amount obtained was insutlicient to determine its com-
po.sition further than that its platinochlorid contained
Pt 38.74. C 10.83, H 3.23 per cent., frum which the
inference is drawn ;liat it is a diamin. probal)ly contain-
ing four or live carbon atoms. Its hydrochlorid crystal-
lizes with great difiiculty, and is very hygroscopic. Its
platinochlorid forms needles, very soluble in water.
This base is actively poisonous. In small doses in rab-
bits and guinea-pigs it causes greatly increased nasal and
lachrymal secretion, dilatation and insensiliility of the
pupils, increased body temperature, acceleration of res|)i-
ration and cardiac action, a tendency to sleep, and in-
creased peristalsis. With larger doses (less than O.OII.i
gm.) the increased secretions become very profuse, the
pupils are widely dilated, and the e,yes protruded. The
animal falls, the jiosterior extremities Vicing first para-
lyzed, then the anterior, and there occur tibrillar spasms
of various groups of muscles. Sometimes the animal
springs up and immediately falls, making faint move-
ments of the legs. Tlie respiration, at first very fre-
quent, becomes slow and labored. The body tempera-
ture diminishes gradually, the movements become more
and more faint, an<l the animal dies in a condition of so-
por. The heart is arrested iu diastole, and the intestines
and blailder are found contracted after death.
Spcniiin. C...HsN(?). a base of uncertain composition,
but probably an imin, has been obtained from semen,
testicles, ovaries, thyroid, pancreas, ancl si)leen,and from
cultures of the comma bacillus. Its phosphate forms crys-
tals, known as Lej'den, Bi'ittcher's, or Charcot's crystals,
which are met with in anatomical preparations preserved
iu alc<iliol, in dried semen, in siiuta and nasal secretions,
in the blood. s]ileen, and other organs of leueocytha'mics
and anamiics, and iu fa'ces. These crystals are insolulile
in alcohol, ether, or chloroform, ditlicultly soluble in
water, easily soluble in dilute acids or alkalies. The free
base forms cr\'stals, which rapidly absorb carbon dioxid
from the air, are readily soluble iu water and iu alcohol,
insoluble in ether, and strongly alkaline iu reaction. Its
hydrochlorid crystallizes in hexagonal prisms, very solu-
ble in water, insoluble iu absolute alcohol or ether. Its
platinochlorid crystallizes iu plates, its auroclilorid in
prisms. It is non-poisouous.
Thiamins. — Guanidin or carbotriamin. IIN: C: (Nil,,)..,
is formed by oxidation of guaniu, but is not a ptoinain.
Its meth}'! derivative, Mctfii/l-r/uiuitdin or >ii<-t/ii/l-)intni/H.
HN:C:('NII:)(NH,CH,), which is a iiroduct of oxidation
of creatin and of creatiuin. was obtained by Brieger from
horseflesh which had undergone putrefaction at a low-
temperature and without exposure to air for four months,
and it has since been obtained from the cull ures of several
species of bacilli. It is undoubtedly derived from cre-
atin, to which it is closely related. It is a colorless, iin-
perfectlj- crystalline, highly hygroscopic and strongly
alkaline base. Its hydrochlorid crystallizes in prisms,
insoluble in alcohol. Its platinochlorid forms very solu-
ble needles. Itsaurochlorid crystallizes in short rhombic
prisms, soluble in ether, sparingly soluble iu water and
in alcohol. Its picrate crystallizes in needles, sparingly
soluble in water, which fuse at 192'.
In guinea-pigs raethylguauidin causes copious diar-
rho'a and increased secretion of urine. The pupils are
dilateii and insensible to light. The animal remains in
one position, even when irritatetl, but soon becomes rest-
less and seeks to move the anterior extremities, while the
posterior are jiaralyzed. The respiration becomes pro-
gressively deeper and more labored, and there is marked
d3'spna>a. The legs become jiaralyzed, and the animal
falls on its side and dies, after .short, general clonic con-
vulsions. After death the heart is found in diastole the
intestine filled with tluid, the bladder contracted, the
cortical portion of tlie kidneys hypeiK'mic, and the papil-
lary portion pale.
HvDu.i-MiNS(0.ry(/w/Hs). — These are derivatives of the
dihydric alcohols, retaining one hydroxyl, and coutain-
ing one amido group, more or less nmdified by substitu-
tion. The ptoraai'ns of this class are trimethylated
ciuarternarv ammonium hvdroxids.
0/wlin, '(CH.olli.CH.'N: :(CH3)3(OH), trimethyloz-
(thjjlaiinimniuiii liydnaid, was tiriginally obtained by
Strecker from ox bile in 1849, and was sub.sequently
shown by Diakonow to be derived from the lecithins,
which, when hydrolyzed, yield choliu, phosphoglyceric
acid, and fatty acids. It is now known to be very widely
distriliuted in both animal and vegetable organisms, and
it is one of the first of the ptoma'ins to be produced by a
number of bacteria, having its origin tuidoubtedlj- in the
decomposition of the lecithins, which occur in almost all
animal tissues, and are veiy prone to decomposition. As
putrefaction advances, cholin gradually disappears,
partly bj' conversion into neurin, or possibly into mus-
carin, and partly by more complete decomposition, with
formation of trimethylamin. until after seven days it is
no longer jiresent. Cholin is a syrupy, highly alkaline
liquid .soluble in all pro|iortions in water, which absorbs
carbon dioxid rapidly from air, with formation of a crys-
talline carbonate. Its chlorid forms highly deliiiuesceut
needles, very soluble iu water and in alcohol, insoluble
in ether, chloroform, or benzene. Its |ilatinochlorid
crystallizes in prisms or in plates, readilj- soluble in
water, insoluble in alcohol or ether. Its auroclilorid
crystallizes in prisms, siduble in hot water or iu alcohol,
almost insolulile in cold water. Its picrate forms needles,
soluble iu water and in alcohol. It is not poisonous ex-
cept in large doses, wheu it produces etiects similar to
those of uuiscarin.
ye.tirih, CH^tCH.N : : (CH3)3(OH), Iriwfthylrinyhim-
moniiim /ti/drojid, an unsaturated compound, difllering
from cholin by HgO less, was obtained by Lieljreicli from
protagon, anil has been obtained from brain tissue and
suprarenal capsule, and by the action of boiling baryta
water upon cholin. It was found by Brieger, along with
neuridin, in the products of putrefaction of horseflesh for
five or six days at the temperature of incubation. It
may originate by dehydration of cholin or by decom-
position of lecithins, in whose constitution it replaces
cholin, the existence of which is probable. The free base
is a .syrupy, highly alkaline liquid, soluble iu water in all
proportions, ami decomposed by boiling of its aqueous
Solution, with liberation of trimethylamin. Its chlorid
crystallizes in needles, hygroscopic, and very sohdile iu
water aud in alcohol. Its platinochlorid forms octahe-
dra, almost insoluble in water. Its auroehlorid crystal-
lizes in prisms, ditficultly sohible in water. Its picrate
forms long needles, sparingly soluble iu water and in
alcohol.
It is actively poisonous, producing effects resembling
those of muscarin. When administered to rabbits it
cau.ses movements of mastication, accomjianied by pro-
fuse secretion of saliva, which is at first thick aud viscid,
then thin and alkaline. The increased secretion of saliva
continues until the terminaton of the poisoning, and varies
786
REFERENCE HANDBOOK OF THE -MEDICAL SCIENCES.
PloiiiaiiiK,
Ploinaius.
in degree with tlie magnitude of the dose. Subsequent!}-
there is increased secretion from theSchneideriau mucous
membrane and tlie lachrymal glands, the latter of short
duration. The respiratory movements are at first more
frequent and deeper than normal: the extraordinary re-
spiratory muscles are brought into action, the head is
thrown back, and the nostrils are dilated. These symp-
tomsof dyspna-a alter in character as <l<-ath approaches, in
that the movements l)ecome irregular, superficial, and less
frequent. The heart's action innuediately after the injec-
tion is accelerated, so that the pulse eaimot be counted : in
a short time it becomes slower, and diminishes constantly
in frequency. Tlie pulsations are at tirst very strong,
but subsequently become progressively weaker until the
heart is arrested in complete diastole. The heart 's action
continues after cessation of respiration. Section of the
vagi has no influence, and the heart responds to artificial
stimuli. Occasionally contraction of the pupils occurs,
an effect which almost always follows an application of
a strong solution of the poison to the eye. Powerful
peristalsis is an early .sj-mptora, causing an uninterrupted
voiding of matters, at first consistent, sidjsequently wa-
tery. Ejaculation and dripping of urine also occur. If
the abdomen be opened at this stage, tetanic contractions
of greater or lesser portions of the intestine are seen.
The spleen is also strongly contracted. Only when lethal
doses are given do strong clonic convulsions occur, in
which the animal soon dies. These convulsions are par-
tially controlled by artificial respiration, but they soon
recur. Locomotion is interfered with, the posterior ex-
tremities being first paralyzed, then the anterior, before
the beginning of the convulsions. In cats there is an in-
creased secretion of alkaline perspiration. Atropin is a
powerful antidote; but atr<ipinized animals are still sub-
ject to the action of the poison. When taken by the
mouth this alkaloid produces the same effects as when
administered hypodermically, but ten times the dose is
required.
Mujimrin (?), CsHisNOs, abase having the above com-
position, and corresponding in physiological action to the
muscarin which occurs in toadstools (agaricus, boletus,
amanita), was obtained by Brieger from putrefying fish.
It forms a deliquescent, (Hfticidtly crystallizable ehlorid ;
a platinoehlorid which crystallizes in sparingly soluble
octahedra ; and an auroehlorid which forms needles, also
difficultly soluble in water. It is not certain that this
base is identical with the muscarin of fungi, or that
either is identical with the " synthetic muscarin " obtained
by oxidation of cholin. The last named undoubtedly has
the constitution sometimes assigned to oxveholin, and
expressed by the formula CH'jOH.CHOH.N: : (CHs)^-
(OII), from its derivation from cholin : CHjOH.CHi.N::
(CHs^aCOH).
Brieger's ptomain. administered in verj- small quanti-
ties tofrogs, causes total paralysis, and arrest of the heart
in diastole. The administration of atropin to frogs un-
der the influence of this base revives the action of the
heart, and the ctfeets of the ptomain are not observed
in atropinized animals. Minute doses, administered to
rabbits, cause greath* increased s;ilivar_y and lachrymal
secretions, contraction of the pupils, profuse diarrhfea,
ejaculation, voiding of urine, and death after convulsions
of short duration.
BiiT.UNS. — These compounds, clo.sely related to the
hydramins, are auhydrids, or, more ]>roperly. lactams, de
X rived from acids correspondini: to the hvdramins. sucli
as (COOH).CH.,.N::(CH3)3(OH) (see cholm). by elimina-
tion of H from COOH and OH from the ammonium
hydroxid group. Thus:
COO
Betdin or trimethylacetic beiain — | \ , is
CH,.N:.(CH:,)3
ranked as a ptomain because of its occurrence in fiesli
poisonous muscles (which uudouhtedly owe their toxicity
to bacterial action) and among the products fif putrefying
gluten. It was first obtained from beet root (whence its
name), and also exists in malt, in cotton seed, and in a
number of other vegetables; and is formed by several
synthetic methods, as b}' the interaction of nionochlorace-
tic acid and trimethylamin.
It forms large, deliquescent crystals, with one molecule
of water of crystallization, very soluble in water and al-
cohol. It is strongl}- basic and forms crystalline salts.
Heat decomposes it, with evolution of trimethylamin.
Its ehlorid forms non-deliqueseeiit plates, insoluble in
absolute alcohol. Its iilatinochlorid forms solulile
prisms: and its auroehlorid sparingly soluble plates or
needles. It is non-poisonous.
Mydataxiii, CoHijNO^, which iiiav be trimethylpropionie
COO
betain, \ '~~^~^ , or the corresponding iso-com-
CH.,.Cm.N:.(CH3)3
pound, was obtained by Brieger from decomposing horse-
fiesh under the same conditions as mydin. The free base
is a strongly alkaline sj'rup, which crystallizes /;; raeuo,
insoluble in alcohol and ether, decomposed by distilla-
tion. Its ehlorid is a tliin, colorless syrup, which forms
no double salt with auric ehlorid, and with platinic
ehlorid a very soluble double salt which fuses and is
decomposed at 193'.
Jlydatoxin is not very actively poisonous. Adminis-
tered subcutaneously to guinea-pigs, the ehlorid of this
base causes increase in the fref|uency of the resiiiration;
at first contraction, and later dihitatiou and insensibility,
of the pupils: and diminution cif temperature with short
chills. Clonic convulsions, frequently of such intensity
that the animal is involuntarily projected forward, recur
at short intervals. The secretions of the salivary and
lachrymal glands become more abundant. The body
temperature falls, and the respiration becomes less fre-
ipient. The ears, at first injected, become pale and cold.
The extremities are paralyzed. The cardiac action be-
comes irregular and less frequent. Convulsions are pro-
voked b_v striking upon the table supporting the animal.
Shortly before death tlie convulsions become less strong,
the extremities are extended, the animal falls upon its
side and dies. After death the heart is found arrested in
diastole, the intestines are strongly contracted, and the
bladder is empty and contracted.
MytiUtixrin CsHisNOj, a base of undetermined consti-
tution but also possibly a beta'in, was obtained by Brieger
from the poisonous mussels which caused the poisonings
at Wilhelmshaven. The free base has a disagreeable
odor which it loses on exposure to air and at the same
time becomes non-poisonous. It is decompo.sed by heat-
ing with caustic potash. Its ehlorid crystallizes in tet-
raliedra and is intensely poisonous, causing the same
symptoms as do the mussels (see Vol. IV.. p. 1^*9). The
auroehlorid crystallizes in microscopic cubes which fuse
at 182\
Amido Acrns. — The amidoacids. formed by substitution
of one or more amido groups (NH;) for hydrogen in the
hydrocarbon groups of other acids, are not usually con-
sidered as ptomai'ns, probably because they were known
as products of the decomposition of proteins, by putre-
faction or otherwise, long before Selnii suggested the
name " ptomain " for substances which he considered to
be alkaloidal. Thus tyrosin was found to be a product
of decomposition of casein liy Liebig in 1 841! ; and Proust
discovered leucin as a product of putrefaction of gluten
and of cheese in 1819. But these bodies contain nitrogen,
and although they are acids by virtue of their earboxyl
groups (COOH), they are also distinctly basic, by virtue
of their amido groups. They therefore come within the
limitations of the class of ptoniains as given above.
Among the diamido acids are included substances, such
as lysin and ornithin, and among their guanidin deriv-
atives substances, such as arginin and probably histidin,
which, although not ptomai'ns, so far as is known, are
products of the earlier steps in the decomposition of the
pioteins, and intermediate in the generation of some, at
least, of the ptoniains.
The amido acids of the acetic series may he obtained
synthetically, either by the action of ammonia upon the
monochloro derivatives of the aei<is, or by the action of
nascent liydrogen upon the cyano derivatives, as well as
787
Ptonia'ins
Ptoiiiaius,
REFEHEXCK IIANDHOOK OF THE MEDICAL SCIENCES.
by ntlicr mctliods. Tlius clycncoll. or iiniid(i-,iocticaoi(l.
iiiuV lie (Icrivfil froni miiiiiKhlcifaci'lir acid: I'lIjCl.-
CO'()lI+NH3 = Cil,(NlI.,).CO()M + ll('l. (ir ln)Mi cyu-
noformic acid: CN. COOK + 211, = ClI,(NU.j).CO()n.
Tlify appear to be ])raeti«illv noii-poisonoiis,
liel/(((imido-n-T(d.ii-i(iiii('<icid,CU~(NiU)ACn-:),.COOH.
one of tlio biitalanius (SalUowski's base), is the lowest
term of tlie series wliich is known to lie a jiiitrid product,
and is formed by decomposition of lilirin and of muscular
tissue. It is a solid, fusinir i)oint l.jl! , very solulile in
water. Its liydrocldorid cryst.illizes in stellate bundles,
and is very soluble in water and in alccjbol. Its jilatino-
cldcuid is soluble in liot water, ditlieultly soluble in cold
water and in alcoiiol. It is not identical witb the amido-
valerianic acid obtained by (Joruii-He.sanc/, from ox
pancreas, or produced synilietically from mouoehloro-
valeriauic acid, as it does not form precipitates witli am-
inoniaeal silver nitrate or willi cuprie acetate,
linii-lire-n-aini(ln-isi>}>ii!iil-(ii;lii- iicid. (CH:,): CII.jCH.j.-
*CH(NH..).COOH. (luiiiinl Iciirin. is one of the twenty-
nine isomeric amidocaproic acids, or leueins, whose con-
stitution is demonstrated bv its format ion from isovaleric
aldehyd, (CHah: ("II.CII.„CHO. It is produced, a\<mg
with tyrosin. in the decom]iosition of proteins with
dilute acids or alkalies, by putrefaction, and by tryptic
diireslion. It is found in the cultures of the bacillus of
malignant (edema, and, alon,ir with tyrosin, in those of
anthra,\ and comma bacilli, and in the products of de-
eomposition of fibrin by strejitcx'oeci. It appears to exist
also as a normal constituent of the panei-eas. spleen, thy-
nuis. lymphatic and sali\ary glands, liver, and kidneys.
Pathologically the i(Uantity of leueiu is much inere;ised
in the liver in diseases of that organ, in ty|ihus and in
variiila; in the bile in typhus; in the blood in leukainia,
and in yellow atrophy <.if theliver; in the urine in ^yellow
atrophy of the liver, in typhus, in variola, and in phos-
phorus poisonini;; in choleraic discharges; in pus; and
in the tiuids of dropsy and of atheromatous e_vsts. It is
probable that levicin exists as a eon.stituent factor of the
proteins, and is split olT during their decom]iosifion, as
is the ease with the hexon liases, arginin and lysin. both
of which are related to it. the foinn'r being the guaniilin
compound of a diamido-valerianic acid, and the latter a
diamidoeaproic acid,
Leucin crystallizes from alcohol in ]iearly plates; but
is more usually met with in rounded masses of closely
grouped, radiating needles. It is sparingly .soluble in
water, almost insoluble in alcohol and ether, but readily
soluble in hot water or alcohol. It is odoiless and taste-
less, and its solutions are neutral. It dissolves readily in
acids and in alkalies, foi'uiing crystalline compounils with
the former. It fuses without decomposition, and sub-
limes at 171)'. Hydriodic acid under the influence of
pressure and heat decomposes it into eaproie acid and
ammonia. Its liot solutions form precipitates with hot
solutions of enprie acetate; and they dissolve cuprie hy-
droxid, but do not reduce it on boiling. When heated
with mereurous nitiate solution it liberates metallic mer-
cury,
Aiiiiiliifitain'c iifiil. Ci JI:i,', (XII.j)O..., has been found by
iSchutzenberger among the products of putrid'action of
niuscidar tissue. The aniido acids. CulLjo^^'jO,-, and CJI...,,-
NoOs, obtained by the same ex|ierimenter, are (irobably
mixtures. The former, on decomposition by caustic
potash, yields, besides ammonia, potassium carbonate,
valerate and butyrate, while the latter under liki^ treat-
ment yields caproate, caprylate. and acetate,
Schutzenberger has also described a class of substances
to which he has given the name " leviceins," dilfering
from the leucins by containing two hydrog<'n atoms less,
possililv amidoaervlie acids. Of these he found biitvric
leucein'. CJI,,(NIl",)0.,. and Vidi'ric leucein, C,.,H;(Mi;.)0.,
among the jiroducts of iiutrefaction of muscular tissue,
Asp.'irticacid, or aiuidosucciriic acid. COOlI.C'lh Nil., I •
CH.i.COOlI, and glutamic acid, or amidoglutaric acid,
COOII,C1I(X1I:),CH.;,C11...COOH. although known as
products of deeompo.sition of proteins by the action of
acids and in tryptic digestion, have not been founil to be
products of putrefaction. Schutzenberger obtained an
aniido acid having the formula CaHjsXOi, which yielded
an isomeie of allylamin, CMInN, on decom|iosition, from
putrefying muscular tissue, and Guareschi obtained a
base, CuH.;oN.;04, from putrid tibrin. These two bases
appear to be amido derivatives of dicarboxjdic acids, al-
though they are not homologues of the aspartic series.
7)/ run/ II . or p-D.ryiilii-nuhihiiiiii (II(.))n)C6H<.CII.j.CH-
(>rH.j).COOH, is one of the earliest known products of
decomposition of the proteins, and is formed from them
by the action of proteolytic enzymes, by putrefaction,
and by the action of acids or of alkalies, always accom-
panied by leucin. It also exists normally in the intes-
tinal contents, and iiathologically in the urine. It has
been obtained synthetically from phenyl-acetaldebyde,
C6Hs.CI-I.;,CII0, It crystallizes in silky needles, ar-
ranged in stellate bundles, difficultly soluble in cold
water, soluble in l.'iO jiarts of hot water, insoluble in al-
cohol or in ether, rather soluble in the presence of acids
or of alkalies. It is not poisonous. Tyrosin is a phenolic
deri\-ative of ii-jilienjil-a-amicloprojnonic anil, CsHs.CH-j.-
CH(NH.;)C0OH, uv p]it?nylaliniin, which is also a product
of putrefaction.
Ar.K.VLOiDs. — There are nine ptonniins known wliich
may, with more or less reason, be called alkaloids. Of
these seven are pyridiu or dihydropyridin derivatives,
related to the ba.ses which occur in bone oil. The other
two are benzopyrrole derivatives.
Di'Cvninck's biise, C^HuN, ((( i'i>llitlui?) was obtained,
along with the base C10H15N, from putrid jelly-tish after
one to two weeks. It is a yellowish, mobile liciuid, hav-
ing an acrid odor, very sparingly soluble in water, solu-
ble in ethylic and methylic alcohols, ether and' acetone.
Spec. grav. O.flSti."). Boils without dei'om]iosition atlJOi;
Turns brown, and absorbs water rapidly from air, but
dose not appear to absorb carbon dioxid. Its hydro-
chlorid forms a fine, yellowish, crystalline, delitpie.seent
mass, very soluble in water. Its platinochlorid is an
orange-eoiored powder, almost insoluble in cold water,
soluble in hot water, and is moderately stable. It forms
a moditied platinochlorid ((',11,, N) PtCl,, with boiling
water. Its auroclilorid is a yellow preei|iitate, iierma-
nent in the cold. It forms two crystalline mercuro-
chlorids. Its iodomethylate crystallizes in needles, and
is colored red by caustic potash. When oxidized liy
potassium permanganate it yields nicotinic, or /J-pieolinic
acid, also formed by oxidation of /3-iiicolin, which by dis-
tillation with lime yields jiyridiu (CJIbN), This base is
isomeric witb Nencki's base, (3-phcnyl-ethyhunin (see
abovel, and appears to be one of the twenty-two possible
collidins, the third superior homologues of jiyridin. It
is not <i-propyl)iyridin, or conyrin, a product of the ac-
tion of zinc chlorid and heat upon eoniin, which boils at
165 -Ifi() , but is said to be either /i-propyl- or /3-isopro-
pyljiyridin. If it be the former, CslLNtCJI;)™, it is that
ptoraain which most nearly approaches the constitution
of the most simply constituted of the vegetable alkaloids,
eoniin, which is « ]u-opyl]iipcridin,,jCi,IIioN(C3H,)(i).
(liiiitiir mill Htiinfx hiixe. ('..HkiN, {ii. piti-polin?) was
founil, alon,g with the base C^IIl3N. among the products
of the prolonged piutrefaction of fish and of horseflesh.
It is an amber-colored liquid, having the odor of haw-
thorn, s]iaringly soluble in water, turning brown and
resinous in air, and boiling above 310°, at which tem-
perature it also decomposes into ammoniaaud asubstance
having a iihenolic odor. Its ]ilatinochloriil is crystalline,
flesh-coloreil. s|iaringly soluble in water, a^nd decomposed
by light. Its auroehlorid is rather soluble in water.
Whether or not this base is one of the fifty-seven possible
parviilins, of wliirli five only are at jiresent known, re-
mains to be determined,
(liiiinm-lii mill .\/iiti.iii'n liime, doIIisN, [K curitliii ?) was
obtained from fibrin after five mouths' putrefaction. It
is a brownish oil witb a faint odor of pyridin and of eo-
niin, sparingly solulile in water, strongly alkaline, and
resinifies rajiii-lly in air. Its liydrocldorid crystallizes in
thin, colorless plates, slightly deliquescent, resendjiing
cholesterin. Its platinochlorid is flesh-colored, erystal-
^88
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
FI<»lllalllN.
PtoiiiaiillB.
line, insoluble in water, alcohol, or ether, not decomposed
at 100°, and does not resinify. The same base was also
extracted from fibrin after eiirht to nine months' putre-
faction. The quantity of liydrogen obtained in all ana-
lyses of this base caused the authors to doubt whether its
formula should not be CioHuN, in place of C10H15N,
which would make it an isomere of tetrahydromethyl-
qninolin. On dry distillation the base yields ammonia
and a liquid boiling at 200% which had a composition
neighliiiring to that of Gautier's hydrocollidiu. Gautier
and other chemists called this base corindin, or better,
coridin, a name already given by Thenius to the base
CioHii.N which he extracted from coal tar. It is not
demonstrated that this base is identical with Thenius' base,
which boils at 211°, spec. grav. OOjO; whose platino-
chlorid is dark orange, sparingly soluble in water, alco-
hol, and ether; and whose aurochlorid is dark yellow.
Guaresch: and JIo.sso's base has a poisonous action re-
sembling that of curare, liut nuich less intense.
De Coniuck obtained from jelly-fish, after one to two
weeks' putrefaction, a base having the same composition
as the above, which forms yellowisli needles, which be-
comes viscid and resinous in air, has an odor which is not
disagreeable, spec. grav. 1.18, boiling at 230^ sparingly
soluble in water, soluble in alcohol, ether, and acetone.
Its hydrochlorid crystallizes in j-ellowish, very deliques-
cent needles. Its platinochlorid forms a reddish powder,
insoluble in water, but forming a modified platinochlorid
(CioHisN) PtCl), which fuses at 206'. Gautier considers
this as identical with Guareschi and Mosso's base. It
does not seem, however, to be identical cither with that
or with Thenius' base. It is probable that each of the
three .is one of the one hundred and five possible coridins.
The formation of the modified platinochlorid is strong
evidence that de Coninck's base is a pyridin homologue.
Guiltier and Moiirijiies' base, CtIIhN, (a diliydi-tAuti-
rf2(i.') constitutes about one-ninth of the bases obtained
by them from brown cod-liver oil. It is a colorless liquid,
oily, alkaline, not disagreeable in odor, absorbs car-
bon dioxid from the air, lighter than water, boiling point
199'. and sparingly soluble in water. Its hydrochlorid
crystallizes in flat needles, bitter in taste. Its nitrate
reduces silver nitrate. Its platinochlorid forms a silky,
j'ellow precipitate, and yielils the modified platinncliln-
rid (C7H11N) PtCU, when boiled with water. lis auio-
chlorid crystallizes in needles or in lozenges. The base
unites with methyl iodid, forming acolorlessiodomethyl-
ate, C7H11N.CII3I, soluble in water and in ether, and
having a disagreeable, nauseous odor. Caustic potash
separates from it a colorless, highly alkaline oil, wliich is
said to be dihydromethyllutidin. When oxidized by po-
tassium permanganate in boiling solution it gives off an
agreeable odor of coumarin, and, on continuing the heat-
ing at 100' in sealed tubes, a inethvl-carbopvridic acid,
C5H3(CH3)N.COOn, is obtained. "That this base is a
hj'dropyridic compound is shown by the action with sil-
ver nitrate, the formation of the modified platinochlorid,
ind the composition of the iodoraethylate. The forma-
tion of the methylcarbopyridic acid shows that it is not
one of the three ethyldiiiydro derivatives, but one of the
six dimethyl compounds.
It is very poisonous. In small doses it diminishes the
general sensibility. In larger doses it causes localized
tremors, particularly in the Iiead, deep depression, with
periods of extreme excitement, paralysis, beginning with
the posterior extremities, and death.
(laiitier and E/ard's liase.C.Hii'N. (a dihydineoUidin?)
was obtained from the products of the prolonged putre-
faction of fish. It is an oily liquid, having a tenacious
odorof lilac, sjiec. grav. 1.0296, boiling point about 210.
In air it absorbs carbon dioxid, and resinifies rapidly. It
has an energetic reducing action. Its hydrochlorid crys-
tallizes in needles, soluble in water and in alcohol. Its
platinochlorid is flesh-colored, sparingly soluble, and is
decomposed by light or heat. Its aurochlorid is soluble
and reduces easily. It was supposed by Gautierand Etard
to be identical with the dihydrocollidin obtained by Ca-
hours and Etard by the action of selenium upon nicotin ;
but as that base boils at 205', and is lighter than water,
it is more probably an isomere. It is actively poisonous.
Even in small dosesit causes vomiting, staggering, tetanic
spasms, followed by paralysis and death,"with the heart
in diastole.
The existence of the base CiuH,tN, described by Grif-
fiths, requires confirmation. "The composition is that of
the dihydrocoridins.
Mvrrhiiic acid, CaHuNOj, was obtained by Gautier and
jMourgues, along with the bases elsewhere referred to,
from brown cod-liver oil. It is oily or resinous^ but crys-
tallizes in flat prisms, or lozenges on standing. It has
an odor resembling that of seaweed. It is both acid and
base, and decomposes the carbonates. It forms no pre-
cipitate with cupric acetate, even on boiling. Distilled
with lime, it yields an oily, alkaline base, which forms an
iodomethylate with methyl iodid. It is a pyridin deriva-
tive, and is supposed by GaiUier and ilourgues to be a
monocarboxylic oxyacid, CiIIsNtOHKCalle.COOH). de-
rivable from a dihydropropylpyridin. It is said to yield
a monobasic acid on oxidation, but it is such itself.
Indole. CpIItN, is benzopyrrole, theoretically formed
by fusion of a pyrrole ring, CHsN, upon a benzene ring,
CoHs, with loss of CiHi, the nitrogen atom occupying a
position vicinal to the benzene ring. It is one of the
products of putrefaction of the proteins by anaerobic
bacteria, occurs in the culturesof the comma bacillus and
of that of tetanus, anil is formed in the intestine. When
produced by intestinal putrefaction it is partly discharged
in the f;eces, and is in part reabsorbed, appearing in the
urine in combination with sulfuric and glucuronic acids
as the so-called urinary indican. It crystallizes in large,
.shining, colorless plates, having the disagreeable odor of
naphthylamin, sparingly soluble in water, soluble in al-
cohol and in etln-r, fuses at .52 and distils with vapor of
water. It is weak base, and its salts are decomposed by
hoiling water. Its aqueous solution, acidulated with
hydrochloric acid, is colored rose-red by potassium ni-
trite. By fusion with caustic potash it yields anilin.
Its alcoholic solution, acidulateel with hydrochloric acid,
colors a pine shaving red. With picric acid it forms a
compound crystallizing in red needles. With sodium
nitroprussid and alkali it produces a red-violet color,
which changes to blue with acetic acid (Legal).
Skatiile, C'alLX, is .3-methyl-indole. It accompanies
indole in the intestinal contents and in fa-ccs, in which it
is the more abundant of the tAvo, and is also formed dur-
ing putrefaction of the proteins, or by the action upon
them of caustic potash in fusion. It crystallizes in bril-
liant plates, fusing point 9.")', insoluble in cold water,
less soluble than indole in boiling water, .soluble in alcohol
and in ether, hasa strong facalodor, Itssolutiou in con-
centrated hydrochloric acid is violet. Its solution in sul-
furic acid iscoloreddeep purple when heated. It formsa
red, crj'stalline compotuid with jiicric acid. It does not
give the pine-shaving reaction, nor the red color with acid
and nitrite, and witli Legal's reaction the alkaline solu-
tion is yellow, and turns violet with acetic acid and heat.
Like indole, it is in part reabsorbed from tlu! intestine
and eliminated with the mine in combination with sul-
furic and glucuronic acids. Neither indole nor skatole
has any notably toxic action.
Ptom.^ixs of Unknown Constitition, — ^fl»^l■!lllin,
C19H27N3, and afeUin, C.jsHojNi, are two of the six
bases obtained by Gautier anil Mourgues from brown
cod-liver oil, the former constituting about one-third of
the total, and the latter a small fraction. Murriniin is a
thick, yellowish liquid, having the odor of hawthorn and
of lilac, lighterthan water, in wliich it is sparingly solu-
ble, strongly alkaline and caustic andabsorlis carbon di-
oxid from air. Its hydrochlorid is very deliquescent.
Its platinochlorid crystallizes in needles, soluble in
water, and is decomposed by heat. Its aurochlorid is
soluble in water. It is non-poi.sonous, but is an active
diuretic. A-^ellin is an amorphous, white solid, odorless
in the cold, but fu.sing and giving off an aromatic odor
when heated. It is almost insoluble in water, soluble in
alcohol and in ether, alkaline, and bitter in taste. Its
7S9
I'loiiinliiM.
I'l4>iiiaiilM,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
salts art soluble iu water. Its hydrochlorid is cr3-stal-
liiio; its platinocliUirid and aiiroclilorid arc unstable. Iu
small duses it prixlufi-s dislurbauccs ot respiration and
stu|ior. and in larger doses convulsions and (ii alli. Pos-
sibly the former, or both, of these basics may be complex
amido acids.
Scumbi'iii. C,7H3bN4, (not to be confounded with the
protamin of the same name obtained from the milt of the
mackerel) was obtained in very small (|Uantity by Gau-
tier and Elard from the mother liciuurs of their alkaloidal
bases, above referred to. Its hy<lrochlorid crystallizes iu
needles, soluble iu water, wliich dc<-i>mpo.se slowly at
100', giving off an odorof lilac. Its platinochlorid crys-
tallizes iu li,ght yellow needles, and is soluble in water.
Brit'r/cr'x 'hiinc, C«HisNO^, isomeric with myilatoxiu and
witli leucin, and prol)ably a lietain, was obtained from
tetanus cultures, and is formed by decomposition of tet-
anin, Cr.,Il3„N.()j. Its jilatinochlorid crystallizes iu
plates, soluble in water and in alcohol, fusing point 197, '
at which temperature it decomposes,
Brieger'.t luixex, CtHitNO... ISrieger hasdescribed three
bases having this composition: Giidinin, from putrid
tish, after five days; ti/p/mto.fiii, from cultures of the
Koch-Eberth baciilus; and an luinamed base from horse-
flesh after prolonged putrefaction at low temperature
with limit<'d access of air.
(idiliiiiii (not to be confoun<led with the brown sub-
stance of the same name obtained by l>e .longh from cod-
liver oil), obtained from the mother licjuors of Brieger's
"niuscarin," forms a hydrochlorid which crystallizes in
thick needles, soluble in water, insolulile in alcohol. Its
platinochlorid crystallizes iu .scales, sparingly soluble in
water. It forms no aurochlorid. It appears to be Uon-
poisonous.
Tiiphiito.vin is a strougly alkaline base. Its hydrochli>-
rid is deliquescent. lis platinochlorid crystallizes in
needles, easily soluble in water. Its aurochlorid crystal-
lizes in |irisins, difficultly soluble iu water, fusing point
176", It forms a dillieultly soluble picratc. With Ehr-
lich's reagent (sulfodiazofienzene) it immediately gives a
yellow color, which is disehaiged by bases. Iu moderate
doses typhoto.xiu causes increased tlow of saliva, and ac-
celeration of respiration. Later there is loss of control of
the museli'S of the extremities, without true paralysis,
the animal lalliug upon its side. The pupils gradually
dilate widely, and become insensible, Couvulsions do not
occur. The frequency of the heart's action aud respira-
tion graduall}' diminishes. During the entire poisoning
there is copious diarrlura. After death the heart is
found contracted iu systole, the lungs are highly hypera'-
mie, the other organs pale. The intestines are strongly
coutraetcd, and their walls pale.
The Kiiiiiiiind Ixixr, CiHjtNOo, crystallizes iu very de-
liquescent ]ilatcs, and has a faintly acid reaction, but it
does not form salts with bases, and does not respond with
Hofmeistcr's reaction with ferric chlorid. It is uot an
amido acid. Its hydrochlorid crystallizes in needles, in-
soluble in absolute alcohol. Its aurochlorid crystallizes
in plates or in needles, difficultly soluble in water, fus-
ing point 176", It does not react with Ehrlich's reaction,
and forms no picrale. It has the physicdogical action of
curare. A base having this composition has also been ob-
tained by Baginsky and Stadtha.ireu from cultures of a
bacillus allied to the Finkler-Prior spirillum.
Titiiiihi. Ci3lI.,nN»Oi. — Brieger, iu his earlier exjieri-
ments with cultures of an anai'robic bacillus founil by
Nicolaier in earth samples, and ca]iable of producing
s_ymptoms of traumatic tetaiuis in animals, and with cul-
tures of the same bacillus bred by Koseul)aeli from the
wound of a man who died with tetanus, otitained two
bases with a sindlar physiological .action — tetania aud
tetanotoxin.
Tetanin is a yellow, strongly alkaline .syrup, which
gives no blue color with ferric chlorid and iiota.ssium
ferricyanid. Its liydrochlorid is deli(piescent. and forms
an easily soluble, crystalline comjiound with phospho-
molylidie acid. Its platinochlorid crystallizes from al-
cohol in light yellow plates, very soluble iu water. The
free base, or its hydrochlorid, when injected into mice or
guinea-pigs, soon causes clonic or tonic convulsions of
the greatest intensity, which teruunate in death. The
course of the poisoning is divisible iuto two stages: In
the first the auimal is depressed aud lethargic, then it
suddenly becomes uneasy, and the diaphragm contracts
energetically. The second is marked by convulsions,
usually tonic, but occasionally clonic. Death occurs fre-
quently in a violent convulsion. Frogs withstand the
action of the poison better than warm-blooded animals,
but when they succumb they become perfectly rigid in a
position of pronounced opisthotonos. Guinea-pigs, when
thoroughly under the inlluence of the poison, exhibit very
clearly the characteristic spasms of tetanus in the human
subject and marked opisthotonos.
Tf'tdiiotoxin, Cf.H,,N(?), is a volatile substance, boiling
at 100°, In relatively large doses it produces in animals
fibrillar contractions of diverse groups of muscles, par-
tic\ilarly those of the neck and face, Jlotiou is more or
less interfered with, until paralysis is established. Con-
vulsions increase in intensity, attacking groups of mus-
cles very violentlj'. The animal lies with the head
thrown back and the extremities extended, and, when
pressed upon, makes movements as in swimming. Fi-
nally the animal falls upon its side, and dies in a violent
convulsion.
Two other bases liave subsequently been obtained by
Brieger from cultures of the tetanus bacillus, both of un-
known composition.
Spasmotoxin, which forms a soluble platinochlorid,
fusing point 210°, causes violent tonic and clonic couvul-
sions iu animals. The other base, unnamed, forms a very
deliquescent hydrochlorid; a platinochlorid which crys-
tallizes iu scales, decomposed at 240°; and a verj' soluble
aurochlorid and picratc. It produces complete tetanus,
salivation, and lachrymation in animals.
It is not surprising that wheu the physiological action
of these bases was first recognized the.y were considered
to bo the specific poisons produced by the bacillus of tet-
anus. But it has been shown that the filtered culture is
vastl)' more active than the combined bases, aud that the
culture contains a uon-l)asic, non-albuminous toxin,
which, still iu an impure condition, has a lethal toxicity
estimated at 0.2o mgm. for the human subject. There-
fore, while the bases above mentioned utidoubtedly have
some action in producing the manifestation of tetanus,
such action is greatly subordinate to that of the toxin.
Lepicrre'c base, CinIlQ3N504, obtained in small amount
from poisonous cheese, is crystalline, odorless, bitter,
faintly acid, and sparingly soluble in water. Its hydro-
chlorid crystallizes iu needles, very soluble iu water. Its
platinochlorid and avu'ochlorid are crystalline. It causes
diarrho'a iu guinea-pigs.
DeUxinier's bane, C32II31N or CstHasN ('?), whose com-
position is quite uncertain, is an almost colorless, oily
liquid, very sparingly soluble iu water, soluble in al-
cohol, ether, and benzene, rapidly oxidized in air, and
forming deliquescent salts. It is supposed to be identi-
cal with a base obtained by Brouarilel and Boutmy,
which bore some vesemblance to veratriu.
SiisDtii.tin, C',(iII.;,iN.2 (Y), abase whose hydrochlorid was
obtained by Novy from cultures of the hog-cholera bacil-
lus. The free base was not isolated. The h_vdrochlorid
is a light yellow syrnp which does uot cr^'Stallize, some-
what hygroscopic, and soluble in water and in alcohol.
It gives olf an amin odor when heated with fixed alkali.
Its platinochlorid is granular and light flesh colored, or
crystallizes in long, thick nee<lles, soluble in water, from
which it is in-ecipitated by alcoliol. It is toxic only in
large doses. It is said to be identical with the siicihitoj-in
of von Schweinitz.
Pj/iiei/ii)iiii. CnHiiNO.; (V), is the coloring matter ol
blue pus, first obtained by Fordos. It crystallizes iu
blue jirisms or scales, soluble iu water, alcohol, and chlo-
roform, less soluble iu ether. Its blue aqueous solution
is neutral, and is changed to cherry -reil by acids, and back
to blu<' liy alkalies. It is oxidized in air to the yellow
pio.vaii(Ji,ise, which also accompanies it iu the pus. Ac-
"!tU
REFERENCE HANDBOOK OP THE JIEDICAL SCIENCES.
Ptomains.
Ptoiuaius.
cording to Kuuz, it contains sulfur. It is supposed to
be au anthracene derivative,
Aidliriichi is the name given by Hoffa to a base,
■C3H0N2 (?) obtained from cultures of the anthra.x bacil-
lus.
The following bases are of unknown composition;
A base obtained by Brieger from liiunau livers and
spleens after two weeks' putrefaction with free access of
air. Its hydrochlorid crystallizes in small, deliquescent
needles: and its platinoclilorid in tine needles, containing
41.30 jier cent, of platinum. It causes long-continued
diarrhu-a in rabbits and guinea-pigs.
Another base obtained by Brieger from the same
source; fluorescent, boiling point about 284% whose hy-
drochlorid crystallizes in long needles, soluble in ab.solute
alcohol. Its platinocblorid crystallizes in tine needles,
very soluble in water, or in plates, containing 30.36 per
cent. Pt.
A base obtained bj' Brieger from putrid fish. Its hy-
drochlorid and platinocblorid crystallize in small needles;
the latter containing 36.03 per cent. I't and 7.81 per
cent. N.
A base obtained by Bocklisch from herring after twelve
days of putrefaction, whose platinocblorid crystallizes in
large, thin plates, easilj' soluble in water, and containing
■28,57 per cent. Pt.
Peptiitoxiii is the name given by Brieger to a toxic suli-
stance (or mi.xture of substances) having some of the
characters of the nitrogenous bases, obtained from pep-
tone, produced by the action of pepsin from the pig
upon fresh fibrin. The same body was obtained from
Wittt's peptone, and from putrefying tilirin, ca.sein. and
brain, liver, and muscular tissues. If putrefaction has
continued for eight days, it is no longer oljtaiuable. It
crystallizes with ditlieulty, passes from both acid an<l al-
kaline solutions into aniylic alcohol, is insoluble in ether,
benzene, or chloroform, but very soluble in water. Its
solutions are neutral. It is quite stable, and is not de-
comiiosed by boiling, or b}' treatment with hydrogen
sultid or with caustic alkalies. With ilillon's reagent it
gives a white precipitate, wiiich turns briglit red on the
application of heat. It precipitates with many of the
general reagents for alkaloids, and gives the blue reaction
with freric chlorid and potassium fcrricyanid. It is ac-
tively poisonous in small doses, causing paralysis of the
posterior extremities, sopor, and death.
PldiKjii.iin is the name given by Leber to a substance
■which is probably not a base, obtained from cultures of
staphylococcusaureus. It crystallizes in needles, soluble
in alcoliol and in ether, sjiaringly soluble in water, and
may lie sublimed. It forms no comiiound with platinic
or auric cblond, and does not precipitate ■\vith phospho-
tungstic, phosphomolybdic, picric, or tannic acid. It
appears to contain sulfur and no nitrogen.
Tyrotoxicon is the name given by Vaughan to a mate-
rial e.xtracted from poisonous cheese, whose chemical
characters are not well defined.
The individual existence of the numerous bases de-
scribed by Gritliths requires continuation.
Nitrogenous liases are also formed during alcoliolic
fermentation. These are not pro|K'rly ptomains, being
produced by j-east fungi, which are not bacteria.
M(iriii'» hase, CtHjoNi, is the best known of these. It
was obtained from the fraction of crude fusel oil, distil-
ling at 17r-lT2\ It is a colorless, mobile, oily lic|\iid,
having a nauseous odor, spec. grav. 0.!)8'36, not alkaline
in reaction. Its hydrochlorid forms needles, solulile in
water and in alcohol, very sparingly soluble in ether.
Its platinoclilorid is crystalline, soluble in water and in
alcoliol, very sparingly soluble in echer. It is decom-
posed by hot hydrochloric acid, ■vvith formation of am-
monia. It combines with ethyl iodid to form a yellow,
crystalline compound, very soluble in alcohol and in
water, very sparingly soluble in ether. Its aqueous solu-
tion does not precipitate with Mayer's reagent, but on
acidulation Avifh hydrochloric acid there forms a fioccu-
lent,}-ellow precipitate, which unites into long, brilliant,
yello^vv needles — a reaction which is uot given by the
pyridic or quinolinic bases. It is poisonous, and in rab-
bits causes stupor and paralysis, beginning with tlie pos-
terior e.xtremities. diminished sensiliility, dilatation and
insensibility of the pupils, diminution of the temperature
and cardiac action, and death in coma. This base is
probably identical with Tanret's glucomii, obtained by
the action of ammonia and ammonium salts upon glu-
cose.
Oxer's base. CjaH-joNi. is produced during the fermen-
tation of pure saccharose by yeast. It isuot volatile,
and is decomposed when heated with acids. Its hy<lro-
chlorid is very hygroscopic, very unstable, and "turns
brown in air. Its aurochlorid is a yellow, tlocculent pre-
cipitate, which becomes crystalline, and is very sparingly
soluble iu water.
A base, .said to lie pyridin. has been found in commer-
cial alcohol by H;iitinger and by Guareschi and Jlosso
to the amount of 0.4 to 0.5 in 1,000. Schrijtter has de-
scribed two bases, CsHuNa and doflieNj, obtained from
the fraction of molasses-fusel distilling at 180-333°.
Kramer and Pinner obtained bases, which they consid-
ered to be ]>yridic, from commercial alcohol. Other im-
perfectly delined bases liave been described as existing
in beer or iu distilled spirits by Siirgeres, Lindet, Moder-
mann, Lermer, vein Geldern, Dannenberg, 3Ie3'er, and
Fassbender and Sehoeiip.
PoiirliLfs buses. CsHioN-^Oi and CtH.^NoOs, cannot be
regarded as ptoma'ins. as the_y were obtained from the
liquid residues of an industrial process of treatment of
bones, flesh, and other animal refuse by sulfuric acid,
and the action of the acid was undoubtedly a factor in
their production.
The ptoma'ins and basic products of yeast fungi above
described are split products of protein material, elimi-
nated by the organisms producing them, and not con-
stituents of those organisms. The distinction between
constituent and excretor}' bacterial products is one of
importance biologically and pathologically, but is one
which is undesirable from the point of view of analj'tical
toxicology, because the bacteria, as well as their elimina-
tion iiroducts, are present in materials submitted to anal-
ysis, and, although the entire bacteria do not give up
their constituent substances to solvents by any means as
readily as they do after comminution b_y Koch's method,
they do so to a certain extent.
The only instance of the formation of a protamiu by
bacteria of which we have knowledge, is the tnheri-ulu-
.idiiiiii of Ruppel, ■which he obtained from the tubercle
bacilli, but not from their cultures. It is, therefore, a
constituent of their organism, in which it exists in com-
bination with a nucleic acid, and not an elimination prod-
uct. Tuberculosamin has the properties of the jirota-
niins: it is extracted by cold, dilute sulfuric acid (one
per cent.), is precipitated from neutral solution of the
sulfate by sodium picrate. forms an alkaline solution iu
water, is strongly basic, does not give the color reactions
of the proteins except the biuret reaction, contains no
phosphorus, and precijiitates the proteins from aminoni-
acal solutions. The protamins form precipitates v.":th
phosphotungstic acid, Mayer's reagent, and other gen-
eral reagents for alkaloids. The_y are actively poisonous,
causing at first acceleration, tlien slowing of the respi-
ration, marked diminution of the blood ju'essure, and
death.
CiiEMico-LEGAt. CoxsiDER.\rio.\s. — The ptomains are
now mainly of interest in connection -with forensic toxi-
cology. From the lirst discovery of these substances,
and until their chemistry and that of tiie vegetable alka-
loids became better known, it was feared i hat their ex-
istence might seriously interfere with or entirely prevent
the detection of vegetable alkaloids, with suflicient cer-
tainty for the purposes of justice, in cases of criminal
poisoning. The ptomains were called "putrid alka-
loids," were considered to be of the same chemical class as
the vegetable alkaloids, and almost all were fnuiid to re-
spond to many of the general tests for the alkaloids In
short, everything seemed to point to a much closer rela-
791
Ptoiuains.
Puerperal lureetion.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
tionsliip between tlie ptoma'ins and the vegetable bases
tlian that which actually exists. But the development
of the chemistry of the ptoma'ins has shown that those of
them which have the most complex molecular structure
are more simple in constitution than their nearest rela-
tives among the vegetable alkaloids, and very much more
simple than the ester-alkaloids, sucli as atropin. or the
still more complex polynuclear alkaloids, such as mor-
pliiu.
While the parasitic bacteria probably cause synthetic
combinations, as in the generation of the toxins, the func-
tion of the saprophytic bacteria, which alone are of in-
terest in this connection, is essentially analytical. It may
be considered to be within the limits of possibility that,
starting with the complex protein molecule, a sub.stance
having the constitution of a vegetable alkaloid might be
produced during the series of hydrolytic decomiiositious
caused by the saprophytes. But a'll observations are
against such an hypothesis, no such substance has been
found among all of llie putrid products which have been
obtained. Moreover, the known products of decompo-
sition of the proteins by other means, through the prota-
mins, the liexon bases, "the nucleins, the purin bases, the
amido acids, and the amins, lead in a direcliou not tend-
ing to the forni.-ition of the alkaloids, excejit in the case
of the formatiiin of the pyridic bases by the action of
heat. The formation, however, of pyridic and. iiartieu-
larly. of hydroi)yri(lic iitomains as late products of putre-
faction indicates the |)ossibility that the analytical proc-
esses of the saproiihytes may be followed by the
transformation of ceitain of the acyclic products int(i
heterocyclic compounds, in a manner similar to the con-
version'of iieutametlivlenc livdroehloiid (i"[daverin) into
pipcridin- H,N.(CH.;)t,.NII.:'lK'l = NH,Cl + CJI„N.
No ptomain lias been discovered which corresponds in
ail of its cliaracters witli a vegetable alkaloid. Two sub-
tances alike in all respects are two samples of the same
substance, and no vegetable alkaloid is known which is
also a product of putrefaction. But there are certain
vegetable alkaloids which resemble certain ptomains in
.several of their properties, while dilTering in others, and,
at the same time, exhibit no known well-marked and dis-
tinctive chemical reactions. Probably the closest resem-
blance is that between the so-called cadaveric couiVn and
true coniin. Both are liquid, oily, volatile, inten.sely
alkaline, similar in odor, soluble in water and in petro
leum ether, and form precipitates with plaliuic chhirid,
auric chlorid, mercuric chlorid, and several of the general
reagents. They differ in that coniin is actively poisou-
ous'y while the ptomain has been found to be inert, ex-
cept in one ease in wliieli Otto obtained a poisonous sub-
stance, which probably owed its toxicity to the presence
of another ptomain. The "cadaveric coniin" is, how-
ever, not coniTn (a-propyl piperidin) but cadaverin
(peutamethylenediamin). Therefore, while it must l)e
admitted tiuit we have no method to separate coniin
from a ]>utrid cadaver, and, in the minute quantity in
which it would prnliahly be olitained, distinguish it froin
cadaverin, or from a mixture of ptomaVus containing ca-
daverin; it may akso be anticipated, the two substances
not being identical, that distinguishing characters of suf-
ficient delicacy will be found to exist.
Attempts have been made to find a characterizing ii'ae-
tion common to all ptomaVns. whereby tiiey might be dis-
tinguished from the vegetable alkaloids. Among those
suggested were the reactions of Brouardel and Bontrny.
andof Trolarelli. But no such reaction can exist, be-
cause the Iitomains do not constitute a <listinct chemical
class, but include amon.g tlieir number representatives of
several chemical classes of tolerably diverse character;
and for the further reason tliat, while the great majority
of ptomains are non-alkaloidal, some are pyridin or hy
dropyridin derivatives, as are also the alkaloids. As Ihe
"general tests" for llie alkaloids for the most ]iart form
precipitates with iitomaTns, alliumins, and nitrogenized
bases other than alkaloids, they are only of negative
value in the rare cases in wdiich they fail to react, or of
eoiifirmatory value by reason of jieeuliarities in the ([iiali-
ties of the precipitates which they produce with certain
alkaloids.
The ptomains which are frequently referred to as
"strychnin-like" or "morphin-like " are quite as notice-
ablebecauseof the differences from those alkaloids which
they ]5resent, as by reason of their resemblances thereto.
The bases obtained by Brieger from the cultures of the
tetanus bacillus, while resembling strychnin in the pro-
duction of tetanic spasms, differ from the alkaloid in not
giving the color reaction, in not being bitter, and in crys-
talline form. Amthor's product was neither bitter nor
crystalline, nor did it give the color reaction of strych-
nin, but an entirely different one. In Ciotto's case the
material supposed to have been strychnin appears to
have given the color reaction, as Selmi, wlm ditVered
from Ciotto in liis conclusions from the observed facts,
concedes this much. But the colors obtained are not
described beyond the statement that they were " tlie
colors proper to the reaction of strychnin," and Selmi. in
the course of the same paper, says that aspidospermin
"behaves with bichromate as does strychnin," while in
fact there are marked ditlerences between the color reac-
tions of strychnin and of aspidospermin under like treat-
ment. But Ciottii's substance was not shown tobe either
crystalline, alkaline, or distinctly bitter, and when ad
ministered to frogs in quantity sufficient to kill them it
dill not cause tetanic spasms. Lombroso and Dupre ob-
tained from the spoiled maize which is regarded as the
cause of pellagra a mixture of bases (pellagrozein) which
is bitter in taste, causes tetanus in frogs, and is said to
give the color reaction of strychnin, but whusi- reaction
only resembles that of strychnin in its initial stage. It
also differs fnim stiyelinin in its crystalline form, and in
that its sulfurie-acid" solution a.ssumes a permanent violet
color when exposed to vapor of bromin. But pellagra is
confined to a comparatively narrow strip of territory (six
degrees) in the south of Europe. Moreover it is no*
proven that the constituents of pellagrozein are bacterial
products; certainly they are not cadaveric ptoniaiiis.
We find reference in "toxicological literature to alleged
"morpliiii-like " ptomains in three cases. In the Snusog-
no case, in Italy, the substance mistaken fi,;- moriiliin did
not .give either the Pellagri reaction, the ferric-ehlorid
reaction, the nitric-acid reaction, or the Erdmann reac-
tion; and it only resembled morphiu in that it behaved
as a reducing agent toward iodic acid, auric chlorid. and
certain other reducible sub.stauces. In the Portuguese
case of Urliino de Freitas not one of the three most nearly
characteristic; of the tests for morphin. the Pellagri. the
Ilusemann, and the ferric chlorid was even tried, and the
experts erred in as.serting the presence of morjihin in a
cadaver upon the evidence of a not entirely satisfactory
Frcjhde reaction, the iodic reaction, and the formation of
a green color with the Lafon test, the last a re;igent who.se
merits had been insufficiently tested. In the Buehaiian
case ill New York, Vaughan makes the unwarrante.l as-
sertion that "all the tests obtained by the experts were
duplicated with putrefactive products." This alleged
duplication was attempted in open court, in the presence
of the author, with the following results: The ferric
chlorid gave a brilliant grass-green, not a blue color.
The llu.semann was improperly applied, and failed, as it
would have done had morphin been present. The Pella-
gri was also improi.ierly applied, and failed, as it would
liave tailed with moriihin in the manner in which it was
used. The Frohde gave a distinct orange color, passing
to yellow, in place of the purple, passing through blue,
dirty green, and yellow to pink as it gives with moiidiin.
The nitric acid gave an immediate yellow, but not the
orange-red changing to 3'ellow of morphin. The iodic
acid gave a faint reaction similar to that obtained with
morphin and with many other reducin.g agents. The six
"ilui.lieations" therefore consisted of five failures to ]iio
dnce similarity, and one faint resemblance.
Whether a vegetable alkaloid is detectable in c;id;n eric
material or no de|)ends now, as it did before our know I
edge of the existence of the ptomains was gained, uiion
the existence or non-existence of a .sufficient nunilier of
!t-^
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
PlolliaiiiN.
Puerperal iQrection.
well-marked physical qualities, chemical reactions, or
physiological actions of that alkaloid. If such exist, and
are not duplicated or interfered with by ptomaifns, the
alkaloid may be detected with certainty. " If they do not,
it cannot be, ptomaVn or no ptomain. In the frequently
cited case of General Gibhone in Rome, it was .sliown by
Selmi that the substance wliicli was claimed to have been
dclphiuin could not be that alkaloid, because it tiid not
have its physiological action. But this affirmative proof
was simply coutimiative of the already convincing argu-
ment that delphinin has no physical characters and gives
no chemical reactions which are sufficiently distinctive to
permit of its identification when present in the minute
quantity obtainable in such an analysis.
That the presence of ptomainsmay militate against the
detection of a vegetable alkaloid, both liy interference
witli its reactions and by similarity of its ph\-siological
action, is well shown in the case of atropin. From the
viscera of a woman, after nine months' burial, the author
obtained a residue (which would have coutaincd atropin
haft it been present) which caused wide dilabitiou of the
pupil and insensibility to light, persisting for .several
hours, gave the peculiar crystals with bromin in hydro-
hromic acid, and reddened phenolphthalein ; but did not
produce Kratter's crystals, or respond to the Vitali reac-
tion. But portions of the same residue, to which atropin
sulfate was adde'd in notable proportion, also failed to
give the Vitali reaction.
While, therefore, the presence of ptomains may inter-
fere to prevent the detection of certain alkaloids which
may be actually present in the materials examined, we
know of no instance in which a ptomain or mixture of
ptomains has given reactions which would cause it to be
mistaken for an alkaloid possessed of sufficiently distinc-
tive characteristics to permit of its certain identiticatiou
in the assured absence of all ptomains. A survey of the
reactions manifested by the reputed "alkaloid-like" pto-
mains shows that their similarities to those of the vege-
table alkaloids con.sist chiefly in resemblances of physi-
ological action, and in their behavior toward ''general
reagents" and toward iodic acid. "We have stated above
that the general reagents play onl_v a very .secondary role
in the identification of vegetable alkaloids, and iodic acid
is merely a test for reducing agents, which is vi.sed for
morphin because the reducing action of that alkaloid is
one of the characters which differentiates it from most of
the other vegetable bases. If we exce|)t one veratrin re-
action olitained by Brouardel and Boutmy, the somewhat
doulitful case of Ciotto mentioned above, andthe state
ments of Vaughau, there is no reference in toxicological
literature to a ptomain which has given a well-character-
ized reaction of a vegetable alkaloid.
Rudolph A. WittJuius.
PTYALIN. See Salh-a.
PTYALISM.
See Mofith. Diftdises of, in The Api'en-
PUBERTY. — Di:finitiox. — The term puberty was
formerly used to designate the whole period of sexual
development, and is still occasionally sn u.sed. Jules
Voisin ' refers to the age of puberty as the time between
the ages of fourteen and twenty two years. In general,
however, writers now confine the term pulii rty to the
initiatory and formative period of sexual development,
while to the entire period of sexual developiiu'iit is ap-
plied the broader term adolescence.
Tlie Age of Pnbertji. — The average age of puberty in
the male is 14.3 years; the average age of first menstru-
ation in the female is about 13.7 years. The period clif-
fers according to race and climate, and may be hastened
by tlie leafling of erotic literature, by suggestion, and by
an early jiarlicipation in social life.
The ]iubescent period begins in girls at least a year and
a half before the first menstruation. This preliminary
period is, according to Armand Delpeuch,^ the time
when the child needs the greatest care, for at this time
the trunk is relatively the shortest, the thorax relatively
the narrowest, and the heart relatively the smallest, and
at the same time the child is doing his most rapid grow-
ing. The female makes the most rapid growth from,
twelve to fourteen, and the male from fourteen to seven-
teen. The pubescent child should, therefore, be guarded
against too violent exercise, and yet should be provided
with much pure air.
Physical Changes. — A general physical disturbance
takes place, shown by the rapid bodily growth, the elonga-
tion of the vocal cords, increased pilosity, a change in
the size and condition of the reproductive organs, and a
profound disturbance of the nervous system. Indeed,
muscles, blood-vessels, glands, and all organs share in the
general disturbance.
Psychical Changes. — The psychical no less than the
physical being is affected by puberty. Mario of Turin ^
says that " puberty exercises a notable infiuenceupcm the
psychical life, which is manifested, in some instances, by
giving to mental symptoms qualities which they did not
have before or which thev bad onlj- to a slight degree, and
in others b}' preparing a waj' for the invasion of psychoses.
Hereditary predisposition is the prominent cause of the
affection."
Periodic Phenomena. — The most notable accompani-
ment of puberty in the female is menstruation (which
.see). In the male there is throughout sexual life and
beginning with puberty a periodicity which is probulily
analogous to that of the female. The .seminal vesicles
possess glandular walls and retain the secretion of these
walls for periods varying from one to four weeks nor-
mally.
The retained secretion distends the walls, and through
pressure stimulates nerves which pass to the erection
centre, which is in turn excited.
By day erotic emotions are easily aroused : at night
when the subject sleeps he may experience an erection
accompanied by an erotic dream and culminating in
an emission ("nocturnal emission "). In this way is the
pressure of accumulating vesicular secretion relieved and
the subject should pass another period free from sexual
impulses. After the period of pubescence is established,
the testes of the male form spermatozoa rapidly under
sexual excitement and slowly during periods which are
free from excitement. In neither case do the spermatozoa
pass into the seminal vesicles; they are retained in the
testes, the vasa deferentia, and ampulUv. The testes form
not only the spermatozoa but a milky fluid in which the
spermatozoa float. The secretion of the testes contains
a mysterious principle whose reabsorption gives to the
male those characteristics which we recognize as distinc-
tive of virility. In the nocturnal emission coming with-
out sexual excitement no spermatozoa are lost; hence
these emissions cause no depletion. /. 11'. Hall.
' St. Louis Med. Review, October 13tli, I'M.
2 La Presse m(A.. Aut.'ust 17th. 1898.
3 St. Louis Med. Review, October 13th. 1901.
PUERPERAL INFECTION.— (Puerperal fever, puer-
peral sepsis, puerpeial M-iiiir;emia. childbed fever.)
Definition. — An acute contagious disease of the puer-
perium characterized by an inflammation of some part of
the genital tract, and frequently associated with a vari-
ety of systemic manifestations. It is caused by a num-
ber of pathogenic and saprophytic micro-organisms.
History. — The disease has "been known from the ear-
liest times. Hippocrates. Galen, Avicenna, and others of
the early writers, as well as many in the sixteenth, seven-
teenth, and eighteenth eecl uries, have described ca.ses. In
the first li.alf of the nineteenth century there were many
frightful epidemics of the disease.' It was the scourge
of the great lying-in hospitals of Europe, and patients
were decimated regularly by its ravages. Oliver AVeu-
dell Holmes in his essay, ""The Contagiousness of Puer
peral Fever." published in 1843. logically proved the
contagious nature of the disease; and Ignaz Philipp
Semmelweiss, who recognized the identity of tfie disease
with wound infection and devised a practical method
i'J'S-
I'llonu'ral IIIfrMTlon; REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
of hand disinfection, pviblislied, in 1861, his monograph,
■' Die Etiologie dcs Bcgritl's mid die Prophylaxis dcs Kiiid-
betttiebers." He introduced hand disirifeelion in the
great Maternity Hospital in Vienna, and ininu'diately the
mortality fell from ten percent, to about one percent.
The teacliings of these classical essays were bitterly o])-
posed, however, and it was not until after Lister had in-
troduced antisepsis iu surgery that its importance in
obstetrics Avas generally recognized. Tlie ancients at-
tributed the affection to "a retention of the locliia. and this
lias Ileeu tlie most common explanation until recent
times. After the intro(hiction of antiseptic and asei)tic
methods in ol)stetrics. there was a marked reduction in
the mortality from puerperal infection in liospital prac-
tice. At the present tune, in the lietter maternity liospi-
tals, the mortality is a small fraction of one per cent. ^ In
private iiractice. however, cases are frequentl_y seen, es-
pecially in the hands of untrained midwives and careless
or ignorant pliysicians.
Etiology. — Puerperal infection is essentially wound
infection. As Senunelweiss and others have shown, the
materies ciintiif/ii is carried to the parturient woman on the
hands of those who have made recent autoiisics or dissec-
tions, or who have dressed suppurating or intlammatory
cases of any kind. With the advance of our knowledge
of the causal relation of bacteria to disease iu the last
fifty years, the infectious nature of the disease has been
■clearly established. Puerperal infection, however, is not
a specific disease, but like wound infection iu general
may be cau.sed by a variety of mier(-i-organisnis. Among
these the streptococcus is found most frequently, and is
present in nearly all the fatal and most serious cases.
The gonococcns conies next in fre(|nency of occurrence,
but causes much less serious infections, and few fatal
cases have been caused hy it alone. The staphylococci,
the colon bacillus, and a nmnber of putrefactive anaero-
bic bacilli are frei|uently fouml. Among the rare forms
are tlie gas liacillus (at'rogcncs capsidatus.* Welch), the
]ieumc)cnccus,^ the diphtheria bacillus'' (Bunun. Nisot,
Williams'), imd tlie tyjihoid bacillus^ (Williams). In
addition to these a number of unidentifieil ai'roliic bacilli
have been found.
Mixed infections, as the streptococcus with the colon
bacillus, the staphylococci with anal'robes, etc., occur
more frequently than infections with a single organism.
The recently emptied uterus with its lacerated bleeding
surface presents a peculiarly favoralile tiehl for the inva-
sion and growth of micro-organisms. Tlie retention of
blood clots and fragments of the jilacenta or membranes
favors infection. Incomplete contraction of the uterus
with consequent dilatation of the lyni])haties and the
formation of large throndii in the venous sinuses is also
a factor, for it is along these vessels that infection most
readily extends.
SoiRcii op Infection. — Bacteria must either be pres-
ent in the uterus or vagina or be introduced from without.
The doctrine of auto-infection has been advanced by a
few observers. Albert ' attributes to a latent microliic
endometritis, which does not prevent conception, many
cases of abortion and premature labor as well as some
cases of ]iuer)ieial infection.
The normal uterine cavity, however, is generally con-
ceded to be sterile.Miut there has been a long controver.s}'
over the bacterial flora of the vagina. Bacterial exami-
nations of the vaginse of a large uumber of pregnant
women have led to contradictory residts. Diiderlein,'
Winter, and others found iiathogenic bacteria in a varying
percentage of cases; while Krdnig,'' Menge. and otjiers,
found none, with the exception of the gonococcns. Do-
derlein.'" made further studies and divided his cases into
two classes: (n) Those with "normal "acid vaginal secre-
tion in whicli he found no pathogenic bact<'ria; and ('/)
those with an "abnormal " weakly acid, neutral, or alka-
line secretion, in ten ]ier cent, of which he found strepto-
cocci. Later Krouig," with improved techni(pie by
which he avoided contamination from the vidvn. fomidno
streptococci in either normal or abnormal cases. These
results have been confirmed recentlv bv Williams.'-'
The bulk of the evidence is now in favor of the view
that infection comes from without in practically all cases.
Experiments have shown that the normal vaginal secre-
tion has distinct bactericidal jiower. Cultures of strep-
tococci ami other pathogenic bacteria, introduced into the
vagina of a pregnant woman, hax'c been destroyed, and
disappear in from twenty-four to forty-eight liours.
The gonococcns forms an exception : as far as known, it
is the only pyogenic coccus winch can live and thrive in
the vaginal secretion.
MoKBiD An.\tomy.' — Any part of the genital tract may
be infected, and accordingly we may have, primarily,
puerperal vulvitis, va.ginitis, endometritis, metritis, me-
tro-lymphangitis, metro-phlebitis, or salpingitis. Exten-
sion of the infection to adjacent structures ma}' give rise
to parametritis, peritonitis, oophoritis, or phlegmasia
alba dolens. Further, with any of these conditions vary-
ing degrees of toxa'inia and bacteria'mia may occur.
Puerperal vulvitis and vaginitis present no characteris-
tics dillering materially from those of firdinary infections
of lacerated wounds. The so-called diphtheritic forms
are usually due to mixed streptococensinfection, although
true diphtheritic intlammation lias been reported iu a few
rare cases (Bnniiii, Nisot, Williams).
Endometritis, or an inflammation of the uterine mu-
cosa, is tlie nio.st common form of puerperal infection.
It is a help in the study of the lesions to divide the
cases into those whicli are due to the streptococcus, the
septic cases, and those which are ilue to putrefactive
bacteria, the putrid cases.
In the puie streptococcus cases the walls of the uterus
are comparatively smooth, there is little or no accumula-
tion of necrotic material, and the discharge is correspond-
ingly small in amount and devoid of offensive odor.
In tlie cases in whith putrefactive bacteria (colon and
anaOroliic bacilli) are iiresent at the same time with the
streptococci, and in the simple putrefactive cases the walls
are rough, the cavity of the uterus is tilled with masses of
fotil-smelling necrotic material, and the discharge is pro-
fuse, offensive, and frecjuently contains gas bubbles.
Microscopically there is in general a typical intlamma-
tory reaction in tlie endometrium. The cavity of the
uterus is lined by a surface layer of necrotic tissue which
is fiUeil with bacteria; beneath this is a layer of leuco-
cytes, the so-called " protective wall " of leucocytes. In
tile virulent streptococcus cases the necrotic layer is slight
or alisent, and the ]irotective wall of leucocytes is poorly
developed ; the streptococci invade the wall of the uterus
along the lymphatics or veins, and can be traced to the
peritoneum, the iiarametrium, and the ovary, and, in
many cases of peritonitis, parametritis, oophoritis, and
phlegmasia alba dolens, to the veins of the pelvis and of
the leg.
Infected emboli from thrombosed veins may be carried
to distant organs and there set u]i secondary sejitic in-
tlainmations, or they may cause a geneial systemic infec-
tion.
In the milder slre|)tococens and sta|)hylococcus infec-
tions tile inliammation may be limiteil to the endometrium,
with little or no invasion of the protective wall of leuco-
cytes, and the general syni]itoms mav be due largely,
as in tile siiiii)le putrefactive cases, to absorption of
toxins.
In the simple putrefactive infectious the necrotic layer
and the protective wall of leucocytes are well develo|ied,
and the tiacteria are confined to the necrotic layer.
In the mixed infections of streptococcus with ]iutre-
factive bacteria we may have a more or. less composite
picture of the conditions aliove described.
Since the discovery of the gas liacillns {aProgenes cap-
sulatus) liy AVelch. in 1S9L it has been found in a nnni-
her of ]nierperal infections. These include cases of
emphysema of the ftetus, puerperal endometritis, physo-
nietra. eni|ihyseina of the uterine wall, and puerperal gas
sepsis. Many of the patients recovered. The fatal cases
were characterized by an extraordinarily rapid develo])-
ment, post iiiniteni. of gas in the tissues and blood chan-
nels of ilie f(etus and mother. It seems probable that
r94
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Puerperal Infeeliou.
Puerperal Iiif'eetioii,
most of the fatal cases of air embolism previously re-
ported were eases of gas-bacillus infection.
Sy.\u"TOMs. — Cases differ jrreatly in their character ac-
cording,' to the variety and virulence of the micro-organ-
isms, the site of the primary infection, and the degree of
€.\tensi(in of the disease. As has been noted, the infec-
tion usually takes the form of an endometritis.
In general, the symptoms are those of a wound infec-
tion w'ith more or less toxa;mia. A chill, fever, general
malaise, rapid weak pulse, restlessness, and headache are
mo.st frequent.
The patient will have done well during the first few
days of the puerperium, and tlien on the third or fourth
dav she will have headache and malaise, followed by a
chill and a rapid rise of temperature to 103° F. or higher.
In the simple cases there is but one chill, while the fever
remains high for some days and then subsides. The
lower abdoinen is tender on pressure. The uterus also
manifests increased tenderness, and is larger and more
" doughy "' in consistency than normal. The character of
the lochia is changed. There is apt to be constipation
and the urine is scanty and highlv colored.
Clinically, tlie cases may be divided into the septic
.and the putrid forms. The well-known variation in
the virulence of cultures of the streptococcus explains
the not infrequent, mild cases due to streptococcus in-
fection.
The severer streptococcus cases are characterized by
rapid onset, often with early delirium, or great mental
prostration and apath}-, although some show a remark-
able absence of mental s\inptoms. With the invasion of
the lymphatics and blood-vessels come the symptoms of
general septicemia, recurring chills, and high, irregular
temjierature; in such cases death usually follows within
a week.
In the milder septic cases, if the infection is limited to
the endometrium, the initial cliill and rise of temperature
are fcillowed by a gradual decrease of the fever. The
lochia are purulent but not profuse, and they are devoid
of markeil odor. Tlie general symptoms subside after
the uterus is washed out, and recovery usually follows,
but a condition of subacute or chronic endometritis may
persist for a long time.
If the infection is not limited to the endometrium, but
■extends along the lymphatics, it may give rise to abscess
formation in the walls of the uterus, in the broad liga-
ment, in the retroperitoneal tissues, or in the inguinal
region; or it may extend to the peritoneum and set up a
local or a general peritonitis. Tiie latter is usuallv fatal.
Again, there may be a direct extension of the infection to
the Fallopian tubes with development of salpingitis or
an abscess. Such extensions are accompanied by chills
and a fresh accessof fever. The aliscess may r\ipture intu
the bladder, the rectiuii, through the skin in the inguinal
region, or into tlie peritoneal cavity. If tlie abscess is
drained satisfactorily tlie sym]itonis rapidly subside and
recovery follows. Rarely an abscess may undergo grad-
ual resorption.
Extension of the infection along tlie thrombo.sed veins
of the uterus may give rise to pya?mia. In such cases
the initial chill may be delayed, the temperature does not
remain constantly high, but instead there is a typical hec-
tic fever with alternating chill, fever, and remissions.
The symptoms vary according to the number and size of
the infected emboli, the organs to which they are carried,
and the virulence of themicro-organi.sms. These emboli
frequently give rise to an often fatal bronchopneumonia.
or less frequently to destructive inflammations in various
joints. In a few eases the thrombosis extends to the
femoral veins and causes phlegmasia alba dolens. This
usually occurs in the second week and is characterized
by severe pain and swelling of the leg, with fever. Tlie
pain and swelling maj' persist for a long time, but un-
complicated cases end in recovery. Tlie sj'mptoms of
thrombosis of the femoral vein may be the lirst evidence
of an infection, the primary inflammation in the uterus
having been so slight as to escape notice.
Putrid endometritis differs somewhat in its symptoms
and course from the septic forms. Tiie onset is usuallj'
on the third or fourth day, and the initial chill and rise of
temperature ma_v be as marked or even higher than in
the septic cases, but the general condition is not so se-
rious. The main difference is in the character of the lo-
chia, which in the putrid form are profuse, offensive, and
frequentl}' have a frothy appearance owing to the presence
of large numbers of gas bubbles. The cases improve
rapidly after the masses of necrotic material have been
removed and the uterus has been waslied out. Nearly
all of the putrid cases terminate in reeoveiy.
Di.\GNOsrs. — T\"pical cases give no difficulty in diagno-
sis. In distinguishing between the septic ami the putrid
forms of endometritis the changes in the lochia are im-
portant. The profuse malodorous discharge and the
roughened surface of the uterine mucosa are very dis-
tinctive in the putrid types; while a smooth uterine sur-
face with scanty purulent discharge and high fever sug-
gests a streptococcus infection.
In the mixed streiJtococeus eases, however, the uterine
wall may be rough and the discharge profuse and offen-
sive. Here the value of a bacteriological examination of
the uterine lochia is particularly evident.
Fever, during the puerperium, may be due to diseases
other than puerperal infection. Angina, acute pulmo-
nary affections, influenza, acute inflaimnatory conditions
of tlie breasts, typhoid fever, and malaria occasionally
occur.
Some cases of puerperal infection are undoubtedly
diagnosed as malaria. But we are not justified in attrib-
uting the fever to malaria unless we tiud the plasmo-
diuiu in the blood, and even then we cannot exclude
puerperal infection until we have proved that the uterine
lochia are sterile.
•' We might say that every rise in temperature in the
puerperium should be regarded as due to puerperal in-
fection, unless we can clearly demonstrate some other in-
fection to be its cause" (Williams).
Fever due to auto-infection from the intestinal tract is
promptly reduced by the effective action of a strong lax-
ative. Certain mental disturbances, such as emotional
excitement, fright, or grief, may be attended with a sud-
den rise of temperature, which falls to normal in a few
hours.
The absorption of sterile exudates and blood clots is
usually associated with a rise of temperature often to
100". but rarely above 101° F., and this rise occurs in the
first thirty -six hours.
Prophyl.\xis. — Puerperal infection is wound infec-
tion. Therefore in order to avoid infection scrupulous
care, according to the principles of surgical technique,
must be taken from the beginning of labor to the end of
the puerperium.
Vaginal examinations in the last days of pregnancy
should be made with antiseptic precautions. During
and after labor they should be reduced to a minimum.
Preliminary antiseptic douches in normal cases are to be
avoided, since they decidedly decrease the bactericidal
power and resistance of the vagina and its secretion.
The use of the ordinary douche and the making of a
vaginal examination by the nurse should be prohibited.
If "the vagina is known to contain pathogenic bacteria,
the obstetrician himself should cleanse it with the utmost
care ; but such conditions should be corrected, if possible,
long before the onset of labor.
Since the hands are the chief carriers of infection, they
should receive careful attention. The following is one
of the most satisfactory methods of hand disinfection;
1. Scrub the hands' and forearms up to the elbows
with a sterile brush, green soap, and hot water for three
minutes, paying especial attention to the finger nails and
]ialniar surfaces of the fingers— change the water at least
once.
2. Trim the finger nails with a sterile knife or scissors,
and clean the finger nails with a nail cleaner.
3. Repeat the Washing for five minutes by the clock,
using a fresh brush.
4. Rinse in fresh water.
795
Puller Sprinjis.
Pulse.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
5. Soak liauils in a liot saturated solution of potassium
permangauate until they are of a deep inaiio,sj;iny color.
6. Decolorize completely iu a hot satiuated solution
of oxalic acid.
7. Soak forearms and hands in a 1 to l,0t10 solution of
bichloride of mercury for three minutes hy the clock, or
until the patient is ready for examination.
It should not be forgotten that sterile hands may be
contaminated readily at the bedside.
The patient also should be carefully jiropured. At the
onset of labor she should be bathed and given a rectal
enema. The external genitals frecpiently harbor strep-
tococci and various pathogenic and putrefactive bac-
teria. They should be carefully washed, before eacli vag-
inal examination, first with soap and hot water, and then
with al to 3. 000 .solution of bichloride of mercury; after-
ward they should be protected, with a towel soaked in
the bichloriili', until tlie physician is ready to m;dve his
examination.
During the second stage an antiseptic towel should be
kept over the vulva and sterile sheets and towels slioiUd
be arranged in .such a manner as to prevent contamina-
tion.
In operativi^ procedures rubber gloves may be worn
to give added protection. They sliould be thoroughly
boiled and then drawn over the sterilized bunds.
Perineal tears olfer ready entrance to bacteria and
shoidd be repaired. The sutures may be placed during
the third stage and ticil after the expulsion of the pla-
centa.
Operations for the repair of laceratiims of the cervix
greatly increase the chanci' for infection, and should not
be done unless imperatively demanded for the control of
heniorrliage.
After the birth of the placenta the jiatient should in'
cleaned and the vulva covered with an ample sterile
dressing, which is held in place by a T-bandagc.
Ergot may be used to secure better conlr.iction of llie
uterus, but should not be given until tlic ])laccnta has
been expelled.
During the puerperiuni the external genitals should be
kept clean bj- frequent irrigation with a 1 to 4.0IH) solu-
tion of bichloride, and the vulval pads frequently re-
newed. Vaginal douches should be used only in excep-
tional ca.ses, and then with tin- utmost regard for surgical
cleanliness. Infections have been caused by the careless
use of the vaginal douche, even in the later stages of the
purperium.
TiiE.\T,\ii:NT. — General treatment alone often gives the
best results in the severe stre])tococeus cases. .Strych-
nine, gr. J„, may be given every two hours with half au
ounce of whiskey every hour, but the cpiantity shoidd be
reduced pronqitly when the jndse shows irniu-ovemeut.
The patient should be kejjt on the verge of strychnine
poisoning and astatcfif druukeime.ss, if necessary. Mild
cases require little medicine. The bowels shoidd be kept
0]ien and good food given in all cases.
Antistreptocoecus serum has given very uns.itisfactory
results. Laboratory experiments have shown that .serum
prepared from a given culture is luxitective for that par-
ticidar culture and no other. Recent reports by Lalius-
quiere. '^ Savor, Blumberg, and Scharfe show results of
doubtful or no value.
The cases of true diphtheritic infection reported by
Bumm, Nisot, and Williams .showed rapid inqn'ovemen't
and recovery following the use of diphiheria antitoxin.
Salt-solution enemata every six hours, given through
the long rectal tube, are often of value in relieving
symptoms and promoting diuresis. The subcutaneous
injection of sterile decinormal salt solution has lieen of
apparent benefit iu some cases. Tincture of li'rric chlo-
ride iu large doses is of value.
Local treatment in the streptococcus cases sliould be
limited to douches, preferably of hoi sterile decinormal
salt solution. These may be repeated eveiy six hours if
necessary. Dilute bichloride douches, 1 to 10.000, im-
mediately followed by the salt solution, may be used.
But antiseptic douches are dangerous and should Ik.' u,scd
with great care. Forty eases of death from bichloride
poisoning have been reported.
Clots and fragments of the placenta may be removed
with the linger or the dull curette. Curetting on the
whole is daugerous, especiall_y if streptococci are present,
for by it we may break down the protective wall of lim-
cocy tes and expose fresh areas to infection, the very thing
we wish to avoid.
Hysterectomy has been advocated for severe cases,
but the results reported by Rochard, Bazy, Terrier, and
Tutlier, with a mortality of from thirty-three toone hun-
dred per cent,, liardly justify a resort to the operation.
Leopold '■■ and Kehling do not favor it. As they show, to
be of value it nuist be done early, before the infection lias
extended through the uterine wall. But at present we
have no means of determining in which cases the infec-
tion will extenii, and in which it will remain limited to
the uterus. Ricard has collected eight hundred and tifty-
one cases with fever at 103,3' F. and higher, showing" a
mortality of thirteen per cent, under general treatment.
Abscesses and ilense areas of cellulitis in the parame-
trium should be opened through the vagina or through
the abdominal wall.
Putrefactive cases with abundant foul discharge are
greatly helped by cleaning out the masses of necrotic
material with the tinger or curette, and following this by
a lai-ge douche of salt solutiim. tlie douche to berepeateil
every six hours. Otto G. liiniimii.
BlBLIOliRAPUT.
' Hirsi'fi : Historisctie ii. patholeffi.sche I'ntersuchuni? iitier Piu^r-
peralflelier, Erlaniren. lst)4.
- Welcli : Boston Uvd. and Surg. Journ., 1900. Complete review uf
liteniture.
= Weifliselliaum : Wien. klin. Wooh., 1888.— Schuhl ; Dne epiUeiiile
d'infeotioii puerperale j\ pneiimoc-ocques. Presse meil., 1897.
' Nisnt; Diplitlicrie vaaino-uteriue puerperale, Serotberapie, (iueri-
snn. Ann. lie ciyn., Is'.w.- Bninin : teller Diplilh. u. KindliHtttlelu-r.
Zelt. f. Cell. u. (;>n., 189.5.— William.s : Puerperal Dipbtlierla. .\m.
Journ. (ll)stet.. 1S9S.
'' Williams: Ceutralbl. f. Gvu., 189S.— Dobbin: Am. Joura. (ibstet..
1898.
• Albert: Archiv t. (iyn., 1901.
' Doderlein: Ari-blv f. (Jyn., 1887.— Winter: Zelt. f. Geb. u. (ivn.,
1888.
" Doderlein: Ardiiv f. Gvn., 18.87.
' Kronip: Ceutralbl. t. (i.vu.. 181M.
'"Doderlein: D.is Scbeidenseeivt n. seine Bedeut. f. d. Pnerperal-
fleber. Lcipsie, 1.S9-.
" Kriiuig: Bakteriol. d. (ienltalkanal. d. Fnui, Lelpsic, 1897.
'* Willi.ims: Am. Journ. lUistet., 1898.
'^ Laliusquiere : Ann. de (iyn. et d'obstpt., 1901.
" Report of IV. Intemat.'Cong. i. Geb. u. Gyn. Rome, 19(S, in
Mouatsch. f. (ieb. u. Gyn., October, liK)2.
PULLER SPRINGS. — Mailisou County, Montana.
Post-Office. — Puller Springs. Hotel.
This resort is reached liy a good wagon-road, and has
semi-weekly mails. The location is in a beautiful valley,
having an elevation of .5,.^30 feet above the sea-level.
The springs ai'c two in number, the temperature of the
water being 9,5° F. for the larger and 105° F. for the
smaller spring. No analysis. "The waters have been
found benelicial in rheumatism and iillied disorders. The
beautiful location of these springs, coupled witli the po-
tential therapeutic propertiesof the water, will undoubt-
edly bring them into extensive use as the State becomes
more thickly settled. Jniius K. Cnmk.
PULSATILLA.— U. S. P,i.t(iuc Flotrerx. The dried herb
oi AiKiiiiiiir J'til>.iiliUii L. and A. prdtciisis L. (fam. lin-
niiiii-ii/iimr). enUected soon after tlow-eriug, carefully ]nv-
servedand kept not longer than one year. Both are low,
hairy herbs and among Uie earliest and most beloved of
spring Howers, For medicinal purposes tlie plant ,sbnulil
be dried in the shade and slored in a cool and <liy phiee.
The drug is thusdescribcd : Silky-villous: leaves' radic:il.
long-iietioled, the petioles usually purplish, the blades
twice or thrice deeply three-parted or pinnately cleft, the
lobes linear and acute: tlowerslong-peduncled,".subtendcd
by an involucre of three jiinnately parted sessile leaves;
calyx of (usuidly six) large, dull purple, hairy .sepals;
petals obsolete; stamens numerous; pistils several, be-
rtc
REFERENCE HANDBOOK OF THE iiEDICAL SCIENCES.
Puller Sprlnss*
Pulse.
coming in fruit long, plumose-tailed akenes; inodorous
and VL-ry acrid.
Constituents. — Pulsatilla yields upon distillation vvitli
water a very pungent, volatile, oil-like principle, from
which ether or chloroform extracts a pe-
culiar camphor, whicli has been called
Anemone ca»ip/un\ iind which possesses llu'
acridity of the oil to such a degree that
it is capable of blistering the skin. Tliis
camphor is divisible into auemciuiu and
iso-anemouic acid. Tlie former is a col-
orless, crystalline, neutral suljstance, of
but little taste when cold, but intensely
pungent when melted. It is but slightly
.soluble in cold alcohol, ether, iir water,
more so in those liijuids when hot, and
is readily soluble in chloroform. Iso-
inu'iiiDnic acid is a white, amorphous, in-
soluble substance, without odor, taste, or
medicinal property.
Action .vnd Use. — Tlie clinical investi-
gation of Pulsatilla has been
greatly neglected by physi-
cians, apparently with little
better reason than that it is
a favorite medicine with
Iiomreopaths and eclectics.
That it possesses powerfully
active properties is sutficient-
ly proven by its action upon
the skiu and the
mucous membrane.
Its action is fairly ^j
well described in a
general way by say-
ing that it resem-
liles that of aconite,
but its sjiccial field
of u.sefulness is well
worthy of careful
determination. It is a
fairly active counter-irri-
tant, and is frequently so
employed. Although ca-
pable of blistering, it ap-
])lied with friction, such a
use of it is not wise, since
the blister is rather un-
controllable. Applied to
the mucous membrane,
it produces a burning and
tingling, followed by
numbness, much as does aconite,
the stomach it acts as a stimulant
in larger amount as an irritant emetic.
Systeraically, it reduces both the rate
and the force of the heart and of the
respiration. It is therefore an anti-
phlogistic, and is somewhat used as a respiratory seda-
tive. Among the iiomo-opaths and eclectics its sedative
action is largel}- utilized in the treatment of inflammatory
conditions of the genitals, although it is also a favorite
emmenagogue.
There is no official preparation. Tlie powdered drug
may be given in doses of 0.0G-U.3 gm. (gr. i.-v.) or the
fluid extract in an equal number of nnnims. The tinct-
ure is probably more used than all other of its prepara-
tions combined. It is commonly made of t wenty-per-cent.
strength, and the dose is 0.5-1 c.c. (niviij.-xv.). The
extract is used in doses of one-half to two grains and
anemonin in doses of one-fifth to one-half a grain.
Allied Dkugs. — Anemone neniorosa L., the common
wind-flower, and various other anemones, have a similar
composition to that of Pulsatilla, and are similarly used.
Various species of Rannneiduf: or buttercup, and of Glem-
(iti.-< or virgin's bower, aLso exhibit resemblances in the
same direction, as does Hepaticji or liver-leaf. All these
pertain to the family linnuncnUicea'. Henry H. En^hy.
PULSE, THE.^Introductory and HisToniCAL. —
The iHilse, literally a beating or throbbing, maj' be
broadly defined as periodic movements caused by the
rhythmic action of the heart. The terra is commonlj'
applied to the changes in size and tension of the
, blood-vessels which may be seen or felt at each
heart beat. In the history of medicine tlie obser-
vation of the pulse, and also its employment in
diagnosis, precetied by many centuries the dis-
coveries which opened the way for its interpre-
tation. Aristotle refers to the pulse, and statei
that it is simultaneous in all parts of the bo<ly;
but he was not aware of its relation to the activity
of the heart. Galen, equally ignorant
of its origin, devoted much attention
to it, but Ills lack of physiological
knowledge led him to form many false
conceptions, and he attached a signifi-
cance to minor variations which later
experience has not justified. He be-
ieved that the arteries expanded and
contracted actively by some force
which they possessed within them-
selves. In China medical science, like
other things, has
changed little in
thousands of years.
The native physi-
cians there have
very crude ideas of
botii anatomy and
physiology, and yet
they describe and
even graphically
depict the pulse in
great detail. They
imagine they find
indications iu it of
the exact seat no
less than the nature
of nearly every dis-
ease.
A more reason-
able claim, wliere
the indications
^ given are better
" supported by other
symptoms. Is ascribed by the i)oet
Browning to Paracelsus, that err-
ing Moses who in the sixteenth
century began to lead the profes-
sion out of the Egypt of tradition.
*' When we would tboroughly know the
sick man's state
Wu feel awhile the flattering pulse,
press soft
The hot brow, look upon the languid
eyes
And thence divine the rest."
The foundation for the scientific study of the pulse
was laid by 'William llarvey, who discovered and de-
scribed the circulation early in the seventeenth century.
Among his conclusions we find that "the heart is the
organ of propulsion for the blood '' and thai " the pulsa-
tion of the arteries is nothing else than the impulse of the
blood within them." In lT(.i7 Sir Johti Floyer states a
little more definitely: "The ])u!se is that sensible motion
which is given to tlie artery by the blood which the heart
injects into it." Still fuller is the account given in
Haller's "Elements of Physiology," published in ITGO;
" The arteries are, iu a living person, always full of blood,
since tlie jet or stream that starts from an artery is not
interrupted by alternate stops, while the heart rests or '
relaxes itself, but it flows on in a continued thread. . . .
Since, therefore, a new wave or column of blood is .sent
into the arteries already full, although it bears but a
small proportion to the whole mass contained in the arte-
rial system throughout the body, . . . yet by its imme-
diatecoutact with the precedent wave or column, which
Fill. :3.'<!)ii.— Anemone Pulsatilla. (Balllon.)
T'J"
Pulse.
Pulse.
REFERENCE HANniSooK OF THE MEDICAL SCIENCES.
moves slower as it gets farther from the licarl. it conse-
quently drives tlie same forward, Icnjrtliciis tlie artery,
and makes it assume a cylindrieiil form, au.irments its
diameter, etc. Tliis dilatation of the artery, wlicrcby its
light or capacity is changed from a less to a greater circle,
is eallril tlie pulse." In 17(17 Henri Fniii|iirl desrribed in
Nuriiial I'ulsi' TrariiiLr.
detail the sensations imparted to his linger by the pulse
and was tlie first in Europe (the Chinese were before
him) to represent the pulse by drawings. In 185o K.
Vierordt describes a rough means of recording the move-
ments of the arteries automatically, thus laying the
foundation of modern sphygmography. On this founda-
tion a host of modern investigators, both laboratory anil
clinical, have raised a substantial structure of useful
knowledge.
Arteriai, Pi'IjSE. — Be.ii'viiition <iiifl Kiiilnimf/nii. —
The arterial puls(^ comprises a succession of waves initi-
ated in and near the heart and propagated through the
arteries. As the contents of the left ventricle are forced
through the semilunar valves, room is made for the blood,
partly by the distention of the aorta, and partly by a
pushing on of what is already there into the smaller
arteries, causing the latter to be distended in turn. This
distention slightly increases the calibre of the arteries;
but what we recognize as the pulse, when we lay our
finger on the wrist, is rather the increase of tension or
pressure within the vessel which occurs at the same time.
In some cases an arteiy may become more tortuous as
the wave of increased tension is passing over it. With
the linger on the pulse, it is sometimes possible to recog-
nize more than one impact or wave. It is difficult, how-
ever, and often impossible to be sure of these so-called
secondary waves by the sensation imparted to the finger,
and we should know very little about them were it not
for the assistance furnished by the sphygmograph. By
means of this instrument it is possible to communicate
the movements of the artery to a lever supplied with a
writing point. This is brought to bear upon a piece of
smoked paper moved by clockwork. The result is a
grajibic rejiresentation of the variations in pressure oc-
curring within the artery. Some of the many forms of
instrument and the method of employing them will be
described in the article on Splnniiiiiuiritplnj. Fig. 3^97
represents the tracing obtained by one of these instru-
ments (Dudgeon's sphygmograph) from the radial pulse
of a healthy man.
If it be examined it will be seen that each pulse beat is
rejiresented by a sudilen rise followt'd by a more gradual
fall. The sudden rise is known ixfi lliv jin'/mtn/ ar per-
cu,mo» wiire and can be traced to the coni taction of tlie
ventricle. The descent is broken by two .secondary
waves, of which the second, known as Ibe dicrotic icare,
is in this case the largest an<l most distinct. This wave
is very constant, being found iiialmnst all pulse tracings.
It is preceded by a depression known as the (licrdir imtcli.
There has been much controversy as to the cause of the
dicrotic wave, one view being that it is due to a rebound
of the blood from the aortic valves at the moment when
they close, and the other that it is a wave retiected back
froin the small peripheral vessels. While a very few still
hold the latter view, it has been discarded by most phys-
iologists as a result of overwhelming evidence that has
been advanced in favor of the rebound theory. If the
wave were due to a reflection of the percussion wave
from the periphery, it would occur earlier in the periph-
eral than in the central vessels, which is not the case.
Jloreover, a number of physiologists, uottibly Karl Hi'ir-
thle, have shown that the dicrotic notch which marks the
beginning of this wave follows immediately the chisure
of the aortic valves. He has invented the so-called dif-
ferential manometer to record the time of closure of the
valves. This instrument recordsthe relation of the jiress-
ure in any two cavities. If connected with the aorta
and left ventricle through a Iliirthle's heart catheter, it
indicates the moment when the pressure in the ventricle
falls below that in the aorta. This moment corresponds
of necessity with the beginning of a liack flow into the
ventricle, and must be directly follo\Yed by closure of
the valves. In Fig. 3898 from Iliirthle's "Beitrage
zur Hamodynamik " A is the curve of pressure at
the root of the aorta, that of the left ventricle, and
D the curve of the dilferential manometer showing the
relation between the pressure in the ventricle and that in
the aorta. When the curve D rises above the base line
the pressure is higher in the ventricle, and blood begins
to flow into the arteries; when it falls below the line,
there is a tendency for a back flow to take place and the
semilunar valves close. The vertical lines 1, 3, 3, 4, 5
show corresiiimding points of time in the three tracings.
The aortic valves close directly after the line 3, which
luarks the beginning of a backward flow into the ventri-
cle. This corresponds in time very closely with vertical
line 4, indicating the commencement of the dicrotic wave.
The close agreement in time between these two events
is strongly suggestive of a causal relation. The corre-
spondence between the closure of the aortic valves and
the dicrotic wave has also lieen successfully demonstrated
by JIartius. Karl Schmid, .Jr., and others by marking the
time of the secund sound of the heart as heard with a
stethoscope upon the pulse curve.
The rebound from the semilunar valves may be ex-
plained as follows: The blood is thrown out of the ven-
tricle at a certain speed and with a certain momentum.
When the ventricle has emptied itself the' momentum
of the blood in the aorta fends to carry it forward away
from the ventricle. This cannot actually take place, or
a vacuum would be left at the root of the aorta, but the
teudencj' in that direction causes a low pressure and con-
sequent suction action at the aortic orifice. This lower
pressure or suction leads to a wave in a backward direc-
tion, completing the closure of the semilunar valves.
This is reflected forward again as the dicrotic wave. The
dicrotic wave is most pronounced when the smaller arter-
ies are dilated and the ]ieriiiberal resistance is low. In
this case the column of blood, meeting with little opposi-
tion, is thrown out of the ventricle with greater speed
and momentum, and the
recoil against the semi-
lunar valves consequent-
ly occurs with greater
force.
Immediately preced-
ing the dicrotic wavi'
another, and in this case
(Fig. 3897) smaller,
wave may be seen which
is known as the pirdi-
cmtic or tidiil tcari\
The cause of this is
more doulitful than that
of the dicrotic wave. It
is found in the curve of
intraventricular press-
ure, and may even be
present under certain
conditions in the tracing
of the transverse diam-
eter of the frog's ventri-
cle (.Marey), so that it is
frequently ascribed to a
peculiarity in the con-
traction of the ventricu-
lar walls," the systole not
being equally sustained " (Foster) or " the outflow remain-
der wave " ( Hoy and Adami ). There are those who ascribe
this wave entirelv to inertia and recoil of the instrument
Fig. S^nS.— Sliows Kl■lation^lll|i lie-
tween Ibe Pressure in tlie \eniii<'le
,incl ibal in the Aorta. (From Hiir-
tllle. )
798
REFERENCE HANDBOOK OP THE IIEDICAL SCIENCES.
Pulse.
Pulse.
used. The iustnimcnt may, and often does, exaggerate
it, but there is little douht of another factor being pres-
ent. The most jilaiisible e.xplanalion is perhaps some-
thing like this: both the pereiissicm wave and the ]iit'-
dicrotic originate within the ventricle during its systole;
the reason of there being a depression or notch divid-
ing them into two is that a sliglit fall of pressure oc-
curs when the semilunar valves open and atlord a pas-
sage for the blood into the aorta; the physical laws here
exemplitied may be studied in the mechanism of the
hydranlic ram as has been pointed out by Karl Sehnnd,
father and son. If the pressure in the arteries is low, the
ventricle nearl}' empties itself with one effort, and the
prcdicrotic wave is scarcely se<'n ; but if the pressure is
iiigli, only part of the blood is forced out at first, and
after a slight fall in pressure at the opening of the semi-
lunar valves, tlie continued eontracticm of the ventricle
raises it again up to or beyond its original height, form-
ing the |iredicrotic wave. It is certainly a practical I'ule
that where the predicrotic wave is pronounced and
reaches a high level the blood pressure is high relatively
to the strength of the ventricle.
Other secondary wa\ es are sometimes seen upon pulse
tracings and are proliably due to oscillations taking place
within the vessels, or in some cases they may be instru-
mental in origin. A multiplicity of secondary waves
points to high blood pressure and consequent tension of
the arterial walls. Elevations or depressions occurring
upon the descending limb of a tracing are called kata-
crotic, those more rarely seen Ujion the ascending lind) are
called anacrotic. A tracing with interruptions ujinn the
a.scent is called an anacrotic tracing, and wp may also
speak of an anacrotic piiUe. Similarly, where there are in-
terruptions on the descent we speak of a katacrotie trac-
ing and kiitacrotic pvhe. A pulse may be both anacrotic
and katacrotie. The normal tracing in Fig. 3.S97 is kata-
crotie only. The tracing shown in Fig. 3899, taken from
a case of aortic stenosis, coidd be classed as both anacrotic
and katacrotie. The predicrotic wave forms the summit
of the tracing and indicates resistance to the outflow of
blood from the ventricle; the primary or percussion wave
forms an anacrotic crest or angle on the ascent, and the
dicrotic wave is seen as an elevation on the descent (kata-
crotie).
F.-vcTOKs Contributing to the Ch.\r.^cter of the
Pdlse. — The exact character of the pulse depends on
three principal factors: the force of the ventricular con-
traction, the degree of elasticity of the arteiies. and the
resistance offered to the outflow of blood from tlie arter-
ies into the capillaries and veins. The quantity of blood
in the body naturally occurs to one as a modifying factor,
but its influence is ditlicult to trace, and in any case it
probably acts chiefly by modifying the ventricular eon-
traction. An additional factor that does, without doubt,
however, exert a modifying influence in special ca.ses is
the condition of the aortic and to a much less extent of
the mitral valves. Of the three principal factors men-
tioned the centriciilar cuiitirictinit determines the rate and
combines with the other two factors to give the pulse its
other qualities. TJie eluKticiti/ of the arterici modifies the
pulse in the direction of less abruptness. The more elas-
tic the larger arteries are, the less sudden is the increase
of tension in the smaller ones. The diminished elastii'ity
of age tends to make the rise of the pulse wave steeper.
In cases of low blood pressure the same effect is noleil,
because the elasticity of the arteries is not fuilv brought
into play. Tlie peripheral resistance depends largely
upon the degree of activity- of the muscular coats of the
arterioles. When these are relaxed the blood pressure
falls, the ventricle empties itself easily, and the pulse is
large and soft. When the arterioles are contracted the
blood pressure rises, the work of the ventricle is increased,
and this is indicated in the puls(> by hardness and a ]ironi-
inent ])redicrotic wave. Advancing age tends to raise
the peripheral resistance by the withering of many of the
capillaries and consequent narrowing of tlie channel by
which the blood must flow from tlie arteries into the
veins. Age also affects the force of tlie ventricles and
the elasticity of the arteries so that the pulse in old peo-
ple varies according to the part of their vascular system
where degenerative changes have been most active. As
the thoughtful observer notes in the pulse the modifica-
tions brought about liy ventricular activity and peripli-
eral resistance, he will find there suggestions of many
po.ssible influences acting through the cardiac and vaso-
motor nerves.
R.\TE OF Prop.\gation.^ — It takes a certain me;isura-
ble time for the efl'ect of the ventricular contraction to
make itself felt in increased tension of the peri])lieral
arteries. In other words, the pulse waves travel at a
certain rate. This " rate of proiiagatioii " varies some-
what, but is usually given as lietween tliree and ten
metres a second. It is considerably influenced by ^■al■ia-
FiG. ;*99.— Anacrotic Pulse (aortic stenosis).
tions in blood jiressure and by the degree of rigidity or
elasticity of the arteries; the more rigid the vessels the
more rajiid the ]ir(iiiagation of the puLs'e.
Furtlier information on some of the subjects treated of
above will be found in the article on Circulation.
The Examination of the Pii.sk and What it .Shows.
— One should not make any direct examination of the ra-
dial pulse until he has obtained w-liat information lie can
by inspection of the visible parts of the body. A glance-
is often suflicient. In the face one can find indications
of the condition of the capillary circulation in the glow
of health or in pallor or lividity. In the neck there may
be violent throbbing of the arteries or distention and pul-
sation of the veins. In the fingers one may find lividity
and clulibing or a capillary pulse. The |iiilsation of the
tempiiral and radial arteries may be visible.
It is inipcirtant to choose for the examination of the pulse
a time when the patient is as little excited as possible. It
is well to distract his attention by conversation. To obtain
the best results the patient should lie or sit in a comfort-
able jiosition. The observer should be in front of the-
|)atient or to his right side The patient's right arm
should be sup]iorted with the elbow flexed and the fore-
arm half pronated. Two or three fingers of the observer's,
right hand should be laitl upon the radial artery where-
it pas.ses over the lower en(l of the radius between the
styloid process and the flexor tendons. The fingers are
to l)e moved up and down the artery and across it, first
with light pressure and then with sufficient to flatten
out the vessel so as to bring out tlic condition of the arte-
rial wall. If the artery can be frit and rolled beneath
the fingers when flattened out it indicates the thickening
of arteriosclerosis or the rigidity of atheromatous or cal-
careous degeneration. If the latter change has taken
]ilace to a marked degree, one can often feel the arterial
wall to be uneven and rilibed. If the artery can be felt
to be tortuous, one is .ju.stified in inferring that the pa-
tient has been the subject of relatively high blood ]u-ess-
ure extending over a long period. In examining the
wall, as di'scribed above, an impression will often be re-
ceived of the calibre or fulness of the arterij. One is ver_v
apt to be misled on this point, according to Leonard Hill,
by the fact that the venie comites accompany the ar-
tery and contribute to the sensation of size given to the
finger.
Tlir arterial jiressiire may be roughly estimated by the
amount of p.-cssure which must be exerted b_v the finger
to obliterate the jiulse in the portion below. The artery
should lie ]uessed directly backward against the radial
bone, and it is well to compress it below as well as above
the examining finger .so as to exclude any "anastomotic
pulse" from a communicating vessel. A correct judg-
799'
PuKc.
Pul«e.
REFERENCE HANDBOOK OF TlIK .MKDU Al> .SCIENCES.
nient as to arterial pressure cmii be acquired only by
nuieli practice. One is very liable to cdiifn.se the sonsa-
ticm given by high arterial pressure uitli lliat of a thick-
ened or calcareous artery.
Low arterial pressure is found in fevers, esjiecially the
later stages, in most wasting di.seases, anil in many forms
of heart disease. High pressure is seen especially in
ne]ilu'iti.s, litha?mia, and lead poisoning.
The pulse proper should bee.xamined witli reference to
its rate, regidarity. size, and quieline.ss. The so-called
fill )■(! ness or noft iu\i.'< of ilie jiiihc is practically identical with
tlie arterial pressure whicli lias just been discussed. Tlie
rate nf tlie pulse, whether frequent or infrequent, is to be
determined by counting the iiul.se beats by a watch for
not less than I'lalf a minute. It is well to note tlie num-
ber of lieats in eacli period of five .seconds so as to deter-
mine whether or not the rate is variable.
AVbeu the pulse is too frequent to be succes.sfully
counted in the ordinary way it is sometimes possible to
calculate its rate by counting every second beat and
doubling tlic result. Wlicn some or all of the beats are
too feeble to be distinguished, the rate can be obtained
by auscultation of the heart. A record of the variations
ill the pulse rate from day to day is often valuable. Be-
fore drawing conclusions from the rate of the pulse, due
weiglit must be given to the fact that it may be modified
by very slight intliiences such as the position of the pa-
tient or slight mental excitement. If the rati^ be abnor-
mally high it should be counted again when any excite-
ment has had time to sulisidc. The rate of the pulse
varies mucli within the limits of health. Aije has a very
great influence. The average rate is soinelhing over 130
in the first year of life, about 90 in the tenth year, 70 in
adult life, and 75 or 80 in tlio.se who have passed the
allotted sjian. 8e.r has little influence, the average in
females being only a few beats jier minute more than in
males of the same a,ge. What little dill'ereiice there is in
the two sexes may with reason be attriliuted to nUe, for,
as a rule, the larger the body the less frequent tlie pulse.
Tables showing in more detail the effects of age, sex, and
size on the rate are given in the article on Circulation.
The time nf da)/ has a slight intluence on the pulse rate,
which is usually five or ten beats higher in the afternoon
and evening than in the morning. Mails, especially if
hot. may increase the rate for one or two liours. Cluiiuje
f'f jiii.iition from lying to sitting raises the rate from two
to five beats per minute. On standing a further increase
of four to eight beats may result. E.verei.se has a still
greater influence, very sliglit exertion sending the pulse
u]! twenty or thirty beats, and violent exercise may more
than double the rate. An increased frequency out of all
proportion to the clTort made is commonly seen in the
debilitated and the diseased.
Piit/iolrifficalfrrr/iiciifi/ of the pulse may be conveniently
divided into three .groups (Mackenzie). First, those in
which the lieart responds to an e.\tra call upon it by an
excessive increase of rate: .second, those in which the
pulse rate is continuously increased; third, those in
wliich periods of increased rapidity take place in irregu-
lar paroxysmal attacks.
To the first group of ohriormal c.reiliihility lielong all
cases in which the reserve power of the heart is impaired.
Tliis may be the i-esult of some .general disease or of val-
vular or other lieait affection. When no other sufficient
cause can be found, one may suspect a neurotic temiiera-
nient or the abuse of some stimulant or narcotic (alcoliol,
tea, or tobacco).
In the second group of ivnitiiiiiiil frei/iirnei/ v;e may
place ((0 most febrile diseases. In fever the jnilse usu-
ally bears some relation to the tenijierature. It is com-
inonly iiicicased about ten beats per minute for each de-
gree Falirenheit of ]iyrexia. Marked execjitions to this
rule are found in typhoid fever where the increase in the
inilse rate is usually small for the amount of pyrexia,
and in menin.gitis Aviiere the rate is very variable, but
may be lower than normal in spite of considerable fever.
(li) Diseases of the heart. Increased frei|uencv of the
pulse is a common but by no means an invariable syuqi-
torn of valvular disease. In disease of the aortic valves,
especially aortic stenosis, the pulse rate is less likely to
be increased than in "mitral disease. In degeneration of
the heart muscle the pulse rate is very variable, and may
be either liigher or lower than normal. The rate is usu-
ally increased in pericarditis and in overstrain from ex-
cessive work. (<•) Exophthalmic goitre, (rf) Numerous
other conditions such as incipient tuberculosis, exhaust-
ing diseases, neuroses, pregnancy, hemorrhage, alcohol-
ism, great anxietj', severe jiain.
The third group of pitro.ri/sinal attm-ks embraces palpi-
tation and jiaroxysmal tacliycardia. In piilpitatiini we
have a sudden onset of rapid, violent heart action accom-
panied by throbbing of the larger arteries. This exces-
sive throbbing does not extend to the smaller arteries,
" the radial pulse, for instance, being rapid but having
no excess of force " (Balfour). True jialpitation occurs in
weakly anauuic individuals, and is induced by psychical
and gastric reflexes of various origins, "never by exer-
cise." The patient is usually painfully conseiousof the
violent action of his heart.
In piiro.ii/siiiiil tiie/ii/rardiii the subjective .symjitouis are
less pronounced. The heart may be beating even more
frequently than in palpitation, and yet the patient be un-
conscious of the fact. The attacks are variable in dm-a-
tion, but ma.y last several days. During the attack the
heart frequently dilates as a result of incomplete empty-
ing by the rapid feeble beats. Mackenzie looks upon the
disease as caused by some local heart stimulation giving
rise to a prolonged .series of )iremature systoles.
Diniiiiisliedf requeue!/ of the pulse must always be care-
fully distinguished from those cases of missed beat in
which only every second pulse is strong enough to be felt
at the wrist. It is a safe rule to count the heart sounds
before diagnosing an abnormally slow pulse. An infre-
(lueut pulse is sometimes present in individuals who
show no other signs of disease. It is said that the pulse
of Napoleon Bonaparte was never over forty. An infre-
quent pulse is most connnon in the latter half of life.
It may sometimes be a symptom of degeneration of the
myocardium. It is often seen in diseases accompanied
by high blood pressure, such as chronic nephritis, and
as a result of poisons produced within the bod_y, as in
jaundice, or introduced from without, as digitalis. The
most marked instances of infrequent pulse, or hriidi/-
eurdiii, as it is called, are those following injury to the
spinal accessory nerve. This nerve arises from the spinal
cord as far down as the fifth or sixth cervical vertebra,
and may be implicated in fracture of the spine or iutlam-
matoiy compression of the cord in this region. In such
cases the pulse may fall to tliirty, twenty, or even lower.
A pulse rate of eight per minute has been recorded. In
such eases syncopal attacks and epileptiform seizures
are common.
Reijiiliiritii of tlie Pulse. — In healthy people who are not
suffering from any disturbing influences, the pulse beats
are usually reguhir in rhythm and volume. This may
be recognized by the examining finger. In some cases,
however, we find variation in the intervals between the
beats or in tiieir volume or both. Such departures from
the normal )iresent themselves in a great variety of tyjies
which are often referred to by different names in the
various books on the subject, so that considerable confu-
sion of terms exists. The following table is .suggested
as a classitication of llie different kinds of irregularity,
although I am (|uitc aware of its imperfections and rec-
o.gnize the f.iet tliat. there is some overlapping so that the
same imlse might be put under more than one heading:
Allorrhytlmiia ((ireck, another rhythm).
I*, alteriians,
P. bigeminus.
P. trigeminus.
P. paradoxus.
Arrhythmia (without rhythm).
P. intermittens (drop]ied beat).
P. deficiens.
P. |isiudo-intermiltens (hemisj'stole).
P. iiitercidieiis (premature systole).
80(1
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pulse.
Pulse.
P. irregularis.
Diastolic.
Systolic.
In aUorrlnithmia the variations in rhythm are them-
selves rhythmical. Thus in the (irst subdivision, piihns
<dlenians, we have alternately a strong pulse beat and a
weak one. This is sometimes ascribed to a strong beat
of the left ventricle and a weak beat of the right ventri-
cle alternating with a weak beat of the left side and a
strong beat of the right side. In P. biyeminux the beats
are in" pairs, two beats with a short interval between and
then a pause. P. bigemiuus must be carefully distin-
guished from P. hixieriens which is a pulse where the
predierolic wave is well marked so that each single piilse
has a double crest. In /'. tiigemintis there are three beats
and then a pause. Cases are reported in which there are
two beats and a pause followed by three beats and a
pause. P. pamdoxHs is where the pidse becomes ex-
tremely feeble or fails altogether at the end of each in-
spiration. When pronounced this form of pulse usually
indicates adhesive pericarditis or great obstruction of the
respiratory passages. A slight variation in tlie pulse at
different stages of respiration may be present in healthy
people.
Arrhythmia includes those forms of pulse irregularity
which iiave no rhythm of their own. P. interndttaris is
where from time to time the finger mi.sses a beat. It is
sometimes spoken of as dropped beat. Where the ven-
tricle misses a contraction altogether we speak of a P.
delicicns. Where there is a beat of the ventricle which,
while it can be heard over the heart, is too weak to prop-
agate a pulse to the wrist, we speak of a hemisi/stole, caus-
ing a false intermission. In P. intercidieiis instead of a
beat being dropped out we have one occurring before its
proper time. We may refer to this event as a prcinnture
systole. Such a premature systole is often too feeble to
be felt at the wrist, and is then a heiuisy stole also. At
other limes it is distinctly felt, and when it occurs at reg-
ular intervals maj' give rise to a pulsus alternans orpulsus
bigeminus. Where there are one full beat and two prema-
ture systoles regularly repeated we get a pulsus trigemi-
nus. Under the heading simply of piihiis irref/i/lnris
we may jnit any irregular pulse that cannot be classified
in any other group. This and pulses of the other groups
as well, may be separated into two divisions of some prac-
tical importance. In the first of tliese the irregularity is
due to a variation in the length of the pause {dinKtolie).
Such irregularity is frequently found in the healthy, and
is of little impoi'tance. In the other division the irregu-
larity is due to variation in the force and duration of the
ventricular contraction (ni/stdir), and the ])ulse beats are
felt to vary in strength. Pulses of this kind are more
ai">t to indicate danger and should be carefully considered
after thorough examination of the lu art. Diastolic irreg-
tdarity is fre(juently seen in children, and M;irkenzie
proposes to call it ihc youthful type of irregularity, al-
though it is often seen in adults too, especially as the
pulse is slowing down during convalescence from a fever.
For systolic irregularity Mackenzie proposes the term
adult type of irregularity. The terms systolic and dias-
tolic seem to the present writer le.ss open to objec'tion.
In looking for tlte cause ofjiulse irregularity we first turn
to the heart and find that sometimes the lack of normal
rhythm is due to independent action of the ventricle and
sometimes may l)e traced back to the auricle. To deter-
mine which chamber is primarily at fault may best be
comijlished by taking simultaneous tracings from the
radial and jugular, as will be further explained shortly in
connection with the venous pulse and also in the article
on Siihynuiiiiiriipliy. Irregularity is frequently a re.=;ult
of the strain put upon the heart ijy valvular disease, but
is not often seen in pure aortic cases. It is especially
in cases of advanced mitral disease in which the aurich'S
are overworked and distended, perhaps paralyzed, that
we get the most pronounced forms. Among other causes
of irregularity are myocarditis and fatty degeneration,
anamia, strain, and digitalis poisoning. The latter is
said to be often characterized by a pulsus trigeminus.
Vol. VI.— 51
One cause of pulse irregularity that requires special dis-
cussion is vagus inhibition. Some writers go so far as
to make influences reaching the heart through this nerve
almost the sole cause. Such a statement is tloubtless
an exaggeration, and yet many influences act reflexly
through the vagus in such a way as to cause irregularity.
Among these we ma.v include emotional shocks, such as
sudden joy, sorrow or fear, mental strain and worry,
gastrointestinal disturbance, pain, injury, cold, either
external or internal.
Fig. 3900 is a tracing from a patient in whom the
heart appeared quite normal. She had sutfered tnuch
from domestic trouble for .several months and it is
possible that that was the cause of the irregularity.
Fii;. 39U0.— Pulse stiowiiif; Preiiiiiture Systole.
To the finger on the wrist it seemed as though there
were an occasional intermission. The pulse tracing
shows that this was not a pulsus deficiens but merely a
weak beat (hemisystole). If careful measurements be
made it will be seen that the weak pulse beat comes a
little before it is expected (premature systole). One fre-
quently finds irregularities of this kind in people with-
out any other symptoms of disease. An instance which
came under my notice recently would suggest that it
may sometimes" be an hereditaiy peculiarity. I had the
opportunity of examining a father and son. both of whose
pulses were irregidar. In the father's pulse there was
a weak prematui-e systole at intervals varying from a few
beats up to thirty 'or more. In the son they occurred
every four or five beats if he kept very quiet, but slight
exertion caused the entire disappearance of the irregular-
ity. Both of these men have hearts rather below than
above the average size, and neither of them has any
symptoms of disease.
As to prognosis in cases of irrcgulurity. such cases as
those just mentioned in wliich tlie heart ajipears quite
soimd need not excite any alarm, especially if the irregu-
larity be known to be of long standing. If the heart is
dilat<;'d the case should receive more consideration. Cases
of diastolic irregularity in the young or convalescent need
not excite any alarm. ' It is a totally ditTerent thing when
an irregularity' develops in a case of old heart disease or
in the course of a fever. In both of these cases it suggests
overloading or paralysis of the auricles, and is a symp-
tom of danger. Cases of pneumonia in which the jiulse
becomes intermittent before the crisis are usually fatal.
As a rule, where people have an intermittent pulse dur-
ing health the onset of fever causes the intermission to
disappear. When this does not occur, it may be taken
as a danger signal. Generally speaking, the more rapid
the pulse the more serious is the occurrence of intermis-
sion or other irregularity. Irregularity can be given its
proper importance only when considered with other symp-
toms. If there are no other serious symptoms and the
heart can respond well to extra calls upon it, then irreg-
ularity is of little imjiortancc. When, on the contrary,
there "are other symptoms that the heart is laboring under
stress of work, then irregularity may be taken as an ad-
ditional bad sign, and the nioieso the higher the temper
ature and the more fre<iuent the pulse.
>V.'f or Excursion of the Pw/.ic— Pulsus magnus or
parvus, large or small pidse. These terms are used to
describe the sensation that the finger has of being lifted
as the pulse wave passes. When the .sensation is very
considerable we speak of a large pulse, when it is slight
of a small pulse. One naturally explains this sensation
by supposing that the artery expands as the result of
iiicreased tension. Many writers, however, among whom
801
Pulso.
PuUe.
REFERENCE HANDBOOK OP THE :MEniCAL SCIENCES.
Fig. 30111.— ijliver's ArtiTioiiipter.
Sir "William Broiiilbdit is proniiiicut, luiiiiiiiize the effect
of arterial expausiuii or deny its oecurreiiee. According
to tlicm llie fmgrr
pressing iiiion tlie
wrist pnslies in
or tlattens the ar-
tery lii^tween the
beats, but feels a
tendency of the
vessel to resume
its cylindrical
shajie under the
inereaseil tension
of the pulse wave.
This latter view-
seems very reason -
able, but some
slight expansion
nuist certainl)'
take ]iUice.
A large pulse
means that a large
(juautity of blood
is being forced
into the arterial
system at each
heart beat and
points to a power-
fully acting ventricle and unobstructed vessels.
A small ]iulse may be present in a variety of condi-
tions. It may be from the ]iresence of some disease of
the valves of the heart putting the ventricle at a disad-
vantage. It may be from .some obstruction between the
veutriele and the wrist, such as aortic stenosis, aneurism,
or tumor. Or the artery being examined may be abnor-
mally small on account of some other artery like the ulnar
being larger than usual. The most obvious cause of all
is a heart beating feebly.
If we get a small pulse in a contracted artery we call
it a wiry pulse, if the arterial tension is still considerable ;
if the tension is low and the pulse very small, we speak
of a thready pulse, which is seen in cases of severe shock
or where a patient is in extremis. A small pulse in a
relaxed vessel is sometimes spoken of as a trembling or
a running pulse.
QiiickiKHK of the Pulse. — Pulsus celer or tardus, quick
or slow pulse. These terms are properly applied not to
the rate of the pulse, but to the suddenness with which
the expansion of the vessel takes place. In the quick
pulse the sensation imjiarted to the tnugcr is that of a
sudden tap. In the slow pidse there is a sensation of
more gradual lifting or heaving, and the feeling of press-
ure lasts for an appreciable time. A cpiick
pulse is seen when the ventricle empties itself
easil.y. It is usually present when the blood
pressure is low, but not in aortic stenosis, for
then there is obstruction to the work of the
ventricle. The most characteristic form of
quick pulse is the Corrigan's or waterdiammer
pulse of aortic regurgitation. The character
of a slow pulse dilTers according to the posi-
tion where the obstruction to thcoulllowof
blood from the ventricle maybe. If the ob-
struction is at the aortic valves the pulse is
slow and of low ten.sion, as in aortic stenosis.
If the obstruction be in contracted peripheral
vessels, then the luilse is slow and of high
tension, as in chronic nephritis.
A dicriitic piihe is one where the dicrotic
wave can be felt as well as the primary wave — ^
It is characteristic of relaxed vessels with a
fairly strong heart action. It is most com-
mon" in fever where the arterial tension is
usually rather low. "When the blood pressure falls very
low. as in a failing heart, the dicrotic wave tends to dis-
apjiear. It will be more fully discussed in connection
with pulse tracings.
Symiuetry of the Pulse. — An examination of the pulse
Fic. 3002.-
is not complete without comiiaring the corresponding
arteries on the two sides of the bod}-. When there is a
difference on the two sides, it is necessary to trace up the
course of the vessel on the side where the jiulse is weak-
est. Somewhere in its course from the heart to the wrist
one may find a tumor or aneurism or deformity causing
pressure and partial obstruction. Dr. Allison, of Edin-
burgh, ma<le the claim in a clinical lecture some seventy
years ago that he had observed in a severe case of fever
that the pid.se had a fuller character on the side on which
the patient was lying,
lie ascribed this to the
influence of gravity act-
ing on weakened re-
laxed vessels much as
it would do after death,
I do not think there is
anything in Oliver's re-
cent experiments to ren-
der this unlikely.
Field of Response. —
This is a term suggested
by Mackenzie for the
ability of the heart to
rise to occasions. We
may also speak flgura-
tivel.v of the heart's
" bank account." This maybe investigated by noting
the effect upon the pulse of various degrees of exertion.
Sometimes a pulse which seems good when the patient is
resting changes its rale and character to such an extent
ou slight exertion as to indicate serious weakness. The
breathing should be noted and may furnish confirmation
of the o|iinion formed from the pulse. This is a method
of considerable value in estimating the seriousness of an
irregular jiulse. The less dangerous forms of irregular-
ity tend to disappear ou slight exeitiou, whereas ca.ses
due to a failing heart may be
expected to show increase
of irregularity and Ijreath-
lessncss.
IxsTRfMENlAL AtDS iu the
examination of the pulse.
T/ie eiillbrc of the nxsel may
be apjiroximately measured
by (Hirer's urteriomiter of
which an illustration is given
in Fig. 891)1. The principle is
that a jiointer on the gradu-
ated dial marks the distance
which the central foot has to
be pushed down from the
-Von Basoti's Sphvfrmo-
manometer.
a3:
Fig. SiHC— G.iertner's Tonometer.
time it liegins to jiress on the artery till it cpiite oblit-
erates it. The readings of this instrument may not be-
absolutely reliable, but it is suflieiently accurate for com-
paring the si/e of the same artery under different cir-
cumstances. In this way it has "been used by the in-
Sn2
refere:nce handbook of the medical sciences.
Pulse.
Pulse.
veiitor for working out the effect of various influences
on the vasomotor tone and the distribution of the blood
iu the body.
Arterial' Pressure. — A number of iuslrunients are on
the marliet for measuring the arterial pressure in mau
and several different principles are reiiresented. The
best known instrument for the purpose is perhaps the
sphiigmomaiutiiuterofTonBasch. This is shown in Fig.
3902. It consists of a capsule which is pressed upon the
radial artery until the pulse is obliterated below, aud a
dial and pointer which indicate how much pressure has
l)een exerted. It is ouly moderately accurate. Leonard
Hill claims that errors as great as from 30-70 mm. of
mercury are made with it. Much would doiibtless de-
pend upon the man using it. The tonometer eif Guertner
(Fig. 390.3) seems to be a very good iustrumcut. Dr. Oir,
of Montreal, reported at a recent meeting of the Canadian
Medical Association an exhaustive study of the pressure
in different diseases in which this instiumeut was used.
The most striking results were the high pressures ob-
tained in many cases of nephritis, and the fact that iu
cases of valvular disease of the heart the pressure average
was not very dilfereut from that found with sound hearts.
With this instrument we measure the amount of pressure
which must be e.\erted around a linger to prevent the
blood flowing through its vessels. The instrument as
shown is well adapted for the office, and a
more portable modification may be obtained
for carrying about.
Othei" instruments for measuring blood
pressure depend upon the principle that the
excursion of the pulse is greatest when the
pressures inside and outside the arterj' are
equal. The sphygmometers of Hill and Bar-
nard, the sphygmomanometer of Rita Rocci,
and the mod-
ification of it
used in the
Johns Hop-
kilis Hospi-
tal, and the
hmmodyiia-
mometer of
Oliver are all
of this type.
Of all these
the simplest
is one of the
two forms
invented bv
Hill and Bar-
nard (Fig. 3904). It consists of a vertical glass tube
five inches in length which expands above into a small
bulb and is closed at the top by a glass top. A small
india-rubber bag partly protected by a metal cup is
fixcil to the tube below. The bag is filled with col-
ored fluid, and on pressing it down upon an artery the
fluid rises in the tube and compresses the air iu the bulb.
The more one presses the more the fluid rises; at a cer-
tain height the lueuiscusof the fluid exhilnts more pulsa-
tion than at any other height. At this point tlie top of
the meniscus indicates the arterial pressure. This instru-
ment has been described at length because it is cheap,
siniide, and fairly accurate if carefully used.
The pulse wares may be made to record themselves
automatically by one o"f the various forms of sphygmo-
graphs. These "instruments, as already said, are contri-
vances by which movements of a blood-vessel arc trans-
mitted ti) a lever, which records them on smoked jiaper.
For the various forms of instrument and the method of
using them the reader is referred to the aitiele on Sphi/y-
mogriiphy. The product is a tracing, of which a normal
example has already been given in Fig. 3S97.
Criticism, and Appreciation of the Sphygntograph. — It
was thoiight for a time that the sphygmograph would
indicate, so that lie who ran might read, the ju'cssure,
size, aud quickness of the pulse, as well as the pecul-
iarities incident to various diseases; these hopes have
Fig. 3904.-SphyBmometer of Hill and Barnard.
proved vain, and we now know that the sphygmograph
is inferior to the finger in most of these points. One
great difficulty in the iuter|)retation of the sphygmogram
is that a great variety of tracings may be obtained from
the same pulse by siui]ily varying the pressure cif the
. : ^ h ,
K.h.'KKk^i
Fig. 39115.— Pulse Tracinsrs wlik-li sliow Efleut of Varying Pi\-ssure.
instrument or by employing different makes. Fig. 3905
shows three pulse ti'acin'gs taken within a few seconds of
each other from the radial arteiy of the writer. The differ-
ences are due to the pad being pressed down upon the
artery with varying foi'ce. Fig. 3906 shows tracings
taken, the upper" fiom the carotid, and the lower from
the radial of the same subject, within a few minutes of
one another. In this case the carotid was recorded by
air transmission and the radial by transmission through a
spring. Features are sometimes found in pulse tracings
which do not represent anything in the pulse at all, but are
dependent on inertia or rebound of the instrument.
In spite of all these pitfalls that beset us, however, it is
possible to take sphvgmogranis that will afford us much
information about the pi'dse and the conditions which
determine its character. In tracings we can see the prin-
cipal events of the pulse iu their proper time relations.
They show us what to feel for, and corroborate or con-
trovert the opinions we have formed of the pulse from
our tactile examination. The sphygmograph is very
useful as a guiile to those who are learning to feel the
pulse and in whose finger tips the tactile sense is not
fully educated. There are points about the pulse, too,
that eveu the most highly trained "thumb aud finger
fail to plumb " which are shown with ease by this in-
strument. The dicrotic wave and the predicrotic wave
usually belong to this category. In irregular pulses
we often have premature systoles or other weak heart
beats causing pulse waves too weak to be felt bv the
finger, but not too weak to be shown by the instrument.
Then tracings enable us to compare the time relations of
the waves iu different arteries or to compare the time of
the arterial pulse with the heart beat or with the venous
pulse. Such tracings are of value in working out the
late of propagation of the pulse and the direction in
which the waves travel. The venous pulse very oft<?n
can only be safely interpreted in the light of such simul-
taneous tracings.
It is doubtful whether sphygmography will ever be a
routine method in general practice, but for the siiecialist,
the teacher, and the investigator it is very valuable, aud,
when the elements are mastered, becomes an interesting
and instructive practice.
Normal Pulse Tracings— High and Low Prcssiin . — The
four tracings shown in Fig. 3907 are all taken from peo-
]ile iu good health without any eirculat(U-y or general
disease.
As far as tracings can do so, the first of these four
sphygmograms indicates rather high blood pressure and
Fig. 3iKKi.— Pu:se Traoinj-'s Takon from the Carotid iC) and the
Radial (A').
the last one low pressure, while the two between repre-
.sent intermediate conditions. One is safer in trusting
the finger for indications of the arterial pressure than in
803
Pulse,
Pulse.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
trying,' to read it from a tracing, but attention to tlie fol-
lowinir points usually enables one to form a fairly correct
opioinn from a tracing. In the first iilaci- the tracing
must be taken liy a person of experience. A |)oorly
aw 17.-. Normal Pulse
Ti'aciii^s, iQdiL'atinf^ Different Arterial
Pressures.
taken tracing is very misleading. Where the blood press-
ure is liigli the rise and fall of the ivaves are moi'e grad-
ual, in low blood pressure quick or steep. In high blood
pressure the dicrotic wave is small and high up on the
descent. As the blood pressure becomes lower this wave
becomes more distinct and approaches nearer to the l)a.se
line, and may appear as a wave rivalling the primary
wave in .size and se]iarated fi'om it by a distinct interval.
If the lilood prcssiu-e lieeoines very low indeed, as in car-
diac failure, then the dicrotic wave becomes smaller again
and may (piite disajipear. A well-marked dicrotic wave
is a sign of rela.xed peripheral vessels and not of a weakly
beating heart. It is seen best developed at the beginning
of fevers when the skin is hot and the lilood disti'ibuted
to the surface, but the heart still beating strongly.
The preilicrotic wave is nmst pronounced in cases in
which thei'c is most resistance to the outllow fiom the
ventricle, and therefore usually indicates high blood
pressure. It is also seen, however, in aortic stenosis (see
Fig. 3899). A practical rule tnr jmlging of the prcdicrotic
wave is given by Gilxson: "Di-aw a line from the top of
the primary wave to the lowest point of the dicrotic
notch." If the prcdicrotic wave fails to reach this line
the ]Mdse is of low or medium pressiu'c. If the ]>i'edi-
crotie wave rises higher and crosses this line the pulse is
of high pressure (better, the resistance to outflow of hlnod
from the ventricle is great). Another peculiarity often
Fig. ams.— lligh-Tensiuu Pulse. (Ilutchisou and Kaiuey.)
seen in high-pressure pulse tracings is the presence of
several o.scillalion waves on the descent such as those .seen
in parts of Fig. 3908.
When interpreting tracings it is well to beiir in mind
that the part from the beginning of the primary wave to
the Ijottom of the dicrotic notch corresponds to the time
when the blood is being driven out of the ventricle into
tlie arterial system. This almost corresponds with the
ventricular systole, and may conveniently be called t/ie
xystdlic portion oi the tracing. From the bottom of the
<iicrotic notch to the beginning of the next primary wave
the aortic valves are closed and no blood is leaving the
ventricle. This may be called the.diastolie poi'tion of the
tracing.
Any peculiarities in the systolic portion may usually
lie traced to the ventricle; but the diastolic imrticm can-
not depend directly upon the ventricle, as during this
time the aortic valves sluitofl the arteries from tlie heart.
Viiriation in the rate of the pidse is brou.nht about prin-
cipally by shdrleniiig or lengthenipg of the diastolic jior-
Fic. 391)9.— Frequent Pulse.
tion. Thus in an infrequent pulse like that in Fig. 3908
the diastolic portion which I have marked D is about
twice as long as the systolic portion 8, whereas in Fig.
39119 where the pulse was 130 as the result of a fever, the
two portions are of about e(iiial duration.
In some ca.ses the shortening of the diastolic portion
takes place to such an extent that the next percussion
wave commences before the dicrotic wave is complete
and cuts into the descending limb of the latter. The
result is a tracing like that shown in Fig. 3910. 6' is
the percussion and D the dicrotic wave. It will be
noticed that the dicrotic notch JV' is the lowest part of
the tracing. Such a tracing is called hypcrdicrotic or ««-
perdicrotk.
The Pulse in Various Pathological Conditions.
— Affections of the Aortic Voire. — The pulse of aortic
regurgitation is one of the most typical, and is known as
Corrigon's piilie, from Sir Dominic Corrigan, who was one
of the tirst to describe it, or as the tri(ter-/unumer pi/lne
from a toy of that name that gives a sudden shock to the
Fig. 3910.— Uyperdicrotic Pulse. (Maekeuzie.;
fingers. Corrigan 's pulse may be described as large and
quick, usually infrequent ami regular. It is sometimes
described as collapsin.g because the vessel seems to be-
come empty between the imlse beats. The impression
given to the finger is that of a momentary tap.
The peculiarities of Corrigan 's pul.se are best made out
by raising the patient's arm high above his head while
feeling liis radial.
The statement made by Henderson, Balfour, and others
that the rate of propagation is slower in aortic regurgi-
tation than where the heart and vessels are normal has
been shown liy Fran(;ois Frank, Keyt, and Mackenzie to
be without foundation. A ]irominent feature of aortic
regurgitation is the violent throbbing of the vessels of
the neck. A capillary pulse may also usually be seen.
In .some cases the pulse wave passes right through the
capillaries into the veins and may be observed in the
veins of the hack of the hand, and, sometimes, a tracing
may be obtained of this rare form of venous pulse. Such
a tracing is figured in Gibson's book on the heart.
S(i4
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pulse.
Pulse.
Tracin.gs froiii the radial in aortic regurgitation are
charaetorizc'd liy a steep rise and fall of the percussion
wave aud by the fact that the predicrotic wave is usually
more pronounced than the dicrotic. The tracing shown
Fig. 3911.— Aortic Regurgitation.
in Fig. 3911 is from a case of moderate severity and illus-
trates these points. In a more pronounced case the di-
crotic wave would be still less marked or even ab.seut al-
together, and the percu.ssion wave might be even steeper
in its rise and fall. The presence of a fairly pronounced
dicrotic wave does not, be it noted, exclude a moderate
degree of aortic regurgitation.
The pulse of aortic stenosis is not so characteristic as
that of regurgitation. It usually feels slow and sustained
to the examining finger, is of normal or diminished fre-
quencj", and, like that of aortic regurgitation, regular in
rhythm and volume. The tracing is usually anacrotic
(see Fig. 3899). The prcdiciotic wave rises higher than
the primary, indicating the difficulty the ventricle has in
emptying itself. The details vary in different cases.
Sometimes the primary and predicrotic waves form two
well-marked crests separated by a distinct depression,
forming the so-called jnilsus bisfericns. In other cases in-
stead of the tracing being anacrotic we may simply have
a priniarj- wave with a gradual rise aud a rounded crest,
followed by a poorly marked dicrotic wave.
In mitral regurgitation and mitral stenosis the pulse
may be quite indistinguishable from the normal. As
one or other of these diseases progresses, however, di-
latation of the ventricle, and especially of the auricle,
takes place; then the pulse tends to become weak, rapid,
and markedly irregular in both rhythm ami volume, con-
stituting the so-called " mitral pulse." This pulse varies
so much in its details in different cases that it is useless
to figure any one form as typical.
Afiections fif the Heart Musele. — There is nothing uni-
form or typical about the pul.se in these conditions. It
may be abnormally slow or fast or irregular. The car-
diac field of response is diminished. Any departure of
the pulse from the normal rate or rhythm should lead one
among other things to consider the probability of the
heart muscle being diseased, but other considerations be-
sides the pidse will have to be depended on for the solu-
tion of the question.
The presence of the pulsus paradoxus in certain cases
of adhesive periearditis has already been referred to.
In aneurism of the transverse part of the aorta the left
radial pulse is often smaller and slower than the right.
It sometimes feels delayed too, but this is questioned by
some writers. The exact character of the radial pulse
varies gi-eatly in cases of aneurism according to the sitii-
ation of the disease, the degree of degeneration of the
vessels generally, and the condition of the aortic valves.
Fig. 3913 shows simultaneous ti'aeings from the aneurism
and the right radial in a case in which a large pulsating
aneurism extended from the chest up the right side of the
neck. The exaggeration of the predicrotic wave seen in
this tracing seems to be very common in aneurism, as it
is in both forms of aortic valvular disease.
Iiiferer we have to distinguish between the effect of
the pyrexia as such upon the pulse and the elTcct of the
disease causing the pyrexia. Moderate pyrexia tends to
modifj' the pulse through both the heart and the periph-
eral resistance. The heart is made to beat more rapidly,
partly by a direct action of the increased temperature on
the heart tissue itself, and parti}' indirectly through the
cardiac centres in the medulla. The superficial arteries
are dilated aud an increased amovint of blood is carried to
the skin. The effect of these changes is to cause a pulse
of increased frequency and diminished pressure with ex-
aggeration of the dicrotic' wave. To the finger such a
pulse feels frequent, large, aud soft. It is often referred
to as bounding. A tracing would more or less approach
the type shown in Fig. 3913.
If the pyrexia runs high or lasts long the heart suffers
and becomes feeble aud often irregular. In such cases
the pulse is verj- frequent and is small, soft, and com-
pressible. Tracings taken at intervals, when the heart
is failing, show gradual disappearance of the dicrotic
wave, the absence of which in a case of fever is usually
a very bad sign. Irregulai'ity of the pulse in the early
stages of a fever or increase of rate in an adult beyond
140 per minute are symptoms which usually indicate
great danger. During convalescence slight irregularity
is common aud of little significance. The character of
the pulse in fever ma}' be much modified by other influ-
ences, such as s]ieciHc poisons or mechanical interference.
SUJIM.\]!V OF THE Dl.\GNOSTIC VALUE OF THE PuLSE.
— The pulse furnishes the best single indication of the
state of efticiency of the circulation. In it we find indi-
cations both of the condition of the vessel walls aud of
the strength of the heart beat.
Very important information may be obtained by ob-
serving the changes in the pulse during bodil_v activity.
The discovery of high tension may direct our attention
to the presence of nephritis or litha'Uiia.
In aortic valvular di.sease a quick collapsing pulse or a
Fig. 3912.— Simultaneous Tracings from a Thoracic Aneurism and
trom the Riglit Radial Artery.
slow, small pulse will indicate the predominance of re-
gurgitation or stenosis.
In mitral valvular disease a rapid irregular pulse is
suggestive of loss of compensation and dilated or para-
lyzed auricles.
In pericarditis with effusion, where the heart sounds
are faint, the pulse is of especial value in indicating the
degree of cardiac failure.
In fever the rate, the tension, and the presence or ab-
sence of irregularity are of great prognostic value. A
sudden change in the ptdse may be the first indication of
a crisis or a fresh complication. In many diseases the
pulse is of value in furnishing indications for treatment
(stimulants) and in exhibiting the effect of the remedies
used.
In the search for all these indications the finger is the
best means toemplo}'. In special cases some of the more
elaborate insti'uments may furnish additional or confir-
matory information.
The VEXors Pulse. — hitroduetorji. — The term venous
pulse is applied to changes in size and tension occurring
in the veins as the result of theaction of the heart. The
Fig. 3yi3. — rulse in siln'iiic Fever. (Mackenzie, i
distention and collapse of the veins caused by the alter-
nate phases of respiration are not included. A true
venous pulse in a healthy animal .seems to have been first
described by Wedemeyer of Hamburg, in 1828. He
made his observations on a horse. Since that time nu-
merous physiologists have seen aud recorded the venous
805
Pulse.
Piilsf.
REFERENCE IIANDDUOK OF THE MEDICAL SCIENCES.
pulse ill licaltliy dogs, cats, ralibits, ami (illicr animals.
It lias lict'ii iKiti'd in llie veins of the tliiira.\. luck, alxlo-
men. ami linilis. jMc>s.so obtained the tii'st venons luilse
tracinij Inmi a liiimau subject iu 1879. Since then those
Fig. 3UU. — Negative VeiKnis l*iilse (dofii.
who have looked for it in man have found it to be very
common. In the writer's experience it may be seen and
recorded iu the majority of people by those who make
the examination under suitalile conditions. It is most
frequently seen in the jugular veins, external and inter-
nal. In the case of the external jugular one can usually
see the blue vein through tlie skin : in the case of the in-
ternal jugularone can see the movements im|iarted to the
skin over it. Sometimes one vein can be seen best, some-
times theolher. For the observation of the venous pulse
two conditions are usually necessary, viz., that the veins
be reasonably distended with blood, and that the neck be
not too fat. Proliably in the majority of jieople the re-
cumbent position is necessary for it to be recognizable.
For the method of taking tracings of the veuous pulse
see Sphiirimographij.
V.Muous Forms op Venous Pulse. — Tlie venous
pulse is seen in many dilTerent forms. This renders its
study more dillicult than that of the arterial and has dis-
couraged many from undertaking it. Its mollifications,
however, may be traced with considerable confidence to
their respective causes, and are replete with indications
of the condition of tlie heart for those who will take the
trouble to familiarize themselves with them. James
Mackenzie, who has written more exhaustively on the
venous pulse than any otlier English writer, claims that
it "gives us far more information of what is actually
going on within the chambers of the heart" than the
arterial jnilse.
The jirinci-
]iul forms met
with may be
designated ac-
cording to
their place of
<irigin as:
1. Auricu-
lar, negative,
iir normal.
2. Ventricu-
lar, positive, or
]iathologi(al.
?,. Arterial.
4. The niod-
ilied negative
of an ricu lar
paralysis.
Tlie iMirifii-
liir or luyiitirc
venous pulse
follows very
closely the
curve of pre.ss-
ure in the
right auricle.
It is obtained
in its most
complete form
when the pulse
is not too frecjuent. Fig. 3914 is taken from the internal
jugular of a dog under" the influence of morphine with
a I'ulse rate of 45 per minute.
It will be observed that the down strokes in the trac-
-\V^\r^\
no. 391.5.— f'lirves of Auricular (aliovi'i iirid
Veniricular Pressures, from a Pdg. Tune iu
seconds.
ing which denote the collapse of the vein (negative pulse)
are far .ste.eper than the rises which indicate refilling.
The fall beginning at 1 is called the si/ntolk cullnpse, and
is due to the diastole of the auricle drawing in blood
from the veins during the ventricular sj'Stole. The tall
beginning at 2 is the dirtstolie collapse due to the dias-
tole of the ventricle. Theascending portions of the trac-
ing, which indicate filling of the veins, are caused princi-
pally by the blood flowing in from the capillaries faster
than the heart can receive it. Just before the systolic
ciillapse ( 1 ), however, we may in some cases observe two
small elevations. \.hepnfii/stiilica.n(l the «,//sM(> ?w. These
may be trace<l back to their origin in the systole of the
auricle and of the ventricle. We speak of the long asceut
leading up to these waves as the diantoUc rise. The
irregularities at the beginning and in the middle of this
diastolic ri.se are unexplained. The interpretation given
above of the .sj'stolic rise as due to an impact propagated
backward through the auricle and veins by the ventric-
ular systole is disputed by some writers (Mackenzie), who
Fni. 3'JIIJ.— Three Types uf .Netiaiive or Auricular Venous Pulse
Hiumau).
ascribe it entirely to a shock imparted to the vein by the
pulse iu the carotid. This view is doubtless partly true,
as there is often a wave iu the venous pulse due to the
carotid impact; but it is equally true that there is quite
frequently a wave at the to]) of the diastolic rise that can
be found both in the venous pulse and in the curve of
auricular pressure, and that may be shown to be syn-
chronous with the ventricular systole. In Fig. 3915
simultaneous tracings are shown of the pressures in the
right auricle and ventricle of a dog taken with Hijrthle's
catheter. Corresponding points of time are marked by
the vertical lines. It will be noted that there is a very
distinct wave in the auricle synchronous with the ven-
tricular systole. This is no doubt due to the rise of press-
ure in the ventricle pushing the tricuspid valves back
and thus imparting a shock to the auricle.
For the rise in the tracing (Fig. 3914), leading up to 3
there is, so far as I know, no satisfactory name. Some
writers call it the first diastolic rise, but it is systolic iu
time. Others call it the ventricular rise, but it is not
caused by the ventricle but by the blood flowing in from
the periphery. Arational term to apply to it would be
the jindiiisti'h'c rise, for it leads up to and is interrupted
by the ventricular diastole.
AVlien the pulse is fivquent the waves are crowded to-
gether, and some of those described are not seen at all or
cannot be identified. Take, for instance. Fig. 3910 where
three examples are given of venous pulse tracings from
liunian subjects. It is very ditticult to distinguish the
ditferent waves described above in these three tracings.
In the hist of the three a method is shown bj' which tlie
difficulty may be partially .solved. In this, simultaneous
sor,
REFERENCE HANDBOOK OP THE IHEDICAL SCIENCES.
Pulse.
Pulse.
records are taken from the external jugular vein (above)
and the radial artery (beloiv). Corresponding points of
time are marked im the two traeings, and by these it can
be seen tliat synchronotiswitli the rise of the radial pulse
tracing there is a fall in the venous, the systolic collapse.
Fig. 3917.— Ventricular Vi'uous Pulse (belowi; Kadial Pulse (above).
(Mackenzie.)
This systolic collapse alone is sufficient to prove the ven-
ous pulse to be of the auricular or negative variety.
L'sing the radial pulse as a guide, it is possible to tiiid
traces of the other waves described as typicak altliough
they are not veiy distinct. Be it noted here that the
sj'stolic and diastolic portions of the jugular pulse corre-
spond very closely in time with the systolic and diastolic
portions of the radial pulse, because, as has been pointed
out by the writer, the greater distance of the radial from
the heart is compensated for by the fact that the rate of
propagation of the venous pulse is only about one-third
that of the arterial.
As a rule, the auricular venous pulse can be readily
recognized without taking a tracing. It is characterized
by a sudden collapse of the veins of the neck followed by
a more gradual filling. AVhere the pulse is infrequent the
collapse is double, corresponding to the systolic aud dias-
tolic collapse seen in a tiacing (Fig. 3914). The proper
organ for the e.xamination of the venous pulse is the
eye, and it is best seen with the patient reclining with
the head on a level with the body (no pillow). The finger
is of little use as the changes in tension arc too slight to
be appreciated by it. It is a g0(jd jilan to have the finger
on the radial as a guide to tlie time relations. In cases of
doubt, as when the pulse is frequent, simultaneous trac-
ings must be taken of the jugular pulse, and cither the
ape.v beat, or the carotid, or the radial.
The presence of the auricular venous pulse has little
significance. I have .seen it at all ages fiom infancy to
old age. and have recognized and recorded it in healthy
and athletic young men as well as in a variety of diseased
conditions. It is practically never absent from health}-
dogs, and I believe tliat when it cannot be observed in a
human subject, who is in a proper po.sition for observation,
it is because the tissuesof the neck are too thick for it to
show through rather than because it is not there. It is
more marked than usual when the tissues of the neck are
specially thin or when the veins of the neck are distended.
For it to be seen at its best the heart must still be beating
with fair vigor. Among the conditions in which the auric-
ular venous pulse is pronounced are nearly all forms of
emaciation and general debility, diseases in which the
entrance of blood into the chest is interfered with, such
as rickets and chronic coughs, conditions in which there
is slight dilatation of the heart as at the end of long con-
tintied fevers or in the various forms of anaemia.
The reittric'ilfir or pomtire renovs pulae is seen where
the high pressure existing in the ventricle during systole
is transmitted to the veins so as to prevent the usual
sj'stolic collapse. In a typical ventricular venotis pulse
the only collapse we have in the veins is the diastolic
collapse caused by the blood being sucked in by the
diastole of the ventricle. In these cases the veins of the
neck can usually be seen to be distended, and the pulse
can be seen in them even with the patient standing or
sitting up. Moreover, the filling or distention of the
veins is seen to take place, or, at least, to be completed
suddenly, and the finger can detect a positive impact
corresponding in time with the carotid pulse. Simulta-
neous tracings from the jugular vein and the radial artery
show absence of the usual systolic collapse. Instead, we
see a continued rise or a sustained elevation of the tracing
during the ventricular systole, succeeded by a sudden
diastolic fall. These points may be very well seen in
Fig. 3917. In this figure siTuultaneous points of time
in the radial and jugular pulses are marked by vertical
lines including between them the systolic period E. It
will be noted that the venous pulse consists of a single
large wave with a divided crest, and that the only pro
nouuced collapse is after the systole is over. A somewhat
less typical case observed by the writer is shown in Fig.
3918. This was taken from a case of tricuspid regurgi-
tation in which compensation had been partly restored by
digitalis.
The ventricular venous pulse is found in three con-
ditions. By far the most usual cause of it is tricuspid
ngurgitiiti'jti, but it cannot quite be called pathogno-
monic of this lesion, as there are two other rare condi-
tions in which it is found. One of these is mitral regur-
gitation with patent foramen ovale, of which a case was
recently reported in " The Johns Hopkins' Hospital Bul-
letin " by W. S. MacCallum. The other is adhesive
pericarditis, in which the contraction of the ventricle
draws in the thoracic wall and causes compression of the
thoracic viscera; sufficient pressure is thus exerted on the
great veins to initiate a positive wave which is propa-
gated into the veins of the neck.
The ventricular pulse may in some cases be confounded
with the pulse of auricular paralysis which will be de-
scribed shortly.
The arterial venous ptitse includes four different forms
of pulsation in the veins, of which none call for more
than a mention.
1. A pulse may be transmitted from the arteries
through the capillaries in aortic regurgitation or where
there is great dilatation of the periplieral vessels.
2. Cases are on record in which there has been an anas-
tomosis between a peripheral artery and vein with conse-
([uent transmission of a pulse.
3. Pul.sations which are arterial in origin are sometimes
seen in the veins of closed cavities like the eyeball.
4. Veins may have a pulsation tiansmitted to them
from arteries as a result of mere juxtaposition. This
last fact must be remembered in interpreting the tracings
obtained from the veins of the neck, especially the inter-
nal jugular, as frequently one of the waves seen is due
to the impact of the carotid upon the vein. Such waves
aie best identified by comparing the tracing with a simul-
taneous one from an artery.
The Te7i<ius Pulse of Auricular Paralysis. — When the
auricle is paralyzed the presystolic (auricular) wave is
absent and so is the systolic collapse (auricular diastole).
Tlie tracings obtained are very similar in form to those
of tricuspid regurgitation, as the tracing continues to rise
until the ventricular systole is complete, and then a fall
due to the ventricular diastole occurs. The venous pidse
of auricular paialysis with competent tricuspid valves
can be distinguished from the systolic pulse of tricuspid
regurgitation better by the finger than from a tracing.
In a tracing, it is true, the rise is more uniform and grad-
ual in auricular paralysis than in the ventricular pulse
where a systolic elevation may be made out; but in some
Fig. 3918.— Venous Pulse from External Jugular (above); Arterial
Pulse froiu Radial (below).
cases it is difficult to decide from a tracing which we have
to deal with. The finger, on the contrary, can recognize
a distinct positive impact in the veins in the case of a
ventricular venous pulse, whereas in the pulse of auric-
ular paralysis no such positive impact is felt. Fig. 3919
807
Piinipkiii Seeds.
Piir^aliies.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
shows a tracing such as we sometimes meet with. This is
from au old woman with a dilated and irregular lieart,
but no murmurs. The venous tracing shows, as a rule,
Fig. 3919.— Jugular Puis.' ial«ivp\ Radial (below). Corresponding
pouUs arf^ marked.
the most pronounced collapse during diastole and re-
sembles somewhat the ventricular pulse .shown iu Fig.
y!U8. There was no jiositivelieat in the veins of thcnecU.
however, and there were no heart murmurs, .so I ascribed
the condition to dilatation and threatening paralysis of
the auricles without any serious amount of regurgitation.
In this tracing a presystolic rise and systolic collapse are
occasionally seen, so that tlie paralysis of the auricles was
not absolute.
The Venoi's Pulse in Ii!hegii..\u He.\I!T Actios.
— A number of observers have recently been making use
of the venous pulse as a means of deriding the primary
seat of irreguUirity in tlie rhythm of the heart. One ex-
ample wilThave to sulliee. " Fig. 8920 is a tracing talven
from one of the cases referred to, in discussing tlie arte-
rial pulse, of a father and son, both in good health and
botli with irregular pulses. This tracing is taken from
the .son. The venous ])ulse is small, as is usually the case
Fig. SiOi.-
-JuKular Pulse Oihove); Radial (belt>\^). Correspouding
points are marked.
in a healthy adult, but sufflees for the purpose. An irreg-
ularity may be seen in both the arterial and the vencnis
pulse of the natureof a premature beat. In theordinary
beats ]ireeediiig and following the ]ueinature one, a faint
wave may be delected in the venous |ndse synchronous
with the primary wave in the radial. This is the systolic
wave. Just preceding the systolic wave a fainter one
whieli is presystolic and due to the auricular systole may
be seen. In the venous beat corresponding to the prema-
ture wave in the radial a systolic wave may also be seen,
but the auricular wave follows it instead of jueceding it,
showing that the auricle iu this case conlracts after the
ventricle, and therefore tlie anomalous stimulus causing
the lU'cmature beat must have acted on the ventricle. If
measurements be made it will be found that the jiulse
intervals on either side of the premature beat are together
equal to the preceding and succeeding ones, or to two
average pulses. This, according to Ilering, Cushny, and
Fig. 31121.— ,\urieular Liver Pulse.
lers. points to tlie auricle not being imiilicited iu the
egularity. When the auricle is the primary seat of
others
irre^^ _, . . . _
the disturbed rhythm, such a correspondence is not usu-
ally found. This rule is said by Gerhard! , howevei
to
be not without exceptions. The full importance of thus
difEerentiating the seat of the irregularity is not fully
worked out, but on the whole those cases in which the
ii'regularity is confined to the ventricle are less serious
than those in which the auricle is also irregular in its
rhythm.
The Liver Pulse. — A pulsation can be felt and re-
corded in the liver in certain cases in wliich the right
side of the heart and the veins are much distended.
In some cases the tracing lias the form corresponding
to the auricular venous pulse. In these cases, accord-
ing to Mackenzie, then" are usually tricuspid stenosis
and auricular hypertrophy, as the normally weak auricu-
lar waves have not force enough to make themselves
felt in the liver.
In other cases the liver pulse has the characters of the
ventricular venous pulse, anil then we may lie reasonably
Fig.
Ventrk-ular Liver Pulse. (.Carotid above : liver below.>
certain of the existence of tricuspid regurgitation. Trac-
ings of tliese two forms of liver pulse taken from ^lac-
kenzie's book are shown in Fig. 3021 and Fig. 3923.
C.iPn.L,\uy Pulse. — This consists in alternate redden-
ing and paling of an area of the skin with each lu>art
beat. It is most freipiently looked for in the bed of the
finger nails, and may be bmught out most distinctlv by
raising the arm. Quincke, wlio first described the cajul-
lary pulse, recommends rubbing gently a spot upon the
forehead and looking for it there. Tlie capillary pulse
may be taken as an indication of aortic regurgitation
with a strongly acting ventricle (hypertrophied).
iVlUiain S. Morrow.
References.
I desire to aoknowledce my speoial indebtedness to the book on
the ptilsf. hv .lanii's .Ma<ke[izi"-. and warmly Im rt'iiimuKMid it to those-
desiring' t" read soint'tliint: uinie e.xbaiistive than Ilii> article.
I have als" reeeived liel|i from tlie follfwUiir : The plivsiolotrles of
Schaefer, Halliburt<in. Houell ami Hall; Vieronlfs "Mediial Diagno-
sis"; Hutehisonand Rainy 's ■'cliiijcal .Methods" ; IVibsou's " liis«ises
of the Heart"; Balfour's " l)isea.^es of the Heart"; Katrse's "Praetiee
of Medieiue"; Greeu's "Examination for Life Insurance "; Ewart's-
" Heart Studies " ; HUrthle's "BeithiKe zur Hiemodyuamik " in Pflii-
irer's Archly, vol. xlix. ; D. Gerhardt's " Klinisehe' Untersuchunffen
liber Venenpulsationen "and " F,ini».'e IJi'i.bachtunffen au Venenpulsen '^
in .\relilv fiir ex|>erimental Path. ii. Phar., vols, xxxiv. and xlvii. ;
Karl Schmidt, Jr., "Herz-Kammer Svstol,. und Putseeiirve." ptliit^er's
Archly, 19(13. Heft r, u. 6; W. S. MacMallum. .lohns Hopkins IPispital
Bulletin, March, ItKlfl; Cushny, "On Iiileniiilieni Pulse," Ittitish .Med.
Journ., September 29th, 1900. A good blblioKiaphy will be fouud in
Gibson's " Diseases of Heart and Aorta."
PUMPKIN SEEDS.— Pfpo, U. S. P. Semen. Peponis.
The dried rijie seed of Cucurbita pepo L. (fam. Cucurhi-
tamc).
The nativity of the pumpkin is not certainly known,
though it was probably North American. It presents
numerous varieties, ami the squashes, at least some of
them, have been regarded by some botanists as pertaining
to the same species. Although sijuash seeds appear to
possess similar properties, they are not included, as a
drug, under the above title.
Pumpkin seeds are about 3 cm, (i in.) long, broadly
ovate, tiat, wliite, or whitish, nearly smooth, having a
shallow groove near to and parallelwith the edge; con-
taining a short conical ratlicle and two flat cotyledons;
inodorous; taste, bland and oily.
The active constituent is supposed to be a small amount
of a soft, green, acrid, and bitter resin, which possesses
tlie same properties as the entire drug. AVith this there
808
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pumpkin Seeds,
Piirgalivcs.
exists a yellow or soraewliat reddish-yellow, bland fixed
oil, to the extent of about thirty-five per cent., a little
sugar, crystallizable albumin, and other unimportant
constituents. The oil, which consists of glycerides of
palmitic, myrislie, and oleic acid, portions of whicli
acids also exist in a free slate, has been credited with the
properties of the drug, but possibly, if pure, does not
possess them.
Pumpkin seeds are markedly diuretic, but their medic-
inal use is as a pleasant and moderately certain ta'nicide.
Only the kernel should be used, and it is commoidy given
in the form of an electuary or emulsion, the dose amount-
ing to from 25 to 50 gm. { 3 f to % iss. ). Fifteen grains
of the resin is an equally efficient dose, though not so
pleasiint.
Throughout the West Indies, Mexico, Central America,
and man_v other countries, ]ium]ikin seeds, as well as
squash seeds, are largely constuned as food.
Henry II. Rxisby.
PURGATIN.— Purgatol, anthrapurpurin diacetyl ester,
is an odorless, tasteless, j'ellowish-broun powder recom-
mended by von Hosslin as an agreeable laxative. It acts
slowly, requiring thirteen to twenty-four hours, and pro-
duces a copious, non-liquid stool. The urine is colored
red. Dose, 0..5-3 gm. (gr. viij.-xxx.).
ir. A. Bastedo.
PURGATIVES, OR CATHARTICS, aie medicines
which are used to produce alvine evacuations. Accord-
ing to tlieir activity and power, they are divided into
laxatives and mild and drastic purgatives.
Purgatives which act very gently, producing soft, fec-
ulent stools without notable irritation, are called larn-
tii-es. This term is also applied to more powerful pur-
gatives when they are given in small doses, so as to act
mildly. (See Lti.ratu-rs in Vol. V.)
Purgatives which operate briskly, usually producing
more or less fluid evacuations, sometimes with griping
and tenesmus, but without serious irritation, are called
7nild or simple purgatives. To this group belong some of
the salts of magnesium, sodium, and jiotassium, which,
from their resemblance in chemical and physical proper-
ties, and in physiological action, are termed saline pur-
gatives.
The term drastic is applied to those purgatives which
operate energetically, producing numerous evacuations,
and, in excessive doses, more or less gastrointestinal irri-
tation.
Purgatives which produce watery stools, especially the
salines and some of the drastics, are called hyilrayarjues,
and those which cause the evacuation of large quantities
of bile, cholagogties.
Mode of Action. — All purgatives accelerate the peri-
staltic movements of the intestines. Radziejewsky care-
fully observed the rapidity of peristalsis iu dogs, both
before and after the administration of purgatives. In
the normal state the movements of the small intestine
were rapid, those of the large intestine verj- slow. After
the administration of purgatives, the movements of both
became much accelerated, but most markedly those of
the large intestine.
It was assumed that purgatives, especially the hydra-
gogues, also induce a discharge of fluid from the intes-
tinal mucous membrane. Experiments on animals at
first seemed to show that this was an error. Thiry com-
pletely separated a portion of the small intestine from
the rest of the bowel, without dividing its vessels and
nerves, sewed up one end. wlilch was returned into the
abdominal cavity, and attached the open end to the
wound in the abdominal wall. Into the cul-de-sac thus
formed lie introduced croton oil. senna, and Epsom salt.
No accumulation of fluid took place. Schilf experi-
mented in a similar manner with aloes, jalap, and sul-
phate of sodium, and Radziejewsky with croton oil and
sulphate of magnesium, both with the same negative
result. Radziejewsky also analyzed the fa'ces before
and after the administration of purgatives. The evacu-
ations produced by purgatives contained more water and
sodium salts than normal ffeces, and sometimes products
of pancreatic digestion, but never as much albumin as
should have been present if transudation of fluid from
the intestinal blood-vessels had taken place. It was there-
fore concluded by these investigators, and is si ill main-
tained by some recent authors, that purgatives do not
induce either transudation or increasedsecretion, and
that the watery character of the stools results only from
the greatly accelerated peristalsis, which interferes with
the absorption of the fluid normally secreted.
Butsubsequent investigations yielded different results.
Moreau introduced sulphate of magnesium into a portion
of intestine isolated by means of two ligatures, and after
some hours found a decided accumulation of fluid.
Brunton, experimenting in a similar manner, found that
croton oil, gamboge, elatcrin, and Epsom salt caused a
decided accumulation of fluid. That the accumulated
fluid was not a transudation was evident from the fact
that it contained very little albumin. Brieger injected
into an isolated portion of Intestine very small quantities
of colocynth. No accumulation of fluid took place, but
the bowel was contracted and slightly reddened. Larger
quantities of colocynth, as well as croton oil, caused an
accumulation of bloody fluid, with decided inflammation
of the mucous membrane. After injecting calomel,
senna, rhubarb, aloes, and castor oil, Brieger found tlie
bowel empty and firmly contracted. Sulphate of mag-
nesium in very dilute solution caused no accumiflation
of fluid, but concentrated solutions of this .salt, so also
Glauber salt, caused very decided accumulation. That
the fluid was a secretion, and not a transudation, was
evident from the fact that it readily converted starch into
sugar and dissolved raw fibrin.
Thus it has been found in experiments that sulphate of
magnesimu, sulphate of sodium, croton oil, gamboge,
colocynth, and elaterlu, not only accelerate the peristaltic
movements of the intestines, but also induce a secretion
of wateiy fluid from the intestinal mucous membrane;
and that castor oil, rhubarb, aloes, senna, calomel, and
minute quantities of colocynth accelerate peristalsis, but
do not notably increase secretion.
Hess, in experiments on dogs, endeavored to determine
the manner in which purgatives increase the peristaltic
contractions. He made gastric fistula' a short distance
from the pylorus, so that he could easily intrmluce ptir-
gatives into the duodenum. After paving determined
the quantity of the purgative (sulphate of sodium, castor
oil, croton oil, senna, colocvnth. gamboge, and calomel)
which would act briskly, he iutroducedinto the duode-
num a .small, empty india-rubber ball, to which was at-
tached a long, fine india-rubber ttibe. After this had
been carried by the normal peristaltic contractions a cer-
tain distance, which varied in the different experiments,
he filled it with water to such a degree as to obstruct the
bowel. The purgatives which previouslj- had acted
briskl)- then completely failed. Hess therefore concluded
that the peristaltic movements excited by purgatives are
probably not propagated through long distances by means
of nervous apparatus, or. according to Engelmann, from
muscle to muscle, but that they are reflexly excited in
each part of the intestine by direct stimulation of its
mucous membrane.
Mii^n PfHG.\TiVEs. — Of the purgatives wliichact vig-
orously, without causing severe irritation of the intes-
tines, the following are commonly employed; aloes, rhu-
barb, senna, castor oil, salines, and mercurials.
Alnes. — In large doses, from five to twenty grains, aloes
produces semi-liquid or liquid stools. The first evacua-
tion rarely occurs before six hours, and often not before
ten or twelve hours. Some griping usually precedes the
evacuations, and they are often attended by a feeling of
heat in the anus, and by straining, especially if the medi-
cine be repeatedly taken. From the slow action and the
tenesmus, it is supposed that aloes influences the rectum
more than other parts of the intestines.
In experiments on r.abbits, Kohn found that aloes
caused moderate hypera^mia of the stomach, intestines.
800
Piirgalivos,
Piiry;atii'<*s,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
and kidneys. In various animals large dusrs of aloin.
iujc'Ctfd into the subcutaneous tissue, were followed by
gastritis, sometimes with hemorrhage and ulceration, and
in rabbits bj' degeneration of the epithelium of the
kidneys.
According to the experiments of Rutherford, aloes in-
creases the secretion of bile and ri'udsrs it more watery.
Various observers have found that it does not act when
bile is absent from tlie intestines.
Aloes was formerly employed in large doses to pro-
duce brisk purgation, when acute disorder of any organ
of the body su]iervencd soon after the cessation of an
habitual hemorrhoidal discharge. It was sometimes
given to produce a revulsive elTect in cases of congestion
of the brain, apople.\y, hemiplegia, and insanity. At
the present time it is rarely used, except in small doses
as a la.xative. According" to G. B. AVood, it sometimes
quickly cures jaundice when other remedies have failed.
Aloes is C(.)ntraindicated in intlammator}' atl'ections of
the intestines and kidneys, in irritalile and bleeding piles,
in uterine hennprrhage. and during menstruation.
It is generally administered in" pillular form, and the
oKi-\a\ pi/lK of (lioes are preferable to other preparations.
Eacli pill contains two grains of aloes.
Rheum. — In dose of thirty to forty grains, taken at one
time, or ten to twenty grains, repeated several times at
short intervals, rhubarb produces semi-liqnid stools in
from live to ten hours, usually with gri]iiug, but without
severe irritation. Some constipation generally follows.
Recent e.\])eriments have conlirnied tlje ancient opinion
that rhubarb increases the se<retion of bile.
Rhvdjarb is a suitable purgative when the bowels re-
quire thorough evacuation in patients who are occasion-
ally subject to diarrhtca. Sometimes it is preferred to
other purgatives in catarrhal jaundice.
It may be given in the form of powder, fluid extract,
tincture, or wine. Aromatics are generally as.sociated
with it to prevent its griping effect. B, Pulv. rhei, 3ij. ;
pulv. aromatic!, 3i. JI. Div. in pidv. iv. Sig. : One
powder every two hours. They may be conveniently
taken in syrup or molasses, or in wafers. The llnid ex-
tract is given in do.ses of tifteen to thirty minims, mixed
with syrup and an aromatic water, ij Extr. rhei tiuid.,
3 iss. ; syr. zingiberis, | ss. ; aq. cinnam., 3 iss. M. Sig. :
One tablespoonfnl every two hours till the bowels move.
The tinctui'c and wine are suitable for feeble patients,
especially if they are accustomed to alcoholic beverages,
and may be given in doses of half an ounce, repeated, if
necessary, at convenient intervals.
Senna. — Senna operates gently and slowly in doses of
fifteen to thirt}- grains, producing one or two judtaccous
stools in from five to ten hours. Large doses act more
briskly. Two or three drachms usuall_v produce semi-
fluid discharges in three or four hours. "The evacuations
are preceded by luetty severe tormina, and sometimes by
nausea and eructations. Borborj-gnu and occasional
small fluid stools often continue for from twelve to
twenty-four hours.
Though it acts vigorously, and produces quite liquid
stools, containing about eighty-five per cent, of water,
senna never causes severe irritation or inllauunation of
the intestines. It is suppo.sed, how-evcr, that large doses
may influence the uterus, and, given during pregnancy,
induce hemorrhage and abortion.
The watery character of senna stools is generally re-
garded as evidence of increased intestinal secretion: but
in careful experiments Brieger found no aceunudation of
fluid in an Isolated loop of inlesline with which senna
had been in contact some hours. That it greatly acceltr-
ates the peristaltic contractions of the small intesline aji-
pears from Kadziejewsky's experiments. This investi-
gator found that in dogs, normally from seven to nine
discharges took place from a fistula in the ascending colon
in three or four hours after a feeding; but when senna
was administered the discharges began in fen or fifteen
nnnutes, and numbered about tlurty in four hours.
Cathartin, the active principle of senna, in doses of gr,
iss.-iiss. , produces thin stools with colicky [lains in from
three to fourteen hours. An amount equal to two grains,
injected into the sidjcutaneous tissue, was followed by
copious evacuations in from eight to twelve hours.
As senna acts rajiiilly and efficiently, it is suitable when
the contents of the intestines require speedy reuKJVal.
Combined with Epsom salt, as in the oHicial compound
infusion of senna, it is frequently employed in the early
stage of inflammatory diseases, except tliose of the ali-
mentary canal. It is better adapted than rhubarb and
some other mild purgatives for patients disposed to cos-
tiveness.
Senna, in large doses, is contraindicated in inflamma-
tion of the intestines, hemorrhoids, menorrhagia, threat-
ening abortion, and jirolapse of the uterus or rectum.
It is generally given in the form of the infnsum senna
mmpDsitiim, ■which, in quantities of ab(Kit two ounces,
repeated several times at intervals of one or two hours,
soon produces copious watery discharges. The fluid ex-
tract of senna may be given in doses of half a drachm to
two drachms with syrup and an aromatic water. I{
Extr. .senn;e fluid., J ss. ; syr. zingiber. , 3 ss. ; aq. cin-
nam., ? iij. M. Sig. ; A tablespoonf id every liour until
the bowels act. The syrup of senna is a convenient prep-
aration forchildren in dosesof from one to four drachms.
(Jleiim Ricini. — Castor oil, in doses of half an ounce to
an ounce, usually produces semi-fluid evacuations in
from three to six hours, generally with little or no griping
or other symptoms indicating irritation of the intestines.
Nausea and vomiting may occur in very susceptible per-
sons, especially if the oil is rancid or tlie stomach dis-
ordered.
From its efficient and speedy operation, castor oil is
well adapted to all cases requiring a thorough cleansing
of the alimentary canal, as when the presence of poisons,
undigested food, or products of decomposition in the in-
testines indicates the use of a brisk purgative. Its gen-
tle, luurritating action renders it suitable when a purga-
tive is required in inflammation of the intestines, inflamed
hemorrhoids, fissure of the anus, metnu-rhagia, and after
parturition. For methods of disguising its taste, see
article on La.nUives.
S.\LiNE Purgatives. — The following saline purgatives
are commonly emidoyed: Sulphate of magnesium, sul-
phate of sodium, citrate of magnesium, tartrate of potas-
sium and sodium, and liitartrate of ])otassinm.
Large doses of .saline purgatives ju'oduce copious
watery stools. This peculiar action was explained by
chemists as resulting from osmosis, the dense saline solu-
tions within the intestines causing the less dense fltnd of
the blood to pass through the walls of the blood-vessels.
But the fact that large doses of salines, wdien given in
very dilute solution, so as to be less dense than tlie fluid
of the blood, act as ellicieutly and often more speedily
than concentrated .solutions proved that this theory was
untenable. Subseipieiitly it was slmwii, by Buclilieim
and others, that only salts of low ditrusibilily are efficient
purgatives, and that this property impedes their absorp-
tion in the intestines, causing them to pass nearly entire
into the lower part of the large bowel and to excite pur-
gation.
For a time it was supposed that the accelerated peri-
stalsis resulting from the presence of saline solutions was
sufficient toexplain their rapidand peculiar action. But
the investigations of Moreau, Brunton, Brieger, Hay, and
others, have conclusively shown that dense saline solu-
tions produce an active secretion of "watery fluid from
the intestinal mucous membrane. Briegerand Hay found
that very dilute solutions, although they may purge
rapidly, do not cause an increase of secretion; and Hay
observed that when concentrated solutions are given, the
quantity of fluid secreted de|ieiuls iqion the degree of
concentration. Solutions containing less than five per
cent, of a salt, produce little or no secretion, but stronger
solutions always have this effect. Under ordinary cir-
cumstances, the amount of fluid secreted corresponds
very nearly to the quantity required to form a five-per-
cent, solution of the amount of salt adnunistered. In
consequence of the secretion of a large quantity of fluid.
810
REFEREXCE HANDBOOK OF THE MEDICAL SCIENCES.
Purgatives.
l'ur;£atives.
■nlien coucentrated saline solutions are given, the fluid
of the hlood becomes proprotionatel)' diminished. This
continues only a sliort time, as the blond absorbs fluid
from tlie tissues uutil it lias nearly regained the quantity
lost by increased secretion.
Thus the mode of action of saline purgatives depends
upon the ciuantity administered and the degree of dilu-
tion. Very dilute solutions e.xcite nointestinal secretion,
but rapidly produce watery stools; 'while concentrated
solutions cause a decided increase of secretion, diminish
the fluid of the blood, excite absorption of fluid from the
tissues, and in a short time produce watery evacu-
ations.
Saline purgatives are preferred toother mild cathartics
for evacuating inspissiited fa'cal masses. As a rule, they
should be given in very dilute solution. In the early
stage of inflammatorv diseases, salines are often employed
for the purpose of loiveriug temperature an<l blood press-
ure, and thus diminishing the inflammatinn. They are
of little use in such cases unless given in concentrated
solution, so as to e.xcite a decided increase of the intes-
tinal secretion. The utility of salines is most conspicu-
ous in casesof ascitesand general dropsy. Administered
in verv concentrated solution, they often in a short time
produce a very notable effect, especially if tlie patient
have entirely abstained from food and drink for some
hours before taking the saline.
Miiff/iesii Sulphas. — Epsom salt is generally preferred
to other saline purgatives. In doses of half an ounce to
an ounce it usually jiroduces wateiy stools in several
hours, the first discharge sometimes taking place in one
hour. This rapid action is rarely attended by severe
griping. As it is readily soluble in water, it may be
given in very concentrated solution, a method strongly
recommended by Hay in cases of dropsy. It is fre-
•quently associated with senna, as in the compound intu-
sion of senna.
Its taste is somewhat improved and its activity in-
creased b}' sulphuric acid. I( Magnesii sulph.. 3 i- ; ai].
<lestill.. Jij.; acid, sulph. arom., 3 ss. ; syrupi, 3 i. JI.
Sig. ; One or two tablespoonfuls every hour. The bit-
terness of Epsom salt may be disguised by strong cotTee
and aromatics, especially cinnamon water. R Magn.
«ulph., 3 i. ; aq. cinnam., 5''j-; syr. aurant., 3 i. M.
Sig. ; A tablespoonful every hour.
Sodii Siilptius. — Glauber's salt has a still more repul-
sive taste than Epsom salt. It is therefore rarely em-
ployed when saline p\irgativesare indicated. According
to recent researches, it causes a decided increase of the
secretion of bileand renders it more water}-. In all other
respects its action closely resembles that of Epsom salt.
The following substances have been employed to correct
its disagreeable taste : Lemon juice, aromatic sulphuric
acid, carbonated water flavored with syrup, and extract
or fluid extract of licorice.
Sodii Plwfplias. — This salt, although an effective pur-
gative in doses of 3 ss.-i., is rarely employed in the dis-
eases of adults. It is sometimes used in laxative doses.
3.ss.-ij., several times daily in catarrhal jaundice and
other diseases supposed to indicate a cholagogue. On
account of its not unpleasant taste, it is frequently used
as a purgative in the diseases of children. The following
is an agreeable mixture: R Sodii phosphatis, 3 ij- ; syr.
rubi idsei, 3 ss. ; aq. destill. q.s. ad |iij. M. Sig.:
One teaspoonful every hour.
Liquor Mdynesii Ci'tmtis. — The solution of citrate of
magnesium has an agreeable taste, and is therefore often
preferred to other saline purgatives for unloading the
bowels in simple constipation. It is, however, less etli-
cient than the sulphates of magnesium and sodium, some-
times operating briskly, sometimes producing no purga-
tive effect. Usually a whole bottie. containing twelve
ounces, taken in several portions at short intervals, is
required. In cases of dropsy and inflammatory diseases
other saline purgatives are preferable.
Potrismi et Sodii Tnrtras. — In doses of half an ounce to
an ounce. Rochelle salt usually produces liquid stools
in a few hours. As it has a less disagreeable taste than
Epsom salt, generally agrees well with the stomach, and
acts gently, it is often employed when a mild purgative
is indicated in the diseases of" children, females, and deli-
cate persons. It somewhat increases the secretion of bile.
From two to four drachms, dissolved in sweetened water,
may be taken at intervals of two hours till the bowels re-
spond.
Potiisitii liitartras. — Large doses of cream of tartar,
half an ounce to an oimce, are followed b_v watery stools,
which are often preceded by flatulence and griping. It
is rarely used alone, but frequently in combination with
jalap. When given in large doses, it should be sus-
pended in an aromatic water to prevent griping.
Merciri.\l PiKGATivES. — Of the preparations of mer-
cury whicli produce catharsis, calomel and blue mass are
frequently used. Metallic mercury is sometimes em-
ployed in obstruction of the bowels.
llydriirgyri Chloridum ^Vi7t'.— Calomel, in doses of from
five to ten grains, usually acts in about six or eight hours,
producing copious senu-liquid, dark brown or green
evacuations. As a rule, no marked incidental effects are
observed; but sometimes, especially after the larger
quantity, the evacuations are preceded by griping, nau-
sea, and depression. Smaller doses, one to three grains,
act more slowly and very gently. Accurate chemical
analyses have discovered in calomel stools bile pigments,
leucin, tyrosin, peptones, sulphide of mercury, and un-
changed calomel, but no skatol and indol.
The presence of bile in the stools was formerly regard-
ed as a certain evidence of an increased secretion of bile.
But in numerous careful experiments on dogs, and in
some observations made on patients having accidental
biliary fistuhe, it was found that purgative doses of calo-
mel notably lessen the secretion of bile. To explain the
presence of bile in the stools notwithstanding diminished
secretion, it was then assumed that calomel greatly in-
creases the peristaltic contractions of the small intestine,
especially of the duodenum, and tlius hurries the bile
alread_y secreted downward so rapidly that realisorjition
cannot take place. The presence of leucin and tyrosin
in calomel stools rendered this view very plausible. But
the fact that some purgatives, which act more rapidly
than calomel, and doubtless strongly accelerate the peri-
staltic contractions of all parts of the intestines, do not
produce markedly biliousdischarges seemed to show that
this assumption was incorrect.
The recent experiments of Wassilieff show conclusively
that calomel produces bilious stools, by arresting decom-
position in the intestines. He divided fresh oxgall into
three portions, each weighing 200 ,gm. ; to one portion
was added 3 gm. of calomel, to another 2 gm., and to the
third none. They were kept in a warm room, and occa-
sionally agitated. The portions containing calomel at
once became green, and retained this color as long as the
expi'riment was continued, which was six days. They
readily responded to Gmelin's test for bile pi.gment. and
showed no trace of decomposition. The portion not con-
taining calomel had become brownish-yellow in one day,
did not exhibit the reaction of bile pigment, and was
soon putrid. Doubtless calomel exerts the same anti-
septic influence in the intestines. L'nder ordinary cir-
cumstances the bile pigments, bilirubin and biliverdin.
become converted into liydiobiliruliin, and hence cannot
be detected in the f*ces. Calomel prevents this decom-
position, and by increasing peristalsis causes the un-
changed bile pigments to be evacuated. In the same
manner it prevents further changes of leucin and tyro-
sin, and the formation of skatol and indol.
Calomel is a very effectual purgative in the morbid
state called biliousness — marked by a sallow complexion,
yellowness of the white of the eyes, a bitter taste, defec-
tiveappetite, and sometimes nausea ; by headache, mental
dulness. and depression ; and sometimes by light-colored
stools and sedimentary urine. By arresting decomposi-
tion and removing bile and other substances before they
can be absorbed, it thoroughly relieves both the intes-
tines and the liver.
In small doses calomel has been found useful in the
811
Purgcativrm.
Piirgalivos.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
gastroenteritis of children. Its utility is probably due
chiefly to its antiseptic action.
Administered in doses of from live to seven grains, for
one or two days, in the first week of typhoid fever, cal-
omel somewhat lowers the febrile temperature and ren-
ders the disease milder. As other purgatives are less
useful, it probably exerts a destructive influence upon
the micro-organisms which cause the disease.
As a rule, calomel is indicated as a purgative in all
acute affections of the intestines resulting from fermen-
tation and putrefaction.
Together with jalap or rhubarb, calomel is sometimes
administered in the early stage of inflammatory disorders
of the internal organs. "Though not useless, it produces
very much less effect on the quantity of fluid in tlie
blood-vessels and on the blood pressure than large doses
of the saline purgatives.
Calomel should not be used in habitual constipation.
It is usually ordered iu powder with sugar, or with
jalap, rhuharb, or bicarbonate of sodium. ^ Hydrarg.
chlor. mitis, gr. v.; sacch. albi, gr. x. JI. Sig. : Take
at once. I^ Hydrarg. chlor. mitis, gr. iij. ; pulv. jalapa>,
gr. X. JI. Sig. : Take at once in syrup or molasses. ^
Hydrarg. chlor. mitis, gr. v.; sodii bicarhon., gr. sv.
M. Sig. : Take in molasses or syrup. In all cases, if
calomel have failed to act after eight or ten hoiu^s, a
saline purgative or castor oil should be given.
Mii,i!«i Ili/dnirr/i/ri. — Blue mass is a somewhat uncer-
tain purgative when given in doses of from five to ten
grains. It is, therefore, usually coml.iined with rhubarb,
aloes, podophyllin, or compound extract of colocynth,
or, if given alone, a dose of castor oil. Rochelle .salt, Ep-
som salt, a senna draught, or a seidlitz powder, is admin-
istered after eight or ten hours. It is held to be efficient
in biliousness, and is usually given in the evening.
llydrnrgyrvm. — ^Metallic mercury in large doses quickly
passes through the alimentar}- canal in consequence of its
great weight. Probably the dragging and stretching of
the mucous luemlirane, resulting from the presence of
large quantities, excite very powerful peristaltic contrac-
tions, which rapidly carry the metal through the intes-
tines.
Metallic mercury has been employed in intestinal ob-
struction when all other ordinary means had failed to
give relief. Betiellieini (Dentsches Arehief. }d. Mei!.. Bd.
32. p. .53) carefully studied seventy cases of obstruction,
reported during the last fifty years, in which mercury
was used. In fifty-seven cases a cure resulted, that is,
the obstruction was relieved either temporarily or perma-
nently. In no case did it cause rupture, inflammation,
or gangrene of the bowel, while in some instances it
saved life. Bettelheim therefore considers it proper to
administer mercury in cases of obstruction due to fa'ces.
ascarides, and even to intussusception or torsion, if other
ordinary means have failed to give relief.
The dose of metallic mercury varies from one to ten
ounces.
Dk.\stic PtRG.\TivES.^Of the cathartics which oper-
ate violently and produce serious irritation of the intes-
tines, when given in excessive do.ses, only the following
are commonly employed : jalap, scamiuony, colocynth,
liodopliyllum, gamboge, crotou oil. and elaterin.
Jaliipii. — .lalap is the mildest drastic, and resembles
senna in its action. In doses of fifteen to thirty grains it
usually soon causes a feeling of discomfort in the epigas-
trium, and sometimes nausea. After two or three hours
tormina and several liquid stools occur. Stualler doses,
five to ten grains, act gently, producing one or two pnl-
taceous evacuations. In very excessive doses jalap causes
vomiting and profuse rice-water discharges, with great
depression.
The resin of jalap, in doses of from one to three grains,
acts as a laxative, but in larger doses, from five to fifteen
grains, it produces watery stools in a few hours.
According to recent investigations, jalap does not act
well when bile is ab.sent from the intestines. In experi-
ments on dogs it was found to increase moderately the
secretion of bile.
On account of its rapid, safe, efficient, and hydragogue
action, jalap is frequently employed when a brisk cathar-
tic is indicated- In cases of acute constipation, and iu
inflammatory diseases, it is usually associated with calo-
mel, and in ascites and anasarca with bitartrate of potas-
sium. The official ptdfisjalapce ciimponitiis, consisting of
thirty-five parts of jalap and sixty-five parts of cream
of tartar, is generally preferred to other hydragogues in
dropsy. In doses of half a drachm to one drachm, it
usually produces watery discharges in a few hours.
The resin of jalap may be given in doses of from one
to eight grains in powder or enudsion. I^ Resin, jalapa?,
pulv. acaci;!?, iia gr. viij. : sacch. albi, 3 ss. M. Div. in
part, a'qnal. iv. Sig. : One powder every two hours till
the bowels move. I? Resin. jalapa\ gr. viij. ; pulv.
acacioe, sacch. albi, aa 3 i. ; aq. menth. pip., § ij. M.
Sig. : One tablespoon ful every two hours. Sometimes
resin of jalap is given in combination with calomel, i^
Resin. jalapa\ hydrarg. chlor. mitis, aa gr. iv. ; sacch.
albi, 3i. M. Div. in part, ajqual. iv. Sig.: One pow-
der every two hours.
Jalap is contraindicated in inflammatory affections of
the alimentary canal.
Scnmmoniiim. — Scammony resembles jalap in action,
but is less certain, sometimes producing little or no effect,
at other times acting harshlv, with griping and tenes-
mus. Usuall.y it is followed by watery stools in a few
hours. The presence of bile in the intestines is necessary
for its action. It is rarely used except in combination
with other ])urgatives. as in the official <■»«//«'/«(/ rulhur-
tlr pills. The dose of scammony, to act briskly, is from
ten to twenty grains, and of its resin, from five to ten
grains.
Culocuntliis. — Large doses of colocynth produce numer-
ous fluid evacuations, with griping and tenesmus. 'E\-
cessive doses cause sanguinolent stools, great abdominal
pain, intense depression, and sometimes clcath.
Small doses, one to three grains, act gently, producing
loose stools without notable griping. But if frequently
repeated, such doses soon cause tormina and tenesuuis,
and slimy stools.
According to Brieger, small quantities of extract of
colocynth, t).0'2 gm. dissolved in 3 gm. of water, in-
jected into isohited portions of intestine, produce sliglit
hypera'mia and peristaltic contraction, but no accumula-
tion of fluid. But larger cpiantities produce decided in-
flanunation and an effusion of bloody fluid.
In experiments on dogs Rutherford found colocynth to
cause an increased flow of watery bile.
On account of its harsh operation, colocynth is rarely
employed alone to produce brisk purgation; but in small
doses, in combination with other laxatives, it is frequently
given in habitual constipation.
The dose of the extract of colocynth, as a laxative, is
one-sixth to two-thirds of a grain, and of the compound
extract, from one to five grains. The latter preparation
is sometimes given in doses of five to fifteen grains, to
jiurge briskly. LTsnaily the extract of hyoscyamus, or
the extract of belladonna, is combined with it, to prevent
griping. I? Extr. colocynth., gr. i. ; aloes, gr. vi. ; extr.
hyoseyami, gr. vi. M. Ft. pil. vi. Sig. ; One jiill at
bedtinu'. R Extract, colocynth. comp., gr. .xij. ; extr.
bellad., gr. ij. M. Ft. pil. vi. Sig.: One pill at bed-
time.
Cii>itljiir/ia. — Gamboge is held to be still more irritant
than colocynth. In experiments Rutherford found, after
large doses, violent irritation of the duodenum and small
intestine generally, with profuse catharsis, but no in-
crease of tlie bile flow.
It is. perhaps, never given alone, but is sometimes
added to other iiurgatives to increase their action, as in
the coin]n>inid cathartic pills. Very small doses, one-
sixth to om- half grain, are said to produce pultaceous
stools without muc-h griping. Generally, doses of three
to four grains cause some nausea and colicky pain, and
several watery stools. Excessively large doses, one
drachm, have caused fatal gastro-enteritis.
Formerly gamboge was frequently employed in obsti-
812
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pursallves.
PurgatiTesc
nate constipation, ascites, anasarca, paralysis, insanity,
gout, and skin diseases. Generally it was given togetlier
with aloes, jalap, bitartrate of iiotassiuni, and calomel.
1$ Cambogia', gr. iv. ; pulv. jalapoe comp., " ij. M.
Div. in pulv. iv. Sig. : One powder every two liours till
the bowels act, in cases of dropsy.
PiluliB Catharticm Composite. — The compound cathartic
pills contain small quantities of aloes, scamniouy, colo-
cyntli, jalap, gamboge, and calomel. On account of
their complex composition they are supposed to affect
all parts of the intestines, and to increase the secretion of
bile. One pill usually acts as a la.xative, while three or
four produce free purgation. They are suitable to acute
constipation not complicated with infiammation of the
intestines, but should not be employed in habitual con-
stipation.
Podophyllum. — This purgative, even in large doses,
tisually acts slowly, from six to ten hours elapsing before
the bowels move. Doses of ten grains rarely cause
marked incidental effects, but twentv or thirty grains are
tisually followed by nausea, and sometimes vomiting and
depression, and severe colicky pain. The evacuations
sometimes have a dark color, from which it was assumed
that they contain a large quantity of bile. In experi-
ments on dogs Rutherford found that moderate doses of
podophyllin cause an increased flow of bile.
The resin of podophyllum, commoidy called podo-
phyllin, is used as a laxative. Doses of one-eighth to
one-half grain usually produce a gentle movement in
eight or ten hours. Large doses, from two to foiu' grains,
cause nausea, sometimes vomiting, severe griping, and
numerous stools, which may be slimy and bloody and
followed by intense depression.
Podopliyllin is not suitable in cases requiring brisk
purgation. But in chronic constipation it is much used,
because it continues to act for a long time without neces-
sitating an increase of dose. It is frequently employed
when symptoms are present which show that the secre-
tion of bile is abnormal. Usually it is given in pillular
form, with extract of hyoscyamus or extract of bella-
donna. 'B, Podophyllini, gr. ij.; extr. hyoscyami, gr.
viij. M. Ft. pil. No. viij. Sig. : One pill at bedtime.
It has also been given in solution as follows: R Podo-
phyllini, gr. ij. ; alcohol, dil., ; ij. ; tinct. zingiberis, 3 ij.
M. Sig. : Ateaspoonful in a wineglassful of water.
Podophyllotoxin is said to act more regularly than the
■official resin. It has been given to adults in doses of one-
sixth to one-fourth of a grain, and to children in doses of
■one-sixtieth to one-twelfth of a grain. Brun employed it
in alcoholic solution as follows: R Podophyllotoxini, 0.5
gm. ; spir. vini rectif. , 7. .5 gm. M. Sig. : From live to
fifteen drops in sweetened water.
(Jhum I'iglii. — Croton oil is a very energetic drastic, a
■drop sometimes jiroducing from live to fifteen watery
evacuations. Often the first evacuation occurs in one or
two hours.
The susceptibility of different persons to its action
varies, in some one drop acting intensely, while in others
it produces only a few semi-liquid stools. In rare in-
stances purgation does not residt from the dose men-
tioned, but there takes place general disorder, marked by
palpitation of the lieart, pain in the extremities, severe
teadache, giddiness, and prostration.
Frequently the action of croton oil is attended by symp-
toms indicating irritation of the stomach and intestines —
a sensation of heat in the epigastrium, more or less nau-
sea, sometimes vomiting, borborygmi, colick}- pain, and
tenesmus.
Excessive doses quickly induce vomiting and purg-
ing, and great prostration. Twenty drops have proved
fatal.
Croton oil is used when a powerful purgative is indi-
cated, and milder medicines have failed to act or cannot
be administered. Sometimes this is the case in obstinate
constipation, lead colic, and diseases of the brain and
spinal cord. AVlicn brisk purgation is necessary, and
swallowing is very ditlicult, the oil is preferred to more
bulky cathartics, "a drop being mixed with a little sugar,
or a little bread crumb, and placed on the back of the
tongue.
The oil has been sti-ongly recommended for the removal
of tapeworm — one drop mixed with one drachm of chlor-
oform and one ounce of glycerin, to be given early in the
morning.
Croton oil is usually given in pillular form. R Ol.
tiglii, gtt. i. ; micie panis, q. s. M. Ft. pil. iv. Sig.:
One pill every hour. It is said that the oil acts more
gently when combined with compound extract of colo-
cynth and extract of belladonna. B, 01. tiglii, gtt. i. ;
extract, colocynth. comp., gr. viij.; extr. bellad., gr. i.
M. Ft. pil. iv. Sig.: One pill every two hours. Some-
times it is given mixed with sugar. R Ol. tiglii, gtt. i. ;
sacch. lactis, 3 i. M. Div. in part. a?q. iv. Sig. : One
powder every hour. It may also be mixed with castor
oil, or made into an emulsion, as follows: 'B, 01. tiglii,
gtt. i. ; pulv. acacise, 3 ij. ; syr. amygdalse, | ss. ; aq.
dcstill., 3 iiiss. M. Ft. emuls. Sig.: One tablespoon-
ful every hour.
Elatcrinum. — Elaterin is the most powerful and drastic
of all purgative medicines. The twentieth of a grain,
given to an adult, will generallv produce watery stools
in one or two hours. Sometimes this speedy action is
not attended by marked incidental effects; but often,
especially if it is given alone, nausea, severe griping,
borborygmi, and some prostration are produced. Ex-
cessive doses may cause intense gastro-enteritis and fatal
collapse.
Elaterin is employed in ascites and anasarca, when
gentler hydragogues have failed to act efficiently. As a
rule, it is given only every other day, and not continued
longer than a week or ten daj's, lest it excite serious in-
testinal inflammation. After an interval of a week its
use, if necessary, may be resumed. It is contraindicated
in dropsies complicated with intestinal irritation, and
must be used with extreme caution in very young, aged,
and feeble patients.
It may be ordered in solution, pill, or powder. R
Elaterin, gr. ss. ; alcohol., j .ss. ; acidi nitrici, gtt. ij. M.
Sig. : From twenty to forty drops in an aromatic water.
R Elaterini, gr. :J; extr. hyoseyami, gr. vi. jM. Ft. pil.
vi. Sig. : One pill every hour till stools take place. R
Elaterini, gr. i; sacch. albi, 3 i. ; ol. menth. pip., gtt.
ij. M. Div. in part, a'qual. vi. Sig.: One powder every
hour until the bowels act.
Geneh.\l iNnicATioNS. — Purgatives are used (1) to
evacuate the intestines; (2) to diminish hypenemia of
remote parts or organs; (3) to promote the absorption of
exudations and transudations; and (4) to eliminate nox-
ious substances.
1. AH purgatires eraeuate the contents of the intestines;
but wlien this is the sole indication for their use, only
laxatives and mild purgatives should be given. In
chronic or habitual constipation those laxatives are most
suitable which act slowly, producing normal or nearly
normal fa-cal evacuations, without losing their activity
in small doses after frequent repetition, and without in-
terfering with general nutrition. Experience has shown
tliat aloes possesses these properties in the most eminent
degree. Podophyllin, cascara sagrada, rhubarb, and
compound extract of colocynth are also eligible. The
saline laxatives are sometimes used in habitual constipa-
tion ; but as their prolonged use is followed hy impair-
ment of nutrition, they should not be given to feeble
patients unless required bj' other indications.
In occasional or acute constipation any laxative or mild
purgative may be employed. If hardened ffecal masses
are present in the intestines, the saline laxatives and cas-
tor oil are most .suitable. Sometimes all the mild purga-
tives fail to act in acute constipation, especially when the
cause of the constipation is still present, as in lead poi-
soning. Drastics, if carefully used, are then appropriate,
and croton oil is usually preferred. MetaUic mercury
has been successfull_y used after all ordinary purgatives
had proved ineffectual.
To remove jjoisons and irritating substances from the
intestines, those purgatives which act speedily and gently
813
Piirpiirsi.
Purpura,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
should be preferred, especially eiistcir oil and saliues.
Wlion irritation of the intestines results from decomposi-
tion or fermentation, calomel is the best |iingative.
2. To diininidi hupentmin of remote ]iarts or organs,
purgatives wliich act rapidly and ])roduic seini-li(|uid
or watery discharges are re(iiiired. Mild purgatives de-
plete indirectly by hastening the intestinal .secretions and
partially digested food downward so rapidly that absorp-
tion is impeded. Saline purgatives, in strong solution,
e.xcite a copious secretion of watery lluid. and thus di-
rectly deplete the blood. Drastics act in a tlireefold
manner, accelerating peristalsis, increasing secretion, and
exciting intestinal liyiienemia. The choice of a purga-
tive will, therefore, depend \\\nm the intensity and dura-
tion of the disease to be iullueuced, the organ alTected,
and the character of the general symptoms. In conges-
tion of the liver, calomel, followed Ijy a saline laxative,
is the most suitalde purgative. In congestion or inflam-
mation of most organs, saline cathartics and compound
infusion of .senna are usually employed; but in ver_y
severe congestion or inflammation of very important
organs— such as the brain and spinal cord— drastics are
preferred, especially crotou oil.
3. To 'promote ahmrption of eindntions and transuda-
tions, the hydragogues are most suitable. Generally the
saline hydragogues, given so as to produce copious
watery stools, soon cause rapid absorption. In cardiac
dropsy they often diminish the dropsical swelling very
notably in "a few hours. Of the drastic hydragogues the
compound powder of jalap and elalcrin an' the most n.se-
ful. Generally the former is preferred on account of its
mild action. Butwhen it fails to act efficiently, or when
an effusion of scrum occurs rapidly, and in such large
quantity as to produce extreme distiess, such as alarming
dyspn(ea in i)leuritis, elaterin is usually given. Some-
times it so rapidl_v induces absorpticju of the effusion as
to give decided relief in a few hours.
4. To elimiiiiite no.rioiis siiliKtunren, calomel, saliues, and
drastics are used. The utility of calomel in biliousness
and congestion of the liver is in part due to the rapid
removal of irritating and decomposing substances from
the alimentary canal. Saline laxatives, especially sul-
phate of magnesium, are indicated in chronic lead
poisoning, to remove the poison from the intestines
as fast as it is eliminated b}' the liver. They are also
suitable in cases of uneniia. especially if at the .same
time it is necessary to induce absorption. In nnemic
coma, croton oil is sometimes preferred to milder purga-
tives.
CoNTR.4iNDic.\TiONS. — All purgatives are contraindi-
cated in peritonitis, intestinal hemorrhage, perforation
of the bowels, strangulated hernia, and extreme debility.
Brisk purgatives are generally inapjiropriate during
pregnancy, especially if previous abortions have oc-
curred, and during menstruation. They should not be
used if there exist severe rectal lesions, or a tendency to
looseness of tlie bowels. Even laxatives are contraiu-
dicated in habitual constipation, mitil all other known
means have failed to establish a normal habit of defeca-
tion. S(uiit(ii JSkkles.
PURPURA. — (Synonyms: Jhemorrhmt petefhi<iU.i ; Fr.,
I'rirpiiiii ; Ger., BliitfltcIiCii.) Purpura isa disease char-
acterized by the extra va.sation of blood into the skin. In
many instances, however, it is not limited to this organ
and may be encountered in almost any structure of the
bod}'. The parts coming most readily under vis\uil in-
spection are naturally the skin and mucous mendiranes.
although in.severeand fatal eases the autojisy sIkjws that
the internal viscera are likewise involved. It may be
asked whether purpura is not rather a symptom complex
than a well deflned alTection ;«;• sc. It occurs under so
many ajiparently varied conditions that one is at a loss
to ascribe to it definite limitations. In this connection,
however, it will be considered from a dermatologieal
standpoint, the skin being the organ most extensively
involved. The clinical manifestations of purpura vary ;
hence several varieties have been described, although
the essential feature is the occurrence of hemorrhage into
the structures surrounding the blood-vessels. In severity
purpura likewise varies greatly, being in some instances
an exceedingly mild affection with extravasation only in
dependent jiarts. as the legs: or it may be an extremely
severe and rapidly fatal disease. Between these extremes
numerous grades, both in appearance and in .severity, oc-
cur. Usually purpura is accompanied by constitutional
symptoms which to a great extent depend upon the
amount of cutaneous heiuorrhage.
For convenience of descri]>tion the various lesions have
received distinct names. Thus we speak of riliiris when
the extravasation of blood into the skin assumes a streaked
or elon,gated form. Ecc/ii/moses are irregular extravasa-
tions of blood iuvolvin,g considerable areas, and giving
Fifi. :j92:J.— Purimra siuiple.x. (Case ef lir. William T. Corlett.)
the appearance of bruises. Err/ii/moniatit ovha>mntomata
are terms used to designate tumors formed by the ex-
travasation of blood, usually occurring when a large
vessel wall has given way. The term jmrjmra pnpiihma
is employed to ilesignate pinhead-sized extravasations
which are usually situated in the upper part of the
derma, lli iiiorrliiniic biiUif are extravasations luiderneath
or between the layers of the epidermis, while lurmiitidro-
sis is a rare condition in which the sweat glands give
forth a bloody exudate. PctecIiiiB are cutaneous areas of
extravasation of various shapes and sizes.
The cutaneous lesions of purpura are characteristic in
that they are symmetrically arranged, are of a dark liluish
color, and do not disajipear on prcssiu'e. At first they
may be of a bright red or claret color, although at an
early stage they take on a purplish hue; as absorption
goes on the color undergoes various changes from a bi'own
to a greenish-yellow tint, such as may be observed in an
ordinary bruise. The cutaneous manifestations occur in
successive crops ; hence various shades of color may be
.seen at the same time. Most cases of cutaneous hemor-
rhage may be grouped under three heads, which will be
treated as varieties of the disease.
Pur/iiiro S/iiijilr.r represents the mildest form of the
di.sease. This is commonly observed in the skin, and is
frequently limited to this structure. As a rule, it is un-
accompanied by constitutional symptoms. It usually
makes its appearance .suddenly, and is lirst seen on the
dependent parts, as the legs (see Fig. 3928), although in
children the arms, neck, and other parts of the body may
be involved. The most usual sites are the inner aspect of
the legs, the dorsum of the feet, and the ]iosterior surface
of the forearms. In this form the mucous membranes may
be involvc'd to a slight extent, that most frequently inqili-
cated being tlie mucous membrane of the mouth, although
\ve have reason to believe that the hemorrhagic process
is not limiled to these structures, but that, on account
of the mildness id' the symptoms, it escapes notice when
occurring in jiarts not easily inspected. In this variety
the lesions consist of variously sized and shaped petechite
814
REFERENCE HANDBOOK OF THE .MEDICAL SCIENCES.
FiiriMira,
Purpura*
■which are at first roundish or oval, and which sometimes
extend at the periphery; at other times tliey remain sta-
tionary until absorption takes place. A more infrequent
form, in which the lesions are jiuuctate (liclun lieidus of
Willan) and surround the exit of a hair shaft, is also en-
countered. The lesions in purpura usually continue to
appear for several days or weeks, although the disease
is self-limited and as a rule terminates in recovery witliin
one or two months. The cutaneous lesions soon undergo
resorption and deposition of hosmatin which leaves an in-
delible stain in the tissue.
Purpura lihenmatiiui, Pcliosis JRheuinatica, Toxic Pur-
pura (Purpura exantliematique of the French) is a more
severe form of the disease, so called because of its associ-
ation with vague pains which are usually referred to the
joints or muscles, and are supposed by some to be closely
related to acute articular rheumatism. In this variety
constitutional symptoms are more marked. In some
cases distinct swellings occur about the joints, there is
a slight elevation of temperature, the tongue is fre-
quently coated, and usually there is anorexia, sometimes
with nausea and vomiting. Extravasation of serum
alone may likewise take place, giving rise to urticarial
lesions in tlie skin (purpura urticaria). In verj' rare in-
stances the serous exudate occurs in the epidermis, giving
rise to bulla; and oedematous plaques. Stehvagou (" Dis-
eases of the Skin," 1903, p. 4G0) has observed swelling
of the lips and throat which he describes as a. fehrile, pur-
puric wkma. Sometimes the eruption becomes associated
with symptoms of a multiform erythema, the lesions
varying in appearance, although always associated with
cutaneous hemorrhage. From the foregoing it ma_y be
seen that this form of purpura is closely allied to the ex-
udative erj'themata.
This toxic form of purpura is sometimes associated
with complications of a grave nature. Thus endocarditis
and pericarditis, together with necrosis and sloughing of
the mucous membrane of the mouth, iiave been observed
bj' Osier.' It is sometimes recurrent and may appear
annually throughout a period of several 3'ears. Henoch -
has called attention to gastro-intestinal symptoms occa-
sioned by hemorihages into the intestinal mucosa: this
has been accompanied by vomiting and diarrho'a, the
stools not infrequently being tinged with blood. Hemor-
rhage may likewise take place to a slight extent into the
liladder. This has been most frequently observed in
children. In severe cases the kidneys are affected, giv-
ing rise to tlie symptoms of acute hemorrhagic nephritis.
In these cases albumin is usually present in the urine.
The spleen is sometimes easily jialpable.
Purpura Ilceuiorrhayicn, sometimes known as morl.ius
maculosus Werlhofii (which see), and also as land scurvv.
This is a more grave affection than the two |ireceding
varieties. The severity of the disease, however, largely
depends upon the cause as well as on the extent of the
cutaneous hemorrhage. The on.setof this variety varies;
it may be insidious, appearing as a mild attack with few
or no constitutional sj-mptoms; soon gradual impairment
of the health becomes manifest, and the patient becomes
weak from loss of blood. The appetite disappears, as-
similation is interfered with on account of intestinal
hemorrhage, and diarriia-a with bloody stools tinalh' oc-
curs. The gums bleed easily, and there is not infre-
quentl}' ha-maturia, epistaxis, or ha-moptysis. The
lesions usually assume the form of large eccliymoses or
ecchymomata, and the mucous membranesare apparently
involved to an equal, if not greater, extent than the skiii.
In the latter the disease may appear on the more de-
pendent parts, although the whole body soon becomes
involved. In severe cases symptoms of collapse occur,
and the disease may soon terminate in death (purpuni
fulmi>inn.i). At other times the disease pursues an un-
interrupted course for several months, when finally reso-
lution takes place and the patient recovers. At other
times extravasation of blood takes place into the brain
or spinal cord, giving rise to s\'mptoms referable to a
tumor in these parts. There is usuall}' but slight eleva-
tion of temperature in this form, although the disease is
sometimes noted to be ushered in with a slight fever, the
teiTipcraturo rising one or two degrees.
Cutaneous hemorrhage may also occur as a symptom
of other well-recognized diseases, such as variola, the
plague, and ccrebro-spinal fever, and in cases of poison-
ing from the bite of poisonous reptiles.
Erioi.oGT. — The (lisease occurs in both sexes, and is
met with at all ages. It is a fairly coiumon disease in
my experience, and has been most frequently encoun-
tered between the ages of sixteen and forty-live. Tlie
general health of the cases that have come under my
obseixation, previous to the advent of the cutaneous
hemorrhages, has been good, although, as has been stated,
there is sometimes a tendency for the disease to recur
from time to time during a period of several years. In a
series of cases which I had the opportunity of observing
a number of years ago, bad hygienic conditions with a
defective food supply were imdoubtedly the chief etio-
logical factors in the di.sease. Of these the chief role
must be given to tlie withdrawal of green vegetables from
the dietary, most notably potatoes, cabbage, and greens;
at any rate, on supplying these articles in moderation the
disease disappeared from various families in which it had
been observed to occur for a long time. Further, in my
experience the disease has been met with more frequently
in women than in men, the nationality most frequently af-
fected being the Bohemian. It lias occurred usually in
people in the lower walks of life. Various drugs liave
been known to produce cutaneous hemorrhage, notably/
potassium iodide, chloral, belladonna, ergot, phosphorus,
iodine, qtdnine, copaiba. These drugs do not produce-
the same eflfeet in all jieople. there being iu some indi-
viduals an idiosyncrasy by which the ingestion of certain
substances, innocuous to others, gives rise to toxic effects.
Again, toxic substances or their ptoma'ins, by acting on
the nerve centres, are thought to be potent factors in the
causation of purpura, notably in the erythematous or
toxic form.
As malaria undermines the general health, it is thought
by some to contribute to this condition. Other diseases
contribute in like manner to purpura, most notably those
w'hich tend to profoun<l anamiia, such as scorbutus, hamio-
philia, pjwmia, sarcoma, nephritis, scarlatina, typhus
fever, cerebro-spinal fever, variola, and rubeola, as well
as various diseases of the nerve centres, such as locomo-
tor ataxia and li3-steria. The venom of serpents must
likewise be mentioned in this connecticm. In new-born
infants the sudden change to which the circulation i&
subjected may give rise to cutaneous hemorrhage, which
should be looked upon as purely mechauical. Various-
micro-organi.sins have likewise been described as associ-
ated with purpura. Martin de Giniard.' Letzerich,^ and
Kolb^ have succeeded in producing the di.sease in animals
by inoculating with pure cultures, and doubtless this
accounts for some cases, especially among the severe
forms. From the foregoing it will appear that the cause
of purpura varies in different cases, and no one condition
can be assigned as invariablv producing the disea.se.
Stehvagon, in summarizing the various causes of pur-
pura, believes that the etiological factors may be divided
into classes, most conspicuous of which are the vaso-
motor, toxic, and infectious; and that some of the latter
arise from auto-intoxications, which have their origin in
the intestinal tract. This latter seems esjiccially true in
those cases which are marked by a multiform erythema
and urticarial lesions. It is evident, therefore, that we
have iu purpura a condition of variable appearance and
widespread distribution, alTecting almost every organ
and structure of the body and producing symptoms which
vary according to the part attacked. "What we know,
therefore, is this: purjiura is a sym]>toin, in the broad
sense of the term, of many conditions, many of which at
the present time are wholly unknown.
P.^Tiioi.OGY. — The most constant findings in purpura
are circumscribed areas of blood extravasation, which
are usually found in the papillary layer of the derma.
Less fre([Uently the epidermis may be invaded, the latter
occurring only when the blood extravasation has beeni
815.
» *-
Purpura.
Pyoklauiu*
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
excessive; as from rupture of an arteriole, or wlien the
disease assumes a toxic form ( peliosis rlieiniuitica). Wlieu
the disease is not Hmited to the sliiii. tlie deeper part of
the derma or even the subcutaneous structures (purpura
hicmonhagica) may be involved. Again, there may be
only a few red blood cells surrounding the vessel (dia-
pedesis), in whicli ease the lesions are usually limited to
the superficial stratum of the derma. If the disease lias
existed for some days the characteristic retrogressive
clianges are found, namely, the presence of coloring mat-
ter from the blootl giving rise to a i-ust-like stain, which
gradually fades awa_v, leaving only a slight iiigm'enta-
tion. Frequently these are the only changes found. At
other times the vessels in the area involved are markedly
dilated (inu-pin-a ectasir/iie of tlie French), and red Ijlood
cells are found outside the vessel wall. This Leredde
regards as due to paralysis of the vasomotor filaments
distributed to the vessel. This form is sup]iosed to bo
of toxic origin involving primarily the nerve centres.
Aside from tbese changes there have been noted dilatation
of the vessels with iiroliferation of the endothelium, to-
gether with an accumulation of blood cells, fibrinous
thrombi, and microbic endioli. Furthermore, amyloid
degeneration of the vessels has been noted, together with
proliferaliou of the connective-tissue cells and necrosis of
the vessel wall. The study of the blood has of late at-
tracted clo.se attention, and Lenoble'' holds that true pur-
pura {P. iiiyt'liii(h) or the toxic form is invariably due to
alterations in the blood. The following, according to
this observer, are alwaj's present and may be regarded as
characteristic :
1. Absence of contraction of the clot and consequent
expression of the serum. This is constant, and it is only
after recovery that the expression of serum becomes
normal. In light cases one can see a certain degree of
contraction of the clot, although occurring a little later
than usual.
2. The appearance of bone-marrow cells which are al-
ways jireseut, sometimes abundant, and are characterized
(rt) b}' the apparition of nucleated red blood cells, few in
the chronic, but more abundant in the acute form; in the
latter ease, however, they are not ]iermanent. These red
cells are in the group of Ehrlich's normoblasts, more rarely
megaloblasts or even microblasts (one case): ('/) bj- the
aiijicarance in the circulation of myelocytes which are
usually neutro]ihilic, more rarely eosino]ihilic. This re-
action is always slight or feeble, and varies from a frac-
tion of one per cent, in the chronic tyjie to six or seven
per cent, in the acute form.
3. Marked changes in tlie blood jilatelets, which are
diminished in number and increased in volume, but
whfise chief alteration is in the more or less complete loss
of their characteristic grou|iing. This loss of the ]iower
of clumping explains the lack of contraction of the clot,
the special ana-mia, and the profuse hemorrhages which
are characteristic of the disease.
These changes, which are con.staut, may persist indefi-
nitelj' in the chronic form. In the subacute form the
duration is variable, and normoblasts may be found long
after recovery is apparently complete.
The following are given as accessory and inconstant
blood changes:
1. Leucocytosis with increase of the i)oIyuuclear eosin-
oplnles and especially of the lymphocytes. These last
are alwa3's increa.sed, and were ondtted from the primary
changes mentioned because they are found in all forms
of purpura. Their presence is as important as is that (jf
the myelocytes, wdiose office it is to rejiair the constant
loss of Ihe large mononuclears which undoubtedly act as
macrophages. According to the Dominici these cells also
give rise to parent cells of the elements which are de-
stroyed by the circtdating toxins.
2. Frequent but inconstant is the appearance in the
pure blood of a reticidum either with a coarse or with a
fine network,
3. Contrast between the numljer of I'cd corpuscles,
wdiich may be much increased, and the amount of ha'mo-
globin per cell, which may remain small.
This disease is thus controlled by a double cause, viz.,
an infection and an ana?nna. Ths intensity of the symp-
toms varies with the intensity of the infection. The
blood shows few changes in chronic, subacute, ami tran-
sient types, but in the acute form the blood apjiears dis-
organized and shows the jiresence of bone-marnjw cells,
while the red blood cells liave become very vulnerable.
This is shown liy the large number of pseudoparasites
whose importance has been dwelt on by Hayem.'
Di.\ciNosis. — Little difiiculty need be experienced in
recognizing a well-marked case of purpura. In puipura
simplex the lesions sometimes resemble fiea-bites or the
bites produced by other insects (purpura pulicom). In
the latter, however, there may be seen a characteristic in-
Hammatory halo surrounding a deep red punctate centre,
which is never present in purpura. Erythema nodosum
nught, late in its course, be mistaken for purpura, espe-
cially when the dark-red infiammatory nodules of the
erythema have receded, leaving bruise-like areas. The
location and Inslory of the affection should enable one to
differentiale between them. It should be borne in mind
that erythema is au acute affection of two or three weeks'
duration, with large, elevated, slightly infiamed and
painfid nodules, usually limited to the anterior surface
of the legs and to the forearms; while the lesions of pur-
])ura appear in successive crops lasting from four to
twelve weeks, are of a dark color, usually not elevated
except in the form of bulla>, and are not inflammatory
nor ])ainful. In erythema the redness disappears on
pressure, while this does not take place in purpura. Pain
has been experienced on pressure in erythema, but press-
ure does not cause pain in purpura. From trauma pur-
pura may be distinguished by the liiultiform character
ami distribidiou of the lesions, and by the absence of any
history of injury.
The late manifestations of syphilis likewise give rise
to pigmentation, but they are also preceded by inflam-
mation, and are always chronic, wdnch offers a sharp
contrast to the lesions of purpura. Even in the necrotic
form of purpura the lesions are smaller, are multiform,
and are of comparatively shorter duration than those of
syphilis. From the various drug eruptions, noticeably
that of cubebs and copail)a, the erythema is of a brighter
red and disappears on pressure. In the acute infectious
exanthemata cutaneous hemorrhages are not uncommon,
not:d)ly in variola and rubeola; but in the former we
have a giave affection which, as a rule, rapitlly advances
to a fatal termination, and in measles the coryza and other
characteristic features of the rash would enable one to
exclude purpura which has a slower evolution and less
often teruunates fatally.'
Pkognosis. — This depends on the extent of the cuta-
neous hemorrhage, the cause of the disease, and the com-
plications i)resent. In simple purpura the prognosis may
be considered favorable, whereas in toxic cases, or in
those accompanied by marked involvement of the viscera,
the prognosis must be guarded. In pvirpura simplex the
majority of patients recover in from four to twelve weeks.
In purpura rheumatica the disease is liable to return, al-
though it is seldom from the primary affection that a
fatal issue ensues. In severe forms the disease is always
grave, if not fatal.
TuE.\TMKNT. — The first consideration is rest in a hori-
zontal position. Except in verv mild cases this should be
maintained very strictly throughout the whole course of
he disease. JIany cases are reiiorted in wdiich fresh crops
of eruption have appeared after the patient assumed the
erect posture. When the lower extremities are mainly in-
volved, it is well to elevate the feet above the horizontal
plane by means of pillows. When the extremities are
the chief seats of predilection, flannel bandages may be
applied so as to give support by gentle pressure. The
room siiould be well ventilated and an abundance of di-
rect sunlight admitted The diet should be simple, nutri-
tious, and easy to digest. In toxic cases diffusible
stimulants may be indicated. The drugs which have
given the best results are: turpentine, in doses of five
drops three times a day, or by inhalation; ergot, or the
816
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Purpura.
Pyoktania.
subcutaneous injection of ergotin, wliich is highly spo-
ken uf by Crocker; silver nitrate, gr. J to gr. f in pill
form; aromatic sulphuric acid; and chloride of lime in
doses of from fifteen to thirt_v grains three times a day.
The latter remedy- should not be given for a longer period
than two or three days, as it acts directly on the coagula-
tion of the blood. Astringents in the form of iron or a
four-per-cent. solution of hydrochlorate of cocaine have
been resorted to in severe cases. Ice in the mouth, or else-
where, may be indicated as a lociil application. Boul-
ioche' recommends the injection of artiticial serum, and
relates a case of fulminating purpura in which death
seemed imminent, but which, under this treatment, made
a complete recovery. In this case 120 c.c. were given.
Absolute cleanliness should be insisted upon, and some
mild astringent and antiseptic gargle may be applied to
the mouth and fauces. Further than this the treatment
depends largely on tlie cause of the disease and the com-
plications which are encountered.
William Thomas Corlett.
Keff.re.nces.
' Osier, William : Practice uf Med.. Philadelphia, third edition, p. 815.
2 Henoch, Ed.; Vurlesungen uber Kinderkrankh.. Berlin, 1S97.
2 Mattin de Giniard : Iiu Purpura hgemoirhagique Primilif, Paris,
18f», cited by Stelwason, Inc. cit.
* Letzerich ; CntersudiuDP ii. die Aetiol. u. die Kenntniss des P.
hffiui.. Leipsic, 18vS9, iidd.
^ Kalbe: Arbeiteu aus dem Kaiserlichen Gesundbeitsamte, vii,,
1891, ihkl.
' Lenoble, E. : Annates de Derm, et de Syph., December, 1903, n.
1097.
' Hayem : Lecons cliniques sur les maladies d» sanfr, Paris, 1900.
* For a more roiiiplete discussion of this stibje4-t the reader is re-
ferred to the writer's treatise on the " Acute Infectn'us Exanthemata,"
F. A. Davis Co., Philadelphia. 1901, pp. 4S cf scq.. »L> ,■( .lei/.
* Boulloche : Bulletin et m^m. de la soc. nied. hop. de Paris, vol.
ivl., 1899, p. 809.
PUS. See Iiifliiuiiiuitii'ii, and Exuthitiioi. Patlwhxjical .
PUTREFACTION. See BccUriit. and Ptoimilns.
PY/EMIA. See i^'eptieceiiiia and Pi/if/nin.
PYELOTOMY. Seo JTidmys, Surgical AffccHoim of .
PYKNOSIS (also spelled Pycnods) is the term apjilied
to that condition of the nucleus in which, in the early
stages of necrosis or just preceding necrosis, it stains
more inteu-sely with nuclear st;iins. At the same time
there is usually a conti-action of the nucleus; but the
nucleus may remain of normal size or even swell. Kary-
orr/icfis may follow pyknosis, or theie may occur a
gradual fifirydysii without a disinlegratinn of the chm-
matiu elements. In sections stained with hiemato.xyiin
the pyknotic nuclei may appear almost black. This
phenomenon is usually e.xplained as due to a condensa-
tion of the chromatin. P3'knosis may be observed in
necrosing cells of all organs and tissues; it is seen par-
ticularly in necrosing syncytial cells, bone-marrow giant
cells, muscle cells, sarcoma cells, etc. Pyknolic cells are
sometimes mistaken for newly formed cells; and in some
cases the differential diagnosis is difficult. This is par-
ticularly the case in striped muscle. Undoubtedlj- many
of the cells regarded as evidences of muscle regeneration
have been cells in a condition of pyknosis.
Aldred Scott Warthin.
PYLORECTOM Y. See Stomach. Surgery of the.
PYOKTANIN.— (.l/f<7(i/? violet.) An aniline dye intro-
duced in l^'Ji). by Prof. J. Stilling, as a powerful anti-
septic for surgical purposes.
Dr. Stilling summarized its qualities as follows; (1)
Pyoktanin is an antiseptic surpassing all others. The
bacteriological researches have shown blue pyoktanin to
be about three times as strongly antisejitie against anthrax
bacilli as sublimate is, and to be quite as efficacious as
sublimate toward the staphylococcus aureus. (2) It is
an absolutely non-to.xic substance. (3) In consequence
of this uon-toxicily it is a matter of indifference in many
Vol.. VI.— 53
cases of wounds, etc., whether somewhat weaker or
stronger solutions, or even the pure drug, be used. (4)
It does not coagulate albumin— a negative quality of
high vaiue physiologically, which pei'tains to no oiie of
the antiseptics heretofore" known. (.5) It passesses an
extremely high degree of diffusibility, permeates the in-
terior of the eye like atropine, and acts similarly in other
tissues.
It was recommended to be used in all inflammatory
affections accompanied by tlie formation of pus. Con-
junctivitis, urethritis, and intlammation of mucous sur-
faces were especially benefiteil, but it was also used with
success in the treatment of ulcers and other suppurating
wotmds. Methyl violet failed to prove itself of particu-
lar value, and has fallen into disuse. In many instances
favorable results were not obtained, and it frequently-
produced marked ii-ritatiou. Its intense coloring proper-
ties also proved particularly objectionable. Probably its
most important use has been in the treatment of inoper-
able malignant disease.
In 1891, Professor von Jlosetig reported a number of
cases treated by injections of pyoktanin, with very fa-
vorable results. For some time he had used the different
forms of aniline as an injection, w'ith the purpose of stain-
ing the nuclei of the cells and thus checking their growth,
but the constitutional symptoms produced had always
been a hindrance to t he treat incut. When Professor Stil-
ling introduced methyl violet he at once began to use it
for this purpose. The germ-destroying power of the
agent, in connection with its diffusibility in healthy and
diseased ti.ssues, made it a very promising agent, "espe-
cially as it was also harmlessand devoiil of any injurious
effect on the human economy. The first case was in a
woman, sixty-si.x years of age, with a large tumor cf the
lower jaAv xvhich prevented her from swallowing and
caused gi-eat suffering. After thirty-five injections of C
gm. of a 1 to 500, and afterward of" a 1 to 3U0, solution,
the tumor was so much reduced without ulceration that
the patient could eat without discomfoi't. In the case of
a man, fifty-eight years of age, with a C3-stosarcoma of
the chest wall, measuring Vd cm. in width by 18 in
length, after twelve injections of 6 gm. of a 1 to 300
solution, the measurements were reduced to 10 b_v 12 cm.
In two cases of adenocarcinoma of the neck, the same
treatment proved so effectual that the patients considered
themselves cured. Another case was that of a woman,
si.xty yeai-s of age, with papilloma of the bladder; for
which 20 gm. of a 1 to 1.000 solution was injected into
the bladder every second day. After the injections there
was notable improvement, the ha»inaturiahad ceased, and
there was little or no pain. Pi-ofessor Musetig also cited
a case of a man, si.xty years of age. with an enormous
sarcoma of the pelvis; colotomy .had been performed.
After si.xteen injections of 6 ,gm. of a 1 to 500 solution
into different parts of the mass, it had shrunk to one-
half its former size, and the patient was greatly relieved
and iible to walk about for a few bonis daily.
Since Professor Mosetig's announcement numerous
cases have been treated and reported. The results have
varied greatly, some surgeons claiming veiy remarkable
cures, while others have failed to observe any signs of
benefit, and look upon it as a [lerfectly useless procedure.
The greater number of those who look with favor upon
the treatment, including its author, do not claim that it
is a curative agent for cancerous diseases, but simply that
during its use the progress of the growth is checked, the
local condition improved, and a temporary relief obtained.
The following directions are given for its employment;
Under proper antiseptic precautions (he part is to be
carefully curetted until all the diseased tissue that is ac-
cessible is remo^'cd. When there is no uiccratiou of the
surface, the curetting is omitted. After the curetting, a
tampon of iodoform gauze is placed in the wound and al-
lowed to remain for forty -eight hours. The surface is then
washed and carefully dried and the injections are made
into the tissue, to the depth of tlie needle if necessary,
according to thee.xt«nt of the tissue involved. Other in-
jections are made into the surrounding tissues, as many
S17
Qiiaraiitiue.
KEFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
as fifteen puiictiivcs bcinji: niude at one sitting. It is
advised to bej;in witli ,tlie drepcr in.jcetions, in order to
avoid a diseoloration of tlie tissues on t\u) surfaee in tlie
early stages. After tlieiiijeetions iiaveall been made, pure
pyokraniu powder rs iiilrod\ici-d into tlie cavity, or gauze
or cotton, medicated, may be used. Tlie tampon is left in
position until the second day, when it is removed and the
parts are thoroughly washed and the iiijeetions repeated.
The introduction of tlie solution exerts an analgesic ac-
tion, and also cheeks the profuse hemorrhage that is fre-
quently present.
Intrapuliuoiiary iiijeetions have also been usi-d for the
treatment of iinluionarv tuberculosis. Tlie liquid em-
ployed was a 1 to "iDO solution, of which eight to sixteen
minims were injected. Tlie injections are reported to
have been well borne, but when tlu' lii|uid iieuetrated to
the bronchi, a violent attack of cougliiug was provoked.
Tliera])entically, it is said to have produei'd a lessening
of the hectic condition and reduced the number of bacilli
lu the sputa, /lriiiiiii<i/it Snuill.
PYRAMiDON— dimethyl-amiilo-dimelhyl-pheiiyl-py-
razoloii. iliiiiethyl-aniido-autipyrin, {'t,n3N".N((.:il3")2.cd.-
CH.NCII3.CCII:, — is a yellowisii-white, tasteless crystal-
line powder, which is soluble in ten partsof water. With
ferric chloride it gives an evanescent deep bluish-violet
color, a distinction from antipyrin which gives a red
color.
Emi)loycd in smaller dosage than antipyrin it lias an
antipyretic action like that body and a inon^ sedative ac-
tion on the nerves, Robin et Bardct found inompt relief
in trigeminal neuralgia. Laudenheimer praises it in the
paius of tabes, alcoholism, chorea, neurasthenia, and
hysterical conditions. Pollak notes sweating and .some
flushing of the face, but reports the drug sjiecially ap-
plicable in the hi'ctic fever of iiulmonary tuberculosis.
Horuelfer found it elfeetive in facial neuralgia but not in
sciatica. ]5ertherand ascertained that doses of 0.;3 gm.
(gr, v.) iiicrca.scd the coetllcieiit of nitrogen elimination
ten per cent, in eight days. In a diabetic who was ex-
creting 2-3 gm. (gr. x\x.-xlv.) of sugar a day, P3'ra-
midon sent the sugar up to 1.V.30 gm. (gr. ccxxv.-ccc);
so it is coutraiudicated in this disease. Tliis investigator
found the profii.se sweating an olijcction. especially in
tuberculous iialients. In sciatica lie obtained gooil re-
sults from hypodermic injection. Albrecht was able to
shorten and modify severe asthmatic attacks in emphy-
sema by doses of 0.3 gm. (gr. v.) two or three times a
day for several d;iys. In pneumonia, typhoid, scarlet
and other fevers the drug has been used with asserted
good results. The dose is 0.()(i-0.(t.5 gm. (gr. i,-x.), and
3 gm. have been given in one day without ill clfects.
TJir piimmidon i-iiiiiiili<ir(iU'.i. both the acid and the x^^■\l■
tral .salts, are preferred by .some therapists in tuberculosis.
Bertherand recommends these comiiounds lor preventing
the excessive sweating of pyramidon. The dose of the
neutral salt is O.'i-O.T.') gm. (gr. viij.-xij.), the larger dose
representing 0..") gm. (gr. viij.)of pyramidon; the dose
of the acid .salt is (.). 7,5-1 gm. (gr. xij.-xv.).
Pjintmidon. siilii'i/lnte is claimed to b- esiiecially valu-
able in neuralgia and rheumatism in dose of 0.7,")-l gm.
(gr. xij.-xv.). \V. A. Jjiislcdu.
PYRANTIN. See J'/ieiio.iiirn'n.
PYRIDINE (CtllsN)— a liquid base present in coal tar
and .sejiarated by fractional distillatieni. It is also ob-
tained from bone oil, or Dipiiel's oil. It is a decomposi-
tion product of various alkaloids, and is present in
tobacco smoke.
It is a colorless liquid, with a peculiar em|iyreum;itic
odor and pungent taste. It is very hygroscopic and
mixes freely with water, alcohol, and oils. Its specific
gravity at 33" P. is 0.9858. Pyridine resembles alkaloids
in its property of forming salts with acids. In toxic
doses pyridine is a jiowerful depressant, causing (laraly-
sis and deatli from failure of respiration. The blood is
also altered and destroyed. Germain See has studied its
action in various forms of asthma and recommends it
when the disease is of a nervous origin. One drachm is
placed in a saucer in a closed room, at a temperature of
68° to 77' F. In about an hour evaporation will have
taken place, and the patient should then inliale the im-
jiregnated atmosphere for fifteen or twenty minutes,
wliich may be repeatetl two or three times a day. The
drug may also be inhaled by placing ten or fifteen drops
ou a handkerchief.
The drug has not, however, establi.slied itself as a rem-
edy of much value, and is rarely employed in this coun-
try. It must not be confounded with pyrodine, which in
a ]>reparation of hydracetini'. Beaumont Small.
PYROGALLOL: PVROGALLIC ACID.— Pyrogallol is
a triatouiiu plieiml, C,ill;,(011)3, ]iroducible by the action
of heat on gallic acid, wlieiiee the common name "pyro-
gallicacid." It is olHcial in the United States Pharma-
copicia under the title Pi/iw/uUol, Pyrogallol. It occurs
in long flattened prisms, or in needles; colorless, odor-
less, but with a bitter taste. It dis.solves in 1.7 parts of
cold water, and very readily in boiling water and in alco-
hol. In solution, exposed, it oxidizes, turning brown.
Pyrogallol possesses the poisonous property, more or less
common to the group of phenols, of alYccting the blood
and bringing about ha-moglobinuria. Administered by
injection to rabbits, this mediciiie has speedily caused
chill, dyspiuea, tremor of the extremities coming on in
paroxysms, and death. The urine in such cases has
shown the characteristic features of ha>moglobinnria, and
the blood lias exhibited discoloration and destruction of
the red blood corpuscles. In rapidly produced death by
large do.ses, the blood has turned black or, in some eases,
of a chocolate color and jelly-like consistence. In the
human subject death has resulted, in cxie instance, from
the application, to one-h.alf the bo<ly at once, of a ten-
Iier-eent. pyrogallol ointment. In this case a violent
chill, with vinniting anil collapse, set in six hours after
making the application of the salve. The patient rallied,
but forty hours later a second attack ensued, ending in
coma, with great reduction of temperature. Death oc-
curred on the fourth day. During the illness the urine
was much diminished in quantity, and showed, in high-
est degree, the condition of luemoglobinuria, being dark
brown in color and, u|ion standing, depositing a thick
sediment of amorphous, blackish material. The blood
was found, post mortem, disintegrated, and the kidneys
bluish-black and stuffed with the same material as the
urinary sediment. Pyrogallol lias been used in medicine
almost exclusively iis a local application for the relief of
certain skiu diseases, notably ji^iunKsia — an appli<'atiou
often successful when other remedies may have failed.
Aiiplied ill solution or in ointment, pyrogallol stains the
skill somewhat, but the stain speedily di.sajipears. Linen
clothing, however, may be perinaiiently injured by the
action of the medicine. To avoid this latter efl'ect, a
solution of pyrogallol in flexible collodion has been pro-
po.sed (Elliot). Such ])reparation, when dried to a film
upcm the skin, seems still to exert the therapeutic action
of the medicine, but, being dried, is without action upon
the clothing. Pyrogallol may be applied in ointment or
in solution, and strengths are used ranging from five to
fifteen [ler cent, of the remedy. The higher percentages,
in ointment certainly, may irritate severely, and should
be used with caution. Aiiplications should never be ex-
tensive at any one sitting, for fear of enough ab.sorption
to bring about constitutional poisoning.
Ediriinl Curtw.
PYROSAL — antipyrin salicyl-acetate— occurs in color-
less crystals of acidulous taste and difiicult solubil-
ity in water. It contains fifty per cent, of autiiiyrin
and thirty-seven percent, of salicylic acid. Introduced
by Riedel. this compound has been used as an antipyretic
anil aiialnesie in ilieumatism, influenza, migraine, sciatica,
etc. The action is prompt, and no untoward efl'ects have
been noU-d. The dose is 0.3-0.7 gm. (gr. v.-x.), repeated
frequently. W. A. Bastcdo.
S18
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Pyranildoii,
Qiiaraiitiiie.
QUARANTINE. — The term"quarantino" has its origin
from the Iialiiui " nuaranta," meaning fori}-, this being
the number of days for wliich vessels were, in thelii-
teenth cenlnrj-, held under observation on account of
epidemic disease. It is now applied to what should more
properly be known as maritime .sanitation. In addition
to this, it is also applied to restrictions against the ad-
vance of epidemic disease on laud.
While it may be fairly assumed that all wdio are in
anywise interested in the subject of quarantine are al-
ready fully conversant witlitbe history of such measures
as have been taken in the past for preventing the spread
of epidemic disease, nevertheless, for the sake of com-
parison with what is now considered proper, and to set
forth morecleai-ly the great strides which have been taken
in sanitary .science and in the methods employed in the ex-
clusion of exotic disease, a short resume will not be amiss.
It is generally understood that tlie tpiarantine which
was established by Venice in 1403 for the exclusion of
plague was the first systematic attenqit to exercise any
kind of surveillance over commerce for the conservation
of public health. It may be remarked, however, that a
species of land quarantine, namely, the i.solation of lep-
ers, was certainly existent fomleen centuries before that
time, possibh' at a much earlier period.
The general idea in the fifteenth century seems to have
been that no measures of purification were indicated, but
that detentions for a period of forty days would suffice
to allow the di.seaso to die out; and in truth this was what
frequently happened. The luifortunate individuals c(mi-
prising the personnel of a vessel in quarantine had to take
their chances, and these were admittedly slight, of escap-
ing the scourge while they were hnddled together with its
already stricken victims, the authorities believing that
the lives of a few were well sacrificed in the interest of
the many, and that their duty ended with providing
food for these unfortunates and keeping them within
fixed bounds.
The foregoing statement may be said to sum up the
maritime quarantine .system as it existed five hundred
years ago. Of land quarantine there seems to have been
none, or, if it existed at all, it was of tlie same brutal
character as that ajiplied to the shipping.
When the bidjonic plagvie swept over Europe with
such appalling results in this same fifteenth century, the
people fled unrestrictedly from any stricken community
and scattered death in their wake. Abject cowardice
and sublime courage shone out in vivid contrast to one
another.
Coming down to more recent times, we find that as late
as IS.'JO a very nebidous idea held sway in the minds of
men as to proper methods for preventing the ingress of
pestiferous diseases, and the forty-days detention period
which was instituted by Venice four' hundred and fifty
years before, and which Spain adoined against yellow
fever from the West Indies a century later, was "still in
vogue and constituted practically the sole maritime
guard of most states agaiu.st disease; while, on the other
hand, some few advanced communities, in sheer disgust
at measures which, while destroying their commerce,
gave no adequate protection against the ravages of yel-
low fever, smallpox, and cholera, the preventable "dis-
eases then uppermost in men's minds, had thrown ojf all
restraints and were willing to risk the disasters incident
to an epidemic, rather than the ills of ruined commerce.
And this indeed was a rational decision; for, however
we may view the matter from a theoretical standpoint,
the question practically put is this: Can a community
better afford to take a slight or even a pronoimced risk
of disease which will destroy a certain percentage of its
population, than to take the risk of commercial death
which will annihilate it as a community? The former
risk is the more rational, and especially when we bear in
mind that all quarantine mu.st of necessitv involve a cer-
tain feat ure of necessary risk ; for, even were it possible to
evolve an absolutely safe system, no community would
allow sucli a .sy.stem to stand, involving as it would most
serious hindrances to commerce.
Oneof the mo.st talented editorsof the American press,
some years ago. denounced the then existent system as
"sanitary savagery," and we tuust admit that"there is
some justification for this aiipellalion.
Tlie sole aim, the very raison d'l'lre, of a quarantine is
the exclusion of exotic disease. If it does much less than
this it fails to fulfil its obligations to the conujuuiily; and,
by doing more than this, it retanls commerce, in"terferes
with legitimate vested right, and becomes an object of
well-merited aversion.
Quarantine is the sanitary vidette and skirmish line,
and it may, and often does, fail to keej) out exotic dis-
ease even though c-uefully and scientifially conducted.
Nothing short of correct lalioratory melhoiis (absolutely
inapplicable to practical quarantine) could under all con-
ditions exclude di.sease. Such being tlie case, we must
view a proper quarantine, to express the matter in
homely parlance, very much as a sieve, which will ex-
clude the major part of the solids from a given volume
of water passing through. Now, if we apply such a
sieve to a river, so long as the water can pass by, leaving
behind most of the detritus carried in suspension, all will
be well; but substitute forlhat sieve an impervious dam,
and so surely as you do, that dam will be swept away.
So, likewi.se, if we place a quarantine of scientific accii-
rac}- at the gateway of an v of our large conunercial cities,
we shall have built practicall}' a sanitary dam, and we
shall soon find that commerce, having sulimil led to what
it considers a reasonable amount of obstruclion, will re-
fuse to accept further restriction, and our saintarv dam
will be swept away by the overwhelming onflow of pub-
lic opinion, which will, rightly or wrongly, tell us. and
tell us in unmistakable terYns, that the public is willing
to take some slight risks for the sake of commcice, and
does take these risks, and will not submit to any system
which seriously interferes with the community"'s means
of olitaiuing a livelihood.
We must liear in mind that while the sanitary aspect
of a quarantine is luidoubtedly of primary importance,
commercial interests demand and should be granted con-
sideration in such matters, and while commercial interests
are secondary, they are entitled to careful thought; for
we must not forget that the condition Ijrought about by
a stoppage or even a slowing of business "in any large
conuiumiiy means suffering and privation to thousands.
When you stop the wages of the breadwinner, you in-
evitably, thougli indirectly, produce sickness, tlie very
thing we propose to prevent, and it matters little to the
victim whether that sickness be of an epidemic or a non-
epidemic character.
When, in the early eighties, the JIarine Hospital Ser-
vice assumed the small quarantine finictions previously
assigned to the National Board of Health, and with these
functions took over the (juarantine stations which had
l.ieen established by the National Board of lleallh at Ship
Island, ^Mississippi, and Blackbeard Isliuid, Georgia, the
system of long-drawn-out detention, plus a funiigation
with sulphur dioxide and some spraying with solution of
bichloride of mercury, was still in vogue; but there was
no clearly defined idea as to how, or why, or when things
shoidd be done.
Dr. A. N. Bell, who was at the time an oflicer in the
United States Navy, had indeed in tlie fiflies made a
most valuable contribution to sanilary science in the
shape of a report of the disinfection done by si cam on
board a United States man-of-war, which had become in-
fecte<l by yellow fever during a cruise in the West Indies,
but no one seems to have taken any particular interest in
tlie matter, and it had been practically forgotten until
al)out 1883, when Dr. .losepli Holt, of New Orleans, the
president of tiie Louisiana State Board of Health, inau-
gurated a system of disinfection near the mouth of the
Mississippi River, the mainstay of which was the appli-
cation of steam. It is probable, however, that the first
really scientific application of live steam to the disinfec-
tion of textiles, etc.. was made by Dr. H. H. Carter, Sur-
geon of the L'nited States Marine Hospital Service, at the
Gulf Quarantine. Chandeleur Island, Mississiiipi, in 1888.
819
Qiiarautiue,
Quarantine,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
He there deinoiistratcd tlie priucipk' that steam, to be
practically effective, must be diffused through the matter
to be treated (must circulate), orelse that a vacuum must
first be provided to insure the peuetratiou of the steam,
as otherwise there would be dead air spaces in wliich only
dry heat of not more than 90' C. would be secured; iu
other words, these areas woidd not reallj' be tlisinfected.
Dr. Carter, at the Gulf Quarantine, and the writer, at
Blackbeard Islaud, Georgia, wei-e during that year simul-
taneously win-king toward the same end, and enileavor-
ing to bring about improveuieuts which establish the
following ba.sic principles that are now, it is believed,
universally acknowledged :
1. That a suspected ship must — if we wisli to make
sure that she shall do no harm — be considered to all in-
tents and pur))oses as an infected ship.
2. Tliat members of the pcrwiuui must be removed
from possible infection as soon as practicable after the
ship arrives in quarantine.
3. That so far as tlie ship itself is concerned, it is as
free from danger five minutes after the completion of a
proper disinfection as it would be in ti\e years.
4. That the longer the ship lies without disinfection,
the more infected, other things being equal, will she be-
come.
5. That the period of incubation of the given disease
having elapsed since the person was removed from pos-
sible e.'ipdsure, such person can safely go at large.
These liypotheses all seem very plain and simple.
Doubtless ihey are at the present time, but ]irior to the
time mentioned, as a survey of the then e.xising stale of
municipal qviaranliue regulations will show, it liad been
at many places the custom to detain a vessel from a .yel-
low-fever port for anywhere from fourteen to forty days,
and to disinfect lier at some time during this detention,
DO particular time being stated.
To Di'. Joseph Unit, of New Orleans, Ijelongs the credit
for the tirst real awakening to the fact that quaranline
should mean sanitation and not punishment of the unfor-
tunate victims of epidemic dLsease.
To Dr. II. R. Carter belongs the credit for the enunci-
ation of the principle that detention of persons under
observation must be rational, and must of necessity fol-
low their complete disinfection or, to state the matter
more clearly, their complete removal from sources of in-
fection; that, scientilically speaking, detention applies
alone to pe mo nit el, and not to inanimate things; that such
detention need be only for tlie jieriod of incubation, and
must be for the full jur /oil of incubation. He worked as-
siduously to inculcate these ideas, and succeeded.
Another point of interest in quarantine, as it existed in
the eighlies, is thealjsolute ina<lcquacy of the appliances
for disinfection and for the general handling of ve.'^sels.
It is true, as above stated, that Dr. l!ell had, iu the tifties,
proved the adequacy of steam disintV'Ction extempo-
raneoiisly applied, and that Dr. Joseph Holt, ]iresident of
the Louisiana Slate Boaid of Health, had announced and
proved his idea of steam disinfection.
These ideas, iKJwever, were slow in taking root; and,
as late as 18110, there were only three quarantines
eqidpped with steam disinfecling apparatus. It was
about 1.S90 that Di'. Oliiihant, of New Orleans, the then
president of the Louisiana Stale Board of Heallh, and
Dr. Kinyoun, of the Marine Hospital Service, )ii-omul-
gated the idea of generating suliihur din.xide by a fur-
nace and obtaining a higher percentage than the 4.5 jier
cent, (by volume) of the gas obtainable by the pot (ilan.
The foregoing is an amplj' sufficient sununary of what
quarantine was.
The system now in practice under the administration
of the United States Public Health and Marine Hosjiilal
Serviceaiid of the most advanced State authorities is, like
almost all institutions which have arisen under the regis
of our race, a conservatively constructed plan, anived at
by slow, steady advances, by careful trial of methods,
by rejection of unlit and acceptance of well-proven
methods, and with the entl constantly in view that every
protection must be given to the people, but that nothing
should be done which will unnecessarily hamper the com-
merce of the nation or of any local community.
All methods of disinfeetiou are thoroughly tried in the
Hygienic Laboratory, and, if proven accejitable there, are
then given what may be termed a field trial, i.e.. a test
under very practical conditions, but under the eye of
scientists who are able to determine their exact value.
Careful investigations are made into the uatuie of the
various infectious di.seases, and the findings of all scien-
tists regarding their causative agencies and methods of
jn'opagation receive thoughtful consideration by those
wlio are working out the problem of how to deal with
each upon the arrival of a ship in quarantine infected
therewith. These investigations are going on day by
day without ceasing, to the end that nothing shall he
done that ought not to be done, and nothing left undone
that ought to be done.
No other of the great powers has such strong reasons
as the Lnited Stales for the establishment and mainten-
ance of a strict system of maritime sanitation, for the
reason that no other nation of prime importance has at
its very doors an endemic disease (yellow fever) con-
stantly demanding admission. It is true that cholera and
I)lague do ou occasion threaten the nations of Europe,
but this is at long intervals. One result of this necessity
for vigilance has been a largely increased interest in such
matters, and, as the outcome of this interest, there has
been established by the L'nited St;ites a system (not as
yet jierfect or general, but widely distributed) of foreign
insiiection of vessels and personinl bound for the United
States. That this foreign service is valuable there can be
no denial ; but equall3' certain is it that it can oidy be an
outpost, and must be strongly backed up by a thoroughly
efficient service at our own ports.
The United States Public Health and Jlarine Hospital
Service has, at the present writing, inspectors stationed at
the principal ports of China, Japan, the Island of Cuba,
Jlexico, and Central America, and it has also in the past,
as occasion ilemanded. placeil inspectors at various other
ports. It is the policy of the service to meet, by detail-
ing inspectors to that point, any e.xigenc}' which arises
in the shape of epidemic disease at any given point, and
which threatens the sanitary integrity of the L'nited
States. As illustrative of the latter statement, it may
be .said that during the major part of 1893 the service
had twelve medical officers stationed at those European
ports from which the passenger traffic to this country
was heaviest. In addition, the State of Louisiana has
inspectors at West Indian and at several Central Ameri-
can ports, which they deem it advisable to watch on ac-
count of the large commerce between those ports and
their own. As the writer has had no accurate knowl-
edge of State insjiection and the work of State inspectors,
he will Hunt tliis discussion to the subject of national
foreign inspection.
At Havana, Cuba, the JIarine Hospital Service, for
several years before the Spanisli War, mainlained an in-
spection service winch was of great value to commercial
and sanitary interests in that it gave data to the consid-
general upon which to issue bills of health, which data,
as a whole, formed an abstract of the sanitary condition
of the port and vessel, and enabled quarantine officers to
decide mcU'C ]iromptly than they otherwise could, what
treatment sliould be accorded each vessel upon her arrival
in this country. It is well known that the Southern ports
and New Vork jjlaced great reliance upon this Havana
bill of lieallh.
At the beginning of the Spanish War this ins))ection
service was, of course, discontinued, Init at the elose of
that war there was eslablished in the whole island of
Cuba a regular system of maritime quarantine, providing
for the inspection and disinfection of both incoming and
outgoing vessels, which system was as near perfect as
circumstances would permit; and this was continued un-
til the spring of 1902, when, the Cuban Government as-
smning charge of its own fimctions, the quarantine was
turned over to them, and the system of inspection which
had hitherto existed was resumed.
820
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
Quarnutliie.
(Quarantine.
Tbe same class of ^ork is now iloiu' at (.IlitT Cuban
ports as at Havana, and wliilr ibu Havana insiiuition is
the most important one in the inland, others arc none the
less valuable as giving a clean-cut idea of the status of the
port and ship on the day of sailing.
'J'lie inspectors in Europe in 1S93 had the difficult task
of endeavoring to prevent, bj- strict surveillance of ports.
ships, and passengers, the introduction of cholera into
the United States. Whether or not this cflort was
worthy of being made may be judged by the facts.
Two ships brought each from Europe with them cases of
cholera to the United States. While this was all that
came to our shores, the non-inspected ships from Europe
for South America, Africa, and other continents at times
had many victims of cholera, and it is doubtful if there
be any sanitarian who has been interested in such mat-
ters who does not remember the dreadful state of affairs
aboard the unfortunate Neapolitan steamers bound to
Rio in 1893. The facts are cjuoted from a report written
at the time fmm Naples:
"The four for South America, with the result in each
case, were as follows: The figures are not official, but are
practically accurate in every respect. All were turned
back by the South American authorities: Vencimio
Fl'irio, about 50 deaths; Andrea Dniio, 90 on way out,
total not ascertained; El Bemo, 84 deaths; Carlo li.,
about SoO deaths.
"To summarize, then, eight ships left Naples. The
water supply was the same and the food about the same ;
tlie class of passengers identical, and their places of origin
similar, in many cases identical. All four leaving [for
South America] without precautions became floating
pest-houses. Of the four for the I'nitcd States, the one
leaving before cliolera appeared in Naples had three
deaths ; the other three were made to conform to the regu-
lations, and all escaped."
The benefits to be derived from foreign inspection,
however, are not by any means comprised in the present
statement of what has thus far been accomplished by
this agency. An honest and well-trained sauitariau at
each port, which by virtue of its uu.sanitary surround-
ings menaces our health, if he be provided with the nec-
essary authority, can and will do a great amount of good ;
possibl}-, nay pVobal)ly. not what the general iniblic may
expect, cerlainly not an absolute sanitation of departing
ships, obviating all necessity of iiuanmtine at home, but
work of great practical value none the less. Under no
condition should we accept a bill of health from these
inspectors as pratique: such bills should only he con-
strued as informaticm, and, when properly made, as e.x-
trcmely valuable information.
Inspectors should have the several duties of, first,
keeping themselves posted, not only as to the health of
the city where each is located, but of all the country
commercially tributary to that city ; .second, reporting at
stated intervals to the home office any facts bearing on
the possibility of the introduction of disease from their
ports, and in extra emergencies they should make cable
reports of svicli facts; third, supervising all vessels, car-
goes, and passengers for the United States in times of
actual epidemic; fourth, collating and submitting for the
benefit of the health authorities at home new facts on the
subject of State and municipal sanitation independent of
epidemic disease: that is to say, new ideas as todraiuage,
sewerage, irrigation, and ventilation, and all such other
matters as may bear upon the public health in any way
whatever. In a word, these inspectors should develop,
for sanitary ptu'poses, as has already been done for busi-
ness purposes, a full-fledged system, a medical consular
system, if you choose to designate it, which may gather
linto itself all matters which may in any way help us to
attain to the end we have in view, and let that end be the
conservation of the health of this nation. To accom])lish
this there is only one path open. It is assumed, in the first
place, tliat to enable an inspector to enforce his demands
and be somelhing more than a mere spy upon commerce,
much authority is needed. This authority can be con-
ferred only by the national Government, and by it only
through treaty with the nation whose ports we should
inspect, unless we evade this by having our inspectors
aiipoiuted deputy consuls, or by having them serve in the
office of the consuls as, under the law of 1893, was done
in Europe, and is now done in the tropics. Inspectors,
then, to have authority, m\ist be national inspectors, be-
cause even though their reports and their work are public
property and would be for the public weal, their work is
not intended alone to benefit Louisiana or New York, ^las-
sachusetts or Georgia, but every State in the Union. Ohio
and Kansas have as much interest in the health of the na-
tion as any- seaboard State, and only by national service
can the whole nation be fully and equally served at an
equal cost to all. It is not certainly known to whom be-
longs the credit of first using this very valuable adjuvant
to an efficient quarantine service, but it is reasonably sure
that it was inaugurated by the State of Louisiana, and
when we have come to learn the full value of a rightly
applied foreign inspection, it is fair to say that the whole
nation will owe a vote of thanks to that State.
Let us practically illustrate some of the workings of an
inspector abroad, from both a sauitaiy and a commercial
standpoint. In September, 1893, becoming cognizant of
the presence of the cholera spirilla in the Elbe River at
Hamburg, and consequently expecting an outbreak of
cholera, the inspector began to put all emigrants for the
United States under observation, and confiscated all food-
stuffs whose history was not clearly known. After taking
away about twenty-five bushels of such food from a lot
of five hundred and seventy-five people bound for New
York lie permitted the vessel to sail. A case of cholera
developed on the second day out. It wasafterward clearly
shown that this case developed from the eating of a piece
of sausage which an emig-rant had concealed in his shirt
bosom. Now let us suppose that nothing had been done
with these people; that they had not been kept under
observation: that they had been allowed to take their
twenty-five bushels of possibly infected foodstuff along
with them, and then let us conjecture how many cases
might have developed, if one developed from one joint
of sausage. This is cited to .show what it is believed any
fair-minded man will concede, viz., that even though
there are occasional errors of omission (and such will occur
in all insi>ectious), an inspection is of immense value.
With the exception of the instance just narrated, and
one other of a similar character, infection occurred only
on one ship out of the hundreds which were given bills
of health in Hamburg in 1893, and all ships Sfiiled on
time. This result forms a .striking contrast with the cases
of the vessels bound from Naples to South America.
Now, as to the commercial aspect of the matter. Upon
the beginning of the inspection work on April 1st, 1893,
it was found that a majority of articles were being sub-
jected to a so-called disinfection — one that was absurd,
uncalled for, and in some instances fraudulent, not a true
disinfection in any sense; that other articles were being
shipiied which it was impossible to disinfect and which
should not have been allowed shipment. The report, of
the Chamber of Commerce was promptly obtained, and
from that was drawna fulllist ofall articles evershipped
from Hamburg to the United States. From this list the
following classification was made: "A," articles to be
shipped free from any inspection; "B," articles requir-
ing a permit from the inspector and possible disinfec-
tion; "C," articles which mtist be disinfected; "D,"
articles forbidden shipment on account of the impos-
sibility of disinfecting them. Disinfection establish-
ments which did a reliable disinfection were then sought
out and specified, and their certificates accepted. At
the hour of sailing tlie ship was Ijoarded and her cus-
tom's manifest presented for inspection. This enabled
the inspector to see at once of what her cargo consisted.
One ship only was held, and compelled to discharge her
forbidden cargo; but during the remainder of the year
l,89;j no other "such trouble occurred. The shippers ex-
]iressed themselves as gratified at the facilitation of their
business by, first, an exact knowledge of what they were
to do or not to do ; second, by the removal of an embargo oa
821
Quaraiiliuo.
Qiiarautiue.
REFERENCE HANDBOOK OP TUE MEDICAL SCIENCES.
many uiMiclus; third, by a k'sseuiiig of cxik'Iisps incurred
through uniifcvssary disinfection. Althouuli the system
has been discontinued since December, IMDIJ, the good
results of tliis European inspection have not altogether
ceased up to tlie present moment. One of tliose results
was the establishment, by German authority, — at Span-
dau, and subsequently at Tilsit and lilowa, the latter two
on the Rus,sian frontier — of stations for the cleansing of
persons and baggage of the hunted and haled ]{ussian Jew.
The.se stations liandle nearly all of that class, and, iu the
event of another Outbreak of chcjleia iu Russia, they will
be of untold advantage both to the I'lnigrant and to the
public. It is not unfair to claim that these stations wouhi
not have been established except for the example of
American inspection abroad. A system almost identical
with that at Hamburg was pursued in Bremen, Antwerp.
Rotterdam. Havre. Naples, and in the chief ports of
Great Britain, and it is a matter of history that only two
very slight infections developed aboard sliips, although
three hundred tliousand |i('i>)de were ins]ieeleil, ke]it tin-
der observation, and embaiked <luring the period alluded
to.
We are compelled to admit that we cannot remedy tlie
sanitary condition of any foreign port except in so far as
criticism may serve to arouse asen.se of shame iu a mimi-
cipality, just as the same weapon might compel a <lirty
boy to wash his face.
Of course, after the actual outbreak of di.sease, we can,
by delaying tlie commerce of the infected town, compel
the authorities to remed}', iu some measure, the defects:
but it is doubtful if we could accomplish this except at
sucli a time, and then it would be too late.
Finall_y, it is ])robabIc that our stron.gest ]irotection lies
in stationing the liest available men as inspectors at all
such ports, and by this means obtaining timely warning
of approacliing danger. Then, when the disease arrives,
we should lie ready to tight it with the most approved
appliances known to modern science, operated by the
most skilled ])hysicians the Government can assign to
this work.
We now come to the discussion of what a maritime
quarantine under the best modern conditions actually is,
how it should be equipiied, and how operated.
The Qr.\u.\NTiN-n Itself.
In tlie selection of a site for a (juarantine station, the
following points should be borne in mind: The station
should be accessible to incoming vessels, and should de-
flect them from their regular cour.se, in coming into ))ort,
only to the minimum extent. There should be as great a
depth of water at the quarantine station as the maxiinuin
draft of vessels entering at that |)ort. It should be so far
away from the port as not to he in the way of the further
growth of the city, thus preventing any necessity for the
future removal of the station, and also avoiding antagon-
ism of public sentiment. A quarantine plant, to be com-
plete in all repects, should com|iri.se;
1. Bo.vRDrNO FACil.rriES.^-Tlie necessities v;i,ry from a
small rowboat at some stations to an able seagoing tug
at others. It may be stated as a general rule that fora
land-locked station, south of the territory in which harbors
become icebound, a good, stanch naphtha launch, not
only will suffice for boarding pm poses, Iiut will be pref-
erable to almo.st any other type til vessel, because ot the
ease with which it can be handled.
2. Anchok.\ges. — .\t a compkt(- quarantine station
two anchorages should be provided, one for infe<'ted and
one for non infected vessels, and they should be siilti-
ciently removed from one another to prevent vessels un-
(lergcnng inspection at the non-infected anchorage being
infec:ted from the other, or infecteil anchorage.
3. Disinfecting Pi..\nt. — The disinfecting ]ilant may
be either on a wharf cu' on a floating plat form. It is lie-
lieved that, other things being equal, a wharf is superior
to the floating platform, and that the latter should be re-
sorted to only where natural conditions interfere with the
erection of a proper wharf or make such construction too
expensive. The disinfecting plant itself should consist
of: (1) Steam disinfecting chambers: {2) means for gen-
erating sulphur dioxide; (3) machines for generating
forinaldehjdc gas: (4) vats for holding disinfection solu-
tions; (o) large, air-tight wooden chambers for the appli-
cation of gaseous disinfection to large quantities of ma-
terial; (G) force pumps for applying disinfecting fluids.
Steam Diniiifcciing Chdinhers. — The probably most ef-
fective and mechanically as well as scientifically most
perfect steam disinfecting chamber in u.se to-day is what
i,s known as the Kinyoun-Francis steam chamber, devised
by Dr. J. J. Kinyoun, with the assistance of Jlr. Francis,
of the Kensington Engine Works, of Philadelphia. When,
as is now generally done, there is attached to this cham-
ber a formaldehyde letort, it becomes a doubly useful
appliance. The chamber is provided with an ejector
wliich will produce a vacuum of fifteen inches in the
largest-sized chamber — a chamber, for example, apju'oxi-
matclj'five feet iu diameter and sixteen feet long — in one
minute. This is, according to the observation of the
writer, about live times as rapid work as can possibly be
accomplished in the production of a vacuum by the ordi-
naiy air pump. The chamber is double-jacketed, and by
a system of jiipes and valves the steam may be forced
through the chamber in various directions, causing a cir-
culation of steam, ami resulting in increased efliciency in
disinfection. When it is desired to use formaldehyde
from the retort attached to the side of the chamber, a vac-
uum is produced, the pressui'e raised in the formalde-
hyde retort to about sixty pounds, and the valve leading
into the vacuum barely opened. It should not be for-
gotten that if the valve is opened wide, the tluiii contents
of the formaldehyde retort will be carried over into the
chamber, thus spoiling the articles to he disinfected.
Lack of space forbids a more thorough description of
this apparatus, which has been exhaustively de.scribed
by Dr. M. J. Rosenau (" Disinfection and Disinfectants,"
p. 57, et «■'?.).
Means for Generating Sulpliur Dio.riih. — The sulphur
furnace mentioned above, which was invented by Dr. J.
:I. Kinyoun, then a medical oflicer of the Marine Hospital
Service, was designed to meet the existing demand for a
greater percentage of sulphur than could be produced by
the pot method, and in careful hands it is capable of gen-
erating a much larger percentage of sulphur dioxide than
the pot method does. It has now, however, been very
definitely ;iscertained that such large percentages of sul-
|ihur dioxide ai'e not only unnecessary, but are so destruc-
tive in theiractionas to render it inadvisable to use them;
con.sequently, the much simpler method of placing the re-
(|iiired amount of sulphur in an ordinary pot, which in its
turn is placed iu a vessel of water, anil the sulphur then
lighted b_v the use of a few ounces of alcoliol, has largely
superseded the furnace and answers every purpose.
Mdclii lies for Generating FormnlrJehyde Gas. — (1) Auto-
clave under pircssure. (3) Retort without pressure. (3)
Generator, or lam]).
The above-mentioned three methods are given, and all
of them, within their ]iroperliinitationsand properly used,
are effective. It may be well to say that, as a general rule,
formaldehyde disinfection should be confined to small
spaces, and not undertaken in such large compartments
as the hold of a vessel, something like two thousand
cubic feet of air space being the maximum limit wherein
efliciency can be attained. In addition to the three ap-
idianccs mentioned above there is a means, which has
previously been mentioned, of applying formaldeli\'de
and dry heat iu jiartial vacuum in a steam chamber.
Tiuihs should be jirovidcd for liolding solutions of car-
bolic acid, bichloride of mercury, permanganate of pot-
ash, or other solutions which may be desirable for use at
the station.
Air-tight iromlen elianihersfur tlie applieation eif gaseous
ilisinfeetants to targe (jiiaiititie-s of material consist simply
of an ordinary room liaving but one door, which is ad-
justed to tit as tightly as possible. The room itself
should have a triple lining ; it should be ceiled first with
wooil ; then iqion this should be placed a lining of tarred
822
REFERENCE HANDBOOK OF THE MEDICAL SClExNCES.
<{ii;ii*iilltilie,
(tliaraiitilie.
papi-i-; nncl finally over this should be fastened a tiglitly
tirtiiif^ wooden ceiiiiij;-. In this aie arranged racks and
)i(Miks for spreading oul, or hanging up the articles to be
tiisiufected.
Force ])umps are simply ordinary Worthington or other
pumps of equal force, made in resist, so far as possible,
the action of bichloride of mercury.
Detention Bahkacks. — There should be provided at
every quarantine station adequate quarters for the com-
fortable housing, without crowding, and for the segre-
gation, if necessary, of such a number of people as may
ordinarily be expected to be held in detention at any
given time. These quarters should be, a.s elsewhere
stated, very thoroughly screened to prevent tlie ingress
and egress of mosquitoes, flies, and other insects. The
plumbing shoidd be of the best and the sewers should be
■SO arranged as to make it po.ssiblo entirely to disinfect
the dejecta. Tlie kitchen, which is to provide food for
the occupants of these quarters, shoidd be far enough
away to prevent any possible risk of contaminalion of
fooil; and at the same time arrangements should be pro-
vided for the disinfection — before tliey are returned to the
kitelii n — of any food carriers which may be used in the
barracks or hosi^ital.
A steam laundry is a vciy useful adjunct to tliis por-
tion of the station.
CuE.MATORT. — The station should be provided with a
crematory capable of handling a liunian body in a decent
and proper manner, or of dis])osing of any contauiinal<'d
material which is deemed to be beyond the reach of mere
disinfection.
Inspection OF Vessels. — Experience has demonstrated
that, prompted by anxiety to avoid delays and to save ex-
pense to owners, the average ship master has no com-
punctions of conscience regarding deception, and will
often deceive the boarding officer if he is not very acute.
In view of this fact, many of the ablest oflicersin tlie
national service make it a custom to indulge iu cursory
inquiries and to stroll about the ship for a few mo-
ments, asking apparenlly careless questions of subalterns
and crew, before beginning the regular ins])ection. The
writer on one occasion found a man in his bunk (con-
valescent from yellow fever), w ho subseciueutl_y stood in
line for insjiection and declared himself well.
After such a cursory glance at ship and personnel, it is
customary to call for the shiii's papers, including the bill
of health which, under the law of February loih, 1S93,
all ves.sels entering a |iort of the United States must bring
from the Unilccl IStales consul at the port whence they
.sailed. The captain, and the ship's surgeon, if one be
carried, are then carefully interrogated as to the minutest
details of the voyage, and as to the health of the crew and
passengers, if the ship has within recent date come from
a suspected port. All bands are then mustered and com-
pared with the ship's papers.
This muster is one of the choice occasions for decep-
tion by the master. lie may report any missing man
as being on duty with the engines, and, if told to send
a substitute to duty and bring the man, will even en-
deavor to pass olf upon the inspecting oft^cer a man al-
ready before him. In dealing with the tire-room force
of an Atlantic liner(often one hundred and lifty or more)
the inspecting officer must remember that this is a trick
easily accomplished.
Wlien the inspection of tlie per.innnel has been cmn-
jdeted, it is then necessary to go through the whole shi|i,
and especially those compartments devoted to tlie oceu-
pancj' of crew or passengers. Every hole and corner in
every compartment is to be searchingly investigated. If
any inspection is needed, an absolutely complete one is an
imperative demand. Firemen have been known to put
tlieir belongings in tlie firebox of a boiler which was leiii-
jiorarily disused, and cover them with cinders. In virw
of the known occurrences of this kind, it is absolutely-
necessary to use the most stringent care in searching
every jiossible hiding jilace, and to bear in mind another
fact which, while well recognized by most quarantine
cifticers, seems beyond belief, viz., that the article most
likely to be so hidden is ahrniin that vMch toith r/rcaiest
ccrliu'nti/ u iiifccinl.
The clothing of a man dead of eonuunnirable disease
was secreted by his comrades iu the finicd sails of a bark
at the South Atlantic quarantine, and only the large and
badly distributed bulk opened the way for its discovery.
Fortunately, cargo is, as a rule, cimiposeil of new
goods, and it is therefore hardly jn'obable that it contains
any infection. Indeed, while I am not as yet willing to
subscribe absolutely to the innocuousnessof cargo, I must
admit that it is likely to come up for serious considera-
tion only as regards one particular; I refer to the cjuestion
of food-stulTs coming from some cholera centre. These
food-stufl's, however, are not, as a rule, of such a char-
acter that thiy would be likely to transport the comma
bacillus in a living state across the Atlantic Ocean. An
examination of the ship's manifest will, therefore, show
fairly well whether there is a necessitj' for taking any
measures regarding cargo, and such measures belong to
the disinfection rather than the inspection of the vessel.
Food and ^^•;.ter supply should be investigated if such
a disease as t/iolera is aboard, and water supply alone for
mosquitoes if yellow fever is found. In the absence of
either, no attention need be paid to these supplies.
Ballast has long been a bugaboo at Southern quarantine
stations, and the writer confesses to having been at one
time a .strong believer in the transmission of j'cllow fever
through irijei-ted ballast, but he is now fully convinced
(through the findings of the Army Yellow-Fever Commis-
sion) that yellow fever cannot be conveyed through the
medium of clean, ilri/ ballast, of the character ordinarily
used, be it either rock or sand. Nor would there be any
danger in sea-water ballast in tanks.
Tliere is probably no doubt that dirty and damp rub-
bish might convey jilague or cholera, and even 3-ellow
fever by serving as a brooding place for mosquitoes; but
clean, dry rock or sand would almost certainly convey
notliin.g of an infectious nature. Dirty rubbish liallast
should be debarred at all ports, and shijis wliich insist on
bringing such st nil should pay the penalty of disinfection.
The inspection of ballast and the determination of its
character are, as a rule, easy of accomplishment. If the
inspection sati.sfies the quarantine otlicer that the vessel
can be admitted to entry without jeopardy to public
health, she is given pratique and concerns him no furtlier.
If, howeve., it is decided that she is infected, measures
appropriate for the eradication of the disease with which
she is known to be infected must be taken.
In order that we may properly consider what measures
are necessary for the correct treatment of a vessel in-
fected with an)- .given quarantinable disease, a brief re-
miine of the salient points of each of these diseases will be
iu order, such resmiie to include, so far as is possible in
each case, the period of incubation, the actual cause of the
disease, the characteristics and viability of the causative
micro-organism, when known, and its manner of spread.
Symplnms of diseases will not be considered, such being
out of place in an article of this character.
Yki.i.ow Feveh. — Considerable space will be given to
tlie discussion of this disease because, as above stated, it
is the<ine perennial threat against the Southern bordersof
the United States. Its period of incubation varies from
a few hours to tive days, and in a few rare instances
slightly more than five days. Its cause is as yet unde-
termined. Its method of transmission has, fortunately,
been determined to be through the medium of the mos-
(juilo, and that it is most probably not conveyed in any
other way. It is now known, therefore, that yellow
fever is not a contagious disease in the same sense as
scarlet fever or smallpo.x is contagious. Conseciuently
there is no danger to be apprehended from a yellow-fever
patient, provided the presence of the mosquito can be en-
tirely excluded. It is evident, therefore, that our whole
effort in prophylaxis against 3'ellow fei'er must be de-
voted to the exclusion, and, wherever possible, to the ex-
tinction, of this insect.
In view of the recent findings of the Army Yellow-
Fever Commission, to the effect that yellow fever is con-
828
Qiiarniiliiie.
Qiiaraiiliiic.
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
vfycil frnni man to man sok'ly through the agcnc}' of an
iutVrnit'iliary host (the Stegomyia fasciata), it becomes at
once necessary to inquire what bearing the acceptance of
these findings in their entirety will have upon the ques-
tion of precautious to be taken against the ailmission of
yellow fever into our ports.
Vessels should be iuspected now before they leave the
yellow-fever port and all mosquitoes destroyed.
The Public Health and Marine Hospital Service, fully
alive to the importance of the facts above stated, has
stationed otlieersat foreign purls to do this work wherever
it can be done without contlict with the laws and regu-
lations of the place. It will not do to assume that ves-
sels camiot carrj' mosquitoes, as some have a.sserted; as
a matter of fact, they do carry them. Thus, for example,
one vessel, the Marin BUtnquU'r, arrived at Sapelo Sound,
Georgia, after a voyage of about forty days from Rio,
with myriads of Stegomyia fasciata alioard, and it only
needed that she should have li.-id one case of yellow fever
in Rio to have had every soul on board stricken en route,
and the vessel (short-handed) be perhaps a castaway.
To sum up, then, we finil that the disinfccticm of ves-
sels from a yellow-fever port, and oul_y a few days out
from such port, is still necessary, and that such disinfec-
tion should compass the cntirr destruction of all mos-
qtntoes on board the ship. The best means to this end
will be a gaseous disinfection by SO.; of not less than four
per cent, volume strength for a period of at least si.x
hours, and better twelve. This disinfection should be
carried out simultaneously in all parts of the vessel, and
scruptdons care shoidd be taken to see that the fumes
reach nil dead air spaces, and partictdarly all parts of
the living apartments.
If a vessel has licen away from a yrliow-fevcr ))ort for
more than ten days, — i.e., several days bej'ond the incu-
bative period of yellow fever. — and if at the same time a
well-authenticated history of no sickness en route has
been obtained, it would be very natural to assume, espe-
cially if the Stegomyia had not been found in the vessel,
that she was not infected and that consecpiently she
might. safely be allowed to pass on without subjecting her
to a process of disinfection. The records, however, show
plainly that it is not always safe to reason in this manner.
Thus, for e.xainple, Stirgeon H. R. Carter, of the Ptdilic
Health and Marine Hospital Service, has pulilished in
Bulletin IX. of the Yellow-Pever Institute, July, 1<J(13, a
report of a number of in.stances in which yellow fever
was ajiparently contracted on board an infected ship.
Owing to the lack of space I shall be able to quote onlj'
one of the instances mentioned in this ri'port.
"HI. British ship Ami, in rock ballast; twenty-two
in crew, four immune to yellow fever. Sailed from Rio
dc Janeiro April SOtli. All well in port and eu route un-
til thirty -eight days out, when a boy in port watch sick-
ened with yellow fever. Taken to hospital, Oulf Quar-
antine, on third day, and died on sixth day. Another
case developed two weeks later in a (jnarantine attendant
who helped me clean up tlie room, sail locker, in which
the boj- was sick aboard sliiii.
" It is remarkable that there should have been only one
case of yellow fever among the crew alioaril this vessel.
At the time, it was ascribed to the fact that this boy, the
only one on the port watch, helped a man, shipped in
Rio de Janeiro and immune to yellow fever, overhaul his
chest a few days before the bov was taken sick. AVhether
there was an infected mosquito in the chest which had
survived this length of time, or whether there was any
relation between the cliest and the fever, may be a ques-
tion. It in no wise aft'ects the present question tliat the
disease was contracted aboard. It was the first case seen
at this station that year. "
Choi,ei!.\. — The period of incrdiation of this disease is
from a few hours to five days; more often it is about three
da.ys. Tlie cause is the comma bacillus of Koch, now
generally known as the Siiirillum cholerac asiatica>. (For
detjiils in regard to tliis disease see the article on Asiatic
Chnlcnt in TuK AfTF.KDix.)
The manner of spread of this disease, the introdnction
of which into the human system is by the alimentary
canal, is through the medium of dirty hands, polluted
food, polluted water. Both fooil and water may be pol-
luted, and probably aie, by files, which, having come into
contact with cholera dejecta, subsequently make their
way to the food supply. These insects probably played
an important part in the great epidemic of cholera in
Hamluu'g in lSi)3, after the disease became general in the
city, though in the beginning it undoubtedly arose from
the presence of the s)iirillum in the main water supply
of the city, the Elbe River, and it was the vdtiniate cor-
rection oi this water sujiply which had more to do, than
any other one fact(u-, with the wiping out of the disease.
In fact, it appears doubtful whether more than occasional
cases of cholera woidd occur in any community where the
water supidy is guarded with great care. It isnot simjily
through drinking it, however, that individuals may con-
tract cholera from infected water; they may also acquire
the disease by eating fruits and vegetables which have
been washed in such infected water.
BunoNic Fi,.\GUE. — The period of incubation of this
disease rarely exceeds seven days, and is more generally
from three to five days. The catise is the Bacillus pestis,
a short rod which is capable of bipolar staining with ani-
line dyes, and whose viability and general characteristics
have been well stated by Dr. j\I. J. Rosenau in his worK
on " Disinfection and Disinfectants." It will suffice here
to state that it siuvives in moist and albuminous sur-
roinidings for quite a long time, and in test tubes in
laboratory work for montlis and e\'en years. It dies
quickly wdien dried, but retains life longer when diied
upon textiles and other similar foniites than in any other
form of dryness, especially if the temperature is' under
19° C. It is, therefore, to be borne in mind that the colder
the climate the greater is the danger to be feared from in-
fected fomites, and the more thorough should be the
procedures adopted for effecting disinfection. A dry at-
mosphere and sunlight kill the bacillus quickly, and in-
versely, darkness and damp atmospheres jiromote its vital-
ity. It is not a water-borne infection, though it may live
for a time in water. It is largely spread to man through
the agency of rats, fleas. Hies, and other small animal life.
It therefore follows that, to disinfect for plague, it is nec-
essary to usesuch agents as will destroy this small animal
life, as well as the plague organism itself.
The past history of this disea.se, although it has been
writti'u in a very unsatisfactory manner, is nevertheless
sufliciently full to indicate tliat it has probably obtained
a footholil in comiuunities, in almost every instance, for
a relatively long time before it has been recognized. It
may be that it has existed among the rats and other ani-
mals for many months before any hinnan being has be-
come infected thereby, and a study of all the great epi-
demics of plague will indicate that it has existed among
men for a very considerable jieriod of time before it has
been recognized as plague, and before measures have been
taken to prevent its spread. There is little doubt that
the great plague in London did not occtrr within one
month or one vear after the disease lirst gained a foothold
in that city. Tt appears very probable tliat it had already
been there for several years, slowly and steadily gaining
a foothold for the great outbreak. Again, it is apparent
that in the beginning of an outbreak this disea.se is more
mild in character than later on in the epidemic. This
characteristic has been observed in the ease of yellow fever
also. There are apt to be mihl, so-called ambulatory
cases, which would not be recognized as plague tnider
any other condition than that of an active epiilemic, and
these maj' spread the disease just as surely as a viruli-nt
case; and it is these which doubtless do spread the dis-
ease from person to person and from place to jilace long
before there is anj' general recognition of its existence.
Sm.\llpox. — The incubative period of this disease has
been variously stated as being from five to thirty days.
These wide limits, Iwwever, are exceptional, and most
authors agree upon an incubative period of from ten to -
twelve days in a majority of ca.ses. An experience ex-
tending over many hundreds of cases justifies the state-
824
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
<liinranllne.
4^iiarautiiie«
nient that in at least ninety per cent, of all cases, the
initial fever of the disease will begin in approximately
ten (lays from the time of exposure, and will hardly vary
twenty-four hours from this time. The cau.sative agency
of this disease is not known. Its mode of transmission
is generall.v through actual contact with a pei'son who
has the disease iu the eruptive stage. It is not denied that
intermediate contact . such as the carrying of the ilisease
by a careless doctor from a smallpox patient to a hcaltliy
famil}' at a distance, may be possible, but such occurrences
are so rare as to be liar(lly worthy of consideration in act-
ual practice. In other words, while such carelessness
might result iu carrying some of the contagium upon the
clothing of the person, and thus the question of interme-
diate fonu'tes be brought into play, it is very much more
geuerally true that when the disease is carried byfomitcs,
it is carried by clothing actually worn and used by a per-
son infected with smallpox, and subsequentiy taken to a
healthy person. Tliere has been much discussion as to
the period when smallpox becomes contagious. While,
generally speaking, it m&y he safe to take precautions
with regard to an exposiu'e to a smallpox patient in the
febrile stage, it iias been found that almost without ex-
ception— and, so far as the writer is aware, absolutely
■witliout exception — no infection has ever resulted from
exposure to either the febrile or the papular stage of small-
pox. It is only after desquamation has begun tliat the
patient is lial)le to communicate the disease to others;
and tills contagiousness will continue until desquamation
has thoroughly ceased. Consequently, it is important,
before di-scharging a convalescent from smallpox, to ascer-
tain if every single scale has been cast olf from the scalp
and froin the palmar surfaces of the hands and feet ; for
it should lie bnrne in mind that the des(|uauiatiou from
the scalp is retarded by the hair, and that this is particu-
larly so with regard to the negro, while the thick epi-
dermis of the palmar surfaces makes them the last to
des(|uamate.
Typhus Fever. — The incubative period of typhus
fever is ordinarily stated at about two weeks; it is prob-
ably a little less than this, some authors giving it as
twelve daj'S. The exact cause of the disease is unknown.
It is exceedingly contagious, prob.ably the most pro-
nouncedly contagious of all the quarantinable diseases.
To quote Dr. Rosenau ; " Typhus fever is believed to
be ' contagious ' in the sense that it is comnumicated by
contact between the sick and the well. When the disease
exists in epidemic form it is the most highly contagious
of all the diseases of man. The nurses, physicians-, and
those who come in contact with the patient are the first
to take the disease. Few escape.
'• It is evident that sanitation is much more needed to
prevent the spread of this disease than disinfection; iu
fact, while disinfection is practised for typhus fever,
there is nothing to indicate that it is efficacious in pre-
venting the spread nf tin' disease."
Disinfection op Vessels for V.^Riotrs Diseases.
Yellow Fever. — As stated in the discussion of yellow
fever, the disinfection of a vessel infected with this dis-
ease necessarily involves the destruction of all the mos-
quitoes aboard such a vessel ; and while this is probably
all that should be done, it is nevertheless still the cus-
tom— and one which probably will continue until all
health authorities are fidly convinced tliat there is no
other means of transmission than tliat alTorded by the
mosquito — to carry this disinfection somewhat further.
To compass the destruction of the mos(|into, it is simply
necessary to introduce simultaneously into each and every
part of the ves.sel — cabin, forecastle, between-decks, hohi,
and any other compartments in the vessel — sulphur di-
oxide gas of a minimum strength of four per cent, per
volume for each thousand cubic feet of air space of the
vessel. In an empty vessel it is de.sirable tO' continue in-
troducing tile gas for from six to twelve hours ; in a vessel
containing cargo it will be necessarj' to provide chan-
nels through the cargo, in order that the gas may per-
meate as far as possible, and to continue the introduction
of the gas for twenty-four hours, iu order to insure the
destruction of all the insects. If the disinfection of bag-
gage and textiles of other kinds is to be undertaken, this
is done for the different articles, according to their class,
in the manner described in detail in the article on Vin-
iiiffction.
From a sanitary standpoint the vessel and its inanimate
contents may now, after sucli a thorough disinfection, be
considered no longer a source of danger, and the owner
may be permitted to remove his ship from quarantine.
As regards these who were on board the vessel at the
time of her arrival, it will be necessary, before carrying
out the measures for disinfection described above, to dis-
po.se of them on shore, at the station. The sooner any
infected persons are isolated or segregate<l, in order to
prevent a further sjireail of iufectiou. the better it will
lie for all parties concerned. The sick .should be taken
to a hospital so thoroughly provided with .screens as to
prevent the ingress or egress of mosquitoes; the healthy
persons should be placed in barracks similarly provided,
iu order to jirevent the spread, to tlie remaining healthy
patients, of infection from any one of them who may sub-
se(|uently be taken sick. This screening must be so al)-
solutely perfect in character that it sliall not only exclude
the most of the mosipiitoes, but all of them; and in the
event that some solitary mosquito should find access to
any of the rooms, steps should be taken to insure its de-
struction. To prevent the liarm which might result from
the accidental contamination, by one or two of these in-
sects, of any ward or barrack building, it will be neces-
sarj- every day to burn a certain cpiantify of the so-calj^d
Persian insect powder in every apartment, and then after-
ward to sweep up anil kill the stupefied insects which
will fall to the fioor upon the inhalation of the fumes.
Finally, any per.son efi'ectually isolated from infection,
and remaining healthy more than five days, may be re-
lea.sed.
Cholera. — Upon the arrival of a vessel at a quarantine
.station with cholera on board, or having had cholera on
board at a recent period during the voyage, it is advis-
able, when possible, to remove from the vessel all of her
perxiiniid (both crew and passengers). Isolating and segre-
gating these people ashore very much after the method
prescribed in dealing with a yellow'-fever ship. In addi-
tion to the precautions to be taken against insects in the
case of yellow fever, it is necessary to provide, in the case
of the cholera suspects, recently cooked food which shall
not have been contaminated by an insect, and a water sup-
ply of undoubted ]iurity. It will also be ncces.sary to make
arrangements for either the disinfection or destruction by
fire of all the deiecta of all persons kept under observa-
tion; for it should not be forgotten that the apparently
healthy person may carry within his alimentary canal the
cholera spirillum, and may infect sewage, which in its
turn may ultimately infect a water supply.
For tlie ship itself, the measures to 1)6 taken are as fol-
lows: 1st. A thorough mechanical cleansing, such as is
very admirably done by the Hamburg-American anil
North German steamship companies on their passenger
steamers when they arrive at the liome port. This con-
sists in washing the vessel with what they know as Seifen-
lager, a very strong solution of soap and water, plus a
certain amount of caustic potash. When every part of
the vessel, which may properly be so treated, has been
cleansed in this manner, and wheu the ornamental wood
and bright work finish, which cannot be so treated, has
been washed with a solution of carbolic aci<l or other
agent which will not damage i^, thorough dryness, so far
as practicable, should be obtained, and the gaseous disin-
fection appbed simultaneously to every part of the ves-
sel. This gaseous disinfection should be preferably of
sulphur dioxide, four per cent, twelve hours' exposure,
as elsewhere stated ; but, in certain comjiartuients on the
finer class of vessels, tliis style of disinreetion would re-
sult in damage, which can be obviateil by using instead,
in such apartiuents, a .six-per-cent. volume of formalde-
hyde gas for a period of from six to twelve hours. All
83&
i^iiiiiiue.
RKFJiRENCi; HANDBOOK OF THE MEDICAL SCIENCES.
textiles whicli will uot be (Inmaged thereliy should be
siibjrcted to live steaiii fcir :i pi-iidd cif thiity miiuites;
luid such as will not beiir ihis trcaliiieiit should be disiii-
leeted bj' the conjoint use of ii vaeiuun and tonnalde-
hyde gas, six per cent, volume, for an exposure of one
hour's duration. All textiles which have been polluted
by cliolera dejecta should without exception be burned,
and no attempt sliould be made to disinfect and re-use
such articles. The detained pcrsi/iiiid may be released
when live daj'S have elapsed since their last possible ex-
posure to infection.
Plague. — Measures to be taken in the treatment of a
vessel infected with plague are identical w-ith those used
in the case of a cholera-infected ship, except that on ac-
count of the peculiar methods of transmission of this dis-
ease (partly through small animals), it is necessary to u.se
a germicidal agent which will destroy animal life as well
as bacteria; and for this ]inrpo.se formaldehyde is uot
strictly reliable; consequently, all gaseous tlisiufection
done on a plague-infected ve.ssel must aud should be
done with sulphur dioxide. The .segregation and care-
ful attention to the individuals, including the adoption
of stringent measures capable of preventing the pollu-
tion of either dejecta or sewage, ap|)ly to this disease as
strongly as to cholera; and for the reasim that small in-
sect life has a Ix'aring in the transuussion of the disea.sc,
the screening provided for cholera and yellow fever,
while not so ab.solutely essential, is nevertheless advis-
able, and, wherever possilile, should be u.sed. Manifestly
the persons uuder detention may be released at the ex-
piration of from seven to eight days since their last pos-
sible exposure to infection.
SiiKil/po.r. — IlcM-e we have to deal with a disease which
does not require such rigid measures as have been applied
to any of theother ([uarantinable diseases. If a person in
any given apartnient of a vessel lias been alflicted with
smallpox, it does not necessarily follow that all the per-
sons on the ve.ssel are to lie detained iu t|uarantiue, nor
that the whole ship is to be disinfected. It will be sutli-
cient if we disinfect with scru]iulous care all possibly in-
fected |ier.soual belongings, and. in the same manner as is
applied for yellow fever, all portions of the vessel which
have been invaded by the disea.se. At the same time it
is imi«)rtant to keepi under observatifm those persons who
have lieen in direct contact with the afflicted party, or
who have not been vaccinated. The usual custom is to
vaccinate immediately all exposed persons and hold tlieni
under observation for fourteen days; to release at once
all those who have uot been expo.sed and who are vac-
cin;iti'(l; and to disinfect such parts of the vessel as have
been in touch with the actual case, releasing the vessel at
once, aud hokiing only the suspects. Should thi' infection
on the smallpox ve.ssel be so general as to justify the
opinion that all on the vessel have been more or less ex-
posed, then it becomes necessary to disinfect the ve.ssel in
the same manner in which it would be done for yellow
fever, and to disinfect it throughout, holding uuder ob-
servation for fourteen da3's all of \\s ju'i-fmiiiid.
7'i/phi/s Feter. — In view of the little that is known of
typhus fever, i.e., as to its manner of transmission, pe-
riod of incubation, etc., it is exceedingly fortunate that
we seldom or never find a general infection of typhus
fever aboard ship. Should such a calamity supervene,
all the personnel should be immediately segregated ashore,
aud the groups placed far enough apart, if sullieient
groimd is obtainable, to pu'event the infection of one by
the other, it h:tving been claimed that aerial infection
|ilays a part in this disease. The vessel sho\dd be disin-
fected in the same manner as for cholera, and the person-
ml kept uuder observation for a period of fourteen days
from their last exposure to possible infection.
Lepnisif. — The quarantine regulations of the ITnited
States demand the retention at quarantine of any alien
leper, and his replacement upou the vessel when outward
bound.
Mihur Ciiiiiinniiiecible Diseases. — There are. in addition
to the diseases above discussed, several others which
at times call for treatment, but which are uot generally
classed as quarantiuable diseases. These diseases— scar-
let fevei', measles, diphtheria, and even some others —
are as a rule passed up to t)ie local board of health for
proper handling.
When treated at quarantine, they call for the same
measures as are applied to smalliiox (except of course
vacciuatiou).
L.\ND Qt;AU.\NTINE.
Because of lack of space onl3' brief notice can be given
this subject, which after all is simply a connnon-sense
ai)plicatiou of maritime rules to exactly the same diseases
on land. The people are to be handled in precisely the
same manner as at a maritime station, and if we simply
transfer our disinfecting agents from a shi]) to a house,
the methods remain the same. The difflcidties of admin-
istration are greater because, while at a maritime station
the quarantine ofHcer is practically .supreme, in laud
quarantine he has to meet the whims and foibles of local
lay authority, or eveu of individuals.
Joseph II. W/eite.
QUASSIA. — Quassia' liriniim or Liriniim Qi/assiw. Ja-
iiiaiea Quassia. Jiitier-ieovd. Bitiee-ash. The dried wood
of I'ierasnai e.rcelsa (Swz.) Planch (Quassia, e. Swz. ; Pi-
cra'na. e.hyailX.; Siinaruba e. DeC. — Fam., Simarubaceie),
U. S. P.
The Jamaica quassia tree is said closely to resemble a
small or medium-sized ash tree. It occurs chiefly in Ja-
maica, but to some extent in other parts of the West In-
dies. Quassia was originally derived from a different
jdaut, considered below, but was later replaced by this
one. The wood occiu's
■"'SiLJ ■ '
_isr
ft
10
r\.^
Fig. 3!)_'4.- .section ot Quas.'^ia Wood.
(Bailli)U.)
in billets of various
sizes, dense, tough, of
medium hardness, and
of a nearly uniform yel-
lowish-white color; in-
ternallv ponms, with a lS^4°'|'^~"N -, /^ ',/~\ oC
minute pith, iurlistinct 'sfeSbV J>'j , ( M\ \S£
rings, and medullary ffe-^^^ '>^l_)n?
rays which, on tangeu- ffl j '^. ^
tial .section, exhibit f lom I'S*—^
two to Hve vertical rows
of cells; inodorous and
intensely bitter.
It is usually met with
iu tlw' form of chips or
raspings.
The powdered wood
is devoid of stone cells,
contains crystals of cal-
cium oxalate, and ex-
hibits the tangential appearance of the medullary rays
described above.
(Juassia contains neither tannin nor starch, and, if pure,
yielils not mcu'c than four per cent, of ash. Its bitter
]uinciiile is the crystalline substance ijua.'^siin, freely
soluble in alcohol and chlorofom. Although it requires
l,2tJ0 partsof water for solution, the dose is so very small
that water constitutes a satisfactory metistrunm. Quassiin
is further resolvable into two crystalline bodies, called
respectively a-pierasmiii and fl-picrasmiu. A minute
amount of alkaloid has been reported, but is probalily
of no medicinal imiiortance.
Action .\.M) I'sks. — Qua.ssia is gi'ncrally regarded as a
pure or simple bitter tonic, like gentian, aud is mostly
>ised as such, being given, either alone or in combination
with aromalics and .stinudants, as a stomachic and appe-
tizer. In debility, iu convalescence from fevers, in dys-
jiepsia, it has been, and is still, iu considerable use. Its
taste is. however, more bitter and disagreeable thau that
of gentian or quinine.
(Juassiin is a jiowerful irritant aud convulsive poison
when concentrated or Used iu overdoses, and is apt after
longadministnilion to.set up a gastric irritiUion. lis use
is therefore better alternated with that of other medicines.
826
REFERENCE HAND BOOK OP THE MEDICAL SCIENCES.
Quassia.
<^ulnliie.
It is particularly poisonous to the lower animals, on ac-
count of wliich it is much used as a rectal injection for
the destruction of ascarides. For the latter purpose,
from a half-pint to a pint of the ten-per-cent. infusion
is employed. The death of an infant has followed such
use. 'I'he freedom fif ([uassia from tannin renders it a
desirable bitter for mi.xing, in preseriptioii. with tlie iron
preparations. The Pliarmacopoia provides an extract
(Exlmetum Qminsiiv), tlie dose of which is 0.03-0.2 gm.
(gr. ss.-iij.), but this is the least desirable preparation fur
use, since the patient fails to receive the beneficial ett'ect
of the bitter taste. The dose of the otBcial tluid extract
is 1-4 c.c. (t1. 3 J-i.) and of the tincture, which is by far
the most elticient of all preparations, 2-8 c.c. (fl. 3 ss.-ij.).
The infn.sion is a jKipular form of administration, and
should be of tive-per-eent. strength. Another excellent
method is to introduce cold water into cups made of quas-
sia wood. The water becomes almost at once intensely
hitter, the patient receiving the full benefit of the bitter
taste, w'ith little systemic effect.
SiiriiMin Quiissia. — This, the original quassia, is still
the one chielly employed in Southern Europe, and isoHi-
tial in nearly all-pharmacopojias. It is the product of
Quassia ama'ra L., of the same family, a slu-ub or small
tree of Northern South America, wlience it extends up
into Central America and into the West Indies. The bil-
lets are much smaller, usually from one to three inches in
diameter, crooked, and still bearing the bark, which is of
an ashy gray color and nearly smooth. The wood is
somewhat heavier than that of the Jamaica variety, and
c.xliibits medullary rays only one row of cells wide on
tangential section. The bark is full of huge stone cells,
which are seen in the powder, since bark and wood are
usually ground together. The active principle of this
variety is practically identical with that of the other, and
the pro|ierties, uses, and doses are the same.
The same statements maybe made concerning East In-
dian quassia and Japanese quassia, derived from other
species of Ficmsma. Henry II. Rushy.
QUEBRACHINOFORM. See Furinaldehyde.
QUEENS ROOT. See StiUingia.
QUERCIFORM. See FurindhJehyde.
QUINAMINE. See Cinchona.
QUINCE SEED.— C(/(/..«n/»i (IT. S. P., 18«0).— The
<liied ripe seeds of the common quince, Cydonia Oydonia
(L.) Lyons (Pyrus Cydonia L. ; Cyilimin nilijarix Pels,
fam. Iiosaee<p) together with the gum in whicli they are
naturally embedded.
The quince is a native of Southwestern Asia and adja-
cent Europe, but the seeds are wholly the product of cul-
tivated plants. They occur agglutinated in masses of
eight to ten or more, being embedded in a colorless, trans-
parent gum, of which about twenty per cent, is obtain-
able, and for which they are valued. One iiart of this
gum makes about 100 parts of mucilage. This has little
adhesive power, but is excellent for tlie ordinary medici-
nal uses of mucilage, such as the making of collyria,
demulcent drinks, etc. When the drug was otHcial, it
was directed tliat the official mucilage be made by taking
2 parts of the seeds with 98 parts of water.
Henry H. Rushy.
QUINETUM. See Cinclwna.
QUINIDINE. See Cinchona.
QUININE. See Cinchona.
QUININE. NEW COMPOUNDS OF.— In tljc f„ll.,w
iiig pi-epaialioiis, the do.se, unless specified, is that uf
qinnine sulphate.
Arctyl-salieyhitc — for rheumatism,
Arseuiie — sixty-nine per cent, quiniue. Dose 0.00.>-
0.03 gm. (gr. ^'^ to gr. ss.).
Bichloride — very soluble. Improvement in recurrent
cancer followed daily injections of 0..5-1 gm. (gr. viij.-
XV.) by Jaboulay in France and Trible in America.
Borate — a yellow insoluble powder, antiseptic.
Caseinate.
Chliiro-carbonate — freely soluble, almost free from bit-
ter taste.
Chloro-phosphate — fifty per cent, quinine; soluble in
two parts of water.
Chloro-sulphate — seventy-four percent, quinine; solu-
ble in one part of water.
Dibroinffiiaiacolate — guaiaquinol.
DihydriAiroinatc, diliydrochloride, dihydroiodate — all
readily soluble and used by hypodermic injection for
whooping-cough. Dose, O.OG-0.2 gm. (gr. i.-iij.).
Dihydrochlo7'ide-carh(iniate—muT\iitii of quinine and
urea. Seventy per cent, quinine; very soluble.
Ethyl carbonic ester — Euquiniue (see Vol. IV.).
Ferri-chlorid — dark reddish-ln own crystals used in t wo-
per-ceut. solution as a ha'mostatic in internal hemorrhage
and in uterine hemorrhage.
Glycerophosphate — kinewin, esjiecially employed in
neuralgia. Dose, 0.1 gm. (gr. iss.).
Onaiacol bisulfonale — guaiaquiu, an odorless, non-caus-
tic substitute for guaiacol,
Ilydroqninone-hydrochloride — antipyretic.
Ichthyol-sulfonatc — sulplio-ichth\olate, employed in tu-
berculosis.
lodo-hydroiodate — insoluble in water. Used as substi-
tute for iodides in syphilis, and in the same dosage.
Lactate — readily soluble.
Lyrjosinate — antiseptic compound of di ortho-eumar-
ketone (lygosin).
Methyl-di-hydrazin-percJdorate — compoimd of quinine
hydroehlorate, caffeine, and antipyrin.
riwspho-hydrochloridc — soluble.
I'luisphoric acid ester — phosphorylquinine.
Salicylic acid ester — salicyl quinine or saloquinine (see
Saloqiiinine).
Salieyl-.'siiHcylatc — (see Eheumatin).
Silico-jiiioride — soluble in water.
Sidph<i-crm,iotate — used in tuberculosis.
Vrethane — very soluble, made by mixing 3 parts of
quinine hydrochloride, l.^i inirts of urethane, and 3 parts
of water. 11'. .1. Bastedo.
QUININE. (TOXICOLOGICAL.)— Any high degree of
toxicity lan hardly be ■.-.■lid toexist in the ordiuaryu.se of
cinrluma audits alkaloids or their salts. There are cer-
tainly symptoms very commonly associated with their
tlierapeutic uses, even in most moderate doses, which are
characteristic and indicate some functional disturbance
of various organs. Such are the sen.se of constriction
about the forehead, the ringing of the ears, and occasion-
ally nausea. In many persons these are not sufficiently
marked to attract attention unless the doses given are
very large or long continued. Of these the sense of ful-
ness and the deafuess are the couunonest, and are looked
upon as necessary acconipaninicnts of the administration
of the drug, not giving rise to uneasiness cither in the
]iatieut's or in the physician's minM, and expected to
ilisappear promptly when the medication is stopped.
They are the physiological evidence of mild cinchonism.
The susceptibility of individuals varies greatly as to the
amount of the drug which will produce such manifesta-
tions. Some persons are occasionally met with who suf-
fer so promptly and acutely from these troubles that treat-
ment to counteract them lias to be instituted in order that
enough of the required drug may be taken into the sys-
tem to produce the desired eft'ect ujion the primary dis-
ease. JIany. on the other hand, show so little suscepti-
bility that astonishingly large and rapidly repeated doses
may be given with only beneficial results.
Liebermeister (quoted by Kunkel) says: "I have up to
this time employed quinine in huge doses in more than
lifleeu hundred patients with abdominal typhus, and also
i]i hundreds of pneumonias and other diseases. The
number of single doses, of from 1 to 2, up to 3 gm..
82;
Qiiluiiio.
Quiniue.
REFERENCE HAXDBOUK OF THE MEDICAL SCIE.N'CES.
■niiich I have prescribed, may run up to ten thousand,
and not once have I seen any essenlial or lasting injury
which one might seem warranted in ascribing to (juinine."
The cause of the disturbances produced by quinine has
not yet found a satisfactory explanation.
Notwitli.standing the int'requency of toxic manifesta-
tions from the use of (piinine, a htrge number of cases can
be foiuid in the perioilical literature of the last half-cen-
tury, some of an acute character after mininmm doses, and
some in which the most inordinate quantities have been
taken. It is these latter which present the most serious
symptoms, and are even followed Ijy death. The former
EQUst be regarded as due to an idiosyncrasy, which also
is not infrequently hereditary, while the latter may prop-
erly be classified as cases of poisoning, whatever the
action of tiie drug or whatever organs are specially in-
volved. There isstillaiiothcrclassof cases, viz., those in
which quinine, given in very moderate doses, especially in
certain tropical districts of Africa, to persons who are al-
ready the subjects of malarial dysci-asia, (piile promptly
causes a sharp advance in temperature accompanied by
ha-raoglobinuria — the Schwarzwassertieber of German
writers. The following may serve as illu.strations:
Hare reports the case of a man of fifty-three for whom
two grains of (luinine. three times a day. was prescribed.
It produced an intense ervthematous rash, which was
sub.sequently followed by desquamation, including the
palms of the liands and soles of the feet. (Jn learning
that quinine was contained in the medicine prescribed for
him, he said that he bad once before bad the same experi-
ence, an eruption having tleveloped after he had taken a
cocktail containing a few dro])s of elixir of calisaya.
This man's daugliter, twenty years of age, also suffered
from a rose rasli followed by desquamation after takii>g
a small dose of <|uinine.
Husemann reports the case of a soldier in good health
who took 13 gm. of sulphate of quinine in a five-per-cent.
solution. He died in four hours in an access of heart
weakness. A third rejiort is by Guersant. A French
physician in a nu'al district was in the midst of an out-
break of malarial fever. When his wife was taken ill he
gave her 240 grains of quinine in the course of a short
time, and she fell into a state of stupor with amaurosis,
deafness, and difticulty of moving, whereupon he gave
her 370 grains more, and the serious symiitoms increa.sed.
Fortunately for her he was about this time taken ill with
the fever himself, and she finally recovered. He admin-
istered to himself, however, 900 grains by mouth and
rectum, which hrouglit him to a condition resembling
that of a man affected w-ith i)neumonia terminating in
hepatization: but be managed to take in the course of
eight or nine days five ounces more of quinine. When
at last he came under the observation of another phy-
sician he was in a cold sweat, deaf, blind, bis resi)iration
difficult an<l rattling, ami in a profound stupor, looking
like a drunken man. Delirium and death soon closed the
scene.
I. 13. Yeo reports his own experience as follows: Fear-
ing that he hail taken cold, he administered to himself
two doses of two or three grains eacli of quinine. The
next morning he foiind upon his leirs au erythema with
much itching, which failed in tlu'ee or four days. He
repeated this experience twice at intervalsof two months,
the last time taking three grains and the rash appe:iring
in a few- hours. Five months later, imagining that tlie
former doses might have contained siime impurity, he
took pains to get the sulphate ot cpiinine from a druggist
of till' best repute, and the usual eruiition in three and a
half hours followed the taking of three grains. Six weeks
later, a dose of one fourth of a grain, directly after break-
fast, was followed by the rash in five hours.
Not to burdi-n this paper with the details of the action
of quinine in disturbance of all the various organs, it will
suffice to mention those of special interest ami importance,
whether such toxic effect is manifested after theintroduc-
tion into the system of such quantities as would every-
where be considered large if not excessive, or of such
minute doses that their poisonous activity is the evidence
of an individual idiosvncrasy. Of these the most promi-
nent are the etfects upon the skin, upon the eyesight and
hearing, upon the kidneys, and upon the pregnant uterus.
Some reference shoidtl also be made to effects upon the
general nervous system.
Cutaneous disorders may arise froiu the local irritating
action of quinine when the skin is denuded, according to
Hngounenq. and it has frequently been observed that the
operatives in quinine factories sutler from similar local
troubles, with also a certain amoimt of constitutional dis-
turbance, even when the skin is sound.
Authorities ditTer in their views of the pathogenesis of
these eruptions, Lewiu saying that no absorption of ipii-
nine takes place through the sound skin, and that the
eruption occurring in quinine workers is not to be re-
garded as an occupation disease, but as an idiosyncrasy
against quinine, which seems not a very tenable theory
in view of the frequency with which such cases occur.
He sa^'s also on the next page that it is the direct contact
of the quinine with the skin, its excretion through the
medium of the sweat glands, among other like possibili-
ties, which chiefly furnishes the explanation of this irri-
tation rather than a disturbance of the stomach or bowels
producing a reliex irritation of the skin or any action of
the drug in solution in the blood acting upon trophic or
vaso-motor nerve tissues.
Morrow considers that the theory of the stimulation of
the sensory nerves of the gastric mucous membrane, pro-
ducing reliex dilatation of the cutaneous vessels, is appli-
cable to only the milder and superficial forms of erup-
tion. He also refers to the theory ot an elective afiinitv
of the sw-eat glands for the drug, its attempted elimina-
tion through this channel causing local irritation. He
says that thv toxic action of quinine upon the skin may
result from electrolytic action, from its use in pomades
or lotions, and from subcutaneous injection as well as
from ingestion of the drug.
Writers report manj" forms of quinine eruption, al-
though that resembling scarlatina is the commonest and
most inqiortant from the point of view of diagnosis. It
is most apt to follow the taking of sulphate of quinine
rather than other preparations.
Thus there is pruritus, which is often limited to cer-
tain regions, s\ich as the glans penis, the hands, or the
legs. Erysipelatous and gangrenous forms are reported,
although the latter is very rare. The urticarial form is
wont to be accompanied with much constitutional dis-
turbance. Hyde and Montgomery remark that it is
hardly to be distinguished from an urtirnrin ab i/ir/ef(ti!t.
The mucous membrane of the throat and fauces may be
involved in this form. Eczematous and bvdious forms
are mentioned, and finally tlie petechial, which may be
accompanied by bleeding from the buccal mucous mem-
brane or by sanguinolent stools, sometimes following
very small doses of the drug. Desquamation of greater
or less extent is a not infrequent sequela of these various
forms of eruption. In the matter of differential diagno-
sis the greatest interest attaches to the exanthematous
form from its likeness to scarlatina. The eru]nion is of
a vivid hue and disappears under pressure. The history
of the case, as to whether quinine has been given or not,
is of the utmo.st importance, and Morrow points out that
there is usually no fever, and that the eruption subsides
when the drug is discontinued. Quinine can also be
easily detected in the urine.
With reference to the effects of quinine upon the sight
and beariug it is observed that they are wont to be more
persistent than otbi-r toxic effects of the drug, lasting
often for years or permanently, while the others disap-
pi'ar on its discontinuance. Tlie symptoms of its injur-
ious action on the eye are increased lachrymation, itching
anil ledema of the lids, photophobia (which may be only
transieut, hut may persist), diminished or lost pupillary
reaction, and sometimes complete but usually temporary
loss of sight, either in one or in both eyes. But the most
typical and persistent lesion is concentric limitation of
the visual field, which ma}' exist even though the acuity
of vision is little impaired, and which may be demon-
828
EEFERENCE IIAXDP.OdK UF THE MEDICAL SCIENCES.
Qui nine.
Quiulue.
sti'able even when the aciiity of vision is completely re-
stored. At the same time tliere maj' be a diminished sense
of liglit, as if a veil wore interposed. There ni,'.y also loe
color blindness, which but slowly disappears. Tlie ehanjres
appreciable by the ophthalmoscope are in the papilla of
the optic nerve and the vessels of the retina, the media
remaining clear. There is a hijih degree of constriction
of all the vessels, tending to atrophy, and the optic nerve
is pale (Lewiu and Kunkel).
Quinine given in even ver}- moderate dcses generally
causes some hardness of hearing with tinnitus or roaring
in the ears. There may even be complete deafness last-
ing for twelve or twenty-four hours. Existing middle-
ear disease may be exacerbated or an otitis externa may
develop. Under these conditions may be observed a
slight injection of the vessels of the handle of the malleus
and some degree of opacity and retraction of the mem-
brana tympani.
It has Ijeen observed that what lias Ijeen called quinine
fever sometimes supervenes upon the administration of
small doses of the drug in persons who are the subjects of
malarial infection, the symptoms consisting in the rather
prompt appearance of chill, fever, and sweating, with
sometimes disorders of the alimentary canal and bloody
urine. No satisfactory explanation has been offered for
these manifestations. When it is added that to quinine
is attributed an occasional irritation of the urinary pas-
-sages leading to albuminuria, and that sometimes tlie
urine also contains blood, htenioglobin, and metluvmoglo-
bin, we are very near to the condition known under the
■German name of Schwarzwasseriieber (black-water fever),
which Kunkel describes as follows: " This is a disease of
the African tropics, and is so far directly associated with
malarial infection that it occurs onh' in men who have
been infected with malarial virus. They are apt to be
-only apparently in good health, or have a malarial dj'scra-
sia. There is always a chill, followed by nausea, intract-
-able vomiting, and other signs of severe constitutional
disturbance, such as diarrhiea, dulncss of mind, restless-
ness, dyspnoea, and irregular febrile movement, as in
cases of septic infection. There are indications of serious
blood decomposition. The urine is of a dark reddish-
black color, and contains pigment granules, renal epithe-
lium, and casts, but no erythrocytes. The symptoms of
acute nephritis are always present. The jirognosis is
bad and death follows with signs of heart failure or of
uriemia. In cases that do not succumb kidney lesions
lemain, and after the seizure the blood corpuscles and
hemoglobin are enormously diminished."
Kunkel enters quite extensively into the discussion of
this subject, and cites many authorities who furnish good
•evidence that in the course of malarial disease, when qui-
nine has not been given, attacks of hajmoglobinuria oc-
cur, and that the_y seem to occur most often in regions
where the local perniciousness of the disease is greatest.
Thus they occur in Greece more than in Germany, and in
Africa more than in India.
Again, in cases in which small doses of quinine are
given to the subjects of malarial infection, but who are
not seriously ill at the time, bloody urine will quite
promptly appear. Thus good authorities agree that in
■certain persons saturated with malaria the blooil corpus-
cles become very sensitive to the action of quinine and
readily break down. The question also conies up. in this
connection, regarding the similar action of chlorate of
potash, of carbolic acid, and of arseniuretted hydrogen as
blood poisons. There seems good evidence also that not
only are small do.ses of quinine not curative in these con-
ditions, but that they excite the disease, which can be
cured by large doses only. 4 gni. for example. Welsford,
however, is of the opinion that black- water fever is a
localized disease, and that some malarious districts in
Africa are free from it; also that quinine certainlj- does
cause hainoglobinuria. but only rarely. He reports a
case in which two ten-grain doses on two occasions in-
duced black urine.
The action of quinine as an ecbolic is based on the oc-
casional occurrence of abortion in malarial districts after
this drug has been given. It is also reported that in
China it is depended on to produce abortion, and that
female operatives in quinine factories frequently aboit.
There is bj' no means an agreement of good aullioiities
on this subject, however, and the best opinion favors tlie
belief that this action is occasional rather than regular,
and should be regarded as an incidental or by-effect
rather than an evidence of toxicity.
It remains to consider the poisonous action of quinine
upon the central nervous sj'steni. It is by no means easy
to discriminate between the eflects of quinine itself and
those due to the disease for wliich it is given, especially
as in severe cases, like pneumonia, intermittent and con-
tinued fevers, where large doses might probably be used,
the disease itself might present such symptoms as head-
ache, sleeplessness, and a state of collapse with loss of
consciousness, delirium, or even tetanic or convulsive
manifestations, such as are said to be due to the action of
the drug upon the nervous system. Therefore cases
illustralive of these elfects are the unusual ones in which
great quantities of quinine have been rapidly taken into
the system when not called fcu' by the existing disease,
or far beyond its requirements, such as some already
cited in this article, or the following, reported bv A. E.
Roberts:
"A woman, aged thirty -five, took about 20 gm. of qui-
nine, became insensible in an hour, and this state lasted
until the next day. She was cold and cyanotic, with
slow and feeble respiration, pulse 4") and veiy weak, pu-
pils widely dilated and insensible. Still she recovered.
Her hearing became normal in a week, but it was two
weeks before she had even a slight perception of light,
and this m as not wholly regained for months."
Such histories are the basis for the o]iinions of Briquet,
A. B. Palmer, and Kunkel, the former of whom sa3's:
" If 2 gm. or more are taken and continued for several
days, we observe an overwhelming, an exhaustion,
stupor, somnolence, weakness of sight, dilatation of the
pupils, and tremblings of the limbs. Very large doses
lead to complete loss of consciousness, loss of si.ght and
hearing, and complete immobility of the limbs. 'l"he de-
lirium or intoxication of quinine is usually ,cay. He con-
cludes that quinine produces a slight and temporary ex-
citation of the encephalon, then soon a sedative aciion,
which gradualh' increases, and which may go on to the
destruction of nervous power."
Palmer describes as quiniuism ("cinchonism," Foster's
"iledical Dictionary") those disorders of the cerebro-
s|)inal functions indicated by headache, giddiness, con-
traclion or sometimes dilatation of the pupil, ringing or
roaring in the ears, deafness, partial blindness, abnormal
toiicli and smell, difticulty of controlling muscular acts,
somnolency, sometimes delirium, at other times stupor,
sometimes a severe sense of stricture about the chest.
These effects are for the most part temporary, but
sometimes more permanent. Kunkel concludes that
with poisonous doses of quinine llie central nervous sys-
tem is progressively paralyzed in all parts. In case of
severe acute poisoning death occurs from paralysis of
resiiiralion, artiticial respiration prolonging life until
paralysis of the heart occurs.
When we come to look for the lessons to be drawn in
the way of prophylaxis against the possibly toxic action
of quinine it is clear that the dangers due to idiosyncrasy
are not serious, for its results are so soon in evidence from
such small doses, and so very uncomfortable to ihc sub-
ject, that he will be quite apt to n'menilier them, and to
avoid the drug in the future. The injurious effects of
(juinine, Lewin tells us, are more ajit to be observed in
women and aged people than in others, while per.sons
with delicate .skins anil those subject to eczema are par-
ticularly liable to quinine exantheniala. To these clas.ses
then, and especially to ]iersons suffen'ng from eye and ear
diseases, quinine sliould be given most cautiouslj' or not
at all.
There is little likelihood that any impurities in the drug
are responsible for the toxic effects attributed to quinine.
In fact, Lewiu declares that there are no dangerous adul-
829
Qnluolorni,
Rablos.
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
teratious of it unless salicylic acid is the adulterant. He
also warns against prescribing sulphate of quinine and
iodide of potassium together, lest iodine shovdd be set free
in the intestinal canal.
There is not much to be said about the treatment of
the toxic efleets of qtunine. Usually stopping the ad-
ministration of the drug is soon followed by relief of the
symptoms. When it is esteemed necessary to give the
medicine, aUliough unpleasant effectsare already present
or may be anticipated, several means of counteracting
them are recommended. The bromides, ami jiarticularly
hydrobromic acid, have quite a re]iutation, while Lewin
and others have foiuid ergotin, given in about et|ual doses
with the quinine, ellicient. Morrow and others recom-
mend linclure of hyoscyamus. In dangerous cases in
whicli there is collapse, I'he usual measures for stinuilat-
ing the circulation by external applications and friction
are in order, as well as the internal use of hot tea and
coffee, and perhaps the subcutaneous injection of tinct-
ure of musk.
]MacGre.gor favors subcutaneous saline injections in
treating lilack-water fever. /. JAieoi Eiiurmit.
BlBLIOGr.APnY.
B.irtliolow, Roberts: \ rr.actica] Treatise on Materia Mefliea ami
Therapeutics, niiilli eiiition. New York. ls9li.
Briquet, P. ; Tiaiif- tliei'apeutiqiie du Quiuquiua, etc.. second eiiition.
Paris, is:,.",, p. fill.
Fostei', Frank P.; Encyclopedic Medical Dictionary, New York, IstKi,
Art. finchonisMi.
Giiei^sant: LUctiuiuiaire de ni^decine on repertoire general. Tome 20,
Paris, isi:i, |ip. r,ii:) 711.
Hare, H. A. : Tlicrapentic Gazette. 3. S.. xvii., WOl. Detroit, pp. 2il4-.").
Hiigounenq. l.oui.s: Tiaite des poisons, Paris, IS'Jl, p. 41U.
Huseniann: Tliera)). M. H., ISSS, p. 7.
Hvde. J. N., and Mont<ronierv ; Practical Treatise on Diseases of ttie
Skin, sixth edition. I'luladelpliia and New Y'ork, ItiUl.
Kunkel. .V. .1. : llamllnicli ilcr ToxicoloL'ie. vol. ii., Jena, ISlfll.
Lewin. Prof. De L. : Die Xeljenwirkuns-en der Arzneiniittel. 3te
AullllL'e. Derlin. IS'.!.).
I.ieii' nniisier: Handl,ncli der speciellen Therapie. vol. i., Jena, 189.5.
Malison, litis Fred.: A Treatise on the Physiological and Therapeutic
Action of the Sulphate of tjuiiiine, Pliila., 18S3, p. 8.5.
Morrow, Prince ,\.: Dnifj Eruptions. New Y^wk, 1887.
Palmer, A. B. : Decriires on Suliihate of Quinine. Detroit, 18.58.
Roberts, A. E. : Lancet, Slaicli titli, l.s'.B, p. Mi.
Welsford: Hrit. Med. .i.iirn., liUHi, ii., p. 17111J.
Yeo. I. B. : Loud. elm. Soc. Trans., vol. .xxii., p. 193.
Sir \V. Maci.ivL'or: Brit. Med. Jour., Dec. a), UHi-'; p. 1889etseq.
QUINOFORM. See I'hnnaldclujde.
QUINOIDINE. See Ciurhona.
QUINOLINE-BISMUTH-SULPHOCYANATE, or RHO-
DANATE. See Crmili.
QUINOPYRIN is an aqueous solution of quinine hy-
droehloriile and anti[iyiiii. It is u.seil Ijy hy])odermic
injection as ;in aiitipyietic and nerve sedative in dose of
1 c.c. ( "[ XV.) severtd times u day. IF. A. Bastedo.
QUINOSOL. See C/iinosid.
RABIES OR HYDROPHOBIA.— Rabiesorhydrophobia
is an ticiite iiifeetinus disease id' the central nervous sj's-
tem which occtu'S in man as well as in other warm-
blooded animals. As a spontaneous disease, as distin-
guished from thiit due to intentional inoculation, it is
met with in the dog and allied species, the wolf, the fox-,
the jackal, the hyena. Cats are also more or less often
affected. Osier slates that the disease is said to |nevail
among the skunks of the Western States of North Amer-
ica. So far, no species of animal except pigeons has been
found to lie rc'fractory to intentional inoculation with the
rabies virus. In these birds the older individuals are not
normally suscejitilile, but they become so on the dejiriva-
tion of food, anil the young birdsare normally susccptilile.
Fniiu the miut)' jioints of analogy which exists between
rabies ami other iicute infectious diseases, the conclusion
would seem unavoiilable thtit rabies is caused by a spe-
cific micrii organism ; but all efforts to establish this liy
experiment and observation have so far proven futile,
tliough several unsiibstiuitiiited claims to this effect have
been made, it is true. Although the specific infectious
agent is not known, it can be propagated in the central
nervous system of living animals, not of dead animals.
By inoctdatiou of animals it has been shown that the
poison is always present, sooner or later after infection,
in the brain, spinal cord, nerve trunks, and saliva of in-
fected animals. It is pre.sent in these situations even
before any symptoms have developed, during the ineu-
bation period, while the animal is apparently well. It is
usually not present at any time in the miik, lachrymal
secretion, pancreas, testicle or semen, aqueous humor of
the eye, cerebrospinal fltiid, or in the fa?tus, though it
has been found occasionally in one or other of these situ-
ations.
Accidental infection usn,ally results from the bite of a
mad dog, and therefore is due to the introduction of the
saliva of the rabid animal into the wounds made by the
teeth. Sometimes iufection results from the licking of
au abrasion by a pet dog that is going through the incu-
batiou period anil before any symptoms of the disease
have niiinifested themselves in the animal. For this rea-
son mtid dogs are specially dangerous while thej' are
going through this stage. They are not suspected of
being mad, and are not avoided as they are after the
symptoms a|ipear. Novi states that midges and files tire
also cttptible of carrying the contagium. Arliticially, as
already stated, the ilisease may be produced by inoculat-
ing animals with tissues from an infected animal. Injec-
tion under the dura mater of suspensions of tlie spinal
cord from an animid dead of rallies in neutral beef broth,
is the method very commonly resorted to, and this pro-
duces the disease very uniformly. The point of tlie hy-
podermic needle is inserted beneath the dura mater
through a small trephined opening at the summit of the
cranium a little to one side of the median line. With
aseptic piecautions and with ordinary care in manipula-
tion, there is no immediate danger to the animal from the
operation itself, either as regards the effect of the trauma
or from infection with pyogenic organisms. Occasional
failuies to pi'oduce the disease by the method just de-
scribed hiivc lieen reiioi-ted. it is true, but thi' failui'e
was probably due, at least in most of these cases, to the
use of too small an amount of material for the injec-
tion. To insure success, the amount used must not be
less than one-thirtieth of a gram by weight of the cord,
according to Kruse, although even smaller amounts are
usually effectual. Johne. Daw.son, Osliida, and others
recommend injecting suspensionsof the cord through the
optic foramen. If this method is resorted to it is recom-
me.ndei! to ana'Stlieti/e the animal, or to keep it perfectly
still by any method, otherwise there may result a fatal
trauma <if the brain. Oshida has succe.ssfully inoculated
rabbits by using a long needle and passing this through
the optic foramen, through the brain, up to the dura
mater. Similar injections into the sciatic nerve or other
large nerve trunks, or into the anterior chamber of the
eye, are also usually successful. Intravenous injections
arc also usually successful in small animals, but not in
lar.ge. The .same is true of intraperitonciil injections.
Subcutaneous injection is very uncertain. The reason
that has been suggested for the frequent failure of sub-
cutaneous injection is that bj' this method the virus is
not brought in contact with an injured nerve, an essen-
tial condition for successful inocuhition, according to this
view. Those olfering this e.xjilanation cite in support of
their position the facts that the disease is more apt to fol-
low from the bitj of a mad dog if the injuiy is situated
on the hands or face where the nerve suppl}' is specially
abundant; also that injections into nerve trunks, the
brain, or the spinal cord, are uniformly successful, and
less so in other situations, as lias been .said: and. tiually,
that dee]) hicerated wounds are particularly dangerous.
\Vlii-llier the abundant nerve supply renders a part
specially liable to infection or no, the danger of infection
from biles on the hands and face is at least enhanced in-
dependently of this by the fact that these are tisuiilly
b;ire, whereas the clothing over the rest of the body may
prevent the infections saliva from coming in contiict with
the wounds. On the other lianil, it has been shown that
aiqilieatiou of the infectious material to the uuinjtu'ed
S30
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
<tii[iior<>rin.
Kabft'N.
conjunctiva, the uninjured genital mucous membrane, or
to the uninjured alimentary mucous membrane may be
followed by the disease ; so it does not seem necessary for
the nerves of a part to be injiired, in all cases at least,
xmless we assume that where infection follows applica-
tions of the virus to the mucous membrane there are mi-
nvite abrasions too small to be detected with the naked eye.
But whatever the portal of entrj', the disease develops
oidy where the poison invades the central nervous sj's-
tem, and all observation goes to show that the course of
the poison from the seat of infection to the brain and
spinal cord is not through the blood or lymph channels,
which are the distriliutors of the micro-organisms and
toxins usually in other infectious diseases, but that the
virus travels for the most part, if not exclusively, bj'
way of the nerves themselves.
In rabies, as in other infectious diseases, there is al-
ways a period of incubation between infection and the ap-
pearance of the .synijitoms of the disease. This period of
incubation varies in rabies not only in different species of
animal, but also in different individuals of the same spe-
cies, lu dogs it lasts for from three to five weeks, seldom
more, and seldom less. Bollinger states that in one case
in a dog it lasted for eight months, and tliat is the maxi-
nunn. In human beings the period of incubation varies
greatly in length in different cases; from six weeks to
two months is common, though cases have been reported
in which the period of incubation is .said to have lasted
for one or even two years; but these long periods of in-
cubation are certainly rare, if they occur at all. The
disease usually shows itself in the course of the second
mouth after the person has been bitten, rarely in less
than fifteen days, more rarely still after three months or
longer. In the rabbit the period of incubation is twelve
to fourteen daj's when the animal is inoculated with cord
from a mad dog, but it becomes shorter and shorter by
successive inoculations of suspensions of the cord from
one rabbit to another through a .series — in other words,
the virus becomes more and more virulent by successive
pas.sages through rabbits. This increase of virulence,
however, cannot be cai-ried on indefinitely, for there
conies a time when further inoculations do not increase
the virulence, and the virulence is then said to be fixed.
Pastevir's " virus fixe " is obtained in this way, and consists
of a portion of cord from a rabbitdead in nine or ten days
of rabies. This explanation of wiiat is meant by "virus
fixe" should be carefully borne in mind in order to under-
stand much of that which follows, for it will be necessary
to use the term frequently. It may also be noted in
passing that this "virus fi.xe" is made use of in the pro-
duction of the " vaccines" for treating persons who have
been bitten by a mad dog, as explained below. By the
use of large rabbits the potency of the virus may be so
increased by successive passages that the period of incu-
bation finally will be six or seven days; and by the use
of small Russian rabbits the period of incubation may be
still further reduced to live or six davs. Successive pas-
sages of the virus through apes, on the other hand, de-
creases the virulence, the period of incubation becomes
longer. In ducks and gee.se the period of ineubation is
fourteen days. In chickens the disease has a period of
incubation of forty days. Chickens, like pigeons, are
partly refractory to rabies, as shown by Dr. Paul Cibier
in 188-1 (ThCse de Doctorat, Paris, 1884).
But tlie symptoms do not apjiear as soon as the rabies
poison invades the brain and spinal cord, for these are
infectious for other animals before any signs of the dis-
ease have shown theniselvi-s in an infected animal. Roux
and his pujiils, and others, have found that not only the
medulla, but also the saliva of infected aninuils is infec-
tious f(n' other animals for from twenty-four to forty-eight
hours — sometimes for three days — Ijefore an\' symptoms
have developed. The different parts of the si)inal cord
become infectious for other animals at different times ; the
part nearest the seat of inoculation becomes infectious
first, as a rule. Hiigyes found that the brains of rabbits
inoculatetl under the dura mater are fully virulent in six
days, as soon as the first characteristic symptoms appear,
but that the medulla is fully virulent before this lime, on
the last part of the fourtii or o:. the first pait of the fifth
day, at the beginning of the febrih; syniplonis. Vestea
and Zigari and others found that after subdural inocula-
tion the medulla becomes infectious for other animals
several days before the luiidiar cord. By inoevdalion
into the sciatic nerve, on the other hand, the" lundiar cord
usually becomes iiileetienis for other aninuils befi ire the
medulla. Nevertheless, tliis is not always the ca.se, for
Kraus, Clairraont, and Keller have shown that the medulla
is sometimes infectious after inoculation into the sciatic
nerve at a time when the lumbar cord is not infectious at
all. This is not the rule, however, for usuallj' the lum-
bar cord is infectious for other animals in six or .seven
days after inoculation of the " virus fixe " into the sciatic
nerve, whereas the medulla does not usually become in-
fectious by this time by similar inoculation. On the
otlier hand, the medulla becomes infectious for other ani-
mals in one day after intracerebral inoculation with " virus
fixe," and in three days, or even in a shorter time, after
subdural inoculation with "virus fixe," less than half the
time required by inoculation into the sciatic nerve for the
poison to accunuilate in the lumbar cord in sutbcient
amount to be infectious for other animals. Enough of
the poison, howevei', gets into tla; lumbar cord in twenty-
four hours after inoculation into the sciatic nerve finally
to cause the disease in the infected animal, as explained
more fully below.
Kraus, Keller, and Clairmont have furthermore shown
that intracerebral injection of the '"virus fixe" causes the
development of the poison more quickly than the sub-
dural injection. In intracerebral inoculation with " virus
fixe " the poison is present in the medulla in twenty-four
hours in sufiicient amount to cause the disease on inocu-
lation into other animals. In subdmal inoculation, on
the other hand, it is not certain that the medulla is ever
infectious in as short a time as twenty-four hours after
inoculation. It is true that rabbits inoculated with the
medulla of rabbits taken out twenty -four hours after sub-
dural inoculation usuallj' die of gradual emaciation, a
sort of marasmus, but they show no sjniiptonis t^yjucal
of rabies, and the medulla of these rabbits is not infec-
tious.
Subdural inoculation, intra-orbital inoculation, and in-
oculation into a large nerve trunk, as into the sciatic
nerve, all have about the same effect as regards the ap-
pearance of the poison in the spinal cord. In no case
does the poison invade the entire nervous system all at
once; on the contrary, there is always a more or less
gradual extension along the cour.se of the nerves or the
spinal cord.
Kraus and his colleagues report one experiment in
wliieli the inoculation was made with "virus fixe" into
the lumbar cord in a rabbit. The cord in this case was
cut out twenty-four hours after inoculation, and cliffcrent
jiortions of it were inoculated under the dura of dilferent
rabbits. The results of these inoculations sh<iwed that
the lumbar ]iortion was typicall_y virulent; tlu' rabbit
inoculated with this died of umnistakable rabies. The
dorsal portion produced no symptoms. The medulla
caused the death of the rabbit in fourteen days without
any symptoms of rabies, it is true, but the medulla of
this animal caused death in another rabbit in sixteen days
with all the symjitoms of rabies. The reason w!iy the
virus in its passage through the dorsal cord to the
medulla from the seat of ino<-ulation in the lumbar cord
should not have found conditions for lodgment and de-
velopment in the dor.sal cord is not apparent. It would
seem as if tliis observation shows that the medulla and
lumbar cord have special allinity and attraction for the
rabies virus. Some of the other observations mentioned
above also seem to indicate tliat the most favorable .situ-
ations for the development of the virus are, first, the
medulla, and next to this thu lumbar cord; and that the
rest of the central nervous system becomes inva<led only
after these two locations have been fully impregnated.
The source of the ral]ii'S virus also affects the length of
time of the developiiK'nt of the disease as well as the ac-
831
Rahlrs.
Rabit's.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
cimiulatiim of the iinisnn in the central nervous system.
Tests upon animals show that the virus present in the
cord of a clog suffering from an onlinary ease of rabies,
the "street rabies," takes longer to invade the nervous
sj'stem and produce the disease than the " virus fixe." the
virus obtaiued liy successive passages through rabbits.
This is shown notoul y in the difference between tJie period
of incubation in the disease produced by inoculation with
'•virus tixe" on the one hand, ami that produced by in-
oculation with the "street \irus" on the other, but also
by the fact that the cord of an animal inoculated wilJi
the " virus fixe " is infectious forother animals in a m\ieh
shorter time after inoculation than is the cord of an ani-
mal inoculated with "street virus." It has been stated
that llie medulla of an animal inoeidated under the dura
with the "virus fixe" becomes vindent in two or three
days after inoculation. The medulla of an animal inoc-
ulated under the dura with the "street virus," on the
contrary, does not lieeonie virulent for other animals be-
fore the sixth day, and usually is not virulent before nine
or ten days, and I lie lumbar cord is frequently not viru-
lent at any time after inoculation witli tlie "street virus."
The reason for this difl'erenee between the " virus fixe "
on the one liaud, arid the "street virus" on the other, is
not ajiparent. The disease without proper treatment is
Justus surely fatal in the one case as in the other, and
the symptoms in both seem to be of equal severity. The
only difference seems to be that in the one case the poison
is generated more quickl_v than in the other.
But. although, as has been stated, the lumbar cord does
not eont.ain enough of the rabies virus to be infectious
for other animals for several days after inoculal ion info
the sciatic nerve, enough of tlie poison gets to the cord
in twenly-four hours by this mclhod of inoculation to
cause the di.sease in the animal itself; for Kraus antl his
co-workers inoculated a rabbit in the sciatic nerve with
"virus tixe," and the animal died of typical rabies in spile
of the fact that a portion of the sciatic nerve was excised
at a point situated between the seat of inoetilation and
file cord. On the other hand. Bombirci ]irevented the
disease from develo|)ing after intra-octdar inoculation by
enucleation of the eye twenty -four houis after infection,
and Babes and Talaseseu also prevented the disease by
cauterization of the seat of infection twenty-four hours
after inoculation. But Babes has shown that even com-
paratively late eauteri/alion or excisicm of the seat of in-
fection delays the ajipearanee of the sympitoms, even if
it does not prevent the disease, an important factor in the
proper treatment of the disease, as will appear in the
proper ]ilace.
The virulence of the virus may be destroyed, decreased,
or increased in various ways. Light, temperatures of
50^ to 60" C, drying, various antiseptics, and artificial
digestion all weakeu or destroy the virulence. Caleriua
found that formalin destroys the virus in fifteen minutes,
but not in five or ten minutes. Putrefaction has but lit-
tle or no effect on the virulence. The virulence is re-
tained by jireserving the infectious material in neutral
glycerin and in the cold. Heference has already lieeu
made to the fact that successive inoculation through cer-
tain animals weakens the virulence for other animals, it
even destroys tlie virulence in some cases, while similar
inoculations through other animals increases tlie viru-
lence. In other words, the rallies virus assumes a certain
definite degree of virulence, wliieh is different and ehar-
aeieristie for each species cf animal; and the degree of
virulence peculiar to a species of animal is attained by a
sufficient numberof successive passages through individ-
uals of the species. If the virus used for the first inocu-
lation in the .series has a shorter period of incubatiiai and
kills more quickly than is normal for the species of ani-
mal under ex|ierinient, the subsequent inoculations cf
the series will take longer and longer to produce the
symptoms and death till the normal degree of virulence
for th(i species is reai-lii'd. It does not ajipear from the
literature at hand just how many jiassages are necessary
to reduce the virulence in a given case, probably very
few. On the other hand, if the virus used for the first
inocidation has a period of incubation longer than is nor-
mal for the species under observation, it will have a
shorter and shorter period of incubation after each pas-
sage till the norm is reached. The acquisition of a high
degree of virulence is slow; starting with the virus from
a mad dog, it takes a j-ear or more to obtain virus of the
hii;hest degree of potency in the rabbit. The virulence
of the virus is in inver.se proportion to the length of the
jieriod of incubation. Thus, as has been already men-
tioned, the virus of rabbits is more vintlent than that
from dogs, because IJie period of incubation between the
inoculation and the outbreak of the sj'mptoms of the dis-
ease is shorter in the rabbit, after a series of inoculations
in these animals, than it is in the dog under similar cir-
cumstances. The virus from the dog is more virulent
than that from apes for tlie same reason, and while it is
true that, starting witli the virus from a dog, this be-
comes more and more virulent for rabbits bj' successive
]iassages tlirough these animals, a degree of virulence is
finally reached beyond which it is impossible to increase
the virulence. When the period of incubation is reduced
to five or six days it is impossible to reduce this any fur-
ther, the virulence becomes fixed. So that for each spe-
cies of animal thiTc appiears to he a normal fixed period
of incubation. And although increased virulence for the
animal tlirough which the virus is passed is usually ac-
comiianied by an increased viridence for other animals,
it is not always so ; for recent observations tend to show
that the "virus fixe," the most virulent virus for rab-
bits, is decidedly less virulent for man. At least Ininian
beings inoculated with this virus do not develop rabies,
in spite of the fact that they are not previously pre]iared
by inoculations with attenuated virus. It is true that in
the cases of this kind so far rejiorted, the ]iersoiis had
been bitten by mad wolves, but it is not clear how this
could diminish the action of the "virus fixe"; on the
contrary, it would seem more probable that it would in-
crease the action of the latter. After all, it would seem
hardly correct to measui'e the virulence of rabies virus
by its relation to the period of iceubatiou on inoculation,
for the vh'us froiu an ordinary case of spontaneous rabies
in a dog causes the disease apparently with just the same
certainty and with equal ,severity as the " virus fixe,"
onl}' the period of incurmtion is longer with the former
than with the latter. The disease, if not treated, is as
surely fatal with the one kind of virus as with the other.
Pigeons are not su.sceptible to rabies, but they become
so by starvation, as already stated. In chickens the dis-
ease has a period of incubation of forty days, and it can
be pro|iagaled by inoculatiim through a series of chick-
ens. For these birds the perioil of incubation is just the
same with the " virus of tlie street." from a case of spon-
taneous rabies in a dog, as it is with the "virus fixe."
AVilh either virus the disease progresses slowly after the
appearance of the symptoms; the fowls usually live
fourteen days after symptoms appear, and finally die of
jirogressive paralysis. In ducks and geese the period of
incubation is fourteen days. Inoculation of rabbits with
the brain of birds dead of rabies is rarely followed by the
disease; so while the virulence of the virus by successive
]5assage through birds is preserved for these, it becomes
weakened for rabbits.
Kraus and Maresch have studied the effect upon the
rabies virus of blood serum of normal animals, and of
blood serum of animals possessing aitificial immunity.
Their results show that the blood serum of ordinary non-
immune dogs and rabbits has no effect upon the rabies
virus; but the blood serum of dogs and rabbits that have
b(^('U given artificial immunity destroys the virulence of
the virus. Of this serum 0.01 c.c. destroysO.o e.c. of the
" virus fixe" diluted in the proportion of one ]iart of the
virus to fifty of indifferent fluid. Pigecms' blood has no
effect, ncilher the blood from normal pigeons, nor tliat
from pigeons that have been previously inoculated with
the virus. Cliieken's blood serum, on the otlier hand,
has the property of destroying the virulence of the virus.
This property is possessed by the blood serum of ordi-
nary, untreated chickens, and it does not seem to be in-
S32
REFEKEXCE HANDBOOK OF THE 31J:D1CAL SC1E:NCES.
Kabies,
Babies.
creased by previously proiluciug immuuity in the chick-
ens. The serum from ;i normal chicken destroys the
virulence of the virus in the jiroportion of 0.5 c.c. of the
serum to 1 c.c. of " virus fixe " diluted iu the proportion
of 1 part of "virus tixe" to 100 of indifferent fluid. A
smaller amount of the serum, 0.25 c.c, does not destro}'
tlie virulence of 1 c.c. of the virus.
Hiigyes found by using dilutions of various concentra-
tion that all strengths above 1 to 200 of the usual thick
suspension of the cord constituting " virus fixe " kill rab-
bits as promptly as the undiluted virus. Even 1 to 250
kills, but less promptly than the undiluted virus. A
strength of only 1 to 5,000 occasionalij' produces death
with "prolonged incubation of the disease. Very feeble
pi-cparations, 1 to 10,000, fail to jjroduce the disease.
During the period of incubation the individual suffers
no special inconvenience, not more than would be caused
hy a wound of equal severity resulting from the bite of
an animal that is not rabid. Indeed, it is stated by Till-
mann that a wound indicted by a rabid animal heals
usually with exceptional rapidity in human beings; nor
are there an}' other symiJtoms during the period of incu-
bation to indicate whether tlie person has been bitten by
a rabid animal or no. This lack of anything to cliarac-
teiize the period of incubation applies to rabies in beasts
as well as in man.
In dogs the first symptoms of the disease consist of
melancholia and moroseness, with restlessness and irri-
tability, loss of appetite, dysphagia, and nau.sea. The
dysphagia is specially noticeable in the ea.se of li(|uids,
aiid the name hydrophobia is given to the disease on this
account. Abnormal appetite is also present; the animal
endeavors to eat straw ov dirt or anything lying around,
no matter how unsuitable it ma_v be as food. These
.svmptoms may be insignificant at first, and for this reason
tiie animal is more dangerous at this time than at a later
period when the symptomsarc more manifest. Tliisstage
lasts from a half day to two or three da}'s, and is usuall}'
followeil by the stage of raging madness. Tliis, however,
is not aiways the case, for sometimes the morose stage
is followed by paralysis affecting the muscles of the jaws
and later of the hindquarters. The lower jaw drops, the
mouth remains wi(".e open, the bark is peculiar and hoarse,
there are also rapid emaciation, tottering, and final com-
plete paralysis of the hindquarters, ancl the animal dies
in two or tiu-ee daj'-s. This form of the disease is spoken
of as "dumb rabies," or as "quiet or niehiueholy rabies,"
and runs a more rapid course than the "raging mad-
ness." In the latter form of the disease the animal is sullen
and morose as in the dumb form ; tliere are also the same
restlessness, loss of appetite, and emaciation, but in ad-
dition to this the animal has paroxysms of maniacal rage
characterized by a desii-e to snap and bite at everything
aromid. Bollinger states that the great aversion to Avater
seen in the earlier stage of the disease is lacking in the
maniacal stage, and in this stage there is only exception-
ally sjiasm of the muscles of deglutition. The maniacal
stag(! lasts for three or four days and then passes into the
paralytic stage, which is the final stage as in dumb rabies,
and lasts for from three to six days. In the paralytic stage
the animal has a bristling coat, the voice is hoarse, dysp-
noea increases, and there are local or general convulsions.
The termination is always fatal.
In rabbits inoculated with unattenuated rabies virus,
either " virus fixe " or virus from " street rabies, " the dis-
ease always takes the form of "dumb rabies." But Ge-
naro has described a jieculiar form of the disease in rab-
bits inoculated with attenuated virus. In this form of
the disease the animals die with progressive emaciation,
without anv of the ordinary symptoms of rabies, but the
Ijiain and spinal cord of these animals produce typical
rabies when inoculated into other animals. An example
of this form of the disease has been noted above in the
citation from Kraus, Keller, and Clairmont's result with
inoculation of a rabbit with the meduUaof arabbit taken
out twenty-four hoin-s a Iter injection of " virus fixe " into
the lumbar cord. It will be remembered also that these
observers noticed that some of their rabbits died of a
Vol.. VI.— 53
sort of marasmus after infection with attenuated cord,
but that the cord in these cases was not infectious for
other rabbits.
In the human subject the first symptoms to appear
after the stageof incubation are psychical. The individ-
ual is depressed in s])irits, excitable, irritable, and rest-
less. He also suffers from sleeplessness and loss of appe-
tite, and in some cases even at this stage there is antipathy
toward liquids. He is also oppressed with a feeling of
impending danger. The reflexes and sensibility are often
great l_v increased. A noise, even loud talking, and a
bright light are distressing. The injection of the larynx
and consequent dilliculty of swallowing, which is the
most distressing as well as the most characteristic symp-
tom of the disease in man. is included in this stage by
Osier. Tillmann reganls this symptom as marking the
onset of the second stage. Some authors note a rise of
temjjerature and acceleration of pulse during this period,
others not. Huskincss of the voice is also present, hut
this symptom depends upon the injection of the larynx,
and is not always included in the prodromal stage. Al-
though the wound is usually healed b}' this time, there
is sometimes a return of inflammation in the cicatrix ac-
companied by pain, burning, and itching at this point.
Pain in the bitten part is often the first manifestation of
the disease and may be present several days before the
on.set of the other symptoms.
If the injection of the larynx with its accompanying
manifestations is regarded as the beginning of the second
stage, the prodromal stage seldom lasts more than twenty-
four hours; for the injection of the larynx, with spasm
of the muscles of deglutition and inability to .swallow,
appears rarely later than at this time. Along with these
.symptoms there appear severe spasms of the muscles of
respiration. These occur in ]iarox}'sms along with the
cramps of the jiharynx, and are brought^on bj' the
slightest excitation of the nerves; even the sight of
li(iuids is enough to cause them. The spa.sms are not
confined to the larj-nx and respiration, but soon become
general, and are usually clonic, sometimes tetanic. The
nerves of special sense are also affected, not only the
sight and hearing, as already noted, but also the sense of
smell. The salivary secretion is also increased. Tha
mind is for the most part clear, but there are ajit to be
maniacal seizures from time to time. The pulse becomes
gradually weaker. After a paroxysm it is greatly accel-
erated. The temperature is somewhat elevated ; it usu-
ally runs to 38° or 38.5° C. (100.4° to 101.3° P.). Dating
from the laryngeal symptoms, the second stage lasts for
from one to three days.
The third stage is marked by weakness, paralysis, and
exhaustion. Tiiere is abatement of the spasms and of the
dillicultj- in swallowing and breathing. This stage lasts
for from six to eighteen hours, when death takes jilace,
sometimes with recurrence of convulsions, but oftener
quietly. By some authors consciousness is. said to be pre-
served to the last, by others it is stated that unconscious-
ness supervenes.
The total duration of the disease in man, from the first
appearance of the prodromal symptoms to death, is rarely
less than two days or more than four days. The ter-
mination is always fatal if the symptoms once develop.
Tlie macroscopic changes shown at autopsy are not
characteristic either in man or iu beasts. The blood shows
insullicient aeration, is dark and thick. The mucous
membranes show a catarrlial condition with hypeiwmia
and eeeli\moses, specially pronounced in the mucous
membranes of the resjjiratory and digestive tfacts. There
are general parenchymatous hypenemia and cyanosis.
In dogs the stomach usually contains various indigestible
stdistances which the anim.-d has swallowed to satisf}- the
abnortnal appetite. Emaciation is also pronounced. But
the most marked lesions are met with in tlie central ner-
vous system. Besides ex ten.sive cedema of tlie brain, there
are vei'y considerable microscopic changes. These consist
of dilTvise myelitis of both white and gray matter, accom-
panied by degeneration of the nerve fibres and ganglia.
The axiscylinders of the nerve fibres of the central uer-
533
Kailtvay ITIediolne.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
vous system are liypertropliiiil. The uervc cells are atro-
phied and contain pigment. Tliese changes are most
marked iu the motor centres. The most characteristic
lesions, however, are seen in the cerebrospinal ganglia,
in which there is a iiroliferation of the eiulotlielial cap-
sule of the ganglion i'v\\< and a corresponding destruc-
tion of the latter cells (V'an Gehuehteu and Nelis).
The diagnosis of rallies presents no dilliculty. It is
true that the disease is simulated by tetanus arising fr(>m
an infected wound in the regions supplied by the cranial
nerves ; then, besides, pharyngeal spasms are also a marked
symptom of this alfeetion. But the history of tlie injury
would suffice in most cases tor a diagnosis; this wnuld
be misleading only in case the tetanus liacilli are iutro-
duce<l into a wound caused by a dog bite, a contingency
which is not at all probable. The different lengths of
the periods of incubation of the two diseases also afford
a point of differentiation. But the surest method of
diagnosis is the inoculation of a rabbit under the diu'a
mater with a bit of the cord or brain (rubbed up iu
bouillon or glycerin) of tlie animal that lias inflicted
the bite. If this animal was really aft'ectcd with rabies,
this inoculation would prod\ice the disea.se iu the rabbit
in from twelve to twenty-one days. Consequentlj', if
this step be taken ])rompll}Mifter the bile has been in-
flicted, tliere wili still be time enough to jn'event the
development of the disease by a resort to the Pasteur
method, to be described later. However, in cases of
bites en the head or face, the treatment must be begun
as soon as possible after the accident, and it would be
very unwi.se to wait for the result of such an experiment.
A <(iagnosis may be reached in twenty-four hours, if the
dog died of rabies or was at least in the p.aralytic stage,
by the method of Van Gehuehteu and Nelis, i.e., by the
micro.scopical examination of some of the cerebro-sjiinal
ganglia, especially the vagus ganglia which are easily
found.
If facilities for inoculating a rabbit are not at hand, ma-
terial from the animal should be sent for diagnosis to some
convenient laboratory. It suffices fidly for all purposes
lo send the nieduUa iu a small vessel containing glycerin.
as recommended by Kempuer. This method not only pos-
sesses the a(lvantag(^ of great convenience, but the mate-
Hal arrives at the laboratory in good condition for in-
oculation, w'hich is not always the case with lie other
methods of siiipment that are recommended.
The disease can be cured, or, rather, prevented from
tleveloping. only during the iueubaticm |ieriod, before
an)' sym]ilonis have developed; after this, the treatment
!p oul_y palliative, and consists in keeping the patient as
quiet and undisturbed as (lossible in a darkened ro<im,
and in the administration of (|uieting drugs. C'urare is
strongly advised by some, while by otheis it is not even
mentioned in the list of suitable drugs. Chloral hydrate.
potas.sinm bromide, and similar drugs are also advised
by .some. O-ier advises resorting to uiorpliine hypoder-
inatieally and to the use of chloroform at the start. Dr.
RamViaud repmts that he has obtaiueil the best results
(experience of about thirty eases) from the employment
of liyii.scine hydrobroniate in dosi'S of gr. -j^,',^ injected
hypodermatieally. Cocaine ap]ilied locally may be used
to diuiiiiish the sensibility of the )iliarynx so as to enable
thr |iiitient to take li()ui(l iiourisimienl where swallowing
iscitheruise impossible. Nutrient enemata are alsn rec-
ommeniled.
Tile disease may be ]irevented from developing by
speedy exeisiim, or by thorough cauterization with the
actual cautery or the si inng mineral aciils, not with nitrate
of silver. These are i;sually of no avail when not resorted
to within a sliort time after the bil.i'. But cauterization
or excision would seem advisable, nevertheless, even sev-
eral hours afli"' the bite, for, as staled iibove, the nb.sorp-
tion of the virus into the nervous system from the seat
of inoculation is sometimes delayed as long as twenty-
four hours. Moreover, as already stated. Babes has
shown that even when the disease is not prevented in
this way, the period of incubation is lengthened by ex-
cision or cauterization, a most desirable result when the
Pa.steur treatment is resorted to, as it .should be, and in
deed now universally is.
Although the disease is altogether beyond treatment
after symptoms develop, and although cauterization anil
excision are uncertain, the Pa.steur method of inoculation
affords a means of prevention that very rarely fails.
The princi|ile of this treatment, or, rather the oljject
aimed at, is the rapid production of immunity in the pa-
tient during the period of incubation of the disease. If
imniiinity can be established before the termination of
the period of incubation, befoie any symptoms have de-
veloped, the progiess of infection is arrested. TI.e met hoi 1
consists iu inoculation once a day, for from fifteen to
twenty-one days, with virus of giaded luitency. The
virus employed consists of bits of the spinal cord of
rabbits possessing such potenc^y, by repeated passages
through the central nervous system of these animals, tliat
it prodvices death from rabies in nine or ten days in rab-
bits by subdural inoctdation. As indicated on more than
one occasion above, this constitutes the "virus fixe" of
Pasteur. The graded jiotency which is reipiired if the
virus is to be used upon huiiiiin beings, is obt;iiueil in the
following manner: The spinal cold of a rabbit that has
died of rabies on the ninth or tenth day after inoculation
is carefully removed and hung up iu a tiask, at the bottom
of which are placed a few pieces of caustic ]iotash. Pro-
tection against dust, etc., is secured by .stulling sterilized
cotton into the neck of the flask wdiich is kept in a dark
room, it a constant temperature. In this way the cord
is subjected to a slowly advancing process of desici a
tion, as a result of which the rabies virus is reiidcied
progressively less virulent. ( )n the day following that on
which the cord was introduced into the flask, it is spoken
of as cord of the second day, or No. 2. On the third day
it becomes cord No. 3; and soon up to the fourteenth
day. After the fourteenth day what remains of it. it not
entirely used, is discarded. It is customary, iit the
Pasteur Institute iu Paris, tou.se for the Hist injection
an emulsion made from portions of the cord of both
the fourteenth and the thirteenth days. In the New-
York Pasteur Institute, however, the first injection con-
tains portions of the cord of the twelfth and eleventh
days. An emulsion is made by rubbing up a segment of
cord measuring 0.5 cm. in length in (3 c.c. of normal salt
solution (sterilized) for one patient. Two .separate in-
jections are made simultaneously, one in the right and
the other in the left hy]iochondriae region. Each suc-
ceeding couple of injections is made with a stronger
emulsion, that is, with an emulsion made from a segment
of the cord that has been subjected to one day less of
liryiug than tlie preceding one. The mo^t virulent cord
used in Paris is that of the third day ; in New York, that
of the second day. The time for using this is I'eached
somewhere between the .seventh and the tenili days, and
then a return is made to the cord of the sixth or tiflh day,
after which a gradual increase is agaiu made tinlil cord
of the third or second da j' is reached. But if the treat-
ment has been deferred, for any reason, so long that
there is danger of the di.sease developing before the en-
tire series of injections can be administered one day
ajiart, the interval between the injections is shortened,
and two or more injections of increasing strength are
given dail\' instead of one each day for the first three
or four days. Finally, when the case conies for treat-
ment very late, and the necessity for such treatment is
therefore urgent, it is maintained by some that all the
twelv- or thirteen injections should be administered in
twenty-four hours, or that the ]ireliminary injections
should even be dispensed with entirely, and virus of full
|ioteiiey adniinistered at the start. The ]irocedure men-
tioned last, the use of nnatlenuated "virus fixe" without
any pri'liniinary inoculation with attenuated virus, has
becu pnietifiid with good results in cases of persons liitten
by wolves, the most dangerous of all forms of infection.
This ]irocc(iure, however, is condemned by the Pasteur
Institute in Paris as well as by the New York Institute,
as it has caused several deaths.
Babes has advanced the theory that tlie rea.siwi u liy the
S3i
REFERENCE HANDBOOK OF THE JVIEDICAL SCIENCES.
Rabies.
Railway Medicine.
" virus fixe " does not itself produce the disease in man is
tliat tlie injections are always made under the skin of the
abdomen where it is not likel.v. owing to the presence of
abundant adipose tissue, that any nerves are injured.
]5ut >Iar.\ is quoted by Babes as autliority for tlie view-
that the virus becomes attenviated for Iniman being's and
for monkeys by being passed through rabbits, althi)Ugh
enhanced in virulence for rabbits themselves.
The writer desires to acknowledge his indebtedness to
Dr. George G. Rambaud, of the New York Pasteur Insti-
tute, for assistance kindly rendered in revising that por-
tion of the text which relates to preventive treatment.
B. 31eade Bolton.
RACHISCHISIS. See Spina Bifida.
RACHITIS.— Sec Bicl-et.<<.
RAG-WEED. — AM13R0SIA. Ambrosia is a genus of the
Compo.sitie, containing about a dozen species, mostl.T
North American. The best-known species is ^4. artemisii
foliah., the common annual rag-weed, and one of the
most abundant and troublesome of weeds. It is best
known to medicine because the presence of the pollen in
the nares is believed to be the principal cause or occasion
of the disease hay fever. This and other species contain
small amounts of amaroid and volatile oil, and have been
employed, especially in domestic practice, as aromatic
bitters". The idea tiiat a preparation of rag- weed can act
as a specific in hay fever is in the highest degree fanciful.
Ill iiry 11. R II shy.
RAILWAY MEDICINE AND SURGERY.— While, as a
matter of cnuise, passengers and employees have been
killed and injured ever since the inception of railways, and
railw^ay surgeons have been known over fifty years (Dr.
W. W. Apply was appointed surgeon for the Erie R. R.
in 1849), the recognition of railway surgery as a special
branch of the healing art is a matter of the last twenty
years, and has reached its highest degree of development
in the Western United States. It seems as fully entitled
to recognition as military surgery, with which it has
many features in common.
Prior to the War of the Rebellion, the mileage was
mostly east of the Mississippi; skilled assistance being as
a rule easily obtainable, there was little demand for sys-
tematic surgical service such as is now met with. Even
at the present tlay in the Eastern States, where railways
traverse thickly poimlated communities, the stations are
almost in sight of each other, and cities ami towns with
well-appointed hospitals occur at frequent intervals. In
the extreme Western States, however, perhaps several
hundred miles of unsettled or sparsely inhabited terri-
tory may intervene between the locations of properly
equipped hospitals. Hence during the building of tlie
great transcontinental lines, provision had to be made for
the care of employees injured during the construction of
the road, all of them away from their homes and in un-
inhabited districts. In many instances this hospital de-
partment became a permanent featui-e atter the roads com-
menced operation.
Except for the fact that it will have a larger propor-
tion of emergency cases, the practice of the railway sur-
geon will not differ materially from that of his surgical
brethren in general. The injuries with which he has to
deal are ver}' similar to the severe crushing injuries from
machinery or heavy vulnerating bodies in ordinary sur-
gical practice. They, however, present some special
features. Thus, for exaniiile, owing to. the fact tiiat the
extremities often become engaged between two im_yield-
ing surfaces — the rail and the flange of the car-wheel. —
these railroad injuries are often extremely severe in cbai -
acter, with great destrtiction and laceration of the soft
parts, and comminution of bones. Again, they are at-
tended by a high degree of mortality, and their etfeet on
the nervous system is overwhelming, shock being espe-
cially noticeable in this class of injuries. In addition to
the crushing force, there should be taken into account the
weight and velocity of the moving train. Th(^ weight
varies from ten tons for emjity flat ears to twelve or fif-
teen for box cars; from twenty to sixty for coaches; and
it amounts to one hundred tons or more for locomotives.
The railway surgeon often has to exert his skill imder
the most unfavorable circumstances and the most de-
]iressing siu-roundiugs, laboring at night with no light
but the trainmen's lanterns, far fiom skilled assistance
or even habitations, and amid rain, sleet, and snow.
The present mileage of steam roads in the United States
is over 200.000. on which over 600,000,000 passengers
were carried last year (l!i01-02). To operate this system
required in 1895 an army of 78.'). 000 men: in 1901 this
number had grown to 1,()71.000. In the Middle Atlantic
States the number of employees per one hundred miles is
1,140; next come the New England States with 827; and
so on, the lowest being the JMiddle Northwestern States
with 303. For the year ending June 30th, 1902, the total
number of casualties to passengers and emplovees reported
was 42,619 (2,819 killed; 39,800 injured)." Passengers
killed, 303; injured, 6,089; employees killed, 2,.')16; in-
jured, 33,711. (Report of Interstate Commerce Commis-
sion.)
As regards the different classesof employees, brakemen
are injured most frequently, then come switchmen, fire-
men, and engineers in the order named. In former )'ears
the largest number of injuries residted from coupling
and uncoupling cars. In 1893 the "Safety Appliance "
law was enacted, requiring the use of automatic coup-
lers. This law went into full eflect in August, 1900,
and the results from this humane legislation are both
surprising and gratifying. The number of emphn'ees
killed in 1902 as compared with 1893 is sixty-eight per
cent, less, and the diminution in the number of those in-
jured is no less than eighty-one per cent., notwithstand-
ing the much larger number of employees. Other tre-
quent sources of accidents to trainmen are getting on or
oil trains in motion, falling from the cars, collisions, and
derailment. The principal causes of accidents to passen-
gers are collisions, derailment, and falls from the cars.
According to Ilerrick, about fifty per cent, of injuries to
emplo_yees involve the upper extremity, thirty-three per
cent, the lower extremity, twelve per cent, the head and
face, and eight per cent, the trunk.
To furnish relief for sick and injured employees there
are four principal methods in operation at ]iresent: (1)
the relief system ; (2^ the surgical service without a chief
surgeon; (3) the surgical service with a chief surgeon;
(4) the hospital system.
1. The relief system is in o])eration on a number of
roa<ls. among them the Baltimore tt Ohio, Pennsylvania,
]{eading, Burlington, and Plant System. Membership
may be either vohmtary or compulsory. Under this plan
the employee is assessed mcuithly according totheam<iunt
of his wages — usually from twenty -five cenis to two dol-
lars. When injured, he receives a certain sum monthly
during this period of disability. Provision is ;dso made
for death, and for benefits in case of permanent disabil-
ity. In some associations membership lapses if tlie em-
ploj'ee cjuils the service of the company, in others the
death benefits may be retained. In others again, addi-
tional features are found in the shape of savings, build-
ing and loan departments, and old-age pensions. The
scoi^e of such a system on a large trunk line may be
gleaned from the last annual report oi the one in operation
on the Pennsylvania west of Pittsburg. The niemliership
was 23, 179, an increase of 2, 122. The average numlier of
members disabled per day was 778. or 3.'5 for each 1,000,
Tlie death rate was 13 for each 1,000. Ajiplications for
membership were 11,010. while the cessations of member-
ship were 8,868, of this number 8,090 having left the ser-
vice. The total receipts for the year were §415,643, the
disbursements 8349,104.
2. The local surgeons are a]ipointed by the sujierin-
tendent or general manager. Local surgeons are gener-
ally located at divisional or terminal points, and along
the remainder of the i jute, — as a rule, about fifty miles
apart.
o. A chief surgeon is appointed who selects his own
835
ICaiUva}* iTIediciue,
Kalt-K.
REFERENCE HANDBOOK OF THE HIEDICAL SCIENCES.
assistants. It is asserted for tliis plan that it reiliices the
number of damage claims. Tliure l)ein.!j; more miles of
railroad in the rural distriets than in cities and towns,
accidents frequently occur at remote points. Conse-
quently it is often the ]iractiee to locate, at convenient
points, division .surycons whoarc sulionlinate to the chief
surgeon and who in their turn have charge of a division
or i)ranch of the line, and of the local surgeons in their
territory.
4. The hospital ]3lan is in operation among other roads
— on the Ulissouri Pacilic. Chesapeake tt Ohio, Wabash,
Southern Pacitic, Santa Fe, St. Louis, an<l San Francisco.
It embraces the care of the employee whether sicU or in-
jured, and whether his illness oci-urs on duty or not.
The chief surgeon is iu cliarge. and the executive board
or board of governors iscomposedof representatives both
from the employeesand from the railroad company. As
in the relief system there is a monthly assessment, and
in addition the company either makes anannual donalion
or meets a deficiency shoidd one arise. ]\Iinor ailments
and injuries are attended to by the local surgeons, but if
the illness proves to be serious or lasting, palieiilsare
sent to the main hospital, or on the longer ,s_ystems to a
branch hosintal which is located at some accessilile point.
The Northern Pacilic Bcneticial Association, wlii<'h was
founded iu 1883, may be selected as a type of this plan.
This body maintains two hospitals — one at Braincrd,
Minn., for the eastern division, anil another at Missoula,
Mont., for the western. I"^>r the year ending June HOth,
1903. the receipts were 8105,8(1.'). 77. and the expenses
8104,003.40. The cases treated at the Braincrd hospital
were 3, l.'iO in number, and by the line surgeons of the
eastern division. 13.333. The jMissoula liospital eared
for 1.994 cases, and the surgeons on the western <livision,
for 13,9(iO cases. A training si'lmol for nurses is main-
tained at Braincrd,
For transporting the injured, several roads have
equipped hospital cars which are kept constantly ready
for use, and are despatched wherever they may lie needed.
The lirst one to be placed in conunission sin'ms to have
been that which was installed on the Baltimore it Ohio
Southwestern in 1894. A general idea of their tittings
may be derived from Fig. 393.") (from Herrick's " Railway
Surgery ").
Nussbaum's dictum that the fate of the wounded de-
pends on the individual wlio makes the tirst dressing is
now firmly establislied, and r.ailwav employees often in-
fect wounds received by them by aiiplying to them
stretcher drill, and those employees who are found to be
proficient are, after examination, formed into ambidance
corps. To keep up interest in the w-ork annual compe-
titions in stretcher drill are held, and the winning team
retains the trophy for the year ensuing. A small man-
ual on first aid has been compiled by C. R. Dickson
especially for railroad men.
In line with this work sonre roads ecjuip their trains
with "emergency bo.xes." containing a supply of gauze,
bandages, etc., which are replaced when used. These
are placed in depots, freight houses, or car shops. The
contents vaiy somewhat; the following is an average
assortment;
1 Heavy rubber bandage.
13 Assorted muslin bandages.
5 Yards sublimate gauze.
1 Ounce absorbent lint.
1 Ounce styptic cotton.
4 Ounces ab.sorbent cotton.
3.5 Corrosive sublimate taljlets.
3 Oimces bicarbonate soda.
4 Surgical needles.
1 Pair scissors.
1 Pair forceps.
1 Case carboUzed silk.
1 Roll rubber atlhcsive plaster.
1 Dozen safety pins.
1 Pyramid of |iins.
1 Fsmarch tourniciuct.
1 Ounce iodoform.
1 Case for scissors, forceps, needles, etc.
Splints.
The idea is to have wounds protected by clean gauze
held in place by a clean bandage, in order that they may
reach the surgeon in an aseptic condition, or as nearly so
as possible. Directions for using the various articles are
pasted on the lid of the box. The; following are those
used on the Southern Pacitic;
"These supplies are for ten)porary relief, until a sur-
geon can be obtained.
"In case of a broken bone straighten out the limb by
stretcliing it, and fit a splint on it by padding with sheet
cotton. Apjily a bandage over the splint to hold it on.
"In case the skin is broken, making an open wound,
apply moist gauze, and cover with cotton or lint and a
Ijandagc.
" If there is severe bleeding, ajiply the strip of duck-
webliing above or toward the body from the wound, put
/
*•
A
\
■^1.1
s
:;:
d]
'■"
D
Fig. ;W;;.5.— Floor rian of u Ilospitul Car. ^1, sitliim-rooiii
iiient aii'l liressincr cii.se: nV. operutincr tiiitle; .s'lt',
iiiatei-iiil.s; L. L, beds, ilierrii-l;: " ranlu::y surirery.
; i>. o()er.it!nir-rooin ; r, tcmsporiaiion-room : C7. closet; .S.S, seats; jr>, instrn-
tenlizeii water and solutions, iu raeks; EX, extra sheets, blankets, and other
toltacco cuds, soiled Wiistc, or dirly luuidkercliiefs. To
guai'd a.gainst this, "lirst -aid" instruction, so successful
in Great Bi'itain. has been introduced into this country
and is slowly finding its way into tavor. Classes of the
cuiployei's are formed at convcnieiil ])oints. aii<l a course
of leciui'es couched in simiilc ]angu:ige, and illusti-ated
by a manikin, etc.. is deliveied lo them b\ the surgeons.
A coui'se may consist of live Icctiu'cs. The liist one is
devoted to elementary anatomy and jihysinlogy ; the
second, to ari-est of hemorrhage; the third, to spi'ains,
<lislocations, and fi-actuies; the fourth, lo asphyxi;ition,
ai'tiflci:il respiration, poisons, etc. ; and the hist lo Irans-
l>ort:Ltion of the iujuied. Instruction is also given iu
a stick under it, and turn until the bleeding ceases. Do
not stoji the circulation altogether. If lileeding doesnot
cease apply bandage on other side of wound.
" For burns or scalds, apply the oxide of zinc ointment,
and cover wit h moist gauze, cotton or lint, and a bandage.
" In case of a cut, where the wound gaps, apply a
stripof adhesive plaster soas to hold the wound together,
and api)ly gauze ami a bandage over it.
"To relieve pain, give one or two opium pills every
three hours, until it is bearable.
"For pain in Iheeyes due tocinder; Dissolvea cocaine
tablet in a few drojis of water and apply to the eyeball
or lids by drojqiing, or by meausof abit of cotton wrapped
s;5<i
REFERENCE HANDBOOK OF THE IVIEDICAL SCIENCES.
Railway medicine.
Rales,
around a piece of wood the size of a toothpick or matcli.
Tlie cinder will often come away witli tlie cotton."
The pliysical examination of employees is becoming
more and more important of late. It is claimed on one
road, where the examination is rigid and great care is
taken in the selection of new men, that the number of
accidents and suits for damages has been lessened over
one-half. Claims for damages are sometimes brought to
recover for hernia or other conditions stated to have been
received while at work, and proved to have been present
before the litigant entered the emi.iloy of the comjiany.
Defective vision and color blindness are frequent causes
of rejection, both for admission to the service and for pro-
motion. Tluis, on tlie Chicago & Northwestern, fifteen
per cent, of the firemen, and ten per cent, of the brake-
men examined were rejected for these reasons. Out of
21,473 examinations on this road since this jilau was tirst
adoiJted in 189.5, some 2,TS,5 applicants were found phys-
ically disqualified. Of these, l,4(i9 had defective vision,
664 were color-blind, and 652 were rejected for other
physical defects. On some roads applicants ai'e rejected
for varicose veins, hernia, epilepsy, heart disease, and
hemorrhoids; others exclude ap])licants with hydrocele,
suppurative otitis, rheumatism, etc. The mental quuli-
fications are generally taken into account also, and the
examinations, as a rule, are repeated at stated iutei'vais.
or whenever occasion arises for promotion. In this con-
nection the age at which ajiplicants enter the company's
employ is becoming important since the adoption of old-
age pensions on a gradually increasing numlier of rail-
roads. At present the extreme limit at which applica-
tions are received on most roads seems to be thiity-live
years; ou one road (Erie) it is forty-five. In the first two
years' operation of the pension plan on the Penns3ivania
road l,f)74 employees were retired.
A constantly increasing field of usefulness for the rail-
way surgeon is that of hygiene. The freedom of the ice
and of the drinking-water from contamination; the dis-
infection of coaches after cases of contagious disease have
been imwittiugly transported, or where, as frequently
happens on some roads, tuberculous passengers are car-
ried to healtli resorts; the cleanliness of cars and depots
— all these are sulijects which come properly within his
sphere.
In common with the members of other branches of
medicine and surgery, the raihva.y surgeons early felt
the need of societies for the interchange of views and
opinions, and as a result several national, state, and local
societies have been organized. The first, composed of
surgeons ou the Wabash Railroad, was organized on Janu-
ary 25th, 1882, at Decatur, 111.; in the same year the
Pennsylvania system's surgeons met and organized. The
National Association "was formed mainly through the
efforts of the late Dr. A. W. Ridenonr. of Massillon,
Ohio, and its first meeting was held June 28th, 1888. In
1897 it increased its scope to include surgeons from Can-
ada and Mexico, changing the name to International, and
at present it has a membership of nearly one thousand.
The American Academy of Railway Surgeons, organized
in 1894, limits its members, and is made up principally
of chief snrgeons. Flourishing state associations are
those of Iowa and New York. There are numerous
bodies com]iosed of surgeons connected with the larger
systems of roads; among them may be mentioned the
Milwaukee & St. Paul, Wabash, Santa Fe, Pennsjdvania,
Erie, and Southern.
A few colleges in the West have chairs, either of rail-
way surgery or of accident surgery in general.
The literature comprises two treatises, annual trans-
actions of the national bodies, and a monthly journal,
besides many contributions to current medical journals.
Lull is J. Mitchell.
Rkkerkscks.
Stemen, C. B. : EailwaT SurRery, St. I.ouis. 1S91.
Herrloli, Clinton B. : i!iiil\v;iv Surgery. William Wood 4 Co., New
York, 1H99.
Dickson, C. R. : First .\id in Aceiili-nts, cijicago, 1901.
Transactions National Association of Railway Surgeons.
Trunsiictions American Academy of Kailwav Surgeons.
The Kailwuy Snrf;''i'n (cmi'cnt),' lil-\vcekly,lS94-1900, montlily, 1900-.
RAILWAY SPINE. See Kenous Si/siem, Traumatic
Affections of.
/\
RALES. — This term is applied to certain abnormal
sounds heard in the chest. It is customary with many
authors to speak of dn/ and ■inoist rales. Sibilant and
sonorous breath souniis are called dry rales, although
there is no more reason for calling these sounds rales
than there is for applying the same term to cavernous
li)-eathing. Certain authors also call these forms of
breathing rhouchi. and use the woid rale to designate
only the moist souud.s. Rhouchus, again, by others, is
used as exactly synon}-mous with rale.
The causes of these abnormal sounds vary consider-
alily. We may have a con.sideiable accumulation of ex-
udation in the trachea and larger bronchi, producing
large bnbbles, or the smaller In-onchi may be more or less
filled, giving rise to small bubbles, or perhaps the sounds
may be produced in the alveoli them.selves. Rales may
also be produced by the rubbing of roughened pileural
surfaces, by the presi'nce of fibrinous exudate on the
pleura, and by the stretching of pleuritic adhesions.
CoAHsis Mrcovs Rales are coarse luibbling sounds
produced in the trachea and largci' lironchi. They are
heard with both inspiration and expiration. They may
sometimes be made to di.sappear for a time by causing the
patient to cough. Sometimes, especially in children,
they may produce a fremitus easily felt through the chest
wall. They are heard most commonly with acute bron-
chitis in its exudative stage, and with bronchopneumonia,
also with chronic bronchitis and plitliisis, some cases of
oedema of the lungs, lobar pneumonia, compression of
bronchi or trachea due to ueojilasm or aneurism, some
cases of pleurisy with effusion, and empyema, especially
with perforation of the lung.
Fine jMrcocs Rales are sounds of the same quality as
the former, but finer. They are heard under the same
conditions.
SrnciiiopiTANT Rales. — These are fine, high-pitched,
bubbling sounds, heard during both inspiration and ex-
piration. They may be produced by the bursting of
small bubbles in the finest bronchioles or air passages, or
they may be caused by fibrin on the pleura, and liy pleu-
litic adhesions. The cause of this rale has been a matter
of considerable dispute. On the one hand, it is held that
the sound is invariably ]iroduced in the finer air passages;
on the other, that pleural changes alone can give rise to
it. The advocates of the ffuincr view hold that sounds
resembling the subcrepitant rale may be produced in the
pleura, but that a good ear can distinguish these from
I he true subcrepitant, bj^ a slight difference in qualitjf.
Believers in the second dictum say that there is not
enough motion in the air in the finer air passages to give
rise to the rale. Both of these views are extreme. There
are cases in which the subcrepitant rale is heard which
show, post mortem, nothing but pleuris.v as a possible
cause, and there are cases of adema of the lungs, with
no pleuritic changes, in which this ntle has been clearly
heard, and in which the serum in tiie lungs is the only
demonstrable factor in its production. It cannot be de-
nied that the sound may be due to either of these causes.
This rale may be heard in picuri.sy, in bronchitis of the
smaller tubes, in bronehoiincumonia, in lobar inu'umoiiia
during the stage of resolution, and occasionally, during
other stages, in phthisis, and in a'dcma of llic lungs.
Crei'ITAkt Rales. — These are very tine sounds tieard
only at the end of inspiration, and sounding very near
the ear. They occur in abrupt explosions. They arc
much finer than the subcre])itant rales, and are usually
compared to the sound produced by rubbing a lock of
hair between the fingers. The causes of this nlle are the
rubbing together of inflamed pleural surfaces, the en-
trance of air into ultimate bronchioles oi alveoli, the
walls of which are partly stiu'k together by exudate, or
perhaps the breaking of very tine bubbles. Of these
837
Rainsgate and I?Iar-
Kauiila. [^ate*
REFERE^'CE HANDBOOK OF THE BIEDICAL SCIENCES.
three possible causes the tirst seems most common, and
it is not unlilicly that this is really the only cause. It is
conceivable tliat if the pleura be coated with a thin layer
of sticky exudation, its surfaces will tend to slick to-
gether until the end of inspiration, and then, in slipping
over one another, give rise to the sound. This rale is
often said to be pathognomonic of acute lobar pneu-
monia. This is not so. The rale is frequently heard iu
the first stage of this disease, but it is also heard in pleu-
risy, bronchopneumonia, and phthisis. Taken in con-
nection with a rational history of acute lobar pneumouia.
the rale is of great value as a sign, especially if with it
other signs be found, but it is uot to be called pathog-
nomonic.
Pleuritic Friction Soi'xds are nlles produced in the
pleura when it is diseased. They may be of a rather
moist, grazing character, or may be creaking and dry.
They may lie heard in all diseases iu which the pleura is
involved." As has been mentioned, the pleural surfaces,
■when diseased, may give rise to crepitant and subcrepi-
tant rales.
Pleuritic Adhesion Sounds. — In some cases of oM
pleurisy, with adhesions, peculiar sounds arc heard,
which may be accurately imitated by applying one end
or a rubber band to the ear and stretching it. The adhe-
sion sounds are probably produced by stretching of old
adhesions.
The JIet-\li.ic Tinkle is a sound resembling that
produced by pouring water iu drops into a bottle. It is
produced either by drops of fluid falling from the roof
of a large cavity in the lung, or from the walls of the
cavity of a hydropneumothorax, or by bubbles breaking
in fluid imder similar circumstances. In different cases
one or the other of these causes may produce the sound.
It is heard over some large cavities, and. in some cases of
pneumothorax, it may occur either when the patient
speaks or while he is breathing.
GuKGLES are coarse rilles which are more liquid than
mucous riiles. They are sometimes lieard in bionehitis,
in some cases of soliditied or compressed lung, and iu
some cavities.
The Mucous Click is a peculiar dry sound, occasion-
alh' heard at the end of inspiration. Its cause and sig-
niticancc are uot clear.
Dry and Moist Cr.^ckles are sometimes mentioned.
They are difficult to distinguish from suberepitant rales.
Sibilant Breathing, sometimes called .sibilant 7'/;o;/-
cliv.s or rale, is a whistling or hissing sound heard in
cases iu which a bronchus is narrowed by intlammatory
thickening of its mucous membrane or by other causes.
Sonorous Breatiiinu is produenl iu the same manner
as the former. It is of lower pitch and softer quality.
J. West ItooscirU.
RAMSGATE AND MARGATE, ENGLAND.— These
two jHipular thougli ]iut the most fashinnablc English
coast resorts are situateil on the Isle of Thanet, about
seventy-five miles east of London. Margate lies to tlie
north, with an eastern sea exposure, while liamsgate,
about live miles to the south of it, has a southern as
well as an eastern sea front. Similar but (juieter resorts
in the near vicinity are Broadstairs, Westgate-ou-Sea,
and Birchiugton.
The general climatic characteristics represented by
these resorts are those of a cool marine climate, with
moderate or quite considerable humidity. Owing to the
intluence of the Gulf Stream here, as throughout all
England, the mean temperature is much higher than
is due to latitude. The winters are mild, the summers
cool; there are no great extremes of tempeiat\ire; and
there is great seasonal and diurnal equability. There
is only a moderate amount of sunshine, and there is al-
ways wind. Such a climatic combination is stimulating
and bracing, and has been found valuable for ana'mia.
malaria, convalescence from various diseases, dysjiejisia
resulting from debility, certain nervous affections, and
particularly scrofula and tuberculous conditions other
than pulmonary.
These resorts are available all the year, although they
are naturally most frequented in the summer.
The soil is of chalk covere<l with a foot or two of
earth, and, consequently, is dry and quickly absorbs
moisture.
Ramsgate, like its neighbor Margate, presents to the
sea high chalk cliff's, with an abrupt descent to the
"sands," which, being thus sheltered from the winds,
affords an attractive resort for the invalid and visitor,
and good bathing. In general, however, here as at Mar-
gate, the winds are frequent and trying, particularly at
certain seasons of the year. By the construction of ter-
races and crescents a certain amount of artificial shelter
is obtained. Nevertheless, " even in its stillest corners the
keen Thanet air is constantly moving." The southern
exposure affords more sun, though the general percent-
age of cloudiness is 0.7. On account of its situation it is
a little warmer here than at Jlargate.
The town contains about 2.5,000 inhabitants, and ap-
pears to be vevy healthy, as the death rate in 1891 was
only 14.6, and more than one-third of the deaths oc-
curred at over sixty years of age; the infant mortality
was lis per 1,000 births. The drainage is thorough and
good, and tlie water supjily is constant and pure. If
one desired to live long this would appear to be a de-
sirable resort, as in 1890 one-twelfth of the total num-
ber of deaths was of individuals at or upward of eighty
years.
Besides the cliffs and sands there are piers for prome-
nading; and the marine view, and the almost daily ar-
rival of foreign fishing smacks afford a constant source
of interest. There are also attractive drives in the vicin-
ity. The temperature of the sea water is 61° F. in ths
summer, thus affording opportunities for bathing. Ewart
("Climates and Baths of Great Britain," 189.5) says that
Ramsgate has an "admiralde winter climate for most in-
valids," and "many," he continues, "are so fortified by a
winter residence as to be able to meet the spring winds
without risk."
A climatic table of Ramsgate is appended; it also sub-
stantial!}" represents that of Margate, which is only about
five miles distant:
CLiMATK OF Ramsgate, Lat. 51° 19' (from "Climates and Baths
OF Great Britaln'").
c
at
&
"3
■5
>
>*
Teiii[if'ialuri'—
AMTji^i- nr normal ...
:w.s°
4(i.:<°
.12.2"
111.2"
«1.4"
49, H"
4.5.(1°
49.3°
Mean dailv range
S.H
11.1
14.2
1.5.2
15.4
I1..S
9.7
12 0
yWiiW nf wannest
WH
4.5.8
.19, :h
l«.K
liH.l
.5.5 7
49,8
.\5 3
Jtcanof <-nl.li-st
■MA
;i4.7
4,5.1
.5=1. K
.53.7
4:^9
4(1.1
4:^.3
Iliiilit'.-^l or niaxilnuni .
;i.5.2
Hli.ti
T7.:^
W.B
Kia
72,9
HI. 3
8(1. «
Liiwest ur niininaim ..
a(i.;i
ai.i
32.9
42.3
44.2
27.8
22,2
19.0
Huiniilitv—
Mean relative at 9 a.m.
s«
wf.
7H^
Uli
74:5
86S
»,Sf.
82S
Prei-ipitation—
Averast* iu inches
i.rt;
1.(4
1.7H
2.o2
1.33
2.8(i
2.,S4
24.23
Davs in whicli rain fell
i.^>
14
12
13
9
15
10
163
Wind—
The
pre
utlnv
vaili
est e
xeep
ludis
t iu
from
Apr!
the
land
S.W.
Weather—
.III
nt'.
Cloud at U A.M
7.:)
li.y
0.1
G.3
6.0
(i.B
7.5
0.7
Slargate (about 19,000 inhabitiints) has been noted for
a century for the treatment of scrofula aud tuberculous
diseases, especially iu children, aud here is situated one
of the oldest and most famous seaside sanatoria for those
sulfering from these diseases — "The I{oyal Sea-Bathing
Infirmary." There are also many other .similar insti-
tutions. The town stands on two hills separated by a
valley, and facing the north are high chalk cliffs at the
ba.se of which is a shallow beach that is quite covered at
higli tide. It is upon these cliffs that the new portion
of the town is situated. The town also stretches some
<listanee liack from the sea over undulating ground, af-
fording op|iortunities to gain a certain amount of protec-
tion from the winds. The water supply is good, and the
838
REFEKENCE HANDBOOK OP THE MEDICAL SCIENCES.
Rniiisgiato and Iflar-
lesiiiiila. [u;il4-.
<lrainage is efficiently accomplished both by natural and
by artificial means.
Till' talile shows the various meteorological data in
detail. Fogs are not frequent. It is rarely uncorafort-
al)ly hot or cold in sunnner. January is the coldest month
in the year, the average temperature being 38.9' P.
Large numbers of children are sent to this resort for
the etfect of the sea air and sea bathing, the majority
sulTering from scrofula and tuberculous diseases other
than pulmonary tuberculosis. The benefits obtained in
tliese maladies in some cases are said to be extraordinary.
At the Ro3-al Sea-Bathing Infinnarv the following per-
centages of cures are given: 1886, 23.5 per cent. ; 1887,
27.84 per cent. ; 1888, 38 per cent. ; 1889, 46. 1 per cent. ;
1890, 52.35 per cent. As it requires a certain vigor of
constitution to endure this climate, weakly children would
probably do better in the milder climate of the Mediter-
ranean shores.
The accommodations at Ramsgate and Margate are
good and of varying price, and there are excellent facili-
ties for all sorts of sea-baths.
Por a more extended description of this region and its
climate the reader is referred to the article of Ewart in
"Climates and Baths of Great Britain," to whom the
■writer acknowledges his indebtedness.
Edirard 0. Otis.
RANULA. — A cystic tumor in the floor of the mouth,
formed by the dilatation of one or more of the acini of
the anterior lingual glands (Ward '), which are known
also as the " Blandin-Nuhn " glands (von Reckling-
hausen*), and are situated at the under side of the tongue
on either side of the fnenum lingua', near the apex.
This definition, the correctness of which has been con-
firmed bj' later investigations,^' •* is founded on the residt
of a characteristically thorough investigation, by the
accomplished Strassburg iiathologist. f)f a typical ranula
accidentally foimd at a necropsy made in his ])athologi-
cal institute. The cyst, about the size of a pigeon's egg,
was found on the under side of the left half of the tongue;
it extended to a little beyond the median line upon the
right .side, and penetrated into the intermuscular spaces
in different directions. The wall of the cyst was of a
nearly uniform thickness of from 1 to 3 mm. ; the internal
surface was nearly sniootli, except in the upper part,
■where, anteriorly, toward the apex, there was a promi-
nence of some 5 mm. in height, upon ■which ■vvere two
furro'ws; one of these, situated near the top of the prom-
inence, allowed the passage of a bristle to the depth of
■2.5 mm., while the other, situated near the base and away
from the apex, ■was impervious. The cj'st was every-
■n'here colorless and translucent, except at the inferior
part, where there ■was an opaque spot of about 20 mm.
in diameter, of a brownish color, having at its edges Iwo
more cysts, each about the size of a pin's head. The
■ducts of the various salivary glands, Wharton's and Ri-
vinus', as well as Bartolini's. were all to be traced outside
of the cyst, having no other relation with it than that of
proximity. The microscopic examination showed that
the epithelial lining of the cyst ■wall was in two layers,
the inner one of eiliatcd cylindrical epithelium, and be-
neath this a layer of small polygonal cells with large
nuclei. The cyst contained a clear, soniewhat thick,
glairy, and viscid mucus, faintly yellow in color. Tlie
morphological elements were cells of an epithelial char-
acter in various stages of "colloid " degeneration, large
brownish granular bodies, and numero\is hyaline corpus-
cles, among which were some quite large, of a diffused,
faint greenish-yellow shade, permeated with countless
4 "vacuoles." The chemical examination show-ed a consid-
erable amount of mucus, but no evidence either of s>d-
phocyanideof potassium or of any fermentative material
for the saccharine conversion of .starch; therefore the
fluid ■was not saliva. This confirmed the investigation
of Besanez ^ made in 1845. Foderl ' describes a ranula
which he dissected as consisting of the dilated duct of the
Blandin-Nuhn gland.
RanuhB, in general, present themselves as translucent
pink or bluish tumors, generally globular in shape and
fluctuating, lying either wholly in the mouth or between
the mouth and chin, according to their size. They i lo-
ject into the floor of the mouth from beneath the tongue,
at first quite to one side of the fra'uum lingua-; but aa
they increase in size toward the mouth they elevate the
tongue, push it over to the ojiposite side, and in time
present themselves against the teeth in front, and may
even prevent their closure. They push the franum tow-
ard the opposite side, but may project beyond it, giving
the appearance of two tumors, or of one tumor divided
into a larger and a smaller portion. As tlie tumor in-
creases in size the interference with speech and deglu-
tition becomes .steadily more noticeable. The elder Cline '
relates the case of a person who was in great danger of
immediate sutTocation b}' a large ranula which thrust the
tongue back into the fauces. When not interfered with
the tumor will project in the neck below the angle of the
chin, and lluctuation may he felt in this situation. AVhen
the tumor is large the aiteratiim of the jialicnt's exjires-
sion is marked; the region of his moiitli looks like that
of a frog, the pale bluish, translucent hue increasing the
resemblance. Hence the name, from I'aiiti, frog (ier.,
FroscJigesc/iiciilsle ; Pr., gniioin'(letle).
Cysts of other organs than the Klaudin-Nidm glands
are also found in this situation. Wharton's duct may be
dilated by the damming Ijaek of the secretion of the sub-
maxillary gland from the foiniation of a salivary concre-
tion in the duct, either at its orifice or in its coiu^sc; and
dermoid cj'sts, often of considerable .size, are also found.
The latter are especially interesting pathologically, as
they undoubtedly represent here the remains of a "fu'tal
organ which normally entirel.y disappears. The branch-
ial fissures of the fojtus are normally obliterated early in
fa'tal life, but occasionally a fold of the tegumcutary or
epiblastic layer becomes included in the deeper tissues in
the jirocess of closing in from the sides to form the lace,
and finally it becomes entirely- separated from its attach-
ment to the external skin. It may remain quiescent,
giving no evidence of its presence, or the cells of the epi-
thelial lining may be excited to growth and the interior
become filled with the products, consisting of broken-
down epithelium, fat, cholesterin cr^ystals, and debris,
i.e., the usual contents of cysts developed from the der-
moid layer. Indeed, hairs, bone, and teeth have been
found in them." These dermoid cysts, however, do not
spring from the same point as do true ranuUe. They are
situated either in the median line, between the twogenio-
hyoglossi muscles, or between one of these and the mylo-
hyoid; but as they grow they extend upward into the
floor of the mouth, or downward in the neck, as far, per-
hajis, as the larynx.'
Di.vcNosis. — These various tumors present points of
dilTerentiation sufliciently marked, usually, to allow them
to be recognized, and as the treatment of each is different,
it is important to have them well in mind. The positions
of true ranula and of the dilated Whartouian duct are,
by the time they have aroused sullicient attention to be
brought to the notice of the surgeon, very nearly the
same; they both lie just under the tongue, to one side of
the fra'Uum, and fill up the floor of the mouth, elevat-
ing the tongue above it, and a]ipearing as a thin-walled,
fluctuating, and translucent tumor. In the case of the
ranula, this tumor has upon its siuface Wharton's duct,
the orifice of which can usually be detected near the
median line, and into which a fine jirobe or bristle may
be jiassed, and be seen to glide along the surface to the
submaxillarj' gland, external to and beyond the cyst.
Careful search will often also reveal the orifices of the sub-
lingual gland, the ducts of Rivinus. Blood-vessels are
frequently seen covirsing in waving lines over the cyst.
When Wiiartcn's duct is the seat of the tumor, the en-
trance of the probe into it will be prevented by the ob-
stacle which is blocking it, be it .salivary concretion oi
infianunatory jiroduct, and removal of the obstacle ■will
usually allow the escape of the fluid. In these cases there
are usually considerable pain and circumjacent swelling,
with other evidences of inflammatory action in all the
839
Rape,
Rapo,
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
parts iniplicak'd; tliefloorof thcinoutli isliotand tender,
the tonjrue is painful on motion, and iindei' ilie jaw tlie
submaxiilary gland is swollen and tender.
The elinical features of the dernuiid cyst arc dilTercnt:
indeed, there sliould be no confusion between tlieui. but
inasmueh as, from its situation and gross appearances,
it is sometimes dcscrihed as ranula. it is well to point
out the differences. The wall is usually thicli and firm,
the contents may be quite thick, even mortar-like, some-
times purulent, or tlie contained Ifnid may be thin or vis-
cid. Tliere may be fluctuation, but it is less distinct than
in ranula, and the surface often [lits on pressure. The
tumor is situated more deeply luider tlie muscles of the
moulli, and, wlicn presenling iniih'r the jaw, is eml)edded
among those of the necl;, and may ]ienetrate even as far
down as the larynx. In the moutli it arises nearer the
median line, altliough as it grows its origin becomes
obscured, and may not be readily determined at the time
when the case comes under the observation of the sur-
geon.
Trk.\tment. — No other than operative interference is
of any avail in the treatment of these cysts, and it is usu-
allv necessary to do more tlian simply to evacuate their
coutcnis. If it be a diJnted W/mri'iiiiini ili,c1, the re-
moval of the concretion blocking up the orifice is usuallj'
sufficient ; but this requires some care, as it is often very
brittle, and if any fragments remain they set up a good
deal of irritation in tlie duct itself, and serve as nuclei
for further colli'Clions. Therefore an opening should be
made in the duct sullieiently large to "shell out " the
stone entire. As these are occasionally ()uite long, it
may recpiire a con.siderable inci.sion in the length of llie
duct, but this is preferable to tnaking a small o]ieniug
and endeavoring to drag the stone out: for if this is at-
tempted it is liable to break, to the subsequent annoyance
of liotli patient and surgeon.
It is better, when practicable, to remove the (Irniinid
cyst entirely, thinigh, when it extends deeply and has
very tirm altachments, this wilt be difiicult. and may be
impossible Avith safety to the jiatient. Wlien the cy.st
is not large it is usually easiest to make a free incision
through its wall — whether in the mouth or under the
cliin. de]3ends upon its accessiliility — and evacuate the
contents. When these arc thick and tenacious this may
be a matter of some dilliculty. After this, the cyst wall
being tolerably tirm, it will bear eousidi rable dragging
upon, and may be enucleated with the handle of the
scalpel, aided by occasional snips with the blade or with
scissors. Cases are occasionally met, however, in which
the operation of entire removal is both dillicult and
dangerous. In Mr. Mayo's' case the tumor extended
down nearly to tlie clavicle, passing between the sterno-
mastoid muscle and the trachea. .Vfter scooping out the
contents and removing ,i part of the wall, he left the rest
to suppurate, first filling the cavity with lint soaked in
turpentine, in order both to arrest the hemorrhagi' and to
hasten the suppuration. The jiatii'ut lecovered after a
considerable time.
8ir William Fergusson's '" case filled the mouth so as
to threaten sufloeation, keeping tlie teeth forcibly apart
and iirojecting iirominently under the chin. He feared
to leave "a sac so large and thick to the certainty of a
violent inflammation." . . and "resolved instead to at-
tenqit the extraction of the whole cyst." Incisions were
made both in the mouth and in the neck, but "the sac
was so amalgamated with the surrounding tissues that a
free use of the knife was re(|uired." No large vessel was
cut. but there was much loss of blood Ixith at the op(>ra-
tion and subsequently; thcnltimate result, however, was
entirely satisfactory.
The true thin-walled ranula requires a dilTerent treat-
ment. Simple incision is not sullicient, for the i-dges of
the wound usualh' reunite and the cyst forms again.
The wall is also too thin to allow its enucleation ui toto.
A seton introduced through its walls, an<l allowed to re-
main for a couple of weeks, more or less, will ,sometimes,
but not always, cure it, and is to be tried first. This fail-
ing, some surgeons recommend the removal of a large
part of the thin wall, in the expectation that the re-
mainder of tlie cyst will collapse and the walls unite, thus
obliteratiugitscav'itv; but, like the seton. this ofteu fails.
A sort of plastic operation has, therefore, been tried,
and it has usually proved successful. This consists in
forming a triangular flap by a couple of converging inci-
sions in the anterior wall, and fastening the apex bvtwo
or three sutures to the oppo.site wall ; adhesions are thus
formed, and the cyst is kepit open until the wall shrivels
up. Sonneuberg recommends that the remainder of the
gland be dissected out of its bed in the apex of the
tongue, thus preventing the development of any other
cysts afterward. This is occasionally done, with very
satisfactory results, when milder measures have failed.
Ilippel" advises the removal of both cyst and gland
through an incision under the chin, as being more acces-
sible and more sure against recurrence. Fef izet '"• thinks
that ho simplifies the procedure of extirpatiug the .sac
by first injecting a solution of boric acid into the tissues
around it ; after which he opens and empties the cyst,
stulfs it full with a sponge, and shells it out as a solid
tumor ( 1) WiUiiim II. Cunimlt.
> Ward, Natlianiel : Article Salivary Glands, in Todil and Bowman's
EncycIopiPdia of Anatomy and Plivsiolopfy, vol. iv., pt. 1. p. ■t.'ii.
= von Recklinghausen : Vircliow's Anhiv. Bd. 84, p. 4a>.
" Sultan : Deutsi'ti. Zeilsclirift. fiir ( liinirsie. Bd. xlviii.. 18G8.
* Jlintz: DeutscU. Zcit^cllrift fiir C'liirurgie, Bd. li., ISW.
' Be.sanez. Dr. (Jonip: Heller's Archiv fiir Plivs. und palholog.
f hemic u. Microsoopie. vol. ii., quoted by Dr. i )wen Rcis in tbe article
Saliva, in Todd and liowman's Enoycl. of Anat, and Pbys,, vol. iv.,
pt. 1, p. 4211.
' Foderl : I.angpnliecU's Arclilv, Bd. 49, l.sfli.
' Cbelius's System of Surgery, vol. iii.. p. 121. Edited by J. F. South,
Philadelphia, 1»47.
■" Butlin. Ilernv s. : Diseases of the Tongue, p. 239. Lea Brothers &
Co., Philadelphia, VHo.
' Mr. Mayo, of Wincliester, England : Lancet, 1S47, i„ p. 007, quoted
In Druitt's Surgery, p. 42^1, Philadelphia, 1.S6II.
10 Fei'gusson's Practical Surgery, p. 445. Philadelphia, ISoS.
" Hippcl; Langenheck's Archiv, Bd. .5.5, 1897.
'■■' Fellzet: Bull, de Chirurgie, 1891, October 21st, p. 60:i.
RAPE. MEDICO-LEGAL ASPECTS OF. -Rape may
be defined ;is the carnal knowledge of a woman through
force and without her consent; or, as it is generally ex-
pressed, "forcibly and against her will."
The physician is concerned but little with the legal
aspects of the subject. Only the more imjiortant facts
will therefore be stated, gi'eater space being given to the
duties of the medical examiner.
Ociici-iil Considrriilioiin. — Ra]ie has alwa_ys been re-
garded by civilized nations as one of the most heinous
crimes. It is a felony in all the L'liiteil States, and its
punishment varies from fine and imprisonment fora term
of years to life ini|irisoniuent or ileatli. The .severest
penalty is imposed in several of the Southern States.
Assault witli intt^nt to rape is recognized as a distinct
offense in some of the States, but not in others. Where
so recognized, it is piinislieil with fine and imprisonment,
[landling, touching, or attempting to touch the genital
organs of a female, or her breasts, forcibly and witliout
consent, is regarded in some States as a felony or ci'imi-
iial assault; in others, as a misdemeanor.
If it cau be shown that the woman gave her consent,
the guilt of the man is removed, providing the woman is
capable of legally giving consent. Tuder the old "com-
mon law" the age limiT, umler wliich a female Avas not
capable of giving consent, was thirteen years. In most
of the States this limit lias beeu rai.seil to fourteen or six-
teen years; in Wyoming, to eighteen years. Carnal
knowledge of a girl under this limit, even at her solicita-
tion, is a felony. An idiotic or insane woman cannot
give consent, and an assault or rape committed upon one
in a state of ana'sthesia or in a hypnotic sleep is generally
regai'di'd ;is being comniitte(i against her will. Consent
obtained by fi-aiid. as wlien a man represents himself, in
the dark, to be the husband, or when the woman unwit-
tingly assumes tliat he is her husband, does not mitig-ate
the otTense, all hough a decision was once given in Eng-
hind in wiiich such deception was permitted to pass
witlioul ))unishment. Previous repeated cohabitation
between tiie mau and w'oman does not remove the guilt
840
KEFEKEXCR TIAXDBOCIK OF THE MEDICAL SCIENCES.
Rape.
Rape,
of raiK', if force lias been used, for tlie common law holds
that even a ])rostitiite may reform or withhcjld her con-
sent. A woman cannot charge iier husband with rape,
for the marriage contract involves her consent. Finally,
all persons aiding in the commission of a rape or assault
are re,garded as principals in tlic second degree.
The testimony of tlic jn'osecuting witness is accepted
as competent through recognition of the fact that the
crime is generally committed in scciet when no other
persons are near. But the character of the prosecuting
witness is important and may be impeached. The wit-
ness is required to answer all iiuestitms put liy the de-
fence without privilege.
Duties of 1/ie Exuiniiier. — The testimony of the medical
examiner is generally employed to corroborate that of
the prosecuting witness, and there are few positions in
which greater care and discrimination must be used. It
is tlie duty of the physician to make an impartial exam-
ination and to submit the facts just as he finds them.
The statements of the victim and those of her friends are
matters for the consideration of the court and should not
in the least influence the examiner. In a large ma.iority
of all casesof alleged assault the allegation is accidentally
or maliciously false. Amos was doubtless correct in his
estimate that there are twelve false charges to every true
one. Tlie estimate is true also of cases in whicli a child
is the principal witness. Even young cliildreu are taught
by designing women to tell the story of an assault; but
they are often taught to use language mo.st unnatural to
their age, and the absolute precision of their statements
is often a ground for suspicion. It is rarely indeed that
an adult can reiterate a false story without introducing
discrepancies. The motives for such deception need not
be discussed. The chief of them is revenge, and this is
often for the most trivial olfense, an unpaid debt, a fan-
cied slight or insrdt, or a cessation of impro])cr relations
with the mother. In such cases the report of the exam-
iner should prevent the case from coming to trial. In
cities where these examinations are entrusted to a medi-
cal officer of the court or Police Department, his decision
is usually accepted and the case is dis])osed of accord-
ingly, but a physician is generally fo>ind by the friends
of the prosecution whose sympathy masters his judg-
ment, or one who may innocently err through lack of
experience. The inexperienced physician should be ex-
ceedingly carefid in all cases.
The e.vaminer, on the other hand, would often err if he
confined his opinion too rigidly to the physical condition
of the victim. He can often further the ends of justice
by carefully interrogating her apart from her friends and
the officers in charge of the case. For his own protec-
tion, however, he should never examine her alone in a
closed room. A child Avhen privately questioned may
admit that she has been instructed ami perhaps injured
by her mother; but the testimony of a young child is so
unreliable that even this admission may be false. The
slightest discrepancy should arouse suspicion, especially
in the case of a girl approaching the age of consent, and
in all cases a careful infpiiry sliould be made into the
possibilit}' of a motive for false accusation. In a case
examined by the writer, a girl of tifteen years charged
her father with incest on two occasions. Her condition
suggested more freciuent intercourse, and she finally ad-
mitted that the charge had been brought thiough re-
venge for being forbidden the attentions of the _young
man who had been guilty of her downfall.
The examination should lie made at the earliest pos.si-
ble moment after the as.sault. but in the case of an adult
woman only with her ccmsent. Refusal to submit to
examination maj' be taken as an indication of false accu-
sation, bvit no more exten,sive injuries were ever foiuid
by the writer than in a young woman who, after reciting
a most incredible account of imprisonment and rape by
five young men, was with the greatest difficulty per-
suaded to undergo an examination.
A complete record should be kept of the examination,
including the name, residence, age, and a|>parent age of
the subject, the exact lime and place at which the as-
sault is alleged to have been committed, and the place
and exact time at which the examination is made. The
injuries, if any, should be described with minuteness.
The most trivial circumstances often prove of value in
the hearing of the case, but particularly the time at
which the crime is ,said to have been committed and the
time which was permitled to elap.se before complaint was
made. An excellent form for this record is given in the
"Medical Jurisprudence" of Witthaus and Becker, vol.
ii., p. 419.
The principal facts to be established by the physician's
examination are: (1) Marks of violence on the woman's
.geidtals; (2) marks of violence on lier person or on that
of the accused ; (ii) stainsof Idood or semen on the per.son
or clothing of either; and (4) the presence of venereal dis-
ease, gonorrluea, syphilis, or chancroid in one or both.
It is better to make the examination of the defendant
with hisconsentand underfull knowledgeof itspurpose,
for it may otherwise be excluded as being in the nature
of an involuntary confession. For the same reason the
consent must be obtained without threat or promise. In
a recent case the victim, a child of four years, was found
to be infected with gonorrlKca, and the accused in a late
stage of the disease. The latter, distinctly degenerate,
willingly submitted to the examination, and admitted,
in the presence of the examiner and an officer, that he had
had the disease and had committeil the assault. The case
was closely contested, but the evidence was finally ad-
mitted entire as a voluntary confession, for it was shown
that he had been informed beforehand of tlie purpose of
the examination and of the official position of both wit-
nesses.
The examiner is generally expected to testify that he
has founil, or that he has not found, evidence of the Jien-
etration of some blunt instrument. It is sufficient that
the penetration has been only slight, as a separation of
the labia. A recent rent of the hymen is one of the most
positive signs that force has been employed and that pen-
I'tration has been effected, but it is not essential. The
fact that the hymen is intact is of little value as negative
evidence, for its firmness must be taken into account.
Hepeated intercourse is sometimes po.ssible without its
ru]iture. And, on the other hand, the membrane maj- be
torn in many ways other than b.y sexual intercourse. It
is probably congmitally absent in rare instances. The
vaginal wall ma}' also be torn. Comparatively few ex-
aminations are made early enough to discover a recent
bleeding rent of the hymen, and after the third day it is
extremely dillicult to determine the recentness of an in-
jury. More than one exaniin;ition should generally be
made, and the statements made at each shotdd be c«ire-
fully compared. In many cases the injury is limited to
one or more abrasions just within the labia minora. The
examiner should .see that this corresponds to a jiossible
injury by sexual contact, and that it is not an excoriation
such as might be made with the finger-nail. He cannot,
of course, testify as to the manner in which the injury
was inflicted, but he may state that tlie injury corre-
sponds exactly to an injury intiicted in a forcible effort
at sexual intercourse.
Complete penetration of the vagina of a ^-oung child
by an adult male penis is impossible without the most ex-
tensive laceration, and this is generally prevented by the
outcry. In more than one hundred examinations of
young girls the writer has seen but one case in which
such injury had been inflicted. When there has been re-
cent complete dellorati<in, complete penetration of a vir-
gin, there are generally well-marked signs of violence.
The hymen is lacerated and the external genitalia are
inflamed to a variable degree. There may be only slight
redness, heat, and sensitiveness, or the swelling and ten-
derness may be so great as to render a thoiough exami-
nation almost impossible. Tlie woman walks with diffi-
culty, and .separation of the thighs causes mten.se pain.
In the course of frcmi forty-eight to seventy-two lumrs
these conditions may subside or they may become more
marked as suppuration develops in the lacerations. Other
evidences of a struggle are generally revealed in cases of
841
Raspberry.
Raynaud's Disease.
REFERENCE HANDBOOK OF THE IMEDICAL SCIENCES.
extreme iujury, especially contusions, abrasious, aud lac-
erations of the tbiglis.
Evidence of seminal emission was formerly I'eqnired
as a proof of guilt, but it has been aliandoned.
Such evidence, if present, however, is of great value
as corroborative of tlie other facts. If stains are found
upon the clothing a small piece sliould be cut out
and submitted to careful niicroscojiic examinatiou.
Spermatozoa may htt found also in the vaginal nuicu.s. on
the skin, or on the inibic hair. (Seenrlicleon Scmiiin/
Marks of violence on either person ari> of \ aluc cliieily
in determining that consent was not given anil that force
was employed. The}' are of greatci- importance, there-
fore, in the case of a woman above the age of consent.
In the case of tlie iiroseciiting witness it is necessary to
e.xcludetlie possiliility that the wounds were self-inflicted.
This is to be susjiected especially in thecaseof a neurotic
or evidently erotic girl, and when the marks consist of
parallel lines corresponding in size and position to possi-
ble positions of her own fingers.
The much-discussed (|Uestii)n of the possibility of rape
upon an able-bodied woman by a man unaided resolves
itself into a question of the comparative strength and
endurance of the t wo individuals, allowance being always
made for the iuHuenceof fright and excitement upon the
woman.
Tlie presence of venereal disease in both jiersons is
highly corroborative of the ciiarge, providing the disease
has appeared in one at a time corresponding to probable
inoculation at the time of the alleged assault. Great care
must be exercised, Imwever, in the diagnostieation of a
muco-iiurulent discbarge. ^Microscopic examination is
generally necessary. It is especially important when
the defendant is accused with having inoculated the
victim with gonorrhiea. Such inoculation is possi-
ble after tlie di.scluirge from the male urethra has be-
come extremely scant and has even lost its purulent
appearance. The discovery of gonococci in it is suffi-
cient evidence of the inoculability of the disease and
goes far toward establishing the guilt of the defendant.
Jiiiiief! M. French.
RASPBERRY. See Rommr.
RAVEIMDEN SPRINGS.— Randolph Ciuuty, Arkansas.
PosT-OFFit K. — Kavi'nden Springs. Hotel Southern, and
numerous smaller liotels and inns.
Access. — Viaixansas City, Fort Scottit Memphis Rail-
road to Ravendeu Station, thence five miles by coach or
hack to s]irings.
This re.s<irt is located in tlie northern part of Arkansas
near the White River Mountains, the range in which the
Eureka Springs have their origin. The elevation is
twelve hundred feet. The geolngieal formation is the
same as that at Kiiieka, but the inouutains are not so
high or so rugged. The siirrouniliiig .scenery is. how-
ever, exceedingly line, ai:<l many features of interest are
pointed out to visitoi's. 'I'lie place takes its name from
the "Raven's Deii." a small cave with a circular opening
a few feet from the topof the highest mountain. In this
cave it is said that many of the feathered denizens of the
forest, particularly the raven, or black ckiw. made their
homes and hatched their young Inr a long ]ieriod of
time. Fish and game are abundant, ami it is slated
that many deer are killed in the vicinity during the
winter months. The following analysis of the wutei- w.as
made by Messrs. Wi'igbt it Merritt, analylieal chemists
of St. Louis, in ISS.j; One United Stales gallon eoiitaiiis
(solids): Lithium carbonate, gr. 1.26; calcium carbunale,
gr. 4.61; ma,gnesium carbonate, gr. 4.4S; calcium chlcn-
ide, gr. 1.24; magnesium chloride, gr. 3.i)SI; sodium
chloride, gr. 3.19; alumina, gr. 2.36; silica, gr. 0.n;i;
iodine, iron, and calcium sulphate, of each a trace; or-
ganic matter, gr. 1.86. Total, 21.82 grains. Gases: Car-
bonic acid, 21.5 cubic inches; atmosjihericair, I'S.'S cubic
inches. Temperature of water, 59° F.
James K. Crook.
RAWLEY SPRINGS.— Rockingham County, Virginia.
Post-OfficI':. — Rawley Springs. Hotel.
Accf;ss. — Via Baltimore it Ohio Railroad to Harriscm-
burg, thence a two-hours drive over a macadamized turn-
pike to springs.
This is one of the famous old Virginia mountain re-
sorts, and it unites luany of the best features of a sum-
mer resting-place. The elevation is two tiiousaud feet
above the sea-level, aud the climate peculiarly dry and
equable. The surrounding scenery is wild and rugged,
but at the same time picturesquely attractive. The hotel
at the springs is a comfortable and handsomely furnished
building containing seventy-seven rooms, with a dining-
room capacity of one hundred and fifty guests. It is
well supplied with modern comforts and conveniences
and facilities foramusement. Thesprings here are three
in number. Tlu^ water of each fountain seems to possess
the same geneial characteristics. It is without odor, antl
possesses a strongly marked chalybeate taste. It exhibits
'a faintly acid odor from the presence of carbonic-acid gas.
This disappears as the paper saturated with it dries. The
water is perfectly clear and transparent as it flows from the
earth, but on exposure to the air it soou begins to deposit
a rust-colored precipitate of tbe oxide of iron. The tem-
perature of the main spring is about 51° F. According
to the analysis made by Prof. J. W. Mallet, one I'liited
States gallon contains: Iron proto.xide, gr. 1.09; organic
matter, gr. 0.(t3; and very small amounts of manganese
protoxide, alumina, magnesia, lime, litbia, soda, potash,
ammonia, sulphuric acid, chlorine, and .silicic acid. The
qualities of the water are improved by the presence of
carbonic acid. It is a very useful, lightly carbonated,
chalybeate water, and lias an extensive sale even at dis-
tant points. JiiiiiesK. Crook.
RAWLINS SULPHUR SPRINGS.-Caibon County,
Wy cluing. Piisr-(_)FKii i;. — Hawlins. Hutels.
These springs are pleasantly located about two miles
from the enterprising town of IJawlins. The situation is
on an elevated plateau, at an altitude of sixty-fonr hun-
dred feet above the sea-level. Tbe surrounding ccnintry
is rugged and mountainous. The following analvsis was
made "in 1894 by E. E. Slosson, of the School of Mines of
the University of Wyoming, at Laramie; One United
States gallon contains (solids): Potassium chloride, gr.
1.40; sodium chloride, gr. 12.18; sodium sulphate, gr.
854; magnesium sulphate, gr. 18.23; calcium suliibate,
gr. 19.28; calcium carbonate, gr. 7.41; silica, gr. 8.23;
carbonic acid, gr. 0.82. Total, 76.09 grains. Tempera-
ture of water at spring, 48° P.
The water is said to be highly sulphureted as it flows.
The above analysis having been made at a distance from
tlie springs, this gas was lost by volatilization. Thera-
peutically, the water has been fully tested in only one
disease, viz., rheumatism. In this affection it is stated
to be very efiicacious, both when taken internally and
when used in the form of hot batlis. The water, as
show n by the analysis, sliould possess very good diuretic
and laxative pro]iert.ies. A tirst-class hotel and bath-
house are much needed to put the resort on a good foot-
ing. The natural advantages of the placeappearto offer
excellent inducements for the i!,stablisliment of a sana-
torium. Jiinus K. Crook.
RAY FUNGUS. See Actinomi/cosis.
RAYNAUD'S DISEASE.— Laveran was the first to ap-
]ily to this disease llie name of its discoverer. To the
lili'iature of the condition Raynaud made three contribu-
tions: bis tliisis in 1862, bis article on "Gangrene," 1872,
and his "New Rcsearclics," 1874. His attention was first
attracted to the subject by a case of spontaneous symmet-
rical gangrene wliicli came under his observation in 1861.
As the result of personal observation and a searching of
medical lileniture lie lirought togelher twenty-flve cases
(Monro) upon which he based his thesis. After a study
of tbe varied phenomena of these cases, he elaborated his
theory of spasm of the arterioles and venules in the
842
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Uaspberry.
KayiiaiKl's Disease*
aflPectcd parts, and suggested that, therapeutically, elec-
tricity might be of value. He believed syinmetry of the
lesiousaiul absence of demonstrable changes iu the vessels
to be two essential features in the disease. He also
thought that the larger arteries might be affected by the
spasm to such an extent that the radial pulse might be
temporarily lost.
In the '■ New Researches " he describes a contraction
of the arteries of the fundus oculi observed iu two cases.
He also elucidates more fully the theory of abnormal
irritability of the vaso-motor centres with consequent
vascular spasm of a reflex nature.
It has long been known that under the influence of cold
the fingers may undergo a change of color, becoming
white and even blue. The former condition has been
designated the "dead finger" (digitus mortuns); Ray-
naud called it "local syncope," and other names, such as
" local ana'mia " (Hardy), or " regional isclKeniia " (Weiss)
have been used to describe it. fiajuaud applied the term
"local asphyxia " to the afl'ected part when it manifested
a blue appearance ; Weiss suggested the term " regional
cyanosis " and Barlow that of " local cyanosis " as more
appropirate than Raynaud's appellation. The same con-
dition was called by Boiseau "uterine cyanosis" because
of its relation to the suppi'ession of the menses. Monro
thinks that, one tymologieal grounds, Sir George John-
son's criticism of Raynaud's use of these terms was cor-
rect, viz., that "local syncope" should be called "local
asphyxia " and " local asphyxia " should be termed " local
apncea," but that the attempt to put this into practice
would cause much confusion. S3mmetrieal gangrene is
the culmination, and one of the most distinctive features,
of Raynaud's disease. Raynaud's clinical trijiod, then,
is local syncope, local asphyxia, and symmetrical gan-
grene. Writers have multijilied t<'rms in their endeavor
to describe the vaiiims phases of this syndrome. I)\it the
clarity of our conception of the subject will be greatly
enhanced by utterlj' disregarding the same.
Symmetrical gangrene is a rare condition, but "Ray-
naud's phenomena" (Hutchinson), local syncope and
local asphyxia or either, may occur for years, Anally dis-
appearing without any gangrenous manifestation. An
illustration of this is Mrs. M. , now under my observa-
tion. When nine years of age, were she to write, knit,
sew, or do any work reqviiring the dexterous use of the
fingers, the first phalanx of the fingers of the right hand
would become white, cold, and numb, eventually assum-
ing a purple of bluish aspect; she could not again use
them until the atta('k had passed and feeling liad re-
turned. This condition continued until her fifteenth
year when it cea.sed and did not again show itself until a
few mouths ago.
Rayna<id'sdisease usually develops before the thirtieth
year, t'hildren, even infants, may be subject to it, but
I have known it to occur after the seventieth year as
well. Females are more susceptible to it than males.
According to Monro the ratio, as found in the medical
wards of the Glasgow Royal Infirmary, has been about
one in three thousand cases, but this proportion he re-
gards as an underestimate, — i.e., if the disease be con-
sidered purel_y as a neurosis, and not in its relation to
other diseases of which it was an incident only. In my
own experience "Raynaud's phenomena" constitute a
not very infrecjueut condition.
Raynaud's disease may occur as a pure neurosis or it
may be associated with a great variety of morbid condi-
tions such as h_ysteria, insiinity, epilepsy, tabes dorsalis,
syringomyelia, mj'elitis, neurasthenia, spinal tumors,
chorea. Graves' disease, lead poisoning, syphilis, phthisis,
infectious fevers. Bright 's disease, chloro.sis, aua'inia,
diabetes insipidus, and a congenitally small aorta; it
sometimes appears also in connection with certain der-
matoneuroses, as urticaria, scleroderma, and erj'tlno-
melalgia. Heredity is present in aliout eight percent, of
the cases (Monro). The most important cau.sati ve agent is
cold. Emotional influences, malaria, diseases of the female
generative organs, and the breaking otT of the morphine
and chloral habits are all important etiological factors.
Local syncope comes first in the trinity of symptoms
which cliaracterize Raynaud's disease. " It niay exist
alone or it may be associated with local asphyxia," a very
frequent combination; or, as is more usual, all three
symptoms — local syncope, local asphyxia, and gangrene
— are present. Numbness and stiiiness in the digit
afl'ected ma.y usher in an attack, or there may have been
in the extremity or parts involved, for days or even
weeks previous, severe pain which is intensified as the
attack develops.
The seizures are paroxysmal. The parts involved be-
come pale or even corpse-like; they do not bleed when
pricked, are cold, and movement is dilficult. This latter,
Raynaud suggests, is due to a defect of afferent impulses
and not to muscular weakness. The nose, cheeks, chin,
and ears are but seldom invaded. The case of 3Ir. G.,
who consulted me a short time ago, well illustrates this
phase. In September, 1902, he noticed that the first
phalanx of the thumb, first and second phalanges of the
index, and first phalanx of the ring finger became cold
and white when exposed to the air or on touching some-
thing cold. The local syncope was at first attended by
pain in the thumb and index finger, and there were also
isolated white spots distributed over the unaffected sur-
face of the ring finger. Occasionally, should the hand
become very cold, local asphyxia would occur on its dor-
sal surface. Sometimes, as the local syncope disappeared,
local asphyxia would take its place. The involvement
of the thumb here observed is very exceptional; it is
usually unaffected.
Local syncope may be imilateral or bilateral. The
upper extremities are more frequently involved than the
lower. The syncope may attack one finger or all, or it may
attack the different phalanges in an irregular manner.
There is no regularity iu the frequency of the seizures;
they may occur once or many times dail_y, or there maj'
be intervals of uncertain length. They mav occur for
weeks, months, or years and then cease, either abso-
lutely or for an indefinite period. In my case of Mrs.
JI., already referred to, there was an interval of twenty-
seven years.
The part affected is cold to the touch, tactile sense is
impaired, and the various forms of sensibility are iriegu-
larly and unequally involved. Temperature sense and
pain sense may be lost, or that of temperature may
be present and those of touch and pain lost. Local syn-
cope may disappear without leaving any trace or causing
any pain. Frequently there occurs a decided reaction ac-
companied b_y pain and by annoying paresthesias.
Local asphyxia constitutes the second stage of this
symptom complex. Usually it is preceded by local syn-
cope, but not invariably so. As already stated, local
syncope may disappear, leaving no trace and causing but
slight discomfort, or it may be followed by a blue, bluish-
black, bluish-white, purple, violetor reddish discoloration
of the skin affecting, sometimes symmetrically, some-
times unilaterally, the hand, fingers, feet, and toes. A
livid marbling of the adjacent parts may be associated
with this characteristic discoloration.
Local c_vanosis difl'ers from local syncope in not being
confined chiefly to the limbs, but iu attacking as well the
ears, face, lips, chin, tongue, and trunk. Raynaud de-
scribes a lividit}- of the breasts, a painful neurosis which
tuerits the appellation of local asphyxia of the mamma=.
The extreme sluggishness of the circulation in the cya-
notic area is shown by the slow disappearance of the
white spot made l.\y ]iressure.
The manner in which the parts are involved is most
irregular, there being no definite order of sequence. The
lower extremities are less frequently attacked than the
tipper. Sometimes an cedematous ccmdition develops in
the asphyxiated parts and instead of a blue or black dis-
coloration of the skin, with a lowered temperature, the
affected area assumes a bright red hue, is hot, and be-
comes covered with perspiration. The anieiua pits ujion
pressure and may jirceede or even take the place of the
cyanosis. One part ina_v be cyanotic and swollen, while
at the same time another may be only swollen. The cede-
843
Kayiiiiiid'M Disease
Kei'i'iilts,
REFERENCE IIANDROOK OF THE JIEDICAL SCIEN'CES.
ma is not confiiicd to (he extremities, as theeais. tlie face,
ami tile tongue may also be affeeted (Mouro).
Loeu! asphyxia may or may not b(^ attended by pain;
often this is absent unless the eyaiiotie part is handled.
The jiain at times becomes neuralgic in character, or it
may lie continuous, and it varies from a slight discomfort
to an intense agony. A patient of my own complained
of irregular attacks of numbness for two years before the
onset of the disease. In this case the pain was most ago-
nizing from the very inception of the local syncope, which
was in a few hours followed by local aspiiyxia, the ap-
peuriuice of the latter in no way mitigating the sutTeriiig.
There may be loss of motion, ti-mperature sen.se, and
tactile sense. Electrical sensibility may also be alfccted.
Monro has collated some interesting cases showing that
vaso-motor instability is certaiidy a marked feature of
this condition. Calniette could readily induce an attack
in the susceptible parts by putting cold water on any
portion of the body. Raynaud, by using electricity on
one hand, caused the disaiipearance of cyanosis from
both, wliile Israel Sohn. by ap|)lying friction to the
upper limbs, caused the disappearance of local asphyxia
from all four extremities.
The character of the onset in local asphyxia is most
eiTatic. Discoloration may precede or follow the pain,
or the two ma.v be associated. The development of the
cyanosis may be very .sudden ; it ma\' take the place of,
p'receiie, or "follow the local syncope: its duration may
be a few minutes, hours, or days; there is no regularity
in the occurrence of the attacks. The pulse may be nor-
mal ov absent. There is no fever, but occasionally there
are depression, headache, insomnia, ajihasia, convulsions,
and even unconsciousness.
Patients who have long been suliject to local asjihyxia
may suffer from changes in the skin called "tachetic"
patches; these purple areas are very persistent, are un-
affected by pressure, and are jirobaljly due to cxtrava-
sated blood pigment in the ileep layers of llu' skin
(Monro). Local asph_yxia, once having been developed, is
very likely to recur ; this liability is not, however, so great
as in syncope. The Scotch verdict. " not proven " should
be applied to lho.se cas<'S which are reported as oircd.
The idea that a disturbed innervation might bear a
causative relation to gangrene was entertained long be-
fore Raynaud wrote his now celebrated thesis. His con
trilmtions gave to the medical profession a new clinical
concept, a disease with certain detinitc characteristics,
viz., local syncope, local asiihyxia, and symmetrical
gangrene, a distinct morbid entity. For more than
twenty years medical men regarded this disease as an
idioiiathic alTeetion depenchait upon a vaso-motor dis-
turbance. Although the clinical entity described by
Raynaud is generally accepted, it is now believed to lie.
in till' majority of cases, merely a symptom (syni|itom
complex) occurring in a great variety of diseases.
Symmetrical gangrene is the last and most important
of this trinity of symptoms. Gangrene is usually asso-
ciated with local aspiiyxia; in a very few instances local
.syncope and gangrene are combined ; often the three
classical symptoms arc all ]n-esent, while in about two
per cent, of the cases gangrene occurs alone.
Raynaud emphasized its symmetrical nature, but it
m;iy occur unilaterally as well.
TIk' p;irts most likely to be alTected are the extremities
and ears; the thumbs suffer less freipiently than the tin-
gers. The tip of the no.se, the cheeks, lips, and chin
may be alfccted. Descinamation of the epithelium may
be the only evidence of the necrosis. Unfortunately this
is but infrei|uent. The nails may fall off. but usually
reap/pear. Raynaud describes a jieculiar type of lilister,
a large bulla, of a deep brown color when dry, due to
gangrene of the papillary layer of the derma. Necrosis
may attack one or more of the phalanges of the digits, or
a portion of the foot, or even the entire foot. In one of
my cases both legs were gangrenous.
The attack inay be .so severe that spontaneous ampu-
tation of the extremities may occur. Recovery is slow,
usuiilly extending over months. If the gangrenous
process is limited to small necrotic areas, the only evi-
dence of its existence, discoverable after recovery, will be
the presence of a slight scar or scars, and the number of
these is an index of the number of previous attacks.
The gangrene is dry and the parts become mummitied.
It is usually accompanied by pain whi( h. in grave cases,
is most agonizing. The general health may suffer seri-
ously through insomnia, pain, and suppurative processes.
Fortunately, "Raynaud's phenomena" often occur for
years without the presence of gangrene; indeed it may
never suiiervene, but its appearance is always a matter
of grave importance.
The ]>i'o,suosis of Raynaud's disease, considered as a
pure neurosis, is, if children are excluded, always good.
When associated with other morbid conditions it is that
of the underlying disease. For example, a patient of my
own died during a very severe attack of Raynaud's
disease, gangrene and mmnmification being very pro-
nounced, but death was evidenth' the result of a chronic
Bright's disease, from which she had sullered for years.
Diagnosis is easy when the three typical stages are
present. The occurrence of local syncope and local
asphj'xia, either sejiarate or associated, constitutes what
is known as " Ravnaud's phenomena,'' but the additional
element of gangrene is necessary to justify a diagnosis of
Raynaud's disease. The age, the sensory, motor, and
trophic symptoms, together with the symmetry of evolu-
tion, will usually enable one to form a correct conclusion.
Gangrene due to old age, ergot, and trauma is wanting
absolutely in etiological and clinical characteristics.
There is a consensus of opinion among authors that
lix-al syncope and local asphyxia are of vasomotor ori-
gin. Local syncope is undoubtedly due to spasm of the
arterioles; authorities are at variance as to whether the
venules do or do nfit participate in this spasm. Local
asphyxia is due to an isolated spasm of the smallest ven-
ules whicliimpedi'S the outflow of the venous blood from
the ca|iilla,rirs, thus ]iroducing stasis (Weiss). The seat
of these disturbances is situated in the vaso-motor centre
of the medulla oblongata, which regulates blood pressure
tliroughthe innervation of the muscle fibres of the blood-
vessels; and this centre, like any other, may be irritated
reflexly or directly, and in each case, varying with the
intensity of the irritation, will there be an increased
tonus of the vasomotor constiictors and a spasm of the
vessels will result (Burdach).
The explanation of the occun-ence of the gangrene is
more plausible on the supposition of the existence of
trophic nerves and a consequent perversion of trophic
influence, than it is under Raynaud's theory of insuffi-
cient nutrition due to the occurrence of local syncope
and local asphyxia.
■\Ye now come to the important question: Is Raynaud's
disease to be r;'garded in all cases as merely a syni])tom
complex of other morbid conditions, or may it occur at
times as an uncomplicated neurosis":' There can be no
doubt that the pro]ier conception would he to class it un-
der both he;ids, with which the present tendency is in
accord. In a majority of instances it is to be regarded
]iiirely as a symiiiom, while in rare and exceptional cases
it is, without doubt, a genuine neurosis.
Raynanil's di.sease offers an excellent exam.ple of per-
nicious liabit on the part of the vasomotor system. The
therapeutic probli'iii is how to overcome its morbid par-
oxysmal manifestations, and, above all. to prevent by
proper hygiene and appropriate treatment the tendency
to recurrence. If the attack is severe and occurs in win-
ter, and especially if the patient is debilitated and ad-
vanced in years, a change to a warm climate is advisable.
The eff<irl should always be made, during the interval
between the attacks, to build up the general and nervous
strength, for by this alone can the paroxysmal tendencies
be retarded and possibly overcome. Everything that
favors a seizure, es]iecially undue exi)0sure to cold, must
be carefully avoided. Appropriate clothing, suitable to
the season, should be worn, constiictionof the circulation
guarded against, and tlie water used in washing ought to-
be at blood heat.
844
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Kayuaud's Disease.
Recruits.
If the attack is at all pronounced, it would be best for
the patient to remain indoors in a uniform temperature.
A nii.xed diet is the most suitable. Great caution should
be emplo3'cd in the use of stimulants, as the liability on
the part of the neurotic to acquire a taste for alcoholics
luust never be lost si.nht of. If the patient has been at
all subject to malarial influences quinine is the remedy
piir ei'ceUence : in any event it is a drug of unq\iestioned
value. Opium has been greatly lauded ; its chief citicacy ,
however, lies in its power to alleviate pain, to promote
sleep, and thus to conserve the strength of the pati<'nt.
Should the severity of the symptoms demand morphine,
it ought never to be given hypodermically at the seat of
pain, as the resulting irritation ma}- cau.se gangrene.
Nitrite of amyland nitroglycerin should be given a trial.
The use of tlu'roid extract is spoken highly of b_y Short.
Iron, arsenic, uux vomica, strychnine, cod-liver oil. and
malt are all useful drugs and potential aids in the proc-
ess of upbuilding.
Spinal galvanization is perhaps one of the most efficient
remedies. The negative pole should remain stationary
over the sacrum, while the positive is slowly moved up
and down the entire length of the spine, care being taken
not to interrupt the current. The current strength
should not exceed fifteen milliam])eres: seances should
be daily, lasting not overlive minutes; if tlie room is
suitably warm, it would be advantageous to vary tlie
spinal treatment by applying the po.sitive electrode
directly over the affected area. Galvanization of the
cervical sympathetic is recommended. Static electricity
is an agent of no mean value, general franklinization
being the method employed, together with a local appli-
cation of the static s])ray. Tliis form of the current is
much more easily applied than faradism, and is in every
way as ellectivc.
Massage, general and local, has in certain eases proved
very efficacious, but great care must be exercised in its
apjiiication, as the devitalized skin is liable to ulcerate if
roughly handled. Should the innnediatearea atfected be
too sensitive to allow of its use. the adjacent jiarls may
be treated. Warm fomentations have been found useful.
A tiftj-per-cent. alcoholic solution of menthol applied to
the members involved, whicli shoidd then be wrapped in'
cotton and covered with oiled .silk, is to be recommended.
It is of first importance that the extremities affected be
kept carefully wrapped in flannel. I have known this
simjile precaution to be of more value than all medica-
tion.
The treatment of the gangrene is a purely surgical
matter. Sufficient time, however, should be allowed for
the demarcation line clearly to show itself, as the actual
gangrene may include but a small part of the affected
extremities.
JIui'h will depend upon the tact and resourcefulness of
the physician, and with all his remedies he must not for-
get the therapeutic value of hope. C. EuQene Ri;ifjx.
REACTION OF DEGENERATION (neR)is the term
applied to ciMlain changes in electrical excitability, pro-
duced by a lesion of the spino-peripheral nevu'on in any
part of its course (the anterior horns of the spinal coni,
or the cerebral motor nuclei, the motor roots of the
nerves, or the peripheral nerves). When the anatomic;d
lesion is profound complete De R is the result. Partial
De R is found in l<-ss severe lesions. The nerves and
muscles exhibit ditlerent reactions to the current. In
complete De R, within a few days after the onset of the
primary disease, the nerve exhibits a gradual diminution
of reactiim to the faradic and galvanic currents, and
within from one to two weeks its irritability is entin'ly
lost. The muscles suinilied liy the nerve react different ly
to the two currents. Their faradic excitability gradually
diminishes with the corresponding lo.ss of nerve excita-
bility. Tlie galvanic excitability, on the other hand,
presents very pecvdiar changes. These are best seen
when an electrode (preferably a large one) is placed upon
an indilferent sjiot, and the other small electrode is placeil
directly "ver tlie muscle to be tested. Normally, it is
found that the muscle responds most promptly to the
closure of the cathode (OaCl), then to the opening or clos-
ing of the anode (AnO or And), and finally to the open-
ing of the cathode (CaO). The contraction of the healthy
muscle is ([uick, lightning-like. In complete De R the
response of the muscle is slow and, on passing the elec-
trode over the belly of the muscle, one set of fibres con
tracts after the other. This slowness is the mcist con-
stant feature of the De R and in itself suffices for the
diagnosis. In addition, the diseased muscle reacts to an
unusuall}' mild current. This is seen very well, for ex-
ample, in Bell's pals\' hj' placing oue electrode upon ilie
chin, when it will be found that the paralyzed chin mus-
cles react to a current wiiich is utterly inadequate to
produce a response in the unparalyzed muscles. Com-
plete De R is also attended by the so-called reversal of
the formula. It is found that contraction (C) is obtained
most readily on AnCl. CaCO also increases relatively
and may be greater than AnCO. As the disease pro-
gresses and the electrical excitability is gradually lost,
AnClC with very strong currents may furnish the last
evidence of the all but extinct muscular vitality. This
is sometimes found even after the muscle has been com-
pletely paralyzed for a year or more.
In partial De R the excitability of the nerves may be
merely lessened, the muscles may still react to the faradic
current, but the contraction to the galvanic current is
slow and perhaps shows some changes from the normal
formula. If recovery takes pliice there is a gradual in-
verse return to the normal conditions.
Leopold PuUcl.
RECRUITS, EXAMINATION OF.— The army of the
I'niled Slates is ordiiiaiily ii( rnilcd by voluntai'v enlist-
ment; in time of war enlistment may be corapiulsory,
under Enrollment Acts.
The Recruiting Service is under the direction of the
adjutant-general of the army, and is organized into fwo
branches: the general, for infantry and artillery, and the
mounted, for cavalry.
The Leg.\l Reijuihe.ments for Enlist.mext. — Any
male person above the age of sixteen and under the age
of thirty years, effective, able-bodied, and free from dis-
ease, of good character, wlio does not appear to be of in-
temperate habits, and who has a competent knowledge
of the English language, may be enlisted, due attention
being given to the restrictions in this article conceruing
minors. This regulation, in so far as it relates to age,
does not appl}' to soldiers who may re-enlist, nor to those
who have served honestly and faithfullj- a previous en-
listment in the armj-. Applicants for enlistment are
required to furnish such evidence of good character as
they can obtain. With a view to determine their fitness
and aptitude for the service, and to give them an oppor-
tunity to secure testimonials, as well as for the inquiry
and deliberation contemplated by the Second Article of
War, they may be retained and provided for at rendez-
vous, for a period not to exceed six days, after having
signed the declaration of inti'ntion to enlist and passed
the medical examination. Men so retained are known as
recruits on probation. The enlistment [lapers of any such
recruit who may be unfit or undesirable for the service,
or who may not desire to remain in the .service, will not
be completed. The enlistment papers of recruits who
are accepted and duly sworn will bear the date on which
the enlistment is (•onqitetefJ by administering the oath (A.
R., Art. Ixxi., 908). . . . Tiie major-general command-
ing the army is of opinion that if satisfactory evidence of
good character, habits, and condition cannot be furnished
by the recruit, or be otherwise obtained, the presumption
should be against him ami he.shouhl not be accepted ; and,
further, that these views are concurreil in by the Secre-
tary of War and should govern in all cases (G. O.. No.
1, lleadquarters Recruiting Service, isot.)).
These rules and articles shall be read to every enlisted
man at the time of, or within six days after, his enlist-
ment, and he shall thereupon take an fiath or affirmation
in the following form: "I, A. B., do solemnly swear (or
845
Rt'<-riillti>.
Recruits.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
aHirm) tliat I will bear true faith ami allcf;iaiicc to the
United States of America ; that I will serve tliein honestly
and faitlifully against all their enemies whomsoever, and
that I will obey the ordersof the Piesident of the United
States and the onU'rs of the otlicers appointed over me,
according to the Rides and Articles of War." This oatli
may betaken before any commissioned ollleer of llie armv
(Article of War).
Every otiicer who knowinglj' enlists or musters into the
military service any minor over the age of si.xteeu years
without the written consent of his parents or guardians,
or any minor under the age ot^ sixteen, or any insane or
into.xicated persons, or any deserter from the military or
naval service of the United States, or any peison who has
been convicted of any infamous criminal otfence, shall,
upon conviction, be disniissi'd finm the service, or suffer
such other punishiueut as u court martial may direct
(Article of War).
Under a recent act of Congress fraudulent enlistment
is declared a military otfence, and is punishable by court-
martial under the Sixty -second Article of War; the pro-
visions of this law are fidly explained to every applicant
presenting himself for enlistment with the information
that any person procuring his eidistnient on or after the
■35th day of September, 1S93, by false representations or
other fraudulent means, will render himself liable to trial
and punishment by court-martial. "Fraudident enlist-
ment " is defined by the law officers of the department as
"an enlistment procured by means of a wilful misri'pre-
sentation in regard to a qualitication or disi|ualiflcatiou
for enlistment, or liy an intentional concealment of a dis-
r[ualitication which had tlie eft'rct of causing the enlist-
ment of a man not ciualitied to be a soldier, and who but
for such false representation or concealment would have
been rejected."
The regulations above quoted .sketch in outline the re-
qvnrements for admi.ssiou to the enlisted brancli of the
military service and the duties of officers in connection
therewith. For the recruiting officer an essential to s\ic-
cess is a knowledge of men and their cliaiacter, and for
the medical officer a painstaking aiqilication of profes-
sional skill. The duty is a most important one, and in
its faithful and thorough performance these officers share
a grave responsibility. The influence of their judgment
and discretion is felt throughout the entire military es-
tablishment, the efficiency of which depends in .ureat
measure upon the sound mental and physical condition
and the intelligence of its enlisted force. From the va-
ried classes and conditions of men presenting themselves
for enlistment tlicy are to eliminate not only those who
are defective physically and mentally, but those who are
defective morally, and if this dut}' be jierformed care-
lessly orindilTerently, men will be adnutted to the service
Willi defects which will .soon render them unfit for dutv,
or with moral obliquities thai will in^Iucc nialingeriiig
and desertion.
Re-eni,istments. — Soldiers who are unable to ])ass the
recpiired examination in nil ns/iects will not be re-enlisted
without special authority from the adjutant-general's
office, and then only for their former commands; apjili-
cation for such authority should Ix' recominciide<l onlv
when it is shown that any existing defects will not pie-
ventthe full discharge of duty asasohlier and Iliat acon-
tinuance in service will be a positi\'e biMU'lil to tlieannv.
Soldiers discharged as ])rivatesu))<>ii expiration of term
of service and failing to re enlist within one month, will
not be again enlisted after they have ])assed tlie age of
thirty-five years, unless for some good reason in the in-
terest of the publicservice, and then only for their former
commands upon s])ecial authority from tlu^ adjulanl-gen-
eral's office.
This limitation as toa,ge will not ajqdy ton soldier dis-
charged ;is II noii-coiiiniisnioiii'ri nflici r in'th i:ifrllnit r/iiirac-
/(';■, and desiringagain toenlist forassignment to a former
command (not already full), either at the sfation thereof,
or at a recruiting depot, provided he passes the riMiuired
examination and furnishes satisfactory evidence in regard
to chanuter and habits since discliarne.
Soldiers who have been discharged with good character
under the provisions of law may be again enlisted without
special autlioiity after a period of two months from date
of discharge, upon passing the required examination and
furnishing satisfactory evidence iu regard to character
and habits since discharge, provided such enlistment is
not barred by any of the above provisions.
Soldiers discharged beforeexpirationof term of service
for any other cause will not be a.gain enlisted without
special authority from the adjutant-general's office.
These restrictions, which are intended more particu-
larly to govern re-enlistments for the line of the army,
need not necessiirily be applied to the hospital corps: the
approval of the surgeon-general will be sufficient warrant
for tlie re enlistment of soldiers into that corjis.
The position of a medical ofiicer at a recruiting rendez-
vous is an advisory one (as a medico-military expert) to
the recruiting officer; unlike the medical examiner in life
insurance, he, in addition to his strictly professional in-
spection of au applicant for enlistment, must express an
opinion u]ion his dptitmlr. both mentally and physically,
for the military service. In times past, this latter duly
was restricted entirely to the recruiting officer, who was
also the sole judge of height, weight, and chest measure-
ments; but experience has demonstrated the importance
of professional skill iu the formation of an opinion as to
the general efficiency of a man for the military service,
and it is now quite as nnich the province of the medical
officer to decide upon the military aptitude of a recruit,
as upon his freedom from grosser physical defects. Of
course, his decisions are conveyed as opinions to the re-
cruiting ofiicer, who alone is legally authorized to make
an enlistment.
In entering upon these duties, the medical officershould
bear in mind the important fact that upon " the faithful-
ness and thoroughness" with which they are performed
depends iu a great measure the health of the army, its
mental and physical efficiency, and especially its niobil-
ity; carelessness or inattention on his part may permit
the admission loits ranlo* of men who soon find tlieir
way into the hospital, whose undiscovered diseases may
1)0 transmitted to innocent comrades, or whose defects
may furnish groundwork for the demoralizing practice
of malingering; examinations made iu a perfunctory
manner will surely result in the unw^itting acceptance of
men whose mental and physical defects are only too
clearl}' displayed in the company organization, and
whose enforced discharge from the service will bring dis-
credit upon the professional skill of the examiner, and
undeserved censure upon the recruiting officer with
whom he has been associated: he should reflect that, in
the sudden emergencies which our troops are so fre-
quently reqidred to meet on the frontier, able-bodied sol-
diers arc iiulisiiensablc to success, or to the saving of life
and property from destruction; and that with an army
so small as oiiis, in time of peace, eveiy man enlisted
must be relied iqion to endure all the hardship of which
a physically perfect human being is capable. Nor is this
less a necessity in time of war with troops of the line,
when eelerily of movement and ability to endure great
]irivalious, as lack of food and inclemency of weather,
Me im|ier;itively deniande<l iu the manipulation of armies
under the modern science of war,
"The exiierience of all nations has demonstrated the
u.selessness of atteni|iting to conduct militarj' operations
to advanta.ee unless ihe rigid scrutiny of the surgeon has
been exerted to exclude such men as were subjects of, or
predispo.sed to, disease, or were unfitted to sustain the
continued fatigue and exjiosure of the march. "'-
There are. however, conditions of the service in time
of war which warrant a departure from this .standard in
some respects, and the acceptance of recruits with defects
which, in time of peace, would be positive disqualifica-
tions; farther on, reference will be made, under the ap-
propriate headings, to these deviations from the peace
standard.
In time of peace every eidisted man is presumed to be
wholly efiicieut, and fit for duty at all times; he who to-
S4i]
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
Recruits.
Recruits.
day is nursing the sicli in hospital may to morrow be in
his place in a company, or a member of the garrison
guanl ; in time of war men iiiiii/ he enlisted who cannot
be strictly classed as " lighting mm." but who may be
e(iually cilective as soldiers in other departments; a man
with a hernia, which is kept in place by a trnss that is
well lltting, is in every way able to cook for a company,
although not titted to weara cartridge belt anil do active
dnty in the tield ; so, also, the loss of certain members —
fingers or toes — wonld not necessarily discpialify a man
from guarding a hospital, or driving a team, and thus
taking the place of an able-bodied soldier whose services
arc more urgentl}' needed at the front. For this reason
it has lieen the custom in all armies to rela.x in certain
particulars their peace regulations, and diminish their
list of disabilities in time of war, holding to service many
men who in time of peace would have been rejected.
Properly to conduct his examinations the medical oflTi-
cer should have plenty of light, air, and time, and good
floors.
The room in which the examinations are made should
be well lighted and ventilated, not less than forty feet
long and twenty feet w-ide, with a well-laid, solid floor;
its furniture should consist of a fixed measuring rod and
slide, good platform scales, steel tape measure, vision test
cards.and a set of test wools for determining color blind-
ness; ill one corner there shoidd be a bed arranged after
the fashion of an operating table, upon which ajiplicants
can lie jilaced for the examination of susp<'cted strictures,
and heights verified, if necessary, by hoii/.ontal measure-
ment, etc. ; the instruments required are a set of steel
sounds, a Cammann's stethoscope, an ophthalmoscope,
a set of Snellen's test types, au astigmatic chart, the nec-
essary apparatus for a rough analysis of the urine in cases
of suspected lesions of the kidnc.y. and the appliances for
immediate vaccination after acceptance of the recruit.
There should also be- adjoining the examination room,
one titted with liatli-tidis, and liberally supplied with
soap and towels, where every applicant for eidistnient
(who must be carefully and thoroughly waslied before
e.xamination) can perform his ablutions under the super-
vision of the recruiting sergeant.
The recruiting oflicer should always be present at the
examinations,^ and, for obvious reasons, all other persons
excepting the recruiting sergeant should be excluded
from the room.
A very considerable and important part of the exami-
nation can be made before the applicant is strip]ied. dur-
ing which defects may be discovered that will render
further ]irocedure inniecessaiy ; he should be closely
questioned as to his personal and family history, his pre-
vious service in military or naval life, his habits, his
health in the past, and the receijit of injuries or wounds,
or any surgical operations which may have been jier-
forme'd upon him. The exanu'ner, d\iring this question-
ing, can form an opinion as to the knowledge of the
English language possessed by the applicant, his age,
intelligence, and general litness, both as to physicpie and
morale, for the duties of a soldier.
A thorough and satisfactory examination can be made
only by pursuing a systematic course, without the adop-
tion of which the most expert examiner will onut impor-
tant points, and, ]u-obal)ly, lose sight even of glaring de-
fects. To accom|dish tins the VVar Department, upon
the recommendation of the writer, adopted a " form " for
the examination of recruits, which contains a series of
questions, to be answered by the applicant, and recorded
by the inspecting or examining oftieer. These forms are
furnished by the adjutant-general of the army to all
recruit ing rendezvous.
When the ajiplicant is ready for the inspection of the
surgeon, let him take the position of a soldier in the best
lighted ]iart of the room; then cxandne him in the fol-
lowing order after the methods elsewhere set forth.
1. Inspect his general physique, skin, scalp, and cra-
nium, ears, eyes, nose, mouth, face, neck, and chest.
2. The arins should be extended above the head, the
backs of the hands being together, anil the applicant be
retpiired to cough vigorously ; any form of hernia may
now be discovered by the eye and finger.
3. The man should be reipiired to take a long step for-
ward with the right focjt, and bend the knee, the hands
remaining extended above the head ; this exposes the
genital organs, and varicocele or other defects in the
scrotum ma.v be recognized by the hand.
4. The arms should now be brought to the sides, and
the man required to separate his buttocks with his hands,
bending forward at the same time; this exposes the anus.
5. Examine the heart.
6. The elbows should be brought firmly to the sides of
the body, and the forearms extended to the front, palms
of the hands uppermost. Extend and Hex each finger
separately ; bring the points of tlie thumbs to the base of
the little lingers; extend and flex the hands upon the
wrists; rotate the hands so that the finger-nails will tirst
be up and then down; move the hands from side to side ;
flex the forearms on the arms n/mrpli/. striking the shoul-
ders with tlie tists; extend the arms outwaid, at riirht
angles with the body, and flex the forearm upon the arm
until the thtunbs rest on the points of the shoidders,
while in this position raise and lower the arms, bringiLig-
them sharply to the sides at each motion; let the arms-
hang loosely by the side; swing the right arm in a circle
rapidljf from the shoulder, first to the front and then to-
the rear: swing the left arm in the same manner, extend
the arms fidly to the front, kee|ung the palms of the
hands together; observe carefully the elbows; carry the
arms quickly back as far as possible, keeping the thumbs
up, and at the same time' raise the body on the toes.
7. Extend the legs alternately, rest ing the heel upon
the floor; move all the toes; raise the heel fr<im the floor,
moving the foot up and dow'n, then from side to side;
present the sole of the foot for inspection ; bend the knee
and strike the slaiulder with it, bending the body slightly
forward at the same time; throw the leg out to the side
as high as possible, keeping the body squarely to tjie
frontT take the military position "to kneel firing," fii.st
on one knee, then on the other; get down on both knees;
S([uat sharply several times in succession ; hop the length
of the room on the toes, first of one foot and then of the
other; take a standing jump as tar as possible; jump up
and strike the buttocks with the heels.
8. Auscultate the lungs.
9. Test the hearing.
10. Test the vision, and for color Idindness.
11. Vaccinate the applicant, if accepted.
Mr. Marshall, in his exccdlent treatise on the examina-
tion of recruits, arranges the causes on account of whicb
recrints are rejected under three headings;
First. " Diseases or debiruiilies which a medical oflicer
from his professional knowledge and acquaintance with,
the <luties of soldiers considers are intirmities whicli dis-
qualify men for servic e in the arm}'."
Second. "Slight blemishes which do not disqualify a
man for the army, but wdiicli an unwilling soldier may
exaggerate, and allege that he is thereliy rendered unfit
for military duty."
Third. "Unimportant deviations from symmetry, or
sliglit variations from the usual form or condition of the
body; technical or nonunal lilemishes which do not in-
capacitate a man for the army, or in the slightest degree
impair his efReiency."
Experienced surgeons will reject all recruits whose de-
fects fall under the first two headings, from a conviction
that they render the men unfit or ineligible for the army ;
but those under the third beading are freipiently rejected
from fear of responsibility— a dread of i.llici.il correspond-
ence if objected to, and an ultimate damage to profes-
sional reputation.
In time of war cases coming under the first heading
should be rigidly excluded, while those coming under the
second and third headings shoidd be as rigidly held to
service.
TuE Geneh.m. Examin.\tion. — C«m;«'fe'»< /nioiclcdge of
the Enr/lish lancpiage is defined by the War Department as
the ability of the applicant to "speak fluently, converse
8-t:
Recriilla.
Recruits.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
intelligently, and fully understand the orders and in-
structions given in that language."
It would seem almost superfluous to refer to this mat-
ter, tlie importance of which is self-evident, were it not
for the fact that so large a number of forei,a:ners have
been enlisted, who were titioii/ if/iinniiit of our language,
who.se blunders and mistakes have caaseil annoyances
and impediments to the public service, and whose effi-
ciency as soldiers has been thereby seriously impaired.
It is of paramount importance that the solilier should be
able clearly to understand the orders which are given to
him, iind to ascertain this fai't bej'ond a doubt is one of
the first duties re(iuired of the medical officer. Excep-
tion to this rule is madt^ in the cases of skilled artisans
and tailors, and more particular band musicians.
Ill tiinc of mir familiarity with the language is not so
necessary, as foreigners are more likely to be a.ssigned to
regiments made up of their own countrymen, with offi-
cers who speak their language; they can also be made
useful in tli(^ administrative departments of the army,
taking the places of men better fitted for field service.
Age. — As has been already stated, the limits of age for
enlistment in time of peace are, "not less than si.\teen
years, nor more than thirty-five years"; "minors under
eighteen years will not Ix' enlisted except for musicians,
. . . and then onlv under authoritv from the superin-
tendent."-'
The regulations of the army reipiire that when minors
present themselves for enlistment, they shall be treated
with great candor; the names and residences of their
parents and guardians, if they have any, shall be ascer-
tained, and notice .sent to them of the minor's wish to
enlist, that they may have an opportnuity to make their
objections or give their consent. When consent is given
it must be in writing. All recruiting officers are enjoined
to be very particular in ascertaining the true age of the
recruit. It any doubt tipim the point exists in the mind
of tile r<'cruiling olti( i-r. he must not be satisfied with the
oath of the applicant, as the sole evidence of legal age,
but if he cannot, in addition, furnish undoubted proof of
the fact, he must be n-jected.^
The maximum limit of a.ge docs not appl)' to ,soldi<'rs
who may re-enlist, or who have served honestly and
faithfidly a previous enlistment in the army.'"
1/1 tune of irar the limitations of age in compulsory
enlistment, under the Enrolment Acts, are twenfj' anil
forty five j'cars: the qu<'Stion of minority between the
twentieth and twenty-first years is not considered, ex-
cept in voluntary enlistments, which are under the Siime
restrictions as in time of jieace.
The medii'al examiner must form liis opinion of the
age of an applicant from his personal observation of men
and upon pliysiological grounds. It is a [loiiit about
which the greatest amount of deceit is practised; con-
cealment being attempted in voluntary eidistmcnts with
a view of getting into the service, and in compulsoiy
enlistments with a view of exemption therefrom. He
must, therefore, be always uium guard against imposi-
tion. Young men who would scorn to tell an imtnith
in otlier matters will lie about their a,ge with the utmost
effrontery, and old men will resort to every artifice to
conceal theirs.
While the divisions of life into periods, liy years of
existence, are in a measure arbitrary, some men maturing
at an earlier age than otliers, it is important to consider
certain common evidences of maturity as fixing the pe-
riod of legal majority, and furnishing a standard, indefi-
niti though it may be, of eligibility for the military ser-
vice. Among the most iirominent of these evidences are
the |]re.sencc of the wisdom teeth, a plentiful supply of
hair in the axilUe, and over the pubes, well-formed testi-
cles, and comiilete corrugation of the scrotal skin. While
tlie.se conditions are liable to variation in individuals, they
may be regarded as common to most youth at maturity,
altliougli no one condition can be regariled as more fre
quently present than another. It has, however, been the
ex)ierierice of the writer to find a peculiarly smooth con-
dition of tlie skin of the scrotum in <'very case of niinorit_v
examined by him, Tliis may be due to lack of develop-
ment of the dartos. Men of mature age do not display
it. but it is very noticeable in minoi-s. The general ap-
pearance and bearing of a j-oung man will, in conjunction
with physical peculiarities, give the surgeon a very fair
idea of his age, and there are few possessed with suffi-
cient hardihood to deny a firm and decidedly expressed
opinion by an observant surgeon upon the subject. In
those whose age exceeds the maximum there will prob-
ably be found presbyopia, the areas senilis in one or both
e_yes, a wrinkled skin, especially about the outer angles
of the eyes and on the forehead, gray hair, and a peculiar
hardness of the nails of the fingers and toes.
Height, Weioiit, ,\nd Cihest Me-\sukemekts. — "The
ininiminu heir/lit oi arecruit is at present fixed at five feet
four inches for all branches of the service, although re-
cruiting officers are allowed to exercise their discretion as
to theenlistmeiit of desirable recruits (such as band musi-
cians, school teachers, tailors, etc.) who may fall not more
than one-fourth of an inch below the minimum standard
of height; the niaxiiiiiim height for the cavalry service is
five feet ten inches; that for infantry and artillery is gov-
erned by the maximum of weight, to which should be
applied the rule for proportion in height."
"The iiiinimum weir/ht for all recruits is 12S pounds,
except for the cavalry, in which enlistments may be
made without regard to a minimum of weight, provided
the chest measurement and chest mobility are satisfac-
tory. The mii.iiiiDim, for infantry and artillery is 190
pounds; for cavalry and light artillery, 16.5 pounds."
The standards of height and weight are, however, sub-
ject to change, instructions to that effect being issued
from the adjutant-general's office "from time to time as
the requirements of the service may dictate,"
These standards are based upon results obtained by
skilled observers who, after carefiU study and the exami-
nation of laige numbers of men in civil and military life,
have established the fact that there is an lo-inii/e prnpur-
iioii. in healthy, fully developed men between the height.
Weight, chest measurement, and chest mobility which
will admit of slight variations without indicating a de-
parture from health. The rules of this proportion may
be formidated as follows:
For each inch of height from .5 feet 4 inches to 5 feet 7
inches, inclusive, there should be calculated 3 jiounds of
Weight. When the height e-reei iJr .'5 feet 7 inches, calcu-
late 2 jiounds of weight for the irlmle number of inches of
height; add to this jiroduct 5 pounds of weight for each
inch of dilference between 5 feet 7 inches and the actual
height ; the sum will be the normal weight in pounds,
'I'lie chext iiieasurenieiit at (xpimtiuu in men from 5 feet
4 inches to 5 feet 7 inches in height should exceed the
half height about half an inch; in those from Ti feet 8
inches to .5 feet 10 inches it should erpuil the half height,
while in tho,se from 5 feet 11 inches upward it should be
sli.ghtly lem than the half hei,ght.
The clieifi molnlity — i.e., the difference between the
measurement at inspiration and expiration — should be iit
h<ixt 3 inches in men below' .5 feet 7 inches in height, and
2i inches in those above that height.
The following table shows this concisely:
5 feet 4 tu 5 feet 7
inclie,'*.
5 feet S to 5 feet 10
in»;lies.
Wei?lit.
Allow for eurli inclj
of heiiilit.
2 pounds
! pounds and .5
Itounds addi-
tioiiiil for eaeli
I inctioverofeet
I 7 luclies.
Cliest measure-
meut.
Cliest
mobility.
Half heigfit plus
half inch.
Half height
2 inches.
2J^ inches
Sli5;:htlv less than 2^ inches
half height. I
For exam|ile. a man who measures ."i feet 4 inches
should weigh 128 jiounds — i.e.. 5 fcet4 inches = 04 inches ;
04 X 2 = 128, the normal weight. Heshoiild have achest
measurement of 32i inches at expiration, being half
8-ls
REFERENCE HANDBOOK OF THE iMEDICAL SCIENCES.
ICi-(-i*uif »•
heiglit; 32 inches plus +iuch = 32i; the chest mobility
should be about 3 ioclies.
A man who measures 5 feet 9 inches should weigh 148
pounds— i.e., 5 feet 9 inches = 69 inches; 09 X 3 = 138;
diH'eieuce between 5 feet 9 inches and 5 feet 7 inches is 2 ;
2x5 = 10; 138 -|- 10 = 148, the normal weight in pounds.
He sliould have a chest measurement of 34.J inches (his
half height), and a chest mobility of at least 2i inelies.
It is not necessary that the applicant should conform
exactly to the figures indicated in the rules, a variation of
a few poiuids from either side of the standard in the
minimum, medium, and ma.ximum weights, and of a
fraction of an inch iu chest measures being permissilile if
the applicant is otherwise in good health and <lesiral)le as
a recrint. The rules ai'e given to show what is regarded
as a fair proportion, J»i tlie vdght iiiiiKt be at least 1-5
poinids except when le.ss is especially authorized by the
superintendent or the adjutant-general.
In such cases the recruiting ollicer's reasons and the
superintendent's order should be noted iu full on the en-
listment papers. Any considevnUe disproportion, how-
ever, of lieiijlit over ircight is cause for re,|ection; but a
marked disproportion of wei'iht over height does not reject
unless the applicant is positively obese.
In order that an intelligent application of these rules
and their variations may be made, the attention of re-
cruiting officers is called to the manner iu which a man's
height is made up.
The chest, containing the heart and lungs, is the most
important division of the body. It contains the vital
machinery and represents tlie stuying powo- oi the man.
It must, therefore, be ample. Tlie function of the li'gs
is U> transport the body ; theyslioukl be well formed and
sufficient, but not unduly long, for length of limb at the
expense of the chest is a disadvantage. A long-legged,
long-necked man with a short chest is objectionable as a
recruit.
The average height of a youth of eighteen years of age,
a "growing lad," is a little over 5 feet 4 inches, aud in-
creases gradually until he reaches tlie age of twenty-five
years — the stage of phj'sieal maturity or manhood — when
iiis average height is between 5 feet 7 inches and 5 feet 8
inches.
During the growing period the framework and vital
organs receive their proper development, and consider-
able departures from the given average of proportionate
height to weight indicate an impairment of the.se organs
which may. and probably will, di'velop into positive dis-
ease after exposure to the hardshi]is incident to the life
of a soldier; hence they are of greater significance in men
of these heights than in taller men, who are presumably
of greater age and more mature growth.
After twenty-five years of age. the body being fully
developed, the excess of nutritive material over and
above that required for its maintenance in health is de-
posited in the tissues as fat, and it will be found tliat a
disproiiortion of weight over heiglit occurs usually in
adults or men in middle life. It is rare to meet in the re-
cruiting rendezvous with very fieshy young men.
The following table is giveu for convenience of refer-
ence :
Tablk of Physical Proportio.xs for Heioht, Weight, and
Chest Measurement.
Height.
Weight.
Chest Measurement.
Feet.
Incbes.
Pounds.
At expiration;
iuelies.
Mobility ;
inches.
hi\
84
128
324
•>
.5/3
Kt
l:!0
33
;»
tf;
6(i
133
?i\\
'>
67
134
34
•i
5A
68
141
34
25
.5,1,
69
148
345
.5 5
70
15.5
35
oi
54
71
163
if
2I
6
7;2
169
2I
6A
73
176
36J
Vol. VI.— 54
A deviation from the rules of physical proportions may
be made in the examination of candidates for admission
to the United States jVIilitaiy Academy at West Point,
aud for members of the graduating class, whenever this
is deemed desirable by the Medical Examining Board.
Habits. — Drunkenness, orliabitsof intemperance, is the
cause of a very large nuniber of the rejections made at
rendezvous. It is the vice of the army, as well as of
most walks in civil life, and the medical examiner cannot
be too careful in scrutinizing every applicant for evi-
dences of this demoralizing habit. Tlie regulations of
the army are very einidiatic on the jioint, declaring that
every man shall be .sober when enlisted, and that men
having the apjiearaiire of being hard drinkers will be re-
jected, "though they may not at the time be intoxi-
cated.'"'
Some recruiting officers go so far as to reject men on
whom the smell of liquor can be detected at the time,
and they are without doubt correct in their opinions and
practice. It is a great mistake to "suspend a final de-
cision . . . for a sufficient length of time to enable a man
to recover from the elTects of a mere temporary de-
bauch," as is recommended by Tripler,' as the man wlio
will indulge in such debauchery Infure enlistment will be
pretty sure to repeat it afterward ; aud such men are not
wanted in the army. If a man has to resort to the stimu-
lation of alcohol to "brace himself up " for the ordeal of
the examination, it is a fair presumption that his habits
as to the general use of stimulants will not bear much
criticism. The evil wrought to the service b}' inen hav-
ing these habits is so great that it is far better to err, and
run the risk of occasionally rejecting temperate men, than,
by relaxing any vigilance, to enlist those who may event-
uall.y prove themselves sots.
While it is sometimes difficult to detect the habitual
drunkard, and the medical examiner is forced to rely, to
.some extent, upon the man himself for such information
as he may be willing to give, yet the long indulgence in
habits of intemperance will almost surely be indicated by
per.sistent redness of the eyes, tremulousnessof the hands,
attenuation of the muscles — particularly of the lower
extremities, — sluggishness of the intellect, an eczematoiis
eruption upon the face, and purple blotches upon the
legs.' Close and skilful questioning will often develop
the facts connected with tin' antecedents of the applicant,
and materially assist the examiner in forming his opinion
of the case.
Ma.tturhators and Sodomites are also to be looked for and
rigidly excluded. In addition to the well-known general
signs of physical prostration due to indulgence in mas-
turbation, Howe, in his little work on "Excessive VeB-
ery , " '" says, " the local signs are sufficient for a diagnosis.
. . . The penis is thinner and smaller than usual. It is
often elongated, and cold to the touch at different points.
The glans is much larger than the rest of the organ. . . .
The veins of the integumeutal covering are dilated and
varicose. In many patients the penis is bent laterally,
and the inclination is generally toward the left side. . . .
The scrotum is also relaxed and elongated, the testicles
are small and soft; . . . sometimes they are extremely
sensitive." The air of embarrassment which so often
overtakes subjects of this vice, when closely questioned,
will aLso lead to their detection.
iSodomy may be suspected if the anus is much dilated,
or is infundibuliform in shape: "The absence of the
radiating folds is considered one of the best medico-legal
proofs of the vice." " Tidy says,'- "a peculiar, funnel-
like depression or hollow of the nates toward the anus,
the anus gaping and the sphincter relaxed," arc signs of
the practice of this vice, to which greater or less impor-
tance may be attached as the circumstances of the case
demand.
Mental Disorders.- — Insanity, idiocy, imbeeility, and de-
mentia are disorders which will call for the closest scru-
tiny and observation by the medical examiner ; their na-
ture is such'tliat a careful diagnosis in the limited time
allotted to the examination of a recruit is rarely possible.
The necessity, therefore, of an acquaintance "with their
U9
Recriiils.
Recruits,
REFERE^^CE nAXDBOOK OF THE MEDICAL SCIENCES.
pliysiosiioiny is apparent. To one skilled in this means
of "diagnusis the detection of the less obscure grades is
not a matter of great difficulty. The idiot, tlie iinhecile,
or the demented patient presents such weU-niarked char-
acteristics that an error can hardly be made. It is in
those unfortunate persons who are on the borderland of
mental deficiencj-, and the insane, that the greatest diffi-
culties of diagnosis may be expected. Unless an insane
person betrays by action or speech snino evidence of this
disease, a correct diagnosis would be a matter of great
difficulty, and no surgeon would be held responsible for
accepting one who afterward manifested insanity.
Should the examiner have reason to suppo.se that the ap-
plicant is deticient iu mental capacity, or has not the ap-
titude to acquire readily a knowledge of liis duties as a
soldier, he should be rejected. It is nuich safer to take
even an extreme view of such cases, and run the risk of
an ei-roneous rejection, than to accci)t one about whom a
suspicion of mental alienation can rest.
P/ii/.ti'quf. — AVhile a decision of cases xmder this head-
ing docs not always fall within the province of the
medical examiner, Iiis opinion is entitled to great w-eight
with the recruiting officer. His knowledge of anatomy
and the jiropcn' proportions of the human frame, as well
as his familiarity with physiognomy, eminently qualify
him to form a correct opinion as to the general ajipcar-
ance, both iihysical and moral, of the applicant, and his
fitness for the duties of a soldiei', in cases in which no
technical disabilit}' exists or can be discovered by a non-
professional man. His experience witlt the fffrrfs of dis-
ease, bad habits, food, and living \ipon the constitution
will enable him to judge as to future efficiency, although
there may l)e no direct evidence in the case before him that
the applicant has ever been subjected to such hardships.
There is probably no one class of men which furnishes
such largenumbers to the hos[iitals, tli(\guard-house, and
the list of deserters as this, designated indifferent ly by
militar3' men as "poor jiliysique," "feeble constitution,''
or "general unfitness."
The leading characteristics of a good ph_ysique may be
brielly enumerated : " A tolerably just proportion between
the dillerent parts of the trunk and members; a well-
shaped head, thick hair, a countenance expressive of
health, with a lively eye, skin not too white, lips red,
teeth white and in good conditinu, voice strong, skin
firm, chest well farmed, belly lauk, parts of generation
well developed, limbs muscuhir, feet arelied and of a
moderate length, hands large." '- The gait should he
sprightlx' and .springy, siiecch pronqit and clear, and
manner cheeiful. The medical examiner should endeavor
to judge from the eyes, from the whole expression of the
countenance, from the conformalinii of the limbs, which
of the candidates are capable of making the best sol-
diers; there are as certain and as well understood indica-
tions for judging of the soldierly finalities of men as there
are for ascertaining the value of a hoise or a hunting-
dog.'^ All lank, slight, puny men, with contracted fig-
ures, whose development is, as it were, arrested, ,should
he set aside. The reverse of the characteristics of a good
constitution, already enumerated, \\ill indicrd.e infirm
health or a weakly habit of body: loose, fialibv. white
skin; long cylindrical neck; long, fiat feel; very fair
complexion, fine hair; wan, sallow countenance,. etc.
Under our present system of recnuting in large cities a
I very objectionable description of men present, themselves
for enlistment, whose health has sulTered from debauch-
ery of various kinds. They are tramps; men who wan-
der about over the face of the country, too lazy to work
and too vicious to live in a well-regulated community —
■ a set of Ishmaelites who seek service iu the army as the
easiest method of getting food, clothing, and sheJler. lint
without the slightest design of performing any more duly
than they are compelled to. They generally appear as
wint<'r apiiroaches, driven by inclement weather to seek
an asyb.im until the opening of spring. No more tinde-
.sirabie or unfit class of men come before arecruiting offi-
cer. They arc' seldom, after enlistment, out of ihegaiard-
hoiise or hospital, and I he company to which they belong
is fortunate if, when thej' take their flight in the spring,
they do not carry awa_y with them all the available cash,
or articles of value, upon which they can lay their hands.
Another class of men, having neither apparent di.seascnor
well-cliaracterizcd physical or moral defect, are equally
objectionable; there is a "something " about them which
satisfies an expert that they will make either indift'erent
or bad .soldiers, for whicli reason they should be rejected.
The power of recognizing these two classes of men Is a
talent which is greatl}- improved by practice, and which
the medical examiner should cultivate to the highest de-
gree, persistentlj- rejecting all about whose ultimate effi-
ciency he has the slightest doubt.
Even in timfi oftcrir. when the urgency for men maj- be
ever so great, there should be no deviation from the gen-
eral rule as to men of tliis stamp and character, who, if
once admitted will serve only to encumber the army
either by their shiftlessness or by their viciousness. An
army, in whatever strait it may be, is vastly better with-
out than with them.
Gexeiiai, IxTiiLijiGEN-CE. — A higher degree of intelli-
gence is now expected from the soldier than was the case
in the earlier days of the republic. Promol ion is open to
him, and he is encouraged in every way to improve' him-
self; libraries are established to which he has ready ac-
cess; reading-rooms, with liberal suppliesof newspapers,
are prepared for him, and .schools an: organized in which
he has opjiort unities for study. "It is worthy of notice
that much of the advantage to be derived from modern
improvements in the mode of educating, training, diet-
ing, and clothing the soldier depends upon his capability
of appreciating the objects with which they have been
introduced," '^ and while it is impos.sible to fm-inulate
any specific standard of intelligence by which his eligi-
bility is to be judged, such a (iirectioii cair be givento
the questions necessarily asked during the phv'sical ex-
amination as will enable the medical officer to form a
TCi-y good ojiiniim of liis general intelligence, and afford
an opportunity to exclude men who, while they may not
be exactly idiotic, are "a .sort of denii-simpleton."
The remarkable strides which have been made during
the past quarti>r of a century in the science and art of
war; the superior mechanism of the rille now in use; the
attention that is paid to target practice, and the etlorts
that are made to instruct the soldier iu the management
and care of his weapon and ammunition, tend to make
his profession both instructive and interesting, and jus-
tify the expectation that men of better tastes and habits
than those obtained in the past will, iu the future, be at-
tracted to the profession of arms.
It is well stated by Dr. Crawford, in the article from
which quotation has been made, that the criminal and in-
validing statistics of the arniv leave no doubt as to the
frequent enlistment of the fatuous and imbecile, as well
as the criminally vicious, and that if the development of
the head, and the symmetry of its proportions were as
careftiUy examined and as dogmaticalh* insisted upon as
is customary iu determining the form, development, and
s_vmmctry of other organs and regions, a proportion, at
least, of such men might be excluded from the .service.
SrECi.\i, Ex.\MiN.\TK>xs. — T/ic Ccreliro-.yniud Si/stcm. —
Epilepsi/, chornt. sttitUring or stiiminiring. all furmii of
jMirah/fifs, Inhes dorxtilh, nenralrjiii, disqualify.
It is not to be expected that the medical examiner will
make a diagnosis of all the different forms and iihases of
this class of diseases. It is sufficient for practical pur-
i:)OScs that he shoidd rccogiu'zesuch general sj'miitoms as
are indicative of grave lesions of the s\'stem, and should
satisfy himself of the incapjtcily of the apjdicant for
military d;ity; in their later stages the manifestations are
so well iironounccd that it is hardlj" piissible for eiTors of
diagnosis to occur; but the earlier symptoms are in many
instances obscure, requiring close observation for their
detection. The personal appearance, facial expression,
and gait will often betray the existence of many fonns of
nervous disordi'r, for which reason the medical exaininer
should require each applicant, after being stripped, to
approach him from a distance, and if ueces.sury, walk
850
REFERENCE HANDBOOK OF THE JIEDICAL SCffiXCES.
Rpcriiitii.
Kccrulls.
about the room, during ■which time he can thoroughly
scan Iiis person, observing particularly any deviations
from the normal conditions. By this means the halting
gait of paralysis of the lower extremities, or the shuffling
unsteady step of tabes ma\' be detected. A careful ex-
amination of the spine should be made by pressuie upon
the spinous processes from the cervical to the lumbar
vertebra?, and auj' tenderness or pain manifested by
flinching made mental note of. Unsteadiness of the
hands and arms should suggest a suspicion of tabes dor-
sal is, and the simple tests of standing or walking while
blindfolded, the tendon reflex, and the tactile sense, should
be made with care.
Stfrmmenng may be congenital, due to habits contracted
in childhood, to malformations of the vocal apparatus, or
to organic lesions in the nervou.i s\'stem ; by whatever
cause it may have been produced, if it is sufficient in de-
gree to interfere material!}' with ordinary conversation, the
applicant should be rejected. Some care will be necessary
in arriving at the degree of this aflfection. because the nerv-
ous excitement incident to the examination will of itself
react upon the patient, whose embarrassmentwilliucrease
his difficulty of speech. A little patience and kindliness
of manner will, however, soon reassure him, and the true
extent of the difficulty be appreciated. Jn time of iriir at-
tempts will often be made to simulate disorders of this class
for the purpose of securing exemption from military duty.
The ditferent forms of jiaralysis and tabes can, by the ex-
ercise of some patience and care, be detected ; indeed, it
would require a man to be possessed of great self-control,
shrewdness, and a considerable knowledge of the symp-
tomatology of disease to simulate, with an\' reasonable
prospect of success, anj' form of paralysis. Ocular evi-
dence of a convulsion should always be obtained by the
examiner before he is justified in exempting a man from
militarj'' service on the ground of epilepsy. No state-
ments, however well substantiated, should lead him to
deviate from this rule. He should satisfj' himself by the
absolute loss of sensiljility of the conjunctiva;, the dilata-
tion and immobility of the pupil, and the character of the
convulsions, that the attack is one of true epilepsy before
recommending the case for exemption. The pain of vcii-
ralaia may be simulated; but true neuralgia of sufficient
intensity to disqualify can hardly exist without producing
such decided constitutional ell'ects as will be visible to
the eye of the examiner.
C»iislitutir)!uil syphilis disqtialifies.
The late forms of this disease, as gummata, rupia, peri-
ostitis, ostitis, caries, etc., are rarely brought to tlie notice
of the examining surgeon, or if such cases should tie pre-
sented, the cachexia will be so well marked that there can
be but little difficulty in making a diagnosis. It is the
early manifestations of the disease which he is to watch
for with great care, partici^larlj'as men are often the sub-
jects of syphilitic infection without being aware of its
existence, and therefore truthfulh' disclaim any knowl-
edge of a disability for the service on that accotuit.
Careful examination should be made of the cervical,
epitrochlear, and inguinal glands, as one of the earliest
and most important manifestations of constitutional
syphilis consists in their enlargement and induration.
Otis, in his work on " Syphilis," states that this abnormal
change extends, to a greater or less degree, throughout
the entire lymphatic system. He descrilics tlie cidarged
glands as varying in size from a small shot to a pigeon
egg: as being hard, moval)le, and painless: those in the
epitrochlear region being the most valuable in a diagnos-
tic point of view, and rarely present before, or absent
after, the tenth or twelfth week succeeding inoculation
of syphilis, whether any roseola can be detected or not.
Sometimes onl}- one gland is enlarged, which may be
aljove the trochlea, along the inner border of the biceps,
and therefore difficult to tinil. There is \'ariation, also,
as to locality in the different cervical and inguinal glands
that are enlarged, a patient search for which will gener-
ally be successful. The next evidence in order is the
classical roseola, with its bright hue in the early stages,
and its faucial intlammatoiy engorgement; the paptilar
eruption with its crop of papules along the upper border
of the forehead, hard to the touch, and painless (the
corona veneris of Ricord); the circle of white scales ar-
ranged about the base of the pai)ules on the body (the
collarette of Bictt); the coppery -colored stain leftafter
the <lisappearance of this papular eruption ; alopecia, and
mucous patches. These, either alone or taken together,
should be s.ufficient evidence of the existence of the dis-
ease in its earlier stages to warrant the examiner in re-
jecting the applicant. As the cicatrices of buboes are
not evidences of the existence of syphilis, they should
not be made a cause for rejection, although tlieir pres-
ence should lead to careful exannnation for signs of the
dis(«se, as heretofore mentioned.
In timt of war this disease (sj'philis) is cause for re-
jection.
Cancer, in whatever form or stage of development, is a
cause for rejection. The " pipe-smoker's cancer, " epithe-
lioma of the lip or tongue, and cancerous atfections of
the testicles, are the forms most likely to be seen among
men desiring enlistment. As, however, the disease is one
of middle or advanced age, it is very rarely met with at
recruiting rendezvous, and is only mentioned in this place
as one of a class of diseases which the surgeon may be
called upon to reject.
The Skin. — All ch ronic, con tagious, and parasitic diseases
of the skin; Tuevi ; extensive, deep, and adherent cicati'ices ;
chronic ulcers ; termin, and indecent tattooing, disqualify.
Although vermin maybe considered to be only tempor-
ary annoj'ances, it will be found, as a rule, that the men
upon whom they take up a residence are undesirable by
rea.son of tilthy habits. The fecundity of vermin is so
great, so many opportunities are afforded for their migra-
tion where numbers of men are associated together, and
their presence is so disgusting, that, in time of peace, men
infested with them should eitlier be summarily rejected,
or acceptance deferred until their persons are rid of the
parasites. The most common form met with at recruiting
stations is the crab louse (pediculus pnhis). Of parasitic
diseases *«(4«',s,/<(/'«,s', tincatonsiirans, and syrosisare most
frequently met with, and should be causes for rejection,
or action should be deferred until a cure has been effected.
The tattooing of indecent dcricesupon the skin, on any part
of the body, is cause for rejection, upon the ground that
a man who will voluntarily submit to such defacement is
morally unfit to be a soldier, 'V\\e presence of cicatrices
from cupping should lead to a close examination of the
internal organs in their vicinit}-, which ma.y have been
seriously damaged by disease, or are liable to become
again affected after exposure to the hardships of a winter
campaign. When crtenisice adherent cicatrices impede the
free motions of the limbs, they are absolute causes for re-
jection; but when seated on other parts, as, for example,
the head or trunk, they are not in themselves objections
in a recruit; as indications, however, of constitutional
cachexia tliey are important." Cicatrices, non-tulherent,
white and smooth, resulting from an incised or lacerated
wound, or a burn, and not involving nuich loss of sub-
stance or lesion of subjacent organs, are not causes for
rejection. Chronic -ulcers are not likely to be found, ex-
cept in persons of broken-down constitution. Those re-
sulting from abrasions or slight wounds, in ])ersons who
do not present any evidence of constitutional disorder,
have probably been kept active from some local cause,
upon the removal of winch the^- Avill heal ; but those in-
volving much loss of substance, with atrophy of a limb,
with a general constitutional disonlei-, or with varicose
veins, especially when located on the lower extremities,
should disqualify; even when healed they are apt to
open again, so soon as the soldier is exposed to any cause
of irritation, such as long marching or inclement weather.
The skin of the negro seems especially prone to ichthy-
osis, and to keloid growths at the seat of even tiivial in-
juries: unless the affections arc extensive, or the keloid
growths so situated as to interfeiv with the motion of
limbs, or otherwise impair the efficiency of an applicant,
they shotild not be considered causes for rejection, Ja
time (^«f<(7- exemption should be given only on account of
851
Komiilfi.
Recruits.
REFERENCE HAXUBOOK OF THE MEDICAL SCIENCES.
long-standiug or iucuraliU' diseases of the skin ; the milder
forms, as acue, herpes, urticaria, etc., as also some of the
parasitic diseases, including scabies, may be treated with
reasonable prospect of recovery in a short time, and the
men accordingly should be held to service. Ulcers may
be produced and purposely kept open with the \iew of
evading service under conscription. Suspicion will nat-
urally be aroused when an otherwise healthy man claims
exemption from service on account of an ulcer of long
standing, as this lesion is seldom seen except in persons
of broken-down constitution, and generally in middle or
advanced age. The appearance of the ulcer, and the tis-
sues .surrounding it, will f\nnish some evidence as to its
age, active inflammation pointing to voluntary irritation
and a recent lesion, while an old ulcer presents character-
istics the reverse of this. Such cases slmuld be placed
under close obs<'rvation in hos]iital. and every means
taken to prevent the patient frnm kee]iing up any irrita-
tion of the parts, the fact being borne in mind that anal-
most endless variety of foreign substances are used for this
purpose, and that the finger-nails are especiall,v conven-
ient for such use; it may even become necessary to put
the patient into a straitjacket before a correct diagnosis
can lie made.
Thi' Ihiiil. — AhnoniKiHy lar;ie heiid ; cnni'itlemMe de-
fiini(Uii'S, tlic conserjtieiice of fnicti/ns ; serious lesions of
the skull, the consequence of coiiiplicnted iroiinds or the
operidion of trephininff ; caries and e.ifoliiitiori of the
bone: injuries (f crtinial nerres ; tineo eoi>ilis ; olojiecio,
disqualify.
Any injiny of the .skvdl alTords ground for suspicion of
consequent injury to the brain, anil the existence of epi-
lepsy' or some disurder, greater or less, of the mental
faculties; hence all such injuries should be carefully ex-
amined as to their extent and seat. It is well known
that the skull mav receive extensive injury without any
subsequent impairment of the faculties, and also that
very slight injuries may be followed by serious conse-
quences, more especially by eiiilepsy; henci\ although
no positive disease may be detected, it is safe to reject
any applicant who has evidence of considerable injury
to the skull, if for no other re;ison than that its presence
affords the man an opportunity fiu' evasion of duty, and,
if he choose to make it, a claim lor discharge fmni the
service on account of some alleged nervous affection,
should nnlitary duty become ilistasteful to him after
joining his command. With the evidence nf an injury
to the head before him, it woidd be diliicult for a medi-
cal ottieer to dis]U'ove any assertion by a malingerer of
the existence of disease.
M'ounds of t/ie sculp, especially if non-adherent, slK>uld
not reject; injuricsefthecronieil nerees. jiioducing paraly-
sis or impairment of function in the parts to which they
are distributed, are causes for rejection; tinea ciijrilis is
laid down in many works on recruiting as a disqualitica-
tion. It is a disease almost exclusively conluied tochild-
liood, and is very rarely met with at a ri'iruiiingshition.
In the examination of several thdusaml men at the depot
at Columbus Barracks, Ohio, the writer did not see a
case, nor has he ever seen one among the soldiers with
whom he has .served. The discover}- of any disease of
this genus in thc^ hairy scalp would be cause for rejec-
tion, not only on accoiuit of its contagiousness, but be-
cause it is both unsightly and offensive. The papulur
eruption of si//ihilis is frei|ucntly situated in the haii'y
scalp, and ma_v be easily felt by ah exandnalion of that
part with the fingers. Alo/iecin. is oeeasionally met with
in recruits, and has given rise tonnich difference of opin-
ion among army surgeons as to its being a disqualil'ying
cause; if it is the result of a pre-existing disease, which
will be manifest by the appearance of the scalp, if the
loss of hair is total, or if but a few tufts remain about
the l>aek of the head and in the neighborhood of the ears,
the man is untitted for service; the head coverings issued
to the soldier not being sufficient, in the absence of the
natural covering, to jirotect him from accidents resulting
from exposure to the heat of the sun nv to the inclemency
of the weather; partial loss of the hair, either over the
crown or above the forehead, is not cause for rejection;
in time of tear baldness is not cause for exemption.
The Spine. — Caries; sp>i net bifida ; liiteral curiviture of
the certicnl, dorsal, or lumbar regions; lumbeir abscess;
rickets; fracture and dislocation of the tertebree ; angu-
lar curcatures, infludiny gibbo.sity of the anterior and
jmsteriur parts of the thorew, disqualify.
Lateral curvatures of the spine are often the result of
some particidar trade or occu|iation; if the curvature is
slight, and unaccompanied by signs of constitutional
weakness, it should not disqualify. An appearance of
lateral curvature frequently results from undue develop-
ment of the muscles of one shoulder. This will be read-
ily detected by m.iking the recruit stoop forward from
the attitude of attention, stretching out his hands over
his head, and curving the back until his fingers reach the
ground. A glance at the recruit's spine, when so bent,
froiu before backward, will enaljle tlie surgeon to esti-
mate the extent of lateral curvature, if it really exists."
The following good rule for the determination of the de-
gree of ciu'vature which demands rejection has been
suggested by Major Daiugerfield Parker, U. S. A. The
recruit standing erect, draw an imaginary line from the
base of tlie .skull to the end of the spine; if the sjiinal
prominences are curved one inch either side of the line,
reject. Anv pronounced angularity of the spine (gibbos-
ity) sufhcient to impair the synuuetry of a man's figure,
or distortion of the chest interfering with respiration,
should reject. The fact that knapsacks and other heavy
weightsare no longercarried by soldiers upon their backs
in modern campaigning removes the objection formerly
made to men having this defect in a moderate degree.
In young men posterior curvature may be overcome by
attention to drills and gymnastics, but in men beyond
twenty-tiv(? years of age it is useless to attempt an im-
provement.
//; ti/ne of tear slight curvatures, lateral or angular,
should not exempt.
7'/((! Ear. — Deafness of one or both ears; all catarrhal
and purulent forms of acute and chronic otitis media';
jiolypi, tind other groirths or diseases of the tyuipemum,
lahijrinih, or mastoid cells ; perforation, of the nienibrewM
tijmpani ; closure of the auditory canal, partial or com-
plete, e-rc^pt from acute abscess or furuncle ; meilforniation
or loss of the e-vternal ear, and all diseases thereof, except
those which are slight and non-progres.<iice, disqualif}'.
Di.seases of the ear inducing deafness are not often
.synunetrical, and affections of one car are much more
likelv to be met with than those of both; hence the fact
should be borne in mind that while an applicant for en-
listment may apparently hear ]ierfeetly, a can'ful exami-
nation of both ears w ill show that he may be deaf in one.
To properly make a preliminary examination of hearing
power for the voice, the examiner should stand at the
side and in rear of the applicant, at least forty feet dis-
tant, while the recruiting sergeant closes the external
meatus of one ear b}- pressing the tragus gently back-
ward and inward. A few words are then to be addressed
to the applicant, distinctly, in a middle tone, and not too
rapidly. If there is any defect in the hearing of the un-
covei-ed ear, it will at once be discovered by the failure
to rejieat what is said ; the same mana?uvre should be
practised with the opposite side. The voice may be
heard at least fifty feet distant in a closed room when
both ears are normal; should there be deafness of either
ear, the applicant n.ust be rejected.
It will be found that deafness is occasionally caused by
the accumulation of cerumen in the ear; in which case,
should the recruit be otherwise desirable, it would be
proper to defer final action, and an opiwrtimity given
him to have the obstruction removed, wlien, if hearing is
restored, Ik; could be accepted.
In time <f irar deafness is frequently simulated. Real
deafness cannot be concealed, but the detection of simu-
lated deafness is at times a somewhat difficult matter.
Here every artifice which ingenuity may suggest will be
employed to deceive the examiner, whose opinion of the
case must be made up of negative evidence entirely, the
S52
REFERENCE IIANDBOCJK OF THE 3IEDICAL SCIENCES.
Kecriiils,
Recruits.
only positive evidence available being the motive of the
conscript, if this can be styled evidence.
Besides that by means of the voice there are three
methods to be employed in testiu!; the pinver of hearing,
viz., the watch, the tiiuing-forU, and the dciuble stetho-
scope of Cammaun, although an opinion should not be
formed from any single test, but from the results ob-
tained by all.
In using the first test, tlie applicant should be blind-
folded while one ear is closed; the watch is to be held
in tlie air at various distances from his head — above, be-
low, in front of, and liehind the unclosed ear. The dis-
tance at which its ticking can be heard by the normal
ear may be determined b\' the operator's sense of hearing.
This being used as a standard, the degree of hearing by
the applicant can be approximately determined. Each
ear should be carefully tested ^by this method, and the
result noted.
To use the second test, uniform sound can be obtained
by striking the tuning-fork on the knee while the leg is
flexed upon the thigh, or even by extending the palm of
the hand and striking the tines of the fork upon its fleshy
part. In the normal ear the tuning-fork, when placed
on the central incisors, is heard equally well in both ears;
the same is true if the fork is placed on tlie vertex or on
the centre of the forehead : if placed on the mastoid proc-
ess, it is heard better in the ear of the same side; it is
heard longer when placed in the air near the meatus, than
on the teeth, etc.
AVhen there is some defect in the hearing dependent on
disea.se located in the middle or external ear, the tuning-
fork placed by its base upon the teeth, or on any of the
central portions of the skull, will be heard better in the
diseased ear. If placed in the air near the ear, it may not
be heard as well as in the previous position. In doubtful
cases, if the fork is laid a little to one side of the median
line, it assists to confirm the diagnosis. For instance, the
patient thinks he hears the fork best in the right ear. and
it is then moved to the left side a little. If he still hears
it as well in the right ear, or even hears it equally well
in both ears, there Is no question of his hearing it better
in the right.'*
In diseases of the labyrinth having a nervous origin
these conditions are reversed, and the ttming-fork will be
heard belter in the good ear — both ears being stopped.
Hence the examiner must be on his guard, when inves-
tigating a case of suspected simulation, that he does not
have a case of labyrinth disease before him. In such in-
stances ocular inspection of the middle ear will be of
value in completing a diagnosis.
The third test, by the use of Cammanu'sbinaural steth-
oscope, is a very ingeinous one. and is best described in
the language of its originator. Dr. David Coggin.'^ It
is. however, serviceable only in siinulate<l absolute deaf-
ness of one ear: "The patient aflirmed that he was deaf
of the left ear. I therefore in.serted a tightly fitting
wooden plug into the right caoutchouc tube, and then
put the two caoutchouc tubes into the metaJ ones.
When I tried the instrument on myself, I fiamd that
words .spoken could not be understood by the right ear.
After the patient had ad.iusted the stetiioscope. he re-
peated without hesitation the words which I had whis-
pered into the bell of the instrument, whiclt served as a
mouthpiece. The tube containing the plug was then
taken out of the right ear, which was firmly closed by
pressure on the tragus. AVhen I again spoke into the
stethoscope, which was still in connection with the left
ear. the patient positively assured me that he could no
longer distinguish the words. lie was, of course, aware
that the tul)e through which he liad before heard was no
longer in connection with the right ear."
It is more than probable, before the examiner has com-
pleted these tests, that the simulator will have become so
confused as to betray himself, when, of course, the ex-
amination woukl cease. He must, however, be pre])ared
to find luen very obstinate, who have made up their minds
to deceive, and he may, therefore, be obliged to employ
all the methods at his command in making a diagnosis.
The preference of the writer is for the tuning-fork,
about the use of which men are ordinarily ignorant, al-
though the tests by tlie watch and stethoscope give
excellent results. Careful inspection of the meatus
should be made for evidence of inflainmatoiy affections
or for morbid growths.
In time of mir cases of otitis may be placed in hospital
for observation, to be exempted from service if subse-
quent treatment develops the fact that organic changes
have taken place, or that |)ernianent deafness has resulted ;
deafness of one ear is not an objection, but when both ears
are thus affected the man should be exempted.
The Eyes. — Class 1. Loss of an eye ; total losss of sight
of either eye ; conjiineiival affections, includiny trachoma,
entropion ; opacities of the cornea, if covering part of a
moderately dilated pupil; pterygium,, if extensive; strabis-
imis ; hydrophtltalmia ; exophtJialmia ; conical cornea;
cataract ; loss of crystalline lens ; diseases of the lachrymal
apparatus; ectropion; ptosis; incessant sjmsmodic motion
of tlie lids; adhesion of the lids ; large encysted tumors ;
abscess of the orbits ; muscular asthenopia ; nystagmus.
Class"2. Any affection of the globe of the eye or its con-
tents; defectire vision, including anomalies of accommo-
dation and refraction; myopia; hypermetropiia, if ac-
companied by asthenopia; prenbyopia ; astigmatism;
amblyopia ; glaucoma ; diplopia ; color-hlindness {for the
Signal Sercice only), disqtialifj'.
For convenience of exannuation the foregoing list of "
disqualifications has been separated into two classes: the
first including those defects which may be discovered by
the unaided eye; the second requiring for their detection
the use of special instruments. Loss of sight of the right
eye, or loss of the entire globe, as well as other defects
interfering with the vision, has been held by the War
Department as cause for rejection. The writer is of the
opinion that these disqualifications should apply to either
eye, exceptions thereto being confined cntirel}- to men
desiring to re-enlist. Aside from the disfigurement,
there are certain manceuvrcs in the drill and other exer-
cises in military life which cannot be properly performed
by recruits unless they have the perfect use of both eyes.
Old soldiers are so well instructed in their duties and
familiar with drills that nearly all military movements
may be exercised by them without the use of both e}'es,
dependence being placed uimn the word of command.
The acceptance of one-eyed men has been advised, pro-
vided the sight of the remaining eye is perfect, and it is
asserted as a fact that some of our best rifle shots among
frontiersmen are thus mutilated. This may be true, and
there could be no objection to such enlistments if the
terms of the proviso could be made continuous; but it is
a well-known fact that when one eye has been perma-
nently injured or diseased, the remaining organ is more
or less liable to attacks of sympathetic ophthalmia, to
avert which enucleation of the defective eye is often the
sole resort. The slighter forms of injury or disease
which may affect vision, if uncomplicated by an affec-
tion of the iris or ciliary body, are not followed by this
result; but it is after the more severe injuries and dis-
eases, particularly when. these bodies are involved, that
s.ympathetic inflammation is to be anticipated. It is not
always possible for the surgeon to form an opinion as to
the cause of blindness in these .severe forms of injury
without careftd ophthalmoscopic investigation, to make
which it is neither desirable nor proper for him to spend
time. The fact that a disease affecting the integrity of
the sound eye is likely to occur at any time would seem
sufficient reason for objecting to the admission of such
cases to the army. Tlie writer is. therefore, of the opin-
ion that loss of sight of either eye should in time of peace
disqualify. Catarrhal affections of the conjunctiva,
whether acute or chronic, are causes for rejection, as it
is impossible to predict what their terminations may be;
a very mild conjunctivitis may develop into a most vio-
lent disorder, attended with total loss of the eye; or a
chronic affection may linger for years, producing tracho-
ma, affections of the lidsT etc. Pterygium, if large and
I encroaching ujion the cornea to an extent that interferes
853
Rerriiils,
Recruits.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
in the slightest degree with vision, and strabismus, eitlier
convergent or divergent, if decided, reject. Any afl'cc-
tions of the globe of the eye, as keratitis, sclerotitis, reti-
nitis, iritis, etc., whether acute or chronic, should reject.
Careful examination should be made for the divergence
of one or both eyes, when the applicant is required to
look steadily at an object (asthenopia), or their oscilla-
tion (nystagmus); both of which conditions are likely to
become more pronounced from the nervous e.Kcitement
incident to the examination.
E.vamiuation of the sigJit should be made with the tit-
most care, as perfectly clear vision is demanded for title
practice as conducted at the present day. The medical
examiner should have a reliable sergeaijt to assist him.
The applicant should stand facing the surgeon, and
twenty feet from him, with his face to the light, as in
this position the iris is mo(h'rately contracted, and oiiaci-
ties of the cornea, which may cover any part of the pu-
pil, will be more readily discovered; the sergeant should
cover one eye with a card, instead of the hand, as is di-
rected in most instances ; if the hand is used, undue press-
ure is, unconsciously, liable to be made on the globe, the
circulation is interfered with, and more or less discomfort
and dimness of vision experienced w hen the eye is un-
covered; or a careless sergeant may, when covering the
eye, so spread his lingers that the apiilicant can see the
objects placed before liim with tlie so-called covered eye,
should the one uncovered be defective.
The instrtictions given by the War Department for
conducting this examination are contained in a geneial
order, from which the following extract is made: "1.
Range of i-iKi'in, ncccs.viri/ in. recniils. Hereafter no re-
cruit shall be enlisted wlio cannot see well, at six hun-
dred yards, a black centre three feet in diameter on a
white ground. This test will be made by means of
cards prepared under the direction of the surgeon-general
of the army. The black spots on the cards will be circu-
lar, four-tenths of an inch in diameter, and the recruit
must be able to count tliem with facility at twenty feet
distance."-'" In compliance with that order the surgeon-
general issued in.struetions from which the following ex-
tract is made: "These test cards are ten in munber, with
black spots arranged like those on playing-cards, and
ranging from one to ten on each card ; . . . the suigeon
. . . exposes successively the faces of two or three of the
cards to the applicant, who must be able to state prompt-
ly the number of dots on each. Tliis e.xaniinatiiui niu.st
be made with each eye separately, and may be varied by
showing to tiieapplieant oneof the highernuinbers, such
as the nine or ten card, and covering up a part of its face
with another card so as to expose one or more spots at a
time. This test does not represent absolutely perfect
vision, but admits recruits with minor degrees of refrac-
tive anomalies. It has been thougl.t best, however, that
recruits with these minor anomalies sliouhl not be ex-
cluded on account of them, jiroviiled their eyi's are
healthy in other respects."
It there should be any doubt ujion the subject with
this simple test, the test types of Snellen should be used.
To determine the degree of errors of refraction, either
the simple optometer or the test glas.ses should be used.
The writer is free to confess that lie has failed to obtain
any .satisfactory results with tli(^ optometer, and has been
comiielled in all cases to resort to the trial glasses for the
desired information. Astigmati.sm may be determined
by the optometer, or by the use of the astigmatic charts
furnished with the cases of trial glasses. Todetect color
blindness a .set of test wools is recjuired, which sliould be
u.sed in accordance with tiie directions luiljlished by
Holmgren, reprinted in Jeffries' work on "Color lillnd-
ness, " p. 310 it set].
In ?«■;«<; M/vrin- the following defects, which disipi;dify
in time of peace, should not exempt drafted men from
service: Lous of either eye; loss of sight of either ei/e ;
ojxieities of the eornea ; strulnsmiis, unless extreme : dis-
eases of the liiehrt/nml iipparatus ; ptosis, niikss e.nm/ilete
and indicatiee of serious brain lesion; iislhenojria and
vystiigmus, unless (.rcessire ; anomalies of refraction, un-
less extreme. The most common defect of vision among
persons in this country is myopia, the degree of which
to disqualify in time of peace, or exempt in time of war,
has not been determined for the United States Army.
Dr. Baxter, in his " Report of the Medical Statistics of
the Provost Marshal General's Office," states that "near-
sightedness does not exempt": Dr. Bartholow states,
"Myopia . . . is not aground for exemption under the
Enrolment Act, unless decided. " -' Tripler says, " Mj'opia
is an objection to a recruit." --'
As has been stated, the range of vision for recruits, de-
termined by the test dot cards, admits them " with minor
degrees of refractive anomalies " ; so far as myopia is con-
cerned, these degrees are such as to admit men from
whom efficiencj' as ritlemen cannot jiossibly be expected.
A man whose degree of myopia is as high as ^':j- can, with
each eye separately, count the dots at twenty feet, al-
though he does it with dilhculty; but it is not possible
for him to read the test types of Snellen, that should be
normally seen at that distance, nor to see the bull's eye
on a target at any of the ordinary firing ranges, and if
accepted as a soldier, he is therefore useless as a ritieman.
Even with so low a degree of myopia as -^j., the target is
seen very indistinctly, and it is a question admitting of
cousideralde doubt whether in such a case the soldier
would ever become efficient as a marksman without the
aid of spectacles; his vision would, however, be suffi-
ciently acute for all ordinary purposes, and hence, if
otherwise adesiraljle man, he might be accepted. The
order promulgating the vision test is so worded that but
few recruiting otlicers would feel themselves compelled
to exact a literal compliance with its requirement for the
recruit to "count with facility," and considering that he
could "'see well," if able to count the dots even with
the difficulty encountered by a myope of ^j degree, they
would accept him.
In time of war, however, higher degrees of myopia
may be admitted without seriousdetiiment to the service,
especially if a system were adojited by which men so de-
fective could be utilized in branches of the service other
than the line, as is the case in foreign armies, where, for
example, as in France, myopes of i and higher, and those
of yV and higher in Italy, Austria, Switzerland, and Hol-
land", are accepted ; to do this, the use of spectacles
wouiil, of course, be necessary. In the English army re-
cruits are admitted to the general service, and without
being graded, with ^tj- myopia; although Professor Long-
more states it " to be very questioualde whether any man
with myoiiia = ^V ought to be accepted as a recruit." -^
When the facts are considered tliat the character of our
service necessitates acuteness of vision in the use of the
rifle, and that wi; have a vast population from which to
recruit a small army, it seems proiier that the highest
standard of vision should be insisted upon, and that re-
cruits should not be accepted in time of peace unless they
have normal vision, as determined by test types, or are
myopic to a degree not exceeding J^ when otherwise very
desirable men. In time of war all degrees of myopia
above ^ should exempt, unless the use of spectacles is
|)erniitted, in which event, of coiiise, most higher de-
grees could be accepted. A very simple method for
roughly determining the higher degrees of myopia in
cases which are free from astigmatism and other defects
of vision is to ascei-tain the distance at which ordinary
newspaper type can be read by the myope. With the
normal eye this type is distinct at forty or forty-eight
inches, and the distance less tlian this at which vision is
distinct in the myope will express the denominator of a
fraction indicative of the degree of his myopia; for in-
stance, if the ty lie can be read at fifteen or twenty inches,
the person exaniine<l is about jV "'' C'V uiyopie, etc.
As in the case of deafness, the surgeon must he pre-
pared, in the examination of a conscript's vision, for the
most artfully laid schemes of di'ceiition; but if he has
patience, and works systematieally, he will, in a large
majority of instances, be able to ascertain the true state
of the case, and expo.-;e deceit if it be attempted.
Several excellent tests for the exiiosure of simulated
Si-i
REFERENCE II.VNDBOOK OF THE MEDICAL SCIENCES.
Rooriilts.
Recruits.
defects of vision Lave been piiblislicd, of whicli, doubts
less, tlie most conveuieut for use at a recruitiug rciulcz-
vous is tbat suggested bj' Ur. Howard Culbertsou, U. S.
A., aud styled by bim "the prisniometer." He describes
it as follows: "The prismometer detects errors of refrac-
tion by means of the displacemeut of the false image
seen through a prism. Its essentials are: a perforated
disc carrying a prism which covers one-half of the per-
foration, its truncated, thin edgedividing the perforation
into two equal parts, and a sbar]ily outlined, dead-white
disc, about 22 mm. in diameter, on a black, lustreless
ground jjlaced at a dist.ince from the prism of 15 to 20 .
This distance and the strength of the prism must be in
such proportion that when an emmetrojiic e3'e is placed
back of the perforation and directed to the "nhite disc, a
true aud a false image will be formed, whose peripheries
will be exactly tangent.
" In case the examined eye is hypermetropic the images
will stand ajiart to a degree varying with the degree of
liy IH-rmetropia : in the case of myopia, on the other hand,
thej" will overlap. The degree of ametropia in either
case is measured by the lens, which, when held before
the perforation, will render these discs tangent. By re-
volving the disc bearing tlie prism through an angle of
180° the false image appears to revolve about the true,
and in case of astigmatism the sejiaration or overlapping
is greatest in^he meridian in which the astigmatism is
greatest. Its axis may be determined by an index point-
ing to a graduated arc in contact with the disc; its de-
gree by the spherical or cylindrical glass which renders
the discs tangent in the meridian in which they varied
most from tangency."
Professor Lougmore •■' describes the prism test of von
Graefe aud the test by the stereoscope suggested b}' Mr.
Lawrence.
All of these tests depend for their success on the con-
fused statements of the .simvdator, wheu compelled to look
with his normal eyes through a prism, or to describe ob-
.iects especially prepared for view through a stei'eoscope.
The stereascopic objects require special preparation, and
while a most excellent test upon men of more than ordi-
nary intelligence, who maj* understand the efl'eot of
prism on visiou, it is not always practicable: any test by
a ]ii ism is a good one, but that proposed by Dr. Culbert-
sou is not only simple but effective, boi;h against simula-
tion aud in the detection of refractive errors; besides
these are the Snellen test with colored glasses and test
types; the xiseof various trial glasses, the ruler test, etc..
the description of which may be found in most works on
diseases of theeye. Valuable information maj' be gained
b}' a careful examination of the pupil in simulated blind-
ness of one e^'e; in an eye suffering from complete amau-
rosis the pupil is moderately dilated, aud but feebly re-
sponds, or:notat all, to the stiuuilus of light falling into
it : but does respond to the stimulus of light thrown into
the other eye. In the simulator, of course, the pupil is
normal. Other defects of the eye mentioned in tije lore-
going li.st should not exempt a conscript from duly, un-
less the vision is ver}' mati-riall}' interfered with, or, as
in the case of disease of the lachrymal apparatus, the
irritation produced by them keeps up a chronic inflam
mation.
T/ie JV'ttse. — Loss of the wlioUi/r part nf the nme ; ilrfwiiii
tics of tlin nose disfiffuriiif/ the face, senxihly altering the
voice, and impeding resjnration ; i>li'noxis and atresia' of
the vasal envity ; chronic r/iinitis{oza:nii) ; polypus ; puru-
lent and fa'tid discharye from the nose, whether due to old
find iucnrabU ukenitions. or to any other lesion of the nasal
nfiicoiis memhrane. disijualify.
Loss of the nose or parts thereof may be congenital,
accidental, or the result of sypliilitic or scrofulous ul<'er-
ations: in the two former iustances. unless the mutilation
is of sutlicient degree loniake a noticeable disfigurement,
or interfere with respiration, it is not cause for rejection :
in the latter instances it -would, of course, disqualify.
Deformities of the nose are generally jiroduced by acci-
dent or by disease, congenital deformities V)eing rare: the
nasal .bones imay be so .flattened, distorted, or destroj-ed
hy caries as to interfere with respiration and speech.
Syphilis creates great liavoc in this location, hence those
deformities should lead to suspicion of that disease, and
careful investigation of the case. Stenosis and atiesia are
either congenital or due to alterations in the natural posi-
tion of the septum, or to hypertrophies of the erectile tis-
sue lining the cavity ; in which latter condition the over-
grown tissue covering the turbinated bones is forced
against the septum, or projected in comb-like growths
into the naso-pharvngeal space: the breathing of persons
laboring under this defect is entirely by the mouth, and
their facial expression is often vacant aud silly ; the irri-
tation produced by the liypertrophied tissue keeps up
an excessive mucous secretion, to relieve which there is
an incessant hawking and spitting, and unless the cavi-
ties are cleared, decomposition takes place and is attended
by its pecidiar and nauseous odor. Deflection of the
nasal septum is probably the most common cause of ste-
nosis and atresia, the bone, in some instances, being
forced against the side of the nostril, to which its m\icous
tissue may become adherent. Chronic rhinitis (ozseua)
is readily detected by the horrible stench which patients
carry about with them; it is generall}' an eviilence of a
low grade of constitution, and aside from its disgusting
local symptom would require rejection. Polypi, puru-
lent discharges, etc., are all causes forrejection. In time
of 'tear, losses and deformities of the nose and oziena. are
tlie only defects which should exempt from militar}'
duty.
The Face. — Kievi; vnsiffhtly hairy sjMts; extensile ci-
catrices crn tlie face, disqualify: "their presence would
subject the man to the impertinent jests of his conn-ades,
to his personal aniRn'ance, and to the prejudice of good
order in his corps."
The Mouth and Fauces. — Harelip, simple, double, or
complicated ; loss of the whole or a considerable jiart of either
lip ; ■UH.fif/htly iimtilation of the lips from wounds, b-urns,
or disease ; loss cf the 'whole (vr part of either ma.rilla ; un-
united fractures ; ankylos~'^ ; dcfm'mities of either jait, in-
terfering irith tnastication or speech ; loss of certain teeth ;
cancerous or erectile tumen-s ; hypcrtropihy or atrophy of the
tongue; mutilation of the to-ngue ; adhesion of the tongue
to any parts, pre'Benting its free inotion ; malignant disease
of the tongue ; chronic xilceruvions ; fissures or perforations
of the hard 'palnte ; salitary or buccu-nasul fistula' ; hyper-
trophy of the tonsiU sufficient to -interfere irith respiration
or phonaiion, disqualify.
At the present da.y the army surgeon has to consider
oidy the number anil condition of teeth required foi- the
proper mastication of food ; the question of bygone days
as to their ittility or necessity in biting cartridges having
been settled by the introduction of breech-loading rifles,
and tlie .substitution of metallic for pajier cartriilges. It
is proliable that for many years to come the majority of
our arm_y will be stationed in the sparsi'ly settled Terri-
lorie.s, and be compelled to make annual campaigns, as
has been dene in the past, for the protection of settlers
from the lawless people aud disaffected or vicious Indians
among whom they have cast their lot. Tliese cam]iaigns.
from a food standpoint, are as trying to the digestion of
the men engaged in llieni as can be au\' campaigus in civi-
lized countries in times of war : for. as the men are moving
constantly from one camp to another, there is b:it little
ojqiort'.nity for the preparation of .soft bread, and tlie hard
biscuit must bo used instead thereof; if cattle are driven
with the command, they soon become poor from constant
travel, scanty food, etc., and their meal is so tough and
stringy that the best of teeih can make but little impres-
sion ujion it. and the strongest stomachs have dilhcnlty
in digesting it. Since the aboliticm of tlie (lajier car-
tridge, the tendency among military writers on tin's sub-
ject has been to underestimate the necessity for sound
teeth, apjiarently forgetting the fact that the soldier is
often placed in circunisiances in which they are an abso-
lute necessity for his health, and certainly indispensable
for his comfort. The statement made by Dr. Baxter-"
that." as a matter of fart, there are not many days in which
the soldier is not supplied with soft Jjread," is a grave
855
Recruits.
Rpmilts.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
mistake; if he had plenty of soft liread the mastication
of commissary beef in tlie field would still reijuire the as-
sistance of a goodly numlier of sound teetli ; hard biscuit
can be softened by a variety of processes, but no amount
of cooking will ever succeed in doing this for Ihe beef re-
ferred to. It has been within the experience of t lie writer
that men have beeudisaljled through sheer debility, while
on a protracted" scout, 'Miecause of their inability to mas-
ticate the food on which the command was obliged to
subsist. The molars and bicuspids, as the principal
agents in mastication, should therefore be in good condi-
ti"ou; it is not necessary that they should all be present,
but the smallest number should" be .six, viz., two upper
and lower molars, and ont; upjier and lower bicuspid on
the same side, all soiuid, and opposed to each other; if
the incisors an<l canines are jjerfect, but the molars and
bicuspids gone, or extensively carious, rejection is de-
manded. Caries of a large nuinber of the teeth, particu-
larly if advanced, with destruction of considerable por-
tions of the crowns, should reject, because it is probable
that, before the expiration of an enlistment, they will be
so far destroyed as seriouslj'to interfere with mastication.
The irritation of the gums caused by carious teeth is also
frequently followed b.y abscess and troublesome swellings
of the face and jaws. " If artificial teeth are worn, the fact
shovdd be noted on the enlistment papers, but the arti-
ficial substitutes cannot be regarded as taking the
places of the natural teeth, noraiTremoving the disability
for the military service arising from their loss. Lesions
of the hard and soft palate must be carefully looked for,
and the tonsils thoroughlj' examined ; ulcerations and
Couse(juent perforations of the hard palate are often situ-
ated in the anterior partof the mof of thenioutb, and un-
less the head is thrown well bad;, and the jaws are widely
separated, the}' may be overlooked. Ulcerations of the
cheeks and guius, and especially on the sides and back of
the tongue, must also bo carefullj' searched for; in the
latter situations they are often difficult to see, unless at-
tention is called to them liy the patient, as their location,
either between the papilla' or following the course of the
musrulartibres, conceals them from ordinary observation,
especially if the tongue lies quiescent in the tloor of the
Dioutli, with its sides (uotected by the teeth. The sub-
jects of excessive hypertrophy of the ton.sils are midesir-
able as recruits, because of the likelihood that, at most
inopportune times, they may be .seized with an acute at-
tack of inflammation of the parts, it being a well-estab-
lished fact that previo\is attacks, of which the hypertro-
phy is the sequel, predispose to subsequent ami i.iore
severe ones at any time; phonation, too, is materially
interfered with, unfitting tli<' man for certain important
duties, especially while detailed as a sentinel.
In time of trur, simple harelip, loss of teeth, cicatrices,
hypertrophy of tonsils, sliovdd not exempt.
Exemption on account of loss of teeth is fre(|uenlly
claimed by con.scripts, and lias been regarded as good
cause; men with such defects can, however, be made use-
ful in the various administrative departments of the
army, where the necessity for having .sound teeth does
not exist; therefore exemptions should not be granted
for tills cause; the wearing of artiticiid teeth may. wider
these circumstances, be favorably considered.
T/ie Seek. — Ooitre ; vlceratiaiis of the ccrHedl f/lniids;
eieatrices tf scrnfulons iilcereitions ; tme/ieiilopeiiiii;/s ; irri/-
tieck : e/iroiiie laryngitis, or nni/ otJier di.ietise of t/ie larynx
irhieli ironld produce aphonia; stricture of Ihe a-mphitr/us,
disqualif.v.
(Joitre is not often met with among the class of men
who are applicants for enlistment; should it be recent
and growing, or of sufficient size to interfere with respi-
ration, or with the hooking of the coat collar, or button-
in.g of the coat, it is cause for rejection. The cicatrices
wiiich are found in scrofulous subjects, who in ehildliood
have had su|ipuration of the cervical glands, are both
unsightly and liable to become irritated in liot weather
by the coat collar; of course, as being indications of the
presence of scrofula either in the past or present, they
render it necessary that a careful inspection slumld be
made of the person for other signs of that disease; if
none exist, and the cicatrices are healthy, the applicant,
if otherwise desirable, may be accepted ; but if they are
numerous, purplish colored, or adherent, rejection is de-
manded. Any ulceration about the neck, either of the
lymphatics or in the tissues, is cause for rejection; wr_y-
neck, if permanent from any cause, should reject. Any
chronic inflammation of the larynx, producing a huski-
ncss of voice sutlicient to render speech indistinct, or to
induce actual aphonia, should reject. Of course the
simple hoarseness of ordinary colds is not to be con-
sidered, but any well-marked alteration of the voice
should lead to an examination of the larynx in which
the existence of organic changes would be cause for re-
jection.
Irt time of war, onlj' very extensive cicatrices, active
ulcerations, or tracheal openings, should exempt; the
presence of goitre, unless very large and unsightly, and
wry-neck, if caused b^y rheumatism or any curable dis-
ease, should not exempt.
The Chest. — Malformation of the chest, or badly united
fractures of ribs or sternum sufficient to interfere irilh res-
piration ; caries en- 7iecrosis of ribs, deficient e.vpan.tire
mobilily ; erident predi.-<position to phthisis ; phthisis pul-
monalis ; chronic •pneftmoni(t. ; entphysema, chronic pleu-
risy ; pleural effusions ; chronic bronchitis ; asthma; or-
ganic diseases of the heart or large arteries ; serious and
protracted functional derangement of the heart; dropsy
dependent v/ion a disease of the heart, disqualify'.
In obtaining measurements of the chest the movements
of inspiration and exjiiration should be confined entirely
to the muscles of respiration; the applicant should be re-
quired to inflate the lungs to their fullest extent by an
easy, though complete, inspiration ; expiration should be
made in the same quiet manner, and is most completely
accomplished by requiring the applicant to count aloud
until the necessity for a fresh supply of air compels him
to inspire again. No contortions of the body .should be
permitted — such as throwing the chest forward a:id
shoulders backward during inspiration, nor forcing the
shoulders forward during expiration. — as these move-
ments can do nothing more than produce erroneous re-
sults. The measurements are to be taken when the man
is stripped; the arms are extended above the head, the
tape is brouglit around the chest in such a manner as to
fall just below the points of the scapuUe behind, and the
nipples in front; the arms are then to be brought down
by the sides of the body, and while the tape is held tight
enough to lie snugly against the skin, the man is di-
rected to respire utter the manner before related.
Attention must be paid to the proper proportion of
the chest; the fact, however, being borne in mind, that
certain occupations have a tendency to change its shape
without producing any lesion of the lung tissue; the lat-
eral flattening of the chest walls so often found in tall,
slender men. or those of slight frame, with projection of
the sternum — the "pigeon breast" — is more likely to be
associated with organic changes in tlie lungs than is the
flat or hollow cliest — the autero-posterior flattening.
Slalformations of the sternum and cartilages of the ribs
are less likely to be present in the pun}' or phthisical sub-
ject, and have little or no significance in pulmonary di.s-
orders. It should lie the object of the medical examiner
to accept only men who have well-formed chests, or. as
it is expressed in the Army Regulations, "whose chests
are ample"; any deviation from the typical be.-ilthy
thorax being considered good ground for susiiicion of
changes in the normal character of its contents.
It is entirely beyond the scope of this article to go intb
the details of a physical examination of the lungs; hence
it will besulflcient to say that both auscultation and per-
cussion should be performed before the examiner is satis-
fled to pronounce ujion the availability of his patient for
the military service; with the exception of the examina-
tion of the heart, there is none other which demands tlie
exercise of so much care. Close questioning should be
made into the family hi.story of every a]ii)licant, as well
as into his own life and habits, for any evidence of a pre-
856
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
Recruits.
Recruits.
disposition to plitliisis or the occurrence of attacks of
pueuniouia or pleurisy ; for a general susceptibility to
changes of climate, weather, etc. ; for the occurrence of
asthmatic attacks, spitting of blood, etc. ; in tine, for any-
thing which would bring out a clew to the previous ex-
istence of any alTection connected with the pulmonary
apparatus. Particular stress is laid upon this subject,
because it is no uncommon thing to And men seeking
army life with a hope that its supposed freedom, regular-
ity of habit, and their own location in particularly salu-
brious climates, might benefit an already existing lung
trouble. Parents consent to the enlistment of their boys
under the impression that the life of a .soldier will "har-
den tlieir lungs." and recruiting officers will often urge
the acceptance of applicants wiiose skin is suspiciously
clear, upon the ground that the service will "bring them
out"; "make new men of them," etc. ; tlie medical ex-
aminer must, therefore, be especially on his guard against
the admission of such men into the service, and recollect
that lie is not required to diagnosticate any particidar le-
sion of a lung in order to reject an applicant, but, if be
has reason to suspirt a predisposition thereto — unhesitat-
ingly to reject.
Dr. Tripler quotes very aptly from Bezin, as follows:
"It is true we run the risk of rejecting men who may
afterward become very robust, and who, by a long and
successful life, ma}' contradict the prognosis we maj'
have pronounced in their cases, but . . . you will be as-
tonished at the number of j'oung men who, received be-
cause no determined lesion of the thorax was recognized
when they were inspected, succundj afterward Avith
phthisis, or whom it was necessary to send back to tlieir
friends and families with broken health, after their
strength had been exhausted." (Aide-Mcmoire.)
Of organic diseases of the heart, those affecting the
valves are easily detected, and recjuire no detailed notice
here ; tliere is occasionally heard, however, a cardiac mur-
mur which is not indicative of any disease of either heart
or lungs, and about which the text-hooks on the general
subject are silent. It has been described by Dr. Hamilton
Osgood, in a pajier read in March, lys3, before the Boston
Society for Medical Improvement, and published in vol.
cviii.. No. 13, of the Boston Medical mid tSiiruical Journal.
Dr. Osgood gives to it the very approjuiate name of a
" misleading cardiac murmur " ; it is heard during the re-
spiratory act, with a portion of which it is synchronous
(especially inspiration), and is located at tlie base of the
heart. When respiration is temjiorarily suspended it
may be heard, although not so distinetlj' as during the
normal act; its true nature is to be discovered by auscul-
tation during forced collapfe of the lunrjs ; mere ordinary
expiration will not uncover the heart, and the patient
must be instructed to force out all the air possible, con-
tinuing his elforfs until air can no longer be expelled
from the lungs; after which the lungs must be kept im-
movable. By this ]irocedure the heart is brought more
clo.sely in contact with the ear, and is freed from the
presence of lung tissue, which, in the inflated lung, par-
tially covers it; the "misleading murmur" will now be
found to have disappeared. Aside from its value in de-
termining this point of doubt, forced expiration of the
lungs is a valuable adjunct in the examination of the
heart under anj' circumstances; when that organ is un-
covered, the natural as well as morbid sounds are more
sharjily accentuated, and deviations from the normal
will be more easily discovered. If the patient is required
to put the anterior chest wall on the stretch by standing
witli his back against a door or post, and his hands car-
ried forcibly liehind his back, the results will be much
more satisfactory.
In the diagnosis of cardiac hypertrophy, associated or
not with dilatation, tlie inexperienced medical examiner
may lie easily misled. The movements of the heart are
so largely under the influence of the synqiatlietic nervous
.system that any cause acting directly through that .sys-
tem may produce such alterations of its rliythmical action
as will lead to the ojiinion that they are the result of or-
ganic change. When the hand is placed upon the chest
of an applicant who has just passed through the prelimi-
nary questioning, and has been strippeil for examination,
the heart will probably be found in tumultuous action ; in
some instances so violent as to produce a feeling of faint-
ness. The excessive use of tobacco and colTee. or either,
will also produce so much functional disturbance, irregu-
larity of action, and palpitation, that organic changes
may be suspected. The powerful, rhythmieal action of
the enlarged organ in true hypertrophy, taken in con-
nection with the permanent change in the location of its
apex beat, will supply the evidence mostly to be relied
upon in forming a correct opinion of the case presented.
It is not, however, always possible, in the short time al-
lotted to the preliminary examination, to decide whether
the abnormal action is functional or organic, and in all
cases of doubt the applicant, if otherwise desirable,
should be kept under observation for two or three daj'S,
in order that he may become accustomed to his .surround-
ings, and recover soniewdiat control of his nervous
system. Should it become apparent that even a func-
tional disorder of the heart is persistent, or so serious as
to interfere with the usefulness of the applicant, he
should be rejected. The sequela' of cardiac lesions,
dropsies, pulmonary engorgements, etc., will require
close consideration, particularly in their earlier stages;
but it is a rare occurrence for men in a state of disease so
far advanced as these symptoms would indicate, to come
to a rendezvous. In all cases of suspected cardiac le-
sions, the urine should be carefully examined.
The directions stated in the "mode of examination," on
a previous page, — viz., to auscultate the heart before re-
quiring the applicant to go through the violent exercise
of running, jumping, etc., — were given for the reason
that the sounds of the heart are best heard when the pa-
tient is at rest. The lungs are best examined while rapid
breathing is induced; hence the directions for their ex-
amination after the exercise mentioned. Should any
le.sion of the heart have been suspected, its rapid action
after exercise will tend to bring out more prominently
the abnormal sound. Advantage should be taken of this
excessive action to examine the course of the blood-
vessels in the neck and other parts of the body, with a
view to the detection of aneurisms.
In time of tear all diseases of the heart and lungs should
be cause for exemption, without exception.
The Abdomen.— All chronic infammations of the gas-
tro-iniestinal tract, inclvding diarrhcea and dysentery ;
diseases of the liver or spleen, includin;/ those caused by mal-
arial poisoning ; ascites; obesity; dyspepsia, if confirmed;
hemorrhoids ; prolapsus ani ; fistula, in ano ; considerable
fissni-es of the anus ; hernia in all situations, disqualify.
Among the list of disqualifications mentioned by Trip-
ler and Baxter are engorgement of the mesenteric glands,
chronic peritonitis, stricture of the rectum, and taenia'.
The first three of these diseases are exceedingly rare, and
their diagnosis is a matter of considerable difficulty at best.
It is not very likely that the sulijectsof them will present
themselves for enlistment, and they are accordingly
omitted from the disqualifying list, because they fail
within the list of general alfections impairing the efH-
cieucy of men for military duty, the mere mention of
which would extend an article into the limits of an elab-
orate treatise, and the discovery of which would natur-
ally be cause for rejection. The existence of any species
of tapeworm is not considered a disqualification, their
ex pulsion from the intestine being so easily accomplished,
and their presence producing so little constitutional dis-
turfjauce in the adult. To ascertain whether chronic in-
flammation of the gasti'o-intestinal tract, or dyspepsia of
an aggravated form, is present, the medical examiner
will iie compelled to rely largely uixin the statements of
the man himself. Accuracy of diagnosis cannot be ex-
pected except after observations conducted for a greater
or less period of time; many instances terminating only
in negative results. The grosser signs of these disorders
may Tead to suspicion of their existence, but in men anx-
ious for enlistment, all evidence tending to establish the
fact will be concealed, although the emaciation attendant
86T
Kccruits.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
upon loiiiT-standiug aud serious cases should put the ex-
aminer ou Lis guard. Fortuuately, but very few of them
are presented, aud the mere mention of tlieir names is
enougli to draw attention to the proliahilities of their
presence. Affections of the liver and spleen are of more
practical moment, when one considers llic fact that a
large proportion of our recruits i .; drawn from ,seetions
of Uic country in which malaria is rife, and where men
whose .systems are broUen down by the iulluenee of this
poison are forced to quit their ordinary employments
aud seek a livelihood in .some other aud more healthful
region : the army offering the easiest means for accom-
plishing the object. In tliese instances enlargements of
the liver and .spleen will be found, and associated with
them the aiuemia and generally debilitated condition
characteristic of maUuiiil poi.soni'ng. From some of the
rendezvous subsidiary to the depot at Columbu.s, O.,
■which were located in malarious regions, the men en-
listed were feeble aud an;emie, with enlarged spleens,
drop.sical legs, and a mental dcjiression which was an
apparent bar to improvement uniler their changed condi-
tion of life; in many instances this change of climate,
etc., brought about a recurrence of the iieriodic fever,
neces.sitating admission to. and protracted treatment in,
hospital, and leaving the men utterly useless for future
service. The evil became so great that orders were
finally issued to discontinue the objectionable rende/.-
Tous, and abandon the infected districts; attention,
then, must be given to the condition of these organs, in
all cases in which the general ap]iearanee indicates mal-
arial poisoning. Obesity, or pendulous abdomen, im-
pairs the efficiency of men for milit;u y duty ; they cannot
take active exercise without loss of breath, or in warm
weather without suffering from e.\coriations, prickly
heat, etc.; and moreover, in ail such cases the presence
■of fatty degeneration of the heart and arteries is to be
suspected. Hemorrhoids are so very common, and of so
many degrees of severity, that it is impossible to lay
down any tixed rule by which all cases are to he decided ;
each must be juilged upon its own merits, and rather by
the elfeets of the disease upon the individual, than by
the size of the tumors or their age. Internal hemor-
rhoiils, except when protruding, cannot be discovered
unless then' are bleeding at, or just before, the time of
examination, the evidences of which v>iU appear upon
the person or clotbiug of the applicant; thev may possi-
bly be ulcerated, in which evei;t there will be a purulent
discharge from the anus, wliieh. however, may occur
from other cau.ses; but its appearance shoidd be the oc-
casion for a careful inspeetiiai of the rectum, if the man
denies being the std)ject of piles. Their existence ia an
absolute cattse for rejection. External hemorrhoids, if
multiple an<l large, ulcerated or inflamed, should reject.
The small, accidental pile, coiuinonly met with in nu'u
of coiislipated habits; tlu! peduuculatioiis found in men
of lax tibre, or old piles in which tlie former mucous lin-
ing has become transformed into a hard and iusmsitivc
covering similar to true skin, arc not causes for rejection,
if the man states that thej- have not given him trouble.
The.se statements .should, however, be taken with many
doubts, as thedesire toenlist will lead men to pi'evaricate
about that point, tind I he medical examiner will beobligc'd
to form his own opinion from thj apiiearaiiees presented
by the tumors, anil from their ell'ects upon the surround-
ing iiarts.
Althotigh fistula in ano may l)e di'^covered by means
of the discharge from its track in most cases, a careful
inspection of the parts near the anus, for the external
opening of the fistula, is ■necessary; in very hairy men,
the hair must beiuislied aside aial every ]ioiiit suggestive
of the apjiearance of a fistula ex))lored with a probe.
Tliere shoidd be but little dilliculty in discoveiiiig any
well-developed forms of hernia; it is those cases which
are incomplete or iiarlially developed aliout which the
surgeon may be perplexed. The examination should al-
ways be made while the man is standing, aud with his
hands extended above his head; tlie surgeon should ex-
amine the umbilicus, and afterward each ingidnal eaual,
carrying his finger well up to the internal ring, aud re-
quiring the man to cough vigorously ; if the bowel
protrudes to any degree from the abdominal cavity into
the canal, it can easily be felt. There can be no doubt
as to the unfitness for service, in time of peace, of an
applicant wlio has a hernia, all varieties of •\vhich,
whether complete or incomplete, are absolute causes for
rejection; cases, however, in which the inguinal rings are
relaxed, in which there is supposed to exist a "tendency
to hernia," are not so easily disposed of; the question as
to the acceptance of men having this tendency' being still
an open one. In some foreign armies it is considered a
sufficient cause for rejection, but in our service the judg-
ment of most medical officers is adverse to such an opin-
ion. While it is true that the exertion incident to certain
phases of military life may produce a hernia in men hav-
ing relaxed inguinal rings, it is equally true that the ac-
cident may happen quite as often (relatively) to men who
do not have tins defect; indeed, there is no especial evi-
dence to show that this is n'lore frequently a predisposing
cause than is any other. The experience of the writer
fully contirms the statement made by Tripler,"-' that "by
far the greater nmuber of Iternia' that have fallen under
our observation h;ive occurred in comparatively robtfst,
thick-set men; just the '.nen who rarely have relaxed ex-
ternal rings. " Tlie exclusion of this class of cases would,
it is believed, result in the loss to the service of many
excellent men, and until it is shown that they are more
liable to the defect than others, rejection is not demanded.
The examination for a hernia should, however, be very
carefully made, and the applicant retpiired previously
thereto to run, jump, or takeother violent exercise; care
must be used in the examination of a .scrotal heruia, that
a mistake be not made in confounding it with other tu-
mors connected ■svith the ciud or testicle — an error one
might very easily fall into when examining any largo
number of men. The tissues covering an umbilical her-
uia are so very thin that there can be but little room for
error in diagnosis; indeed, the fact is that any thinning
of the abdominal walls in that vicinity amounts practi-
cally to a hernia; but one must not confound witli a her-
uia a not uncommon malformation of the umbilicus, in
which, through some morbid process during the separa-
tion of the cord, a nipple-like tumor has been left that
bears no small resemblance to an iimliilical hernia.
Ill iijiw of win- it would not be proper to reject men
who had hemorrhoids, unless, if internal, they were very
large, and the constitutional elTccIs produced by the
bleeding, or the irritation set up by their presence, was
plainly visible; in case of external hemorrhoids they
should be very large, painful, and of long standing, to
be cause for rejection. Herni:B which are easily reduc-
ible and retained in position by a well-fitting tru.ss, or
those which are incomplete, should not be cause for ex-
emption. All other tlefects which disqualify in time of
peace do so cipially in time of war.
The Geiiilii-L'riiHiri/ Oiyanfi. — Ainj acute uffeclion of the
rjenitiil oryniix^ liirlinli iig ganorrha-d and venereal sores ; loss
if the penis: 2'hiiiiosis ; stricture of the wethra ; loss of
both, tcaticlcs ; juriiKiiiciit ri traction of one or liiith testicles
icithin tlie e.iterual ring ; auji chronic disease of the testi-
cle ; hydrocele of the tunic find cord: atrophy of the testi-
cle; varicocele ; inaforniations of tht genitalia ; inconti-
nence of urine; urinary fstulie; enlargement of the
prostate; stone in the bladder; chronic cystitis ; all dis-
eases of the kidney, di.sqiialify.
The existence of gouorrhfra, or a venereal sore upon
the peni.s, should be cause for rejection: aside from the
fact that the subject of either of these affections is liable
at any time to communicate it to his comrades, it is not
possible for any one to foresee the complications which
may arise during the com'se of either form, nor the se-
quela' it may leave behind. Venereal diseases are so
Very common, and held in such light estimation by the
laity, and indeed by many of the profession, that their
existence is looked upon rather as an inciilent in the ordi-
nary life of a soldier, than as a serious matter which may
disable the victim for life. Jlcn who have been iuadver
-858
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Recruits.
Kccrults.
tcntly enlisted with some form of veuereal disease shoukl
he placed iu li()S]iil;il at once, both as a measure of cure
ami for the purpose of isolation. It is to tlie iuterest of
the service that such cases should receive prompt atteulion
as, eveu if their progress toward a cure is not delayed by
■complications, their teruiinatinns are liable to be marked
liy peruiauent disabilities, demanding linal discharge.
Cases of gonorrhcea arc frequently followed by stricture
of the urethra, and veuereal sores are almost as likely to
jirove syphilitic as iuuoceut. The instructions laid down
iu te.xt-books for the differential diagnosis between chan-
croids and chanens will prove but a poor defence should
a recruit wlio at the time of eulistnieut is the subject of
a chancroid be afterward discharged on account of con-
stitutional sypliilis. The princijile that the Government,
is justified iu caring for such cases in its hospitals, for
the purpose of securing tlie services of good men tem-
porarily unfortunate, is entirely wrong, aud the desired
result is seldom attained. The experience of the writer
is to the effect tliat the large majority of such cases ter-
minate by discharge, before tlie subject lias been able to
render any considerable portion of the service for which
he was enlisted.
The existence of any stricture of the urethra is cause for
rejection; its presence can be delinitely determiued only
by the u.se of the sound, a iiroce<lur<' deuiande<l in all
cases giving ground for a suspicion of disease; the con-
dition of the stream passed in urinating must be carefully
inquired into, and all information relative to a history of
the case elicited by closely questioning the patient, before
resorting to the use of an iustrumeut. Simple narrowing
of the meatus, which is congenital iu many persons,
should not be considered a cause for rejection.
Phimosis, if complete, is liable to give a great deal of
trouble to a soldier by repeated attacks of balanitis; if
there is adhesion between the prejiuce and the glans,
partial or complete, gi'aver symptoms may present tliem-
selves, and his elliciency may be impaired by retlex pa-
ralyses, epile|isy, or other nervous atfections, for the relief
of which surgery is required ; for these reasons it is made
a cause for rejection. When both testicles are absent
from the scrotum, the inguinal canals must be carefully
e.xamined for evidence of their retention therein ; loss by
injury may be known by the .scar remaining on the scro-
tum ; shruild one or both testicles be found permanently
resting in the inguinal canal, or absent from the scrotum
from any cause, the applicant should be rejected. In
affections of the testicle, discrimination must be made
between true diseases of this organ and morbid changes
in the cpidid3'mis, the result of inllammatory action.
The most common defect among the class of men who
present themselves for enlistment is tlie enlargement
from interstitial deposits following orchitis — .sarcocele —
which, when inconsiderable in size, is not a cause for re-
jection; a diagnosis must, however, be made between it
and other enlargements of the testicle, cither syphilitic
or malignant ; aud should there be reason to believe that
tlie enlargement is due to either of the latter causes, or
should its size be such as to give annoyance to tlie pa-
tient, rejection is demanded. A Iiydrocele may mislead
one in cases of this nature, and the test by transmi.ssiou
of light should tlierefore not be omitted iu any examina-
tion of tlie organs.
It is exceedingly rare to find a varicocele of such size
as to become a real disability to a willing soldier iu any
branch of the servi(-e. excepting perhai)S that requiring
him to Tie mounted^under whieli circumstances he may
injuie it or thi^ testicle — which iu these cases han.gs very
low. — against the saddle; but as it is a defect which may
lie made to ajipear a disability, the soldier has an ever-
present excuse for the evasion of duly, or a ground up(in
which to base an a])plicatiou fcr discharge. So long as
he can demonstrate the existence of a disease or defect in
any organ, so long will it be impracticable to insist upon
a performance of his duty, and it is this circumstance
rather than any well-grounded belief in the disqualifying
nature of a varicocele, as well as the more general princi-
ple that no men should be enlisted who are the subjects
of any recognizable physical defects, whieli leads to its
being placed tipon the list of causes for rejeelioii. The
rule laid down by Tripler is an excellent one for the de-
termination of the degree of varicocele wliich should re-
ject: "If the testicle on that side is atrophied, whatever
may be the volume of the circocele (varicocele), or if the
volume of the latter exceed that of the former, the recruit
should be rejected." ■'
Among malformations may be mentioned epi- and hy-
pospadia, where tlie urethra terminates at a distance
nearer the body than one-fourth the length of the jienis.
Incontinence of urine may be suspected by a urinous odor
about the person of the applicant, or by the appearance
of his clothing, which may be stained ; of course there can
be no evideuce of the fact except after certain ohserva-
tion, and, therefore, the statement of the man must be
taken as to its absence before he can be accepted.
If any disease of the kidney is suspected, a careful ex-
amination of the urine should be made by chemical rea-
gents, extended if nccessaiy to an examination by the
microscope. It is, of course, presumed that the applicant
will be closely questioned as to the existence of any symp-
tom which would point to renal trouble; the presence of
albumin, sugar, blood, or pus iu the urine, although duo
to temporary ailments, is ground for ab.solute rejection,
as would also be dropsical efl'usions into any of the tis-
sues in the body.
In time of war acute affections of the .generative organs
should not exempt ; the subjects thereof can be iilaced in
hospital until cured of the immary ditliculty, and those
who are free from constitutional taint, or who have very
slight strictures, should be sent to active duty. Phimo-
sis, loss of testicles, hydrocele of the tunics and cord, un-
less interfering with locomotion, and spermatoi'rho'a. are
not causes for exemjifion, as men sullering from these
defects rrai be made u.seful in the administrative depart-
ment, and iu some cases in the line of the arm_y.
Affectinns Common to both Upper and Lotcer Rrtremities.
— Vhroiiie rheumdthm ; chronie discuses of joints ; old or
irreducible dislocations or false joints ; serere spriiins ; re-
In.mtion of tlie ligaments or capsules of joints ; dislocations ;
fstiiliB connected with joints or any part of hones; drojisy
of joints; badly united fractures; defectire or ci'cesi-i re
eurminre of long bones; rickets ; caries; necrosis; exos-
tosis ; (itrophy or pandysis of a limb; extensire, deeji, or
adherent cicatrices ; contraction or permanent retraction if
a limb or portion thereof ; loss of a limb or portion thereof,
disqualify.
N earl}' all defects in the extremities are apparent by
some impairment of the natural shape or motion of the
limb, and can hardly escape the notice of one who exam-
ines atleiitively his cases; indeed, iu the inspection of
large numbers of men one becomes so expert as to dis-
cover departures from normal sliapc ami motion as if iiy
intuition. Diseases which affect the coutinuity of limbs
but which do not necessarily interfere with motion or
alter shape, ma}' occasionally require careful search for
their detection.
It is more frequently the case that the surgeon is called
ujion to exercise his judgment in deciding how far an
existing blemish may iuqiair the etticicncy of !iu appli-
cant, tlian he is to exercise his skill in .searching for hid-
den or obscure disqualifications; this is particularly the
case in .severe sprains, dislocations, targe cicatrices, and
chronic rheumatism. It sliould be remembered, in the
]U-eliminary examination of the shoulder-joints, that it
occasionall.v hajipeiis that men cannot touch tlie point of
the shoulder with their fingers, anci a careful .search fails
to reveal any imperfection of the joints of the extremity.
It is iini>oitaut, in such a case, that the elbow aud wrist
should recei\'e especial inspection, as a defect is most
likely located at one or both of these points; but rejec-
tion is not demanded unless a defect is clearly made out,
as an extreme muscular development may be the cause,
or a congenital .shortening of some of the bones exists
without an interference with any other than this particu-
lar movement. Men desiring to enlist will seldom, if
ever, admit the presence of chronic rheumatism, and it is
85»
Remiits.
Rertiiiii.
REFERENCE HANDBUOK OF THE MEDICAL SCIEN'CES.
oulj' wlifii, as a result of tliis discnsp, one or more joints
arcswolk'U or otlierwise disabled, llii\t the surgeon can
he aware of its existenee. The absence of any of these
evidences will occasionally enable a man to enlist who
has been previously discharged from the service ou ac-
count of alleged chronic rheumatism, in which event
the medical examiner would be blameless of the charge
of carelessness, as in all probability the discharge was
procured through fraud and malingering. Chronic rheu-
matism of sufficient severity to warrant a discharge from
service shtiuld be followed by tangible evidence, in the
shape of swollen or distorted limbs, deposits in the .joints,
or enlargements in the siuTounding tissues, and these are
not likely to disajipear ; close inspection must be made of
all joints to discover any swelling or other evidence of
sprain: lameness of an inferior extremity, or stiffness of
a superior one. slioulil be an indication for careful ques-
tioning as to the receipt (d' injiuy.
It is not always wise to place too much confidence in
the statements of men us to their freedom from pain or
ability to move joints which have been injured. It is
well known that the remote effects of sprains and other
joint injuries, particularly of the ankle and wrist, arc lia-
ble to manifest themselves, even at a late period, in swell-
ings or pain after severe exertion ; and however lioncst
one may be in I he Indief of his perfect cure from such an
injury, and ability to jierform all duty reqtiircd of him,
there lUiiy bean actual defect of which he is ignorant.
The n)edical examiner, therefore, must exercise his own
judgment from the appearance of the parts, their sensi-
tiveness, etc., as to whether this is the case or not, and he
sliovild reject in all instances which give room for doubt.
Fractures which have been properly treated, and have
united without deformity, arc not of themselves causes for
rejection, but when they are followed by neuralgic pains,
or if lliere has been much disiilacement of fragments, so
that tlie synunetry of the limb is destroyed, or if from
excessive bony dejjosits there is impairment of motion,
they are causes for rejection. Fractures of the bones of
the forearm are very likely to give troul.ile by interference
w'ith the motions of pronation and supination, both of
which aw necessary in handling the rifle during the exer-
ci.ses in the manualof arms. Jtalformationsof the limbs,
as excessive eiu'vature — bow-legs— are objections rather
because of the awkward gait the.v induce than from any
interference with tlie abilitj' of the man to march; when
the curvature is caused by a constitutional taint, as rick-
ets, etc., there can be no question as to the propriety of a
rejection, .\bnornial cartilaginous or bony fornial ions in
the muscles, or Ioo.se <'arlilages in the knee-joint, are ob-
jections when they imjiair the use of the joint.
Jii tiiiif of iriir especial care is necessary, particularly
in those affections which present but little external evi-
dence of injury, to detect deception: chronic rheuma-
tism, sprains, allegeil dislocations and fractures, must not
be made causes for exemi>tion unless the evidences of
impaired strength and motion of the parts in which they
are located are indisputable. Allegations of pain, loss of
motion, involuntary contractions, etc., Avill constantly be
made, and if the surgeon has no other means of conqilet-
ing his diagnosis in a ease of sus]iiciiin. he shoidd resort
to the use of ana'slhetics, imder which simulation ceases,
and the true state of an alleged disability will be made
apparent. One must, however, bear in mind the fact that
in central lesions of the brain contractions disappear dur-
ing chloroform narcosis. It should be stated that author-
ity for the u.se of an.-esthctics is limited "to cases of ])ro-
fessed rheumatic contraction of joints when unattended
with peiceiitible alteration of form or structure." ■' al-
tliougli it is recommended in a wider range of cases by
Tripli'r and Bartholow, both atithorit.ies recognized by
the War Dejiartnient. Au ingenious test for simulated
contractions of limbs — flexures — has been suggested by a
Russian military surgeon, and is published liy Zuber.'-'
It consists in ajiplying tight!}' to the aft'ected lindi an
Esmarch bandage, as if for aminitation ; when the band-
age is removed, the rubber cord remaining, the limb
Straightens itsidf involuntarily. The test has been tried
in but few cases, and may not invariably succeed, but it
is worthy of further trial.
All otli<'ers of experience in tlie examination of malin-
gering soldiers agree upon the fact that their most vul-
nerable point is in an exaggeration of the symptoms which
they endeavor to simulate. When a man comes limping^
before a surgeon with every expression of pain upon his
countenance, or assumes the most unnatural and con-
strained positions of body or limb, he ma_y. in nine in-
stances out of ten, be set down as a malingerer, if he
]iresents no external jjh.vsical signs of disease; there is
something about a real sulTercr or cripple which is very
hard to describe, but which every surgeon will recog-
nize; and in a large number of instances the problem
will be, not so much in recognizing the deception, as in
compelling the subject to admit it.
The Superior Extremities. — Fraeture of tlie cUiricle ;
fracture of the radius and ulna; icel/hed finr/ers ; perma-
nent fe.rion. or extension, of one or more fnc/ers, as well as
irremediable loss of motion, of these parts; total loss of
either thumb ; mutilation of riglit thumb; total loss of the
index finger of the riyht hand; loss of the first and second
phalanges of all the fingers of cither hand ; total loss of any
two fingers of the same hand, disqualify.
Fractures of the clavicle, which are almost invariably
followed by more or less deformity, are causes for rejec-
tion in conseiiuence of the painful pressure made at the
Seat of injury by the ritle, during certain movements in
the manual of arms, and by the "sling straps" when
carrying the knapsack or haversack. The mere fact that
the clavicle has been fractured is not of itself cause for
rejection, and even the presence of a slight deformity
should not be objectionable, provided there is neither
pain on pressure nor interference with the free motion of
the arm. The improved means of transporting the bag-
gage of the soldier have in a great measure (.lone away
with the necessity for his knapsack; the few articles of
clothing which ho requires in the tield are rolled in his
blanket, which is slung over the shoulder and across the
chest, and thus carried without inconvenience or pain to
any part of the clavicle which may have sustained an
injury. The haversack strap may, however, on long
mareiies, or when the sack is well tilled, produce painful
]u'e.ssure, or eveu excoriate the skin, and the gun is very
liable to injiu-e a prominent d.-formity on this bone.
Therefore a tumor at the seat of fracture, from whatever
cause, if considerable, would be a valid objection to en-
listment. Any fracture of the radius and ulna, particu-
larly Codes', is liable to be followed b_v iuqiairment of the
motions of pronation and supination of the forearm —
movements indispensably necessary in the drill of the
manual of arms, the "set up " drill, and other military ex-
ercises. fShouUl this be the case, rejection is demanded;
otherwise, union and motion being perfect, the injury is
not a cause for rejection. The degree of mutilation of
the hand which should disqualify can be determined only
by the facility with which a man so injured can handle a
rifle. In loading tic Springfield (army) ritle, the breech
block is thrown open and the cartridge thrust home by
pressure of the right thumb, the ritle is also cocked liy the-
same member; hence it is very im]iorlant thai it should be
intact: and any injury which materially interferes with its-
flexion or strength is a cause for rejection. The common
distortion of the extremity due to contusion or felon need
not disqualify; the loss of the entire memlier would, of
course, reject; loss or mutilation of the last ])halanx of
the left tbuml) need not disqualify. The first and second
phalanges of the right index finger may be lost or mviti-
lated withi>ut necessarily disqualifying an otherwise very
desirable recruit, or a soldier who desired to re-enlist; it
is ordinarily the finger used in pulling the trigger, Init
this can be done with facility by a stump, or by the mid-
dle finger, as is the case with many marksmen whose
fingers are perfect; it should, however, be the rule for
recruits to have a perfect right fori'linger. departures
from which rule should be tnade only in rare instances and
for Very good reasons. Permanent flexion or extension,
or loss of motion of anv lingers, so materially interferes-
860
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
KL'C'tUIU.
with a military use of the hand as to demand re.iection.
Tlie conj.'-eiiital malformatiouof the little linger of one or
bcitli hands, which is so commou, is not considered a dis-
<inalilication,
III lime of war, the loss of the right thumb; loss of
any two lingers of the same hand; loss of the first and
second phalanges of the lingers on the right hand ; per-
manent flexion or extension of two fingers of the right
liund. or all the fingers united (webbed), are causes for ex-
emption.
T/ie Loircr E.vtreinitics. — Varieose veins; knock-knees ;
club-feet; splay or Jiiit feet ; ircbbed toes ; the toes double or
braiictiinfj ; the great toe crossiiin tlie other toes; bunions;
corns; overriding or superposition of ani/ of the toes to an
extreme degree; loss of a great toe ; loss of any tiro toes <f
the snnic foot ; permanent retraction if the hint phalanx of
any of the toes, or fexion at a right angle of the first phalanx
of a toe upon the second, vith ankylosis of the articulation ;
ingrowing of the nail of tlie great toe ; bad-snielling feet,
disqualify.
Dr. Baxter, in his "Report of the Provost Jlarshal Gen-
eral's Bureau," sa_vs that to be cause for rejection vari-
cose veins must be" voluminous and multiplied." There
is no doubt of the fact that the judgment of many sur-
geons is in error as to the degree of varicosity of tlie veins
of the leg which should disrjualify, and men have been
discarded with veins so slightly enlarged that they could
hardly be called varieose. The network of small veins so
often seen in the popliteal space, and inside of the tliigh,
upon men of spare habit, or in those whose occupations
have recjuired them to stand a great deal, are not suffi-
cient in degree to cause rejection; nor. indeed, is such
the case when a single vein may be more or less enlarged
wiilidUt the function of its valves being imjiuired. It is
only when several veins are very large and tortuous, with
failure of their valves, or when there is a'dema, thicken-
ing of the integument, or much ulceration, that they be-
come disqualifications. An exception to this rule should
be made in cases in which hemorrhoids are ]iresent, when
even slightly varicose veins are causes for rejection. One
may see occasionallj" an instance in a very muscular man,
where there has been a rupture of the sheath of some
muscles in the leg, which closely resembles a varix: if
the finger is placed over such a tumor during the con-
traction of the muscle, its true nature will be aiijiarent.
Knock-knees, if existing to such a degree as to interfere
with the free use of the limbs, should disqualify ; as a
general rule, if the inner borders of the feet, from the
heel to the ball of the great toe, cannot be brought witliin
one inch of each otherwithout passiugtlie iiinercondyles
of the femur, resjiectively, in front of and behind each
other, the applicant should be rejected. Flatness of the
feet to a degree reipiiring rejection is very seldom met
with among applicants for enlistment, notwithstanding
the fact that it is supposed to be very conunon among
the laboring population; as a cause for rejection it has
been very much exaggerated; the ordinary flatness of
foot so often seen, especialh' among negroes, is not more
likeh- to become a cause of disability in marcliing than
is the more shapely foot, unless an ill-fitting shoe is worn ;
the anatomical peculiarity which disqualifies has been
described by Gorcke, of the Prussian service, sulistan-
tially as follows: The inner ankle is very prominent, and
is placed lower than usual; a hollow exists below the
outer ankle of a greater or less extent ; the dorsum of the
foot is not sulflciently arched; the foot is broader at the
ankle than near the toes; the inner side is flat and some-
times convex, and when the foot is pla<ed on the ground
the sole projects so much on the inside that the finger
cannot be introduced below it; the body rests on the in-
ner side of the sole, and the usual motion of the ankle-
joint is impeded.
Bunions, if large and presenting evidences of old or re-
cent infiarnmalion, should always reject ; they are a fruit-
ful .source of disability on long marches and in hot
weather, the pain produced by the pressure of the shoe
setting up an irritaticm which extends to the entire foot.
The same may be said of coi'ns when located on the sole
of the foot; those under the liead of the metatarsal bone
of the great toe are the mo.st painful, and jn'oduee lame-
ness sooner than any others; they are, moreover, very
intractable. Of the malpositions of tlie toes, that in
which the first phalanx is flexed at riglit angles upon the
second to such an extent that the man walks upon the
end of the nail (hammer toe) is the most painful, and
will disable more speedily than the others; there is no
shoe which can be made thai will remedy the defect, and
it is in consequence an absolute cause for rejection. In-
growing of the nail of the great toe, if deep and accom-
panied with signs of irritation, inflammation, or suppu-
ration, renders a man uuHt for service; if, however, he is
very desirable otherwise, the simple operation of shaving
away the redundant tissue on the border of the toe, in a
majority of instances elfectually cures the disease, after
which he may be accepted.
The fetid odor exhaled from the feet of some inen is such
as to make their presence in a sqtiad room unbearable to
their comrades. The excessive perspiration causing this
odor keeps the toes and under surface of tlie feet soft and
the skin macerated, for which reason very sliglit exerci.se
produces painful excoriations and unfits the man for
duty. When the feet show evidence of this condition
the applicant should be rejected.
In time of war veiy large varicose veins, club-feet, an
excessive knock-knee, loss of great toe, and flexion of the
phalanges of the other toes to an extreme degree, shoidd
exempt; men having otiier defects of the feet, if unfit to
join the active line, can be made useful in the administra-
tive departments and should be held to service.
Charles R. Qreenleaf.
Referencks.
* .\rmy Regulations, LSsi, paragraphs 7.57 and 7So.
5 Statistics. Provdst Mai-slial General's Bureau. I,s7,i, p. viii.
^ Army Regulations, issi, paragraph 7&4. ■* IhiO., paragraph 762.
" Hid., paragraphs 76li. Tiil. « Ihid., paragraph 757.
' lliii}., paragraph 7.")7.
^ Tripler's Manual for E.xaminatiou of Recruits, p. Iti.
0 IhiiK. p. 16. i» (Ip. cil., pji. 68. 69.
11 KpIspv : Diseases of the Rectum and Anus, p. It™.
1= I.Hual MiMi. ino, \ol. ill., p. 142.
13 Minshail : Hints to Young Medical Officers, p. 6S.
" Trir>lir's Manual, p. 12.
1^ Crawford: Observations on the E.xainination of Recruits, British
Army Medical Reports, 1862. " Tripler's Manual, p. 78.
" Crawford : British Army Medical Reports. 1862, p. iXU.
1^ Pomeroy : Diseases of the Ear. pp. :j:i-:iii.
1^ British Medical Journal. No. Ill'7. ji. lliU.
■' General Order, No. ,S2. Adjutant-General's Office, 1879.
-' Bartholow : Manual for E.\auiination of Recruits, p. 3U.
'-'- Tripler's Manual, p. 46.
-3 Longmore : Manual of Army Surgeons, p. 76.
■' Ihid.. p. 84.
-^ Provost Marshal General's Report, p. 167.
■-' Tripler's Manual, p. 66. " ni!((., p. 70.
'-'" Statistics Provost Marshal General's Bureau, vol. I., p. .">.
-' Des maladies simulees daus I'armee moderne, par Dr. G. Zuher,
1882.
RECTO-VAGINAL FlSTUL/€. See Vagina, Diseases of.
RECTUM, MANUAL EXPLORATION OF THE.— In
18T'3 Professor tSiiiicm, ol ileidc^llierg, published, in the
Archil: fiir klin. Chirurgie. an article "On the Artificial
Dilatation of the Anus and Rectum for Exploration and
Operation." in which he first described a method of ex-
ploring the lower bowel by the introduction of the entire
hand. By this method of examination he asserted that
not only was he able to explore :ill of the pelvic organs
and to distinguish any pathological changes they might
have undergone, but that the giciiter jiart of the abdonii-
n;il cavity could also lie reached. lie furlher asserted
that this method was so entirely free from danger that he
had not hesitated to practise it on patients ;ina>sthelized
for other purposes.
Manual exploration of llie rectum is now only of his-
torical interest. It is no longer employed, and has been
superseded by the no more dangerous and much more
wide-reaching and Siitisfactoiy method of exploration,
viz., by abdominal section. A". P. Dandridge.
RECTUM, SURGERY OF THE.
tllin. {^Surgical. j
See Anus and Uec-
861
Ked Boiliiis Springs.
ICodii('tioii-Divi§»ioii.
HEFEREXCE UAXDBOOK OF THE MEDICAL SCIEXCES.
RED BOILING SPRINGS.— Macon COimty, Tennessee.
PosT-l.lFFici;. - liril Jii)ilin^- Sprinirs. Ilnlel.
Access.— Via Luuisville iuid Naslivillc Hailroiid to Gal-
latin; thence bv private cnuvevancc to the sptings.
This resoit is located in the footliills of the Cumber-
land Mountains, si.\ly-tive miles northeast of Nashville
anil seven miles froni the KeiitncliV line. It has an eli ■
vation of abinil twelve hundred feet aliove the sea-level.
The visitor will at this resort llnd a cool and pleasant
retreat for the summer months. The hotel is said to be
\V(dl kept and comforliible. and the cuisine of an excel-
lent character. There are three springs in the group-
two red sulpliur springs and one black sulphur spring;.
Those most generally used are tlie '-Little Ked '' and the
"Black Suliihur" Springs. The former was analyzed
by Lucius Pitkin, aiialviical and consulting chemist, of
Kew York City, in 1890, with the following results:
IJtth' lifd Spn'iii/.— One United States gallon contains
(solids): Sodium chloride, gr. 5. .57; sodium sulphate, gr.
0.1(4; calcium sulphate, gr. .S.18; potassium sulphate, gr.
0.41; calcium bicarbonate, gr. 3.20 ; magnesiiun bicar-
bonate. i;r. 4.."i."); iron biearlionate, gr. 0.15; silica, gr.
0.80. Total, 2;!. 80 grains.
Sulphureted hydrogen giis is present in large quanti-
ties.
The foUowing analysis was niadi' by James T. Ander-
son, of tlie Alabama State AgricuUural and Jleclianical
College at .\uburu:
Jieil Sjiriiir/ .\,i. :;'.— One United States gallon contains
(solids'): Sodium chloride, gr. 10.73; sodium carbonate,
gr. 1.03; calcium carbonate, gr. 9.04; calcitini siilphate,
gr. lo.3G; masnesiuni sulphate, gr. 7.07; alumina, gr.
0.10; iron oxide, gr. O.OS; silica, 'g!'- ^*'>^- organic and
volatile uKitter, g'r. 2.31. Total, 47.^3 grains. Sulphu-
reted hvdrogen gas is present in oidy small quantity.
The tei'uiieratun-s of the waters are 54" and 52' F., re-
spectivelv. and thev do not ^ary during the year.
These waters aie s:nd to be actively diuretic, and to
exert a general tonic and alterative effect u]ion the sys-
tem. Hot and cold sulpliur liatiis may ahso he. had at all
hours. A competent physician is always at hand to ex-
plain the proper use of tlie wiiti-rs. .hni^.s K. Vi-cul-.
REDLANDS AND RIVERSIDE, SOUTHERN CALI-
FORNIA.—These two places may be taken as represent-
in- (he eliniate of the eastern foothills of Southern Cali-
forni;i, where are to be found many resorts favorable for
a winter or an idl-tlie-j-ear round residence.
Hdlliiiiih ( l,3."i0 feet"), in San Bernardino County, lies in
the East .San Bernardino valley, and is surrounded by
inountaiiis from 5.000 to 12.0lHi feet high ou the north,
east, and soutli, and lies open to the sea ou the west,
from which it is distant about eighty miles. The city is
beautifully situatid and sulistanlially built, and contains
about six tliousand inhabitants. Ii is a favorite place of
winter residence for Eastirn people, and in attractive-
ness of situation and the character of its inhabitants
and residences is comparable to Pasadena. Parks, many
churches, a tine public libraiy, exivllent schools, clubs,
golf links, good hotels, are all to be fmuid here. The soil
is porous and rich, and especially favorabh' for the cul-
tivation of the orange, which is the iirincip.-d fruii grown
here. The water-supply is a line one, ami allords irriga-
tion for the orange gioves. There is a sewer and storm-
water svstem, and tlie sanitaiy condition apjiears to be of
the best.
Redlands h;ls good railro;id connections and electric
roads; and from it one can easily reach tlie vi'rious at-
tractive mountain resorts ou the one side and those of
the coast on the other.
One rarely meets with a more attractive town, even in
Southern California, than Uedlands, exhibiting as it does
so many of the natural attractions peculiar to all this re
gion. "AYherever there is irrigation, flowers of endless
variety abo\md, and the most luxuriant vegetation tlour-
ishes. " The dust of the streets is laid by the crude
petroleum, so al)undant in tsouthern California. _ By this
process an almost perfectly dustlessroad is obtained, ami
remains so for many weeks from a single application of
the oik
The characteristics of the climate of Redlands, as, in-
deed, of all this eastern foothill region, are equability,
comparative dryness, abundant sunshine, and a small
rainfall occurrhig mostly in the winterand spring. Early
morning fogs, so-called "high fogs." may also be consid-
ered a climatic characteristic, for they are not of infre-
quent occurrence here, as elsewhere in Southern Califor-
nia.
The average rainfall is 15.59 inches, of which 7.45
inches falls in the spring and 6.-55 in the winter. The
mean annual relative humidity as given by Bridge ("The
Climate of Southern Califoriuia." Transactions of the
American Climatological Association, 1901) is 64.4 per
cent. The average mean winter temperature as given
l.iy the same authority is 51.7°; for summer, 75.3°;
spring, 63= ; autumn, 66° F. (Solly). Sanborn ("The Cli-
mate of the Eastern Foothills," by Dr. C. A. Sanborn,
Uedlands, Cal.. Transactions of the American Climato-
logical Association, 1902) gives for Redlands the follow--
ing extremes of temperature from an average of three
years for the three months exhibiting the greatest ex-
tremes of heat and cold;
January
February
July
Au.i?ust
I Moan maximum teiuperatiire fi2 de^ees.
> Mean niiainium " -W)
I Mean i!ia.xiiiiuin *" ...atiuutlisl
*( Mean nnnimmn " 42
1 Mean maximum " . . . al»f»iil tt."> "
'/ Mean minimum *' a*> "
) Mean maximum " ...aliouttjl
1 Mean minimum *' •'>S
The average mean relative humidity of Red lands for these
months is given by the same authority as 55.7 per cent.
In the summer thetemperatm-e occasionally goes above
100' F. in the middle of the day, but with the dry atmos-
phere this is not so uncomfortable as might be supposed.
The difference between the day and night temperatures is
great, something like 20' to "30'. Similarly, there is a
great difference "between the niglit humidity and the day
humidity. " This means to an inv.alid," as Solly remarks
("Medical Climatology"), "a climate possessing, iii the
course of the day, perhaps six hours of moderate dryness,
and eighteen hours of positive dampness."
These two characteristics of the fall in temperature and
increase in <lainpness at niglit probably account for the
apparent cliaiiness with which the residents open and
keep open their windows, and the fear they have of sit-
ting out of dooi-s at niglit. As paradoxical as it may
seem, one can evidently sit out of doors more evenings in
the year in New England than in Southern t'alifornia: or
else "the New Englander is more venturesome and hard-
ened in enduring the evening air than is the Califoruian
of the South.
Freezing -n-eatheris very rare.
The mountains to the north of this valley shut off the
winds from the deseit, but the sea breeze blows daily,
beginning usually about ten o'clock in the forenoon, and
lasts untU sunset. There are said to be over three hun-
dred .sunshiny days in the year at Redlands. At San
Bernardino, about" eight miles to the northwest, the total
number of clear days, as given by Dr. A. K. Johnson, a
volunteer observer (period not given), is 235; fair days,
95; cloudy, 35; rainy, 33*. According to Sanborn (hic.
fil.) "patients with pulmonary lesions, not far advanced,
do w<'!l in this climate (l!cdlai"ids and vicinity), especially
in that part of the valley where oi'.-mge growing and the
consequent dampness fi-om irrigation do not prevail."
Sanborn also refers to the irritation of the respii-atory
tiact brought about by flic extensive tise of commercial
fertilizers. " He has noticed a pi-evalence of tonsillitis and
pharyngitis occurring at the time of using this material.
" Xervousness" is sai^i to be increasing liei-e as well as in
other piirtionsof Southern California, and it is attributed
by Sanborn to various causes, climatic and others, such
as eve sti'ain from a succession of bright days, and nos-
tals'ia.
Five nules from Redlands, on the line of the Southern
862
REFEREXCE HANDBOOK OF THE MEDICAL SCIENCES.
Red Boiliiis; Springs*
Kc<t net loifDi Vivian.
Pacific Railroad, is tlie Loma Linda Sanatorium (about
twelve liimdR'd feel), bcaulifully situated on the hillside
about two hundred feet above the surrounding country.
It is approached through a stately avenue of pepper
trees, and is surrounded by orange proves and beautifid
gardens. The view from tlie sanatorium is extensive and
grand, the lofty " Arrowhc'a<l " anil its liot springs lying
directh' in front. The buildings of this institution are
well equipped, containing operating-rooms, etc., and ex-
cellent accommodations are olTered to the nervous and
other invalids, as well as to tho.se who oidy desire to rest
imder such favorable conditions of situation and climate.
The tuberculous are not received here.
Bivemide (elevation eight hundred and fifty feet) is a
city of ten thousand inhabitants, about sixteen miles by
rail -,outhwe.st from Kedlands. It is the most famous
orange-growing district in Southern California, and is
well supplied with water for irrigation and domestic
purposes, from a number of artesian wells near the
mountains. The drainage is good, and the city affords
every opportunity for comfortable living, either for the
transient or for the permanent resident. There are at-
tractive parks, in one of which is the curious "cacti gar-
den." There are also beautiful estates, many churches,
line school buildings, a Carnegie libraiy, miles of pleasant
roads through the orange groves, and avenues sliaded by
the eucalyptus, the pepper, and the palm, among them
the famous Magnolia Avenue.
The vegetation, as at Kedlands, is most luxuriant, and
besides the orange, the pomegranate, olive, persimmon,
fig, and other fruits are found here. Flowers abound in
a wild profusion, and this whole area seems like one vast
park or garden.
The accommodations are good. Besides the lovely
drives and walks, there are opportunities for golf, polo,
and tenuis.
The climate is similar to that of Redlands. The aver-
age yearly rainfall for fourteen years was ten inches,
February and March being the rainiest months (Solly,
"Medical Climatology "). The relative humidity for the
year 1888 was 65.5 per cent. The mean monthly tempera-
ture for the seasons, covering a period of twelve years
is as follows; Spring, GO'; summer, 74°; autumn, 74';
winter, 51° F.* The mean for July is 76°; maximum,
106" ; mean for August, 76° ; maximum, 104° ; mean for
January, 50°; minimum, 29°. The average variation lie-
tween the day and night temperatures, as given by Saw-
}'er("A Study of Kivcrside Climate," etc.. Southern
California FractiUoncr, 1887), for January is 20°, and for
July, 34". "The ordinary wet seasonal Rivcr.side,",says
the same author, "is much drier, has less rain, and a
larger proportion of dry, clear sunshiny days than the
average summer in New York, Boston, or Chic;igo."
The amount of sunshine is great, and, according to
Sawyer, there were two hundred and eighty absolutely
clear days from July, 1885, to July, 1886.
Thirty-tive miles southeast of t'olton, which is eight
miles north cjf Riverside, is the little town of Hemet, the
starting-point for the carriage ride to the health resort of
IdyUwild. This is a journey of twer.ty miles, the last ten
of which are up a steep mountain road. IdyUwild has
an elevation of 5,250 feet, and is situated in the Straw-
berry Valley, in a large forest tract of fifteen hundred
acres, which is again bounded by extensive government
forest reservations. The valley is well timbered, the iiine,
cedar, and live oak predominating. The climate possesses
the characteristics of the high altitudes in a eomparati vely
wariu latitude, the atiuosphere being dry and pure; and
the temperature warm but not hot in summer, and in
winter cool, but not generally going below the freezing
point. As is generally true of this whole region the ma-
jority of the days are sunny.
The IdyUwild Sanatorium occupies a well-protected
situation, and besides a large, well-appointed central
building containing fifty-one rooms, there are several
* Quoted Ity Solly from a meteorological record issued by the Kivcr-
side Boai'd of Trade.
cottages of three and six rooms, tents, etc. There are
appliances for furnishing steam heat and clectricitj', an
ice plant, and a steam laundry. Families wlio come with
their invalids can also find accommodations here, and
means of recreation in riding, golf, tennis, etc. There is
also a school for the younger children. The sanitary
conditions are Wi.W looked alter. The water comes from
a pure mountain spring, and there is a well-constructed
.sewer system. The plumbing is modern and good.
Pulmonary tuberculosis in the curable stages is the
princiijal disease treated here, and there are a resident
physician and nurses.
From a personal visit the writer can testify to the wild
beauty of the scenery, the delicious purity of the air, and
the energy and devotion of the managers in building on
this mountain jjlateau a well-equipped and extensive
sanatorium, with all modern improvements. For one
who desires to take the open-air treatment in the high
altitudes, and at the same time avoid the severity of the
winter climate found in the altitudes farther north, such
as at Coloradoand in the Alpine resorts of Europe, Idyll-
wild would seem to afford ideal conditions, not only of
climate, but of accommodations. The only drawback is
the long, tiresome carriage ride, but this in time will
probabl)' be obviated by a mountain railway.
Edward 0. Otis.
RED SULPHUR SPRINGS.— Monroe County, West
Virginia. Pcst-Officis. — Red SnlphurSprings." Hotel.
Access. — Via Chesapeake and Ohio Railroad to Alder-
son's, thence bj' stage to springs.
These springs are beautifully situated on Indian Creek,
and are surrounded by pine-clad mountains. They are
two in number, and flow two hundred and ten gallons
per hour. The water has a temperatuie of 51 "F. It
was analyzed in 1843, but the results were not very satis-
factory. The total soliils found to be present in one
United States gallon amounted to about twenty-four
grains, and approximately one-third of this consisted of
sulphur.
A new analysis of this water is very much to be do-
sired. Its virtues are jiresumed to rest to a great extent
upon the sulphur which it contains. Aside from this
substance it contains ingredients which justif}- us in
classing it as a light saline calcic water. From abundant
corroborative mtdical testimony there seems to be no
doubt that the water causes a decided slowing of the
heart's action in an excited state of the circulation. Tlie
water further seeius to exert a soothing influence upon
the mucous membrane of the lungs and bronchi, allaying
irritation and diminishing expectoration. In virtue of
these properties it has often proved decidedly beneficial
in hemoptysis, earlj' ])hthisis, chronic bronchitis, chronic
idiaryugitis, and chronic laryngitis. In small quantities
the water is said to be cathartic, while in larger doses it
is diuretic. Janus K. Crook.
REDUCTION-DIVISiOIM.— When in the course of cell
division the chromatin is distributed to the daughter nu-
clei in such a wajf that the material forming one daugh-
ter nucleus has a diff'erent 'ancestral bistoiy from the
material forming the other, the division iscalied a reduc-
tion, <n', better, reducing diHsion ; and is thus distin-
guished from the ordinarj' c^'ial dirisimi, in which every
jiarticle of the chromatin is divided equally between the
two daughter nuclei (see article Oil).
I'/ieontical. — If we suppose that the phy.sical basis of
heredity consists of distinct units iir the chromatin ma-
terial of the nuclei of the germ cells, then at each union
of two germ cells in sexual reproduction the niunber
of ancestral units, or ancestral germ - plasms, will be
doubled. And, uidess prevented in some way, this
doubling will continue with each successive .sexual
union, until cither llic genu cells will be increased to an
enormous size, or else the units will be reduced in size so
mncli that they are smaller tlian the protcid moleetde.
Houx in 1884 puljlished an ehiliorate review of the
whole subject of mitotic cell division, so far as it had
863
ItoliK'lioii-Itii isioii,
Ki'tluvtlou-DiviKluii.
UEFERENCE lIANUliooK OF THE MEDICAL SCIENCES.
been develoiied at that time, aud his conclusiou was tliat
tlie lo/if/itiidiiiti/ xplittiiiij cif tlie cliioniosiiiiH-s aud the
whole mechanism by wliieli the two halves of an origi-
nally single chromosome are always carried to opposite
poles of the spindle, has for its object the distribution of
the ehromatiu, both as to quantity and as to quality, in
exactly eijual proportions to t!ie "two daughter cells (see
Chromosoiiie).
A study of the phenomena of heredity led Weismann
to suppose the chromatin to be made up of elements as
indicated in the previous paragraidi (see also article Ik-
reditu) :""! that these ancestral germ-plasms lUiiintain
their individuality through successive generations. Aud
this led to the further supposition that sexual reproduc-
tion can be continued only in ease there is a reduction in
the uundjer of ancestral "germ ])iasms. a reduction that
must be reiJcated in every generation. But Kou.x's con-
clusions would seem to m'ake such a reduction improbable
so longas tliedivision takesjdace by the ordinary method
accompanied by a longitudinal siiiiltingof the chromo-
somes.
Writing in 1887, Weismann says; "This is the only
kind of liaryokiuesis whicli has been observed until re-
cently; butif the supposed nuclear division leading to a
reduction in the numlier of ancestral germ-iilasms has
any real existence, there nuist be yet ani'ther kind of
kai-yokincsis in which the primary equatorial loops are
notsplit longitudinally, but are separated without divi-
sion into twogroups, each of which forms one of the t wo
daughter nuctei. In such a case the required reduction
in tiie munlier of ancestral gerin-jdasms would take place,
for each dauglitcr nucleus woidd receive only half the
niuuber which Avas contained in the mother nucleus."
After discussing the work of van Beneden (1888) and
Carnoy (1886), then recently imblished, Weismann defines
the terms "reducing division " aud "equal division," and
then adds the following ex]iIauation of his prediction:
"The ' reducing division ' nuist be always accompanied
by a reduction of the loops to half their original number,
or by a transverse division of the loops (if such division
ever" occurs); although reduction can only occur when
the loojis are not made up of identical pairs. And it will
not always be easy to decide whether this is the case.
On the other hand" tlic. form of karyokinesis to which a
longitudinal splitting of the loops takes place hijarc they
$ Jut ^
•p-.St
rV :o;s4 6 a '^oB
p z A 7\ /\ /\ /\ \\ \\
ty O .p. OOQ OO O O OOOOOOQ
/./. A /i /I A i\ i\ A /\ /\ i\ \\ \\ Vv V\
QOOpOOOOOOOQOOOOOOOtooObOOQ
A/WI A/\ /\ A /\/\ /Wl A/l/\/i A/\ n A /w. a /^Al^ a
.OlOOOOQ
/\ ,/\ /\/\/W\A
'^
somatic cells
••••
/1A/W\
germ cells
Fig. .3026. — Diagram showirij^ tin- rcditrrve of tin- CJerin Cells of
A.sraris. Z, FerUlIzeil ess;; l'\. l\. eto.. iirotnEoiKu-yles ; (;,
[iiimorclial germ cell (P^, Fig. 2U14, arlicle Ilrrcdihi) ; .n',,.s.j, etc.,
primary .somatic cells; A ami C, primary Hciinii-niial cells; E,
primary endodermal cell ; 3/, cell which prodm-cs mcsudcrm and
part of ectoderm. (ModlUed from Boveri.l
sepai-ate to form the daughter nuclei must always, as far
as I can see, be con.sidei'ed ;is an ' equal division.' "
This ju'ophecy is one of the most famous in the annals
of science, because it has been one of those most fertile
of results, having furnished the stimulus for a large
number of very careful investigations. It is the purjiose
(^f the present article to describe some of these results,
and to consider whether they show a fulfilment of this
prediction.
7'/ie (ieniiinal Ci/ch\ — The complete history of the germ
cells has not yet been followed through all its stages in
any animal or plant. But enough is known to make it
germ cell
oogonia (many
more genera-
tions)
primary oocytes
sec o nd a i' y |
oocytes and 1
first polar I
body 1
egg and sec- 1
ond p o 1 a r ^
bodies. )
multiplication
maturation
FIG. 3927.-
Diagrain showing the Genesis of the Egg. CModifled
from Boveri.)
clear tliat there is a complete continuity of generations
of cells in this history, which consists of a series of
cj'cles, and we may consider each cycle as having its be-
ginning and its end in the act of fertilization. These
cycles follow one another in unending sequence so long
as the race remains e.xtant.
The germ cells arc those which have for their pur|iose
the pr(.)vision of the material out of Avhich future gener-
ations are to be produced, and they form but a small
portion of the body of an}' nuilticellular organism. The
greater part of the body is made up of soiiiatie eelh, which
serve to sliclter and nourish the germ cells. The history
of the somatic cells is likewise a series of cycles having
their beginnings in the act of fertilization. But there is
no continiutj- between the cycles. For the somatic cells,
having fulfiiled the purpose of their being, die, and have
no genetic relation to the cells forming the body of the
next geneiation, except commtmity of origin in the ances-
tral germ cells.
In the history of the germ cells each cycle may be di-
vided into several periods, and tlie cells in each period
have been given dLstiuctive names. We shall follow in
the main the termiuologv recently adopted bv Waldeyer
(1903).
By the union of an ovum and a speririatozoon tliere is
formed a single cell with a nucleus of double origin (see
liiijiiri/iiiitioii). This cell is tlie fertilized egg, or oosper-
tii/iiiji. Iiiimediately after fertilization there follows a
series of cell divisions resulting in what is known as the
segmentation of the ovum (see article Scuniciitntitin uf the
Oeiim). The result of the first division is tlie formation
of two cells — the lirst primary somatic cell and the first
stem cell, or protoyomieiite (.Si and P^ Fig. 3926), The
latter divides again to form a second iirimary somatic cell
and the second protogonocyte (^i■^ and P2). This series
of divisions continues through a series of generations of
cells, the number of which varies with the species (see
Hemliti/), until tinally tlie last protogonocyte gives rise
to a primary .somatic cell aud the primary germ cell or
arehiffoiioei/te {S^ and G, Fig, 8026), In the mean time,
of course, the somatic cells havt^ been dividing to form
the tissues of the embryo.
The second jieriod begins with the division of the
arehigonocyte to form two r/niioei/tes. These continue to
multiply by division until, according to Heard, they reach
a certain number, which may lie a]iproxiinately constant
for the species. Finally, whether by migration or other-
wise, the gomieytes come to lie in the germinal epithelium
upon thi.1 genital ridge. (For the sake of clearness we
864
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Rcducliou-Di vision.
Uoductiou-DiviNioiia
will confine our attention to the higher animals for the
present.)
The beginning of the third period coincides with the
ditTereutiatiou of tlie genital ridge into ovary or testis,
and in this period the history of the germ cells begins to
diverge in the two sexes. In the female the last "gener-
ation of the gonocytes may pmduee two kinds of cells.
Some produce follicle cells or other cells serving to
nom-ish the eggs, while others give rise to the first gener-
ation of odc/oma, or primordial eggs. The oogonia con-
tinue to multiply for an undeterniincd number of gener-
ations. Finally this period of multiplication is followed
by a period of growth during which division ceases.
The oogonia have now become primary oocvtes (see Fig.
3937).
The perioil of growth is followed by the period of ma-
turation, during which two cell divisions occur, usually
in rapid succession. The primary oocyte, having at-
tained its full size, divides very unequally to form the
secomiuri/ oocyte and the first polar body. Then the
oocyte divides again unequally, forming the second
polar body and the ripe ovum, or an' urn (Greek ijion, egg),
as Waldeyer prefers to call it. The tirst polar body may
divide also at the same time, so the maturation divisions
result in the formation of four cells — the relatively large
ripe egg and three very small polar bodies. The view
now universally held, that the polar boiiies are abortive
eggs, was first stated by Mark in 1881.
These periods in the history of the egg are exactly
parallel in the history of the spermatozoon. In the male
the last generation of gonocytes may likewise give rise
to nutritive cmOIs and to sperinaiofjoind.. The latter mul-
tiply by division for an indefinite number of generations
of cells and the last generation gives rise to primary sper-
matocytes, which then enter upon a period of growth (Fig.
3938). This is followed, as in the egg, hy two matur-
ation divisions. In the first the primary spermatocj'le
separates into two secondaiy spermatocytes, and by the
second division each secondary spermatoc.yte produces
two apermatiiU. Thus the maturation divisions result in
the production of four cells, but in the male these are all
of the same size and all arc capable of becoming func-
tional.
But in order to become functional the cell must pass
through another jieriod, not represented in tlie history of
the egg. This is the period of histogenesis, during which
germ cell
spermatogonia
(many more
generations)
pnmary s p <■
mato'cytes
secondary sper-
matocytes
spermatiiis
spermatozoa
/\ A A l\
• • • •
I M I
multlplicaliun
sMiapsis and
growth
n.;iuiiation
liJ.>;togeuesis
FIG. 3928.— Diagram showing the Genesis ot the Spermatozoa.
(ModiQed from Boveri.)
the spermatid undergoes a remarkable metamorphosis by
which it becomes transformed into a upermatoznon witii
the characteristics peculiar to its species (sec article tipir-
matozua). With the entrance of the spermatozoon into
Vol. VI.— 55
the egg and the union of the sperm nucleus with the egg
nucleus the ohl cyc\e ends and a new one begins.
During the periods from the first cleavage of the ovtnn
to the last division of the oogonia or spermatogonia the
number of chromosomes present during the i)rophases of
division is always the same in individuals of the same
species and is, with rare exceptions, the same as the
number found in the somatic cells (Figs, oljotj, 3937, and
3929, B) . But at the beginning of the growth period the
nuclei of the germ cells tmdergo a remarkable series of
transformations, which result in the reduction of the
number of chromosomes to one-half the number present
in the earlier periods; and the reduced nuiuber is found
in the oocytes, spermatocytes, and spermatids, and in the
egg and sperm nuclei previous to their union. (Com-
pare the figures cited above with Figs. 3938, 3940, and
3939 i.)
Therefore, if a reducing division, as defined by Weis-
mann, really occurs, it is to be sought for in one of the
two divisions immediately following the growth period.
These are the maturation divisions.
In considering the results of investigations U])on this
subject, the reader should bear in mind that before the
material can be studied it must be killed, hardened, em-
bedded in paratfin, cut into sections, stained, and
mounted in balsam; and that each one of these oper-
ations is a possible source of error. Moreover, the ob-
jects are so minute that they can be studied only with
the aid of a microscope of high magnifying power, and,
further, it is impossible to view any one of these objects
from more than one side. It is doubtless due to these
difiiculties of observation that the published descriptions
of what takes place during this most interesting and im-
portant iieriod in the history of the germ cells are so ili-
verse and so often contradict one another. Altlinugh
much has been written on the subject, the diversity of
results is so confusing that it is impossible to formulate
anj' geueial description that will apply to all species.
Nevertheless there is sufficient agreement to encoiu'age
the hope that the progress in the improvement of meth-
ods will eventually lead to such a uniformity of results
as to make it ])ossible to formulate a general law appli-
cable alike to all species of animals and plants.
At present the most complete and consistent accoiuit
is to be found in a series of papers by Montgomer.y, who
has studied the spermatogenesis in forty-tw o sjiecies of
bugs, hemiptera heteroptera. and in Peripatus. a form of
special interest on account of its sujiposed rel.'ition to the
ancestral type of the insects and their allies. The follow-
ing general description will be based, therefore, chiefly
upon Jlontgomery's results, supplemented by the work
of Paulmier upon spermatogenesis in the squash bug,
,1 //(/.>•(( triKlis (Fig. 3929). The general account will be
followed b}- sections, treating briefly of the parallel idie-
nomena in oogenesis, and by others referring to variations
to be found in other animals and in plants.
The Lust Sptrmatdf/imic Dirisiati. — In the resting sper-
matogonia the chromatin appears to be scattered irregu-
larly throughout the nucleus, but the granules an- con-
nected by the threads of linin. The nucleus is like a
lacework ball made of strings of beads, in which the
thread is the linin and beads tlie chromatin. In the early
prophase of division the chromatin becomes arranged
in a single long winding thread covering; according to
Montgomery, a single strand of linin. This is the dense
spireme stage. The spireme continues to shorten, and at
the same time the chromatin liecomes segmented into the
luimber of chromosomes characteristic of the species.
This number varies from eleven to twenty-eight in the
bugs. But the linin remains intact and connects the
chromosomes by their ends. The achromatic spindle is
formed, tlie chromosomes are arranged in the equatorial
|ilane, split loni,ritudin;dly, and the lialves are drawn to
o|qiosite poles in the typical manner.
In I'eripatus the chromosomes are rod-shaped at this
.stage, and in the late anaphase they lie parallel to the
spindle fibres. The ends pointing toward the centro-
some arc called the central ciulx and tlie opposite ones are
865
Rediirt ioii-DiviNioii.
Rcdiioliou-Diiit^iuii.
liEFERENCE HANDBOOK OF THE MEDICAL SCIEXCES.
the dhtnl ends. The distal ends of sisti-r chromosomes
are joined by "connecting fibres" of linni, and although
unable to prove it. Montgomery thinks that ])robably the
linin in each daughter group of chromosomes still forms
a continiious spireme, so that each clu'omosome is con-
nected by it at the central end with its neighbor on one
side, and at the distal end to the neighbor on tlie other
side. Kinally the chroiiiosomes become massed in a dense
group, but not fused, near each ceiurosome, and the cell
body liecomes constricted in the middle. The two
daughter cells are primary spermatdcytes.
Si/ti'ipsis. — The young primary spermatoc_ytes are ea-
sily distinguished from yoiuig spermatogonia by the
peculiar condition of the nucleus. The changes Avliich
Flo. 3!i:.*^.t.— Various Stasis in Spermatoirfiiosi.'i frnm Scrtions "f tlie Test('s nf Uip
S))U;.sli liufr. .t. SptTinaloEroniiini ; /J. spiTniali'L'nimun itrcparintr for division. eros.s
ser-tion of etpiatoria! plate showinfr twcnly-tw* liroainsoirips ; (,'. division of sperma-
tofronium nearly coinplctfil ; D anci K, primary spprnialocvle in synapsis; V. 'V. If.
and /. staccs in tlio fonnation of tetrads; K. L. M, ami .V. first division of sperma-
tocyte; o and /*. sofond division of spermatooyro ; o. aecessorv chromosoiue.
I From Wilson, after Paiilmier.)
take place at this stage were first described by J. E. S.
IMoore in 189.5, under the title si/najms {(jvi-d--i.>, to fuse
together). And it now seems probable that the synapsis
is a, stage of universal occurrence in the history of the
germ cells of both animals and plants. An especially'
characteristic feature of the synapsis is the grouping of
the chromatin in a dense mass on one side of the nucleus,
leaving a large clear space on the other side, between the
chromatin and the nuclear membrane. (Compare Fias.
3929 D and £. 39:13 B. 3934, and 3938.) The interest
attached to this phase is due to the fact that when the
chromatin emerges from this tangle it is found to be
divided into segments of just /iii/f the number pres-
ent in the previous anaphase, and these segments ate
either split longitudinally or soon after be-
come split. It is at this time, then. th:,t
the rcdiirtion in the number of chromo-
somes takes place ; and it would seem th;.t
this reductiim without division, as h:.s
been lield by Moore, Farmer, and others,
destrovsa'l ground forWeismann's theoiy
of a reducing division.
In most forms the mass of chromatin
during the sjniapsis is so dense that it is
impo.ssible to see what takes place within
it. But in Perijiatus Jlontgomei'v was so
fortunate as to tiiul a form in wliich it is
possible to distinguish the individual chro-
mosomes, and he was able to determine
that they become f'ised in pnirs by i/uir
central ends, an<l a similar result has been
obtained by vSutton in the grasshopiur
(Fig. 3938). Thus if the twenty-eight
chromosomes that enter the synapsis stage
in Peripatus are univalent, the fourteen
that emerge from it are bivalent, and no
true reduction has takcu place after all,
fi^r there has been no discharge of chro-
matin from the nucleus. The bivalent
c'hromosomes liave the form of the letter
V or U. ai.d the angle of the V or U marks
the position of the central ends, which in
some cases can lie seen to be connected by
a short band of linin.
On emerging from the synapsis stage
the chromosomes gradually elongate, and
tinally fill the nuclear space again. Dur-
ing this process the chromatin becomes
separated into graiuiles, all connected by
an axial band of linin. Then the granules
become flattened and filially divide in tlie
plane of the longitudinal axis of the chro-
mosome, forming a row of granules on
each of the ojiiiosite edges of the now flat-
tened axial baud (Figs.-SO'ig Fand 3939).
Finally the axial band splits and the
rows of chromatin granules lieeome more
widely separ;tled. At the same time very
fine filaments of linin appear to connect
each pair of granules, and to connect there
in turn with pairs of grannies in neigh-
boring chromosomes. Thus the nucleus
passes gradually into the resting condi-
tion of the growth period, in which it is
rarely possible to distinguish the boun-
daries of individual chromosomes. In ex-
ceptional cases the resting condition of
the nucleus appears to be entirely omit-
ted at this stage, as in two families of
bugs, the CoreidtB and Reduvidia', ;ind
also in plants (Figs. 3929 and 3938).
The First Maturation Dirisiuii. — The
]iroiihase of the first maturation division
in Peripatus begins with the coming to-
gether of the chromatin grantiles to form
an irregular reticulum. There is no spi-
reme, but the reticulum appears to give
rise to the chromosomes directly, and
866
REFERE^XE HANDBOOK OP THE MEDICAL SCIENCES.
Rediictiou-Di vision.
Reductiou-Divisiou*
Montgomeiy gives reasons for believing that the reticu-
lum is onlj' ajiparent, and is really formed of overlap-
ping and interlacing cliromosomes that have never lost
Fig. 3930.— Chromosomes from Primary Spermatocytes of the Squash
Bug. showing i-han'.M'S of shape leadini^ to the forHiatioii of tetrad.
a. Distal end: d. rintnil end ; 6. completfd ti'trad with long a.\is
correspondiuR to the Icmyitudinal split. (After Paulmier.)
their identity. The chromosomes shorten and assume
a great variety of form, most of them being more or
less U- or V-shaped. Sometimes the two limbs of the
U are twisted together, sometimes they are united at
the ends to form a ring. These chromosomes are seen to
be bivalent, that is, composed of two univalent chromo-
somes united by a band of liuin at the bend of the U, and
each univalent component is split longitudinally. The
chromosomes which take part in.tlie tirst maturation di-
vision are therefore similar in form as well as equal in
number to those at the end of synapsis.
By the time that the chromosomes reach the equators of
the spindle they have become very much condensed, so
that the central linin band is covered with chromatin and
the longitudinal split is represented by a mere notch at
the distal end. In Peripatus the chromosomes at this
stage most frequently have the form of a bent dumbbell.
6 .^
' 6'
Fig. 3931.— Primary Spermatocyte of Batrachoseps in a Stape Im-
mediately Preceding the Metaphase. Eight (jf the twelve ehromo-
somes are seen approaching the equator of the spindle. >: ahout
l,oOO. (After Eisen.)
sometimes it is a straight dumbbell, sometimes two IhicU
parallel rods, and more rarely a ring-shaped cliromosoiiie
is found. In many insects and Crustacea the chimin. >-
somes at this stage iiave the form oi tetrads {Fig. 3929 K);
that is, each bivalent chromosome is seen to be composed
of four minute balls of chromatin more or less closely
pressed together. In vertebrates and in the higher
plants the chromosomes are more or less ring-shaped at
this stage (Fig. 3931).
The chromosomes now divide in a plane at right angles
to the axis of the spindle, and the halves are drawn tow-
ard the opposite (u'ntrosomes. In the case of Peripatus
the dumbbells are divided transversely. Where the
tetrads are present, the daughter chromosomes are di/adi,
each composed of two balls of chromatin (.1/ and JS',
Fig. 3929). The ringshaped chromosomes are broken so
as to form two horseshoe-sliaped bodies (Fig. 3932).
If this division of the bivalent chromosomes takes place
in such a way that their original univalent components
are separated, we have here a reducing dicision, as de-
FiG. 3932.- Primary Spermatocyte of Batrachoseps in the Meta-
phase, Chromosomes Dividing. X about 1,.'>()0. (After Eisen.)
scribed by Weismann. But if the daughter chromo-
somes consist of parts of two originally separate chromo-
somes, then we shall have to seek farther for the reducing
division.
The question can be decided only by very careful study
of the changes in form and structure exhibited by the
chromosomes from tlie beginning of the synapsis to the
completion of this division. This has been done by Paid-
mier in the case of the squash bug, and by Jlontgomery
in forty-two Ilemipteiaandin Peripatus. They find tliat
in all of these species the tirst maturation division is
transverse, and is a tfue rcducinr/ dirision. se)iarafing each
bivalent chromosome into its original components.
Both Montgomery and Paulmier figure each daughter
chromosome as being drawn toward its respective centro-
sonie b}' two spindle filircs (K, Fig. 3929). Soon each cen-
trosome divides into two preparatoiy to the ne.\t cell
division, and it is found in Euchistus and in the sqtiasli
bug tliat of each pair of spindle fibres one is connected
with one daughter centrosome. and the other fibre is at-
tached to the other one (.1/. Fig. 3929). With the divi-
sion of the cell bodies the first maturation division is
completed, forming two xemixlun/ sjiri'mntitri/fes.
The Sei'imil Mutiirnlioii Diiisinii. — Usually there is no
resting condition of the nucleus between the first and
s<'eond maturation divisions. The longitudinal split
which appeared in tlie chromosomi'S during tlie prophase
S67
RodiK'tiou-Divifiiioii.
Reduction-DI) imiiiii.
15EFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
of tlif! first, division lias reappeared during the anaphase.
At the tieirinniiig of the .second division the daugliter
centrosonics move tlirougli an angle of ninety degrees,
and u spindle is forineil with tlie ehromo.sonies anang(rd
in an eipiatorial jiiate. They are arranged now so that
the s]ilil is at right angles to the spindle. During the
anaphase the halves of the chromosomes are drawn to
opposite poles (0 and P, Fig. 3929).
The secondary s)H'rmatoeyte then divides, forming two
spcriiiiitiun. Tlie cliange from a group of chromosomes
to a resting nucleus, which ensues at this stage, is pecul-
iar in that it is ('Ifected by the swelling of the chromo-
somes. A vacuole appears in each cliromosome, so that
each one becomes a small vesicle. These vesicles uniting
form the resting nucleus, around which there is finally
developed a niulear inendirane.
The history of tlie spermatid in the final period of liis-
togeuesis. during which it becomes transformed into a
functional siiermatozoou, will be treated elsewhere (see
article Sjh n/nitoX'/n).
The MiUiiration nfilie Efjij. — The parallel between the
CDurse of development of tlie egg and that of the sper-
matozoon in their external features has been pointed out
in a preceding paragraph. Tlie iiarallel extends also to
the nuclear changes, as was first clearly suggested by
Platuer in 1889. Comparison of tlie processes of sperma-
togenesis and oogenesis in Ascaris led Boveri to make a
more positive staterneiit in 1890, and its truth was com-
pletely demouslrated, so far as Ascaris is concerned, by
O. Hertwig a few mouths later.
These discoveries relate chietly to the divisions of the
chromosomes. The S3'napsis stage was first clearly rec-
ognized in the development of eggs by Woltereck "(1898)
through his studies on the Ostracoda. In 1900 von
Fii4. :i9:B. - Nuclei from the Ovary of a Iliuiian Fu'tiis of about Sevt-ii
.Mouttis, sliowing consecutive stjiKe.s in the development of the
oocycte. ii, Synapsis ; ii, nucleolus. X 1700. (After Winiwarter.)
"Winiwarter ])ublislied an elaborate description of this
stage ill the liisfory of mammalian ova (Fig. 39.33). An
abstract of his results is given in the article Onim.
As in the corresitonding stages in spermatogenesis,
sliorfly after the last division of oogonia, the nuclei of
the young oocytes pass through the synapsis stage, eluir-
acterized by the massing of cliromatin filaments tit one
side of tlie nucleus (Fig. 3933 B). The cliromosomcs
emerge from the tangle with their number reduced to
half the number present during the jircvious anaphase.
Thi-se chromosomes are, or soon become, sjilit longitudi-
nally. They continue to elongate, and finail}- the nu-
cleus enters into the resting condition. It remains in
this condition during the growth period, during which
the oocyte increases enormously in size This period
may extend through manv J'ears, as in man.
Just before, or very soon after, the egg is discharged
from the ovary the first maturation division occurs, wliich
results in the budding off of the very small first polar
body from the egg, which then becomes a secondary
oocyte The nuclear plienomenaat this time are exactly
like those to be observed during the division of the pri-
mary spermatocytes of the same species.
In the same way the process of formation of the second
polar body is like the division of the secondary sperma-
tocytes of the same species.
Thus the processes of oogenesis and spermatogenesis
are parallel in every essential particular; the main dif-
ference being that in the maturation divisions of the
spermatocytes, the resulting cells are equal in size, while
those that result from the divisions of the oocytes are
very unequal; and the spermatids undergo a" further
metamorphosis associated with the special function of
the spermatozoa, a change wliich the special function of
the egg renders entirely unnecessary,
\(iri(ttkins in the Process of Mattn'cilion. — The forms of
the ehromo.sonies and the details of their divisions during
UKituratiim dilTer widely in different groups of animals,
and this has resulted in various interpretations of the
process by different writers.
Many authors have confirmed Weismann's prediction
that a reducing division takes place. But they are not
all agreed as to the time when the reducing division oc-
curs. \Veissmann predicted on theoretical grounds that
the reducing division would occur during the formation
of tlie .second polar body. Paulmier and Montgomery
found, on the contrary, that in Ilemiptera the first is a
reducing divi.sion, the second aneciual division. Similar
results were obtained ]ireviously by Koschcldt in an an-
nelid, Ophryotrocha, by Wilcox in a grasshopper, Calop-
teuus, and by Henking in a firefly, Pyrrhocoris. On
the other hand, Iliicker, von Hath, and liiickert are
agreed that in the copepoda the reducing divisiion conies
idler an etpial division, as predicted" by Weismann.
Similar results have been obtained by von Rath in the
mole cricket. Gryllotali)a, by Calkins in the earth-worm,
JjUnibricus, by Griffin iu Thalassema, and by Sutton in
Braclij'stola.
In Ascaris and various vertebrates, chiefly selachians
and amphibia, it has been found that both maturation
divisions arc aecouipanied by longitudinal S])litting of
the chromosomes, and authors working upon these forms
have bi-un led thus to deny the existence of any reducing
division. In Ascaris the two chromosomes, 'which ap-
]iear in the oocyte preparing for division, are elongated
and sjilit longitudinally in two planes at right angles to
one another. By the shortening of these rods each chro-
mosome becomes a typical tetrad, which divides in the
usual manner; that is, iu the first maturation each tetrad
divides, forming two dyads. One dyad of each pair re-
mains in the C'gg and separates into two single chromo-
somes, one of each pair going to the .second polar body,
so that tlie first polar body receives two dyads, the
second polar body and the ripe egg each two single
chromosomes.
In the vertebrates the chromosomes in the S])ermato-
cylcs preparing for the first division are U-shajied. At
an early period a longitudinal split appears at the bend
of the r. but the two halves remain united at the ends
iiiid open out toforin a ring (Fig. 3931). In the ineta-
jiliasi' the ring-sliaped chromosomes separate into two
F's Iiy bi'caking across at the points of union (Fig. 3932).
Tliis form of mitosis was called heterotypical by Fleni-
ming, and is highly characteristic of this stage" in the
vertebrates. In the next division each cliromosome again
splits longitudinally. Montgomery has rightly contended
that it does not necessarily follow that both divisions are
equal, even if they are both longitudinal. In the Ilemip-
tera it was shown that the chromosomes of the first sper-
matocyte are bivalent, having been formed by the union
868
REFERENCE H^SJ^DBOOK OF THE SEEDICAt, SCIENCES.
Kc'diiction-Dlvitilon.
Ki-cliK'tiuii-DIvlsion.
FIG. 3934. — Pollen Mother-
Cell of the Lily nitb Nu-
cleus in Synapsis. X 5So.
(After Sargant.)
of two tinivak'iit chromosoiiics eud to end, find it is per-
fectly possible that iti the vertebrates the correspouiliug
bivalent chromosomes ate formed by the tiuion of two
univalent ones side by side. In this case one of the lon-
gitudinal s])littings would be a
true reduciii.g division, separat-
ing tlie original chioinnsomes or
tlie halves of originally .separate
ones. This question can be set-
tled only b\' a very careful study
of the fusion of the chromosomes
during synapsis.
Bediirtion in Pliints. — In the
vascular cryptogams and the
flowering plants the phenomena
attending a reduction in the
number of chromosomes pre-
paratory to sexual reproduction
are closely parallel with those found in animals, but
present interesting differences.
In these plants the cell corresponding to the last gen-
eration of oogonia or spermatogonia in animals usually
lies .just beneath the epidermis and divides parallel to the
surface into an outer tupetnl ctll and an inner cell, the
arc/teKjio>i>nn. The mitosis is typical with the normal
number of chromosomes. When the arehesporiiiin pre-
pares for division the chromosomes reappear reduced in
number to one-half, and the normal number is not re-
stored until the male and female pronuclei unite in fer-
tilization. Usually the archesporium divides twice in
lajiid succession. The result in the Hepatica> and ferns
is the jiroductiou of four spores. Each spore may then
divide b_v typical mitosis, but with half the normal num-
ber of chromosomes. It tluis, by continued cell division,
forms a prothallium, which exists for some time as an
independent plant, and bears the sexual organs, in which
the ova. and spermatozoa are produced.
In the male flowering plants, the archesporium gives rise
to four pollen grains. It is not, however, the primary
nucleus of the pollen grain that forms the male pronu-
cleus, but it is its granddaughter nucleus. In the female
flowering plants Schniewind-Tliies ( ISiOl) has found three
tyjies of develoiniient. In the first the archesporium
divides into two daughter cells, and each of the.se divides
into two, making four cells in a row perpendicular to the
surface. One of these cells is the young "embryo sac,"
the others are cover cells, which subsequently undergo
degeneration, and may be compared to the pular bodies
of animals. Within the embryo sac three nuclear divi-
sions occur, and one of the resulting nuclei is the female
pronucleus. In the second type the archesporium divides
into two daughter cells, one of which becomes the em-
b\'ro .sac, in which three divisions
occur as before. Finally in the
third type the archesporium itself
becomes the embryo sac. In each
case the reduced number of chro-
mosomes first appears in the arch-
esporium and the divisions of the
archesporium and its two daugh-
ter cells differ from the typical
mitoses, being described as hetero-
tj'pical and homceotypical respec-
tivel}'. These terms were applied
originally to the first and second
maturation divisions in verte-
brates, and their use here indicates
the striking similarity of the phe-
nomena.
As to wliether a reducing divis-
ion does or does not take place,
opinion is much divided. Some
good observers, notably Ishikawa
and Belajeff, regard the first as an equal division and the
second as a reducing division. But the majority of au-
thorities, led by Strasburger. insist that both divisions
are equal.
This result may be due in part to the fact that most of
FIG. 3985. - Section of a
Pollen Mother-Cell in ii
Later Stage, showins^
twisted chromosomes
with double row of
granules, u, Nm-leolus.
X 585. (A f ter Sargant. )
Fig.
these authors havecompletely i.gnored thesyna]isis stage,
and in their search for a reducing division, undoubtedly
influenced by Weisinann and Iliteker, have concentrated
their attention upon the daughter cells instead of upon
the archesporium.
The history of bcitli tlii' pullen grain and the embryo
sac of LUinni miir/nr/nii has been studied and desciibed
with great care by Miss Sargant. In both series she finds
a typical synapsis; but it is at the end, instead of at the
beginning, of the growth period (Fig. 3934). The chro-
matic filaments, which
showed signs of split-
ting before the synapsis,
emerge from that stage
as long flattened bands
of liniii bearing a row
of chromatin granules
u))on each edge, as in
Peripatus. These bands
are bent and twisted to-
gether (Fig. 393.5). As
the chromosomes be-
come more contlensed
the granules merge into
a solid mass of chroma
tin, apparently covering
up the linin; and when
it reaches its place at
IG. 3936.— Spermatogonium or Lutj- the equator of the spin-
ber Grasshopper in Early Prophase, ,]i„ „„„i. nl„-oi-nosonie is
showing very tine spiremes ar- ""-• cacn cnioraobonie is
ranged~in their respective diverti- conqjosed ot two limbs
cula of the nucleus. From a sec- tightlv twisted too-ether,
tion. (After Sutton.) g-,.;,,; f ,,g ^ppeai-Snce of
a minute skein of yarn:
or, better, a very much twisted doughnut. In the ineta-
phase the two limbs of the chromosomes are separaleil,
and as they are pulled apart, they often assume a V shape ;
and apparently the original longitudinal split may reap-
pear at this stage, as is indicated by Strasburger's figures.
At any rate Miss Sargant finds, and her results are con-
firmed by manv' others, that in the second division llie
chromosomes are separated into two equal halves b\' a
longitudinal split.
But, aside from their inferences to the contrary, the
writer is unable to find anything in tl;e facts, as .shown
by the descriptions and figures published liy Miss Sar-
gant, Strasburger, Farmer, and Schiiiewind-Thies, that
is inconsistent with the inference that the chromosomes
previous to the fir.st division are bivalent, formed by the
union during synapsis of two univalent chromosomes
end to end, and lliat the two limbs separated during the
anaphase are originally indepenilent cliromosoines.
That the apparent reduction in the archesporium pre-
vious to division may be due to fusion of pairs of chro-
mosomes end to end, was suggested by Strasburger in
1894, and Farmer,
who first clearly
recognized the
synapsis stage in
plants, suggested
in 1S9.5 that the
first one might be
a true reducing
division, separat-
ing the univalent
constituents of bi-
valent chromc-
somes. But he re-
garded this view
as untenable, " for
in animals no
' red uetion ' is
claimed at this
stage." Now the
work of Mont-
gomery, Paulmier, and others has made it clear
Fig. 393r.~Polar View of Eqnatorial Plate of
Spermatogonium. showing twenty-two
chromosomes and accessory, .r : /, ,/, /i. three
pairs of small chromo.som'es. From a sec-
tion. (After Sutton.)
that
reduction may occur in animals at this stage, the first
maturation division, and thus the chief ground for deny-
869
Rcdiictluu-Di vision.
Reflexes.
REFERENCE HANDBOOK OF THE JVEEDICAL SCIENCES.
ing the existence of reducing division in plants appears
to'liave bfeu removed. Moreover, the similarity is so
close at this stage that many of the figures drawn by
Strasburgei-, Miss Sargant,
and SehuiewindTbies to
illustrate forms of chro-
mosomes in ]ilaiits might
be substituted f(ir s;iiue of
I'aulmier'.s or ibrntgom-
(Mv's ligures, represent-
ing corresponding stages,
with very little change.
Si/niip.iis. llcdiiclinn. luid
Tft irditi/.—Aa stated in
ilic^ introduction, the con-
ecption "reducing divis-
ion" had its origin in an
attempt to satisfy the re-
quirements of a theory of
heredity. The conception
has very recently gained
new interest and importance through an auuounce-
nieut made by E. B. Wilsuu (1903) and the publication
of prelinnnary jiapers by Sutton and Cannon. It was
found by Jloutgomery that in certain species of bugs
the spermatogonia coulaui a pair of clironnisomcs that
Fig. .3ft3.s.— Primary Sprruuitoi-yto
of Lut)t)pr (Jrasshoppf'r in syuaj)-
.sis(t('l<)pt!asfof spcrinjitof-niiiium'.
Only a few of tiie^ chnmiDst.ines
are sliown. (After Sultmi.)
Fio. :3941.— Polar A'iew of E<|iiatonal
Plate of SHcoudary Speniiatoeyte.
showing eleven cliromosomes and
tlie accessory, x. t.^fter Sutton.)
Flfi. 3tt30. — Spiremes, oi- rtiromosomes. from a Priinarv Spcrmalnc;
Early Prophase. I>r:nvn iii two t^roups lo avoid <^on!usioii. I'touia
preparation. (After Sutton.)
are unusually large or otherwise peruli.u'. ami that after
the synap.-is in tiiese cases there is only one large chro-
mosome. Evidently the two peculiar ones liave muted.
As a result of the matinatiou divisions each s|ieiinatid
likewise contains one i)eruliar (din'mn.soiue. The same
is piiiliulily tiue iif
>ne
the rgu;. 80
llii'si' liodics in the
spcrmatoLionium is
pr(il)alily of i.;iternal
and the cither uf ma-
Ici-nal oiigjn. For
this and otlier ica-
s(ms Jloutgiinu'iy
reaches the import: lit
ciiiiclusiou that dur-
ing the synapsis each
liivalent chiiimosome
formed is lialt of pa-
teriiul and half of
matrrn.al origin, and
tile suli>c(|ucnt re-
ducing di\isi<in re-
sults in the M'|iara-
Fui. :i!l4().— Cliromosomes from Primary ticn of homolnirims
.Spermatocyte in Middlo Prophase, palernal and niater-
sliowlng Lon^tudinal Split, ti. '1. c, ||,|i elements Miid
etc., same as in Fis;. tltiai. lAfPr Sul- ,, ... , . ,■. ' .
[Qy ) ' llicir Imal isolalmn in
separate gi iin cells.
Now, as announced by Wilson, W. S. Sutton has t'oiind
in the study of the spermatogenesis of a g'rasslinpper.
Braehystola, nearly complete proof of this infeiciiee, and
W. A. Cannon has come to the same conclusion from the
study of the inatiiration divisionsof hybrid cotton plants.
The chief results of Sutton's work are illustrated by
Figs. 3936 to 3941. The
last generation of sperma-
togonia have lobed nuclei,
and each chromosome is
formed in a se|iarate di-
verticulum (Fig. 393(1).
In the late proiihase of
division the chromosomes
are seen to be of different
sizes, and there is one pair
of each size, as ?', ■/', /■,
Fig. 3937. In the follow-
ing synapsis stage the
chromosomes are seen to
unite in pairs by their
ends (Fig. 393S) and in the
subseiiuent propha.se there
are eleven bivalent chro-
mosomes, a, b, c . . . k.
Figs. 3939 and 3940, corresponding to the pairs in the
spermatogonium. The second maturation division is a
true reducing division (Fig. 3941). If the oogenesis is
the same, and the individuality of the chromosomes is
maintained throughout the germinal cycle, then, of
the two clirianosomes that unite in synapsis, one
must lie of paternal and the otiier of maternal
origin.
It was disenvereil recently liy Boveri, that when
the chromosomes in the segmenting ovum of a sea
urchin have become disarranged as the result of
double fertilization, and consequently unequally
distributed to the blastoineres, abnormal larva^ re-
sult. He inferred from this that the chromosomes
diller (pialitatively and stand in detinite relation to
inheritable eharaeters.
Taking all these results together, Wilson points
out that they seem to contirm iiud to show a pbysi-
ctil basis for ^lendel's ]u'inciple of heredity, Wi.ich
is lieing much discus.sed at present (see lierersinn).
Whether .Mendel's theory be true or not, it is cer-
tain, as Wiis sliown iu the article dealing with he-
redity, that it is in the nucleus of the germ cells,
aad especially in their chromatin constituents, that
must kok to tinil the physical basis for heredity,
therefore the ilianges which these constituents un-
;o in the course of sexual reproduction possess the
deepest interest for all students of liiology.
H'Aert I'ai/ne Difjdoic.
Bini.ionR.irniCAL Rkferescks.
lioveri, T. : Bcfruchtuni.'. F.iwli. Anat. u. F.ntw., vnl. i., 1S92. pp.
tiSti-Ts.i. — Ui'Per inclirpoliiie Milosen als MlUel zur .\nalvse des
Zclllierns. \'er. plivs.-naHl. Gcs. Wiirzhurg, N. F., Hd. M, VM2, pp.
07-11(1.
Cannon, W. A.: A ('vtoloi:ii'al Basis for the Mendeli.ui Laws. Sull.
Torrey Bot. (luh, vol. .xxi.x., put', pp. Sjr-CUI.
Farmer, J. B. : Spore-Foniui lion and Nuclear Division in the llepaticiE.
Annals of Bot.. v.^l. l.\.. isdri. pp. 46!l-.)2t.
Hiickor, v.: Praxis and Theorie der Zellen- and Berruchtunffslehre,
.li'iia, I'ischer. isiitl.
Moiitirnniery, 1". H., .Ir. : Siiermatoirenesis in Pentatoma up to the
Fonnation of the Speniiaud. Zool. Jahrb. .\nat., vol. xii.. isiis, pp.
1-SS. — SpeniKUiiLreiU'sis <if Peripallls (PeripatonsisI Itaifoiiri up 1*1
the Formation or tlio speiuiaiid. I.e.. vol. xiv., 19U:i, pp. 2r.'>-:!(l.s.-A
Study of the Chromosoiiies of the (ierm-Cells of Meiazoa. Trans.
Amer. Phil. Soc.. Phila.. N. s.. vol. xxii.. Ifldl, pp. l.')4-2)(i.
Woore. J. K. S. : 1111 the Structural Chamres in the Reproductive Cells
dur'ns Sperinaloji:enesis of K'a.sinoliranchs. Quart. Jour. Mie. Set.,
N. S.. vol. xxxviii„ l.sil.">. )ip. ,'.'7.V;!I4.
Paulmier, F. I'.t TheSperiiiaio!.'eiieMsot Anasatristis. Jour. Morph.,
vol. XV., supiit.. ISit9, pp. 22:>-2T2.
Sar^'U^t, Kthel : The Foriiiaiion of Sexual Nuclei in I.iliuui Marlatron,
I. Ooprenesls. Annals of !!nt.. vol. x., hSilll, pp, t4,")-477. II. Sper-
matoirenesis. /.c, \ol. xi., IS'.17, )i|). IS7-224.
Schniewind-l hies. J.: Pie Iteduktion der Chromosomen-Zahl imd
die ihr foltreuden Kernleiluiigen in den EmltryosacKmuttcrzellen
der Antriospermen, Jena, Fisciier, IdOl.
Strashurger. E. : Petier Kediiktionstlieilunff. SpindelhiMung. C^en-
trosomen and Cilleiihildner iiu t^flanzenreich. Jena, Fischei-. KKIh.
Sulton, W. S. ; The S|iermah)L^oiiiat Iii\isious in lirachvostola tuairna.
Kansas Pniv. Quart., vol. ix., l(««i. pp. IS-Vltai. -1111 the MorpholoL'y
of ttie Cliroiiiosiime oroup iu Braehystola magna. Biol. Bull., vol.
iv., lat;, pp. 24-3U.
yte in
mear
we
ani
der
870
REFERKSCE HANDBOOK OF THE 5IEDICAL SCIENCES.
Redurt ion-Division.
Reflexes,
■Weismann, A. : On the Number of Polar Bodies and tbeir Significance
ill Heredity, li<87.— Kssays upon Heivclity, oxiord. IHSli, pp. 333-»il.
"Wilson. E. B. : The Cell in Development and Inheritance, sei-^md
(Oition, .N. Y., IIKIO, pp. :i:ti-2S8. Mendel's lYinciple.s of Heredity
and the Maturation of the Germ Cells. Scienee, N. S., vol. xvi., liKJ:;,
pp. !«l-!i9:i.
■Wolteieek, R.: Ziir Bildung und Entwickluiiff des Ostracoden-Eles.
Zeitseh. f. wiss. Zool., vol. Ixiv., isut;, pp. .u9U-(!2S.
REEDY CREEK SPRINGS.— Mtirioii County, South
C.uolitui. PosT-Ob'i'icK. — Lilt la. Hotel tiud cottages.
Tlii.s resort is locatnl about tliiee-<iuitrtcrs of a mile
fi-oiii the Atlantic Coast Line Kailroail. The surrouud-
iiig country is level and covered b.v the long-leafed pine.
The springs are three in number, and have had a local
reputation for more than thirtj' years. The ^vater has a
constant temperature of 4.j^ F., audits flow is very large.
Jlr. John L. Dew, of the springs, sends us the following
list of ingredients resulting from a partial analysis by
former Stale Chemist Chizzell: Iron carbonate, calciuni,
magnesium, and suliihur. The water is used more par-
ticularly for stomach, liver, and kidney disorders and
debilitated states of the system. Jitmes K. C'rvok.
REFLEX ACTIONS OR REFLEXES. See Enee-.Terk.
REFLEXES. (CLINICAL.)— Descartes introduced the
conception of relle.\es into biological literature. In
" Passions de I'ame " he stated that stimulation of a sen-
sory nerve impulse may be trausniitteil through the brain
to motor nerves and therebj' give rise to contraction of
muscles, and that tliis coutractioa takes place without
volition, and even contrary to it. The general reflex
centre he believed to be the glaudula iiineahs.
This definition of reflc-\cs was correct in the early
days of biology, hut. with the advance of knowledge,
our conception of llie reflexes has been enlarged.
The term is used in medical literature lo-day in a two-
fold sense:
1. tivecificalli; , as in pupillary, knee, plantar reflexes,
etc.
2. Gfiicrutillij, as in reflex neurosis, reflex spasms, re-
flex cough, etc.
In boYh the strict sense (pupillary and knee reflexes,
etc.) and in the broader sense (reflex cough, reflex neuro-
sis, etc.) reflexes are centrifugal plienomena pi'oduced
by reflexion and eventual transmutation of centripetal
siimulation. In other words, reflexes are physiological
or jiathological, motor, vaso-motor, viscero-motor, secre-
tory or trophic phenomena, the cause of which is to be
found in sensory siimulation.
There is still another group of phenomena called "re-
flex," to which the foregoing definition does not apply.
Tills group is represented by a set of centripcdd phenom-
ena— reflex pains, reflex neuralgias, etc. Investigation
shows that these phenomena are not genuine reflexes.
One group of them, for instance pain in the distribution
of the fifth nerve due to disease of the teeth or other
structures of the head, or arm pain accoiujianying an
anginoid attack, is, according to Ilead. an irradiation of a
sensory stimulus to other parts or branches of the per-
ipheral sensory apparatus <d" the alTceted locality.
Another group, for instance headache due to disease of
the abdominal viscera, is, according to the same author,
due to irradiations of the sensory stimulation to a central
sensory station, and from here to allied sensory structurea.
Thus the difference between the two types becomes quite
apparent.
The genuine reflex phenomena consist of neural stimu-
lation that is reflected from one set of neurones (centrip-
etal neurtmes) to a physioiogically different set of neu-
rones (centrifugal neurones).
The other t_vpe consists of neural stimulation that is
irradiated and jiropagated from one set of neurones (ceii-
tri|ielal) to another physiologically homologous set (ceu-
tri]ietal neurones).
Finally, tlft term reflex is used promiscuously in medi-
cal liteiature to denote a phenomenon, the cause of whieli
opeiates at some distance from where its effects are
manifest.
According to tlie conception of genuine reflexes out-
lined above, all organic functions, save perhaps tlie tlis-
tinctly voluntary functions, and some automatic visceral
functions, may be looked upon as reflexes. Whether this
be fully so or not, we will not attempt to decide. Tlie
considerable interest bestowed uptm these phenomena,
since the times of Descartes, testifies to the great impor-
tance of reflexes. (For further details in regard to these,
consult the article on Knec-.lerk in Vol. V.)
In 1875 Erb and AVest|)hal, working independently,
demonstrated the clitiical value of reflex phenomena, and
since then their importance is daily more appreciated.
Prior to the publications of Erb and Wesfphal reflexes
were observed and registered at the bedside in Charcot's
Clinic. Charcot apparently divined tlieirim]iortance, but
he had not yet ajjiu'cciated their clinical significance.
Abundant clinical, exiierijcental, and histological facts
have been coUecled f(U- the proper theoretical iiuerjire-
tation of reflex phenomena. However, a unanimity of
opinion has not yet been reached. Some accept the
original teachings of Erb, who interpreted reflexes, par-
ticularly tendon reflexes, as true reflexes; others adliere
to Westphal's teaching, who believed that they were not
true reflexes, but phenomena dependent upon the muscle
tonus. Cowers calls tlie teudun reflexes mvotatic jdie-
nomena, and liis conception is akin to that of AVcstphal.
AYe shall not consider here the evidence which tends to
substantiate cither of these theoretical views. Here the
theoretical basis of the reflex phenomena will be discussed
only in so far as is necessary for a iirojier and intelligent
interpretation of these phenomena at the bedside. The
best-known and most studied of all reflexes are the ten-
don reflexes, and their classical representative is the kuee-
jerk.
The subsequent remarks apply to tendon reflexes in
general, and to llie knee-jerk in particular.
A reflex is a neural phenomenon which originates in a
■sensory end organ, travels along a centripetal pathway,
passes a .ganglionic station, and leaves it changed or un-
chan.gcd in ciuality or (luantity, and pursues its wa_v out-
waid on a centrifugal pathway to a centrifugal end or-
gan. The anatomical structure subserving this consists
of: A sensory cud oi\gan, a peripheral sensory lihre, a
ganglion cell, a peripheral motor fibre, a motor end-or-
gan— in other words, a sensory and a, motor neurone of
the iicripheral kind.
Tliis anatomical structure is called a reflex arc. The
primary reflex arc is under the influence of one or more
secondary arcs, which are represented by an analogous
arrangement of secondary neurones.
The centrifugal branch of one of the supposed second-
ary iircs is represented h_y the fibres of the pyramidal
tracts. The centripetal partner and the central connec-
tion of the two are not fully known. The former is
probably found in the ascending cerebral and cerebellar
tracts, and the central station is probably situated in the
gray matter of the cerebrum and cerebellum, and in the
nuclei and gray matter of the mesencephalon. The ten-
don phenomena are accompanied by conscious sensation.
AVhetherthis sensation is caiTied up along the centripetal
jiathways above mentioned or not is luit known. l"su-
ally. when a reflex arc is spoken of. only the strict neural
elements are understood to represent it. while the sen.sory
and motor end-organs are not included. The ganglionic
slations are spoken of as reflex centres. In addition a
reflex arc is under the modifying influence of individual
segments of the spinal cold above it.
In the lowest forms of life the anatomical substratum
of most reflexes is represented by one reflex arc only.
This is the case also in some of the simpler forms of re-
flexes.
All that has been said thus far applies inirticularly to
the tendon phenomena. For other reflexes, shin reflexes,
visceral reflexes, etc., analogous anatomieal structures
are supposed to exist. Their exact localiim and connec-
tions arc fully known in some instances, not entirely in
others, while" ia still others they are altogether hypo-
thetical.
an
ICollexos.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES,
Rcfli-x centres are eoiistituted citlier by the gray mat-
ter of tlie cereliro spinal axis, or liy tlie uray matter of tlie
symiiallii-tie (visceral) system. The afferent, and I'lTereut
pathways are either exclusively ceielirosirinal, or exclu-
sively symiiathetic (visceral) or mixed.
It is believed that a reflex arc is constantly traversed
by neural enerjiy which establishes iu this arc a sort of
functional equilihriuin. Under normal conditions this
cijuililiriuru is altenjd in con,sequeuce of changes in the
Secondary reflex arcs, and this results in vf)luntary action
or reflex action. Within physiological limits a variety
of general and local causes, acting on all or some partsof
the'rcMi'x arcs, will greatly modify reflex activity. This
will be still more so in the domain of.patliology.
It is thus .seen that the semeiological value of reflexes is
not exclusively reserved for neuropathology. Diagnos-
tic and ]iartic'ularly prognostic aid is occasionally re-
ceived from a, study of reflex phenomena in general dis-
eases. Attention has lately been drawn to this fact liy
Pfaundler and Luethye in their investigations on the be-
liavior of reflexes in pneumonia and other acute infec-
tious diseases (.1/«»c/(. iind. Wocheri'Schr/ft, Julv, August,
I'JO:.').
The systematic study of reflexes in ueuro-visceral dis-
eases will probably yield valuable information.
The theoretical controversy about thenatureof reflexes
is exclusively <-oncerned with tendon reflexes and hinges
upon the question of the interrelation and interde]iend-
euce of tendon jihenomena and so-called ni\iscle tonus.
The nature of all other reflexes (skin and visceral) is ap-
parently undisputed; they are believed to be genuine
reflexes.
Acccuding to .Tendrassik reflexes investigated at the
bedside may be divided into three categories, according
to the sup|)osed situation of their centres.
1. Sp/'iKil: Tendon, muscle, periosteum, bone reflexes,
jaw-jerk.
2. Vivehnil (cortical) cutaneous reflexes: Scapular, ab-
dominal, cremasteric, scrotal, gbiteal, plantar, jialpebral,
conjunctival, pharyngeal, anal.
3. rw-ovf/ (sympathetic): Sneezing, swallowing, vom-
iting, coughing, erecti<in, ejacidation, etc.
The tirst group, alsocalli'd physiological spinal reflexes,
is chaiacterized liy the following points:
(1) The reflex is elicited from moderately sensitive
areas.
(2) The reflex movement is usually not aeeomiianied
by specific sensation.
(3) The exciting stimulus is a simple meclianieal irri-
tation.
(4) The intensity of the reflex movement is not so va-
riable as in the second gioup.
(5) It i-an be elicited oti one's self as well as on others,
(t!) The iieriod of latency is the shortest.
(7) The reflex movement is a simple twitch and is ap-
parently not adapted to certain ends.
(8) >iu.scular exertion increa.ses this reflex.
(9) In diseases of the brain (after a certain time) these
reflexes are increased.
(10) Delay is not ob.served.
(11) Mental influences are of little effect. Distraction
of attention makes the demonstration easier.
Reflexes of the second group are characterized by the
following points:
(1) The elicitation of the reflexes takes place from very
sensitive localities.
(3) The reflex is accoui]ianied by sensation.
(3) The exciting stimulus must be of sutficienl dura-
tion to jircjduce a distinct sensation.
(4) The intensity of the exciting stimulus is not always
proportionate to the result. Individual variations are
great.
(5) Tlii'se reflexes ciui be elicited on one's self only witli
great ililliculty.
(6) The Iieriod of latency is longer than in the first
group and not as constant. The period of latency is
proportionate to the spi'cd of the sensory conduction.
(7) The resulting movement is more complicated and
seetns to have the jiurposeof removing the irritated parts
from the source of irritation.
(8) Increased muscular activity frequently diminishes
these reflexes.
(!)) These reflexes are diminished or absent in cereljral
lesions.
(10) They are delaj'cd in appearance when the sensory
conduction is delayed.
(11) JNIental influences increase or diminish these re-
flexes. Dislraction of attention frequently diminishes
them.
Reflexes of the third group are characterized hy the
following points;
(1) These reflexes are elicited from sen.sitive jKiints.
(2) They are accompanied by specific sensation. The
sensation here is of greater importance than in the reflexes
of the second group.
(3) The time for the necessary stimulation is here the
longest.
(4) These reflexes have great individual variations.
(.")) They are elicitablo on one's self, but depend upon
speeilic stimulation.
(()) The time of latency is the longest.
(7) The resulting movement is very complicated — bilat-
eral.
(5) ;\Iu.scular exertion diminishes these reflexes.
(!t) In cerebral lesions they are increased or diminished.
(10) Mental influences are of great importance.
Dejerine divides reflexes, according to the nature of the
periplieral jiarts of the reflex arc. into four groups:
1. Reflexes, the centripetal and centrifugal branches of
whose arc are represented by cerebrospinal fibres: tendon
reflexes, cutaneous reflexes, reflexes of deglutition.
2. Reflexes, the centripetal branch of whose arc is a
cerebrospinal fibre, and the centrifugal branch a synqm-
thetic( visceral) fibre: salivation, blushing, intestinal con-
traction, jiaiu reaction of the iris.
3. Reflexes, the centripetal branch of whose arc is a
synqiathetic (visceral) fibre, and the centrifugal branch a
cerebrospinal fibre. This group is represented mostly by
pathological reflexes: reflex phenomena due to irritation
or disease of the abdotninal viscera.
4. A grou]) which logically would be presented by re-
flexes, the centripetal and centrifugal branches of whose
arc are built up of sympathetic or visceral fibres. Physi-
ological: .secretion of digestive juices. Pathological:
Visceral congestion, redness or pallor of the skin in con-
se(|uence of liepatic colic, etc.
In Dejerine's originalarticle,*however, this last-named
group is tluis characterized:
4. In the last group can be placed the reflex acts whose
paths of conduction do not arise from the .sympathetic
system. Phy.siological: The secretion of intestinal juices-
in the course of digestion. Pathological : The iihenome-
na of vi.sceral congestion, blushing, pallor, coldness of
the skin |iroduced by organic affections (colics, etc.).
For the clinical understanding of the tendon phenome-
na, Sherrington's classification seetns helpful. He be-
lieves that one ought to distinguish under the name of
tendon reflexes two dilTerent varieties of phenomena:
1. True S]iinal and cerebrospinal reflexes, excited by
stimuli applied to the tendons.
2. Peudo-reflexes, commonly called tendon phenomena
or tendon concussions.
The true tendon reflexes have no considerable clinical
ini|iortance. The pseudo-reflexes are not genuine reflexes
because: (1) The time occupied for their production is
very short. (2) The muscular contraction is a simple
twitch and not prolonged or tetanic; therefore the kni'c
phenomenon is not a true spinal reflex, but a direct re-
spouse of the muscle to a sudden mechanical tension.
Only when the muscle is in connection with its neural
sujiply can this response be obtained. For the produc-
tion of the knee phenomenon the tonus of the muscle is
iudispensal-ile.
* I'M. Bmirlianl : " Semelologie (tes Iteflexes." "Traite de I'^tlio-
logie generale," tome v., p. H99, 1901.
872
REFERENCE IIxVNDBOOK OF THE MEDICAL SCIENCES.
K4'II('X08«
It <■ ilexes.
Tlie number of reflexes so far described is quite con-
siderable. Additions are constantly being made, and the
future will imdoubtedly bring more. Onlj' a few of this
large number have general clinical importance. The
others gain in importance and prove useful and reliable
guiiles in segmental and topical diagnosis, in proportion
to tlieir aiKitomiral elucidalion.
The following reflexes are among the older and better
known :
A. Superficial Reflexes: Palpebral, corneal, conjunc-
tival, piiaryiigeal, interscapular, epigastric; upper,
Iducr, nuddle abdominal; cremasteric, scrotal, anal,
gluteal, lumbar, pilomot(n' or goose-skin reflex.
B. Deep or Tendon lieflexcs : Patellar, Achilles, tricei)S
or olecranon, biceps, ulnar, radial, masseter or jaw-jerk.
C. Yiscenil Reflexes: Pupillary, bladder, rectal, sexual.
Some of the newest reflexes are : The lumbo-fenioral of
Becliterew, the infraspinatus of Steiner, the supra-orbi-
tal of McCarthy.
Tlie exciting stimulus necessary for the production of
a reflex varies in quality and quantity. The pupillary
reflexes respond to specific irritation of the optic nerve^
photic stimuli. The superticial reflexes are evoked by
stiiiiidation of the tactile or algetic senses. The tendon
reflexes are the result of mechanical stimulaliDU of the
tendon. Under certain conditions mechanical stimulation
of the adjacent structures (periosteum, bone, articulator}-
surface) yields a reflex contraction.
The sensory (tactile or algetic) stimulation of the skin
around the knee occasionally gives rise to a contract ion
of the quadriceps nuiscle. This is not a genuine tendon
phenomenon, but is known under the name of pseudo-
knee-jerk, and has been described by Wespthal, with a
note of warning to keep this phenomenon dislinct from
the genuine tendon jerk. The jiseudo-knee phenomenon
may be observed even when the genuine knee-jerk is
absent.
The intensity of the sensory stimulation necessary for
the production of a reflex has an upper and lower limit
of eliicacy. Below a certain limit of irritation the reflex
phenomenon dependent upon this irritation naturally does
not ensue. Equallj' disturbed is the reflex response in
its clearness, or it is even entirely frustrated when the
sensory stimulus is above a certain limit of intensity.
Therefore the intensity of the sensory stimulus may be
looked upon as an index of the reflex activity of the cen-
tres or arcs, which vary considerably within physiologi-
cal limits. The intensit}' and extensity of the reflex re-
sponse are also quite variable. The muscidar contraction
is sometimes vigorous, quick and lightning-like, at other
times sluggish and less active. When the reflex response
is considerably exaggerated, the irritation is followed by
a succession of contractions, known as clonus (patellar
clonus, ankle clonus, wrist clonus). In a still higher de-
gree of increased reflex irritability, this clonic response
spreads over wide territories, and is then called "epilep-
sie spinale."
Under certain conditions the muscular contraction is
limiicd to one muscle only, and at other times it spreads
to neighboring nnrscles, or even to homologous nuiscles
of the opposite side of the body. Furthermore, a cunm-
lative quality of the sensory stimulation is occasionally
observed. A reflex occurring at times from one stinnda-
tioii will need at other times a repeated stimulation for
its production. Sometimes the reflex resjionse shows a
peculiar e.xhaustibility. This is seen when the same
stinudation is fcjllowed at one thne by a normal contrac-
tion, at another by a much weaker one or by none at all.
Another expres.sion of tlie same tendency is to be seen
when a reflex that responds to a stimulus becomes ex-
hausted after frequent stimulation, then reap|iears again
after a short interval of rest. These variations when oc-
curring under the same conditions of stimulation also
permit the inference as to the state of the reflex acliviry
of the centres or ares. At the same time these variations
of the reflex res]ionse may be lu'ofltably ke|it distinct
from the variations of the response depending upon the
Intensity of the stimulation. The latter may be desig-
nated as variations of the reflex irritability, and the former
as variations of reflex mobilit}\
Frequently the attempt has been made to express the
described variations of the sensory stimulation and motor
response of the reflex phenomena in more exact terms.
A]iparatuses have been devised for the purpose of meas-
lu-ing the one as well as the other; these investigations
have aided the physiological conception of reflexes; but
clinically they have not been of nnich value.
If all of the foregoing be borne in mind, the following
propositions will be self-evident;
Reflexes are Inereasecl.- — 1. ^V■hcn the sensory end ap-
paratus, or the centripetal fibre, or the centrifugal fibre,
or the (irimary reflex centre, is in a more or less marked
state of irritation.
2. When the inhibitor}' influeuce of the secondary re-
flex arc is diminished or paralyzed.
Reflexes are Dim uris/ied or A/jseii t. — 1 . When the sensory
end-apparatus, or the centripetal fibre, or the centrifugal
fibre, or the primary reflex centre, is in a state of more or
less marked jtaresis or paralysis.
2. When the stimulating influence of the secoudaiy re-
flex arc is dinnnished lu- paralyzed.
Lastly, reflexes will be increased or dinnnished accord-
ing to theincreaseor diminutionof the exc itingstinndus.
There are a maximum and a nnuimuni of conditions-
favorable to the elicitation and demonstration of reflexes.
F(U- the pupillary reflexes it is necessary that the differ-
ence between the stinuilations (light and dark) be quite
marked. The skin and tendon reflexes are considerably
inqjeded by the will and by concenlrate<l attention; the
skin reflexes less so than the tendon reflexes. Dilticulties
encountered clinically in the demonstr.ation of pupillary
reflexes are obviated by exandning the patient in a dark
room, with artificial light, and by taking care that ac-
commodation is excluded.
In the case of skin and tendon reflexes, various means
have been devised for distracting the patient's attention
during the examination. To obviate these diflicullies re-
course is had to what is commonly called the metliod of
reinforcement, ortlie.Tc'udrassik m<'thod. This consists of
the following: The ]iatieut is diiecled to link his hands
into each other and then toatteiupt to pidl the hands forci-
bly apart. Care must be taken that the tap of the tendon
is synchronous with the greatest effort of the patient.
A characteristic and peculiar degree of muscidar con-
traction is indispensable for the demonstralion of tendon
reflexes. A muscle contracted above a certain limit is
incapable of expressing an additional contraction, and a
muscle relaxed beyond a certain limit is also irresponsive
to reflex stimulation. Finally it is not to be forgotten
that recent or previous disease of the structures arotuid
the knee- or ankle-joint is carefully to be excluded.
It should not be said that a reflex is absent unless the
examination has been made with the above-mentioned
precautions.
At the end of this article will be.found a list of all re-
flexes with their respective anatomical locations and con-
stituenis. and their clinical significance.
It remains only to discu.ss in detail the most important
reflexes; the pupillary phenomena, the knee-jerk, the
Achilles jerk, and the plantar reflex.
PuPIM..\nY PlIENOMEN.^.
The lollowing points are noted in the examination of
pupillary phenomena:
1. The size of the pupils.
2. Their shape and outline.
3. The light reactions (direct and consensu.al).
4. The accommodative and convergence reactions.
h. The pain reaction.
Recent or previous disease of the structures of the eye-
ball (cornea and iris, anterior chamber, etc.) must be care-
fidly excluded before any conclusionsare drawn. Under
average physiological conditions both pupils are of me-
dium dilatation and equal when exposed to diffused day-
light. Inequality of the pupils (anisocoria) is, as a rule,
873
Reflexes.
Rcflexesk
REFEKExNCE HANDBOOK OF THE MEDICAL SCIENCES.
patliolnsical. Exceptions to this rule are few and not
fully lUHk-rstorid. Wtv wi(l<' pu|iil.s (mydriasis) are
sometimes witliin pliysiological limits, but art' most often
observed in sensitive uenrotic subjeels. Very small pu-
pils (myosis) are more often patliolojrical tlian the pre-
cedinj!;." It is not to be forgotten that drngs are occasion-
ally the cause of the mentioned slates of the pupils
(belladonna, ojiiates).
Normally the outline of the pujiil is circular, and the
free bonier smooth. Serrations of outline and imperfec-
tions of the circle are significant. As a rule I his denotes
previous syphilitic infection.
The direct rea<-tiou consists of dilatation of the pupil
■when light is shut out, and of contraction of the pupil
when light is admitted.
To ascertain this reacticni, the i)a,tient is directed not to
acconunodate for any near object, and both juipils are
alternately exposed to and in-otected from the light, and
the result' is watched. Tills reaction, "reaction to light,"
is never absent in health.
When the light reaction does not ensue, and cave has
been taken to avoid the mentioned possibilities of error,
the pupils are said to be "still." This constitutes the
Argyll-Robertson phenomenon.
Tile consensual reaction consists of contraction or dila-
tation of the pupil of the oppo.site side, following the
adnifssion or exclusion of light from the other iui|)il.
This is best examined for "as follows: The pupil is
watched while the lid of the other eye is raised or low-
ered. This reaction is rarely distuibed alone. It is seen
sometimes in conjunction with other disturbances of the
pupillary play.
The accomniodalion reaction consists of contraction of
the pupil on fixation of near objects and of dilatation of
the pupil when looking into the distance.
The convergence reaction is a conlraction of the ])u]iil
on conveigence of the eyeballs (simidtaneous innervati(jn
of both internal recti).
The pain I'eaction consists of a dilalalimi of the ]iu]nl
upon iiainfid slimulation of face or neck, or sometimes
upon painful slimidation of any part of the body.
The hemiopic ])upillary reaction of Wernicke is a rare
pupillary iihenoLiienou. It occurs in cases of hemianop-
sia, central or peripheral.
Light reaction occurs only on stinuilalion of the sensi-
tive half of the retina, and does not ensue when the non-
sensitive half is irritated. It is best demonstrated when
one-half of the ])upil is protected by a small shield atul
the other is alternately stimulated by admission and ex-
clusion of light.
Occasionally' one finds in literature the term paradoxi-
cal pupillaiy n'action. The leaclion is said to be ]iara-
<loxical when the jiupil dilates on adnifssion and contracts
on exclusion of liglit.
Sluggish and lively pupillary reactions are likewise
spoken of. These dejieml of cour.se upon the sjieed with
which, and extent to. which, reactions take jil.ace.
Lastly a jdienomenon has been descrilied by Strasbur-
per and Saenger {.\eiirol. Cciitrdlhl., 11102) tuider the name
of myotonic pupillary reaction. They mean reactions
that occur in such a way that the iris remains for a .short
time in dilatation or contraction, as the case may be, be-
fore cbangin.g.
Pu|iillary rcaelions liave also been observed as a tvpe
of associated movements coincident with looking upward
or upon forcible closure of the eyes.
It has further been slated, by goodaulhority, that even
the meie suggeslion of light and dark, for instance to
totally blind people, is sometimes followed by the corre-
sponding pupillary reaction.
A slate of imrest and constant change of width of pu-
pil has also lieeu noticed at times, and been given the
name of liippus.
Knee-Jerk.
The knee-jerk (knee kick, knee reflex. ]iat('llar refiex,
knee iihenomenon. Erb or Westjibal phenomenon) is the
name given to a contraction of the quadricejis femoris,
that follows a blow upon the iiatellar tendon. The con-
traction is more marked in the internal division of the
muscle (vastus internus). The knee-ierk is rarelj' absent
in healtli.
In order to demonstrate this phenomenon, it is neces-
sary, as was exiilained before, to ijrevent inhibition on
the ])art of the patient.
Tlie knee phenomenon is elicited in the following way:
1. The knee is allowed to swing freely on the exam-
iner's hand, or the foot is put llatl}' upon the lloor, .so
that the leg and thi.gh form a slightly obtuse angle, or one
leg is crossed upon the other, and the leg is allowed to
swing freely.
3. A sharji tap is made u]iou the patellar tendon willi
the tips of the fingers, with the ulnar border of the band,
with a percus.sion liannner, or with any other suitable in-
strument. Tlieretii)on a contraction of the quadriceps
muscle ensues, moie or less (puck and vigorous. This
contraction can freipiently be .seen and felt, and it gives
rise to a more or less marked excursion of the leg. This
reflex varies quite considerably within i)liy.siological and
pathological limits. These ■frariatious are designated by
the names of normal, lively, increased, diminished, exag-
gerated, etc. In states of exaggeration, a reflex response
is elicited not only upon mechanical stimulation of the
tendon, but also u|ion irritation of a wider area aroiuid
the knee and the upper part of the tibia. In states of
diminution of the retle.x respon.se, the reflexogeuic zone
is considerably narrowed, and the reflex response is more
liable to occiu' upon stimulation of the median than upon
stimulation of the lateral half of the p;itcllar tendon.
Evidence of greater exa.g.geration of the knee reflex is
patellar clonus. This is (lemonstrated in the following
Avay :
Tlie lower extremity is slightly hyperextended and
the patella is pushed (piickl3- downward, and percussed
or tapped in this position. A sharp clonic contraction
is the result. Sometimes the reflex contraction is not
limited to the quadriceps nuiscle alone, but is observed
in the adductor group of muscles of the same side, or oc-
c.isionally of the opposite side of the body. Rarely the
contraction occurs even in the quadriceps muscle of the
other side. The titter phenomena are called crossed ad-
ductor and crossed knee-jerk respeclively.
Direct mechanical stimulation of the belly of the mus-
cle is also followed by contraction of the muscle. This
is, however, the expression of the so-called mechanical
muscular initability, and reveals itself clinicallj' in two
forms:
1. The contraction is fascicular and limited to the site
of I he iriitation.
2. The entire muscle contracts.
This last-named contraction is not to be confounded
with the true knee reflex. It is frequently found, for in-
stance, in cases of tabes, in which the reflex is alisent.
The occurrence of a pseiulo-knee phenomenon — a con-
traction of the quadriceps niional.getic stimulation of the
skin around the knee — has been mentioned above.
Acini.i.i:s .Tkkk.
The Achilles jerk consists of a contraction of the calf
mu.scles upon ta]iping of the Achilles tendon. This retiex
is cxannneil for in the following way:
1. The foot is slightly dorsillexed. the knee is slightly
flexed, and the Achilles tendon is tapped. A plantar
lle.\ion of tlu^ foot ensues.
2. The lower extremity is slightly flexed at hip and to-
tally flexed at knee, and in this position tlie entire leg
rests on a chair while the foot is free. In this position
the Achilles tendon is tapped, and a plantar flexion of
the foot is the result.
When this reflex is exaggerated, a forced dorsiflexion
of the foot is followed by a succession of conlraetions.
This is called the ankle clonus. This clonic contraction
keeps uj) as long as the dorsiflexion of the foot is main-
tained. Al other times it soon ceases and may or may
not reappear. The ankle clonus which is difficult to de-
874
referexc:e haxl)B()ok of the ]\iedical sciences.
Reflexes.
Reflexes.
monstrate, and in which the clonic contractions are not
vigorous and are easily exhaustible, are sometimes spoken
of as pseudo-ankle clonus.
Sometimes difliruUies are encountered in the demon-
sti'atiou of ankle clonus, and then it is well to use the
following procedure; Bend the lower extremity slightly
at hip- and knee-joints; exert sharp dorsillexion of the
foot, and in addition tap repeatedly liie Achilles tendon.
The pseudo-ankle clonus is very rarely evidence of or-
ganic disease, although undoubtedly cases of disease of
tiie pyramidal tracts occur in which the ankle clonus is
of a pseudo type.
On the other band, the genuine ankle clonus ivhich is
expressed by vigorous clonic contractions, which persist
as long as the dorsiflexion of the foot is kept up, is usu-
ally, though not always, evidence of organic disease.
The question of the occurrence of genuine ankle clonus
in hysteria is not fully decided. There are undoubtedly
a few cases of hysteria with marked ankle clonus on
record.
Care should be taken not to confound the genuine
Achilles reflex witli the expression of the mechanical irri-
tation of the muscle. The Achilles retiex is rarely, if
ever, absent in health, although it is not believed to be
as constant as the knee-jerk,
Plant.\r Reflex.
The plantar reflex is the most constant representative
of the skin reflexes. It consists of a sequence of contrac-
tiunsof a variety of museles of the lower extremities, fol-
lowing tactile or algetic stimulation of the sole of the foot.
For the production of the refle.x, the median half of
the sole is more sensitive than the lateral half. Under
normal conditions, and under mild stimulation, the nuis-
cles most frequently seen to contract are the tensor fasciae
and the plantar flexors of toes and foot.
In states of increased reflex excitability the whole foot
is dorsiflexed. and in a still higher degree the entire
lower extremity is removed from tlie source of irritation.
The same takes place wiien the exciting stimulus is
stronger or frequently repeated in succession.
Reflexes.
Corneal and con-
iiuictival.
Pupillary (light)
Pain reaction of
pupil.
Pharyngeal . .
Jaw - jerk (chin
phenomenon
Mimetic reflex of
face.
Scapular
Palmar
Epigastric . . .
Abdominal .
Cremasteric ....
Gluteal
Plantar
Triceps
Biceps
Wrist- jerks
Patellar reflex.
Achilles reflex.
Neuuai. Mkchaxism.
Afferent.
Fifth nerve.
Optic nerve...
Cerebral or spinal
sensory nerves.
Ninth nerve .
Fifth nerve..
Nerves of special
senses. Psychic
stimuli.
Seventh nerve.
Cervical sympa-
thetic flbres.
Seventh nerve . .
Motor portion tif
fifth.
Facial nerve.
Sensory roots
llfth cen'ical to
flrst dorsal.
Sensory nerves,
seventh cervical
to Ili'st dorsal,
Sensory nerves,
fourth to seventh
dorsal.
Sensory neiTes,
seventh to
eleventh dorsal.
Sensory nerves,
flrst to third
lumbar.
Sensorv nerves,
fourth to fifth
lumbar.
Sensory nerves,
flrst to second
sacral.
Sensory nerves,
si,\th cervical
Sensory nerves,
sixth cervical.
Sensory nerves,
sixth to eighth
cervical.
Sensory nerves.
_ sefoiid to fourth
lumbar.
Sensory nerves,
third to flfth
sacral.
Same motor rooti
Motor nerves,
seventh cervical
to fii^st dorsal,
Motor nervi
fimrth to seventh
dorsal.
Motor nerves,
seventh to
eleventh dorsal.
Motor nerves,
flrst to third
lumbar.
Motor nerves.
fourth to flfth
lumbar.
Motor nerves,
flrst to second
sacral.
Motor nerves,
sixth cervical.
M(ttnr ner\'es.
sixth cervical
Motor nerves,
sixth to eighth
cervical.
Motor nerves,
second to fourtl'
lumWar.
Motor nerves,
third to flfth
sacral.
Nucleus of
seventh nerve.
Ciliaiy ganglion
(V).
Cilio-spinal cen-
tre, fourth to
seventh cervical
Nucleus of
sf'venth nerve,
Moior nucleus of
urtii.
Thalamus opti-
cus (V).
.\nterior horns,
seventli cervical
to first dorsal.
Anterior horns,
seventh cervical
to thst dorsal.
Aiit^Mior horns,
fcmrUi to seventh
dorsal.
Anterior horns,
seventh t o
eleventh dorsal
Anterior horns,
fli-st to third
lumbar.
Anterior horns.
fourth to flfth
luiuhar.
Anterior
flrst to
sacral.
horns,
second
Anterior horns,
sixth cen'ical.
Anterior horns,
sixth cervical.
Anteiior horns,
sixth to eighUi
cervical.
Anterior horns
st^cond to foiirti
luml)ar.
Anterior horns,
thiid to fifth
sacral.
Demonstraticri.
Imtatiiin of coniunctiva or
conio;!. fiilli>\ve(l hv contrac-
tion of oi'hicuhiris nruli.
Alternately illuminating and
shading the pupil.
Painful stimulation of skin any-
where. p;irticularly around
neck, followed by dilatation
of pupil.
Tickling of palate, followed by
contraction of velum.
Penussion of lower jaw. with
mouth siiiThtly opened, fol-
lowed by contraction of luas-
seters.
Laughing or crying on appro-
priate mental stinmlation.
Tactile or algetic stimulation of
skin, along inner border of
scapula. Adduction nf scapula
Tickling of palmar surfai'c of
hand, followed by closure of
hand.
Tactile or algetic stimulation of
upp(»r abdomen. Contraction
of abdominal muscles.
Tactile or algetic stimulation of
lower abdomen (below urn
bilicus). Contraction of ab-
dominal muscles.
Ta('tileoralL^<-ti« stiinuialion of
skin around inner and iii'pfr
partof thiuh. followed hy ]»ull.
Ing up of testicle.
Sensory or algetic stimulation
of skin of buttocks. Contrac
tion of glutei.
Ta<-tile oraigetic sfinnilatiimof
sole of font, followed by c.
traction of various mu.srtes of
lower extremities.
Relaxed and semiflexed upper
extremity. Tapping of ten-
don of triceps. Contraction of
triceps.
Relaxed and semiflexed upper
extremity. Tapping of ten-
don of biceps. Contraction of
hi.-eps.
Tapping of ends of ulna or ra
dius. followed by flexion oi
extension, respectively.
Mechanical irritation of the
patellar tendon followed liy
e.mtniction of the quadriceps
femoris.
I'lanUir flexion of foot upon
tapping of Achilles tendon.
Remarks.
Diminished in Basedow
(StoUweg phenomenon.)
Absent in tabes and general paresis.
Absent in diseases of cervical sympa-
thetic.
Believed to be absent or diuiiuished
in hysteria.
Inconstant in health. Exaggeration
observed in disease of upper part of
pyramidal tracts.
Absent in disease of thalamus. In
exaggeiated states. impulsive
laughter and impulsive crying. In
Intraeranial disease, particularly of
basal ganglia.
Absent in disease at this level. In-
constant.
Very inconstant.
Absent in disease of this level of the
cord. Diminished or absent on one
side in disease of coutralatenil cere-
bral heiMis|there.
Absent in disease of this level of the
cord. Diminished or absent on oi.e
side in disease of contralateral cere-
bral hemisphere.
Absent in disease of this level of the
cord. Diminished or absent on one
side, in disease of contra la lei'al
cerebral hemisphere. Not to be con-
founded with the tunica dartos re-
flex.
Babinski phenomenon-
Inconstant. Exaggerated in disease
of pyramidal tracts.
Inconstant. Exaggerated in dtsease
of pyramidal Iraets.
Inconstant. Exaggerated in disease
of pyramidal tracts, occasionally
wrist clonus. Kon-ihle dorsille.xion
of hand followed by clonic palmar
flexion.
ST5
Refuse Disposal.
Refuse Disposal.
REFERENCE HANDBOOK OP THE JUiDlCAL SCIENCES.
The pluntar rcllex has latc'l\' been invested with con-
sideralile clinical importance tlironi;h the investigations
of ]5abinski. Under the name of Babiuski iilienomenon,
or l)ij;' toe phenomenon, the following variations of the
jilantar reflex have been described:
Upon stimidation of the sole of the foot, tlie big toe is
dorsitlexed, and the other four toes are plantar-flexed.
When this occurs slowly this is the typical Babiusld phe-
nomenon. It is believed to denote disease of the pyram-
idal tracts.
In children below two years of age, in whom the pyram-
idal tracts are not fully iuedullated, this variety of plan-
tar retiex is normal.
While the typical Buhin»l-i jj/tenomenon, as just de-
scribed, is believed to be undisputed evidence of disease
of the pyramidal tracts, with the mentioned exception in
children, its absence does not prove that the pyramidal
tracts are not diseased.
There are many combinations and changes of the Ba-
binski phenomenon, and the significance of all of them is
still under dispute.
At present it is best for clinical purposes to accept the
following guide:
The Bal.iinski jihenomenon is positive, and the inference
Ihercfriim justitied:
1. AVhen" upon stimtdation of the sole of the foot there
is dorsiflexion of the big toe and plantar flexion of the
other toes.
2. Wlien upon stinuilation of the sole of the foot there
is dorsiflexion of tlie big toe only.
o. When upon stimulation of the sole of the foot, there
is diu'siflexion of all tlie toes.
The significance of the third variety is doubtful. All
authorities do not agree that theBabinski phenomenon is
always an indication of organic disease of the pyramidal
tracts.
In examining for the plantar reflex, it is well to observe
carefidly the result of the first stimulation. After re-
peated stimulations, the patient's attention and conscious
interference can never be fully excluded and a variety of
cerebral reflexes occur which obscure considerably the in-
terpretation of the restdt.
As a result and consequence of disturbed and changed
reflex activity, a set of phenomena have received clinical
study and attention. These phenomena are comprised
under the name of associated movements and
contractures. From among them the .so-called
Striimpell phenomeuou is of clinical value,
although limited.
The Striiiiipdl plienonienon consists of the
following:
When the patient is asked to flex the thigh
upon the hi]), and the leg upon the knee,
there is an associated plantar flexion of the
foot observed in cases of disease of the pyr-
amidal tracts.
Un<Ier physiological c(iiidition.s, or when
there is no disease of llie ]>yramidal tracts, the
foot is dorsiflexed under the above-mentioned
condition's. The so-called Kernig sign, which
is believed to be pathognomonic of cerebro-
spinal meningitis, also belongs to this group.
The Kernig sign is an inability on the part of
the patient to extend the leg when the thigh
is flexed.
Contractures and muscular rigidity are fre-
quent accomiianimenls of exaggeration of
tendon reflexes; the exceptions to this rule
are few.
The state of the reflexes has been of con-
siderable value for diagnosis and correct
anatomical interpretation of pathological motor jilie-
nomen;'.
The ierms flaccid and spastic paralysis refer jiailicu-
larly to tin- state of the retlexesof the paralyzed muscles.
A flaccid paralysis is a more or less marked motor jia-
ralysis, with loss of reflex activit}' and diminution of the
reflex tone.
876
A s])astic paralysis is a more or less marked motor pa-
ralysis with increase of reflex activity, and increase of
tonus. Joseph Fraenkel.
LlTER-iirRE.
Cl). Bourharrl : Traite de patholopio generate, tonic v., 19I1I.
Jendra.s.sik. Slierrinpton, van Gehurhien : XIII. Cougres Internal, de
Mr'tiectne, I'aris, imto. SertiDn de Neurologie.
Muii'lL-I'iti-rsnii. H.: Pie Haurielle.xe und ihre Nen'enl»ahnen.
lieiK^iiie Zeitsclir. iler Nervnilif jlkuiiile. Hand lii, 3 u. 4 Heft.
Sternijerg. Ma.xlniilian : Die Setiueurefle.xe. 18!)3.
JeiiUia.s.^ik : DeutscUes Archiv f. kiln. Med., I8i33, xxxiii.. In. 189t.
lit, .'iiW.
Fi-aeiikel and Collins: Joum. ,Ment. and Nerv. Dis.. 19f»l, x.xvii., 375-
l.ueihve, Hupi: Jlijnch. med. Woeliensclir., .MiL'iist l^'lli. IWL'.
Pfaundler, Meinhard : Miinch. med. W.ulieiiMlrr.. .Inly -^'d. IIIIC.
V(tn IteelitfTew. W. : Ueber den Lumbu-femural Uelle.\. Neurul. Cen-
tralhl., I'.lie, No. 18.
Saengei-, .\ Itied : Ueber myotonische Pupillaer-BeweRungen. Neurol.
Ceiitranil., 1902, No. 18.
Fraenkel, Joseph : The State of the Reflexes in Supralumbar Lesion
of iiie Cord. Medical Record, May 15th, 189".
Erii : Archly f. Psychlatrie, 187.5, vol. 793.
Muskens, J. : Neurol. Centralbl., 1899, xvili., 1074. Brit. Med. Journ.,
19IHI. il., 839.
Fraenkel, Joseph: Welterer Beitrag znm Verbal ten der Reflexe bei
hohen Qnerschnittsmyelitiden. Deutsche Zeitschr. f. Neryeuheilk.
Bd. xiii., 1898.
REFUSE DISPOSAL.— By this term is here meant the
disjiosal of the \\a.-~te matters of a city, town, village, or
family, not including the sewage which is deposited in
and escapes through the undei'ground system of sewers.
The items usually embraced in the term " refuse," as dis-
tinguished from "sewage," are the following:
Garbage or offal, consisting of the organic waste mat-
ter from kitchens; ashes; house dust; waste paper and
rags; tin cans, crockery, bottles, and broken glass; street
sweepings ; night soil," or contents of vaults, cesspools,
and pail systems.
Broadly speaking, the term refuse includes sewage, but
since this'form of waste product is usually disposed of by
a distinct system of underground pipes luanaged by a
board of sewer commissioners, the term refuse will here
be limited to its usual significance, that of the material
gathered periodically from liouscs, hotels, and streets, by
'a system of collection intended for this purpose. The
municipal management necessary for conducting this
class of work often constitutes a serious problem, in con-
sequence of tlie liability of causing nuisance, either in
Fio. ;jU43
-I'lish-Cart I'sert for Collection of Street Siveepiut's. U'roni leijorl of
street Department, Boston, 19(10.)
the methods of storage, collection, and transportation, or
in the final disposal of the material.
(iAUisAoK. — Garbage is usually defined as the waste
lu-odiiiis of food material. In addition to this, Cluipin '
enumerates, under the head of "refuse," such waste ma-
terials as glass, crockery, street sweepings, oyster and
clam shells, sawdust, corkdust, old boots and shoes, dead
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
ICeliiNe Disposal,
Refuse Disposal.
aniniiils, lawn clippings, bottles, earthen, tin or iron ware,
rubhish, tin cans, poisonous matter, excrement, urine,
coal, and dirt. Dead animals and slaughterhouse refuse
add value to garbage if it is to be made into fertilizers.
FIG. :394;3.— (iarbage Cart at an Angle for Washing or Easy Loading.
If the materials are sorted and such articles as tin cans,
bones, and paper are selected out for utilization, then
there is no objection to the deposit of such articles with
garbage. But it the garbage is to be fed to hogs, or
ploughed into the ground, tin cans are usually e-xcluded.
The rules and regulations in force at Lowell provide that
"kitchen refuse, apple and potato parings, corn husks,
cabbage leaves, .shoes, rubbers, old bedding, soiled linen
or cotton, and all refuse that can be burned shall be
placed in the garbage vessels."
lluiiseliold Storage. — In order that nuisance may be pre-
vented, it is desirable that proper receptacles shall be
provided by householders, hotel and restaurant keepers,
and others "for the storage of ashes, garbage, waste paper,
etc., and that these be placed inconvenient and accessible
places for collection. Receptacles for ashes are best
Fig. 3Sm.— " Columbian '
Dumping Cart showing Use ol Dumping
Lever.
made of metal. Those intended for garbage should be
water-tight and pi'ovided with a well-fitting cover to ex-
clude rain, prevent leakage, escape of odors, and access of
dogs and other animals. In some cities separation of
ashes, gai'bage, and paper is required by regulation ; in
others such sepai'ation is not so required.
Frequency e/ Bemoeeil. — Garbage is usually collected
three times a week, but in some cities collection is made
oftener, and in others not so often. In some cities defi-
nite hou7-s are specified for such removal.
I'eJtir/es of Reinovnl. — The best form of vehicle for re-
moval of garbage is made of metal, and so constructed as
to admit of dumping instead of shovelling the contents.
In some cities stout wooden barrels or iron casks are used,
ten or more making a load.
In some large English cities where the pail .system of
collection for the removal of excremental waste is em-
Iiloyed. the receptacle is removed from each house witli
the contents, and replaced with an empty or clean pail or
tub. These receptacles are usually of metal painted and
have a capacity of about a half-bi'ishel. (Fig. 3943.)
The vehicles used for this purpose should always be
provided with covers, either fixed or movable, for use
when diiving through the public streets.
Oi/liclion of Garbaye. — In some cities garbage is col-
li'rted liy contract, and in otlieis by some city authority.
Jluuicijjal removal, however, as a general rule secures
the most satisfactoiy service.
The following data present the cost and amount of col-
lection of garbage in some of the largest American cities,
the data referring either to 1898, 1899, or 1900. The
following table relates to garbage onl}' :
City.
Brooklyn
Baltimore
Boston
Buffalo
Cleveland
Milwaukee
New York (Borough of Manhattan)
Philadelphia
Pittsburg
St. Louis
New Orleans
Amount
collected— tons.
Ue.tKXI
49,IKK)
22.S,«1
isjiti
152.(100
19S..3.57
2.5,(100
Ofl.tKU
UT.oOO
Cost
of collection.
§130,00(1*
6.i,4(«
112.(J41
;«,(ion*
eo.ttx)*
(;i,ss:j
101.840
398.000*
92,1X10*
99.673
9T,200*
* Cost of collection and disposal.
The Separation of Sefnsc. — In veiy many cities it is the
custom to separate the refuse into two or three or even
more sorts; a verj* common method requiring the separa-
tion of the ashes, garbage, and paper or light combustible
rubbish into three classes, the ashes being usually dis-
posed of as a filling for waste lauds, the garbage "being
fed to hogs, and the paper or light ruljbish sokl or
burned. In addition to other classes, it is quite a com-
mon practice to separate the tin cans, bones, old iron and
glassware, each of wiiich has a eerbiin market value.
Such separation is often made a requirement by city
regulations, and may be enfoi'ced by a penalty.
The English law relating to refuse is as follows (Sec-
tion 42 of the Public Health Act, 187.5): "Every local
autliority may. and when reqiiireti by order of the Local
Government Board, shall theiuselves undertake or con-
tract for the removal of house refuse from premises : the
cleansing of earth closets, privies, ashpits, and cesspools,
either for the whole or for any ixirt of their disti-ict."
By Section 43 of the same act, the local authority is
made liable to a penalty of five shillings per day, |iuv-
able to the occupant of a house, for faibnr to remove ref-
use after notice in writing from such occupant.
The street refuse of Loudon is removed daily b}- boys
with shovels and bru.sh, and placed in iron dust biii.s,
which are stationed at intervals along the edge of the
pavement. In dry weather the streets ai-ew'atered before
being swept. The manure and dii't are removed by carts
and taken to depots generally close to the river or to a
railwa.y station.
Each house has its dust bin or a.shpit for the house
refuse, from which the contents are collected periodically.
The necessary depots for refuse are subject to the follow-
ing general regulations:
1. The depots must be as distant as possible from in-
habited places.
2. The refuse must not be put into pits, but above
the ground level. If necessary, a special floor, three
inches above the ground, must be made.
3. The ground should be drained and paved with im-
permeable material.
4. The depots should be sheltered fiom sim and rain,
but the air should enter freely.
.5. The ground leading to the depot should be well
paved, so as to prevent ])ollution of the soil.
The custom of sorting refuse is vigoi-ously opposed by
some authoiities. Mr. Goodrich • tpiotes Dr. Sedgwick
Saunders as foHows: " When the dust carts arrive at the
wharf their contents are tipped into heaps at a place most
877
Rofiiso l>iM|>o!^al.
Refuse Disposal.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
convenient to the people who are engaged as sorters.
Ahdiit seventy persons, chielly women, were engaged in
this degrading and loathsome work, most of wlioni are
paid liy piece worli, bnt female sillers received seven
shillings and a little coal and wood weekly. The ap-
pearance of the women is most deplorable, .standing in
llic midst of line dust piled up to their waists, with faces
and ujipercxlremilies hegrimed with black liith, and svir-
rouuded by, and breathing, a fool, moist, liot air, sur-
charged with the gaseous emanations of <lisintegrating
organic compovmds. I shall not forget visiting some of
these poor creatures in a hospital, and witnessing the
condition of their skins."
In Paris, previous to 18^7, tlie refuse was put into the
street in the evening. The ragpickers came and col-
lected the rags, paper, liones. and glass. Tlie refuse
thus became scattered about the streets, rendering the
collection difficult. The custom was forbidden by a de-
cree of March 7th, 1887. The greater part of tlio refuse
is taken to depots outside tlie city, where it is allowed to
decay for live or six months, at the end of which time it
becomes valualde as maniu'e. Part is talien in boats to
Corbeil, up the river, and to Pontoise. lielow the city.
The removal of these heaps is done at luiu'h expense, the
loss to the city averaging 2.000,(100 francs (8400.000.)
In BrusseLs'the refuse is collected at 7 A.^i. from Octo-
ber 1st to .March 1st, at C);;!0 a.m. from March to Septem-
ber, and again at 6 p.m. from A])ril l.st to September 1st.
All refuse is conveyed in carts daily to the ash yard on
the landing step of one of the canals, whence it is con-
veyed in boats directly to farmers, or to a tlepotat Evt^re
outside the city.'
Tlie Vispiiml of Garhcufc. — Briefly enumerated, the
methods of tinal disposal of the garbage of cities are the
following; Private or individual dis|iosal. dumjiing at
places designated for the purpose, ploughing into laud,
depositing in
water, feeding
toanimals. eco-
nomic reduc-
tion, and cre-
mation or
burning.
Till' method
which is ]>rac-
ti.sed in some
households, of
disposing of
the garbage hy
hii niinriW. eith-
er in the kitch-
en range or
stove, or in
some ajipli-
ance connected
with the same,
is liotli neat
and cleanly,
and avoids tiie
stiiraire of such
Fig. 3nt.">.— Domestip fiarlmire Cailiniiizer
plit'il to Kitrlipn Stove or Raiiire.
as Aj)-
Xoul odor wliich invariably attends the
material in receptacles of any sort. Seveial appliances
have been invented for the purpu.se of faeilitating this
method of disposal (see Fig. Slli")).
The dis]iosal of refuse hij (hmtpiKfi at jilaces designated
for the purpo'ie is the most object iimalile. and unsanitary
of all methods so far as organic or |mtre.scible refuse is
concerned, since it is sure to give rise to foul odtirs, and
thus to become a source of cipm]ilaint. even to persons
living at a considerable distance. The habit of wild
and domestic animals, of vi.sitinir such places and scat-
tering the deposit, increases the nuisance. Frequent cov-
ering with earth in some degree obviates tlie trouble.
Such dispo.sal of ashes unmixed with organic matter,
however, is not objectionable, nor is their use for the
filling iif waste lands to be condemiied. This method,
usually called "tipjiing" in Eniiland, is acknowledged,
however, to be extremely unsatisfactory. Over eight
hundred local authorities in England and \Yales alone,
each with a population exceeding two thousand, still
either tip their refuse or dispose of it in some other
equally primitive manner.*
With reference to the economy of using coal ashes for
the purpo.se of lilling waste land, the following quotation
is worthy of note ; " It is .said that from the JIanhattan and
Bronx Boroughs, Kcw York, there could be recovered
one hundred and fifty thousand net tons annually of
small coal, thrown away with aslies from domestic and
other tires. What wasteful people the Americans must
be if these figures are correct. Viewed in the light of
modern practice in this country, such use for land de-
velopment is quite astounding." '-'
Plouijhinrj into the Land. — Tliis method of disposal
allows the garbage to be used as a fertilizer for growing
crops, and is less objectionable than dumping. Chapin
gives a list of eighteen cities where it is practised eitlier
as a whole or in part. In several other places it was mice
disposed of in this way until it became a nuisance, and
was then abandoned.
Depoxitiiir/ ill Water, either Salt or Fresh. — Several cities
situated either ujion the sea coast or near great rivers or
lakes find it convenient to de])osit garbage directly into
the water, either directly from a wharf or by towing it
to a distani'c in scows or other vessels designed espe-
cially for such work. Coal ashes and other heavy ma-
terial thus treated sink to the bottom, but light material
floats upon tlie surface, and while this method may be
satisfactory to the city which adopts it, other places may
find it a source of annoyance when favoring winds, tides,
or currents deposit the filiating matter upon their shores.
FeeiJi'i;! to Aiiiiiints. — While this is perhaps the most
economical mode of getting rid of the waste food prod-
ucts of a community, it is open to serious objections in
consequence of the liability to cause a nuisance whereso-
ever large numbers of swine are kept for this purpose,
and because of its liability to produce disease in such ani-
mals. The feeding of city otfal to milch cows is forbid-
den by law in some States, and should not be permitted
except in such institutions as require tl(e very careful se-
lectiiin and separatiiin of bread and vegetables from the
waste food immediately after it is received from the
tables, and the use of the same before decomposition has
begtm. In the neighborhood of many large cities, pig-
geries exist having one thousand animals and more in
each, to which the foul and offensive offal of cities is con-
veyed for feeding such animals. This process cannot be
conducted without causing a nuisance to neighboring
communities. So urgent has this matter become in the
metropiililan district of Boston as to induce one large
raiser nf hogs to purchase a tractof unoccupied land in a
neighboring State, where he proposes to feed ten thou-
sand to fifteen thousand hogs, and to transport thither by
rail the garbage of a large part of the district.
Pork raised in this manner, however, is much more lia-
ble to become infected with trichinic than that which is
produced by feeding godil and wholesome food.
Creiiiiiti'iiii. — When the questiim of expense is not con
sidered, burning by fire is undoubtrdly the most satisfac-
tory nioile of refuse disposal, (.ireat Britain is the prin-
ci|ial couutr_v where this process is emploj'ed more thaa
any other. Goiidrieh enumerates one hundred and twelve
cities in which the refuse is treated by destructiou by fire
(all in England and Scotland). The material, however,
whichisscnt to the crematory, differs essentially from that
which is so treated in America, sineein England the ashes
(mostly of soft coal) are quite generally mixed with other
refuse, and burned in the destructors. The product of
such destruction is an ash or cinder, which may be used
for making roads or walks, and to some extent for build-
ing construction. There is also added in some cities the
material from the pail closet system, where this jilan of
disjiosal still exists. This primitive system is ra|)idly
diminishing in its extent, and giving way to the intro-
duction of water-carried sewage in all large cities. In
some places, as at Ealing, the sewage sludge from pre-
cipitation works is burned in the destructor. In >Ian-
chester, England, the dried excreta from the pail closets
878
REFEUENCE IIA^'DBOOK OF THE MEDICAL SCIENCES.
Refuse Disposal.
Refuse Disposal.
sell for £3 per ton. At Liverpool tlie Ijulk of tlie refuse
is sent to sea in steam barges, eucli carrjiiig four hundred
and tifty tons at a load. The deposit of this material
causes complaint along the \Velsh coast. It is rare to
find in the reports of any of the English cities instances
in which the destructors are of sufficient capacity to deal
second fire pass downward and underneath the grate, and
are finallj- dischar.L'ed tlirough the chimney. By this
second tire tlie liquids which drop through the grates
from the garbage upon the JK.-arlh ar<^ also evaporated.
The general features of tlie I Ji.xon furnace do not differ
essentially from those of the Eugle, but the Smith de-
O Q .,.,, Q O
^RRRHRFiRRHRRmqRRRHmRRflaflFIRflRFiFiRRRRRRRRflRfi
_0 0__ r^
;f=v^
Fig. 394ii.— Eagle (jarbage IncineratDr. (From "Report of Brooklyn Heall
Departiiu'iit," l.'sOG. )
UTZI
vnI'vM^'U'ii
with the entire refuse of the city. Tlie following list
shows the disposal of the refuse of Birmingham for 1S97:
Tons.
Refuse sent to the tips, principally barged 84.703
Refuse dealt witb by destructor !«,3II9
Mixed manure, ashpit manure, flsb, sweepings sent lo
tips by boat, to fields by cart, or sent away by mil . . 74.85.5
Brickbats sent to tips 416
Material sold :—
Oyster shells I.'i
Glass 19
Scrap tin 29t>
206,613
In consequence of the location of English destructors
in or near the populous parts of large cities much atten-
tion has been given to the subject of avoiding the nui-
sance arising from foul odors. This has been accom-
plished by the use of tall chimneys, high temperatures
for combustion, and l\v the provision of secondary fii'es.
At present much attention is being given in England
to the secondary use of refuse, that of steam raising for
the purpose of generating electricity, sewage and water
pumping, and other purposes.
The principal types of destructors employed in Eng-
land are the Fryer, Horsfall, Warner, and Meldrum,
while in America preference is given to the Eugle, the
Dixon, and the Smith,
The Engle consists of a brick furnace with chimney at
one end, seventy -five to one hundred feet higli. Several
cii'cular openings are made upon the top of the furnace,
one being large enough to admit the carcass of a lai-ge
animal. Dilveways lead to the platform upon the top,
the whole being enclosed in a covering house of brick or
iron. On one side of the furnace there are doorsfor fuel,
and another set of doors below them for removal of ashes.
Between these two sets of doors are placed the grate bars
upon which the refuse is dumped tlii'ough the openings
ill the to]i. At each end of the furnace a fire bo.\- is
placed. Below the garbage gi'atcs is a long combustion
tlue connecting with the base of the chimney, and con-
trolled by a damper. A similar damper governs the ad-
mission of heat from above. (Fig. 3946.)
When the furnace is charged with a qtiantity of gar-
bage, the flames from the tirebox near the chimney (the
upper damper being closed) pass over and through the
refuse, driving the smoke and gases into and across the
second fire where they are consumed. The liames of this
structor is constructed on an entiiely different plan from
either. It consists of two sets of furnaces to which gas
is supplied as fuel from a generating apparatus. Each
furnace is a simple pot or tank lined with fire brick.
There ai'e no grates, the garbage resting upon the bot-
tom. The gas is made to pass into the furnace, which is
charged with refuse, the gases of combustion then pass
on to the empty furnace of the pair, and thence to the
flue leading to thecliimney. This flue isfilled with open
brickwork, which being heated to a white heat burns the
resulting gases, and deprives
them of foul odor. Wlieu
the charge is consumed, the
process is reversed, the emjify
furnace being filled and the
gases passed in the opposite
direction, the same chimney
being used in each instance.
Reduction. — The refuse of
cities contains a considerable
projjortion of material which
is utilizable. Hence various
processes have been devised
by which this luateiial may
be recovered and sold. The
valuable portions are the fat
or grease, the niti'ogeu, phos-
phate and potash, these latter
ingredients being useful for
conversion into fertilizers.
Colonel Waring, under whose
supervision the collection of
refuse was efficientl.y carried
on in New York, estimated the average coiuposition of
3,000 tons of summer garbase as follows:
Fig. 3U47. — Cross Section
showing Location of Charg-
ing Door, Stoke and Asli-
dooi-s.
Pounds.
Per cent.
Mil
1.4^1
40
4(H)
71
Grease
Tankage
2
20
2.H)II
100
The tankage of one ton contained about 13 lbs. am-
monia, 13 lbs. phosphoric acid, and 3 lbs. potasli; if these
8T9
Rrrnse Disposal.
Refuse Disposal.
REFERENCE HANDBOOK OF THE :\1EDICAL SCIENCES.
iucrcdieiits ccnild be utilized, garbage would be worth
aerordiiig to WariDg 83.47 per ton.
The I'ollowing estimates are made of the amount, iu
(lounds, of garbage collected per capita annually in large
cities;
Boston ^T
Buffalo 137
Milwaukee '^'^
New York H"
Patei-son t*0
PhilatielplJla 321
St. Louis 223
Dr. Chapin makes the following just comment upon
the foregoing tigures: "If the above average be correct,
millions of tons must be collected annually from our
large cities, wortli double that number of millions of dol-
lars. It is not to be wontlered that energetic efforts have
been made to .save this waste."
From Waring's ligures it appears that more than
seventy per cent, of the garbage consists of water, which
must be removed before salable products are obtained.
Hence the practice in .some cities of allowing the gar-
bage to drain before it is treated, eilher by reduction or
cremation. In Ealing near London, the garlxige, ashes,
and sludge from the town sewage works are stacked in
pens for some time before treatment, by which means the
mass is deprived of much of its water.
The following brief description ivdates to one (jf the
more common methods employed tor tlie reduction of
fN^
^
.f^.
Mer2 Process.
CurfQCrion ApporoTub.
£r
LL J/.»»».«-- JJ.
S
Dryer arid Condenser
Fig. ;i04S.— Mt*rz Redui'linn .Apparatus. (From "Report of Brooklyn
Health Department," 18(16.)
garbage, the Merz process; When tirst re<'eived at the
works, the garbage is put into a steel hopper and lh('
suiierlluous water is allowed to drain into the sewer.
The rags, bones, tin cans, etc., are then .selected out and
sold, and the garbage is put into the dryers, which c<m-
sist of jacketed cylinders with revolving shafts and arms
sto stir the garbage while drying. Each dryer holds
about three tons. The dark-brown product is then put
into the extractors, wliich consist of closed tanks with
false bottoms. Naphtha percolates through the mass
to extract the
greaso. The
grease in solu-
tion is drawn
off, the naph-
tha separated
from it and the
grease barrelled
for sale. This
grease is of a
brownish color
and of inferior
quality. The
dry residue af-
ter separation f,q 3949 —Barnev Dumping-Boat, after Dlsctarg-
of the grease ingatSea.
is ground, and
sold to fertilizer mauufactiu'crs. The Simonin process,
like the ]\Ierz pioeess. extracts the grease from the garb-
age by the use of naphtha. It lias this advantage over
the Jicrz process, in that the garbage can be at once
placed in the cxtractcn-s without previous drying. It
was carried on at Providence and at New Orleans, but
was abandoned at both places. This method is now
conducted at Cincinnati, but the advance in the price
of naphtha has made it un])rofitalile.
Chai>in believes that this method can be successfully
conducted Avilh a moderate di'gree of jirofit, even without
the payment of a bonus; but that this can be done cmly
iu a city where the garbage is very carefully separated.'
Another pi'ocess, known as the Arnold process, is con-
ducted at Boston, New York, and Philadelphia. It con-
sists in rendering the garbage to recover the grease and
drying the residue to be ti.sed as a fertilizer. Little at-
tempt is made to prevent odors arising from the process.
It is evidently considered by the operators to be cheaper,
not to try to prevent nuisance, but to seek a location
where the nuisance will affect oidy a few persons.
The cost of collection and disposal of garbage varies
greatly in dift'erent cities, from a minimum of about 60
cents per ton to a maximum of 83.40 per ton, and from
a minimum of 10 cents per capita to about 80 cents or
more per ca])ita.
Dry Ill-fuse. — Dry refuse in many cities includes ashes
and all the rubbish which accumulates in piivate hcmies
and in stoi'es, nuirkets, etc. Manufacturing wastes are
not usually removed by municipal collection. At the
present day it is quite customary to require that tliree
receptacles be provided, by the householder — one for
ashes, one for garbage, and one for paper and other light
refuse. The receptacles should be made of galvanized
iron or other metal.
Usually diy refuse is disposed of by using it as a filling
for lowlands, the owners of which are glad to have it
disposed of in this manner.
In a few instances a small revenue of 10 to 15 cents per
load has been received from the sale of ashes.
Experiments made in New York showed that the aver-
age a.sh of that city contains twenty per cent, of luiburued
coal, but probably some of this is finely divided and can-
not be recovered with ordinary sifting jirocesses. In
some cities situated u)ion tlie seacoast and upon large
rivers, the dry refuse is dumped into the water. In Bos-
Ion the Bai'ney dumping-boat is used, the material being
dumped in the water at a distance of at least ten miles
from tlie city on the ebb tide. On arriving at the point
of disposal the two halves of the boat are separal<'d by
means of a liinge motion, very much like that of a clam
shell. TIk' towboat is starled forward and tlie dumiiing
boat is rapidly Hushed out by the swiftly running water,
and the two halvi's are brought together again. Tlie boat
is provided with water-tight compartments (see Fig. 3949).
880
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES,
Refuse Dir^poNal.
Kfluse I>lM|>usal.
Fig. 3050. — Uuloudiug GarbaKf* intu Scow at Wharf.
In Boston and New York attempts are made to utilize
a portion of the material found in diy refuse. The plant
for this purpose at Boston consists of a large room in
which the wagons dci)osit their loads.
A long travelling apron, four feet wide, runs from the
front of this room, through it into the furuace-room,
where it discharges into the furnace. The power for
moving the apron, for baling, and for furnishing liglit is
obtained from the furnace. The persons who cidl out the
paper, rags, metal, glass, rubber, etc., and sort and pre-
pare it for sale, stand at the sides of the moving apron.
About eighty per cent, of this ref-
use is marketable, and the value
of the daily collection is about §60.
The following are the prices
obtained for the principal market-
able portions of this dry refuse : ■■
the garbage and di-y refuse are collected and disposed of
together. This was for many years the plan adopted
in New York, and is still in use in several quite large
cities. When thus collected the garbage, ashes, and dry
refuse are mixed together in the receptacles, "which are
usually of metal and are provided with covers, butciuite
often nothing better than ordinary Ijarrcls and boxes are
employed. Regulations provide for the location of the
full receptacles either on the sidewalk or upon the house-
holder's premises. Piovision is also made for regular
hours and frequency of collection. Disposal is usually
Manilla papc-r i
-0..50 per 100 pour
NfwspapfTs
.ai ■' 100
MixHil pa|"-r
.25 "100
Straw li"ard paper
.25 " 100
.30 " 100
Wliite rags
l.iJO " 1(N)
Mixed racs
.<K1 •• KM)
Woollen raffs
7.00 " IIM
Soft^back carpets .
.!)0 " 100
Hard-back carpets
.30 " 100
Linsev carpets
M " 1(K)
Twine
.U ■' KHI
Old shoes, good. ..
.12 " IIMI
Old shoes, poor
.11 " 100
Baggmir
.40 " KMI
Mixed bolUes
.45 per barrel.
Old iron
9.00 per t<iu.
Copper
.11 per pound.
Brass
.11
Lead
.04 "
Zinc
.10 "
In New York (Manhattan dis-
trict) the amount of rubbish col-
lected and disposed of in a siinil*-
manner in 1898 was 94,000 tons.
and for this the sum of $03,500 was
obtained.
Mixed Etfn.ic. — In some cities
Vol. VI.— 56
Fig. 3951.— Niglit-Suil Barrel, Used in ConnecUon with Odorless Excavation Apparatus.
Chapin's " Municipal Sanitation.")
(From
881
Re<2:o aeration.
Ref^oueralioii.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
made by dumping either upon lowlands or into water.
The former usually creates more or less nuisance, but is
tolerated because of its economy. lu San Francisco the
mi.xed refuse is cremated, in Troy a portion only (the
Fiu. 3y")«.— ()ilurless Excavating .\piiaratus iu (_tperali»ni.
mostofEeusive part) is cremated, while in a few Southern
cities parts of the garbage and dry refuse are burned in
the open air at the dump.
yir/ht S('il. — By this term is meant the liquid or semi-
li(iuid contents of privy vaults and cesspools, derived
from the household wastes of the water-closets, bath-
tubs, and other fi.\tures, including that of the kitchen
sink. The latter often proves troublesome in conse-
quence of its gn'asy cliaraeter and its liability to clog the
traps and jiiiies througli wliich it tlnws.
On account of the liability to cause nuisance iu the
performance of tliis work it is customary to require that
the scavengers, or other persons who conduct it, shall be
licen.sed and jilaced under carefid supervision.
It is customary to recpiire the use of tiglit receptacles
for the removal of night soil, eitlier barrels or tubs pro-
Fig. 39.?3.— Garliage Destruitur U<v Tsi-
Faclurii's. etc.
iu rulilli' Institutions,
vidcd with handles and tight-fitting covei-s. (Fig. 3951.)
Boxes or movable tanks are al.so em])loycd. The so-
called pneumatic odorless pumps ate well adapted for
tliis class of work. (Fig. 3952.) Tubs and barrels are
conveniently handled, ten or twelve of such receptacles
usually constituting a load.
It was formerly customary to remove such material
only at night, but this practice is gradually being substi-
tuted by removal in the
daytime, when with im-
proved apparatus it is
practicable to do the work
in a more cleanly manner.
Disposal. — In some cities
the night soil is taken to
suburban districts and
there used upon farms as a
fertilizer, a practice liable
to cause nuisance to the
nciuliliorhood, if thus dis-
posrd of in the vicinity of
dwellings. In some idaces
it is dumped into water,
either a large river, lake,
or the ocean. In a few
English cities where the
pail system fif e.xeicmeut
removal is still in use. the
contents of the pails are
taken to the crematory and
burned together with other
sorts of refuse.
77ii' Jiff use - disposal of
Puhlic Institutions and
0th i: r Estiiblishments. —
Special destructors are
now made of smaller size
than those in use b}- cities,
for the destruction of the
waste products of public
institutions, hotels, de-
partment stores, factories,
medical colleges, and other isolated estalilishiiients.
Such forms of apparattis (Fig. 39.")o) ai'e specially adapted
to the destruction of infected bedding, clothing, rags, ami
other infected luati-rial which is not worth the trouble
and expense of saving by any process of disinfection.
Saniuel W. Abbott.
References.
' Cliapin : Municipal Sanitation in tbe Unilt'il States, Providence, R.
I., I'.HIl.
'W. F. Goo.lriih. .\.I.M.E.: The Economic Disposal of Town's
Refuse, Lon.lon, I'.mi.
3 Palinliert:: Public Health and its Applications, p. 242.
< Boston Tost. January 21st. ISKXI.
REGENERATION.— Regeneration is the process which
leads to the replacement of lost tissue. The term is ap-
]diod equally to tbe reproduction of cells to take the
place of those cast off under normal physiological con-
ditions on the one hand, and to the repair of tissue de-
stro3-ed by lesion on the other. In both cases the process
is essentially the same. The new tissue is formed b.y the
proliferati<m of cells in the immediate neighborhood of
the area from which the cells have been cast off or de-
stroyed. Moreover, the new tissue is derived fiom re-
maining tissue of like kind, cmmective tissue from con-
nective tissue, e]iithelium from epithelium. AVliere
reproduction of epithelial tissue does not take place, or
where the reproduction is incomplete, the defect, it is
true, is filled with connective tissue forming a scar; but
this scar tissue is derived from the connective tissue
around the defect, and not from the epithelium. Physi-
ological regeneration goes on continuously to supply tis-
sue waste; regeneration after lesion occurs in the healing
of wounds, iu the restoration of the mucosa after catarrh,
and in similar processe*
There are two methods of nuiltiidieation of cells, direct
division or amitosis, and indirect cell division or karyo-
kinesis, mitosis or karyomitosis. In the former of these
two methods the mother cell simply increases in size and
882
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
Reg<* Deration.
Regeuerallou.
finally divides into two daughter cells after a division of
the nucleus. In karyokinesis the process is more com-
plicated, consisting as it does of a c^'cle of definite
changes in the chromatin of the nucleus preceding the
division. Direct division or amilosis is said by some
authorities to lake place only in cells which are no longer
capable of forming new tissue, whereas mitosis occurs
in active vigorous cells which form new tissue. Other
authorities, on the contrary, regard the two processes as
of etpial significance.
The power of reproduction differs in different tissues.
Surface epithelium and epithelium lining glands are ca-
pable of regeneration to a very large e.\tent, as are also
nerve fibres and many of the other tissues of the connec-
tive-tissue group generally. Of the latter, the perios-
teum is capable of the greatest degree of regeneration,
whereas cartilage has only a limited power of regener-
ation. Ganglion cells once destroyed are probably never
replaced by ganglion cells in the adult, and glandular
epithelium is completely restored only where the defect
is slight and wliere some of the original cells remain un-
injured in the area of the lesion.
Uegeiiera'tion of Epithelium. — In regeneration of epithe-
lium the protoplasm of the cell divides in the later stages
of karyokinesis, or after this is complete. In some cases
the ceil sends out processes of protojilasm, and the new
nuclei wander out from the parent cell into these before
the protoplasm is constricted off to form the new cell.
In a lesion of an epithelial surface, where the area de-
stroyed is not too great in extent, the epithelial cells pro-
liferating from all sides completely repair the defect; if
it is more extensive, the defect is incompletely filled by
connective tissue, thus forming a permanent scar. In
the latter case, the connective tissue forming the scar
results, as in all cases, from the proliferation of pre-exist-
ing connective tissue, not from proliferation of epithe-
lium. Epithelium reproduces epithelium, never connec-
tive ti.ssue, but it is also true that the cliaracter of
epithelium reproduced is not always the same as that
which is lost; for squamous epithelium may replace
cylindrical epithelium, as is seen in atrophy of tlie mu-
cosa of the bronchi and stomach in chronic inflammation
of these surfaces.
Minor defects of epithelial surfaces, where underlying
tissues are not destro3'ed, are quickly and completely re-
stored by the proliferation of tlie surrounding epithelium.
In recovery from acute Bright's disease, or in tlie healing
of an ulcer of the stomach or intestines, the epithelium is
often completely restored b}' the multiplication of the
remaining mucous glands as well as by growth down-
ward of the epithelium on the surface. Lesions of the
liver are also completely restored by multiplication of the
cells of the parenchj-ma and by the formation of new bile
ducts.
Larger defects of epithelial tissue, particularly where
the underlying structures are involved, result in a scar,
with more or less incomplete reproduction of glands
which are for the most part usually atypical.
Reyenemtion of Structures Conmsting of Cvnnectire Tis-
sue.— Defects of .structures made up of connective tissue
in any of its various forms may under favorable circum-
stances, as where the lesion is not too extensive, or in
lesions of certain of the tissues of this group, even though
they be extensive, be completely restored by the new
formation of tissue identical in character with that origi-
nally present. Where the lesion is more extensive, par-
ticularly in one that occurs in certain of the connective-
tissue structures, the defect is more or less filled up by
connective tissue of a different type from that originally
present. Connective-tLssue structures such as the perios-
teum, bone marrow, blood and lymphadeuoid tissue, are
all readily restored coiupletely after lesion. On the other
hand, cartilage does not readily reform, and defects in this
structure are reiilaced b,y ordinarj' scar tissue or by bone.
New bone is formed not from pre-existing bone but from
the remaining periosteum antl from the bone marrow.
Sometimes new bone is formed in other connective tissue,
as in the intermuscular connective tissue and from the
perichondrium. But muscle tissue is formed only from
pre-e\isting muscle, never from connective tissue of any
other kind. Ganglion cells are probably never restored
after injury, defects in this tissue being replaced by scar
tissue or by glia cells; but nerve trunks are readily re-
stored, provided that the ganglion cells from which they
spring are uninjured, for the regeneration is brought
about bj- the growth of the axis-cylinder processes. The
peripheral portion of a severed nerve always undergoes
degeneration, it is never restored ; all parts of it finally
break down into granules and are dissolved away. The
central portion of a severed nerve, on the contrary, un-
dergoes degeneration for only a short distance from the
end, back to tiie first or second Ranvier constriction from
the end. In a few days after the occurrence of the lesion
the axis cylinder in the central portion of the severed
nerve begins active proliferation. At first the new axis
cylinders are naked save for a layer of protoplasm rich
in nuclei, but soouer or later the proper sheaths are re-
formed. If the degeneration of the peripheral segment
of the severed nerve has not yet affected the Schwann's
sheath, the new axis-cylinder processes may enter these
and fill them out again. The regeneration of nerves takes
weeks or months for completion.
In regeneration of connective tissue, as in reconstruc-
tion of other tissues, the proliferating cells are always
much larger than the cells at rest. The proliferating
cells, or formative cells as they are also called, not only
possess a relatively large amount of protoplasm, but the
nuclei are large and vesicular and contain nuclear bodies,
many of them showing, by proper methods of hardening
and staining, the various stages of karyokinesis. Fre-
quent 1\' the formative cells contain more than one nu-
cleus, sometimes even a large number of nuclei, forming
giant cells (Fig. 3904, i). The tissue made up of these
* t'
Fig. 39.>t. — Cells met with fn New Formation of Councclive TissuSi
(After Ziegler.)
formative cells is appropriately called embrj-onic tissue,
and the character of the permanent tissue arising frofl"
the development of the embryonic tissue is determined
by the nature of the embryonic cells. If the foriuative
cells are destined to form scar tissue they are called fibro-
blasts; if they are to form cartilage they are called chon-
droblasts; if bone, osteoblasts.
The formative cells are of man}' different shapes ; some
are large, round, or oval masses of protoplasm (Fig.
39.54. It), others sjiindle-shaped (Fig. 39.54. <■). others
roughly star-shaped (Fig. 3954, g), others irregular with
long processes (Fig. 3954, c. d,f), or bundles of fibres at
the ends as if the jirotoplasm were fraved out (Fig.
3954, h).
If fibrillated connective tissue develops from the em-
bryonic tissue, fibres make their appearance between the
formative cells, and by continuous increase they encroach
more and niore upon the latter till the formative cells
finally lie compressed in fissures between the densely
packed fibres.
Cartilage develops by the fonuation of a homogeneous
intercellular substance instead of fibres, but the forma-
tive cells are encroached upon and compressed just as
in the case of ordinary fibrillar connective tissue. The
883
Ki-Kislral'on of Dis,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
formative cells become much reduced in size, and finall}'
lie in tlie characteristic openings in the homogeneous in-
tercellular substance.
Tlie process of new formation of bone is similar to the
new formation of cartilaue; tlie lime salts are linally de-
posited in the intercellular substance.
JIucous, lymphadenoid, and fatty tissues may all arise
from embryonic connective tissue.
Fibrillated connective tissue may arise from an}- form
of connective tissue that has suffered lesion, and has been
converted into embryonic tissue.
From what has been said, it is evident tliat the stage
■which is preliminary to the new formation of permanent
tissue after lesion is characterized by the apiiearance of
embryonic tissue. The further development of this em-
bryonic tissue is not the same in all cases; in some instan-
ces there is perfect reproduction of tissue in all respects
like the originaJ, or restitutio ad inter/rtim. In many eases
the restitution is only partial ; in others again there is re-
placement of the original structure by connective tissue
of a ditferent type from the original. The replacement
of the original structure by connective tissue of a differ-
ent type from the original may occur in any kind of con-
nective tissue, and is in tnitli a very common occurrence,
constituting the formation of a scar, where the original
structure is rejilaced by dense tibrous connective tissue,
whose only function is to fill a gap. Where the original
structure is endowed with any special function, the scar
tissue is incapable of taking on this function. If, forex-
amiile, the scar tissue is formed to fill up a defect caused
by a lesion in a muscle, the scar tissue serves only to
unite the divided ends of the muscle fibres, but is not
itself capable of contraction. Scar tissue formed in the
brain, in the liver, in the kidney, in the spleen, or in
the lung does not perform the peculiar function of the
tissues of these organs. The substitution of conucelive
tissue of lower functional power than that originally
present constitutes a fin-m of degeneration, and is met
■with in cirrhosis of the liver and other organs. But al-
though these processes are spokeu of as degeneration, it
■n'ould perhaps be more correct to regard them as hyper-
trophies of the connective tissue, for this is what the.y are
in fact.
Regeneration of the formed elements of the blood does
not differ essentially from regeneration of the other con-
nective tissues. Tiie leucocytes are reju^oduced in the
13'mpliadenoid tissue in various ])arts of the body as well
as in the circulating blood, as is shown by the fact that
white corpuscles showing karyokiuetic figiu'cs are met
with abundantly in these situations. Direct nuclear
divi.sion and fragmentation also occur, as is shown in the
lobed and disrupted nuclei of the polymorphic nuclear
leucocytes.
JW'w Forinatidii of Bhind-Vcuxih. — A very important
factor in regeneration is the new formation of bldml-ves-
Fi(4. 3(15.').— New Fnniiiitinn (if lilnoil-Vessuls. (.\ftiT TilliiKUi.)
sels. These are formed by sjirouts arisinu' fiom llic ves-
sels beneath the injured area. Each sprout is al first a
solid arch, in reality a long cone or horn, of jirofoplasm
projecting from the wall of the vessel (Fig. 39.55, a)
terminating in a long-pointed process. The solid arch
may even senil out several long processes (Pig. 39.5.5,
b, c). Sooner or later the solid arch becomes hollowed
out by liiiuefaction of the interior, forming a cavity
which finally opens into the parent vessel, or the arch
may be liollow from the start and consist merely of a
bulging of the ■n-all of the parent vessel (Fig. 39.5.5, c).
In either case the arch next becomes a tube by the press-
ure of blood flowing in from the parent vessel, and this
also causes the long processes to split and form hollow,
conical tubes. Meanwhile nuclei formed by karyokinesis
of the cells of the endothelium of the parent vessel wan-
der into the walls of the hollow tube and convert it in
this way into a capillary. The capillaries produced in
this way have walls consisting of fiat endothelial cells,
but these cells are frequently quite thick ; and when this
is the case, the new-formed capillary resembles a tubular
gland on cross section. The long, slender processes from
fliearchesunitefreely with the similar processes from other
vessels (Fig. 3955, //) and even direetlv with the walls of
other vessels, or they may luiite with the parent vessel at
a different point from the origin (Fig. 39.55, c). In this
■wa.y abundant anastomosis between the vessels is formed.
This is not the only origin of the new capillaries, for
certain cells which at first have no connection with blood-
vessels also take ]iart in the process. These cells are
spindle- or club-sha|ied masses of protoplasm which lie
free in the tissue at first, but later become united with
the long processes from the arches (Fig. 3955, h). After
they become united with the processes from the arches
they become perforated by a central canal and finally as-
sume the character of capillaries.
Many of these new-formed capillaries subse(|uently
change to arteries and veins by thickening of their wail
through proliferation of the cells of the walls. The dif-
ferent coats tin.illy become differentiated.
The account here given of the new formation of blood-
ve.ssels is that given by Ziegler. and is the one that has
found univer.sal acceptance. But some authorities claim
that the blood-vessels are also formed in other ways.
They maintain that the cells that wander into the area
of the lesion miite to form capillary vessels, and that they
also form new reil blood corpuscles in a manner similar
to tlie formation of vessels and blood in embryonic tissue.
This method of new formation is not recognized by Zieg-
ler in pathologieal regeneration.
Another process of new formation of blood-vessels
claimed b.y some authorities is that certain spindlc-shajicd
cells form in parallel rows, leaving a canal between them.
Vessels ajijiarently formed in this w.ay may be seen in
organizing blood clot, but Ziegler regards these as really
deceptive offshoots from pre-existing blood-vessels.
B. Mcadc Bolton.
REGISTRATION OF DISEASES. See Vital Statistics.
RELAPSING FEVER.— (Synonyms: Febris recidiva:
typhus recurrens; famine fever: bilious typhoid ; spiril-
lum fever; epidemic remittent fever; remitting icteric
fever; fievre ;i rechute; fievre reeurrente; typhus a re-
chute; Hungerpest; Hiickfallsfieber; Wiederkehrendes
Fieber; Armentyphus; tifo recidivo, etc.)
Definition. — A specific, contagious fever, which ma)'
prevail as an epidemic among the destitute, and csjie-
cially among those who live in overcrowded tenements,
during seasons of imusual scarcity of food; hence the
name famine fever. It is characterized by the jiresence
of a mobile spiral filament in the blood — a spirillum or
spirochaOte ( .s'. Oheriiitieri) — which is found during the
relapses as well as during the initial paroxysm, but is
absent during the apyretic intervals. The first febrile
paroxysm lasts for from five to seven, or even nine days,
and is terminated abruptly in profuse persiiiration; after
an apyretic interval of a week or more a relaiise commonly
occurs, which is similar to the initial paroxysm, but of
shorter duration : in some instances a second, a third, or
even a fourth relapse occurs.
88i
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
ResiNlralloii of DIs.
Kelapslll;; Fever,
HiSTOKT. — Tlie attempt has been made (Spittal, 1844)
to show that some of the fevers described by Hippocrates
correspond with relapsing fever. This view is considered
by Hirsch to be cjuite erroneous. He says: "It is clear
that Hippocrates spealvs tliere of bilious remittent malar-
ial fever. " The first notice of the occurrence of relajising
iever iuEurope isfound in the writingsof the Scotchand
Irish physicians of tlie early part of the eighteenth cen-
turj'. Hirsch says: "I have searched in vain, in the de-
scriptions which the physicians of the sixteenth and
seventeenth centuries have given of the fever epidemics
observed by them, for any indications of relapsing fever
that would be in some measure preci.se." The fact that
the disease was not recognized, and ditfercutialed from
other specific febrile alleclious, cannot, however, be
taken as evidence that it did not exist prior tii the date of
the first clearly recorded epidemic in Ireland (1739). An
account of this epidemic has been given bj' Rutty, who
wrote in 1770. The earliest accounts of the disease in
Scotland date from 1741 (Hirseli). But tlie literature re-
lating to relapsing fever belongs for the most part to the
past century. It prevailed in Ireland and in Scotland
during the years 1799-lHOO, 1S17-19. 1X20-27, 1N43-
48, and in the latter year (1848) it invaded several of
the larger towns of England.. In 1868-70 it again pre-
vailed in England and Scotland, and cases are reported to
have occurred in London as recently as the year 1873.
On the Continent the first accounts we have come from
Russia— Odessa, iu 1833; Moscow, 1840-41. In the au-
tumn of 1803 the disease reapjieared in Odessa; the fol-
lowing year it became epidemic over extensive areas in
Russia, and extended to Livonia and Finland (1S6.5),
to Siberia (1806), and to Poland (1x08). Aei'ording to
Hirsch, the di.sease continued to prevail iu Russia over
extensive areas during subsequent years, and was ob-
served among the Russian troops as late as 1878-79. In
Germanjr an extensive ejiidemic broke out iu 1868, as a
result of importation from Ru.ssia (Hirsch). A second,
more restricted, epidemic occurred in 1871-72, and a
third in 1878-79. In the west and southwest of Europe
— Switzerland, France, Ital^y, Spain — the disease is as yet
unknown. In India relajising fever has, no doubt, pre-
vailed for many years, but the differential diagno.sis be-
tween it and remittent fever, or the specific continued
fevers which prevail there so largely, was not clearly
made out by the earlier observers. During the last forty
years, however, numerous outbreaks of this disease in
various parts of India have been recorded, and Carter has
demonstrated that tlie disease, as it occurs in that coun-
try, is identical, as regards its clinical history, willi re-
lapsing fever as described by recent European authori-
ties, and also that it is characterized by the constant
presence of the spirillum discovered by Obermeier in
blood drawn during a febrile paroxysm. Relajising fever
lias several times been imiiorted to the United Statrs, but
its prevalence has been limited to restricted areas in our
largest si'aport cities. In ]S44 fifteen eases were le
ceived into the Philailelphia Hos|iital from an emigrant
ship sailing from Liverpool; in 1848 a few cases arrived
iu New York, and in 18.'i0-.51 Dr. Austin Flint saw a
number of cases, among recently arrived Irish emigrants,
received into the Buffalo City Hospital; but nocpidemic
resulted from these importations, and it was not until
some years later (1809-70) that the disease became epi-
demic in certain sections of the cities of New York and
Philadeljihia. Parry, who made a careful investigation
with reference to the origin of the first ca.ses in Philadel
phia, was unable to trace it to importation; but this can
scarcely be questioned in view of what is known of the
history and etiology of the disease, and in cousidi'ralion
of the fact that Philadelphia is a seaport city which has
coDstant communication with ports on the other side of
the Atlantic which at that time were known to be in-
fected. Parry and Pepper have given us admirable ac-
counts of this epidemic in Philadelphia. We quote from
a recent article by the last-named author the following
statement, relating to its progress and extent: "In Phil-
adelphia, of 1,17(5 cases iu which the date of occurrence
is known, there occurred in September (1809), 4 cases;
December, 6 cases; January (1870), 5 cases; February,
13 cases; March, 124 cases; April, 209 cases; May, 325
cases; June, 293 cases; July, 11.5 cases; August, 19
cases; September, 28 cases; October, 15 cases; Novem-
ber, lease; December, 2 cases; Januarj' (1871), 2 cases;
February, 1 case; March, 2 eases; May, 7 ca.ses; June,
3 cases; September, ? cases; October, 2 eases.
The coincideuce of relapsing fever and typhus has been
noted in many of the epidemics which have occurred in
Europe, but the history of this coiucidence does not jus-
tify the supposition that there is any etiological relation
between these diseases other than that furnished by com-
mon predisposing causes, viz., the depressing effects of
overcrowding, insuffi-
cient food, and filthy sur-
roundings. This view is
supported by the fact
that either disease may
occur alone, and by the
circumstance that some-
times one and sometimes
the other has the prece-
dence iu time iu those
epidemics in which co-
incidence has been ob-
served.
Etiology. — The dis-
covery by Obermeier, iu
1873, of a minute vege- ^ .„,. . „ . .,, . „ ,
*„i,i^ „„,.„!,„ f ,^. Fk;. 3!t)0. — Spirilla of Re ap.s ng
table parasite — ^/-i™- pj^^er. (After Soudakewitsch,
rhiule Olierincicn — in the Annalea de I'lnslitut Pasteur,
blood of patients suffer- vol. v., 1890.)
ing from relapsing fever,
and the subsequent demonstration, by numerous observers
in various parts of the world, that this micro-organism is
constantly jjresent iu the blood of relapsing-te\'er pa-
tients during the febrile paroxysms, has thrown a flood of
light upon the etiology of this disease, and is one of the
most significant facts with reference to the etiology of
the infectious diseases in general wliieli have been brought
to light by modern microscopical researches. Conservat-
ism suggests the jiossibility that the parasite may be sini-
pl)' an accompauimcnt of the disea.se, and not directly
concerned in its etiology as the essential and specific
cause. This hypothesis seems to us to be hardly tenable
in view of what is now known of the pathogenic action
of certain other micro-parusites of the same class, and of
the following facts: (/i) The parasite is constantly 'i)r<'S-
eut iu the blood during the febrile paroxysms', and in
smaller numbers during the latter part of the jieriod of
incubation, and is absent during the apyretic intervals.
(4) This parasitic organism is peculiar to the disease un-
der consideration, i.e.. repeated researches by competent
microscopists have failed to demonstrate the presence of
a similar organism in any other disease. (<•) The ]iarasite
is present in the blood in such luimliers that its patho-
genic power can scared}' be questioned. Carter says:
"During specific fever several organisms (e.f/.. five to
ten) are visible in the field at one time; not seldom they
are too numerous to count, and occasionally they are
present in swarms, being apparently nearly half as com-
mon as the red discs themselves. " ((/) The di.sease may
be communicated to man (Motsehntkofl'sky) and to the
monkey (experiments of Koch and of Carler) by inoeula-
lionswith blood containing the s]iirilluiii. and the jiara-
site is found ill great numbers iu the lilood of the inocu-
lated individuals during the felirile paroxysm which
results— after an incubation period of lliree or four days
(Carter) — from such inoculatious. The morphology of
the relapsing fever "germ " is shown in Fig. 3950. The
spiral filaments are exceedingly .slender, their diameter be-
ing not more than 1 // (0.001 mm., Lebert), or. aeeording to
( 'arter, ^j
to xTOTTJi "^f '^" inch. The lenglli v.iries from
two to six times the diameter of ared blood disc (Carter).
The motion of these spiral filaments, iu blood recently
drawn, is very lively, "rotar.y, twisting, and rapidly
progressive, but soon ceases under the ordinary coudi-
886
Relapsing: Fever.
Relapsing Fever,
KEFEREXCE HANDBOOK OF THE MEDICAL SCIENCES.
tions of microscopic examination" (Lcbert). According
to Carti-r, tlie movements may continue for from a few
hours to one or two days or longer.
A good ob.iective and a certain amouut of sliill in the
use of tlie microscope are required for tlie detection of the
spirillum in fresh blood. This is shown by the fact that
Obernieier liimself failed to recognize the presence of the
parasite in the microscopic researches made Ijy him some
years prior to the date of his discovery ; and by the fail-
ure re]>iiited by some of those who have since attempted
to verify his ul)servations. Carter says: "That, as re-
gards the examination of fresh blood, obstacles do exist,
is proved by the fact of the organism being originally
found only after long-repeated scrutinies; and at Bom-
bay I have met with observers, not unaccustomed to the
use of the microscope, who could never clearly see the
filaments." The demonstration is more readily made
when a tliin lilm of dried blood attached to a cover-glass
is stained, ■iiciiiuliiw mii m, with one of the aniline colors
— an aqueous solution of methyl violet, or of Bismarck
brown, or fuchsin.
lit is not yet certain whether the spirillum of relapsing
fever is reproduced bj" spoies as well as b}' " spontaneous
fission," but it seems extremely ijrobable that this is the
case. Carter supposes that certain short tilainents which
he has observed in the blood are germinating spores, and
remarks that "the practical facts of contagion require
the presence of fertile spores, since spiral filaments are
absent in the serreta and excreta of the body, and propa-
gation by blood inoculation is obviously not the rule in
common life." The same author gives several instances
in which an attack is supposed to have been due to acci-
dental inoculation while making an auti)]isy. Other
cases are ascribed to simple contact with the dead body,
independently of any wound. That the disease may be
transmitted from individual to individual by direct con-
tagion, or indirectly through fomites, is demonstrated by
a multitude of observations; and, indeed, we have no
satisfactory evidence that it is transmitted in any other
way, or that the specific infective agent — spirillum — is
capable of multiplication in an external nidus, and thus
of giving rise toan epidemic independently of direct con-
tagion, as is undiiubtedly the case in certain other dis-
eases, <,.'/.. typhoid fever, cholera, yellow fever. On the
other hand, the evidence on record shows that in well-
ventilated apartments and hospital wards the attendants
upon the sick and patients sutfering from other diseases
arc not very liable to contiaet the disease. Where, how-
ever, the sick are massed together in insufficiently venti-
lated liospitals, or when cases occur in the overcrowded
tenements of the poor, the transmission of the disease to
attendants and others exposed to contagion is far more
frequent.
Up to the present time attempts to reproduce the
spirillum of relajising fever in a series of cultures have
not been successful. Carter has, however, observed a
growth of the spirilla in length, and the development of
a tangled network of long filaments in a culture cell con-
taining aqueous humor. ke]it in a warm chamber at a
temperature of 40..j^ C. (10."i F. ).
PiiEDisposiNG Causes. — There is no evidence that cll-
mate or .scaison has any marked iuHuence U]ion the preva-
lence of relapsing fever; the disease has prevailed in Si-
beria as well as in India, and its ]irefereuce for certain
localities is quite independent of climatic conditions, re-
lating rather to circumstances connected with the mode
of life and Iiygienic surroundings of the po]iulation. No
0(/e is exempt, and sc.r has no ajiparent intluence; but
children are more subject to be attacked than adults, and
susceptibility seems to diminish to some extent with ad-
vancing age. According to Murchison, only 195 out of
2,111 cases received into the London Fever Hospital, in
twenty-three years, were over fifty years of age. To
appreciate the value of these figures it would evidently
be necessaiT to know how large a proportion of the ex-
jposed ]io]iulation were over fifty years of age.
Iii.iiipiri( lit fiiiitl is generally recognized liy medical
writers as a potent ])redisposing cause, and epidemics
Jiave so frequently been observed to coincide with pe-
riods of uiHisual scarcity that the name " famine fever "
has beenapidied to tlie disease. Some authors have even
gone so far as to ascribe to starvation and its accompani-
ments, overcrowding and filth}' surroundings, an essen-
tial role in the development of the disease. But, as in
the case of other specific contagious diseases, there seems
to be very little foundation for the idea that relapsing
fever may be developed de miro in times of famine, and
its epidemic prevalence at such times is to be ascribed
rather to increased vulnerability, on the part of the starv-
ing population, to the action of the specific exciting
cause of the disease. We know that under favorable
hygienic conditions the disease has but little disposition
to spread, and that in the severest epidemics it finds its
victims almost exclusively among the destitute. On the
other hand, in the numerous instances in which ship-
wrecked mariners, Arctic ex])lorers, etc., have been sub-
jected to alisolute starvation, we have no account of the
development of any such disease as relapsing fever.
Ofercroitdiiig is considered by Parry to be a more potent
predisposing cause than starvation, and his careful study
of the circumstances of those who were taken sick during
the prevalence of the disease in Philadelphia (1870) seenis
to justify this conclusion — .which is, moreover, supported
b_y the observations of Muirhead, Bennett, Lebert, and
others.
One attack of relapsing fever does not protect the in-
dividual from subsequent attacks, and second, or even
third, attacks during the same epidemic have been noted.
Carter's experiments upon the monkey have led him to
the conclusion that "the human virus becomes intensified
in its passage through this animal. " It is noticeable that,
with one or two exceptions, there was but a single febrile
paroxysm in the nuineroussuccessful inoculation experi-
ments made by the author quoted. This does not in-
validate the value of the evidence furnished by his ex-
periments as to the identity of the disease produced in
the monkey with the specific infectious disease of man
known as relapsing fever, for this single paroxysm was
characteristic in its origin, duration, and termination,
and in the constant presence of the blood parasite which
is peculiar to this disease. Moreover, in man the relapse
is not an essential feature of the disease. Thus Carter,
out of a total of 411 cases, found that in 98 (33.8 per
cent.) there was but a single febrile paroxysm. Pejiper
has recorded the fact that iu 10 out of 181 ca.ses observed
in Pliiladeli)Iiia there was no relapse; and jMurchison. in
a series of 2,425 cases collected from various sources,
found that there was but a single paroxysm in 30 per
cent.
Ci>ixic.\i. History. — As a rule, the primary febrile
jiaroxysm begins abruptly, without noticeable priidr<jriie.i.
In certain cases, however, the patient experiences a cer-
tain amouut of malai.se, loss of appetite and headache,
for a day or two prior to the suilden access of fever.
The perlud of incubation has usually a duration of from
five to seven days (five to nine days — ilurchison), but
instances of a longer or shorter incubation are not infre-
quent. In several cases of accidental inoculation, at au-
topsies, which came under the observation of Carter, the
period of incubation was from three and a half to seven
days; and in the successful inoculations in the monkey,
made by the same author, the mean duration of this pe-
riod was aliout ninety hours. Speaking of these experi-
ments, the author referred to says: "My experiments
showed conclusively that prior to the onset of the fever
there always occurs a more or less prolongeil period of
visible bliHxl contamination: and hence that the interval
between infection and fever is divisible into two parts,
viz., an earlier and usually longer non-spirillarsta.gc. and
a final stage of sjiirillar manifestation during which the
body heat, si> far from being augmented, is often rather
depressed."
The initial paroxysm of fever is commonly inaugurated
by a decided chill, or at least by slight chilly sensations,
accomjiaiiiiil by headache, jiain in the back i ud limbs,
and a feeling of weakness, with indisposition to exertion.
8S6
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
ICelapsiug Fever,
Kelapnliig Fever.
Tlie tongue is coated ; nausea and vomiting are of common
occurrence; and there is usuallj- a certain amount of ten-
derness on pressure in tlie epigastric region. Enlarge-
ment of the spleen occurs early in the attack, and usually
a certain amount of enlargement of the liver may also be
detected after the second or thiid day. Jaundice is of
frequent occurrence in certain epidemics, and in others is
quite rare. The abrupt seizure usually occurs during the
daytime, and is marked by a rapid rise of temperatvn-e
and a correspondingly rapid pulse. The pyretic move-
ment exhibits a somewhat remittent character, the even-
ing temperature being one or two degrees higher than
the morning temperature, and attaining a ma.\inium of
103.5' to 10.5° F. during the lirst twenty-four hours — a
maximum which may be exceeded by a degree or two
during subseiivient evening exaeerliations. The distine-
ti\e ciiaraeter of the pyrexia is its sudden terminal inn by
crisis, as a rule on the fifth or seventh day — more
rarely as early as the third or as late as the twelfl h
day. This sudden termination of tlie febrile par
oxysm is commonly attended with profuse perspi
ration, and occasionally by a critical diarrhwa, or
hemorrhage from the nose, rectum, or \agin,i.
The temperature frequently falls, during this ter-
mination of the paroxysm by crisis, as much a'-<
10" or 13° F. in a few hour.s, and, as a rule, a sub
normal temperatiu'e is quickl}' reached, and may
persist at tlie morning observation for two or tlirer
days. Defervescence may occur at any time during
the twenty-four hours, but the observations of
Carter indicate that in a majority of the ca.ses
<()6.6 per cent.) it happens between the hours of A
P.M. and 7 a.m., or in other words, that it is most
likely to occur during the night. It is attended
by a" complete relief of the distressing symptoms
w'hich marked the febrile paroxysm, and with tin
exception of a feeling of lassitude the patient has
nothing to complain of, his tongue cleans up, his
appetite returns, and within three or four days
lie nu'ght be considered convalescent, were it not
for the known tendency of the disease to relapse
after an apyretic interval of about a week. In one hun-
dred and ninety cases analyzed by Carter the mean dura-
tion of the apyretic interval was 7.4 days, the extreme
range being from three to twelve days.
The /W'fywc, occurring commonly on the fourteenth day
from the date of seizure, resembles the initial paroxysm
in its sudden onset and abrupt termination, but is usually
of shorter duration — three to seven days. The tempera-
ture not infrequently attains a higher point than during
the initial paroxysm, and there is acorrespondin,i;ly rapid
pulse, but with the exception of increased debility the
other symptoms are, for the most part, of a milder char-
acter. Defervescence is attended with profuse perspira-
tion, and, as in the first apyretic interval, a subuormal
temperature is quickly reached. After a, second (ipi/retic
pen'iiil, of from six to fourteen days, a serorid rehtpse of
still milder character and briefer duration may occur,
and, in exceptional cases, this may be followed by a third
or even a fourth relapse.
SPECi.ii.. Sy.mpto.ms. — The characteristic features of
the pyrena are shown by the accompanying chart (Fig.
39.57) of a case reported b}' Murchison, which, however,
cannot be taken as entirely tyiiical, inasmuch as the ini-
tial paroxysm and the relajise are of about the same
duration, whereas the rule is that the relapse is not so
protracted, and the date of its occurrence is more com-
monly the fourteenth rather than the twelfth day, as in
this case. Variations from the typical form are, how-
ever, the rule rather than the exception, and the most we
can say is that there is a tendency to crisis on the seventh
da}', and to relapse on the fourteenth day. The remit-
tent character of the pyretic movement is often more
marked than in this case, and especially so in the re-
lapses. We remark, also, that the subnormal tempera-
ture which follows crisis and sudden defervescence is less
marked than usual in this case, after the first febrile par-
oxysm, although shown very well in that part of the
chart ■which represents the second apyretic interval.
This is a very noticeable feature of the disease, although
not iieculiar to it. a subnormal temperature being ciuite
common during the "calm stage" of yellow fever. We
have the authority of Jlurehison for the statement that
the temperature may fall as much as 14.4° in the course
of twelve hours, reaching as low a point in certain cases
as94 , 93°, or even 92° F.
Pepper has observed a fall from 107.3° to 95°, and
states that this is as low a point as is commonly reached.
The observations of Carter, also, indicate that a fall be-
low 95°, in non-fatal cases, must be extremely rare. The
acme of temperature is commonly reached during the
twenty-four hours immediately preceding the crisis, and
in certain cases a sudden rise of several degrees has been
noted to occur just before the abrupt fall which termi-
nates a iiaroxysiii. In a typical series of cases analyzed
iSaBailSSSISSiSAi^l
BBI
filililHa
i|!|i!fliin|!§
BsBUbIB
SBHEnsr
SsSssan
FHj. :i'J.57.— Temperuture Curve iu a Case of Relapsing Fever.
b}- Carter the maximum ti'mperature observed during
the initial paroxysm was 10H°, on the evening of the
sixth da_y; the maximum temperature noted during the
relapse in the same series of cases was 106° F. Pepper
has recorded a temperature of 107.5° as having come
under his observation, and in a typical case, of which he
gives a chart (up. cit., p. 3S0), a temperature of 107° was
reached at the termination of the initial paroxysm, and
also during the relapse. In this chart a slight febrile
movement is seen to follow the subuormal depression
after the relapse. "Reactionary fever" of this kind, of
moderate degree and irregular in its course, iscommi>nly
seen to follow the febrile paroxysm and subsequent sub-
normal depression of temperature in _yellow fever. In
relapsing fever it is not perhaps so conmion, but is suffi-
ciently so to have attracted the notice of Carter, who
speaks of it as the " rebound " or ".secondary fever," and
states that it was observed in about one out of six of his
cases. "Its duration is brief, and the blood spirillum is
invariably absent."
The pulse in relapsing fever presents no distinctive
character. During the pyretic movement it is very fre-
quent, and at the outset iscommonly full and tense; but
with defervescence there is a ra))id reduction in its fre-
quency, and during the first jiortiou of tlu^ ajiyretic iu-
tervals, when the temperature is sulmurmal and the pa-
tient is in a state of partial collapse, it becomes small and
feeble, and occasionall}' extremely slow — as slow even as
in the corresponding stage in cases of yellow fever.
Thus, Obermeier lias seen it as low as 44, and other ob-
servers have seen it even lower than this — JIuirbead 34,
Stille 30. While, iu general, the rapidity of the pulse
corresponds with the pyretic movement, yet this is not
an invariable rule, and according to JIurchison is less
true as 'regards the relapse than in the initial paroxysm;
thus, he has seen a pul.se of 90 when the teinperature was
10(i°. On the other hand. Carter has noted that in the
887
Ki'lnpNins Fovcr.
Relapsing Fever.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES
Bombay epidemic tlie sudden fall of temperature mark-
ing the crisis was not attended with a corres]iiinding de-
cline in the frequency of the pulse. During the height
of the fever the number of pulsations per minute, in
adults, may be stated as from 110 to 140. wliile in chil-
dren it often reaches 100 or even 170. After the crisis,
an irrcLMilar or dicrotic pulse is not infrequent, and as a
ruleit'is feeble and compressible. At this time there is
danger of sudden death from syncope. A soft systolic
murmur heard over the base of the heart and along the
large vessels is frequently discovered, both during tfie
priniary paroxysm and during the relapse.
I'ltiii in the back and limbs is complained of during the
'first davs of the jirimary attack, and to a less extent dur-
ing the relapse. Articular pains, unaccompanied by
swelling, may also persist during the apyretic interval.
But theTmost distressing pain is felt in the head. Head-
ache is usually frontal : it is an early and often very per-
sistent symptom, disappearing only with the crisis, and
recurring with less severity with the relapse. Other
symptoms referable to the nervous system are: Vertigo,
induced by assuming an erect position; especially com-
mon at tiie outset of the attack, and often persisting
throughout the paroxysm ; delirium, usually of an hys-
tericar character, and "most common among tlie victims
ot chronic alcoholism ; or the low muttering delirium
which accompanies supjiression of urine, and which, in
the absence of relief, passes into stupor and coma; con-
viiUiijiis. the result of urtcmic poisoning or of extreme
nervous irritation due to severe and protracted pyrexia;
intiomtiia. due largely to the distressing pains, and not
readily controlled by hypnotics; piirtili/si^. limited to
single muscles or to groujis of muscles— of rare occur-
rence. Of these symptoms vertigo and insomnia are the
only ones which are so common as to constitute a charac-
teristic feature of the disease.
The symptoms referable to the diffesdre S!/xlcm are those
common to febrile comi)laints generally, viz., thirst, loss
of appetite, a coated tongue, torpid bowels, and nausea,
with vomiting of ingcstaaud bilious matters. Tlie timyiie
usually remains moist and is coated with a thick white
fur which may become yellowish or. in cases having a
typhoid tendency, brown and dry. It is usually some-
what swollen and indented at its edges by contact with
the teeth. This appearance, together with the frequent
absence of coating upon the edges and over a triangular
space at the ti|), which remains bright and red, has been
regarded by some authors as of diagnostic value. Occa-
sionally llie tongue is red ami glazed, and it may become
deeply" tissured. or in severe and protracted cases dry and
browii. The tongue q\iiekly clears up and appetite re-
turns when the febrile paro.xysmhas terminated by crisis,
and when a relapse occurs it again becomes coated and
there is a return of anorexia and gastric disturbance.
Isnusea and romitiiir/ arc almost constant symptoms at
the outset of the attack, and, less frerpiently. recur dur-
ing the relapse. Occasionally a con.sideralile quantity of
biie is ejected; more commonly the vomited matters con-
sist of ingesta or glairy mucus tinged with bile. " Black
vomit," due to the presence of blood in the vomited mat-
ters, has been seen by several observers, and in certain
epidemics seems to have been not very infrequent. It is
a symptom ot grave impin-t. Three cases out of four in
wh'ii'h it was noted by P<'ppcr terminated fatally. This
author observes that, "judging from the frequencj- with
which in fatal cases we find eechymoses of the gastric
mucous membrane, with blood-stained mucus in the cav-
ity of the stomach, we should expect black vomit to be
more often observed than is the case." More or less ten-
derness and pain on pressure in the epigastric region is a
conunon symptom during the early part of the febrile
paroxysm ; in this particular, as in several others, there
is a noticeable resemblance to yellow fever.
The lii/in Ik are commonly constipated at the outset of
the attack, but later diarrhoea is not infrequent, and this
may be profusi^ and of a critical character, occurring at
the" close of afebrile paroxysm, and to a greater or less
extent taking the place of the usual critical sweating.
Enlarfjement of the liver may usually be demonstrated
by careful percussion, and in some instances this organ
extends to three inches below the margin of the ribs tow-
ard the close of the febrile paroxysm. Pressure in the
hepatic region causes pain, and occasionally hepatic ten-
derness is (juite a constant cause of distress. Juundice is
a prominint symptom in certain epidemics, occurring in
from twenty to twenty-five per cent, of the cases. At
other times it is comparatively rare. It appears toward
the close of the priniarj' paroxysm, or in one of the suc-
ceeding febrile paroxysms, and usually disappears after
the crisis. According to the observations of Pepper and
of Stille. it is more frequent in the negro than in the
white man.
Fiihrrr/emeiii vf the S}deeii is a constant and early symp-
tom, and it is not unusual for this organ to attain from
three to fcnir times its normal bulk. It may be detectetl
as early as the second day. projecting below the margin
of tlie "ribs, and toward the close of the febrile paroxysm
it often forms a visible tumefaction on the k'ft side of the
abdomen. During the apyretic interval its volume rap-
idly diminishes, to increase again during the relapse.
The K/.iii is free from any characteristic eruption, but
occasionall)' an eruption of pinkish or rose-colored spots
lias been observed (Carter), and " true petechite have been
quite common in some epidemics" (Pepper). Sudamiua
and herpetic eruptions about the mouth and no.strils are
of common occurrence. Desquamation of the cuticle,
especially from the hands and face, is not infrei|\ient.
Several obsiTvcrs have noted a peculiar odor, exhaled
from the body ot the patient, which is .said to resemble
that given oil by "burning straw with a musty odor."
The urine is somewhat scanty and high-colored during
the febrile paroxysms, and, as is usual in such cases, has
a higher specific gravity than normal ; its reaction is usu-
ally acid, and it deposits, on standing, a more or less
copious seiliment of urates, associated sometimes with
crystals ot oxalate of lime. The amount of urea present
is subject to consideralile variations, li\it the general rule
seems to be that it is increased duiing the paroxysms,
and decreased at the time of the crisis, to increase again
during the first part of the apyretic interval. In certain
cases the critical sweating is replaced by an abundant
discharge of light-colored urine of low specific gravity,
but under ordinary circumstances the amount of urine is
greatly reduced at the time of crisis; subsequently the
qu;iulity is increased and the specific gravity is reduced
to a minimum, and this ma}' per.sist for some time after
convak'sci'iice is established. Thus, Carter reportsa case
in which the daily amount, for two weeks after the re-
lajise, was one hundred and thirty ounces, while the spe-
cific gravity was only 1002.6. Slight (dbuminiirii) has
been nfjfed by several observers as commonly occurring
toward the close of the febrile paroxysm, or sliortly after
its termination. According to C'arter, other evidence of
acute renal congestion, such as blood discs and tubular
casts, is almost never found. Other observers, however,
have reported the presence of tube casts in those cases in
which t he urine is albuminous, and Obermeier has claimed
that acute desquamative nephritis is one of the ordinary
phenomena of the disease under consideration.
Kj'idii.ri,i is of rather frequent occurrence iu relapsing
fever, and iiemorrhage from the stomach, from the
bowels, iukI from the kidneys, has been noted in rare
cases. Pep]icr reports fifteen cases in which very pro-
fuse epistaxis <iccurred at the crisis, evidentlv as a criti-
cal discharge, replacing to some extent the usual [lerspi-
ration.
Coi/riilexnnre is usually rapid in the absence of any
eomplii'ation, but, after very severe and prolonged at-
tacks, a considerable interval must elapse before the
emaciated iiatient regains his usual strength. The aver-
age duration of the jieriod included between the date of
.seizure and eonqdete convalescence is about six weeks
(Wilson).
V.\niKTiF,s. — At least one relapse, occurring after an
ayjyretic interval, is necessary to constitute a typical case
of relapsing fever. But iu a certain proportion of the
888
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Rrlapsiu;!
Kelapi<»in^
FeYcr,
Fever.
cases occurring during an epidemic, there is but a single
febrile paroxysm — alx>rtire form (Carter) — whicli, how-
ever, is undoubtedly due to the same specific cause, *as is
shown by the constant presence of the spirillum of Ober-
meier in blood drawn during the pyrexia. These cases
are often mild iu character, and in the absence of a mi-
croscopic examination of the blood, and demonstration
of the jiresence of the spirillum, the diagnosis would re-
main uncertain. The form of fever denominated bilious
ijlplioid by Griesinger and other German authors is un-
doubtedly a variety of relapsing fever. It is character-
ized b_v intense jaundice, a tendency to suppression of
of the urinary secretion, to hemorrhages from mucous
surfaces, and to those grave symptoms which constitute
the typhoid state, viz., great prostration, muttering de-
lirium pa.ssing into stupor and coma, hypostatic conges-
tion of the lungs, a dry and brown tongue, etc. These
symptoms may be developed during the primary febrile
paroxysm in such a manner as to interfere with the ter-
mination of this paroxysm by crisis, and to render ob-
scure the ap3'retic interval which, in typical cases of re-
lapsing fever, distinctly separates the initial paroxj'sm
from the relapse.
Co-MPLic.\Tio.ss. — One of the most frequent and fatal
complications of relapsing fever is ptKuntonin. It com-
monly occurs after the crisis of the primary paroxysm,
but ma}" also follow the relapse, or maj' occur as a more
remote sequel of the disease — three or four weeks after
the close of specific pyrexia. In 97 autopsies Carter
found evidence of pneumonia in 27 instances. Out of 23
autopsies. Pepper found the lesions of this complication
iu 8. It is more frequent in adult males than in females
and children. Phtiri^y was foimd hy Carter to coexist
with pneumonia 13 times in 21 autopsies in which in-
flammation of the lungs was verified. Deaths from
pneumonia commonh' occur within a week or ten days
after the first crisis. The onset of this grave complica-
tion is marked by the usual symptoms and physical
signs, and by pyrexia, which may be confounded with
that of the relapse due to specific blood contamination.
The pyrexia attending this complication is, however,
distinguished from tliat of the preceding or sulisequent
specific febrile paroxysm by the absence of spirilla from
the blood. The same is true of the " secondary " or " re-
actionary " fever, which iu severe cases sometimes follows
the critical defervescence, and which is independent of
any recognizable organic complication.
l)iari'/ia-<i, in certain ejiidemics, is rather common as a
complication or sequel, and may be the immediate cause
of death. It occurred in 33 per cent, of the cases ob-
served by Pepper in Philadelphia, and in 50 per cent, of
the cases in the Konigsberg epidemic. Pni-otitisoccnTred
in from 3 to 3 per cent, of the cases collected by Carter,
and was observed by Pepper in 3 cases out of 185. It
niaj' result iu resolution, or more commonly iu suppura-
tion. As a rule, it is developed during the first apyrefic
interval. Hiccough is a distressing complication which
frequently occurs in severe cases, especially iu those at-
tended with jaundice. It is most common toward the
end of a febrile paroxysm, and usually disapi)ears after
the termination of the paroxysm by crisis. Bronchitis of
a moderate degree of intensity is a frequent complication
which is developed, for the most jiart, during the febrile
paroxysms, as a result of congestion of llie bronchial
mucous membrane, and disappears, or is greatly modified
in degree, during the apyretic intervals. AcHtc larynrji-
tis^ with oedema, is an occasional complication. Kn-
largement of the spleen is so constant that it may be con-
sidered an essential feature of the disease, rather than a
complication. In certain cases the enlargement persists
for many weeks, and is attended with marked debility
and anitmia. lluptnre (f the spleen has been reported by
several authors, and splenic abscess has been noted in cer-
tain rare cases. The former accident is marked by sud-
denly developed pain and collapse, and is quickly fatal;
the latter commonly gives rise to pyjfmia, or may induce
acute peritonitis or pleurisy, by discharging into the
cavity of the abdomen or the left pleural cavity. Other
complications which liave been noted as events of rare
occurrence are: hemorrhage from the stomach ; metasta-
tic abscesses of the lung; suppuration of the mesenteric
glands; general peritonitis; thrombosis of veins, and
cerebral hemorrhage. When pregnant women are at-
tacked with relapsing fever, obortion is almost sure to
occur; and in those cases in which menstruation occurs
during the attack, it is usually profuse, and sometimes
dangerously so. Among the sequeUv of the disease, we
may mention as most prominent: diarrhoea, dysenterj',
antrmia, neuralgic pains, local palsies, keratitis, and in-
flammation of tlie deeper tissues of the eyeball, mental
hebetude, uuvuia, and in rare instances gangrene of the
feet, nose, or ears, as a result of arterial thrombosis
(Wilson).
Diagnosis. — The early diagnosis of relapsing fever is
made easy by the discovery of Obermeier, and hj the fact,
now verified by numerous observers, that the spirillum
peculiar to this disease is found in the blood during the
entire period of pyrexia — including the relapses — and
usually for a short time in advance of the febrile parox-
ysms. Without this test the diagnosis must always re-
main somewhat uncertain for some days, inasmuch as-
there are no pathognomonic symptoms marking the out-
set of the attack. The sudden termination of the initial
paroxysms by crisis, and the relapse after an apyretic in-
terval of five to twelve days, will, however, be sufficient
to establish the diagnosis in t^'pical cases; but, as in other
specific febrile diseases, there are many atvpical cases in
which the diagnosis might remain uncertain if it de-
pended upon the clinical history alone. This is espe-
cially true of the so-called "abortive form." in which
there is but a single paroxysm, in that form which has
been denominated bilious typhoid, and in ca.ses in which
the typical character of the pyrexia is masked by compli-
cations of one kind or another. In countries where severe
forms of malarial fever prevail there can be no doubt that
cases of relapsing fever, especially at the outset of an epi-
demic, before the prevalence of this disease has been gen-
erally recognized, are often ascribed to malarial poison-
ing, and fall under the denomination " remittent fever "
— a term which iu former years, and in the absence of
precise knowledge, has been made to do duty in tabular
statements of disease and mortality for more than one
Kpecific disease, e.g., typhoid fever, yellow fever, relaps-
ing fever. The investigations of Carter make it appear
I robable that relapsing fever is by no means a new dis-
ease iu India, yet it has been only recognized during
recent years, and the available records of an epidemic
which prevailed in Bombay so recently as 1863-6-1-65
do not permit the author mentioned to decide positively
whether the enormous mortality from "fever termed re-
mittent " wasin truth due to relapsing fever or to typhus,
as was claimed by some of the local practitioners. The
differential diagnosis between relapsing fever and true
malarial remittent presents no serious difficulties, al-
though there are many symptoms — such as headache,
vomitiug, epigastric tenderness, enlargement of the
spleen, and jaundice — which are common to both dis-
eases. The character of the pyretic movement, the sud-
den termination by crisis, the failure of quinine favor-
ably to influence the course of the disease, the protracted
apyretic interval, and the relapse, will suffice. But in
addition to these facts relating to the clinical history,
there are various circumstances relating to the epidemic
prevalence of the disease which will aid greatly iu its
recognition. Thus, relapsing fever is transmitted from
individual to individual by contagion, and is a disease of
towns, and especially of the overcrowded portions of such
towns where the poorer classesof the population are con-
gregated inid<'r unfavorable sanitary conditions ; whereas
remittent fiver is especially a disease of the countiy, the
prevalence of which depends upon circumstances relating
to locality, climate, and season, and not upon personal
intercourse and social condition. As a rule, it may be
said that a fatal epidemic disease which prevails among
the crowded population of a large city is uot remittent
fever, whatever else it may be.
889
Rrlapmiiig Fever,
RelapKiug Fever.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Tyiilius fever and relapsing fevci- are often associated
as regards their epidemic prevalence, although there is
no evidence that they bear any etiological relation other
than that due to common predisjiosing causes. That
they are specifically distinct is well established, and the
clinical history of each is sufficiently characteristic. The
eruption of typhus, the continuous course of the pyretic
movement, and the fatal tendency of the disease are all
in contrast with relapsing fever" A more detailed ac-
count of the clinical points of difference is hardly neces-
sary in view of what has preceded, and of the ready
means of establishing the differential diagnosis which is
furnished by the microscope. The same may be said as
regards enteric fever, which disease is also characterized
In" a less abrupt onset, and a pyrexia which presents
peculiar features essentially dift'erent from that of relaps-
ing fever, together with special symptoms, such as a ten-
dency to delirium, abdominal distention, an eruption of
rose spots, etc. The dilTerential diagnosis in that form of
relapsing fever which is denominated by Griesiuger " bili-
ous typhoid " may perhaps present greater difficulties, and,
before the discovery of the spirillum of Obermeier, much
"jncertainty existed as to the etiological relations of this
fatal form of disease. In addition to the presence of the
spirillum it is distinguished from enteric fever by its
mode of onset, by the early appearance of jaundice, and
by the character of the pyrexia, together with a tendency
to hemorrhage from mucous surfaces, a more decided en-
largement of the spleen, and the absence of rose-colored
spots.
Bilious typhoid might very easily be mistaken for yel-
low fever in countries where this disease prevails, and
we have tlie authority of Murchisou for the statement
that this mistake has been made by Graves. Stokes, and
C'ormack. The two diseases have manv features in com-
mon, but also essential points of diiference. Thus, yel-
low fever prevails only in certain latitudes and during
the summer season, while relapsing fever is quite inde-
pendent of climatic conditions. Yellow fever is ex-
tremely fatal, and a single attack protects from subse-
quent "attacks; tlie reverse is true of relapsing fever.
Relapsing fever is propagated by direct transmission
from individual to individual : yellow fever is not, and
its extension depends upon external conditions. The
negro has a partial immunity from the effects of the yel-
low-fever poison, but is especially susceptible to relaps-
ing fever. There are also essential differences in the
clinical history of the two diseases. In one — yellow
fever — the acme of temijerature is commonly reached
during the first twenty-four hours, and defervescence is
gradual; in the other defervescence is rapid and accom-
panied by a critical discharge, and the acme of tempera-
ture occurs, as a rule, shortly before the crisis.
The " stage of calm " in yellow fever is a period of the
gravest danger, the urine is scanty and highly albu-
minous, and complete suppression is a common, and al-
most invariably a fatal, event; the febrile paroxysm is
usually not so protracted as in relapsing fever, and is
attended with less distress, but the effects of the specific
poison upon the blood, the kidneys, and the mucous
membrane of the stomach are of such a nature as to
place the life of the patient in the greatest jeopardy.
The apyretic interval in relapsing fever is. on the other
hand, a period of comparative safety and comfort: the
urinary secretion is abundant, the appetite returns, and
the stomach resumes its functions. This apyretic inter-
val is. however, not so clearly defined in severe cases of
bilious typhoid, as death occurs in from thirty to fifty
per cent, of these cases, and most frequently during the
initial paroxysm, or as a result of com)>lications which
interfere with the normal course of the disease; and as
there are jaundice, albuminous urine, and a tendency
to hemorrhages from nuicous membranes, it is easy to
see how mistakes may arise, and the diagnostic value
of the microscopic test, demonstrating the presence
or absence of the spirillum, becomes apparent. It must
be remembered, however, that the spiiillum is not
found during the reactionary fever which sometimes
follows the crisis, or during the pyrexia attending a
complication.
PnoGNosis AND MoRT.^i.iTY. — The mortality from re-
lapsing fever, in the absence of complications, is low.
Out of 3,115 cases admitted to the London Fever Hospi-
tal in twenty-three years (1847-70), there were 39 deaths
(1.84 per cent.). Murchison, to whom we are indebted
for these figures, has also analyzed the statistics fur-
nished by Scotch phy.sicians. In a series of 6,300 cases
the mortality was 4.13 per cent., and in a second series of
10,444 cases it was 4.42 per cent. According to Pepper,
the mortality in the Philadelijhia epidemic was 14.4 per
cent., the total number of cases being 1,174. These fig-
ures scarcely sustain the statement that relapsing fever
is a comparatively mild disease, and the mortality in the
cases in which jaundice was a prominent symptom —
'■ l)iliiius typhoid " — which is said to have been not less
than fifty per cent., places this form of the disease on a
level with yellow fever and typhus, so far as its fatality
is concerned. In India, out of 616 cases collected bj-
Carter, there were 111 deaths(18.02 per cent.). It is evi-
dent from these figures that it is only by excluding cases
coniiilicated liy jaundice, pneumonia, etc., that the state-
ment is justified that "the death rate in relapsing fever
is low." Death may occur during tlie initial paroxysm,
the apyretic interval, the relapse, or subsequently to this.
In an analysis of 99 fatal cases Carter ascertained that in
48 death occurred during the primary paroxysm, and of
these 37 died at orabout the apparent acme of fever, and at
the stage of defervescence 11 ; 34 deaths occurred during
the first apyretic interval ; 6 during the first relapse ; 11 dur-
ing the second interval, and 1 in a second relapse. The
apparent cmixe "fdtdt/i in these cases is said to have been in
63 cases exhaustion, resulting from the immediate effects
of the pyrexia and its attendant symptoms; in 17 cases
pneumonia as a complication; in 2 copious gastric hemor-
rhage; in 1 femoral thrombosis; in 7 cerebral hemorrhage
was ascertained by autopsy ; there was acute dysentery
in 8 cases, and hepatic abscess in 1.
The influence of age upon mortality is shown by the
following table, which we copy frotn Wil.son («;). cit.).
who obtained it from the statistics of the London Fever
Hospital as given by Murchison.
Of the 3,115 cases admitted there were:
Cases.
Deaths.
Per cent.
Under 20 rears
804
322
119
66
6
3
4
8
9
7
0.37
.71
40 •■ .50 '•
2.48
Sa "60 "
7..T6
ffi "711 "
10.60
70 "SO "
33.33
The favorable influence of youth, as shown in this table
— 0.37 per cent, for all cases below the age of 20— is
not in ciorespondence with the data obtained by Carter
in India. He s;iys; "The influence of age was apparent
in the greater comparative mortality at both extremes
of the scale of years; thus, the general mean death rate
being about 18 per cent., the rate was 27 per cent, up to
the age of ten years, and then in the two succeeding de-
cennia declining to 11 percent. (11 to 20 years), and 16
per cent. (31 to 30 years), it rose with advancing age above
the mean to 24.5 per cent. (31 to 40 years). 29.4 per cent.
(41 to 50 years) , and 37.5 per cent. (51 to 60 years).
The mortality is greatest at the outset of an epidemic,
and the proportion of cases complicated with jaundice is
larger at this time. .S.r has no apparent influence upon
the death rate, when we exclude the decided influence of
intemperate habits, and take account of the fact that
more males than females are attacked.
Anatomic.\l Lesions. — Most authors assert that there
are no constant anatomical lesions in relapsing fever, but
Ponfick, of Berlin, who has made the most elaborate re-
searches yet published, based upon sixty-five autopsies
made during tlie epidemic of 1873-73, asserts "that cer-
tain changes in the spleen, the marrow of bones, the
890
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Rrlapfilus; Ferer.
IfelapMiu^ Fever.
lilood (large granule cells) ; also those of the liver, kidneys,
and muscles (especially of the heart), pertain directly to
relapsing fever, and taken together are pathognomonic."
The splenic changes are said to be absolutely constant,
and this assertion at once disposes of the conunonlj" re-
peated statement that there are no constant local lesions
in relapsing fever. Liver changes, too. were invarialile;
but some difficulty here arose from the likelihood of prior
lesion due to alcoholism. It is evident that the epidemic
at Berlin was a severe one, there being seen several ex-
amples of typlnia biliostis. The following is a summary
of Poufick's results. Lirer : The turgescence ensuing
during specific pyrexia may be greater than occurs in
any other infectious disease; the individual lc>1)ulcs be-
come enlarged, their outlines indistinct, and tint a gray-
ish-red. Microscopicalh', the increased volume is due to
cloudy swelling of the hepatic cells (always present), to
their peripheral fatty degeneration, and lastly, to an in-
filtration of small cells in the portal canals; from an ana-
tomical point of view, no distinction here is possible
between the mild and the severe forms of relapsing fever ;
jaundice was present sixteen times (twenty-four per
cent. ), and it results from biliary engorgement. Kidneys :
Changed without exception, and in correspondence with
alterations noted in the urine; they may be doubled in
size ; parencliyma flabby ; the cortex broad and clouded ;
the Slalpighian tufts pallid. Or parts alone maj' be
changed, and when dark streaks are visible, then not
only is the tubular epithelium more or less fatty, but the
lumen of the tubes is occupied by fibrinous or blood-
tinged plugs. Such cylinders with red discs have been
found in the urine (not at Bombay, H. V. C). There is
also evident, in the extreme degree of swelling, a copious
small-cell infiltration of the iutertubular tissue: and be-
sides, an amyloid thickening of the vessels, which may
be attributed" to previous «)"/*»» Brightii. Striated mus-
cles: Lesi(m of the myocardium is very frequent, its con-
sistence flabby, tint pale gray or brownish. wholl\' or in
streaks, where tlie fibres liave undergone fatty degenera-
tion ; such degeneration may be as extreme as in the most
virulent kind of infectious disease, or even in poisoning
by i)hosphorus. Dr. Poufick naturally applies these data
in explanation of certain fatal cases of fever, where death
<iccurs by syncope, and no other lesion is found after
death. I have above remarked that the like were not
witnessed among the temperate natives of West India.
Spleen : Changes here are localized or dilTuscd : the latter
are always present, and induce a swelling of the organ,
sometimes greater than occurs in leuktmitia. The pulp is
then dark, livid, and projecting; the Jlalpighian bodies
much enlarged or even eff'aced, their tint gray or yellow-
ish; at a later stage of fever their outlines become more
defined. In cases of unusually rapid turgescence of the
spleen, rupture of its capsule maj- occur, and death, with
or without peritonitis; this change is compared with
that taking place in enteric fever. Swelling is due to
distention of blood-vessels, and to a great increase of the
cell elements, including large multinucleated forms in
near relationship to the cavernous veins. Dr. Ponfick
could not find any spirilla among these cells. Numerous
pulp cells were seen containing red blood discs and pig-
ment ; and others filled with bright granules which look
like spores, but probably are not such; tliese structures
are not peculiar to relapsing fever, though found here in
relativcl_v larger numbers than in other fevers; they may
be seen in the blood circulating during life, and wlien
very abundant, may be concerned with death of patient.
Ca.ses are quoted such as occurred at Bombay. There is
also another contamination of the blood wiiicli can be
demonstrated during life in severe cases, viz., by vascu-
lar endothelium cells in a state of fatty degeneration ;
this, too. is not absolutely peculiar. As to localized
splenic changes, the chief pertain to the venous system
and comprise the so-called ' infarcts,' which were present
in forty per cent, of all autopsies; they resemble closely
embolic infarcts, but arise from another cause than
arterial obstruction, and hence are peculiar to relapsing
fever." (Quoted from Carter, op. cit.)
Ponfick also describes certain changes in the marrow
of bones which he considers peculiar to relapsing fever.
"These changes consist in proliferation and subsequent
degeneration of the lymphoid cells of the marrow, with
multiplication of the nuclei in the walls of the minute
vessels and fatty degeneration of their coats. As a result
of these changes spots of puriform softening may form,
chiefly in the cancellous tissue of the extremities of long
bones, with the production of localized necrosis, and pos-
sibly with extension of inflammation to the neighboring
articular cavity." (Quoted from Pepper, op. cit.)
In addition to these constant changes, a variety of le-
sions arc found which appertain to the complications
which occur in this disease with greater or less frequency.
Most prominent among these are the lesions due to pneu-
monia. Pepper found evidence of lobar pneumonia in
thirty-three per cent, of his autopsies, Carter in twenty-
eight per cent., and Ponfick in twenty per cent.
Tre.^t.ment. — All efforts to cut short an attack of re-
lapsing fever by specific medication have thus far proved
unsuccessful, and the knowledge that the disease is due
to the presence of a minute vegetable parasite in the
blood has not resulted in any decided improvement in
our therapeutic resources. The evident indication is to
destroj' or restrain the development of this blood parasite;
but in the list of known therapeutic agents there is not
one which can be safely administered in suflicient quan-
tity to accomplish this purpose. Quinine in full doses
has been tried again and again, but the testimony of
Murchison, of Pepper, and of Carter is in accord as to its
failure to exercise any specific therapeutic power. The
last-named observer sa3's that " the blood spirillum and
the febrile symptoms remain unaffected after quinine
given largely to cinchonisin, after narcotism by chloral,
and after the freest exhibition of spirituous liquors; also
after the administration of the carbolates and very large
doses of the salicylates. " We have no precise data show-
ing the action of germicidal agents upon the spirillum of
Obermeier; but Carter states thai he once found that
weak neutral solutions of quinine seemed to kill the spi-
rillum ; and Dr. Litten has ascertained that the move-
ments of the parasite are arrested by a one-percent, solu-
tion of carbolic acid. The experiments of Ceri show
that the development of schizomycetes is prevented by
the presence of muriate of quinine in the proportion of
1 to 800 in a culture solution. The development of
certain species is prevented by a considerably smaller
amount, but so far as our experimental data go the in-
dications are that at least one part in two thousand will
be required to prevent the development of organisms
of this class in the blood. This would require the con-
stant presence of something more than a drachm of
muriate of quinine in solution in the blood to prevent the
multiplication of bacterial parasites present in this fluid.
The therapeutic possibilities in the case of carbolic acid
are not so favorable as this, and the writer has else-
where estimated the amount of this agent which would
he necessary to restrain the developimeut of pathogenic
organisms in the blood to be something nvire than two
drachms. Arsenic was fairly tried b_v Pepper in the
Philadelphia epidemic, and his conclusion is that "there
seems to be no reason whatever for anj' further use of
this drug in relapsing fever." Large doses of sodium
salicylate have been demonstrated by Unterberger and
by Kiess to exercise a marked antipyretic effect, but to
be impotent for the arrest of the febrile paroxysm or
for the destruction of the blood parasite. "Unterberger
has seen the temperature brought down 3^ C. (.5.4" F.),
yet the attack was not apparently cut short, or splenic
enlargement prevented, or the active blood spirillum
visibly affected. Dr. L. Reiss. after essay on twenty-six
cases, thinks that it is possible to cut short or mitigate
the symptoms (especially the temperature) of specific
relapses by very large doses (one hundred grains or more
daily), noting, however, that even when the lieat is re-
duced to normal or below it, the spirillum still persists."
(Quoted from Carter.) Another remedy, tried by Pep-
per in a large number of cases, is the hyposulphite of
891
Rrniltleiit malarial
Konniii. [Fever,
REFERENCE HANDBOOK OF THE MEDUAL SCIENCES.
soda; his verdict is that "it is certain that it exerted no
specific efTect upon the disease."
In the absence of any known specific, our therapeutic
resources are reduced to those measures whicli are best
adapted to tlie control of the niosl distressing s_vmptoms,
and to tliat watcliful care and anticipation of complica-
tions which enables us so often to tide a patient safelj-
through the critical stages of an iid'ectious disease, and
to save many lives, notwithstanding our acknowledged
inability to cure these diseases. Although the high
pyrexia is not so inunediately dangerous to life as is the
case in certain other continued fevers, it will always be
advisable to keep it within bounds, and the tendency to
death toward the close of the febrile paroxysm, primary
or secondary, sliould beliorne in mind. Tlic evidence on
record is in favor of sodium salicylate, rather tlian qui-
nine, as an antipyretic medicine; it may be given to the
extent of one liundred graius, or more, in the twenty-
four hoiu'S, and is said to be well borne. Its persistent
use, however, interferes with the patient's appetite, and
it will be best to reserve it for tlmse casts which arr marked
by a specially liigli pyrexia, and to administer it, in full
doses, only when the temperature apjiroaches 100 F. For
a more moderate elevation of temperattu-e. cold sponging
of the surface, and the administration of simple febrifuge
remedies, such as effervescing draught, or solution of
spirit. of nitrous ether, will suffice. Aconite, in small and
repeated doses, may be given — one drop every two hours
— in combination with moderate doses of spirit of nitrous
ether, and if any routine treatment for the fever is con-
sidered necessary tliis may Ijc recommended, as less liable
to disturb the stomach than certain other drugs which
are sometimes used in similar conditions, e.</., veratrum
viride, digitalis. Tliere is a tendency to constipation,
and a mild aperient will commonly be reqinred at the
outset of the attack; a dose of castor oil, or a simple
saline imigative, will ai\swer the ]iurpose; later the
bowels may be moved, if necessary, by enemata; emetics,
as a rule, do more harm than good. Jlendarhe is to be
combated by cold applications to tlie head. Insomnia
is a marked and distressing feature of tlie dis<'ase ; Carter
l)refers to administer cliloral and brondde of potassium
for the relief of this symptom, rather than to give ojii-
ates. Pepper, on the contrary, says that "opium and
morphine must be regarded as the liasis of the rational
treatment of rela|)sing fever. It is called for by the in-
somnia, the severe headache, and the pains in various
parts of the body, the uau.sea and vomiting, and the
P3'rexia." One-fourth of a grain of morpdiine, given at
intervals of six to twelve hours, was found by tlieaulhor
last mentioned to relieve pain and vomiting, and often to
induce refreshing sleep. It is contraindicatcd in those
cases having a typhoid tendency, as shown by a disposi-
tion to stupor and deficient urinary secretion. In the
cxiierience of Peiijier during the Philadelphia e]iideniie,
bronude of potassium in full iloses failed to proiliice sleeji
or relieve headache, and chloral, in doses of twenty to
forty grains, cotild not be depended upon, although it
sometimes gave relief. In view of the tendency to heart
failure in this disease, the author named very properly
points out tlie possible danger ■which may attend the
administration of chloral. For the relief of (excessive
tiiiilcnuss of the liver or sjileen. Carter recommends hot
fomentations and poultices in preference to cold applica-
tions, "which are seldom .grateful to the patient." To
control excessive irritabiliti/ of the stomac/i, Pepjier ad-
vises the use of small doses of calomel, gr. ^-t every two
hours, or gr. ^ of nitrate of silver, dissolved in thin
mucila.ge of acacia, administered at intervals of three or
four hours. Ilinyiuf/h is a distressing symptom, which
often defies all remedial measures. In Pep])ei's experi-
ence, chloroform is the most useful remedy for its relief.
As death from Iieartfiilure may occur at the acme of the
pyrexia, or during the depression, often amounting to
collapse, which follows crisis, it will be necessary to
watch carefully for the slightest indications of such fail-
ure, and to guard against it by the administration of
di.gitalis, or strychnia, and the early use of alcoholic
stimulants. When the symptoms of collapse are de-
veloped, it will be necessary to resort to the subcuta-
neous injection of ether, or of strychnia, and to apply
artificial heat to the surface of the body.
In this as in other specific febrile diseases running a
protracted course, it is necessary to commence with a
supporting trtatiuerit at an early date. As soon as the
stomach will retain it, liquid nourishment should be ad-
ministered at stated intervals — every two or three hours;
meat brotlis, milk, or gruel may be given if the condition
of the stomach admits of their being retained; if not,
koumiss, chicken water, or skimmed milk diluted with
lime water, may be given in small quantities and at
shorter intervals. When the stomach is very irritable, it
is probable that iced champa.gnc, or a teaspoonful of
good brandy poured upon broken ice in a glass, and
taken as cold as ice will make it, will be found the best
form of stimulant. Whiskey toddy or milk punch may
be given during the ai\vretic Interval, or until convales-
cence is fairly estalilished, or a good wine may be substi-
tuted for these if the patient prefers. In tliis disea.sc, as
in yellow fever, sudden death is liable to occur from car-
diac syncope, as a result of very trifling exertion made-
when the patient is apparently out of danger. It there-
fore becomes necessary to insist upon absolute quiet and
the maintenance of a recumbent position until such time
as the strength of the patient is fairlv restored. Thia
precaution is especially imperative at the time of crisis,
and during the period immediately following it, when
there are a subnormal temperature and other evidence of
a state of collapse. George M. Sternberr/.
BlBLIOGBAPHV.
An Acfoiint of the Rise, Progress, and Decline of tlie Fever lately
Epi.leiiilr ill Iii'liind, etc. By F. Barker, M.D., and I. Cheyue, M.D.
Lond(.Ti ami liiihlin, 1S27.
A Treatise en tlie Continued Fevers of Great Britain. By Charles Mur-
ehisou, M.D.. Id^.I-i., F.K.S., second edition, London, iST;^.
Griesinper: in Vircbow's Handbucli, Band xi., Atit. 11 (l.S(>4).
Observations ■■11 lii-laiisiiiir Fever, as it Occurred in Philadelphia In the-
Wluter .if isiiiiaii.l IsTii. Bv .lohn S. Parry, M.D. Am. Jour. Med.
Set, l'hilaili-l|ihia, i l.>l.,hiT. Isvn.
Leberl : Ariicl^- in Zi^■ul^s■■l^s ('vclop;vdia, vol. i. (.\m. edition, William
Wood and i'l^iiipany. Ni'W York. 1ST4I.
Miilrhead; Relapsiii'; Fever in Edinburgh. Edin. Med. Journ., .luly,
1870.
Obernieier: Vorkommen feinster eine Eigenbeweeiinff besitzende
Filden im Bliite vt^n Uecnrrenskranken. Centralblatt f. d. med.
Wissensch., N^^. Ill, Miirz, 1S73.
Gnttinann : Ziir Histolofrie des Blutes bei Febris Recurrens. Vlr-
cliuw's Archiv. l.xx.x., I.SSO.
Sphiihim Fever. By H. Vandyke Carter, M.D.. London, 18S3.
Hirscli : (ieog. and Hist. Pathology, vol. i. (pp. 593-610, New Syd. Soc.»
■ •■I. iss:!).
Moiscliutkoffsky : in Centralblatt f . d. med. Wissensch., 1870, No. 11,
p. 1114.
Ponllck : in Vircbow's Archiv, Bd. Ix., Hft. 2, 187t, p, 162; also in Ceii-
trallilatt f. d. med. Wissensch., 1.S74, p. 2.5.
Miiiliituser: in Virchow's .\nliiv. Julv Vitli, 1884.
fnl.-rberffer: Jalirb. f. Kinderlieilk., vol. x., 1870.
Riess: iM^iitscli. med. Wocbelisch.. December, 1879.
Wilson : Tile Continued Fevers, pp. 302-343, Wood's Library of Stand-
anl Me.lical Aulhors. 1S81.
Pepper: sv,.;teiii of Mediclni', vol. i.. pp. 31)9-433, Philadelphia, ISS5.
REMITTENT MALARIAL FEVER.
cttses.
See Malarial Dis-
RENNIN. — This name for the milk-curdling enzyme
of ilii' gastric juice was first lU'oposed in Foster's "Text-
book of Physiology," and is now in common use in Eng-
lisli-speaking countries. The name of cliyiimsin was that
given to it by Deschanips; it was later termed Inb by
Ilauimarsten, and this name is occasionally used liy Eng-
lish writers.
The most valualile researches into its mode of action
and isolation aie due to Hammarsten, who was the first
to show that it is distinct from pepsin. This view is
now almost universally accepted, although it has recently
been stated by Pawlow that rcnnin and pepsin are iden-
tical. Pawlow's experiments, which consist chiefly in a
demonstration of a parallelism of intensity of action of
gastric juice in digesting proteid and coagulating milk,
are not, however, very convinciii.g against the careful
experimentation of Hammarsten in the separation of the
two enzymes, as described later on in this article.
Sff2
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Remittent ITIalarlal
Ki'iiikiii. [Fever,
Renniu and milk-coagulating ferments allied to it are
very witlely distributed, for renuiu occurs not only in the
mucous membrane of tlie stomachs of all mammalia wiiicli
have been tested for it. but is also found in tlir stomachs
of birds and ti.shes where its function is at present un-
known, A similar if not identical ferment is found in the
cell sap of many plants, such as the butterwort, tig-tree,
and artichoke, and in certain of the Schizumycetes.
It is usually prepared commercially as i-ennet in the
form of solution, powder, or tabloids, preserved with
boracic acid, from the fouvtli stomach of the calf; care-
fully prepared ])roducts preserve their power of coagu-
lating milk almost indetinitely, and long after proteid
decomposition may have taken place in the other con-
stituents admixed with the rennin.
Rennin is present in man at Ijirtli, and in this respect
differs from pepsin. In its distribution in the gastric
mucous membrane it closely resembles pepsin, being
present only in small cjuantities at the pyloric region.
Like pejisin, also, it is pi-esent in the gland cells as a
Z3'mogen ; in fact, it was in the case of rennin that a pre-
cursory form or zymogen (Labzymogen) was tirst de-
monstrated b}' Hainmarsten in 1873, some years before a
similar demonstration was made in the case of pepsin by
Langley and Edkins.
The zymogen appears to e.xist in a more stable form in
some animals than in others, for while a neutral extract
of the nuicous membrane of the sheep or calf contains
the enzyme in an active form, similar extracts from birds,
fishes, and certain mammalia exert an action upon milk
only after these extracts have first been treated with very
dilute acid and again neutralized.
Rennin and ]iepsin and their corresponding zymogens
behave very similarly on treatment with dilute alkalies;
thus both rennin and pepsin are very rapidly destroyed
by traces of caustic alkalies. The active ferments are
also destroyed in both ca.ses much more rapidly than their
zvmogens by the alkaline carbonates in dilute solutions,
and this fact lias been utilized, especially in tlie case of
pepsin and pepsinogen, for proving the existence of the
zymogen.
Rennin differs from pepsin in that it will act in a neu-
tral or even in a faintly alkaline medium, but it acts most
quickly when the medium possesses a slightly acid reac-
tion. Excess of acid destroys its activity.
The optimum, temperature lies at 37^ C. to 40' C. ; at
this temperature the reaction takes place with three
times as great rapidity as at 25° C. ; activity ceases at 50°
C, but the enzyme is not destroyed very rapidl}- at this
temperature, and becomes active again as the temi^era-
ture is lowered toward the optimum. The enzyme is
destroyed, however, in five minutes when lieated to 70°
C. in neutral solution, or at 65" C. in aciil solution. Its
activity is also removed by standing under alcohol, but
less rapidly than is the case with pepsin.
That the action is a truly enzymic one is shown not
only by the above-mentioned destructions of activity,
but also by the fact that it can occur in the presence of
antiseptics, and by the infinitesimally small amount nec-
essary to evoke the coagulation, one part of " puritii'd "
rennin being capable of coagulating, according to Sbld-
uer, ten million parts of casein.
The most successful attempt at its isolation was made
by Hammaristen, who utilized Brilcke's principle of
mechanical precipitation by tirst neutralizing a gastric in-
fusion with magnesium carbonate which precipitates the
greater part of the pepsin. The filtrate was then par-
tially precipitated by solution of acetate of lead to re-
move the remainder of the pepsin, and finally the rennin
was thrown out by further addition of lead acetate and
ammonia. This last precipitate was dissolved in very
dilute sulphuric acid, and the rennin again mechanically
thrown out with stearic acid by the addition of a solu-
tion of an alkaline slearate. The rennin was then finally
obtained in solution in water liy suspending the stearic
acid in water and shaking up with ether, which dissolved
the stearic acid and left the renniu behind in the acjueous
layer.
The solution obtained finally did not act at all upon
fibrin, but powerfully coagulated milk in neutral solution.
This solution behaved in many uiipnrtaiit respects diller-
cntl}' from a proteid solution, viz.. it was not coagulated
by heat, did not give a xanthoproteic reaction, and was
not precipitated by alcohol, tannin, iodine, or neutral
acetate of lead.
The chief facts as to the chemistry of the action of
rennin upon milk are to be ascriljcd also to Hammarsten's
researches upon the subject. When milk clots the
greater jiart of the proteid separates in an insolul)le form
as casein (jiaracasein of Hammarsten), which entangles
all the fat in its meshes as it contracts and so expresses a
clear fluid called the whey, while the coagulated casein
and entangled fat are called the curd. The whey con-
tains the inorganic salts, lactose, and a small amount of
albumen and globulin, which are called laetalbumin
and lacto-globulin. Hence the casein is that important
constituent which is chemically concerned in the process
of coagulation.
The proteid from which the casein is formed in the act
of clotting is termed rdseiiduien (casein of Hammarsten),
and is present, according to some observers, in suspen-
sion in fine globides, and, according to others, as a col-
loidal solution. This proteid body has the properties of
a very weak acid which is in fresh milk present as an
alkaline salt ; when it is set free from its combination it
becomes iusohdjle. It is natmally soset free in the sour-
ing of milk, when lactic acid is fcirmed by bacterial action
on the milk sugar, and it is for this rea.son that sour milk
curdles. For experimental purposes, such as the study
of the properties of caseinogen and its changes during
coagulation, it is best precipitated by the addition of a
few drops of acetic acid. It can then be rcdissolved, after
washing away the acetic acid, with distilled water, by
the addition of water containing traces of alkali or by
rubbing U]) with precipitated chalk.
As in tlie formation of fibrin from fibrinogen in blood
clotting, it is found that calcium salts are necessary for
the coagulation to take jilace, but more exact research
has demonstrated that the role of the calcium salt is dif-
ferent in the two cases. For while the calcium salt has
been shown by Hammarsten to be necessary for the for-
mation of the thriimhiixui which acts as a ferment in blond
coagulation, the same observer has also demonstrated
that the calcium salt in milk coagulation does not share
in forming the ferment, but has its purpose in a second
stage of the reaction in actually combining with the
caseinogen wliich has been modified in the first part
of the reaction (soluble casein) to form the insoluble
casein.
Hammarsten's two stages can easily be demonstrated
by taking either a solution of caseinogen, or pure milk to
wlrch a few drops of ammonium oxalate have been added
to throw down. the soluble calcium salts, adding in either
case a few drops of rennet, and then warming in a water
bath to body tem])erature for ten to fifteen minutes,
when no apparent change will be ob.served. Still a
change has occurred, for if the milk be now boiled so as
to throw the ferment out of action in the sul>scquent
operation, and then a few drops of calcium chloride be
added so that there is a calcium salt in solution in the
fluid, on warming again for a few minutes a clot forms.
Here no ferment action can take [dace in the second
process, and as the addition of calcium .salt only, and
subsequent warming, produce no effect upon milk which
has no been treated with rennin as in tlie first part of the
process, it follows that the rennin must in the first por-
tion of the experiment have formed somi' soluble modifi-
cati<in of the caseinogen, which is then tlirown out as in-
soluble casein in the second portion of the experiment.
Working with caseinogen solutions Hammarsten fur-
ther demonstrated tliat in the action of rennin upon
caseinogen tliere is detached from the caseinogen a solu-
ble portion, which he termed " whey-proteid," that does
not undergo any coagulation, and hence is fountl after-
ward in the clear fluid, or admixed in the whey with the
iactalljumin when milk is used instead of caseinogen
893
Keparallvo Siiry:ory,
Krparalite Siirgfry.
KEFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
solution. This proteid has been referred to as lacto-pro-
teiii by otlicr workers upon the subjcft.
The process may lieuee be summarized .ts follows: 1.
The renuin acts upon the easeino,!,'en of the milk and
forms two soluble proteiils (calcium salts bciii.s absent),
"soluble casein" and laclo-protein. 2. Tiie "soluble
casein" combines with calcium, when calcium salts are
present, so forming casein. 3. In the coasrulation of
whole milk the casein entangles the fat glohules forming
the curd, and on contracting presses out the water, in-
organic .salts, lactose, lactalbumin. lactoprotein, and
lacto-globulin which form together the whey.
Benjamin Moore.
REPARATIVE SURGERY.— Plastic reparative surgery
is that department of the operative art which contem-
plates the repair of defects and deformities, congenital or
acquired. Limited in its early history to the restoration
of parts destroyed by trauma, plastic surgery has. in the
course of centuries, widened its range of ulility until
its present achievements have been carried tci all parts of
the body covered by the general integument and to many
of the cavities lineil with mucous memlirane. When the
nose is destroyed by lupus, the eyelid shrivelled out of all
semblance by chronic intlammation, the palate cleft, the
fingers webbed, or the arm bound down by the scars of
a liurn; when a gastric or vesico-vaginal fistula, an ever-
sion of tlie bladder, or a ruptured perineum makes life a
burden — a plastic oiieration is the only measure of relief.
lIisToiiv. — The history of plastic operations presents
fluctuations of use and oblivion unknown to the general-
ity of operative measures. For its earliest development
we must look to the shores of the Ganges, where from
time immemorial nuitilations of the face were inflicted in
tile way of punishment or revenge.
Later, the practice became the portion of the potters
and brickmakers, who knew nothing of sutiires. but re-
tained the parts in position liy the application of clay.
There is no evidence that the skill of any of the operators
of anti((uity went beyond the restoration of mutilated
noses, or that they attempted the repair of other parts.
It is generally believed that before the Christian era the
Brahmins had achieved great protieic^ncy in the restora-
tion of noses, forming them from integument brought
down from the forehead or transplanted from another in-
dividual, and pret'erably fnjm the gluteal region. What
is truth and what is fiction as regards tlie rhinoplastie
skill of the early priests of India, only appears from the
recent translations of relevant parts of ihe Siisrtiids Ai/nr-
reda, according to which the nose was formeil from the in-
tegument covering the cheeks. "The physician takes a
leaf the size of tlie nose to be formed, and, placing it on
the cheek for a measure, raises a flap of skin in such a
manner as to leave it attached at one part. After vivi-
fj'ing the scarred part the new nose is quickly brouglit in
position, elevated, and retained by placing two tidies in
the nostrils." ' The classical writers of Greece and Rome
were for the most part unacquainted with transplanta-
tion of skin as a method of relieving defects, which were
treated only by freshening the edges by incisions and
drawing contiguous ]iortions of skin together.
(.)n the other hand. Celsiis certainly entertained a ra-
tional idea of the gliding of flaps. He advised that the
defect be removed in the form of a square and that two
parallel incisions be continued transversely outward and
inward, so that the loosened edges might be easily united.
If this could not be done, he recommended that t wo semi-
lunar lateral incisions, which should involve only the
skin, be made with the concavitv looking toward the
defect.-
Although Galen and Paul of ^Egina repeated the pre-
cepts of Celsu.s, the little that was known of plastic
operations lapsed into an oblivion even greater than that
which befell general surgery, and from which it was hot
recovered for over a thousand years. In 1443 Pietro
Lonzano, bishop of Lu, published a statement in the
Aiinales du Monde that a Sicilian named Branca had
found a new method of supplying the loss of a nose.
Whence he derived his knowledge does not appear.
Among the ]iupils of Branca was his sou Antonio, who
had improved and extended his father's method by tak-
ing tlie integument from the arm, and by re]ilaeiiig the
lo.ss of li|)S and of ears in thesame way. Plastic surgery
diuibtless spread rapidl\' in Italy from the time of the
elder Branca, since Vesalius, Fallopius, and others make
mention of it. It remained, however, for Gaspardus
Taliacotius or Tagliacozzi, professor of anatomy at Bo-
logna, to develop plastic surgery to a degree unknown
before him. and to publish the first scientific work on it
two years before his death in l.")99. In it are descrilied
his methods of operating and of retaining the parts in
position: and the illustrations accompanying the te.xt
have been utilized from century to centurj- by almost all
authorities who have written upon the subject. A
father of conservative surgery in its best sense, respected
by his confreres and beloved by his students, Tagliacozzi
well merited the marble statue erected after his ileath in
the amphitheatre of Bologna. In this monument he
contemplates a nose wliicli he holds in his hand. The
metliods of Tagliacozzi failed to obtain a permanent
foothold — Pare. Fabrieius, Heister, and many others de-
nied the possibility of success. A little over a hundred
years after Tagliacozzi's death, the art which he had
perfected had again fallen into disuse. Dionys, Desault,
Richter, antl Choiiart only mentioned his practices to con-
demn them. Such was the stale (pf plastic surgery when,
in 1794, a JIadras journal brought to England theaccount
of a successful rhinoplasty practised by one of the Koo-
mas, who transplanted skin from the forehead. Al-
though the first rhinoiilasty in England was made by
Lucas, it was not a success. In 1814 Carpue was more
successful in replacing the lower portion of the nose. In
1816 von Graefe introduced plastic oiierations on the
Continent, giving preference to the method of Tagliacoz-
zi. Since the last-mentioned date the utility and feasi-
bility of plastic surgery have not been seriousl}' ques-
tioned, and iiarticularly within the last twenty-five years
so many additions and improvements have been made
that the achievements of the present day doubtless
eclipse the best efforts of all former masters in this spe-
cial art. Associated with the more recent progress of
plastic operations are the names of Skey, Liston, and
Fergusson in England; Sedillot and Joliert in France:
Dielfeiibach. B. von Langenbeck, Fritze, and Tlii<'rscli in
Germany: and the elder Paucoast and Gurdon Buck in
this country.
Indic.\tions. — Congenital or acquired defects and de-
formities demand the resources of jilastic surgery when,
from their exposed position, a'sthetic reasons make their
removal desirable, or when disturbances of function and
impaired utility are iilainly due to them in parts that are
hidden from view. Hence it is evident that, regarding
the imperativeness of plastic operations, cases in which
they are indicated may properly be divided into two
groups, in which the necessity to interfere varies as much
as the end to be obtained. In the first class of cases the
operation is designed merely to improve the appearance
of the patient by removing a distorting scar, by suturing
the fissured lobule of an ear, or by elevating a ilepressed
nose. Here the indications for an o]ieration aic far from
imperative, and it is not infrequently the importunity of
the patient that impels the surgeon to operate. It is widl
to remendier that operations done .solely for cosmetic
effects are ordinarily the least satisfactory : it is within
the experience of almost every surgeon that results ob-
tained by plastic operations in this group of cases,
although eminently gratifying to himself ami deemed ex-
cellent by his colleagues, are sources of deep disappoint-
ment to the patients themselves. In the second group of
cases the chief indication for operative measures is the
repair of defective function or the protection of parts
that are exposed. AVhen the absence of the lower lip,
destroyed by lupus or noma, )ieruiits of the continuous
loss of saliva, derangements of the digestion and of the
general health necessarily follow. When the lower eye-
lid is everted or lost, the defect causes characteristic
894
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Reparative Surgery*
Keparatlve Surgery.
changes in tbe eye and face which often make vision im-
perfect, and the overHow of tears adds the suffering from
an eczema to the otlier ills of the patient. A large ure-
thral fistula at the penoscrotal angle, while neitlier dis-
figuring nor det-
<? ^ r i m e n t a 1 t o
\te(^^<B|«>"CT;TOgww^7r " health, is a liar
\v' '"--X^ '7/ - ti> tlie full exer-
^Sfc lise of the proereative func-
^ lion. In each of these cases
the indication for recourse to
plastic surgery is apparent, and its
imperativeness is commensurate with
the impairment of function caused by
the deformity. To this group of
cases belong extensive destruction of
the lips, the nose, or the eyelids; cleft
palate, cieatri.x from burns, or web-
bing of the lingers; listuhT?, urethral, vesicovaginal, or
recto-vaginal; lacerated perineum, and exstrophy of the
liladder. In this group of ca.ses must also be included
those in which the operative iiroiluction of a defect is to
be immediately followed by its closure by plastic means.
Thus an ulcer of the leg that has proven refractory to
all other means frequently yields to excision and "im-
mediate transplantation of skin; or an extensive epithe-
lioma of the lip can be relieved only by extensive abla-
tion of the part, the large defect being at once closed
by dermatoplasty.
In considering the urgency of a plastic operation, it. is
necessary to con.sider the pathological nature of the de-
fect which it is intended to overcome. A loss of sub-
stance may be congenital, traumatic, or the result of
destructive neoplasms, like lupus, ulcerative syphilides,
or epithelioma. In congenital deformities plastic opera-
tions are generally not urgently demanded, unless, as in
the case of deficiency of the rectum, the life of the child
depends upon their correction. But there are milder
cases, congenital in character, in which greater deformity
can be avoided by early interference. This is true in
cases of harelip associated with cleft palate. In simple
fissure of the lip the surgeon may abide his time. In
complicated cases, on the other hand, early closure of the
labial cleft must be advocated, since it has an undoubted
influence in approximating the edges of the bony cleft
and greatly increases the probability of success in subse-
quent attempts to close it. In two complicated cases in
wliich I have thus operated during the first week the
result was eminently satisfactory. Due regard should
necessarily be paid to the general nutrition of tlie chilil
before a plastic operation of considerable severity and
entailing the loss of no slight amount of blood is per-
formed. Defects that are traumatic in origin almost in-
variably demand removal by plastic operation while the
wound is in condition topromi.se immediate union. This
applies particularly to wounds of the face, the soft parts
of which are so mobile that tlicy may be stretched to
almost any extent, provided the soft structures be thor-
oughly lifted from the bone. When suppurative proc-
esses have been established it is, as a rule, best to delay
operative procedures until complete cicatri?ation shall
have taken place. When the loss of substance is in-
tiicted by the surgeon in the removal of malignant
growths, its immediate repair is indicated, since there is
every reason for believing that when this is accomplished
the danger of recurrence of tlie primary disease is mate-
rially decreased. In such cases the all-important object
of the operation is the removal of all diseased tissue, irre-
spective of the size and form of the wound that remains.
In the category of defects that result from destructive
inflammations, or from tuberculous or .syphilitic ulcer-
ations, operative measures are never indicated until the
complete cessation of the original disease has taken place.
It is in these cases that patients are most importunate in
their demands for relief, and injudicious haste on the part
of the surgeon is most frequently followed by disaster.
Until a lupous or syphilitic ulceration is entirely under
control, until, indeed, the whiteness of the cicatrix and
the absence of other evidences of constitutional vice give
us reasonaljle assurance that there is no tendency to re-
currence, a plastic operation should not be attempted.
An operation too soon performed will often give a new
impetus to a disease that has simply been dormant.
No.MEN'Ct>.\TUi!E.— A number of terms have been sug-
gested as suitable for designating plastic operations.
French and German writers generally prefer the word
autoplasty (airoc, self, and ^/.aaatn; to form). In rare
cases, in which the trans]ilanted tissue is taken from a
subject other than the patient, this term is evidently in-
appropriate. To overcome this objection, Velpeau and
Guerin have suggested the word anaplasty, signifying to
form anew or again. In this country and in England
these terms have been generally discarded for the less
objectionable one of plastic surgery. When, however,
such an operation is performed for the repair or new
formation of a particular part, the latter properly gives
to the operation a particular name. Thus the formation
of a nose is called rliinii|ilasty ; of the lip, eheik)plasty ;
of the eyelid, blrpharoplasty ; of the mouth, stomato-
plastj'; of the urethra, urethroplasty, etc. The scope of
this article will not permit tlie consiileration of all the
plastic operations. Those of the palate, fingers, urethra,
perineum, and vagina are treated of in other parts of the
H.\NDBOOK, while in the following pages will be studied
the principles underlying plastic operations in general,
and the methods of repairing deformities and defects of
the face only.
The underlying basis of plastic surgerj- is the inherent
vitality of the various tissuesof the body. This permits
them, after partial or total separation, to maintain an in-
dependent existence for a greater or less p<'riod, and to
form new and ])ermanent attachments when brought into-
contact with freshly wounded surfaces in proximity to,
or at a distance from, their original sites. The introduc-
tion into defects of strips of epidermis, of the cutis vera,
of tendon, of nerve, or of bone, which have been entirely
•severed from their former coimections, constitutes trans-
plantation or grafting. In plastic operations proper, this,
severance is never complete, a small bridge always being
left through which the part to be utilized in the closure
of a defect continues to live under the influence of the
circulatory, and probably, also, of the nervous, apparatus,
of the structures whence it was taken, until perfect ag-
glutination in its new position ensues. This occurs in
from twenty-four to forty-eight hours, when no untoward
complications in the process of wound repair supervene.
By the end of a week the union is solidified by the free
interchange of blood-vessels between the edges of the
defect and the part inserted into it. In wounds of skin
more than in those of any other structure is there a mani-
fest tendency to early and firm repair, without which-
plastic operations would rarely succeed.
JlETtfoDs. — The pathology, nature, and extent of a
cutaneous defect, and the condition of contiguous parts,
will direct the surgeon in the choice of one of a number
of methods that are at
T T T -: his disposal. Thus he
(^ may utilize the integu-
ment from a near or
distant part of the body for its closure.
Referring, for the present, to the former
method only, I will state that the skin in
the vicinity may be made serviceable by
(!) traction, (2) by gliding, and (3) by
transplantation of skin flaps. While typi-
cal illustrations of each of these methods,
differ sutticiently from each other to war-
rant a separate consideration of each, it is well to bear
in mind that in their jiractical apiilication the simpler
often verges into the more conijilicated jiroeedure.
1. The method of closing a cutaneous defect by trac-
tion on the vivitied edges of the integument surrounding
it is based on the extent to which skin can be stretched
and yet retain its vitality. This is well illustrated after
removal of the breast, in which even the largest wounds
can ordinarily be readily closed. In the surgery of the
Fit;. 39.59.
89&
K,.|>araiivp Sur^.-rr. i^eperej^ce HANDBOOK OP THE MEDICAL SCIENCES.
Keparativc Surgrry. "^'-'i J-'"^^'^-^
face, liowever, plastic procedures b}' traction alone are
justified only in wedge-shaped or oval ilefects. tlie mar-
irins of wliicli can be easily approximated and retained
-^
ric. :i9iiii.
in position without dangerous traction on tlie sutiu-es.
If there be any strain on theui after complete closure of
the wound, it inay be relieved by an incision through the
skin on either sidi' of the
wound, parallel with, and at a ^ 4 . 'f
short distance fmm it. This
method is llierefore a|)plicable
for the closure of lissures and
tistuUe, aud for the removal of prominent and un-
gainly cicatrices.
2. 'When the size and form of a defect preclude
the possibility of its closure by traction alone, the
skin in the inunediate vicinity may be dissected up
in a patch of reciuisiie size, and by a process of glid-
ing be brought edgewise into the position of the
jiart to be repaired, wliere. after _proper adjust
displaced. "This displacement, however, should be ef-
fected in such a way that the displaced skin, retaining a
connecting (ledicle for its support, may be made to change
r/
no. 39G1
mcnt, it is retained bv sutures.
^'
^=^
Triangular and
rectangular defects,
such as result from
the partial removal
of the lower and up-
per lip, respectively,
can be best remedied
in this way. This
methdd of operating
by gliding, although
mentioned by Celsns.
as Liidiart suggests, was probably practised before his
time, since every operatur, even if without previous
knowledge, would naturally adopt it,
3. The above methods are applicable only when the
integument in the im-
'■(/
Fic. ;>»ii:.'.
f/
r
iiieiU'iite vicinity of
the defect can be util-
ized. If this is not
feasible the borrowed
integument, after
being given t h e
shape of the defect
and being raised from
its substructure, is
transferred into the
defect, but retained
in relation with the tissues of its former position by means
of a pedicle. Around this latter the Hap must tlieu nec-
essarily be turned or twisted. Such atlaii, in being trans-
ferred to its new site, may lie made to describe an arc of
t
FHi
3063.
-/^
Fio. :iiir4.
90', or even ISO . In urder that the raw under surface
of tlie flap may be everywhere in contact with the s\ib-
jacenl surface, the skin bminding this must in part be
/^
/ ^
:>;ii)i>.
Fig. 3i)6.5.
places with the transplanted flap, and thus contribute, as
far as it can, a covering for the surface that has been left
bare." ^ As illustrations of this method may be cited the
formation of a nose from the
Y - Y ' Y T ■ t! f*5reliead, and of the upper eye-
lid from the integument of the
temple.
Although cvcrj' case requir-
ing a plastic operation is a law unto itself, there are
certain characteristic forms of defect the effacement
of which can be effected in well-defined ways. In
following the diagrammatic representations of
Denuce,'' Szy-
manowsky.^and ________^ .^t/
Konig,' the ^
reader must bear
in minil that the
shaded ])arts of
each illustration
represent the de-
fect, that the dotted
lines indicate the in-
cision, and the ar-
row the direction in
which a flap is to be displaced. The supplementary illus-
tration, in each case, indicates the appearance of the parts
after union. (Konig.)
(rt) Small triangular defects may often be closed by
gliding the angles of the wound toward its centre, and
suturing the edges, which, when the integument is freely
movable, can readily be
brought in contact with
each other in the form of
a small triradiate star. If
the defect is too large to
be closed in this manner, one or two
flaps may be easily prepared by car-
rying a straight or curvilinear in-
cision from one or two angles of the
triangular defect. Figs, 3958. 3959,
3960, 3961. 8963, and 3963 illustrate
Fii;. 3'.i(i7. iiie manner of sliding the flaps into
position. Should the tension of the
tlapsbe too great, liberating incisions may be made (Fig.
3964, (0, 'he wounds thus left healing by granulation.
If, in a<lditinnto the incision c rf, a second incision (Figs.
3965 and 3966, d c) be made, parallel to the .side of the
triangle, a quadrangular flap will be obtained for the
closure of the defect (Dief-
feubach, blepharoplasty), fT' ■ , ^ /T^
and a small triangular
wound left to granulate.
If the first incision be
made at an angle to the
margin of the dereet, anil
the second be made in the
manner already described,
the woiuui can generally
be entirely closed by su- y
tures (Figs. 3967 and y'
8968). When the Irian- ^
gular defect lias a large fig. 3968.
v
896
REFERENCE HANDBOOK OF THE ilEDICAL SCIENCES.
Reparative Surgery,
Keparative Surgery,
basf. as is oricii tlie case aflt-r ic-muval of an cpilliflioma
from the lower lip, straight or scmihiuar iiicisluus carried
from the apc-x in the direc-
tion of its siiles (Figs. 3969
and 3970) will ontiine two
flaps that, by sliding, can
be brouglit itilo apposition
along a line at right angles
lo Ihe ba.se of the original
(lefecl. Burow, of Kouigs-
Ijerg, has devised a method
of closing triangular defects
which, probably because it
sacrifices healthy tissues,
received the attention which it merits. It is
I'-iii. 3969.
From the base of the defect, and
XITO.
3974. 397
has not
practised as follows:
continuous with it,
a straight or curvi-
linear incision is
made (b d. Fig.
3971), somewhat
larger tliaa the base
of ihe defect. From
the side opposite to
this a triangular
piece of integument
(/« (?), equal in di-
mensions to the de-
fect, is removed. The flaps c h d and a f c, being then
dissected up and glided along the base line a d.^ readily
close the wound. The line
of suture is shown in Fig.
3972. If tlie defect is a large
one, Burow sacrifices two
smaller triangles of healthy
integument, as shown in Figs.
3973 and 3973.
(h) Quadrangidar defects
can, as a rule, not be effaced
by suture alone. It is usually
necessary to continue the in-
cision in one or two direct ions,
making one or two flaps, after
the method of C'elsus (Figs.
3976, 3977). The tension on these flaps will
be materially decreased by making angular or semilunar
Hberating inci- . _
siims as indi- y «
cated in Figs.
3978 and 3979.
When the de-
fect is a large
one, smaller
flaps may be
obtained from
three direc-
tions as ilUrs-
trated in Figs.
3980, 3981.
Quadrangular
defects may often be closed by the formation of one or
two flaps, which arc turned intotheir new positions around
a broad pedicle (Figs. 3983, 3983, 3984, 3985. and 3986).
(c) Ovalandellip-
' tical defects can
generally be closed
by a little traction
along the line of
their long axes. If
the defect is broad-
er, a liberating inci-
sion (Figs. 3987 and
39S») may be made,
for the purpose of
overcoming danger-
ous tension in the
C sutures. Lisfrane
Fifi. 3973. closed defects by
Vol. VI.— 57
%.
V
FiO. 397:
-^ — f-
^
*r*-t-
constructing two flaps from one side of the ellipse by
an incision perpendicular to its axis (Figs. 3989 and
3990). If this does not suflice, two curvilinear incisions,
b d.bc (Figs. 3991, 3992), will facilitate the closure of the
^_
;f-
■+-
-^
>-^
-/
riu. 3975.
wound by two flaps that can easily bo displaced to cover
the wound. The flaps may also be so devised that they
can be obtained from both sides, if the integument on one
.side be insufficient. Thus, by the incisions a c and b d
J
-+-
-4-
FIG. 3977.
-it-
-/
FIG. 3970.
(Figs. 3993 and 3994), two semilunar flaps will be formed
that almost completely cover the defect. Weber's meth-
od of obtaining two flaps from one side, the one under-
neath the other, is shown in Fig. 3995. It is especially
serviceable in de-
fects of the lips. ^ — > — f — ^^ — '^ ■ ^
(d) Circular de-
fects, i f n o t too
lirge, are most read-
ily overcome by
converting them
into oval or triangu-
lar wounds, prefer-
alily oval. If the
defect is large, a semicircular flap must be obtained from
the vicinity Taud turned into the wound in the manner in
which the quadrangular defect was closed.
It frequently hajipeus that the integument in the im-
mediate vicinity of
<r the defect is un-
>, available for plastic
ptirjioses. Thisap-
j)lies particularly to
the extensive rav-
ages inade in the
face by lupus and
noma. After the
cure of those dis-
eases, extensive ci-
catrices often re-
main in the skin for
a considerable distance around the defect. It then be-
comes necessary to go to a part farther removed from the
latter for healthy skin. Tlius the surgeon may be forced
to fashion an eyelid from the skin of the temple, or a
III ISC from that
:i.-.
Fig. 3978.
/
^^
¥~c
of the forehead
(Indian meth-
od). In excep-
tional cases, it
may even be
deemed advis-
able to go still
farther "from
the defect for a
flap of healthy
skin.asin the'ltalian mcthodof rhinoplasty, in which the
nose is formeil from the skin of t lie arm. In the same man-
ner, the place of a cicatrix from a burn of the wrist may
be supplied by skin taken from the abdomen, or, as Maas'
897
Fig. 3979.
Reparnlivo Siirgerj'.
Bi'pai-utive Surgery.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
demonstrated to the cnugress of Ocniuui surgooiis in
188G, otherwise iucural)le erural ulcers may readily he
closed with a flap of skin ohtaiiied fnnii llie sound leg.
lu every case iu which flaps are thus brought from a
./.
O
r/
S-
J
s
^^R^'^^^IW^^SW'
■y
A-
Fig. •'insn.
considerable distance, the part whence the integument is
to be borrowed must lie retained iu relation witli the de-
feet for a varying length of tiiue. In rhino|)lasty afler
the Italian method, this is aeeompHslied by appropriate
bandages. In the case of Maas, the jiarts were retained
in position by a plaster-of Paris dressing until union was
Beeured.
Nearly all plastic operations may be subdivided inio a
aumber of steps which refer, resjicetively. ( 1 ) to t lie |iii'p-
aration of the
>^ T j I Ti;.. r r
'?+;/
f-i I oAn
--(■
ff-^-y
defect; (2) t
formation and
transplanta-
tion of a flap
and the meth
ods of assuring
its vitality;
and (;>) the jier-
manent and
speedy closure
of th(^ wound.
1. The ap-
position of
freshly wound-
ed surfaces be-
ing practically au essential of success iu plastic surgery,
the tirst ste|i in any oix'ration of this kind is the fresh-
ening or vivifying of the defect. In recent traumatic
defects, aceidcai tally intlicted or proilueed intentionall3-
by the surgeon in tlie removal of a neo]ilasm, this step
of the operation is sulliciently simple. In cases of acci-
dent, it is well to bear in luind that the wounds are often
irregular in the c.vtreme and their margins brui.sed, lac-
erated, and ill suited to ]irimary union. Here it is al-
Fni. 39:-l.
Fig. 'Xm.
Fig. 3ns;i.
ways essential to give the defects as regular an outline as
may be, and t^i remove, with scissors or knife, the con-
tused parts before attempting closure with or without
the aid of a flap. AYhen the defect follows the extirpa-
tion of a growth, antl is to be closed at once b.y a plastic
operation, every sacrifice must be made to ]5rocure radi-
cal removal of the neoplasm. The size of the defect
is of secondary importance. Nevertheless, the incisions
may he so arranged that the closure of the wound
mavbe areat-
\^
V\a. :J!i«.
ly facilitated
A irlance at
Fig. 3090 will
make this
sufficient ly
evident. In
many cicatri-
cial contrai-
tions and in
congenital
deformities,
as in poly-
daetylism, the preliminary step is also the formation of
the defect for immediate closure. This is easily effected
by the linear division of the cicatrix or connecting bands,
and the restitution of the parts to their normal positions.
AVhen the defect has a free border, on the other liand. as
iu harelip, tistuhe, oral deformities, etc., the initial step
of the operation is the paring or vivilication of this
margin, whereby the mucous, cutaneous, or cicatricial
tissues are removed in such a manner as to procure a
surface that is clean, smooth, and well adapted for
]irimary union. Whether the paring be accomplished
Avith sci.s.sors or knife, it is an essential of success that
the border be removed in its entire thickness, since the
presence of any undenuded spot in the line of proposed
union destroys the
possibility of a per-
fect result. To in-
sure a broader sur-
face for contact,
and thereby greater
probability of firm
uni<in. it is advis-
able to vivify the
defect obliquel_y.
This is particularly
serviceable wlien,
as in defects of a
miicous membrane
or of old cicatrices about the face, the margins are thin
and would, if divided perpendicularl)-, oiler a small sur-
face for ailhesion.
2. The most available material should be selected in
forming a flap; its .size should be such that tension is
nowhere exerted, and every jirecaution must be taken to
insuie a sufficient blood supply. The shape and size of
the flap vary according to the defect. It is to be remem-
bered, however, that integumentarv flaps invariably
shrink after, and often before, their transplantation.
The amount of refraction varies with the subsequent dis-
position of the flap. If a raw surface is brought in con-
tact with a idane surface or denuded bone to which it can
form adhesions, the
danger of primary .^
retraction is less
imminent. Tliusit
is certain that a
periosteal fla]) only
slightl}' larger than
a fissure in tlie
|ialate will easily
suffice for its clos
live, whereas al
most twice the in-
tegument must lie
taken from the tcm-
jile to form an eyelid. In all other cases it is we
make the llaii one-fourth or one-third larger than
breach it is intended to cover. Operators of large
1 to
the
ex-
Iicrieuce can fashion the flap without a pattern. Dief-
898
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Kfparative Surgory.
lC4'l»aralive Surgery,
*,^/
¥— ^^
FlC
3089.
ffubuch always coudemned its use, giving to tlio jiart
to lie foniR'd ample diniensious at first, ami veniodclliug
it b_v su|)plemeiitary incisions. It is certainly safer in
all cases to make an accurate model of the part to be
replaced, of paper, leather, adhesive plaster, or soft
wax, which can
\^ . ff be directly ap-
plied to the part
from which the
integument is to
be taken, and
serve as a guide
to the lines of
incision. The
closest attention
isrequired inthe
delineation and
management of
the pedicle. It
■m-l. FIG. 3988. should never, in
a formal plastic
operation, measure less than one-third of an inch in
width, the probability of the survival of the flap being
in direct proportion to the width of its pedicle and its
capacity for arterial supply. As far as possible, there-
fore, the flap should be so outlined that the incisions
will not necessitate the divis-
ion of large arterial twigs.
For the same reason, e.xcessive
torsion of the pedicle must be
scrupulously avoided. Ver-
neuil ^ aptly proposes the name
of hilum for this portion of
the flap, since this term ex-
presses its important function
in the nutrition of the flap.
Into the composition of the
flap there should enter, as far
as possible, tissues histologi-
cally analogous to those of the
part to be rejiaired. Skin should therefore, as a rule,
be replaced by skin, and mucous membrane by mucous
membrane; although the pos.sibility of the convertil)!!-
ity. in the course of time, of the one into the other,
should be borne iu miud. Thus the integument maj',
without difliculty, be made to
substitute the mucosa of the
bladder or of the nares. Mu-
cous membraues, liowever, do
not, as a rule, assume the char-
acteristics of common iulegii-
ment, although that of the va-
gina forms an exception. The
mucous lining of tlie nares, of
the lips, of the nose, and of
the bladder may be exposed for years without sensibly
approaching the appearance of the skin. When skin
enters into the composition of a flap it should, as far as
may lie, resemble that of the part lost. The delicate
integmuent of the eyelid would not be suitalile for re-
pairing defects of the up-
per lii), nor would the ap-
pearance of the nose be
improved by a patch of
hair on its end. Above
all things, the integument
to lie utilized for the flap
should be healthy and
freely movable.
The incisions being
made, the integument, to-
gether with more or less ~ '' "" "'
of the sulicutaneous eel- Fig. 3991.
hilar tissue, is to be dis-
sected up from the underlying structures. The thick-
ness of the flap should always lie commensurate with ils
other dimensions. Large and thin flaps often succumb
to defective nutrition. The subcutaneous cellular layer
fr^
f/
Flc. 3119(1.
./-
is an essential of all large flaps, since it is the medium
through which the skin receives its nutrition. An excess
of adipose tissue, however, is an element of danger to the
vitality of the flap. It has been claimed that muscular
tissue should not enter into the composition of a flap
when it can be avoided, on the ground tliat muscle with-
out function is speedily converted into fibrous tissue, and
the presence of this ci-
catricial tissue may be-
come an important factor
in marring the final re-
sult in many plastic oper-
ations.' In those upon
the face muscular ele-
ments cannot be ex-
cluded, siuce they are
directly inserted into the
skin; nor would their ex-
clusion be advisable, since without them the moliility of
a newly formed lip or eyelid would be out of the ques-
tion. The periosteum may also, in exceptional cases, be
included iu the flap in plastic operations. B. von Lan-
genbeek'"and Oilier" have thus .sought to utilize the
osteogenetic function of the periosteum in rhinoplasty
and uranoplasty, in the belief that the new bone devel-
oped by it -would give the normal resistance to the re-
paired part.
Verneuil, Sedillot. and others question the utility of
this procedure, believing, and iu some instances with
good reason, that the iuclusiou of the periosteum in a
flap is an element of
_„,- ^ danger to the vitality
y''' of the part whence it
Fii;. 39112.
O'
Fig. 3993.
FIG. 3994.
is taken, and that it increases the jii-obability of sepsis.
AVith modern wound treatment this is excluded. Re-
garding operations on the palate, the danger of necrosis
after periosteal denudations is certainly theoretical.
Langenbeck,'" who has probably operated oftener than
any'one else for cleft palate, by this method, has never
seen the bone exfoliate, lie has, however, noticed such
an accident after rhinoplasty. Nor can there be any
question as to the formation of new bone from peri-
osteal flaps. Iu every congenital defect of the palate
operated upon by this distinguished surgeon which was
under observation more than four weeks after urano,
plasty the forma-
™ 11 our TinTin .- — — — • -—.^^izr- —
tion of new bone
was confirmed. It
begins about the
third week, and is
completed at about
tlie fourth week,
although it snbse-
(luently gains in .so-
lidity. So far as
time is concerned,
the periosteal regen-
eration of bone after
jilastic operations
may then be said to
lie chronologically analogous to that which takes ]ilace in
the repair of fractures. Nor, any more than after fract-
ures, is there any tlanger that the newly formed bone
will subsequently undergo retrograde changes.
./
899
Rrparatlvo Sursery.
Krparalive Surscry.
REFERENCE HANDBOOK OF THE MEDICAL SCIEXCES.
To increase the tliickncss ami, therefore, the vitality of
large tiaps, ami at tlie same time ai)l)roximate the repaired
part to the normal structure and function, very tliiek and
even duplex tlaps must often be formed. Thus, wliile a
larije defect of the lower lip may be covered with a. flap
from the neck, the new lip will be thin, devoid of mus-
cular tibre, and, therefore, of movement, and soon be-
comes tirndy attached to the lower jaw. It is preferable,
therefore, when possible, to make tlie flai>s of the entire
thickness of the cheek, covered with skin and mucous
membrane, which, when brought into position, subserve
in tlie best manner possible tlio puqioses of the iiart de-
Etroved. Or it may be piacticable. if it be deemed best
FlK. 399t'i.— I'lastio OperaUoll fi
'r CiinetT iif I.ip. Showini: \A) l!i'
(B) Ibe completed "iirniEinn.
to use the flap from the chin, to reflect the mucous cov-
ering of the alveolar border for a lining to the cutaneous
flap. As will be seen in o|ierations for rhinoplasty and
exstrophy of the bladder, tliis doubling of ihe flap may
be practised with two folds of skin, the lower of winch
snbsetpiently lif comes converted into mucous membrane.
For this metliod Ad. Richard.'' in ISbi, proposed the
term "autoplastie par doublure."
3. The transplantation and permanent attachment of
the Hap constitute the last steps of formal plastic oper-
ations. At present all authors are agreed that, Sitve in
exceptional cases, tlie fixation of the flap should at once
follow its formation as .soon as all oozing has ceased.
Tagliacozzi, however, in his rhinoplasties, allowed the
imiler surface of the- flaji, taken from the arm. to supint-
rate before fixing it in the new position. Graefe. on the
other liand, successfully practi.sed fixation while the sur-
faces were fresh. In very rare cases the old oj^eration
may be followed by good results. Thus the author, in
187"(), saAV }5illrotli close a gastric fistula with a flap that
had been lifted from its surface one week liefore fixation,
the reason given for this being that the suppuraling sur-
face would be less affected by the deleterious influence of
the gastric juice than one recently prepared.
In IS*^!) Mr. Croft described an operation which was
based on this principle, and wliicb was ]iarticularly use-
ful in relieving the s<-ars following extensive burns.
The w riter employed it to relieve a dense scar wliich held
the thigh firinly bound to the abdomen. A broa<l strip of
skin. six. eiglit, or ten inches long, is lifted between
parallel incisions from the underlying structures, but left
attached aliove and lielow. Strips of gauze are inserted
underneath for six or .seven days until granulations have
formed. Tlie lia]) thereby becomes thickened. At the
.second operation, after tlie defect is vivified, the granu-
lations ar-; curetted from the Hap, its attachment at one
end is severed, and the placing In position follows as in
the one-time operation (Med.-Chirurg. Trans., 18!S9).
In 1854 Roux was compelled by circumstances, in a
defect of lip and chin, to resort to a practice which some
writers havesought toelevate into aspecial method, that
by successive migrations. "It consists in fixing a flap
temporarily in a new position, from which, after the
lai)se of several weeks, it is removed by a second oper-
ation to a part nearer the defect, where, after a number
of migrations, it is finally deposited, '"■' Buck has resorted
to a somewhat similar expedient in extensive deformities
of tlie face. It is only in these that it is ever practicable.
To facilitate the transplantation of a flap and to relieve
tension, liberating incisions
are often required. Thus, in
harelip, success is not gener-
ally attainable without freely
liberating the segments of the
lip which are more or less
bound down to the maxilla.
Such liberating incisions can-
not always be concealed, as
in the instance cited. They
should then be made as small
as is consistent with the elYect
desired, and in the manner in-
dicated {g i h, in Fig. 3978).
To close the wounds result-
ing from these liberating in-
cissions is permissilile only af-
ter the defect has been covered
and when it is evident that
closing the secondary incis-
ions does not cause traction
on the more important line of
sutures closing the primary
wound. Where there is any
doubt, it is best to leave the
liberating incisions tinsu-
tured, and the wounds to
heal by granulation. In very
many cases these wounds can
at once be closed by skin-grafting or by using a Wolff
or Krauso flap. (See S/.iii-gmftinf/.)
The fixation of the flap by sutures forms the final step
of lh(! plastic operation. The care and accuracy in ap-
position of the raw surfaces observed in other surgical
procedures are particularly demanded here. The alisence
of blood within the wound is an essential to success.
Hence DielTenbach, Lisfranc, and others often postponed
fixation for two or three hours until all oozing had ceased.
As Verneuil justly says, while admitting the value of
this method in former times, "in our day operations are
generally made under amesthesia, from which, when the
patients awake, they like to believe that the operation is
completed ; hence it is a ,source of great sutferiiig to mind
and body to delay the completion of the operation."
In clcising the' wound the continuous or interrupted
suture may be employed. Whenever applicable, the
buried subcuticular suture should be used. Suture
marks are in themselves often cjuite disfiguring. As a
rule, small needles should be used. The angles of the
surfaces are first approximated. AVhile the number of
sutures must besutiicient for accurate aiipositiou and the
avoidiuice of wrinkles in the flap, an exci'ssive number is
doubtless harmful, since every suture, however fine, in-
terferes in a measure with the circulation in the part, and
every suture may become a source of suppuration. AVhen
ciins'idcrable traction must be made to hold the flap in
position, one or even two deep sutures of heavy silk
may ))rofiialily be inserted far from the edges of the
Wound, as after amputation. In this way the tension on
the more numerous siiperticial sutures is elTectually re-
moved. The material used for sutures varies according
to the length of time they are to remain. In jilastic
operations about the face an iron-dyed silk proliably an-
swers the best purposes. These sutures can be removed,
a few at a time, in from forty-eight hours to five or six
propist'il lines of incision, and
900
REFERENCE HANDBOOK OP THE JIEDICAL SCIENCES.
Kcparalive SurKery.
Kcparative Surgery,
days after the operation, according to the union obtained.
Wiien it is desirable to vetain the sutures longer, as in
operations on the vagina, silver wire is to be preferred,
since metals produce vastly less reaction in the tissues
than silk.
Regarding the after-treatment, little need be said.
The wounds are frequently in a position where aseptic,
measures cannot be successfully carried out; as, for ex-
ample, about the lips or nose. In these cases dry gauze
compresses, held in position by properly adjusted band-
ages or adhe.'iive strips, will go far toward supporting
the parls and assuring primary adhesion. The writer has
found gauze strips steeped in collodion an e.xcellent
dressing in many small plastic operations on the face.
Wounds made for plastic purpo.ses should be frequently
examined to determine the condition of the parts, and
particularly if a flap has been utilized. Immediately
after its application a flap is cool, pale, and insensitive.
Within from twelve to twenty-four hours, as cii'culation
is established, its temperature rises, and a marked red-
ness distinguishes it from the integument surrounding
it. This redness easily yields to a bluish discoloration
and excessive swelling, both indications of venous stasis,
whicli, if not cheeked, often leads to sloughing. Loosen-
ing one or two sutures, or seariiieation of the flap itself,
may avert such a result. If suppuration under the flap
is suspected, the most dependent sutures must be re-
moved for proper drainage. With proiier precaution the
presence of suppuration does not necessarily entail failure
of the operation, since the flap may be held in position
with small strips of adhesive ]ilaster or by a number of
sutures inserted at its salient points.
Supplementary treatment and even ojjerations are
often necessary after coniiilete closure of the wound.
Thus constant attention must be given the nostrils after
rhinoplasty, the lower lip after cheilojilasty, lest the
former close, or the latter become adherent. Or it may
be that the contraction of the fla]) lias not ensued to the
degree anticipated, anil the newly formed organ pre.scnts
wrinkles of redundaut skin. In the same way, the pedi-
cle of a flap which has subserved its jiurposes must be
excised if at all prominent. Such redundant masses can
always be easil}' removed by oval incisions. In the ease
of the pedicle, several months must elapse before its ex-
cision is even to be thought of. A premature attempt in
this direction of improving the result of a pla-stie oper-
ation may casilv annul the advantages already obtained.
As has already been observed, every case requiring a
plastic operation is a law unto itself. The more compli-
cated the defect, the greater the study and practice re-
quired in overcoming it. When the destruction of tissue
lias been very extensive, as in noma, lupus, or burns, a
single 0)jeration rarely suffices. Three, four, and even
more ojieratious may be necessary before the aiipearanee
of the face is in a measure restoi'cd. In these compli-
cated cases, too much should not be attemjited at one
time, and an interval of from one to si.x months may
often be advantageously observed between the dilferent
ojK'rations. It is in this way that the most successful
workers in this field have, by reiieated efforts, often ex-
tending over a period of two or three years, given a new
life to individuals who, from very extensive destructions
of promhient parts of the face, have been objects of dis-
gust to themselves and of horror to those with whom it
was tlieir misfortune to come in contact.
Bi.EPU.\iiopi,.\sTy. — Plastic operations in the eyelids as
a rule come under the care of the ophthalnuc surgeon.
A full description of the various methf>ds of blepliaro-
jilast}' is givei; in the article by Ur. Van Fleet on Eyelixis,
etc.
CiiEiLOPLASTT. — The reconstruction of a lip after its
partial or total destruction liy injury or disease is termed
cheilo|)lasty. In the preponderance of cases it is ]ier-
formed for epithelioma, and for the most part, therefoic,
is pr.actised on the lower lip. The upper lip, also, at
times is destroyed by noma, lupus, burns, or wounds,
and thus becomes tlie suhje<-t cd' plastic repair. Excejit
in cases of epithelioma these operations are particularly
complicated, and tax the ingenuity of the surgeon
through the involvement and distortion of the angle of
the mouth and of more or less of the integument of the
cheek or of the nose. Owing to the great variety dis-
played bj- individual defects of the lips, many methods
have becii devised for their j-elief. Only those are very
serviceable in whieli a flaji covered by integument with-
out and mucous membrane within can be utilized. In
all other methods, although at times they must be fol-
lowed, the flap speedily becomes adherent to the maxilla,
immovable, useless for mastication, and incompetent to
retain the saliva. Another defect in the immediate residt
that appertains to almost all methods is the disparity in
size between the sound and the reconstructed lip. The
latter usually being smaller, the other projects far be-
yond, wliile the month presents an unnaturally con-
tracted appearance. Still, this abnormal condition is re-
covered from after the lapse of a few months, the mouth
being sjwntaneously remodelled.
In all eheiloplasties it is essential that the flap be ob-
tained from the immediate vicinity of the defect, since
faihu-e is certain to follow any attempt to obtain it from
a distance. The mobility of the partsduring mastication
is such that flxatiim of the arm cannot be maintained for
a sufficiently long time or accurately enough to prevent
the loss of the flap.
Cheiloplastic operations may be divided into: (1) Those
that affect the lower lip; ('2) those that affect the upper
lip ; and (3) tho.se that affect the angles of the mouth, or
the mouth as a whole (stomatoplasty).
1. Since the lower lip is repaired most frequently for
epithelioma, the surgeon can often shape the defect in a
way to facilitate its closure. If the neoplasm involve
only a slight extent of lip, it should be removed by a
V-shaped incision, when, ordinarily, no difficulty will
obtain in closing the gap with deep sutures, even if the
entire thickness of the lip has been removed. When the
disease, however, covers a large area but is superficial,
removal by a curvilinear incision is preferable, since the
defect thereby produced will readily be supplied without
plastic procedures. When the entire lip is involved, in
thickness as well as in height, rectangular or curvilinear
incisions alone are serviceable for tho^'emovalof the neo-
plasm. When, as is often the case, the disease involves
the angle of the mouth, the incisions must necessarily be
more complicated and altogether regulated by the extent
of the disease. Even in extreme cases the gap can often
be closed by a combination of V- or W-slia]ied incisions.
AVeber mentions a case in which the disease was very
exten.sive. AVhen circumstances compel the surgeon to
borrow the material for the flap from the chin or neck,
the methods of Chopart, of Lisfranc, or of Berg may be
adopted. In Chopart's operation the diseased tissiie is
incliuled between two parallel perpendicular incisions
carried over the chin and on to the neck as far as the
hyoid bone, if necessary (Fig. 3097) (Nelaton). When
the diseased part is then re-
moved bj' a horizontal incis-
ion, there remains a quad-
rangular flap which, when
dissected up, is brought by a
process of gliding to the level
of the laliial commissures,
wliere it is retained by s\ilures.
Lisfranc preferred to remove
the neoplasm by a curved in-
cision, from tlie centre <if
which (Pig. 8998) a perpendic-
ular cut of greater or less
Icniith, carried downward, out-
lined two flaps which, when
detached, were bi'ought into jnisition. Berg also gave
the defect a curvilinear outline, but prefiared t.o use a
single fla]) from the chin and side of the neck. Fig. 3999
shows the manner of delineating the flap, of bringing it
into jiosition, and of closing the jiriniary and second.ary
wounds. If the upper margins of the flap b(^ covered,
from each angle of the mouth, by a portion of the ver-
FlG. 3997,
901
Kcparallvo Surgery.
Roparalive Surgery,
REFERENCE IIANOBOOK OF THE MEDICAL SCIENCES.
milion border borrowed fronj the upper lip, the result
will be excellent, alUiough the oral aperture raa.y tem-
porarily be matei-ially decreased iu size. To accomplish
Flc. 3!WR.
the same end Serre, in an e.\ten.sive epithelioma of the
lower lip, jiractised Choi.iart's operation, preserving the
mucous membrane of the lip for a covering to the flap.
Flli. 399!).
It is almost needless to say that it is only in exreptional
cases of very superlicial neoplasmata that this method is
at all applicable.
When the defect after removal of an epithelioma is tri-
angular, with base involving the greater part of the li|i,
the operations of Dieilenbaeh or Malgaigue may be pm-
Kii;. tnnn.
fitably resorted to. That of the German surgeon consists
in making an incision on each siile from the angle of the
mouth toward the masseter and in the line of the labial
Assure. The length of the horizontal incision is half that
of the base of the defect. The quadrilateral tlajis thus
raised are brought together in the median line by their
FIG. 4an.
internal borders. The ojieration of Malgaigne iliffers
from this in that he refrains from the use of thi' jierpen-
dieular incision. To overcome the redundancy of the
upper lip, a triangular portion ma_y be excised (Fig.
4000). In either operation the new lip can easily be
lined with mucous membrane, if that of the cheek be di-
vided at a higher level than the integument in the hori-
zontal incisions from the angles of the mouth. In cases
in which the defect is triangular and shallow its closure
by later incisions, after the method of Syme, presents
many advantages. By this method the incisions are pro-
longed downward and outward for an inch, whence they
are carried upward and outward for a varying distance.
The Haps thus outlined are dissected off the bone and
brought together iu the median line. Tlie mucous mem-
brane and skin are stitched together along the upper
edge, and the triangular interval on each side is left to
heal by granulations. To facilitate union of the Haps,
the tip of the spur left below the apex of the defect may
FIG. 4003.
FIG. 4003.
be removed after the Haps have been raised (Fig. 4001)
(Nelaton). Tlie very great advantage of tliis nielliod
over those preceding it is that, since the integument cov-
ering the cliin is not disturbe<l, tlie rlaps cannot sink or
be drawn downward toward the ueek, and tlie new lip
will maintain its original height, t^jiadrangular defects
of the lower lip ma}' be successfully overcome by resort-
ing to two rectangular flaps taken from the chin or from
the side of the chin. Sedillot (Fig. 40(t0) made the flaps
at right angles to the line of the mouth from the side of
the ciiin, wliile Brims preferred to make them obliijuely
and from the cheek. When the flaps are raised tliey are
turned on their respective
pedicles, when their inner
borders meet iu the median
line. When circumstances
permit of a choice between
the method of Sedillot and
that of Bruns(Fig. 31184, dia-
grammatic), the former
shoulil be preferred, since in
the latter there is consider-
able dangerof traction on the
cheeks with a resulting de-
formity. The operation of
Sedillot also offers a better opportunity for covering the
upper edges of the flaps with part of the vermilion border
of the upper lip. When this is severed for half an inch
or more on each side from the upper lip. the flajis form-
ing the lower lip can be almost entirely covered. Sehuh's
practice of tattooing the edge of the lip for cosmetic pur-
|io.ses has probably never been followed by other oper-
ators. In 180!) Langenbeck first practised a cheiloiilasty
which has gained many followers iu Germany. In this
method the di.sea.sed lip is re-
moved by a curvilinear incis-
ion (Fig. 4003). A flap is
then prepared from the in-
tegument of tlie chin (1) the
base of which is on the side
of the oral angle. The free
extremity of tlie defect is not
directly under the oral defect, -
but separated from it by a
triangular |)orti(in of skin (2).
Iiotli tiajis beini; raised, the
lower is elevated into the de-
fect, while tlieother is utilized in closing the breacli below
(Fig. 4004). The |iresenceof the spur prevents the sink-
ing of the lip.
When it is desirable, the upper edge of the flap may be
covered with a portion of the mucous border of the up-
per lip. Gurdoii Buck ("'Rep. Surg. ," y. 22), and Est-
Fu:. 4(HH.
902
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Jleparalive Surgeryl
lauder {Arc/i. f. Cliir., xii.). closed defects of tlie lower
lip with flaps taken from the upper. Buck, after remov-
ing the growili by a V-shaped incision, or by one hori-
zontal and two perpendicular incisions in more compli-
cated cases, brought the sides of the gap together
directly, or. in the case of the quadrangular defect, by
forming two horizontal lateral flaps wliich were secnred
to each other in the median line by pin sutures. After
closure of the wound had been elfected, a secondary
operation was performed to transfer the redundant tissue
of the upper to the deficient lower lip, and thus to restore
the symmetry of the mouth. This operation is performed
as follows: A point is selected aliout a finger's breadth
below, and a little -without, the oral angle on each side,
and marked by the insertion of a pin tlnough tlie skin.
Another pin is'inserted on each side at the junction of the
vermilion border of the upper lip with the skin, about
one-tifth of the distance from the angle of the mouth to
/
FlU. 41106.
the median line of the lip : and a third pin on each side is
inserted into the integument of the cheek, about an inch
and a half above and witliout tlie angle of tlie month.
The points indicated by the tirst and third pins arc then
to be united by an incision tlirough the entire thickness
of the cheek, and in like niauuL-r the jioints indicated by
the second and third pins. A triangular flap is thus
formed, with its base toward the angle of the mouth.
From the point indicated by the first pin, a vertical in-
cision is now made to the liase of the jaw. The integu-
ment in this region being in a state of great tension, the
edges recede and form a space fiu' the reception of the
Fifi. 4007.
triangular flap, with its apex toward the base of the jaw,
and its base, including a portion of the vermilion border
of the upper lip, supplying the deficiency of the corre-
sponding side of the lower lip. "SVhen the operation on
both sides is completed the configuration of the mouth is
nearly normal. (Figs. 400.5 and 4O00, from Buck.)
Estliinder's operation differs from that of Buck in tliat
the outer incision is curvilinear, and that the plastic
operation at once follows the extirpation of the tumor.
(2) In reconstructing tlie upper lip, the operator
has the choice of a number of methods. In cases of total
deficiency, the method of Bruns, already referred to
(Fig. 3984), yields excellent results. Berard utihzed
two lateral flaps from the cheeks, inchuling them be-
tween jiarallel horizontal incisi<ins, carried outward to
the masseter, the upper from the angle of the nose, the
lower from the angle of tlie mouth. The flaps thus
formed are brought into position by gliding, and united
by pin sutures in the median line. Abetter operation for
severe cases is that of Sedillot (Fig. 4007), which is per-
formed as follows: On each side of the oral angle a quad-
rilateral flap, of the width and half the length of the lip,
is outlined by two perpendicular incisions and one hori-
zontal incision on each side. The inner of the ijerpen-
dicular incisions is carried higher than the outer. AVhen
the flaps have been thus outlined, the}- are raised from the
underlying tissues. The entire thickness of the cheek is
Fin. tons.
included in the flaps, which are therefore lined with mu-
cous membrane. When the flaps are brought into posi-
tion, their lower borders meet in the median line, the
inner borders are sutured to the upper margin of the de-
fect beneath the nose, while theouti-r borders assume the
position of ihe free border of the lip. With a little trac-
tion the mucous membrane and the integument of this
border can be united by a number of very fine sutures.
When the defect of the upper lip is central and not
very extensive, the method of Dieffenliach presents much
to recommend it. It consists in transfixing the cheek on
each side of the angle of the nose, and forming a flap on
903
Keparalivo Surgery,
Kopai'alive Surgery,
REFERENCE IIANDUOOK OF THE MEDICAL SCIENCES.
FKi. 4'10!1.
each si<lo l)_v a cni-vilinfar incision (Fisx. 400s). Wlicn
these tlajis are raised from their attachnienis to tlie alve-
olar border, they ai'e easily brought inio a|i)iosition by
their internal margins in the median line. 'Phe method
of fixing tlie flap
beneath the nose is
alsoslinwn in the il-
hisl ration. The ad-
van tago of this
method, when it is
applicable, is in the
gieaterheig'ht given
by the curvilinear
uicisidu into the Map
m the median line,
and in the fact tliat
its free bordfcr is uat-
uially covered by
mucous lueiubrane.
Ledrau and Roux
utilized one-half of
tlic lower lip for re-
jiairing di^formities
in which the outer
half iif tlieui)perlip
was lost. r>oth of
these operators
transplanted a quadrangular flap with it-; pedicle outward.
Tliis methcul was greatly iinprovc-d upon by Buck, who,
placing the pedicle internally, temjiorarily reihieed tlie
length of the oral fissure. This lucthod of operation is
shown in Fig. 4009. The extremity of the hnver lip,
where it joins the right cheek, is divided througli its
entire thickness at right angles to its border, and for a
distance of an inch {k, b). A second incision is made from
the end of the first, parallel to the labial border, for a dis-
tance (if one inch and a half (h c) : from c a short incision
{e d) is luaile toward the free border of the under lip, and
parallrl to the incision (<f h). The quadrilateral tl.ip thus
formed from the lower lip is now turned upon its pedicle
to uieet the remaining portion of the upjier lip, to which
it is attached by its free e.xtremity (n h). Fig. 4010 .shows
the result of this operation, and the method of overcom-
ing the <leformity of the angle of the mouth wliieh re-
sults.
3. Stom.\topt,.\sty. — Destructive ulcerative processes
about the li]is and angles of the mouth oc<-asionally give
rise to defonviil ies which, by gri'ater or less closure of I he
oral aperture, interfere with tlie ])roeess of mastication,
and eventually threaten the life of the individual. In
extreme cases the labial fissure is contracted to a degr( e
wliieh compels the jialient to live (ju liijuid food alone.
Until Diell'enliach's remarkable contributions to plastic
surgery, it was customary to treat these cases by the in-
sertion of a seton of silk or of wire. As in cases of syn-
dactylism treated in this way, the result was genenilly
unfortunate. DielTcnbach's uietliod, which, unless the
mucous membrane is everywhere adlu'rcnt to the alveo-
lar border, is as a rule successful, is iicrfoinicil as fol-
lows: On each side of thecontraeted oral orifice a narrow
triangular strip is excised from the skin. The base of
the triangle is internal, its rounded a]iex external and at
the jioint where the angle of the lumitli is to be. The
excised triangular portion should include everything
down to the luucous luembrane, which ri'uiains intact in
the floor of tlie wound. The mucous membrane is then
divided in the floor of the triangle, thus forming an up-
per and a lower flaii, which, when everted, will clothe
the free borders of the new ll])s and meet externally at
the angle of the mouth. The exi'css of mucous mem-
brane is thustttili/eil ill forniingthe vermilinii borders of
the lilts.
Buck's method of stomatoplasty, abi^ady alluded to,
dilfers somewhat from tliat of DietTenliacli. He makes
an incision along the line of the vermilion border, cir-
cumscribing half of the mouth, and extending to an
equal distance above and lielow (Fig. 4010, ;/ b). This
ineisiou should divide the skin and subcutaneous tissue.
but not involve the mucous membrane. A sharp-pointed
double-edged knife is then inserted between the skin and
the mucous iiiembraue, and these parts are separated
from each other as far outward as the point propo.si-d for
the angle of the mouth. The skin aloni! is tlieii divided
with strong scissors along the line which is to separate
the upper from the lower lip (c d). Tlie mucous niem-
Iirane is next divided along the same line, but not so far
outwaid, the ditference in the length of the division of
skin and mucous membrane being a little less than the
thickness of the cheek. The angles at the outer ends. of
the two incisions are then caiefulh' united by a .single-
thread suture, and the operation is completed as in
Dieffenbach's meihod. To accommodate the mucous
luembrane to the liorders of the lips, thin slices of integu-
ment must, as a rule, be pared from the upper and lower
borders of the wound.
liiiixopi.ASTV. — The nose gives character to the face
by its prominence and central position. Its absence or
deformity is therefore more naturally observed than that
of any other feature. It is only through familiarity with
the nasal defects caused 1)}^ .syphilis or lupus that one
without unusual vanity can understand why Tagliaeoz-
zi devoted a special chapter to the "dignity of the nose."
and can appreciate the saying of Lavater, that "a beau-
tiful nose is worth a kingdom." Pa.ssion, disease, love
of lionor, and punishment for crime, have all, in times
past, contributed to producing the greatest facial dis-
figurements by attiicking the nose. Ilcnee the surgical
art was taxed early to repair the deformed part, and rhi-
noplasty became tlie foundation of plastic surgery in
general. In previous centuries, "when the loss of a nose
was a punishment for crime, or was voluntarily inflicted
to preserve virtue, rhinoplasty was doubtless a more
common operation than now. Sixtus V. freed Rome of
its bandits by cutting off the no.ses of all who were
caught. The Abbess of St. C\"r disfigured her.self and
forty of her nuns in the same manner, to preserve their
virtue when the Saracens raided Marseilles. Inour more
civilized times, nearly every case requiring rhinoplasty
is one in which the defect is the result of disease; al-
though, in exceptional instances, a vicious bite or, as iu
Germany, a duel, is the cause for plastic interference.
Notwithstanding the accumulated experience of gen-
erations of surgeons, and the closest attention to every
technical detail that could further the results of rliino-
jdasly, it must still be admitted that the best nose tiiat
can be formed by ajilastic operation is hardly as present-
able as the natural
feature that is even
far removed from the
ideal. It is far pref-
erable, however, to
the artificial nose
formed of vulcanized
rubber, and retained
in position with col-
lodion or b_y means of
aspring. Afterarld-
noplasty that isatall-
successful, the catar-
rhal condition of the
no.se and pharynx is
improved, the senses
of smell and of hear-
ing return, anil the ir
ritatiug cough which
so often is present in
extensive defects of
the nose, rapidly dis-
appears. A success-
ful rhinoplasty is productive of benefits whicli cannot
follow the use of any nose fashioned by prosthetic skill.
Since the time of DielVenbach, rhinoplastie operations
have been divided into the total and tlie partial. It is par-
ticularly in partial rhinoplasty that great strides have
been made within the last half-century. To consider
systematically the different operations for repair of the
904
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Reparative Siirgrrj-.
Reparative Surgery,
Fig. 4011.
nose, nasal deficiencies, according to Gross, may be classi-
ticd as follows : ( I) Loss of the entire organ, bones as well
as soft parts, (a) Destruction of the whole or greater
portion of the cartilages, the bridge remaining inlact.
(3) Mutilations of the tip, as wlien a. small piece is cut or
bitten off, including a part of the wings. (-1) Loss of
one wing, either alone or together with the nasal col-
umn. (5) Perforation of the
nose, cither on top or at the
side; in the latter case with or
without participation of tlie
cheek. (6) Sinking of the or-
gan from dcst ruction of the car-
tilaginous septum of tlic nose,
the soft structures being but
little, if at all, affected. (7)
Loss of tlie column. (8) Muti-
lation of the nose and upper
lip, in- the nose, lip, and cheek.
When the entire nose has
liceu lost, there is generally a
large i)yriform aperture which
allcjws free inspection of the
narcs and nasopharynx. For
the alleviation of this condi-
tion, it is always best to fashion tlie nose from a flap
taken from the forehead, by what is known as the In-
dian method. Before proceeding to a total ihinoplasty,
the defects should be covered with a model of clay,
wax, or dougli, which should aiiproximate as much
as possible iu size and form an ideal nose. Over this
is accurately tilted a piece of soft leather or moleskin
plaster, the lower margin of which is pressed imo the
no.strils and made to cover the nasal column. The shape
of this piece of leather or plaster, when removed from
the model, is pyriform, with its base below and apex
above. A second piece of leather or of plaster, one-third
larger in all its dimensions, should then be prepared from
the first, the increased dimensions being allowed for
shrinkage. The model thus prepared, when apjilied to
the forehead, is shown in Fig. 4011 (Liubart). Tlie plas-
tic operation proper is preceded by freshening the edges
of the defect. This must be done as liberally as possible,
in order to procure a wide surface of contact for the flap.
The vivified border should everywhere measure one-third
or even half an inch in width. When this step of tlie oper-
ation is completed, the leather or moleskin model is ap-
plied either perpendiculariy or obliquely to the forehead.
The latter is probably tiic better method, since less
rotation of the flap is required to bring it into position.
"When the forehead is decidedly low, no alternative is
presented to the operator, since the central excision of
the flap would necessitate the inclusion in it of a con-
siderable portion of the hairy scalp. Kouig and others
maintain, however, that the frontal scar resulting from
central location of the flap is less disfiguring than that
which follows the other procedure. Lisfranc, Linhart,
and von Langenbeck prefer to take it from the side.
When the operator has applied his model in the desired
position, an incision down to the periosteum is carried
around it. The incision, as shown in the figure, begins
at the right margin of the defect, iscarried obliquely over
the right eyebrow, and descends on the left side of llie
model, terminating above tlie internal end of the left
brow. In terminating this incision, it is essential not to
inti-rfore with the angular arteiy, since tlie vascular suj)-
ply of the new uo.se, in a large measure, depends upon
the integrity of this vessel. The pedicle left between
the ends of the inci.sions should measure from one-half to
three-fourths of an inch in width. Tlie flap thus out lined
is now rapidly raised, being made to include, besides tlie
integument, tlie aponeurosis and fibres of the occijiilo-
frontal. In the lower part of tlie flap the periosteum can
safely be included. Langenbeckincluded it in the entire
width of the flap, except in the parts of which the col-
umn and ahia of the nose were to be formed. Wlien
hemorrhage from the edges and raw surface of the flap
has been controlled, it is rotated into position in such a
way that tlie raw surface looks backward; and its base
naturally comes in contact wiih the fresliened margin of
the upper lip. The next step of the operation is the
formation of the septum and aUe. This is readily accom-
plished by two oblique incisions, one inch in length
(dotted line in Fig. 4011), which, running toward each
other, are separated at their centralends b}- an undivided
interval nearly an inch wide. When the triangular flap
included between these inci.sions is doubled ujiou itself,
the column and septum of the nose are perfectly formed.
By an upward duplication of the lateral parts of the
flap, the ala? and nostrils are next formed, and main-
tained by transfixing sutures. To facilitate the closure
of the frontal wound and to obtain larger nostrils, Lan-
genbeck does not remove the small triangular portions
.seen on each side of the base of the flap, but makes the
central portion, from which the septum is made, rectan-
gular and one incli wide. When the nose has thus been
formed and the raw surfaces have been thoroughly
cleansed, the new organ is brought into position and re-
taining sutures are applied. The most important sutures-
are those which hold the ala; of the nose to the cheek and
the septum to the upper lid. For each wing and the
septum three sutures are requisite ; for tlie wings one ex-
ternall}-, one internally toward the nostril, and one beneath
toward the lip. Since it is the septum that most fre-
qnentl}- fails to unite with the upper lip, unless extraordi-
nar}^ care lie taken, it is ad^•isal-lIe to make a special groove
in the central ]iart of the upper lip, three to five liues in
length, into which the lower end of the septum is firmly
implanted after it has been divested of cuticle. The oper-
ation is then completed by suturing the lateral margins
of the new nose to those of the cheek, particular care
being given to securing a good apposition of the pedicle
in the upper end of thedefect. If the wound in the fore-
head is very large, it may in part be closed by sutures,
although the greatest caution must be observed to pre-
vent traction on the pedicle. If the entire wound of the
forehead is left to granulate no harm results, and the scar
is probably not more ungainly than that which follows
what is ordinarily an unsuccessful attempt at obtaining
its closure by priniar}^ union. To maintain the patency
of the nostrils, and at the same time to further adhesion
of tlie doub'e in-
tegumentary
folds, it is wi !1
toinlroduce por-
tions of a drain-
age tube into the
nostrils after the
operation is com-
plete. The new
nose may then
be lightly cov-
ered with oiled
silk and antisep-
tic gauze or lint,
care being taken
that no foreign
material be-
comes adherent
to the sutures.
There are lare
cases in which
previous di.sease
lias unfitted the
integument of
the forehead or
of the cheek for
rhinoplastie pur-
poses. Under
such ciicum-
stances only is one j ustified in resorting to the Itali.an oper-
ation of rhinoplasty from the arm. The first step in this
procedure is to outline a flap of integument from the inner
surface of tlie middle of the arm, measuring four inches
in length and three in width. The flap is raised between
two parallel longitudiual incisions, but retained above
905.
ICoparatilo Snru:orj',
Koparafiie Siiry:<'ry.
REFERENCE HANnr.i ti iK OF THE MEDICAL SCIENCES.
and Iii'liiw ill ■nhilinii willi ihc riiiKiiiiiiiL' iiitrL'UiiiriH.
To prevfut reunion a iiiecf of oiled lint is ]ilarud uiidcr-
ueatli the flap. The inthxnimatoiy process whirli follows
the elevation of the flap causes this greatl.v to increase in
thickness, while its inferior surface, in from two to three
■weeks, hccomes clothed with granulations and eventually
cicatrized. When, after the lapse of this time, the fia]!
issufiiciently thickened, its uiipcr connection with the arm
is severed by a transverse incision which lea\es a wide
raw margin at the upper end of the Hap. whii h is sutured
to the vivified martrins of the nasal defect. This part of
the operation Tagliacozzi usually performed in the fourth
■n-eek after the first o])eiatioii. Since it requires fi-nni one
to two weeks before tlie lower end of the tiai) can be
safely severed from the arm. the latter must he supported
in relation with the head and fai-e. Fig. 4013 shows Tag-
liacozzi's method of accomplishing fi.xation of the iirm
by means of a cap and .iacket. AVutzer's apparatus for
obtaining a similar end is shown in Fig. 401?!. In taking
the skin from the forearm or back of the wrist, lie found
it necessary to supjiort the arm and forearm in splints.
When such an ai)))aratus has been woru for from one to
three weeks, the upper end of the flap will have fiecomc^
firmly united to the
apex and sides of
the triangular nasal
defect, and it is then
safe to sever its bra-
chial connections,
when the foi'mation
of the wings and
septum can be com-
pleted as in the
Indian method.
Craefe luodiheil the
Taliacotiau opera-
tion by at once fi-X-
iiig the flap to tlie
vivified edges of the
defect, thereby ap-
p irently curtailing
tlie period of fix-
ation of the arm.
This, which is
known as the Oer-
mau method, has
found even fewn-
fnllowers in recent
times than the old-
er operations. It
manifestly gives
greater opportunity
of shrinkage of the
flapandsulijectsthe
patient to the an-
noyance of a large
supiiuraiiiig sur-
face near the mouth, wliicli by the older operation is
-cicatrized before it is transplanted. Diefleubach ex-
■ceeded both Tagliacozzi and Graefe in the extent to
which he reformed the nose from a brachial flap, in
that the entire nose, with the exce|ition of one ala. was
formed as the first step of the o|ieratiou. After shrink-
age and cicatrization had followed, the actual transplan-
tation of the nose was effected in from six to eight weeks.
The operations thus far described, unless gangrene
supervene in the flap, efTecfually close the nasal defect.
For the most part, jiowever. the newly formed nose,
irrespective of its original prominence, sinks and con-
tracts until eventually little more than an integumentary
curtain closes the detect. To obviate this result a nuni-
ber of iirocediires have been adopted, among wliirh that
of Thiersch jn'obably deserves most pirominent mention.
As the first step of the operation, he forms on each side
of thedefect a rhomboid llap from the cheek, the atttiched
base of which is in relation wifli the freshened edge of
the defect, its free border being external. When these
flaps are raised from the cheek on each side they are iia-
FiG. 4111:).
T\i.. 41114.
verted, so that the cutaneous surfaces look toward the
iiares, the raw surfaces outward, and in the median line
are in contact with each other. The nostrils and septum
being thus formed, a frontal flap is brought down to
cover the flajis from the cheeks, the operation being com-
|)leted in the ordinary way. Verneuil procured a perma-
nent elevation of the bridge of the nose by a somewhat
similar operation of super-
^ position of the flaps. In this
case the frou tal fla]) was taken
from the median line, and de-
flected in such a manner that
the cutaneous surface looked
backward. Over the raw sur-
face two quadrilateral flaps
from the cheeks were brought
by a process of gliding and
united along the median line.
Finally, Langenbeck and Oi-
lier have given the new nose
an osseous substructure by
sawing a strip one-fourth of
an inch wide from the nasal
processes on each .side. This
strip, after being broken
through its atfachnients be-
low, is deflected toward the
median line, where it meets
its fellow of the ojiposite side. If the nasal bones are
]n-esent and only depressed, which they generally are,
they must he brought into position by the free use of
the elevator.
Quite recently Ki'mig (Lrnigcnh. ArrJi., vol. xxxiv.. p.
lfi.5) presented to the Congress of German Surgeons a
method of obtaining an osseous framework for the repair
of sunken no.ses, and for the permanent elevation of the
nose after total rliinojilasty. The inefhod is virtually
one of superiin)iosed flaps, both being taken from the
forehead. A median flap of the requisite length and half
nil inch in width is formed from the forehead in the me-
dian line. The incisions bounding this narrow strip are
carried down to the bone. When this flap is raise<l the
external table of the frontal hone is rai.sed with it as far
as the root of the nose. The flap thus elevated is in-
verted, so that the cutaneous surface faces the nasal fos-
sa'. Over the raw external surface a second frontal flap
is then placed and flxed as in the ordinary Indian oper-
ation. In four cases in which Konig performed this
o|ieration ffir a sunken condition of the nose, the repaired
organ retained its solidity after from one to nearly four
years had elaiiseil from the time of the operation.
The partial destruction of the nose also presents many
interesting peculiarities that require partial rhinoplast}-.
When the tip and al:e of
the nose are intact, while
the body and bridge are lost,
the defect should be closed
by a frontal flap (Figs. 4014
and 4015). In this case Lin-
hart removed an epitheli-
oma involving almost till the
cartilages and ii portion of
the bony framework of the
nose — only the margin of
the nostrils on each side
was |)reserved. JIutilations
of the tiji of the nose can
also be repaired bva frontal
flap. Figs. 40 10." 4017, and
401.S illustrate the defect and
the results of operation in a
case of Buck's, in which the
tip of the no.se was bitten
away. In this case the
freshening of the edges of the defect was followed by
the elevation of the patch of skin above the defect as far
as the root of the nose between the eyel.irows. A frontal
llap of requisite length and width was then brought into
Fifi. 4l)lo.
906
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
ICfpai-alM'c Surgery,
ICi'parat jve Surgerj',
the breacli, the skin previously displaced from the nose
being fitted into the frontal wound. In Fig. 4017. a
and b indicate the disfiguring prominences resulting
from rotation of the flaps. AVhen the.se were excised the
admirable result shown in Fig. 4018 was obtained.
The tip of the nose mav also be rejiaired with a flap
from the cheek (Liuhart) (Fig. 4019). The pedicle of this
FIG. toii;.
flap extends quite to the root of the nose; its broad end
may be divided by two incisions (dotted lines) for form-
ing parts of the nostrils and septum, as in totjil rhino-
plasty. Before the flap can be inserted, the remaining
integument of the nose must be divided in the median
line and reflected on each side. It freqiieutly happens
that with the tip one of the nasal ala» and the column are
Fiii. 4iiir.
lost. To repair this detect the integument of the root of
the nose, of the glabella, and of the internal angle of the
orbit was utilized by Busch (Fig. 4020). The pedicle of
the flap is placed on the healthy side of the nose, low-
down, and on a level with I lie defect. Wlien the flap is
brought into po.sition, its lower portion forms the tiji and
column of the nose, while its ujijier part, when dupli-
cated, replaces the lost ala. Tlic re|>air of defects of the
nasal wings can be accomplished by a nmnber of proced-
ures. When the defect is long but narrow, it is prob-
FiG. t018.
ably best, as Diellenbaeh taught, to refrain from attempt-
ing a plastic operation, and to produce a similar defect
on the opposite wing. In some cases it is advisable to
excise the defect in a triangular way, and to close the
breach with a flap from the side of the nose. Fig. 4U31
illustrates the method of obtaiuiug it and the incisions
(dotted anes) necessary for placing it in position. In
larger defects of a nasal wing it is advisable to procure
Fig. 4(119.
a rtap, quadrilateral in shape, from the cheek or from the
upper hp. In Figs. 4022 and 4023 the method of Bonnet
is shown; to givt'the angle of the nose a more shapely
907
Reprodiiclioii.
Resec'tiou of Joints.
REFERENCE IIAXDlJnoIv OF THE MEDICAL SCIEiSX'ES.
:?^
Fig. 4020.
form, and to facilitate the rotation of the flap, a wedge-
shaped portion (b) may be excised from the basi- of the
flap. In llii^ operation tlie vermilion liorder of tlie 11a])
must be removed, and tla^ fissure in the lip is to he elo.sed
at once. Perfoi-ations of the nose
resultin<; fi-oni wounds or ulcera-
tive processes are Kencrally .seated
at the sides of tile nose. They
may readily be closed liy flaps of
suitable shape and size, taken fi'om
the forehead, from the cheek, or
from theopiiosile side of tlie nose.
The nasai column, when it alone
is dcfeclive, can be admiialily re-
paired from the central portion of
the upper lip, which must be in-
cluded between parallel perpendic-
ular incisions. When the flap thus
fornird isbrousht in eontiu-t with the nasal septum, its
mucous surface is of course exposed, ami is eventually
converted into skin.
In the most complicated of nasal defects, Anally, other
parts of the face are also, as a rule, dericient. This is par-
ticularly true of the upper lip, of portions of the palate,
and of the cheek. In such complicated cases, as has al-
ready been iutimate<l. many operations are required before
the face can be made at all presentable. In eases of this
character the lip, the angle of the mouth, and the nose
all riqiiire separate operative treatment. If. Iiowever,
from one to three years be devoted to the judicious mau-
agenicnt of such a case, tlie result will iu every way re-
pay patient and operator for the patience displayed.
Piiriijin Injections in lli piinitire Surijiry. — In order to
fill up the scrotum of a very sensitive young man, which
liad been left empty after a castration, Gersuny '■' in 1900
devised the ingenious method of injecting vaseline. En-
couraged by the good result oblaine<l in this case, he ex-
tended the procednre to cases in which other than the
distinct cosmetic effect was desired. The result which
Gersiiu}' " obtained in a case of urinary incontinence in a
female, which had resisted all other methods of treatineni,
was so luilliant that other surgeons at. once took up the
new procedure, and so its use soon liecame wicU'spread.
Aconsiderableamountor good work liasljcen doiieat von
Bergmaun's Klinik by Stein.'' lie prepares |iarathn,
which sliould have a melting point bi'twerii A'i and 4y C,
by melting and liUering witli a hot water funnel, such as
is used in the filtration of bacteriological culture media.
The tillered paralliii should be jiiit into wide-mouthed
flasks, such as Erlennieyer's, and ]iliigged with cotton
wool. In these it is stei-ili/ed in tlie hot-air oven at a
temperature of 200' C. for a half hour, and can then be
preserved indefinitely, ready fnr U!<{- at any time. ISefore
using, the flasks containing tin- par.illin are healed in a
water bath to the melting point. The injection is made
with a Pravaz syringe, wholly made
of glass, holding about 1 gm. The ob-
ject is to have a syringe devoid of all
sliar|i corners and edges, so that the
parallin does not so easily congeal.
Before injecting the parallin. the lilicd
syringe is again juil into hot water and
then the needle is screwed on. The
injection is made by lil'ting \\\) a fold
of skin with tlie left hand and with
the right inserting the needle ai.d in-
jecting slowly until tliedesireil amount
has been used. The needle is then
withdrawn and a small piece of i)lastrr
fastened over the puncture. The par-
allin is now moulded into the desired
sliaiie, while an assistant allows the i m.. i"-i.
ethyl chloride spray to jilay upon tlie
part. Several injections may be niad<Mt <lill'eieiil time-.,
but. care must be used not to insert the ni'edle nver the
area ])reviou.sly injected, as it .should be inseiied to the
side of it. According to .luckotf" parallin after its in-
jection acts like any foreign body, and causes a reaction-
ary inflammation with the formation of new tissue. Some
of the parallin is absorbed here and there, so that finally
we have the mass pervaded by connective-tissue strands,
which emanate from a fibrous capsule
around the whole. This ca])sule is
fusi'd with the adjacent tissue.
This excellent method is not without
a small amount of danger. The fol-
lowing unfortunate ociairrences have
taken jilace: Embolism of lung and in-
testinal organs from tin- accidental in-
sertion of the needle and injection into
a vein: infection from faulty asejisis;
gangrene and sloughing from the intro-
duction of too much iiaraflin, as a re-
sult of wdiich obliteration of the blood-
ve.ssels has occurred.
The method is applicable to cases in
which the normal contour of the body
is lost. It has been used with distinct Fig. 403:;.
benefit in saddle nose following caries
of nasal bones. In one case treated at vou Bergmaun's
Klinik, the result was striking. Several injections were
made at difl:erent places and the nose was thus grad-
ually built up. The injection should be made with care
so that none of the paraffin shall find its way into the
orbit. Cleft jialate may be treated by this method,
which is chiefly applicable to those cases in which a
small foramen has remained after staphylorrhaphy.
The contour of the cheek might be re-established after
removal of the superior maxillary bone. The scrotum
may be filled up after castration. The
method is applicable to another class
of cases, namely, those of urinary in-
continence, especially in the female, in
wdiich condition a ring of parallin is
injected about the neck of the urethra
so as to re])Iace the sifliincter. A cyst-
ocele has also been treated, with dis-
tinct benefit, by injections between the
vagina and bladder wall. By estab-
lishing a paraifln depot around the
rectum fecal incontinence has been
cured. The method is still new and
sulticient time has not yet elapsed to
establish the permanency of cure in
man}' of the brilliantly successful
cases: nor have there been many op-
portunities to examine the changes
produced in the tissues, beyond those produced experi-'
mentally on animals in the laboratory. The method
promises much in tlie future, and certainly is a valuable
aid to our surgical techuiiine. Josepli liansoiioff.
' Zeits. (1. Literal, unci Ccscli. tlerplast. Cbir., Lcipzisr, l.s(>i.
- Celsus : l^il3. \ii., eap. i.\.
= Gurdon Uuel; : liepur. Siirs;., p. II. 1S76.
■* Deniiee; Aroli. ^^eii.. l^ihu t. vi., p. 4(13.
^ SzyiiiiUiuwsKy : tipi^r. on tlie siirface iif the Body, Tview, 1S6."). In
llussiiin only. ''Konii;: Lelirli. der Cliir.. Bd. i.
' .\n-li. f. kliii. Cliir., yol. xxiii.. p. :?-':j. »('liir. Kepiiniirii'e. p. 116.
» (). Weher: Pitlia unci Hillroili, lid. iii., i., p. I.I.S.
1" Ardi. f. kill), rhir., i., p. tiri.
" oilier: Coiiiiil. rend., l.sid. S;!. p. 84.
1= .\ich. f. kiln, rliir., .% p :«. '= Cuz. liebd., i., p. 4IG.
" f'blr. Kepar., p. lis, IX'A, Verneuil, p. :fll.
IS IHM-Sllliy: Zeilsclirift f. Hellkunde. IIIIIO. Hit. i.. Heft, '.1.
i« GersullV: Celltlalhlatt f. Gviliikolotfie. IIIIHI, No. 4.S.
I" Sleiu : fleutsehe llied. WoellellMlirift. 19III, .N'o.s. :i:i and 40.
'* juekoff: i:el]er die VerlJleituilt'sart siilieutan., el<'. .Uch. t.exp.
Patlioloffie, lid. xxxii.
REPRODUCTION. — The various processes by which
new urgaiii^iiis :ire produced are iuciuded iu tlie general
terin. ri ^rchn-iion.
It was thought by the ancients that many orgumisms
of comiilicaleil structure, such as worms, insects, jdaiits,
etc., could be formed from mud, decaying material, and
other deail matter by a process of spontaneous gener-
ation, or iibiDf/ene.six. It was proved by Kedi in IfiSsi that
abiogenesis does not occur in insects, but it remained for
Pasteur and his colleagues iu the latter half of the nine-
teenth century to show that even the minute and simply
Fig. 4023.
90S
REFERENCE IIAXDCOOK OF THE MEDICAL SCIENX'ES.
Reproduction.
R4'»('<*tiou of Joints,
organi/.c'd bacteria are always produced by division of
the living substance of pre-oxistiug individuals of the
same species; tliat is, reproduction in the present condi-
tion of the world is always a jiroeess of Moffene/iis. Xot
only is every organism ]iroduced by a pre-existing organ-
ism, but every cell arises by division of a pre-existing
cell, and every nucleus by division of a pre-existing nu-
cleus. (See Cell.) Moreover, there is good evidence for
the belief that the minute but apparently important ele-
ments of the nucleus, known as c/immosomes{q. r.), are also
produced only b\' division of pre-existing chromosomes.
So reproduction, like all other vital functions in healtli
and disease, must be regarded as essentially a cellular
phenomenon.
Reproduction may be either sexual or asexual. The
essential feature of scrtml reproduction is the develop-
ment of an embryo from a. fertilized egg, that is, a germ
produced by the union of an oi^um and a spermatozoon, or
their equivalents (see articles Ovum, Spermatozoa, and
Impregnation). The capacity to produce one or the
other of the reproductive elements, together with the
associated peculiarities, constitutes the quality of se.v
(g. •!'.). Both of the reproductive elements are cells de-
rived from appareutlj' indifferent germ cells b)' an inter-
esting process of development, which is discussed under
the heading Reduction-Division. This process takes place
in certain special organs, for wliich the general name is
gonad, the female gonad being called the oeiiry and the
male gonad, the testis. "W^hen the eggs or spermatozoa
are ripe they are discharged from the gonad, and fertiliza-
tion may take place outside of the body, as in most fishes,
or within the oviduct (Fallopian tube, uterus, etc.), as in
man. In man and other mammals the discharge of the
ova is associated with certain peculiar physiological phe-
nomena described in the article on Menstruation.
Fertilization having taken place, the egg proceeds to
divide by the usual process of cell division, and b}' re-
peated divisions forms a mass of cells wliich becomes the
embryo. The details of this process vary in different
animals, as will be seen by reference to the ai'ticle on the
Segmentation of the Ovum,. Sooner or later the cells of
the embryo begin to differ among themselves in accord-
ance with their destiny in the formation of organs. The
causes of these changes are discussed under the title
Differentiation, and the development of the embryo in
form and structure is described in detail in the articles
Fceliis (in The Api'EXDIx), Area Euihrgonalis, etc.
Both during development and in the adult condition
there is a noticeable similarity between parent and off-
spring at corresponding stages. This is a fact of great
importance, and is fully treated in another place (see
articles Heredity and &version).
"When reproduction takes place by some method T\'ith-
out the aid of a fertilized egg, it is said to be a.ie.xual.
In the bacteria and some of the lower animals the repro-
ducing individual divides into two or more nearly equal
parts. This is called fission {(]. v.). In the yeasts, the
higher plants, and some animals, a small part of the par-
ent grows more rapidly and becomes differentiated into a
new individual. This is budding {ij.r.). A tlufd form of
reproduction occurring normally in some species is known
as parthemigeiiesis (r/.r.), which may be regarded eitlier as
an asexual or as a degenerate sexual process. In such
cases the ollsjiring is produced b}' the development of an
egg without fertilization. livhert Payne Bigelotv.
RESALDOL is a light-brown powder prepared by the
action of chlormethj'l-salicyl on resorcin bj' means of
acelylization. It is insoluble in water, ether, chloroform,
benzol, and acids, and .soluble iu alcohol, acetic ether, and
alkalies. Its taste is insipid and astringent. On account
of its insolubility in acid media it causes no derangement
of the stomach (Hermann), but in the intestines sets free
the diresorcyl radical and acts as an astringent and anti-
septic. Hermann recoinmends it in acute and chronic
diarrhoea, colitis, the early diarrhoea of typhoid fever, in-
testinal putrefaction, and infantile diarrha-a, and he finds
it useless in nervous diarrh(ea or that due to mechanical
irritatioD. Brochocki employed it in twelve cases of tu-
berculous enteritis, four of ai:ute g,-ist,ro-euteritis, three
of catarrhal dysentery, and three of Ijiihoid. All except
the typhoid cases imjiroved, though xeroform, bismuth,
and opium had failed. The dose is 1-1.5 gm. (gr. xv.-
xxiv.) three times a day. W. A. Bastedo.
RESECTION OF THE JOINTS.— The history of this
operaticm dates from the year 17^3, when Henry Park
formally proposed the operation for the removal of dis-
ease, in 1786 Moreau first performed it,, and became its
stanch ad\'ocate as a metliod of treatment. Little was
done, however, until Syms iu 1831 in the elbow, and
Ferguson in the hip, knee, and wrist, made use ef this
operation as a conservative metliod of treatment ("' Exci-
sion of Joints," K. M. Hodges, Boston, 1861). Since this
time this method of treatment has been wonderfull}- ad-
vanced and lias been adopted by the ablest surgeons.
A resection is the removal of a portion of the skeleton
without great sacrifice of the soft parts. Applied to
joints it has for its object the more or less complete re-
moval of the bones forming the joint, the preservation
of the sensibility, contractility, and vitality of the soft
parts influencing the joint, and the ultimate restoration
of motion or the production of ankylosis.
When motion is desired — the ideal object of articular
resections — the ends of the bones left in contact must be
adapted to one another, and so fashioned in sliape as to
reproduce the joint surfaces removed. The muscles
which move the joint must be left undisturbed in their
attachment: or, if disturbed, restored so that their func-
tional action is not compromised.
The ligaments and fibrous bands which subsequently
develop and unite the bones must be analogous to those
present Ijefore operation. To obtain this end, all liga-
ments must be preserved 'ndtli their bony or periosteal .
attachments.
To attempt a nearthrosis with a sacrifice of the muscu-
lar and ligamentous attachments often results in a useless
pseudarthrosis, inferior in ever}" respect to a useful anky-
losis.
To obtain mobility with steadiness and strength in ac-
tion the preservation of the muscular and ligamentous
attachments to the periosteum and the continuity of the
articular cap.sule with the periosteum must be made the
main object of the operation. Such a metliod of operat-
ing is known as the subperiosteal or subcapsulo-peri-
osteal resection. Its object is motion with strength and
steadiness in atttion.
In case a .solid union — ankylosis — is desired, two condi-
tions arise which influence the result. The first is seen
when the divided ends of the bones can be brought into
apposition and their fusion takes place directly. In this
case ankylosis is assured, provided the disease is re-
moved. The second condition exists wlien tiie divided
ends of the bones cannot be brouglit into apposition, but
are separated by an appreciable distance from one an-
other. The tmion here takes place ijriueipally through
the agenc}' of the periosteum, and ankylosis, more or less
doubtful and dependent upon the osteogenic jiovver of
the periosteum, results. It is in this latter variety that
the pseudarthrosis and flail joints occur.
Wlien ankylosis is desired and is reasonably attainable,
the preservation of the muscidar. ligamentous, and ca])-
sular attachments to the periosteum are of secondary im-
portance.
When bone or a Ikuiv prondueuce is sejiarated and
replaced in situ in order that diseased tissue can be more
thoroughly removed, the resection becomes an osteoplas-
tic one.*
Again, resections arc either comjilete or partial: com-
plete when the component bony surfaces are removed;
])aitial when one or niori', but not all the articulating
sm'faces are removed.
Resections may therefore be partial or comjilete, par-
* Tbis term is sometimes used nud applied to operations in wliieh
liones not normally apposed are Lirougtit togettier after removal of liie
intervening bone or boues.
909
Resoctioii of Joints.
I€o$(M'ti<»ii of J(»iii(s,
REFERENCE HANDBOOK OF THE JVIEDICAL SCIENCES.
osteal or subcaiisulo-pcriosleal. Tlicj- ma}' also be osteo-
plastic.
Till Incisitin. — They should avoid nerves and vessels.
When jiossible. tendons and muscles should lie spared.
This is attained liy nsinj; the intermuscular
septa in approaching the joints.
Incisions should be ample, to expose the
joints without forcible retraction. They
should be so situated that the entrance
through the capsule and into the joint is
the most direct one. (Jcntleuess should be
exercised by all throirgliout the operation
Maltreatment of the soft tissues not only in
terferes with the process of repair, but de
strop's an otherwise successful result. Caic
should be used in protecting the soft parts
from the saw. The tendons, if possible
should be left undisturbed witliin thdi
sheaths. Their insertions should lie left ni
contiutnly with the iieriosteum, or a small
piece of bone (Vogt) may be removed witli
the insertion. If it is neces.saiT to divide
tendons, tlicy should be carefully sutured.
If muscles must be ilivided, tliey should be
cut in the direction of their fibres, the ner\t
being avoided. If this is impo.ssible, tht\
may be divided transversely or nbliquely as
near tlieir origin or insertinu as possible.
Tlie management of the periosteum is still
in dispute. Some advocate the sidjperiosteal,
others the parosteal method.
Fig. 4034. It' m'lst lie remembered in any given case
that the value of the periosteum in procuring
bone is very variable, and is dependent mainly: (n)
Upon age. The bealtliy physiological periosteum has
hut little osteogenic power except in youth, (h) Its
power to develop new bone depends upon the thickness
of the different bones, (c) Pathological processes involv-
ing the periosteum and causing a thiclvening of the oste-
ogenic layer will increase its osteog<'nic power. In but
few cases can a comparison lie made betweeu these meth-
ods in reference to these three points; and since many
subperiosteal operations are very im]ierfectly performed,
it is not surprising that a division of opinion should
exist.
Oilier, Langenbeek. Sayre, and otliers have long in-
sisted that the traumatism produced by the subperiosteal
(/.<■., subcapsulo-])eriosteal) metliod was less
than by the parosteal method, and have main-
tained that the reparative process itself was
le.ss impaired because of the protection to
the soft parts afforded by the capsule and
l)eriosteum.
My own opiinon favors tlie subperiosteal
method, both for the protection to the tis-
sues, for the luodiiction of new bone, and
for the aid to the reparative process.
Time is not sacrificed in the subperiosteal
method, for the separation of the jieriosteum
can be rapidly accomplished by a tij-and-fro
motion of the rugiue. AVhen one ajiproaches
a prominence of bone or a tendinous in.sertion
is met, a small piece of l)one may be separ-
ated with the periosteum by the cinsel or the
rugine; such a piece may act as a centre of
bone growth. During the separation the ru-
gine is to be pressed against the bone, sep-
arating the periosteum entire and not injur-
ing its connection with the overlying tissues.
In the management of the bones, we strive
to remove the smallest amount of bone which
will remove the disease or correct the de-
formity. Where the bones can be protrudi'd
through the incision and the soft ]iartssulli-
Fii;. 4i):;5. ciently protected, the butcher, the Knnnerich,
or the broad Hat-bladed saw (carpenter) may
be used. When the bones cannot be displaced and the
protection of the soft parts can be secured by gentle
FIG 40'b
Fig. 4027.
traction, the Gigli saw can be used. Other varieties of
saw J .seem scarcelj' necessary in resections.
IIiS sawing is usually done in plane surfaces at right
an.'.i.'slo the line of pressure. In some instances, espe-
cially where an attempt to obtain motion is-
mailc, mortises and tenons are fash-
ioned, which tend to favor reten-
tion of the fragments and to pre-
serve the shape of the joint ends of
the bones.
In pathologically involved joints
after removal of the articular cuds,
further removal of foci may be re-
quired with the gouge or spocm.
After removal of the disease from
the bones tlieir fixation is necessary,
either in the attempt to obtain mo-
tion or in that to secure ankjdosis.
For this iiuipose, silver, copper,
aluminum bronze, wire, stcid and
steel-plated nails, bone pins(Marsli,
Brit. Mid. J'jnnitil, 1S87. i., p.
389), and steel drills (Wycth's)have
been used. My own experience
teaches me that fixation is not nec-
essary for a longer pieriod than ten I @
to fourteen days, and that in the
majoritj' of cases in which good ap-
pliances are obtainable the fixation
is not required, inasepticcases, fora
longer period than that during which
the lirst dressing must be kept ap-
plied. I have therefore relied completely upon chromi-
eized catgut, which is prepared to resist absorption for
from two to three weeks. This has been my practice for
fifteen years, and I see no need of subjecting the tissues
to the juesence of a foreign body, which, if pathological
deposits exist in the hone, only offers a ?'«'!/« reiUtentim
minoris for infection from within or withoiit. I must
add, however, that in some instances, as in the hip-joint,
it is not always feasible to produce fixation by the catgut
suture. In these instances the steel nails, drills, or bone
pins may be used. The bone pins are absorbable.
The management of the synovial membrane, capsule,
and :iganient requires the removal of all pathological
deposits affecting them, even if it in-
clude t lie entire removal of these parts. ^
When possible, the synovial mem-
brane, the capsule, and the ligaments
should be saved ia part or entire, since
the perfection of motion in nearthro-
sis depends in no small degree iipon
the jH'esence of these structures.
The instruments whicli are specially
used in resections are: 1. Those which
divide the soft tissues immediately
investing tlie bone, or joint-knives.
The.se should have strong handles
and short-cutting blades to insure
precision and force in action (Figs.
4024 and 402.")). 2. Those intended to
detach the periosteum from tlic bones
— rugines (Figs. 4020 and 4027). 3.
Those intended to fix the bones while
the soft parts are being detached and
the bones sawed (Fig. 4028). 4.
Those intended to divide the bones.
When the bones can be displaced and
a straiglit saw can beapplied, eitlier a
bow saw with a rotating blade (Fig.
4029), or a solid straight back saw (Fig.
4030) may be used. When the bones
cannot be displaced .so that a straight
saw can be used without injuring the Fig. 402S.
soft parts, the chain saw (Fig. -1031).
or the Gigli saw should be used. The former is used
when the surface to he cut is in one plane : the latter when
the cut surface is to be concave or convex. Electrically
910
REFERENCE HANDBOtiK OF THE MEDICAL SCIENCES.
Rewoclion of Joints.
Kesofllou of Joiiils^
proiicllcd saws soem to have no advantages in resections.
5. 'I'lidsc intended to cut away spicula or prominences
of bone with the periosteum at-
fte- ___.^ tached: (<() Bone forceps (Fiffs.
" ' -Ok 4083 and 4033); (b) chisels (Fh.
4034). 6. Those intended to re-
move diseased foci in the bone af-
ter the sections are made; (c)
Gouges (Fig. 4035) ; (A) spoons
(Fig. 4036). 7. Those intended
for diilhng the holes required for
the wli-e nails or catgut suture
(Fig. 4037).
Tlie IhdknUons for the liesections
of the Joints. — In tuberculosis re-
sections are usually looked upon
as a sequel to ratlier than as a sub-
stitute for the conservative treat-
ment. In the j'oung, resections
should be partial rather than complete.
They should be subcapsulo-periosteal ra-
ther than parosteal, with as little interfer-
ence with tlie epiphysis as is consistent
with removal of the disease.
Primary tuberculosis of the lung with
secondary joint involvement usually cou-
traindicates operation, while the reverse in-
dicates it. Tlie mortality following resec-
tions of all varieties performed u|ion 117 pa-
tients was 21.3 per cent. ,wi til 1.5. 3 per cent.
of this number from tuberculosis (Konig).
Whether earl}" resection or the expectant treatment gives
better results as regards mortality, function and a cure,
must remain in doubt until similar cases are treated by
each method and are compared. Undoubtedly many
Fic. 4I«9.
FIG. 4030.
cases treated expectantly and regarded as tuberculous
are not so. The same cannot be said of resections, since
the cases resected are proven before or after operation by
microscopical or bacteriological e.xami- /\
nation as tuberculous in
almost all instances. Jly
own experience leads me
to the expectant as the
initial treatment, while
resection is reserved as
a secondary method.
In acute suppurative
arthritis and synovitis,
arthrotomy, not resec-
tion, is indicated. In
chronic suppurative ar-
thritis, resection is indi-
cated for the removal of
the disease and the ii-
lief of the deformity. In
arthritis deformans, re-
section may be indicated
for the tlail joint. Tin'
rarefying osteitis must
here runitscour.se, how-
ever, in order to give a
solid ankylosis. In
chronic rheumatoid ar-
thritis, resection is indi-
cated in appropriate
FIG. 4031. cases. In syphilitic ar- fig. 4032.
thritis, resection is indicated for the removal of gum-
matous foci, which have not .given way to medicinal
treatment. In gunshot and oilier injuries, resection is
preferable to amputation. With the present weapons, the
expectant tieatmint is the iiiiiial method, to be followed,
in case of failure, liy the partial or the complete resection.
In malum senile, arthritis nodosa, urica, or neuropathica,
resections are practised onl^' in exceptional instances.
The functional results of resections are usually classed
as; (1) Bad. This includes cases in which the bones re-
main at a distance from one an-
other and are held together li}-
tibrous bands onlv- The limb
is witliout muscular colli rol and
cannot b(! tised. (2) Jledioere.
This includes cases in which
there is also a pseudarthrosis,
but the tibrous union is short
and strong. The joint is Hail,
but nevertheless it obeys the
muscles in man}' ways and can
be made useful bj- apparatus.
(3) Good. This includes those
cases in which there is a near-
throsis and a sutHcientlj- |)erfect
one to differ from a normal joint
only in the extent of the motions.
In most resections ankylosis is
the common result and is in
some joints to be preferred to
any other result than the ideal
one (3). Flail joints are rare,
ilediocre results are common.
During the operation the Es-
niarch bandage is a great help
iu exsanguiuating the field of
operation. It allows a comidete
inspection and renders (lossible
careful dissection of the tissues,
discretion, and must not he employed in those w^hose
arteries are diseased. Again, the exsanguination of the
tissues should not be extended over a great length of
time. This can be avoided in a measure by the more
rapid wfirk which it renders possi-
ble. After removal of the bandage
there is some vaso-inotor paralysis,
but it soon yields oris corrected by
elevation of the limb. In apjdy iiig
the bandage, care must be u.sed to
avoid direct compression of the
motor and sensory nerves between
the bone and the bandage.
The limb should be completely
exsanguinated as regards both llie
arteries and the veins.
Resection op the Intekpii-s-
i..\NGEAL Joints of the FiNnrus
(Fig. 403S). — The nmst iiiipnr-
lant of these joints is that of Hie
thumb.
ladicatiom. — Complete destruc-
tion; chronic tuberculous ar-
tliritis; chronic suppurative ar-
lliritis; chronic uon-suppurative
arthritis.
The preferable situation for the
incision is the ilorso lateral aspect
of the joint, somewhat nearer the
dorsal than the palmar surface.
The incision may be a single one
upon the internal surface of the
lliunib and forefinger and upon
the external surface of the little
linger. Wherevur listuhe are present the incision may
best be made so as to include them. The preferable
melhod, however, is that of two incisions placed dorso-
laterally. one upon each .side of the extensor tendons. By
means of these two the denudation of the bones and the
Fig. 4033.
It must be used with
Fig. lii;34.
911
KosectJou of J<»iikts.
Kcscctiou of JuiutN*
REFERENCE IIA.XDIJUOK OF THE MEDICAL SCIENCES.
•exposure of the joint are easily accompHslied. Earli in-
cision is carried throu<:li tlie capsule and tbf ]ieriostciini
for the full lungth of the skin incision, which slmuld ex-
tend aliove and l}clow the joint
snilicicntly to expose and to dislo-
cate the articular ends of the
lioues. AVith a sharp and curved
rugine, the deinidation of the
liones is made from lioth incisions.
Fine blunt retractors are used to
expose the IWmeand to jiroteetthe
scjiaratcd pcriosleuni and capsule
and the tissues covered by them.
\Vhen tlu^ capsule and periosteum
have been fieed suliicicntly (sub-
ca]isnlo - periosteal method), the
ends of tlie bones are luxated Avith-
out force tbrougli the more con-
venient of these inci.sious. Tlie
articular ends are now removed bj'
the saw or cut away piecemeal
by the bone-cutting scissors or
rongeur forceps. After this is
aeciimplished, the synovial mem-
brane of the joint and the patho-
logical foci in the soft parts about
the joint are removed, preferably
b\- dissection. The emis of the'
bones are now drilled, and one or two ten-day chromic-
acid catgut sutures are inserted, bringing them in close
apposition if ankylosis is desired. They are only loosely
tied if an attempt at pseudarthrosis is made. In case a
nearthrosis is desired, uo sutures are necessary, as the
suture of the divided periosteum and caji.sule will sulli-
cieutly hold the bones in tlieir normal layer of tissue.
If an Esmarch bandage has been u.seU. it is now re-
moved. The larger vessels are .secured. The periosteum
and capsule are sutured with catgut or silk. The re-
mainder of the wound is closed, with catgut for the sub-
cutaneous tissue and silk for the cutaneous. Drainage is
not employed unless suppuration is already present. "' An
aseptic dressing is applied. A lixatlon splint is aiiplicd
over the dressing. The s])lint dressing is removed in ten
■days. At the end of two weeks all splints are removed.
At the end of three weeks gentle
passive motion is employed, un-
less ankylosis is desired.
Ri':si:("rioN ok the 3Iet.\cai;-
i'o-i>ii.\i..\NGt:.\i, Joints (Fig.
4038). — Here also a single or
two incisions may be used.
When one is used it is jilaecd
upon the external dorso-hiteral
aspect of the thumb and index
finger, tipou the inteni.al for the
little linger, and upon eil her side
for tile other lingers. If two in-
ci.sious are used, they arc made
as in the interphalaiigeal joints,
on each side of the extensor ten-
dons. For the metaearjio-plia-
langeal joints a single incision
will often sulVice. If feasible
the o]ieration should be the suli-
capsulo-]icriosteal one. The in-
cision is carried directly tlirougli
the skin and subcutaneous tissu<'
to the periosteum and capsuh', of
suflicieiit length to expose the
joint well aboveand below. The
digital nerves are avuidi-d it
Seen. The short mu;-cles ]kiss-
'"■■ "™- iiig lietw-een the metacarp.il
bone of the thumb and its ]iliu-
lanx, as well as the aponeurotic canal for the extensor
and llexor tendons in the lingers and thumb, are also
avoiiled. Th(^ cajisule and periosteum are now exjiosed
and are incised. The deniulation of the periosteum and
■
the elevation of the capsular attacliments are carefully
made, especially at the metacarpo-phalangeal joint lif
tli(! thumb, in order that the
muscular insertions may be pre-
.served.
When this is accomplished, the
bones are dislocated through the
incision and are divided with the
saw or by the rongeur forceps.
In some instances the Gigli saw
can be used without dislocation of
tlie bone. If the operation has
been a subcapsulo-periosteal one.
no sutures in the bones are need-
ed, provided a nearthrosis is at-
tempted. If not, and a pseudar-
throsis is desired, a retention bone
suture is used, with a small iu-
terve.l between the fragments.
When ankylosis is desired, the
bones are held in apposition by
the bone sutures.
Hi;.siiC'noN oi'' the Whist. —
The history of this operation dates
back as far as 1750, when Cooper,
of Bunga\', removed the lower
end of the radius and ulna for in-
jury. In 1703 Bagieu excLsed the
joint for a gunshot wound. In
171)1 ]Moreau excised the joint for
di.sease. Lister in 1865, Boeekel
in 18G7, Langenbpck in 1874, and
others gave a great incentive to
this operation b}' admirable pa-
pers ; yet in spite of these papers
the ojieration has never been a
popular one. Its unpopularity
was not due to its mortality, for
this, according to Culbertson,
amounts only to from one to 1.73
per cent, for all cases (Prize Es-
.say, p. ()'.i8), and, according to
Gurlt's "Jlilitary Surgery;" to
sixteen per cent. It was due to
the failure to arrest the disease or
because of the utter worthless-
ness of the hand after recovery. At the present time,
with an improved technique and the aseptic treatment,
these bad ellects are to an extent avoided, and as a re-
sult the operation is again being stronglv advocated.
AiKitcnini of the llVv.v/ (Fig.^4039).— The anterior or
inilmar surface of the wrist is so well covered with ten-
dons, arteries, and nerves that an approach from this side
is not feasible. Ujion the dorsal or lateral siu'faees the
bones are more easily exposed. Upon the back one can
enter between the tendons with-
out coming in contact with ar-
teries, unless upon the external
and posterior surfaces of the
tiape/.ium. The usual places
selected are tho.se between the
extensor indicis and the exten-
sor se"undi internodii pollicis
upon the outer side, and be-
tween the extensor carpi nlnaris
and extensor minimi digiti upon
the inner. In this interval one
encounters only the extensor
Carpi radialis brevior before en-
tering the joint. None of the
tenilciiis to the fingers passing
over the dorsum of the wrist is
attached to the wrist, so that
they can be easily retracted to
either side without injury.
rjion the outer side of the dorsum the extensor carpi
radialis Immior and brevior and the flexor carpi radialis
are intimately connected with the joint and bones to
Fig. lOSr.
912
REFERENCE IIANDP.OOK OF THE MEDICAL SCIENCES.
RoKorlioii of Joints,,
Ri'^eclioii or Joiuts*
lie removed. Upon tlie inner side the extensor and flexor
carpi uluaris are inserted into the base of the fitth nieta-
carjial bone, and are intimately associated with the cap-
snle and ligamcnls.
Tlie bone a\ hicli phiys the most important part in this
operation is the trapezium, Aviiich conceals and retains
upon its anterior surface tlie flexor carpi radialis, and is
covered by the radial artery upon its dorsal surface. From
ils crest it gives origin to the annular ligament, and by
its articulation with the metacarpal bone of the thumb it
becomes very necessary for the function of the thumb.
Proviileil the tendons are not incised, any incision which
will enter the joint upon the dorsum, either to the inner
or to the outer side of the mass of tendons made up of the
extensor communis digitorum. extensor proprius pollieis,
and extensor minimi digiti, will be found sufficient.
The liones of the carpus are united by a capsular liga-
ment, of which the anterior is the strongest portion.
The carpus itself may be regarded as one short and
wide bone, artictdating above and below with the bones
of the forearm and those of the hand. The lower epiphy-
ses of the radius and ulna join their shafts at twenty
years. The radial epiphysis is entirely within the joint.
The ulnar epiphysis reaches as high as the top of the
radio-ulnar articulation.
A total resection of this jninl includes the removal of
the articular ends of the bones of the forearm and those
of the metacarpal bones besides the bones of the wrist.
Any resection short of this is a partial one.
Jiidii-iitioiix. — In both civil an<l military practice partial
rather than egmplete resections are indicated. This holds
good in most gunshot wounds, in compound and com-
plicated fractures and dislocations. For tuberculosis,
chronic suppurative arthritis, syphilitii^ arthritis, resec-
tion is indicated after medicinal and expectant treatment
fails. Such is the case in other forms of joint disease
where resection, jiartial or complete, is used to relieve
deformitv or increase motion.
Resection, es]K'cially tlie complete, is not permissible
ber<ire the fifth j'carof life. It is rarely demanded before
jmberty. Wlien it is demanded, the epiphyses of the
iioncs of the forearm are not interfered witli, and the op-
eration is an informal or iucomjilete one. The object is
to remove the diseased tissue and nothing else. After
puliert}' tlie operation has its best results, and it is here
that complete resections are made with good chances for
functional results.
When, in an adult, tuberculosis exists in the carpus,
with tuberetilosis elsewhere in the body, the question to
be decided is between amputation and complete resec-
tion. The general rule is that amputalioii shovdd be
selected if the local process succeeds the i)ulmonary, and
that resection .should be preferred if the local antedates
the puhnouary. This must be taken with reserve, how-
ever, as i::aiiy such cases of primary wrist involvement
do best with amputation.
The older the subject the more we must consider am-
putation in preference to resection.
The methiids of incision for entering tliis joint are:
1. The radio-dorsal incision, which, commencing at the
centre of the ulnar border of the metacarpal bone of the
index finger, is carried upward to the middle of the dor-
sal surface of the radial e])ipliysis between tlie tendon of
the exten.sor indieis and that of the extensor carpi radi-
alis brevier, and thence between the tendons of the ex-
tensor indieis and the extensor .secundi internodii pol-
lieis. The length of this incision varies between 8 and
12 cm., of wdiieh one-third should be above the articula-
tion (Boeekel, Gazette Metlicult' de Striishi>iir;i, 1S67, and
Langenbeck, Afcliiefiif klin. Cldr., No. xvi.).
'2. The dorso-ulnar incision. In abduction ami slight
flexion an incision of 7 to 8 cm. is made from the lower
third of the fifth metacarpal over the tilna and vertically'
upward. In the lower part the incision passes between
the tendons of the extensor carpi ulnaris and the extensor
minimi digiti; over the ulna it passes in the interstice lie-
tween the extensor carpi ulnaiis and the extensor indieis
muscles (Ivocher. Arcliivfiir kliii. Chir., No. 37).
Vol. VI.— .-,8
ii. Both radial and ulnar incisions. Both are upon the
dorsum (Oilier, "Mf-tral These," 1882, p. 45). One is
dorso-radial and the other ulnar (Lister, Lancet, 1865).
Where two dorsal incisions are used : The radial eoni-
niences opposite the centre of the shaft of the second
metacarpal bone, and is continued upward along the ex-
tensor indieis tendon until it meets a line joining the two
r/i
tilkv^/ii;v/il?://,A|
Fitt. mm.
styloid processes. From this point it passes upward in
the axis of the forearm. The ulnar incision extends from
the centre of the fifth metacarpal bone along the radial side
of the extensor carpi ulnaris and the ulnar side of the ex-
tensor minimi digiti until it reaches the ulna. From this
jioiut it passes between the muscular bellies of the exten-
sor carpi ulnaris and the extensor indieis. Onethird of
both incisions is above the radio-carpal ailiculatii>n ; two-
thirds below it.
Where one dorsal and one lateral iiicisiiin is used: The
r:idio-dorsal commences at the middle of the dorsal as-
pect of the radius at a level of tlie styloid process, and is
carried toward the inner aspect of tin' melacarpopha-
iangeal joint of the thumb, running jiarallel to the ten-
dons of the .secundi internodii pollieis. \Vhen the radial
border of the second mctacarixd bcnie is reached, the in-
cision is carried along this border for one-half its length.
The ulnar incision commences 5 cm. above the extremity
913
Resection of Joiiils.
Besectlon oT Juliits.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
VuVA
\
Fig. 411)0— KoiluT's Incision.
of the ulna, and passes behind but parallel to tlie flexor
carpi ulnaris as far as the middle of the fifth metacarpal
bone.
Which of these incisions is the best depends largely upon
the position of the fistuUe or the degree of development
of tlie disease.
"Where the disease
is mainly upon
the ulnar side,
Kocher's incision
is the best to com-
mence with (Fifi;.
4040); if tlie dis-
ease is upon the
radial side, Lan-
E^enbi'ck's incision
^Fig. 4041). Hthe
disease is exten-
sive and reijuires
a comjiiete ar-
threctomy, no
method makes so
perfect an expos-
ure as the Oilier,
i.e.. the two dor-
sal incisions. We
will therefore de-
scribe fust tlie Langenbeck and then the Kocher method,
and will expect the reader, from these two descriptions,
to imagine that of the double dorsal incisions.
Method liy the radio-dorsal incision (Boeckel-Langen-
beck); An Esmarch bandage is applied. The hand and
xvrist arc placed ujion a cushion with the thumb aliducted
and extended. The ladio-carpal interspace is noticed by
the po.sitiou of tlie styloid processes. The tendons of the
extensor iiidicis and" the extensor secuudi iuternodii pol-
licis are also seen.
The incision usually begins above the wrist between
these temlous and descends along the tendon of the in-
dex finger to the middle of the second metacarpal bone.
One-third of this incision isaliove the radio-carpal articu-
lation; two-thirds is below it.
Tliis incision is made through the skin and exposes the
cutaneous terminal hraiiches of the radial nerve, which
are often cut. The external border of the tendon of the
extensor iiulicis is recognized and is retracted with the
inner flap out of the way. Incise toward the capsule of
the wrist-joiut and recognize the tendons of the extcusfu-
carpi railialis brevior attaclied to tlie third metacarpal
bone. Above the .joint cany the incision between the
tendons of the extensor secuudi iuternodii pollicis and
the exteiLSor indicis, separating them without entering
their sheaths. The periostenui of the radius is now in-
cised and the cap-
sule of the wrist-
joiut is divided
along the inner
side of the exten-
sor secuudi iuter-
nodii pollicis.
Avoid cutting the
tendous of the ra-
dio-carpal exten-
sors. With the
rugine (curved or
straight), the peri-
osteum of the ra-
dius and the cap-
sular fibres of the
wrist - joint (in-
cluding the radio-
carpal extensors)
are respectively
separated from
the outer half of
the posterior surface of the radius and from the bases of
the second and third metacar])al bones.
The ca]isvile is now retracted outward aud the scaphoid
u\//
Fi<:. tail. — I,aiiijenln'cl<'s Incision.
and trapezoid are separated from their attachments to the
capsule on their posterior surfaces. The trapezium is
not detached until a later stage. The capsule is now re-
tracted inward and the periosteum and capsule are sep-
arated from the inner half of the posterior surface of the
radius, the triangular cartilage, and the posterior surface
of the ulna. It is detached also fmm the posterior sur-
faces of the semilunar, cuneiform, os magnum, unciform,
aud the bases of the remaining metacarpal limies.
If the soft parts are not extensively infiltrated and the
movements nf flexion and extension can be made, the ra-
dius and ulna may be luxated aud sawn at this time aud
before the carpal bones are removed.
If this can be done, the hand is flexed and pronated
and the external flap is retracted. The rugine now sep-
arates the periosteum ujion the anterior surface of the
radius. The hand is now flexed aud supinated and the
remaining portion of the radius and the ulna are denuded
upon their anterior surfaces. The liand is now forcibly
flexed, the flapsare retractetl, and the radiusand ulna pro-
ject througli the wound. These can then be sawn trans-
versely. This section should be as narrow as possible,
usually within 2 cm. of the cartilage (Fig. 4043). A re-
FIG. 4043.
tractor is now |daced iu the external wound, the wrist i»
flexed, the scaphoiil bone is seized with the forceps, aud
its anterior aiul i-xtenial surfaces are freed from the peri-
osteum and ligaments.
The bone is next separated from the semilunar and is
torn away easily. The internal flap is then retracted to
the inner side and the semilunar and cuneiform bones arc
separated and removed in the same waj-, leaving the
pisiform. The os magnum is now seized with the for-
ceps, its anterior surface is denuded with the rugine, aud
its connections with the unciform, trapezoid, and meta-
carpal bones are severed. Tlie trapezoid is finally re-
moved iu the same manner.
With more extensive wound retraction, the unciform
may be seized and its anterior surface denuded until the
base of its process is reached. This process is now sep-
arated with the cutting forceps, and a freeing of the bone
U]iiin its internal surface allows its removal.
If the trapezium is to be removed, a retractor draws
outward the external fla]). the left hand seizes the thumb,
and the rugine clears the posterior and then the anterior
surfaces of periosteum. The trapezium is now seized
with the bone forceps, its external border is denuded, and
the bone is removed.
Pro\ided the ]iisitonn and the hook of the uucifcoin
are to remain, and jn'ovided also the synovial meiulinme
has been removed, the Esinarch bandage should be loos-
ened and the larger arteries tied. In many instances,
where one is certain of not iujurinir the larger vessels,
the bandage is not removed until after the first part of
the penuuneut dressiug is applied.
914
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Resection of Jolnis'.
Sutures between the ends of tlie bones have always
been used by me, because I have always believed that a
mobile pseudarthrosis with mobility of the lingers was tlie
best obtainable result. Two chroiuicizcd catgut sutures
FIG. 4u«.
are inserted, bringing the bones within one-fourth to one-
half inch, or 0.6 to 1.25 cm., of one anotlier. If the
tendons of tlie e.xtensor secundi internodii pcillicis or the
e.xtensor carpi radialis longior and brevior have been
divided, they are to be carefully resutured or reinserted
if seijarated from their insertions.
The capsule is sutured with catgut. The sUiu is su-
tured with silk or catgut.
Provided the operative field is an aseptic one, catgut
is employed for the skin. No drainage is used except
that which occurs at the lower portion of the wound, near
the index finger, where the skin and capsule are not su-
tured in order that any undue tension in the wound may
be relieved. If the process is infective, drainage is em-
ployed through the incision by gauze packing.
Tlie method by the dorso-ulnar incision (Kocher) : The
disadvantage of the preceding method, in Kocher's opin-
ion, is the necessary separation of the radio-carpal ex-
tensors and the imperfect dorsal flexion, and possilily the
volar subluxation resulting. The advantages of the
dorso-ulnar incision are seen in the less important action
of the extensor carpi ulnaris as a dor.sal flexor and its
greater importance as an adductor. Hence when it is sepa-
rated its loss of action is favorable to the better position
and action of the hand. Though the extensor tendon of
the little finger is liable to be negative in action, this dan-
ger is not so great nor is its loss of function so iiuportant
as that of the proprius pollicis in the preceding method.
Hence he selects an ulnar ami dorsal incision.
The incision is made as descrilied above. It avoids
the dorsal cutaneous branch of the ulnar nerve. The
fascia and the dorsal annular ligament are divided and
the sheath of the extensor minimi digiti is incised. This
tendon is drawn outward, and, following its ulnar bor-
der, the capsule of tlie joint is divideil, and with the in-
sertion of the extensor carpi ulnaris it is loosened from
the base of the fifth metacarpal bniie. Along tliis latter
tendon the incision is carried upward upon the ulna in
the interstice between the extensor carpi ulnaris and the
extensor proprius pollicis. The tendon of the extensor
carpi ulnaris is now retracted inward and the capsule sur-
rounding the ulna is separated by the rugiue suhcapsulo-
periosteally, if possible and if indicated; but, if not in-
dicated, it should iie divided by the knife, which should
sever the attachiuents of the capsule to the uhia and to
the base of the fiftli metacarpal bone, leaving the tlexor
carpi ulnaris attached. The joint is now entered and the
articulation of the pis_iform and cuneiform and the pro-
cess of the unciform come into view.
The tendons upon the volar surface are retracted and
the attachments of the cajisule to the fifth, fourth, and
third metacarpal bones are divided. The attachment of
the flexor carpi radialis to the base of the second metacar-
pal bone is preserved. In lilie manner the attachment of
the capsule to the radius is separated.
Upon the dorsum, the extensors of the fingers are
easily exposed and the capsule beneath the radio-carpal
extensors and the extensors of the thumb is loosened
from the radius. The two radio-carpal extensors at-
tached to the bases of the second and third metacarpal
bones are not separated from their insertions.
The hand is now carried outward and in slight flexion
until the thumb touclies the radial side of the forearm.
The lower ends of the raditis and ulna appear in the wound
to the inner side, while externally is seen the first row of
carpal bones ( Fig. 404^). The removal of the carpal bones
and a removal of thin sections from the radius and ulna
and metacarpal bones are now easily carried out. It is
only in the region of the trapezium and the trapezoid
that the field is restricted when the bones of the forearm
and the third metacarpal bones are being removed.
AVhen the bi}iies have been removed and the capsule
extirpated, the bones of the forearm and the metacarpal
bones are placed in apjiositiou if a nearthrosis is wished.
If a pseudarthrosis is desired, the bones are held in ap-
position more or less closely by chromic-acid catgut.
The capsule and skin are now sutured. Drainage in
aseptic cases is secured by leaving a small portion (1 to .
2 cm.) of the incision open : or, if the wound be septic or
hemorrhage be im]x-rfectly stopped, by gauze packing
through some portion of the inci.sion.
When the disease is upon the radial side of the carpal
or metacarpal bones, or when the radial side of the joint
is exclusively the seat of the disease, the radio-dorsal in-
cision is the incision of choice. When the disease is con-
fined to the ulnar side or the joint as a whole is involved
bilt not greatly infiltrated and swollen, the dorso-ulnnr
incision is the incision to be selected. When the whole;
joint is involved and the tissues are greatly infiltrated in
front and behind the joint, both dorsal incisions are pref-
erable to either singly. Hence we wotild select for these
cases the incisions recommended b}' Oilier. These inci-
sions are the same as those already mentioned as Langen-
beck's and Kocher's. The direction of the skin incision
varies somewhat, but the route to the joint is between
the same structures. Excellent results have been ob-
tained by Drs. Mynter and Taylor by means of a method
suggested by Professor Stuekgaard, of Copenhagen, in
]8§i'. This method consists in splitting the hand between
thesecondaud third fingers. The incision is both palmar
and dorsal. The incision upon the dorsum begins at the
radius and extends to the interdigital fold between the
second and third fingers. The palmar incision extends
from the interdigital fold not farther than the superficial
paliuar arch.
The dorsal incision divides the skin and the subcutane-
ous tissue, but no tendons. It avoids, in passing between
the metacarpals the annular volar ligament, the flexor
tendons and the superficial arterial arch. The wrist is
now split between the trapezoid and os magnum in the
second row and between the scaphoid and semilunar in
the first row. Retraction of each side now allows of a
complete exposure of the wrist-joint {Annals of Surgery,
September. 1900). This operation has never been per-
formed by the author ujion the living. Upon the cada-
ver it is feasible and gives an excellen"t exposure without
915
Resection of Joiuls.
Resection of Joints.
KEFEREKCE HANDBOUK OF THE 3IEDICAL SCIENCES.
injuiy to tlie doi-sal tencloiis. It is here meutioued be-
cause of its ajjpuiviit value.
No matter \vlii<;li metliod of resection may be cliosen,
(1) tire trapezium sliould be saved if possible, so tliat tlie
motions in tlie nictacarpo-carpal joint of the thumb may
be preserved; (2) the section of the bones of the forearm
should be made wilhin 3 cm. of tlieir articidar cartilages;
(3) in so far as is feasible the operation should be a sub-
periosteo-capsular one.
The After-Treatmint. — The limb is to be placed upon a
properly padded splint in such a manner that the baud
shall be sustained in the position of dorsal fle.xion (Figs.
4044 and 401.j). These splints fix the wrist- joint but allow
passive motion of the lingers. Thi'V pass from above liie
elbow to the fingers and tlmmb. The latter pass beyond
the splint and can be easily grasped for passive luotion.
Where the wounds are asejitic and no drainage is re-
quired, as in a case of simple injury, the wound usually
heals in from ten days to two weeks.
Where the ojjeration is done for disease, the cavity is
often packed with gauze, and, as it requires often two
or three revisions with the curette, the healing of the
■wound may be delayed for from four to si.\ weeks.
As soon, however, as the ti-ssues are solid, though the
splint is to be continued for a long jicriod to prevent pal-
mar dislocation and adduction, passive motional the wrist
must be assiduously practised if we desire a nearthrosis
or a mobile pseudarthrosis (Oilier, "Traite des Ke.sec-
tions, " 1888). If we desire an ankylosis at the wrist,
passive motion may be interdicted.
Passive and active motion of the fingers is practised as
earlyas possible, in some inslaneesat the third lolitthday
after operation. After removal of the splint, a jtrothetic
apparatus nuist be worn. This apparatus should allow
fie.xion and extension at the wrist if desired.
From this time on. the patient's aim must be to in-
crease the range of motion in his fingers and in the wrist.
jVIucli depends upon his own exertioiisin securinga good
result.
The functional r<'sults after this opeiation vaiy. Cnl-
bertson, in .58 cases of gunshot wounils. reports the fol-
lowing results: Good, l.T ]}er cent. ; indillerent, 37..') per
cent. ; had, 13.7 per cent. ; amputated, 3.4 per cent. ; not
stated, 53.4 per cent. In 14 cases of injury the results
were as follows: Good, 38. ,5 per cent. ; indifferent, 57+
per cent. ; not slated, 14-|- i)er cent. In 7!) cases in
which ri'section was performed for disease the results
wci-e: Good, 7.5 per cent.; indill'ereiit, 45.5 per cent.;
bad, 13.9 per cent. ; aniiint;ited, 13. (! per cent. ; not
stated, 3(1.3 per<'enl. In our own civil war ("Med. and
Surgical llistnry of the W:u' of the Keliellion," part ii..
Vol. ii., Otis), (i c;ises of complete resection gave an in-
<lill'erent result in 83.3 per cent. ; amiuitation and death
in Hi. (J per cent, (iurit's statistics of militiiry surgery
gave ideal results in (!.35 ]ier cent.; good results in 50
percent. ; indifferent results in 37.5 per cent. ; bail n'Sults
in (i.'.'5 ]ier cent. Nc-|iveu (A'l /■»(■ i/c Cliinirnif, 1883, p.
;131) gives a collection of 30 c:ises. The results were
satisfactory in 41.(i ])er cent. ; indillerent in 3(1. 1 percent. ;
had in 33.3 per cent. Oilier {On:, mfd. ik J'tirit.; 1SS2,
"Traite des Resections," 1888) believes, and has shown in
two cases following a traumatism (partial resection), that
ideal results maj' be obtained b)' carefully performed
operationsand long-continued after-treatment. Tlie mor-
tality statistics are about ten per cent, for all cases of
resection. For gunshot w'ounds the mortality is aliout
fifteen per cent. For disease, a death following opera-
tion is a rarity.
Resicction of the Elbow-Joint. — Wainman in 1759
and Filkin in 1703 excised ])ortions of this joint for in-
jury or disease, but the first methodical operation is
ascrilx-d to Moreau in 1794. This methoci was enthusias-
tically accejited in England by Syme, and has since been
established by numerous surgeons both in civil and in
military practice. Resection of the elbow consists in re-
moving the inferior extremity of the liumerus and the
upper extremities of the radius ami ulna. In all eases
tiie in.scrtlons of the brachialis anticns and of the biceps
must be preserved, or if detached they must be rejdaced
in order to insure the functi m of the joint.
Usually less than 2 cm. shoidd be removed from the
radius and ulna. More can be removed from the hu-
merus without destroying its function. Usually the line
of section is at the upper border of the epitroclilea, i.e.,
the section is made well above the articular surface (Oi-
lier, "Traite des Resections," t. ii., p. 303). When more
is removed than is here recommended, one must expect
a fiail joint, unless special precautions against it are
taken. When the section is lielow the epitroclilea — i.e.,
just above the articular cartilage — one can e.xpecta near-
throsis, a pseudarthrosis. (U' an ankylosis. If ankylosis
results, the bones must be placed at a right angle with
the radius in semipronation. This will give a very useful
and serviceable extremifj'. If a nearthrosis follows, then
the following condition most frequently occurs: The
bones become fashioned so as to fit one another. They
become smooth, polished, and shaped so as to allow flex-
ion and extension. The lateral ligaments prevent any
lateral displacement at the new articulation, and the
movements of supination and pronation, though limited,
are sufficiently supplemented by rotation at the shoulder-
joint. Tlie movement of the elbow, liand, and fingers is
suliicieutly strong for all onliiuiry work. Such a condi-
tion is the best result attainable, and should be con.sid-
ered ideal.
If pseudarthrosis exists, the union of the bones is by
means of connective tissue. Such a union, if the bond
is not too hmg, gives a good result. Where the union
is short and where no lateral displacement at the point
of union ocr-urs, if the muscular power is sufiicient, (|uite
as useful a limb can be obtained as by the developiment
of a nearthrosis.
TJie Iiith'cdtioiu. — Yov giinxhat iiijiiriif! in young and
healthy persons in whom the articuhir cartilages are in-
tact and in whom the ti.ssues about the joint are not
extensively damaged, the conservative treatment or at
tlie most restricted oiieration should be made use of.
In Kcrrn- bone injuries of the elbow-joint, including
the articular cartilages with slight or no injury to the
ve.ssi-ls and nerves, a partial or a coiniilete resection is
indicated, provided the age of the patient or his gcmeral
condition (Iocs not demand an immediate amputation.
In sen ir iiijiirie.t of the articular cartilages and of the
bones, with severe injurv to the vessels and nerves, am-
put.atiou is reipiired. especially in the aged.
In old iiijiirits to the joint, resulting in ankylosis or
pressure upon the main vessels or ni'rve trunks, a com-
plete nitlier than a partial resection is inilicated, becau.se
the tendency to .secondary ankylosis is great by reason
of the marked reparative pow'er in all the tissues set up
by previous injury. In old dislocations it has been my
practice to reduce the dislocation by operative means,
unless the contracture of the soft tissues demands a
resection ratlierthan a reduclion. The earlier theold dis-
localion comes into the surgeon's hands the more success-
ful will be tlie reduclion by oiierative interference.
.[/i/ii/losix in a faulty ixi.sition, resulting from injurv or
disease, is curable by complete resection only when the age
int;
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Kescctioii or JolulN.
Resectiou of JoiutM.
of the patient (from twenty to thirty-five), the condition
of tlie muscles, tlie presence of cicatricial bands about
the joint, or the new bone jinxhictiou iu and around the
joint, will not interfere with the atter-resiilt.
In cases in wliich these conditions exist and the ten-
dency to new bone production is a marked one a partial
opciation with a correction of the faulty position is alone
indicated.
2'iibeiculosis. — After conservative treatment has failed,
a complete resection is usually indicated. Durini; the first
three or four years of life resection is not recoinmended,
At this time curetting is sufticient. After three years,
make partial operation, if pos.sible, or a complete one if
uecessar\'. In either case, however, we must remove the
disease. Resection is indicated in some cases of fiiippi/ra/dre
arthritis (chronic), in arthritis tlcftirinmis in a single joint,
and in tumors involving the bones of the joint (exosto.ses).
It must be remembered that only one-tenth of the total
growth of the arm and forearm is contributed by the
epiphysis at the elbow (Oilier), so that earlier resections
may be attempted here than elsewhere. In general we say
that in injury and gunshot wounds, jiartial rather than
comjilete <iperatiiins are indicated. For disease, com-
plete rather than partial ii|)erations are indicated. For
ankylosis, complete rather tlian partial operations are
indicated.
In youth much can be expected in the production of
pseudo- or nearthro.ses. In the a<hdt, unless some chronic
irritation (infiammation) is present or the amount re-
moved is small, the joint is liable to be a fiail one.
Awitmny. — The elbow is a pure hinge joint. The
re-establishment of its function demands that the bones
be so shai)ed as to fiex and extend easilv wliile in con-
tact, that the lateral ligament holding the joint be short
and not yielding, and that the attachment of the muscles
which move the joint in flexion and extension, as well
as iu supination and pronation, be preserved.
As the anterior portion of this joint is not used for
entrance into the joint, we will consider only its lateral
and posteiior aspects.
The ]iosterior branch of the radial nerve, which is a
motor nerve for she extension of the hand and fingers
and for extension and abduction of the thumb, enters the
supinator brevis muscle about 2 cm. below the articular
surface of the head of the radius and jiasses obliquel}"
through its fibres around the radius until it emerges 3 to
4 cm. below the interarticular line iu the posterior inter-
osseous space. I"|ion tlie inner side the ulnar nerve
passes behind the internal condyle between the extensor
car))! ulnaris and the periosteum covei-ing the internal
lateral s\n'f.ace of the ulnar. These two nerves are to be
avoided. Both the braeliialis antieus and the biceps are
attached at points sufficiently removed to be saved in the
more typical and complete operations. The supinator
hmgus, because of its attachment to the external inter-
muscular ridge, can be preserved in its attachment even
when a large extent of the humeius is removed.
The short supinator, which is so necessary for sujiina-
tiou, is rarely injured because of its read}' sejiaration
from the humerus with the periosteum. Such is the
case with the mu.scles attached to the internal and exter-
nal condyles of the humerus, which can with care always
be separated from tlie bone and kept in relatimi with
the periosteum of the humerus and the fascia, forming
the intermuscular septa and the lateral ligaments of the
joint. The trice|is, however, is an important muscle.
The major part of its tendon is inserted into the olecra-
non process of tlie ulna. It has, however, lateral attach-
ments connecting it with the deep fascia of the |iostcrior
surface of the forearm. Of these connections, that with
the fascia covering the anconeus and the posterior sur-
face of the forearm is very strong, while that, with the
fascia covering the internal siui'ace is thin and not strong.
It is necessaiy, therefore, to maintain this connection
with the deep fa.scia of the forearm when the attachment
to the olecranon is removed, if we wish to obtain after
resection the full power of extension.
The arterial supply of this joint is carried on by the
circle formed by the ladial and ulnar reeurrents, the
interosseous recurrent, and the anastomotica magna.
These may be avoided by the subperiosteal metliod.
The interarticular line of the elbow-joint is represented
by the middle two-thirds of a line joining the tips of
the two condyles.
Tlie humero-radial articulation is represented by a
horizontal line; the humeio-uliiar, by an oblique line,
passing from without inward and above downward.
The external condyle of the humerus is less tlian 3 cm.
above the articular line. The internal condyle is more
than 2.5 cm. above it.
The lower cpijihy.sis of the humerus joins the shaft
at the seventeenth or eighteenth year.
The epiplij'sis of the radius joins the shaft at the six-
teenth or seventeenth year.
The epiphysis of the ulnar (olecranon) joins the .shaft
at the .seventeenth }'ear.
These epiphyseal cartilages iiave finished their growth
by the seventeenth .year, and resections of large piortions
may be made at this age, although the muscles mentioned
as important must be preserved to obtain the best results.
AVhen they are sacrificed, protlietie apparatus must be
used to supply the deficienc}'.
TuE IIethods op Incisions.
The incisions used in resections of the elbow joint may
be divide<l into: (1) those which enter the joint upon the
ulnar side; (2) those which enter upon the radial side ; (3)
those which enter upon both sides or from behind. To the
first belong the incisions of Listoii, Langenbeck, Gurlt,
and Jaeger (" Manuel Operatoire," Parabanif, p. 715). To
the second belong those of Oilier ("Traite des Resec-
tions "), Stimson ("' Operative Surgery "), Roux and Nela-
ton (" Manuel Operatoire," Faraba'uf), Koclier (Are.hivfur
Hilt, (jhir., No. 37, p. 787), and Cavazzani (Centrttlblatt
fiir C/iir., 1889, pp. 708 and 1121). To the last belong the
H-sliaped incisions of Moreau and Dupu3'tren ("Manuel
Operatoire, " Parabwuf ), the lateral incisions of C. Hueter
("Gelenksreseetiunen ") and of Vogt (Lobker; "Opera-
tionslehre "), and the jjosterior triangular Hap of Teitor
("Manuel Operatoire," Faraba?uf).
Of all these incisions we iind that four are sufficient
for all resections, coni|)lete or pai'tial. In ankylosed
joints and in old dislocations a coinbinaticm of the
Kocher's radial incision and the ulna incision of C.
llueler will be found in the severer cases to be most
satisfactory. In injury and in disease other than the
above the Langenbeck, the Cavazzani, and the Kocher in-
cisions are preferred.
These latter incisions are snperior to the rest because
they do the least injury to the fibrous expansion of the
triceps insertion ami no injuiy to the
nerves supplying the triceps or the
anconeus muscles.
The Langenbeck or dorso-internal
incision is recommended when the
disease involves ]>articularl3' the in-
ternal segment of the joint.
The Kocher, or dorso-radial, incis-
ion is cspeciallj' useful when the
disease involves more especially the
radio-humeral in addition to the hu-
niero-uhiar articulations.
The bilateral incisions above recom-
mended are useful in old dislocations
and in severe ankylosis following dis-
ease, injuiy, or operation. I will
describe these methods.
I. Lcnr/erihec/i's Metliod. — The Es-
marcli bandage is to be applied, if not
contraindicated. The top and crest
of the olecranon process having been
determined, an incision is commenced
4 to 5 cm. above the olecranon, pass-
ing through the tendon of the triceps and along the inner
border of the crest of the olecranon to a point where the
Flci. 4046.
ai7
Kosectiou of Joints. jjepereNCE HANDBOOK OF THE MEDICAL SCIENCES.
Resectiou of Joiiils*
process disappears in the sliaft of tlic ulna (Fig. 404fi).
Usually this point is 4 to 5 cm. from the tip of the olec-
ranon. This incision iscarrietl down to the bones t hrounh-
out. A retractor is jilaced in the external llap. and. with
^^ ■■•N
the forearm extended, a rnsinc or knife
separates the periosteum of the olecranon
and the ulna, carrying with it thein.sertion
of the triceps, that of the anconeus and
that of the su]>inalor brevis.
Having reached the external condyle, the
surgeon should separate till! external lateral
ligament and the common origin of the extensors and
supinators from the condyle subperiosteally or by remov-
ing "witli these slruclur<'S a part of the epicondyle (P.
Vogt). When this is sultieiently free and the humero-
ra<iial joint is exposed, the forearm may be flexed to
complete the subperiosteal separation upon the anterior
surface of the hnmerns. This completed, the internal
flap is detached with the periosteum, while the forearm
is extended until the internal siu-face of the olecranon is
free and the eoronoid pvoress below and the internal con-
dyle above are fully ex|iose(l. With the retraction of the
periosteum of the liumerus and olecranon, the ulnar
nerve and the lateral ligament are carried away and are
free from all danger. When the lower part of the hume-
rus is sufticiently free, the forearm is again flexed and the
ulna and radius are separated from it. The perio.steum
and capsule of the joint are separated from the anterior
surface of the humerus as far as is necessary. The
latter is then seized with the lion-toothed forceps and
the bone is .siwu transver.sely, just above the articular
cartilage or, better, in a line joining
the epicondyle and upper part of cpi-
troehlea (Oilier, "Traite des Resec-
tions," t. ii., p. 203). The olecranon
]iroeess is seized with the forceps and
tlie periosteum and capsule are sejia-
rated from the eoronoid process to its
base, as m>ich of the insertion of the
lirachialis amicus as passible being
saved. The anterior fibres of the annu-
lar ligament arc .separated with the
periosteum of the ulna and are dis]ilaced
diiwnward so I hat the head of the radius
("in be reiuoved close to the shaft if
desirrd. The olecranon and eoronoid
process are now removed together from
the shaft, if desired and if thought nec-
essary (Fig. 4047). Otherwise.'if suHi-
cicnt bone can be left to form a new
iilceranon )irocess, the bone is sawn as
in Fig. 404S. This will give a project-
ing portion representing the former
Fiii. ■lots. iileeianoii, which is very useful in pre-
venting forward dislocation of tln' ulna
diiring the after-treatment. After removal of the ex-
tremities of the bones the synovial meiubrane is dis-
sected out completely, and such sinuses as appear are
excised or curetted.
The sawn surfaces of the radius, ulna, and humerus are
placed in apposition and at an angle of 135° — i.e., in
nearly complete extension. In this position the tendency
to forward dislocation of the radius and ulna through
contraction of the flexors is avoided. If firm ankylo.sis
is desired, the humerus and idna are
drilled and sutured with two-weeks
chromicized catgut sutures. If a mobile
pseudarthrosis or a nearthrosis is de-
sired, chromicized catgut sutures are
used only for the purpose of retaining
the position of the bones during the ap-
plication of tlie primary dressing. Such
■sutures should not last longer than a
few days. The Esiuarch bandage is
removed and the larger arteries are li-
gated.
The capsule and the periosteum are
sutured with catgut in position over the
ends of the hones. The skin is sutured
with catgut, providing the case is an
aseptic one, and a small jjortion of the
wound (3 cm.) at its liighest point is
not sutured, in order that leakage of
blood may take place easily during the
next few hours. If one so desires, a small
piece of rubber tissue may be inserted
through this opening to prevent its
closure. What I prefer is to hold apart
this small opening in the wound by two
catgut sutures, one upon each side of the woimd. These
sutures will be absorbed within a few days (JIaas'
method) and will allow the wound to close before the
first dressing is changed. The forearm is slightly flexed
and sennpronated. It is retained in this position by a
splint, either jdaster of Paris reinforced by sterilized
basswood strips or the Esmarch'swire splint (Fig. 4049).
With either of tlu'se the arm and forearm are elevated
and retained in this position by suspension.
Kiiclier's Method. — Ry the Langeubeck incision, dis-
ease in the radio-humenil articulation is not so easily at-
tacked as by the Oilier bayonet incision. OUicr's incis-
ion, which jiasses in the interstice between the external
head of the triceps and the anconeus, must divide the
nerve supijlying the anconeus, since it is a branch of the
division of the radius sujiplyiug this portion of the tri-
ceps. Ilenec! Koeher jilanned an incision which avoids
this nerve division and does not negative this portion of
the triceiis.
The forearm is flexed at an angle of one hundred and
fifty degrees, and a stirrup-shaped incision is made,
which begins 3 to 5 cm.' above the
epicondyle and over the external bor-
der of the humerus, and descends to
the head of the radius. From this
Flfi. 4049.
point it descends downward and slightly inward, fol-
lowing the external border of the anconeus until it
reaches the ulna at a point from 4 to 6 cm. from the tip
of the olecranon. From this latter point it curves over
the posterior surface of the ulna inward and upward for
a distance of from 1 to 3 cm. (Fig. 40.')0). This incision
above the ei>ieondyle passes in the interstice between
the supinator longus, extensor carpi radialis longior, and
the common tendon for the supinators and extensors of
the hand and wrist and fingers in front and the triceps
and anconeus behind. From the epicondyle to the lat-
eral svirface of the ulna, the incision pa.sses in the inter-
stice between the anconeus and the extensor carpi ulnaris
until it reaches the ulna at a point 6 cm. below tlie tip
918
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
K4'K4-i'ti(»ii or JlkilllK,
Ki'KCC-liuii or Joints,
of the olecranon. Tlie latter part of the incision usu-
ally divides the lowest fibres of the anconeus, as they
often extend a lonjrer distance up on the shaft of the ulna.
This incision passes in the interval between those mus-
cles innervated by the posterior muscular branch of the
musculo-spiral and those supplied by the external mus-
cular and posterior interosseus branches of the same
nerve. The external ridge of the humerus, the epicon-
dyle, the radio-humeral joint, and the supinator brevis
muscles are now exposed, and the capsule of the radio-
humeral and hiunero-ulnar joints are in view.
H the olecranon is diseased, the chisel may be placed
iipon its base and the process be renioxed from the shaft
together with the attached triceiys and anconeus mus-
cles. Tills flap is retracted inward and the joint is ex-
posed to its fidl extent. If the olecranon is not diseased,
the periosteum beneath the external head of the triceps
and the capside are separated from the posterior surface of
the humerus. In like manner the anconeus is separated
from the epicoud.vle and the outer surface of the ulna, in-
cluding withit the posterior humero-ulnar ligament. This
dissection is continued over the ulna and olecranon, sep-
arating the triceps from the olecranon and a small part
of the tlexor carpi ulnaris from the internal surface of the
ulna. The epicondyle is now fidly exposed by separat-
ing the common tendon of the supinators and extensors
subperiosteally and retracting the flap inward. This ex-
poses the external lateral antl the anterior ligaments pass-
ing from the condyle to the annular ligament of the
superior radio-humeral joint. These are divided. The
foreai'm is now extended and adducted. The joint is
then brought into full view and the internal lateral liga-
ment can be loosened from the inner surface of the idna
and of the trochlea (Fig. 40.')1). With this separation,
the humerus is easily cleared of all muscles anteriorly and
posteriorly and the bone section made as recommended in
the preceding operation.
The annular ligament is now- divided and the head of
the radius is removed separately from the ulna. If pos-
FlCi. 4050.
sil)le, the section of the ulna should be such as will leave
a process simulating in slight degree the olecranon.
Such a method is useful in preventing the anterior sub-
luxation of the idua. The section is the same as is shown
in the former operation.
When the disease is tuberculous, it is best not to incise
the synovial membrane imtil the dissection of the soft
parts is completed and the dislocation of the radius and
ulna from the hiunerus is ready to. be made. When the
synovial membrane has been completely removed and the
sinuses, if any, are excised or curetted, the parts are
brought into apposition and sutured. Drainage, if nec-
essary, is made with gauze at the lower angle of the
wound beneath the anconeus. If drainage is necessary
for only a few days, the JIaas method is (he preferable
one (see Langenbeck's operation).
Sutures, both deep and superficial, are made with cat-
gut if the wound is to be an aseptic one and if it is to
heal tuider one dressing; if not, silk is used for the skin.
If ankylosis is desired, suture the bone with two-weeks
chromicized catgut. If a nearthrosis or a mobile pseudo-
arthrosis is desired, suture with catgut, which will last
but a few days and will simply retain the bones in posi-
tion during the application of the primary dressing.
The extreiuity is placed in such a si)lint as has been pre-
viously recommen<led and is suspended and elevated.
These two methods are undoubtedly the methods of
choice for both injtiry and dLseaso in the vast majority
of cases.
There is a method very similar to Kocher's, except in
the skin incision and in some of the minor details, which
Fig. i0.5I.
may be used for it in cases of exploration, partial resec-
tion, and sj'uovial extirpation. This is the method of
Cavazzani. In two of my cases of synovial artlirectomy
this method was found to be exceedingly valuable.
Methodof Carttsziiiii. — Three landmarks are taken — one
the tendon of the biceps, one the head of the radius, and
the third the olecranon process. Two centimetres below
the epicondyle u]Km the outer border of the tendo bici-
pitis an incisiun through the skin and sidicutaneous tis-
sue begins aiul passes transversely outward parallel to the
interarticular line of tlie joint. At the outer side of the
forearm it passes obliipiely from beliind u]nvard and
ends at the inner border of the ulna near the tip of the
olecranon (Fig. 40.")2). During the first half of tliis incis-
ion the forearm is extended. During the last half it is
in half-flexidu. This stretches tin; skin and prevents
slipping. The ui)per flap is dissected up sufliciently to
expose the interval between the
anconeus and the muscles arising
from the epicondyle, i.e., the in-
terstice between the anconeus and
the extensor carjii ulnaris.
The epicondyle being exposed,
the aponeurosis covering this in-
terstice is divided over the neck
of the radius and above the epi-
condyle. The epicondylar mus-
cles are now loosened subperios-
teally and are retracted inward.
The capsule is thus exposed as
far as the coronoid (uocess. Ujion
the posterior surface the anconeus
is also separated subperiosteally
from the humerus and the ulna
together ; the tendon of the triceps
is separated over the external half
of the olecianon process. If one
wishes to disregard the anconeus
nerve supply, one may cut trans
versel}' in the interstice of the tri-
ceps and anconeus from the epicondyles to the outer sur-
face of the ulna. TIk^ posterior caiisule is now exposed.
The joint is next opened by dividing the external lateral
FIG. 4052.
919
Reseclioii of Joint!-*.
Resei-tiou of Joiut!^,
REPEREXCE HANDBOOK OF THE MEDICAL 8CIEXCES.
ligament from the corouoitl process anteriorly- to the tip
of the olecranon posteriorly. A movement of lukine-
tion will now dislocate the forearm from tlu' arm.
After the operation is finished, the forearm is replaced,
the lateral ligaments are sewed, and the muscles about
the epieondyle sutured in place. No vesselsor nerves are
injured. The radial nerve is not stretcheil. The tendon
of the triceps is preserved in half its detachment. The
epicoudylar muscles are pr(>servcd.
For exploration and synovial extirpation, Cavazzani"s
method is very satisfactory, for the reasons above stated.
For ankylosis Mu\ for the r<'duction of old (lislocntions,
the method of .leftrcy, which has been more prcci.sely
described by JIaraiigos (These de Lyon, 1S83), and
that of Ihie"tcr (" tleleukskraidiheiten,"' vol. if, p. ."J-Vi)
are undonbtcdly the best. TJiis is especially so in fract-
ures with disloeatiim, where the reduction reciuires tlie
removal of the callus with or %vithout a partial resection ;
in old dislocations which require the removal of tlie callus
and the adhesions in orilcr to effect reduction; in all im-
practical ankyloses followingdisease, injury, oroperation,
which aie to be made practical ankyloses or in which ar-
throlysisis to be attempted; and. lastly, in eases in which
redislocation has followed the operative reduction of an
old dislocation (Biinge, Inc. Ht.).
AVith the posterior incision or the single lateral inci-
sion, one comes njion the joint at a disadvantageous side
for the correction of an ank\iosis or for the removal of
callus.
Li ankyloses it is not possible to dislocate the bones,
and the removal of the necessary wedge or piece of bone
must be done without displacement. For this reason,
Hueter and others accepted the bilateral incisions which
Jeffrey formerly used in all resections. These incisions
hare been greatly moditied by sub.sequent operators, but
the method here described will, I think, be found to
approach the ideal method. It consists of the radio-
hnmeral incision of Koclier and the ulnar incision of the
bilateral method.*. Tlie incision upon the radial side
commences .5 or 0 cm. above the external condyle, and
penetrates between the triceps and the supinator longus
and extensor carpi radialis longior, until it reaches tlic
external humeral border and descends to jvist behind the
epieondyle. It here passes obliqtiely downward and in-
ward in the interstice between tlie anconeus and external
carpi ulnaris for a distance of from 2 to 'A cm. Unless
the radius is involved, the annular ligament is avoided.
Now clear the anconeus and the triceps from the cajisule
or tissues beneath them ami retract them inward. Clear
the supinator and extensor group from the epieondyle
and retract them inward.
An ulnar incision is next made ujiou the internal border
of the eiiitroclilca or at the place where it had been broken
olf or displaced. This incision is from 8 to 10 cm. in
length. The ulnar nerve is freed and displaced back-
ward. The pronator and flexor grou]>s of muscles are
displaced outward and in front after lieing freed from
the internal border of the humerus and the epitrochlea.
These incisions descend to the bone, and one separates
subperiosteally with the rugine, or supraperiosteally with
the knife, the soft ]iarts from the bone upon both surfaces
of the humerus. In the reduction of old dislocations, the
method pursued must be cxtraperiosteal (Bunge, AirhiB
fiirlUii. C/iii\, No. 60, p. .5.")T). A blunt retractor is now
inserted in front of and behind the humerus, for the pur-
pose of guarding and lifting the soft tissues from the bone.
If one desires, the bime sect ion may now be made with the
saw. If it is thought better, the adhesions lietween the
humerus, olecranon, ulna, and radius may be divided, and
the humeral cxtiemity first and the radius and ulna after-
ward displaced through iheexternal incision. They may
then lie sawn and re]ilaced. If the case be an old disloca-
tion, the librous bands between the internal condyle and
olecr.'tnon must be divided. The epitrochlea, if torn off
and dispiace<l, must be loosened and returned. The troch-
lea of the humerus and the sigmoid cavity of the olecranon
must be cleared of all librous or bony tissue. When this
is accomplished, a movement of adduction of the fore-
arm will expose the humeral extremity in the external
wound and allow the removal of the new- formation in tlie
olecranon fossa. When this is finished the radius and
ulna mavbe expo.sed in the same manner and the process
of clearing their articular surfaces completed. With the
completion of the work upon the bones the extremitiesare
apposed, sutured if desired, and immobilized at an angle
siilhcient to prevent dislocation. In the reduction of old
dislocations, this is usually a right angle, with the fore-
arm in full pronation to prevent redislocation. In resec-
tions in which motion is desired, the position is one of
nearly complete extension, with semipronation. In cases
in which an ank}dosis is desired, the forearm is left at an
angle a little less thanli right angle.
'I'lic Ajlir-Trciitment. — It is to be borne in mind that
there is always a tendenc)- to displacement of the frag-
ments, that too wide a distance between the extremities
of the bone tends to a flail joint, and that too close a dis-
tance tends to ankylosis. The usual distance for obtain-
ing a false joint is between 1 and 3 cm. In children an-
kylosis is to be especially feared ; consequently, as soon
as possible passive motion must be enforced. Usnall_v
upon the third day passive motion is begun, and is re-
jieated daily in the wrist and fingers. On the twenty-
first day the forearm is moved in flexion every second
day, and returned to the original position of extension.
In from four to five weeks the forearm can be easily
moved to ninety degrees and returned to the original
position of extension.
The movements of supination and pronation are made
at the same time as those of fiexion and extension.
At the end of from si.x to eight weeks a splint can be
dispensed with, when massage and electricity are used.
The dail}' use of the arm must be secured. At four
months the movement in the new joint should be sufiicient
to allow the patient to feed and dress himself and to carry
quite heavy weights. It will require one year before one
can see the best results iu' motion and stability.
If large quantities of bone have been removed and
the operation has been subperiosteal and subcapsular, it
is best to be satisfied with an ankylosis at a right angle
and in semiiironation rather than run the risk of a fiail
joint.
If ankylosis is attempted, passive motion in the wrist,
fingers, and slumlder is daily practised, iu order to pre-
serve their full jiower.
If the amount of bone removed has not been great, say
enough to allow from 1 to 2 cm. between the bones of the
arm and forearm, and if the operation was subcapsnlo-
periosteal or partly so, it is best to attempt a nearthrosis
or a pseudarthrosis. After the third week, when the
wound is healed and passive motion at the elbow is be-
gun, an angular hinged splint should be applied, which
will prevent, during the exercises of Hexion, extension,
su|>inatiiin, and pronation, any lateral displacement of
the bones. Very great care must be given by the patient
and the surgeon to obtain the ideal result.
One factor must not be lost sight of during the after-
treatment, and that is that an angular ankylosis with
movement at the fingers, wrist, and shoulder is more
useful to a laborious occujiation than the excessive mo-
bility often resulting from these resections. Another
fact to be liorue in mind is that in the young motion is
to lie begun early. Ip the adult, in whom there is less
danger of ankylosis than there is of a fiail joint. pas.sivo
motion need not be begun until Some firmness is present
in the joint.
The mortality, according to Culbertson, is as follows;
Gunshot irouiiils: Partial resection, 27.02 per cent.;
complete resection, 2.5.30 percent. Injury: Partial re-
.seetions, 7.4 per cent. ; complete resections, 21.0.J per
cent. .Disease: Partial resections, ILH percent.; com-
plete resections, 9.94 per cent.
In the Franco-German war (1870-71), resections for
gunshot injuries gave a mortality of 27.41 per cent.
(Ourlt). In our own civil war, gunshot injuries, when
resected, gave a morlality of 23.70 per cent. Salzman,
quoted by Oilier, gives the mortality of resections for
920
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Resoolloii of Joints.
Resectlou of Joints.
ankylosis as 1.47 per cent. Functional results are in the
main good, cspeciully in civil practice.
For disease, Culhertson gives 0 perfect and 32 useful
joints in 40 cases of partial resection, and 32 perfect and
196 useful joints in 2ilO complete resections.
Gurlt's statistics, obtained from tlie German wars
(1848-77). gives 5.(i3 per cent, as very good, 23.06 per
cent, as good. .53.24 per cent, as moderate, 14.37 per cent,
as bad, 3.09 per cent, as very bad.
Nepveu ("'Bulletin et Jlenioirede la Societe de Chirur-
gie," 1883, p. .191) presents 21 eases witli extensive resto-
ration of tlie parts. The general form of restoration is
brought about by the osteophytic growth of the condyles
of the humerus.
lu Kocher's Klinili, 1872-97 (Oschmann, " t'ber die
operative Behaudlung des tuherculoseu Elleubogenge-
lenks und ihre Endresultate," Berlin, 1897), where a
large number of good functionating joints were obtained,
it was noticed that rotation at this joint was better
tlian fle.xiou and extension. It was observed that much
value is to be placed upon the preservation of the anco-
neus for obtaining full power in extension of the fore-
arm. It was also observed in three cases tliat repeated
resections were necessary to secure good function.
Hence the importance of a thoroiigh removal at the tirst
operation is plainl}' seen in these cases. After healing
had taken place, the most frequent impediment to flexion
seemed to be enlargement of the internal condyle or of
the coronoid process. For these cases secondarj' resec-
tions, removing the impediment to motiou, are proper)}'
indicated.
The functional results of resection for old, unreduced
dislocations show that 70 ]ier cent, have good results, 30
per cent, have bad (C'uhorst, Beit. z>/r kliii. Cliir., Bd.
XX.). while the bloody reposition of these ohl disloca-
tions gave 76.9 per cent, of excellent results, with 23 per
cent, of bad results, no one of which can be considered
due to the methotl of operation (Bunge, loc. cif., p. 594).
Resection of the Superior R.\.Dio-TrDMER.vL Artictj-
LATiox. — This operation is occasionall}' made use of in
old dislocations, in fracture of the head of the radius, im-
peding the motions of rotation, of flexion, or of extension.
Operation.^ Am incision of from 5 to 7 cm. is made in
the same manner as the Kocher incision for the resection
of the elbow-joint. This incision passes in the interval
between the anconeus jjostero-internall}' and the exten.sor
carpi ulnaris anteroexternall.v. After their attachments
to the epicondyle have been loosened, the tissues are re-
tracted and the capsule is exjxised. This is incised and
the head of the bone is removed as close to the shaft its
possible. The section should be at the point where the
annular ligament is closely applied to tlie neck of the
radius. With this incision there is no danger to the mtis-
culospiral nerve anteriorly. The posterior interosseous
nerve, as it crosses witliin the fibres of the supinator
brevis muscle, is distant from the epicondyle of the
humerus 4 cm. on the external surface of the forearm.
On the posterior surface, where it meets the interosseous
artery in the interval between the supinator brevis and
the extensor ossei metacarpi jDollicis, the distance from tlie
epicondyle is usually 6 cm. or over. Hence it is dillicult
to injure it unless the incisions are prolonged further
than recommended. After the head is removed, the
capsule and ligaments are sutured and a nearthrosis or
pseudarthrosis is attempted.
At ten or fourteen days passive motion is begun and
continued for several weeks. It has usually required
three months to obtain the best results, and great assist-
ance has been derived, as I believe, from the daily use of
the hot air by means of the Sprague apiiaratiis. In tliirc
cases of fracture of the head of the radius with abolition
of supination and pronation in marked degree, removal
of the head and conservative after-treatment have given
almost perfect results.
Resection op the Shoulder-Joint. — History. —
James Bent, England, 1774, probably did the first ex-
cision; the elder Jloreau probably the first complete ex-
cision, 1780.
In theSchleswig-Holstein campaign (1848). in the Cri-
mean War (1855), and in our own civil war (1801-05) the
operation gained greatly in proniiuence and has since
then become fully established.
To obtain a nearthrosis or a good pseudarthrosis, the
line of section in the humerus must be below the tuber-
osities to which are attached the rotators and above the
adductors. In all cases as little is sacrificed as is possi-
ble, in order that the functions of the forearm and hand
may be preserved in their entirely. In children, in
whom the growth is almost finished, uperations with sac-
ritiee of the muscular attacbnients ami w itli little loss of
the humerus give good functional results with either a
nearthrosis or a pseudarthrosis. lu adults, especially if
the periosteum is not saved and tlie muscular attach-
ments have been sacrificed, ankylosis or a flail joint will
result, for the periosteal activity in adults is often want-
ing and no reproduction takes place.
In all cases the constant tendency to forwaril displace-
ment of the humerus must be avoided. In all cases the
humerus must lie held in contact with the scapular bor-
der or the glenoid cavity in order to obtain a fixed but
movable joint ujion which the muscles may move the
humerus. The mobility of the scapula compeu.sates in
great measure for immobility at the gleno-humeral union.
Imtiffitimis for I{(section of tlie Shoulder-Joint ft>r In-
.jury. — In slight injuries and in gunshot wounds, expect-
ant treatment and at the most a partial resection are indi-
cated. In severe injuries to the head of the humerus, and
in comminuted fractures from gunshot wounds with the
nerves and vessels intact, a primary resection is indicated,
lu severe injury to the head of the humerus and to the
acromion process and the scapula, the operation is not
necessarily contraindicated, provided the nerves and ves-
sels are intact. In ca.se tlie latter are involved, amputa-
tion is in all probability the only successful i.ssue. In
case the nerves are injured, the main vessels escaping,
and provided the injured nerves can be sutured, amputa-
tion should give way to resection of the joint and suture
of the nerves.
In some cases of compound dislocation or of old unre-
duced dislocations, whh or without fracture through the
surgical neck of the humerus, resection has been made
necessary ; yet these cases are becoming more and more
infrequent, owing to the aseptic treatment and to the
earlier reductions by incisions (confer here Dollinger,
Devt. Zeitschrift fi'ir Ohiriirrjit., No. 66).
1. I can quote no better authority on the unreduced
dislocation of the shoulder-joint than Souchon (Trans.
Amer. Surg. Association, 1890. p. 409). He maintains:
I. That operation is justifiable only in recent cases in
full-grown subjects of sufficient age to insure no great
shortening from want of growth in the bone. II. That
resection should be performed in all instances except
when the head and glenoid cavity are 'in good condition;
when reduction can be accomplished without great elTort
or extensive dissection ; and when the head, once reduced,
readily remains in place.
2. In fracture of the upper part of the surgical neck of
the humerus and dislocation cf the head reduction of the
dislocated head and suture of the fracture will be pref-
erable to resection in a recent case (ilcHurney, Annals
of Svrgery, 1894, vol. i., p. 399); but when union fails
and the joint becomes useless, or if the dislocated head
cannot be reduced without too extensive interference with
its nutrition, it must be removed.
3. In recurrent dislocations resection lias been pcr-
forined not infrequently, yet attempts at more conserva-
tive methods are recommended (Burrell and Lovett,
Trans. Amer. Surg. Association, 1897. ii. 293). Such a
conservative method is described in the above paper.
For D-isetise. — Here partial and comjilete resections are
indicated, although the functional results are not much
better than in cases of ankylosis following expectant treat-
ment. 1. In tuberculosis and in the deslrviction of a
joint following epiphysitis and suppuration, gonorrhiral
infection, injury and infection, or from suppurativ(' sub-
deltoid bursitis, [lartial or complete resection is indicated
921
Koscotion of JoiiifK.
iCfst't'tiou of Joiiii!!».
REFERENCE IIAXDIIOOK OF THE MEDICAL SCIENCES.
as soon as conservative surgical treatnieut fails to cure.
2. In anlvvlo.sis following acute rlicumatic arthritis and
acute traumatic artliritis with supiiuratiou, resection is
indicated in some instances.
Far iiiniors inmlriinj the boncsof the joint. A few (four)
instances exist in which a part of the humerus has been re-
moved for sarcomatous growths
involving the ioiut.
Anotiimy. — Theauatomy of the
shoulder joint is veiy simple.
All the bony prominences in its
vicinity can be easily felt. The
groove between the jn'ctoralis
major and the deltoi<l, in which
lie the cephalic vein and the
acromiothoracic artery, are ea-
sily made out. The circumflex
nerve and tlie posterior circum-
flex arteiy cross the humerus
in a horizontal line one linger 's
breadlli lielow the centre of a
Hue drawn from the acromion
Fig. 4053. to the deltoid insertion. These
two structures usually pass just
below the capsular attachment upon tlie internal surface
of the anatomical nccl<, which puint is opposite the so-
called surgical necl; of tlie humerus — the point above men-
tioned. The uppei(pi|)liysis beenmes united t(j the sliaft
at twenty years. The deltoid niuscli; is so situateil that
the only place where it can be divided without injuring a
portion of the nerve supply is ckwe to llie margin of tlie
acromion process and of the spine of the scapula. This
method of inci.sion, recommended formerly by Ni'laton,
Neudijrfer, Perrin, and Ourlt, avoids injury to tlie cir-
cumflex nerve and at the same time permits union of the
muscle to the bones without atrophy of the mu.scular
bundles. As a result, the himicral end is held in eoiitact
with tlie glenoid cavity or the border of the scapvda
in a firmer and stronger manner than can be obtained
when atrojihy of muscular lilires follows operation.
This method of entering tlie joint is not convenient for
observation of all parts of the articulation, especially of
the anterior portion.
Another nietlioil of entering the j(]iiit is by means of
incisions which traverse the deltoid muscle 'anteriorly.
There are two of these incisions. One (Baudfiis, Ahil-
gaigne, and Langenbeck, "Esmarch's Ilandbiich" and
Archinfurklii). C'/iir., xvi.) divides the anterior tibres of
the deltoid muscle and necessarily paralyzes the anterior
fibres of this muscde. Its field of observation and manipu-
lation is a direct and extensive one. The other anterior
incision (Oilier, "Traite des Resections") pass<'S nearer
the interval between the peetoralis major and the deltoid
muscles, paralyzes less of the deltoid' nuLscle, and gives
an opcrati\c field -(luile as good as that obtaineil by the
Langenbeck incision. The posterior incision is anatom-
ically the better one, but incisions must be maiie to ex-
pose di.seased areas and to render possible a full inspec-
tion of other portions of a joint than those thought to be
alone involved. Fortliis reason incisions wliieli traverse
the anterior portion of the deltoid muscle have been
selected by most surg<'ons as the best.
We will describe two methods of operation, one by the
anterior incision, the other by the posterior incision.
Both methods should be performed subperiosteally if
possilile, since the partial reproduction of bone greatly
aids the function of the joint by giving a more perfect
fulcrum for the muscles of the shoulder (von Langenbeck,
Arr/iip ///>• /,i/». Vhii:, 18T4, xvi., and Oilier. "Traite
des Re.sections," t. i. and ii.).
Operation tiji the Anterior Jiieisioit. — The patient is
placed upon the back with the elbow slightly raised from
the side and the band resting tipon the iliac spine of the
same side. An incision is begun at the outer extremity
of the eoracoid process, and descends over the deltoid
muscle ]iarallel to its tibres (i.e., slightly outward) for a
distance of li-oni 0 to 1 0 cm. (Oilier, ?ef. rvY. ; Ilnetev, "Oe-
leiikskrankheilen," vol. ii., ."),s7i. The ninsele is exposed in
this incision. The muscle is incised parallel to its fibres,
and the capsule, the humerus, and the coraco-acromial
ligament are exposed. The boiclers of the wound are
now retracted and the bicipital groove in the humerus is
noted. The capsule is divided longitudinally and exter-
nally to the sheatli containing the biceps tentlou. This
division of tlie ca]>snle extends above as far as the gle-
noid ligament. Below, the capsule and the periosteum
are divided close to but external to the commencement
of the bicipital groove in the humerus. With the rugine
when one can, and with the knife when necessary, the
periosteo-eapsular attaehnicnt of the internal flap is sep-
arated along the external ridge of the bicipital groove,
acrcss the groove, and beyond the lesser tubero.sit}'. To
facilitate tliis work the arm is rotated outward, and as
one aiiproaches this tuberosity the head is made promi-
nent in the wound by lowering the elbow during the act;
of rotation. In this manner, with good retraction, the
cajisule and the periosteum, or the capsule alone, maybe
separated beyond tlie insertion of the subscapularis mus-
cle. After this is accomplished the arm is returned to
its original position and the separation of the periosteum
and capsule of the external flap is commenced.
With a retractor beneath the capsule, the flap is raised
and the separation of the capsule and the periosteum
over the tuberosities and below upon the shaft is com-
menced. This is facilitated by rotating the arm inward
wliile it is slightly adducted and the elbow is lowered.
This mana'uvre is continued until the altachments of the
supra- and infiaspinatus and teres minor muscles are
passeil.
The arm is now allowed to hang to the side of the table
in a vertical po.sition, an<l when the retractors separate
the flaps and the biee]is tendon is drawn aside the head is
jnished upward through the wound and presents itself to
view. The capsule and the iierjosteum are now cleared
from the iiiternal surlaee of the shaft, and when they are
sufiicieiitly so the saw is applied. During the section of
the bone the head is held firmly with the long-toothed
forceps while an a.ssistant grasps the arm and steadies it.
Gigli's saw or a bow saw (Ilelfericii's) is usually pre-
ferred in making the section. The line of section is from
within outward and from below upward for oue-haif the
diameter of the bone. For the rest the section is more
horizontal (Fig. 4(15:3, ^4 A). As much of the shaft of the
bone must be saved as is comjiatible with removal of the
disease. The section should be made just below the ar-
ticular surface if ])ossible. In such a section, the whole
length of the humerus will act as a fulcrum for the del-
Fiii. 4a)4.
toid muscle in {■levating the arm. and a greater (lowcr
will lie retained than when the .section is nearer or through
the surgical neck.
The glenoid ca\ ily is now examined and is curetted or
922
REFERENCE HANDBOOK OF THE ]\IEDICAL SCIENCES.
Kesecllon of Joints*
Resei-Ilou ul' Joiul««.
cut away with the chisel or cutting forceps. If this is
necessary, the capsule aud the insertions of tlie triceps
and biceps muscles should be freed from the bone before
its removal.
In eases of bony ankylosis, the line of union may be
divided, and when the humerus is movable the resection
may be completed as above ile-
scribed, or one may saw
through the humerus first and
subsequently extirpate the
head from its capsular aud
uuiseular attachments.
In tuberculous diseases, much
time must be spent in remov-
FlG. 4055.
ing the synovial membrane and clearing up the sinuses
au^ the b'ursaj involved. When oozing is present, these
cases are best partiall}' sewed aud tamponed for sev-
eral days, but when hemorrhage is fully stopped they
should be sewed up completely. The same holds true for
other infectious aud for tumors. AVhen the hemorrhage
has been ehecUed, the capsule and the periosteum are
sutured with catgut. The deltoid is held together by
catgut sutures involving a few of its fibres, but suffi-
ciently to close the opening. Drainage w'hen required
may be obtained by an opening through the capsule pcs-
teiiorly. The skin is sutm-ed with silk.
The'position of the arm should be one of slight abduc-
tion, wilh the humerus pushed upward and backward
and in contact with the glenoid cavity or the border of
the scapula, where it is retained during the dressing by
chromicized catgut sutures inserted before closing the
capsule.
The Metliod hy the Poxterior Incmon. — This method of
incision is recommended at the present time by JlcCor-
mac and Kocher. McCormac ("Surgical Oiieratious,"
Vol. ii.) recommends it when the site of section in the
humerus is to be above the tulierosities. Kocher believes
that this method is advantageous in allowing perfect
drainage aud in preventing a forward dislocation so fre-
quent after resection by leaving intact all that part of
the joint and muscle attachment between the biceps ten-
don and the lower border of the subscapularis muscle.
His metliod of inci.sion, he believes, overcomes the inter-
ference with the exposure of the joint produced by the
prominent acromion, and likewise avoids the danger of
injury to the cireuniHcx nerve, as it passes close to the
humeral attachment of the capsule and the teres minor
muscle. His method leaves the deltoid practicall.y un-
injured, so that its action in elevation of the arm sull'ers
in no degree (Fig. 40.j4).
An incision is made, passing from the acromio-elavicn-
lar articulation over tlie prominence of the shoulder,
along the spine of the .scapula to its middle. From here
the incision inclines in a curve downward toward tlie
posterior axillary fold, ending about two fingers' breadth
before reaching it. The ujiper limb of this incision di-
vides the tissue over the acromioclavicular joint and the
spine of the scapula, exposing each. The lower limb di-
vides the tense fascia close to the posterior border of the
deltoid tnuscle and expo.ses the muscle for a distance of
from 3 to 3 cm. from the spine of the scapula. The mus-
cular fibres of the deltoid nuiscle which are inserted into
the spine behind this incision must now be divided. This
is the only portion of the muscle which is divided and
is deprived of action. The trapezius muscle is next sep-
arated subperiosteally as far as the acromioclavicular
articulation from the upjier border of the spine of the scap-
ula. Likewise, upon tlie lower border of the spine of the
scapula, the deltoid insertion is separated subperiosteally
as far forward as the spot marked by the junction of the
acromiou process aud the spine of the scapula. At this
point the spine is separated from the acromion process
either with the chisel or, better, with the Gigli saw.
(Fig. 405.5). Care must be exercised not to injure the
suprascapular nerve as it passes from the supra- to the
infraspiuous fossa. It is well also to make two drill lioles
before dividing the spine from the acromion process, so
that the)- can be more easily sutured at a later date.
When this separation is completed, the acromion proc-
ess with the attached deltoid muscle is luxated forward.
The deltoid muscle is thus raised from the teres minor,
the infraspinatus, aud the supraspinatus muscles, to
wliich it is but looseU' attached by connective tissue.
After the dislocation of the acromio-deltoid flap, the in-
sertion and the muscular bellies of these three muscles
which cover the humeral head are exposed (Fig. 4056).
The elbow is now brought forward and the arm is rotated
outward. Along the U]iper border of the supraspinatus
muscle an incision is made from the margin of the glenoid
cavitj' to the spine of the greater tuberosity, exposing the
tendon of the biceps muscle in its whole length within the
joint. The outward rotators are next loosened subperi-
osteally from the greater tuberosity, and, while still at-
tached to the periosteum of the shaft, are retracted pos-
teriorly. If one wishes, a small part of the tuberosity
Fk;. iOaO.
may be cut away with the chisel, leaving thus a nucleus
for" the future development of a new tuberosity (^'ogt's
method). The bicejis tendon is now loosened from the
bicipital groove and is drawn forward. The insertion
92;;
Rosec-lfoii or JoiutN.
Kcsei-tiou uf j€>iut».
liEFERE^T'E HANDBuoK OF THE JIEDK'AL SCIENCES.
of the subscapular muscle is seen at its attaehinent t<>
the lesser tuberosity and to the spine of this i\ibi-rosity.
It should be separated subperiosteally and diiiwn fcirward
and inward. Tlie circumflex arteiy and nerve are to be
avoided at the lower border of this muscle. As soon as
the liead is thus freed, it can be easily ju-Dtruded through
the woiujd (Fig. 40.")6). After it has been removed, the
glenoid cavity should be freely exposed and to an extent
which is unattaiuable b.y any anterior incision. This ex-
posure is best accomplished, after the head has been re-
moved, by exerting traction U]ion the clliciw while it is
held in the position of adduction. Tlie importance of
the exposiu'e of the glenoid cavity in tuberculosis of this
joint cannot be questioned, and therefore tliis method
has its specitic application.
After the synovial membrane, the bursa', and the bones
are removed, the capsule and the ])eriosteiun ari' sutured,
and the wound is closed. If drainage is necessary, the
capsule should be incised below the border of the teres
minor, and care taken to avoid the circumflex nerve and
artery as it emerges beneath t lie muscle. These are easily
recognized, however, sinte the field is so well exposed.
After this is accomplished, the spine of the scapula and
the acromion should be sutured. The trapezius and the
deltoid are sutured over the acromion or spine of the scap-
tda if necessary; if it is not thought ncces.sary, they are
left unsutured. The skin should be sutured separately.
Sir Willia'u MacCormac jirefers entering the joint be-
tween the teres minor and the infraspinatus muscles,
clearing the infraspinatus, supraspinatns, and the sub-
scapnlaris muscles and the biceps tendon forward, until
the bone is free, and subsequently clearing the teies minor
muscle with tlie capsule posteriorly. In some instances
this is undoubtedly a good method of approach after the
deltoid has been "retracted forward ("Surgical Opera-
tions," part ii.).
After- Tn'titiiient. — The main point in the after-treat-
ment seems to be the retention of the head in ccmtact
with the glenoid cavity or with the border of the scapula.
This contact may be secured by the use of chromicized
catgut, which lasts long enough to instirc no slipping
during the primary dres!sing. A large pad made like the
Stromeyer's cushion is now jilaced in the axilla, and the
arm resting upon this jiatl is secnred to tlie side, while the
forearm is supported by a sling. This jiad supjiorts the
htimerus. fixes it, and prevents the tendency which the
pectoralis major and the latissimus dorsi have, to dis-
place the upper end of the humerus in an inward direc-
tion, beneath the coraeoid process. This tendency will be
more difticult to counteract if the external rotators have
been divided.
Tiie flrst dressing is not changed for from six to ten
days if possible. The movements of the Angers, wrist,
and elbow are gently exercised dail_y from the very first.
It is useless to begin moving the shoulder until the deep
parts of the wound aie sulficiently healeii. i.i:.. usually
in the .second or third week. In this manipulation abduc-
tion must be made with cire, for fear of ilislodging the
head and forcing it beneath the coraeoid process. Daily
application of massage, electricity, and snperheated air
(Sprague apparatus) to the muscles of the shoulileris very
useful m preventing too extensive ankylosis.
The deltoid and the rotator nuiscles should lie daily ex-
ercised by appropriate manipulations. This should be
continvie(i for from four to six weeks, after which the pa-
tient must carry out his own exercises, such as biinging
a gun to the shoulder, lifting weights with the arm ab-
ducted, and appropriate exercises upon the various kinds
of gymnastic weights and pulleys.
The after-treatment must be maintained for a long time
in order to obtain the best results. Langenbeek refeis to
a CA'AO (Airliii\fiir kliii. C/iii:. xvi., p. 3!)3) in which the
arm increased in strength for two years following the
operation.
li'i's'ilfs. — According to C'nlbertson, the mortality was
as follows: For gu-ushot wounds (85.1 cases), 31.44 per
cent.; for disease (IIG cases), 1.5..S4 per cent. According
to Otis, the results were as follows: Out of 2,309 cases
of gunshot wounds, .577 of which were treated by the
expectant mi'thod, there were O")! cases which were
treated by excision, with a mortality of 36.6 per cent.,
and 841 cases which were treated by amputation, with a
mortiility of 39.1 percent. The mortality for the 2,369
cases was 25. 1 percent. According to Souchon, the re-
sults, in cases of old irreducible dislocations, with or
without fractuie of the humerus, were as follows: In
those treated by reduction, the mortality was 10 per
cent., and in those treated by resection it was 12 per cent.
T/ie Fuiii-liiiiKd JicS'ilt. — Usually flexion and extension
are good ; adduction is also usually good. Rotation and
abduction are usually feeble. The tendency in this joint
is toward ankylosis ratherthan toward a flail joint. The
subperiosteal metliod ((_)llier) gives the most perfect func-
tional result, and should be practised whenever feasible.
According to Giurlt ("Ueber Gelenksreseetionen nach
Schusswnnden," Berlin), the results in 213 cases were
as follows: Very good, almost perfect, in 1.S7 per cent. ;
good, not perfect, but useful, in 43.2.5 per cent. ; moder-
ate, of limited use, in 47.88 per cent.; bad, useless, ia
7.98 per cent. In the German wars (Langenbeek,
Ari-hic filr klin. Cln'r.. xvi.), conservative treatment gave
at least as good results as the resections which were then
performed. Thus, in 44 cases of resection of the head
of the humerus, the results were good in 2 instances,
while in 31 cases the shoulder hung like a flail, and the
elbow, hand, and fingers were more or less useless. On
the other hand, in .54 cases treated con.servatively, there
was ankylosis in 43 instances, but the elbow, hand, and
fingers continued to be useful. " When the subperiosteal
method is emiiloyed and the supraspinatns, the infraspi-
natus, the teres minor, and the subscapularis muscles
remain in connection with the periosteum of the shaft of
the hinnerus. a flail joint will not rcsuit." "The good
results are obtained when the subperiosteal method is
carried out." He reports 8 cases with excellent results.
^VegUiff {C /ill rite An /Kilen . 1901, Bd. xxv.) alsoreportsan
excellent result following resection of this joint for caries
sicca (tuberculosis).
The Kiosection of the Lower Extremity. — The
small joints of the foot occasionally require resection.
Corresponding joints in the toes are removed in the same
manner as those in the fingers. As a matter of fact, re-
section of the toes is seldom done, since their deforma-
tions do not demand it.
Resections of the metatarso-phalangeal joints are per-
formed in the same manner as in the liand. The inci-
sions arc placed to either .side of the extensor tendon in
the second, tliird, and fourth metatarso-phalangeal
joints, to the inner side of the tendon in the first meta-
tarso-phalangeal articulation, and to the outer side of
the tendon in the fifth metatarso-phalangeal joint.
Of these joints, the metatarso-phalangeal articulation
of the great toe is not infrequently resected for hallux
valgus. As these cases are quite often complicated with
a bunion which requires removal at the same time, this
incision is a semilunar one. It extends from a point on
the metatarsal bone, 2. .5 to 3.5 cm. above the joint. It
descends in a curve over the lower quadrant of the bunion
initil it reaches its mid-point, whence it ascends iu a
curve to the centre of the outer border of the flrst plial-
anx. This flap with the deep connective tissue is dis-
sected fiom the biuiion until its base is reached. The
adventitious tissue and the bunion are now removed, after
which the subperiosteo-capsular method is pursued in
freeing tlie ends of the bones. "When the periosteum and
the caiisule are loosened to beyond the centre of the ar-
ticular surfaces, the ends of tlie bones may be made to
protrude through tlie wound. (Fig. 4057.)
Tiny may now be removed completely or partially as
desiied. Since it is very necessary to retain the sesamoid
bones, the separation of the periosteum and of the cap-
sule u]ion the inferior surface of tlie joint must be done
with can'. After removal of the articular ends of the
bones tliey are jilaced in apposition and sutured with
catgut if one desires an ankylosis. If a pseudarthrosis or
nearthrosis is desired, no suture of the bones is made.
f)2-i
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
R<'»<i<><-ti4>ii 4ir Joiikts*
Itpset'liou of Joluls.
Aukylosis is obtained b_v maintaininjr the lioiies in appo-
sition. Pseudartlirosis or nearthrosis is obtained wlien
the ends of the bones are left witliin tlie capsule wliieli is
closed over them. JIany deformities in haUn.\ val.srus,
where the bunion and the deforniitv are not great, may be
corrected l>y a cuneiform osteotomy of the lower third of
the metatarsal bone, and such an operation is to be ad-
vised in the minor cases of this condition.
Resections involving either the metaUir.so-tarsal. the
tarsal, or the talo-tarsal joints, are rarely performed, lie-
cause disease is scarcely ever confined to any one of these
several joints. It is rare to have only one of the seven*
articular synovial cavities of the foot involved.
Disease or infection from injury commencing in any
one of these seven cavities soon spreads through the can-
cellous tissue of the bone to the neighboring synovial
cavities, so that the process rapidly becomes a diffuse
synovial, parasynovial, and periosteal one (Fig. 4058).
'For this reason resections of single joints are rarely
made on account of disease. In injuries to these joints
and in deformities congen-
ital or acquired, resections
of single joints can rarely
be performed in even mi-
nor grades of the injury or
deformity. We must look
upon the foot as a whole
and o])erate without re-
gard to tlie joints, with the
sole idea of removing the
condition for which we
operate.
There are several pro-
cedures which are appli-
cable to injury or disease
of this legion: (1) Those
of Bardenheuer and P.
liruns; (i)tlioseof Wladi-
miroft-]\Iikulicz and Klim-
mell. For di-scase or in-
jury situated between the
bases of the metatarsal
bones and the calcaneus
and talus, Bardenheuer's
method is especially ap-
plicable, lu the majority
of cases the involvement
of the tarsal bones and tlie
periosteal tissues is so
great that an extensive ex-
posure iiuist be made in
order to remove the diseased tissues completely. AVliere
the disease involves the mctatarso-larsal, the talo-cal-
cauco-uavicular, and the caleaneo-cuboid articulations,
the method of H. P. AVatson (Jacobson's "Surgery,"
*I. Between ttie first metatarsal and the inM.'rnal cuneifurm bones.
II. llctUfiiilheNTiinil and tbird iiicmtafsal and the middle and I'.MiT-
nal runeifnnii imtics \\liich romnuillifate wilh IV. III. Kidwern tin-
fourth and tiflli metatarsal and the cuboid. IV. Between the three
cuueif(.riu and tlie sc-aiiiiold bones whlcli comiuunii'ates with II. V.
Between thecubriid and calcaneus. VI. Between the navicular and
the calcaneus and the talus. VII. Between the talus and calcaneus.
FIG. 4038.
Fig. 4059.
voT. ii., p. 707) is not satisfactory and a more extensive
exposure is retiuired. It is here that Bardenheuer's
method is most applicable.
Anterior Tarsectomy (Bardenheuer, "Mitthcilungen aus
ilem Koluer Bi'irger-Hospital," 1-4). — An Esmarch ban-
dage is applied. An incision is made through the skin,
subcutaneous tissue, tendons of the extensor communis
longus and brevis and proprius pollicis, and the cuta-
neous nerves, down to the bones from the tirst to the
liftli metatarsal bones at their bases (Fig. 40.'i9). From
the extremities of this incision, two incisions are curved
upward along the
internal and exter-
nal borders of the
foot to beyond the
medio tarsal joint.
These incisions also
extend through to
the bone, dividing
the tendons of the
peroneus tertius
and of the tibialis
anticus. If neces-
saiy, these lateral
incisions may be
prolonged upon the
metatarsal bones,
the U-shaped incis-
ion being converteil
into an H- shaped
one. This Hap as
marked out is dis-
sected from the
periosteum and the
ligaments of the
bones until it can be
reflected above the
level of the medio-
tarsal joints. Here
it is best to enter the joint, dividing the ligaments upon
the anterior and lateral surfaces, when, if the forefoot is
firmly held and depressed, the plantar ligaments holding
the calcaneus and scaphoid and the calcaneus and cuboid
can be divided. This division frees the tarsus, and allows,
,as in Lisfranc's am-
]iutation. an easy __.^-''" "\
separation of the /'' '•
tendons of the tibi- ■ \
alls posticus, the j '•;
peroneus long u s.
and the less import-
ant muscles from
the tarsus as far as
the bases of the
metatarsal bones.
At this point a blunt
retractor is passed
between the bones
and subjacent tis-
sues, and tlie bases
of tlie metatarsal
bones are sawn at
the distal side of
their articular sur-
faces. The articular
surfaces of the
cali'aneusaudof tlie
talus are now saAvn
olT(Fig. 40G0). The
disease involving
the muscles and the
sheaths of the ten-
dons is next re-
moved. The ves-
sels ;ire ligated, the
Ksmarch bandage is removed, and the .sawn extremities
of the bones are apposed and sutured with cliromicized
catgut. If the disease is not thoroughly removed, or if
X.
\l
i' cat cat
Fig. 4UiJ0.-
T)iaijra?n Illustratini^ Biirtlcn-
925
]trso<-tioii of .Toiiils.
UI'^FERENCE HANDBOOK OF THE MEDICAL SCIENCES.
one so dcsivcs for any otber reason, the wdiuhI ma}- be
parked until granulation appcat
uring is done.
In this operation tlie tendons
are rarelj- sutured. It has been
found tliat in healing li\' granu-
lation the fibrous ciealrix unites
the tendons so tliat motion in the
toes is often good. It is, liow-
ever, advisable that the tendons
be sutured whenever the wotnul
treatment allows it. If possible.
when a .secondary sui-
FiG. 41)1)1.— Liitei;il Viuw of ttie Bones after Bardenlieuer's ResecUoii
of tile Tarsus.
the tendons to the first toe should be sutured in all
cases. In some cases sensation has returned though no
suture of the nerves was attempted.
O. WollT (Verb. d.
deut. Ges. f. Chir..
1896) has presented
53 cases operated on
by this method, in
w'hich the anterior til)-
ial artery was cut. In
5 cases the posterior
tibial artcrj- was also
cut. In 3 of these
cases gangrene fol-
lowed and required
amputation. Of the.se
cases, 42 were tubercu-
lous in character, for
which 9 complete tar-
seetoniies, 7 j) a r t i a I
with subsequent com-
plete tarsectomies. and
13 partial tarsectomies
were performed, with
29 complete cures.
Two cases escaped sub-
sequent observation.
Three cases were ampu -
tated for gangrene and
8 cases remained luider
treatment at the time. In all the cured eases the foot re-
mained a " tlat " one, but the functional results were good.
The after-treatment is mainly devoted to maintaining
the forefoot in position and
in apposition with talus
and calcaneus.
Bardenheuer ("Mitthei-
lungen aus dem Kijlner
Burger -Spital," 188«) re-
ported 17 cases of tubercu-
losis, in which none died as
the result of ojieralion.
Twelve cases were cured
with one operation, and of
these 3 died subsequently
of tuberculous meningitis;
3 required subsequent revi-
sions befoie a cure was ef-
fected; 1 required aniiiuta-
tion. One case of resection
was due to loss of substance
from iniurv ;ucure resulted.
(Figs. mn. 4(162, and 4063.)
Tibi'ri - Ceil.aniean licmc-
Hon. — The statistics of Audry ("Sur les tubereuUxses an
pied," licfiic (/<■ Chintf'jic, 1890) show tliat tuberculous
Fifi. 4002.— Anterior View of the Bones
after Burdeubeuer's Itesectiou.
Fir.. 4IHi;!.-Vt,'W of Ciei
l^afdenlieiler's IJcsecti
Tarsus.
Fig. 4064.
disease involves the ankle, the talo-calcanean, and the
talo-ealcaneo-navicular joints in fourteen per cent, of the
tuberculoses in the foot, and that unless amputation
be performed at the ankle (Syine's or PirogotT's) some
method must be found by which all of these joints can
be opened and resected. Such a method has been elabo-
rated by P. Bruns in 1890 (BeitraQe zur klin. Chir., No.
7, p. 223). This
operation, made a
t y J) i c a 1 one by
Bruns, was previ-
ously done in an
atypical fashion
by Te.xtor, 1853,
and 51 u 1 v a n e y,
1866, and has sub-
sequent ly been elab-
orated by Heiden-
liain, Hel f e ri c li,
Cramer. Kiitlner,
and Kummer
The indications
for this operation
are the same as
those for Pirogoff's
amputation: name-
ly, disease involv-
ing the talo-calcane-
au, talo-navicular,
and talo-c rural
joints, with foci
within the bones.
Its advantage rests
in the fact that it preserves the forefoot and gives a
more useful member than is obtained by an amputation.
The method is as follows; An Esmarch bandage is ap-
plied. In order to obtain sufficient exposure an incision
is made from one malleolus to the other in a broad curve
over tlie dorsum of the foot in the neighborhood of the
metatarso-tarsal joints (Fig. 4064). This curved dorsal
incision, first made by Houssey (Ileyfelder, " Resec-
tionen," 1861) and subsequently used by Bardenheuer in
his excision of the tar-
sus, is no disadvantage
because of the division
of the te n do n s and
nerves. The tiap thus
marked out is deep-
ened, passing above
the peroneal tendons
on the outer side and
dividing U|)on thi^ dor-
sal and intern.'il sur-
faces the ]ien>neus tei-
tius, extensor loiigus
digitorum, p ro p r i u s
poUieis, and tibialis
amicus tenilons, to-
gether with the
branches of the ante-
rior tibial and nuiscu-
locutaneus nerves and
the d<')r.salis pedis ar-
ter_y. This llap is dis-
sected from the bones
until the anterior tibial
margin is reached.
The talo - crural joint
is opened bv a transverse incision which divides the an-
terior fasciculi of the lateral ligaments. The foot is
pulled forward and depressed, when the middle and
posterior fasciculi of the lateral ligament are divided as
close to the astragalus and os calcis as possible. With
farther depression, the posterior ligament of the ankle-
joint is divided transversely, exposing the flexor longus
pollicis tendon. The talo-navicular and the calcaneo-
cuboid articulations are next entered and the superior
and lateral capsular bands divided. If the astragalus
Fir,. 4()6o.
926
REFERENCE HANDBOOK OP THE ]\H:DIC'AL SCIENCES.
Re»(ecti<»il of J<»iiilN»
K4'S(*i-tioii ol' JoiulN.
is now cleared upon its lateral surfaces and llie knife is
passed into the sinus tarsi and carried from before back-
ward and toward tiie sustentjiculuin tali, the iuterosseous
ligament will be divided. The astragalus is now held
only by a few unoi\ idi'd capsular fibres of the posterior
talo-caleaneaii artieidalion and can be easily removed.
Tlie navicular, caleanean. and cuboid bones, the tibia
and the tibula, are now inspected for disease, and if tbey
FIG. 40150.
are involved tbey should be treated as follows: The tibia
and tibula are sawn so as to preserve their mortise sliape.
This is usually accomplished by cutting away the articu-
lar end of the tibia with the chisel or gouge, preserving
its hollow shape, and by sawing the malleoli obliquely,
leaving a small projecting edge beyond the surface
of the tibia (Fig. 4U65). The superior surface of the
calcaneus is made to tit accurately the space between
the malleoli. This will not infrequently require a re-
moval of the sustentaculum tali. The calcaueo-nf. vicular
and the inferior calcaneo-cuboid ligaments are now di-
vided or separated from the interior surfaces of the cuboid
and scaphoid bones, so as to allow a vertical section with
the saw. After this section, the anterior surface of the
calcaneus is sawn in the same plane. The tendims. their
sheaths, the ligaments and the mascles are next inspected,
and if involved by disease they shoidd be removed, after
which the calcaneus is apposed to the tibia and fibula and
to the cuboid bone. These lioncs are held in apposition
by catgut sutures. The scaphoid bone will be seen to rest
against the anterior margin of the tibia. The Esmarch
bandage is now removed. The liemorrhage is controlled.
The tendons, the nerves, and the deeper tissues are sutured
to one another as far as is possible. As regards this point
it may be said that most surgeons do not suture the several
tissues to one another, but while no bad results may fol-
low the adoption of this course, yet the time required for
healing is undoubtedly lessened by a perfect apposition
of like tissues. In tlie face of severe infections, the
wound is left open and is jiacked until granulation ap-
pears, when secondary suture is made.
The after-treatment consists in absolute rest and eleva-
tion of the foot for from three to five days in au immov-
able splint, which holds the foot at right angle to tlie leg.
At the end of ten days any deviation of the foot can be
corrected with ease.
This operation ran also be performed by a ]iosterior
curved incision which expo.ses tlie malleoli. The incision
is deeiieiieil and is can led through the tendii Aeliillis,
after which the joint is opened, the malleoli are .sawn,
and the talus is extirimted. The o|)eration is compleled
as in the operation by the anterior incision.
The time required to obtain healing by first intention
(5 cases) was from 28 to 48 days ; for cases healing by sec-
ond intention, 35 to 60 days (2 cases). H recurrences-
take place (2 cases) the time is naturally more extended,
i.e., 84 to 397 days — an average of 210 days (Kiittiier,
Vxitrwie znr hUn. (J/ilr., ii., p. 749). The mortality from
the operation is nil.
The Final Result of Operation. — The shortening in the
leg is usually from 1 cm. to 1..5 cm., and that of the foot
about 1 cm. The apjiearance of the foot after operation
is seen here (Figs, 400(i and 4067).
The function of the foot is good It allows use all day
and requires only an ordinary shoe.
The p.seudarthrosis between the calcaneus and the fore-
foot gives elastieily to the gait, which is wanting in ar-
tificial limbs. '
The talo-ealcaneus resection is to be preferred to am-
putation, either Pirogoff's orSyme's, because it preserves
the foot. It is preferable to the \Vladimiroff-JIikulicz
resection because it is ea.sier of execution and requires no
subsequent prothetic apparatus.
Postcn'vr J'arscrtomy. — (Kiimmell, Ci-iitrnllilaltf, C/iir.,
1893, No. 47; Verhaiidl. der deuts. Ges. f. Cliir., 1889, i.,
."i7.) When disease involves not only the ankle-joint but
the medio-tarsal and tarsal joints as well, one of three
things must be done: either an extensive atypical resec-
tion (Ivtimmelland Cramer), ora AVlailimirotf-MiUulicz re-
section, or an ampulation at or just above the ankle-joint.
A priari. it may be thought that a removal of the cal-
caneus, talus, tarsal bones, the malleoli, and the articular
surface of the tibia would give a bad functional result.
This is not the case, however (Cramer, Verhandl. der
deutseheu Gesellsehaft t. Cliir,, 189.5, i., 16). The ex-
tensive removal of these bones, leaving a fofit formed of a
part of the tarsus, the metatarsus, antl phalanges, gives
a better result than the einiinus position of the foot seen
in the "WladimirolT-Mikulicz resection. It is true that
the foot is shortened, but a foot with a sole is better than
the equinus of the Mikulicz operation, because a movable
foot is obtained and because the pressure-bearing surface
is a natural one and greater in area than is obtained by
the Jlikuliez resection.
Indications. — Tuberculosis involving the ankle-joint,
the calcaneus, talus, and tarsal bones, with tistuhe. In
children and in young adults the operaliim is indicated.
In adults who have tuberculosis elsewhere and are not
holding their own against the disease, and in the old and
ana'mie, amputation is preferable. No matter whether
the fistuhe are ujion the dorsum or upon the plantar sur-
face of the foot, the operation with the dorsal incision is
equ:illy indicated.
The incision for exposure of the bones is similar to that
used in the P. Bruns method. The removal of the talus
is similarly carried out;
after which the bones of
the tarsus are removed fit
iN(ix.v, as is recommenilc d
in the Bruns methoil
This removal of the tai
sus is often complete, so
Kii;. mi~.
that the section of the bones includes the bases of the
metatarsal bones. Tlu^ lower ends of the tibia, and filiula
are remo veil with a transverse section, unless the calcaneus
can be parlly saved, when the section is similar in shape
to that rei'ommeiided in the preceding resection. No
matter how little of the calcaneus is saved, the resulting
shortening and the functional result are much imiiroved.
After removal of the diseased bone the bases of the meta-
tarsal or tarsal bones are apposed to the anterior sur-
927
Rcsorlioii of
ICosoi'tioii <>r
JoinlN,
Join I (4.
liEFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Fl(i. -lUBS.
uiiil the pnipcr position of the
" " , is maint.aiuctl 1)\' ap-
face of the lower cud of the tibia, where they are fas-
tened with sutures it possible. In Kiimniells first case.
in which 2.0 cm. of the tibia and lilnda and all the tarsal
liones were removed, the resulting-
sliorteuing was about 3 cm. In two
of Cramer's eases the resulting short-
ening w;is less,
Atter-Treatment. — Frequently the
large cavity left after extensive re-
moval of the hemes cannot be closed,
and must be packed with gau/.e and
treated as an oiien woimd because of
tlie jiresence of tistul;c. The cavity
left between the tarsus and the tibia
and tilnila closes rather
quick ly. The soft
parts of the planta pe-
dis draw up between
these bones and a ])il-
low is formed under
tlie tibia. The time re-
quired for this is usu-
ally two months. Dur-
ing this time the W(juud
is dressed as refiuircd,
forefoot in its relation to the tibi;
propriate right-angled sjilints.
Tlie residts of this o]ieration show
that the gait is elastic and not "hob-
bling."as istlie case with the equinus
]i(isition of tlie foot after a AVladimi-
rolV-.'Mikulicz resection or the amputa-
tions or disarticulations. Thiselastic
gait is due to the jiseudarthrosis lie-
twccu the tibia and fibula, or the cal-
caneus, and the foretont. Another
adv;intage claimed for this procedure
is to be tVnuid in the fact that pro-
llielie aiqiaratus will not be needed
after the cure. iSi.x
cases rei)orted by Cra-
mer gave two cures in
children of three; and
1 1 )ur years of age. Two
cases of adults of ten
and twenty years of
Fk;. am. ai-'e were still under
treatment at three and
four months. Twd cases <lied of generalized tubercu-
losis following o])eration. A view of a fo<it following
such an operaticni is seen here {Figs. 4008 and 4(Ki!l).
When the disease is of the same extent as would lead
one to perform the foregning oiieratiou, while at the same
time the greater pail of the lieel is the seat of destructive
disease and of listuhe, the reseetio tar.sea totalis of Wladi-
mirolI-Mikuliez may be considercii.
The indications for this proceduri! are: (1) Caries of llie
tdus, calcaneus, and tarsus (Mikulicz): (-) extensive loss
of the tissues of the heel (Mikulicz) : (S) injtiries destroy-
ing the heel (MikiUicz); (4) new growths involving the
bone (calcaneus) or tissues of llu: heel (SchlitTo.scw sky
andWahle); (5) to increase the length of the extremity,
as occurs in infantile paralysis (Caselli); (fi) for jiaialytic
eqnino- varus (limns).
The object of the ojieration is to secure an artilieial
pes equiuus. The toes and metatarsus are ]U'eserved and
are apposed, in a vcrlic;il plane, to the tibia ami tibula.
Tlie patient walks upon the heads of the metatarsal bones
with the toes bent at right angles to the leg. The
operation was tirst iierformed by WladimimlV in ISTl
and bv Mikulicz in \>^>ii) (Arc/iir'f/ir Idin. rliir., \\\\.,
p. 497).
Coiiijilclc Tiiyxiflo))}ji (Uisi'Ctii) Tursi'ft IhtdliK). — All Ks-
niarch bandage is a|iplied. The patient is placed iijioii
the abdomen with the foot extended. Just in front of
the tuberosity of the .scaphoid bone, upon the inner side
of the foot, then; is mack; an incision which passes trans-
versely across the planta pedis to a point just behind the
tuberosity of the fifth metatarsal bone. From each ex-
tremity of this incision, iipou each side, an incision is car-
ried upward and backward to the malleolus. The ex-
tremities of the latter incision upon the malleoli are now
united by a transverse incision across the posterior surface
of the leg. When the bones of the leg must be denuded
at a higher level than is usual, the lateral incisions must
be carried beyond the malleoli (Fig. 4070).
All incisions pass directly down to the bones, dividing
tile muscles, tendons, nerves, and arteries. The posterior
capsule of the ankle-joint is divided, together with the
posterior, middle, and anterior fasciculi of its lateral
ligaments.
The foot is now thrown in dorsal flexion and the talus
and calcaneus are carefull3- separated from the soft parts
no. lOTO.
of the dorsum (d'tlie font until the medio-tarsal joints are
reached. Here these bones are sejiarated from the cuboid
and navicular, and are removed with the heel li;ip. The
lower ends of the tibia and fibula are now sawn across.
The cuboid and navicular bones are likewise sawn trans-
versely (Fig. 4071).
The Esmarch bandage is removed and the arteries are
tied. When hemorrhage is completely stopped, the cu-
boid and navicular bones are ajiposed to the tibia and
tibula and are retained in jiosition by chromieized catgut
sutures (Fig. 4072). The wound is
now closed with deep catgut sut-
ures and over the aseptic dressing
is placed an inuuovable plaster
dressing holding the parts firmly.
Soiiietimes in placing the bones in
.'ippo.sition the folding of the an-
terior bridge of soft tissues dis-
places the forefoot. 'When this oc-
curs, the bridge of tissue must be
folded and retained by a few mat-
tress sutures.
The after-treatment consists in
elevating the foot and retaining
Fig. 4071.
this position for firim three to five days: after this it
may be lowered. In from six weeks to two months the
union is complete. The lengthening of the limb is usu-
928
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Resection of Jolnls.
Resection oT Joints.
ally 1.5 cm., which can be casilj- overcome b_v a heel upon
the opijosite foot. Fig. 4073 shows the foot healed.
Kohlhaas (/iciVw^;; zur klin. Chii:, viii.)has collected
seventy-three cases of this operation with one death from
pyamia and one requiring- amputation for gangrene.
Several cases presented localized areas of gangrene, but
did not require other than simjjle treatment. Three
cases failed to liave a firm luiion between the bones of
the leg and foot and required sub.sequeut operations.
Fifty-six cases gave good results and required no e.xtra
prothetic apparatus or shoe. Nine cases gave moderate
results and required special prothetic shoes.
To a's'oid the division of the posterior tibial arteiy and
nerve, and the disturbances in nutrition and the gangrene
which may residt therefrom. Lotheisen (BtitrOge zur kiln.
Chir., xviii.), P. Bruns {iliUL), and OllierC Traite des Re-
secti(ms ") have devised various modifications in the incis-
ions. Lotheisen's incision is as follows: Tlie patient lies
upon the back. Tl]e extremit}' is raised and the foot is
dorsally flexed. Ujion the other surface an incisi<m,
commencing 1.5
cm. above the at-
tachment of the
tendo Achillis and
between the fibula
and the tendon, is
carried obliquely
forward and down-
ward belov.' the
malleolus, ending 3
cm. behind the tu-
berosity of the fifth
metatarsal bone
(Fig. 40T4). I'pou
the inner side a
similarly placed in
cision is made, be-
ginning above tipon
the same level and
to the inner side of
the tendo Achillis,
descending forward
behind the internal
malleolus, and end-
ing just in front of
the fuller calcanei
(Fig. 40T.i). The
extremities of these
lateral incisions are
united across the
sole by an oblique
incision (Fig. -lOT(i)
and across the leg
by a horizontal one.
The enucleation of
the talus and the
sawing across the
tarsus and the bones
of the leg are ac-
comphshed as in the
former method. A very similar method was described
by Jaboulay and Lagaite ("'Nouveau procede pour pra-
tiquer I'amputation osteoplastique de I'arrierepied,"
Vol. VI.— 59
Fig. «iT3.
Lfioii medical, 1889, No. II), but it offers no advantages
over the above. The result of Lotheisen's method is seen
in Fig. 4077.
To avoid the same result, P. Bruns has recommended
strongly the simple median posterior
incision, especially in cases in which
the heel is intact and free from ulcera-
tion. Bruns' incision begins on the
posterior surface of the leg, four fin-
gers' breadth above the tubercles of
the calcaneus, passes downward over
the centre of the heel and to the cen-
tre of the sole of the foot. This incision
extends immediately down to the bones.
The talus and the calcaneus are re-
moved subperiost<'ally after opening
the ankle- ji lint. The bones are sawn
and apposed and held by suture. Bruns
meets the objection made by Lotheiseu
and by Oilier to the enormous mass of tissue left in the
heel, which forms an ugh% thick, projecting hump on the
posterior surface, by show-
ing the photograph of his
case of paralytic talipes
equino-varus operated upon
" " "■ 4073
esec-
FiG. 41174.
tions," iii., p. 691) has described a similar incision, but
lie liad not performed it ujion the living subject at the
time wlien Bruns used his incision.
Of the incisions used
for the total tarsectomy,
none seems to meet the
surgical requirement so
well as Lotheisen's,
which avoids injury tc
Fig, 4075.
the posterior tibial artcrj' and nerve and allows the tis-
sues of the leg and sole of the foot to be easily ap-
posed and sutured one to another. In cases of paralytic
equinus or equino- varus with extreme shortening, the
Fu;. 40TG.
posterior incision of Bruns or Oilier has given as good
results as the methods of Lotheiseu and Jliknlicz. _ In
this particular class of cases the objections to be raised
929
Ro)«4>otioii of JoiillK.
Ki'sfftion <>r Joiiils.
REFEREXCE IIANOnoOK OF THE MEDICAL SCIENCES.
Fic;. 4077.
a.sainst tlie incision, the subperiosteal enucleation of tlie
bones, and the projecting mass of the heel when 1 he parts
are apposed, do not hold as they do in disease or injury.
It maybe said willi truth that
the total" tarsectoniy (Wladiniiroff-
Mikulicz) and the extensive resec-
tions of Ivummell will sc;ncely ap-
jjeal to many surgeons, when they
compare the time spent in olitain-
ing these results, the extent of the
procedure, and the drain upon
an ahead}' woi'n-out subject. An
amputation (Syme's, Pirogoff's,
Guyou's) witli the raiiid healing
and the iiraelical prothetic appli-
ances made in this country will. I
doubt not, cause mo'.t surgeons to
advise amputation whenever the
patient can oljtain an artificial limb.
()nly in the very ]ioor and in those
of moderate age and good health
(especially such as have congeni-
tal and paralytic deformities or
injuries) will tlie extensive pro-
cedures of KUnimell and Jlikulicz
be adopted. Ou the contrary, the
anterior and posterior tarsecto-
mies of Bardenlieuer and Bruns
give such excellent feet after op-
eration that no (juestion can be
raised as to their advisability in
suitable cases and their superi-
ority to amputations.
Kesection- of tut-; Anklk-Jotxt. — This operation was
first performed by IMoreau in 1793. Subsequently, owing
to the complicated character of the joint, tlie presence of
tendons and sheaths in the immediate neiglilxirhood, and
the relapses following operation, surgeons gave up the
method and resorted to amputations.
Better methods of approach, more complete removal
of the disease, and the aseptic treat numt of the wound
have so lowered the mortality that amputation now pre-
sents no advantage in this respect. At the Siime time
the patient is left with a foot which is more useful
and ajsthetically lietter than the stump of an amputa-
tion. (See Fig." 4080.)
Partial resections are those which remove the whole or
a part of tlic artictdar surfaci-s of the tibia, the fibula, or
the talus. Com-
plete resections
do remove all of
these surfaces.
The talo-cru-
ral articulation
isbestai>proach-
able from the
sides. In front,
it is covered Ijy
the tibialis ami-
cus, the ex-
tensor 1 o n g u s
digitornm and
proprius poUicis
and the peroncus
t e r t i u s. the
nerves, and the
anterior tibial
artery. Behind.
ir. is covered by
I he tendo Achil-
lis in the centre,
and upon either
side of this bj-
the peroneal ten-
dons or tlie tibialis posticus, flexor longus digitornm.
iongns poUicis, together with the nerve and the posterior
■tiliial artery. For this reason the lateral surfaces are
much used for incisions. The ankle-joint is a powerful
"H
\.
FIG. 4078.
/ \
joint because of its bony construction as well as by reason
of its strong ligaments.
The ligaments uniting the malleoli to the tarsus are
strong. Those for theiiitcrn-il cnrt^irr. are three: the del-
toid uniting the
malleolus with
the su.steutacu-
lum tali, the an-
terior uniting it
with the scaph-
oid, and the jios-
terinr uniting it
with the talus.
Those for the ex-
ternal surface
are: the anteri-
or, uniting the
external malle-
olus with the
talus; the mid-
dle, uniting it
with the calca-
neus; the poste-
rior, uniting it
with the talus.
The anterior and
posterior liga- ^- — -'
ments are thin
and insiguili- i :,... i ...
cant. The syno-
vial membrane lines the capsule, and extends beyond the
limits of the articulation both in front and behind. At
the sides it is delimited by the articular surfaces.
The epiphysis of the tibia includes the lower end and
the internal malleolus. It unites with the diaphysis
at about the nineteenth year. The epiphysis of the fibida
unites with the diaphysis at about the twenty-first _year.
The outlines of the malleolus are easily felt and .seen.
The head of the astragulus is felt in full extension of
the foot. The ankle-joint lies opposite a transverse hori-
zontal line 1.2.5 era. above the tip of the internal mal-
leolus.
T/ie Iiidiriitiims. — Partial resections are indicated in
gunshot woiuids; in compound fractures and iu disloca-
tions when the nerves and vessels are intact; and in sup-
puration following injiuy and infection when this resec-
>
f
.i
Fio. 4().S0.
tion removes and clrains the focus of infection. For
tuliercidosis in childliood, expectant treatment and iodo-
form injections may precede the partial resections, i.e.. the
erosions or the artlirectomies, but delay must not be too
long before resorting to the resection. " In adults formal
930
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Resection of Joints.
Resecliou of JoiiitK.
ii'sectious are used. In older people, with otliei- tuljer-
cidous foci, amputation is preferable to resections. As
a general rule, wheu tuberculosis is apparently primar}-
iu the joint, resection is
to be preferred. "When the
ankle-joint is involved, sec-
ondarily to otiier well-de-
fined deposits in the lungs
and elsewhere, amputation
is jireferalile.
There are about thirty
Flii. 4nsi.
six incisions (Faraboeuf, "Manuel Operatoirc"; Oilier,
"Traite des Resections"; Karewski, " Cliirurgische
Krunkheiten des Kindesalters " ; Kocher, Archie Jiir
kluvische Chirurgie, No. 37) M'hich have been recom-
mended for entering this joint. All surfaces of the
joint have been made use of to gain an entrance. Even
the .sole of the foot, i.e., the heel, has been included in
the incisions. No incision has so many advantages as
that of Lauenstein. This incision resembles Kocher's
incision (Langcnhvk's Atrhir, 1887 and 1888), but it
gives a better exposure of the posterior angle of the
ankle-joint and of the neighborhood of the internal mal-
leolus. Kocher's incision was an improvement upon
Reverdin's (Rcriie Medicale de la Suisse romandc, 1883,
Mars). Lanenstein's (Verhandl. der deut.sch. Gesellsch.
filr Chir., 1890, ii. 71) is an improvement U|)on Kocher's.
The method is as follows: An Esinarch's bandage
is applied. The foot is placed upon its inner side.
An incision is begun tipon the fibula at the point where
the fibula appears between the peroueiis brevis and
the peroneus tertius muscles. This incision is carried
through the skin to the tip of the malleolus, where it
bends forward in a broad curve to the talo-navicular
joint, passing over the heads of the extensor brevis
digitorum and exposing the tendons of the peroneus ter-
tius (Fig. 4081). It is now deepened, exposing the perios-
teum of the fibula, tlie antci'ior fasciculus of the lateral
ligament, and the capsule of the ankle-joint. Upon the
posterior border of the fibula the sheath of the peroneal
tendons is opened, and the tendons are retracted poste-
riorly. The knife now seiiarates from the periosteum of
the tibia and fibula, the muscular fibres of the peronei
and the flexor longus pollicis until one-half the transverse
diameter of the tibia is freed.
The retractors used in retracting these structures are
now removed and are inserted into the anterior Hap.
The ankle-joint is opened in front of the external malle-
olus and the blunt retractor is inserted, lifting and pro-
tecting the capsule and the sui^erjacent tissues. The
upper and lower attachments of the capsule to the talus
and to the tibia are severed until the median line of the
tibia and the talus are both of them reached. The foot is
now supinated and the three fasciculi of the external lat-
eral ligament are divided. When they have been divided,
if the foot be placed in the equinus position and be gently
thrown into supination, it will turn upon the internal
malleolus as au axis, provided the tissues in front and be-
hind the joint have been freed to a point beyond the me-
dian line of the joint. With a little force the foot can lie
completely inverted, so that the planfa pedis looks up-
ward and the articular surfaces of the talus and tibia are
tipon the same plane, separated by the internal malleolus
(Pig. 4082). By means of bhmt hooks every ]iart of the
articular surfaces of the talus, tibia, and fibula can be
reached: every pocket of the synovial cavity, including
the inferior tibio-fibular prolongation and the po.sterior
surface of the synovial luembrane ; the sheaths of the ten-
dons of the tibialis posticus, llexor longus digitorum and
pollicis, as well as the bursa and fat in front of the teudo
Achillis. When these are inspected and all foci of dis-
ease have been removed by curettage or excision, the
foot is easily pronateil and thrown into proper position.
The only structures injured arc the vena saphena parva
and the arteria perforans peronea. Tlie advantage of the
incision over Kocher's is that it allows a greater stretch-
ing of the borders of the incisicm and an easier dislocation
of the foot. It moreover parallels the sheaths of the ten-
dons and permits a surgical treatment of them when in-
volved. If in operating by this method it becomes neces-
sary to remove the talus, it can be accomplished easily by-
dividing its ligaments which are exposed to view. In-
deed, the method renders the extirpation of the talus a
very easy matter.
If disease involves the medio-tarsal and the talocrural
joints together with the neighboring bones, or if this is
only recognized by' the operator after he has entered the
talo-crural joint by the Lauenstein incision, the suggestion
of lleidenhain (Verhandl. der deutschen Gesell. f. Chir.,
1891, ii., p. 137) may be adopted for the treatment of the
case. This suggestion consists in continuing the lower
end of the Lauenstein incision across the dorsum of the
foot below the medio-tarsal joint and dividing the tendons
p. t.
Fifi. 4flR3.— Laupnstein'.s Metlioti. Parts exposed ready for resection.
t.. Talus; p. (., iicroneal tendons; c. m., external malleolus.
of the peroneus tertius and longus digitorum but preserv-
ing if possible the tibialis anticus and pro)irius pollicis.
This incision gives all the advautaiies of the Lauenstein
931
Resection 4>l J<>liil!i««
Rescctiou of Joiuts.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
and P. Bnms resectious, and opens to view for easy at-
tack tlie meilio-tarsal articulation.
Ajjain, if tlie talo-calcancau or the talo-navicular joint
is alone involved, we can adopt tlie following suggestion
of Jjauenstein and approach these parts with the same skin
incision: Instead of opening tlie talo-crural articulation,
we divide the calcaneo-tihular division of the external
lateral ligament, and then, passing a thin knife into the
sinus tarsi, carry it backward and inward to the susten-
tacuhiin tali, dividing the interosseous ligament. After
this division the anterior lalo-calcanean capsular ligament
is made tense by everting the calcaneus and is divided.
This is followed bj' division of the muscular fibres of
the extensor brevis digitorumand the talo-navicular liga-
ments upon the outer and superior surfaces of this joint.
If strong supination is now made upon the foot, the cal-
caneus will lie lu.xated or rotated upon its inner side
over the inallcolus iutermis. In this manner the talo-
calcanean and the talo-navicular joints may be exposed
without opening the ankle-joint. During the luxation of
the calcaneus the peroneus tendons are retracted posteri-
orly and do not obstruct the field. From this pnsition of
the foot the talus maj' be easily removed by division of
its lateral li,gaineuts. In extensive disease in this region
the Lauenstein incision permits an entrance into the talo-
crural articulation, and if desired allows an expo.sure of
the medio-tarsal and talo calcanean joints with removal of
the talus. The medio-tarsal and talo-<aleaneau articula-
tions may be entered first, and if susjiicion exists as to
an involvement of the talo-crural articulation this may
be exposed by removal of the talus. This incision gives
the best approach to the ankle-joint. It allows of such
modifications as will insure successful results in spite of
unsuspected foci of disease, since through one iucisiiui
the talo-crural, the talo calcanean, and the medio-tarsal
joints can be approached and the talus removed. In a
pure resection of the ankle-joint the .synovial membranes
and the articular surfaces of the talus ami of the tiliia and
fibula are removed, their shape biing i>ri'servcd as far as
possible. For this reason the section of the tibia and
fibula is usually made concave from side to side, while
that of the talus is made convex. If the talus is removed
on aeeour.*^ of disease, this concavity in the tibia and filiula
is made so as to tit the calcaneus, while the scaphoi<l rests
upon the anterior border of the tiliia. When but little of
the articular surfaces of the tibia and fibula is I'eiuoved, it
is best to shorten the malleolus so that the tiliia may rest
upon the calcaneus directly. It lias been my custom to
sutun> the sca])hoid, tibia, fibula, and calcaneus together
with two or three chroinicized catgut .sutures. It is rare
that a single artery requires ligature, and if any bleed
exces.sivel)' they will stop upon elevation of the limb. I
usually blood-clot these cases, excepting where it is im-
possible to remove all tuberculous material. In the latter
instance the wound is packed until healthy granulation
tissue appears.
The after-treatment is a matter of imjiortance. When
the wound is sewed u]) and blood-clotted the foot is ele-
vated at an angle of forty-five degrees for from three to
five days, after which it is lowered. In this method the
first dressing is made about the tenth day. AYhcrc \V( muds
are packed, the foot is usually elevated for twenty-lour
to forty-eight hours, after which it is lowered. The
dressings should be changed every two or three days.
A suitable splint is difficult to find. A splint which
will maintain the foot at a right angle with the leg and
will ju-event lateral deviation of the foot is the one de-
sired. Upon the whole, a plaster-of-Paris dressing pro]i-
crly and carefully a|)plied is the best. This iilaster-of-
Paris dressingemay be used alone or in conjunction with
the jMeCormac splint (Jacobson's "Operative Surgery,"
vol. ii., p. 690). If it is applied alone, it is well to
jilace this dres,sing within a Volkniann's posterior sjilint,
where it will be held firmly. After two weeks' treat-
ment the other sidints may be discarded and a splint
]ilaster-of-Paris dressing will be sufficient until union is
com]>lete.
R.tiills. — The mortality, in the different classes of
cases, was as follows: For gvnxlint wounds {A^ cases) it
was, according to Culbertson, 36 jier cent. ; according to
Otis (33 cases in the civil war), 29 per cent. ; and, ac-
cording to the same authority (1.50 cases from all sources)
33 per cent. For injuries in ciril practice (153 cases) it
was, according to Culbertson, 12. .5 per cent. For disease
(134 cases) it was, according to Culbertson, 8.06 per cent,
for complete resection, and 6.55 per cent, for partial re-
section; while, according to Isler and Kappeler, it was
almo.st nothing in cases of tuberculous disease.
Functiomd Resxdts. — Some say that a flail joint is very
rare, some that it is unknown. Ankylosis is often ob-
tained, and when it occurs the medio-tarsal joint compen-
.sates in great measure for the stitfuess iu the ankle. In
seventy-five per cent, of the cases recovery takes place
with a useful limb, and in many instances, especially in
the subperiosteal method, the nearthrosis is a remarkable
one, giving a most useful joint (Langenbeck).
According to Isler, the results of resection functionally
are divided as follows: Very good, 40.8 per cent. ; good,
26.8 per cent. : moderate, 7.6 per cent. ; indefinite, 8 per
cent. ; bad, 6.3 per cent. In children the good results
are more frecpicnt than in adults, since the disease is usu-
ally less extensive.
Schmidt Monnard gives the good results as 74 per
cent, for the first fifteen years of life. In Bardeleben's
clinic good results were obtained in 81.2 per cent, of the
cases. Karewski iu 30 cases had 35 good results, 3 deaths
from scarlet fever and tuberculosis respectively, and 3
cases with recurrences (" Chirurgische Kraukheiteu ties
Kiudesalters ").
Resectiox of tue Knee-Joint. — In 1762 Felken at-
tempted a partial resection of this joint. Park in 1T81,
and iloreau and Roux before 1830, operated, performing
a complete resection, liut the unfortunate results obtained
by their imitators deterred many surgeons until W. Fer-
gusson in 1850 restored the ojieration. From this time
the operation has been practised extensively and remark-
alily good results are now obtained in every country
(llodges, "Excisions of Joints," Boston, 1861).
The eases operated upcm are divided into those which
are typically resected and those which are atypieally
treated. The typical operation consists in the extirpa-
tiiiu of the s\'novial membrane and the removal of the
bones intra- or extraepipliAseally. The atypical one con-
sists in the extirpation of the synovial membrane without
removal of the bone exceiJt where di.scased. This is the
;irthreelomy of Volkmann (Verhandl. d. deut. Ges. f.
Cliir. , xiii.) and the erasion of Wright (Lancet, 1881, vol.
ii., p. 903).
The atypical operation is undoubtedh' the operation
for children, since in eighteen per cent, of the cases in
which the bones were not at all or only very slightlv in-
volved, movable joints have been obtained. In the .sec-
ond place, no shortening, at least no more than follows
conservative methods, takes place (Maudry, Beitrage zur
/din. Cliir., iii., p. 235).
A comparison of these atypical cases with the intra-
epiphyseal resections (IIolTa, Arcltio fiir klin. C/iir.,
1885, xxxii., ]). 795) shows that the only real iid vantage
is the jiossibility of obtaining in the most favorable cases
a movable joint, and since this occurred in nearly eigh-
teen per cent, of the seventy cases collected (Jhiudry), it
oilers a substantial advantage iu favor of the atypical
operation. The di.sadvantages of the atypical method
consist ( 1) in the liability of leaving beneath the articular
cartilages foci of disease, (2) in the greater tendency to
contracture of the flexor muscles. The first di.sadvautage
is more ajiparcnt than real iu the cases of cliildren, be-
cause iu making an intra-epiphyseal section one must
cut the bone below the level of the articular cartilage.
" Every bone section in children must be surrounded by
a line of articular cartilage to be certainly intra-cjiiphys-
eal " (Konig). This section is so thin that foci may not
be revealed by it. just as when the articular cartilage is
liresent. The advantage which belongs to the typical
intra-epiphyseal method, and which does not belong to
the atypical method, is the firmer union which takes ])lace
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Resection of JolntN.
Ucseetiou of Joiuts.
between the bones and the slighter tendency to deformity.
The hick of this advantage in tlie atypical incthod is coiii-
pensated for by prolonged mechauical aftur-treatnient.
When the bones are .slightly involved and the .synovial
FIG. 4083.
membrane is the principal scat of disease, the atypical
operation is indicated because of the eighteen per cent,
of movable joints which have been secured liy its employ-
ment. If in adilition to the synovial membrane tlie bones
are involved, the intra- or extra-cjiiphyseal resection is
indicated, according to the extent of disease in the bones.
This is because of the firmer ankylosis in the extended
position which is obtained by the section of the bones,
and also because it is not possible to ol)tain motion on ac-
count of the destruction of the articular cartilages. It is
to be remembered that in resections shortening is greater
if done before than after the fourteentli j'ear.
Indications. — For disease: 1. Tuberculosis. Excision
in these cases slio\dd be performed (n) in all cases in which
tlie articular cartilage is found eroded, wliether suppura-
tion is present or not ; (4) in cases with backward disloca-
tion of the tibia; («) in cases that have lasted over six
months, in which the expectant treatment has been tried
andhasfailed and in which the disease is in all probability
an epiiiliyseal osteitis; (il) in cases of .s\"uovial tuberculosis
whicli lias extended over the articular cartilages. In the
child before fifteen years, tliis operation affects the growth
of (lie limb. In adults of twenty years and over, the
length of tlie limb need not be considered, but tlie con-
ditions of the viscera and the general healtli become im-
portant considerations. In all cases the prestaice of amy-
loid degeneration; tuberculous disease of tlie lungs and
other viscera; great emaciation and extensive involve-
ment of the soft parts about a joint di-mand ain|)Utation
rather than resection. 3. Chronic arthritis, with caries
of the bones. 3. Chronic osteoarthritis in a single joint
in middle life. 4. Ankylosis of the knee in a bail jiosi-
tion after osteotomy has failed. 5. In infantile jiaralysis
for tile produelion of ankylosis. In these cases the re-
section is usually a complete one.
For injury : Gunshot wounds and other compound and
coniplicate(i wounds. In these cases the resection is usu-
ally ]iarti:d ratlier tlian complete.
Aiiiitiiiinj. — The axis of tlie femur is directed inward at
the knee. That of the tibia is straight, i.e., in the axis
of the body. The joint obtains no strength from the
shape of the bones. It derives its strength from its cru-
cial and posterior ligaments rather tliau from its lateral
and anterior ligaments. The cavity of the synovial
membrane is extensive and the bursie about the joint are
numerous. Of these bursa', that between the inner con-
dyle, the semimembranosus, and tlie inner head of the
gastrocnemius communicates with the joint. The bursa
beneath the tendon of the poplitcus comnmnicates with
both the knee-joint and the superior tibio-tibu-
lar articulation. In like manner, the bursa
beneatli tlie vasti and the rectus coinniuni-
cates in eighty per cent, of the cases with the
joint (Fig. 4083). The popliteal artery and
\ 1 are quite closely associated witli the liga-
1 nt of Winslow, and care must be given in
h secting out diseased tissue in this region in
ler to avoid injuriitg them (Fig. 4083). The
t cular arteries should if possible be avoided,
I t, if they cannot b(^ avoided, they should be
ti 1 before closing the wound, even when the
1 1 od-clot method is used. The superior articu-
lii arteriesare situated just above the condyles,
1 le the inferior pass beneath their respective
1 t ral ligaments, the internal below the tibial
t 1 erosity, tlie external above the head of the
nl ila. It is to be remembered that the upper
I it of the femoral eiiiphysis is represented by
I 1 ue passing across the femur at the tubercle of
tl adiluctor niagnus. This epiphyseal line is
t acapsular. The tibial epijihysis is marked
t tlie sides by aline just including the fibular
1 t cular surface, and tlie de])ressiou for the
semimembranosus tendou behind this line just
includes tlie tuberosities. In front the epi-
physis descends to the lower margin of the
tubercle. This epiphyseal line is extracapsu-
lar. The femoral epiphysis joins the shaft at
twenty, the tibial at twenty-one 3-ears(Fig. 4084, « and
b). In a child, scarcely more than 1 cm. of the tibia and
Fig. 4nsi.
1.5 cm. of tlie femur can be removed without compro-
mising the growth of the limb. After puberty (seven-
teen years), 1.5 cm. of llie tibia and 2 cm. of the femur
can be removed (Farabieuf). WoUa. {An hhIh af Sii i-gery ,
933
Rese<-1ii»ii or .Toiiits,
Rcsootioii of .loiiil!i«.
KEFERE^'CE HA^'D1500K OF THE IIEDICAL SCIENCES.
FIG. 40&').
March, 1886) saj'S tbat (1) in one case tlic removal of both
epiplij'ses at the end of ten years guvi: ^'0.5 cm. shorten-
ing; (3) ill one case at tlie end
of two years there was 10 cm.
sliorteniug; (S) the loss of the
femoral epiphysis alone in one
case gave IT cm. shortening at
the expiration of si.\' years; (4)
the loss of the tibial epiphysis
alime in two cases ga^e respec-
tive!}' 15.5 and 6 cm. shortening
in six years; i.e., an average of
10 7 cm. Petersen {Arckiv f.
klin. CJiir., xxxiv., p. 445), in a
child of si.K years of age, at six
years from the time of the resec-
tiiiii, found a shortening in the
femur of 10.2 cm., of which 8.5
cm. was due to tlie loss of the
lower femoral epiph3-sis. In the
tibia, tlicre was 5 cm. shorten-
ing, of which 3 cm. was due to
the loss of the ujiper tibial epi-
physis.
It is to be remembered that
when the knee is lli'xed the ex-
tension of the synovial mem-
brane aliove the femur and be-
neath the quadriceps femoris
ti'iidon searcel_y reaches abo\e
the articular cartilage of the femur; when the leg is ex-
tended, the same rises to a mueli gri'ater distance.
Incisions. — Many incisions have been recommended for
this operation, and of tlic great nunib<'r variously used by
Park, Moreau, Fergusson. Mackensie, Bird. Volkmann,
Langenbeck, Oilier, Textor, Sanson, and liegin, no one
seems to me to he as advanlageous as that recommended
hy Mackensie, FarabrtHif, Erichsen, and Kocher, i.e., the
transverse curved incisions of Textor.
The object of this resection is usually to produee anky-
losis witliout con.siderable shortening, i.e. without short-
ening over 10 cm., which can be corrected by a high slioe
and by tlie inclination of the pelvis. For this reason only
such incisions are useful which will expose all parts of
the joint and enable one accurately to remove only the
di.seased tissue. To obtain this exposure, the transverse
incision is preferable to the longitudinal. The longitu-
dinal incisions were designed to save the iiatella and to
aid in producing mobile joints, liut the Iiest results are
usually those in which ankylosis exists, and in these the
patella is not neces.sary.
The operation by the longitudinal incision is difficult
and tedious, and in disease tails to expose all parts of the
synovial nienibrane. For this reason alone, in disease,
the transverse is to he preferred to the longitudinal inci-
sion. In some few ca.ses of injury with partial resection
of the bones, the longitudinal inci.sion is indicated, but in
the vast majiirity of cases no incision is so satisfactory as
the transverse.
Method of Openition. — Typical resection. The patient
lies upon the back, with the leg at the end of the table,
so tliat in flexion at the knee the foot may rest on the
table. The surgeon stands upon the side to be operated.
One assistant, opposite the surgeon, manages the thigh,
another manages the leg. A third manages the spong-
ing, etc. During the skin incision, the leg is held tirnily
flexed upon the thigh. The incision, at lirst involving
the skin and subcniaiieous tissue, passes from the epicoii-
dyle of one side to that of the other in a broa<l curve,
whicli crosses tlie ligameiitnm patelke midwa}' between
the tubercle of the tibia and the lower margin of the
patella (Fig. 40S5). Tliis incision avoids, as it ap-
proaches the internal epicondyle, injuring the saphena
magna vein and tlie internal saiihenous nerve. The flap
marked out is dissected from the capsule and the patella
and is rcHecled above the upper border of tlie ]iatella.
An oval-shaped iiiece of the anterior capsule, including
the patella and tlu' synovial memliraiie, is now excised
by two incisions passing from the posterior borders of
each lateral ligament across the upper and lower extrem-
ities of the patella (Fig. 4086). With the removal of this
piece the joint is fully expo.sed. This is the method of
procedure in non-tuberculous processes, in injuries, and
in deformities, where the ultimate aim is ankylosis. In
tuberculosis Kocher's suggestion is the proper one. After
reflection of the skin and subcutaneous tissue as above,
an incision is carried through the lateral ligaments, the
fascia of the vasti muscles, and the ([uadriceps tendon in
a curve above the patella down to but not through the
synovial membrane. The flap above is cleared from the
synovial membrane until the attachment of the latter to
tiie femoral articular cartilage is reached. In like man-
ner, the flap below is separated from the synovial mem-
brane as far as the lalter's attachment to the tibia, the
ligamentnm patell.-e being divided at its attachment to
the patella. In this manner the tuberculous synovial
membrane, together with the patella, is removed in one
piece. Whichever way one has proceeded the joint is
now open and the crucial ligaments are seen. With in-
creased flexion by the assistant, the crucial ligaments are
rendered more evident and the division of the anterior
and then the posterior close to the femur is made. The
leg now hangs loosely upon the femur. It is flexed to a
I'ight angle, with the foot resting ujion the table and the
femur rai.sed. In this position the femur is cleared of its
soft parts — including the periosteum if desired and if in-
dic'ated by the local condition — up to the line of intended
section. The pojiliteal sjiace is protected b_Y a broad re-
tractor and the bone is .sawn with a solid-bladed saw.
The plane of section is sagittally at right angles to the
axis of the femur. Frontally it is parallel to the plane
of the articular surfaces of the condyles.
The tibia is now jjulled forward while the foot still
rests upon the table. The popliteal tissues are put upon
the stretch and brought into a lower plane than the artic-
ular surface of the tibia. This is exaggerated by freeing
the tibia piosieriorly wliere tlie ligament of Winslow is
attached. The tibia is now held tirmly in this position and
is cleared of all tissues to the line of bone section. It is
sawn at right angles to the axis of its shaft. Tlie sec-
tion in the bones is in the young always within tlie epi-
ph_y.seal line; in the adult, the
section is made as often extra-
e]piphyseally.
The tissues in the ])opliteal
s]iace are in no danger, since
I hey are placed at a lower level
than the bone section, owing
to the traction tipon the leg
held in the vertical position.
In non-tuberculous cases and
in cases of deformit}-, the syn-
ovial membrane is now dis-
.sected from the bones and the
capsule. It is usual to begin
with that above the femur and
Iieneatli the quadriceps tendon.
This with the bursa is removed
as a continuous membrane and
can in almost all instaiu'cs, ex-
<-el)t where disease has ad-
vanced beyond its limits, be
removed without ftn-ther in-
cisions. Ill the more cxt.eusive
c:ises a vertical incision must
be acldid to the transver.se one.
So iiifre(|uently is this the case
and so thoroughly can one, by
means <if Ibis additional incis-
ion, approacli without excessive injury the space beneath
the vasti and <iuadriceps muscles, that I have rejected
entirely all incisions with their curve upward (Ilahu,
Verhandl. der deutsclien Gesell. f. Chir., No. xi.) which
are ilesigncd more fully to expose this region.
The advaiilagi's obt.diied liy tliis method of procedure
are, taken aU in all, more than those derived from inci-
Ftg. 4(ISi;.
934
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Resection of Joiuls.
Resection of Joints.
sious tk'Stiiit'cl to expose the space beneath the quadriceps
muscle at the expense of tlie rest. The areas next in ini-
portance are the immediate neijiiiborhood of the tibia and
the popliteal space. The synovial membrane about the
sides and front of the libia and the adjacent synovial
membrane are now removed, including the bursa beneath
the ligamentum patella'. At this stage an assistant places
his hand in the angle formed by the tibia and femur, and
by pushing apart tlicse bones puts the tissues in the pop-
liteal space upon the stretch, which renders the removal of
the bursiE already refen-eil to an easier matter than when
their tissue is not Ih'nily stretched. If I'cmoval of the dis-
ease iu the rest of this region is now undertaken and if
sinuses exist licre, it is best to locale first the position of
the artery and \ein and then to pi'oceed to the removal of
the diseased parts. Providing the resection has been an
extensive one, it is my custom at this time to remove the
Esmarch bandage and to t ic t he articular, the auastomotica
magna, and the recurrent tibial arteries. All hemorrhage
from the bones stops wlieu they are apposed. If the op-
eration lias not been so extensive, then in all probability
these vessels have not been cut or at most only one or two
of them ; under these circmiistances I do not remove the
Esmarch bandage, but rely entirely upon the firm dress-
ing and the elevation of the limb for controlling the hem-
orrhage. Two openings are now drilled in the femur
and in the tibia, and through thenr are passed large-sized
chromicized catgut sutures, vvliich, after the popliteal
li.ssues are held away from the bones and after the bones
are apposed, are tied tightly. These stilches are not for
the purpo.se of holding the bones after the operation is
completed but rather at the time of applying the primary
dressing. They enable the assistants to feel that the bones
remain in situ and have not slipped from their original
position. Complete reliance is placed upon the dressing
for liolding the bones in position.
If large sections of tlie fenuir and tibia have been re-
moved a piece of the circumference of the femur may be
sawn out and transplanted to the space between the tibia
and femur, as iu a flap operation iipon the soft parts.
Sykow was successful in one case in preventing shorten-
ing and iu having the consolidation of the limb perfect
in three montlis. His success may well be imitated in
suitable cases (C<;«<rrtZW</«/«7- Chir., 1902, No. 15).
After the suture of the bones the capsule, the liga-
mentum patella?, and the tendon of the quadriceps fe-
moris are united with catgnt. For the tendon and the
ligament I use the chromicized catgut, which lasts for
from fourteen to twenty days. For the capsule, I use
simple catgut. The skin is sutured also with catgut.
Drainage is established only to give e.xit to the excess
of blood, so that the employment of Maas' method or the
insertion of rubber tissue into the incision wound is quite
sufficient.
In operating upon joints which are flexed, it is best to
straighten them as much as jiossible before operating.
In this way one avoids removing too much bone and at
the same time removes enough, so that the tissues in the
popliteal space are not too much stretched. This stretch-
ing tends to displace the fragments, and by closing the
vessels tends to produce gangrene of the foot and leg.
The author's method of dressing these cases has been
most satisfactory. It consists in applying an even and
not lumpy dressing of gauze from the ankle to the upiier
third of the thigh. Upon the outer si<le of this gauze
dressing eight to twelve tliin bass or white wood splints,
cut iu strips 2 lo 8 cm. wide and boiled until they are not
only aseptic but perfectly pliable, are applied over the
joint and are bandaged (juite loosely in position. Over
this is placed a sufficient cotton dressing which is fixed
with plaster-of- Paris bandages. This plaster of Paris is
not thick; it is scarcely more than two bandages thii'k,
except where it covers the knee. It extends from the toes
to the upper third of the thigh. The limb is now placed
in ,■! Volkmann's splint, which can be suspended or raised
in bed to the required heiglit. No dressing nor splint
which I have seen used holds the knee so firmly and
without undue pressure as does this combination. The
wood splints or strips, applied directly over an evenly ap-
plied gauze dressing, can be trusted, when Ihey harden,
to render slip]iing of the bone surfaces impossible. The
plaster of Paris applied outside of the cotton and from the
toes to the middle of the thigh holds the foot, leg, and
thigh immovable, and excrt,s an even ]H-essure upon all
these parts. The Volkmann's splint protects and sustains
the plaster-of-Paris dressing, which on this account need
not consist of more than two thicknesses of bandage.
Thissutlices for the immediate dressing, but fixation must
be continued for a varying period after operation. Some
have placed the period when ankylosis becomes complete
at two months (Riedel, Dent. Zeits. far C/iir., Bd.
XV.), others at from six to eight months (Wilkmanu's
klin. Vortriige, 51), and still others at one year (Ilotfa,
Arch, fur kUii. Chir., Bd. xxxii.). Duiing this period the
limb must be kept perfectly straight, and for this purpose
plaster-of-Paris dressing is still used with perfect satis-
faction. Windows can be made where necessary and the
wound kept clean and health}-. There seem to me to be
no advantages in the Howse or Hodgson splints which
are not foimd in the above plaster-of-Paris dressing. Al-
most all the splints employed have the disadvantage of
being complex and difficult to adjust. After splints have
been removed, a leather support is usually aiiplied. In
children a support sliould be worn for from two to three
years.
Results. — The age of the patient is important. The
results are best, for either injury or disease, between five
and fourteen years. Esmarch (" Beitrage zur Statistik der
Kniegeleuksresectionen." Kiel, 1883) had no deaths in 30
easesrVolkmann(Vcrhandl. derdeutschen Gesell. f. Chir.,
xiii.) uo deaths in 20 cases. Hahn, Maas, and Schede have
had similar results. In 180S Napalkow rei^orted 26 cases
operated upon between se\enteen and twenty -five years
old, with no deaths ("Chirurgie," 1898, p. 345). these
statistics for tuberculosis bring the mortality very low.
The general mortality for all cases and under all condi-
tions is at present about ten per cent. (Botlie, Bcitr. z.
klin. Chir., vi., ]). 282). The former high mortality of 7
per cent, for gunshot wounds, 40 per cent, for injury, and
:iO ])er cent, fordisea.se is being gradually reduced by a
better selection of ca.ses and an improved "technique.
The final results of resections iu children up to the
fourteenth year show (Hoffa, Archie f. klin. Chir., xxxii.,
p. 763) that 6 per cent, of failures ocein-, most of which
require amputation; that 7 per cent, die of tuberculosis
in other organs at a subsequent period; that 58.47 per
cent, have an ankylosis in the straight position, with
neither genu valgum nor genu varum; that 41.53 per
cent, have a flexion contracture due (1) to a faulty posi.
tion of the leg and thigh at the time of operation, (2) to
contracture of the flexors and atrophy of the (piadrieeps
femoris, and (3) to the weight transmitted through the
limb iu faulty position. All of these conditions are
avoided by obtaining a bony ankylosis in the extended
position before the limb is used. Eighty-seven jier cent,
of the cases were permanent cures (54 per cent, without
subsequent fistuhe, 33 per cent, with fistuhc requiring
from one to twenty -one months to c.ire). One hundred
per cent, of the cases show some interference in the growth
of the limb, yet in 93 per cent, this is not gicater in the
intra-epiphyseal resections than in the conservatively
treated caavs (Ice. cit., p. 794). In 8 percent, of the cases
measured by Botlie {/idtnif/e ^ur /din. Chir.. vi., p. 208)
lengthening had taken place. The final results in resec-
tions in which the subjects are older and iu which the
operation is either intra- or extra-epipliyseal, iu so far as
the bone section is concerned, are as follows:
111 operations for tnhercnlous disease (443 eases) (Botlie,
I. c). Healed and useful limbs, 67.4 per cent. ; incom-
pletely healed, 13.7 percent. ; aiuputated, 8.8 per cent.;
useless, 17 per cent.. ; mortality, 10.1 per cent.
In operations for r/unshot wounds. Useful, 60 percent. ;
required amputation, 24 percent. ; unknown, 10 percent.
In operations for relief of def or nut y. Perfect. 19.5 per
cent. ; useful. 08 i)er cent"; unknown, 13.5 per cent.
The Ali/pical He.vcliou.— By this is meant the method
935
Kosectioii <»l JttiiitN,
Reseetiou of Joiut^,
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
employed l\v Wright uiidei- the name of erasion aud
b}' Volkmaiui uiulei' tlie uame of artbrrctomy. It is an
operation in which the synovial memljniue and bursie
are removed entire and in which t!ie bone foci aregoiig(/d
out, scraped out. or chiselled out, while all that is healthy
is left intact. An operation of this kind in more favora-
ble cases consists of a synovial extirpation with the goug-
Fii;. -11^7.
ing out of one or more small osseous foci ; in the more
extensive cases it consists of a nearlv complete removal of
the articular cartilage, i.e., of an almost typical resection.
The operative technique is usually carried out hj' a
transverse incision tlirough the skin, subcutaneous tis-
sue, lateral ligaments aud fibrous capsule, down to the
synovial membrane; retlectiou of this flap upward; and
extirpatinn of the synovial membrane as recommended by
Koeher for tyiiical resections. It is now my custom,
after the crucial ligaments are diviiled aud tiie menisci
removed, to examine the bones carefully, in order to
determine from the beginning whether I cau be con-
tent with a limited destructi(m of the articular cartilage.
or whether this must be removed in greater part. It
is at this stage that I delermiae whether m_y operation
is to be the erasion or the intra-epiphyseal resection.
Provided the former is the selection, the foci in tlie
bones are removed by a gouge or chisel, aud as much of
the articular cartilage is saved as is possible. If two-
thirds of the articular surface is intact. I then attempt to
obtain a movaljle ,ioint (eighteen per cent, in seventy
cases, Maudry), and after dissecting away the iiosterior
synovial membrane and the bursa; I suture carefully the
capsule, the ligamentum patella-, aud the skiu. I treat
the joint sul)se([uently as in fractured patella, with abso-
lute rest for from four to six weeks. If one-half to two-
thirds is removed l)y the gouge or chisel, I remove the
remaining articular cartilage b.y sawing intra epiphvse-
ally and I attempt to obtain an immediate bon}' union in
the extended position. In my opinion the atypical and
the typical intra-epiphyseal operations should be com-
bined in this manner to obtain the best possible result of
each methoil. Koeher, in order to avoid the cutting of
the quadrieeiis tendon, makes the usual curved anterior
incision, dividing the skin, subcutaneous tiss\ie, and the
fascia' of tlie vasti nuiseles. He then makes upon each
side of the <iuadriceps tendon two vertical incisions,
which, meeting the incision in the fascise of the vasti,
form two right-angled flaps which are retracted outward
(Fig, 4087). The capsule and synovial membrane are
now cleared as in the typical resection, and are re-
moved together with the menisci and ligamenta alaria
(Koeher). The crucial ligaments having been previously
separated at the tibial eminence, the femur is disloeateil
outward or inward in order that the posterior and pos-
tero-lateral portions of the capsule be rendered accessible
for removal. The condyles are now examined, aud if
necessary foci a'-e removed. The patella is at last turned
completely upon itself and cleared of all tuberculous or
diseased tissue.
Eilhei-of these methods of exposure may be selected.
For myself, I prefer the former method, dissecting out
the synovial membrane in the manner recommended by
Koclier for tlie typical resection.
Resection of the Hip-Joixt. — This operation was
first performed by Whyte for deformit^v in 1818, for dis-
ease by Ilewsou in 1823 or by Brodie in 1836, and for .gun-
shot injury by Oppenheim in 1829. The resections are
class(!d as complete when tlie acetabulum is partially re-
moved together with the femur, as partial when only the
femur or the acetabulum is removed. They are typical
or atypical, according to the modifications in the method
of aiipro.-ich and the manner of attacking osseous ti.ssue.
The indications for the operation are:
1. Gunshot wounds, where partial and at.ypica! resec-
tions rather than typical aud complete methods are un-
doubtedly indicated. With the new projectiles, conserv-
ative methods rather than operative should be employed
unless the operative interference is confined to a correc-
tion tending to production of better wound healing.
3. Tulierculosis. where operative procedure is not to
be delayed, liut earlier interference recommended.
;3. Deformities from injury or disease. Here partial or
complete resections are alone indicated when osteotomy
cannot correct.
4. (_)ld dislocations from disease or traumatism, where
partial operations are (juile sufticient.
5. Intracapsular fracture of the ueck of the femur fol-
lowed liy di.sability and ]iaiu. Here the partial resection
confined to the femur is beneficial.
6. lu dislocation of the head and fracture of the neck
of the femur. Here removal of the dislocated heail is
sullicient.
7. Congenital dislocation in adults which have failed
of reduction by mauipulatiou, (Loreuz and HolTa. )
8. In acute infectious arthritis. Here artbrotomy
rather than resection ^^ ill be found to be more beneficial.
Uisiilts. — The mortalit}' of resections for gunshot
wounds is, according to Culbertson, 89.07 per cent.,
while according to Gurlt it is 88.23 per cent. Gurlt
classifies this mortality as follows: 92.68 per cent, for
jiriinary resections; 94 per cent, for intermediary I'esec-
tions; 89.39 per cent, for secondar_y resections; 00 per
cent, for late resections, Otis gives a mortality of 90.9
per cent, in the primar}' resections, while similar cases
treated eoiiservativelj' give 98.8 per cent., aud by exar-
ticulation 83.3 per cent.
The mortality for disease is low. Culbertson ,gives
44.8 percent., of which 6.93 per cent, represented deaths
from operation directly, leaving 37.89 percent, for deaths
from the disease and its complications. Gro.seli {('cnlnil-
lihill fiir Chir.. 1882, p. 228) gives a mortality, in 120
cases of tuberculosis treated antiscptically and observed
to tli<' end, of 36.7 per cent., which, compared with the
results of Culhert.sou in pre-antiseptic times, shows that
the cases dying from operation have been excluded by
the present methods of operation, but that tlio deaths
from the disease have not beeu diminished. Nor can it
be said that the time of after-treatment is shortened, nor
is the functional result better. These statistics include
only eases o])erated upon late in the disease. The results
of the operative treatment are better in proportion as the
operation is early perfinnied. and better in children than
iu adidts. The mortalitj- in the first stage, i.e., in the
936
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Rcdtectioii of Joiuls,
Rescelioii of Joints.
Stage in which the cliaiijrcs in the joint arc slisrht ami in
wliich sinuses have not formed, is 0 per cent. The mor-
tality in the second stage, i.e., in the stage in which fi.s-
tnlii' liave forniid and pus is present, is 24.1 per cent.
Tlie morlulity in tlic tliini stage, i.e., in the stage in which
tlie patients are already dcltilitated by long-standing sup-
puration and tistula'. isGT.r> per cent. Two-thirds of the
deaths following operation are due to general tuberculo-
sis or tuberculosis of other organs; one-third is due to
septic infection, suppuration, and amyloid degeneration
(Bruns, Beilrucje zur klin. C/iii:, xxii., 1894). The mor-
tality at present is in the ueighborhood of tive per cent.
(Wright, 3 : 100).
Fnnetional Uenultti. — Baehr reports 44 cases of resection
which were able to walk : 8 with perfect motion =18 ])er
cent. ; 23 with restricted motion — .52 per cent. ; 11 with
ankylosis = 25 per cent.; 1 willi a flail joint = 2..5 per
cent. Baehr also found that resection of the head alone
gave 0.9 cm. shortening; of tla; head and neck. 1.5 cm.
Subtrochanteric section gave a shortening of 4 cm. His
views substantiate Riedel's: namely, that the early
resections give less shortening than the continuance of
the disease will give, and that motion in the joint is
equally good or lietter {Dent. Zeits. f. Chir., No. 30, p.
349). Mauninger (Dent. Zeits. f. Chir., No. 65, p. 1) gives
the .statistics of 41 cases carefully observed. The shortest
time during \\liicli a patient was kept under observation
after operation was one year and si.x months. The fol-
lowing are the clas.sified results: 41.02 per cent, were
healed without listuUe ; 17.07 per cent, were healed after
treatment for fistuhe or after subsequent operations ; 9, 75
per cent, were healed, but now and tlien a fistula would
open and close. Tlie general health of these patients was
good. In 67.84 per cent, the results were good. In 11.-
195 per cent, of the cases the health was bad, and the
wounds -suppurated profu.sely ; 21.95 per cent, of the pa-
tients died. The results were bad in 33.145 per cent, of
the cases. Of the deaths (21.95 per cent.), 1 was due to
fat eml)oli in the lungs. In about 10 per cent, the cause
was miliary tuberculosis, which followed the operaticm
in from one to tive months, and the development of
winch was probably hastened by the operation. In an-
other 10 per cent, of the cases death was due to tuliereu-
losis of internal organs, the di.sease develojiing from one
to ten jears after the operation.
Functional results in these cases must lie considered in
reference to the condition of the e.\tremity at the time of
operation. In no case had the disease in the hip lasted
less than two and three-fourths years, so that the opera-
tion liad to do with (1) the shortening of the extremity
due to an atrophy fnuu inaction — 4 to 8 cm. ; (2) slipping
upward of the head of the femur upon the ilium — 2 to 3
cm.; (3) contracture of the soft parts (nuisclcs, etc.),
usually a flexion-contract ure of thirty degrees and an
adductiou-contracture of twenty degrees; (4) atrophy of
the musculature of the pelvis and femur. Yet. in spite
of this condition of affairs, in 50 per cent, of the cases in
wliich good results were obtained good motion was pres-
ent; in 50 per cent, of these cases a cane with or without
a high shoe was used in walking. With the excejition
of one case, all limped more or less; i.e., most patii'uts
walked from two to four hours without pain or special
fatigue. All followed their vocations. In 50 per cent,
their general health was good ; in 50 per cent, it was vi'ry
good. With the exception of one case in which multiple
caries existed, no case was suspected of having tubercu-
losis in other organs. Mauninger collected, inaddilion to
these ca.ses. 304 cases which were ojierated in the aseptic
period of surgery. Permanent healing took place in 65.8
per cent. The mortality was 17.4 per cent. The cpies-
tion to-day is whether con.servative treatment will give
as good or better results than the operation.
The statistics of Gibney, Waterman, and Reynolds, of
114 cases examined five years and upward after leaving
the hospital, show that 107 were cured and able to fol-
low an occupation without trouble; 7 ca.ses were cured,
but with considerable dcbiriiiity. for which osteotomy or
excision was done. Aliout 14 jier cent, sliowed perfect
motion, 20.5 per cent, good motion, 38 per cent, limited
motion, and no motion in about 8 percent. Shortening
of the limb averaged 1.75 in. {i.e., 4 cm.) iu all the cases
except in 21 in which it was absent, i.e., 19.5 per cent.
{AnimLs of Sunjen/, 1897, vol. ii.).
The statistics of Jlaiininger {loc. eit.), obtained for the
con.serv.atively treated cases, give the following results
as regards the cures and dcatlis: purulent eases, 27.1 per
cent, healed, 48.8 per cent, mortality; non-purulent
cases, 74.2 percent, healed, 16.5 percent, mortality.
The results of conservative treatment are therefore, in
reference to mortality, no lietter than those obtained b}-
the operative method, for even if the casesof death due to
operation alone or induced by the operation be included,
still the operative cures present a mortality of only 17.4
per cent, as against 16.5 per cent, in the nonsuppurative
cases and 48.8 per cent, in the sujiiiurative eases treated
conservatively. If in this comparison eases be deducted
in which the disease is attacked early before suppuration
exists, the mortality ranges from 0 (Bruns) to 3 pcM- cent.
(Wright) — a result far superior to that shown by the sta-
tistics of the cases treated conservativel}-, and even better
than the results obtained by Gibney — 8.8 per cent. — or
by 3Iarsh — 6 to 8 per cent.-— ("Diseases of Children ") for
the conservative treatment.
The functional results are quite as good — perfect mo-
tion being obtained in 18 per cent, of the operative cases
(Baehr), iu 14 per cent, of the conservative (Gibnej', et
III.). Even in the cases reported hy Mauninger, oper-
ated after two and three-fourths years of the disease, 67
per cent, were good results ; oue-half of these patients had
motion and one-half "walked with a cane. All could follow
their vocations. These exeelleul results obtaineil by both
methods of treatment depend much tipon two factors.
In the first place, in the conservativelj' treated, sonie
eases of restitutio ail intei/nim are due to the fact that
the disease was non-tuberculous (Karewski). Again, in
the cases treated by operation much will depend upon
the time at which the o|)eration is performed. Opera-
tions are not to be performed because conservative treat-
ment has failed, but at an early stage when fistuUx' aiul
suppuration arc not present, or, if they are iiresent. only
to a .small extent (Wright, " Diseases of Children " ; Bar-
ker, Laveet, 1900, vol. i., 1099).
The shortening In the limb is less by the operative
treatment than by the conservative treatment. In the
older cases the average shortening from operative pro-'
cedures is not increased over that which is invsent at the
time of oiieration and which is due to the atro|diy of in-
action, the slip])ing upward of the head of the femur,
and the contracture of the limb. In the early cases, the
statistics of Baehr .show that shortening for any section
made on a line situated higher up than below the tro-
chanter is very slight (0.9 to 1.5 cm.), while average
shortening in the conservative treatment is 4 cm., with
19 per cent, of the cases showing practically no shorten-
ing (Gibney), i.e., less than 4 in. or 1.25 cm. Our view
is that operation should be carried out as soon as it is
clear that conservative measures cannot prevent suppura-
tion. A re.section is indicated so soon as suppuration
exists in the joint and before fistuhe are present (Konig,
"Das Hiiftge'lenk," Berlin, 1902).
In the wealthy class, where long-continued mechan-
ical treatment can be carried out and where iodoloriu in-
jections can be made as indicated, su|ipuration can often-
times be prevented and a result obtained which, as we
have seen, gives perfect motion in fourteen per cent, of
the cases. In the poorer class, who caimot afford or will
not carry out this long-continued mechanical treatment,
suppuration is more frequent, the deformity is greater,
and the di'Struction of the bones is more marked than i.s
the case in those who have been able to command me-
chanical treatment .and have followed it faithfully. In
these latter cases operative treatment is friMjuently indi-
cated and will give results superior to those offered by
the conservative treatment both in respect to function
and in respect to mortality, when like degrees of disease
are compared.
937
K<>se(-ti4»ll f>l' .li»iii(s.
lCo»ectiou or Joiikl!!>,
REFERENCE IIAXDIJOOK OF THE IVIEDICAL SCIENCES.
FlO. 4U'v'^.
Aiiii/tii/ii/. — T1}C hipjoiut is dei/ply placed ami is iiu-
mciiiatclj' surrounded by the psoas and iliaeus inusclos;
by tlie quadratus fcmoris. the obturator interuus, tlie
gemelli, and tlie pyriformis behind; by the gluteus
niedius, gluteus minimus, and rectus femoris externally ;
and linally by the pectineus and obturator externus in-
ternally. Beneath
these muscles is (he
thick capsule, the
au.xiliary bauds of
wliich are the ilio-
femoral, the pec-
tiueo- femoral, and
the ischiofemoral,
the border of wliich
latter is known as
the zona orbicu-
laris. Between the
ilio- and ischio-fem-
oral bands tlie cap-
side is stroug; op-
posite the lower
and back part of
the femoral neck
and o|>posite the
cotyloid notch it is
thin. Within the
joint is the liga-
nientum teres, a tiat
band extending
from the acetabular
notch to the depres-
sion in the head of
Ihe femur. The
marginal libro-car-
t i 1 a g e and the
transverse ligament
complete the liga-
mentous structures.
The synovial mem-
brane lines the capsule and passes over the border of the
acetabulum to cover the round ligament. The burs.-t: are
numerous and of fre(|Uent occurrence: upon the outer and
anterior surfaces there are live, while upon the posterior
surface there are four.
The bones consist of the innominate and ihe femur.
, The former contains the acetabulum, a liemispherical
cavity which receives the femur. The latter consists of
a rounded head and a neck, w hich latter is long and joins
the shaft obliipiely, i.e., at an angle of one hundred and
twenty -five degrees.
Ossitication occurs in the head of the femur aud in the
greater and lesser trochanters, respectively, at the first,
fourth, and tliirteentli years. Tliev join the shaft in the
reverse order at the eighteenth, ei'gliteeulh and a half,
and nineteenth years.
The acetabiiiuin ossifies at the sixth year from the
Y-shaped cartilage oeeiipying its centre." At the four-
teenth the ilium and ischium unite with the aQetabiilum.
The pubis does .so at the fifteenth year. C)s.sification is
completed in the acetabulum at the seventeenth year.
Owing to the oblitpiity and the length of the'neck of
the femur, tlie miiscularattachments to the bony promi-
nences have great leverage aud a wide range oi' motion
is jiossible. When the head is removed these muscles
tend to draw the femur upward unless the neck is en-
gaged in tlie cotyloid cavity. If tlie neck is also re-
moved, the abduction and rotation of the femur are lost.
The pelvi-trochantcric aud all muscles passing between
the jielvis and the femur cause the femur tO ascend,
which ascension is limited only by the tension of the cap-
sule. The shortening. tIk'Ii. iii aiiv resection will depend
upon; (l)Tlie loss of the i iiiphyseal cartilage. This is
sliiihl. (2) The amount of bone removed. (3) The mus-
cular displacement of the femur. (4) The atropliy of the
limli from disuse.
'Phis shorteninir is partly corrected bv the inclination
of the pelvis on the siile ojierated. The" object to be ac-
cpiired in a resection is a nearthrosis or a tight pseiidar-
throsis. They give the best results in walking. To ob-
tain either, the neck must be retained in the acetabulum
or in apposition with the bone at this level, and not al-
lowed to ascend. Owing to the inclination of the pelvis
after shortening, ' the femur must be retained slightly
Hexed and abducted upon the pelvis. The main points,
then, are to preserve the greatest possible length, to ob-
tain a solid, slightly mobile union with the acetabulum,
and, lastly, to prt'serve the proper pcsition in the limb.
Mi'thods. — The hip-joint has been removed by several
methods of incision.
1. By the externallncision. First proposed by Charles
White in 1769, and modified by Langeubeck in 1867
(Lanr/eiibeck's Archiv, No. 16, p. 24), by Sayre in 1874
(personal communication fnmi son), and still later l.iy
Oilier ("Regeneration des Os," t. ii., p. 384) and Koclier
(CurrespondemhliMf. Sclncekcr Aerzte, 1887, Dumout).
3. By the anterior incisions. («) The lougitudinal
(Schcde, Verhandl. der dcut. Gesell. f. Chir., i., p. 68,
1878; Llicke, CeiHmlUait fiir Chir., 1878, p. 681; Hutcr,
1878, "Chirurglsche Operationslehre," Liibker; Parker,
Transactions of the Clinical Societv, vol, xiii., 1880; Bar-
ker, Brithh ^^cll. Journal, vol. i., p. 1326, 1888). (If) The
transverse (Roser, " Chiriirgisch-anatomisches Yademe-
cum," 1870).
3. Posterior incisions, Hueter ("Die Gelenkserkrankun-
gen, " 1877) ; Guerin (" 3Ianuel Operatoire " of Farabceuf) ;
\^\'.\Ai;v {Liingcnheck's Archil', No. 39).
4. Superior incisions, Bardenheuer (Laiigciibci'k's Ar-
cliir. No. 41), H. Schmid (Verhandl. der dent. Gesell. f.
Chir., 1891); Sprengel {FesUehrift Braunschiceiffcr Aerzte,
1898).
In adilition to these, there are from fifteen to eighteen
other modifications of these methods of approaching the
joint (".Manuel Operatoire, "Farabamf). They are of little
value. Of these methods of entering the joint three are
selected: 1. The external incision. 2. The anterior lon-
gitudinal incisiim. 3. The superior incision.
1. Oiienitinti hij ihe Exteriinl liiei-nuii. — The patient lies
U]ion his sound side wdtli the thigh flexed upon the pel-
vis at an angle of forty-five degrees. It is also rotated
inward. One assistant holds flie limb with one hand
upon the knee and the other upon the foot and luoduces
the required positions during tlie operation. The oper-
ator stands behind the thigh aud is usually aided by two
as.sistants.
An incision is made which may correspond to that of
Langeubeck, Saj'ie, Oilier, or Kocher. If Langenbeck's
is selected, it passes from the posterior superior iliac
spine over the great trochanter behind its centre and
follows the axis of the femur. Two-thirds of thisinci-
I'lu. 4as9.
sion is above the trochnnter, one-third is below it. If
Sayre's incision is selected, it passes from a point mid-
938
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
K«-!<ie4-(i<»ii of Joiiil!».
Koscctlou of Joints.
way between the anterior inferior spine and t!ie tro-
chanter across the top of the great trochanter behind tlie
centre, and curves tlience forward and inward. If Ol-
lier's incision is selected, we fle.\ the thigh on tlie pelvis
at one hundred and tlnrty-five degrees. From a jjoint
four fingers' breadth behind the anterior superior spine
\ '}
Fig. 4090.
and the same distance below the crest of the ilium, the
incision passes downward and forward in the direction
of the fibres of the gluteus medius to the trochanter,
thence forward and downward in the a.\is of the femur.
If Kochcr's incision is selected, it commences at a point
opposite the upper border of the great sciatic notch in a
line connecting the posterior .superior spine of the ilium
and the centre of the trochanter major, and descends
parallel to the fibres of the gluteus maxinius to the tro-
chanter major on its external surface. Prom this point it
bends backward and downward. The ujiper limb of this
curve is usually 8 cm. in length, the lower 6 to 8 cm.
{Dumont, Comsjmndcihzhhttl, f. Scfiircizi'r Aentc, 1887).
Of these incisions I prefer Kochcr's, because of the
ready exposiu'e of the parts which it affords, and the
easy access which it gives to the joint through the mus-
cular interstices, thereby avoiding the arterial and nerve
supply of the muscles (Fig. 4088, E F).
Having selected the latter incision, the surgeon should
divide the skin and deep fascia and thus expose the fibres
of the gluteus maximus in the upper two-tliirds of the cut.
These are divided parallel to their length and in the line of
the skin incision. Two or three branches of the gluteal ar-
tery are usuall_v cut here in tlieir middle. Two retractors
are" inti-oduced, the gluteus medius and pyriformis are
exposed beneath tliis muscle internally, while externally
the trochanter is felt. The knife now divides the strong
fascial attachment of the gluteus maximus, passing over
the troeliantcr and descending in the interstice between
the vastus externhs and the quadrat us femoris (Fig.
4089). In this incision the tendon of the gluteus maxi-
mus is in part divided, and this divi.sion, by reason of
the resulting retraction, expo.ses the muscles covering the
joint behind and the trochanter in front. It is here that
the external circumflex artery is sometimes cut. The
interstice between the pyriformis behind and below, and
the gluteus medius above and in front, is seen in the an-
terior part of tlie exposed area. Below this is seen the
interstice between the jiyriformis above and the gemelli
and obturator iuternus below. It is between the latter
muscles that the incision is deepened, since in the upper
retracted fla|) will lie the gluteus medius and pyriformis
supplied by the superior gluteal nerve, while in the lower
retracted flap will be the obturator interims and gemelli
supplied by the inferior gluteal artery. The joint cap-
sule is now exposed throughout its length and should be
divided by an incision which runs parallel to the axis of
the neck of the femur, and at the same time divides flic
periosteum of the neck, the orbieulai' zone of the ischio-
femoral band, the capsule and the circumferential fibro-
cartilage of the acetabulum. This incision is usually suf-
ficient to allow dislocationof thoheadof the femur, but. if
it docs not suffice, a transverse incision may be added near
the acetabular margin. The internal circumflex artery is
usually cut here as it passes over the capsule. The in-
cision in the periosteum of the neck is now continued
over the trochanter major upon its posterior border, and
the periosteum, togetlier with the attacliment of the glu-
teus medius above, the pyriformis internally, the gluteus
minimus, the vastus externus, and the Y-ligament ante-
riorly, is separated with the rugiue. This separation is
greatlj' facilitated by flexion and rotation outward of
the thigh. It is here that the external circumflex artery
is often cut a second time. This flap can now be pulled
forward over the trochanter. It contains within, if we
exclude the small portion of the vastus externus. only
those muscles which are supplied by the superior gluteal
nerve. The thigh is now less flexed, adducted, and rotated
inward. The tendons and the periosteum are separated
with the ruginc from the apex and posterior half of the
trochanter as far as the origin of the quadratus femoris
from the linea quadrati. These tendons, namely, the
gemelli, the obturator iuternus and externus, and as
much as is necessary of the quadratus femoris, are now
retracted backwai'd and downward with the ea])sule.
These muscles are all supplied fiom the inferior gluteal
or sciatic, whose branches are uninjured.
When these caijsvdo-periosteal flaps are freely retracted,
the postei'ior surface of the head of the femur, its neck,
and tlie trochanter are in view. The sciatic nerve is free
from danger, being carried away from the joint when
the oliturator iuternus, the obturator externus, and the
quadratus femoris are divided and retracted.
The thigh is now strongly flexed, adducted, and ro-
tated inward. The round ligament is divided if intact
and the head is luxated (Fig. 4090). The remaining peri-
osteum and capsule
upon the neck is sep-
arated wiih the rugine.
The head is now held
firmly with the lion-
toothed forceps, the
soft jiarts are protect-
ed by the retractors,
and the bone is sawn
with the Gigli saw
just below the level of
disea.sc or injury.
The acetabulum is
next removed with the
gouge, chi.sel, or Volk-
niann's sjioon, accord-
ing to the indications.
The sj'novial mem-
brane and parts of the
capsule are removed
after the bones are
cleared of disease. If
sinuses arc present
they must be excised
or curetted. Hemor-
rhage usually consists
of oozing, and can be
stopped by hot saline
solution ; if it is very
troublesome the wound
may be packed with gauze
and no sinuses exist the wound niaj- be closed directly.
If, however, abscesses, sinuses, or great oozing is present,
it is best to pack with gauze, for a time at least.
The section in the bone should be niad<' in the neck if
Fk;. torn.
Where no oozing is ijresent
939
Rosootion, [?IIa,xilla.
Resectiou of Superior
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
possible : if not, tlirouuli or Itcncath tlic trochauter major,
because of the sliorteiiiiiir "wiiieli is lialile to ensue.
A ueartlirosis is best sccureil when the section passes
tbrougli tlie neck near llie bead, j'et subtroclianteric .sec-
tions liave given
as good I'esults in
the restoration of
tlie joint. Such
cases are seen in
t li c a u tops y
sliown by J. Isra-
el (German Sur-
gical Congress,
1883) and in the
collection made
by Sach (Deiitudic
Zi it .sell rift fill-
Chir., .x.xxii.). In
some of these cases
a newly fcn-meil
head covered with
tibro - cartilage, u
new trochanter,
and s y n o vial
memliraue were
reproduced to a
considerable ex-
tent. To obtain
the best results,
one must fiperate
earl}' in the dis-
ease, early in lif(!
(three to tifteen
years), and sub-
periosteally, and
must preserve as
much of the bones
as possible, so as
to diminish the
shortening.
When a ueartlirosis is not attainable or is inadvisable,
the after-treatment should secure the rclcntion of the
limb in abduction with the slightest tii-xion. This gives
a very good and u.seful limb.
2. Operutiun hi/ tlie Anterior Ineisiun. — The only incis-
ions here considered are those which are longitudinal.
The transverse are too destructive of the soft ])arts.
According to Liicke and Schede, the incision com-
mences one finger's breadth bi low and to the inner side
Fro. 4092.— Loliker's Sponn-Elev.qtflr.
(About Vi natural size.i
Flu. am.
of the anterior sjiine and descends in the long axis of the
fenuir for a distance of 10 to 13 cm. (Fig. 4091, BB). As
it is deejiened it passes lo the inner side of the sartorius
and the rectus muscles and to the outer side of the ilio-
psoas muscle. The crural nerve and the external circum
flex artery are avoided. The assistant tlexes, abducts, and
rotates outward the thigh, i'he sartorius and rectus mus-
cles are drawn outward, the ilio-psoas muscle and the
crural nerve inward. The capside of the joint is exposed
and is divided by a cross<-d incision, the transverse portion
parallel to tlie neck passing from the acetabuluiii over to
the anterior intertrochanteric line, while the vertical por-
tion crosses this line at a right angle. The neck is now sawn
withaGigli saw and the head is extracted after dividing
the liganientum teres by Lobker's spoon-elevator (Fig.
40y'2) or by a lion-toothed forceps. For the extraction of
the head alone this incision may suffice, but if we wish
Mr:. 4004.
to reach the trochanter in addition we must advocate the
incision of Hneter which has been much used and
strongly advocated by Barker. In this latter method,
the jiatient rests supine with the thighs extended ; the
surgeon makes an incision which, according to Huetcr,
pas.ses from the middle of a line drawn from the anterior
superior iliac spine to the trochanter luajor. downward
and sliglitly inward along the outer border of the sar-
torius. In children the incision is 6 to 8 cm., in adults 10
to 1-5 cm. in length. According to Barker, the incision
commences in the anterior surface of the thigh, one-half
inch below the anterior superior spine of the ilium, and
runs downward and inward for three inches (Fig. 4091.
AA). With cither incision, the dissection is carried in the
space between the sartorius, anteriorly, and the tensor
vagin:E femoris and the gluteus inedius behind. The in-
cision isdee]iened to the bone and some fibres of the vastus
exti'i'nusare divided. In the lower angle of the wound is
.seen the external circumflex artery, which may bedivided.
These muscles are retracted, the joint capsule is seen and
is incised by the same cross incision mentioned in the
Schede-Lueke method. After this exposure of the head
and neck, the spoon-elevator maybe used and the Iro-
chanter freed of its muscles sufficiently to allow an easy
exposure of the joint. Thediseased head is now removed
after encircling the ueck and ilividiug it with the Oigli
saw. The removal of the head is often diliicult unless
it be much diseased. With the lion-toothed forceps the re-
moval is often very diliicult and the soft parts and the
head are often crushed. The easier method is to pry the
head (Uit of the acetabulum by introducing a strong,
gently curved elevator or Lobker's spoon in the space be-
tween the head and the acetabuluni. and after the liga-
nientum teres has been divided the head is then easily
remoyed.
The bleeding by this anterior incision is small in
amount if one avoids the anterior circuiuHex artery.
Drainage of the wound will require not infrequently a
posterior opening, but in many cases operated early all
necessary drainage can be secured through the anterior
incision.
In neither of these methods by the anterior incision are
muscles oit. Neither nerves uor vessels are injured. In
both methods the route to the joint is a direct one. The
advantage of the liueter incision over the Lucke-Schede
940
REFERENCE IIANDHOOK oF THE MEDICAL SCIENCES.
ICosi'i'iioii, [.llaxllla.
K«'N<M-li4»ii orsiiporior
incision is that the trochanter, as well as the head and
neck, can be reached.
When the acetabulum is primarily involved, or the x-ray
and the clinical symptoms show that the disease whii'Ii
affects it must be especially attacked, the methods iiifio-
duced by Bardenheuer (lac. cit. ) and Schmid (Itic. cit. ) gi\ e
the best chances for radical cure. As usual methods, these
jM'ocedures are considered at present too extensive. In
Bardenheuer's liands, the mortality due to the operation
alone was 4.3 per cent. In Schmid's hands, the recur-
rences were not lessened by the procedure, two of the four
cases dying of continued tubercidosis. In the large ma-
jority of cases the Kocher incision will give sufficient ex-
posure to enable us to chisel or gouge away the diseased
acetabulum; and as tliis method is less extensive and
more easily accomplished it should be preferred.
Operation by the Superior Inchion. — In a few cases, Koch-
er's operation is not sufficient, and we recommend for these
the suggestion of Sprengel (" Zuroperaliven Nachbehand-
lungalterHiiftresectionen,"i'>s/«f/( ;■//■(:, 1898), which con-
sists in making an extensive incision along the crest of
the ilium from the posterior superior spine of the ilium
to the anterior superior spineof the same. This incision
divides the muscles and the
periosteum. At the bordei'
of the gluteus medius and
the tensor vaginae femoris
this incision descends to the
trochanter major. (Fig.
40H8. ABC.) this quad-
rilateral flap is removed
sidj|ii_-riosti'ally from the
ilium until the joint is op-
ened and the head and
neck of the femur are ex-
pose). As the ner\;es and
vessels are avoided by this,
the muscidar paralj'sis and
hemorrhage are practically
nil. If the disease is well
forward in the aci'tabulum
and pubis, especially if a
flexion -contracture exists,
the incision is made in front
of the tensor vagina; femo-
ris, sartorius and rectus,
and these muscles are sep-
arated with the rest (Pig.
4088. AIW). After expos-
ing the head of tlie femur,
it is rotated inward or out-
ward, as occasion demands,
and adducted strongly. If
the acetabulum alone is to
be removed, this can be
easily accomjdished with
the chisel or gouge through
the incision first recom-
mended (ABC). If the dis-
ease requires a resection of
the acetabulum and the sur-
rounding bone, tlie second
incision is used (ABD). In
this latter case the outer
surfaces of the ilium, t)ie
acetabulum, and the outer
margin of the great sciatic
notch are bared of their peri-
osteum. In like manner
the internal surfae(> of the
ilium, the iliac fossa, is freed from the pelvic fascia and
muscles until the great sciatic notch is readied. A Gigli
saw is then inserted through tlie sciatic nutch beneaTth
the iliac muscles anti over the anterior inferior spine of
the ilium and the bone is sawn (Figs. 4093 and 4094,
,17?). The horizontal ramus of the pubis is next cleared
of its periosteum, carrj'ing with it the vessels, which are
displaced from 1 to 2 cm. internally. An aneurism
Fig. 4095.— a Patient Three and
a Half Years After Removal of
One-Half the Pelvis and the
Head of the Femur. (Koeher.)
needle now carries a Gigli saw around the ramus and
out of the obturator foramen (Fig. 4094, CD). The bone
is sawn. As the bone is now cut upon two sides, it
can he displaced outward somewhat. The periosteum is
next removed from the descending ramus of the ischium
from above downward with gri'at care to avoid injur-
ing the vessels and nerves as they pass out of the pel-
vis. The Gigli saw is again passed around this ramus
at a point one finger's breadth beneath the acetabulum
(Figs. 4093 and 40<J4, J^F). The bone is sawn. The ace-
tabulum and surrounding bone can now be quite easily
removed with the heavy lion-toothed forcejjs. If the
head of the femur is to be removed with the acetabulum,
it is best removed before we attempt the resection of the
acetabulum.
After the hemorrhage has been controlled the wound
is closed with sutures except in some portion where the
]iacking emerges. It is best in all cases to ]iack the large
wounds for from twenty-four to forty-eight hours.in order
to control hemorrhage completely. After this, that por-
tion from which the gauze emerges can be left for drain-
age or it may be sutured at this time.
After- Triiitini'iit. — The after-treatment in resection of
the hip is important. An aseptic dressing, equable com-
liression and rest for the wound are the first deside-
rata. The position to be maintained is that of extension
and abduction of the thigh, with the neck or the trochanter
closely apphed to the acetabulum or ilium. During the
tirst three weeks, since these wounds are packed with
gauze and require secondary suture or dressings, a Buck's
or Volkmann's extension apparatus with ]daster-of-Paris
spica passing to the knee is most frequently used. After
this period, when the packing is removed or the wound
is healed in great pait, a Thomas splint or the plaster-of-
Paris dressing may be used for the next three weeks.
If the patient is up and about upon crutches (children),
a Thomas splint is very inexpensive and satisfactory. If
the patient is confined to bed, a plaster-of-Paris splint
which can be readily removed for the active exercise of
the joint is the more useftd form of splint. During this
period of three weeks, active exercise in the new joint is
made every two or three days.
During the following three to six weeks patients are
allowed to walk with their sjiliuts, and during this time
the Taylor hip splint or some modification of it is sub-
stituted for the former apparatus. These splints allow
fiexion, extension, and abduction when applied, and the
surgeon must continue the extension and alidiiction of
the limb for a long time to overcome the constant ten-
dency to flexion and adduction. It is only by this care-
ful after-treatment that a good functional result can be
obtained. Frank Hartley.
RESECTION OF THE SUPERIOR MAXILLA.— His-
ToKV. — Partial removal nf the superinr m.ixilla for alve-
cilar growths, necrosis, disease of the antrum of High-
more, etc., has probably been practised for a very long
time, but the complete, formal resection of this bone ap-
pears to have been first proposed by Lizars in 1826.
In the following year Geusoul, quite independently
of Lizars' suggestion, performed the operation, and there-
fnre seems entitled to the credit of having first executed
this procedure.
The indication for resection of the upper jaw is almost
invariably the presence of a new growth. Hueter states
that the jawsare more frequently the seat of tumors than
any other bones of the skeleton. Almost every variety
of neoplasm is found in connection with these bones.
Benign tumors such as C}'sts, epulis, adenomas, fibro-
iiias, chondromas, osteomas, etc., require partial resec-
tinns only; merely enough of the bone being removed
to give access to the tumor or to effect the complete re-
moval of the latter.
Complete resection of the superior maxilla is usually
dciue for malignant growths, i.e., carcinomas and sarco-
mas, affecting the bone. They occur with about equal
frequency. The majority of the former begin in the
alveolus.
941
Rosootioii of Supe-
rior iTIaxilla.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Anatomy. — The superior maxilla i.s Ihe largest bone of
tlie fiioe, the lower jaw (inaudible) excepted, and with
ils fellow forms tlic whole of the upper .iaw. Each bouc
forms a part of the wall of three cavities: the mouth, the
na.sal fossse, and the orbit. It is hollow, its cavity beiug
known as the antrum of Highmore, wliich communicates,
by an aperture with the middle meatus of the nasal fossa.
Either of these cavities may be the seat of new growths
which involve the maxilla; the mouth and the antrum
being most freiiucntly ailccled. The mucous menil)raue
of tiie iuitrum is frequently the seat of a catarrhal or
pundent intiammatiou, giving rise to an exces.sive dis-
charge tliroiigli the uo.se, or if the fluid is prevented from
escaping, the thin walls of the bone yielil, uud jirotrude
toward the clieeli, toward tlie mouth, or in botli direc-
tions, the appearances then simulating tliose observed in
solid growths of 1 he bone.
Lislrijiiieiiti: lia/Hirid. — ^louth gag, sponge holders,
scalpels, toothed di.ssectiug forceps, ha-mostatic forceps,
scissors, keyliole .saw, Hey's saw, tooth forceps, !)oue-
cutting forceps of differeut angles, chisels and mallet,
lion-jaw forceps, sequestrum forceps, Paiiuclin cautery,
tracheotomy tube, needles, straiglit and curved, ligatures,
sutures, marine sponges.
Partial resertioii for alveolar tumors and necrosis ma\'
be carried out through the mouth in most instances, with-
out makin.g anj- external incisions. The removal of other
benign growths must be carried out on general surgi-
cal principles. The affected part is approached by in-
cisions designed to avoid imjiortant structures and to give
tlie best exposure with the mininuim resulting deformity,
and tlie neoplasm, together with the bone to which it is
altaclied. is then removed.
If the tumor is open to tlie susjiieion of being malig-
nant, a generous portion of the adjacent bone in all direc-
tions should be renujved, or the complete resection may
be advisable.
The dangers of resection of the sujierior maxilla are:
hemorrhage, the entrance of blood into the air passages,
and septic pneumonia.
Various means have been a<lopted b_v dilTerent oper-
ators with the view of controlling the hemorrhage. The
internal maxillary and temporal arteries, anil the external
carotid artery have been ligated as a preliminary step in
the resection. Thecomtiion carotid Ikis been compressed
and subjected to t.em|iorary and permanent ligation.
Crile has devised a clamp to be apiilied to one or both
comtnon carotids, as may be necessary, for tlie temporary
control of bleeding during ojierations on the head and
face if serious hemorrhage is proliable.
With tlie view of preventing the lilood from flowing
into the air passages. Rose advises that the patient's
head be allowed to project beyond the end of the fable,
and to drop well down so that the vertex piiints vertically
to the floor. In this position the mouth and nose are on
a lower level than the larynx and the blood would escape
from them before it would enter the latter.
The objection to this position is that tlie surgeon is
obliged to work at a great di.sadvantage. and the hemor-
rhage is greater when the head is dcpen<leut than when
it is elevated.
Some surgeons perform a preliminary traclieotomy, in-
troducing a tube, and continue the atuesthesia thi'ough
this, so that the pharynx may be ]i:icked with marine
sponges to which stout strings have l)een attaelied to as-
sist in their withdrawal. The sponges absorb the blood
that tiiids its way to the phaiynx and prevent any from
flowing into the iraehea.
Of this procedure it maj' be said that while a carefully
lierformed t-ra,cheot.omy that is well cared for afterwaril
does not add much to the dangers of the operation, it is
an additional com|ilication. and is usually unnecessary.
The use of Tri'iidelenburg's tampon cannula for "the
trachea answers the same purpose as the traclieotomj",
and is o]ieii to none of its objections.
The nirthods which are employed in lu-eventing the
entrance of l)lood into the hums do not diminish in llie
least the aniount of blood lost. By having the imtieut
only partially anaesthetized, he will be able to spit out
the blood and thus keep bis air passages free. In this
way the necessity for adopting the measures spoken of
will be avoided, and if the operation be expeditiously
performed, the amotint of blood lost will not be great.
To summarize, it may be said: (1) That Rose's posi-
tion is not to be recommended. (2) If no complications
are to be expected, the operation may bo done with the
patient but partially ana'sthetized." If this iihin In;
adopted, evi'iylhlng that may be needed should be at
hand, and there should be an ample number of assistants,
so that not an unnecessary moment shall be lost after the
operation has actually begun. (3) In performing the op-
eration for vascular tumors affecting the bone, or wdien
for any other reason unusually free bleeding may be ex-
pected, it will be advisaVile to pass a loop of silk about
the external or common carotid, traction upon which will
occlude tlie vessel, or, if at hand, one of Crile's clamps
ma3' be applied. lu either case, especial care must be
exercised to prevent infection of the wound exposing the
artery, as such an occurrence may readily be more serious
than the resection of the bone. (4) If there is no reason
to expect serious hemorihage, these precautions become
unnecessary. On the other hand, if a more deliberate
operation is reijuiri'd, as in ca.ses in whicli turners have
jiassed the limits of the m:ixilla and must be followed in
whatever direction they have taken, the advantage of
having a dry w'ound. so that every portion may be in-
spected without being obscured by blood, cannot be
overestimated. In these instances some method of con-
trolling the circulation is of inestimable value.
Septic. ])neu inoiu'ii is best prevented by having the naso-
jiharyux treated before the operation by cleansing sprays,
douches, and gargles, and by keeping the cavity sweet
and clean after the operation.
Uperatimi. — A number of methods have been devised
for resecting the superior maxilla, and many of them
have been named after the operator who devised them.
The chief variation is in the skin incisions employed to
expose the bone, the mode of actually removing the latter
being essentially the same in all.
In the classical resection the incision variously known
as the median, Fergusson's, Nelatou's, Listen's, Weber's,
etc., is beyond question the best. It gives ample expos-
ure and is followed by less disfigurement than is any
other incision. For partial resections and special cases
.some of the other incisions may be more suitable.
The incision from the angle of the mouth to the malar
bone has been aseribi>d to Lizars and to V'elpeau. Langen-
bcck exiio.sed the bone by a (J -shaped flap, beginning at
the side of the nose, at the point of junction of the nasal
cartilage ami bone, and carried downward, outward, and
U|iward. terminating at the middle of the malar bone,
ijiston's incision extended from the angle of the mouth
to the external angular process of the frontal bone.
Gensoul made three incisions : the first from just below
the inner eantlius, down the side of the nose, and through
the iqiper lip; a second at right angles to this, on a level
with the floor of the nose, as far out as a lineperiiendicu-
lar to the external angidar process of the frontal bone;
and a third, from the termination of the .second to the ex-
ternal angular jirocess. .
The aiia'sthetic may be either ether or chloroform,
according to the custom of the surgeon. If the thermo-
cautery is tolieemploved to control bleeding, chloroform
should' be administered on account of the inflammable
character of tlie vapor of ether.
The |)alient should be |>laci'd on his b;iek, with the head
and shoulders raised on pillows, the alTeCted side beiug
ujiiiermost. Ilis face should have been cleanly shaven.
The median inci.sion is made in the following manner:
The knife should enter the skin about half an inch below
the inner canthus. and the incision should then be carried
downward in the line of junction of the nose and cheek
to the ala nasi, around and close to the latter, and it .should
stop just shi>rt of the middle line of the lip, from which
point it should lie extended vertically through the lip to
its free border. The incision should be carried down to
9-i-2
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
lSoNO<'ll<>u <»!' Supe-
rior illsi.\illa.
Fig. 4096. — Resection of the Superior
Maxilla. 1, The median Incision (also
called Fergusson's, Nelaton's, Listen's,
and Weber's) : 2, Langenbeck's in-
cision ; 3, Lizars' or Velpeau's incision.
the bone at oik(\ all bleeding points being caught by
pi-essure forceps. Finally, a second incision is to be
carried along the lower border of the orbit from the be-
ginning of the tirst to
the malar bone.
The Hap thus out-
lined should be ra-
jiidly dissected from
the bone, all bleed-
ing points being se-
eui'ed by forceps or
by sponge pressure.
At this stage it is
well to tie oti' such
forceps as .interfere
with the subsequent
steps, and to arrest
all bleeding as far as
possible. The malar
bone is next divided
at about its middle
by Hey's saw. If
it is proper to leave
the orbital plate a
second saw cut is
made in the line of
the second incision,
beneath the orbit
as far as the nasal
process. If the orbital plate is to be removed, the peri-
osteum is incised along tlie lower boiik'r of the orbit anil
carefully separated from the bone as far back as ueeessarv,
and the floor of the oibit divided at the proper line with
a chisel and mallet;' or if it is necessary to remove the
orbital plate entire, the periosteum is fully separated and
it is wrenched from its connections at the time of remov-
ing the maxilla.
The nasal bone and nasal cartilage are next separated
from the maxilla bj' means of a saw or chisel. The upper
centi'al incisor tooth in the affected maxilla must now b'e
extracted and the mucoperiosteum covering the hard
palate divided near the middle line fi'om before backward :
the soft palate should also be .separated by a transverse
incision along the posterior border of the bard palate on
the diseased side. By means of a keyliole saw intro-
duced into the nostril the hard palate is divided in the
line of the incision in the mucoperiosteum as rapidly as
possible. The bone is then grasped by lion-jaw forceps
and wrenched from its remaining attaelnneiits, the prin-
cipal one being the pterygoid process. At this stage the
use of the bone-cutting force]is bent at an angle may lie
required to sever anv tjrm connections. Sponges sliould
be instantly thrust into the cavity and pressure exerted to
check the bleeding, and the patient's tluoat should be
cleai'ed of any collection of blood. The sponges may
now be removed one by one, and the bleeding poiius
dealt with by ligation or by tlie thcrmo-cautery. Usu-
ally the hemonhage will cease after a few moments'
pressure.
It will be necessary to pack the wound with gauze
■which will eiTectually arrest oozing, but it must not be
depended upon to control spurting vessels. Each piece
of gauze introduced should have firmly attached a strong
thread to assist in its removal. After the operator has
assured himself that the hemorrhage is controlled, he
should replace the Hap and should suture it in iiosition
by means of silkworm gut. Especial care should be ob-
served in adjusting the free margin of the lip.
If the bone is much diseased it is apt to break, and
must then be removed in fragments. In such eases every
portion should be examined for evidences of remaining
disease and all such ti.ssue removed.
The advantage in leaving the floor of the orbit when
possible is that the eye is not disturbed. When it is re-
moved, the eye drojis somewhat, and the lower lid is apt
to remain red, swollen, and distorted.
The removal of both superior maxilUe becomes neces-
sary in rare instances. Tlie technique is the same as that
described above save that it is duplicated on the oppo.site
side.
After-Treatment. — Tlie gauze tampon should be re-
moved on tlie day following the operation unless there is-
reason to expect free hemorrhage, when it may be allowed
to remain another twenty-four hours. The mouth must
be kept as clean as possible liy the frequent u.se of washes,
douches, and spravs. These should consist of mild anti-
septics like solutions of boric acid, salicylic acid, etc.
Nourishment during the first few days is maintained
preferably by nutrient encmata, and later bj- milk,
broths, and oilier liipiid foods given by the mouth.
MortaUty. — This varies in difl'erent collections of eases.
Butlin in 1S87 found the mortality to be about 30 per
cent. Bryant's collection (l.Siifl) showed 14 per cent, of
deaths. Of C6 more or less complete unilateral and .5
bilateral resections, collected by White and Wood (1896),
but 6 percent, died as a result of the operation. The
records of St. Bartholomew's, St. Thomas', and Univer-
sity Hospitals, London, have been examined by Butlin
(1!K)0), who found Vil cases of resection for malignant
disease with IG deaths (I'-J.G per cent.). INIarfens (quoted
by Butlin) reports from the Clinic of Kijnig. in Gi'ittingen,
74 total resections, from 1875 to 1896, with nearly' 30 per
cent, mortality.
Osteoplnstic resection of the siipeiior ma.villn is occasion-
ally performed for the purpose of removing nasopharyn-
geal tumors. Nelaton'.s' method consists in. the division
of the soft palate antero-posteriorly, and the removal of
the posterior half of the hard palate after the mucous
membrane and periosteum have been separated from the
middle line toward the alveolus on either side. After the
removal of the polj'p the palate is closed by sutures.
Chalot separated the upper lip from tlie superior max-
illa until the nasal foss;e were opened, then extracted the
two upper canine teeth and made an incision through
the mucoperiosteum of the hard jialate from the point
occupied by the extracted teeth, along the alveoli, to the
]iosterior border of the hard palate. The alveolus and
palate were next divided liy a mallet and chi.sel and the
fragment was separated from the vomer and turned down
into the mouth, being attached only to the soft palate.
After the removal of the tumor tlie bone should be re-
placed and held by sutures.
Se\'eral methods have been proposed by different sur-
geons for reaching these tumors by temporary resection
of portions or all of the nose, the most tiseful perhaps
being that of Rouge. This consists in separating the
upper lip from the
maxilUo by divid-
ing the mucous
membrane close to
the bone ; the seji-
tnm and the al:c
;irc also detached
from tlieir attaeh-
meiits to the bone
and turned upward
by inverting the
upjier lip and mak-
ing traction, After
the removal of the
tumor the parts
fall naturally into
place.
This procedure is
suitalile for tumors
situated anteriorly
c li i e II y. Some
m cans m u s t be
adopted for pre-
venting the blood
from getting into
the larynx. Langenbeek makes two incisions: one from
below tlie inner canthus to the malar bone, and another
from the nostril to join the out<'r extremity of the tirst.
The lioiie is sawn through in the lines of the incisions.
The bone still attached to the soft parts is then rai.sed
FIG. 4(1)7. — Resection of tlie Superior
Maxillii. .1, (lensoul's incision; B,
Lans-'crilieck's incision for osteoplastic
resectiou.
94-3
KeM|»irall(»ll.
UEPERENCE IIA>;DB00K OF THE MEDICAL SCIENCES.
and thrown over on the opposite cheek. The jiaits are
restoreil anti sutured in jilace after tlie tuinnr is rcrmived.
Alfml r. W.uh/.
RESINS. Siv Actirc Pnnciples.
RESOPYRIN. See Antipi/rin.
RESORBIN is a readily absorbable ointment base made
by enndsilyiuf; expressed oil of almond with yellnw wax,
soap, gelatin, and water, and adding lanolin to give it a
proper consistency. It was introduced by Leberniann,
wlio used it as a vehicle for mercury, as more readily ab-
soi'bed and less greasy than blue ointment. He also em-
ployed it in various sUin diseases. In course of time it
tends to bec'ome rancid. II'. ^1. Bastaii.
RESORCIN: RESORCINOL.— Rcsorcin, chemically
■!i>rtii(li<u-;//i, iizciir. t',:l 1 1(( »1 1 )j. is one of a trio of Isomeric
diatomic plienols, of which pyrocatechiu and hydroqiu-
none are the other two memiiers. It is official in the
United States Pharmacopieia under the title Itesurcimim,
Resorcin.
Hesorcin occurs in colorless, needle-.shaped crystals,
having a peculiar smell, resembling that of carbolic acid,
and a bitter-sweetish taste. Resorcin dissolves readily in
water, and still more readily in alcohol and in ether. In
itselTccts resorcin resembles its congener, carbolic acid,
but is, in g(aieral, less active than that substance, and, in
particular, very nuich indeetl less poisonous, constitu-
tionally. Resorcin inhibits bacterial growth, but prob-
ably less potently than carbolic acid. Locally, the drug
is without effect upon the sound skin, but applied, tuidi-
luted, to a nioi.st nnicous membrane, it is mildly cau.stic,
while at the same time ana'Sthetic and healing. By rea-
son of the ana>stliesia it produces, resorcin may lie ajiiilicd
even to such sensitive parts as the mucous membrane of
the larynx (Andeer). Internally, resorcin may be given
in very considerable doses, as compared with carbolic
acid, and such doses, administered to a fevered subject,
will show to a marked degree the pecnliar antipyretic
effect so characteri.stic of the phenols. After a dosage
of from 2 to 3 gm. (from gr. xx.x. to gr. xlv. ) there set
in. in a few minutes, iiuickening of heart action and of
breatlu'ng, reddening of the face, and buzzing in the ears,
with giddiness. AVilhin fifteen nnnutes sweating begins,
speedily beconung active, whereujion the antecedent de-
raugenients abate, and at the same time the pyrexial
temperature rapidly falls— so rapidly as perhaps to reach
the normal point within an hour. The sweating does not
last long, so that afterihe lajiseof an hour from the time
of dosing, the fever patient may have a naturally moist
skin only, with tem|ierature and juilse rate reduced to
the normal. But while defervescence by resorcin is
quick to occur, it is also quick to give way to the natural
tendency of the fever to regain its former height. Within
from two to four liours, therefore, the temperature often
begins its succeeding rise, and within a single additional
hour may have attained its original height. Such rapid
after-risings of temperature may be attended by a chill.
Resorcin is variable in its aeti(jn; sometimes the fall of
temperature is slight, and sometimes the by-eff'ects are
exces.sive and even alarming. Thus, after medicinal
doses, there have been observed delirium and illusions,
with muttering speech and convulsive trembling of the
hands, and, in one ease at least, a deep comatose sleep.
In ovenlosage resorcin is eom]ietent to induce constitu-
tional poisoning after the general type of poisoning by
the phenols — producing gidiliness, insensiliility, profuse
sweating, gre.-it redm/tion of temperature, and general
collapse, with olive green coloration of the urine. Such
alarnn'ng condition has followed a succes.siou of doses in-
creascil from half a drachm to two drachms. Therapeu-
tically, resorcin has been used forl)oth local and constitu-
tional medication. Locally, resorcin is possibly available
for a simple "antiseptic" etfeet, but is surpassed in this
therapeiisis by so many otlier agents as to be little used for
t'ne purpose. But tola <'omliiued autizymoticaud heitliiKj
effect the local application of resorcin may be quite ser-
viceable. Thus injections of a five-per-cent. aqueous
solution have been made into the bladder, in cystitis, and
into suppurating cavities, with good effect, and salves of
resorcin have abated malignant and syphilitic ulcerations.
A spray of a two-percent, solution has been used in
whooping-cough; and a ten-percent, solution has been
praised for local application to the throat in diphtheria.
Internally, resorcin has been used for its antipyretic ac-
tion, in which application the medicine presents the feat-
ure of a fair degree of safety and effleieuey combined ;
but the action is evanescent and attended bj' disagreeable
excitement and sweating. The dose of resorcin for an
antipyretic effect ranges from 3 to 4 gm. (from gr. xxx.
to -xlv.), b.est given in divided doses and administered,
dry, in a wafer or capsule, or in solution in water, sweet-
ened and aromatized. Constitutional effects are also as-
.serted (Andeer) to be procurable, in diseases attended by
an affection of the skin, by inunction of resorcin in ad-
mixture with vaseline, in proportion of from five to
eighty jjer cent., such efl'ects being the abatement of
symptoms in so-called zymotic diseases, Andeer claims
tiuis to have produced striking amelioration in such dis-
eases as smallpox, scarlet fever, measles, and leprosy, by
inunctions, over the whole body, of resorcin vaseline.
Ri'soriin has been used as an intestinal antiseptic, under
a variety of conditions, in doses of one or two grains
every two hours. Eihrard ('nrtix.
RESPIRATION. PHYSIOLOGY OF.— Respiration is
the runction by wliicli living cells olilain 0X3-gen and get
rid of carbonic-acid gas. It is an essential factor in the
existence of both animals and plants, being a necessary
accompaniment of the chemical processes underlying life.
In the higher aniniiils respiration is a very complicated
process, consisting of many stages, but in lower forms it
is comparatively simple and may be studied to iidvan-
tage.
Co.Mi'.UiATiVE. — Pi-oiiizoa. — Simple one-celled organ-
isms like the amreba, live in a fliud medium, water,
which surrounds themon allsides. From this surround-
ing medium the dissolved oxygen is absorbed by the
general surface of the body, and distributed to all parts
by diffusion or by currents set up by the contracting
vacuoles, or by some unknown form of cell activity.
The carbon dioxide is got rid of by a reverse process.
This simple form of respiration is probably very similar
to the process by which the cells of the higher animals
obtain their supply of oxygen and return their carbon
dioxiile to the surrounding
lymph, constituting the so-
called " internal or tissue res-
piration. "
Cii'h'iilcrtilii. — In this group
each animal consists of a cen-
tral cavity surrounded by two
layers of cells (see Fig. 409S).
Oxygen is taken in to some ex-
tent by the external surface,
but also by the ci-ntral body
cavity, which serves the dou-
ble purpose of food absorption
and respiration. This pre-
jiares us to lind the lungs of
lugber animals having a com-
mon <Mnbryological origin with
the organs of digestion, and
stiggesls the close relationship
of the two processes. The
<'urri'ntsset tipt<i and from the
central cavity by the move-
ments of the iiody wall and of
the tentacles facilitate the res-
juratory iiroeesses by bringing
fresh fluid with a liew supply of oxygen within reach
of the absorbing cells.
Worms. — In this heterogeneous division of the ainmal
kingdom wc liiul a circulating fluid or blood capable of
Fig. 4n9S.— Hydra, rliaffram-
malic, showing limiy Cav-
ity ^('. lioily watt ill two
layers rti atid tr, tentacles
r, and limulli nu (.\rter
Bell,)
04-4
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Kesius.
Respiration.
oarryins: the oxygen from the surfaec of the body where
it is absorbed, to tlie eells in llie interior uinih liave need
of it. In some eases the blood e(]ntaius a speeial sidi-
stance, hsemoglobiu, witli which the oxygen can enter
i-R
Fig. 4(199.— Two Type.^ nf Nemertinea sliowinp Ruriimeiitary Kp.spira-
tory Organs, /?. Leading in toward thr Brain. Hr. In A, B is a
simple pit and in li it is a duet ending l)lindly anions Itie cells of
tlie brain. (After Bell.)
into loose combination wliile 1)eins cairied alioiit. In tlie
worms we tind for the tii'st tinn' sjiecial organs of respii'a-
tion. Sometimes tliese are little more than grooves or
pits supplied with eilia to favor the renewal of tlie oxy-
gen-containing medium. In other cases we find these
pits becoming deeper so as to form ciliated dncts (Fig.
4099).
Insects. — In insects we find a system of tnbes (trachctF)
adapted for air breathing. These are distributed through
the body, and the renewal of the air wilhin them is
favored b}' movements of the legs and wings.
Ilighrr Aiiiinah. — As we ascend the scale we find fur-
ther developments of the organs of respiration, such as
to ofl'er the greatest respiratory surface in the smallest
possible space. This is seen botli in the gills of fishes
and the lungs of air-breathing animals. The arrange-
ments for the renewal of the oxygen-containing medium
aie elaborated and reach their highest development in the
bony thoi'ax of the higher vertebi-ates with their costal
and dia])hi'agmatic bi'eathing. 'I'he blood-vascular sys-
tem also becomes better adapted for taking up oxygen
and carrying it rapidly all over the body.
The liiimiin ciiihryo in its respiratory function, as in
other things, passes through many of the stages repre-
sented in lower forms. The one-celled ovum, like the
amoeba, takes in oxygen b)' its general surface fi-ora the
fluids which surround it in the uterus. As gro\vth pi-o-
cecds it develops a blood-vascular system, but for a time
continues to take in its oxygen by tlie general surface
of the surrounding membranes. When the placenta is
foi'med, the fo'tus has a special organ oF resjiiration, but
obtains its suppl}' like a fish from a fluid medium, the
mother's blood. At birth the tying of the cord shuts olT
the placenta, and the consequent deficienc}' of ox3'gen
stimulates the centie in the medulla to initiate the fii'st
resiiiratoiy movements. The opening up of the lungs
diminishes the pi'essui-e in the pulmoiiaiy ves.sels. and
thus deterinines an inci'eased blood supply to these or-
gans. The foi'amen ovale closes and the adult condition
is rapidi}' established.
The di!G.\NS OP Respiration. — These include the air
passages leading into the lungs from outside and coiiipris-
ing the nose, pharynx, larynx, trachea, and bronchi; the
hnigs -which contain the respiratory surfaces (air sacs or
alveoli) in which the interchange of gases takes pUute,
the divisions and ramifications of the bronchi leading
down to the alveoli, and the supporting conneclive tissue
in which run the bloo<l and lymph vessels and the nerves ;
the pleurm which cover the lungs and line the thoracic
walls with a smooth slippery membrane facilitating
movement; the tlioracic iriilh which enclose the lungs
and which are strong enough to jirotect them and yet
mobile enough to be the meilium through which the ex-
Voil VI.— 6(1
jiansion of the lungs is elTected; thv muscles of respira-
tii'ii. including the diaiihiagm and the muscles acting
upon the ribs; the nerruiis iiiic/nuiistii. through which all
the respiiatory jiroccsses are initiated and regulated.
The none serves a useful jmrpose in warming the in-
spired air and thus pidtectiiig the other air passages from
too sudden changes of temperaluie. The larynx is espe-
cially concerned in s|ieech and voice production. It also
plays an important pait in preventing dust particles and
noxious ga.ses from entering the lungs by the cough and
spasm which tliese substances excile when they come in
contact with its mucous menibrane. The trachea and
bronchi consist of tubes of fibrous and elastic tissue sup-
ported at regular intervals by incomplete rings of carti-
lage. Tlie portion behind, where the cartilage is absent, is
supplied with jilain muscle tissue by which the tubes can
be .somewhat constricted. The mucous niembiane con-
sists of loose lymphoid tissue. It is supplied with mucous
glands, which keep the surface moist, and is lined with
ciliated cnhnnnar epilhelium. The cilia carry the mu-
cous secretion and inhaled du.st piarticles up toward the
larynx. The lungs. As the bi'onchi enter the lungs
they divide and subdivide, forming the bronchial tubes,
to the smallest of which the name bronchioles is applied.
The structure of the trachea and bronchi is continued
into the bixmchial tubes with certain modifications. The
cai'tilaginous rings are replaced by irregular plates of
cartilage distributed at intervals around the tubes, and
even these are not found in the veiy smallest bronchioles.
The unstripcd muscle becomes relatively more abundant
as the size of the tubes diminishes au<l it forms a continu-
ous layer of circular fibres. The epithelium changes from
colunmar to cubical, and in the smallest tubes mucous
glands are not found. The lungs may be seen to be di-
vided into innumeralile tiny sections known as lobules, of
which each has adi;iiiieterof 1-3 cm. Th<-y are of pyram-
idal shape, and are divided from one another bj- a little
fibrous tissue. A bronchial tube entering such a lobule
divides sevci'al times, foriinng tiny bronchioles. If we
follow the bronchiole along we will find the epithelium
changing from culiical to pavement, and we will see an
occasional air sac or alveolus opining out fi-om the side.
These tubes suiiplied with alveoli are known as respira-
tory bronchioles. Each respiratory bronchiole ends in a
dihit(<l passage called an alveolar duct, into which open
a number of infundibula. An infundibulum is a cone-
sha])ed expansion with the apex toward the duct. Ex-
tending out from it are numerous liemispherical expan-
sions known as air sacs or alveoli which very greatly
increase the total surface (see Fig. 4100).
The wall of an infundibulum consists of a thin base-
ment mendirane lined by epithelium, the so-called " respi-
ratory epithelium." The
cells composing this epi-
thelium are of two kinds :
non - nucleated platelets
resting upion the blood
capillaries and smaller
nucleated cells between.
Around the infundibula
is spread out a netwurk
of capillaries so dense
that the meshes are nar-
rower than the vessels
them.selves. Between
tiie air in the air sacs
and the blood in the cap-
illaries nothing inter-
venes but the two lay-
ers of epithelium belonging to the alveoli and the ca|)il-
laries respectively. In some cases the caiiillai'v may be in
contact with the epithelium of two contiguoiis alveoli
(see Fig. 4101).
The capillaries distributed to the air sacs are from
branches of the pulmonary artery. The walls of the
bronchial tubes and the coiuiective tissue of the lungs
are supiilieii by the bronchial arteries belonging to the
systemic circulation. The connective tissue which inter-
945
Fig. 4100.— Diaffriiinmiitic Reprt'sen-
tatioii of the Endiii*r tif a linmrhial
Tube in Sacculated IiifuiMlil'iila.
(After Scliaefer.)
Kespiration.
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
venes everywliere between theiiiiuiidil)ulaauil under the
pleuni is rich iu elastic tissue. Tlie nerves of tlie lung
come from tlie anterior anil posterior iiulmouary ple.xuses,
which are formed by branches from tlie pneumogastric
and sympathetic. The sympathetic fibres come ott from
the inferior cervical ganglion, annulus of Vieusseus and
stellate ganglion, and can be traced back to the upper
thoracic nerves. See also Anstd Otriticf!. Lan/ii.v, etc.
Pnvsic.vL Rkl.\tioxs of the Lings to the Chest
"W.M.I. -\ND THE EXTEKX.VI, ATMOSPHERE. — Before birth
the lungs are solid organs; that is to sa}-. the opposite
walls of the alveoli and bronchial tubes are in contact,
and f I irm merely potential spaces conununica ting through
the respiratory pa.ssages with the outside. At birth the
thoracic cavity is enlarged by the action of the nuisclcs
of respiration. The additional space which results nuist
be tilled up as it is formed, for "nature abliors a vac-
uum." The only aveniie through which anything can
enter the thorax to till it is through the respiratory pas-
sages, and so air enters, e.xjianding the lungs and keep-
ing them in contact with the receding chest wall.
Throughout life the lungs continue to follow the move-
ments of the chest wall. If the chest is enlarged, air
enters the lungs, expanding them sutflciently to fill it up.
In doing this the air has to ovcrconuithe elasticity of the
hmgs. During rest the air exerts upou the inside of the
lungs the same pressure as upon the external surface of
the body. 760 mm. of mercury m- fifteen pounds to the
square inch. When the chest is suddenlj' expanded, as in
inspiration, the air within the hnigs is rarefied and the
pressure within the lungs, t/ie ijilrn/Kilinonun/ prcKxiiir.
is diminished. During expiration tlie thorax diminishes
in size, compressing the air in the lungs, and the iutra-
pulmonary pressure rises. In either case movement of
air in or out of the lungs takes place till the intrapul-
monary pressure is again eijual to atmospheric when
equililirium is established.
The jiressure in the pleural cavity and in the media-
stinum is known as the intrdthiirncic pviiisiiir. It is al-
Flfi. 4101. — Section of Injected Uins, Includine Several ContiBuous Alveoli. (F. E.
Schnltze.) (Highly inaRiiitleii.) «, n. Free edcres of alveoli: c. c, partitions between
neiirlihorinu alveoli, seen in section : /». small arterial branch driving off capillaries to tbe
alveoli. Tile loopine: of the ve>sels In either side of the paititions is well exhibited. Be-
tween the ca[)illaries is seen the houieL'eneniis alveolar wall with nuclei of connective-
tissue corpuscles and elastic hbres. ISchaefer.)
ways less than atmospheric because the elasticity of the
lungs lends to ptill them a\va_y from the chest wall, and
protects the latter from part of the intrapulmonary
pressure. The more the chest is expanded the more is
the elasticity of the lungs brought into play, and the
more does intrathoracic pressure fall below atmospheric.
The intrathoracic jiressure is often spoken of as negatire,
meaning tliat it is less than atmospheric. The fact that it
is so may be seen when an opening is made in the chest,
as in this case air is drawn into the pleural sac and the
lungs collapse. During ordinary breathing intrathoracic
pressure varies from 758 to 752 mm. of mercury, which
is 2-10 mm. below atmospheric. This is expressed by
saying that there is a negative iutralhoiacic pressure of
2-10 mm. During forced inspiration, when the lungs
are very much on the stretch, there may be a negative
intrathoracic pressure of 30 or 40 mm.
Renew.\i, OK THE Air ix the Alveoi.i is effected by
the movements of respiration supplemented by diffusion.
The respiratory movements are primaiily movements of
the thoiacic walls, which lead to changes in the capacity
of the thorax and indirectly to expansion and contraction
of the lungs. The size of the thorax can be increased or
diminished in three directions — vertical, antero-posterior,
itnd transverse. The vertical diameter can be increased
by the descent of the arched diaphragm and by the back-
wanl and downward movement of the lower ritis. It
can be diminished by the pas.sive return of the diaphragm
to its arched jiosition of rest, assisted by the contraction
of the abdcimiiial muscles, which force the viscera up
against the dia|)liragm and increase its arch.
The antero-jiosterior diameter is increased by the rais-
ing of the rilis from the resting position, iu which they
slant downward, to one in which they extend more di-
rectly forward, carrying the sternum with them. In
quiet breathing the upper end of the sternum acts as a
fulcrum and tlie lower end is pusheilout; but iu very
deep inspiration the upper end is also raised and extended
forward. The antero-posterior diameter is diminished
by the thorax returning to a position of rest as a result
of gravity and elastic recoil.
The transverse diameter is increased by the outward
and upward rotatiim of the ribs. Any tendency of the
contracting diaphragm to draw in the lower ribs is over-
come by the fact tliat the abdominal
viscera are compressed by its descent
and tend to press the ribs outward.
Muscles of Resi"ik.\tiox. — In ordi-
nary inspiration the vertical diameter
is increased by the descent of the din-
ji/inigm, assisted by tlie fjundmtiis Itnn-
hitriijH and Sfvi'iiti pogtici hifen'areK,
which fix the lower ribs. The antero-
posterior and transverse diameters are
increased by the necileni. leeatores cos-
I'lnim, and serruli pnnlici svperinres,
whicli fix the two upper ribs and as-
sist the elevation and eversion of the
others, and by the e.ttefital inteirostais
which raise the lower ribs. Both the
i.iiiriiiil mill iiitiritiil iiitcrcosfah by
their contraction give strength to the
intercostal spaces and enable them to
withstand the atmospheric pressure.
Expiration is largely passive, being
brought about by the influence of
gravity and the elastic recoil of the
thorax, and by the relaxation of the
diaphragm which allows it to be forced
up again by the pressure of the ali-
(lominal viscera. Some claim that the
descent of the ribs is as.sisted by the
contraction of the interosseous portion
of the iiitcvniil intercostaU.
In forced inspiration a great numlier
of additional muscles are called into
])lay, first those having attachments
to the ribs or sternum, and later a very
great number which indirectly assist the enlargement
of the chest or the opening up of the respiratory pass-
ages. Forced expiration is assisted by the action of
the abdominal muscles, which press on the viscera and
so push up the diaphragm, and also by those muscles
940
REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
Rer«|>iralioii.
Respiratiou.
of the abdomen and back wliich pull down the lower
ribs.
Types of REspinATiox. — xVu infant breathes inostl\'
with it.s diaiihragm. Such breathing i.s spoken of as the
(Uaphnigmatic or abdominal type. In adults we find u
Fio. 4102.— .1. Infi'Tlor Costal and B. siipen'nr Costal Type of Breatli-
ing. a, n. Outline uf hinly in fm-ced f,\piration ; ?>./». lieavy 0(jn-
tinuous line. Tlie outer niai'ffin indirales the contour of the body
in ordinary tnsiiiration and the inner niartrin that of ordinary e.\-
piration. The iviativi- tliirkne.ss of this line' in the two sexes shows
that in the male tlif proaler itiovement takes place in the abdomen
and lower thorax (inferior eostal) and in the female in the upper
thorax (superior costal), o. c. Contour of forced inspiration. Note
that forced inspiration is of the superior costal type in both sexes.
(.\fter Hutchinson.)
difference in the manner of breathing between tlie male
and female. In the male the movements of the aljdomen
and lower part of the th(3ra.x are more jirnnounced. form-
ing the so-called inferior custal ti/pe. while in the female
movements of the upper chest predoini;iate, and we
speak of the superior costal type. This ditTerenee in the
sexes is not found in all races, and so is ascribed 1)\' some
to the influence of dress, but others see in it an adaptation
of woman f(5r her sexual life, pregnancy, through nat-
ural selection (see Fig. 4102).
The Qi'.\xTiTy of Am Breathed. — During ordinary
quiet breathing about 300 c.c. of air is taken into the
lungs with each inspiration and expelled with each ex-
piration. This is called the tidal air. By a forced in-
spiration an additional quantity, known as the coinjile-
mental air, may be taken in. Its volume is about 1,700
c.c. The air that can be expelled by an elTort after an
ordinary expiration is the supplemental air. and meas-
ures about 1.500 c.c. The air remaining in the chest
after the most powerful expiration is the residual air,
amounting to about 1,000 c.c. The total quantity thai
can be taken in after a complete exi)ii-atiiin or breathed
out after the fullest inspiration is called the rital ca-
pacity, and includes the complemental, tidal, and stip-
plemental air. It measures therefore in a typical ctise
about 3,000 c.c. Lung capacity is the total quantitv
of air in the lungs after a forced inspiration, and is
equal to the vital capacity plus the residual air, or
about 4, .500 c.c. All these <niantities naturally vary
very much in different individuals and under diffei-eiit
conditions, but the above numbers may be taken as
more or less typical.
The quantit}' of air breathed in any given case can be
estimated by means of an instrument known as a spirom-
eter (see Fig. 4103).
The Changes th.^t Take Pl.\ce in the Air. — In the
lungs certain things are taken from the air and others
added, as shown in the following table, in wliich the
quantities are given in volumes per cent. :
Nitrogen
Oxygen
Carbonic acid.
Aqueous yapor
Argon, etc. ...
Inspired air.
79
ai.iXi
.1)4
Variable.
Traces.
Expired air.
79
l(i.03
4.4
Saturated.
Traces.
fi
y
^
h
It is to be noted that the volume of oxygen lost, 4.93,
is slightly gi'eater than the volume of CO^ added, 4.36,
so that the total volume of the expired air is slightly less
than tliiit of the inspii-ed air.
The ex]iired air is warmed to the temperature of the
l)od_y and is also fouled Ijy organic emanations given off
from the lungs and respiratory passages. The principles
on which the analysis of expired air is carried out may
be conveniently
studied in the ap- c?
1.1 a r a t u s designed
by AValler. which
is one of the sim-
l)lest and yet suffi-
ciently iiccui'ate for
most purposes (sec
Fig. 4104).
In other methods
the carbon dioxide
is absorbeil by soda
lime or by baryta
water instead of by
sodium hydrate,
and arrangements
may be made for
]i a s s i n g the aii-
through a chamber
containing sulphur-
ic acid for the ar-
rest and estimation
of the aqueous va-
por.
r e s p 1 11 .\ t o i! y
Quotient or Res-
piRATDiiY Coeffi-
cient. — As is
shown in the table
given above, the
volume of oxygen
absorbed is greater
than the volume of
carbon dioxide ex-
creted. The rela-
tion of one to the
otherisexpressed as
CO2
\^^
■\
and is l^nown
0.,
as the respiratory
([uotient. If all the
oxygen taken into
the body reap-
])eared in the ex-
])iied air as CO2,
the volumes would
be equal and the res-
piratory quotient
'^'*-'' would be 1.
On
Some of the oxy-
gen, however, com-
bines with hydro-
gen to form water,
and is excreted as
Fig, 410:!.— Diagram of Huti-hinson's Spi-
rometer. (Landois.) -4. (iraduated cyl-
inder serving as a receiver for the lireath ;
it is supplied with a stopcock at the top
for the ready expulsion of air, and is bal-
anced by weights passing over pulleys.
iJ, Mouthpiece with tube reaching nearly
to the top of the graduated lereiver (.1),
when the latter is sunk in the reservoir
ready for an experiment ; there is a stop-
cock in this tube near the flrst angle to
pi'event reiruri-'itatioii of air. C, Reser-
voir for the giaduated I'eceiver. In using
the spirouietei- the i-eservoir and gradu-
ated receiver aiv lilled with water, or. to
prevent (he absoriitioti of carbon dioxide,
with a saiuraied aqueous solution of com-
mon salt (.\acli. \\\wn ready for an
experiment, the stopcock at the top of the
receiver is cl<jsed and that in the tube of
the mouthpiece ojieued, and the breath
forced into the receiver. The receiver
rises as fast as the breath displaces the
water, .\fter the Itreatii is forced into the
receiver the stopcock in the tube of the
mouthpiece is closed, and the water out-
side and inside the receiver brought to
the same level, so that the air within the
receiver shall lie at the atiuospheric press-
ure. The amount of breath within the
receiver is then read directly from the
scale attached to the receiver. For accu-
rate measurement the breath should stand
a few minutes to acquire the temperature
of the liquid over which it is collected,
then the various corrections for aqueous
vapor tension, and the variations from
the standard temperature and pressure,
should be made.
aqueous vapor by
the lungs, or as water by the skin and kidneys, and thus
does not leave the body "as CO; at till, but as" HjO. The
respiratory rpiotient vtiries with the relative projiortions
of carbon, hydrogen, and oxj'gen in the food. Carbohy-
ilrates contain in themselves just enough oxygen to sat-
947
Krspir:
R<'s|>li-i
lion.
■ ion.
REFERENCE HANDBOOK OF THE JHODICAL .SCIENCES.
i.sfy all llic hydrogi'ii proscnt. so tliat only the o.\idatinn
of the earbou has to be iirovkled for by the o.xygeii taken
in l)y the Inngs. Thus tlie presence of a large amount of
carbohydrate in tlie diet lends to make the respiratory
quotient approai h 1. Fats ami |iroteids, on the other
hand, contain a rela-
tive excess of liy-
drogen, and require
oxygen for combi-
nation witli it, so
tliat the COj ex-
creted represents
only part of the
oxygen ab.sorlied
'' and tlie respiratory
ijvioticnt falls be-
low 1.
Temporary vari-
ations in tlie' res-
piratory quotient
may be due on the
one hand to oxy-
gen being alisorbed
in excess and stored
tip as tissvie oxy-
gen, or on tlie otber
band to tissue oxy-
gen taken in long
before being made
use of for oxi<liz-
iug some of tlie car-
bon. The fonnei
tends to lower tlie
respiratory quo-
tient and is .seen
during rest; tiie
latter raises it and
is seen in conditions
of activity and
quickened metab-
olism.
Vl;n'til.\tiox. — ■
The witlidrawal of
oxygen from the
air and the addi-
tion of COj and or-
ganic matters that
takes jilace during
respiration renders
it vitiated or luitit
to be breath e d
again. When a
r o o m h a s b e e n
breathed in until
the amoimt of CO..
bas risen to 0.07
voliune ])er cent.,
the air beconi es
more or less stulTy,
although in very
badly ventilated
rooms th.e propoi--
tion may reach t<ai
times tills figure.
The closeness or
stuffiness is diu'
principally to the
organic emana-
tions.oi which some
are of an odorous
nature. This is
shown by the fact
that much larger
quantities of C()»
can be added to the
air of a room in
other ways without
causing any incou-
Fir,. 4104.— Estiiiiiitidn of O3 and ot rO^ In
Expired Air. (Waller.) A IIHI c.i'. nieus-
uriiiff tube pradiciti-d in Ifiitlis nf 1 c.c.
between 75 and liHi. A lllliiiL'bulb. Two
pas pipettes. The nii.asiiriii!,r lubf- ccini-
nuinieates by ttiree tuties liiiarded by
simple taps 1. 2, :^. with tlie inlt.I and with
the tras pipettes. It is tli-st eharjied with
acidulated water up in the zero mark by
raisiiiL' the iiniiiir bulb. lap 1 beins^>pen;
it is then tilled wiih 100 e.i-. of e.xpired
air, the illlini; bulb beini; lnwereil until
the fluid in the bureiie has fallen t(i the
100 mark. Tap 1 is iii.w cj.ised, the ineas-
Urilllr tube e.inlainiliir ion e.e. of e.\pired
air with unknnwn qiiaiilities of cii.jand
of O2. Theainoiiiit ..f (11.^ is ascertained
as ft.llows ; Tap ~ beiinr upeni'd. the air is
expelled into a ^'as pipelle cniitaiiiins
KHO by raisins the llllins; bulb unlil the
fluid has risen to the zero mark of the
ineasuriuL'' tube. 'I'ap 2 is now elt .sed, and
the air left in the sias pipette for about a
minute, diiririff whieh the CO.. pri.sent is
entirely absorbed. The air is then drawn
back into the ineasurin^' tube by loweriiiK
the tlliintt bulb while tap ;i is open. The
volume ot air (minus the (JO,, whieli is
beinff absorbed) is read, the fllling bulb
beinff adjusted so that its contents are at
the same level as tlie fluid in the bui-eUe.
, The amount of (ig is next ascertained in a
' preriselv similar manner by sendine the
air into a semnd !2:as pipette containing:
sticks of plios[>liorus in water, and meas-
uring the loss ot volume (ilue to absorp-
tion of ().,) in the air when drawn back
into the tube. A «as pipette works thus;
fluid in its lower half is displaoed into its
upper half, when air is driven in from the
measuring? lube, and returns to its orig-
inal place, when air is drawn back. If
desireil, the apparatus can be connected
with a vessi'l In which a fropr or mouse or
excised muscle has l>een placed and the
conseiiuent alterations of the irasesOaand
CO2 measuretl in a similar manner. ((,
Inlet or outlet; /i, tas pipette for alisorp-
tionoiOd.j; c, tlllillKbulb; 1/, nas pipette
for absorption of ( >.;.
venicnce to the inmates. Air containing even as much
as twenty-five per cent, of CO2 can be breathed safely
for a short time if tliere are no other impurities in it,
and if it contain plenty of oxj-gen. An ordinary iudi-
vidual rei|iiircs about 2,000 cubic feet of air jier hour if
the -propiirtion of COo is not to rise above 0.07 volume
per cent. Tliis may be supplied liy allotting 1,000 cubic
feet of space to each iiidiviilual, and providing ventilat-
ing arrangements for renewing the air twice every liour.
Tlie smaller the space allotted to each individual the
more frequently must the air be changed by ventilation.
'I'lie following table may be useful for ready reference
on some of the iioints discussed above, although the
exact numbers vary very much in different people. The
jiroporfions given in cubic centimetres and litres are
somewhat less than those usually given, but are prob-
alily more correct than the larger quantities given in
inches and feet.
Amount of
One Bkeath.
twenty-focr
Hocks.
Cu. in.
C.e.
Cu. ft.
IKO
17.5
15
50,0011
Litres.
.30
1.5
1.3
5,000
300
15
13
50,000
7 000
( ixyiren absorbed
;i(H)
Air rendered close
1 Proiiortion of ( (i„ raised to 0.07
volunie per cent.)
1,000,000
The Bi.ood and Its Gases. — While the air on one side
of the respiratory epithelium is being constantly chaiigeil
by the movements of the chest and by diffusion, the blood
on the other side is being changed by virtue of the circu-
lation. The blood is brought in a venous condition by
the pulmonary artery and its branches, and is carried
away in an arterial condition by the pulmonary veins.
The gases of the blood are the same qualitative!)' as
those of the atmosphere, but are not present in tlie same
lirojiortions. The proportions naturally vary somewhat,
Imt the fcillowing are apiuoximate in volumes per cent,
of blood :
Blood.
0.
CO,.
N.
20
10
40
4li
1-2
1-2
In considering the nature of the connection between
the blood and its gases it is necessary for us to kee|) in
mind the various constituents of blood iind their power
of taking in gases. The plasiiin may for our present jnir-
])ose be considered as made up of water, salts, tind pro-
tcids. llVr/cr is capable of holding a certain quantity of
gas in solution, the exact amount dejiending on the na-
ture and tension of the gases surrounding it, and on the
temperalure. if water be exposed to a mixture of gases
it will abscirb iiiid liold in solution a (|uantity of ciich.
which will depend on the quantity of that particular
gas in the mixture. Each gas present in a mixture ex-
ists at a. certain tension, and exerts what is called apur-
tiiil j)ir.isiire. This partial pressure is not affected by the
amount of any other gas that may be present. Thus if
;i jar were iiajf full of water and the rest of it occupied
by air. the water would take up from the air a certain
amoiiiit of nitrogen and a certain amount of oxygen. If
now |)ure nitrogen were jnimped into the jar without
allowing any of the air already there to escape, the ten-
stun or jiartial pressure fif tlie nitrogen in it would be in-
creased and t h(^ water would take a proportionately larger
amount into .solution. The tension or partial i)ressiire of
the oxygen would remain, however, what it was before,
anil the water would not absorb any more. If now [lure
oxygen were pum]ied in, the partial pressure of oxy.gen
in the jar would be increased and the water would take
a pro]iortionately larger amount of this gas into solution.
The nitrogen o'f the blood is held chietly in simple solu-
9iS
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
K<>8piraliou.
Respiration.
tion in the water of the plasma. Tlieoxy.cen and carbon
dioxide, liowever, are present in nuicli larger proportions
than water could take into solution at the tension or par-
tial pressure of these gases prevailing in either the lungs
or the tissues. These gases must therefore be attached
to the other constituents of the plasma or to the corpus-
cles. The salts of phiitma include among others consider-
able quantities of sodium carbonate. This salt is capable
of combining with carbonic acid gas to form sodium bi-
carbonate. There is reason to believe that the carbonic
acid is principally held in the blood in this chemical com-
bination. Sodium phosphate, another constituent of the
plasma, may combine with carlionic acid too, forming
sodium bicarbonate and sodium bijihosijhate. The jini-
teids of the plasma, especially the globidins, are also
claimed to have some power of combining with carbonic
acid gas. The eorpuscles, both red and white, may simi-
larly carry a certain amount of CO3 in combination with
their salts and proteids.
The chief interest of the corpu.scles for respiratory
purposes, liowever, is connected with the colored proteid
haemoglobin of the red corpuscles.
IhfinoglMn makes up about ninety per cent, of the
solids of the red corpuscles. It is a substance possessing
a remarkable property of forming loose chemical com-
binations with various gases. As it exists in the blood
it is combined with oxygen to form oxyhoemoglobin.
One molecule of hamioglobin can combine with one mole-
cule of oxygen or 1 gm. of hoemoglobin can attach to it-
self 1.34 c.c. of oxygen. In arterial blood the ha?mo-
globin is nearh' saturated with oxygen, and in venous
blood it still has some oxygen associated with it. Oxy-
gen-free hoemoglobin or reduced hemoglobin is not usu-
ally present in the body, but can be demonstrated in parts
where the circulation has been stopped for from forty to
three hundred seconds (Vierordt).
There are a number of compounds and derivatives of
luemoglobin which can be most readily distinguished by
the absorption bauds in their spectra. In the article on
Blood in another volume of this H.\ndbook, they are
described in some detail, and their spectra are figured.
Oxyhmaficjluhi n is the bright red substance which gives
the color to arterial blood. In this corapoiind the oxy-
gen is present in a very loose chemical combination, and
may be readily taken up by the
tissues of the body or by reduc-
ing agents.
Metlitumoylobiii is a brown sub-
stance formed by the action of
oxidizing agents on oxyhoemo-
globin. It is found in the blood
in cases of poisoning by clilorate
of potash and similar svibstauces.
Methajmoglobin is of no use for
respiratory purposes, as the oxy-
gen is too firmly united to be
abstracted by the tissues, al-
though it is readily taken up by
strong reducing agents, such as
ammonium sulphide, with the
formation of htcmoglobin (re-
duced).
Oi rhon ie- Oxide IlamogMiin. —
If illuminating gas be inhaled
the carbonic oxide which it con-
tains unites with the h;emoglo-
bin of the blood in place of the
oxj'gen b}' virtue of the fact
that CO possesses the stronger
aflinit}' of the two for haemo-
globin. This cpiite destroys the
oxygen - carrying properties of
the blood and results in death.
Other gases, such as NO, H2S, etc. , luay also destroy
the oxygen-carrj'ing power of the blood by replacing tlie
oxygen, or by otherwise changing the ha;iuoglobin mole-
cule.
llainatin. — Hfemoglobin may be decomposed under the
Fig. 4111.").— Hill's Mercurial Gas Pump,
action of heat and acid or alkali into two parts, a proteid
of unknown nature, usually referred to as globin, and a
brown coloring matter rich in iron and designated lue-
matin.
UiTmochromogev , or reduced alkaline ha>matin, may be
foriued by the action of reducing agents on hrematin, or
by breaking up iKemoglobin in the absence of oxygen.
Ihemochromogeii has the same power of uniting with
gases as ha'iuogloliin has, and in fact has been shown to
be able to attach to itself the same quantity (of CO) as
the corresponding amount of htemoglobin. Hojipe-Sey-
ler taught tliat hiemochromogen existed as such in hae-
moglobin, and lent it its gas-carrying property. This
is disputed, however, by Gamgee (Schaefer's "Text-
book").
The proteid part of the htemoglobin molecule is be-
lieved by many to be of the nature of a globulin. It is
probable that the small quantity of CO2 that can be car-
ried by ha'inoglobin is attached to this proteid part.
The Mercurittl Pump. — The gases of the blood are ob-
tained for analysis by subjecting the blood to the vac-
uum of a mercurial pump. One of the simplest am.
best is that of Leonard Hill (see Fig. 410.5).
A is a reservoir filled with mercury which may De
raised or lowered. By rai-sing it and manipulating the
various taps the whole apparatus is filled with mercury.
By lowering it the blood chamber F is made a vacuum,
i'^'is .separated from the apparatus, weighed, and partly
filled with blood. It is then reattached and the gases are
drawn off from the blood into the reservoir B. By rais-
ing and lowering A repeatedly with manipulation of the
taps, the gases are all drawn off from the
fTsf^ blood in F into the reservoir B and then
VtT forced over into the eudiometer tube//,
where they are collected over mercury and
measured. The amount of CO2 is meas-
ured by inserting potassium hj'drate which
takes up the CO.; to form a carbonate.
The diminution which takes place in the
total volume of gas is the amount of CO^
which was present. The amount of oxy-
gen can similarly be measured by using
a solution of iiyrogallic acid, which unites
with it. The gas remaining unabsorbed
is nitrogen.
Blood does not give off its oxygen in
the mercurial pump in proportion to the
diminution in the pressure as woidd be
the case if it were in simple solution. On
the contrary, very little comes off until
a certain degree of vacuum is reached,
and then large (luantities are given off.
This points to its being in loose chemical
combination.
With regard to the CO2, the fact that
blood even when exposed freely to the
air can retain an amount of COa greatly
in excess of what it could hold in simple
solution proves that this gas too exists in
chemical combination. Now if plasma be
exposed to the mercury pump anrl the
pressure sufficiently lowered,
much of the CO2 is given off',
and must therefore be quite
loosel}' combined. Another por-
tion is not given olT without
the addition of an acid or ha-mo-
globin (red corpuscles), which
seem able to liberate it from
some more stalile comjiound.
The nitrogen is given off in
proportion to the diminution in
the pressure, and the view gen-
erally held is that it is in simple solution in the plasma.
The Interchange of Gases Between tuk Bi.ood
AND Air. — Here we find ourselves face to face with the
f\indamental question of the relation of epithelial cells
to the processes taking place through them. Does the
919
7
RoNpiralioii.
Ri')»|iii*ali4>ii.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
interchange of gases between the blood on the one side
of the respiratory epitlielinm and tlie alveolar air on the
other side take |ilaee In- a mere process of diffusion, or
does tlie functional activity of the epitlielial cells exert
some controlling or modifying intlucnceV Our answer
to tliis (jucstion nmst be (ictcrmiucd by a consideration
of wliat we know of the properties of epitliclium else-
where, and by the possibility of explaining tlie inter-
change on a jmrcly physical basis.
There is an increasing tendency to attribute more im-
portance to liningcpitlielium in tlie absorption and secre-
tion of liquidsand solids. Tliisis seen in the change that
has recently taken place in tlie teaching of the text-books
with regard to intestinal absni|iti(in and the process of
secretion. The fact that epithelium may also play an ac-
tive part in the secretion of gases has been amply demon-
strated by a number of investigators in connection with
the secretion of gases in the swim bladder of fishes.
Bohr has shown that this process is under nervous con-
trol.
With regard to the possibility of explaining the inter-
change of' gases in the mammalian lung on a purely
physical basts, it might be explained by the laws of sim-
ple dilTusion and osmosis if tlie partial pressures on the
two sides of the epithelium were always such as to favor
the exchange that takes ]ilace. This question has been
investigated as follows; ]''irst air is drawn oil from the
alveoli by one of the inslruments devised for the pur-
pose, of wliicli Pjliiijir's Iniiij catliilcr is the best known.
Then lliis air is analyzed ami the partial pressure oi each
gas in the alveoli can be calculated. Next the partial
pressures of the gases in arterial and venous blood are es-
timated by some form of aerotuiio/inti'roT/iieiiuildi'rntm'trr,
and aconi|)arisonof the results obtained from the alveolar
air and the arterial and venous blood in any given case
will sliow whether the partial ]iressures are favorable to
the iuti rchange or not. Tlie ]irincii>le of t]ii; iiernfiiiioiii-
(ier is as follows: It is an apparatus in which blood is
brouglit into close relation with two gaseous mixtures,
in one of which the COj tension is aliove, while in the
other it is below the anticipated tension of the blood.
As blood tlows through the apparatus an interchange of
gases takes place between it and the gaseous mixtures
contained. By analyzing the latter before and after, the
tension of gases in the blond can be approximately deter-
mined.
Fredericii gives the fnlli.wing as a typical result of
such an invesligatinn in a dog;
E.xteniiil air. Alveirtl. ArtiTial lilnofl. Tissues.
Tension (if o.^VKen.. L'll.!!.") > IS > U > U
External air. Alveoli. Venous ttloud. Tissues.
.11;! < 2.S < 3.S1-.5.4 < .5-9
Tension of raibon
dioxide
In this case the tensions or ))artial pressures of the
gases are such that oxygen would tend by mere ditlusiou
to pass in from the air to the blood ami CCKiu the reverse
direction.
Other workers, however, notably Bohr, ami Haldane
and Lorraine Smith, emiiloying somewhat different meth-
ods, have obtained results which seem to .show that oxy-
gen may be taken in and CO-j excreted even when the
partial pressures are such as to oppose the pirocess. If
these experiments are reliable, as seems probable, we
must look to some active secretory power of the respira-
tory epithelium for the explanation.
Dr. Wesley Mills has maiiilaincd this view for many
years, and his text-book, published in ISS'J, was one of
the first to recognize it in the following terms; "The
view expressed by some physiologists to the effect that
dilTusion explains the whole matter so far at least as c;ir-
bonic anhyilridc is concerned, and that the epithelial cells
of the lung have no share in the respiratory process, does
not .seem to be in harmony either with the facts of respi-
ration, or with the laws of biology in general."
The St;AT ov the Oxidation which Occrns in the
Body. — At the beginning of the last century physiolo-
gists were divided in opinion as to the principal seat of
oxidative processes in the body. Some, who followed
Black, believed that these processes took place exclu-
sively in the lungs, while others, led by Le Grange, re-
garded the blood as the seat of these changes. During
the past tifty years Pllliger and others have shown that
neither of the old views was correct, but that oxidation
is continually taking place in all the tissues, and that it
varies to a great extent with their functional activity.
It has been shown, moreover, that the taking up of oxy-
gen and giving off of CO2 do not necessarily run parallel,
but that the former may be stored up in excess during
rest as tissue oxygen, and may remain in some more or
less stable combination until a time of functional activity,
wlien a di.ssolutiou of the molecule occurs with the set-
ting free of CO.. Some of the facts on which these
views are founded are the following; If the blood of a
frog be replaced by saline solution, the animal ma}' live
for hours or days, and continue to take up oxygen and
excrete CO3 (Oertman). Bleeding, although diminish-
ing the quantity of blood in the body, has no effect on
the amount of gaseous interchange (Pembrey and GUr-
ber). If a muscle be made to contract in. niciio, it will
give off CO;, derived from its tissue oxygen, in sufficient
quantity to be determined (Hermann). If a solution of
fresh bfood be supplied to a frog's heart, the oxylia'ino-
globin will lie reduced more quickly during activity than
during rest (Yeo).
"Tlie avidity of the different tissues for oxygen varies
greatly, and the differences are doubtless expressions,
broadly speaking, of the relative intensities of their re-
spiratory processes" (Reichert).
Cininiiuaud records the following absorption capacities
for 100 gm. of different tissues submitted for three hours
to a temperature of 38 ' C. ;
O.r.
. . 2;3
tirain ...
Liver . . .
Kidney.,
C.c.
Spleen 8.0
Lungs 7.2
Adipose tissue (i.O
Bone .5.0
Blood 0.8
Internal or Tissue Respik.\tion is the term applied
to the interchange of gases between the blood and tin;
tissues. The partial pressures of the gases in the tissues,
lymph, and blood are said to be such as to favor the tak-
ing up of oxygen by the tissues, and the giving off of
CO2 in accordance with well-known physical laws, but
this fact does not necessarily exclude some participation
of the endothelial and tissue cells in the process.
GuAriiic Rkcokd OF Respiratoky Movements. — In-
numerable devices have been employeil for this purpose.
Some, either because they require a cutting operation or
Fig. 410().— a rranperaent of Traelieal Cannula and Marey's Tain hour for
Rect>rdiiig Changes in Intrapulmonary Pressure. (Langendurff.)
for other reasons, are employed only on animals; and
others may be used clinically on man. To the former
category belong the /i/nrndgvuph, by which the move-
ments of the dia])liragm are recorded by the use of a
lever or rubber bag passed up between the liver and dia-
050
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Kesplrallon,
KoNpiralioii.
phragin and connected with a recording lever : various
forms of sounds and cannulas, ■\vliicli can be passed into
the pleural cavity or llie ft'!<opliai;us and connected with
a recordini; tandiour t<i register llie variations in intra-
thoracic pressure; a tracheal cannula or a nose cap from
either of which the volume of air brenthed can be recorded
Fig. 4107.— RpoeiTing Tambour of Marey's Pneumograph, New Form.
(LangHUilorff.) /). 7), Belt to go around chest; h\ h', strings to sus-
pend the instrument from the neck.
by the (H'rophthysmograph of Gad, or the changes in intra-
pulmouary pressure can be registered by a Jlarey's tam-
bour. In either case it is usual to have an air chamber
Tjetween the animal and tlie recording apparatus, so that
the same air will not be breathed over and over again
(see Fig. 4106).
Among the methods which may be employed in man
are the p/iei/mograpji or slit/iof/ruji/i. in which a belt sur-
rounding the chest is attached to some form of receiving
tambour from which a rubber tube leads off to a recorcT-
ing tambour, and indicates tlie changes in the girth of
the thorax (see Fig. 4107). In the stit/iomeler of Burdon
Sanderson the changes in the antero-posterior diameter
of the chest are recorded.
Perhaps the simplest method of all is to connect a re-
cording tambour through a piece of rubber tubing with
a small funnel, and to press the latter into the episternal
notch. A fair record of the respiration may be obUiined
in this way.
Tlie curves obtained in these various ways differ in
their details, but the tracing shown in Fig. 4108. and ob-
tained with Marey's pneumograph, may be taken as a
type.
As the figure shows, inspiration begins somewhat sud-
denly and advances rapidly, being followed immediately
by expiration, which is carried out at first rapidly, but
afterward more and more slowly.
Nervous Mechanism of Respir.vtiox. — The muscles
of respiration act rliythmically under the intiuence of
nervous impulses, which origiuale in the medulla olilon-
gata and pass out by the motor nerves. The resiiiratory
centre in the ineduUa sends out these impulses as the
result of a constant stimulus imparted to it by the blood.
The e.\planati(m of the rhythmic action of the centre un-
der the constant stimulus of the blood is to be sought for
in the fundamental propel ties of protojilasm. The action
of the centre is modified by impulses reaching it by
afferent nerves, of which some are constantly in oper-
ation and others only act occasionally.
The Respiratory Centre. — All the brain above the me-
dulla may be removed without serious interference with
the breathing. If tiie S|iinal cord be seiiarated from the
medulla all respiratory movements of the trunk cease, but
some of the facial muscles, still in connection with the
medulla through the cranial nerves, continue to exhibit
movements of a respiratory character. Injury of the
medulla in the lower part of the floor of the fourth ven-
tricle (calamus scriptorius) is sufficient to cause cessation
of respiration and death, all the rest of the nervous sys-
tem being intact. These facts suffice to localize the
respiratory centre in the floor of the fourth ventricle, but
the exact nerve cells which constitute it cannot be pointed
out. From the fact that cessation of respiration has fol-
lowed injury to different parts in the hands of different
investigators, the respirator}' centre is probably made up
of several separate groups of cells or nerve nuclei and
bundles of connecting fibres.
If the medulla be carefully divided iu the median line
respiration continues; and if the pneumogastric nerve on
one side be divided, the movements on that side will be-
come slower tiian on the otiier, iuid we may have the two
halves of the diaphragm contracting independently, each
with its own rhythm. This shows that the respiratory
centre consist of two halves, each more or less complete
in it.self. Normally, however, they act in harmony,
being co-ordinated through commissural fibres, which
cross the median line from one side to the other.
From the fact that certain influences affect especially
inspiration and otiiers expiration, it seems logical to as-
sume that the respiratoiy centre is physiologically divided
into an inspiratory and an expiratory centre, but we can-
not separate these anatomicall_y at present.
Subsidiary Centres. — .Stimulation of various parts of
the brain gives rise to modification of the respiratory
movements. This fact has ledtoa numberof structures,
among which are parts of the cerebral cortex, the tuber
cinereum, the optic thalamus, the pons Varolii, and the
anterior and jiosterior corpora quadrigemina, being dig-
nified with the name of " snl'sidiary resjriratory centres."
As will be shown later, a tonic inhibitor}' influence seems
to be exerted on the respiratory centre by the posterior
corpora quadrigemina, but the other structures named
are probably mere stations through which afferent im-
pulses from the various sensory nerves may affect the
respiratory centre in the medulla. Brown-Sequard,
Langendorff, Wertbeimer, and others lay great stress on
the fact that after separation of the spinal cord froiu the
medulla in young animals a kind of respiration is carried
on by the cord alone. It is very different in its charac-
ter, however, from normal breathing, being "rapid and
irregular" (Wertheimer). and in many cases it does not
occur at all. One, therefore, feels dis'posed to look upon
these so-called spinal centres for respiration as rather co-
ordinating centres for the respiratory muscles, which
usually perform their functions under the control of the
respiratory centre in the medulla. In some cases they
seem to have retained a vestige of their original proto-
plasmic power of rhythmic activity.
T/ie Influence of tlie Blmid on. the Rcspirntnry Centre. —
If the amoimt of oxygen in the blood be diminished or
the proportion of carbonic oxide become higher, there
follows increased activity of the resiiiratory centre. The
respirations become deeper and often quicker, constitut-
ing the condition known as hyjurpnav. If the change in
the blood be greater the resi)iratory movements become
still more pronounced, additional muscles are called into
play, and expiration, wliicli is normally largely passive,
becomes an active muscular act like inspiration; this
condition is known as dyspnwa. Dyspnoea may pass into
the condition known as asj'hy.rin. Tlie form of asphyxia
caused by occlusion of tlie trachea and deprivation of
oxygen is characterized by convulsions, followed by ex-
Fic. 4108.— Triiclns erf Thoraoii' Kespiralnry Movements obtained by
means of Marey's Pneumograph. (Foster.) A wtiole respiiatory
phase is comprised between" r( and a ; inspiration, during whicli the
lever dc^sccnds, e.\tending from a to b, and e.xiiiraliou from b to a.
The undulations at c are caused by the heart's beat.
haustion and death. In asphyxia due to breathing an
atmosphere in which carbonic acid gas is in excess, but
where oxygen is not greatly deficient, the animal pas.ses
from dyspnn?a into a state of stupor, and dies without
passing through the stage of convulsions. The condition
of the blood affects the centre directly, and not through
951
Ros|>iralioii.
Retiiia.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
the aflV'i'cnt uerves, as is shown by the so-called "cross
circulatiou " experiment. In this e.xperitneut the neck
vessels of two dogs are joined in such a waj- that the
liead of each is supplied from the carotid arteries of the
Fig. 41U9.— Illustrates tlie Action of the Vasus uu Kesplialion.
Taken by the writer with an apparatus Hke that shown in Fig. 411^7.
I, Normal bivatliinfr of raltbit iiiKier ether; ?/, lioth vaffi eut, res-
piration deeper ami slower; ///. eereliral hemispheres removed
also; jy, weak stimulation of vaL'-us opposite \ertiral line showing
Shallowing and quiekeniug; t'. stronger stimiilatit.iu showing com-
plete inhibition. Note: IJownstrokes, inspiration; upstrokes, ex-
piration.
Other. The result is that the Ixuly of No. 1 and the
brain of No. 2 receive the same blood tuid rice rimi. If
now the respiratory intercluiujxo of No. 1 be interfered
with, the blood siiiiplying )iis body will become venous,
but his brain will continue to receive arterial blood from
the other dog and his biciithing will be unaffected. Dog
No. '2, however, whose brain receives venous blood, will
Decome dyspnteic. although the rest of his body is re-
ceiving good iirterial blood.
Cei ttiin substances, other than carbonic acid, are pro-
duced in the muscles during activity, substances which
also increase the activity of the respiratory centre. It has
been shown that v:irious acid substances have this eifect,
and the uidaiown sulist;iti(/es formeil in muscle are prob-
ably acid in nature.
The so-called autoraalic activity of the respiratory cen-
tre is believed to ile|iend on a stimulus received from the
blood, but it is yet undetermined whether the most im-
portant factor in" this stimtdus is a deficiency of o.xygen.
the jiresence of carbonic acid, or the action of the acid
products of metabolism, although much can be said in
favor of the last named.
77(f hifliK'iici- <'f Affcmit J\"<7-(r.s.— There is only one
pair of nerves wiiii'b'have a tonic influence on the respi-
ratory centre, as showai by a change in respiration when
they "are cut. These are the pneumogastrics.
C")n cutting one viigus (pneuiuogastric) the breathing
becomes slightly deejier and slower for a time. Later
the effect may p'tiss olf and the lueathing become normal
again. If bo"th vagi are cut. the deepening and slowing
of the breathing is more pronounced and tlie effect is-
more lasting.
The effects of stimulating the central end of one vagus
are differently described by different writers. Nearly all
agree that weak stimulation frequently produces shallow-
ing and quickening, so that the breathing becomes more
or less like what it was before the nerves were cut. With
stronger stimulation various results are oijtained accord-
ing to the way in which the experiment is carried out,
being influenced by the employment of anesthetics and
to some extent by the kind of stimulus used. This being
the ease, some writers believe that the pneumogastrics
carry impulses which stimulate the respiratory centre to
increased activity; and others, among whom is the
writer, believe that it carries principally inhibitory im-
pulses.
The impulses which normally ascend the vagus, exer-
cising a constant inhibitoiy intlueuce on the respiratory
centre, are dependent upon the lung being distended, for
Loewy has shown that opening the pleural cavity on one
side so as to allow the lung to collapse has exactly the
same effect on respiration as cutting the vagus on that
side.
By rapidly inflating the lungs with a bellows the-
breathing may be entirely inhibited, the condition known
as ajmaa being produced. The result follows, no matter
whether air be used for inflation, or some neutral gas,
such as hydrogen. It air be drawn out of the lungs,
diminishing their distention, very deep inspirations re-
sidt. Hering and Breuer, who obtained these results,
and also Head, who repeated their experiments, endeavor
to explain them on the assumption that there are two
kinds of tibres in the vagus, of which one set brought
into action by distention of the lung favors expiration,
and another set acting when the lung is collapsed favors
inspiration. Their results are far more simply explained
in tlie light of Loewy 's work, by saying that the mode-
rate distention of the lung normally present causes weak
inhibitory impulses to ascend the vagus, which control
the respiratory centre; increased distention gives rise tO'
stronger impulses, which inhibit it altogether and pro-
duce a condition of a]ui(ea; while during collapse of the
lung the centre acts more powerfully in the absence of
the usual inhibitoiy impulses.
In considering the effect of stimulating the libres of
the vagtis directly we must remember that besides the
respiratory tibres proper we can have passing up the
vagus impulses of general sensibility and of pain, and
these may cause changes in respiration through the son-
sorium like any other afferent nerve. The umre com-
pletely we prevent the animtd from feeling pain, the less
likely are we to get pain elfects and the more certain to
see the dii'cct action of the vagus on the respiratory cen-
tre. If an anim.al be experimented on without being
completel}' narcotized, artificial stimulation of the vagus
may produce almost any imaginable effect on the breath-
ing, either insjiiratory spasm (gasp), expiratory sjiasm
(cry), or iuliibilion. If, on the contraiy, the animal be
well iUKcslhetized or decerebrated pain effects are elimi-
nated ;iMd ]iure inhibition is nearly alwa^'s seen, as shown
by sliallowiiig and qtnckening with weak stimulation,
]i;issing graduall}', as the stimulus is increased in strength,
into a stale of complete inhibition or standstill in a posi-
ti(ui intermediate betw'een inspiration and expiration (see
Fig. 4109).
Even in tinnarcotizcd animals the ascending constant
curicnl which stimuhites without causing pain has al-
most always an inhibitoiy effect.
The other afferent uerves have no tonic action on the
centre, for cutting any of them does not proiluce any
change in the breathing. In special emergencies any
afferent iierve may ctiriy impulses that modify the action
of the centre. If the na.sa! mucous membrane (fifth era-
ni;il nerve) be stimulated we get a sneeze, consisting of a
gradual iiis|iiration followed by a sudden spasmodic ex-
])ir;itiou Ihrough the nose. If the ylossopharynrienl nerve
be stiiiiuliited, as in swallowing, we get inhibition of
respiration, which prevents food being drawn into the
H53
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
KcMiifratioDr
Ki'Iliia.
larynx. Certain kinds of stimuli applied to the mucous
membrane of tlie pliarynx and tonsils cause the complex
act of vomiting in which the muscles of respiration play
a part. Stimulation of the laryiigcfd nerves causes in
some cases mere slowing of the breathing; but if the
stimulus be strong, we see inhibition of inspiration and
expiratory spasm or cough. Stimulation of the splanch-
iiics inhibits respiration. Stimulation of the optic or
auditor}' is said to increase inspirator}' activity. Stimu-
lation of other .sensory nerves, such as the sciatic, pro-
duces in many cases one or more deep inspirations with
weak stimulation, and a strong expiration or cry if the
stimulation is strong; but the results are by no means
uniform.
7V«' Influence of the Posterior Corpora Qnndrigemina. — ■
Removal of the brain in front of the jxisterior C(jrpora
quadrigemina has little effect on the breathing; but
separation of these from the medulla has an effect just
like bilateral section of the vagi; that is. the respiration
becomes deep and slow. If the vagi be cut as well and the
animal lias been protected from excessive hemorrhage
the respiration becomes still deeper and very infrequent.
Usually in this case inspiration and expiration are sepa-
rated from each other by long pauses. Restoration fif
the respiration, to about its normal character, may be
effected by a well-cho-sen stimulus applied either to one
of the vagi or to the corpora quadrigemina.
Cliet/ne- Stokes Breathing. — If the upper part of the
medulla itself be injured the breathing is sometimes
seen to take on a periodic character; tliat is to say,
the respirations occur in groups of three, imr, five,
or more, of which the first respiration in each group
is the deepest (Markwald), and the groujis are separated
by intervals in which respiration is in abeyance. A
similar kind of respiration is seen when a blood extra-
vasation presses on the region of the ala; cinereae near
the respiratory centre. These facts are interesting in
connection with the .so-called Cheyne-Stokes breathing
occurring in various diseases of the brain, heart, and
kidneys, which bears certain resemblances to this ex-
perimentally induced periodic breathing (see article on
Dyspmra).
Tlie Conditions vnrterwhteh the Centre Acts. — A rational
intei'pretation of all the facts given above would seem to
be as follows:
1. The respiratory centre is situated in the nieiUUla, in
the lower part of the floor of the fourth ventricle.
3. It receives a constant stimulus from the blood.
3. Acting alone it would expend all its energy by re-
sponding at long intervals with a very great res])iratory
effort.
4. It receives inhibitory impulses from the jiosterior
corpora quadrigemina, and Ijy the vagi nerves i'rom the
lungs which control its action and convert the deep in-
fre(juent resi^iratory acts into the shallower and conse-
cjuently more frequent ones that we know as normal
breathing.
.5. In special cases the centre may be influenced by im-
pulses reaching it by other nerves.
The Efferent A'crns are the phrenics to the diaphragm,
the intercostals, and the motor nerves to the other mus-
cles of respiration. If the spinal cord be injured above
the first dorsal vertebra the intercostal nerves and muscles
are cut off from the centre and thoracic respiration ceases.
If the injury be as high as the fourth or fifth cervical
vertebra the phrenic nerves and diaphragm are also cut
off from the centre and death en.sues.
For the effect of breathing air at various pressures and
air containing impurities see articles on Air, Aerotlnra-
peutics, and Caisson Disease. William »S'. Morrow.
References.— In preparing this article use has been made of the
boohs of Schaefer, Mills, Foster, " American Text-Hook " (Reichert),
Hall, Halliburton, Jeffrey Bell, Bohni and DavidofT, Quain's ■'An-
atomy," Hennann's "Handbook" (Rosenthal:. Laiiiiendorll's
"Physiologlsche Graphik" ; also of numerous journal articles and
data from pxpprimcnts performed by myself. Special acknowl-
edgment Miiist licni.-clcnf assistance received from twct papers by
Max l.cwandnwsky in On Uois-Reymoud's Archiyes for 18% on
"Die Regulieruut; der Athmuug."
RETINA, DISEASES OF.— The retina is seldom af-
fected by disease which is limited to itself alone, or even
to the eye alone, but most often lesions of the retina aro'
part of a general disease and are frequently of assistance
in I he diagnosis of the latter. The diseases most apt tO'
produce serious retinal complications are, diseases of the-
kidneys, syphilis, diabetes, .septica;mia, and leukaemia.
Among ocular affections choroiditis and optic neuritis-
almost always lead to retinal changes, the former because
of the close anatomical relationsiiip of the choroid and
retina, and the latter on account of the interference of
the retinal blood siqiply jiroduced by the swelling of the
disc. Both choroiditis and optic neuritis, however, are
usually in turn dependent upon some general disease.
Vascui.au Disturbances of the Retina. — Pulsation
of tlie retinal reins on the disc is frequently seen under
normal conditions, and can readily be produced by a
slight pressure of the finger upon the eye. It is particu-
larly associated with increased iutra-ocular tension from
any cause, and hence is common in glaucoma. No bet-
ter explanation of the phenomenon than that of Dontleis
has been advanced. According to Donders it is due to
the changes in arterial tension being communicated tO'
the veins tlirough the vitreous humor. True transmitted
venotis jitilsatiou has been seen in valvular heart disease,
arteriosclerosis, and antEmia, but never under normal
conditions.
Pulsation of the retinal arteries is always pathological,
and imlicatcs either an increase in intraocular tension or
decrease in the arterial pressure. It may occur in glau-
coma, anaemia, .syncope, senile arteriosclerosis, aneurism
of the arch of the aorta, aortic insufficiency, and Base-
dow's disease. It may also result from compression of
the central artery by tumors of the nerve or orbit.
llypercetnia ef the retina may be either arterial or ve-
nous in nature. The general redness of the ftmdus de-
pends to such a great extent upon the degree of pigmen-
tation of the choroid, and the tortuosity of the vessels
varies so much under normal conditions, that it is impos-
sible to diagnose retinal hyperajmia unless the disc is also
reddened. Arterial hi/pera-mia manifests itself by disten-
tion and tortuosity of the arteries which sometimes lie in
anteroposterior jilanes so that they project toward the
observer. It may result from eye strain due to improper
illumination or errors of refraction, irritation of the eye
from any cause, such as the presence of a foreign body
on the cornea, and from keratitis, choroiditis, and iritis.
It is common in meningitis, and may be noted in Base-
dow's disease, plethora, and neurasthenia. Strangely
enough, it may result fiom excessive loss of blood or
from chlorosis, and in tlie former case it may be so in-
tense as to give rise to retinal liemorrhages. ]'enous hy-
pcrii'inia is characterized by dilatation and tortuosity of
the veins, which appear darker than normal, and is al-
ways associated with hypeiu'inia of the disc. It is not
infreciuently accompanied by retinal hemoirhages. The
arteries may show no change, or they may be narrowed
owing to the same obstruction which is producing stasis
in the veins. In general, venous hy]iei;emia is due to
some hindrance to the outflow of venous blood from the
eye, as, for instance, to compression of the central vein in
optic neuritis or glaucoma. Sometimes the obstruction
lies in the orbit, as in cases of tenonitis and orbital cellu-
litis, or even in the cranial cavity, as in intracranial tu-
mors, thrombosis of the cavernous sinus, and meningitis.
Rarely it is a part of a general venous stasis due to
valvular heart disease. A few cases of particularly ex-
aggerated venous congestion have been .seen associated
with congenital heart disease, the condition then being
spoken of as cyanosis retince.
Throniljosis of the central rein of the retina, which pro-
duces the highest grade of veuous hypera-mia, is very
rare. It usually is monocular and occurs in patients
affected with general arterio.sclerosis, and hence most
often between the ages of sixty to seventy, but some-
times it occurs as the result of orbital ceilulitis. The
affection comes on suddenly without prodromal symp-
toms, and though vision is much diminished, blindness
953
Rotiiia,
Koliiiii.
REFERENCE HANDP.ooK OF THE MEDICAL SCIENCES.
is not producffl at ouce. In maiked cases tlie rctiual
veius are frailly distended and tortuous, the arteries arc
alteimated, and tlie fundus is covered with lieinorrliages
wliieli are largest and most numerous around the disc.
The disc itseli' is sutfused with blood, and there is apt to
be a small hemorrhage in the centre of the macula. In
less marked cases the thrombosis may involve only a
branch of the central vein, the disturbances then being
coulined to a limited portion of the retina. The intra-
ocular tension is not increased. Ultimately the thi-om-
bus ma,v break up. freeing the lumen, or organization
may occur, |U'oducing iiermanent olistruction, though it
would seem po.ssihie t hat even in the latter case canaliza-
tion of the thrombus might take place so as to re-estab-
lish the circulation. Vision is not entirelj' destro,ved for
some time and may undergo marked tem]iorary imiirove-
ment. but relapses occur .so that blindness is linally ]iro-
ilueed. If large extravasations of blood are pcuued into
the vitreous body, as is sometimes the case, sight is early
destroyed.
The tniitment of h_ypera?mia of the retina must in every
case be directed toward the cause, but the application of
cold compresses to the eyes and the use of smoked
glasses are often advisable. In thrombosis of the cen-
tral vein treatment is of little avail, though strychnine
has been advised, and jiofassium iodide and mercury
niav be given in the ho|ie of hastening the ab.soriitiou of
the'ettusc'd bloud.
Anii'iiiiii iij tin- Patina. — All degrees of mis occur up to
the complete cessation of the retinal circulation. In-
complete retinal ana'una may be either chronic or acute;
in the former ca.se it is usually dependent U]ion chronic
general anaunia, either primary or secondary, and is not
associated with any distui'bance of vision, while in the
latter it most often results from excessive loss of blood
and frequently produces jiermanent blindness. It is
rather remarkable that instead of ana-mia, loss of l)lood
may give rise to relinal liypera>mia and hemorrhages.
Ineojnplete retinal aiuemia is also an aceompaniment and
no doubt often the cause of retinal atrojihy, and is con-
stantly seen as the ri^sult of optic atrophy. The retinal
changes seen in albuminuric I'ctinitisarealsoin all jiroba-
bility dependent upon the anaemia resulting from sclero-
sis of the retinal vessels, and the impairment <if vision in
acute giauccuna is thought to be due to amemia from
pressure t)phthalmo.scopic examination in incomplete
an;emia .shows constricted arteries, dark veins, pallor of
the disc, and sometimes arterial pulsation. As a matter
of fact, however, uidess the changes are quite marked,
the condition is apt to be overlooked.
hchiviiiiii, or conqdete anaMuia of the retina, is iisuallv
due to obstruction of the ciaitral artery, and may be the
result of embolism, iirimary thrombosis, s|iasm of the
muscle walls of the artery, hemorrhage into the optie
sheath, direct injury to the artery within the nerve, or to
pressure exerted upon the artery liy a neoidasm. It was
considered one of the earliest and most jiositive signs of
death, but recent observations have shown that it cannot
always be relied iip(jn.
EmhuUmii. iif tite rnitnil mii iij is of very rare occur-
rence, probal)ly more so than is generally believed,
many cases diagnosed as such being due to some other
cause. This view has recently been urged by II. II.
Thompson, who states that the few anatomical examina-
tions that have been made are unsatisfactory, and sug-
gests that the ma.iorityof the lases of so-called embolism
are due to spasm of the central arterv. Embolism is said
to be more connuon in men tli:ui in women and to lie al-
most always unilateral, occurring more frequently in the
left eye. The diagnosis nf embolism is practically al-
wa.vs made when in aildition to ischremia of the retina
there is reason to suspect the jire-sence of emboli in the
circulation, as in eases of endocarditis. The embolus
mav lie carried to a branch of the central artery, the
aiuenu'a then involving only a portion of the retina.
Sometimes the maiailar region alone escapes in this way.
If the embolus is infected, supptn-ative pauophtlialmitis
results. Tliroiiihosis of the cent ml artery has been diag-
nosed in a few cases, but usuall.y upon insufficient evi-
dence In one ease, however, Ilaab has recently deiuon-
strated the |irocess of thrombosis by means of serial sec-
tions, lleiimrrliage into the sheatli of tlie optic mrre has
never been demonstrated bv- an anatomical examination
to lie a primary cause of ob.s'tructiou in the central artery,
but it occurs as a result of trauma to the eye or from" a
iiemorrhage at the base of the brain, forcing its way along
the nerve. (Plate L.. Fig, 2.)
Spasm of tlie Muscle Walls (f the Central Artery. — In
migraine attacks of temporaiy blindness not infrequentl}'
occur, and naturall,y enougli have been attributed to
spasm of the central arterj', especially so since the in-
halation of amjd nitrite gives such prompt relief.
W'a.genmimn observed one of these attacks ojihthalmo-
scoiiicall.y, and saw the retina become iuarkedl\- ana-mic
and then return to its normal condition within an inter-
val of about ten luinutes. Si.x months later a similar
attack occurre<l in this case, and resulted in permanent
blindness with the ophthalmoscopic jiicture oi'dinarily
considered characteristic of embolism. Quinine in large
doses may also cause constriction of the retinal arteries,
which may be seen with the ophthalmoscoiie. There is
great im]iairment of vision together with contraction of
the visual lield. In some cases there is comiilete blind-
ness, and a cherry-red spot has even been seen in the mac-
ula. Central vision is ultimately recovered, sometimes,
however, only after many months, but the ]ieri|iheral
field is apt to remain contracted. Some recent investiga-
tors have maintained that the impairment of vision in
such cases is due to the direct action of the drug upon
the .ganglion cells of the retina, but the ophthalmoscopic
findings certainly point strongly to spasm of the arteries
as till' primary factor.
In iselKemia of the retina, no matter what the cause of
the shutting off of the blood 'supply, the changes pro-
duced are alwa,vs much the same The disc is pale; the
arteries are so much reduced in calibre that they can be
followed only for a short distance, and interrupted col-
umns of blood may be seen in thein. If the case is seen
early, a to-and-fro motion of the blood may be otiserved,
such as is seen in the vessels of a frog's web when the
circidatioh is beginning to stop. The veins are also con-
tra<'led, liut to a nnicli less degree and pulsation m;i_v
still lie brought out in them liy pressure on the globe.
The retina soon becomes opaque, first near the vessels,
the opacity being most marked around the macular re-
gion. But the most striking as well as the most charac-
teristic feature of retinal ischaunia is a cherry-red spot
about one-third the diameter of the disc, w hich makes its
ap|iearance in the centre of the m.aeula. This spot is not
invariably present, however. The cxjilanation usually
given for its occurrence which was first offered by von
Graefe, is that it isdue to thedark and congested choroid
showing through the thin fovea, the general wdiite opac-
ity of the rest of the retina, especially the surrounding
macula, rendering it unduly conspicuous. A later theory
is that the spot is due to a hemorrhage, and a recent ob-
servation leads the writer to believe that this view is cor-
rect. A short time ago, at the Massachusetts Charitable
fjye and Ear Inlirmaiy, there was enucleated and sub-
mitted to the writer for examination an old glaucoma-
tous eye upon which an optico-ciliary neurectomv had
been ]ierformed ten days previously, the optic nerve and
with it the artery and vein being severed close to the
globe. It will readil.v be seen that such an eye presented
an exceptional opportunity for the anatomical stialy of
retinal iscb.-emia, since eyes affected by embolism, etc.,
ordinarily offer no indication for enucleation, or at least
not sutlieiently early to be of much value from the stand-
point of pathological anatomy. The eve had undergone
no outward change as the result of the first operation, but
it was removed on account of an unsightly squint. On
macroscopic examination there presented itself the typi-
cal sharply dclincd red spot in the centre of the macula,
and on nncroscopie examination this (iroved to be a hem-
orrhage. The extravasation of blood was limited to the
macula, and there was no hemorrhagic infiltration of the
9.^)4
EXPLANATION OF
PLATE L.
EXPLANATION OF PLATE L.
Fig. 1.— lleinonliages into tlie lirlina ; licliiKil Aiioplcxy. (Fmiu Noyes: " Diseases of Uic Eye,'"
AVoods Liliiary of Stauilurd Autlmrs, ISSl.)
Fk;. 2.— Iscliaiiiia of the Hetiua (due to Eiiiliolisrn of the Ceiitial Artery V). (From Noyes: Op. cit.)
Fiii. 3. — Serous HetiiiitiV. (Fnmi Noyes: d/i. ci/.)
Fu;. 4. — Alliuiiiiniirie lirliiiitis, (Froni Noyes: " I)ise:ises of the Eye," IS'Jll.)
Fig. 5. — Alliiiiiiiiiuiit liiliiiiiis ,it :in Advanced Stage. (From Stellwag's "Diseases of the Eye,"
Translation of llael,liy ;ind Itoosa. 18(i.S. )
Fig. 6. — Se|iaration of the Itetina. (Frnm Stellwag.)
Reference Handbook
OF THE
Medical Sciences.
Plate L.
Diseases of the Retina.
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
ICi'liiia.
Rt'liua.
choroid beliiud it. a fact wliicli showed that tlic blood did
not come from the clioroiilal vessels. The retiua was al-
most completely iieei'otic. especially in its inner layers,
and there were iiuirked jiioliferatiou and migration of the
cells of the pigment layer. In almost all of the retinal
vessels the reel Mood corpuscles stained very feebly, but
in the hemorrjiage itself, and in a few of the vessels near
the macula, the blood was well preserved, thus indicat-
ing that the source of tlie hemorrhage' was the eiliu-reti-
nal vessels. The fact that the hemonhage was compara-
tively fresh, and that there were no other retinal
liemorrhages, went to show that it was not the result of
the glaucoma but that it was dependent upon the cut-
ting off of the circulation in the central arterv.
In a number of cases of supjiosed endiolism the circu-
lation after a time has been seen to renn'n. This has
possibly been due to the hreaking up of an cndjolus, or
more likely to the establishment of a collateral circulation
through the cilio-retinal vessels, but on the other hand
it certainly supports the view that the eases in whicli it
occurred were really due to spasm. Sometimes the di-
rection of the circulation is reversed. The return of the
circulation gives rise to numerous hemorrhages, most of
them in the macular region, and no doulit'due to the
injury to the vessels jiroduccd by tlie cessation of the
flow of blood. The final picture is that of atrophy of the
retina and optic nerve.
As a result of ischamia of the retina, vision is almost
instantaneously lost. Occasionally a part of the vi.sual
lield may remain intact for a while, but later it also be-
comes blind. It is .said that in some instances the macu-
la is sulficiently well nourished liy the <ilio-rctinal vessels
to prevent impairment of central vision. If the circula-
tion returns quickly, as in migraine, vision is completely
restored, but in total embolism it is almost always jicr-
mauently destroj'cd.
Treatment of Uetinttl Aiuvmin. — In the simple variety
of retinal anannia dependent upon general anemia, treat-
ment appropriate to the latter must be adopted. If the
aua'mia is very marked, lowering the heail at intervals
(luring the day may be practised. The aciUe retinal au-
tfinia resulting from excessive loss of blood should be
combated by saline inftisions and general supportive
treatment. Inhalations of amyl nitrite are of great value
in spiasm of the central artery associated with migraine.
In embolism, paracentesis of the cornea, iridectomy, and
massage of the cornea with the purpose of dislodging the
embolus, have been recommended.
Reliiiiil Ihiiiiiri-hiii/is. — Aside from traiuua, which is of
course a frequent cause, hemoirhagcsinto the retina may
occur as the result <jf a general di.scase, less counnouly as
the result of disease confined to the eye alone, or they
may occur occasionally in yoiuig people without any
assignable cause. As already noted, hyperfemia of the
retina frequently gives ri.se to them, esjiecially the ve-
nous hypera^mia resulting from thrombosis of the central
vein, ojitic neuritis, or neuroretinitis. When they are
the jiredominant feature in tlie latter, the condition is
usually di'signatcd by the term lu'morrliiigir re/ in it is.
Venous liypera'Uiia d\ie to pressiue on the central vein
at the disc is also proliably the cause of the retinal hem-
orrhages which sometimes occur in primary glaucoma,
and the intense hyperauui.i resulting frimi sulfocatiou is
also likely to [iroduce them. Their occurrence as an
after-effect of emboli.sm has already been referred to.
The retinal hemorrhages that occur as the result of gen-
eral disease are dependent either upon alterations in the
retinal vessels, associated in most cases also with high
arterial pressure, or upon changes in the chafacter of
the blood itself. Thus they are seen with comparative
frequency in general arteriosclerosis. Bright 's disease,
gout, diabetes, anaunia, leukaemia, purpura, and sctnvy.
When such predisposing factors are present the immedi-
ate cause is often violent e.\erti{jn, such as cotighing or
straining at stool. In arteriosclerosis they may a]ipear
quite suddenly in great nundx'rs, just as in cerehral
apoplexy, and in such eases the condition is, in tact,
often spoken of as retinal apople.xy. Retinal hemor-
rhages also occur as (he result of menstrual disttn-bances,
sometimes as one of the manifestations of vicarious
menstruation, Tlicy frecpicntly occur in new-born in-
fants as the residt of e.xce.ssive j.ircssure on the liead
during delivery, but they are quickly ab.sorbed without
leaving any macroscopic changes. Iii this way no doubt
many obscure cases of congenital anibl3'opia are |iro-
duced. Among other general causes may be mentioned
l>oisons, especially' lead and plios])hiirus, jaundice, pretr-
nancy and parturition, malarial lever, .septica'Uiia, and
pya'mia. (Plate L., Fig. 1.)
Ht'tinal hemorrhages vary greatly in regard to size,
shaiie, number, and posirion. When few in number
they are usually situated not far from the disc or near
the macula. They occur in any of the retinal layers that
contain blood-vessels, but most frei|uently in the nerve-
fibre layer where they a.ssume a characteristic striated
" flame-like " shape, due to the fact that the blood insinu-
ates itself in between the nerve fibres. Owing to the
radial arrangement of the fibres around the disc, hemor-
rhages in its neighborhood tend to take the form of red
radii. The extravasations of blood may break through
the retina into the vitreous humor producing vitreous
opacities, or they may foice their way between the retina
and clioroid. Sometimes the blood collects beneath the
hyaloid membrane, forming the .luhhi/iiloid lienmrrhiige.
This most frequently occurs in the macular region, ap-
pearing as a shariily defined dark red disc. When re-
cent, retiiial hciuorrhages are bright red in color, but they
soon become darker, often almost black. The blood
is absorbed rapidly, esjiecially when the hemorrhage is
small, but white spots in many cases are left to mark
their sites. The white spots are due to necrosis of the ret-
inal tissue and may contain fat globidcs and cholesteriu
crystals. They may finally di.sapjicar or they may re-
main permanently, not infrequently becoming more or
less pigmented, owing to the migration of cells of the
pigment layer into them. It is said that the pigment
stria', known from tlieir resemblance to obliterated ves-
sels as (ingiiiiil strrnkK in the retina, are due to meta-
morpliosis of retinal hemorrhages. Extravasations that
have broken into the vitreous humor but that still
ren'iain attached to the retina, sometimes undergo or-
ganizatiim and become converted into connective tis-
sue. It is in this way that retinitis pivlifemiis is
thought to arise.
The disturbance of vision produced by retinal hemor-
rhages obviously depends ujion their size and position,
and of course is particidarly great when one of the hem-
orrhages occupies tlie macula. Sometimes tliere is
metamorphopsia, less often photopsia'. Even small
hemorrhages may proiluce a temporary clouding of vis-
icm if they break tluough the retina into the vitreous
humor. The prognosis is favorable when they are small
and the tendency to relapses can be successfully over-
come. It is partieidarly unfavorable when they occur
in connection with a general retinitis. The subhyaloid
hemorrhages wliich occur at the macula are usually ab-
sorbed and vision is com|dctely restored. When thehem-
orrhages are dependent upon a general disease the treat-
ment must necessarily be directed chiefly toward the
latter, but rest in bed, the application of cool compresses
to the eyes, and the administration of mercurial inunc-
tions or potassium iodide to favor the absorption of the
effused blood, are usually indicated. Leeching, purging,
and the production of diaphoresis by pilocarpine are also
advised,
Plilehectasia retina' is a name given to a rare condition
in which the retinal veins show dilatations and constric-
tions, sometimes producing a decided beaded appearance.
In .some cases it is probably due to vasomotor disturb-
ances. Schobl describes a ease in which the condition
was also ju'escnt in the conjimctival veins and was evi-
dently dependent upiui suppression of the menses, the
phenomenon disappearing wdien the menstrual flow was
re-established.
Retinal ancunnmn are of very rare occurrence, but they
have been seen in the living subject and also in enucle-
955
Retiua.
Rrliiia,
REFERENCE nA:NDBOOK OF THE JIEDICAL SCIENCES.
ated eyes. Most frequently they are multiple, miliary in
size, and situated ou the smaller retinal arteries ; but some-
times a single large aneurism may furm on one of the large
arteries. An arterio-veuous aueurism liasbeeu known to
occur as the result of an injury. Treatment is of no avail.
Sclerosis af the retinal vessels probably always occurs
where there is general arteriosclerosis, but the alterations
in the retinal vessels are rarely sufliciently obvious to at-
tract attention on ophtlialmoscopic examination, owing,
no doubt, to the fact that the vessels are much smaller
than those in which marked atheromatous changes are
ajit to occur. Both the veins and the arteries may show
white borders, due to an increase of connective tissue in
their walls, and sometimes constrictions and sjiindle-
shaped thickcning.s. Often, however, the first evidence
of disease of the retinal vessels is the occurrence of reti-
nal hemorrhages. In syphilis changes are met with in
the retinal arteries similar to those seen in cerebral syphi-
lis, so that they are of diagnostic significance as regards
the latter. Owing toobliteratingendarteritis, thearteries
appear as thin white bands, and there may be hemor-
rhagic infarcts. The veins are broad and dark colored.
Vision is unaffected for a long time.
Retinitis. — This term strictly should signify inflam-
mation of the retina, but as a matter of fact most of the
retinal conditions to which it is applied are not of an in-
flammatory nature, but are due either to degenerative or to
atrophic changes, or they are dejiendent upon obstructive
oedema and hemorrhage. In fact, there is probably only
one condition, suppurative retinitis, in which the retina
is actively inflamed. When retinitis occurs in associ-
ation with neuritis the condition is spoken of as neuro-
retiuitis. In not a few cases retinitis is secondary to op-
tic neuritis, the swelling of the disc interfering to such
an extent with the venous outgo as to lead to (edema
and hemorrhage. On the other hand, in many general
diseases, neuritis and retinitis may be produced inde-
pendently, either one or the other predominating. The
chief varieties of retinitis are as follows:
Sii pjiii nit i re Retinitis. — This most commonly occurs as
the result of penetrating wounds of the globe or follow-
ing operations, particularly those for the removal of cat-
aracts, and almost always results in or forms a part of a
general panophtlialmitis. It is usually due to micro-
organisms which have been introduced into the eye, but a
comparatively mild form of it can be produced by chemi-
cal irritation due to the disintegration of a foreign body,
especially if tlie latter contains copper. The condition
may also be metastatic in origin, particiUarly in pui'rjieral
septica'miaand in theacute infectious diseases of chililren.
In these metastatic cases tlie inflammation maj' be e<in-
fined throughout to the vitreous chamber, and thus, in
children, it may result in one of the conditions which
gives the clinical picture known as jmiidn-f/Hi'iiiii. Con-
trary to what has been generally believed, in ])ano]ih-
thalmitis it is the retina, not the choroid, from vvliieli the
purulent exudation mainly arises. In a large number of
cases of panophthalmitis examined microscopically by
the writer, the retiua has invariably been fo\U]<l densely
infiltrated with ]ius cells, while the choroid showed
scarcely any purulent iufilti-alion. It might lie thought
tliat the pus cells in the retina came there from tlie cho-
roiil. but they can be seen in the act of emigrating from
the retinal vessels around which, too, the}- are most
abundantly collected. The choroid seems to play the
part of an abscess wall, aiul is congested, more f>r less
o'dematous, and infiltrated with lymphoid and plasnui
cells. The choroid also early gives rise to a formation of
granulation tissue. In the cases diagnosed clinically as
metastatic choroiditis the condition is usually that of
metastatic retinitis, although the micro-orgauisnis no
doubt often reach tlie e}'e through the choroidal vessels.
If seen sufficiently early, the retina in these cases isfound
to be hazy and covered with hemorrhages, but the vit-
reous Innnor soon becomes so cloudy that the later
stages of the process cannot be followed by means of the
ophthalmoscope. Suppurative retinitis from any cause
may pursue either an acute or a chronic course, and ulti-
matelj' results in phthisis bulbi. The treatment is that
suitable for |ianophthalmitis. and is of little avail. Re-
cently the introduction of jiowdered iodoform in the vit-
reous chamber has been tried, sometimes, it is claimed,
with successful results.
Retinitis Septica (Roth). — In pyamiia and septicnemia
tlie retina frequently shows hemorrhages and whitespots
not unlike those seen in albuminuric retinitis. There are
no .signs of active inflammation and no pain. Vision is
not much affected and the luognosis is favorable so far
as the eye is concerned. Roth believes the condition is
not due to the presence of micro-organisms in the retina,
but to toxic snbstiinces circulating in the blood produced
by the septic processes elsewhere. Some observers claim
that the hemorrhages are due to the lodgment of septic
emboli in the retinal vessels, but the ab.sence of inflam-
matory symptoms and the mild course pursued by the
affection are decidedly against this view.
Retinitis Simpfej; Senms Retinitis. Retinnl (Eelenia. —
Under certain conditions not understood, the retina be-
comes hypera'iiiic and shows a haziness evidently due to-
cedema, which either may be diffuse or may occur in
circumscribed patches. This mild form of retinitis is
supposed to result in some instances from eye strain. It
is also said to be an earl)' manifestation of sympathetic
ophthalmia. Vision may be considerably reduced and
there may be megalopsia. micropsia, and metamorpho])-
sia. Under complete rest the conditiim entirely disap-
pears. A special variety known as emnmotio retinee is-
due to a blow upon the eye. This also clears up, usually
in about three davs, with complete restoration of vision.
(Plate L., Fig. 3.)
Albuminuric Retinitis. — In some cases of Bright's dis-
ease the retina shows changes which are met with under
almost no other conditions, and which therefore may be
regarded as praeticall)' characteristic of renal disease.
Such plainly marked cases of albuminuric retinitis, as
they are named, occur in only a small ])er cent, (about
seven per cent.) of patients suffering from Bright's dis-
ease. On the other hand, if carefully searched for, less
characteristic retinal changes — such, for instance, as al-
terations in the vessels and hemorrhages — will be found
sooner or later in imiliably one-fourth of these patients.
Tyjiical albuminuric retinitis may occur in anv form of
renal disease, whether acute or chronic, but it is met
with by far the most frequentl_y in chronic interstitial
nephritis and least often in amyloid disease of the kid-
neys. It is rarely limited to one eye, though the retinal
changes may differ considerablj- in the two eyes, both in
extent and in character. AVhile the retinal affection ap-
pears only in cases of renal disease wliicli have lasted some
time, yet not infrequently it is by means of the ophthal-
moscope that the serious condition of the kidneys is first
discovered. The most characteristic feature of the affec-
tion is the jire.sence of a "star-shaped figure in the macu-
la," consisting o{ a greater or less number of white striae
which radiate from the centre of tlie macula, frequeutU',
however, without completely encircling it. The fovea
is usually not involved and stands out as a clear red spot.
( Itlier changes almost always present are hemorrhages,
oilenia, and irregular white patches of various sizes.
The latter iiave ill-defined edges and are situated in the
inner layers of the retina, often obscuring the vessels that
cross them. The arteries are narrowed anil frequently
show white borders, wliile the veins are broad and tor-
tuous. The narrowing of the arteries is not uniform, so
that the same artery ma)' show variations in widtli along
its course. Thearteries are also somewhat tortuous, and
the light streaks in tlieir centres are much brighter than
in the case of normal arteries. AVlien an artery crosses a
vein the latter sometimes appears pale for a short dis-
tance on each side of the artery, due no doubt to com-
pression. Optic neuritis is commonly present, and in
some cases is tfie most iirominent feature. In other cases
hemorrhages predominate, while in still others the most
striking ch.ange is that due to ledema. As just noted,
the ap])earauces may be quite <lifferent in the two eyes.
Thus in one eye the principal change may consist in the
9;jG
REFERE>XE HANDBOOK OF THE MEDICAL !SC1E>;CES.
Kctiua.
Rftiua.
■Star-shaped figure about tlie macula, while in the other
this may be absent and the retina covered with licmor-
rliages. " If at any time tliere has been severe optic neu-
ritis the retina and optic nerve ultimately undergo atro-
phy. Rarely the retina shows folds or even complete
sep"aratiou, the latter most often in the albuminuria of
pregnancy. (Plate L., Figs. 4 and 5.)
The retinal condition most likely to be mistaken for
albuminuric retinitis is that which results from a high
grade of optic neuritis, especially that associated with
brain tumor. In this the star-shaped figure may be pres-
ent in a perfectly typical form, so that if at tlie same time
tliere sliovdd be a trace of albumin in the urine and the
general symptoms of brain tumor should not be plainl_y
niarked. the diagnosis miglit be difficult. In such cases,
however, sight is almost always lost, whereas in albu-
minuric retinitis complete loss of vision rarely occurs. It
should be remembered, too, that a high grade of optic
neuritis does not occur in Bright's disease except in ad-
vanced cases in which the diagnosis is plain. Finally,
renal disease could be excluded in most cases by a micro-
scopic examination of the urine. In lead poisoning, too,
the retina may present appearances identical with those
seen in albuminuric retinitis (s«/»/-o?'ne retinith), but it
is not certain that they are not due in reality to kidney
lesions jiroduced by the lead.
Anatomically tlie most important lesion in albuminuric
retinitis, and one that gives the key to the other changes,
is a widespread endarteritis and liyaline degeneration of
the vessels. This is, of course, not limited to the retinal
vessels, but it produces more serious damage in the
retina than in the other structures of the eye. The
atheromatous condition of the vessels associated with the
ffeueral liigh arterial pres.sure results iu numerous hemor-
rhages, while the insufficient blood supply leads to
■degenerative changes in the retinal tissue. >[ost of the
white patches seen by the ophthalmoscope are produced,
in tliis way, but some of them are left by retinal hemor-
rhages that have undergone absorption. Tlie degene-
rated areas show fatty degeneration of the retinal tissue,
including the ganglion cells, nerve fibres, and fibres of
!Miiller, and contain fibrin and granular detritus. Pro-
liferation and migration of the cells of the pigment layer
occur in the later stages. The degenerative changes
make their first appearance at the macula because here
the vesselsare least numerous, but the fovea centralis or-
dinarilv escapes, since it is well nourished by the chorio-
capillaiis behind it. The star-shaped figure is said to
owe its form to the radial arrangement of the fibres of
Midler about the macula, though the degenerative
changes are not limited to them. It seems to the writer
more" likely that its form is determined by the radial ar-
ranirenu'nt" of the vessels in this region. The retina in
general is apt to show marked (edema, usually in asso-
ciation with a high grade of optic neuritis, though the
retinal trdema is sometimes quite niarked where there is
very little swelling of the disc. The cause of the ojilic
neuritis is obscure; some observeis attribute it to cere-
bral disturbances secondaiT to the renal disease. In
addition to the other change's, the retina may show a cer-
tain amount of round-cell infiltration and hyperplasia of
its connective tissue.
The disturbance of vision usually is slight when com-
pared to the extensive retinal changes, and in the milder
forms vision may be entirely uiiaffeeted. The fact that
the fovea centralis is but seldom alTected accounts for the
almost constant preservation of central vision. Complete
blindness is rare, and when it occurs it is usually the re-
sult of secondary atrophy of tlie optic nerve and retina
Oi is due to separation of the latter. It should be re-
membered, however, that in Bright's disease, whether or
not there is retinitis, attacks of blindness, vnvmic niiiaii-
i-'txin, may come on within a few hours as the result of
ura'niic poisoning, though they are more common in acute
nephritis than in the chronic form., of renal disease. Here
the blindness in all proliability is due to the action of the
ura'inic poison upon the brain itself, the luijuls in most
•cases still reacting to light. It is associated with other
urannic symptoms and disappears when the ura'mia is
overcome.
The prognosis of albuminuric retinitis depends chiefly
upon that of the renal disease, and since the retinal alfec-
tiiin occurs only in advanced stages of the latter, it is al-
most always bad. Conversely, the proguosisof the renal
disease, and hence the prognosis in regard to life, is par-
ticularly bad when albuminuric retinitis has made its
appearance. The prognosis in regard to sight is of little
importance, because the patients seldom live long enough
for the visual disturbance to beeonie of serious moment,
death usually occurring well within a-year, rarely later
than two years, after the discovery of the retinal disor-
der. Thenephritis associated with pregnancy is an im-
portant exception to this rule, complete recovery being
of frequent occurrence after it. Recovery also sometimes
follows the nephritis which accompanies the acute infec-
tious diseases. In these cases the retinal disease ceases
to progress, and many of the retinal alterations disap-
pear. The star figure at the macula, however, seldom
entirely disajipeais.
Asid'e from the measures usually employed in severe
cases of nephritis there is no treatment that will benefit
the retinal disease iu any way. It sometimes happens,
however, that the retinitis may undergo decided im-
provement under treatment directed toward the kidneys
and yet death ensue in the usual short time. In the al-
buminuric retinitis of pregnancj', especially if it appears
early, the induction of aliortion is often advisable.
Diabetic Retiiiilix, Uh/coxuric lidinitis. — This afTection
is certainly rare, though just liow rare is not definitely
known. It is a late manifestation of the general disease,
and according to Hirschberg it is always present in dia-
betes which has existed for twelve years. In some in-
stances the retinal changes are no doubt due, in part at
least, to an accompanying interstitial nephritis: but it is
generally believed that they may be entirely independent
of kidney lesions, and there is no question but that in
typical cases they ditTer decidedly from those seen in
typical albuminuric retinitis. The affection is probalily
confined to dialietes luellitus, tliough it is claiiued that
diabetes insipidus has produced it. It is likely that the
retinal changes that have been seen in supposed cases of
diabetes insipidus have not been due to the latter dis-
ease, but that the polyuria and the retinitis have inde-
pendently been due to a tumor of the brain. It is possi-
ble, too, that the polyuria of chronic Blight's disease may
have been mistaken for that of diabetes insipidus.
In the form of retinitis most characteristic of diabetes,
reiitritl punciitte retinitis of Jlirsclihirri, the retina shows
great numbers of small bright shining spots, sometimes
trregular in shape, which are most numerous near the
discand in the macular region, without, however, hav-
ing a .stellate arrangement. Scattered more generally
over the fundus there are many punctate hemorrhages.
Neither the retina nor the disc shows evidences of oedema,
and the retinal vessels are apiiarently normal. Larger
white spots are also occasionally seen. Sometimes in dia-
btites the white spots are entirely absent and the retina
shows only various kinds of hemorrhages. This condi-
tion is the lietiKirrltftriie (lii(/utic rctinitin of Hirschberg,
though why it should receive the name retinitis is not
evident. In diabetic albuminuric retinitis the changes
characteristic of nephritis are associated with those of
diabetic retinitis. Albuminuric retinitis may also occur
alone in diabetic patients.
Diabetic retinitis is always sooner or later binocular.
Vision is apt to be considerably ini|iaired. especially cen-
tral vision. an<l then' may be contraction of the per-
ipheral field. It is dillicul't to say in a given case, how-
ever, -ivhethcr or not the disturbance of vision is due to
the retinal changes, since amblyopia is common in dia-
betes even when the opiithaliiioscopie examination is
negative. Insome cases tlie<listurbaiice of vision is very
slight. Not infrequently vitremis opacities due to hem-
orrhages occur and may produce total lilindness, and
glaucoma secondary to hemorrhage is also met with.
Total blindness, however, is rare in diabetic retinitis.
957
Reliua.
Reliua.
REFERENCE IIANDIK )( >K OF THE MEDICAL SCIENCES.
Tlie ]H-ognosis of the retinal affection is bad, tlie latter
seUlom showing improvement under treatment, and oe-
eurring as it does in the later stages of the general dis-
ease, (iiabetic retinitis is of evil signiticanee in regard to
the duration of life. This is particularly true of tlie
hemorrhagic form, since a tendency toward lieuiorrliage
on the part of the cerebral vessels is in<licated. The
treatment is that suitable for the general disease.
Lcukmmic Retinitis. — In all severe (^ases of leukcemia
the retina presents an abnormal appearance, but actual
retinitis is relatively uncommon. The fundus is apt to
appear light yellowin col(n- owing to the altered color of
the blood in the choroidal vessels, but where the choroid
is highly pigmented this may not be noted. The arteiics
are pale an<l sometimes small ; the veins arc dilated, fre-
i|uenlly tortuous, and their walls may ap|iear thickened
owing'to inliltratiou with whil(' cell's. Retina! hemor-
rhages are extremely common, in fact, the_y are the most
constant ocular lesion met with in Icuka'Uiia. In addition
to these changes otlier lesions sulliciently marked to war-
rant the name of retinitis sometimes occur. These are
confined almost entirely to the spleno-myclogcnous type
of leukaemia, and consist of haziness of the retina and
tlie presence of white spots with red borders. The latter
are most numerous at the peri|ihery and in the macular
region, and are due to collections of while cells iu thi'
centres of hemorrhages. Though not often seen, they
are highly characteristic of leukiemia. Other white
spots, due to degeneration, also occur. The disc may
be practically unaffected, or it may be greatly swollen
owing to fcilema and to infiltration with cells. Both
eyes are almost always affected, tliougli in dilVerent de-
grees. The impairment of vision (U'pends upon tlie
position and numlier of the wliite patches and hemoi--
rhagcs; a hemorrhage in tlie macular region will of
course cause loss of central vision. This may be of the
subhyaloid variety, however, and aft<'rward clear u|i.
A largo hemorrhage into the vitreous humor may cause
permanent loss of sight and in some cases glaucoma. Al-
buminuric retinitis may occur as a comphcation. Tin-
prognosis is hopeless as regards both the general and the
local affection.
Si/iihUitic Retinitis is far less common than syiihilitic
chorioretinitis (see Vol. III., p. 04), but still it does oc-
cur. It is met with in both accjuired and congenital
syphilis, though in the latter only the final stages are
seen. In the acijuired form it may develop four to si.\
months after the iirimary infeclion. The retina shows a
grayi.sh-white opacity which is most marked near the
vessels, and along the lalter small white spots are frc
quently seen. Tlie vessels themselves are ai)parcntly
not much affected, the arteries are somewhat thinner,
and the veins thicker than normal. Dust-like opacities
are almost always present in the posterior jiart of the
vitreous humor, and may persist after the retinal affec-
tion is cured. Hemorrhages are rare. .Microscopically
the imporlant changes found have been diffuse round-
cell infiltralion of the ri-tiua, cndarteriMs of its vessels,
and nodular collections of round cells in the choroid.
No distinct gummatous formations have been oViseivcd
in the retina, but the nodules in the choroid are said to
resemble gummata. Proliferation and migration of the
cells of the pigment epil helium have been noted. An
early subjective symptom of the disease is a constant
shimniering of light, due, according to Ilirschherg. to
insullicieiit blood supply to the retina. A'isual acuity is
much reduced and there is frequently night blindness.
Ring scotomata are sometimes detected. The retina and
with it the optic nerve ultimately may undergo atro]ihy.
The prognosis and treatment are similar to those of sy phi
litic chorioretinitis.
Rildpsiii;/ Si/piii/itic f'liitriil Riiiititis.- — This is an ex-
tremely rare aff'ectiou, first ilescribed by von Graefe,
characterized by repeated sudden attacks of marked
impairment of vision. At first the vision returns to nor-
mal during the intervals, but finally it becomes perma-
nently impaired. The retina shows slight dimness in the
nia('ula around which fine dots are fre(iuently seen, and
in the later stages of the disease pigmentary changes oc-
cur in thi^ macular region. Reduction in central visual
acuity usually persists even after prolonged antisyphi-
litie treatment, owing to the structural alterations in the
retina.
Retiiiitix Priilifcriiiis (Mauz). — In this disease masses of
connective tissue arise fi'om the retina and extend out into
the vitreous humor. They are usually attached near the
disc, rarely directly to the latter. There is little doubt
that the condition is brought about through the organiza-
tion of retinal hemorrhages. The progress of the disease
is slow, but it usually leads to total blindness. Iridocycli-
tis or separation of the retina ma}' occur, and the globe
finally undergoes atrophic changes. It is .said that mer-
curial inunctions and jiotassium iodide are of benefit.
Retinitis: Pniirtii/ii AllicxiriiK (Jlooren). — As indicated
b\' the name, in this affection the retina is studded over
with numerous small white spots which arc most numer-
ous around the disc and in tlie macula; the fovea, how-
ever, usually esca]ies. Central vision is reduced and
there are sometimes night blindness and contraction of the
peripheral field. The disease is extremely rare and oc-
curs in young persons.
Consanguinity in the parents seems to be an important
factor in its occurrence and several members of the same
family may be attacked. Aside from the ophthalmo.sco-
pic picture, it is thus veiy similar to retinitis pigmentosa.
Rttitiili-t Oirciiinta (Fuchs), a very rare disease of un-
known etiology, always occurring in elderly jiersons, is
characterized by the presence of a number of small white
s])ots situated around the macula in the form of a more
or less complete circle, with a diameter two or three
times that of tlic disc. AVithin the i-irele, but not (|uite
reaching its circumference, the macula shows a grayish
opacity. The white spots lie deeper than the retinal ves-
sels and sometimes are slightly pigmented. Small reti-
nal hemoniiages occasionally occur, especially in cases
of long standing. Along with these cliangcs there are
diminution in central vision, limitation of the visual field,
and a small central scotoma. Vision gradually becomes
more and more detective, but absolute hlindness doi's not
occur. The affection may be either monocular or binocu-
lar. According toFuelis, the spots sometimes disappear,
but the disease is not lienefited by treatment.
Retinitis f<triiitii (Nagel), another very rare affection
of the retina, owes its name to the presence in the retina
of gray stripes situated in front of the pigment layer, but
behind the vcs.sels. The .stripes vary in width, but may
be three or four times as wide as a vein. They may run
from the disc like radii, or they may have no sjieeial ar-
rangement. In addition to these stria' the retina may
show pigmentary changes. The disease appears at an
early age, runs a chronic course, and although there is
some reduction in visual acuity, blindness does not gen-
erally result. The etiology and pathology of the atfec-
lion are unknown, though some observers hold the view
that thestrijiesaie due tometanior|ihosisof hemorihagcs,
as in the case ol angioid .streaks in the retina. L. Caspar
maintains that they are the result of a reliiial separation
that has undergone spontaneous cure. Tieatmcnt is of
no avail.
lutiiiilis from e.rpiaiire to liriiilit liijht is sometimes met
with, occurring most often as the result of exposure of
the retina to sunlight during an eclipse (solar retinitis),
or less fre([uently to exposure to an electric arc light.
There is produced a central scotoma which may or may
not persist, and, later on, pigmentary changes may be
seen in the macula.
Snow lilindness, which results from long exposure of
the eyes to the brilliant light retlected from large ex-
panses of snow, is not dependent, as might be tliought,
U]ion retinal changes, but it is due to the jihofopliobia
and lilc'pliarospasm resulting from a peculiar form of
conjunclivitis. It is .said, however, that sometimes the
retina may he liypei;eniic. and that there may be some
actual diminution in visual acuity.
Amiiiirotie Finni/i/ htioey (Tay). — In this very rare dis-
ease the retina presents an appearance as striking as it is
95S
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Itctiua.
Retina.
cliarafteristic. There is a grayish-while jiatch in the
Tiuiciilar region, about twice the size of tlie ilise, the cen-
tre of whicli is occupied by a small red spot similar to
that seen in embolism of the eenlial artery. Otherwise
the fundus appears normal. The disease makes its aji-
pearanee within the tirst year of life, both eyes being
affected in the same way and the child showing marked
symptoms of idiocy. It occurs almost e.\chisively in
chiktren of Hebrew parentage, usually attacking several
cliildren of the same family. Optic atrophy followed by
blindness gradually ensues, and death inevitably occurs
within a very short time, most often before the child
reaches the age of two years. Anatomically the chief
lesion found is an extensive degeneration of the cells of
the cerebral cortex. According to Ilolden, there is a
similar degeneration of the large ganglion cells of the
retina, which, he thinks, gives thee.xplauation of the oph-
thalmoscopic lindings, since these cells are absent in the
fovea and most numerous in the mat-ula surrounding it.
Retiniil atropliy is the tinal outcome of embolism of the
central artery, thrombosis of the central vein, and of the
severe form of retinitis. It also occurs as the result of
separation of the retina and in the late stages of glauco-
ma. It is characterized particuhirly by luarked tliinning
of the vessels, which sometimes become almost invisible,
and by secondary atrophy of the disc, the latter taking
on a pale dirty gray color ami presenting an atrophic
excavation. Pigmentary changes not infrequently take
place in the retina. An aiiparently idiopathic form of
retinal atrophy is that known as eJtorioretiiiitis pigiuen-
tosa {see Vol. III., p. 69), or more commonly as retinitis
pigmeutiisii.
Sepahation op the Retina, Amotio Retin.h, — Nor-
mally the pigment epithelium of the retina is adherent to
the choroid, but not to the rest of the retina, the latter
simply being held in contact with it by the pressure of
the vitreous humor. In so-called detachments of the
retina the pigment layer is, in general, always left behind
and the condition should therefore be spoken of as a
separation, not as a detaclimeut. although the fatter is
the term almost universally used. In enucleated e_yes,
these two portions of the retina separate with the great-
est ease, pud indeed it is a dilKcult matter to obtain liis-
tologica' specimcus of the retina with the pigment layi'r
in situ. Notwithstanding tills fact, however, separation
of the retina, though not rare, seldom occurs except un-
der conditions which in themselves are of a most serious
nature. Thus the most common conditions which lead
to it are advanced myopia, severe injuries, especially if
accompanied by lo.ss of vitreous Itumor, iridocyclitis,
choroiditis, intra-ocular tumors, and hemorrhage. Idio-
pathic separation (that is. separation of the retina without
obvious cause) does occur, however, and is most common
in youth and in old age. An important tliough uncommon
cause for retinal separation is albuminuric' retinitis, espe-
cially that associated with pregnancy. (Plate L.. Fig. (i. )
The large luajority of separations are fmuid l)clow.
tliough in many cases they no doubt started elsewhere
and sank downward, the retina becoming reap|ilied at
the site of the original separation. Owing probably to
the position of the disc, separations are less fre(iuent on
the nasjil than on the temporal sitie. Localized separa-
tions at the macula are rare. The best ophtlialmoscopic
view of a retinal separation is to be obtained by the in-
direct method, though it is advisable also to make use of
the direct method, holding the instrument some distance
fiom the eye of the patient. In large separations that
have come far forward the retina can often be seen by
oblique illumination alone without the aid of an oplithal-
nioscope. The retina, if the separation is recent, projects
forward into the vitreous humor as a tremulous, translu-
cent, gray membrane, showing a greater or less number of
folds over which the lilood-vessels are .seen to take a tortu-
ous course. The latter lose their light streaks and ajipear
smaller and also much darker than normal owing to the
reflection of light from the choroid behind. Ordinarily if
the media are clear the condition is readily recognized.
but when the separation is fiat and extensive the diag-
nosis is sometimes difflcufl. If the separation continues
to increase, as is usuall.y the case, it ultimately becomes
total, the retina remaining attached at the disc and ora
serrata only, and forming a plaited funnel behind the lens.
Most often, however, it cannot be seen with the ophthal-
mo.scope at this stage owing to lenticular or vitreous
opacities. In the case of intraocular tumors, distinction
should be made between an actual separation of the ret-
ina and tlie lifting up of the latter, due to the growth of
the tumor beneath it. While the retina is attached to
the tumor it is of course not tremulous, shows no folds,
and the color of the tumor luay be recognized through it.
Even very small ttunors. however, may early cause com-
plete separation of tlie retina, and when this takes place
the separated retina ditTers in no way from that wiiieh
occurs under other conditions. The portion of the retina
first to become si'parated is usually that covering the tu-
mor, but not infrequently this portion of the retina never
becomes separated and is overgrown and destro_yed by
the tumor cells. Even when this is the case, the remain-
ing portion of the retina usually undergoes separation.
The apparent color of the seiiarated retina depends-
upon that of the subreiinal fluid; if the latter is tinged
with blood, the retina takes on a greenish color. Owing
to degenerative changes, the retina very soon becomes
opaque, but it Anally becomes translucent again when
atrophy' sets in. Quite frequently' ruptures can be de-
tected in sci.iarated retina'.
The tension of the eye as a rule is diminished and the
anterior chamber is deep, the iris frequently showing
iridodonesis. Where the separation is due to an intra-
ocular growth, the tension is almost always increased, or
at least not diminished, a fact of great diagnostic impor-
tance. Liipiefaction of the vitreous humor in association
with vitreous opacities is common, and in old cases cata-
ract and a low grade of iritis are apt to occur.
The separated retina frequentl}^ is a'deniatous and
sliows hyperplasia. Calcification, more rarely ossifica-
tion, may occur, and cholesterin crystals may form in
it. Pigmentary changes and hemorrhages are not often
seen. Rarely cysts are formed. The blood-vessels re-
main pervious for a con.siderable length of time, but
many of them finally show sclerosis and thrombosis.
The nervous elements of the retina atrophy, and the
layer of rods and cones soon undergoes maceration owing
to the lack of the nourishment normally furnished hy the
choroid.
The manner in which separation of the retina is brought
about is ajiparcjit in a large number of cases, but in an
equally large number it is a matter of dispute. Cyclitis
produces separation by the contraction of exudates that
have been poured in the vitreous chamber. Choroiditis
may proiluce it in a similar manner, or by giving rise to
exudates which collect in front of the rods and cones.
Traumatic .separations are produced in several ways.
Wlnai occurring immediately or soon after an injury or
operation they are usually due to hemorrhage or to the
loss of vitreous humor, wliich by lowering the intra-ocu-
lar tension allows serum to collect behind the retina. In
other cases the retina is rujjttued by the injuiy and the
vitreous liumor passes behind it through the rupture.
The separations that occur some time after the injury are
due to the traumatic cyclitis and choroiditis that liave been
set up. Fori'ign bodies in the vitreous chamlier may
cause separation of the retina if they produce a severe
inflammatory ri'aition ; but. on the other hand, the\' may
remain attached to the retina for j'cars without separa-
tion resulting. Finally, spontaneous subretinal hemor-
rhages from ,any cause, glaucoma for instance, may juo-
duce separation of the retina.
To explain other cases of separation a number of
theories have been advanced. In myopia it seems clear
that the elongation of the eyeball plays the chief role,
but the exact way in which it does so is not certainly
known. Iwanolf f(.uind that in myopic ej'es the vitreous
body became separated from the retina posteriorly, and
that the preretinal space thus formed was filled with se-
rum; but he failed to explain satisfactorily how this led
95&
Itelroperlloural
XiiiiiorH.
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
10 retinal separation. De \Vcel<er suggested tliattlie lat-
ter was line to s|ioiilaiieous rupture, jierniittiug the se-
rous lluiil to liiul its way behind the retina. Leber and
Nordensen maintain tha"t in the laigo majority of cases
retinal separation isdiu' to a tibrillar eoudition of the vit-
reous lioily leading to its shrinkage and lience to traetion
upon tlie "retina. The peculiar condition of the vitri'ims
bodv is said to be (le]icndeut upon a clinmie choroiditis.
Suddeidy developing separations, according to this
theory, are due to rtipturc of the retina resulting from
the traction. liaehlman. however, has called attention
to the fact that the fibrillar condition of the vitreous
body, noted by Leber and Nordensen, may be secondary
to tiie separation, and that separations may occur when
the vitreous body is perfectly fluid. He holds the view
that a process of'ditTusion plays the most important part
in the production of retinal separations. According to
his dilTusion theory, an allauninous exudate first collects
behind the retina, and then fluid passes by dillusion from
the vitreous body through the retina, gradually increas-
ing the amount of rtui<l liehind the latter, and separating
the retina more and more from the choroid. It seems al-
most self eviilent that separation of the retina having
once begun, the process of diffusion must play an impor-
tant part in carrying it on to completion.
Among the early sulijectivc symptoms of retinal .sejia-
ration are photopsia'. chmmatopsia?, and metamorphopsia,
followed by the appearance of a dark cloud which
•obscures part of the visual field and produces a positive
scotcuna. Vision at the macula is maintained so long as
the sejiaration has not involved this region, but it is ajit
to be imjiaired in any case. The separated retina may
retain light ]iercciition for a short time, and if it soon be-
<-(iines readapted, it may comjiletely resume its function.
Thus the macula may be separated at tirst and then be-
come rea]iplicd to the choroid and regain its function as
the .separation sinks lower down. But the prognosis in
retinal sejiarations is very unfavorable, though in rare
inslances a s|iontaneoirs cure has residted. Small sepa-
rations occurring after an injiuy or as the result of reti-
nitis, such as albuminuric retinitis, oft'er the best progno-
sis so far as the sejiaration itself is concerned. UsiuUly
the separation in<'rcases until it iscmniilete and there is
absolute blindness. The ju-ognosis is particularly unfa-
vorable in myopic ca.ses bccau.se there is no way in which
we may combat the myopia. Idiopathic .separation also
has a highly unfavorable lu'ognosis.
Until recently the iiuthod o( traitniriit considered most
satisfactoiy was rest in bed and the administration of
diuretics, diaphoretics, ami luirgalives, in the hope of
causing absorption of the subretiual fluid; but of late
much more l)rilliant results have been obtained by re-
peated subconjunitival injections of normal or physi-
ological saline solutions. Unfortunately, however, even
after this method of treatment recurrences are common.
Many surgical measures have lieen tried, but with indif-
lereiit success; incising the letina. withdrawing the sub-
retinal fluid by means of a syringe, and injecting iodine
with the ]nu'iiose of setting up an ailhesive inflamma-
tion, have all been recommended, but it is likely that
they will be generally replaced by the method of sub-
conjunctiva! injections.
SuBHETiN.\n CvsTicERCfs. — The cysticercus has been
found as a jiarasite within or beneath the retina, but tlie
condition is an extremely rare one, especially in this
country. At first the retinal seiiaration produced is lo-
calized over the iiarasite. and the movements of the lat-
ter can sometimes be observeil under it. The vitreous
humor soon licc<nnes cloudy and the retinal separation
becomes total, producing com|ilele blindness, and the eye
finally undergoesatro]ihic changes. Sometimes the para-
site works its way through the retina into the vitreous
htunor. Drugs given with the object of killing the para-
site have always proved imtTeitual. 'When the attempt
is made sullici'ently early, the entozoon may be success-
fully removed by o]ieration with preservation of sight.
TtTMOiis OF THE Ketin.\. (See Vol. IV., p. 112.)
Frederick Ileniuin Verhoeff.
RETROPERITONEAL TUMORS.— This subject has re-
ceived its full share ot attention during the past decade
and with satisfactory results. That it is still at the ])res-
ent time a subject of much thought and earnest research
cannot be denied. Thus far, investigations go to show-
that in the past there have been mucii confusion in the
pathology of these growths, many errors in diagnosis,
and not a very satisfactory record regarding operative
interference. Like many other problems in this great
field of surgery, an early, careful study of the case, a
judicious weighing of all symptoms, subjective and ob-
jective, an experienced touch, no haste, are doing much
to jdace on a more secure basis of classification these rare
growths. Careful workers in the pathology of these tu-
mors are doing much to clear up doubtfid points, and
establish on a more .secure basis their truenatiuv. Oper-
ating surgeons, when the tumor has obtained full size.
have not found the work of removal at all encouraging,
yet it is phnnly to be observed that when the growth has
been reached earl}-, a fair jiercentage of recoveries has
been secured.
A carefid study of retroperitoneal tumors shows that
many of them are of a mi.xed variety, containing the ele-
ments of both lipoma and myxoma, tissues which are,
histologically, very closely associated.
Bol h of these tissues are found normally in the rctroperi-
toneum, and doubtless many of these growths arise, under
suitable conditions, from congenital neoplasms. These
tumors are sometimes active in their growth, often be-
come cystic, and at times reach immense proportions.
Cases are reported of tumors of this kind w-eighing eighty
pounds. The distribution of the elements is very diverse
The fat maj- be regularly distributed throughout the
tumiu- or may occur as islands located here and theic
These grow tlis are very often a-dematous, and by chemi
cal analysis present a large percentage of mucin. The
microseoi.ie, besidesrevealing the usual elements of lipoma
and myxcnna, very often reveals a numerous round celled
infiltration in the stroma of the growth, pointing to a .sar
comalous element in their character. While not present
ing all the features of active malignancy that carc-inonia
and s;ucoma do, yet they often show a marked tendency
to recur locally when removed.
Clinical histories and pathological research both sliow
that tumors containing embryonal elements are very apt
to be malignant; indeed, it may truly be said that they
are always so.
The tumors found in the kidneys of young children
are, for the most part, mixed tumors, chiefly myosareo-
inata. Many are surely congenital, and are an example' of
a new growth developing from embryonal tissue. They
have, by (irawitz, recently been compared to a scries of
embryonal grow-ths w-hich spring from the suprarenal
cap.sules, and have the appearance of adipose tissue, but
are usually sarcomatous. (Orth, "Pathologische Diag-
nostik.")
Even though the tumor may not at first present the con-
dition of true malignancy, yet the operative surgeon has
learned to know that the semi-malignant growth is very
a|)t to return either in the cicatrix or in the neighboring
connective tissues, and to involve important structures,
such as the large secreting glands or the lymphatics.
A careful investigation" of the reported cases, together
with an examination of all accessible works on jiath-
ology, im|)re.sses one with the belief that the most fre-
quent (uigin of these growths is in the connective ti.ssue
of the capsular envelope of the kidney: the next most
frei|uent seat being the suprarenal capsules.
.^Ir. Hulke of Sliddlescx Hospital, reports a ca.se of
myxoma which enveloped the left kidney and upon
winch he operated. A median section w-as made through
the tumor when it presented itself. The incision was
continued thriuigh the posterior blade of the peritoneum,
just beyoiul the descending colon. The tumor proved to
be a myxoma, and, although the patient recovered from
the operation, the growth returned locally. The kidney
was not invi}lved by the tumor, and could have been
enucleated.
MO
REFEREKCE HANDBOOK OP THE MEDICAL SCIENXES.
Kotroix-rlloiical
XiiiiiorA.
The growths embraced in this class are peculiar in sev-
eral respects. None can be said to lie absolutely benign,
even those which are made up entirely of the histological
eleinenis of either liiionia, libroma, or niyxonia. and not-
withstanding tlie fact that they do not tend to the forma-
tion of metastases or to the infiltraiiou of immediately
surrounding tissues. It is true that they show no great
teudencj' to recurrence when comjiletely removed, yet
from the great size to which they ilevelop, and from their
tendency to uudergo degenerative changes, they cannot
be classed as innocent growths.
The late Dr. John Homans, of Boston, has called atten-
lion in two pajiers to the reported cases of |)ure lipoma,
among which were .some on which lie had liiniself oper-
ated.
Subserous lipomas rarelj- of themselves reach a large
size. However, those going out from the peritoneum
may be of sixty pounds' weight. Lipomas are usually
slow-growing, the subserous paiticularly so. Subcula-
neons lipomas sometimes grow rajiidly after remaining
stationarj' for years. Lipomas seldom change to other
varieties, but they may primarily be mixed in character
— myxolipomas.
The character of the latter group can never be deter-
mined w itli cortaint}- without careful microscopical ex-
amination, as many growths liaving the appearance of
lipomatous tissue often have the elements of myxoma and
sarcoma as well. They ma_v reach great size, but show
no dis])osition to return after removal.
Sir Spencer Wells reports, in his tirst edition of "Ab-
dominal Surgery," a case iu which the removal of such a
growth was undertaken, with fatal results.
Sarcomas, either in typical form or in combination
with myxomatous, lymphomatous, or tibroniatou? tissue,
also occur, and have beeu observed cjuite often. ^laiiy
of the tumors which liave been described as Siircoinas of
the mesentery were doubtless retroperitoneal sarcomas,
arising at the root of the mesentery and presenting them-
selves anteriorly, after ,separating its folds.
Carcinomas are very rare, and present the strongest
type of malignancy. They are of the hard, solid variety,
soon forming deep and firm attachments, and olVering lit-
tle to be hoped for from an operation.
Varieties such as fibroma and c\"sloma have been ob-
served. It may be said of the latter, for the most part,
that they either spring from the walls of the pelvis, or
from the subperitoneal connective tissue of that region.
Virehow looks upon this series of growths as being an-
alogous to those tumors which arise from the deep tissues
of the neck.
A few remarks may be made iu regard to the starting-
point and relations of all these growths. Those which
spring from the walls of the ]ielvis encroach upon or in-
volve the bladder, uterus, and rectum, very often pre-
senting features which are exceedingly perjilexing in
diagnosis. The origin of a smaller number is reported
respectively as from the retroperitoneal hmphatics, the
bodies of the vertebra; and bones of the pelvis, and the
root of the mesentery. In by far the greater proportion
of the cases no exact origin is given; indeed, from the
subsequent changes iu anatomical relations, it would
seem quite impossible to determine the exact point of
origin of many of the very large retrojieritoneal new
growths. Tlie\' have almost uniformly presenteil them-
selves in the line of tlie^east resistance, that is, anteriorly.
In my case, reported in the Aiiie)icJin.]oufn<d of the Medi-
cal Scieiires, January, 18!l'2, the tumor presented itself in
the back — a condition which can be attributed to its ori-
gin from the extreme upper border of the kidney, where
it was less coniijletely bound down by the lumliar mus-
cles and fascia. When the growths have reached a suffi-
cient size to attract the attention of the patient, they are
found presenting themselves at either side of the umbili-
cus, somewhere in the region of the lateral lines drawn
iu the arbitrary divisions of the abdomen into regions,
although they may appear centrally. As the growths
increase in size the viscera are displaced, not infrcquenlly
completely to the opposite side, although those growths
Vol. VI.— 01
which spring from the left kidney may have the descend-
ing colon externally. Owing to circulatory disturbances
within them, and to tlieir liabilily to a subsequent ma-
lignant iiililtratiou, as well as to the development of
cachectic conditions, they in-e.'ieni, clinically, features
which suggest a condition almost immediately hazardous
to life.
As with an\- large abdominal growth, there is always
a certain degree of caicroachmeiit upon the thorax and
pressure ujion other organs. In my second case, the
tumor pushed the inferior border of tlie liver up to the
fourth intercostal space, while the ca-cum and ascending
colon were displaced toward the left side of the abdo-
men.
Diagnosis. — Notwithstanding our constantly increas-
ing experience in abdominal surgery, Ave must admit that
an exact diagnosis as to the true nature of these growths
is not always possible. Nor can it be said to be abso-
lutely necessary, especially in the lesser and more mov-
able varieties.
I cannot well imagine a more severe task for a writer
than to attempt to outline the sj'mjitoms and diagnosis
of a condition which, until the present time, has baffled,
quite without exception, the skill of all who have met
with it. Yet, recognizing the importance of the factor
of exact diagnosis, especially iu abdominal surgery, I
wish to call attention to all such symptoms as may be
a.ssociated with these growths, and, after carefully
weighing them, put together what seems useful.
In the first place, there is not a single sj-niptom that is
pathognomonic, and we are dependent for diagnosis upon
the process by exclusion. Diseases and neoplasms of the
uterus and its appendages, of the liver and the gall blad-
der, of the spleen, pancreas, and kidney, are to be ex-
cluded, as well as aneurism of the aorta, tumors of the
mesentery, and of the abdominal walls.
The sex of the patient or the history of the case may
enable one to exclude the organs of generation at once,
and bimanual examination will rarely fail to locate the
uterus and its appendages and determine any pathologi-
cal changes in them. Pelvic congenital cysts from tlie
spinal cord or membranes should not be "lost sight of.
Subperitoneal fibroids are the only ones likely to tie eon-
fiiunded with this condition: but then uterine fibromas
are more easily movable within the abdomen, and their
attachment to the uterus can be made out. Solid tumors
of the ovaiy and broad ligament jire-sent greater difiicul-
ties, which at times cannot be surmounted.
Diseasesof the liver, together with newgrowthsof that
organ, have very often been mistaken for retroperitoneal
neoplasms. Hyijcrtrophic cirrhosis, jimyloid degener-
ation, hepatic abscess, hydatids, obstruction of tlfe cys-
tic duct, and distention of the gall bladder, together with
carcinoma and sarcoma, present physical signs which
may be confounded with retroperitoneal tumors. The
history of the case, together with a painstaking weighing
of general symptoms, will naturally assist in clearing a
doubtful diagnosis.
Disturbances of biliary excretion may occur from
pressure on the common duet by the tumor. Again, tu-
mors of the liver always move synchronously with the
respiration. Retroperitoneal ones do not, as a rule.
Very often a line of resonance is found betweeu liver ami
tumor, which at once shows that the grow'th is uot con-
nected with the former organ.
My own ex iierieuce teaches me that growths connected
with thes|)leen make the case at limes very embarras.sing.
It has beeu said that the differentiation from hypertro-
phy and tumors of the spleen presents less dilliculty than
does the differentiation from tumors of the liver. Here
palpation and percussion will be (juite sutficient, if em-
ployed to locate the spleen in its normal position. Tu-
mors of the omentum lack the fixed position of these
growths. The absence of digestive disturbances, with
fatty stools, will serve to exclude the rare new growths
of the pancreas.
As stated, many of these tumors have their origin in
the capsule of the kidney, or in the connective tissues
961
Reversion.
Keversiou,
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
■surrouuding: it. They present, at least in their earlier
stages, physical signs diU'ering in uo respect from tumors
of ^he nephritic pareneliyma. An c.\amination of the
urine may give au e.xact clew to tlie diagnosis. In none
of the eases reported had renal Iieinorrhage or albumi-
nuria, with or without casts, occurred : conditions whicli
are the rule witli tumors of the parenchyma of tlie l;idney.
Regarding tlie use of the aspirator, wliile I must admit
that up to lite present time it has been of no special value
in the diagnosis of my cases, yet I believe tliat in many
instances the fluid w'ithdrawn by this instrument ami
carefully examined, would enable us to make a diagnosis
as to classification of the tumor. In a recent case of sar-
coma of the kidney, by means of the medium-sized needle
I was able to draw' olf ".sufficient fluid fully to demonstrate
the nature of the growth, the diagnosis being confirmed
later by the autopsy. AU thing's considered, I believe
that tlie instrument "may of be value in the diagnosis of
retroperitoneal tumors.
Dr. W. G. ^lacdonald's suggestion to insufflate hydro-
gen gas into the rectum, is, I believe worth}- of trial,
especiallj' where a careful examination has been made
before, and the percussion areas have been outlined with
care upon the abdomen. The process of insufflation
should be carefully watched, that the relation of the in-
testinal tube to the tumor may be establi.'ihed.
Tr,E-\TMKNT. — Withotit operative interference there is
but one termination. The rapidity of the fatal termina-
tion varies somewhat with the character of the growth.
Pure lipomas are slow-growing until a certain volume is
reached, when they proceed with great rapidity to a fatal
termination. From a study of the clinical histories found
in the literature, I am of the opinion that the mean dura-
tion oi life, after the discovery of the tumor, is not more
than nine months. Operati\'e treatment offers to us much
]iromise. Recovery has followed the removal of retro-
peritoneal tumors of great weight, oven those weighing
fifty jicmnds. The immediate mortality following oper-
ations is great, f rom necessit_v ; yet from the hopelessness
of the conditions au operation is to be urged with great
earnestness upon the part of the surgeon. Incomplete
operations have been immediately more fatal than those
in which tlie tumor has been completely removed. Like
all surgical lesions, these tumors illustrate the necessity
of early diagnosis and prompt operation.
Czerny, in concluding a paper in which he had reported
three cases, says: "In all cases operative interference
can be safely undertaken ; when the tumor is no longer
encapsulated, the incision had better be closed, otherwi.se
the growth should be enucleated."
Operations for the removal of rctrojieritoneal growtlis
will, from necessity, be subjeet;'d to consiilerable modifi-
cation in detail. The choice of incision will usually fall
in the liiH^ of the linea semilunaris, on one side or the
other; Langenlieck's incision for removal of the kidney
may be made use of. Frequently, when the incision is
at first ex])loratory it must be made in the median line.
When the anatomical relations can be maile out, and the
operation continued by an extension of the cut, then the
more favorable incision is in the linea semilunaris. By
the separation of the peritemeum from the internal bor-
der of the tumor, it maybe attached by sutures to the
anteru;il border of the abdominal wound, making the
whole field of the operation extraperitoneal.
The iiici.sion of the jiosterior fold or blade of the peri-
toneum sliould be external to the attachment of the mes-
entery of the colon, although this is not absolutely nec-
essary. The removal of the growth by enuchalion must
be accomplished with great care ; particularly is it always
dcsirabh; to (letermine the source of tlieblood su]iply and
its relations to I he great vessels. The vena cava has iierii
wounded by accident in the enucleation (^f these growths.
There are likely to be large, tliiii-walled veins located
deeply in flu- wound, and requiring ligation. It will be
found at times necessary to remove the kidne\ with the
tninor. and here I he danger of hemorrliage is very great.
The supply vessels of "tlie kidney wiU frequently be
found verv short and difficult to reach.
Tlie length of time required for the performance of the
operation will vary necessarily. As long a time as two
and oue-lialf Ikhiis has been consumed in a ditiicult oper-
ation. As in all strictly abdominal work, the operator
must be jirepared for any and every possible complica-
tion.
After enucleation, as well as when the kidney has been
removed with the growth, the cavity must be thoroughly
drained, cillier by "lull-sized drainage tubes or by tampo-
nade with iodoform gauze.
The after-trealment presents uo indications for man-
agement other than those of a severe case of abdominal
.section.
As in all other conditions in surgery, there is certainly
at the present time a better understanding of these cases.
A inore correct and early diagnosis, as is the case in all
that pertains to medicine and surgery, will surely bring
a larger percentage of recoveries.
These are purely surgical cases ; no medicines, no min-
eral waters, or baths, electricity, or other lines of thera-
peutics, have as yet been of any service.
-4. Tander Vecf.
REVERSION. — Reversion is a special case of heredity,
an(l the term is usually applied somewliat loosely to in-
clude all cases in which the offspring does not resemble
the immediate parents, but exhilnts correlation with a
more remote ancestor, or group of ancestors. Recently
Pearson has sought to give greater precision to the use
of the term. He distin'guislies (1) regression, (2) rever-
sion, anil ('■'>) atavism.
If we take any pair of characters, as, for example, the
lengths of the thumbs of the riglit and left hands of the
.same person or the statures of father and son, and con-
struct a correlation table from a sufficiently large num-
ber of cases, it will be found that for any given dimen-
sion in one group (the "subject," e.;/., length of right
thumb or stature of father) the dimensions of the asso-
ciated characters in the other group (the "relative," c.y.,
length of left thumb or stature of son) will be on the
average nearer the general average of the whole popula-
tion. This is nr/ir.'airm, and is a general phenomenon of
correlation when the correlation is not perfect, as is
almost always the case (see article IlimUti/. Table I. and
Fig. 2000). But as every imlividual produced sexually
has two parents, four grandparents, eight great graiid-
jiarents. and 2h grandparents of the /itli degree, one need
go back only a few generatiims, if there has not been
much inbrf eding, to find a group of ancestors sufiieiently
numerous to give a fair sample of the population as a
whole. !^o, in cases of direct heredity, regression may he
said to be a tendency of the offspring to depart from the
peeuliarily of the parent toward the general average of
the ancestry.
/icrei-.sioi',, in the strict sense of Pearson, is a deparlure
from thepeculiarity of the parents toward the peculiarity
of some particular ancestor. From the many recorded
cases we may select for illustration two cases cited by
Darwin. A "pointer bitch produced seven puppies, four
of which were marked with blue and white, a very tin-
usual color for pointers. One of these puppies was pre-
served and it was found laterthat he was the great-great-
grandson of Sa]q)ho, a pure bred pointer bitch, which he
closely resembled. 'I'lie other case is that of a black bull
in Kincardinshire, the son of a black cow with white legs,
while belly, and part of the tail white. In 18T0 a calf
was born which was the great-great-great-grandchild of
the bull and had the same very peculiar markings as the
bull's mother, all the interme"diate ancestors of this calf
having been black like the bull himself.
Aliirhiii (Lat. (itiiriis, an ancestor) in the strict sense, is
a return to the peculiarity of the ancestral form of the
species. As this ancestral form is generally unknown,
the explanation of an unusual variation as due to atavism
is in most eases merelj- conjectural. For examide. the
dark stripesthat appear sometimes upon the back, shoul-
ders, and legs of horses have been attributed to atavism
by Darwin, Ewart, and others; the presence of these
9G2
REFERENCE HA:NDB00K OP THE MEDICAL SCIENCES.
Reversion,
Reversion.
Stripes beinj,'- regarded as ovideme of a striped ancestr.y
when considered in connection ivilh the coloring of otheV
species of the genus Equus. lil^e the zebja, quagga, etc.
Another example of atavism is the occasional appearance
of supernumeraiy mammae and teats in women and in
men. In women they have been observed to produce
milk. These are regarded as atavistic because in the
Lemuroidea, the lowest grou]! of Primates, there are, in
addition to the well-developed functional mamma; on the
pectoral region, rudimentary teats upon the abdomen and
groin. They thus approach the condition found in dogs
and pigs, wliile in the aj.ies and man there is normally
but a single pair of mamnue.
Sometimes it is dithcult to determine whether a given
unusual variation is a case of atavism or a sport. For
example, it is known that the ancestors of the horses liad
three toes, and it is probable that the ancestors of the
modern cats and dogs had five digits on all four feet, but
dissections in some cases have shown, and it is probably
true in luost cases, that when polydactylism occurs in
these animals the phenomenon is s"imila"r to polydactyl-
ism in man, which is certainly a sport and not a'tavistic.
Darwin showed that the crossing of distinct breeds of
animals may result in the appearance of atavistic charac-
ters. For example, in his experiments with pigeons he
found that when he crossed two distinct breeds, even
when the}- showed no trace of blue color or of bars on
the wings, the mongrel offspring would frequently ex-
hibit some of the blue color or traces of the wing bars of
Columha linn, the wild rock pigeon, wliich species he
regarded as the ancestral form of the domestic pigeon.
More striking results were obtained by again crossing
the mongrels, the best case was the result "of pairing a
mongrel female barb-fantail with a mongrel male barb
spot, neither of which mongrels had the least blue about
them. The offspring exhibited the general blue color
and every characteristic mark of the w'ild rock pigeon.
When individuals of separate races or species are
crossed, the mongrel or hybrid offspring of the first gen-
eration may be more or "less intermediate in character
between the two parents, or they may resemble one par
ent only iu some resjjccts. But in subsequent generations
there is greater diversity among the offspring, and rever-
sion to one or the other parental type is common. Tlie
facts were noted by Darwin, but the fii'st one to study
them by statistical methods was Gregor JMendel, abbot of
Brlinn in Austria. Mendel's work ■\\';is published in 1866
and 1870, but it remained practically unnoticed imtil
1900, when De Vries. hajipening to tind a reference to it,
looked it up and was surprised to discover that JFendel
had anticipated results which De Vries himself was th<'U
about to publish. Mendel worked with varieties of gar-
den peas and studied one character at a time, first te.sting
the varieties to make sure that they would breed true.
He found that when the parents possessed certain con-
trasted characters one character of each pair woidd fail
to appear iu the first generation of offspring, but would
reappear in subsequent generations. He catled the char-
acter that appears exclu.sively iu the first generation
dominant, while the one that reappears only in later gen-
erations he termed recessii-e. In peas he fiumd thatthe
rounded form of the seed is dominant and the wrinkled
form recessive, the yellow color of the cotyledons of the
ripe seed is dominant, the green color recessive, and the
same is true of a ntimlier of alternative characteristics.
Now the point of Mendel's work is that he found the
dominant and recessive characters to reappear in suc-
ceeding generations according to a definite and simple
numerical law.
If a certain dominant character be represented by ,1
and the corresponding recessive b}- «, then all the "off-
spring of the first generation will have apparently only
the charactered. But if the flowers of this generation
are fertilized with their own pollen, the next generation
will contain \a to 3.1. The.se plants being again .sclf-
fertiiized. all of the recessives, «, are found 'to breed true
and to continue to do so during succeeding generations.
One-third of the doinhiants also breed true in the same
way, but the other two-thirds give rise to both forms, as
the hybrids did, in the same proportion of one to three.
These relations may be represented by the following
diagram :
ParenTs
A a
-
A
Second generation . .
. A
1
2A
la
Third geaeralion...
] A
1
A
1
A
2A
la
a
a
a
Fourtli generation..
Flftli generation
1 A
1
A
2 A
la
1
a
a
1
a
If we represent pure dominants bv .1 and dominants
capable of producing both kinds of offspring by Aa, and
suppose each plant to produce only four seed"s, the fol-
lowing ratios will be obtained:
Second generation .
Tbint [jeneration...
Foiirtli generaiiou..
Fifth generation
.^ixtti generation .
A
: A a :
a
1
: 2 :
1
■A
2
a
7
: 2 ;
7
l.i
: 2 :
l.i
SI
2
31
1 -t- 7ith genoratiou 3'i — 1
If we consider two or more cliaracters at a time, the
results become correspondingly complicated, for charac-
ters that are not mutually exclusive may appear in the
offspring in any pos.sible combination. Thus the seed
may be dominant in shajie and recessive iu color, or Hce
rersa, or it may be dominant in both or recessive iu both.
Mendel offered as an exjilanation of these relations the
supposition that in cases of this kind the alternative cliar-
acters are not combined in the germ cells, but each car-
ries the pure heritage of one parent only with respect to
any one character, e.g., the shape of the seed. That this
view_ harmonizes with recent studies of the maturation
divisions was pointed out in a previous article (see Reduc-
tion Dirision). If the chromosomes trausiuit the bases of
separate groups of characters, as is indicated by Boveri's
recent work, we may represent a pair of homologous
chromosomes iu the hybrid by the symbol Aa. In the
maturation of the germ" cells with a re'ducing division the
chromosomes would be separated into four cells thus:
A-\-A-\-a + a;
and when fertilization takes place by union with an equal
number of germ cells of opposite sex containing Jl' -|- .1' -|-
a' -\-fi' , the following combinations are possible:
AA' -\-Aa' -\-aA' + a(t', the most probable proportion
being 1 ,4.4 : 2 Aa : Ion.
This would give one recessive to three dominants, btit
only one dominant out of three would breed true, for the
other two would contain recessive chromosomes in their
germ plasm.
^ The difliculty with Mendel's theory is that the statis-
tical results obtained by other observers do not always
show the exact proportions required, and that the domi-
nant and recessive characters are variable and therefore
sometimes difficult to distinguish. .\nd also for this rea-
son it is not easy to determine whether a race is breeding
true or not. The theory has been criticised on these
grounds by Pearson and'Weldon: while it is defended,
and its results are confirmed, by De Vries, Correns, Bate-'
son. Castle, and others. Jiobcrt Payne Birjeloio.
BIBLIOGRAPHICAI. EEKF.EE.NCES.
Bateson. W. : Mendel's Principles of Heredity, with a Translation of
Mendel's Original Papers on Hybridization, Camhridce, iwe.
Bateson. W. and Saunders, Miss E. R. : Report ol the Evolution Com-
mittee of the Royal Society. London, 19112.
Boyeri, T. : Teber mehrpoiige Mitosen als Mittel zur Analyse des
Zellkerns. Ver. phys.-nied. Ges. Wiirzburg, N. F., vol. .x.\xy., 19ii2,
pp. fi7-90.
Castle, W. E. : Mendel's Law of Heredity. Proc. Amer. Acad. Arts
and Sci., vol. xxxviii., 1903, pp. .537-.")4,S.
Darwin, c. : The Variations of Animals and Plants under Domestica-
tion, second edition, 1875.
Enart, .1. f. : The Penycuik Experiments. London. 1899.
Pearson. K. : The Law of Ancestral Heredity. Biometrika, vol. ii.,
1903, pp. •Z\\-£>&.
963
Hlialaii]-,
RiKMiiiialiKin,
REFERENCE HANDBOOK OF THE IVIEDICAL SCIENCES.
Vries. H. (le: Die Miitatioustheorie, vol. ii., I.eipsio, UHVi-Ci:!.
Weldon, W. F. Ii. : Mendel's Law of Alternative Inlieriiuiice in Peas.
Biometrika, vol. 1., 1803, pp. 228-254.— On the Amljiguil.v of Meuuiel's
(.'ateirones. Biometrika. vol. ii., 1IK)3, pp. ii-i'yK
Wiedei-slieim, R. : Tbe Structure of Man, an Inde.K of bis Past Ilis-
ti)rv. London, 1S9.5.
Wilson. E. B. : Mendel's Principles of Hereditv and the Maturation of
the Germ Cells. Science, N. S., vol. xvi., 1!K)2, pp. SWl-'JUo.
RHATANY. — {Knaiiciin, U. S. P.; Kmmcriiv Radix.
B. P.; ;,',(-//./• I{h,i1<i„i,r, P. G.) The dried roots of sev-
eral speeies of Kriuneriu, especially of K. triiiiuh'n H. et
P., A'. Ixina L., aud A', aiycntea St. Hil. (fam. Knimeri-
acea').
The last mentioned is not now official In the Vnifed
States Pliarniaeoiiteia, but will doiibtless be so in the
forthcoming edition. The Kramerias are low or semi-
prostrate shrubs of tropi-
cal or warm temperate
parts of America. They
have very long, thiciv
roots, noted for the
thickness of their bark.
Since tiic active constit-
uent exists mostly in
the corte.\, the tliieker-
barked varieties are the
better. Thi^ lirst-named
grows in the liiglnT An-
des and yields Peruvian
Krameria, tlie poorest
variety. The second
comes fi-om the Santa
JIarta riglon of Colom-
bia, aud is aI)ont iuter-
nieiliate in quality be-
tween file first and the
thiid, wliich latter comes
fidin Northern Bi'azil.
This is iistially sokl as
Savanilla, the geimiiie
Savauilla now reaeliing
tlie market only ocea-
sionallv- A. htiifiiihita
Torr., of tlio Soutli west-
ern Uiiiled States and
Noithern Jlexico, yields
a good Krameria, Init it
is scarcely a commercial
article.
Descrtptio.n, — /Vrw-
Tian Kraiiicriii. — Koot
brandies usually occur-
ring with several or
many attached to a
short, hard, and woody
tap root, which is l..')-4
cm. (i-li in.) thick,
rouglily fissured aud
supports a knotty, sev-
eral- to many-headeii
crown ; of inditiiiite
length, rarely exceed-
ing 50 cm. (SO in.) and
usually less than 1 cm.
(| in.) thick, cylindrical,
flex nous or wavy, very
flexilile: externaliy light
red-brown, more or less marked witli dark, scaly jiatclies.
especially u|nvan:l, otherwise smoothish. devoid of trans-
verse fissures; fracture tough aud s|ilintery, the pinkish-
brown bark oeeu|)yiiig less than one-third of the r.adius,
the wo(.d yellowish or pinki.sh-Avhite, tinely railiate;
inodorous aud of a very astringent taste.
Briizilidii Krameria. — Branches usually occurring de-
tached from the ta]) root and crown, less flexuoiis than
those last descrilieil, externally of a dei']) purple-browu
or elun'olafe-ln'own aud with numerous transverse cracks
or fissures; frai'turo less tough than that of Ihelast, the
bark and wood both ihirker, the former (jccuiiying two-
FiG. 4110. — Kraineiia
transverse seetitju of ni
Ion.)
fifths, or even more, of the radius, the taste more astrin-
gent than that of the last.
The most important constituent is from eight to twenty
per cent, of kramiriU'tannic acid or rhita iiia-ta niric acid,
a brilliant deep red amorphous mass, soluble in alcohol
aud, if pure, in water also. It is usuall}' only partly
water-soluble, owing to the cliange of a portion of it
to plilolKiphene b}' dehydi-ation. Krameria-tanuie acid
gives a dull green color with diluted acids, and is flesh-
colored with gelatin. It is decomposed by dilute mineral
acids into sugar aud rhatauia red.
Pul)lished statements as to the relative percentages of
tannin in the different varieties are not reliable, since it
is the very commonest occurrence for the varieties to be
confused in commerce and iu experiments.
Rhatany is a relialile and useful astringent, owing to its
tannin, and is aiiiilieable to all conditions in which gallic
or tannic acid is useful. The crude drug may be given
in powder, iu doses of 1-3 gm. (gr. xv.-xxx.), though a
liipiid ju'epai'ation is preferable. The pharraacopa'ia pro-
vides au extract, the dose of which is two to four grains,
a fluid extract, dose fifteen to thirty minims, and a
twenty-per-cent. tincture, the dose of which is from one
to two flnidrachms. Henry II. liaslii/.
RHEUMATIN is tlie salicylate of saloquinine, and rep-
resents ;i large percentage of the salicylic radical in
coml)ination with quinine. It occurs in tasteless white
acicular crystals, "which are but sparingly soluble iu
water. Overlaeh finds its action jtracticali}' specific iu
acute rlieum;itism, without any digestive flisturbances,
aud distinct from that of a mixttire of quinine and sali-
cylic acid. Pieper found it valuable in trigemiual neu-
ralgia as well as in rheumatism. The dose is 1 gm. (gr.
XV.) three or four times a day. 11'. A. Basfedn.
RHEUMATISM, ACUTE ARTICULAR.— Definition.
— \i\ infectious disiasr. caused by a germ or germs not
yet identified, and characterized by (1) a general consti-
tutional reaction ; (2) an irregular febrile movement ; and
(?.) non-sn]iiinrative iuflammaliou of the connective-tis-
sue structures of the joints, the muscles, and the heart.
IIisTouY. — In former times articular rheumatism was
confounded Avith gout. Sydenham, in the closing years
of the eighteenth century, first made plain the diil'erence
between the two diseases.
Nature. — Rheumatism is now regarded almost uni-
versally as an infectious disease caused by germs from
without. Two other tlieories were formerly held: first,
that it is due to the presence of an excess of lactic acid
in the blood; second, that it is of neurotrophic origin.
Tliese views are no longer held by the best men. AVith
regard to the first, it need only be said that it offers no
reasonable suggestion as to the cause of the excess of lac-
tic acid. An excess of lactic acid is almost alwaj'S pres-
ent, but it is no more logical to say that the lactic acid
causes the joint troubles than that the joint troubles
cause the laelie acid, or that the fever causes both.
The seeoud, or neurotrophic, theory is o]ien to objec-
tion on the ground that it offers no cause for the neuro-
trophic disturbances. Furthermore, if so serious and
acute a disease as rheumatism be neurotrophic in its ori-
gin, we ouglit to find in every case serious disturbance of
th(! central nervous system, while as a matter of fact such
disturbance is very uucoiumou. Again, all other diseases
of proven neurotrophic origin are of slow progress and
conspicuously slow recovery, which rheumatism, under
proiier trealment, is not. The neurotroi>hic theory is
really i'oiiiHled upon a confusion between articular rheu-
matism and rheumatoid arthritis. The latter di-sease is
now regariled as neurotrophic, but its morbid anatomy
and clinical piicf ure are so ditTcrent from those of rheuma-
tism that the two diseases may be said to have nothing in
common excei't the fact that "they both aff'ect the joints.
In favor of the germ theory of rheumatism we may
urge the following ar;:uments: (11 All other aeiife diseases
with fever and constitutional reaction are now believed
to be infectious. Jlost of them have been proven so.
9(M
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Rliatiiii) .
Klioiiiiialisiii,
(2) All other acute inflammations of joints— e.ff., pyajmic,
gonorrhoeal, tuberculous, and syphilitic arthritis— are
known to be infectious. (3) Acute rheumatism has .sev-
eral times been found to occur in epidemics. (4) There
are two cases on record in which parturient women, suf-
fering' from rheumatism, have liorne children wlio shortly
after liinh developed fever and polyarlhiitis.
Tlie bacteriology of rheumatism is still in doubt. In
1891 Achalme, of Paris, claimed to have identified the
germ. He isolated from the blood and pericardial fiuiil
of, in all, eight rheumatic patients, a bacillus which he
regarded as characteristic. It was fouud, however, that
cultures of this bacillus, injected into animals, produced
not the ordinary lesions of articular rheumatism, but local
congestion, destruction of tissue, and gas bubbles. West-
lilial, Wasserman, and MalUolf, iu IMIIil, found in a fatal
case of post-rheumatic chorea a veiy few diplococci
which produced in animals fever and non-suppurative
polyarthritis. Poynton and Paine, of London, in 1900
found a diplococcus which may prove to be this same
germ. They isolated it from eight cases of severe acute
rheumatism, finding it in the blood, tlie pericardial fluid,
the vegetations from diseased heart valves, the tonsils,
and the urine. They also demonstrated its presence iu
the joint c-xudations of inoculated rabbits. These rab-
bits showed multiple, non-svippurative arthritis, valvular
endocarditis, pericarditis, and moderate pyrexia. Passed
along from one animal to another, tiie germ showed great
constancy in its effects. These results are very striking,
but up to the time of writing no confirmatory reports
have been published.
A view which has gained some support during the
past year is that rheumatism is due to the jiresencc in
the bodv, not of bacteria, but of toxins. F. W. Pack-
ard, of Philadelphia, has declared in favor of this view,
and has also stated that in a large number of cases the
intoxication results from an infected tonsil. It is certain
tliat tonsillitis is of very common occurrence at the be-
ginning of an attack of rheumatism, and it may be im-
agined" that the lymphoid tissue of the tonsil, by its
power of filtration (.Maufrcdi) allcnvs the toxins to pass
through and st(i|is tlie bacteria. The eniigraliou of the
inrtanunation from joint to joint, so often seen during an
attack of rheumatism, seems to suggest a local intoxica-
tion rather than infection, and so also does the rapid and
complete recovery under proper treatment. And sali-
cylic acid, while a very weak germicide, is known to
have a powerful chemical action upon toxins, cji., diph-
theria antitoxin. There is need for further investigation
along this line.
E-iioLociY. — Rheumatism is seen everywhere.^ It is
most common in temperate climates. In New York it
occurs most frequently during the early months of the
year. A series of .51-1 consecutive cases from the records
of the New York Hospital gave the following residts:
Season of year: July 1st to January 1st, 140 cases;
January 1st to July 1st, 374 cases.
Sex; Of all ages, 337 males, 177 females.
Of cases under 20, 43 males, 44 females.
Age: Under 10 years, 6 cases, or 1.17 per cent. ; 10-20
years, 81 cases, or 1.5.8 per cent. ; 20-30 years, 200 cases,
or 38.9 per cent.; 30-40 years, 130 cases, or 25.3 per
cent. ; 40-.50 years, 66 cases, or 12.8 jier cent. ; 50-60
years, 23 cases, or 4.47 per cent. ; over 60 years, 8 cases,
or 1.55 per cent.
These figures are iu general agreement with those for
the iMontreal General Hospital, quoted by Osier. It will
be seen that rheumatism is pre-eminently a disease of
early adult life, nearly sixty-five per cent, of the cases
occurring during the period of greatest bodily and men-
tal strain, or between the ages of twenty and forty. The
difference in susceptibility between men and women is
hardly explainable exeeptupim the ground of dilTcrence
in ocruiiation and women's freedom from the alcoliolic
anil lobacj-o habits.
Alany observers claim a distinct hereditary jiredisiiosi-
tion (Osier. Church and Cheadli', Lyman). But, as many
ditlereut conditions have iu the past been grouped to-
gether under the common name of rheumatism, the im-
portance of an hercditiiry [jrcdispusitiou may have been
exaggerated.
Exposure to cold, esjiecially (hitiip cold (Lyman), is the
exciting cause in a certain number of cases. Men who
lead outdoor lives, exposed to all kinds of weather, and
who arc — as this class oftiMi is— somewhat alcoholic, are
very liable. Second and thiid attacks are common. Of
the 514 cases qmited above, 64 had had one previous at-
tack, and 43 more than one; so that one attack of rheu-
matism confers no iumumity as regards subsequent
attacks.
MoiiBiD An.vtomy. — Typical rheumatism always at-
tacks more than one joint. A case of monarthritis with-
out history of previous attacks should be viewed with
doubt. The inrtanunation is exudative in type, with
congestion and a fibrino-serous exudate, containing a
few leucocytes, in all the tissues of the joint proper, and
also in the cellular tissue and tendon sheaths around the
joint. There are rarely, if ever, iu an uncomplicated case
enough leucocytes to make the exudate purulent. The
synovial flind, with which the joint cavity is distended,
is sometimes of acid reaction and may be blood-stained.
The cartilage cells in tlie joint cartilages proliferate, and
the intercellular substance splits up, assuming a velvety
appearance. All these changes are susceptible of rapid •
repair.
The blood shows increase of fibrin, fats, cholesterin.
and extractive matter. The serum remains alkaline.
L'rea and uric acid are not increased. Red blood cells
are much diminished. No di.sease produces pronounced
anamiia qineker than acute rheumatism.
The urine is acid, high-colored, and of high specific
gravity. It deposits, upon standing, a sediment of
amor|:ihous urates and sometimes luie-acid crystals.
There is an excessive excretion of sweat. This is of
neutral reaction, but quickly becomes acid if the pa-
tient's skin be not kept .scrupulously clean.
Ci.iNic.M. HisTouv. — In the majority of cases the first
svmptom noticed is lameness of one or more joints. This
may be preceded, during a few days, liy the symptoms
of an ordinary coryza or acute pharyngitis or tonsillitis.
The slight lameness and soreness are usually overlooked,
and the patient continues to follow his ordinary occu-
pations. After a few days more the symptoms grow
worse, swelling and redness appear in the atlected joints,
the pain increases until the least motion causes agony,
there is a febrile movement, with or without distinct
chills, anorexia, consti|iation, and profuse sweating, and
we have the full clinical picture developed. In a few
cases the disease is u.shered in by a rigor, with an imme-
diate development of all the symptoms; or the case may
begin in a mild way, and later develop suddenly the
graver and more acute type.
Wlieu the disea.se is once established, it shows very
little tendencv to spontaneous termination. Under the
older systems of treatment it would run for many weeks.
The iutlammation may move entirely in a few hours fidut
one part of the body to another — from knee to wrist,
from wrist to ankle, or from one leg or arm to the other.
Of tlie location of the disease it is a noteworthy fact
that it shows a marked tendency to attack the same joint
on both sides of the body. In tlie above-quoted series
both knees were involved iu 213 cases, the left knee alone
in 79, the right knee alone iu 59. All the joints of the
body showed at least a ]ilurality of cases of symmetrical
involvement. The knee is the most frequent seat of in-
flammation. 351 cases showing affection of one or both.
The ,ankle came second in my series with 256 cases; next
the wrist, 125 cases; shoulder, 116; foot, 109; hanii, 97;
elbow, 78; hip. 44; an<l lastly the sternoclavicular joint,
1 case. The fever is irregular, rarely very higli except
iu cases of liyperjiyrexia, and yi<4ds more readily to the
salicylates than do the joint trouliles.
Cii-MPniCATiONS. — Of these the most important are
those which atfect the heart. Indeed, were it not for the
cardiac complications, an attack of rheumatism would be
little more than a disagreeable incident in a man's life.
965
Rlieiiinatism,
Kliouiualisin.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Endociirdilis ordiuarily adds but little to the severity or
immediate diingur of theattack, but it leaves permanently
damaged valves wliicli, except in a very few cases, never
regain their perfect function. As to the frequency of
this complication authorities differ. Of the 514 cases
quoted above, 152, or 29.57 per cent., showed murmurs
distinctly valvidar. Of these 104, or more than two-
thirds, gave the signs of mitral insiiOiciencj'. Only two
showed a pure mitral stenosis, while 24 showed a double
mitral lesion. In 23 cases there were murmurs at the
base of the heart, of whicli 8 were systolic, 6 diastolic,
and 8 double.
Rheumatic endocarditis is usually an inflammation of
the connective-li.ssue portion of the endocardium of the
valves. The endothelial covering, according to ^lacLa-
gan, is affected only secondarily as a result of friction
caused by changes in the shape of the valve. By this
means the eudotlu^liinu is rubbed off, leaving a rough
spot upon which the fibrinogcnic elements of the blood
coagulate, forming so-called "vegetations." Poynton
and Paine rejiort diplococei in the base of the valve, but
not near the surface. Jlalignant ulcerative endocarditis
is very rare in rheumatism. Where it occurs, it is prob-
ably alwaj'S duo to secondary infection.
Rheumatic endocaiditis usually gives no symptoms.
It is generally discovered by the attending physician,
■who must always be on the lookout for it. In bad cases
there may be indefinite pain referred to the pra?cordium,
or slight "ilyspncea and palpitation. There maybe em-
bolic attacks, due to detachment of a vegetation.
Pericarditis, either diy or with effusion, often occurs.
It shows the ordinary morbid anatonn" of an exudative
Inflammation of a serous membrane. The symptoms
vary according to the character of the exudate. In dry
pericarditis there is .irreat pain in the pra'cordium, with a
violent and irregular pulse. The characteristic ".see-
saw " murmur may be present, or there may be only a
systolic murmur, or a faint clicking sound, or even no
rnurmur at all. With elfusion we get muffling of the
heart sounds, upward disjilacement or total disa]>pear-
ance of the apex beat, incre.-ise of the pra'cordialdulness,
and the patient complains of great weakness and urgent
dyspnaa on the slightest movement. General!}', but not
aiways, there is increase in the fever, and there maj' be a
distinct chill at the invasion of the pericarditis.
Myocarditis is rare in rheumatism. It is seen in mid-
dle-aged or older patients, whose aorta' and coronary ar-
teries are not of the l)est. Fatal ca.ses which come to au-
topsy show a slight degree of granular degeneration of
the heart muscle, due to the systemic poi.souing.
Bc.ijiiratiirii Tnu'l. — As stated above, corj-za, pharyn-
gitis, and tonsillitis are often seen early in the disease.
Laryuuitis and bronchitis occasionally occur. Pleuri.sy
and pneumonia are sometimes found, usually in the cases
with heart complications. Among the live hundred and
fourteen cases mentioned there were lif teen pleurisies and
live pneumonias. The pleurisy is generally accompanied
by serous effusion. The pueniuonia is patchy, and lobu-
lar in type. According to Osier, severe and fatal pul-
monary congestion is sometimes seen.
jyerniiis Sysfnii. — The peripheral nerves are sometimes
affected by rhenmatism. The sciatic nerve is the most
common seat of troul)le, but occasionally a pait or the
whole of the brachial plexus is involved. These com jili-
cations are sometimes slow to yield to treatment. ,AIore
severe are the (Yy(7;yv(/ com plications. Rheumatic menin-
gitis is certainly verj' rare, and probably in some cases
salicylic-acid jxiisoning has lieen mistaken for it. The
cerebral symiUoms most eonunonly seen are delirium,
stupor, and occasionally convulsions. These symptoms,
in connection with excessively high temperature, con-
stitute the condition known as /i!/pcf]iyrexia, which is
always grave and often fatal. The liigh temperature
(sometimes reaching 1 10 F.) seems to be due to paralysis
of the heal control centre in the medulla.
Chorea is sometimes, especially in children, seen in asso-
ciation with rheumatism, but moi-e fre<iuently combined
with endocarditis than with polyarthritis. It is apt to
occur late in the disease. The nature of the connection
between the two diseases (rheumatism and chorea) is not
known.
Ei/c. — Rheumatic iritis is certainly a genuine disease.
It presents the ordinary appearance and symptoms of
iritis, and yields to salicylates. It is usually mild.
Iridocyclitis with destruction of the eyeball belongs rather
to gonorrhcea than to rheumatism.
Skill.- — Sndamiua are conunon. as might be expected
from the profuse perspiration. Erythema nodosum has
been reported bj' Osier. Scarlatiniform erythema is seen
from time to time. Purpuric spots occurred in three
cases in my series.
Subctitiiiieoiis Tisstii'S, Faxcia, etc. — Occasionally, in
severe cases, small lumps are noticed imder the skin in
the neighborhood of affected joints. These are called
"rheumatic nodules." They consist of librous tissue
with a number of small round cells. Poynton and Paine
report having found diplococei in some of them.
Coi:i!SE .\.ND Prognosis. — As to whether or not rheu-
matism is a self-limited disease authorities differ. It is
certain, however, that the disease without treatment runs
a tedious and uncertain course, and is liable to relapse,
and to develop a low form of chronic arthritis, the so-
called chronic rheumatism. The prognosis is almost al-
ways ,good as to life. Only two deaths occurred in the
live hundred and fourteen cases cited. This is a low-
ratio, less than 0,4 ])er cent. Piobably the usual mortal-
ity is betweifu 0.5 and 1 percent. It would .seem from
the literature (and Lyman indorses thi.s) that the disea.so
runs a milder course in America than in England. The
fatal cases are those with severe acute heart and lung
complications, or hyperpyrexia. As regards complete
reco\'ery the pi'ognosis must always be guarded on ac-
count of the heart complications. Most of these leave
permanent damage, to give trouble perhaps many years
later. Life insurance mm say that second and liiird at-
tacks are less likely to all'ect the heart than fiist attack.s,
[jerhajis because the second and third attacks come later
in life. It is certain that the most serious rheumatic car-
diac lesions are seen in young persons. The mitral valve,
when not too (;xlensively damaged, is able sometimes to
a<lai)t itself to new conditions, and regain perfect com-
petency.
Di.\uNOsis. — Articular rheumatism may be confounded
with gouty, gonorrlucal, or septic arthritis, with tuber-
culosis and syphilis, with acute septic epiphysitis, and
with arthritis deformans. Gout occurs late in life, in its
acute form is monarticular, and the history of inherited
tendency, of faulty hygiene, and possibh^ of previous
attacks, helps to distinguish it. Gi'iiorrliaal aiihnti.t is
also fre(|U(nlly monarticular, the jomt has less of the
appearance of an acute intiammation, is less painful, and
an urethral discharge ma_y be discovered on careful ex-
amination. Tiihere'ibms is also monarticular, and of
subacute or chronic type. At the beginning of the sec-
ond stage oi -v/p/i ill's tlwK are sometimes joint pains with
the slight febrile movement which precedes the roseola.
Here the liistory usually serves, and the appearance of
the rash dispels doubt. Septic arthritis and acute epi-
physitis are always due to some septic focus elsewhere in
the body, the course of the temperature is pya-mic. and
the symptoms do not respond to salicylates. Some forms
of rhe\uuatoid arthritis are occasionally mistaken for
rheumatism, but careful examination will almost always
reveal tin- characteristic deformitj- of the att'ected joints,
Ulieumatism may, however, occur in a ]iatieut who is
already the victim of rheumatoid arthritis. Here the
diagnosis may be dilliculr, and one may have to rely
U]>on the prngress of the inflammation fi'om joint to
joint, or upon the test of treatment. It may be repeated
here tliat without the history of previous attacks, a cer-
tain diagnosis of rlieinnatism is impossible unless more
than one joint is involved.
Ti;i;.vrMi:NT,— The patient must be put to bed and
kept there. His paj.-imas or night gown should be of
flannel, and hi' should lie between blankets whenever
possible. Tlie bowels must be opened freely at the out-
9G0
REFEKENCE HANDBOOK OP THE MEDICAL SCIENCES.
RlioiiiiiallKiii.
Rlieuiiiatlsiii,
set. The best purgative is one grain of calomel, given
in quurter-gniin doses every fifteen minutes, and fol-
lowed, four hours later, by a Seidlilz powder, or a fidl
dose of citrate of magnesia, or half an ounce of Kochelle
salts. No more bed clothes slioidd be allowed than just
enough to give reasonable warmtli. If their weight
cause pain or discomfort, they must be supported ujion
some kind of a framework. The patient must l)e sponged
olT with warm water, often enough to keep his skin per-
fectly clean. The copious sweat rajjidly undergoes acid
fermentation, and if not removed causes itching and .sore-
ness. The diet shoidd consist mainly of milk. This may
be varied, from time to time, with small quantities of
Ijeef tea aud clam broth. Plenty of water should be al-
lowed, or vichy, or soda water, or lemonade. These
drinks help to keep the urine bland, and ease the strain
upon the kidneys. The drug of drugs to be used is sali-
cylic acid in one of its forms. It may be given as the
salicylate of soda, or as oil of wintergreen, or as saliein.
Salicylate of .soda is the cheapest, and most patients bear
it well, but it sometimes upsets the stomach. Oil of
wintergreen is said to bo quicker in its actiou, but it has
no ad\antago so far as the stomach is concerneil, for
patients quickly tire of its penetrating odor and taste.
Saliein is less active than the other two, but delicate
stomachs bear it better. Whichever of these drugs is
chosen must be pushed to the limit of toleration. Tliis,
aud only this, should be the limit of do.sage. Salicylate
of soda is usually given in watery solution, the other two
usually in capsules. It is best to begin by giving t wcnty
grains every two hours, and to continue this until d(af-
ness and tinnitus aurium begin to develop, "when the dose
.should be lessened, or the intervals lengthened, or both.
It is good practice to give ten or twenty grains of bro-
mide of sodium when tlie tinnitus begins. Elderlj- jieo-
ple, whose arteries and kidneys are worn, do not bear
salicylates well. Stich patients must be carefully
watched, and the dose regulated to suit them. Symp-
toms of poisoning sometimes develop quite rapidlj*.
The writer has seen maniacal delirium, lasting two days,
as the result of two and one-half drachms of oil of
wintergreen, given in the course of twentv-four hours.
Should poisoning occur the salicylates must be discon-
tinued, bromides and chloral must he given, the heart
being carefully watched, and in most cases no permanent
harm results. As the pains suljside, and the temperature
comes down, the dose of salicylate may be reduced, but
the medicine must be continued for several da_vs after all
pain has disapjieared, otherwise the synqitoms may re-
turn. Some authorities claim that relapses are raoie fre-
quent under the salicylates than under tlie older systems
of treatment. This does not seem to be the case, pro-
vided the medicine be continued long enough. The sa-
licylates have no effect ujion a cardiac lesion, once estab-
lished, but by their actiou in .shortening the disease and
lessening its virulence and severity, they certainly pro-
tect the heart to some extent.
How the .salicylates act is a question difficult to answer.
They are not strongly antipyretic and analgesic, like
acetanilid and phenacetiu, and, according to Jliqiul,
the}' are rather feebly antiseptic, salicylic acid being
effective in preventing bacterial growth in a strength of
1 to 1.000, while salic.ylate of soda requires a strength of
1 to 100. Salicylate of soda has been found u.seful in re-
lieving unpleasant symptoms due todi|ihtlieria antitoxin,
and if we suppose rheumatism to be due to intoxication
rather than to infection, this may bo the answer to the
question. The efficacy of the salicylates is beyond ques-
tion, but the reason tor this, efficacy needs further inves-
tigation.
There are some unfortunate patients who, on account
of idiosyncrasy, cannot take salicylates at all. For these
we must rely upou the old-fashioned alkaline treatment.
Twenty grains each of citrate and bicarbonate of soda
may be given every two or three hours. The results of
this treatment are not brilliant.
Local treatment of the alTccted jointsis advisable, with
the idea rather of increasing the patient's comfort than
of affecting the course of the disease. The joints must
be kept at rest in the least uncomfortable position attain-
able. They .should be protected by bandages of llannel,
or lightly packed in cotton batting or wool. They may
be dressed with a ten-per-cent. ointment of .salicylic acid,
or with pure oil of wititergrecu, or with guaiaeol, dis-
solved in olive oil, (U' incor])orated with lanolin or lard.
The joints must not be handled at all. The writer has
seen most exquisite agony in a case tmderhis care, caused
by an ill-advised friend of tlie patient, wdio insisted upou
gently stroking her inflamed wrist. The manipulation
gave momentary comfort, but within an hour the wrist
swelled almost to twice its normal size, and throbbed
until it was necessaiy to use iced cloths to relieve the
pain. Ice lias betu commended as an application in
rheumatism, also heat in various forms. In some cases
hot or cold applications are of use, the choice Ij'ing with
the one which gives the greater comfort, but iu most
cases protection and ointments will give all the comfort
attainable. Occasionally after an obstinate ca.se of rheu-
matism, one or more joints exhibit a low grade of chronic
.synovitis. These are best treated by blistering, followed
by a tight bandage.
Of the complications of the disease, endocarditis calls
for little or no direct treatment. The patient must be
kept absolutely quiet, with the head low. If the heart
be overacting, ice may be applied. Very rarely, if ever,
does i-heumatic endocarditis cause urgent cardiac weak-
ness. Should this appear, the salicj'lales must be
stopped, and a little strj'chnine may be w.vy cautiously
administered. No more than necessary should be .given,
for every extra heart beat may cause the endocarditis to
spread. Pericarditis, on the other hand, calls for active
treatment. An ice bag, or a cold coil, should be applied
over the heart, aconite, in one-drop do.ses of the tincture,
may be given under careful observation, and morphine
or codeine niaj' be needed to relieve the pain. If effusion
appear, lilisters and diuretics are required, anil if these
fail to cause absorjition the pericardium may require tap-
ping. Of the nerviuis complications, the neuralgic pains
are best treated with local applications of pure oil of
wintergr(>en, or of menthol, twenty-five per cent, in alco-
hol. Hyperpyrexia must be treated bj' cold baths. No
other antipyretics are of the least use. Alcohol aud
strychnine are also needed. The treatment of this con-
dition is ([uite similar to that of sunstroke, to which it is
|irobably akin. The neurasthenic and melancholic eou-
ilitions seen sometimes during convalescence require ap-
])ropriale care, but these conditions have no peculiar feat-
ures depending upon the rheumatism that caused them.
The skin complications require no treatment. The
treatment of the respu'atory complications is on general
principles.
The after-treatment requires tonics, general hygienic
regulation of the daih- life, and avoidance of over-exer-
tion. It is well to have the throat carefully examined
and. if necessary, treated, for there is ample warrant for
believing that future attacks may occur as the result of
infection of a diseased tonsil. Donald M. Biirstoic.
RHEUMATISM, CHRONIC ARTICULAR.— Defini-
tion.— A chronic allectioii, characterized by still and
painful joints.
Etiology. — The impression is gaining ground that
chronic, as well as acute, articular rheumatism is of bac-
terial origin, although the responsible micro-organisms
have not as yet been identilied. The disea.se, according
to continental writers, is a frequent seipiel of acute rheu-
matism, but in Nortli America it is more commonly iude-
pendent of antecedent acute or subacute attacks. It oc-
curs most frequently after the middle period of life,
especially among those who. in additiiui to contending
with the hardships o/ poverty, must engage in occupa-
tions of a laborious character which involve expostu'e to
cold and dampn(!S.s, such as day laborers, farmers, hun-
ters, washerwomen, and the like.
Pathology. — The cavity of the joint is not iu fre-
quently dry. The synovial membraue and its villi are
9cr
KllcuInatoVd ArtliHtis, REFERENCE HANDBOOK OF THE JIEDICAL SCIENCES.
thickened and injected, and adliesions may form Ijetwecn
tlie "piiosinu sui-faccs. Tlie arlicular cartilages aie dis-
torted, perliaps eroded and partly absorbed in cases of
long duration. The capsule and liuraments of the joint
and the tendon sliealhs a<ljaceut to the aft'ected articula-
tion are thielieued. Alropliy of the muscles in the
vicinity of a cluonically rheumatic joint is b}' no means
uncommon, especially when single large articidations
(l;nce, slioulder, hip) are involved. Atrophy from disuse
is likely to occur if the joint becomes ankylosed. Per-
ipheral neuritis arid pressure from exudation on the
muscles themselves or their nutrient vessels have aLso
been designated as factors in the muscular wasting.
Symptoms. — The cons]iicuous symptoms are pain and
Stitfncss in the affected joint. Jlost commonly the onsi't
is slow and insidiovis. The pain u.sually liecomcs more
severe during rainy weather, particularly in the variable
climatic conditions of spring and autunm. The stiffness
is most marked in the m(jrningand after rest, and lessens
after exercise. The pain is aiit to be increased by move-
ment, and is often very troublesome at night. The
affected joints may lie tender upon palpation, but swell-
ing, if present, is usually slight. The inflammation is
rarely of sufficient intensity to cause redness of the joint.
The course of the disease is as a rule afebrile, but if mauy
joints piarticipate in au exacerbation there may be a slight
aud transient rise of temperature. The disease may be
monarticular, involving a single large joint, the knee,
shoulder, or hip in particular, but generalh' a number of
joints, both large and small, are implicated. The joints,
if the disease is of some duration, are likely to creak or
grate when moved, because of the dryness and roughness
of the articidar surfaces. In cases of long standing the
joints are enlarged aud distorted, the mobility is decrea.sed
in varying degrees, and they may become completely
ankylosed. Muscidar atrophy takes place, and the pa-
tient may, in the severest cases, become bedridden. The
joint changes when established are usually jiersistent,
and do not shift from one articulation to another as in
rheumatic fever. In mild cases the general health may
remain wellnigh unini]iaired, but in the severer and
more painful cases gastric disturbances, emaciation. an.'V-
mia, and neuralgias may be present with varving intens-
ity. Other complications arc not common, but chronic
endocarditis, witli resultant valvular defects, may be as-
sociated with the joint changes.
Dr.\i:;Nosis. — (Ihronic articular rheumatism may require
to be dilferentiate<l from chronie artieuhir gout and ar-
thritis deffirmans, although in the majority of cases the
diagnosis is easily made.
Gout is more apt to affect tlie smaller joints. There is
usually a history of acute attacks involving the great
toe-joint, tojihi if found are distinctive, and the evi-
dences (.'f arteriosclerosis and granular kidney are much
more common in gout tlian in chronic rheumatism.
It is difficult, and reailily may be impossible to distin-
guish between arthritis deformans aud chronic rheuma-
tism in the early stages. In more advanced cases the
former presents greater deformity of the joints, while
rhetunatism tends rather to ankylosis with comparatively
slight alteration in shape, and moveover is likely to at-
tack a larger number of articulations than arthritis
deformans. It is proper to slate that by some writers
arthritis di'fornians is regarded as an advanced stage of
chronic rheumatism.
PiiocNosis. — The presence of chronic rheumatism is,
as a ruli'. r.ot inecuniiatible with a long life, but it is es-
sentially a chrouii^ ailment, anil the majority of cases ate
obstinately i-esistant to all tfierapeutic measures. In ex-
ceptional eases great im])rovement or apparent curi' may
take pl.iee; in many the dis.ability ami pain ma_y be much
relirved: in s.nni' the disease may seriously affect many
joints and rcMider tlie patient helpless.
Ti!i:.\TMi'.XT. — If circumstances jiermit, the patient
should live or ,at least spend the winter months in a
warm, equable, dry climate, such as that of Southern
California or the South of Europe. Otherwise the ut-
most care slmuld be taken to shi.'ld the subject from
damjmess, cold, and liad weather bj' good shelter and
warm clothing. The digestive functions should be main-
tained in good order, euemata and laxatives being em-
ployed w'hen they are reciuired. The diet should be
regidated so that it is digestil)le and ample in order to
keep the nutrition of the body at its best. Moderate ex-
ercise should be taken when possible. A daily cold
sponge followed by a good towelling is usually lulptul,
aud those who lind that the sponging disagrees with them
should employ the dry friction alone.
Local treatment is of prime importance. Counter-irri-
tation shotdd always be used, by means of stimtdating
liniments or by painting with tincture of iodine; by tlie
ap|)lication of a series of small blisters; or by "striping"
the painful joint with the P,a(]Uelin cautery, or, what
answers as well, with a glass rod, the end of which has
been heated in an alcohol tlame. The application of
iehtliyol and iodine, salicylic acid (gr. xxx. to 3!.) or
belladonna ointments, is at times of much service. Sys-
tematic ma.ssage and passive movements arc useful, "es-
pecially for the prevention of ankylosis and atrophy, and
for the lessening of swelling and stiffness. Electrical
treatment mayor may not be of service, but is always
worth a trial.
Ilydriatic measures of various kinds should not be
omitted. At home a hot bath at night often mitigates
pain and secures a more restful sleep; so also do hot
fomentations of the painful joints. (.)r, finally, the af-
fected joint may be wrajiped in three or four thicknesses
of linen wrung out of cold water and covered with flan-
nel and oiled silk or, in lieu of the latter, thick brown
[laper.
Complete and systematic hydriatic measures, including
also the hot-air treatment (baking the affected joints)
generally require a daily visit to. or, if practicable, a stay
of .some duration in, an establishment provided with the
necessary apparatus and trained attendants, particularly
in the sanatoria which avail themselves of natural medi-
cinal aud thermal waters. Among .the latter are the Hot
Springs of Arkansas and Virginia, Rielitii Id Springs of
New York State, Banff on the Canadian Pacific IJiiilway
in the Kocky Mountains, Mt. Clemens in Alichigau, and
Santa Rosalia* in Jlexico. Here aud in Europe a variety
of baths — Turkish, Roman, sand, mud, and peat— have
been emjiloyed. Thorough and jiersistent hydrotherapeu-
tie treatment usually secures great relief, and even in ob-
stinate eases a permanent cure is sometimes obtaineil.
M<'(lieinal treatment is not very satisfactory. As a
rule the administration of iron, quinine, strychnine, ar-
senic, and other reconstructives is helpful ; so also is a
course of cod-liver oil, mixed fats, or extra butter ami
cream in the dietary. Iodides, guaiacum, colchicum, al-
kalies, and bichloride of mercury, are occasionally use-
ful. The salicylates are unquestionably beneticial during
marked or subacute exacerbations.
GlcntiroH/i 7i'. Jliiile):
RHEUMATISM, MUSCULAR.— (Synonyms; :\Iyalgia,
rhi'uuialie iiiynsitis. )
DKFiNiTiok. — A disease characterized by (1) stiffness
and soreness on motion of certain nniscles; (3) tenderness
on deep pressure over certain points in their substance;
;ind occasionally (3) a general constitutional reaction.
('AtsR. — Muscular rheumatism is prob;ibly, like tlie
articuhir variety, a local manifestation of a general foxa'-
mia. Of the primary causes little is known. Some
cases are pirobably of infectious origin. Others .seem to
belong to the group of auto-intoxications whereof gout
is the clissic type.
Mouiiii) A\.\T(i.MY. — Adler (New York Malii'ul Ilccord,
vol. Ivii., ]i. K'^) describes the process as follows; In one
or more ]ilaces hypera-inia, sometimes accompanied by
*"SantiL linsjiliii, ii citv of Southern Cliiliiialuiii, MH.xirn. on tlie
Mp.xic'MM Centriil Biiihvay, :iio miles soulli of El Paso. It iscelebrtitej
for its hot snliniiirspriTiKs, Ions known to he i-urative hy aw nalives,
anil mil h ivs,,ii,.i| to hy invaliils. They are e.siH'dally iisi-ful in in-
tlamiiiaioiy rhoiiiiiatism. Population estiinated at S.iKill." Kr-oin
■■■rill- rnivnsal ('vclii|Keilia aud Atlas." .\enly reyiseil edition.
Appletou iV Co. liHIl.
9()S
REFERENCE HANDBOOK OF THE SIEDICAL SCIENCES. uheunlalLVdArU.rltls.
small hemoniiagts, takes place, followpcl by emigration
of cells into tlieiiiterslitial tissues, crowding between tlic
bundles of muscle tilires and even between tlie single
filjiils. Soon tlie inlerstilial tissue proliferates actively,
bringing about anintiltratiou of the muscle, whicli varies
in extent and density according to tlie intensity of the
process. In the mikler cases the process ends here, the
infiltrating material is absorbed, and the muscle returns
to practically the normal condition. In severe cases,
however, there is more extensive formation of new con-
nective tissue, which compresses the muscle fibres so that
tbey degenerate and are absorbed. In cases of the sever-
est type, there results a hard white mass of cicatricial
tissue, in structure like a bit of tendon. Often the proc-
ess is not confined to the muscles. The neighboring
joints, fascia?, tendons, and especially nerves, may be in-
vol\ed. The nodules are recognizable on palpation by a
trained hand. The^'are not necessarily found in the spot
where the pain is felt, for if a nerve be involved, the pain
will usuall}' be referred to the peripheral distribution of
that nerve.
Ci.iNTC.\L History. — The disease most commonly af-
fects one of four localities as follows: (1) The deltoid
muscle; (2) the lumbar muscles (lumbago); (3) the inter-
costal muscles (pleurodynia) ; and (4) the sterno-mastoid
muscle (torticollis, wrj--neck). The relative frequency
of these locations is hard to ascertitiu, for many patients
are not sick enough to go to bed, and hence go to the dis-
pensary rather than to the hospital. Less frequently we
find the tiouble located in the muscles of the bead, espe-
cially the suboccipital region, and oreasionally in the
muscles of the jaw. Adler (lor. cit.) reports three cases of
rheumatism in the abdominal muscles, one case simulat-
ing biliary colic, the other two suggesting appendicitis.
No one of the voluntary tnuscles is altogether exempt.
The disease may be ushered in by a chill, a febrile
movement, and all the signs of an acute infectious dis-
ease. This is uncommon. !Most patients develop their
symptoms graduall_y, and the disease runs a subacute
course, although it is rarely without some fever. The
pain is not usually excessive. It is increased by at-
tempts to use the aiTected muscles, and also by lying
upon the ailccted side. It is dull and aching in charac-
ter, and verj- tiresome and wearing. In some cases,
where nerves are involved, the pain is paroxysmal and
radiates over a wide surface. Such cases are often
puzzling.
Di.vGXosis. — In tyi^ical cases this is very easy. Lum-
bago and wry -neck are common enough, and not easily
confused with anything else, although in the former case
pyelitis, and in the latter, deep cervical cellulitis, must
l)e thought of. Deltoid rheumatism has been confused
with necro.sis at the upper end of the htunerus. Inter-
costal rheumatism may be mistaken for pleurisy. Sub-
occipital rheumatism may be confused w ith neuralgia,
neurasthenic headache, or migraine. Abdominal rheu-
matism may sinndate disease of the liver and gallblad-
der, the appendix, or the uterine adnexa. In doulitful
cases the diagnosis lunst lie made by palpation of all the
muscles in the region where pain is felt. "The infiltra-
tion varies in size, shape, and consistency. After sub-
sidence of the acute stage the infiltrations may lie recog-
nized by careful palpation. . . . They may be round,
fusiform, or flat, hard and firm or soft and doughy, with
surface smooth or uneven. . . . While normal muscles
react upon a certain vigorous grip w ith contraction of
the part touched, the diseased'tissue will react with
diminished vigor or not at all; it also shows diminution
of the normal elasticity. After the acute stage is past,
although the muscle resumes its function without pain,
yet the diseased areas remain tender upon pressure. . . .
NVhen examining, it is necessary to compare the two sides
of the body. Aside from other changes, the diseased side
will always be found abnormally sensitive" (Adler, loc
cit.).
Course and Prognosis. — The course is uncertain.
Some cases clear up rapidly, others are very olistinate.
In a general way it may be .said that muscidar rheuma-
tism runs a slower course than the articular variety, and
also has a greater tendency to relapse, as sliglit lesiona
usually remain in the musch; substance after the subsi-
dence of the attack. It also has a strong tendency to be-
come chronic. Therefore the prognosis as to complete
recovery should be guarded.
Ti!E.\TMENT. — 111 all but very mild cases the patient
shotdd be put to bed whenever possible, in order tliat the
affected muscles may be at rest. A brisk purge is essen-
tial, if it be our aim to promote elimination of the toxins.
Further treatment depends upon the cause of the attack,
in so far as the cause can be made out. If the affection
be a true rheumatism, the salic}'lates must be given in
full doses for two or three days; if it be an auto-intoxi-
cation, the salicylates are generally iiseless, and an elimi-
uative treatment, as for gout and allied conditions, must
be adopted. An exclusive milk diet, with the bowels
freely opened every day, is useful, and this may be given
to the walking cases, provided they will take enough
— at least four quarts a day, and six if possible. Jlilk
is diuretic, and comparatively free from toxalbumins.
Local treatment, in the shape of counter-irritation in
various forms, is usually necessary. It may take the
form of a blister, or a few quick strokes with the actual
cautery at white heat, or acupuncture, or painting the
skin over the affected muscle, with guaiacol, or the oil
of wintergreen, or a twent3--five-per-cent. alcoholic solu-
tion of menthol crystals. "W. G. Thompson recommends
injections of sterilized w-ater into the deeper parts of the
substance of the muscle. Adler commends massage very
highly, but declares that the masseur must be sjiecially
trained to the work. Of course massage cannot be used
tmtil after the acute stage is passed.
The after-treatment of these cases is highh^ important.
The patient must keep his skin in healthy activity Ly
daily bathing. Overclothingniust be avoided. The test
of tills is, that there shall be sufficient for comfort, but it
must be so regulated that in any ordinary weather the
skin shall not be moist except after brisk exercise.
Moderate and regular daily exercise, in open air and da\'-
light, ju'oiuotes complete oxidation of the food, and thus
protects the system against auto-intoxication. Regard-
ing diet, it may be said that the albumins should be some-
what restricted. Alcoholic liquors should be taken only
in small quantities. A good whiskej', well diluted, is
proliably the least harmful stimulant. Large quantities
of water — four ]iintsaday — should be taken to keep all
the urinary sidts in complete .solution. Over-fatigue and
sudden violent exertion are to be avoided.
Dtiiuild M. BarsUiw.
RHEUMATOID ARTHRITIS.— (Synonyms: Rheumatic
gout; deforming arthritis; chronic rheumatic arthritis;
rheumatic joint; osteo-arthritis.)
Definition. — A chronic and progressive disease of the
joints characterized by deforming changes in the synovial
membranes, cartilages, and bone, will, peri articular bony
outgrowths which interfere to a greater or less extent
witii the mobility of the affected articulations.
Etiology. — As a rule the disease develops between
tliirty and fifty years of age-, although it may occur in
children under twelve. It exists with preponderating
frequency in women, from one-half to four-fifths of the
cases occuriing in this sex, especially at the time of the
inenopiiuse. Sterility and uterine or ovarian disease ap-
jjarently predispose. There is in some cases a family
liistory of a tendenc_y to gouty or other disease of the
joints, cr to tuberculosis of the lungs; and two or more
cases ma_y occur in thesame family. Worry, grief, men-
tal shock or overwork, exposure to cold and dampness,
insufficient diet, and local traumatisms apjiear at times
to be exciting causes. There are two theories as to the
essential cause of the disease; one, that it is of nervous
origin; the other, that it is a chronic infection. Accord-
ing to the former theory the disease is akin to the arthrop-
athies of nervous origin. Thus the joint changes in
arthritis deformans are very similar to those which may
occur as a result of locouiolor ataxia, syringomyelia.
9C.9
RheiiniatoSd Arthritis*
Rliiuosoleroiua.
REFERENCE HANDBOOK OF THE jMEDICAL SCIENCES.
hemiplegia, and iujuries of nerve tniuks. The uot iu-
frequent preseuee of neurotrophic phenoinen;i. such as
marked muscular atrophy, gloss)' skin, and alteralious
in the nails and hones, is of somi; si.niiifieanee: so also is
the occurrence of nurahnes.s. tinjrlins, and severe pain,
involving special nerves or nerve trunks. Moreover, the
joint lesions are usually symmetrical.
On the other hand, the idea that the disea.sc will prove
to he a chronic infection is gaiuiug adherents, although
a specific microhic agent has not as yet been identified.
In favor of this vievr is the fact that, in a considerable
proportion of cases, arthritis deformans follows an acute
infection, especially gonorrlKea and epidemic influenza.
In some instances the onset is acute and the joints are
red, swollen, and paiuful; and in chikh'cn there may be
splenic enlargement and swelling of the lymphatic
glands.
Pathology (or Morbid Ax.\tomv). — The morbid
changes begiu in the cartilages of the affected joints,
which after proliferating become softened and, especially
in the centre and at the points of greatest pressure, are
absorbed or worn away. Tlie exposed articular bone
surfaces become smooth and ivorydike (eburnated). The
proliferating cartilages and synovial membranes at the
laorder of the joint form an irregular fringe of nodules
and polypoid bodies which ossify (osteo[}hytes) and inter-
fere more or less seriotisly with the mobility of the joint.
The ends of the bones may become enlarged, and the
ligaments are greatly thickened. Complete ankylosis is
not infrcqueut, due principalh' to the locking of the
joints b}' the osteophy tic growths (Haygarth's nodosities)
and the thickened ligaments. In elderly persons and in
cases of longduratiou thearticuUir ends of the bones may
undergo wasting, so that the head of the humerus, or of
the femur (morbus cox;e senilis), nia.y practically disap-
pear, causing partial dislocations and false joints. The
affected articulations are more or less misshapen and the
deformity may reach an extreme grade. When the hand
is affected the lingers frequently bend laterally toward
the ulnar side. The great toe is deflected toward the
outer border of the foot. The vertebra? when diseased
may be completely ankylosed by bony outgrowths, and
the spinal column thus consolidated. Atrophy of the
muscles about the joint, sometimes of extreme degree, is
of common occiuTeuce.
Symptoms. — Five varieties of the disease are recog-
nized— the general progressive form, the monarticular
form, the vertebral form, the form affecting children,
and Heberden's nodes.
The general pi-tx/ressirc form may he acute or chronic.
The iieiile outbreak occurs especially in .vouug women in
connection with ])arturition and lactation, or in older
women at the menopause; it is occasionally ob.served in
children. The symiitoms resemble those of rheumatic
fever. A nunilier of joints become swollen, seldom red-
dened, and there is a moderate rise of temperature. The
subjects become ana'mic, low-spirited, anil lose flesh and
strength. In some instances the disease may greatly im- |
prove, only to renew its onset under the influence of
further child-bearing or nursing.
The c7tro>i/c variety is that which is observed in the
majority of the cases. As a rule one or two joints, usu-
ally of the hands, are first involved; then tliose of the
knees and feet and other articulations; finally, in the se-
verest cases, all the articulations ma}' be implicated. The
involvement is usually .sj'mmetrical. The earliest symp-
toms are slight swelling in or about the joints, and pain
on movement with impaired mobility. Tliere may or may
not be effusion into the joint. The pain may be ex-
tremely severe and continuous, or .slight and variable.
It isusntdly worse at night and during the exacerbations.
The disease progresses irregularly, days or weeks of im-
provement alternating witli renewals of pain, swelling,
and stilTness. Slowly the joints become deformed by
ligamentous thickening and the formation of bony out-
growths. The mobility of the joint decreases and creak-
ing or grating is felt or heard upon motion. In the end
the joint may be ennipletely immobile, owing to the
checking action of the osteophytes and the fibrous thick-
ening of the capsular ligaments. The disused muscles
waste away, and when coutractured may give rise to
persistent flexion of the affected members. In the worst
cases the patient is bedriddeu and almost if uot quite
helpless. In one case under observation practically
ever J- joint in the body was aukylosed; even the lower
jaw was wellnigh immovable. Tingling, numbness,
glossy or pigmented skin, onychia, rapid muscular atro-
phy, and increased reflexes have been okserved. Anaemia
and gastro-intestinal disturbances are not uncommon,
especially during the exacerbations of the disease. The
heart is not often involved, but in one personal case, that
of a young woman, there were advanced arteriosclerosis
and an aneurismal dilatation of the aorta.
Tlie moneirdciiletr form affects especially the hip, knee,
or shoulder, occurs mainly in old people, and uot infre-
quently is an apparent sequel to an injury. The path-
ological changes are similar to tlio.se of the chronic
general form, and tlie muscles early undergo atrophv.
When afl'ecting the hip the disease constitutes the mor-
bus cox;c senilis, the anatomical alterations of which have
been described.
The rerlehnil form, spondylitis deformans, is a progres-
sive rigidity of the spine, due to ankylosis of the verte-
bra?. Two types are described. The "first is tlie so-called
spondylitis rhizomelia (Strumpell-ilarie), which attacks
men only at or beyond middle age. It begins usually in
the hip-joints, which become ankylosed, the process sub-
sequently extending to the spine and shoulder-joiuts,
very rarely to the knee-joints. Tiie spine becomes rigid,
the rilis flexed, and there is some kj-pliosis. The dorsal
and gluteal muscles are atrophied and exostoses are
found upon tlie vertebra' and sacral bones. There is but
little pain attending the process. In the second (Bech-
terew-JIarie) type the disease begins in the spine, which
becomes ankylosed and kyphotic, the shoulders stoop,
the head is lo-wered and carried forward, and there is
much intercostal pain, with anicsthesia, muscular atro-
phy, and other signs of involvement of the roots of the
spinal nerves. The hi]i- and shoulder-joints are slightly
if at all affected. The di.sease is often hereditary.
There is little doubt that both types are forms of arthri-
tis deformans, and are not, as formerly supposed, inde-
pendent diseases.
Heberden's mHlen, knoliby enlargements of the proximal
ends of the terminal phalanges of the fingers, are much
more common in women than in men ; they begin, as a rule,
between thirty and forty years of age. They are ix'garded
as indicative of a long life, but it has been stated that can-
cer occurs with undue frequency in women who have such
nodosities. While the nodes are forming the affected
joints may be tender and swollen, perhaps slightly red-
dened. Exacerbations may be e.xcited by dietary errors,
or slight accidental traumatisms; but in most instances
the attacks alternate with periods of quiescence without
apparent cause. Fortunately, those who develop Heber-
den's nodes seldom have the larger joints affected.
The jurenileform occurs more frequently in girls than
in boys and, as a rule, before the second dentition.
While the disease may be a replica of that affecting
grown jiersons, the most important class of cases differ
in many respects from the adult alfection. The onset
may he acute, with fever, possibly with chills, but gen-
erally the first svmptom is a slight stiffness in one or two
joints, others slowly becoming affected. There is no
crepitus in the alfected joints, and the main anatomical
change is a general thickening of the peiiarticular tissues
and enlargement of the joint with little or no alterations
in the bones. The mobility of the joint is impaired, jier-
haps totally destroyed. There may be marked atrophy
of the muscles, Tlie most interesting feature of the mal-
ady is a general and marked swelling of the lymph
glands, occurring especially in the cases attended by
fever and increasing with the latter. The spleen also is
enlarged and jialpalile. Profuse perspirations are rather
common. Tlie lieait is rarely affected. The subjects are
ana-mic, weak, and ill developed.
»70
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES,
Kheuinatoid Artlirlll^.
RliiU4>si-l<*roiiia.
Diagnosis. — In the early stages it is always diftifult
and frequently impossible to distinguish arthritis defor-
mans from chronic rheumatism. When the disease is well
developed tlie diagnosis is seldom in doubt. The peeuliar
joint deformities in advanced cases are quite characteris-
tic. The more acute cases may be mistaken for rheuma-
tic fever, but the slighter fever, the lesser pain, redness,
and swelling, and the usual absence of cardiac complica-
tions separate it from the latter. From gout artliritis
deformans is distinguished by the absence of chalky de-
posits and. usually, of cardio-renal disease, as well as liy
the fact that gout usually attacks the metatarso-phalan-
geal joint of the great toe.
Prognosis. — In a majority of cases the progress of the
disease is arrested, leaving several joints more or less
crippled. In other cases the disease advances irregularly,
with periods of quiescence, and persists throughout the
life of tlie patient. A few become heljjless and bedrid-
den. As a rule the milder forms of tlie disease are not
incompatible with fair health and a long life, but the
disability may be veiy .great.
Ti!E.\TMEXT. — It is of prime importance to maintain
the general health at its highest point. Plenty of fresh
air, daily cool or cold sponging followed by vigorous
toweling, well-ventilated sleeping-rooms, ample hours for
sleep, daily exercise according to ability, laxatives and
digestive tonics when needed, and a liberal dietary of
meat, eggs, milk, butter, wine and malt liquors, should
be considered essentials.
Local treatment embraces cold or hot compresses cov-
ered with oiled silk, and left on for two or three hours 'at
a time, massage carefully given and long continued, jaer-
sistent hot-air treatment (baking), small and repeated
blisters, "striping" from time to time with the thermo-
cauter}-, friction with ointments containing iodine and
ichthyol, systematic passive movements, and even the
forcible breaking of adhesions in selected cases.
Hydriatic treatment should be begun early and is of
great value. At home a nightly plain hot bath, hot
Nauheim bath, or hot-air Imth may be employed. If the
patient is able he shotdd go to a hydriatic establishment
in connection with a natural thermal or medicinal water,
such as the Hot Springs of Virginia or Arkansas, Mt.
Clemens in Michigan, Richfield Springs of New York,
Green Sulphur of Florida, or Sharon Sjirings: Bath in
England; Baden, Wiesbaden, Ai.x-les-bains, Carlsbad,
Gastein, Homburg, or Wildbad on the continent of Eu-
rope, or the sand baths, mud baths, and peat baths of
various localities.
Electricity may be employed, but its effects are uncer-
tain.
Medicinal treatment is at times very helpful. Iron,
arsenic, and cod-liver oil in full doses are the remedies
that are especially' indicated. Iodide of potassium (live
to ten grains), or the syrup of the iodide of iron (ten to
twenty minims) three times daily are especially useful if
there is much periarticular thickening. In the acute
polyarticular attacks the salicylates are unquestionably
of great value. Gletitwurth li. Butkr.
RHIGOLENE.— Of the products of the fractional dis-
tillation of petroleum the lightest is obtainable as a fluid
by condensation, and consists mainly of the paraffin hii-
tane, a body gaseous under ordinary conditions. This
condensed distillate is termed eymnrjene. The distillate
of next higher boiling-point boils at aliotit 18° C. (64.4"
F.). Such distillate consists largely of the fluid paraffin
peiitaiie ("amylic hydride"), CsHio" and is the sid.)Stance
commonly known as rliiogolene. Rhigolene is a colorless,
mobile fluid of slight and not unpleasant odor and taste;
very light, very inflammable, and, as its boiling-point
predicates, very volatile. It mixes in all proportions
with common (ethylic) ether. Rhigolene was proposed
by B. W. Richardson as a substitute for ether for the
production of local anesthesia by freezing, after his
method. Because of the low boiling-point of rhigolene —
lower than that of ether— the cold produced liy the
evaporation of a spray of rhigolene is very intense and
very rapidly attained. Dr. Richardson observed an area
of skin become hard, white, and insensible at the expira-
tion of tiro seconds after beginning the driving upon it of
a rhigolene spraj'. But such very rapid freezing Dr.
Richardson found to be tmdesirable, becau.se the intense
cooling of the superficial frozen area prevents the ab-
straction of heat from below, and so limits undidy the
depth to which the ana'sthesia can he carried. Hence
Dr. Richardson proposed a mixture of rhigolene and an-
hydrous ether in equal parts. Rhigolene dissolves cam-
phor, spermaceti, and iodine, and has been used by
Richardson, again, as a solvent of those bodies for use
for local applications. A rhigolene solution of camphor
and spermaceti together Rieliardson found to make an
excellent conjoint cooling anodyne and healing applica-
tion to burns. The vapor of rhigolene, inhaled after the
manner of vapor of chloroform, is readily taken, and
produces general anaesthesia with great rapidity. But
in this application rhigolene has shown itself dangerous,
and has never come into practical use.
Edward Curtis.
RHINOSCLEROMA.— A chronic infectious disease af-
fecting chiefly tile nose, the mucous membrane of the
mouth, pharynx, and larynx. It is due to a bacillus re-
sembling in some respects the bacillus of Friedliinder, and
is characterized by the formation of dilfuse and nodular
swellings of extreme hardness, often followed by dense
cicatrices. It is a disease of extreme chronicity. and has
not been found to be amenable to any form of treatment.
The disease was first described by Hebra in 1870 as a
tumor formation situated in the nose or its vicinity. The
growth is constant, but exceedingly slow; it is hard and
indurated and sharjily circumscribed, the surrounding
tissue showing no iuflanmiatory or other change. The
growth appears in the form of smooth nodes of various
size or as a diffuse induration. The surface is smooth
and shiny, and either of a brownish-red or normal color.
It is painless in itself, but painful on contact. It pro-
duces no danger to the organism save by mechanical in-
terference with respiration.
Kaposi gave a more detailed description of the process
in 1873. In this hc'calls attention to the frequent involve-
ment of the soft palate, dtie to the extension of the proc-
ess from the nose. It begins in the mucous membrane of
the side of the nose or in the cartilaginous septum. It
may produce narrowing and even complete closure of the
nares, and from the nose it extends to the pharynx, to the
upper lip, to the hard palate, and to the alveolar proc-
esses of the upper jaw.
We owe our chief knowledge of the disease to tw'o
monographs, one by Mikulicz {Arch.f. Chinirgie, 1876,
vol. xxvii.), and the other by Wolkowitsch (Arch. f.
Chirvrgic, 1889, vol. xxxviii.). There have been in addi-
tion a series of publications of single cases often giving
detailed histological reports, and the discovery of the
liacillus by Fritsch in 1882 has been followed liy a long
series of articles on the presence of the bacillus, its rela-
tion to the lesions, its cultural characteristics, morphol-
ogy-, etc.
The investigations of Mikulicz were made on two
cases. One of these had lasted for sixteen years, and the
growth had so interfered with function that operative
removal of a considerable part of it became necessary.
The growth began on the inner surface of the left nostril
as a small nodtde, which gradually increased in size.
Nodules accompanied by dilluse induration almost com-
pletely closed the nose and extended to the septum and
the upper lip. The alTectrd jiarts were dark red and ex-
tremely indurated. The nose, whi<'h was at first greatly
enlarged, gradually sank and its form was lost. The
infiltrated upper lip was drawn upward and backward,
and the entire area aifected became a flattened indurated
mass. There was gradual narrowing of the mouth,
which became so hard and stiff as to interfere with eat-
ing. The opening tinally became so narrow that only
the point of the small finger could be passed into it. An
operation was performed consisting in enlargement of the
971
RliiiioNcIeroina.
Rhubarb,
REFERENCE HANDBOOK OP THE JIEDICAL SCIENCES.
nioutli 1)}' extensive removal of tlie iniliii'ated tissue about
it. Tlie entire upper lip and a jiart of the cheek were
adhereut to the alveolar processes. The middle of the
hard palate was covered with irregulai' cicatrices, wdiich
e.vtcudcd to the soft palate and were joined witli similar
cicatrices in this. The diseased tissues, although so haid
to the touch, gave little resistance to the knife and the
hemorrhage was slight. In the second case the disease
appeared as an enlargement and induration of the nose,
which after five years became double in size. The tissue
removed was similar in chai'acter to that removed in the
first case, and was so hard that fair microscopic sections
could be made of it in the fi-csh slate.
At the time of the puliHcation of Woljjowitseh the dis-
ease had become much better known. Q"'''^' ^ number
of cases had been published, and on account of the ex-
tent of the lesions in the pharynx, which had been
largely neglected by the lirst authors, the name pharj'n-
goscleroma had been proposed as a substitute for ihino-
scleroma. It had been further found tliat the disease
often extended into the lower part of the larynx, and es-
pecially on the lower surface of the vocal cords ami
sometimes into the trachea. The laryngeal and tracheal
lesions have been specially studied liy (>. Chiari and
Bendler. In 1ST8 Gerhardt described under the name of
■' cliorditis voealis inferior hypertropiiica " a form of dis-
ease of the larynx which he characterized as a chronic
intlanniiatory hypertroidiy fif the vocal cords leading to
stenosis. From a review of the literature he concluded
that the condition had been known before, but not recog-
nized as an indcpriiiirnt disease.
Langliofer in INSO studied the condition histological!}',
and fovuid the lesions characteristic of rhinoscleroma.
He held the two conditions to be the same, and that
scleroma could appear in the larynx and trachea inde-
pendently of any atfection of the nose. This was shortly
contirnied by O. Chiari, and in 188-5 Chiari and Rliicl col-
lected thirty cases of rhinoscleroma, in nine of which the
disease had extended into the larynx. In Handler's case,
which was studied from autopsy, the larynx was stc-
nosedin high degree by a thick, hard mass of tissue extea-
sively ulcerated. The trachea wasstenosed: its wall was
0.75 cm. thick. This thickening came chietly from the
mucosa and submucosa, whicli was converted into a hard
mass of tissue, partlv covered with thi<-kened epithelium
and partly ulceratccl. On the inner surface of tlie tra-
chea there were radiate cicatrices. Tlie intiltration ex-
tended down to the bifurcation, and for a distance of
from 1 to 1.5 cm. into the primary bronchi. The lesion
extended up to the ]iharynx and narcs, but without alter-
ing the external appearance of the nose.
Wolkowitsch gave a complete clinical and anatomical
descri]ition of eleven cases, together with short descriiv
tions of all of the ca.ses which he could collect from the
literature. In his first case ulceration was ]irominenr.
The disease often begins with the apiiearance of a nodule
or as an induration, either at tlie sides or in the median
line of the nose. In certain cases the induration extends
over the whole nose and down to the lip, or the chief ex-
tension may be backward, or it ma\' extend in both direc-
tions. Ulceration is rarely a prominent feature, but in
certain cases large crater-like ulcerations, with elevated
indurated edges, are formed ; they present some similarity
to carcinoma.
In other cases the growth seems gradually to fill up
the nose. It grows more rapidly from the interior than
from the exterior. The nose becomes enormously en-
larged and flattened laterally.
The disease is usually found in the lower clas.scs, and
it is difficult to get information as to the manner of on-
set. Sometimes catarrh was noticed as the first syni]i-
tom. When ulceration is present, the ulcers di.scharge a
thin fluid which is often offensive. There may be exter-
nal nodules which represent an exteu.sion from the interior
and give but little ideaof the extent of the process. The
upper part of the nose is not affected, so that the sense of
smell is not lost as long as the external opening is left.
In rare cases the disease begins in the pharynx and
larynx, and the disease of the nose is secondary and may
not appear. The lachrymal sac has been secondarily
affected in a few cases, and the disease has also extended
into the Eustachian tube. The deeper parts are rarely
aft'ected, but in some instances both thickening and
ulceration of the cartilage and of the bones has liccn
found. Wlii'U the disease appears in the nostrils there
is a great tendency for it to extend to the upper lip, es-
pecially upon the external surface. The nodules are often
covered by a network of veins. The gums are thick-
ened; irregular, hard, dark or bluish-red nodules, which
sometimes extend to the mucous membrane of the palate,
are formed on them. The teeth lose their direction, be-
come pressed forward or backward, and often thrown
out. The disease is almost invariably symmetrical,
affecting chiefly the middle line and extending equal
distances laterally. The growth extends very slowly
but continuously. In one of Jlikuliez's patients there
was more rapid growth at each pregnancy. Like so
many affections of the skin there is a continuous per-
ipheral extension with central cicatrization and contrac-
tion. There seems to be but little tendency for the le-
sions to become the seat of pyogenic infectious or other
secondary processes.
In one case a carcinoma developed in the lesion after
the disease had existed for twent3'-tlve 3'ears.
The first histological examination was made by Kaposi,
who regarded the process as a sarcoma. He founci the
papillary body and .superScial coriiim thickly infiltrated
by small cells, while the deeper layer.; showed a thick
connective-tissue network with slight celluliir infiltration.
The next investigation was that of Geber, who disagreed
with Kaposi, and considered the disease a chronic in-
Hainmatory process and not a tumor. Mikulicz also re-
garded it as a chronic inflammation. Microscopically, he
found areas of round-cell infiltration, and, among tliese,
cells which \vere much larger and paler, with a pale
Vesicular nucleus. The growth was sharjily separated
from the normal tissue. Proceeding from the normal
tissue to the growth the first change seen was atrophy of
the .sebaceous glands and the hair follicles. The intiltra-
tion was chiefly in the deeper layers of the corium, the
papillary body showing little change other than atrophy.
Mikulicz considers that the lesions in the ejiithelium are
due to the deep cellular infiltration; the vessels passing
through this are in jiart compressed, and they serve
rather the nulrition of the growth than that of the nor-
mal tissues. Tlie sweat glands also become afro|ihied.
The connective tissue at first is unaltered, its fibres being
simply pressed apart. In places it loses its fibrillar char-
acter and the inlercellular substance becomes homoge-
neous. Nerve bundles maj' be found running through
the infiltration, but they seem to be especially resistant.
The muscles are destroyed much earlier than the nerves.
They are alroidiied, often show the degenerative prolifer-
ation of nuclei, and in places where the infiltration is
more rapid they become hyaline. Fat cells are often
ju'esent to a considerable extent. Mikulicz thinks that
the large cells arise from the connective tissue.
Cornil ami Alvares in 1883 called attention to the ap-
pearance of hyaline masses in the large cells first de-
.scribed by ^likuliez. They found that the bacteria were
in relation to the hyaline masses, which, as they sujiposed,
in part represent the bacterial ca]isules. and in part are
due to a hyaline degeneration of flie cells brought about
by the bacteria. Wolkowitsidi lielieved that the large
cells representeil a special form of degeneration of the
granulation cells. The hyalin has the general charac-
teristics of hyalin as described by von Recklinghausen.
The cells occasionally break down and leave the hyalin
free. The peculiar refraction of the fresh tissue and its
peculiar induration are due to the hyalin.
The rhinoscleroma bacillus was first described by
Fritsch in issi in all of the twelve cases which he inves-
tigated. The bacilli have been found constantly by every
investigator. They are present in large numbers, and are
chiefly in the large cells, though thev may be found be-
tween them; they vary somi'what in size; they are short.
972
REFERKNCE HANDBOOK OF THE MEDICAL SCIENCES.
12liliii»M<'li>roiiia.
Kliiibarb.
often appearing in double form, and they present some
reseinblaiice to the pneunioeoeei, but they are usually
nuicli larger. The capsule formatiou is a permanent
characteristic aud may be demonstrated even in the tis-
sues. The best way of showing them is to harden the
tissue in one-per-cent. osmie aeiil and then to stain it with
sonic aniline color. The eapsidcs by this means become
very iirmnineut, and have a gra\ish-bniwu color.
From the appearance of the organism and from its cul-
tural characteristics it was considered liy many to be iden-
tical with the bacillus pneumonia' of Friedlander, aud a
great deal of the bacteriological literature has been on
this subject, but the general opinion now is that it is dis-
tinctly (lilTerent. The organism in culture has the fol-
lowing characteristics: Itiorms a mucoid cap-like colony
on gelatin jilates; no gas in sugar-agar; no acid in milk-
sugar bouillon. The best description of the differential
diagnosis between the scleroma bacillus and Friedliinder's
bacillus is that of Paltauf, who investigated fifteen cases.
The principal points of dilTerence between the two are
these: first, tlie superficial whitish extension of the scle-
roma bacillus on gelatin is drier and more consistent than
the corresponding growth of FriedUinder's bacillus; sec-
ond, there is an entire absence of gas formation in sugar-
.agar; and, third, the organism develops very imperfectly
on acid media.
The geographical distribution of the disease is nari'ow.
The first cases were seen in Austria, and the disease has
always been more frequent there tlian elsewhere. The
disease is also not imcommou in Russia, where Wolko-
witsch studieil his cases, but Central America and chieHy
the republic of San Salvador seem to be the priiiei|ial
seat of the disease after Austria. Cases have also been
observed in France, Germany, Belgium, and- Cairo. Only
live cases have been reported in the United States, and
only one of these was a native American.
The disease belongs to the geneivd class of granulation
tumors. The large cells are of the epithelioid character,
and resemble the epithelioid cells formed iu tuberculosis,
anil the masses of them may suggest some similarity to
tutiereidous granulation tissue. They do not undergo
caseation, nor is there any necrosis in mass. They are
particularly prone to hyaline degeneration, which ap-
pears to be due to the action of the bacilli, wliich they
often contain in large uumliers. With their complete
hyaline degeneration they disappear, and their place is
taken by dense masses of connective tissue, to the con-
traction of which the cicatrization is due. The fcirnia-
tion of these masses of large cells appears to be the pri-
mary and essential process; the other lesions are those
common to all similar processes. It is probable that we
must regard the disease as due to the bacillus which is
always associated with it. The disease is a peculiar one,
and the bacillus is iu relation with the cell formation,
wdnch constitutes its histological specificity. It is an
organism which is easily cultivated, but no characteristic
lesions can be proiluced by inoculation of animals. It is
pathogenic only in large doses. In spite of its similarity
to Friedlander's bacillus and to the group of the bacillus
mucosus capsulatus, both iu morphology and iu some
cultural characteristics, it should be considered to be an
independent organism. None of these organisms lead
to a proliferation of tissiie, and their general action is to
produce exudations. The uarnjw geographical ilistrl-
bution of the disease also points to a (listinet etiology.
In view of the wide distribution ot the bacillus mucosus
capsulatus, it is unlikely that a variety of this would
have so restricted a field. W. T. CovnHliinin.
RHINOSCOPY. See A'rtsn? Carities, Diseases of : Gcn-
eriil J)i,ii/iii'm's.
RHODANIDES. Sec Siilji/ioa/K nidi's.
R»^}B^KB.— Ofnnese Rhubarb ; Rheum. U. S. P. ; Rhei
RiKjir, li. P.; Radix Rhei. P. G. ; Tthiibarhe de C/iiiie.
lihuharbe de Muscmie, Rliubarbe de Reese, Codex jNIcil,
■etc.
V.
The dried rhizome and larger roots of R/teiem offieinale
Baill., Rheum palmatirm L., and probably of other spe-
cies of Rheum (fain, Polijr/onaeece), deprived of the outer
corky laj'crs.
The general features of the rhtibarb jilant arc well
illustrated by the common garden pie-plants, R. vhiipnii-
licuin, etc. There are twenty or more species, all from
Southern and Central Asia, the drug being collected in
Northwestern China, Thibet, and the adjacent regions.
Both of the above-named species have been introduced
to cidtivation in Europe, and have produced a drug
identical in its essential features with Chinese rhubarb.
The second named has not been cultivated upon a com-
mercial scale, but R. vjjirinide is quite extensively so
cultivated in England. The product is .smaller, retains
more of its bark, is more spongy, and less esteemed than
the Chinese product.
The underground portion consists of a short, thick,
erect rhizome, which gives off several thick roots.
These are dug in the autumn and the rhizomes and roots
jireserved separately,
the former constitut-
ing the most and the
more highly esteemed
portions of the drug.
They are two or three
times as large as the
roots. The outer corky
bark layer is removed
and the pieces are !
dried, mostlj' by being f
s u s ]) e n d e d upon f
strings passed through i'
perforations made f(n'
the purpose.
Descriptiox. — Rhu- ; ,-
barb occurs mostly '*<'
either in uncvenl)' bar- \
rel - shaped piece s — •
from two to five inches
in length and one-
third to two-thirds as "- -_
thick, the ends truncat-
ed, the surface show-
ing the, angular mark-
ings left by peeling,
though these are more
or less rouniled oil — or
in longitudinal halves or slices of such barrel-shaped
pieces. Usually the pieces are perforated by a rather
large hole. The siu'face is of a bright light yellow aud
covered with a fine powder, which should consist of
the rhubarb substance, bvit is sometimes powdered cur-
cuma. That wdnch lias been kiln-dried or " high dried "
possesses a surface roughened with broad ridges, sepa-
rated by broad groovi'S, the latter freciuently discolored
to appear snuidgy or blackish. The surface is less ]iow-
derj'. Underneath this superficial powder the surface of
rhubarb is found reticulated, the oblong or lozenge-
shaped ends of the reddish-brown or deep yellow-brown
medullary ravs being separated by intersecting bands of
a grayish-white parenchymatic tissue. The fracture is
irregular but not at all fibrous, and of a grayish-red
color. Upon transver.se section the larger (rhizome)
pieces sliow, near the periphery, a nearly continuous
circle of pretty stellate fibro-vascular bundles, these
being wanting in the root pieces. Upon this transverse
view the direction of the medullary rays is seen to be
very irregular, less so toward the pieriiihery. Rludjarb
possesses a peculiar fine aroma, which, however, becomes
coarse, heavy, an<l a little empyreumati<' in the high-dried
form. When chewed it produces a very gritty etfect be-
tween the tC'th, is mucilaginous, colors the saliva yellow,
and imparts a bitter, astringent, and somewhat aromatic
taste.
Powdered rhubarb is frequently adulterated, more es-
]iecially with turmeric or curcuma. This may lie recog-
nized under the microscope by its large, solitary, oval
;■/
Fig. 4111. — Piece ot Round Cliinese
Rbubarb, sliowing the wliite lozenpe-
sbaped reUculalioh on its surface aud
Ibe irregular aiedullary rays on the
section. (Baillou.)
y:;
Rloo.
REFERENCE IIAXDP.dOK OP THE MEDICAL SCIENCES.
starcli grains, and by the fact tliat the particles quickly
impart a lU'cji yellow color to acolorlcss volatile oil close
to their margins, when placed iu contact with it.
Co.vsTiTCENTs. — From a therapeutic point of view
most of the constituents which have been isolated from
rhubarlj are unimportant. An active substance which
has been extracted (usually to the extent of from three
to five per cent.) is "cathartic acid," common to a num-
ber of important purgative drugs. In doses of from
three to live grains it produces the general purgative
effects of rhubarb. It is, however, not a simple suh-
stauce. The resinous constituents remaining after the
extraction of the crystalline bodies named below appear
also to be quite active. This resinous body has been
separated into portions respectively called pha;oretin,
aporetin, and erythroretin. No one, however, has seri-
ously projiosed the sul)stitution of the use of any one con-
stituent of rhubarb for the entire substance or its prep-
arations.
The three constituents which have attracted the most
attention from a chemical standpoint, though the second
only ajipears to have any activity, are chrysophanic acid
(not an acid however),' emodin, aud rheiu. They are
successively, in the order named, oxidation products
from some'oriainal body which has not been determined,
thus: Chrvsophanic acid, C',sHk02.(OH): : emodin,
C,5H,0;.(On)3; rhein, C, Jl60.;.(OH)4. Rheotamiic acid
is a glucoside yieUling rlieumic acid. There exist also
an irastudied bitter iirinciple, an odorous oil, also a de-
rivative product, about two-thirds of one per cent, of fat,
starch, and calcium oxalate, the last reaching to a fourth,
or possibl\' more, of tlie weight of the drug.
History and V.vrieties. — Rhubarb has been u.sed in
China from the remotest ages (2700 B.C., Fluckiger). and
possitdc references to it are found in the earliest Euro-
pean books on medicine. As early as the .seventh cen-
tury of our era, there can be no doubt of its occurrence
in Euroi)e, and by the tenth or eleventh it was well
known and highly valued.
For about a hundred years previous to 1800 the Rus-
sian Go\'e'-umeut monopolized the rhuliarb trade between
Siberia and the Chinese provinces, aud established an ex-
ceedingly strict ins])cction of all the roots exported that
way, condemning and destroying all but those which
were ab.solutely perfect. In this way an exceptionally
fine finality was obtained, and exjiorted, after iTs long
haril jouiiiey, from Moscow. Curiously, in England and
this country the old aud entirely hiappropriate name
" Turkey rhubarb " was given to this variety. Since IWIJO
this inspection has been discontinued, and this grade of
rhubarb has entirely disappeared froiu English and
American commerce.
The great liulk of the present comtnercial product is
known as Canton rhubarb, though this name also has
ceased to be descriptive.
Sliensi rhubarb is preferred
to Canton, aud a specially
fine variety is that known
as Tze-chueu. The round
pieces are in general prefer-
red to tlie flat aud tlie natural
to the high-dried. For house-
hold use rhubarb is frequent-
ly cut into pretty little forms,
fingers, crescents, stars, etc.
Action and Use. — "When
chewed rhubarb stiimdates
the saliva. In small doses,
in the stomach, it seems to
act as a digestive stimulant;
in larger ones it a))pears to
be a simple purgative, hast-
ening along the contents of
the bowels b.v increased per-
istalsis, carrying the liquid contents of the small intes-
tine ra|iidly down, to soften and force along the more
solid mass in the colon and recttun. Intestinal secretion
is su))i)0.sed tn lir less stimulati'd by it than by salines
.—European Rhubarb.
(Fliiokiiier.)
'i
Fig. 411:*.— European Ithubarb;
surface of a transverse see-
tiuu. (Fliickiger.)
or the cathartic resins. Its coloring matters are ab-
soTlied. and may tinge the milk and urine.
Rhubarb is mild and fairly certain in its action; it pro-
duces comparatively little pain, no depression in moder-
ate doses, and its action is not prolonged. The tannin in
it is credited with producing some constipation after its
use, but the simple emptying of the bowels without iiTi-
tation of the mucous mem-
brane would be enough to
explain tliis result. Rhu-
barb is given in almost all
conditions in which simply
emptying the bowels is de-
sired.
ADMINISTIiATION. — Rb U-
barb is offered by the Phar-
macopa'ia in a great variety
of forms; it is also found in
a good many of the popular
proprietaiy laxative mixt-
ures. It makes a fine, deep
yellow powder which is
sometimes given, but not
often, (m account of its very
nauseous taste. Two or three
decigrams (gr. iij. to v.), once
or twice a day, would be a
veiy mild tonic-laxative dose ;
a single dose of 1 gm. (gr. xv.) is mildly, while one of 2
gm. (gr. XXX.) would be severely, cathartic. Rhubarb iu
substance is frequently taken b.y chewing and swallow-
ing a piece of the root as large as a pea or a bean, once a
day or so, preferably after eating; the taste, when the
drug is used in this way, being less nauseous than that
of tiie powder. The tonic, almost carminative, action of
rhuliarb upon digestion, has led to its being widely useil
iu this way. The following are the preparations of the
United States Pharmacopeia;
Extract, of about 300 per cent, strength ; fluid extract ;
tincture, containing 10 per cent, each of rhubarb and
glycerin and 3jiercent. of cardamom; aromatic tincture,
tw'ice as much rhubarb. 10 per cent, glycerin, 4 per cent,
each of cassia-cinnamon and cloves, and 2 per cent, of
nutmeg; sweet tincture, 10 per ceut. each of rhuliarb
aud glycerin, 4 jier cent, each of liquorice and anise, and
1 per cent, of cardamom; compound powder, 2.5 per
cent, of rhubarb, C.5 per cent, of magnesia, and 10 per
cent, of ginger; pills, each containing 0.3 gm. of pow-
dered rhuliarb and 0.06 gm. of scap; compound pills,
each containing 0.13 gm. powdered rhubarb, 0.1 gm.
purified aloes, 0.06 gm. powdered myrrh, and 0.00.5 c.c.
oil of iiejipermint. From the fluid extract is prejiared
tlie syrup, of 10 per cent, strengtli, with 1 per cent,
potassium carbonate, 5 per cent, each of glycerin and
water, and a little spirit of cinnamon ; also the mixture of
rhubarb and soda, containing o.g per cent, each of sodium
bicarbonate and spirit of peppermint, 1.5 percent, fluid
extract of rhubarb, 3.5 per cent, glycerin, and a little
fluid extract of ipecac. The aromatic syrup is made of
1.5 per ceut. of the aromatic tincture, with 85 per ceut.
of syrup.
Allied Plants. — The genus contains about twenty
species, most of whose roots have qualities sinnlar to the
above. Several of these, i?. rhnpunUcum, and others,
are cultivated iu Austria and elsewhere in Europe! for
this juirpose, and the European product is trimmed and
prepared so as closely to imitate the Chinese. It can
generally be told by its didler color, more spongy text-
ure, absence of gritty crystals wlien chewed, and tlie
more regular arrangement of its medullaiy rays; the
stellate spots are absent. It is very inferior to genuine
rhubarb. Henri/ H. Jiushi/.
RICE. See Starch.
RICE BODIES.— (Synonyms: Corpmcida Ori/soidcti ;
vhloii-sinl Ijodics.) Inchronic tuberculous affections of
the tendon sheaths, bursoe, and synovial membranes.
974:
REFEREKCE HANDBOOK OF THE MEDICAL SCIENCES.
RIee.
Rickets.
there are frequently formed small hyaline bodies resem-
bling grains of rice or boiled sago. On section they are
either homogeneous or granular, or concentrically lami-
nated. In the central portion there is usually a small
cleft. Many of these bodies possess a definite ca]isuli',
whicli is narrow, and is made up of concentric layers
containing a varying number of nuclei. In the main
mass nuclei are either not present at all or are found in
very small numbers. Others consist of a hj'alinc fibrous
tissue which in certain parts may show few uucl<i.
Some are made up wholly of fibrin, Avliile in otliers the
fibrin con,sisls of bands seatlered throughout the connec-
tive tissue. Giant cells are often present. As shown by
the staining reactions these bodies for the greater part
represent organized masses of fibrin which have under-
gone a hyaline change. All stages of the process may
be seen. Some of the bodies stain throughout as fibrin
witli the Weigert fibrin stain; in other cases the hyaline
substance stains red witli Van Gieson's method. Double
staining shows in others the presence of fibrin threads
in the midst of the iij'aline fibrous tissue. Van Gieson's
method causes some of the liodies to take a yellow or
brownish stain, the material of which these are composed
not giving a fibrin reaction. A deep dilTuse blue stain-
ing with ha-matoxylin shows the presence of lime salts
in others. There has been mueli dispute over the origin
of the fibrin in these bodies, some writers holding that it
is the result of a "fibrinoid degeneration " of granulation
tissue. The actual facts, however, tend to support the
view that the majority of these bodies are formed fronr
masses of exudative fibrin, which becoming organized
undergoes a hyaline change.
As shown by the staining the genesis and nature of
these bodies must vary. They may consist of fibrinous
masses loosened froiu a fibrinous exudate covering tlie
inner surface of the tendon sheath or bursa; or of partly
organized masses of fibrin which have become loosened.
The most common mode of formation is from loosened
masses of tuberculous or S3-philitic granulation tissue.
The inner surface of the tendon sheath fjr bursa in such
cases presents a polypoid or villous apjiearance due to
organizing masses of filirin. The connective tissue
grows into the fibrin, organizing it, antl after organiza-
tion becomes changed into a h3aline substance possessing
no nuclei. At the end of the villi there are thus formed
more or less firmly attached hyaline liodies, which wlien
loosened from their attachments become rice bodies.
Around the detaelied body fresh deposits of fibrin take
place, through the organization of which the body ac-
quires a concentric laminated appearance. The hyaline
change may begin at the periphery or centre of the body,
or in any portion of its substance. It is also probable
that portions of necrotic tissue loosened from the inner
surface of a tuberculous Iiygroma may give rise to rice
bodies.
By the majority of writers the presence of rice bodies
in the joints, in tlie sheaths of tendons, or in the burs:t.
is regarded as positive evidence of the tuberculous nature
of the affection. In the great majority of cases the proc-
ess is undoubtedly tuberculous; tubercle bacilli may be
found in nuiubers upon the surface of the rice bodies,
and occasionally witliin their substance. The formation
of these bodies is, however, characteristic of a fibrinous
exudate within the structures named, whether due to
tuberculosis, sypliilis, or other infection. Tlie number
of the bodies bears a certain relation to the chrouieitj' of
the process.
In many cases great numljers of the bodies may be
present within the distended sheath or hygroma. In
some cases they may be distinctly felt, and give a marked
crepitation when moved upon each other. On cutting
into the sac the little hyaline bodies may roll out in great
ninnbers. Aldred Scott Wart/tin.
RICHFIELD SPRINGS.— Otsego County, New York.
Post-Officj;. — Richfield Springs. Hotel and cottages.
Access. — From New York via New York Central and
Hudson River Railroad; also via Delaware, Lackawanna,
and Western Railroad. From Philadelphia viit Delaware,
Lackawanna, and Western Railroad. From Washing-
ton and Philadelphia vui Pennsylvania Railroad.
This charming summer resort is picturescjuely located
on Lake Canandarago, at an altitude of 1,750 feet above
the sea-level. Richfield may be clas.sed among the most
attractive of our summer resorts. In writing of his visit
here Charles Dudley AVarner well and truly said, "The
charm of Richfield is in tlie charaeler of its landscapes."
It is scenery "that one grows to love, and that responds
to one's every mood in variety and bi'auty. In a whole
summer the pedestrian will not exhaust the inspiring
views, and the drives over the hills, round the lakes, by
woods and farms, increase in interest as one knows them
better. The artist is here year after year, one season
being too short to satisfy the demands which the charms
of the region make upon his love of the beautiful." The
art of man has added much to the natural attractiveness
of the location. The greatest attraction of Richfield,
however, is found in the fine White Sulphur Springs.
There are sixteen springs at this resort, and some of
them have become widely celebrated. The bathhouse
in connection with the springs is one of the most com-
plete in the world, and jirovides for the therapeutic use
of water comliined with massage and electricity in a
thoroughly scientific manner. It contains sixty-seven
rooms for sulphur balhs, Turkish and Russian baths, a
large swimming pool, a pulverization room, inhaUuion
rooms tor the treatment of bronchitis and catarrh, elec-
trical rooms, douche rooms, and a sun bath. The bath-
house is situated on the grounds directly in front of the
Hotel Earlington. The following analysis of the princi-
pal spring, l;nown as the White Sulphur Spring, was
made by Professr.r Chandler, of New York:
One United States gallon contains (solids); Sodium
hydrosulphate, gr. 1.73; calcium hydrosulphatc, gr.
0.U9; potassiuiu sulphate, gr. 1.67; calcium sulphate, gr.
112.34; strontium sulphate, gr. 0.01; magnesium sul-
phate, gr. 5,1.5; sodium hyposulphite, gr. 0.38; magne-
sium bicarbonate, gr. 31.74; sodium chloride, gr. 0.52;
lithium chloride, gr. 0.(J2; silica, gr. 0.()4; and traces of
alumina, barium sulphate, iron bicarbonate, and calcium
pliosjihate. Total, 154.28 grains.
Sulplnireted hydrogen gas is present to the extent of
14.20 cubic inches in each gallon. This spring, it will be
observed, is very heavily charged with sulphureted
hydrogen gas. Other important springs at Richfield are
the Iron and Magnesia Springs, besides additional sul-
phur springs. The drinking-waters are obtained from
siirings west of the village, and are pure and abundant.
A course of baths at Richfield lias been found of value
in cases of insomnia from overwork, in nervousness, in
stomach disorders resulting from abused digestion, in
chronic malarial infections, in gout and rheumatism, and
in some of the disorders of the liver and kidneys. The
visitor will find in the Hotels Earlington, St. James, and
smaller places accommodations to please any taste or ex-
chequer. James K. Crook.
RICKETS.— (Synonyms: Rhachitis or Rachitis; Fr.,
Nouiire, liuehitisine ; Ger., lUiaehitis, Eiiqlische Krank-
luit.)
Definition. — A general disease of infancy and early
childhood, chiefly characterized by alterations in the bony
skeleton and by impaired nutrition. In severe cases there
may also be changes in the viscera.
History. — The disease was knowu to the writers of
antiquit_v, but was often confused with other maladies
causing deformities of tlie skeleton, especially with tu-
berculous spondylitis. AVe owe the first accurate descrip-
tion of the cond'ition to the English physician Glisson,
who published a work upon the .subject in 1650. The
disease .seems to have been especially prevalent in Eng-
land at that time and later, and has always been the sub-
ject of study by English physicians; hence its name of
the Euglischc Kranklieit.
During the eighteenth century the French physicians
made many contributions to our knowledge of the rachi-
975-
iCickcts.
Kiekcts.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
tic jiroccss. while more recently the Germans have been
most active. Among the names whicli will always be
connected with the history of the study of this important
disease of infancy may be mentioned Trousseau, Guiriu,
ELsasser. Virchow. KiJlUivcr, RolvitansUy.and Kassowitz.
Etiology. — The nature of tlie agent which underlies
the pathological changes wliieli we find in racliitic chil-
dren is still luiknown. It has been assumed to be caused
by an insufficient amount of calcium salts in the blood.
and color has been given to this theory li_y the oft-qtioled
experiments of Sutton and others, in wliich rachitic
changes were thought to be produced in animals by nour-
isliing them on food practically free from lime salt.s. It
has been recently shown, however, that the changes
which were produced in animals by this means are rather
those of osteomalacia than a true form of rickets. Tlie
similar belief that an imperfect ab.sorption of the lime
.salts from the intestine was responsilile for the rachitic
condition has been shown to be tmtenable, for the urine
of rachitic chililren contains an amount of calcium (|uite
sufficient to supply the needs of thi' skeleton; and if
larger amounts of calcium salts are administered to either
rachitic or healthy children the excess is i apidly excreted
in the urine.
The chemical theorj'that the lime .salts either could not
be deposited because of the dimini.shed alkalinity of tlie
blood or that they were dissolved out l>y the action of an
acid circulating in the fluids of the liody, lias been shown
to be without foundation. The blood of rachitic rhildren
contains m-ither an excess of acid nor an excess of alkali.
The view brought forw.-ud by Kassowitz that the bone
changes are purel.y intlammatory in nature is not in entire
accord with the anatomical lindings. The most recent
suggestions are that the disease is an infection or that it
is an auto-intoxication. Neither view has been supported
by sufficient experimental evidence to warrant its accep-
tance, however attractive the assumption m,-iy be. Al-
though, therefore, we do n<it know the actual cause of
the disease, there are many predis|)o.sing conditions which
are known. Among these are chiefly imperfect food and
unsuitable hygienic surroundings.
The disease is most frequently seen among the children
of the poor, especially those who have been reared upon
an artificial diet containing large quantities of carbohy-
drate and small amoiuits of fat. It is rare in children
who have been breast-fed, the exceptions being princi-
pall}' the children of the laboring classes, where the
mother begins to work soon after the delivery of the
child, or in children who have been nursed for a long
period until the milk becomes insufficient for the needs
of the infant.
Children fed upon sweetened condensed milk are fre-
quently racliitic, wiiile those obtaining the unsweetened
form are not likely to sulfer. Boiling the milk is also
thought to set up obscure changes in the composition of
that fluid which affect the nutrition and may cause
rickets and especiall_y scurvy. The exact form in whicli
the liygienic factors exert their influence is not so clear
as it is with food. Sonic oliservers, notably Jle\', are in-
clined to consider lack of light and fresh air as very jio-
tent forces in the production of the rachitic jirocess;
others, for example Lange, regard the liygienic factor as
oomparativelj' unimportant and, tliough acknowledging
that tlie disease is more prevalent in cities where the
hygienic surroundings are had. they lay the most stress
upon the food factor. It is certain, however, that rickets
is very infrequent in the country, in high altitudes, and
in the tropics. It is also true that the children born in
these conditions are much more likely to Ik; breast-fed
than those in the tenement districts of large cities. The
influence of race in the susceptibility to rickets is .seen in
the negro and in the Italians. The children of both of
these races, when eonfiued to the tenement districts in
cities, offer our most marked examples of advanced and
severe rickets. Congenital influences play some part in
the causation of rachitis, tliough at jiresent the trend of
opinion is against a true congenital form of the disease.
Cases so descrilied are regarded as distinct from rickets,
though showing bone lesions closely resembling those
seen in rachitic children. Parental syphilis is a strong
predisposing factor in the production of rickets, though
it does not seem to be the cause of the disea.se. as Parrot
attempted to show. Tuberculosis and alcoholism in the
parents also predispose to rickets, chiefly by reducing the
child's power of resistance. Both sexes are ecpially sub-
ject to the disease, though in hospital statistics a "larger
number of males will be noted. This apparent anomaly
is due to the fact that a larger number of male children
are received for hospital treatment than female, and large
statistics, including private cases, will show about cqiud
numbers affecteil. The clinical development of the dis-
ease is most noticeable in the second year of life, though
a large proportion of children show signs of tlie disease
during the first year. After the third year the disease is
infrequent. Late cases have been described in children
even up to the twelfth year, but such observations are
extremelj' rare. The disease is one which concerns the
period of the most active growth and formation of tlie
bones, progressively' diminishing as the skeleton assumes
its definitive condition.
P.\TUOLOGY. — The constant and characteristic lesions
of rickets are to be found in the bones; the visceral
changes are comparatively slight and secondar3-. A ra-
chitic bone, when examined in a fresh condition, is softer
than normal, and the actively growing portions — that
is, those parts near tlie epiphyseal junction in the long
bones and the ossification centres of the cranial bones —
are larger and much more vascular than in uininal bones
from a child of the .same age. The periosteum is thick-
ened and strips with some difficulty from the surface,
leaving irregular areas of soft, newlv foi-med bony tissue
adherent to tfie inner layers of the periosteum. The bone
from which the periosteiun has been removed is soft and
very vascular, and has a spongy ajipearance. The same
changes may be noted if one of tlie long bones is split
o|ienand the internal layer of tIiep<'riostenm isexamined.
Tlie calcification zone at the epiiiliy.seal junction, which
in normal bone is well defined and narrow, is broad and
not sharply defined in rachitic hone, and may be quite
unrecognizable. In the later stages of the disease, when
the acute jirocess has ceased, the rachitic bone is usually
harder than normal bone, especially where an active pro-
duction of new bony tissue has taken place. This new-
formed bone may resemble ivory in its density and text-
ure. FreqiieuUy, however, when the restoration of the
bone has been incomplete, it is soft and porous, and con-
tains a considerable quantity of fat scattered through the
substance. Such bones are very light and fragile, and
green-stick fractures are fre(pient. The microscopical
changes correspond to the gross lesions. The centres of
the flat hones of the skull are vascular and the bony layers
are replaced b_v osteoid tissue. This may be very abun-
dant in amount, in which case the hone is so soft that it
can he easily indented by the flnger, and gives a soft
crepitus when palpated, a condition known as cranio-
tabes; or the osteoid tissue may he located in small areas,
a few millimetres in diameter, and give the bone an ap-
pearance of a coarse sponge. The osteoid thssue may
not ossify, and the aperture thus left in the bone may
he closed simply by the iiericianium. Such marked
changes in the regular course of os.sification of the cranial
bones are as a rule rare, and confined chieflv to the jios-
terior portion of the cranium.
The more frequent course is for the osteoid tissue to
be gradu.-illy replaced liy bone, either by direct o.ssifica-
tion or by the replacement of the abnormal tissue by nor-
mal bone. When the osteoid tissue ossifies directly the
structure ]n'odueed is as a rule more dense than normal
and resembles ivory. In the long bones the most marked
lesions are at the epiphyseal junction. It should be re-
membered, in order to understand the pathology of the
subject, that the hones grow in length at this point, while
they increase in diameter by the production of new bone
from the inner layers of tiie periosteum. At the same
time the medullary cavity is enlarged by absorption of
the inner layers of bone! In rickets the pathological
iiTG
REFERENCE HANDBOOK OF THE JUiDICAL SCIEN'CES.
Rickets.
RIokets.
changes consist in tlie distortion of these uoi'mal comli-
tions. The inner layers of tlie periosteiini produce au
excessive amount of very vascular osteoid tissue, which
imdergoes either ossification or absorption. Tlic ossifica-
tion which takes place is of a very imperfect sort, so that
the new bone is soft, spongy, and very mucli more vas-
cular than normal. In the medullary cavity the process
<if absorption is very irregular and" often excessive in
amount. The cavitj' may extend into the epiphysis, or
it may be filled with osteoid lissue, which replaces the
normal bone marrow and thus may contribute to the
anamiia from which rachitic children sulTer b\' directly
diminishing the production of the blood cells. Tlie
course of the bone growth, which taUes place at the ejii-
physeal junction, is also disturbed liy a combination of
the same processes which contribute to the irregular bone
production by the periosteum. The cartilaginous area of
the epiphyseal portion of the bone is broken up and pene-
trated by a vascular osteoid tissue, which may be prema-
turely ossified or may form marrow cavities. The carti-
lage cells also proliferate and become dislocated from their
noi'mal positions. Absorption of these masses may occur
or the}" may become ossified. The normal calcification
zone becomes irregular and is broken up by the advance
of the osteoid tissue into the epiphysis. After a variable
period of from three to eighteen months the active proc-
ess ceases and the formation of bone begins in a normal
manner. The swelling of the epiphyses diminishes, the
extreme Tascularit_v is reduced, and the areas of osteoid
tissue become calcified. The structural reparation is
never quite complete, though a large amount of the dis-
tortion of the bone may disappear.
The effect of these changes in the str\icture of the
bones is first to delay their growth, and second to cause
deformities. The results of the first condition may be
seen in the small bodies and shortened limbs of children
that have sntTered from rachitis of a severe type. The
softness of the bones permits their easy distoriion under
pressure, as is so well .seen in the chest, while the deform-
ity which results from growth alone is best noted in the
square form of the cranium or in the curvatures of the
upper extremities.
The lesions of the viscera are not an essential portion
of the rachitic condition, but they are quite frequently
met with in severe cases. The lungs frequently show
acute or chronic bronchitis or a bronchopneiunonia.
When the deformity of the chest wall is considerable,
the lungs may be the seat of a marked cmiihysema in the
areas upon which there is no pressure, while tho.se por-
tions which are compressed by the incurving of the
thorax may be in a condition of atelectasis. The spleen is
frequently increased in size owing to an interstitial
splenitis of a chronic form : the liver occasionally sliows
similar changes. The lymph nodes are often swollen and
hyperplastic. Hydrocephalus is no more freriuenl in
rachitic children than in others, the enlargement of the
head being due to the increase in thickness of the cranial
bones. The muscles of the body are flabby and atro-
phied.
Symptosis. — The symptoms of the disease vary with
the stage of the malady. The earliest symptoms are
restlessness during the night, sweating of the head, cra-
niotabes, and the beading of the ribs. The beading of
the ribs is an especially early and valuable symptom, and
consists of a row of nodules formed at the costo-chondral
junction. The beading is often more marked internally,
especially in cases with extreme incurving of the che.st
wall. The craniotabcs is often an early symi>tom, and
may best be demonstrated by gently palpating the poste-
rior sm-face of the head with the tips of the fingers.
Small areas, softer than the remainder of the skull, will
be fell, and the tissue may crackle under the jiressure.
In rachitic children the skull appears relatively large
and the frontal prominences are well marked; alterations
w-hich, when associated with the ]>rominent jiosterior part
of the head, give to the latter the characteristic square
appearance, the t(te carvee of the French. The anterior
fontanel is larger than normal, and its closure may bi'
Vol. VI.— 62
delayed even to the third or fourth year. The two lat-
eral openings are often late in closing, as are also the
sutures. The su]jerior and inferior maxilUi? are slightly
distorted in seveic cases, chietly by muscular action. The
teeth are delaycil, not a]ipearing until the end of the first
year, or even later, and there are often irregularities in
the time and order of appearance and arrangement of the
different groups of teeth. Some observers consider the
teeth of rachitic children to be especially ])rone to decay.
The thorax, as has been mentioned above, is frequently
deformed. In mild cases the only change noted is the
swelling of the costo clmndral junction, forming the so-
called rachitic rosary. The llexibility of the bones of the
chest permits the pressure of the atmosphere to exert a
considerable infiueuce in the production of deformities,
so that a distinct deju'cssion frequently exists along the
line of the ends of the ribs, or there ma_v be a transverse
groove parallel to the line of the insertion of the dia-
phragm. The deformities known as funnel breast and
pigeon breast are largelv dependent upon an antecedent
rachitic process. Any obstruction to the free admission
of air to the chest, such as is associated with chronic
bronchitis, enlarged ton.sils, or adenoid growths of the
pharynx, is liki^ly to exaggerate any chest deformity.
The lessened capacity of the thorax causes the liver and
spleen to be much more prominent than their increase in
bulk from hyperplasia would warrant. The abdomen is
usuallv distended, the enlargement being chietly due to
the distention of the intestines with gas. aided by the
weak condition of the muscles of the gut wall and of the
abdomen.
In rachitic cbildreti the spinal column is much more
flexible than normal, owing to the imjierfect ossification
of the vertebra' and the relaxation of the spinal ligaments.
When such children assume an erect position a marked
kyphosis can usually be noted, which disappears when
the child assumes a recumbent posture. The curve of
the rachitic kyphosis is rounded in form, and involves the
bodies of a number of vertebra', in contrast with the sharp
projection of the k\'photic curve in spinal tuberculosis.
There is usually a comijensatory lordosis in the lumbar
region and rarely a left-sided scoliosis.
The clavicle and the scajiula may be curved slightly.
The pelvis is often the site of serious deformities. It is
flattened laterally and the promontory approaches the
arch of the jnibis, wliicli is also narrowed. The approxi-
mation of the promontory to the pubis is in part due to
tlie rotation of the sacrum on a horizontal axis, in part
to the inward displacement of the ischia. These pelvic
deformities are often periuanent, and render the bearing
of children difficult or impossible. The extremities very
early show the characteristic enlargement of the epiphy-
ses, especially of the lower end of the radius, ulna, and
tibia. Such epiphyseal swellings may also ajjpear at tlie
upper and lower ends of the humerus and femur, but are
much less marked.
If the disease is of a severe type the diapliyses of the
bones may become curved. The convexity of the femur
is forward and outward ; that of the tibia and fibula is
often lateral, but may also be forward ; that of the radius
and ulna is toward the extensor surface, while the humerus
is bent forward. The irregular growth of the epiphys-
eal ends of the bones, comliined with the curvature, gives
rise to deformities which are especially serious in the
lower extremities. The axis of rotation of the knee-joint
may remain Irorizontal. or. as is .seen in advanced cases,
tlieaxis may be rotated either inward or outward, so that
a simple osteotomy of one bone will not suffice to correct
the deformity, but both the femur and the tibia will have
to be severed and the axis of the joint restored to its nor-
mal rotation plane.
The cause of these deformities is not. as is usually as-
sumed, the result of allowing the child to walk before
the bones are sutticiently haril. but is due to the rachitic
curvature of the shafts of the bones and to the uneven
enlargement of the comlylcs of the femur. A moderati^
amount of deformity may be increased, however, by al-
lowing the child to walk while the rachitic bone is still
9TT
Rlrkrts.
Riviera.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
soft. The otlier symptoms of the disease not connected
with tlie slieleton are eliietly those relatius to the diges-
tive, respiratory, and nervous systems. Tlie frequency
of respiration of racliitic cliildren is increased in those
cases in whicli there exists a considerable diminution of
T:lie respiratory capacity, owing to tlie defnnuity of tlie
chest wall and the pressure of the gas-distended intestines
against tlie diajihragra. Bronchitis and atelectasis very
frequentl}' complicate the respiratory and circulatory
changes produced by the narrowing of the thorax.
LaiTngi.smus stridulus is a not uncommou complication
of rickets, and is responsible for a considerable prt>por-
tion of the fatal terminations of the alTection. General
convulsions are a frequent complication of the disease,
and tetan}- is also oeeasionally seen.
A chronic gastro-intestinal catarrh is usually present in
rachitic children, and is easily increased in severity liy
slight indiscretions in diet. The stools are either consti-
pated or thin and Huid. They are as a rule paler than
normal and may be very foul-srnelliug. They contain an
excess of calcium salts derived in part from tlie food and
partly from the softening bone. The blood shows an
ana?mia of the chlorotie type with a moderate reduction
of the red cells and a considerably les.sened haemogloliin
content. A moderate leucocytosis ma_y also exist, which
is in all probability not characteristic of the disease, but
is dependent upon the respiratory and intestinal compli-
cations. The urine shows no striking alterations. Occa-
sionally tliere may be a trace of albumin present and a
diminution in the excretion of the ]ihosphates and the
chlorides. There is no alteration in the amount of lime
salts excreted in the urine.
Fever is not a regular accompaniment of the disease.
When present it is due to one of the complications. The
skin of the rachitic child is ]iale. Eczema is not infre-
quent, and occasionally multiple skin abscesses are seen.
Severe sweating is the rule in all cases of rickets. The
subcutaneous fat is well preserved, though the patients
are soft and flabb\'.
Coi:rse and Prognosis. — Cases considered to be conge-
nital rickets have been described b}' competent observers,
but as a rule the symptoms of the disease begin in the
latter half of the first year of life; and in a majority of
the cases tlie disease runs its course inside of eighteen
mouths or two years. Very chronic cases, lasting for
years, are exceedingly infrequent. The condition which
has been classed by some clinicians as acute rickets is proli-
ably a form of scurvy'. The prognosis of au uncompli-
cated case of rickets is good so far as life is concerned.
The disease is self-limited and often disappears without
treatment when the child is old enough to begin a mixed
diet. The prognosis of the bone deformities is not so
good, and many of the severe cases are permanently de-
formed, though surgical interference will often allow the
complete correction of the deformities of the lower limbs.
Death results in all cases from some intercurrent disease
and not from the lioue lesions alone. i\Iarasiiins and
laryngismus stridulus are responsible for a considerable
proporticm of the fatal cases, while the others are carried
off either by bronchopneumonia, or by tuberculosis, or
by some intestinal condition. Whoojiing-cough is au
especially dangerous coniplieatii>n in rachitic children
with marked deformity of the chest.
Di.\GNosis. — A well-develope(i case of rickets is easy
of recognition, especially at a time when the bone lesions
are most prominent; but in children in the early stages
of the disease the diagno.sis is more dillienU, and "must be
made from the general symiitonis. The most important
of these are the restlessness at night, the sweating of the
head, the general tenderness of the body, and tlie malnu-
trition. The craniotabes and the persistent and wide-
open fontanel are valuable synqil.oms, as is also the late
eruption of tlie teeth. The bone lesions of syphilis are
in the nature of thickenings under the periosteum rather
than of an increase in the size of the bone, and the necro-
ses seen in syphilis are not present in rickets. The other
evidences of congenital lues will aid in the differential
diagnosis. Confusion between the kyphosis due to tu-
berculous spond3'litis and that due to rachitic softening
of the vertebiw and intervertebral cartilages will be
avoided if it be remembered that the curve in tubercu-
lous disease is shar]i and alfccts the bodies of onlj- one
or two Ixnies, while that due to rachitic disease is more
gradual and less limited. The rachitic bones are not very
tender to |iressure, and the kj-phosis can be overcome by
placing the patient on a flat mattress. Pott's disease is
rarely seen in children under two years of age, a time
when rickets is most likely to be well developed.
Rickets is dilferentiatetl from scurvy by the absence of
the ecchymoses and the changes in the gums.
Pi!(ii'iiYi,.\xis. — The prevention of the disease depends
naturally U|)on the avoidance of the conditions deter-
mined as the immediate factors in the causation of the
malady. This is perfectly possible among people of
good circumstances, but becomes a matter of great diffi-
culty when we must cope with the conditions of tene-
ment life among the very poor.
Every care must be taken with the children of parents
who have previously Iiorne rachitic children, as the pre-
disjiosition increases with each child. The mother should
be allowed to nurse the child if it is po.ssible fcu' her to
avoid hard, manual labor during the course of lactation.
But if she is not able to do this, the better plan will be
to feed the child on Pasteurized cow's milk. A con-
venient form of ajiparatus for this purpose, and one re-
quiring a minimum of intelligence on the part of the
luser, is that devised by Dr. R. G. Freeman. During the
hot .season of the year the child should be sent to one of
tlie seaside hospitals or to the cimntry for a time; or if
this is inipo.ssible, it should be given every opportuuit}'
to obtain fresh air that is po.ssible.
Treatment. — The care of rachitic children sliould be
begun as early as the diagno.sis can be made, in order to
prevent severe bone lesions and also to obtain the maxi-
mum result from the treatment, as the best results are
secured in cases in which the disease has been recognized
in the first stages. The diet should be altered from that
under which the child has developed the disease to one
which is more nearly normal. If the child is breast-fed
the quality of the mother's milk should be determined,
and if necessary it may be supplemented by cow's milk in
the ]iroper modification. If the mother cannot nurse the
child, it must be fed upon properly prepared cow's milk.
The diet should In: rich in fats and proteids, and contain
but a small amount of carbohydrates. This will elimi-
nate all of the proprietary infant foods. Cod-liver oil
should be administered in small doses as soon as the
stomach will tolerate it. Arsenic and iron are useful to
combat the anaemia. The excessive sweating may be re-
lieved by cool sponging, and by atropine in doses of
about gr. ^^ per day. Opinions vary as to the value of
the phosphorus treatment of rickets. Originally recom-
mended l)v Trousseau, it lias been reudercd popular
through the efforts of Kassowitz, who regards it as a
specific. It may be administered in the form of a solu-
tion in oil, made by diluting the official oil of phosphorus
with olive oil, in doses of gr. -r^^ three times a day after
meals. The use of extracts of tlie thyroid, thymus, and
adrenal glands has not given satisfactory results.
The hygienic treatment of the child is nearly as im-
portant as the correction of the food. The child sliouM
spend a large portion of the day in the open air and in
the sun if possible. Such open-air treatment is best car-
ried out in the country; but if this is impossible, the
child should be taken on excursions on the water or to
the countiy, and during the rest of the time be kept in
the parks and open squares of the city. The roof of one
of the tenement houses is better than the street for such
a child, and if the weather is not too hot such a place is
often the best possible. The child will be strengthened,
and is much less likely to catch coUl, if it is sjionged otf
with cold water every day. The addition of some sea
salt to the bath is of u,se if the child is strong enough to
stand the stimulus, while massageor even gentle rubbing
of the body and limbs before or after the bath is of the
greatest value in keeping up the general nutrition.
978
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Kl<'k<'l8.
Riviera.
The correction of the deformities of the extremities is a
matter of surgical interference ; but much can be done to
prevent (lie curvature from becoming severe by not
allowing the child to assume a posture which will in-
crease the deformity, and also In' keeping up the muscu-
lar tone. The kyphosis may be relieved by allowing the
child to sleep on a Hat, hard mattress without a pillow.
If the deformity of the occiput is marked, the pressure
may be prevented by the use of a firm horse hair pillow
with a concavit}' to receive the flattened portion. If the
kyphosis is extreme in a child which is old enough to be
about, and in which the bones of the legs are firm enough
to permit walking, it maj' be advisable to fit the thorax
with a jacket or a steel brace, which should be worn
only when the child is in an erect posture. The use of
braces in order to prevent or to cure deformities of the
lower extremities is of but very slight benefit. It is bet-
ter to wait in these cases until firm ossification of the
bones has taken place and then to correct the deformity
by a proper osteotomy. Francis Citrtcr Wuod.
RIGOR MORTIS. SeeCa<1arer,Lcrj<ilSt,itNs/>f.
RIO DE JANEIRO, BRAZIL.— Rio de Janeiro, the
largest city in South America, with a pojiulation of
about 779,000, is situated upon the western side of one of
the most magnificent harbors in the world. It is in no
sense a health resort, — indeed, quite the contrary, — but it
is mentioned as an illustration of a tropical or equatorial
climate, and also to convey some knowledge of its cli-
mate to those who for any reason, either temporarily or
permanently, are obliged to reside there.
The city itself occupies flat land with hills In the out-
skirts, and beyond rise precipitously mountains of from
fifteen hundred to three thousand feet high. Foreigners
are advised to make .some of the high-lying suburbs or
towns in the vicinity their place of residence, at least dur-
ing the warmer months, in order to escape the continuous
heat and great atmospheric humidity which combine to
make the climate of the city itself so debilitating.
The population of the "city is a heterogeneous one,
composed of Portuguese, Italians, Germans, French,
English, and negroes. There are parks, a national
library, museum, colleges, various schools, hospitals,
and an observatory. An immense amount of coffee —
.said to be more than one-half of the world's product — is
exported frotn here.
The water supply is good Init somewhat inadequate,
and the drainage is said to be satisfactory. Jlodern sani-
tary conditions exist. In the outskirts, among the hills
and mountains, the scenery is most beautiful and the
vegetation luxuriant.
The climate can be summarized as a moist, warm,
tropical one; warmest in what is our winter and spring,
and coldest in our suinmer and autumn, but at all times
warm or hot. The rainfall is liigli, the largest amount
occurring in our autunui and winter. T)ie air is often
sultry and very del)ilitating. There is general!}' a daily
.Sea breeze from the south and southeast — part of the
trade winds come from tlie southeast ; — it begins about
1 P.M. and lasts until about four or five o'clock. The
nights are usually calm. The climatic chart has been
arranged from the very elaborate series of observations
published by L. Cruls, ilireetor of the Observatory at Rio
de Janeiro, and the reader who desires to make a more
exhaustive study of tliis climate is referred to this work.
The temperature arrives at its maximum at the begin-
ning of February, and at its niininuim the beginning of
July. The mean annual variation does not exceed 10. .S
F., and the mean diurnal variation does not reach 5A" F.
The humidity is really greater than would appear from
the average relative humidity as .shown in the table, on
account of the high temperature, for a humidity of over
seventy per cent, at a temperature of over 70" F. is very
moist. The excessive moisture is one of the striking
characteristics of this climate, and renders the heat so un-
bearable. The daily occurrence of the sea breeze, how-
ever, mitigates this condition. - There is a large amount
of cloudiness and there are but few clear days. The
average yearly rainfall is 42. .5 inches, and there are
one hundred and twentj'-seven days of rain. March and
December are the rainiest months and July is the driest
month. The most prevalent wind is from the south and
southeast — the sea breeze, — and next in frequency is that
from the northwest — the land breeze.
Yellow fever is generally prevalent dtiring the warm
months, and there are severe epidemics at intervals. In
the lowlands intermittent fever prevails. The negro
population suffers from smallpox. There is, at St. Sebas-
tian, a large hospital which was founded in 1888, and
which is devoted to the treatment of epidemic diseases.
One would naturally infer that the mortality in such a
climate and with so many epidemic diseases would be
high, but from the official statistics the average mortality
from 1897 to 1901 is found to be 19.4 per 1,000. Tuber-
culosis causes much the largest number of deaths of any
one disease, and bronchitis and bronchopneumonia come
next in frequency, while infantile diseases rank third.
It would appear, then, that any one individual resident
of Rio de Janeiro had many more chances of dying of
tuberculosis than from yellow fever, and that this dread
disease (tuberculosis) may be quite as prevalent in warm
countries as in cold. Edward 0. Otis.
RITTER'S DISEASE. See Dermatitis Exfoliativa
Keunatoruiii, and Pemphirjus.
RIVIERA, THE. — .\s the various especial resorts upon
this coast have been, and will lie, quite thoroughly dis-
cussed, only a very brief and general reference will be
Clim.\te of Rio de Janeiro. Latitude, 23' .54' 23" S. ; Longitude, 43° 8' 34" W. From Observations
MADE AT THE OBSERVATORY OP RiO DE JANEIRO, PERIOD OF OBSERVATION, NiNE TO FoRTY YEARS.*
Temperature (degrees Fahrenheit) —
Averatre or normal
Mean iiiaxilnum
Mean Miiniiiiiini
HiKhest iir iiia.\imum, 102° Dec. 8th, 1889.
Lowest ur uiinimura, 50.3° Sept. 1st, 1882.
Humidity-
Average relative
Precipitation —
Average in Inches
Wind-
Prevailing direction
Weather-
Average nuraber clear da.vs
Cloudiness+
Average number days of rain
Average number days of storm
Jan.
Feb.
March.
May.
July.
August.
Sept.
Nov.
Year.
79.45°
94.4
66.7
79.6°
94.7
68
78.6°
91.6
66.3
72.4°
84.6
59.7
69.1°
78.3
57.4
70.1°
83.9
57.8
70.8°
S6.1
58.1
74.4°
93.3
61.3
74.2°
88.7
55.8
'»i
80?
79*
79!5
78S
77^
aw
77*
7S«
4.6
4.3
5.3
3.5
1.4
1.7
2 3
4.3
43.5
S. S. E.
S. S. E.
S. S. E.
N. W.
N. W.
N. W.
S. S. E.
S. S. E.
S. S. E.
11.2
61
13.6
6.3
9
(a
12
5.3
12.8
59
11.5
3.8
10.9
60
10.6
9.6
16.8
.50
5.9
.4
13.5
77
6.5
.6
5.7
71
11. 1
■■ 1.4
9.1
64
11.8
131
W
127
30
* " Le Climat de Rio de Janeiro," par L. Cruls, Director of the Observatory of Rio de Janeiro, from observations talsen during the penod of
ia51 to 1890, Rio de Janeiro, 1893. . -
+ 100 is talien to represent a completely covered sky, and 0 a completely clear sky.
979
Roanoke Spriu;L£f«.
Rock Castle Sprlugs.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
made here to this region as a whole, ami the reader is re-
ferred for more detail to the articles upou Ahigiiio, Bor-
diijhfra, Cuniits. Jl//i're», JVerei, AVec, Mtnldin', Monte.
Carlo, and Sa/i lifimt.
The I{iviera is a strip of coast extending B23 miles
along the shore of the Mediterranean at the foot of the
maritime Aljjs and their ollshoots. The jiortiim from
Hyeres to Genoa, 203 miles, is called tlie AVestern Ui-
vii'ra; and that extending from Genoa to Leghorn, 113
miles, the Eastern Riviera. It is the former portion that
is ihc more frequented, and is what is generally meant
when one speaks of the Riviera. The topograpliy of this
region is that of "a long shelf, or rather a series qf
shelves, on the south side of a very high mountain walV,
which wall, up to the level of llwsn shelves, is sub-
merged in the waters of the .sea " (Richards).
The general climatic features of all this region are the
same, varying at one resort or another in certain tninor
aspects according to the local peculiarities of situation,
principally with regard to shelter from the winds.
These climatic featiu'cs — and here the colder months of
the year are only considered — are comiiarative warmth,
moderate dryness, a large auKjunt of sunshine, and great
heat of tlie sun's rays; the small number of rainy days,
and relative imnnmity from cold winds. No station is
entirely exempt from these cold winds, but some are
more exposed than others, as has lieen shown in treating
of the various resorts. ^Moreover, the seasons differ from
one year to another. The latitude of the Riviera has not
so much to do in the production of its miUl winter climate,
but this is rather due to the protection aU'orilcd by the
maritime Alps from the cohl northerly winds, and also
partly to the southern exposure and partly to the warm
water of the Mediteiranean Sea.
The mean temperature for the three cold months (De-
cember to February) according to Weber ("A System of
Piivsiolosieal Therapeutics." vol. iii.. Book I., " Health
Resorts,"" F. Parkes Weber, 1901), is from 47° F. to 49.8°
F. ; for the .six cold months (November to April), about
51° F.
According to the same authority tlie mean relative
humidity is from sixty-inve to seventy jier cent., and the
amiual rainfall from twenty-eight to thirty-one inches,
the greater ]iart falling dining Odolu-rand November.
Tlie princi]ial winds are the northwest — the "mistral,"
a cold dry wind jnevailiug in JIareh; the northeast, ov
"bise,"a cold wind; and the southeast, or "sirocco" a
"warm, wet, enervating wind."
Quoting Weber again, "during the si.x winter months
one hundred days or more may be expectrd to be Ihie
enough for most invalids to be in the oiien air for .sev<'ral
hours."
Besides the danger from the high winds, especially the
dreaded "mistral," tliere is also to be meiitiourd the great
dirt'erence betwern the sun and the shade temperatures,
and the rajiid fall of the temperature after sunset, with
the increased humidity at that time. Tlie dust is also an
objectionable feature of this region. The Riviera season
extends from about the end of October to the end of A]uil.
Abundant and good accommodations, all more or less
expensive, are to be found in all the Riviera resorts.
As to tlie natural attractions of the Riviera, they are
too well known to require any exleiided description.
"Nothing." says Lindsay, "can exceed the loveliness of
this stri|i of flowery coast land, with its jutting crags
and circling bay.s, bounded on one siile by spurs of the
Alps, and on the otlier by the Mediterranean, now glit-
tering in brilliant azure, a,gain rippled into sapjihire by
the breeze." In comparing this region with the littoral
of Southern California, tlu^ latter is undouVitedly superior
in climate, but in beauty of scenery supplfiuenteil by
art, the former is by far the more attractive.
The Riviera is visited in the winter liy great numbers
from Northern Europe, who desire to escape the cold and
more or less cheerless winters of their own rcgi<iu. This
climate alfords a blessed relief for those who desire to
spend the winter in a warm, sunny climate amidst mo.st
attractive sunouiidings. The aged, the feeble, the con-
valescents; those with diminished powers of resistance,
and tiiose sutfering from various chronic affections with
deticient powers of reaction, all find more or less com-
fort, relief, and healing here. The diseased conditions
for which this climate is recommended are chronic brou-
ehitisand emiiliysema. bronchial asthma, certain varieties
of pulmonary tuberculosis, scrofula, chronic pneumonia,
and au;rniia.*
The Riviera is now easily and comfortably reached by
steamers sailing from New York or Boston direct to
tienoa, and from Genoa the railroad runs along the shore
of the Mediterranean parallel with the celebrated Corniche
road for a good part of the way. Express trains also run
from Paris tlirect to the Riviera. Eilirurd O. Otis.
ROANOKE RED SULPHUR SPRINGS. — Roanoke
County., Virginia.
Post-Ofkice. — Roanoke Red Sulphur Springs. Hotel
and cottages.
Access. — Viii Norfolk and Western Railroad to Salem,
thence nine miles north to springs.
This resort is located under the shadow of the outlaying
ranges of the Alleglianies, twelve miles from Roanoke
City. The manifold attractions of the Virginia mountain
region hud here a faithful exemiilification. The high and
dry location, the pure, fresh air, and the unsurpassable
mountain scenery unite to form a most delightful sum-
mer health resort. In the hotel will be found all the
comforts and attractions which go to render a stav at a
watering place enjoyable. The Roanoke Red Sulphur
waters have been examined by Prof. 31. B. Hardin with
results as follows: One United States gallon contains
(solids): Calcium carbonate, gr. 6.54; magnesium car-
bonate, gr. 5.S3; lithium carb(mate, gr. 0,02; manganese
carbonate, gr. 0.02; iron carbonate, gr. 0.06; sodium
chloride, gr. 0.24; ammonium chloride, gr. 0.02; calcium
chloride, gr. O.Oo; strcmtium sul]ihate, gr. 1.71; calcium
sulphate, gr. 2.19; sodium sulphate, gr. 3.04; potassium
sulphate, gr. 0.33; sodium hyposulphite, gr. 0.03; am-
monium nitrate, gr. O.O-J; silica, gr. 0.S3; organic matter,
gr. 0.76; biearbonates, gr. 5.96; and traces of copper
carbonate, lead sulphite, barium sulphate, alumina, and
arsenic. Total, 27.66 grains. The gases present in one
gallon of the waterare: Carbonic acid, 12.4 cubic inches;
sulphiireted hydrogen, 2.44 culiic inches.
These waters are useful in those classes of eases which
require a fairly concentrated sulphur water. They pos-
sess alterative, diuretic, and tonic properties. It will be
observed that they contain an unusually' large proportion
of strontium, an element wlio.se therapeutic properties
are not as yet full}' understood.
The following analysis of the chalybeate spring at this
resort was made by Dr. H. Froehling: One United States
gallon contains (solids): Calcium carbonate, gr. 0.45;
magnesium carbonate, gr. 0.95; iron carbonate, gr. 2.09;
manganese carbonate, gr. 0.09; sodium carbonate, gr.
0.44; biearbonates, gr. 2; and very .small quantities of
sodium chloride, potassium sulphate, sodium sulphate,
aluminum sulphate, aluminum phosphate, silica, am-
monium carbonate, and organic matter. Total. 7.20
grains. Free carbonic-acid gas, 12.30 cubic inches.
This water is very useful in an;emia and debilitated
states of the system. The Roanoke Sulphur Springs are
much resorted to in the treatment of chronic bronchial,
pulmonary, and throat affections. The waters of the
spring, combined with the wholesome atmospheric con-
ditions of the neighborhood, are believed to be almost a
specific for bay fever. J(nnes K. Crook.
ROCHESTER, NEW YORK.— Rochester, N. Y., a city
of 16'.i.(i0S iidiabitants, is situated on lioth sides of the
Gene.see River, seven miles from Lake Ontario. It lies in
the so-called " Lake Region " of the L'nited States, which
region has the climatic peculiarity of great winter cloudi-
ness in comparison with that of the Oregon winter, and
* vide: ".\ Juiut luquirv as to wliat Icindof Patients should lie Seat
to the French liivivra." bv Stanley M. Reudall. M.D.,of Mentnne.aud
Tli'iiiias Linn, M.D., ot Nice.— The Cliuiatulogist, November l"ith, 1S91.
yso
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
ICoaiiok*' S|iriii^h.
Ko<-k ('a8llo Sprlii;:
of the St. Lawrence Valley district. As will be seen by
the climatic chart, the number of clear and fair days arc
least in winter, and the relative humidity is highest. The
rainfall is least in autumn.
"During tlie six months, April to September inclusive,
the relative humidit_y of the atmosphere is maikeclly
lowerat Rochester than at New Yorli. and tlie cloiidiness
is nearlythe same at the two])laces; during the midsum-
mer months it is actually less at the former than at the
latter. Thus, during tlie winter season, Rochester is de-
cidedly damper and more cloudy than New York; dur-
ing the summer season, and especially the midsununer
season. New York is markedly damp<'r aud a trifle more
cloudy than Rochester " (Ricliards, previous edition of the
Handbook).
These springs are located in a glen-like nook formed
by the spurs of the North and Mill Mountains, and they
break fortli from a mass of slate rocli at the base of the
ridge. Tins slate contains large quantities of alumina
and the salts of iron, and tlie springs are formed liy the
percolation of water tliroiigh this mass. Four different
reservoirs, numliered respt'otively No. 1, No. 3, No. 3,
and No. 4, have been formed. The immediate surround-
ings of this resort are very attractive. The hotel and
cottages afford comfortable accommodations. Tlie nu-
merous springs here vary somewhat in their analyses, the
proportion of alum ranging from 6.88 gm. per gallon in
Spring No. 6, to 81.05 gm. in Spring No. 7. Different
chemists liavealsoarrrived at different results iu analyses
of the same spring. The following analysis, by Prof.
Cli.mate op Rochester, N. Y. LATrTUDE, 43° 8'
Longitude,
Y'eaks.
42'. Period of Obseuv.\tiox, Thirteen
Temperature (dejirees Fahr.) —
Averaffp or normal
Avemsjc 'i:iily rauge
Mean df warmest
Mean nf cuWi-sl
Hipliest or maximum
Lowest or minimum
Humiciity—
Average relative
Precipitation-
Average in inches
Wind—
Prevailing direction
Average velocity in miles
■\\'eather—
Average nuniliei" of clear days
Average number of fair days
Average number of clear arid fair days. .
January. February.
34.4°
33.1
14.0
1.5.6
Til. Si
34.1
Hi. 9
IS. .5
fiil.ll
W.O
l-'.O
-13.0
SOAi
3.31
W.
11.1
1.5
S.3
9.7
76.%
2.68
W.
11.3
3.3
10.8
14. L
March.
30.1°
.56. S
14.5
18.8
39.. 5
63.7
24.!)
46.9
69.0
90.0
T.O
23.0
3.41
w.
11.6
3.9
11.0
14.0
3.31
9.6
9.;
12.:
21.'
70.9°
17.9
80.0
62.1
96.0
48.0
66. 7?
9 2
14.7
2:3.9
August.
69.4°
18.0
78.fi
60.6
96.0
47.0
67.3?:
8. W.
6.9
10.4
13.7
24.1
36.2°
13.5
45.0
31.5
71.0
1.0
75.5^
2.91
W.
10.3
3.9
9.3
12.2
71.4^
36.78
W.
9,6
71.5
13:i.3
204.8
It will further be noted from the chtirt that the tem-
perature range is great, a characteristic of the climate
in the temperate zone; and that the prevailing wind the
year through is from the west or southwest. If this
chart is compared with tliat of Porthuid, Me., given in
the present volume, it will be seen tliat there is a close
resemlilance in many of the data. The temperatures are
very nearl}- the same. At Rochester the average mean
annual temperature is 46.8°, and at Portland, 46..') ; for
the winter, in the former place, the average is S.J.V , and
in the latter, 2.^.6° F. ; and so of the other seasons. Tlie
rainfall for the year in Portland is 3'J.il4 iiielies, and in
Rochester, 36.78 inches. The average relative humiility
is 71.4 per cent, at Rochester, and 69.7 per cent, at Port-
land. We notice, however, that there is more wind at
Rochester, and tlie direction is more constant. When we
come to the number of clear and fair days, there is a de-
cided ilifferencc. AYIiile the number of clear days at
Rochester is only 71. .5 per annum, it is 107.7 tit Portlainl ;
and the number of clear aud fair days at the latter place
exceeds by forty-seven the number at Rochester. Jlore
sun and less wind, then, are to the advantage of Port-
land.
Where an outdoor life under clear skies and in sunshine
is desirable for a ]i;dieiit, it is evident that he must seek
some other locality than that of this "Lake Region" as
represented b}' Rochester.
Forty-four miles south of Rochester is situated the
Jackson Sanatorium, for the treatment of certain chronic
cases, such as neurasthenia, etc. It is said to be well
equipped with ajiparatus for the various forms of treat-
ment by hydrotherapy, eleclricity, etc.
Ed mini 0. Otin.
ROCKBRIDGE ALUM SPRINGS.— Rockbriilge County,
Virginia.
Post-Office. — Rockbridge Alum Springs. Hotel iind
cottages.
Access. — Via Chesajieake and Ohio Railroad to Goshen,
thence by stage to springs.
M. B. Hardin, of Spring No. 3, is fairly representative of
the group:
One United States gallon contains: Sodium sulphate,
gr. 0.03; caU-ium sulphate, gr. 3.33; lithium sv:h:.!.ate,
gr. 0.03; magnesium sulphate, gr. 5.61; potassium
sulphate, gr. 0.41; aluminum sulphate, gr. 43.01; man-
ganesium sulphate, gr. 0.09; iron persul]ihate, gr. 1.95;
nickel sul|)liate, gr. 0.14; calcium phosphate, gr. 0.17;
sodium chloride, gr. 0.11; silica, gr. 3.70; sulphuric acid,
gr. 3.83 ; aud traces of cobalt sulphate, zinc sulidiate, lead
sulphate, ammonium nitrate, calcium fluoride, antimony,
copper, arsenic, and organic matter. Total, 63.35 grains.
The following gases were also found in one Uniti'd Stales
gallon; Oxygen, 1.49 cub. in.; nitrogen, 3.98 cub. in.;
and carbonic acid, 10.89 cub. in. These have long been
regarded as among the best alum waters known. They
are clear and odorless, but possess a strongly astringent
and styptic taste. Their temperature ranges from 50 to
56° F. They are of nndoulited ethcaey in cases retiuiriug
an astringent chalybeate. They have proved valuable in
atonic anil cataiTlial states of the dilTereut mucous mem-
branes— for example, in chronic diarrlnea, in leucorrhiea,
iu pharyngitis, in rhiniti.s, etc. They an: veiT useful
locally in scrofulous ulcers and in other slow-healing sim-
ilar conditions. The waters sometimes prove imrgalive
in large doses and are always diuretic in doses of one-
quarter to one-half of a small tumblerful taken six, eight,
ten. or twelve times a day. The ellVcts of the water
often last far beyond the [leriod during whicli the}' are
taken.
Janus K. Crook.
ROCK CASTLE SPRINGS. — Pulaski County, Ken-
tucky.
PosT-OFr'iCE. — Rock Castle. Springs Hotel.
These springs are located in the Rock Castle River,
and are accessible by the Louisville and Nashville and
Queen and Crescent Railroad lines. There is daily con-
nection by sttige with morning and afternoon trains at
London. The situation is one of great natural charm
081
KO'i'k Kiioii !>>|>riii;!
REFERENCE HANDBOOK OF THE MKDICAL SCIENCES.
aud beauty, l)uing iu the lieart of the Cumbeiiaud Moun-
tains, at an elevation of over two tliousand feet above tlie
sea-level, and snn-ounded by a vast natural park of pine
trees. The pvu'e air and ecjuable temperature, as well as
t!ie isolation from tlii^ thoroughfares of travel, eonibiue
to render the location one of e.xeeptional freedom from
the ills of hot weather. A comfortable liotel, with am-
])le arrangements for the comfort of guests, is at hand.
The siu'rounding forests, hills, and fields offer many
attractions for the botanist, the naturalist, and the sports-
man. The following analysis was made by Dr. Robert
Peter: One United Slates "gallon contains: 'iron carbon-
ate, gr. 0.84; calcium carbonate, gr. 3.58; magnesium
carbc'inale, gr. 0.86; calcium sulphate, gr. 0.17; magne-
sium sulplmte.gr. 0.12; sodium sulphate, gr. 3.09; so-
diiun chloride, gr. 0. l.j; silica, gr. 0.74. Total, 8.55
grains. A considerable (|uantity of free carbonic acid
gas is also present.
The waters of the s]uings have been in u.se .since 1843.
They are said to possess excellent tonic and diuretic prop-
erties. It is also ni;nntained that the location is very
beneficial for cases of hay asthma, nasal catarrh, laryn-
gitis, etc. James K. Crook.
ROCK ENON SPRINGS— Frederick County, Virginia.
Posi-OiFK i:. — Kiiik Eiion Sl)rings. Hotel.
Ac(Kss.— Via Valley Branch of the Baltimore and Ohio
Railroad to AVinchestei-, thence by coach over pieturesi[tie
moinitain road si.xiccn and one-half miles to springs.
Time from Washington, si.x and one-half hotu's.
This resort is located in the great North jMountains.
It is snrroinided by the primeval forest, aud nestles
under the shadow of a majestic peak iu a romantic
gorge, through which flows Laurel Brook, a beatitiful
stream which is supplied by the mountain springs, and
which winds about the Initel and its attractive lawn.
The locality is free from swamp lands and malaria. The
hotel has a location of twelve hundred feet alxive tide
water. This is a model caravansary, and the visitor may
feel asstired that every device for bis comfort, health, aud
amusement has been arranged for by the thoughtful pro-
prietor. The .scenery iu the neighborhood is exception-
ally fine. Close to tiie hotel are three mineral sju-ings.
wliicb have been foiuid to possess well-marked medicinal
pro|ierties.
The ( '/iiili/hi'iite i^priiu/ was analyzed by Professors Gale
and New, of the Smithsonian Institute, Washington, who
found it to contain, in one Uiuted States gallon, the fol-
lowing solid constituents: Sodium carbonate, gr. 1.31;
calcinm carbonate, gr. 5.13; calcium sulphate, gr. 3.56;
magnesium sulphate, gr. 13.89; magnesium chloride,
gr. 1.13; iron oxide, gr. 14.35; manganesium oxide, gr.
1.05; alumina, gr. 0.80; silica, gr. 0.43. Total, 40.43
grains.
The water resembles that of the Pyrmont Spring in
Waldeck, Germauj'. It is a strong chalybeate, and ])0s
sesscs aperient and diuretic properties.
A (pialitative analysis of the Alkaline Spring by Pro-
fessor Luptou, late of the University of Virginia, showed
the presence of potassium and magnesiiuu carbonate,
sodium chloride, calcium sulphate and carbonate, silica,
and carboiuc, sulphuric, anil hydrochloric acids. The
water is aidaeid, diuretic, and aperient, and is u.sed in
aU'ections of the kidneys and uiinary passages, in dys-
pepsia, in gout, and in catarrhal alfeetious.
The Old Ccjijicr Sjir/iit/ once gave its name to the resort,
and it is styled Capper's Springs in the older books. It
has been iu use for more than a century. The water is
described as being efhcacious in rheumatism ami iu dis-
eases of the skin, and as a cure for certain of the intes-
tinal worms.
White and blue sulphur sju'lngs of excellent (piality
are also foviud in the neighborhood. The following
data show the mean temp.erature at Rock Enon for July
aud Avigust during the past ten years: July, 7 .\.M., 66'
F.- 13 M., 77 ; 3 "i'.m., 78'; 6 P.M., 75°; and 10 p.m.,
66.35". For Atigust. at the same hours, the record was
64.5", 74.5', 76', 73% and 66' F. James K. Crook.
RODENT ULCER. See Carcinoma of the Skin.
ROENTGEN RAYS, USE OF, IN MEDICINE AND
SURGERY.— 'Phe discovery by Wilhelm Conrad Roent-
gen, in 181)5, of the kind of radiant energy now known
as the Roentgen or .r-rays, was at once recognized as giv-
ing a most important addition to the armamentaiiiuu of
the diagnostician in surgeiy. W^ith improved appara-
tus and technique, and witli more extended experience,
the application of the Roentgen rays has graduallj' ex-
tended until their use is now universally regarded not
only as indispensable in surgery, but as most valuable
fiu' 'diagnosis ami therapy in many di.seases not classed as
surgicak
Aatiire and Action of tJie Roentgen Rii/s.—Thu Roent-
gen rays are produced by the passage of an electrical
current of snxtll toltime and hiyh tension through a spe-
cially constructed vacuum tube of high exhaustion. If
an electrical current is passed through a glass tube from
which the air has been but partly exhausted, an arc of
light will be projected from the cathode (negative jiole)
to the anode (positive pole). If a similar tube of high
exhaustion is used, no arc of light will form, but a pecul-
iar fluorescence will appear at the anode. This fluores-
cence appears to emanate from any body exposed to the
cathode of a vacuum tube. In the ordinary Roentgeu-
ray tube, the anode is a platinum plate placed in a line
with the cathode, aud the electrical energy passing from
the cathode falls upou the anode, and from thence both
fluorescent and Roentgen rays are projected. If the
cathode is concave and directed toward the side of the
tube, fluorescence will appear to emanate from the side
of the tube at the i)oint toward wliicli the cathode is
directed. Not only does the body fluoresce upon which
the cathode rays are directed, but it will glow with heat
if the electrical current is strong. In conse((uence, if the
cathode rays are directed toward the side of the vaeiunn
tube, the tube will become heated at the point of im-
pingement, will soon soften and be destroyed by the giv-
ing way of the melted glass. For this reason the cathode
rays are in practice directed toward a platinum plate
winch forms the anode, and which is set at an angle of
about 45", so that the Roentgen rays are directed from it
outward at about a right augle to the long axis of the
tube (Fig. 4114).
The visible fluorescence which appears in the tube
must not be mistaken for the Roentgen raj's.
The Roentgen rays are themselves inrisible, and are
appreciable to the senses only by their effect upou cer-
Fk;. 4114. — T)ia{i;ram of Itoentffen-liay Tulie with Lines of Roti'iuiXeii
Riuliatlnn. Tile lines diveriiinff from tlie annile sliow by tlieir rel-
ative prcximity to eacli otber those parts of the hemisphere in
front of the anode which are more or less acted on by the Roentgen
rays.
tain substances. This effect is manifested in three ways:
(a) by the fluorescence of certain chemical substances
when" the rays fall on them; (A) by the reduction, when
exposed to the rays, of certain silver salts ordinarily used
for photography; ami {<•) bj' changes produced in living
ti.ssnes when the rays act upou them for a sutflcieut
length of time.
The first of these etiects, i.e., the fluorescence of cer-
982
REFERENCE HANDBOOK OF THE .^lEDICAL SCIENCES.
Rock I'^iioii Springs*
Itoi-ulj^eii Kays.
tain chemical substances, is tlie means used for jjiotlucing
visual ctlccts dircclly from the vacuum tul)c. When the
Roentgen rays fall iijion certain substances, notalily cal-
cium tungstate, the double cyaniile of platinum and ba-
nc;. 4n.5.-Diagram sliowing tlie Fluoroscopic Method of olnaiiilnK
Visual Images by Koentgen Rarliatioii. <(, Anoiie; li. Roentgen
rays passing to ligtit-exduding cliamlH-r wilb lluorescent screen (?,
on wbieh appears tlie tluorescing image formed by rays passing by
or tlirougli the object c.
riura, platinum and magnesium, platinum and potassium,
zinc oxide, etc., these substances glow with visible fluor-
escent li*ht, the fluorescence in a degree depending upon
the number and strength of the impinging rays.
This property of producing visilile fluorescence is util-
ized to give visual effects from the rays. A chemical sub-
stance wliieb will fluoresce, usually the double cyanide
of potassium and barium, is spread and ti.xed on some
plane surface wlii^'h is opaque to light. Upon excluding
light and allowing the Roentgen rays to pass through the
support and fall upon the coated surface, this is seen to
glow to a degree depending upon the amount of radiant
energy which falls upon it. The amount of energy
affecting the fluorescent surface depends upon the energy
given out by the tube, the distance of the tube from the
plate (the effect varying inversely as the square of the
distance), and the extent to which the passage of the
Roentgen rays to the fluorescent surface is obstructed
by objei;ts placed between the sensitive surface and the
tubet'Fig. 4115).
The visible images produced by the Roentgen rays are
in every sense shadow pictui-es. The objects outlined bj*
the rays are not themselves seen, but only their shadows
cast u]ion a fluorescent screen or impressed on a pholo-
gra]ihic ]ilate. It is of the greatest importance in inter-
preting these shadow images to recognize the fact that
they are shadows and not real images of the objects ob-
served.
Roentgen rays are always projected in straight lines
from the fluorescing anode, and unlike light rays they
are incapable of refraction, dispersion, or regular reflec-
tion. Consequently the shadow iiuages formed are simi-
lar to shadow images made by ordinai'v light when pro-
jected from a point, and therefore depend for shape and
size not only upon the shape and size of the ol)jeet pro-
jecting the shadow, liut upon the position in which the
object is placed, its relative distance fi-om the souice of
the rays, and the plane u])on which the shadow is cast.
These facts are of the utmost importance in judging the
radiographic image, and a competent observer in reach-
ing a conclusion always considers all these factoi's and
their relation to each other. Correct estimation of the
relative value of these factors is of especial iinportatice
in ascertaining the size and position of foreign bodies
lodged in the tissues, and is to be iiarticularly considered
in medico-legal cases where deformity ma)' be inferred
from malposition of tube or plate, or from erroneous
reading of the shadow picture.
In addition to their non-deviation from the direct lines
in which they are projected. Roentgen rays difl'er from
light in that they are capable of passing through or pene-
trating all substances. This transparency (to use the
term) to Roentgen radiation is not, however, the same
with all substances, but appears to be in lai'ge measure
in inverse ratio to the density of the substances. The
pi'operty of olistructiiig the passaire of the rays differs
markedly witii dillVrent tissues, both normal and abnor-
mal, of the human body; and as the rays which pass
through the least resistant tissues are thus alile to e.xert
their greatest effect upon the fluorescent screen or photo-
graphic plate, the shadow image gives the outlines of
certain ti.ssues, and by dilTerence in density it may fur-
ni.sli evidence of normal and abnormal conditions. Thus,
for instance, not only are the outlines of a long bone
clearly marked out by the rays, but the medullaiy cavity
is shown as well; and, while in radiographs of the nor-
mal lung the denser bronchi only are sliown, in pulmo-
nary tuberculosis the tuberculovis thicki'uings from their
greater resistance to the rays appear as clearly defined
sliadows.
As to the real nature of the Roentgen rays many hypoth-
eses have been advanced, some phj-sicists holding that
the}" arc longitudinal vibrations of the luminifeious ether,
others that: they are minute ]iarticlesof matter driven out
fiom the cathode, and others that they differ from ordi-
nary light rays only in the numl)er of vibrations. While
consideration of these h3'potheses is of interest to the
physicist, to the phj'sician and surgeon the practical
facts are: (o) that lioeiitgfiirdfliatioiiis afinin of energy
projected in straight lines from its smiree ; (h) that the ease
if its passage through the hurruni hudy depends vpou the
structure and density of the tissues; (c) that it is capable
of producing molecular and clieurind rlianges in certain
substances iised for making its action, visible, such as the
fluorescent screen and p!iotograpbic plate ; aial(d) that it
con produce tissue changes by affecting the metabolic action
of liring cells.
Practically, the selection of apparatus which will best
produce these visual, chemical, and physiological effects
is a matter of much impcutance, and as there are many
variations in type of appaiatus for producing Roentgen
radiation, a careful study of the apparatus and the prin-
ciples upon which they are constructed is necessary be-
fore the}' can be ]>roperly understood and judicious selec-
tion made.
RoENTGEN-R.\Y APPARATUS. — There are two types of
apparatus commonly employed for prodiicing the elec-
trical curi-ent of small volumeand higli tension necessary
to excite the vaciuim tube to Roentgen radiation — ^the
static machine and the induction coil.
Tlie Static Morhine. — The static machine is the onlj'
apparatus in which an electrical current of requii'cd
strength and tension is directly pi-oduced. In this appa-
iatus the electrical current is produced by the macliine
and carried direct to the tvibe, the electrical energy given
out being deiived from the mechanical energy used in
driving the machine. Two forms of static machine are
most used — the Wimshurst and the Iloltz. C)f these the
Iloltz form is most used in America, while the Wims-
hurst is almost exclusively tised in England. The use of
static machines for Roentgen-ray work is much more com-
mon in tlie United States than in any other country. In
this country much attenticm has been paid to this form
of a]iparatus, and a type of apparatus considerably mtpdi-
lied from the original Iloltz has been developed, which
is, with certain limitations, quite satisfactory. The ma-
chines now most used (Fig. 4116) have from eight to six-
teen circular glass jilates mounted on an axle. These
plates rotate in onedii-ection, and between them are fixed
inductor plates of glass.
The special adeantoges of the static machine are that it
is easy to operate, that with oiilinaiy care it is not liable
to get out of order, and tliat it is capable of producing a
steady and fairly jiowcrful output, which is not injuri-
ous to vacuum tubes. For good work it is necessar_v to
have a static machine of large size, twelve to sixteen
plates, thirty-two inches in diameter, or even larger, and
it should be driven not by hand but by power, a one-half
horse-jjower motor with speed regulation being required
to give good results. The disadvantages of the machine
983
Roentaoii Kayx.
Roeilt^^'cii Itayw.
REFERENCE HANDBOOK OF THE .MEDICAL SCIENCES.
are tliat it occupies much space, tliat it is liable (unless
carefully inauagcd) to fail in dump weather, and tliat
as powerful effects cannot be ol)tained with it as with
the larger coil apparatus. Under proper inanasrenient a
Fii;. 4116.— Static Machine Arranged for r-Ray Work.
large static machine will do satisfactory fluoroscopic and
photograjihic work, but where therapeutic work has to
be done the majority of ojierators consider a coil apjia-
ratus indispensable. With a static machine great care
must be taken to keep its interior free from moisture; a
tight case and the occasional use of calcium chloride for
drying being necessary. In o|ii-rating it, steady and
sufficiently rapid revolution of the jdates and careful at-
tention to the use of the '"spark gaps" and Leyden jars
is indispensable to success. Tlie static machine is to be
particularly reconuuended wliere commercial electrical
currents for running a coil cannot be had, as under these
conditions a large static machine run by a water, steam,
or gasoline engine will give much better satisfaction
than a coil apparatus energized by a juimary battery.
Cuil Aiijiiinihis. —TliL' ]iiiiiripal parts of a coil appa-
ratus are the induction (HulimkorlT) coil, the interrupter,
the vacuum tube, and a suitable electrical source. In the
coil apparatus, the secondary current of small volume and
high tension necessary to e.xcite the vacuum tube is ob-
tained by induction frmn a priraar.v current of lar,ge vol-
ume and relatively low tension. The primary current is
obtained from primary batteries, storage batteries, or
dynamos — wlien from the latter, the dynamo current for
electric liglitiiig is usually employed — and is carried to
the coil by insulated wires. In tiie coil (Fig. 4117) the
primary ciuTcnt traverses that part of the coil which is
called the primary and, being interrupted with high fre-
quency by the interruptor, by induction produces a cur-
rent of high jiotential in the secondaiy part of the coil,
from which it is carried by insulated wires to the vaevium
tube.
Tfie Induction Cvil. — Induction coils are made of va-
rious sizes and are wound to correspond to the primary
current by which the.v are supplied, whether from bat-
tery or from dynamo. They should be used only with the
current for which they are designed. Their size is given
in iuclies, this indicating the length of s)iark they give
when supplied with a jiroper current. The longer the
spark length, the greater the care which must he em-
ployed in manufacturing the coil (to prevent its being
destroyed by the jiowerful currents which are necessary
to energize it) and the more the resulting work which
the coil is capable of dcjing. For practical Roentgen-ray
work, coils exceeding eighteen inches in spark length are
unnecessary, as tlie vacuum tube has not yet been
devised which can dispose of all the electrical energy
given b}' an eighteen-inch coil when giving its
ma.ximum output. Coils below six inches are not
to be recommended except for very light work,
and for really satisfactory work coils giving a large
twelve- to eighteen-inch spark are to lie preferred.
T/ie Iiitn-riiptn-. — To produce the reipiired sec-
ondary current it is necesstry more or less rajiidly
to interrupt or break the primary
current. The interrupter is a most
important part of the coil appara-
tus. The essentials of a good in-
terrupter are suddenness of break,
good contact at the make, and ad-
justment for regulating the fre-
quencj- of the interruptions. Tlie
greater the aliruptness with which
the current is cut and the more in-
stantaneous and perfect the con-
tact when the current is made, the
greater will be the effect on th&
secondary coil; also adjustment for
regulating the frequency of the in-
terru]itions and the length of the make "s neces-
/■, sary in order to adjust the induced current to the
capacity of the tube in use. Manj- forms of in-
terrupter have been devised in order to meet these
re(juiremeuts. There are three main types of
these now used — the vibrating spring t^'pe, the
mercury type, and the electrolytic type. Of
these ditTerent types the vibrating spring inter-
rupter (Neff's hammer) is the original and sim-
plest form (Fig. 4117).
An upright spring, carrying a heavy piece of iron at
its upper end, is ti.xed on the baseboard so that the iron
head is opposite one end of the core of the coil. On the
face of the hammer furthest from thecore is fixed a piece
of platinum, and opposite this is another piece of plati-
num tixed in the end eif a screw held in a brass pillar.
The electrical current is carried from one pole of the bat-
ti-iv through the coils of the piimary to the vibrating
hammer, thence, when the platinum points are in contact,
to the screw and from it to other pole of the Ijattery.
The current magnetizes the soft-iron core, which attracts
and pulls the haminia' toward it and awav from the
T
Fic. 4117. -Tiintrnmi of InductioD-Coil Apparatus witli Vibratinff^
llanimer Interrupter, -t.l'cintact; 7?, battery; .<, secondary ; C,
soft-irou core ; /f, tianimer; c, condenser: T, tube.
screw. This breaks the current, the core is demagne-
tized, and the spring carries the hammer back against
the screw, which again completes the circuit, and the
process is repeated. By adjusting the screw and the
984
REFERENCE HANDBOOK OP THE JIEDIC'AL SCIENCES.
Kuiulj^vu Kays.
tpiisiou of till' S]irin,!r, the rate of the vibrations and the
relative length of break and contaet can be reg\ilated to
a eertain degree to eorrespond with the tube used.
The advantage of this interrupter is its siinplieity, but
it is not adapted to eoils giving a spark over six inches
i^
Flo. 411.'!.— Diaprora of Independent Vibrator, h. Hammer; if. mov-
able weifrht ; ?i.s., hammer spring; c, fontael points ; c. s., contact
spring; -4, &'. .I, adjnsUngf screws.
in length. The break made bj' it from its occurring
when the hammer starts to move, is not abrupt, and the
contact from the wearing of the platinum is apt to be
imperfect. Also the intense heat develoiied at the point
of contact sometimes welds the platinum points together
and stops the working of the appaiatus. Large coils,
requiring heavy currents, cannot be used willi the inter-
rupter, both from the liability of welding the platinum
and from the jumping of the current across the gap at the
break.
The riidependent ribi-atiiir/ iiiterri/pter {Fig. 4118) is a
moditicalion of, and a great improvement on, the Neil
hammer. With it coils up totifteen inches, energized Ijy
commercial currents up to one hundred and teu volts, can
be ([uite satisfactorily worked. In tliis form the inter-
rupter is operated b_v a secondarj' brttery coimected liy
a sluuit from the main circuit, and is entirely indepen-
dent of the main coil.
In this interrupter the ciu'rent pas^^es from the liattery
to the coil and returns (Fig. 4118) through cc. <•. and S'..
imless broken at c. The current is broken at c, by the
screw o striking the contact s|)ring. when the hammer is
attracted by the core of the small coil. This interrupter
gives a relatively long contact, and the break is very
sudden as the contact spring is struck when the hammer
is moving at high speed. The rapidity of the interrup-
tions can be varied in wide range by raising or lowering
the movable weight {>r) on the hanuner spring. The ad-
vantages of this form of interrupter are tliat it is easy to
manipulate, that it does not readily get out of order, and
that it gives good results on all but the largest coils.
Mercury Interrupters. — ^Thu mercury interrupters are
of two types — the dip interrupters and the turbine. The
di)) interrupter (Fig. 4110) consists of a small electric
motor which, when iu motion, rapidly dips one (>r two
silver needles, hiuig ou an eccentric of the shaft, into
mercin-y, overlaid with petroleum, contained in glass
receptacles.
The needles being connected with one pole of the bat-
tery and the mercury with the other, the current is made
and broken by the entrance and exit of the needles from
the mereur}-, while the number of interruptions is regu-
lated by the sjieed of the motor, and the relation of make
to break is determined by the time the needles remain in
or out of the mercury.
The tur/iine interriiplerx (Fig. 41".i0) consist essentially
of a hollow metal cj'linder iu which openings are cut,
and within which a rapidly revolving turbine wheel,
by centrifugal foice, throws otitward a stream of mer-
cury. The cylinder being connected with one pole of
the current and the wheel and meicury with the other,
the current is made when the stream of mercury im-
pinges against the wall of the cylinder and is broken
when it passes througli the openings. The rapidity of
the interruptions can be regulated b}' the speed of the
motor which rinis the turbine wheel, an<l the length of
the make and bieak, by the size of the openings in the
cj'linder and the distance between them. In practice,
tiie openings are triangular sectors, and the relation of
make to break can be varied by raising or lowering the
cylinder. The break, from the force with which the
mercury is thrown, is e.xtremely sudden. The mercury
is used dry, and requires only occasional cleaning.
The dip and turbine interrupters give the highest at-
tainable results They can be used on the largest coils-
and with direct cinrents up to two
hundred and fifty volts. The tur-
bine are in many respects better
than the dip iutenupters. as thej'
are easier to manage and, in the
best forms, are capable of more
varied adjustment. They are ex-
pensive, compared with other inter-
rupters, but for ci'itical and pi-o-
fessional Rocntgeu-ray work are
unexcelled.
EUetrolytic Jnterriipters. — These
interrupters are entirely
dilTerent iu principle-
fiom those above de-
scribed. Their action
FIfi. 4119. —Coil with Mercury Dip Inlerru|ilcr.
depends ujion the electrolytic action of an electiical
current. These interrupters consist essentially of a large
sheet of lead connected with the negative pole of an
electrical current and a small surface of platinum con-
nected to the positive i'"le. both being inuuer.scd in
dilute sulphuric acid (Fig. 4121). AVhen a current is
passed, electrolytic action occurs in the fluid and the
sudden formation and disappearance of a nonconducting
9S5-
Koeiitgeii Ray8.
Roeiil^eii Kays.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
<Mivi'loiic of gas alir)ut tlie i'xpos<'d plat-
iiiiim alternately breaks and makes the
fill-rents. In practice, at least forty
volts at the tcrniinals of the interrupter
must be used to give good results.
These interrujiters, from tlie rapidity
of the intcrni])tions, give a .steady and
intense light for fluoroscopic purposes,
but for photographic work tlie radiation
is not so energetic as that given by the
mercurv interrupters. The advantages
of this interrupter are its cheapness anc
simplicity. Its disadvantages are that
it is not fully con-
trollable, that it is
liable to explode,
and that it is not
possible to work it
long at a time, as
the fluid soon be-
comes overheated.
Infernijitci's far
Use with Alterniit-
ing Ciinriits. — All
tlie interrupters so
far discussed, with
the exception of
the electrolytic
type, can be used
only on Oirert cur-
Tents. The electro- \
lytic interrupter
can be used on an
alternating cur-
rent, and is the
cheapest method of
using such a cur-
rent; but it does
not give as good results as when used on a direct cur-
rent and the platinum corrodes rapidly. For some rea-
Fic. 4120.— Coil .\pparntiis with Turbine In-
terrupter auii \\ ilti \V:ill Pliite tiavinir Vnll
and .\niperi*iiH'iiT, Suitrhfs. Saft'ty Fuse.
Rheostat for MauU'unvnt, and Auxiliary
Rheostat for Motor of Interrupter.
flG. 4121. — Elpotrolytic (Wehneltl Interrupter. ,4, Interrupter; ft,
platinum wire in porcelain cylinder ; c, lead plate : d, coil ; e, wires
connecliuj^ interrupter and coil with an electrical source.
son the electrolytic interrujiter does not explode or
"choke" (cease working) on alternating currents.
SynchronouK interriipttrn oi the turbine mercury type
are considerably used abroad for utilizing alternating
cun-ents. They depend iu principle upon the make
being synchronous with the alternation of the
current, so taking only tlie crest of the alternat-
ing waves and thus giving a direct current.
Recently, in the United States, a form of dip in-
terrupter has been put on the market, known
as the Ileinze interrupter, which can be used
with either direct or alternating currents.
This interrupter
consists essentially
of a small motor
whose crank eccen-
tric rapidly carries
a platinum needle
into ami out <d' di-
lute sulphuric acid.
The principle is a
combination of the
mercury dip and
the electrolytic.
The interrupter is
completely under
ci}ntrol when ^vork-
ing with a continu-
ous current, and liy
means of the con-
trol lever the make
and break of the
interrupter can be
made synchronous
with the alterna-
tions of an alternat-
ing current, and so
send a unidirection-
al current through
the coil.
2'hc Condcnuer. —
This part of a coil
apparatus (Fig.
4117, c) consists of
a number of sheets
of tinfoil, insulated
from each other,
and connected with the wires by which the coil is con-
nected with the electrical source. The function of the
condenser is to act asasjionge and, when the iiiterru]iter
breaks the current, instantly to absorb the electricity in
the ])riniary and so completely and immediatel}' to de-
magnet ize't lie core, thus gi'eath- increasing the energy in
the secondary. So energetic is this action that a twelve-
inch coil without a ccmdeuscr will barely give a two-inch
spark. The condenser is usually placed in the base of
the coil, Init may be mounted separately. With the
electrolytic interrupter no condenser is used.
yni-iiinn. 7'iilics. — Tubes are graded from low (soft) to
high (hard). A high or hard tube is one of high vacuum.
Thcfe tubes ri'({uire powerful currents to excite them,
and they produce rays of great iutensit}'. With such
tubes the shadows of the bones viewed with a tluoro-
scope aii]iear gray, and metallic objects are readily seen
through them. Tubes of this character are veiy ener-
getic in action on the photographic plate, and are useful
for work tbrough thick parts, as tlie hip, pelvis, or head.
A low (U- soft tube is one of low vacuum. Low tubes
arc readily illuminated by currents of low power, and
therefore give ra_ys of low intensity and penetration. Be-
tween the low and high tubes there are all gradations.
Low tubes have too little in/netration for work with an_v
but extremely thin parts of the body, while very high
tubes give such jiowerful rays that sufficient contrast
between the. bones and surrounding tissues is lost and
critical dilTerentiation of structure is impossible. jMod-
erately high tubes are best for general work both in
radiograi)liy ami in thera]iy.
In using a vaeunni tube it is necessary to adapt the
current to the tube or the tube to the current, or both to
eacli other. The current is regulated in the static ma-
chine by the ra]iidity of revolution of the plates and by
adjustment of the spark gaps. In the coil apparatus the
use
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
Strength of the primary current is regulated by a rheo-
stat, and the quality of the secondary current is confornieil
to the tulie liy adjustment of the interrupter. "With re-
spect to eonforniing the tube to the current, tubes are
divided into non-ri'gidatin.i; and regulating tubes.
Regvdating tubes consist of tiie usual vacuum t\die
witli a small attached bulb containing a chemical whicli
when heated gives off vapor and reabsorbs it when
cooled. When the vacuum of the tube becomes tooldgh
it can be lowered by heating the Indb by the passage of
an electrical current, so forcing vapor into the tube. A
very ingenious and useful self-regulating tube has been
•devised by Queen (Fig. 412i). In this the chemical is
heated by the current passing to an adjustable spark
point, and by adjusting the distance of this jioint Irom
the cathode connection any desired degree of vacuum
may be maintained.
In tubes to be used with the powerful currents given
b_y the larger coils and rapid interrupters, special provis-
ion has to be made to prevent rapid destruction of the
anode liy the powerfid cathode stream which impinges
upon it.
Where the current is moderately powerful, tubes with
«xtra thick anti-cathodes will resist the cathode stream.
With powerful apparatus the water-cooled tube (Fig.
4123) must be used. In this tube the anti-cathode is
placed at the ba.se of an inwardly projecting cylindei'. so
that it can be kept cool by running water and thus with-
stand the great energy developed.
Success in the use of the Roentgen ray-apparatus de-
pends largely upon proper manipulation of the tube and
the current supplied to it. When a tube is used, care
should be taken not to allow the platinum anode to
become overheated. As a rule, radiation is at its best
when the anode is ju.st short of white heat at its centre,
•where the greatest energy of the cathode stream is ex-
erted. For this radiation, tubes with thick or water-
<:ooIed anodes are required, as thin anodes are soon
perforated and destroyed. When in operation the tube
slibuld be constantly watched, for on account of tlie heat
■develojied the vacuiun in the tube becomes gradually
lower, and as the current passes more readily the anode
may become overheated unless the operator reduces the
current. Tubes become higher with use. When a tube
refuses to illuminate, careful application of heat will
■overcome its resistance for a time; but, with use. it will
finally become so hard that no current can pass through
it. When this occurs, re-exliaustion is the only remedy.
EL!iiTuic.\L SouiiCES. — Three soureesof electrical cur-
rent are used for Roentgen-ray p\irposes — dynamos, stor-
age batteries, and primary batteries.
The (lynnmo currents generally used are from commer-
cial electric-light circuits, and this kind of current is best
Fig
-Queen Selt-Reguhitmi;
for Roentgen-ra}' work, where it can lie had, as it affords
sufficient energy to operate the coil and the discharge
may be made as heavj^ as desired. Commercial currents
are either continuous or alternating. The ointintiDiiit
current, unless of very high voltage, can be carried
direct to the coil, requiring only a rheostat f(u- regulating
it and a safety fuse to prevent accidents. These curreuts
are usually one Inmdred and ten volts, and all forms of
interrupter can be used with them. Currents of higlier
volfctge may be used, but with two Inindred and twenty'
volts, or higher, the "reactive kick" of the primary
becomes so great as to b(^ a source of danger to the oper-
Kii:. H:;:i — Watci-i uciled Tube.
ator in ease of accidental contact with certain parts of
the ajiparatus. With these high-volt currents it is best
to use a current transformer which reduces the current tc
a point of safety.
The alternating current can be used only with an elec-
trolytic interrupter, a Heinze interrupter, or a synchro-
nous mercury interrupter.
Storar/e Jjiitterhs. — Next to a dynamo current that fron;
a storage battery gives best satisfaction. Storage bat
teries, like batteries generally, have the disadvantage ot
being more or less difiicidt to keep in order. The
"chhu-ide accumulator" is probably the best type and.
in its more compact form, is useful for making part ot
))ortable apparatus. These batteries can l)e charged
from dj'namo currents or from prinutr}- batteries. To
charge from an alternating current, a current rectifier,
which takes oidy the crests of the alternating waves,
must be used. To give a good output, a little more than
one cell of a battery is required for each two inches of
sjiark length given by the coil.
Primary Batteries. — This form of electrical source is
the least desirable of any iised for energizing coils for
Roentgen-ray work. Primary batteries are bulky, re-
quire a great deal of attention to keep them in order, and
are expensive to maintain. They can be recommended
for use only where commercial circuits or storage bat-
teries cannot be employed. Any of the more ejiergetic
forms of battery will run a coil, but, from the trouble
incident to working them, only one form — the Edison-
LeLande battery — can be satisfactorily used for this pur-
pose. This battery requires comparativelj' little atten-
tion, and gives a very constant electromotive force.
About four battery cellsare required for every two inches
of spark length given by the coil.
InftaUalinn of Apparatus. — The method of assembling
a coil apparatus depends upon the current supplied, the
form of interrupter used, and the size ot the coil. With
a small apparatus having a hammer interrupter and ener-
gized by a primary or storage battery, it is only neces-
sary to connect the coil direct to the battery. \\ hen a
continuous commercial current is Tised a safety fuse and
rheostat should be placed in tlie main circuit to protect
the coil from injvuy and to regulate the current. When
a mechanical interrupter is used it is run by ashiuit from
the main circuit, and should have a separate rheostat and
safety fuse (Fig. 4134).
In installation of the larger coils the addition of a volt
and ampere meter is useful to show the quantity and
quality of the ciu'rent, and wall iilates are inaile having
safety fuse, rheostats, and volt and anijieremeters con-
veniently as.sembled on them (Fig. 4120). AVith an elec-
troh^fic interrupter the installation is somewhat simijli-
fied. as the interrupter is jilaced directly in the circuit
which su]iplies the coil (rheostat and safety fuse being
used) and a condenser is not required (Fig. 412.5).
SfRGic.\L Uses op the RoENTGt:x R.ws. — The prin-
cipal surgical uses to which Roentgen radiation is put
9S(
R(>onf;;eii Hay»i.
Koeutj2;eii IfiayN.
UKFKUENCK IlAXDIidUlC OF Till-; MKDK '.VI. ^^CIENCES.
arc: (a) to diagnose fractiires and determine the form
and c.xlciit of tlie bone lesions: (h) to diagnose disloca-
tions; ((■) to di'lcrminc the exislcnce and extent of acute,
chronic, and nc-i)])lastic patliologic clianges in the boius:
c
Fig. 4124.— Diiifrram nf In.stallation of an Apparatus witti Merhanioal
Interrupter, r. Win-.s to maintain oii-ciiit : l\ safet.v fuse; .^',
switch for nmnccting current; 7f. rheostat for current to coil;
Ap, V, ainpei'e and volt meters: Li, wires to coil; X2, wires to
interrupter; Ji*-, rheostat for interrupter; J, interrupter.
(d) to determine bone malformations and deformities; (<■)
to determine tlie ])rcseiice iind location of foreign bodies.
Tlie pccidiar resist:ince of osseous tissues to tlie Roent-
gen ravs makes ti'aumatisms of the.se particularly easy
to determine. By tlic ju-oper use of the niys the ju'cs-
ence or absence of fi;iclurc, and, if present, tlic form
and extent of the bone trauma can be accurately deter-
mined. Cases of dillicult diagnosis are made pliiin, and
since the rays have come intons<Mt has been demonstrated
that fracttu'e is present in many olisenre cases thou,eht
to be seveiv sti'ain or sprain. Tlje attention of the -n-riter
has been parlicidarly <'alled to this fact in connection
with injuries of the knee-joint. Uecently two cases of
persistent lameness were ri'fcrred to him, wliich Avere
supposedly due to severe strain. In one of ihcsi' ca.scs
the external condyle of the femur was s]ilit oil to tlie
intercondyloid notch (Fig. 4lL'()) with no displaceiiieiit,
and in the other the iiilci ii.il tubeiosity of the tibia was
similarly fracttu'cd. In Imth these ca.ses no crepitus
could be elicited; the only ]irominent symptoms weie
persistent swelling and )niin at tlie joint and the patients
walked about with the aid of a cane.
Not only lias the use of the lays given the snr.sreon a
sure method of detcrniinin.s the jire.sencc of fracture, but
it has greatly increased hisknowledgeof fractures result-
ing from indii'ect and direct violence, particularly those
forms whicli are due to .cunshot injury. The facts dis-
closed have been extremely valuable from the standiioint
of treatment, for it has been conclusively proven tli;it
conservatism is indicated even in cases of most extensive
bone lesion, provided the wound is not infected. In fact,
as a result of Roentgen-ray observations combined with
clinical exjierience. the rule may now be formulated that
whatever the extent or form of a fracture, if no infection
is present, operation is contraindicated, unless the bone
fragments are so disjilaced that they produce deformity,
may interfere with the function of the pnirt, or are press-
ing upon vital or important structures.
When the diagnosis lies between a suspected fracture
and a dislocation, as in obscure injuries of the elbow-
joint, the rays at once determine the matter accurately.
They are cqindly eflfective in sliowing the result of treat-
ment, and at once enable the surgeon to determine wliether
or not adisloeation or fracture has been properly reduced
(Figs. 4127 and 4128).
In determining the presence and extent of bone lesions
it is most important that the raj-s be properlv used. As
before stated, visual efl'ects fi'om tiie rays are from oli-
servcd sluidows. and these shadows depend for sliape and
size not only niion the sliape and size of the olijccts east-
ing the sh;iilows, but upon the relati\e position of the
light and object and their distance from each other. For
these reasons, to reduce distortion to the minimum, radio-
,t;raplis should always be made with the tube so placed
tiiat the anode will be as nearly as possible 011 a line per-
pendicular to the long axis of the bone above the place
of fracture, and at least eighteen inches dist;int from it.
Also, when the ]>art injured admits. radiogni|ilis sliould
alw;iys be taken from two directions, prefei'aljly at right
angles to each other. Unless this precaution is taken, a
fracture may be overlooked from the fragments overlying
each other in a direct line and so throwing a straight con-
tinuous shadow, when a radiograph taken at another
angle will at once show a disjilacement.
Ill this connection the iiicdico-legal aspects of radiogra-
]ihy may be eoiisidered. ;ind here again the fact must be
emphasized that radiographs are shadow pictures, not
actual pictures of the objects themselves, that conse-
ipiently the images are never accurate representations of
the objects, that distortion is always present to greater
or less extent, and that proper reading of iadii>grapbs
can, iu dilhcult cases, be arrived at only after much ex-
licricncc on the part of the expert; and then information
must be at his disposal, giving the relative pi.i.sition and
ilistance from each other of the tube, the plate, and the
object radiograidicd. It is also primarily essential to
expert opinion that this opinion be based upon full
knowledgcof radiograiibic pictures of normal structures,
liarticuhirly of the shadow images given Ijy the bones at
the articulations.
For medico legal as well as for .liagnostic purposes, it
is to be noted that bmu; enl/iis is at tirst quite transpar-
ent to Roentgen rays, so much so that a fnictuic which
is quite lirmly united may show on the photograpliic
plate as though no callus existed, and so .give the ap-
])earance of an ununited fracture. For this reason the
Roeutgcu rays cannot iu all cases be relied on to give
the actual condition of union or non-union of fracture.
27ie lAic(ili;iitio/t of Fardgn Bodies in. the Tisniie.i loiel in
the Biidi/ I'liriliis. — The advantagesof the Roentgen rays
over all other means of locating foreign bodies are now
so well understood th:it their use has practically entirely
suiiersediHl all otiier methods.
The dillicnlties of using the probe for locating lodged
missiles is well known. The eontraetilitv of tissues-
Ki(i. 4I"i."».— l>ia^'ram of bistallation of Apparauis with Electrolytic
Interrupter, .s', Switch ; F. safety fuse ; i?, rheostat ; .-Ip, ampere-
meter ; /, elect rolytie iiuerriipter,
and the shifting of muscular and fascial structures by
cliiingc of jiosition may completely obstruct the wound
track; and after the wound is healed, unless the foreign
988
REFEKE.XCK JIANDIiooK oF TlIK ilEDK'AL SCIENCES.
Roentgen Rayw;
Roentgen Raj'H.
bdily can be felt beneatli tlie skin, its looalizatimi by
other lliLiii the Rui-iitgeii rays is usually iin|ii)ssible.
With these all pails of the bodj' may be painlessly and
safely explored, and the jireseuee or absence of foreign
bodies determined, and if
found, they may be aceu
ratcly located. In a gveai
majority of cases the loruli
zation of a foreign body in
the tissues is a compara-
tivel}' simple process.
Direct observation with a
fluoroscope or a radiogra
phic picture ■will give all
neces.sary information. In
such cases the position of
the foreign bod.v relative to
surface markings and
points on the bones will
materially aid in determin-
ing its position.
The depth at which a for-
eign body lies and its jio-
sition ma.v be determined
with absolute accuracy by
views taken at dilTerent
angles. The principle in-
volved is that as the anode,
the object, and the shadow
of the object are always iu
line, when two observations
are made with the position
of the anode changed, it
must follow that the object
must lie at a point where
the lines drawn from the
shadow to the anode at each
observation cross each
other. In other words, if
two observations are made with the anode in different
positions for each, and these positions and the places
where the shadows of the object fall at the surface of
the body are marked, the object can be located at the
point where lines cross each other, which are drawn
from the positions occupied by the anode to the places
on the surface of the bodv where the shadows of the ob-
ject were cast. Various means have been devised for de-
FiG. 41;.'0.— Radiograph slioniiis;
of the
termining the positions of the anode and the .shadows of
foreign bodies ri-lalively to tlie surface of the Ixidy. Of
these the JlacKenzie-Davidson ap|iaratus, or one of its
modifications, is most convenient and accurate, and with
such apparatus foreign
bodies can be located with
mathematical exactness.
For locating foreign
bodies in the eyeball. Dr.
Sweet has invented a very
ingenious and satisfactory
apparatus.
Cidckli. — Recently great
advances have been made
in determining the presence
of pathologic foreign
bodies in the urinary and
gull bladders and in the
kidne\-.
The jiathologic concre-
tions formed in the.se or-
gans, from their difference
in compositiim and conse-
■ iuent resistance to the
Roentgen rays, differ ma-
terially in the ease witli
which they may be detect-
ed. Those calculi which
contain inorganic material,
such -as the liiineral salts,
ma.v be most easily made
out. For this reason gall
stones arc difficult to radi-
ograph, as they are gener-
ally composed of organic
matter. Uric-acid calculi
are quite transparent to the
rays and consequently dif-
ficult to determine. For
these reasons while a radiograph showin.g a shadow cast
b)- a calculus is proof positive of the presence of a calcu-
lus, the ab.sence of a shadow is no indication that a calcu-
lus may not be present, as the calculus may lie so trans-
parent as to cast no shadow. However, with proper
technique, the presence of calculi may be demonstrated,
when present, in a large iimentage of cases.
Fracture ot the External Condyle
Femur.
FIG. 1127. I'ifi. 4I:;s.
Figs. 4127 and tias.—nudlogravilisof aFrac-ture of the Radius and t'lua before Reduction (Fig. 4127). and after Reduction and Wiring (Fig. 4128;.
9S9
Rocntst'U Kays.
Uoent$:en Rays.
REFERENCE HANDBOOK OF THE 3IEDICAI. SCIENCES.
Via. 412H.— Calculi in the Pelvis of (lie Kidney. Rafiinemph made with
intensifying screens— e.\iK»sed one second. (Zienissen-Rieder.)
For the detection of ealriili the cliaraeter of tlie tube
is of the greatest importatiee, a "critical tube," giving
the maximum of dill'eieutiation, being necessary. The
difficulties incident to this work ai'C well known to all
practical workers, but advances are conslantly being
made, and here it is well to mention the work recently
done with the aid of iiitciixifi/in!/ sc/ccns. lu this melhod
a photographic film
is placed in a light-
tight envelope, be-
tween two screens
coated with fluoies-
cent salts. When
exposed to the
Roentgen raj'S the
intensifying screens
fluoresce and so
greatly shorten tlie
time of exposure. In
this way almost in-
stantaneous expos-
ures may be made
through the thickest
part of the body
(Fig. 4129).
With improved
technique much has
been done in deter-
mining the patho-
logical conditions of
the organs within the
thorax. The value
of the rays in deter-
mining tubi reiiloiis
changes in the lungs
is now fully reeog
ni/.ed, and must rank
with, if not higher
t h a n, auscultation
iuid percussion. In
fact., by the rays tu-
berculous changes
may be determined fully as early in most cases as by
lihysic"il signs, while the location and extent of the
pathological changes can be definitely shown (Fig. 4130).
Similarly, empyema and pleui'isy with eiTu.sion can be
shown by the shadows giveu by the fluids in the pleural
cavit}'.
In diseases of the Itenrt and iifirta the alterations in
form of these organs are jilaiuly and accurately shown,
Ihrreliy enaliliiig the ob.scrver to determine definitely the
condition pi'esent. In valvular disease the shape and
size of the heart are more acoirately determined than is
possible by most careful perctission. Likewise in aneur-
ism of the arch of the aorta, the abnormality in form of
the aorta is shown, so giving invaluable aid to the diag-
nostician (Figs. 4131 aiTd 4133).
R.MJiOTiiKitAPY. — The thei'apeutic uses of the Roent-
gen rays depend upon their al.iility to affect the metaliolie
action of the body cells. AVhen living ti.ssue|is exposed
for a sufficient length of time to rays having considei'able
power, peculiar clianges are effected in the cells, these
changes being expiTssed fir.st by increased cellular activ-
ity, and afterward b}' cell death. These cell changes are
not produced at once, as when ordinary heat is applied to
a part, but appear onlj- after a considerable time has
elapsed. Thus in the .r-nii/ burn, due to exposure of
the skin to too powerful or too prolonged exposure to the
Roentgen rays, the tirst signs appear usually about the
third day after the exposure. The first evidence of
the effect of the rays is a slight redness of the skin. This
deepens and extends, and in a day or two small blebs
appear, which bieak. and from these tissue destruction
extends by cell neci-osis until finally large denuded areas
may form, which are very painful and slow to heal.
The action of the rays upon the bod_v cells has been
ascribed to the true light rays given otT from the vacuum
tube, but it is really due to tlie Roentgen rays, as the
skin is affected when covered by a sheet of hard rubber,
wliich shuts off all light rays, but allows the Roentgen
ra\'s to pass readily.
"So far. the therapeutic use of the raj's has been mainly
confined to diseased conditions of the skin, tlie mucous
membrane, and the tissues lying directly beneath them.
The effect of the rays upon the deeper tissues, both
U'.iuiiis^^eu-liiuUcr.)
KlL'hl LllIlL' .Nm1i]i;U.
!l!tO
REFERENCE HANDBOOK OF THE 3LEDICAL SCIENCES.
Rooiit»;r-u Rays.
Roeutgeu Rsyit.
normal and abnoruial, is a field having many possibilities,
but one in which no definite results have yet been re-
corded.
In certain patliological conditions of the sUin and sub-
cutaneous tissues many brilliant cures have been made,
and radiothei'apy is now acknowledged to be; a most
valuable aid to the i)ractitioner. Tlius. cases of lupus,
3. The "normal exposure" in a single sitting, and
await reaction.
Treatment by any of these methods is appropriate
tmder proper conditions. The second is the method to
bo preferred, inasniuch as the lirst is tedious for lioth
patient and physician, and the third demands a certain
cxixrienee CM tlic pait of the operator. After the first
i
^
p 'fl
\ "W-
%
1
[ 1
1 .rj^^
1
E??S
w
^fl
Vn
r
'.
J^^^^^^^^^^l
^^^^HBk. 'i^
K-'* - \
ti
fe^
l^^^^l
^mf
H
Fig. 4131. Fir.. 4irS.
Figs. 4131 a.nd 4132.— liadiopcraphs showing Normal Heart and Aorta (Fig. 4131). and an .\neurism of the Arch of the Aorta (Fig. 4132).
eczema, syco.sis, favus, epithelioma, rodent ulcer, and
carcinoma have been relieved or cured without produc-
ing any inflammatory reaction or inconvenience to the
patient.
Practical Application, of Eadiothernpy. — Radiotherapy
requires a complete armamentarium consisting of an in-
duction coil of at least twelve-inch spark length, an in-
terrupter capable of adiustment, and a suitable vacuum
tube, preferably of the regulating kind. In treatment
much depends upon the tube used. With a low tube the
radiant energj- is not powerful, penetrates but little, and
in consequence its acticm is largely confined to the super-
ficial tissues. With an extremely high tube the radiation
is very penetrating, and appears to pass too deeply, or
through the part exposed. A medium tube is, therefore,
best in that its radiation penetrates sufficiently and yet is
largely absorlied by the tissues.
The tube used should be capable of producing a good
picture of the thorax of a medium-sized man, when
viewed through the fluoroscope at a distance of 60 cm.
from the focus. With a tube of this kind the time re-
quired for each sitting will be between five and twenty
minutes. Although a five-minute exposure will pro-
duce a slight effect, a radiance lasting twenty minutes
maybe regarded as the "normal exposure." Such an
exposure will have the following results: On normal
skin, after a period of lateiicj- of fourteen days, the hair
tvill fall out. accoin]iauied by an erythema lasting a few
days ; on skin affected with sycosis tlie loss of hair will
occur as earl\' as the eighth day, accompanied b_v the
formation of numerous pustules; lupus tissue will be-
come exfoliated after a lapse of a week. On the other
hand, the effect of a normal exposure of twenty minutes
can be produced by dividing the action of the radiance
over several sittings of shorter duration.
Taking into consideration the intensity of the radiance,
the number of seances, and the length of intermissions,
we mav formulate the following three methods of radio-
therapy :
1. Daily sittings, with a radiance of slight intensitj-,
lasting five minutes, continued until the first symptoms
of reaction appear.
2. (a) Sittings, with a radiance of medium intensitj',
twice a week until reaction begins to be manifest (about
two weeks); or (//) three or four .sittings, with a radiance
of medium intensity, given on alternate days.
sign of reactiim appears it is advisable to await the ter-
mination of the characteristic inflammatory process, and
then, if necessary, repeat the exposure. If, in using the
second and third methods, absolutely no reaction occurs
at the end of three weeks, we may feel justified in re-
peating tlie "normal exposure"; if, however, a mild re-
action, non-progressive in character, has taken place, an
additional exposure, less than normal, can be ajiplied.
As stated above, the second "normal exposure" is made
after the subsidence of the inflammatory reaction excited
by tlie first: thus this treatment may involve, in accord-
ance with the nature of the case, repetition of a'-ray
apjdications extending over months or even years.
Often in cases of hypertrichosis, in some cases of sycosis,
and in nearly all cases of herpes tonsurans and favus, a
single "normal exposure" usually suffices, i.e.. by using
method No. 3, a perfect cure results after a single sitting.
Finall}', it may be stated that radiotheraiiy is as bene-
ficial in the hands of an expert as it may be harmful if
im]iiopcrly used. Over-exposure or too frequent expos-
ure to powerful radiation may induce a severe ulcerative
process, which is very painful, slow to heal, which may
even endanger life, and require surgical intervention
before a cure can be effected.
The physician can no longer shield himself behind a
su]iposcd idiosyncrasy of his patient. It appears that
patients in poor health, whose vital resistance is lowered,
are more ca.sily affected by the rays than are persons in
full health, and this should be taken into account; but,
in general, the tissue changes induced are directly in pro-
portion to the amount of radiant energy which falls ujion
the part.
The TiiERArEUTic Action op Light. — Actinother-
apy, like radiotherapy, is based upon the effect which
light produces upon living cells. This effect is mainly
manifested in two ways: (n) the effect of light ujion the
organism generally; and (//) the local effect of light.
The Effect of Liijlit upon the Orr/anism as a ^Y]lule. — The
effect of light upon living organisms is shown in nature
in a multitude of ways, and is illustrated by the differ-
ence in appearance presented by plants grown in the
shade and the same species grown in sunlight ; also, it is
well known that pensons who live in dark or ill-lighted
habitations lack the ruddy, healthful appearance of those
who lial)ituall_y live out of doors. It is true that while
this difference in vitality is due not alone to the dimin-
1)91
Roclll<£<'ii RayK.
Ko<>iitg<-n Rays.
REFERENCE ilANDISdoK OF THE MEDICAL SCIENCES.
islied amount of light, but is Urgcly owing to otlier un-
favorable conditions, such as lacli of fresh air, exercise,
etc. ; still, ligiit is a decided factor in favoring health,
and is one of the agents ■which, combined with fresh air,
exercise, sanitarj' habitation, and suitable climatic con-
ditions, is of tlic^ greatest benetit in the treatment of de-
bilitating diseases.
Tlic eliicacy of a combination of the above-named fac-
tors in tlie treatment of tubercnlosis is too well known to
recjuire discii.ssion. and the accentuation of the light fac-
tor lir the u.se of "light baths" is an important addition
to the therapy of this di-sease. It is true that the use of
sun batlis dates Ijack to remote antiquity, Init the fact
tiiat the sUin and soft parts are more or less permeable to
rays of ordinary liglit has not until recently been con-
clusively demonstrated. The bactericidal elTect of the
aclinic rays has now been conclusively sliowu, and the
lieneticial effect of sun baths in pidmonary tuberculosis
has been ascribed b_y some to the bactericidal action of
liglit; but it is more probable tliat tlie good effect of
sunlight is due to a general favorable stiuuilation of
tlie body cells, whereby tlieir metabolic activity is in-
creased and tlie tissue resistance to bacterial action is
raised.
The Loral Applications of AcHnotlicrnjiy. — The local
us(! of liglit for tlie cure of disease is in many ways anal-
ogous to the use of Roentgen radiation.
Both light rays and Roentgen rays apiicar to act liy
altering the metabolic action of the cells upon which
their energy is exerted, but the resulting cell changes
caused by these agents appear to be materially differ-
ent. Theeffeet of Ruentgen radiation upon living tissue
has been discus.sed under radiotherapy, to which the
reader is referred for an account of the tissue changes
produced by that agent. Theeffeet of light in the treat-
ment of pathologic conditions appears to be largely, if
not entirely, due to the chemical or ai'linie elf<'ct of
certain of tlie light rays. Relative to the biologic and
therapeuiie effects of light, it is important to note that
light is not a siiii|)le entity, but that every ray consists
of a series of distinct parts, each of which has its par-
ticular pii)]ierties. Tile effects of solar radiation may be
arranged in three different groups — heat, light, and
chemical action. The heat rays are mainly found in the
infra-red, red, and orange of the spectrum; the yellow
and green rays make llie strongest impression upon the
human retina, wliile chemical action is chieliy found in
the blue, violet, and ultra-violet rays. While all solar
wave lengllis, even the infra-red rays, induce chemical
change under favorable conditions, tlie ultra-violet, vio-
let, and blue are the must powerful in the order men-
tioned. This chemical action of certain light rays is par-
ticular!}'shown in the action of light in reducing silver
salts in photographic ]irocesses. The .s.-ime rays of .solar
light wliicli produce clieniieal changes in inorganic com-
pounds produce vital eheinieal or metabolicaetion in liv-
ing cells. The action of liglit uiion the skin has lieen
noted by mountain climbers, who siilTer from "sunburn,"
due to the intense action of sunlight in high altitudes,
wdiere the cold is so great as to negative the supposition
that the sun's heat could produce the condition. Tills
intlammation of the skin, eriitliiina snlarr. was formerly
called erythema caloricum, as it was thouglit to be due
til overheating of the integument. This heat theory of
erylliema was liist comliated by Charcot in is.j'j, "and
has since been entirely refuted by tlii' fact that severe
erythema occurred in persons travelling among ici^ fields
and in the ])olar regions with the fempeiature iiiiieh
below zero, and in persons expo.sed to an elect rie are
light, where the light is intense and the heat biint.
Widmark, of Stockholm, by the use of glass and rock-
cryslal jilati'S, demonstrated experimentally tli;it the
jiower of light to affect living tissue rested mainly in the
violet end of the spectrum. Glass absorbs most of the
ultra-violet rays from an electric light, but rock crystal
allows them to ))ass through. With a rock-crystal lens
Widmark caused the ra\'s from a twelve hundred candle
])ower arc light to become parallel. When the rays were
directed ii))on the skin and a glass plate interposed, so
obstructing the ultra-violet rays, no intlammation was
produced, but when a rock crystal plate was used which
allowed the ultra-violet rays to pass, a severe inflamma-
tion was set up.
The experiments of AVidmark were corroborated by
tlio.se of Finsen; and the hitter's ajiplication of the prin-
ciples adduced to the treatment of certain pathological
conditions of the skin, notably lupus vulgaris, gave rise
to the so-called Finsen treatment of skin diseases and the
red-light treatment of smallpox.
The treatment of siiiallpo.r by red light has given re-
markable results. By the exclusion of all ex<-ept the red
rays of light the course of the eruption and of tlie disease
it,self in many cases is markedly changed. The unfavor-
able action of lightupon the course of smallpox was noted
by Pictou in 1833, by Black in ls(i7, and by Barlow and
"^Vaters in 1871, but"it was reserved for Finsen (1893) to
define a treatment based upon the deleterious effect of the
actinic rays. Arguing from the fact that the actinic rays
are able to produce inllammafion in the heallhy tissues,
lie arrived at the conclusion that their exclusion in in-
flammation of the skin might be beneficial. This view
is supported by the
fact that in small-
pox the deepest
erupt ions are found
on the liands and
face, which are the
parts of the body
most cxjiosed to
linht. Total exclu-
sion of light or the
ex ) insure of the
skin to those rays
only which are nnl
harmful (nou- ac-
tinic ravs) is there-
fore indicated. As
total darkness is not
conducive to the
patients' well-be-
ing, it is preferable
to let them lie in a
room lighted by red
light only, the red
rays Iieing non-ac-
tinic and therefore
harmless. The ar-
rangement of the
red room is very
simple, being sim-
ilar to that of the
dark loom used in
phot.igiaphy. The
w i n d o w p a n e s
.should be of red Fig. 4133.— Finsen Appuriitus for Use witli
glass, or, where a SiuUigUt.
room has to be ex-
temporized, the room may be darkened by thick curtains
at the windows and illuminated only b}' the light from
red lanterns, such as are used for photographic purposes.
Uiiward of two hundred cases of smallpox treated by
this method have been reported, and all jihysicians who
have given their experience with the method state that
the results are remarkably good. If the jiatients were
brought into the red light before the beginning of the
suppurative stage, as a rule no suppuration occurred.
The vesicles continued clear and after a few days dried
to crusts, which fell off without leaving a scar. By the
non-appearance of suppuration all the symptoms de
jiendent upon that condition were absent. When the
primary fever disappeared, the temperature remained
aliout normal and the secondary fever of suppuration
did not occur. In consequence the duration of tlie dis-
ease was shortened and the mortalit}' lessened.
Uceently Finsen 's red light treatment has been tried in
other infectious exanthemata, and Backmann and Chati-
9!)2
REFERENCE IIANDIiOOK OF THE MEDICAL SCIENCES.
Roentgen Rays.
Roentgen Rajs.
niure liave dbtaincil especially satisfactory results witli
it in the treatment cif measles.
Adinothern/)!/ iij'icr Finsen's MetJtod. — The Finsen
method of the local treatment of skin diseases has for its
4i;!t.- liiiscii A|i|«iratus fell- Trc-atiiu-iit widi Elwtrir Ligbt. (Bie.)
practical basis the experiments made hy himself and
Widmark in producing local inflammation of the skin
by the ultra-violet rays. In theory this treatment rests
upon the many experiments showing that the chemical
raj'S affect the metabolic action of living cells and cause
the death or inhibit the growth of bacteria. The investi-
gations of Bie and others have shown that the bactericidal
power of light resides almost exclusively m the blue,
violet and ultra-violet rays, and that only a small per-
centage of such potency exists in the red, yellow, and
green. The rays of
liglit which have
strong bactericidal
action are, there-
fore, the same as
those which will
produce iutlanuna-
tory action in thi'
skin. That lii;ht
can pass through
the skin was de-
monstrated by God-
netT. He placed
small glass tubes
containing silver
chloride under the
skin of dogs and
cats and then kejit
some of the animals
in the dark and
others in direct siiu-
light. After an
hour he removed
the tubes and foiuid
the silver ehlnridc
blackened in those
animals kept in the
light, but not in
those kept in the
dark.
Finsen then de-
monstrated that ac-
tinic light better
Vol. VI.— 63
penetrated those tissues ■which are deprived of blood.
His treatment, therefore, consists of concentrating ac-
tinic light through rock crystal lenses upon living tissue
made ischemic by pressure. Sunlight or artificial light
may be used, but the
latter is most gener-
ally useful, as it is al-
ways available and
controllable. When
sunlight is used it is
concentrated on the
part b.v a large hol-
low lens composed of
a fiat and a convex
glass enclosed in a
brassring (Fig. 4133).
The lens is filled with
a watery ammoniacal
solution of copper
s\dphate. The water
at)Sorbs the infra-red
(ilark heat) rays and
the blue solution ab-
sorbs a part of the
red, yellow, and
green rays.
In treatment Ij.v
electric light an arc
lamp, taking sixty to
eighty ampferes of
current, is used.
Current from an elec-
tric-light circuit is
used, the amperage
being raised and the
voltage reduced by a converter constructed for the pur-
pose. The apparatus consists of three parts: (1) the
light; (2) the cooling apparatus; (3) the light-concen-
trating apparatus (Fig. 4134). The arc light is sur-
rounded by a shade to prevent the ej'es of those present
from berag dazzled. From this light there radiate four
01 more telescopes, each telescope conveying the light to
a patient The telescope lenses are of rock crystal, as
this obstructs the active rays less than any other material.
The space between two of the lenses is tilled with "water
Fu:. 4i:i.j. f'K). 4136.
FIGS. 4135 AND 4136.— Case of Lupus Vulgaris, before (Fig. 4i;i5) aud after (Fig. 4136) Treatment by tbe Finsen
Metbod. (Bie.)
903
Roflllelu.
Roellielu.
KEFEKEXCE HAN'DBOOK OF THE MEDICAL SCIENCES.
to moderate tlie temperature, aud an enclosins water-
jaeket still further reduces the heat. The lenses are so
arranjred as to render converjjent the divergent rays from
till' arc light ; t liese rays then being brought to a focus by
a lens cooleil by water and held by a nurse and pressed
by her firmly on the affected jiart. The patient lies on a
table or is seated in au adjustable cliair, the position of
which can be varied so that the liglit will fall perpen-
dicularly on the surface to be treateil. Each application
lasts about an hour and is repeated daily. Although the
light is cooled in its pass;age through the concentrating
ajiparatus. it is yet too hot to be directed on the sUin
without detriment ; hence the water-cooled lens, applied
to the skin, is used in all case;-., whether sunlight or elec-
tric light is used. The effect of the treatment on the
patient is in no way painful. A few hours after the first
application there is a certain amount of "reaction " ; the
part swells, becomes reddenetl and tender, but there is
little pain. The reaction varies in degree in difi'erent
cases, being always seen in lupus vulgaris, but does not
occur in lupus erythematosus. The beneficial effects of
the treatment are often manifested in a few days, and
recovery sometimes follows a very few applications.
Generally fifteen to twenty-tive applications must be
made before a cure is ettected. The results are very sat-
isfactory; the skin becomes soft, smooth, and pliable,
and scarring is hardly noticeable, other than to the extent
deiiendent upon the tissue destruction caused by the dis-
ease (Figs. 413.5 and 4186).
The Finsen method has been most successfully used in
the treatment of lupus vulgaris, but recently encourag-
ing reports have been made of the treatment of alopecia
areata, epithelioma of the skin, and nievus va.sculosus.
M'llliam CUne BonUn.
ROETHELN. — Disfisitiox and IIistohv. — Roetheln
is an e.vaiilhcmatous disease of mild character, attended
with a slight elevation of temperature, propagated by
contagion, and beaiing a close lescmblance to measles
and scarlatina. It is widely known in this country uudir
the above a|ipellation, and also, in common parlance, by
the term "German measles." The latter name, being
English, is generally- used. Thus in its nomcnclatm-e
Roethein resembles the other exanthemata, which have
each a technical and a common name. The Germans,
however, use the names Roethein and rubeola as syno-
nyms: and this tends to confusion, since we signify by
rubeola the different disease, true measles or morbilli.
Various other names liave been given to the di.sease by
dilTeient writers, prominent among them being epidemic
roseola, rubeola scarlatinosa! rubeola morbillosa, rubeola
notha, and rubella. The last-mentioned name has been
suggested as most appropriate, since it is a diminutive
of rubeola, and thus the two words express the analogy
existing between the two diseases, just as do the terms
variola and varicella. For the reason, however, that
Roethein is more widely recognized, the writer retains it
in this article.
Roethein is, so far as definite knowledge is concerned.
a new disease. As late as ISSQ the "Index Jledicus"
gives it no separate place, and the articles on the subject
are grouped under the heading of measles; yet the num-
ber of communications, treating of this affection, which
have been written during the past ten years or so (1877-
1S87), will aggregate more than one hundred. Before
that time, however, the disease hail been from time to
time spoken of, as far back as a century aud over; thoiigh
until the time of the present generation the greater num-
Ijer of observcis did not con.sider it a distinct disease, but
believed it to bea modilication of measles, generally, and,
in Slime instances, of searialina. .Mention was made of
epidrmics in 184.5 and ls."j:i and in 1873-74 the disease
was carefully described, though under the name of epi-
demic roseola. In Germany attention was given to the
sulijeet many years before any English or American
writings appeared. Now almost all [ihysieians grant its
individuality, and the arguments supporting this view
will be presented hereafter.
Agi3 op P.iTiENTS. — Roethcln is generally classed as
one of the diseases of childhood; and, since there are no
clearly proved instances of its second appearance in the
same individual, it follows that those affected are usually
young in years; the general rule being that any one of
the contagious exanthemata is e.x|)erienced but once
iu the lifetime of an individual. Still, it is much less
prominently an affection of infants and children under
five years of age than are the other er\iptive fevers.
Adults are frequently attacked, but the majority of
those who suffer 111 im this disease coutraet it sometime
before the age of puberty. In other words, the time of
life when susceptibility is greatest is between the ages of
two and fifteen years. Young infants do not seem to
contract it, and it is believed that sucklings are not sus-
ceptible. As, however, it is a disease of less frequent
occurrence than measles or scarlatina, and as it .seems to
be less actively contagious than those diseases, manv
growing children escape it; and these facts constitute a
possible ex]danatiiin of the circumstance that adults are
not iufrequeutly attacked during the prevalence of au
epidemic.
Theseason of the year docs not seem toexert any influ-
ence on its prevalence. Epidemics occur indifferently iu
hot aud in cold weather.
ErioLOGY. — Roethein is propagated by contagion, and
by this means alone. The inateries morbi is believed to
be portable, but the cases iu which the source can be
traced point toward the necessity of close contact for the
transmission of the disease from the sick to the well. In
a single epidemic the total number of cases among those
unprotected by having previously experienced the dis-
ease is found to be small in comparisou with the other
contagious exanthemata. Especially is this noticealile
with reference to measles, which will attack, simulta-
neously or successively, all the susceptible children in a
household almost with certainty; while we generally
meet with a single, or perhaps two, cases of Roethein,
and the greater number of those exposed, in greater or
less degree, escape. J. Lewis Smith, in one epidemic,
saw forty -eight cases in twenty-one families — an average
of a little more than two to each family. In an institii-
tion, such as an orphan asylum, the number of cases
would be comparatively larger, since the exposure would
be of necessity greater at first. Isolation, therefore, can
be expected to accomplish more in the direction of pre-
vention than it does with measles or scarlatina.
Roethein is encountered almost exclusively in epidem-
ics, and sporadic cases are very rare. This is probably
more decidedly the case with this disease than it is with
scarlatina, and po.ssibly also with measles.
Considerable ditlieulty is experienced in tracing cases
of Roethein to their sources— largely, no doubt, because
affected persons are frequently unconfineil, owing to the
general mildness of the disease, and the absence of alarm
concerning it. Undoubtedly, however, if its origin could
always be traced, an exposure to contagion would be dis-
covered. In other words, it is practically- certain that the
disease does not originate de mn-o ; nor is it produced by-
general causi'S, such as imiirojier hygienic surroundings
in the matter of ]ioor ventilation, overcrowding, or in-
sultieient or improper dietary conditions. Ou the con-
trary-, it is not found to be a disease of greater propor-
tionate prevalence in tenement-house districts, where the
conditions referred to are iu prominent existence. A
large proportion of the cases are encountered iu the fami-
lies of the better classes, and, most of all, iu institutions,
such as orphan asylums.
We may reasonably conclude that Roethcln is less ac-
tively- contagions than measles or scarlatina, since so
many of tlio.se exposed escape. Under the same condi-
tions of exjiosure the number of cases arising of either of
those two tliseases would probidjly considerably exceed
those of Roethcln.
The age at which susce]itil)ility is greatest iias been
mentioned, being considerably more advanced than that
which obtains with the other exanthemata; but as yet
there is little definite knowledge as to the stage of the
f•fl-^
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Roetllelu.
Roetiielu*
disease itself in wliioh propagation 1)y contagion is most
lilscly to ocfur. We can only say UiiiL the jirobubility is
in favor of contagiousness during the whole course of
the disease — from the time when prodromal symptoms,
if present, appear, until the eruption has entirely disap-
jieared.
Clinical, History. — Slage of Incubation. — Much atten-
tion has been given to the duration of the stage of incu-
bation—the time elapsing between a traceable exposure
and the onset of the disease. This is freijueutly made
difficult of accurate investigation for the reason before
mentioned, that isolation is not observed because of the
mild character of the alTeclion, and sometimes even cou-
lincment within doors is not enforced. The general ex-
perience is that tills stage occupies from fourteen to
twenty-one days; though in some epidemics the duration
has been considerably less. Shuttleworthhad the oppor-
tunity of ascertaining, in an asylum, that twenfy-oue
days lapsed after the first case appeared before the second
occurred, isolation being enforced, and two days later
two fresh cases developed. Goodhart says that the in-
cubation, in twenty-three out of twenty-live cases, was
from fourteen to twenty-two days. Edwards gives six
davs as the shortest and twenty-one days as the longest.
Clieadle a.scertaiued it to be eight days in one instance,
nine in another, and (approximately) twelve days in five
more. GrifRth's experience was that in twenty -.six cases
the eruption appeared between the fifth and twelfth days
after the first case was discovered. Therefore it must
be granted that considerable variation exists in the length
of tills stage, although we ma}' consider that a period of
fourteen days represents the average. The incubative
stage of measles is much more constant — standing, as it
does, at thirteen and fourteen da3"s.
Stiiye of Invasion. — In very many instances the erup-
tion is the first thing which calls attention to the existence
of sickness. Since many of the patients are old enough to
describe any subjective symptoms which maybe present,
it follows that the stage of invasion is freciuently attended
witli little or no disturbance of general health. "With
children too young to describe their own sensations, the
attention of parents is often attracted by no manifestation
whatever — such as restlessness, or crying, or digestive
disturbance — tnitil the eruption becomes visible. It is,
however, probable that there is always present a slight
rise of temperature, not sufficient to cause discond'ort;
and close questioning might elicit au admission of a feel-
ing of malaise. But, as stated, the breaking out of the
rasli is what causes uneasiness, and leads patients or par-
ents to consult a physician for the purpose of ascertain-
ing the nature of the sickness.
There are, on the other hand, eases in which there is
more or less decided disturbance of health prior to the
appearance of the eruption. Eiiidemics undoTd5tedI_y
vary greatly in severity, as do individual cases in a sin-
gle epidemic; and froiu the average of descriptions it
would appear that the disease is more severe, as well as
of more frequent occurrence, in Europe than in the United
States. These more severe cases present certain indica-
tions of .sickness, before the rash appears, which, taken
in connection with known exposure, point toward Roe-
tlielu as the oncoming disease; but in themselves the)'
have little value as regards the difTerential diagnosis,
especially, from scarlatina and measles. The s_vmptoms,
when present, have special reference to the mucous
membranes of the air passages, and to the digestive sys-
tem. They are: mild inflammation of the throat and
tonsils, shown by swelling and redness on examination,
and by pain and slight cough; a slight degree of coryza;
conjunctival irritation, lachrymation, and a little ten-
dency to edematous swelling of the eyelids. Nausea
and anorexia have been frequently observed, and in rare
instances vomiting. Frontal headache in a few instances
is thesourceof much discomfort. Tlie digestive disturb-
ances appear to have been prominent in some and absent
in other epidemics. With these symptoms — and, it is
not improbable, in their absence — tliere is a rise of tem-
perature to 99" or 100° F. iu mild, and as high as 103" F.
in severe, cases. In adilition to these indications there is
one .symptom highly characteristic of tlie fully developed
disease, as will herealtcr be seen, — a symptom which
has been observed iu the ])rodroinal stage. This is en-
largement of the post-cervical lyni])hatic gland.s — not
(hose at the angle of the jaw, as olitains in scarlatina and
diphtheria, but those in the back of the neck. This en-
largement should alwaj'S be looked for. since it is the
only feature of diagnostic value iu the stage of invasion.'
Jaccoud found it, in five out of thirty -two cases, four or
five days before the efiloresccuce. Associated with this,
stilTnessof the neck with pain on movement of tlie head,
in slight degree, should be sou.glit for.
Any throat inflammation present might easily be ac-
counted for iu expecting scarlatina to develop; and cory-
za, cough, and conjunctival irritation belong to the clini-
cal history of measles. Rise of temperature also, of
course, accompanies the onset of both these diseases; and
consequently, excepting only the glandular enlargement,
so far as these general symptoms are concerned, it is only
in their lesser degree of severity that they are character-
istic of Roetheln rather than of the other two affections.
These indications, when present, precede the eruption
by a period, in the great majority of cases, of less than
twenty-four hours; al! hough in some instances malaise
is present for three or four days before this stage is
ended. Cheadle, in describing a severe epidemic, ob-
served that the prodromal symptoms persisted longer iu
severe than in mild cases. Edwards gives the average
duration as three days.
It is therefore observable that the stage of invasion,
when present, is subject to considerable variation — both
as to length and severity — and is, in fine, a much more
uncertain quantity than is that of scarlatiua or measles.
Staffe of Eniplioii. — The prominent feature of the dis-
ease is the eruiHion, often, as before stated, being the
only phenomenon perceptible, and geueralh' being by far
the most prominent manifestation of a condition of sick-
ness. Veiy great dilferenccs, in different epidemics and
in indiviilual cases, are to be found : and, considering the
eruption alone, a diagnosis might well be dilHcult, if not
impossible. As the symptoms other than the eruption,
such as those found in the prodromal stage, present con-
siderable variation, and as this fact holds with the erup-
tion itself, we may conclude that the disease, as a whole,
is far less stalile than scarlatina and measles. Tliese are
more than variations of degree — they alfect the essential
characters of the symptoms and of the eruption.
Scarlatina, for instauce, may be verv mild or very
severe as regards the throat inflammation and fever ; and
its eruption may be dilficult of detection, or as marked as
a pronounced rash of erysipelas; but tliese are differences
of degree, and the sore throat and eruption are uniformly
present, and are «Hi grncris. The same rule holds with
measles. The essentials of the diseasi — the catarrh of
the respiratory tract, and the characteristic eruption —
may, one or both, be very mild or very severe; but they
must both be present in any case in which the diagnosis
is undoubted. Roetheln, on the other hand, may consist,
from beginning to end, of the eruption only, or maj" pre-
sent some of quite a variety of sj'niptoins affecting the
mucous membranes of the air passages or of the digestive
api^aratus.
]{ei;arding the eruption itself, its characteristic points
are as follows: Its color is ginerally a pale rose, less dis-
tinctly roso-hued than that of measles. It is very fre-
quently brownish, brownish-red, and sometimes quite
distinctly brown, with no tinge of rose or pink to be de-
tected, and giving the general effect of duskiuess.
As to location, no ])art of the surface is entirely ex-
empt. The palms of the hands, the soles of the feet, and
the scalp have been observed to present it; although
usually it is not to lie found in tliose regions. As a gen-
eral rule, the face, trunk, arms, and legs break out suc-
cessively before the fiual disap])earance of the rash; al-
though cases are often descrilied in which the affected
area is much less extensive.
Either the face or the upjier part of the bod}' may be
995
ICoolllclll,
ICocllielii.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
first affected, niul the spread of tlie eniplionis rapid —
one day or less sulticiiitifor its appearance ontlie remoter
parts after its initial appearance. Tlie maximum of in-
ten.sity is very quickly attained. Beginning on the face,
for example, iu ver3' faintly marked sjxits, after a period
of a few lioiu's. and certainly witliin one day. it will be
at its height, and the spots "will be plainly visible. Then
a fading process sets iu, gradually pi-ogressing, accom-
panieil with, or followed by, some desipiamation, an<l
continuing for about two days; so that, in any selected
locality, from the tirst appearance to the linal disappear-
ance, an average period of three days is occupied. This,
however, is not a delinitely fixed time: sometimes it em-
braces but two days, and at otlicr timesit is jirotracted to
six or seven.
The duration of the eruijtion as a whole, without refer-
ence to an_y special part of the surface, is conseipunitly a
little limger than that of its presence ir. a given locality —
by the ti}ne occupied in the spreading from the region
first to that last attacked. As this generally rci |uires one
day, or somewhat less, the eruptive stage of the disease
can be expected to continiu' about tluee days on the
average, though sid)ject to the variation sjioken of, Iiav-
ingas extremestwoand seven days. It will be ob,-erved,
from the rapidity of development in a selected Icjcalily
as compared with the rapidity of the spn'ading to other
I'cgions, that dilferent parts will present the eruption iu
greatly varying conditions; and that at no given time
Avill it be at its maximum uniformly over the entire sur-
face of the body. In other words, it may cvcai reach its
height in one part before appearing iu another. This is
a point of value in diagnosis, and of contrast to scarlatina
and measles, in both of which there is generally a station-
ary period as regards the spread anil intensity of the
cruiiticni after the maxinunn has been attained.
The eruption is jiapular. If the hand is passed gently
over it. a sense o( roughness, at least, is perceptible,
showing a certain degree of elevation above the surround-
ing skin. From this very slight condition of elevation
dilTerences are to be found up to a state in which the ele-
vation is distinctly and at once visible — as much so as iu
a fully developed rash of measles. But. in some degree,
elevation of the spots is always present, and therefore it
is a mistake to describe the eruption as macular.
The size of the papules is oue of the points in which
there is considerable variatiou. In geneial they are
smaller than the papules of measles, varying from the
diameter of a pin's head to that of a jiea. In a certain
proportion of cases the spots are so small as to constitute
mere piuictatiou, and the skin jiresents the ajipearauce of
being covered with innumerable tine dots. They are of
irregular shape, but with a more decided tendency to as-
sume the circular form than is observed in the spots of
measles. In a given case there is generally some uni-
formity in the matter of size — either the (lapules are for
the most Jiart of tla^ larger size, or they are nearly all
small. Still greater dilTerences of size have been ile-
scribed, however, pa|iules of one-third of an inch in di-
ameter having not infrenuently been encountered.
Generally the skin between the jiapules presents a ]ier-
feetly healthy appearance, although carefid investigali<in
will occasionall.v reveal the existence of minute line lines
or proces.ses connecting adjoining papules. A general
<'rythematoiis redness of the skin has also been noticed.
Conlluence of the papides is very rare, though not iiui-
forinly absent.
Vesicles have been observed, but this has clearlv been
a coincidence, and not at all apart of the ordinary conr.se
of the eru)ition. They are probably found qiute as often
with measles, and in either case must be regarded as
anomalous. Theeruption has been observed lodisai)|)ear
sudilenly, and after a short time to reappear; and un-
usual warmth, as from heavy clothing, renders it more
distinctly visible. A ceitain amount of itching is ofteu
lu-esent, though not .severe, and the heat and burning,
which are a simrce of discomfort in scarlatina and mea-
sles, are not at all pronoiuiced in Roetheln.
To sum U]i the characteristics of the eruption, we may
make a division of the cases into two classes, which cor-
respond with the descriptions formerly given of rubeoloid
Roetheln on the one hand, and scarlatinoid on the othei.
In each variety the resemblance to the other disease, as
far as the eruption is concerned, may be very close —
often sufficiently so to render the diagno.sis extremely
uncertain, if the other points of history and S3'mptoma-
tology be not carefully considered.
In the first class of cases, comprising the greater num-
ber, the papules are of larger size, perhaps abundant
enough to be considered confluent, of somewhat irregu-
lar shape, pale rose color, and raised considerably above
the skin. It will be seen that this state of affairs can
olilain with measles cjiute as well as with Roetheln.
In the second class the papules are smaller, nnu-e circu-
lar iu shape, less elevated al)ove tlu' skin, of darker hue,
much more numerous, and sometimes very closely aggre-
gated, so as to give the punctated appearance alluded
to. If this be the appearance, there may easily be noth-
ing in the eruption by which to discriminate" it from a
scarlatinal rash at the onset or during the tirst day of the
disease. A fully developed rash of scarlatina is' contin-
uous, leaving no skin normal in appearance between the
eruptive spots; and iu Roetheln the papides are distinctly
sejiarated from each other.
If. therefore, an extreme case of either variety be taken,
it will be found that other points iu s\'mptoniatology and
history are requisite, and possilily a delay fcjr oue or two
days may be necessary, in order definite!}' to eliminate
doubt in the diagnosis.
Denqiiiniiiition. — Desquamation is the mode, or perhaps
a better term would be the accompaniment, of the termi-
uatiou of the eruptiou, beginning on the second or thinl
day. It is furfuraeeous in character, never occurring in
large scales or pieces of skin as in scarlatina. It is fine,
and iu this resembles more the desquamation of measles.
It is much less decided than in .scarlatina, and is often so
slight iu amount as to be pereeiveil only on very careful
inspection, and freiiuently passes unnoticed by either the
jiatient or the physician. Jlany writers on the subject
do not make mention of the process, an<l frecpicntly the
statement is made that it is not a part of the clinical his-
tory of the disease. The writer cannot contradict this,
though holding the view that it is present iu some degree
iu all cases. As fading of the color of the eruption very
quicklj' sets in, and is progressive until its final di.sa])-
pearauce, the desiiuamaliou is the acconq^animent of
this.
The des(piamation is not to be found affecting at one
time the entire surface which has jiresented the eruption.
It follows the appearance of the rash, and, consequently,
is visible on one part of the surface before it is on an-
other. Furthermore, it does not take place over the en-
tire affected s\u'face — much of the eruption fades away
without desquamation, and the latter is to be searched
for aljout the trunk, legs, and arms especially. The face
and extremities usually escape. In this there is another
point of reseudilance to measles.
Following the customary division of the eruptive fevers
into stages, we may consider the stage of desquamation,
fading, or decline, to occtqiy the time from the second
da}' of the eruption to the end of the disease. But it
must be borne in nunil that the line of division between
these two stages, i.e., of eruption and of desquamation,
is much less distinctly marked than iu scarlatina or mea-
sles.
Occasionally a faint staining or pigmentatii>n has re-
mained for sever.al days after the di.sappearance of the
rash pro])er.
Sjiiiiptom.i Clllirr tlmii tin- Kriiptian. — These have been
iu ]iart considered luuler the head of premonitory symp-
toms. (U' those presenting themselves in the stage of in-
vasion, and are. in great jiarf. simple contiuu;itions of
them. They are found, like those (jf scarlatina and mea-
sles, to have special reference to the mucous membranes
of the uose, throat, and conjunctiva, together with more
(u- less disturbance of the digestive fimctions. The in-
flanmiatorv condition cd' the throat and tonsils, which is
{•00
REFERENCE HANDBOOK OF THE .MEDICAL SCIENCES.
Rot'llicln.
Kofllielii.
the most frequent of these symptoms, varies greatly in
degree, and, beginning in the stage of invasion, persists
up to the time wlieu the rash has reached its lieight. and
then subsides with the disappearance of the rash. Slight
cough sometimes persists for a few days longer. The
conjunctival irritation and the aMlenuifons swelling of
the eyelids arc not often pronounced, and follow much
the same course as tlM throat symptoms.
The nausea, wliicli presents itself often enough to call
for special mention, is generally noticeable only until the
rash has developed.
The tongue is commonly coated, but does not at all
present the appearance of the strawberrv tongue of scar-
latina. All these symptoms, w hen picsent at all, are of
decidedly milder character than they are in scarlatina
and measles.
The temperature range has been referred to as being
liable to differences in epidemics and in individual cases.
As a general rule, the rise is much less than that of the
two other diseases. An elevation of from one to two de-
grees— to 99.5^ or 100.5' F. — is what we may look for ; it
persists for about three days, and in the given case docs
not present the fluctuations characteristic of measles, but
reinains at the same level until its final subsidence.
The pulse and respirationsare accelerated iu proportion
to the rise of temperature.
In general a severe case presents a greater variety of
these symptoms, as well as a greater severity, and a mild
case, absence, or nearly such, of them.
The .single phenomenon, over and above the eruption,
which is characteristic, and one might almost sa}- pathog-
nomonic, of Roetheln, is the enlargement of the post-cer-
vical and suboccipital lymphatic glands. Probably in
no case is it found wanting. This occurs at the onset of
the disease, and therefore, as stated, may not infrequentl_y
be discovered before the appearance of the eru ption. The
number of nlands affected varies from one or two up to
seven or eight. Search should be made for them from
the occiput down to the level of the slicndders. and tow-
ard the middle of the neck rather than at the sides or
near the angle of the jaw. In scarlatina, diphtheria,
and other throat affections, the glands which present en-
largement are those at the angle of, as well as beneath,
the lower jaw. Iu such instances the swelling seems to
be proportionate to the severity of the throat intlanuua-
tion, and to be associated with it, as in adenitis in the
neighborhood of iuHammation elsewhere in the bod 3'.
But the adenitis of Koethelu cannot be so explained, as
it is found equally in the cases with considerable sore
throat, and iu those with none. Therefore it shfudd be
regarded as a distinct phcnonienou of the disease, and
not as an accessory.
Associated with the enlargement is stiffness of the neck,
and pain on moving the head, in some degree, though
never very severe. The enlargement itself varies, the
glands being of about the size of a split pea or bean;
suppuration does not occur, and the swelling and pain
subside with the disappearance of the eruption. Occa-
sionally a single gland will remain perceplildy eidarged,
though painless, for an indefinite length of time.
Valuable as this point is, there are yet sources of error,
and glandular enlargement from other ca'.ises must be
excluded.
The condition which we recognize as struma, indicat-
ing the general condition of ill health due to bad hygienic
surroundings and malnutrition, has. as a pronunent feat-
ure, general glandular enlargement, perceptible iu the
groins, axilla;, etc., as well as in the neck: and syphilis
may present the same condition. According!}', search
should be made in those other localities before assigning
a cervical adenitis to an oncoming, or present, attack of
Koetheln. Enlargement of the glands at the angle of the
jaw is to be attributed to other causes. Children with
eczema capitis have, almost always, large lymphatic
glands in the neck.
During an epidemic of measles in 1886, the writer luade
investigation with special reference to this jioint, and
found that in twenty-four out of twenty-nine cases an
enlargement of glands exactly similar to that of Roetheln
was present, and constituted a prominent feature of the
cases. This was evidently a peculiarity of tliat epidemic,
as the writer lias neitlur l)cfore nor since found it to be
the case, except iu isol.ited instances. Grillilh states that
he hasnot infrequently found it. Care was taken to ren-
der the diagnosis of measles certain, and mention is made
of this point here to sliow that the adenitis characteristic
of Roetheln is not ab.solutely pathognomonic, and will not
in itself suffice for difl'erential diagnosis from measles.
Non-idenlity irith Jfcadcs und t^caiiatiixi. — The writer
has, of necessity, made frequent mention of Roetheln as
contrasted with scarlatina and measles, and the reasons
for considering it to be an independent disease must now
be considered. There are still some who consider it a
hybrid, consisting of elements drawn from both those
diseases, and being intermediate iu character between
them. This position is scared}' tenable, and is ncit sup-
ported by clinical facts; since the greater number of
cases, though having points in conunon with bcitli, pre-
sent, each one, strong points of resemblance to one or the
other of the two affections, and not to both at the same
time. That is, any single case is either decidedly scarla-
tinoid or decidedl}' rubeoloid : and the differential diag-
nosis lies between two and not tluve diseases. Further-
more, hybrids are not at all common, and analogy is
opposed to this view. Generally, what is called a hybrid
can be resolved into its elements, and maj- be pronounced
a conjunction of two or more diseased conditions. Un-
doubtedly scarlatina and measles may be foimd coexist-
ing in the same individual, or following each other so
closely as to overlap, the inmates of a household being
exposed to and contracting both diseases at the same
time, or in rapid succession. These cases, however, pre-
sent the phenomena of both diseases in such a manner
and degree as to exclude uncertainty in the diagnosis,
and they bear no closer resemblance to Roetheln thau does
an_v single well-pronounced case of either disease.
The ciuestion of its identity with one or the other of
these diseases calls fm- more careful consideration.
There are but few who believe Roetheln to be identical
with scarlatina, but many consider it of the same nattire
as measles. In a scarlatinoid case the princiijal points in
common are: the short period of invasion, the existence
of some sore throat, and the fine punctate appearance of
the rash at first. Roetheln is liable to be confounded
only with a very mild case of scarlatina; for the vomit-
ing, high fever, pronounced sore throat, and character-
istic tongue of average scarlatina are not encountered in
the former disease. The points of difference are most
prominent in the longer duration of the eruption in scar-
latina, its greater uniformity, its macular character, the
nature of the desqviamation. and the presence of sequelm
which do not occur in Roetheln. Iu addition to which
the adenitis of Roetheln is not to be found in the other
disease.
As to measles, the similarity also exists in a certain
proportion of cases of mild character. The symptoms
which may be common to both are the rose color and
papular character of the rash, the shoiter duration of the
period of eruption, the tine desquamation, and possibly
the adenitis. The main point of ditference is the pres-
ence, iu measles, of twoorthiee days of fever, with ca-
tarrhal inflanunatidn of the resjiiiatory mucous mem-
branes, uuifonnlv preceding the eruption. The sequehe
of measles, also, are not to be expected in Roetheln.
As stated, these resemblances are encountered only in
extreme cases. Average cases of each disease have spe-
cial characteristics sufficient to clear away doubt : and
the differences just enumerated go far toward proving
non-identity in either direction. But the strongest rea-
son for believing iu the individual natvire of Roetheln —
constituting, indeed, a conclusive proof — is that no nui-
tual protection is atTorded. That both scarlatina and
measles are. if the expression be allowed, autoprophylac-
tic has been proven by thousands of observations. Sec-
ond attacks of scarlatina are so rare as to be curiosities in
the history of medicine; and with measles, although the
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I{EFERE^■CE HAXDIiooK OF THE MEDICAL SCIENCES.
rule is not so free from exceplion, yet a second attack is
a very iutrcqueut occurrence. Tliis rule apjilies to Roe-
tlieln. As yet tliere are few, if any, uutlieniic rccordsof
second attacks. But wlien the question of mutual pro-
tection, which wouUl be a sine (j'lii in'ii to the supposition
of identit)', is considered, the most conclusive evidence
of its absence is presented.
Of J. Lewis Smith's 48 cases, 19 had had measles, and
1 contracted the disease subseiineutly. OtShuttleworth's
30 cases, more than half had had measles, and 4 scarla-
tina. In one case the jiatient hail measles live mouths,
aud scarlatina f>ne month, lu't'ore. In 13 of the cases, in
which sulisequent observation was |iossible. 7 contracted
measles and 6 scarlatina after the lapse of a few \-ears.
Goodhart ob.served that 3!) out of C3 cases had had mea-
sles.
Instances might be; multiplied to a very large number,
but it is lunieccssary ; for the non-e.xistence of mutual
protection is too well established to admit of doubt.
There is, however, another aspect of this question, or,
ratlier, another explanation of the facts, which has been
presented with considerable appearance of piobability.
It is that Iioetheln is siuqily the luodilicatiou of measles
presented in second attacks, bearing the .same relative
position that varioloid does to smallpox. There are two
reasons for regarding this jxisition as untenable. The
first is, that |nonouuced attacks of true measles have, in
a large number of instances, followed, aud not jU'ecedeil,
Koethelu, and these cases have presented no nioditication
in kind or severity of the symptoms which go to make
up the clinical history of measles. This applies with
equal force to scarlatina. The second reason is. that in
the individuals who have been the subjects of second at-
tacks of measles, the sjuiqiloms have been as uniform
and pronoiHiced as in the first.
On the contrary, a mu<'li closer analogy can be traced
between smallpox and varicella ou the one hand, and
measles and Koethelu on the other. The ratio is much the
same in regard to corresponding severity, and iu similar-
ity of appearance of the eruption.
The final separation, iu tlie minds of medical men, of
the former pair from each other was beset by the same
uncertainties as that of the latter.
Another fact of significance is that rtoetheln occurs in
epidemics, when neither scarlatina ncu' measles is prevail-
ing; aud, iu the same epidemic, most of the cases w ill be
rubeoloid, aud a smaller number scarlatinoid.
Text-book descriptions of measles commonly refer to a
variety of the disease under the designation of "rubeola
sine catarrho," this name indicating a condition iu which
there is fever, with aiieru])tiou siniilarto that of ordinary
measles, and at the same time ab.sence of the intlammation
(d'ihe respiratory apparatus. Perhaps it is fair to regard
these as cases of Koethelu; and a significant observation
made by Watson, iu his "Practice of Jledicine," gives
support to this view. He says: "It is observed that
ruliciila sine catarrho confers no jnotectiou against recur-
renci — is commonly succeeded by an attack of measles in
its true form." Meigs aud Pep|ier make the same obser-
vatinu as to their experience.
T'l suuunarize, the points demonstrating the non-iden-
tity iif Hoetheln with measles or scarlatina are:
1. The dilfevence in clinical liistory.
'.2. Absence of nnitual protection,
3. Alisence of modification in second attacks of those
tu ') diseases.
4. Occurrenceof eiiidemics while theolher two are not
ju-cvailing,
■"i. In any epidemic, resemblauceof some of the cases to
one, :iud of some to the other, of the two diseases.
.V further differentiation of the two varieties into two
disiiiu-t diseases is ])o.ssilile; but it would be a refinement
almost beyond our present powers of oliservation.
I)i.\oxosiK. — The diagnosis is principally made by
process of exclusion, because, at the o\itset, the presence
1 4' .scarlatina or measles is generally suspected. From
scarlatina at the outset, or in the first day or two of sick-
ness, in certain mild cases, the points of difference are:
In Roethelu, the absence of, or presence in a milder de-
gree, of soi-e throat ; the afiseucc of the strawberry tongue,
aud the existence of a whitish coating if any chsuige
be present; the absence of contiuuity of the eruption;
and the presence of post-cervical adenitis, th<' glands at
the angle of the jaw being unaffected. After the lapse
of two or three days the course of the eruption iu Roe-
thelu is to reach its maximum aud begin to disappear
quickly, and the desquamation, when perceptible, is
tine, and not in flakes or patches of some size.
Prououncedcasesof scarlatina do not resemble Roetheln
snflieieutly to render the diagnosis uncertain.
From measles the discrimination is to be based mainly
on the absence of the stage of fever with catarrh jncced-
ing the eruption, or its very mild character and shorter
duration. The cervical adenitis has much weight,
thiiugb it is not absolutely conclusive. Though the rash
may very closely reseudile that of measles, yet the pap-
ides are less elevated, smaller, less aggregated, less de-
cidedly rose-colored, and ruu their course more quickly —
desquamation setting iu two or three days before it would
be likely to occur iu measles.
Subjoined is a comparative table of these three diseases
in their different stages, giving also the average duration
of each st;ii;e:'
Measles.
noF.TUEi..\. Scarlatina.
Singe I.—Iiicuhation.
tninition.six to t wen- Two to fourteen il.iys. Twelve to flfteen days.
Iv-nnn d;iy.s.
Inconstant. Constant.
Stage JT.—Iuvtisiait,
fine dav or less. Less than one day.
ofti-n absent. Never al>sent.
Malaise, slight. Vomiting.
Sore tliroat and lacb- Decided sore throat,
rvination.
Cervical adenitis.
Temperature, Siy -100° Tpniperatui-e, 10a° +. Tempeniture, 102° -|-.
Two to four days.
Never absent.
Drowsiness, rough, co-
ryza, eoniunctiviUs,
I)hoto[ihol>ia.
Thive days.
Begins ou face or
chest.
Papular, slightly.
Pale ro.se. or darker
and brownisti.
Not continuous,
t'eases siiroailing in
one or two days.
No stationary period.
Burning or itching,
slight.
Stage III.—Eruplinu.
Six to eight days.
Begins on chest.
Macular.
Deep-red scarlet.
Continuous.
Ceases spreading in
three or foui'days.
Stationary perind of
two to three days.
Burning, often great.
Four to live days.
Begins ou face.
Papular, decidedly.
Hose.
Not continuous.
Ceases spreading in
two or three da\s.
Stationary period of
two to three d:ns.
Burning and itthing,
decided.
Stage Il'.—Desquaniati<iit.
Very slight and tine. In scalesofiiuife large Furfuraceous, and
size. ofU'n not pro-
nounced,
ovi^ilaps statre of Preceded by station- Preced(^d by station-
erujition. ary period. ary period.
Last two oi' three days. Lasts ten days, and Lasts about four days,
.soinctiines longer.
Leaves dull - colored
stains.
OimpIieatiii})ti.
Acute form of Briglit's Bronchitis,
diseasf'.
None characteristic. rtheuinatisiu. Pneumonia.
Otorrhiea, and necro- Tuberculosis,
sis of temporal bone.
Inflammation of the
intestines.
In addition to these other exanthemata, certain simple
skin diseases must be consiilered iu the di:ignosis. Some-
times the eruiition of nuliaria ]iapulosa (prickly beat) re-
sembles that of Koethelu; but it occurs iu well-defined
piitches of several inches in diameter, is associated w-ith
unusual sweating, and lasts many da_ys longer. Also,
there are no febrile and constitutional symptoms accom-
ptxnyiug miliaria, and the itching is usually great.
The most careful investigatiou possible into the origin
or sources of contagion should be made; and in cases of
','S
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Koelliclll.
doubt a positive diagnosis slioiild be witliheld for one or
two days. It may be advisiil)le to explain tlie uncertain-
ties, and to adopt tljo precautious a.s to isolation, etc.,
uecessary in scarlatina.
CoMPLicwTioxs. — Complications or sequeku character-
istic of the disease do not exist. A condition of transient
albuminuria is spoken of, but it is not indicative of renal
disease. After the rash disappears we may expect to lind
the usual condition of health present. The prognosis is
therefore good.
Tre.\t.ment. — Because of the mildness of the disease
there is generally nothing called for in the matter of
medication — simple restriction of diet and avoidance of
exposure during the continuance of the elevated tempera-
ture being all that is necessary. Practically the interest
and importance attaching to Roetheln lie in recognizing
it as a separate disea.se, and in the exclusion of the more
•serious atfections, scarlatina and measles.
Biui-iOGT!.\Piiv.— Besides the treatises of Meigs and
Pepper, J. Lewis Smith, Vogel, Day, Goodhart, Eustace
Smith, and Ellis, on "Diseases of" CUiildren " ; tljose of
Bristowe, Bartholow, Loomis, Aitkin, and Flint, on the
"Practice of JMedicine " ; and DaCosta's work on "Medi-
cal Diagnosis," the following articles may be mentioned:
Hardaway. in "Pepper's System of Jlcdieine"; Harts-
horne, in "Reynolds' System of Medicine"; Thomas, in
"Ziemssen's Cyclopaedia": Cheadle, Shuttleworth, and
Squire, in tiie Trans. Internat. Med. Cong., 1881:
Grilfith. in the New York Medical Rieonl, Julv 2d and
9th, 1887; Edwards, in the Am. Jour. Med. Set., 1884;
Jones, Boston Med. Jonrn.., 1881; Sholl, Med. and Surg.
Reporter. 1882; T. D. Swift, A'. T. Medical Journal.
November 2Tth, 1880; Harrison, Am. Jonrn. OlMet., 1885;
Duckworth, ErsUine, and
Gowers, in London Lancet,
1880; Dukes, Had.. 1881:
Yonge-Smith, ibid., 1888
and 1886; Strover and
Jaccoud, ibid., 1886; Shut-
tleworth, Brown, Burnie,
Davis, Rooke, and Wil-
son, in Brit. Med. Jonrmil,
1880; Byers and Sadell,
Hiid., 1881; Lawrence,
ibid., 1882; Shackelton
and Cullingwortli. ibid.,
188;!; McLeod, /*/(/., 1885;
and Ryle, iljid.. 1886.
Thomas D. Sir/ft.
ROSEMARY.— y?<>m
>na rill i. (lias ni n r i n u s.
U.S. P. 1880.) The dried
leaves of Rosnariii ii.i offici-
nali.t L. Fam. Lahiatce.
These leaves are ob-
tained from a small, slen-
der, evergreen, blue-flow-
ered shrub, native of the
Mediterranean region, and
somewhat cultivated for
medicinal purposes and as
a decorative shrub. The
flowering twigs are also
sometimes e m p 1 o y e d.
The leaves are about 2.5
cm. (1 in.) long, oblong,
but so strongly recurved
at the edges as to appear
linear in tlie dried condi-
tion, obtuse at l.Kith ends,
destitute of a petiole, en-
tire, coriaceous, dark-
green with a slight bluish
cast above, and grayish-
green and densely woolly
and glandidar underneath.
The odor is characteristic
Fli:. 41;i;.— Rosmarinus nfflcinali
lloaering branch. ( Baillnu. i
and somewhat camphoraceoiis. the taste aromatic, pun-
gent, and some^vhat teribinthinate. Although the use
of the drug has now largely been superseded by that of
its one or two percent, of volatile oil, theaclicm is not
(luile the same in both of them, since the drug itself
also contains considerable tannin and resin and a little
bitter substance, The latter, therefore, is a useful aro-
matic bitter and tonic. The fresh decoction, or the fluid
extract, applied to unhealthy woimds, is a gor)d vulner-
avy, though somewhat irritating unless carefully em-
ployed. The dose of rosemary is 0.5-1 gm. (gr. vij.-xv.)
Oil of R".iemar;/ (Olciuii Ru.siiiarini, V. S. P.) presents
the a(>pearauce of a colorless or at most a pale yellow
fluid, has a specific gravity of from 0.895 to 0.915, is
freely soluble in alcohol, and possesses the characteristic
odor of the drug and a similar and somewhat camphor-
aceous taste. It contains cineol, borneol, and camphor,
with other less important stdistances. It possesses all
the activity of the drug, but in aJi intensified degree. It
is often given internally as a carminative and general in-
testinal stimulant, though its use has greatly declined.
The do.se is from one to five miuims. It eniers into the
compound tinctme of lavender. Owing to its actively
local stimulant or irritant properties, it is considerably
used as a local application for promoting the nutrition
of the skin and also as a vulnerary. Henry II. Itusby.
ROSEOLA. — Roseola is often incorrectly used as syn-
onymous with rubella or Roetheln. L'nquestionably
many efflorescences wliicli have been called roseola are in
fact the efflorescences of rubella, and the rever.se is quite
true, that many of the reported cases of rubella are noth-
ing more nor less than roseola. When properly used, the
word roseola should simply indicate a rose-colored rash,
a form of erythema, ami should not be spoken of as a
specific disease.
A roseolous efflorescence may often precede the appear-
ance of the exanthemata of rubella, scarlet fever, measles,
variola, and vaccinia, but should not l)e confounded with
the sjiecific efflorescences which are characteristic of these
atfections, and which usually occur later in the course of
the disease. A roseolous rash may also occur in other
conditions such as cholera, typhoid, diiditheria, and mal-
aria— in fact, in almost any condilion which gives rise to
fever. If the word is to be used at all, one should desig-
nate the disease accompanying it, as, for instance, "rose-
ola syphilitica," "roseola vaccinia," "roseola febrilis,"
"roseola typhosa," etc., but the tendency is to drop the
term entirely from medical nomenclature!
Whereas the roseolous erythema may closely resemble
the efflorescence of rubella, measles, or scarlet fever, it
has the following points of distinction : It is neither con-
tagious nor epidemic; there are no characteristic prodro-
mal symptoms; it is not confined to anv special portion
of the bodv ; there is either no fever at all, or, if the fever
be present, it does not run a characteristic course ; it may
last a few hours, or it may disappear after a few days
without desquamation ; theerythernatousareas are not "so
crescentic as in measles nor so punetiform as in scarlet
fever.
A roseolous rash is very common in infants and in chil-
dren as a result Of dentition, gastric or intestinal disturb-
ances, or in counectiou with the many febricid;e seen in
early life, for which no sufficient cause can be found.
Again, it may occur in infants who are in perfect health,
and in whom nothing else abnormal may be detected. It
is in these special cases that the term "roseola infantilis"
has been used. Maynard Ladd.
ROSES. — The genus Rosa L. (fam. R'lsacecr) comprises
upward of a hundred species of jjrickly shrulis. Al-
though of little medicinal value, strictly speaking, these
species contribute several articles possessing important
uses in flavoring, perfuming, and coloring and exerting
a mild stimulant, antispasmodic or tonic action. Three
of these articles are official, as follows:
Rasa Oallicii or Red Rose, " the [K'tals of Rosa Gcdlica
L., collected before expanding."
y?[>
ICo) al-IOi-Balus.
HEFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Riisa Centifolia, White Rose, Pole Rose, or Hundred-
leaned Ruse, "the petals of Rosa centifoliii L."
Oleum. Rosiv. Oil i if Rose, Otto or Attur of Rose, "a vola-
tile oil distilled from the fresh flowers of Rosa Damaseena
]Miller."
Although the red rose plant is native in Europe and
adjacent Asia, the otticial jiroduct is obtained wholly
from cultivaled plants, chiefly in Southern and Central
Europe, especially in France. The peculiar structure of
the flower renders it quite an easy matter to collect the
cones of une.xpanded petals. Tlie calyx lobes, having
spread backward before the opening of this cone, a sharp
knife is drawn about the base of the latter, which is then
lifted otf, leaving the stamens still attached to tlie rim of
the caly.\ tube. The cones are tlien very carefully dried
in the .shade, or the}' may be [lacUed in salt. In the finest
grades they mostly cohere in tlie cone, though loose pet-
als may also be of fine quality. They should preserve a
deep purple-red color and a fine velvety surface, as vieW
as a strong and fine rose odor. The taste is bitterish,
astringent, ami very slightly acrid. The individual pet-
als have a romidish outline, a notched summit, and a
very short, broad, yellowish-white basal claw. Fragrant
as they are, tlie amount of volatile oil in them is minute.
The important constituent is alieautiful bright red. read-
ily soluble coloring matter. Mildly astringent proper-
ties are imparted by a small amount of gallic acid. Small
amounts of fat and cpierciirin also e.\i.st. Red rose is
practically inactive, thougli a sentimental effect is often
gaiiitd by administering it in mild cases of h_vsteria.
The Fharmacopieia jirovides a flind extract, made with
diluted alcohol and 10 per cent, of glycerin, and a con-
fection consisting of 8 percent, of the No. 60 powder,
64 per cent, of sugar, 12 per cent, of clarified lioney, and
16 per cent, of stronger rose water. There is an olficial
Vl.'i per cent, syrup of the fluid extract. Red rose also
enters into the pills of aloes and luastiche. There is, of
course, no particular dose.
White rose is native of Western Asia, and is believed
by some to he a mere variety of the reil. Its constituents
are identical with those of red rose except that the amount
of coloring matter is extremely small. The use of this
drug is therefore restricted almost wholly to flavoring.
It is likely to be dropped from the next edition of the
Pliarmacopfcia.
Rush Diiiiiiisciii:!. the Damascus rose, is cultivated for
the production of rose oil, chiefly in Bulgaria. This oil,
being then exported and repacked in other countries,
becomes the chief source of the various commercial
brands bearing other geographical names, although a
moderate amount of tiiis product is actually distilled
from roses grown in other countries. The oil is simply
distillid with water. The following is the official de-
scripticju :
"A iiale yellowish, transparent li(|uid, having the
strong, fragrant odor of rose, and a mild, slightly sweet-
ish taste.
"Specific gravity: O.SG.j to O.SsO at 20" C. (6S' F.).
"It is but slightly soluble in alcohol, and neutral to
litmus paper moistened with alcohol.
"The congealing and melting ]ioints of the oil are sub-
ject to .some variation, de|iending U|iiin the amount of
stearopten, b\it, when slowly cooled to a temperature
usually between 10° and 31° C. (60.8= and 6S).8° F.), it
becomes a transparent solid, interspersed with numerous
slender, .shining, iridescent, scale-like crystals. Upon
the application of the heat of the hand, the crystals
should float in the upper portion of the liquefied oil.
"If to five drops of the oil, contained in a test tube,
five drops of concentrated stdphuric acid be added, a
reddish-brown, thick mixture will be pmduced. but no
white fumes or tarry odor should be develojied, and the
fragrant odor of the oil should not be destroyed. If this
mixture be then shaken with 2 c.c. of alcohol, the result-
ing li(iuid may be turbid, but should be nearly colorless,
and should not at once assume a red or reddish-brown
color (absence of oil ofgiiif/er-gntss or I'urkish oil of {/cra-
nium, from Andropogon >Sc/iwnanthus L. [Fam. Orami-
nece'\, and of oil of rose geranium, from I'tlargonium
Radula [Cavanille.s] Aiton, Pelargonium capilatiim Aiton,
and Pelargonium odoratissimum [L.] Aiton; Fam. Ger-
aniaeeu')."
The important odorous con.stitucut of ro.se oil is gera-
niol, long regarded as a distinct substance under the name
"rhodinol." There is also a small quantity of citronel-
lol. Various derivatives of these also occur.
Although rose oil undoubtedly has antispasmodic and
stimulant properties, practically its entire use is for per-
fuming and flavoring.
Olficial rii.se irotcr may be regarded as indirectly a
preparation of rose oil, although not prepared from that
substance. It is recognized under two titles, namely,
Aqua Rosir. or Ruse Water, and Ar/ua Ros(e Fortior, or
.Stronger Rose Water. The latter is the water, saturated
with the oil, obtained as a by-product in the distillation
of rose oil. The former is made by mixing, immediately
when required for use, equal volumes of the stronger
rose water and distilled wafer. From stronger rose
water is prepared the Ointment of Rose Water or Cold
Cream (Unguentiim Aqiiat Rosa; V. S. P.), made with
12.5 per cent, of spermaceti, 12 per cent, of white wax,
60 per ceut. of expressed oil of almond, 19 percent, of
stronger rose water, and 0.5 of 1 ])cr ceut. of sodium
borate, these figures being approximate, since part of
them respond to weights, part to measures.
In addition to the above official products, there is used
in Europe, and there to only a very slight extent, a con-
fection made from the fruits of Rosa, eanina L. . the dag
rose. This fruit contains only sugar, malic and tannic
acids, and their compounds, and is a very inferior prepa-
ration.
Rosacea;. — This great family includes several subfami-
lies regarded by many botanists as themselves entitled
to family rank (Pomaeeo.', the apple family; Drupaeew,
tlie prune family, etc.). Thus considered, it is doulitless
the most important fruit-producing familj-, yielding
raspberries, blackberries, strawberries, plums, peaches,
cherries, and similar stone fruits, the apple, pear, quince,
medlar, etc. From a medicinal point of view, the family
is of considerable importance, yielding the almonds, wild
cherry. North American ipecac, koosso, prune, quillaja,
blackberry bark and the roses, all elsewhere considered,
besides a number of minor drugs, several of which are
considered below.
Raapljerrji, or Rutins Ida iis, U. S. P., is the fruit of Rii-
hiis Idams L., the cultivated red raspberry of European
nativity. The Pharmacopu'ia provides tiiat the Ameri-
can wild red raspberry (R. strigosiis 3Ix.) or the black
cap {R. occidentalis L.)"may he employed in the absence
of R. IdiTiis. This fruit contains only sugar, fruit acids,
and their salts, like others of its class, and its medicinal
properties are mei-ely those of a mild laxative, refrigerant,
and antiscorbutic. Its line flav(]r and beautiful r<'d color
make it a very useful adjuvant or vehicle. an<l an oflicial
syrup of the fresh fruit is provided for this purpose.
Although not otticial, a similar syrup made of strawber-
ries is in common use.
Astuini:knt Dkugs. — Proliably the most common
and important property of the drugs of the rose family
is their astringency. due to the presence in them of con-
siderable i|uantities of tannin. In such jiroducts as the
leaves of the blackberry, rasiiberry, and strawberry, this
tannin is accompanied by appreciable quantities of gum,
thus favorably modifying tlie action, and these are very
largely employed as domestic astringents. Tormentilla,
the rhizome of Potentilla Tormentilla L., as well as the
rhizomes of other .species of Potentilla, contains about
the same amount of tannin as geranium, and is similarly
employed. The .same is true of .Saugnisnrlia and of var-
ious species of Aca;na. and of the root and bark of several
species of .Spiraia, Hardhack, or Steeple Bh.i/i, the leaves
being also employed like those of the strawberry and
rasi.iberry, Under the names Meadow Sieeet. Queen of
tlie .Meadow, and Vlmaria. the leaves of Spirmi Ulmaria
L. are also employed in the same wa.v.
Henry H. Rushy.
it too
REFERENCE HANDBOOK OP THE MEDICAL SCIENCES.
Roses,
Koyat-les-Baiiis.
ROSSCOMMON SPRING.— Mouioe County, l\unsyl-
vaiiiu.
Post-Office. — Wiud Gup. Hotel.
Access. — From Philadelphia via Reading Railroad;
from New Yorli via Central Railroad of S'ew Jersey.
The Ros.'icomniou depot is only a few hundred feet from
the hotel.
The summer resort known as Rosscommon is situated
in the Wind Gap of the Blue Ridge Mountains, on the
north incline of the range, one thousand feet above tide
water. The location is fifteen miles west of the Dela-
ware Water Gap, twelve miles from Stroudsliurg, and
fifteen miles from Easton. The hotel, known as the
Rosscommon Inn. is situated on a handsome plateau, half
a mile square, and surrounded b_v forests. Theueighbor-
liood is entirely free from m.daria and mosquitoes, and
a tine breeze prevails almost constantly ; hence the name
Wind Gap. The accommodations at the inn are plain
and unpretentious, but very comfortable and home-like.
The spring, discovered a few years ago, adds consider-
ably to the attractions of the jilace. The water flows
from a fissure in the rock at the bottom of the spring, and
constantly discharges a large volume of carbonic acid gas.
It was analyzed in 1887 b_v Prof. William 11. Chandler,
of the Lehigh L'nivcrsity, with the following result:
Neutral (lightly carbonated). One United States gal-
lon contains: Sodium chloride, gr. 0.08; sodium sulphate,
gr. 0.09; potassium sulphate, gr. 0.05; magnesium
sulphate, gr. 0.03; calcium carbonate, gr. 0.39; magne-
sium carbonate, gr. 0.10; silica, gr. 0.47; iron carbonate,
a trace. Total solids, gr. 1.30. Carbonic-acid gas (free
and partially free), 1.43 cubic inches.
This analysis does not present a mineral water in the
strict acceptation of the term. It is probable that very
few common potal)le waters would show so light a min-
eralization ; yet it is entirely free from organic matter,
and has sufficient gas to give it a bright sparkle and to
render it very palatable. The water is bottled and sold.
JtiDus K. Crook.
ROYAL GORGE HOT SPRINGS.— Fremont County,
Colorado.
Post-Offick. — Canyon City. Hotel.
Access. — From Denver via Denver and Rio Grande
Railroad. Canyon City is also the western terminus of
the Arkansas Valley branch of the Atchison, Topeka,
and Santa Fe Railroad.
The towncjf Canyon City, with a jiopulation of thirty-
five hundred inhabitants, is rapidly becoming a cliarming
city of healthful and comfortable homes. It is the county
seat of Fremont County, and is situated on the north and
south banks of the Arkansas River, one hundred and
sixtv miles south by west of Denver, and one hundred
miles below Leadviile. The scenery about the place is
grand and romantic to a high degree. A walk of a few
minutes takes the tourist to the famous Royal Gorge,
where the granite cliffs tower 3,000 feet above the head.
The altitude of the springs is 5,300 feet above the sea-
level. The location is protected by the moimtains on
three sides, and the report of the United State Meteoro-
logical Bureau shows that for any given mouth in win-
ter the temperature on an average is si.\ degrees warmer
than at any other point in the Stale. The rainfall is only
fourteen inches per aimum, and it is said that there are
over three hundred sunny days in every year. The
capacity of the hot springs is difficult to estimate, as they
break out into the Arkansas River in several places.
One of them, which issues from the earth a little above
low water, yields fifteen gallons per minute, but the
combined flow of the springs woidd be many times
greater. Within half a mile of the hot springs are cold
soda and iron springs. E.'ccellent bathing facilities have
recently been provided at the hot springs. The follow-
ing analyses arc by Prof. Oscar Loew. of the United
States Geological Survey. That of the Royal Gorge Hot
Springs shows that one United States gallon contains:
Sodium carbonate, gr. 73.30; magnesium carbonate, gr.
13.80; calcium carbonate, gr. 38.50; sodium sulphate,
gr. 79.30; sodium chloride, gr. 18.20; lithium chloride, a
ti-ace. Total. 317 grains. Temperature of water, 102' F.
The analyses of the Royal Gorge Cold Soda and Iron
Springs show that one United States gallon contains:
Solids.
Iron iHJkL'.
Grains.
Little Ute.
Grains.
Sodium <'hlori(h'
83.00
12.20
76.80
33.00
U.BO
Traces.
Traces.
118 00
12.10
Sodium earl)onale
76.40
ral<"ium carhoniite
22.50
Mafrnesiiun c'trlniuiK'
U.OO
Iron
Litbia
Total
219.60
243 00
The waters of both cold and hot springs are highly
charged with carbonic acid gas. The hot baths here are
strongly recommended for rheumatism and skin diseases.
Dr. Prentiss, of Canyon Cit\-, informs us that persons suf-
fering from pidmouary trouble are usually much im-
proved by a sojourn in the sunny, even climate of this
region. James K. Crook.
ROYAT-LES-BAINS, FRANCE.— This well known
French s|ia is situated in the centie of France, being one
of a group of mineral-spring resorts in this region of the
Auvergne Jlountains. Not far distant are Mont Dore,
La Boui'boule, Chatel Guyon. Vichy, and others.
Royat, a small town of 1,528 inhabitants, is beautifully
situated in a narrow valley watered by the Tiretaine,
and surrounded by the lower Auvergne Mountains, All
the surrounding country is charming, and there are
many most attractive excursions, particularly to the Puy
de Dome, where an extensive and gi'anil view is obtained.
This resort has been called the "Ems" of France, but in
climate, picturesqueness, and charm of situation it is far
superior to the German spa.
The climate exhibits the characteristics of a mountain
climate of moderate elevation, the altitude being 1,475
feet. There are sudden tivansitions of tempcratui'e: sud-
den storms of wind and rain with thunder: a dry atmos-
phere; and brilliant sunshine. Tlie soil is volcanic, and
the dust from sucli a soil is abundant and blown about
in clouds b)- the wind. The peculiar situation of Royat
itself, as Yeo sa_ys ("Health Resorts," J. Burney Yeo),
also modifies the climate. "Lying as it does in the Hoor
of a somewhat nari'ow valle_y, surrounded on all .sides by
mountains, and open only to the east, running, moreover,
in a direction east and west, and facing the east, it is
particularly exposed to the direct heat of the sun." "It
is therefore." continues Yeo, exceedingly ditficult to find
any kind of shady walks in the immediate vicinity of
Royat when the sun is up and the sky is cloudless."
Therapeutically the climate is invigorating and refiesh-
ing.
The "waters are what are known as " warm muriated
alkaline." containing bicai'bonates of soda, potash, lime,
and magnesia, to.gether with chloride of sodium and a
small amount of lithia. Ai'senic in veiy minute quantity
is also found in these waters, as are also the salts of iron
and manganese. All the springs are rich in free carbonic
acid gas. The natural temperature of the water is from
68° to 95' F. In this country the Healing Springs of Vir-
ginia and the Hot Springs of North Cai'olina are some-
what similar in their composition and uses. There are
four principal sources: the Eugenii^. St, Mart, Csesar,
and St, Victor. The Eugenie is the warmest (95,9' F.),
and is the most highly minei-alized. The St, Victor con-
tains the most iron and arsenic. These springs together
furnish 1,533,000 litres of water a day. The water is
clear and transparent, and has no odor.
The waters of Royat are employed for drinking, bath-
ing, gargling, and inhalation. The bathing establish-
ment is complete, and said to be one of the finest in
France. A specialty of this spa is the running water
bath, where the water is led directly from its source and
at its natural temperature into the bathtub, and con-
1001
Kiibbrr.
KiillaiKl.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
stantly flows in and out. There are arrangements for
douches with massage attached to each bath, and also
independent apparatus for douches of various forms.
There are inhalation rooms: facilities for gargling, irri-
gation, and pulverization; baths and douches of water
fharged with carbonic acid gas; liydro-electric baths; a
Ullage public swimming bath; and a gymnasium.
The chief drinking fountain is "from the Eugenie
Spring, and is situated in a pleasant parli. The water is
very agreeable to drink. There are two casinos witli
music, concerts, balls, and theatrical performances.
"The excursions," says Yeo (7«c. cit.). "are numerous,
varied, and interesting; for no more remarkable country
to the geologist, the naturalist, and the archieologist can
be found than this great mouutainous district of e.xtinct
volcanoes, old meduvval towns, historic churches, and
Roman and even earlier remains."
The accommodations are abundant, good, and of rea-
sonable price. AUIiougii open throughout the year, the
season is from the Ifith of May to thelr.th of October.
Royat is about nine liours distant from Paris via Cler-
mont-Ferrand, which is lifteen minutes distant from
Royat.
the disorders for which these waters are of value^ are
chietly arthritic and aua'niic affections. Rheumatism;
gout associated with amemia ; skin diseases, such as
eczema, acne, and pityriasis; chronic laryngitis and
bronchitis; bronchial asthma; neuralgia; sciatica; atonic
dyspepsia; varimis uterine aft'ections; gouty glycosuria;
biliary and renal lithiasis; neurasthenia; and various
forms of aua-mia are all treated here. The contraindica-
tions are organic cardiac affections, a tendency to hemor-
rhage, organic affections of the central nervous system,
scrofula, and other tuberculous atfections.
For the after-treatment the seaside for a short time is
recommended, except in joint and bronchial afl'ections,
for which a winter in the south of France is preferred.
Not far from Royat is Durtol, 1,705 feet high, where
is a sanatorium, opened in 1S98.
For a further consideration of this resort, as well as
others in France, the reader is referred to "Stations Hy-
dro-3Iinerales, Climateri(iues, et Ularilimes de la France,"
Paris, 190(1. Edinird 0. Otis.
RUBBER.— iJ^c/.s/Avf, U. S. P. Caimichoiic, Fr. Cod. ;
India ridtber. Ginii (Id.itii; etc. The concrete milk juice
of several species of lima. Aubl. (fam. Eiiphorbincin),
known in commerce as I'lti-n ruhher.
From a commercial standpoint, the substance bearing
the above names is derived from a large niunber of milky-
juiced plants, growing in the tropics (if both the Okl and
the New World, these plants belonging to many and dis-
tantly related families, but more especially, in the order
named, to the Enpiiorhiucea', Urticump, Apncyiiiiinr, and
Asclepiadaceit'. Besides these, which yield rubber on a
commercial scale, the substance caoutchouc occurs in
small amounts in a very large number of milk juices.
The rubbers from these different botanical sources nat-
urally differ widely in appearance and cjuality. Some
of tliem— perhaps inore because of the maimer in which
the milk juices are treated than because of natural ilif-
ferences in the latter, they being often mixed with ashes,
soap, and other substances, and allowed to ferment in
holes in the groiuul — are qtnte unfit for official use.
Others, though clean, and not, strictly speaking, objec-
tionable, arc inferior from the standpoint of deficiency in
their uscfid jiropc'rties. Para rubber has been selected
for official purjioses because of its cleaidine.ss. purity as
^■aoutchom-, high elasticity, durability, and ready solu-
bility in appropriate liquids.
Origin. — The plants yielding Para rubber are large
trees, frequently exceeding a hundred feet in height and
five or .si.x feet in diameter, growing in the valleys of the
Amazon and its tributaries. The basin of the Madeira
and its tributaries produces the largest amount. Tlmugli
mostly exported vi;i Piira, whence the name, much of thf
same "grade comes out through the west coast of Soutli
America. The milk juice is obtained by gently tapi>ing
the outer and middle bark layers with a sharp pick and
catching the exudation in small cups attaclied to the
trees. The milk is then gathered and carried to the
smoking stations, where it is coagulated in successive
layers upon a flat wooden paddle, by being held in the
smoke of smothered fires, special articles being preferred
for this fuel. When a suitable quantit}' has been gath-
ered upon the paddle, an incision is made at the upper
end of the mass, called a bohtcho or "bottle," to permit of
its l)eingsli]iped off' from the end of the paddle. It then
possesses a flat form, a whitish color, and smooth surface,
and may weigh from a few up to seventy-five pounds,
or even more. The product of the upper tributaries is
usualh' in bolachos of about twenty-five pounds, the
larger bolachos coming mostly from the lower Sladcira.
The rubber soon begins to turn j'cllow, then brown, and
ultimately black, first upon the surface and then grad-
ually toward the interior, the complete process of dark-
ening requiring several years. At the same time it loses
water, and of course weight. It ma}- be exported in the
original bolachos, but owing to the danger of adulter-
ants in the form of sand, stones, etc., it is now mostly
cut into small pieces in Para.
Dkscuii'TIon. — The following is the official description
of elastiea ;
In cakes, balls, or hollow, bottle-.sliaped pieces, exter-
nally brown to brownish-black, internally brownish or
of lighter tint; very elastic; insoluble in water, diluted
acids, or diluted solutions of alkalies; soluble in chloro-
form, carbon disulphide, oil of turpentine, benzin, and
benzol. When heated to about 12.5° C. {2.i7" F. ) it melts,
remaining soft and adhesive after cooling. Odor faint,
peculiar; nearly tasteless.
Co.Mi'osiTioN. — The percentage of caoutchouc in india
rubber varies with the anwuint of water which the sub-
stance has lost. In its original liquid condition there is
said to be abmit thirty-two per cent, of this hydrocarbon
(CjoIIss). With caoutchouc exist a little wax, a free
acid, and some proteid matter. There is a little free car-
bon, which results from the smoking process.
PuofEUTiKS .\NIJ UsKs. — On continued exposure to the
atmosiihere, rubber undergoes changes which render it
brittle and weak, and this may be prevented by keeping
it under water, which preserves it by inducing superficial
fatty changes. Viilranizcd rubber is produced by com-
bining the original rubber with sulphur, under the influ-
ence of heat, iiy various processes. It still retains its
elasticity, but liecomcs harder and is no longer .soluble in
the same liquids as before. Hard rubber or ebonite may
be obtained l)v combining rubber with various other suli-
stances than sulphur.
Strictly speaking, rubber has no meiliciiial i>roperties.
since it is in.soluble in all the fluids of the body. The
original milk, being drunk by mistake, has invariably
coagulated into an insoluble ma.ss in the stomach, the
result being fatal in the absence of surgical trtatment.
Its uses are w liolly mechanical. The most important is
as a mass for idasfers. Such a mass possesses very good
(lualitics. although experiments seem to indicate that the
I'ficet of theincor|>orati(l medicinal substance is somewhat
less than when comliined with the official plaster mass.
Rubbcr-ma.ss adhesive plasters for surgical dressiugs,
Esmareh's and other elastic bandages and wrappings,
orthopedic aiiiilianees, nipples, syringes (hard and soft),
jiessaries, artificial teeth, siiecula, catheters, etc., reiire-
seiit imiiortant uses of rubber, wdiich require only
enumeration. Articles of rubber, either hard or soft,
slanild be kejit in a closed box or drawer, and occasion-
ally used or washed to pfcvent their becoming too dry
and brittle. Silver instruments should never be kept in
the same enclosure with them. Soft rubber is sjioiled
after a short time by oils and fats, and eventually
hardens in spite of precautions.
By dis.solving rubber in appropriate licjuids, with or
without the addition of other adhesives. various forms of
cement or glue can be obtained, and impervious cover-
ings can be" produced by applying such substances and
permitting evaporation. Ilcnnj II. linsby.
1002
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
Riibbor.
iCiillaiid.
RUBELLA. See lioctMn.
RUBIDIUM AND AMMONIUM BROMIDE. -A double
salt having the eluMuieal foniiula KbBr,iiXlIjBr. It is
a white or yellowisli-white crystalliue powder, soluble in
water, and jiossessed of a cooliug and saline taste.
This salt has been proposed as a more suitable means
of administering bromine than the ordinary ammoniiuii,
potassium, or sodium salts. Laufenauer "( Therap. Mo-
7}(itnch., August, 1889), reasoning from the fact that lith-
ium bromide is more powerfid tiian ammonium bromide,
the sodium salt more so than the lithium, and the
potassium salt still more powerful, was led to believe
that the more strongly electro-positive the salt, and the
higher its atomic weight, the greater its power in disease.
As rubidium is powerfully electro-positive and has a high
atomic weight, the bromide of rubidium and ammonium
was prepared, and in a series of experiments was found
to prove more .satisfactory than the other bromides iu
epilepsy and other conditions iu which bromides are in-
dicated.
Furtlier use of the drug has proved its efficacy, but
•has not shown any decided advantage over other bro-
mides. It, however, has not the depressing eflfects of the
potassium salts, and may be given where the more com-
mon compound lias to be discontinued. As an anti-epi-
leptic remedy, it is given in doses of si.xty to ninety
grains in divided portions. As a hypnotic and sedative,
sixty grains may be given in a single dose.
Rubidium bromide and rnbidimn iodide have also been
prepared, but their therapeutic value has not been estab-
lislied. Beaumont Small.
RUBINAT MINERAL SPRINGS.— Province of Lerida,
Spain. These springs, wliich siijiplj- the well-l;nown
waters of the Kubiiiat grou|i, are located at a high ele-
vation in the Pyrenees, near the village of Rubinat. We
are informed that some of tlie springs have been known
from time immemorial, and were resorted to in the Mid-
dle Ages by pilgrims from all over the kingdom. In
recent years the waters have come into commercial use,
and those of some of the springs are exported in large
quantities to the American markets. Among the better
known waters of the grou]i are the Rubinat-Condal,
Rubinat-Serre, and Rubiuat-Llorach, all of wliich are
extensively sold in the United States. Following are
analyses of the first two :
Ruhinat Condal. — One United States gallon contains:*
Sodium sulphate, gr. 5.407.34; potassium sulphate, gr.
13.22; magnesium .sulphate, gr. 183.97; calcium sul-
phate, gr. 109.44; sodium chloride, gr. 11,5.94; silica,
alumina, ferric oxide, gr. 2.08; loss, gr. 0.98. Total,
5,832.97 grains.
Ridjinat Scrre. — One United States gallon contains;*
Sodium sulphate, gr. 4,695.97; magnesium sulphate,
gr. 135. .54; calcium sulphate, gr. 79.57; calcium bicar-
bonate, gr. S9.40; sodium chloride, gr. 262.23; potassium
silicate, gr. 86.83. Total. 5,239.54 grains.
These analyses sliow very ]iotent waters of the sul-
phatcd saline group. They owe their purgative proper-
ties chiefly to the presence of the sulphate of sodium in
large quantities, although both contain considerable sul-
phate of magnesia. They act as very efficient saline
■cathartics and are indicated in conditions where such
remedies are useful. The dose varies from one to eight
or nine ounces, according to the indications, and the
water is best taken in the morning, on rising. Accord-
ing to the author's observation these waters are not so
likely to cause grijiing as are some of the stronger bitter
waters. James K. Crook.
RUE. — Riita. — The li'uves of Ruia 'jnircohns L. (fam.
Rviacea).
This is a perennial herbaceous or partly wood}" plant,
two or three feet in height. It has pale green, cylin-
drical, branching stems, alternate, smooth, light green,
* Converted from grams per litre.
glandular dotted leaves, which usually dr\' yellowish ;
the lower twice or three times pinnate and long petioled,
the intermediate once or twice iiinnate, tint U]ipermost
simple and .sessile; divisions wedge shaped, rounded, or
blunt at tlie extremity.
Flowers yellowish, in a
terminal corymb, with
the parts in fours or
fives; stamens twice as
many; sepals
small, pointed ;
petals large{one-
lialf inch long),
Tounded aud
hooded at the
ends, narrow be-
low. Fruit a dry,
dehiscent capsule,
containing numerous
angular, blackish
seeds. Rue is a na-
tive of Southern Eu-
rope, the Levant, etc. ,
and is also cultivated. It h
a strong disagreeable odor
and a bitter, sliarp taste.
The aromatic properties of
rue are due to about one-
fourth of one per cent, or
less of a peculiar, very light
volatile oil, usually more or
less yellowish in color, am
of an extremely powerful
and disagreeable odor. Its
bitterness is due to the crys-
talline yellow glucoside rii'tiii
(C42H60OS6), also known as
rutinie acid, aud said to be
contained also in buchu, ca-
pers, and some other drugs.
Considerable quercitin and
sugar also occur.
Action a-su Uses. — Rue
is one of the most ancient of drugs. Its action appears
to be that of the volatile oil, differing chiefly iu its lesser
intensity. Taken internally, in small doses, it is stoma-
chic, laxative, aud stimulant to the secretions, especially
to those of the intestine and kidneys. In somewhat
larger doses it is a powerful anti-spasmodic. It also acts
as an emnienagogue, and is in overdoses an irritant in-
testinal and renal poison and an abortifacient. Among
the ancients it was used for its aphrodisiac properties.
The dose of the drug ranges from ten to twenty grains,
and it is best given in the form of a twenty-per-cent.
tincture, made with diluted alcohol, dose fifteen to sixty
minims.
Oil of me was official in the United States Pharmaco-
pccia of 1870 and 1880. It possesses all the above-named
properties of rue iu a greatly intensified degree. It is a
powerful counter-irritant, capable of producing vesica-
tion similar to that from croton oil. It is a well-known
and dangerous abortifacient, and is capable of acting as
a fatal irritant-narcotic intestinal poison. It is not often
given internally at the present time. The dose is from
two to five minims. Henry 11. Ruxhy.
RUMINATION IN MAN. iii:e Stomach, Diseases of the.
RUPIA. Sec Si/iihi!i.i.
RUSSEL'S BODIES. See Carcinoma.
RUTLAND, MASSACHUSETTS. — Rutland, Mass.,
situaleil in almost the geographical centre of Jlassachu-
setts, fifty-four miles from Boston, is the seat of the " Mas-
sachusetts State Sanatorium " for pulmonary tuberculosis,
the first institution of the kind establi.shcd in the United
States, having been opened for patients October 1st, 189S.
Fi(i. 4i:W. — Flowering Brancn
of Rue. (Baillon.)
1003
Kye.
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES.
The site occupied by tlie sanatorium aud its grounds
cousists of about two hundred and fifty acres of laud, at
an elevation of 1.160 feet, protected onthe northwest by
a wooded hill rising 100 feet higher. The climate is that
of inland New England modified by the elevation. The
winters are cold and long, with much snow, and the tem-
perature is very variable. The average annual rainfall
is high, and although, taking the year through, there is
a good deal of sunshine, there are usually not many suc-
cessive sunny days. The atmosphere, however, is pure
and free from dust, and there is a clear sweep of country
round about.
The sanatorium buildings consist of a series of one-
story wards radiating toward the south, connected by a
long convex corridor. In the rear toward the north are
the kitchen, dining-room, assembly hall, heating, electric
and laundry departments. At the centre of the curved
corridor and connected with it by an open passageway is
the administration building, looking toward the south.
The patients sleep, for the most part, iu open wards,
there being only a few isolated rooms. At the southern
termini of the wards are sun rooms aud piazzas. In the
neighboring woods are various [licturesque camjis made
of boughs and other material where much of the day-
time is spent both in summer and winter. There are
accommodations for two hundred and fifty patients and
still further additions are contemplated. (Plate LI.)
The whole establishment is under the charge of a resi-
dent physician and superintendent, with two visiting and
several house physicians. Only the incipient cases are
received, or those whose condition offers a reasonable
hojie of radical improvement. Both male and female
patients are received.
The treatment is the hygienic-dietetic, essentially the
same as that which is pursued iu all modern sanatoria for
pulmonary tuberculosis- "Constant life in the open air;
judicious exercise, varying with individual cases, iu con-
junction with the ' rest cure ' ; and a iiroperly regulated
diet of nutritious food * (Bowditch, Sixth Annual Report,
1902). It is a part of the regulations that patients must
spend at least eicjlit lumrs out of doors daily, unless ex-
cused by the physician; and that all windows are to be
opened and closed by the nurse or attendant only. When
there is a driving storm, and in winter when the patients
are getting up or going to bed, the windows of the wards
are clo.sed, but at other times they are constantly kept
open. "Medicines are used as little as possible."
Male patients, whose condition will permit it without
iujur}-, are utilized in light work upon the farm connected
with the institution. Jlost patients are obliged to furnish
S4 a week toward their board, which is somewhat le.ss than
half of the actual expense.
As to the results obtained, the last report, up to Sep-
tember 30th, 1902, shows 73 per cent, of the incipient
cases for the previous year apparently cured or arrested,
and 19 per cent, of the moderately advanced cases. Tak-
ing all stages of the disease, there were 48.33 percent,
apparently cured or arrested, and 43.49 per cent,
improved. This for the previous year.
For a more extended consideration of the yearly results
and of tlie subsequent histories of former patients, the
reader is referred to the yearly reports of the trustees pub-
lished by the State. For a more detailed description of the
sanatorium and the treatment, one is referred to the article
of Dr. V. Y. Bowditch, one of tlie visiting physicians,
in the Boston Medical and Surgical Journal for February
8th, 1900: also to the yearly reports of the sanatorium.
Numerous boarding-houses and small sanatoria have
sprung up in the vicinity, most of tliem conducted by
former patients; they receive consumptives at a mode-
rate rate, and carry out the " treatment " as learned in the
sanatorium. Edicard 0. Otis.
RYE. See Starch.
luui
END OF VOLUME VI.
REFERENCE HANDBOOK
OF THE
WEDICAL SCIENCES
PLATE LI.
AJiniSL^Tl^TlON bl-'lL-OIN*
THE STATE SANATORIUM AT RUTLAND. MASSACHUSETTS
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